LETTERS shows insuffi cient coverage among Pierre Loulergue,1 potential for nosocomial outbreaks. Euro students currently being trained as Jean-Paul Guthmann,1 Surveill. 2011;16.pii 19764. 9. Gagneur A, Pinquier D. Early waning of HCPs in university hospitals within Laure Fonteneau, maternal measles antibodies: why im- the Paris area. Thus, all unvaccinated Jean-Baptiste Armengaud, munization programs should be adapted students (20.7%) and ≈5% of the 50% Daniel Levy-Brühl, over time. Expert Rev Anti Infect Ther. who have received 1 dose could be and Odile Launay 2010;8:1339–43. doi:10.1586/eri.10.126 10. Schmid K, Merkl K, Hiddemann-Koca susceptible to measles. Moreover, Author affi liations: Assistance Publique K, Drexler H. Obligatory occupation- a rather low proportion of students Hôpitaux de Paris, Paris, France (P. al health check increases vaccination knew that measles vaccination was Loulergue, J.B. Armengaud, O. Launay); rates among medical students. J Hosp Infect. 2008;70:71–5. doi:10.1016/j. recommended, as described for HCPs and Institut de Veille Sanitaire, Saint- jhin.2008.05.010 (7), which may explain the insuffi cient Maurice, France (J.-P. Guthmann, L. coverage. Fonteneau, D. Levy-Brühl) Address for correspondence: Pierre Loulergue, In France, this situation has DOI: http://dx.doi.org/10.3201/eid1709.110141 CIC de Vaccinologie Cochin-Pasteur, 27, resulted in several measles outbreaks Rue du Faubourg Saint Jacques, 75014 Paris, within hospitals in recent years (8). References France; email: [email protected] Particular efforts should be made in certain units, such as pediatrics, 1. Muscat M, Bang H, Wohlfahrt J, Glis- because an early waning of maternal mann S, Molbak K. Measles in Europe: antibodies has been demonstrated (9). an epidemiological assessment. Lancet. 2009;373:383–9. doi:10.1016/S0140- Measures should be taken to reinforce 6736(08)61849-8 the vaccination policy in this well- 2. Parent du Châtelet I, Floret D, Antona defi ned group; information can be D, Levy-Bruhl D. Measles resurgence in obtained and follow-up vaccinations France in 2008, a preliminary report. Euro Toxigenic Surveill. 2009;14:pii 19118. can be provided easily during their 3. Calendrier vaccinal. Bull Epidemiol Corynebacterium training period. A mandatory health Hebdo. 2011; http://www.invs.sante.fr/ check could contribute to increasing beh/2011/10_11/beh_10_11_2011.pdf ulcerans in Woman the vaccination coverage (10). 4. Fonteneau L, Guthmann J, Collet M, and Cat Vilain A, Herbet J, Levy-Bruhl D. Vacci- Our study provides original nation coverage estimated based on data To the Editor: Diphtheria and data for measles vaccination found in 24th month health certifi cates coverage in HCSs in France. A of infants, France, 2004–2007. Bull Epi- diphtheria-like illness are caused by similar conclusion applies to HCS- demiol Hebdo. 2010;31–32. http://www. Corynebacterium spp. that harbor invs.sante.fr/beh/2010/31_32/index.htm recommended vaccines for which we the diphtheria toxin–encoding tox 5. Atkinson WL, Markowitz LE, Adams NC, gene. Recently in many industrialized found insuffi cient coverage (<50% Seastrom GR. Transmission of measles in had received a pertussis booster medical settings—United States, 1985– countries, cases of diphtheria-like in the past 15 years and only 6/27 1989. Am J Med. 1991;91(3B):S320–S4. infection caused by toxigenic C. doi:10.1016/0002-9343(91)90389-F without a history of varicella have ulcerans have outnumbered those 6. Villasís-Keever MA, Pena LA, Miranda- caused by toxigenic C. diphtheriae been vaccinated against varicella). Novales G, Alvarez y Munoz T, Dama- Such evaluations should be performed sio-Santana L, Lopez-Fuentes G, et al. (1,2). C. ulcerans infection was regularly. Although our data were Prevalence of serological markers against originally associated with consumption measles, rubella, varicella, hepatitis B, collected from a representative sample of raw milk and dairy products or hepatitis C, and human immunodefi ciency contact with cattle, but C. ulcerans of students in Paris, it is likely that virus among medical residents in Mexico. the situation is qualitatively