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We studied food and water-borne diseases (FWDs), sexually transmitted diseases (STDs), vector-borne diseases (VBDs) and diseases vaccinated against in the Swedish childhood vaccination programme among Swedish international travellers, in order to identify countries associated with a high number of infections. We used the national database for notifiable infections to estimate the number of FWDs (campylobacteriosis, salmonellosis, giardiasis, shigellosis, EHEC, Entamoeba histolytica, yersinosis, hepatitis A, paratyphoid fever, typhoid fever, hepatitis E, listeriosis, cholera), STIs (chlamydia, gonorrhoea and acute hepatitis B), VBDs (dengue fever, malaria, West Nile fever, Japanese encephalitis and yellow fever) and diseases vaccinated against in the Swedish childhood vaccination programme (pertussis, measles, mumps, rubella, diphtheria) acquired abroad 2009-2013. We obtained number and duration of trips to each country from a database that monthly collects travel data from a randomly selected proportion of the Swedish population. We calculated number of infections per country 2009-2013 and incidence/million travel days for the five countries with the highest number of infections. Thailand had the highest number of FWDs (7,697, incidence 191/million travel days), STIs (1,388, incidence 34/million travel days) and VBDs (358, incidence 9/million travel days). France had the highest number of cases of diseases vaccinated against in the Swedish childhood vaccination programme (8, 0.4/million travel days). Swedish travellers contracted most infections in Thailand. Special focus should be placed on giving advice to travellers to this destination.

To establish strategic priorities for the Public Health Agency of Sweden we prioritized pathogens according to their public health relevance in Sweden in order to guide resource allocation. We then compared the outcome to ongoing surveillance. We used a modified prioritization method developed at the Robert Koch Institute in Germany. In a Delphi process experts scored pathogens according to ten variables. We ranked the pathogens according to the total score and divided them into four priority groups. We then compared the priority groups to self-reported time spent on surveillance by epidemiologists and ongoing programmes for surveillance through mandatory and/or voluntary notifications and for surveillance of typing results. 106 pathogens were scored. The result of the prioritization process was similar to the outcome of the prioritization in Germany. Common pathogens such as calicivirus and Influenza virus as well as blood-borne pathogens such as human immunodeficiency virus, hepatitis B and C virus, gastro-intestinal infections such as Campylobacter and Salmonella and vector-borne pathogens such as Borrelia were all in the highest priority group. 63% of time spent by epidemiologists on surveillance was spent on pathogens in the highest priority group and all pathogens in the highest priority group, except for Borrelia and varicella-zoster virus, were under surveillance through notifications. Ten pathogens in the highest priority group (Borrelia, calicivirus, Campylobacter, Echinococcus multilocularis, hepatitis C virus, HIV, respiratory syncytial virus, SARS- and MERS coronavirus, tick-borne encephalitis virus and varicella-zoster virus) did not have any surveillance of typing results. We will evaluate the possibilities of surveillance for the pathogens in the highest priority group where we currently do not have any ongoing surveillance and evaluate the need of surveillance for the pathogens from the low priority group where there is ongoing surveillance in order to focus our work on the pathogens with the highest relevance.

The outbreak of highly pathogenic avian influenza of the H5N1 subtype in Asia, which has subsequently spread to Russia, the Middle East, Europe, and Africa, has put increased focus on the role of wild birds in the persistence of influenza viruses. The ecology, epidemiology, genetics, and evolution of pathogens cannot be fully understood without taking into account the ecology of their hosts. Here, we review our current knowledge on global patterns of influenza virus infections in wild birds, discuss these patterns in the context of host ecology and in particular birds' behavior, and identify some important gaps in our current knowledge.

