Vol. 16 | Weekly issue 14 | 7 April 2011
Europe’s leading journal on infectious disease epidemiology, prevention and control
Change of guard in Eurosurveillance
by K Ekdahl
First detection of Echinococcus multilocularis in Sweden, February to March 2011
by E Osterman Lind, M Juremalm, D Christensson, S Widgren, G Hallgren, EO Ågren, H Uhlhorn,
A Lindberg, M Cedersmyg, H Wahlström
Gonorrhoea treatment failures to cefixime and azithromycin in England, 2010
by CA Ison, J Hussey, KN Sankar, J Evans, S Alexander
Outbreak of rotavirus gastroenteritis in a nursing home, Slovenia, December 2010
by A Trop Skaza, L Beskovnik, T Zohar Cretnik
Surveillance and outbreak reports
Outbreak of Shigella sonnei infections in the Orthodox Jewish community of Antwerp,
Belgium, April to August 2008
by K De Schrijver, S Bertrand, I Gutiérrez Garitano, D Van den Branden, J Van Schaeren
Change of guard in Eurosurveillance
K Ekdahl (email@example.com)1
1. Public Health Capacity and Communication Unit, European Centre for Disease Prevention and Control (ECDC), Stockholm,
Citation style for this article:
Ekdahl K. Change of guard in Eurosurveillance. Euro Surveill. 2011;16(14):pii=19835. Available online: http://www.eurosurveillance.org/ViewArticle.
Article published on 7 April 2011
In March 2007, Eurosurveillance moved to the European
Centre for Disease Prevention and Control (ECDC) from
its two previous hosts, the Institut de Veille Sanitaire
in Paris, France (Eurosurveillance Monthly) and the
Health Protection Agency in London (Eurosurveillance
Weekly) . This marked an important date for the then
young ECDC, as this was the first major European Union
funded public health project moving to the Centre 
and I was proud to become the journal’s Editor-in-chief.
From the start, my aim was to build on the success-
ful work of my predecessors in Paris and London and
to continue to provide and further develop a platform
for the exchange of scientific information for all those
engaged in the surveillance, prevention and control of
communicable diseases . Moreover, I was convinced
that the opportunity to have the editorial team for both
publications physically in the same place for the first
time would open new possibilities such as merging the
two formats into one. It would allow Eurosurveillance to
be strengthened and established as a prime European
source of scientific information in its field, in other
words to become Europe’s journal on infectious dis-
ease surveillance, prevention and control.
In fact, relying on a strong network of dedicated
experts across Europe and a committed team of editors
and with the editorial independence guaranteed by two
consecutive ECDC Directors and the ECDC Management
Board, Eurosurveillance is now firmly established.
In 2009, the journal applied for and was accepted
to receive an impact factor  and during the 2009
influenza A(H1N1) pandemic much attention was paid
worldwide to the timely publication of peer-reviewed
papers in our journal [4,5]. Timeliness has been and
will remain a strength and key distinctive feature of the
journal. The rapid sharing of information has on several
occasions contributed to linking and detecting similar
outbreaks and to controlling them [6-9]. Moreover, a
recent reader survey has demonstrated a high level of
satisfaction and much support for our journal.
After four exciting years as Editor-in-chief of
Eurosurveillance, I take over new responsibilities
at ECDC where I will build up the new Public Health
Capacity and Communication Unit . Therefore I
am now handing over the full leadership of the jour-
nal to Dr Ines Steffens. Ines has since the transfer of
the journal to ECDC in 2007 been Managing Editor of
Eurosurveillance, leading the day-to-day work of the
Editorial Office. In this position she has been instru-
mental in the successful development of the journal,
not least broadening the group of authors and readers
to a truly global one.
Ines has a firm public health and communicable dis-
ease knowledge and passion for quality. Together
with an enthusiastic editorial team, her vision is that
of a strong journal, which provides knowledge and
evidence for decisions that help to prevent and con-
trol infectious diseases thus contributes to the many
efforts in improving health overall. I am therefore con-
vinced that Eurosurveillance will continue to thrive, and
although with a sad eye the heart is light when now
stepping down from the lead of the journal. I will con-
tinue to follow the development of the journal and sup-
port it as Associate Editor in the future.
