Nontoxigenic Corynebacterium diphtheriae Infections, Europe

References 1. Fürst T, Keiser J, Utzinger J. Global burden of human foodborne trematodiasis: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12:210–21. http://dx.doi.org/10.1016/ S1473-3099(11)70294-8 2. Sripa B, Echaubard P. Prospects and challenges towards sustainable liver fluke control. Trends Parasitol. 2017;33:799–812. http://dx.doi.org/10.1016/j.pt.2017.06.002 3. Aung WPP, Htoon TT, Tin HH, Thinn KK, Sanpool O, Jongthawin J, et al. First report and molecular identification of Opisthorchis viverrini infection in human communities from lower Myanmar. PLoS One. 2017;12:e0177130 http://dx.doi.org/10.1371/ journal.pone.0177130 4. Sanpool O, Aung WPP, Rodpai R, Maleewong W, Intapan PM. Human liver fluke Opisthorchis viverrini (Trematoda, Opisthorchiidae) in central Myanmar: new records of adults and metacercariae identified by morphology and molecular analysis. Acta Trop. 2018;185:149–55. http://dx.doi.org/10.1016/ j.actatropica.2018.05.009 5. Chai JY, Park JH, Han ET, Guk SM, Shin EH, Lin A, et al. Mixed infections with Opisthorchis viverrini and intestinal flukes in residents of Vientiane Municipality and Saravane Province in Laos. J Helminthol. 2005;79:283–9. http://dx.doi.org/10.1079/ JOH2005302 6. Sohn WM, Yong TS, Eom KS, Pyo KH, Lee MY, Lim H, et al. Prevalence of Opisthorchis viverrini infection in humans and fish in Kratie Province, Cambodia. Acta Trop. 2012;124:215–20 http://dx.doi.org/10.1016/j.actatropica.2012.08.011 7. Chai JY, Han ET, Guk SM, Shin EH, Sohn WM, Yong TS et al. High prevalence of liver and intestinal fluke infections among residents of Savannakhet Province in Laos. Korean J Parasitol. 2007;45:213–8. 8. Yong TS, Shin EH, Chai JY, Sohn WM, Eom KS, Lee DM, et al. High prevalence of Opisthorchis viverrini infection in a riparian population in Takeo Province, Cambodia. Korean J Parasitol. 2012;50:173–6. http://dx.doi.org/10.3347/kjp.2012.50.2.173 9. Yong TS, Chai JY, Sohn WM, Eom KS, Jeoung HG, Hoang EH, et al. Prevalence of intestinal helminths among inhabitants of Cambodia (2006–2011). Korean J Parasitol. 2014;52:661–6. http://dx.doi.org/10.3347/kjp.2014.52.6.661 10. Sohn WM, Shin EH, Yong TS, Eom KS, Jeong HG, Sinuon M, et al. Adult Opisthorchis viverrini flukes in humans, Takeo, Cambodia. Emerg Infect Dis. 2011;17:1302–4. http://dx.doi.org/ 10.3201/eid1707.102071


Corynebacterium diphtheriae Infections, Europe
(1). Among the cases, 2 patients originated from Poland; each experienced an invasive disease, 1 endocarditis and 1 sepsis. Poland and Germany are neighboring countries. In Poland, we also observed an accumulation of nontoxigenic C. diphtheriae infections during 2016-2017. In both countries, most infections were caused by isolates belonging to sequence type (ST) 8 biotype gravis, which we previously suspected of having increased pathogenic properties (2).
ST8 has been causing infection in Poland since 2004 and was isolated in Russia before that (2,3). However, the first ST8 isolate was not obtained in northern Germany until 2015, suggesting spread of pathogenic ST8 from eastern to western Europe. Comparing epidemiologic data from Poland during 2012-2017, we confirmed 48 cases of nontoxigenic C. diphtheriae, increasing from 3 cases in 2012 to 20 in 2017. As seen in northern Germany, most affected patients in Poland were male (>80%), and ≈30% of patients were homeless, alcohol addicted, or both. We did not identify HIV as a risk factor. We saw a sharp increase in cases during the time of the Dangel et al. report as well, from 10 cases in 2016 to 20 in 2017. Nevertheless, in Poland, 40% of isolates (19/48) during 2012-2017 were obtained from invasive infections, whereas in Germany only 9 isolates (≈12%) were obtained from cases with severe invasive complications. None of the cases in Poland were related epidemiologically.
We hypothesize that pathogenic ST8 could spread to other countries in Europe in a few years and that persistence of ST8 isolates in the population might be related to increases in the number of invasive infections. The scale of the problem of nontoxigenic C. diphtheriae infections in Europe remains unknown because only toxigenic infections are registered. Lack of registration leads to lack of prevention and, thus, to outbreak development and spread. The authors did not relate this finding to previous reports of ≈2 times lower incidence of sepsis (2) and ≈1.5 times lower incidence of death from infectious diseases (3) in white persons in the United States.

Racial/Ethnic
A national study of community antibacterial dispensing in relation to ethnicity in New Zealand (4) found that the dispensing rates were highest in Pacific people and Maori, consistent with their higher incidence of infectious diseases. However, the ethnic disparities in dispensing rates were substantially less than the ethnic disparities in the incidence of some infections. For example, even though the incidence of hospitalization for rheumatic fever was 63 times higher for Pacific people and 27 times higher for Maori than for persons of all other ethnicities combined, the annual dispensing rates of penicillins for Pacific people and Maori were <1.5 times higher than in other ethnicities.
Olesen and Grad suggest that ethnic disparities in antimicrobial drug use will lead to disparities in the prevalence of colonization (and disease) by antimicrobial-resistant bacteria. The New Zealand study found that dispensing rates of topical antimicrobial agents (predominantly fusidic acid) for Pacific and Maori children were approximately twice those for children of other ethnicities and suggested that these high dispensing rates might have contributed to the higher proportion of staphylococcal infections caused by methicillin-resistant (and fusidic acid-resistant) Staphylococcus aureus in Pacific people and Maori (5). We suggest that improved understanding of ethnic disparities in the incidence of infectious diseases and in the level of consumption of antimicrobial agents might usefully inform antimicrobial stewardship targets and strategies.