Pathogen Incid - ence Absent -eeism Health care utilizatio n Chronicit y of illness or sequelae Case fatalit y rate Public health action s Tren d Public attention Preventio n possibilite s and needs Treatment possibilitie s and needs Total scor e Re- scaled score Prio grou p Influenza virus 1 1 1 -1 0 0 0 1 1 0 4 100 1 Respiratory syncytial virus (RSV) 1 1 1 0 -1 0 0 0 1 1 4 100 1 Calicivirus 1 1 1 -1 0 0 1 1 1 -1 4 100 1 Tick borne encephalitis virus 0 0 0 1 0 0 1 1 0 1 4 100 1 Human immunodeficiency virus (HIV) 0 0 0 1 0 1 0 1 0 0 3 92 1 Streptococcus pneumoniae 1 1 1 0 0 -1 0 0 0 1 3 92 1 Hepatitis B virus 0 0 0 1 0 1 0 0 0 0 2 85 1 Hepatitis C virus 1 0 0 0 0 1 0 -1 1 0 2 85 1 Escherichia coli (shiga toxin producing i.e. EHEC) 0 0 0 0 0 1 1 0 0 0 2 85 1 Salmonella spp (non-Typhi and non Paratyphi) 1 0 0 0 0 1 -1 1 0 0 2 85 1 Echinococcus multilocularis -1 -1 -1 1 1 1 0 1 0 1 2 85 1 Clostridium difficile 1 0 1 0 0 0 0 0 0 0 2 85 1 Staphylococcus aureus incl. methicillin resistant (MRSA) 1 1 1 -1 -1 0 0 0 0 1 2 85 1 Human papilloma virus (HPV) 1 0 1 1 -1 -1 0 1 0 -1 1 77 1 Neisseria meningitidis -1 -1 -1 1 1 1 0 1 0 0 1 77 1 Measels virus -1 -1 -1 1 0 1 0 1 0 1 1 77 1 Varicella-zoster virus 1 1 0 1 -1 -1 0 0 0 0 1 77 1 SARS and MERS coronavirus -1 -1 -1 0 1 1 0 1 0 1 1 77 1 Campylobacter spp 1 0 0 0 -1 0 1 0 0 0 1 77 1 Borrelia burgdorferi 1 0 1 0 -1 -1 0 1 1 -1 1 77 1 Escherichia coli (non-gastro illnesses) incl.ESBL 1 1 1 -1 -1 0 0 0 -1 1 1 77 1 Chlamydia trachomatis 1 -1 1 0 -1 1 0 0 0 -1 0 69 2 Mycobacterium tuberculosis 0 -1 -1 -1 0 1 0 1 1 0 0 69 2 Epstein-Barr virus (HHV-4) 1 0 0 0 -1 -1 0 0 1 0 0 69 2 Shigella spp. 0 0 0 0 0 1 0 -1 0 0 0 69 2 Rota virus 1 1 1 -1 -1 -1 0 0 1 -1 0 69 2 Rabies virus -1 -1 -1 -1 1 1 0 1 0 1 0 69 2 Helicobacter pylori 1 -1 1 0 -1 -1 0 0 1 0 0 69 2 Klebsiella spp incl.ESBL 0 -1 0 -1 0 0 1 -1 0 1 -1 62 2 Enterococcus spp. (blood) incl. vancomycin resistant (VRE) 0 -1 0 -1 0 0 0 0 0 1 -1 62 2 Hepatitis D virus -1 -1 -1 -1 1 1 0 -1 0 1 -2 54 2 Mycoplasma spp. 1 1 1 -1 0 -1 0 -1 -1 -1 -2 54 2 Bordetella pertussis 0 0 0 -1 0 0 -1 0 0 0 -2 54 2 Mumps virus -1 -1 -1 0 -1 1 0 0 0 1 -2 54 2 Naegleria fowleri -1 -1 -1 0 1 1 0 -1 -1 1 -2 54 2 Giardia lamblia 0 0 0 0 -1 0 0 -1 0 0 -2 54 2 Cryptosporidium parvum and hominis 0 0 -1 0 -1 0 1 -1 0 0 -2 54 2 Bacillus anthracis -1 -1 -1 -1 1 1 0 1 0 -1 -2 54 2 Pseudomonas ssp. 0 -1 0 -1 0 0 0 -1 0 1 -2 54 2 Enterobacter spp. incl ESBL 0 -1 0 -1 0 0 0 -1 0 1 -2 54 2 Treponema pallidum 0 -1 -1 -1 -1 1 0 1 0 -1 -3 46 3 Human T-cell lymphotrophic virus (HTLV) -1 -1 -1 -1 0 1 0 -1 0 1 -3 46 3 Herpes simplex virus (HSV)-2 1 -1 -1 1 -1 -1 0 0 -1 0 -3 46 3 Parainfluenza virus 1 1 1 -1 -1 -1 0 -1 -1 -1 -3 46 3 Rhino virus 1 1 1 -1 -1 -1 0 -1 -1 -1 -3 46 3 Pneumocyctis jiroveci 0 -1 0 -1 1 -1 0 -1 0 0 -3 46 3 Cytomegalovirus (HHV-5) 1 -1 -1 0 -1 -1 0 -1 1 0 -3 46 3 Sarcoptes scabiei 0 -1 0 -1 -1 0 0 0 0 0 -3 46 3 Echinococcus granulosis -1 -1 -1 1 0 0 0 0 -1 0 -3 46 3 Acinetobacter -1 -1 -1 -1 0 1 0 -1 0 1 -3 46 3 Burkholderia cepacia -1 -1 -1 -1 0 1 0 -1 0 1 -3 46 3 Staphylococcus epidermidis (coagnulase-negative staphylococci) 0 -1 0 0 -1 -1 0 -1 0 1 -3 46 3 Herpes simplex virus (HSV)-1 1 -1 -1 1 -1 -1 0 -1 -1 0 -4 38 3 SARS- and MERS coronaviruses 1 1 0 -1 -1 -1 0 -1 -1 -1 -4 38 3 Aspergillus spp. -

