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  • 1.
    Banhart, Sebastian
    et al.
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    Jansen, Klaus
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Buder, Susanne
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Tamminga, Thalea
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Calvignac-Spencer, Sébastien
    Project Group 'Epidemiology of Highly Pathogenic Microorganisms', Robert Koch Institute, Berlin, Germany.
    Pilz, Tanja
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    Martini, Andrea
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    Dudareva, Sandra
    Charité Universitätsmedizin Berlin, Berlin, Germany; Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Nikisins, Sergejs
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Dehmel, Kerstin
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Zuelsdorf, Gabriele
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Guhl, Eva
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Graeber, Ingeborg
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Kohl, Peter K.
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs.
    Bremer, Viviane
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Heuer, Dagmar
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    GORENET, Study Group
    Molecular epidemiological typing of Neisseria gonorrhoeae isolates identifies a novel association between genogroup G10557 (G7072) and decreased susceptibility to cefixime, Germany, 2014 to 20172020In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 25, no 41, article id 1900648Article in journal (Refereed)
    Abstract [en]

    Background: Emerging antimicrobial resistance (AMR) challenges gonorrhoea treatment and requires surveillance.AimThis observational study describes the genetic diversity of Neisseria gonorrhoeae isolates in Germany from 2014 to 2017 and identifies N. gonorrhoeae multi-antigen sequence typing (NG-MAST) genogroups associated with AMR or some patient demographics.

    Methods: 1,220 gonococcal isolates underwent AMR testing and NG-MAST. Associations between genogroups and AMR or sex/age of patients were statistically assessed.

    Results: Patients' median age was 32 years (interquartile range: 25-44); 1,078 isolates (88.4%) originated from men. In total, 432 NG-MAST sequence types including 156 novel ones were identified, resulting in 17 major genogroups covering 59.1% (721/1,220) of all isolates. Genogroups G1407 and G10557 (G7072) were significantly associated with decreased susceptibility to cefixime (Kruskal-Wallis chi-squared: 549.3442, df: 16, p < 0.001). Their prevalences appeared to decline during the study period from 14.2% (15/106) to 6.2% (30/481) and from 6.6% (7/106) to 3.1% (15/481) respectively. Meanwhile, several cefixime susceptible genogroups' prevalence seemed to increase. Proportions of isolates from men differed among genogroups (Fisher's exact test, p < 0.001), being e.g. lower for G25 (G51) and G387, and higher for G5441 and G2992. Some genogroups differed relative to each other in affected patients' median age (Kruskal-Wallis chi-squared: 47.5358, df: 16, p < 0.001), with e.g. G25 (G51) and G387 more frequent among ≤ 30 year olds and G359 and G17420 among ≥ 40 year olds.

    Conclusion: AMR monitoring with molecular typing is important. Dual therapy (ceftriaxone plus azithromycin) recommended in 2014 in Germany, or only the ceftriaxone dose of this therapy, might have contributed to cefixime-resistant genogroups decreasing.

  • 2.
    Berçot, Béatrice
    et al.
    Université Paris Cité, INSERM, IAME, Paris, France; APHP, Infectious Agents Department, Saint Louis Hospital, Paris, France; French National Reference Centre for bacterial STIs, Associated Laboratory for Gonococci, Paris, France.
    Caméléna, François
    Université Paris Cité, INSERM, IAME, Paris, France; APHP, Infectious Agents Department, Saint Louis Hospital, Paris, France; French National Reference Centre for bacterial STIs, Associated Laboratory for Gonococci, Paris, France.
    Mérimèche, Manel
    Université Paris Cité, INSERM, IAME, Paris, France; APHP, Infectious Agents Department, Saint Louis Hospital, Paris, France; French National Reference Centre for bacterial STIs, Associated Laboratory for Gonococci, Paris, France.
    Jacobsson, Susanne
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Ӧrebro University, Ӧrebro, Sweden.
    Sbaa, Ghalia
    APHP, Infectious Agents Department, Saint Louis Hospital, Paris, France; French National Reference Centre for bacterial STIs, Associated Laboratory for Gonococci, Paris, France.
    Mainardis, Mary
    APHP, Infectious Agents Department, Saint Louis Hospital, Paris, France; French National Reference Centre for bacterial STIs, Associated Laboratory for Gonococci, Paris, France.
    Valin, Cyrille
    Laboratoire Anse, Biogroup, Lyon, France.
    Molina, Jean-Michel
    AP-HP, Hôpital Saint-Louis, Lariboisière, Département de Maladies Infectieuses et Tropicales, Paris, France; Université Paris Cité, UMR S976, INSERM, Paris, France.
    Bébéar, Cécile
    University of Bordeaux, USC EA 3671, Mycoplasmal and Chlamydial Infections in Humans, Bordeaux University Hospital, French National Reference Centre for Bacterial STIs, Bordeaux, France.
    Chazelle, Emilie
    Santé Publique France, French National Public Health Agency, Saint-Maurice, France.
    Lot, Florence
    Santé Publique France, French National Public Health Agency, Saint-Maurice, France.
    Golparian, Daniel
    Örebro University, School of Medical Sciences. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Ӧrebro University, Ӧrebro, Sweden.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Ӧrebro University, Ӧrebro, Sweden; Institute for Global Health, University College London, London, United Kingdom .
    Ceftriaxone-resistant, multidrug-resistant Neisseria gonorrhoeae with a novel mosaic penA-237.001 gene, France, June 20222022In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 27, no 50, p. 17-22Article in journal (Refereed)
    Abstract [en]

    We report a ceftriaxone-resistant, multidrug-resistant urogenital gonorrhoea case in a heterosexual woman in France, June 2022. The woman was successfully treated with azithromycin 2 g. She had unprotected sex with her regular partner, who developed urethritis following travel to Vietnam and Switzerland. Whole genome sequencing of the gonococcal isolate (F92) identified MLST ST1901, NG-STAR CC- 199, and the novel mosaic penA-237.001, which caused ceftriaxone resistance. penA-237.001 is 98.7% identical to penA-60.001, reported in various ceftriaxone-resistant strains, including the internationally spreading FC428 clone.

  • 3.
    Chisholm, S. A.
    et al.
    Sexually Transmitted Bacteria Reference Lab, Health Protect Agency, London, England..
    Unemo, Magnus
    Natl Reference Lab Pathogen Neisseria, Dept Lab Med, Örebro University Hospital, Örebro, Sweden.
    Quaye, N.
    Sexually Transmitted Bacteria Reference Lab, Health Protect Agency, London, England..
    Johansson, E.
    Natl Reference Lab Pathogen Neisseria, Dept Lab Med, Örebro Univ Hosp, Örebro, Sweden.
    Cole, M. J.
    Sexually Transmitted Bacteria Reference Lab, Health Protect Agency, London, England..
    Ison, C. A.
    Sexually Transmitted Bacteria Reference Lab, Health Protect Agency, London, England.
    Van de Laar, M. Jw
    European Center Disease Prevention & Control, Stockholm, Sweden.
    Molecular epidemiological typing within the European Gonococcal Antimicrobial Resistance Surveillance Programme reveals predominance of a multidrug-resistant clone2013In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 18, no 3, p. 14-23, article id 20358Article in journal (Refereed)
    Abstract [en]

