Partner notification is mandatory for Chlamydia trachomatis infections in Sweden. A significant quality improvement of partner notification for genital chlamydia was achieved by increasing the skills and reducing the number of individuals conducting partner notifications. By centralisation of the partner notification to a specially trained team of nurses, an additional 12% of genital chlamydia cases were found. Routine partner notification achieved a score of 3.3 notified partners per index case, and shows how important this activity is for detection of asymptomatic chlamydia infections in the community.

A general aim was to combine molecular typing methods with clinical background information to increase epidemiological knowledge about Chlamydia trachomatis infections. An outbreak of Lymfogranuloma venereum (LGV), caused by a more invasive variant of C. trachomatis, was reported from the Netherlands in 2003 among men who have sex with men (MSM). All Chlamydia positive specimens from a venereal disease clinic for MSM in Stockholm during one year were genotyped. No spread of LGV was found, apart from three symptomatic cases. The same ompA genotypes were found among MSM in Melbourne, but the genotype distribution was different compared to findings among the heterosexual population in Sweden. The standard method for genotyping of Chlamydia is ompA-sequencing, but it has low resolution because one genotype predominates. A multilocus sequence typing (MLST) system based on five targets was developed. In a sample of 47 specimens, 32 variants were found with MLST, but only 12 variants with ompA-sequencing. The polymorphisms in the hctB gene, one MLST target, are caused by an element of 108 bp that is present in two to four repetitions and in different variants. Although the DNA-binding function of Hc2 that is encoded by hctB has been studied, our findings of a considerable size variation show that new studies are needed. In 2006, specimens with a 377 bp deletion in the cryptic plasmid covering the target region for diagnostic test systems from Abbott and Roche were discovered in Sweden. Applying MLST to these specimens indicated that there was a single clone, denoted nvCT. The proportion of nvCT in all detected Chlamydia cases was higher (20% to 65%) in counties using Abbott/Roche compared to counties using the BectonDickinson test system (7% to 20%). The proportions of nvCT converge in counties with high or low levels when detection systems were adjusted to detect nvCT.

A new variant of Chlamydia trachomatis (nvCT) was discovered in Sweden in 2006, and it could not be detected by diagnostic systems from Abbott and Roche, whereas the third system used, from Becton Dickinson (BD), detects nvCT. We analyzed 3648 samples from 2 counties that used Roche and 2 counties that used BD methods from 2007 to 2011. After implementation of a Roche method that detects nvCT, its proportion has decreased and converged in the 4 counties but are still at different levels in Roche and BD counties. Future studies are needed to see if nvCT will decline further.

BACKGROUND:The significance of Chlamydia trachomatis (Ct) infection in the pharynx, and possible symptoms, are under discussion. Most studies have involved only homo/bisexual men. We report findings of pharyngeal Ct (PhCt) infections in patients with long-lasting throat discomfort and the prevalence of PhCt in genitally Ct-infected young people in a Swedish primary care setting.METHOD:Sub-study 1 (SS1) included 48 persons aged 15-35 y, with pharyngeal discomfort for more than 14 days. Sub-study 2 (SS2) included 150 persons, aged 15-35 y, with genital Ct. Questionnaires concerning symptoms, sexual behaviour and sexual identity were completed for both groups. Samples for Ct testing were taken from the pharynx, and in SS1, samples were also collected to ascertain genital Ct.RESULTS:In SS1, 2 of 48 persons (4%) with pharyngeal discomfort had PhCt. In all, 35 of the 48 persons (73%) included in SS1 reported unprotected oral sex during the previous year. In SS2, 11 of 92 women (12%) and 4 of 58 men (7%) tested positive for PhCt. More women (94%) than men (83%) had given unprotected oral sex. Persons with PhCt had more symptoms from the upper respiratory tract (p = 0.04).CONCLUSIONS:Some primary care patients with long-lasting throat discomfort have a PhCt infection. PhCt infection is not uncommon in genitally infected sexually active people. More heterosexual women than heterosexual men had given unprotected oral sex and were infected by Ct in the pharynx. Thus, research on PhCt should not focus on homo/bisexual men only. Information about Ct should include the risk of contracting a PhCt infection as well as a gender perspective.