similar Prev Med. 2001;32:424–8. doi:10.1006/ has increasingly been isolated from in other regions and therefore could pmed.2001.0825 domestic animals such as pet dogs 7. Loulergue P, Moulin F, Vidal-Trecan G, contribute to future nosocomial and cats (3–5). So far, isolation of an Absi Z, Demontpion C, Menager C, et identical toxigenic C. ulcerans strain epidemics. Mandatory vaccination al. Knowledge, attitudes and vaccina- of HCPs against vaccine-preventable tion coverage of health care workers re- from an animal and its owner has been diseases protects not only the HCP garding occupational vaccinations. Vac- documented only for dogs (3,4) and cine. 2009;27:4240–3. doi:10.1016/j. and his/her family, but also protects a pig (6). We report the isolation of vaccine.2009.03.039 an identical toxigenic C. ulcerans the patient. Increased vaccination 8. Botelho-Nevers E, Cassir N, Minodier of this group should contribute to a P, Laporte R, Gautret P, Badiaga S, et al. strain from an asymptomtic pet better control of measles outbreaks in Measles among health care workers: a cat and a person with pharyngeal diphtheria-like illness; therefore, it France. 1These authors contributed equally to this might be speculated that the woman article.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 9, September 2011 1767 LETTERS has acquired her infection from the the patient’s close contacts (6 family Our fi ndings of transmission cat. members, the physician, and 19 nurses of toxigenic C. ulcerans between In November 2010, an 86-year- and other health care workers) was a woman and her cat underline the old woman with arterial hypertension conducted. Although all close contacts zoonotic potential of this organism and rheumatoid arthritis was admitted had completed the series of diphtheria and highlight the need for more to an ear, nose, and throat clinic in toxoid vaccinations, they were all studies investigating the carrier status Dresden, Germany, with a 3-day given postexposure prophylaxis with of companion animals such as cats and history of sore throat, hoarseness, and erythromycin. dogs. Although clindamycin is not a nasal respiratory obstruction. Fever Because of the zoonotic potential fi rst-line drug for diphtheria therapy, was not reported. Because the patient of human C. ulcerans infections, the intermediate susceptibility of had visible fi brinous rhinitis, a nasal nasal and pharyngeal swab samples C. ulcerans against clindamycin and pharyngeal swab was obtained were collected from the patient’s underscores the necessity of before treatment with amoxicillin asymptomatic pet cat. Strains of tox- standardized susceptibility testing for was begun. The patient had no positive C. ulcerans (which we named diphtheria cases because clindamycin- history of recent travel abroad or KL251 and KL252) grew on culture; resistant toxigenic C. ulcerans contact with livestock. Her complete the API Coryne code was identical to strains in human infections have vaccination status against diphtheria that of the human isolate KL246. In been recently reported (6). Toxigenic was unknown, but she had received a contrast to the human isolate, which C. ulcerans strains are rare, but the vaccination booster in 2006. yielded a weakly positive Elek result, numbers of human wound infections Toxigenic C. ulcerans grew from both isolates from the cat showed or diphtheria-like disease caused by culture of the nasal swab specimen; Elek-negative results. C. ulcerans have increased in the it was identifi ed by biochemical Antimicrobial drug susceptibility past few years. However, detection differentiation (API Coryne code testing of the 3 isolates was performed of toxigenic C. ulcerans is often still 0111326; bioMèrieux, Nürtingen, on Mueller-Hinton blood agar incidental, often resulting in delayed Germany), rpoB sequencing (6), (supplemented with 5% sheep blood) specifi c therapy, including patient and MALDI-TOF analysis (MALDI by using the Etest system after isolation or contact tracing. Biotyper; Bruker Daltonics, Bremen, overnight incubation at 37°C and in