    Treatment of gonorrhoea is threatened by antimicrobial resistance, and decreased susceptibility and resistance to recommended therapies is emerging in Europe. Current associations between resistance and molecular type remain poorly understood. Gonococcal isolates (n=1,066) collected for the 2009 and 2010 European Gonococcal Antimicrobial Surveillance Programme were typed by Neisseria gonorrhoeae multi-antigen sequence typing (NG-MAST). A total of 406 sequence types (STs) were identified, 125 of which occurred in >= two isolates. Seven major genogroups of closely related STs (varying by <= 1% at just one of the two target loci) were defined. Genogroup 1407 (G1407), observed in 20/21 countries and predominant in 13/21 countries, accounted for 23% of all isolates and was associated with decreased susceptibility to cefixime and resistance to ciprofloxacin and raised minimum inhibitory concentrations for ceftriaxone and azithromycin. Genogroup 225 (G225), associated with ciprofloxacin resistance, was observed in 10% of isolates from 19/21 countries. None of the other genogroups were associated with antimicrobial resistance. The predominance of a multidrug-resistant clone (G1407) in Europe is worrying given the recent reports of recommended third generation cephalosporins failing to treat infections with this clone. Identifying associations between ST and antimicrobial resistance aids the understanding of the dissemination of resistant clones within a population and could facilitate development of targeted intervention strategies.

  • 4.
    Christensen, P. B.
    et al.
    Department of Infectious Diseases Q, Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, Odense, Denmark .
    Debrabant, B.
    Department of Mathematics and Computer Science, University of Southern Denmark, Odense, Denmark; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark .
    Cowan, S.
    Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.
    Debrabant, K.
    Department of Mathematics and Computer Science, University of Southern Denmark, Odense, Denmark.
    Ovrehus, A.
    Department of Infectious Diseases Q, Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, Odense, Denmark .
    Duberg, Ann-Sofi
    Örebro University, School of Medical Sciences. Department of Infectious Diseases, Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Sweden .
    Hepatitis C time trends in reported cases and estimates of the hidden population born before 1965, Denmark and Sweden, 1990 to 20202022In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 27, no 50, p. 30-38Article in journal (Refereed)
    Abstract [en]

    Background: According to the World Health Organization, hepatitis C virus (HCV) infection should be under control by 2030.

    Aim: Our aim was to describe the size and temporal changes in reported cases of chronic HCV infection in Denmark and Sweden and to estimate the size of the hidden (undiagnosed) population born before 1965.

    Methods: We extracted all HCV infections reported to national surveillance systems in Denmark and Sweden from 1990 to 2020. Prediction of the size of the hidden HCV-infected population was restricted to the cohort born before 1965 and cases reported up to 2017. We applied a model based on removal sampling from binomial distributions, estimated the yearly probability of diagnosis, and deducted the original HCV-infected population size.

    Results: Denmark (clinician-based) reported 10 times fewer hepatitis C cases annually than Sweden (laboratory and clinician-based), peaking in 2007 (n = 425) and 1992 (n = 4,537), respectively. In Denmark, the birth year distribution was monophasic with little change over time. In recent years, Sweden has had a bimodal birth year distribution, suggesting ongoing infection in the young population. In 2017, the total HCV infected population born before 1965 was estimated at 10,737 living persons (95% confidence interval (CI): 9,744-11,806), including 5,054 undiagnosed, in Denmark and 16,124 (95% CI: 13,639-18,978), including 10,580 undiagnosed, in Sweden.

    Conclusions: The reporting of HCV cases in Denmark and Sweden was different. For Denmark, the estimated hidden population was larger than the current national estimate, whereas in Sweden the estimate was in line with the latest published numbers.

  • 5.
    Cole, Michelle J.
    et al.
    UK Health Security Agency, London, United Kingdom.
    Day, Michaela
    UK Health Security Agency, London, United Kingdom.
    Jacobsson, Susanne
    Örebro University, School of Medical Sciences. Örebro University Hospital. World Health Organization Collaborating Centre for Gonorrhoea and other STIs.
    Amato-Gauci, Andrew J.
    European Centre for Disease Prevention and Control, Stockholm, Sweden.
    Spiteri, Gianfranco
    European Centre for Disease Prevention and Control, Stockholm, Sweden.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. University College London (UCL), London, United Kingdom; World Health Organization Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden.
    The European response to control and manage multi- and extensively drug-resistant Neisseria gonorrhoeae2022In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 27, no 18, p. 37-43Article in journal (Refereed)
    Abstract [en]

    Because cefixime and ceftriaxone resistance in Neisseria gonorrhoeae and gonorrhoea treatment failures were increasing, a response plan to control and manage multidrug-resistant N. gonorrhoeae (MDR-NG) in Europe was published in 2012. The three main areas of the plan were to: (i) strengthen surveillance of antimicrobial resistance (AMR), (ii) implement monitoring of treatment failures and (iii) establish a communication strategy to increase awareness and disseminate AMR results. Since 2012, several additional extensively drug-resistant N. gonorrhoeae (XDR-NG) strains have emerged, and strains with high-level ceftriaxone resistance spread internationally. This prompted an evaluation and review of the 2012 European Centre for Disease Prevention and Control (ECDC) response plan, revealing an overall improvement in many aspects of monitoring AMR in N. gonorrhoeae; however, treatment failure monitoring was a weakness. Accordingly, the plan was updated in 2019 to further support European Union/European Economic Area (EU/EEA) countries in controlling and managing the threat of MDR/XDR-NG in Europe through further strengthening of AMR surveillance and clinical management including treatment failure monitoring. The plan will be assessed biennially to ensure its effectiveness and its value. Along with prevention, diagnostic, treatment and epidemiological surveillance strategies, AMR surveillance is essential for effective control of gonorrhoea.

  • 6.
    Donachie, Alastair
    et al.
    Infectious Disease Prevention and Control Unit (IDCU) – Health Promotion and Disease Prevention Directorate, Valletta, Malta; European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
    Spiteri, Gianfranco
    European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
    Barbara, Christopher
    Department of Pathology, Mater Dei Hospital, Msida, Malta.
    Mellilo, Tanya
    Infectious Disease Prevention and Control Unit (IDCU) – Health Promotion and Disease Prevention Directorate, Valletta, Malta.
    Hadad, Ronza
    WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Farrugia, Alexandra Gauci
    Genitourinary Clinic, Mater Dei Hospital, Msida, Malta.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs.
    Padovese, Valeska
    Genitourinary Clinic, Mater Dei Hospital, Msida, Malta.
    Lymphogranuloma venereum (LGV) in men who have sex with men (MSM): a re-emerging problem, Malta, 20182018In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 23, no 43, p. 2-6, article id 1800541Article in journal (Refereed)
  • 7.
    Duberg, Ann-Sofi
    et al.
    Örebro University, School of Health and Medical Sciences.
    Janzon, R.
    Bäck, Erik
    Örebro University, School of Health and Medical Sciences.
    Ekdahl, Karl
    Blaxhult, A.
    The epidemiology of hepatitis C virus infection in Sweden2008In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 13, no 21Article in journal (Refereed)
    Abstract [en]