Utvardering av projektet "Sex med spex" vid Strombackaskolan i Pitea. Rapport till Socialstyrelsen.

Objectives: The so-called small-world effect can have a great impact on efforts to control the incidence and prevalence of sexually transmitted infections. This is because a small number of so-called spatial bridgers (individuals who, through sexual contacts, interconnect geographically distant areas) can drastically lower the average path length in the sexual network and, as a result, make locally based intervention programs much less effective. The objectives of this study were to analyze the sociodemographic characteristics of these bridgers and to compare the result with the remaining study population. The purpose was to determine whether it is possible to identify them for targeted intervention programs. Study Design: During 2001, contact tracing was performed in approximately 98% of all cases with positive test results in Värmland County. The sexual networks obtained constituted a study population of 851 individuals. Statistical analysis was used to characterize individuals engaged in spatial bridging behavior. Results: Approximately 8% of the study population was characterized as spatial bridgers. Using multivariate analysis, we found almost no significant differences between these individuals and the rest of the study population when it came to sociodemographic variables, including education, economy, and ethnicity. Conclusion: The number of spatial bridgers is high enough to create a small-world network with links that can fuel the endemic chlamydia in Värmland County. Sociodemographic information could not be used to characterize spatial bridgers. In interventions against chlamydia, spatial bridgers shall be considered as potentially important for sustaining the disease.

METHODS AND RESULTS In March 2003 questionnaires were sent to a random selection of the elderly population, 65 years and older, in the county. Reminders followed up the questionnaires to the non-responders after 3 weeks. Out of the 1491 questionnaires, 1313 (92%) were returned. The proportion of elderly persons accepting the influenza vaccination offer was 47%. Analysis, using logistic regression, of the results from the questionnaires showed a clear trend of decreasing proportions of vaccinated persons over time (pB/0.001) (Fig. 1). There was an average 23% reduction of persons compliant with the vaccination programme for each week delay of returned questionnaires. The cumulative proportion compliant with the vaccination programme fell from 52% the first week to 47% the ninth week (p: 0.197). Since there was a marked drop in questionnaire responders after the first 2 weeks in our study, the deviating results from the late responders did not greatly influence the result.

Objective To study the genetic diversity among consecutive blood culture isolates of Streptococcus pyogenes T1, in order to examine the possibility of different bacterial clones being responsible for two epidemics during the period 1986-95. Methods DNA-fingerprinting patterns were obtained by use of the following methods: macrorestriction of genomic DNA followed by pulsed-field gel electrophoresis (PFGE), random amplified polymorphic DNA (RAPD) analysis, and restriction fragment length polymorphism of the vir regulon (Vir-typing). Possession of the speA gene was investigated by use of a polymerase chain reaction (PCR) method, and further characterization of the gene was done by sequencing of the PCR products from six strains. Results All isolates contained the speA gene. Sequencing data from six isolates revealed the presence of the speA2 allele. Using RAPD analysis. it was possible to distinguish between DNA-fingerprnting patterns of the S. pyogenes T1 strains from the two epidemics. Conclusions The present study reveals different DNA-fingerprinting patterns from blood culture isolates of S. pyogenes T1 from two local epidemics, 1988-89 and 1994-95. Since the differences seen do not necessarily reflect different antigenic properties or changed virulence among the isolates, further studies addressing this question should be performed.

The numerous reports in the last ten years on the serious diseases caused by Streptococcus pyogenes indicate the continued significance of this pathogen. Furthermore, clinical studies and modern techniques have yielded new information on S. pyogenes and its pathogenic mechanisms. Although much still remains to be discovered about the biology of S. pyogenes, two different strategies - the 'epidemic' and the 'endemic' strategy - can be seen in the interaction of different S. pyogenes strains with the human host. The challenges posed by these two groups of bacteria are also outlined.