Norovirus outbreaks severely disrupt healthcare systems. We evaluated whether Websök, an internet-based surveillance system using search engine data, improved norovirus surveillance and response in Sweden. We compared Websök users' characteristics with the general population, cross-correlated weekly Websök searches with laboratory notifications between 2006 and 2013, compared the time Websök and laboratory data crossed the epidemic threshold and surveyed infection control teams about their perception and use of Websök. Users of Websök were not representative of the general population. Websök correlated with laboratory data (b = 0.88-0.89) and gave an earlier signal to the onset of the norovirus season compared with laboratory-based surveillance. 17/21 (81%) infection control teams answered the survey, of which 11 (65%) believed Websök could help with infection control plans. Websök is a low-resource, easily replicable system that detects the norovirus season as reliably as laboratory data, but earlier. Using Websök in routine surveillance can help infection control teams prepare for the yearly norovirus season.

The Swedish school-based vaccination programme offers HPV vaccine to girls born ≥1999 in 5-6th grade. In 2012, all counties introduced free-of-charge catch-up vaccination campaigns targeting girls born 1993-1998. Varying vaccine uptake in the catch-up group by December 2012 suggested that some implementation strategies were more successful than others. In order to inform future vaccination campaigns, we assessed the impact of different implementation strategies on the county-level catch-up vaccine uptake. We conducted an ecological study including all Swedish counties (n = 21), asking regional health offices about the information channels they used and where vaccination of the catch-up target group took place in their counties. The uptake of ≥1 dose by 30 September 2014 was estimated using data from the voluntary national vaccination register. We investigated associations between counties' catch-up vaccine uptake, information channels and vaccination settings by calculating incidence rate ratios (IRR) and 95% confidence intervals (CI), using negative binomial regression models. County level catch-up vaccine uptake varied between 49-84%. All counties offered vaccination through primary health care settings. Apart from this eight (34%) also offered the vaccine in some of their schools, four (19%) in all their schools, and two (10%) in other health care centres. The information channels most frequently used were: information at the national on-line health care consulting web-page (100%), letter/invitations (90%), and advertisement (81%). Counties offering vaccination to girls in all schools and counties offering vaccination in some of their schools, reached higher vaccine uptake compared to counties not offering vaccination in any of their schools (all schools adjusted IRR: 1.3, 95% CI: 1.1-1.5, some schools adjusted IRR: 1.2, 95% CI: 1.1-1.3). Counties offering HPV vaccination to catch-up groups in schools reached the highest vaccine uptake. No information channel explained differences in county-level vaccine uptake. Our findings suggest that catch-up vaccination outside the national vaccination program can reach a high uptake at the population level if it is implemented primarily with an organized delivery (e.g. in schools).