    In Sweden, infection with hepatitis C virus (HCV) has been a notifiable disease since 1990, when diagnostic methods became available. Blood donor screening indicated that about 0.5% of the Swedish population (9 millions) had been HCV infected. Here we present the Swedish hepatitis C epidemic based on data from all the HCV notifications 1990-2006. During this time about 42,000 individuals (70% men) were diagnosed and reported as HCV infected. The majority (80%) were born in 1950 or later, with a high percentage (60%) born in the 1950s and 1960s. Younger people, 15-24 years old at notification, were reported on the same level each year. The main reported routes of HCV transmission were intravenous drug use in 65%, blood transfusions/products in 6%, and sexual in 2%, though unknown or not stated in 26%. Approximately 6,000 of all notified individuals have died during the study period. To conclude, the Swedish HCV epidemic is highly related to the increase of intravenous drug use in the late 1960s and 1970s, with a high proportion of people now chronically infected for more than 25 years, resulting in an increase of severe liver complications in form of cirrhosis and hepatocellular carcinoma. Furthermore the unchanged number of notifications of newly infected younger people indicates an ongoing HCV epidemic.

    PMID: 18761966 [PubMed - indexed for MEDLINE]

  • 8.
    Eyre, David W.
    et al.
    Big Data Institute, University of Oxford, Oxford, United Kingdom; Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
    Sanderson, Nicholas D.
    Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
    Lord, Emily
    Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
    Regisford-Reimmer, Natasha
    Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
    Chau, Kevin
    Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
    Barker, Leanne
    Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
    Morgan, Markus
    Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
    Newnham, Robert
    Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
    Golparian, Daniel
    Örebro University, School of Medical Sciences. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Örebro University Hospital, Örebro, Sweden.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Örebro University Hospital, Örebro, Sweden.
    Crook, Derrick W.
    Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; National Infection Service, Public Health England, Colindale, United Kingdom; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom .
    Peto, Tim E. A.
    Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom.
    Hughes, Gwenda
    National Infection Service, Public Health England, Colindale, United Kingdom.
    Cole, Michelle J.
    National Infection Service, Public Health England, Colindale, United Kingdom.
    Fifer, Helen
    National Infection Service, Public Health England, Colindale, United Kingdom.
    Edwards, Anne
    Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
    Andersson, Monique I.
    Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
    Gonorrhoea treatment failure caused by a Neisseria gonorrhoeae strain with combined ceftriaxone and high-level azithromycin resistance, England, February 20182018In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 23, no 27, p. 2-7, article id 1800323Article in journal (Refereed)
  • 9.
    Golparian, Daniel
    et al.
    WHO Collaborating Centre for Gonorrhoea and other STIs, Swedish Reference Laboratory for Pathogenic Neisseria, Örebro University Hospital, Örebro, Sverige; Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Johansson, E.
    WHO Collaborating Centre for Gonorrhoea and other STIs, Swedish Reference Laboratory for Pathogenic Neisseria, Örebro University Hospital, Örebro, Sverige; Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Unemo, Magnus
    Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and other STIs, Swedish Reference Laboratory for Pathogenic Neisseria, Örebro University Hospital, Örebro, Sverige; Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Clinical Neisseria gonorrhoeae isolate with a N. meningitidis porA gene and no prolyliminopeptidase activity, Sweden, 2011-danger of false-negative genetic and culture diagnostic results2012In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 17, no 9, p. 5-7, article id 20102Article in journal (Refereed)
    Abstract [en]

    We describe a Neisseria gonorrhoeae strain, found in Sweden in 2011, that harbours a N. meningitidis porA gene causing false-negative results in PCRs targeting the gonococcal porA pseudogene. Furthermore, the strain had no prolyliminopeptidase (PIP) activity that many commercial biochemical kits for species verification in culture rely on. Enhanced awareness of the spread of such strains and screening for them can be crucial.

  • 10.
    Golparian, Daniel
    et al.
    World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Ohlsson, A. K.
    Dept Clin Microbiol, Karolinska Univ Hosp, Stockholm, Sweden.
    Janson, H.
    Dept Clin Microbiol, Cent Hosp Växjö, Växjö, Sweden.
    Lidbrink, P.
    Dept Dermatovenereol, Karolinska Univ Hosp, Stockholm, Sweden.
    Richtner, T.
    Dept Dermatol, Karolinska Inst Södersjukhuset, Stockholm, Sweden.
    Ekelund, O.
    Dept Clin Microbiol, Cent Hosp Växjö, Växjö, Sweden.
    Fredlund, Hans
    Örebro University Hospital. World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Unemo, Magnus
    Örebro University Hospital. World Health Organization Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Four treatment failures of pharyngeal gonorrhoea with ceftriaxone (500 mg) or cefotaxime (500 mg), Sweden, 2013 and 20142014In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 19, no 30, p. 2-5, article id 20862Article in journal (Refereed)
    Abstract [en]

    We describe four cases in Sweden of verified treatment failures of pharyngeal gonorrhoea with ceftriaxone (500 mg; n=3) or cefotaxime (500 mg; n=1) monotherapy. All the ceftriaxone treatment failures were caused by the internationally spreading multidrug-resistant gonococcal NG-MAST genogroup 1407 clone. Increased awareness of treatment failures is crucial particularly when antimicrobial monotherapy is used. Frequent test of cure and appropriate verification/falsification of suspected treatment failures, as well as implementation of recommended dual antimicrobial therapy are imperative.

  • 11.
    Golparian, Daniel
    et al.
    Örebro University, School of Medical Sciences. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Sexually Transmitted Infections, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Rose, Lisa
    Department of Clinical Microbiology, University of Dublin, Trinity College, St. James’s Hospital, Dublin, Ireland.
    Lynam, Almida
    Guide Clinic, St. James’s Hospital, Dublin, Ireland.
    Mohamed, Aia
    Department of Clinical Microbiology, University of Dublin, Trinity College, St. James’s Hospital, Dublin, Ireland.
    Bercot, Beatrice
    APHP, St Louis Hospital, Laboratory of Microbiology; French National Reference Center for Bacterial STI, Associated laboratory for gonococci; Paris Diderot University, IAME, Sorbonne Paris Cité, Paris, France.
    Ohnishi, Makoto
    Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan.
    Crowley, Brendan
    Department of Clinical Microbiology, University of Dublin, Trinity College, St. James’s Hospital, Dublin, Ireland; National Gonococcal Reference Laboratory, St. James’s Hospital, Dublin, Ireland.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Swedish Reference Laboratory for Sexually Transmitted Infections, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Multidrug-resistant Neisseria gonorrhoeae isolate, belonging to the internationally spreading Japanese FC428 clone, with ceftriaxone resistance and intermediate resistance to azithromycin, Ireland, August 20182018In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 23, no 47, p. 6-9, article id 1800617Article in journal (Refereed)
    Abstract [en]

    We describe a multidrug-resistant Neisseria gonorrhoeae urethritis case with ceftriaxone resistance and azithromycin intermediate resistance in a heterosexual man in Ireland, August 2018. Whole-genome sequencing showed that the isolate IR72 belongs to the internationally spreading multidrug-resistant ceftriaxone-resistant FC428 clade, initially described in Japan in 2015. IR72 was assigned MSLT ST1903, NG-MAST ST17842 and NG-STAR type 1133, including the ceftriaxone resistance-mediating penA-60.001. Global awareness of spreading ceftriaxone-resistant gonococcal strains that threaten recommended dual therapies is essential.