1. Eurosurveillance editorial team. Eurosurveillance changes
hands! Euro Surveill. 2007;12(9):pii=3146. Available
2. Regulation (EC) No 851/2004 of the European Parliament and
of the Council of 21 April 2004 establishing a European Centre
for disease prevention and control. Official Journal L 142,
30/04/2004 P. 1 - 11. Available from: http://www.ecdc.europa.
3. Steffens I, Ekdahl K. Accepted for the impact factor –
what is the impact of Eurosurveillance?. Euro Surveill.
2009;14(38):pii=19339. Available from: http://www.
4. Bloomberg. Swine flu in Greek students may point to outbreak
in Edinburgh. 28 May 2009. Available from: http://www.
5. The Cybercast News Service (CNSNews.com). Republicans
press Sebelius on slow production of swine flu vaccine. 21 Oct
2009. Available from: www.cnsnews.com/news/article/55901
6. Lewis H, Ethelberg S, Lisby M, Madsen SB, Olsen KE,
Rasmussen P, Kjelsø C, Vestergaard LS, Qureshi K,
Howitz M, Mølbak K. Outbreak of shigellosis in Denmark
associated with imported baby corn, August 2007. Euro
Surveill. 2007;12(35):pii=3257. Available from: http://www.
7. Stafford R, Kirk M, Selvey C, Staines D, Smith H, Towner
C, Salter M. An outbreak of multi-resistant Shigella sonnei
in Australia: possible link to the outbreak of shigellosis in
Denmark associated with imported baby corn from Thailand.
Euro Surveill. 2007;12(37):pii=3266. Available from: http://
8. Løvoll Ø, Vonen L, Vevatne T, Sagvik E, Vainio K, Sandbu
S, Aavitsland P. An outbreak of measles among a travelling
community from England in Norway: a preliminary report. Euro
Surveill. 2007;12(21):pii=3198. Available online from: http://
9. Ripa T, Nilsson P. A variant of Chlamydia trachomatis with
deletion in cryptic plasmid: implications for use of PCR
diagnostic tests. Euro Surveill. 2006;11(45):pii=3076. Available
online from: http://www.eurosurveillance.org/ViewArticle.
10. European Centre for Disease Prevention and Control (ECDC).
ECDC changes organisational structure. Available from:
cefotaxim. PFGE was performed on 20 of the 32 iso-
lates and showed that all strains isolated during this
outbreak displayed the same restriction-fragment pat-
terns, confirming the relatedness of these isolates.
The outbreak strain in Antwerp was compared to 12
different outbreak strains detected in Shigella sonnei
shigellosis outbreaks in Orthodox Jewish communities
in Israel between 2000 and 2008. Figure 2 presents
the results of a cluster analysis on the basis of PFGE
fingerprinting of isolates from Antwerp and Israel. The
isolate called ‘Lane 13 gel Israel’, S. sonnei isolated in
2008 in Israel, was indistinguishable from the Belgian
outbreak strain. The isolates shown as ‘Lane 11 and 12
gel Israel’, also isolated in Israel in 2008, had a closely
related profile with the Belgian outbreak strain. Five
unrelated S. sonnei strains originating from national
Belgian collections (‘Control strain Belgium’ from
2008) were used as internal reference.
Secondary attack rate study
For the 29 affected households with confirmed cases,
we identified 175 household contacts, of whom 15
developed shigellosis. A secondary attack rate of
8.5% (95% CI: 4.3–12.7) was calculated. Information
on hand washing, the number of toilets in the home
and the use of disposable towels was only provided
by four of the 25 interviewed households. These ques-
tions were excluded in the analysis. The calculated
crude and adjusted RRs for the other risk factors are
shown in the Table. In the uni- and multivariate analy-
sis, having more than three children in the family, hav-
ing children younger than 12 years who assisted their
parents washing siblings and helping them go to the
toilet, and having children younger than five years,
were significantly associated with a higher risk of
secondary transmission. Having more than three chil-
dren in the household was associated with the highest
risk, with an adjusted RR of 9.17 (95% CI: 1.21–69.13).
