Surveillance status and recent data for Mycoplasma pneumoniae infections in the European Union and European Economic Area , January 2012

Citation style for this article: Lenglet A, Herrador Z, Magiorakos AP, Leitmeyer K, Coulombier D, European Working Group on Mycoplasma pneumoniae surveillance. Surveillance status and recent data for Mycoplasma pneumoniae infections in the European Union and European Economic Area, January 2012. Euro Surveill. 2012;17(5):pii=20075. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20075

In the first week of January 2012, the Norwegian Medicines Agency reported a likely shortage of erythromycin in the country following an unusually high number of mycoplasma infections [1].Additional epidemic intelligence activities conducted at the European Centre for Disease Prevention and Control (ECDC) highlighted that similar increases in M. pneumoniae infections had been observed during the autumn of 2011 in various northern European countries, including Sweden, Denmark, Finland and the Netherlands [2][3][4][5][6].
With this epidemiological background and because M. pneumoniae infection is not notifiable at the European Union (EU) level, ECDC, in collaboration with EU and European Economic Area (EEA) Member States, conducted a brief survey among countries in order to verify whether unusual increases in reporting rates were recently observed, to describe existing M. pneumoniae surveillance activities and availability of guidelines for the treatment atypical pneumoniae which might include M. pneumoniae infections for clinicians in the country.
An email-based questionnaire was sent to EU/EEA Member States contact points (listed as Competent Bodies for Threat Detection) on 10 January 2012.
Countries were asked to provide answers by the evening of 12 January 2012.
The questions asked in the email questionnaire are shown in the Box.

Disease background information
Mycoplasma pneumoniae, a bacterium lacking a cell wall, is a major cause of respiratory disease in humans.Infection can lead to prolonged carriage and therefore serve as a reservoir for the spread of the pathogen to others [7].It is transmitted from personto-person by respiratory droplets and its incubation period varies from one to three weeks, although it can be as short as four days [8].M. pneumoniae infections tend to be endemic, punctuated by epidemics at fourto-seven-year intervals [9,10].Climate, seasonality and geographical location are not thought to be of major importance, although in North America most epidemics usually begin during summer, peak in late autumn/

Box
Email questionnaire regarding Mycoplasma pneumoniae infection sent to EU/EEA countries, January 2012 early winter and fade out during winter [8,11].However, this pattern seems to differ between continents [8,11].
M. pneumoniae infects the upper and lower respiratory tracts in children and adults and is one of the aetiological agents of community-acquired pneumonia [11,12].Studies have shown that it can cause up to 40% of community-acquired pneumonia and 18% of hospitalisations in children [13].Most M. pneumoniae infections lead to overt clinical disease and although these infections are often self-limiting, 1-5% of cases may require hospitalisation.The most prominent symptoms are malaise, fever, headache and cough and in children aged less than five years, coryza and wheezing [13].
M. pneumoniae infection can also result in extrapulmonary manifestations, which can be present before, after or even in the absence of respiratory symptoms and have been reported with varying rates.Extrapulmonary manifestations of infection are rare, but when they occur can affect the central nervous system (including encephalitis and cranial nerve palsies) [11,14] and can also result in dermatological, haematological and cardiac manifestations [13].
Diagnostic testing for M. pneumoniae includes, among others, polymerase chain reaction (PCR) and serological assays, each with varying sensitivities and specificities and limited standardisation between testing protocols [15,16].PCR is the preferred method in some countries [17]; however, no testing method has proven reliable in the context of an outbreak [14].Surveillance data for M. pneumoniae infections are likely to be underestimates because of the challenges in diagnosis as well as the fact that in many cases, the infection is often subclinical and usually dealt with in outpatient settings.
National and international guidelines are available for the management of community-acquired pneumonia, including for those caused by M. pneumoniae.Therapeutic decision-making is up to the clinical judgement of the treating physician based on clinical presentation, co-morbidities, risk factors, assessment of pneumonia severity and the available evidencebased guidelines.Effective antibacterial agents for the treatment of M. pneumoniae include macrolides, tetracyclines and fluoroquinolones.Prudent use of antibiotics is urged for all cases of M. pneumoniae infection because of worldwide reports of macrolide resistance.Moreover, it is suggested that treating clinicians be vigilant when prescribing macrolides for suspected or confirmed cases, particularly in areas with high rates of macrolide resistance, as treatment might fail in patients infected with macrolide-resistant isolates.