  • 12.
    Golparian, Daniel
    et al.
    Örebro University, School of Medical Sciences. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Vestberg, Nora
    Department of Clinical Microbiology, Karolinska University Hospital, Huddinge, Sweden.
    Södersten, Wiktor
    Department of Venerology at Karolinska University Hospital, Stockholm, Sweden.
    Jacobsson, Susanne
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Ohnishik, Makoto
    Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan.
    Fang, Hong
    Department of Clinical Microbiology, Karolinska University Hospital, Huddinge, Sweden.
    Bhattarai, Karin Haij
    Department of Clinical Microbiology, Karolinska University Hospital, Huddinge, Sweden.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Ӧrebro University, Ӧrebro, Sweden; Institute for Global Health, University College London (UCL), London, United Kingdom.
    Multidrug-resistant Neisseria gonorrhoeae isolate SE690: mosaic penA-60.001 gene causing ceftriaxone resistance internationally has spread to the more antimicrobial- susceptible genomic lineage, Sweden, September 20222023In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 28, no 10, article id 2300125Article in journal (Refereed)
    Abstract [en]

    We report a ceftriaxone-resistant, multidrug-resist-ant urogenital Neisseria gonorrhoeae in a female sex worker in Sweden, September 2022, who was treated with ceftriaxone i g, but did not return for test-of-cure. Whole genome sequencing of isolate SE690 identified MLST ST8i30, NG-STAR CCi885 (new NG-STAR ST4859) and mosaic penA-6o.oo1. The latter, causing ceftriax-one resistance in the internationally spreading FC428 clone, has now also spread to the more antimicrobial -susceptible genomic lineage B, showing that strains across the gonococcal phylogeny can develop ceftri-axone resistance.

  • 13.
    Hedberg, Sara Thulin
    et al.
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden.
    Törös, Bianca
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden.
    Fredlund, Hans
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden.
    Olcén, Per
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden.
    Mölling, Paula
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden.
    Genetic characterisation of the emerging invasive Neisseria meningitidis serogroup Y in Sweden, 2000 to 20102011In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 16, no 23, article id 19885Article in journal (Refereed)
    Abstract [en]

    Neisseria meningitidis serogroups B and C have beenresponsible for the majority of invasive meningococcaldisease in Europe. Recently, an increase of N. meningitidisdisease due to serogroup Y has been notedin Sweden (in 2010, the proportion was 39%, with anincidence of 0.23 per 100,000 population), as well as inother northern European countries. We aimed to investigatethe clonal pattern of the emerging serogroup Yin Sweden during 2000 to 2010. The serogroup Y isolatesidentified during this time (n=85) were characterisedby multilocus sequence typing and sequencing ofthe fetA, fHbp, penA, porA and porB genes. The mostfrequent clone (comprising 28 isolates) with identicalallele combinations of the investigated genes, waspartly responsible for the observed increased numberof N. meningitidis serogroup Y isolates. It was sulfadiazineresistant, with genosubtype P1.5-2,10-1,36-2,sequence type 23, clonal complex 23, porB allele 3-36,fetA allele F4-1, fHbp allele 25 and penA allele 22. Thefirst case with disease due to this clone was identifiedin 2002: there was a further case in 2004, six during2006 to 2007, eight during 2008 to 2009, with a peakof 12 cases in 2010. An unusual increase of invasivedisease in young adults (aged 20–29 years) caused bythis clone was shown, but no increase in mortality ratewas observed.

  • 14.
    Johansen, Tone Bjordal
    et al.
    Norwegian Institute of Public Health, Oslo, Norway; European Public Health Microbiology Training Programme (EUPHEM), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
    Kløvstad, Hilde
    Norwegian Institute of Public Health, Oslo, Norway.
    Rykkvin, Rikard
    Norwegian Institute of Public Health, Oslo, Norway.
    Herrfurth-Erichsen, Einar Bredo
    Fürst Medical Laboratory, Oslo, Norway.
    Sorthe, Joakim
    Fürst Medical Laboratory, Oslo, Norway.
    Njølstad, Gro
    Haukeland University Hospital, Bergen, Norway.
    Ebbesen, Marit Helen
    Haukeland University Hospital, Bergen, Norway.
    Nygaard, Randi Monsen
    Haukeland University Hospital, Bergen, Norway.
    Sandmoen, Ellen Kristin
    Tønsberg Hospital Trust, Department of Medical Microbiology, Tønsberg, Norway.
    Thilesen, Carina
    Unilabs Laboratory Medicine, Department of Medical Microbiology, Skien, Norway.
    Onken, Annette
    Vestre Viken Hospital Trust, Department of Microbiology, Drammen, Norway.
    Liljedal, Inger
    Levanger Hospital, Department for Laboratory Medicine, Levanger, Norway.
    Hadad, Ronza
    Örebro University, School of Medical Sciences. WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine.
    The 'Finnish new variant of Chlamydia trachomatis' escaping detection in the Aptima Combo 2 assay is widespread across Norway, June to August 20192019In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 24, no 42, p. 2-6Article in journal (Refereed)
    Abstract [en]

    The 'Finnish new variant of Chlamydia trachomatis' (FI-nvCT), escaping detection in the Aptima Combo 2 assay (AC2), is widespread across Norway. From June to August 2019, 84% (81/97) of available AC2/Aptima CT discordant samples from five laboratories were confirmed as FI-nvCT. Two additional CT variants (CT 23S rRNA C1514T and G1523A) also escaped AC2 detection. The high FI-nvCT proportion might indicate a long-term national spread and it cannot be excluded that FI-nvCT emerged in Norway.