Although extensive data exist on avian influenza in wild birds in North America, limited information is available from elsewhere, including Europe. Here, molecular diagnostic tools were employed for high-throughput surveillance of migratory birds, as an alternative to classical labor-intensive methods of virus isolation in eggs. This study included 36,809 samples from 323 bird species belonging to 18 orders, of which only 25 species of three orders were positive for influenza A virus. Information on species, locations, and timing is provided for all samples tested. Seven previously unknown host species for avian influenza virus were identified: barnacle goose, bean goose, brent goose, pink-footed goose, bewick's swan, common gull, and guillemot. Dabbling ducks were more frequently infected than other ducks and Anseriformes; this distinction was probably related to bird behavior rather than population sizes. Waders did not appear to play a role in the epidemiology of avian influenza in Europe, in contrast to the Americas. The high virus prevalence in ducks in Europe in spring as compared with North America could explain the differences in virus-host ecology between these continents. Most influenza A virus subtypes were detected in ducks, but H13 and H16 subtypes were detected primarily in gulls. Viruses of subtype H6 were more promiscuous in host range than other subtypes. Temporal and spatial variation in influenza virus prevalence in wild birds was observed, with influenza A virus prevalence varying by sampling location; this is probably related to migration patterns from northeast to southwest and a higher prevalence farther north along the flyways. We discuss the ecology and epidemiology of avian influenza A virus in wild birds in relation to host ecology and compare our results with published studies. These data are useful for designing new surveillance programs and are particularly relevant due to increased interest in avian influenza in wild birds.

Background In the winter and spring of 2011 a large outbreak of cryptosporidiosis occurred in Skellefteå municipality, Sweden. This study summarizes the outbreak investigation in terms of outbreak size, duration, clinical characteristics, possible source(s) and the potential for earlier detection using calls to a health advice line. Methods The investigation included two epidemiological questionnaires and microbial analysis of samples from patients, water and other environmental sources. In addition, a retrospective study based on phone calls to a health advice line was performed by comparing patterns of phone calls between different water distribution areas. Results Our analyses showed that approximately 18,500 individuals were affected by a waterborne outbreak of cryptosporidiosis in Skellefteå in 2011. This makes it the second largest outbreak of cryptosporidiosis in Europe to date. Cryptosporidium hominis oocysts of subtype IbA10G2 were found in patient and sewage samples, but not in raw water or in drinking water, and the initial contamination source could not be determined. The outbreak went unnoticed to authorities for several months. The analysis of the calls to the health advice line provides strong indications early in the outbreak that it was linked to a particular water treatment plant. Conclusions We conclude that an earlier detection of the outbreak by linking calls to a health advice line to water distribution areas could have limited the outbreak substantially.

Oseltamivir is the main antiviral for treatment and prevention of pandemic influenza. The increase in oseltamivir resistance reported recently has therefore sparked a debate on how to use oseltamivir in non pandemic influenza and the risks associated with wide spread use during a pandemic. Several questions have been asked about the fate of oseltamivir in the sewage treatment plants and in the environment. We have assessed the fate of oseltamivir and discuss the implications of environmental residues of oseltamivir regarding the occurrence of resistance. A series of batch experiments that simulated normal sewage treatment with oseltamivir present was conducted and the UV-spectra of oseltamivir were recorded. Our experiments show that the active moiety of oseltamivir is not removed in normal sewage water treatments and is not degraded substantially by UV light radiation, and that the active substance is released in waste water leaving the plant. Our conclusion is that a ubiquitous use of oseltamivir may result in selection pressures in the environment that favor development of drug-resistance.

A source of infection is rarely identified for sporadic cases of Legionnaires' disease. We found that professional drivers are five times more commonly represented among community acquired sporadic cases in England and Wales than expected. We therefore investigated possible risk exposures in relation to driving or spending time in a motor vehicle. A case control study including all surviving community acquired sporadic cases in England and Wales with onset between 12 July 2008 and 9 March 2009 was carried out. Cases were contacted by phone and controls were consecutively recruited by sequential digital dialling matched by area code, sex and age group. Those who consented were sent a questionnaire asking questions on driving habits, potential sources in vehicles and known risk factors. The results were analysed using logistic regression. 75 cases and 67 controls were included in the study. Multivariable analysis identified two exposures linked to vehicle use associated with an increased risk of Legionnaires' disease: Driving through industrial areas (OR 7.2, 95%CI 1.5-33.7) and driving or being a passenger in a vehicle with windscreen wiper fluid not containing added screenwash (OR 47.2, 95%CI 3.7-603.6). Not adding screenwash to windscreen wiper fluid is a previously unidentified risk factor and appears to be strongly associated with community acquired sporadic cases of Legionnaires' disease. We estimated that around 20% of community acquired sporadic cases could be attributed to this exposure. A simple recommendation to use screenwash may mitigate transmission of Legionella bacteria to drivers and passengers.