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      Management of a Lassa fever outbreak, Rhineland-Palatinate, Germany, 2016

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          Abstract

          Due to rapid diagnosis and isolation of imported cases, community outbreaks of viral haemorrhagic fevers (VHF) are considered unlikely in industrialised countries. In March 2016, the first documented locally acquired case of Lassa fever (LF) outside Africa occurred, demonstrating the disease’s potential as a cross-border health threat. We describe the management surrounding this case of LF in Rhineland-Palatinate – the German federal state where secondary transmission occurred. Twelve days after having been exposed to the corpse of a LF case imported from Togo, a symptomatic undertaker tested positive for Lassa virus RNA. Potential contacts were traced, categorised based on exposure risk, and monitored. Overall, we identified 21 contact persons with legal residency in Rhineland-Palatinate: seven related to the index case, 13 to the secondary case, and one related to both. The secondary case received treatment and recovered. Five contacts were quarantined and one was temporarily banned from work. No further transmission occurred. Based on the experience gained during the outbreak and a review of national and international guidelines, we conclude that exposure risk attributable to corpses may currently be underestimated, and we present suggestions that may help to improve the anti-epidemic response to imported VHF cases in industrialised countries.

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          Most cited references 21

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          Lassa fever. Effective therapy with ribavirin.

          In a study of Lassa fever in Sierra Leone, West Africa, we identified two variables associated with a high risk of death, and we evaluated the efficacy of ribavirin and Lassa virus-convalescent plasma for the treatment of Lassa fever. A serum aspartate aminotransferase level greater than or equal to 150 IU per liter at the time of hospital admission was associated with a case-fatality rate of 55 percent (33 of 60). Patients with the same risk factor who were treated for 10 days with intravenous ribavirin, begun within the first 6 days after the onset of fever, had a case-fatality rate of 5 percent (1 of 20) (P = 0.0002 by Fisher's exact test). Patients whose treatment began seven or more days after the onset of fever had a case-fatality rate of 26 percent (11 of 43) (P = 0.01). Viremia with levels greater than or equal to 10(3.6) TCID50 per milliliter on admission was associated with a case-fatality rate of 76 percent (35 of 46). Patients with this risk factor who were treated with intravenous ribavirin within the first six days after onset of fever had a case-fatality rate of 9 percent (1 of 11) (P = 0.006), whereas those treated after seven days or more of illness had a fatality rate of 47 percent (9 of 19) (P = 0.035). Oral ribavirin was also effective in patients at high risk of death. Lassa-convalescent plasma did not significantly reduce mortality in any of the high-risk groups. We conclude that ribavirin is effective in the treatment of Lassa fever and that it should be used at any point in the illness, as well as for postexposure prophylaxis.
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            Lassa fever.

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              Imported Lassa fever in Germany: surveillance and management of contact persons.

              This study sought to assess the risk of secondary transmission after import of Lassa fever into Europe. A total of 232 persons exposed to a case of Lassa fever imported into Germany were identified. The level of exposure was determined for 157 persons (68%), and 149 (64%) were tested serologically. High-risk or close contact was reported by 30 (19%) of 157 persons. No symptomatic secondary infections were observed. However, Lassa virus-specific immunoglobulin G antibodies were detected in a serum sample obtained from a physician who examined the index patient on day 9 of illness. The physician received ribavirin prophylaxis and did not develop symptoms of Lassa fever. On the basis of these data, the contact was classified as having a probable secondary infection. The study indicates a low risk of transmission during the initial phase of symptomatic Lassa fever, even with high-risk exposures. The risk may increase with progression of disease and increasing virus load.
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                Author and article information

                Journal
                Euro Surveill
                Euro Surveill
                eurosurveillance
                Eurosurveillance
                European Centre for Disease Prevention and Control (ECDC)
                1025-496X
                1560-7917
                28 September 2017
                : 22
                : 39
                Affiliations
                [1 ]Federal State Agency for Consumer & Health Protection Rhineland-Palatinate, Koblenz, Germany
                [2 ]Postgraduate Training for Applied Epidemiology (PAE), Robert Koch Institute (RKI), Berlin, Germany
                [3 ]European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
                [4 ]These authors contributed equally to this article and share first authorship
                [5 ]Health Department Alzey-Worms, Alzey, Germany
                [6 ]Federal State Ministry for Social Affairs, Employment, Health, and Demographics Rhineland-Palatinate, Mainz, Germany
                [7 ]Institute of Public Health, University Hospitals, Heidelberg, Germany
                [8 ]Department of Infectious Diseases, Medical Microbiology and Hygiene, University Hospitals, Heidelberg, Germany
                Author notes

                Correspondence: Philipp Zanger ( philipp.zanger@ 123456lua.rlp.de )

                Article
                16-00728 16-00728
                10.2807/1560-7917.ES.2017.22.39.16-00728
                5709955
                29019309
                This article is copyright of The Authors, 2017.

                This is an open-access article distributed under the terms of the Creative Commons Attribution (CC BY 4.0) Licence. You may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence, and indicate if changes were made.

                Categories
                Surveillance and Outbreak Report
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