  • 15.
    Larkin, Lesley
    et al.
    Gastrointestinal Infections and Food Safety (One Health Unit), UK Health Security Agency, London, United Kingdom.
    Pardos de la Gandara, Maria
    Institut Pasteur, Université Paris Cité, Centre National de Référence des E. coli, Shigella et Salmonella, Unité des Bactéries pathogènes entériques, Paris, France.
    Hoban, Ann
    Gastrointestinal Infections and Food Safety (One Health Unit), UK Health Security Agency, London, United Kingdom.
    Pulford, Caisey
    Gastrointestinal Infections and Food Safety (One Health Unit), UK Health Security Agency, London, United Kingdom.
    Jourdan-Da Silva, Nathalie
    Sante Publique France, Direction des Maladies Infectieuses Unité EAZ, Paris, France.
    de Valk, Henriette
    Sante Publique France, Direction des Maladies Infectieuses Unité EAZ, Paris, France.
    Browning, Lynda
    Clinical and Protecting Health Directorate, Public Health Scotland, Glasgow, United Kingdom.
    Falkenhorst, Gerhard
    Robert Koch Institute, Department of Infectious Disease Epidemiology FG 35 - Gastrointestinal Infections, Zoonoses and Tropical Infections, Berlin, Germany.
    Simon, Sandra
    Robert Koch Institute, Department of Infectious Diseases, Unit for Enteropathogenic Bacteria and Legionella / National Reference Centre for Salmonella and other Bacterial Enterics, Wernigerode, Germany.
    Lachmann, Raskit
    Robert Koch Institute, Department of Infectious Disease Epidemiology FG 35 - Gastrointestinal Infections, Zoonoses and Tropical Infections, Berlin, Germany.
    Dryselius, Rikard
    Public Health Agency of Sweden, Unit for Zoonoses and Antibiotic Resistance, Stockholm, Sweden.
    Karamehmedovic, Nadja
    Public Health Agency of Sweden, Unit for laboratory surveillance of bacterial pathogens, Stockholm, Sweden.
    Börjesson, Stefan
    Public Health Agency of Sweden, Unit for Zoonoses and Antibiotic Resistance, Stockholm, Sweden.
    van Cauteren, Dieter
    Epidemiology of infectious diseases, Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium.
    Laisnez, Valeska
    Epidemiology of infectious diseases, Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium; ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
    Mattheus, Wesley
    National Reference Centre for Salmonella and Shigella, Sciensano, Brussels, Belgium.
    Pijnacker, Roan
    National Institute for Public Health and the Environment (RIVM), Centre for Infectious Disease Control, Bilthoven, Netherlands.
    van den Beld, Maaike
    National Institute for Public Health and the Environment (RIVM), Centre for Infectious Disease Control, Bilthoven, Netherlands.
    Mossong, Joël
    Health Inspection, Health Directorate, Luxembourg.
    Ragimbeau, Catherine
    Laboratoire National de Santé, Epidemiology and Microbial Genomics, Dudelange, Luxembourg.
    Vergison, Anne
    Health Inspection, Health Directorate, Luxembourg.
    Thorstensen Brandal, Lin
    Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway.
    Lange, Heidi
    Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway.
    Garvey, Patricia
    HSE -Health Protection Surveillance Centre, Dublin, Ireland.
    Nielsen, Charlotte Salgaard
    HSE -Health Protection Surveillance Centre, Dublin, Ireland; ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
    Herrera León, Silvia
    Instituto de Salud Carlos III. Centro Nacional de Microbiología, Madrid, Spain.
    Varela, Carmen
    Instituto de Salud Carlos III. CIBER epidemiología y salud pública. Madrid, Spain.
    Chattaway, Marie
    Specialist Scientific Reference Service (Salmonella), Gastrointestinal Bacteria Reference Unit, UK Health Security Agency, London, United Kingdom.
    Weill, François-Xavier
    Institut Pasteur, Université Paris Cité, Centre National de Référence des E. coli, Shigella et Salmonella, Unité des Bactéries pathogènes entériques, Paris, France.
    Brown, Derek
    Scottish Microbiology Reference Laboratories, Glasgow, United Kingdom.
    McKeown, Paul
    HSE -Health Protection Surveillance Centre, Dublin, Ireland.
    Investigation of an international outbreak of multidrug-resistant monophasic Salmonella Typhimurium associated with chocolate products, EU/EEA and United Kingdom, February to April 20222022In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 27, no 15, article id 2200314Article in journal (Refereed)
    Abstract [en]

    An extensive multi-country outbreak of multidrug-resistant monophasic Salmonella Typhimurium infection in 10 countries with 150 reported cases, predominantly affecting young children, has been linked to chocolate products produced by a large multinational company. Extensive withdrawals and recalls of multiple product lines have been undertaken. With Easter approaching, widespread product distribution and the vulnerability of the affected population, early and effective real-time sharing of microbiological and epidemiological information has been of critical importance in effectively managing this serious food-borne incident.

  • 16.
    Lindstedt, B A
    et al.
    Division of Infectious Diseases Control, Norwegian Institute of Public Health, Oslo, Norway.
    Torpdahl, M
    Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark.
    Vergnaud, G
    Université Paris-Sud, Institut de Génétique et Microbiologie, Unités Mixtes de Recherche (UMR) 8621, Orsay, France; Direction Générale de l'Armement (DGA)/Mission pour la Recherche et l’Innovation Scientifique (MRIS), Bagneux, France .
    Le Hello, S
    Institut Pasteur, Unité de Recherche et d'Expertise des Bactéries Pathogènes Entériques, Centre National de Référence E. coli/Shigella/Salmonella, Paris, France.
    Weill, F X
    Institut Pasteur, Unité de Recherche et d'Expertise des Bactéries Pathogènes Entériques, Centre National de Référence E. coli/Shigella/Salmonella, Paris, France.
    Tietze, E
    National Reference Center for Salmonella and other Enterics, Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany.
    Malorny, B
    Federal Institute for Risk Assessment (BfR) National Salmonella Reference Laboratory Department Biological Safety, Berlin, Germany.
    Prendergast, D M
    Central Veterinary Research Laboratory, Department of Agriculture, Food and the Marine, Kildare, Ireland.
    Ní Ghallchoir, E
    Central Veterinary Research Laboratory, Department of Agriculture, Food and the Marine, Kildare, Ireland.
    Lista, R F
    Health Corps Italian Army, Department of Molecular Biology, Immunology and Experimental Medicine, Army Medical and Veterinary Research Center, Rome, Italy.
    Schouls, L M
    Laboratory for Infectious Diseases and Perinatal Screening (LIS), Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
    Söderlund, R
    The National Veterinary Institute (SVA), Uppsala, Sweden.
    Börjesson, Stefan
    The National Veterinary Institute (SVA), Uppsala, Sweden.
    Åkerström, S
    The National Veterinary Institute (SVA), Uppsala, Sweden.
    Use of multilocus variable-number tandem repeat analysis (MLVA) in eight European countries, 20122013In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 18, no 4, article id 20385Article in journal (Refereed)
    Abstract [en]

    Genotyping of important medical or veterinary prokaryotes has become a very important tool during the last decades. Rapid development of fragment-separation and sequencing technologies has made many new genotyping strategies possible. Among these new methods is multilocus variable-number tandem repeat analysis (MLVA). Here we present an update on the use of MLVA in eight European countries (Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway and Sweden). Researchers in Europe have been active in developing and implementing a large array of different assays. MLVA has been used as a typing tool in several contexts, from aiding in resolving outbreaks of foodborne bacteria to typing organisms that may pose a bioterrorist threat, as well as in scientific studies.