Germany) (7). Toxigenicity was 5% CO2. In the absence of standardized Acknowledgments verifi ed by real-time PCR (8) and a breakpoints for C. ulcerans, sus- We thank Wolfgang Schmidt, modifi ed Elek test (6). ceptibility was determined by Karola Grünwald, Marzena Maggipinto, Because the microbiological using the Clinical Laboratory and Daniela Sebah for cultivation result suggested diphtheria-like ill- Standards Institute criteria for broth and microbiological and molecular ness, the patient was transferred to microbouillon dilution susceptibility characterization of the Corynebacteria. an infectious diseases department in testing for Corynebacterium spp. an academic hospital, where she was (9). All C. ulcerans strains were The study was partially supported isolated and treated with amoxicillin susceptible to amoxicillin, benzyl by the Bavarian State Ministry of the for 12 days. Because the patient’s penicillin, ceftriaxone, erythromycin, Environment and Public Health, by the condition was stable and no severe and tetracycline (MICs 0.19–0.5 European Commission’s Directorate complications occurred during her μg/mL) but less susceptible to General for Health and Consumer Policy hospital stay, she was not given clindamycin in vitro (MIC 2 μg/mL). through the Diphtheria Surveillance diphtheria antitoxin. Her predominant Sequencing of rpoB and tox Network, and by the German Federal symptoms, such as sore throat and showed 100% homology between Ministry of Health through the Robert earache, improved after antimicrobial the strains from the woman and the Koch-Institute and its National Reference drug therapy, and she recovered cat. Ribotyping revealing a U3-like Laboratories Network. quickly. Electrocardiogram performed ribotype (5), and multilocus sequence before discharge from hospital showed typing (10) confi rmed the clonal Anja Berger, Ingrid Huber, no signs of myocarditis or other toxin- identity of the strains. Sophie-Susann Merbecks, related effects, such as neurologic The cat was given a combined Ingrid Ehrhard, Regina Konrad, disorder. preparation of benzyl penicillin and Stefan Hörmansdorfer, Although person-to-person trans- streptomycin. After completion of Michael Hogardt,1 mission of C. ulcerans has not yet therapy, C. ulcerans no longer grew and Andreas Sing1 convincingly been demonstrated, from nasal swab specimens from the 1These authors contributed equally to this an outbreak investigation involving woman or the cat. article.

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Author affi liations: National Consiliary strains by a novel real-time PCR. J Clin confi rmed Mycobacterium tuberculosis Laboratory for Diphtheria, Oberschleißheim, Microbiol. 2008;46:2822–3. doi:10.1128/ isolates obtained from hospitalized JCM.01010-08 Germany (A. Berger, R. Konrad, A. Sing); 9. Clinical Laboratory Standards Institute. patients during January 2000– Bavarian Health and Food Safety Authority, Methods for antimicrobial dilution and December 2010. A nonduplicate isolate Oberschleißheim (A. Berger, I. Huber, R. disk susceptibility testing of infrequently was defi ned as 1 isolate collected for Konrad, S. Hörmansdorfer, M. Hogardt, isolated or fastidious bacteria; approved evaluation from 1 patient who visited guideline. 2nd ed. Wayne (PA): The Insti- A. Sing); and Public Health Laboratory tute; 2006. p. M45–A2. the hospital (as inpatient or outpatient). of Saxony, Germany (S.-S. Merbecks, I. 10. Bolt F, Cassiday P, Tondella ML, Dezoysa If multiple isolates were available Ehrhard) A, Efstratiou A, Sing A, et al. Multilocus from a patient, only the one fi rst sequence typing identifi es evidence for re- isolated was analyzed. All specimens DOI: http://dx.doi.org/10.3201/eid1709.110391 combination and two distinct lineages of Corynebacterium diphtheriae. J Clin Mi- were processed and pretreated as described elsewhere (3). Patients with References crobiol. 2010;48:4177–85. doi:10.1128/ JCM.00274-10 multidrug-resistant TB were excluded 1. Bonmarin I, Guiso N, Le Flèche-Matéos on the basis of evidence for differences A, Patey O, Patrick AD, Levy-Bruhl Address for correspondence: Andreas Sing, in the epidemiology of isoniazid- D. Diphtheria: a zoonotic disease in Bavarian Health and Food Safety Authority, resistant (rifampin-susceptible) TB and France? Vaccine. 