Survey findings
Of the 30 countries contacted, 20 replied to the questionnaire (response rate: 67%).Of those that replied, 13 reported having some type of surveillance activities providing data to monitor M. pneumoniae infections.Table 1 summarises the situation in 2011 and in previous seasons as well as surveillance activities.Seven countries had no available data that could be used to indicate changes in reporting rates for M. pneumoniae infections during 2011 compared with previous seasons.Of the 13 countries monitoring M. pneumoniae, seven indicated observing an increase compared with 2010 while six indicated no such increase (Belgium, Malta, Portugal, Slovakia, Slovenia and Spain).Of these six, Slovenia reported that reporting rates for M. pneumoniae infections were higher in the autumn of 2010 compared with the same period in 2011.
None of the responding countries reported major recent changes in the existing surveillance systems that would account for the observed increases.However, Sweden did highlight that awareness of M. pneumoniae among clinicians may be higher during this winter season, which may have resulted in more testing.Also, the widespread use of PCR for testing might have had an impact on current surveillance data.
With respect to which methods were used for laboratory diagnosis of M. pneumoniae, ten countries were able to provide some information.Five of these countries (the Netherlands, Norway, Spain, Sweden and the United Kingdom) reported using a mixture of serology and PCR.The Czech Republic and Portugal used mainly serological tests.Denmark and Slovenia reported data for samples confirmed by PCR and Finland reported using serology, PCR or culture for the diagnosis of M. pneumoniae.
A total of 15 countries reported some form of guidance available for clinicians for the treatment of atypical pneumonia, including M. pneumoniae infection; 10 countries have guidelines that are considered national (Table 2).Six reported the existence of guidelines that can be used in institutional outbreaks.Even though none are specific for M. pneumoniae infection, these guidelines would be applied in the occurrence of an outbreak of M. pneumoniae infection in institutional settings.

Limitations of the study
This survey was conducted as a part of epidemic intelligence activities conducted at the EU level.The questions included were not comprehensive enough to provide a complete and detailed overview of the functioning of the surveillance systems for M. pneumoniae infection in all countries.Details of diagnostic tests used, indicators for surveillance, frequency of surveillance, implicated stakeholders, etc. are therefore missing from this report.Furthermore, as clinical data and type of diagnostic test used for the diagnosis of each case were also not provided in the responses to the survey, we have not been able to provide a direct comparison of such data between countries in this report.Additionally, given the short deadline, it may have been difficult for several countries to collect the relevant information in time.

Conclusion
As expected, surveillance for M. pneumoniae infections across responding EU/EEA countries is highly variable in terms of data collected and methods of laboratory detection of cases.For this reason, comparisons of surveillance data from different countries have limitations.However, information from predominantly northern European countries (Denmark, Finland, the Netherlands, Norway, Sweden, United Kingdom) and the Czech Republic does suggest that the autumn of 2011 had an increase of M. pneumoniae infections reported through the existing surveillance systems.Data from Denmark as presented earlier and in this issue [9,23] and Sweden [24] suggests that the epidemic wave started in 2010.With the results from our study, however, we cannot assess whether the reported increases fit into the expected four-to-sevenyear epidemic waves even though this seems to be indicated by data from Finland, Norway and Denmark in this issue [23,25,26].
Available data seem to suggest that Member States from southern Europe are not yet facing an increase as important as that reported in the northern countries.
Increasing awareness among healthcare providers in countries not yet heavily affected could strengthen surveillance activities and ensure timely diagnosis and appropriate treatment of the disease in affected patients.It would be interesting to analyse whether in the countries where increases in M. pneumoniae infection rates were reported, similar increases or concurrent decreases in reporting rates for other respiratory pathogens took place during the same time period.However, this was beyond the scope of this assessment.
For the responding countries for which information was available, it is clear that all treating clinicians

Denmark Yes Yes
Almost twice as many samples were investigated in 2011 compared with 2010, but the proportion of M. pneumoniae-positive samples remained the same.
An epidemic was also seen in 2010 [9].

Spain Yes
Case treatment: several national guidance documents for clinicians on treatment the atypical pneumonia prepared by scientific societies such as the Spanish Society of Infectious Diseases and Clinical Microbiology and Spanish Association of Paediatric Primary Care.
Institutional settings: infection control guidance for institutional care settings and nosocomial outbreaks, including respiratory tract infections.

Sweden Yes
Case treatment: STRAMA (Swedish strategic programme against antibiotic resistance) guidance on how to treat pneumonia in outpatient care.

United Kingdom Yes
Case treatment: guidance on the management of community-acquired pneumonia by the British Thoracic Society, which includes consideration and treatment of, M. pneumoniae infection [http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPGuideline-full.pdf].
Institutional settings: the Health Protection agency has guidance on the management of outbreaks of acute respiratory infection in institutional settings.

Cyprus
Data not available -

Poland
Data not available -

Table 1
Availability of surveillance data for Mycoplasma pneumoniae infection and comparison with 2010, EU/EEA countries, January 2012

Table 2
Existence and details of clinical guidelines available in EU/EEA countries for treatment of Mycoplasma pneumoniae infection, January 2012 guidance on the management of M. pneumoniae infection is included in guidance of management atypical pneumonia, which has been prepared by a working group of experts from the Slovakian Pneumological Society.national treatment guidelines exist [http://www.szd.si/user_files/vsebina/Zdravniski_Vestnik/2010/marec/245-64.pdf].