  • 17.
    Lucidarme, J.
    et al.
    Meningococcal Reference Unit, Public Health England, Manchester, United Kingdom.
    Scott, K. J.
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, Glasgow Royal Infirmary, Glasgow, United Kingdom.
    Ure, R.
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, Glasgow Royal Infirmary, Glasgow, United Kingdom.
    Smith, A.
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, Glasgow Royal Infirmary, Glasgow, United Kingdom; College of Medical, Veterinary & Life Sciences, Glasgow Dental Hospital & School, University of Glasgow, Glasgow, United Kingdom.
    Lindsay, D.
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, Glasgow Royal Infirmary, Glasgow, United Kingdom.
    Stenmark, Bianca
    Örebro University, School of Medical Sciences. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Jacobsson, Susanne
    Örebro University, School of Medical Sciences. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Fredlund, Hans
    Örebro University, School of Health Sciences. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Cameron, J. C.
    Health Protection Scotland, NHS National Services Scotland, Glasgow, United Kingdom.
    Smith-Palmer, A.
    Health Protection Scotland, NHS National Services Scotland, Glasgow, United Kingdom.
    McMenamin, J.
    Health Protection Scotland, NHS National Services Scotland, Glasgow, United Kingdom.
    Gray, S. J.
    Meningococcal Reference Unit, Public Health England, Manchester, United Kingdom.
    Campbell, H.
    Immunisation Department, Public Health England, London, United Kingdom.
    Ladhani, S.
    Immunisation Department, Public Health England, London, United Kingdom.
    Findlow, J.
    Meningococcal Reference Unit, Public Health England, Manchester, United Kingdom.
    Mölling, Paula
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Borrow, R.
    Meningococcal Reference Unit, Public Health England, Manchester, United Kingdom.
    An international invasive meningococcal disease outbreak due to a novel and rapidly expanding serogroup W strain, Scotland and Sweden, July to August 20152016In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 21, no 45, p. 15-23, article id 30395Article in journal (Refereed)
    Abstract [en]

    The 23rd World Scout Jamboree in 2015 took place in Japan and included over 33,000 scouts from 162 countries. Within nine days of the meeting ending, six cases of laboratory-confirmed invasive serogroup W meningococcal disease occurred among scouts and their close contacts in Scotland and Sweden. The isolates responsible were identical to one-another by routine typing and, where known (4 isolates), belonged to the ST-11 clonal complex (cc11) which is associated with large outbreaks and high case fatality rates. Recent studies have demonstrated the need for high-resolution genomic typing schemes to assign serogroup W cc11 isolates to several distinct strains circulating globally over the past two decades. Here we used such schemes to confirm that the Jamboree-associated cases constituted a genuine outbreak and that this was due to a novel and rapidly expanding strain descended from the strain that has recently expanded in South America and the United Kingdom. We also identify the genetic differences that define the novel strain including four point mutations and three putative recombination events involving the horizontal exchange of 17, six and two genes, respectively. Noteworthy outcomes of these changes were antigenic shifts and the disruption of a transcriptional regulator.

  • 18.
    Luijt, D.
    et al.
    Department of Medical Microbiology, Groningen, Netherlands.
    Di Lorenzo, C.
    Quality Control for Molecular Diagnostics, Glasgow, United Kingdom.
    van Loon, A. M.
    Quality Control for Molecular Diagnostics, Glasgow, United Kingdom.
    Unemo, Magnus
    Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and other STIs, Swedish Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Most but not all laboratories can detect the recently emerged Neisseria gonorrhoeae porA mutants - results from the QCMD 2013 N. gonorrhoeae external quality assessment programme2014In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 19, no 8, p. 2-5, article id 20711Article in journal (Refereed)
    Abstract [en]

    We describe the results of the Quality Control for Molecular Diagnostics 2013 Neisseria gonorrhoeae external quality assessment programme that included an N. gonorrhoeae strain harbouring an N. meningitidis porA gene which causes false-negative results in molecular diagnostic assays targeting the gonococcal porA pseudogene. Enhanced awareness of the international transmission of such gonococcal strains is needed to avoid false-negative results in both in-house and commercial molecular diagnostic assays used in laboratories worldwide, but particularly in Europe.

    In recent years, false-negative test results using PCRs targeting the Neisseria gonorrhoeae porA pseudogene have been reported from Australia, Scotland, Sweden and England [1-4]. Further investigations revealed that the gonococcal strains were not clonal, but all had replaced large segments or their entire N. gonorrhoeae porA pseudogene with an N. meningitidis porA gene.

    This report describes the results of the Quality Control for Molecular Diagnostics (QCMD) 2013 N. gonorrhoeae External Quality Assessment (EQA) programme. It included an N. gonorrhoeae strain containing an N. meningitidis porA gene which gives rise to false-negative results in molecular diagnostic assays targeting the gonococcal porA pseudogene. QCMD (www.qcmd.org) is an independent international organisation which provides a wide range of molecular EQA services in the field of infectious diseases to over 2,000 participants in over 100 countries.

  • 19.
    Pleininger, Sonja
    et al.
    Austrian Agency for Health and Food Safety, Vienna, Austria.
    Indra, Alexander
    Austrian Agency for Health and Food Safety, Vienna, Austria.
    Golparian, Daniel
    Örebro University, School of Medical Sciences. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs.
    Heger, Florian
    Austrian Agency for Health and Food Safety, Vienna, Austria.
    Schindler, Stefanie
    Austrian Agency for Health and Food Safety, Vienna, Austria.
    Jacobsson, Susanne
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs.
    Heidler, Stefan
    Urology Department, LKH Hochsteiermark, Leoben, Austria.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Institute for Global Health, University College London, London, United Kingdom.
    Extensively drug-resistant (XDR) Neisseria gonorrhoeae causing possible gonorrhoea treatment failure with ceftriaxone plus azithromycin in Austria, April 20222022In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 27, no 24Article in journal (Refereed)
    Abstract [en]

    We describe a gonorrhoea case with ceftriaxone plus high-level azithromycin resistance. In April 2022, an Austrian heterosexual male was diagnosed with gonorrhoea after sexual intercourse with a female sex worker in Cambodia. Recommended treatment with ceftriaxone (1 g) plus azithromycin (1.5 g) possibly failed. Worryingly, this is the second strain in an Asian Neisseria gonorrhoeae genomic sublineage including high-level azithromycin-resistant strains that developed ceftriaxone resistance by acquisition of mosaic penA-60.001. Enhanced resistance surveillance and actions are imperative to prevent spread.

  • 20.
    Poncin, Thibault
    et al.
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France; French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France.
    Fouere, Sebastien
    Dermatology Department, CeGGID (Free Information Screening and Diagnostics Centers), Saint Louis Hospital, APHP, Paris, France.
    Braille, Aymeric
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France; French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France.
    Camelena, Francois
    Infectious Agents Department, Saint Louis Hospital, Assistance Publique – Hôpitaux de Paris (APHP), Paris, France; French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France; IAME, UMR 1137 Université Paris Diderot, Paris, France.
    Agsous, Myriem
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France; French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France.
    Bebear, Cecile
    USC EA 3671 Mycoplasmal and chlamydial infections in humans, University of Bordeaux, Bordeaux, France; French National Reference Center for bacterial STIs, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
    Kumanski, Sylvain
    French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France.
    Lot, Florence
    Santé Publique France, French National Public Health Agency, Saint-Maurice, France.
    Mercier-Delarue, Severine
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France.
    Ngangro, Ndeindo Ndeikoundam
    Santé Publique France, French National Public Health Agency, Saint-Maurice, France.
    Salmona, Maud
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France.
    Schnepf, Nathalie
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France; French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France.
    Timsit, Julie
    Dermatology Department, CeGGID (Free Information Screening and Diagnostics Centers), Saint Louis Hospital, APHP, Paris, France.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs.
    Bercot, Beatrice
    Infectious Agents Department, Saint Louis Hospital, APHP, Paris, France; French National Reference Center for bacterial STI, Associated laboratory for gonococci, APHP, Paris, France.
    Multidrug-resistant Neisseria gonorrhoeae failing treatment with ceftriaxone and doxycycline in France, November 20172018In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 23, no 21, p. 1-3, article id 1800264Article in journal (Refereed)
    Abstract [en]

    We report a multidrug-resistant Neisseria gonorrhoeae urogenital and pharyngeal infection with ceftriaxone resistance and intermediate resistance to azithromycin in a heterosexual woman in her 205 in France. Treatment with ceftriaxone plus doxycycline failed for the pharyngeal localisation. Whole-genome sequencing of isolate F-90 identified MIST1903 , NG-MAST ST343, NG-STAR(233) , and relevant resistance determinants. F-90 showed phenotypic and genotypic similarities to an internationally spreading multidrug-resistant and ceftriaxone-resistant clone detected in Japan and subsequently in Australia, Canada and Denmark.