2009;27:4196–200. Veterinärstraße 2, 85764 Oberschleißheim, doi:10.1016/j.vaccine.2009.04.048 multidrug-resistant TB (4). Immigrant 2. Wagner KS, White JM, Crowcroft NS, De Germany; email: [email protected] populations in Taiwan are limited; Martin S, Mann G, Efstratiou A. Diphthe- therefore, we did not analyze the origin ria in the United Kingdom, 1986–2008: of the patients. the increasing role of Corynebacterium ul- cerans. Epidemiol Infect. 2010;138:1519– After excluding patients with 30. doi:10.1017/S0950268810001895 multidrug-resistant TB, we analyzed 3. Lartigue MF, Monnet X, Le Flèche A, 4,289 nonduplicate isolates, of which Grimont PA, Benet JJ, Durrbach A, et al. 3,842 (89.6%) were susceptible to Corynebacterium ulcerans in an immuno- compromised patient with diphtheria and Isoniazid-Resistant isoniazid and the other 447 (10.4%) her dog. J Clin Microbiol. 2005;43:999– were resistant to isoniazid. In terms 1001. doi:10.1128/JCM.43.2.999-1001. Tuberculosis, of demographic associations, patients 2005 34–<44 years of age were more 4. Hogg RA, Wessels J, Hart J, Efstratiou Taiwan, 2000–2010 A, De Zoysa A, Mann G, et al. Possible likely than those >74 years of age zoonotic transmission of toxigenic Cory- To the Editor: Vinnard et al. (1) to have an isoniazid-resistant strain nebacterium ulcerans from companion reported that the risk factors associated (Table). In addition, patients with animals in a human case of fatal diphthe- with initial isoniazid resistance among extrapulmonary TB were less likely ria. Vet Rec. 2009;165:691–2. patients with tuberculous meningitis 5. De Zoysa A, Hawkey PM, Engler K, than patients with pulmonary TB to George R, Mann G, Reilly W, et al. Char- in the United States during 1993– be infected with isoniazid-resistant acterization of toxigenic Corynebacterium 2005 included young age (25–34 TB. We also identifi ed 34 patients ulcerans strains isolated from humans years) and foreign birth (1). In a with TB meningitis. After excluding 2 and domestic cats in the United King- previous survey, conducted in Taiwan dom. J Clin Microbiol. 2005;43:4377–81. patients with multidrug-resistant TB, doi:10.1128/JCM.43.9.4377-4381.2005 during 2000–2008, we found the rate we found that 31 patients (mean age 6. Schuhegger R, Schoerner C, Dlugaiczyk of antituberculosis drug resistance 56.6 years) had isoniazid-susceptible J, Lichtenfeld I, Trouillier A, Zeller-Per- to be lower for older patients than TB meningitis and a 50-year-old man onnet V, et al. Pigs as source for toxigenic for younger patients (2); however, Corynebacterium ulcerans. Emerg In- had meningitis caused by isoniazid- fect Dis. 2009;15:1314–5. doi:10.3201/ current information about the patient resistant TB. eid1508.081568 characteristics associated with Our results are in agreement with 7. Konrad R, Berger A, Huber I, Boschert isoniazid-resistant tuberculosis (TB) those reported in a previous study V, Hörmansdorfer S, Busch U, et al. in Taiwan is lacking. Therefore, to Matrix-assisted laser desorption/ionisa- in the United States, which found tion time-of-fl ight (MALDI-TOF) mass determine the risk factors associated that the rate of isoniazid resistance spectrometry as a tool for rapid diagnosis with initial isoniazid resistance among was lower for isolates from elderly of potentially toxigenic Corynebacterium patients with TB in Taiwan, we patients (1,4). This phenomenon may species in the laboratory management of conducted a retrospective study. diphtheria-associated bacteria. Euro Sur- be attributable to the reactivation of a veill. 2010;15:pii:19699. The study was conducted at the dormant infection. Because isoniazid 8. Schuhegger R, Lindermayer M, Kugler National Taiwan University Hospital, was introduced to Taiwan for the R, Heesemann J, Busch U, Sing A. Detec- a 2,500-bed tertiary care center in treatment of TB in 1952, elderly tion of toxigenic Corynebacterium diph- northern Taiwan. We analyzed culture- theriae and Corynebacterium ulcerans persons in Taiwan probably did not

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