Hospitalisation and treatment with antibiotics of the
household index cases were not significantly associ-
ated with a lower risk of secondary infection, with a
respectively adjusted RR of 0.88 (95% CI: 0.61-3.1) and
an adjusted RR of 1.8 (95% CI: 0.80-4.34).
To prevent further spread of the disease, parents of
the affected families were advised of the importance of
hand washing with running water and liquid soap after
using the toilet or washing the children and also on
the importance using disposable towels and cleaning
the toilets with chlorine. The need to decontaminate
toys was highlighted. In June 2008 educational pres-
entations for parents, caregivers and teachers were
organised. Information was also published in the local
media. Physicians were informed via articles in the
local medical infectious disease journal. Schools were
informed on the hygiene of hand washing facilities. We
insisted on excluding symptomatic children for a mini-
mum of 48 hours after clinical recovery from day care
centres, preschool and school attendance .
We identified a cluster of 42 cases of shigellosis in the
Orthodox Jewish community of Antwerp with 32 iso-
lates laboratory-confirmed as S. sonnei with the same
genetic profile. Temporal and spatial clustering in one
area of town affecting one specific community sup-
ported the hypothesis of a single ongoing outbreak,
maintained through person-to-person transmission.
Statutory laboratory-based surveillance of shigellosis
failed to identify concurrent cases outside this com-
munity. Two additional S. sonnei cases notified in the
study period in the province of Antwerp in people who
were not Jewish were most probably not linked to the
outbreak. The disease started during a stay in Egypt
and they were classified as travel-associated cases.
The index case was most probably infected by their
father, who had suffered from gastrointestinal prob-
lems during a stay in Tel-Aviv, Israel until two days
before symptom onset in the index case but did not
seek medical care. No exceptional family gatherings
could be identified except for synagogue attendance.
The father also reported having been in contact with
relatives coming from London.
To investigate a possible link between the outbreak
in Antwerp and an ongoing outbreak in Israel , the
circulating strains in both outbreaks were compared.
Such a link was supported by the microbiological anal-
ysis in which the main strain circulating in Israel at the
time and the outbreak strain in Antwerp were indistin-
guishable. The father of the index case also reported
having been in contact with relatives coming from
Risk factors of illness among household contacts of an index case with shigellosis, Jewish community Antwerp, 17 April–31
August 2008 (n=42)
Univariate analysis Multivariate analysis
>3 children in household
Children with nappies
Children <5 years in household
Children <12 years assisting parents washing siblings
Index case in household hospitalised
Index case in household treated with antibiotics
Crude relative risk 95% confidence interval Adjusted relative risk 95% confidence interval
London. Addiman et al. reported on an outbreak of
shigellosis in London starting a month before the onset
of our outbreak in Antwerp in 2008 . A strain from
the outbreak of London 2008 could not be obtained for
Outbreaks of shigellosis with S. sonnei and recurrent
increases in the number of cases in Orthodox Jewish
populations have already been notified in 2008 and
before in different countries. Calderon-Margalit et al.
showed that between 1998 and 2006, outbreaks of
shigellosis followed a biennial pattern in Israel with
annual rates that ranged from 18 to 353 cases per
100,000 population . Also in 2009 outbreaks of
S. sonnei in Israel were still continuing . Close con-
tacts, day care attendance and having many young chil-
dren in the families were considered risk factors. The
characteristics of the outbreak in Antwerp are compa-
rable with prolonged outbreaks of S. sonnei reported
by Sobel et al. in North America in traditionally observ-
ant Jewish communities between 1994 and 1996  ,
with outbreaks reported by Garret et al. in New York in
2005  and with the outbreak in London in 2008 .
The secondary attack rate of 8.5% found in this study
is comparable to those noticed in other studies [2,15].
In larger studies, secondary attack rate differed
according to age and to the species of bacterium .
Due to the limited number of cases in our study, age-
specific attack rates could not be calculated. Dupont
et al. showed that for one to four year-olds, the sec-
ondary attack rate can reach 40% . The combination
of high communicability due to the low infective dose,
crowding, and frequent contacts are known explana-
tions for the high secondary attack rate for shigellosis
[2,14,15]. In our study we analysed specific risk factors
which might explain the noted secondary attack rate.