  • 21. Reischl, U.
    et al.
    Straube, E.
    Unemo, Magnus
    Örebro University, School of Health and Medical Sciences.
    The Swedish new variant of chlamydia trachomatis (NVCT) remains undetected by many European laboratories as revealed in the recent PCR/NAT ring trial organised by Instand ev, Germany2009In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 14, no 32, p. 14-17Article in journal (Refereed)
    Abstract [en]

    The May 2009 round of INSTAND's ring trial "Chlamydia trachomatis detection PCR/NAT" included a sample with high amount of the Swedish new variant of C. trachomatis (nvCT). A spectrum of at least 12 different commercial diagnostic nucleic acid amplification tests (NAATs) and many different in house NAATs were applied by the 128 participating laboratories which reported 152 results. Approximately 80% of the results correctly reported the presence of C. trachomatis in the nvCT specimen. The nvCT sample was mainly missed, as expected, by participants using the Roche COBAS Amplicor CT/NG (15.5% of reported results) but also by several participants using in house NAATs. The trend towards using nvCT-detecting NAATs is obvious and in addition to the new dual-target NAATs from Roche and Abbott, and BD ProbeTec ET, also a number of new CE mark-certified commercial tests from smaller diagnostic companies as well as many different in house NAATs were used. Laboratories using commercial or in house NAATs that do not detect the nvCT are encouraged to carefully monitor their C. trachomatis incidence, participate in appropriate external quality assurance and controls schemes, and consider altering their testing system. The reliable detection of low amounts of the wildtype C. trachomatis strain in other samples of the ring trial set indicates a good diagnostic performance of all applied commercial NAATs while also detecting the nvCT strain.

  • 22.
    Smith-Palmer, A.
    et al.
    Health Protection Scotland, Glasgow, United Kingdom.
    Oates, K.
    NHS Highland, Inverness, United Kingdom.
    Webster, D.
    NHS Grampian, Aberdeen, United Kingdom.
    Taylor, S.
    NHS Shetland, Lerwick, United Kingdom.
    Scott, K. J.
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, Glasgow, United Kingdom.
    Smith, G.
    International Health Regulations National Focal Point, Public Health England, London, United Kingdom.
    Parcell, B.
    NHS Grampian, Aberdeen, United Kingdom.
    Lindstrand, A.
    Public Health Agency of Sweden, Solna, Sweden.
    Wallensten, A.
    Public Health Agency of Sweden, Solna, Sweden.
    Fredlund, Hans
    Örebro University, School of Health Sciences. National Reference Laboratory for Pathogenic Neisseria, Örebro University Hospital, Örebro, Sweden.
    Widerström, M.
    Stockholm County Council Medical Officer, Stockholm, Sweden.
    McMenamin, J.
    Health Protection Scotland, Glasgow, United Kingdom.
    Outbreak of Neisseria meningitidis capsular group W among scouts returning from the World Scout Jamboree, Japan, 20152016In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 21, no 45, p. 8-14, article id 30392Article in journal (Refereed)
    Abstract [en]

    The 23rd World Scout Jamboree was held in Japan from 28 July to 8 August 2015 and was attended by over 33,000 scouts from 162 countries. An outbreak of invasive meningococcal disease capsular group W was investigated among participants, with four confirmed cases identified in Scotland, who were all associated with one particular scout unit, and two confirmed cases in Sweden; molecular testing showed the same strain to be responsible for illness in both countries. The report describes the public health action taken to prevent further cases and the different decisions reached with respect to how wide to extend the offer of chemoprophylaxis in the two countries; in Scotland, chemoprophylaxis was offered to the unit of 40 participants to which the four cases belonged and to other close contacts of cases, while in Sweden chemoprophylaxis was offered to all those returning from the Jamboree. The report also describes the international collaboration and communication required to investigate and manage such multinational outbreaks in a timely manner.

  • 23.
    Törös, B.
    et al.
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology/Molecular diagnostics R&D, Örebro University Hospital, Örebro, Sweden.
    Thulin [Hedberg], Sara
    Örebro University Hospital. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology/Molecular diagnostics R&D, Örebro University Hospital, Örebro, Sweden.
    Jacobsson, Susanne
    Örebro University Hospital. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology/Molecular diagnostics R&D, Örebro University Hospital, Örebro, Sweden.
    Fredlund, Hans
    Örebro University Hospital. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology/Molecular diagnostics R&D, Örebro University Hospital, Örebro, Sweden.
    Olcén, P.
    National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology/Molecular diagnostics R&D, Örebro University Hospital, Örebro, Sweden.
    Mölling, Paula
    Örebro University Hospital. National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology/Molecular diagnostics R&D, Örebro University Hospital, Örebro, Sweden.
    Surveillance of invasive Neisseria meningitidis with a serogroup Y update, Sweden 2010 to 20122014In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 19, no 42, p. 25-33, article id UNSP 20940Article in journal (Refereed)
    Abstract [en]

    An increase of invasive meningococcal disease caused by Neisseria meningitidis serogroup Y has been noted in Sweden since 2005, and to a lower extent throughout Europe. The present study describes the epidemiology of invasive N. meningitidis isolates in Sweden in the period between 2010 and 2012, with a focus on serogroup Y. We also aimed to find an optimal molecular typing scheme for both surveillance and outbreak investigations. All invasive N. meningitidis isolates in Sweden during the study period (n=208) were genetically characterised. Serogroup Y predominated with 22/57, 31/61 and 44/90 of all invasive isolates (incidence 0.23, 0.33 and 0.46 per 100,000 population) in 2010, 2011 and 2012 respectively. In each of these years, 15/22, 22/31 and 19/44 of serogroup Y isolates were genetically clonal (Y: P1.5-2,10-1,36-2: F4-1: ST-23(cc23), 'porB allele 3-36, fHbp allele 25 and penA allele 22). Our findings further support those of others that currently recommended FetA typing could be replaced by FHbp. Moreover, in line with a previous study that we conducted, the current results indicate that highly variable multilocus variable-number tandem repeat analysis (HV-MLVA) can be used as a first-hand rapid method for small outbreak investigations.