A novel method for the in vitro culture of tissue biopsies is presented. Infected tonsillar biopsies were successfully cultured by means of the continuous flow of media without the addition of antibiotics. Histological and immunohistological examinations were carried out on sections of Streptococcus pyogenes-infected cultured tonsillar biopsies and sections from the surgically removed tonsils of asymptomatic S. pyogenes carriers. Low numbers of intracellular S. pyogenes were detected inside epithelial cells in eight out of 12 (67%) S. pyogenes-infected biopsies, and in four out of 11 (36%) tonsils of asymptomatic carriers. Our findings support the hypothesis that the sanctuary where S. pyogenes avoids antibacterial treatment is intracellular, which may provide a possible explanation of recurrent tonsillitis.

Staphylococcus hyicus subspecies hyicus has not previously been reported to cause human infections, but is a well known cause of diseases in a variety of animals. We report a wound infection following a donkey bite.

Numerous theories have been presented that attempt to explain the frequent recurrences of pharyngotonsillitis caused by Streptococcus pyogenes; these recurrences occur after seemingly adequate antibiotic treatment. We previously have demonstrated that S pyogenes can survive for up to 7 days intracellularly in immortalized human respiratory epithelial cells grown in an antibiotic supplemented medium. Viable S pyogenes were externalized, and established an extracellular infection, whenever the extracellular antibiotic was removed, We have investigated the presence of intracellular S pyogenes in two in vivo studies using respiratory epithelial cells collected from patients with tonsillitis and the tonsils of asymptomatic carriers. Electron microscopy and immunohistochemistry demonstrated intracellular S pyogenes in pharyngeal epithelial cells in 13 of 14 patients with tonsillitis (93%). Furthermore, intracellular S pyogenes were found in macrophage-like cells in eight (73%) and in epithelial cells in four (36%) tonsils from 11 asymptomatic S pyogenes carriers, These in vivo data strongly support the hypothesis that intracellular S pyogenes can constitute a reservoir of bacteria with the potential to cause reinfections.

During the period 1989-1995, the T-type distribution pattern of Streptococcus pyogenes pharyngeal isolates was compared with the annual incidence of culture-verified S. pyogenes bacteremias in Uppsala county, Sweden. An exceptional increase in the number of S. pyogenes bacteremias was seen in 1994. During the study period, the annual number of blood culture isolates was shown to correlate with the proportion of S. pyogenes serotype T1 among pharyngeal isolates.

During the period 1989–1995, the T-type distribution pattern of Streptococcus pyogenes pharyngeal isolates was compared with the annual incidence of culture-verified S. pyogenes bacteremias in Uppsala county, Sweden. An exceptional increase in the number of S. pyogenes bacteremias was seen in 1994. During the study period, the annual number of blood culture isolates was shown to correlate with the proportion of S. pyogenes serotype T1 among pharyngeal isolates.

In recent years, several DNA fingerprinting methods have been tried for the epidemiological investigation of Streptococcus pyogenes isolates. We chose the Random Amplified Polymorphic DNA (RAPD) method for the typing of pre- and post-antibiotic treatment S. pyogenes isolates obtained from 14 patients with pharyngotonsillitis. Isolates from 4 patients had been collected 10 years earlier than from the others. Hence epidemiological connections between the strains were unlikely. Both pre- and post-antibiotic treatment isolates showed identical RAPD patterns, indicating that recurrences in these patients had been caused by homologous strains of S. pyogenes. It was possible by means of RAPD to differentiate between 12 different T-types and occasionally between clones of the same serotype of S. pyogenes. The RAPD method is an easier alternative to traditional DNA-typing techniques and provides quick results with minimal technical complexity.