Having more than three children in the household and
having children younger than five years of age was sig-
nificantly associated with the occurrence of secondary
cases, which is consistent with data from other authors
. Contrary to what we expected, having children
with nappies in the household was not a significant
independent risk factor in our study. This could be due
to good hygienic habits of the adults when providing
care for their babies. That the index case of the fam-
ily was hospitalised was hypothesised to be a pro-
tective factor, but the adjusted RR was 0.88 (95% CI:
0.61–3.10). The low number of cases and the different
intervals between onset of the disease and moment of
hospitalisation of the cases might have interfered with
the association. Being treated with antibiotics was not
significantly associated with a lower risk of second-
ary transmission either. Different delays in the start
of therapy, the broad spectrum of used antibiotics and
the small number of cases might explain the calculated
RR of 1.8 (95% CI: 0.80–4.34).
However, it was remarkable that children younger than
12 years, helping their parents take care of babies,
was associated with a higher risk of secondary cases
(adjusted RR: 5.45; 95% CI: 2.44–12.17). In families
with a high number of children, older children were
asked to help. There is a risk that these young children
are less sensitive or less knowledgeable than their par-
ents on the risk and the practice of hand hygiene.
Visiting friends and relatives in areas with higher risk
of shigellosis might be the seeding event leading to
shigellosis outbreaks in especially susceptible com-
munities. This is the case for Jewish communities in
Antwerp that are more susceptible due to the high
number of children in the families, the many social
contacts, living in a relatively small community, and
the frequent contact with relatives who live in areas of
higher endemic prevalence of shigellosis, like certain
neighbourhoods in London or Israel [11,12].
The high hospital admission rate in our study (32 of
42 cases) suggests that we have probably detected
only the most severe cases, whereas milder cases
could also have been expected. Presenting bloody or
mucopurulent diarrhoea was noted in 18 of the cases.
This is unusual compared to the expected picture of a
S. sonnei infection which is normally associated with
a milder disease [2,3,5]. We have therefore reason to
consider under-diagnosis and under-reporting in this
outbreak, which is also mentioned in similar outbreaks
of shigellosis elsewhere .
Several limitations of the study especially for the sec-
ondary attack rate study should be noted. Firstly, the
number of cases was limited. This raises concerns
about the interpretation of the calculated relative
risks. Secondly, we assumed that secondary cases
acquired their infection at home. Alternatively they
might have been infected during pre-school and school
attendance or by visiting friends and relatives. Thirdly,
personal questions like ‘did you wash your hands after
toilet use?’ and ‘how many toilets do you use at home’
were often not answered, most probably due to their
sensitive and private nature . It is likely that not all
possible risk factors could be explored in the study of
Early notification of shigellosis enabled prompt reac-
tion, and implementation of the advice most probably
put a stop to further propagation. We presume that
especially the intensive hand washing campaign in
families and schools, the educational presentations
and specific information to physicians contributed to
stopping the outbreak.
PFGE in studies of clusters has been shown to be a
highly effective method of characterising S. sonnei
and an important tool for outbreak investigations .
Provided that the same protocol is used, it allows com-
parison of strains detected in different outbreak. The
genetic relatedness of the strains in this study provides
strong evidence that this cluster was a single outbreak
and associated with recurrent endemic shigellosis in
In conclusion, this is the first well-documented out-
break of S. sonnei in the Orthodox Jewish community
of Antwerp and Belgium for which a direct link to an
ongoing outbreak of endemic shigellosis in Israel could
be identified. The combination of case finding, source
tracing, and comparing different strains with PFGE was
essential for confirming the hypothesis of import of an
outbreak strain from Israel into the local community,
and implementation of hand washing was important to
stop the propagation of the epidemic.
We thank physicians, microbiologists and public health
nurses for their collaboration during the study. We thank
Emmanuel Robesyn for his support during the analysis of
the data, Annick Lenglet for the critical comments, and we
are grateful for the assistance of the Social Service of the
Jewish community of Antwerp for contacting people. We also
thank Lea Valinsky from the Central Laboratories Ministry of
Health, Jerusalem Israel who provided the PFGE pictures of
different outbreak strains detected in Israel.
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