  • 24.
    Unemo, Magnus
    Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    The '2012 European guideline on the diagnosis and treatment of gonorrhoea in adults' recommends dual antimicrobial therapy2012In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 17, no 47, p. 27-27, article id 20323Article in journal (Refereed)
  • 25.
    Unemo, Magnus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Getman, Damon
    Hologic Inc., San Diego CA, United States.
    Hadad, Ronza
    WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Cole, Michelle
    National Infection Service, Public Health England, London, United Kingdom.
    Thomson, Nicholas
    Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom.
    Puolakkainen, Mirja
    Department of Virology and Immunology, University of Helsinki and Helsinki University Hospital, Huslab, Helsinki, Finland.
    Spiteri, Gianfranco
    European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
    Letter to the editor: Chlamydia trachomatis samples testing falsely negative in the Aptima Combo 2 test in Finland, 20192019In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 24, no 24, p. 20-21, article id 1900354Article in journal (Refereed)
  • 26.
    Unemo, Magnus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Hansen, Marit
    World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hadad, Ronza
    World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lindroth, Ylva
    Department of Laboratory Medicine, Medical Microbiology, Lund University, Skåne Laboratory Medicine, Lund, Sweden.
    Fredlund, Hans
    World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Puolakkainen, Mirja
    Department of Virology and Immunology, University of Helsinki and Helsinki University Hospital, HUSLAB, Helsinki, Finland.
    Sundqvist, Martin
    Örebro University, School of Medical Sciences. Örebro University Hospital. World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Finnish new variant of Chlamydia trachomatis escaping detection in the Aptima Combo 2 assay also present in Orebro County, Sweden, May 20192019In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 24, no 26, p. 10-14, article id 1900370Article in journal (Refereed)
    Abstract [en]

    We identified the first two cases of the Finnish new variant of Chlamydia trachomatis (F-nvCT) beyond Finland in two clinical urogenital specimens in Orebro County, Sweden. These Aptima Combo 2 assay-negative specimens were Aptima Chlamydia trachomatis (CT) assay positive and had the characteristic C1515T mutation in the 23S rRNA gene. From 22 March to 31 May 2019, 1.3% (2/158) of the CT-positive cases in Orebro County were missed because of the F-nvCT. International awareness, investigations and actions are essential.

  • 27.
    Unemo, Magnus
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Lanjouw, E.
    Department of Dermatology, Erasmus Medical Center, Rotterdam, the Netherlands.
    European STI Guidelines Editorial Board, Group author
    The '2015 European guideline on the management of Chlamydia trachomatis infections' has now been published2015In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 20, no 48, p. 28-29, article id 30080Article in journal (Other (popular science, discussion, etc.))
  • 28. Vagoras, A.
    et al.
    Butylkina, R.
    Juseviciute, V.
    Hallén, A.
    Unemo, Magnus
    Örebro University, Department of Clinical Medicine.
    Domeika, M.
    Diagnosis of non-viral sexually transmitted infections in Lithuania and international recommendations2006In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 11, no 7, p. 161-164Article in journal (Refereed)
    Abstract [en]

    The aim of this study is to evaluate the range, quality and availability of diagnostic services for non-viral sexually transmitted infections (STIs), i.e. C. trachomatis, N. gonorrhoeae, T. vaginalis and T. pallidum, in Lithuania from September 2002 to December 2003. Surveillance data describing the organisation and performance characteristics of non-viral STI diagnostic services in Lithuania were collected using a questionnaire and subsequent site-visits. International evidence-based recommendations for non-viral STI diagnosis were used to evaluate the quality of the STI diagnostics. There were 171 facilities providing non-viral STI diagnostic services for the 3.5 million inhabitants of Lithuania. However, only 6% (n=9) of the respondents (n=153) could provide a confirmatory diagnosis, in accordance with international recommendations, for the full minimum range of relevant non-viral STIs in Lithuania, i.e. C. trachomatis, N. gonorrhoeae, T. pallidum, and T. vaginalis. In addition, accessibility to STI diagnostic services differed significantly among the different counties in Lithuania. Several of the respondents analysed low numbers of samples each year, and overall the sampling size was extremely low, especially for C. trachomatis diagnostics. In Lithuania, optimisation of non-viral STI diagnostics as well as of epidemiological surveillance and management of STIs is crucial. It may be worth considering a decrease in the number of laboratories, with those remaining having the possibility of performing STI diagnostic services that are optimised, in concordance with international recommendations, standardised, and quality assured using systematic internal and external quality controls and systems. In addition, establishment of national inter-laboratory networks and reference centres for non-viral STIs is recommended.

  • 29.
    Wallensten, A.
    et al.
    Public Health Agency of Sweden, Solna, Sweden; Department of Medical Sciences, Infectious Diseases, Uppsala University, Uppsala, Sweden.
    Fredlund, Hans
    Örebro University Hospital. Department of Laboratory Medicine Clinical Microbiology, Communicable Disease Control Unit, Örebro University Hospital, Örebro, Sweden.
    Runehagen, A.
    Communicable Diseases Control Unit, Kronoberg County Council, Växjö, Sweden.
    Multiple human-to-human transmission from a severe case of psittacosis, Sweden, January-February 20132014In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 19, no 42, p. 34-39, article id 20937Article in journal (Refereed)
    Abstract [en]

    Proven transmission of Chlamydia psittaci between humans has been described on only one occasion previously. We describe an outbreak which occurred in Sweden in early 2013, where the epidemiological and serological investigation suggests that one patient, severely ill with psittacosis after exposure to wild bird droppings, transmitted the disease to ten others: Two family members, one hospital roommate and seven hospital caregivers. Three cases also provided respiratory samples that could be analysed by PCR. All the obtained C. psittaci sequences were indistinguishable and clustered within genotype A. The finding has implications for the management of severely ill patients with atypical pneumonia, because these patients may be more contagious than was previously thought. In order to prevent nosocomial person-to-person transmission of C. psittaci, stricter hygiene measures may need to be applied.

  • 30.
    Weinbaum, Barbara
    et al.
    Research and Development, Hologic Inc., San Diego, United States.
    Williams, Analee
    Research and Development, Hologic Inc., San Diego, United States.
    Hadad, Ronza
    Örebro University, School of Medical Sciences. World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Vinluan, Bryan
    Research and Development, Hologic Inc., San Diego, United States.
    Puolakkainen, Mirja
    Department of Virology and Immunology, University of Helsinki and Helsinki University Hospital, HUSLAB, Helsinki, Finland.
    Unemo, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. World Health Organization Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections (STIs), National Reference Laboratory for STIs, Department of Laboratory Medicine.
    Getman, Damon
    Research and Development, Hologic Inc., San Diego, United States.
    Validation of an Aptima-format Finnish new variant of Chlamydia trachomatis (FI-nvCT) surveillance assay, 20192020In: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 25, no 5, p. 16-22, article id 2000038Article in journal (Refereed)
    Abstract [en]

    The Finnish new variant of Chlamydia trachomatis (FI-nvCT) is escaping diagnostics in Finland, Norway and Sweden. We have developed and validated an Aptima-format nucleic acid amplification test (NAAT) designed specifically to detect the FI-nvCT. This NAAT has high sensitivity (100%) and specificity (100%) for the FI-nvCT strain, enabling further investigation of the geographic distribution, prevalence and transmission of this diagnostic-escape mutant in screening populations in Europe.

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