Infectious diseases remain a threat to public health in today's interconnected world. There is an ongoing debate on how responses to threats of infectious diseases can best be coordinated, and the field remains nascent in understanding which specific structural governance arrangement will perform best. The present paper contributes to this discussion by demonstrating that it is possible to develop working hypotheses specifying the relationship between the type of infectious disease crisis and type of response to the crisis. For type of crises and type of response mechanisms there is still a lack of research, but the hypothesis combining these two provide a perspective for a future research and action agenda. It certainly prevents us from choosing between schism or hypes when it comes to crisis response. It provides instruments to realize that no single type of response is the most effective and that not all responses are equally effective in a concrete case.

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BackgroundIn May 2014, Middle East respiratory syndrome coronavirus (MERS-CoV) infection, with closely related viral genomes, was diagnosed in two Dutch residents, returning from a pilgrimage to Medina and Mecca, Kingdom of Saudi Arabia (KSA). These patients travelled with a group of 29 other Dutch travellers. We conducted an epidemiological assessment of the travel group to identify likely source(s) of infection and presence of potential risk factors.MethodsAll travellers, including the two cases, completed a questionnaire focussing on potential human, animal and food exposures to MERS-CoV. The questionnaire was modified from the WHO MERS-CoV questionnaire, taking into account the specific route and activities of the travel group.ResultsTwelve non-cases drank unpasteurized camel milk and had contact with camels. Most travellers, including one of the two patients (Case 1), visited local markets, where six of them consumed fruits. Two travellers, including Case 1, were exposed to coughing patients when visiting a hospital in Medina. Four travellers, including Case 1, visited two hospitals in Mecca. All travellers had been in contact with Case 1 while he was sick, with initially non-respiratory complaints. The cases were found to be older than the other travellers and both had co-morbidities.ConclusionsThis epidemiological study revealed the complexity of MERS-CoV outbreak investigations with multiple potential exposures to MERS-CoV reported such as healthcare visits, camel exposure, and exposure to untreated food products. Exposure to MERS-CoV during a hospital visit is considered a likely source of infection for Case 1 but not for Case 2. For Case 2, the most likely source could not be determined. Exposure to MERS-CoV via direct contact with animals or dairy products seems unlikely for the two Dutch cases. Furthermore, exposure to a common but still unidentified source cannot be ruled out. More comprehensive research into sources of infection in the Arabian Peninsula is needed to strengthen and specify the prevention of MERS-CoV infections.

Abstract. Recently, two patients of African origin were given a diagnosis of Plasmodium falciparum malaria without recent travel to a malaria-endemic country. This observation highlights the importance for clinicians to consider tropical malaria in patients with fever. Possible transmission routes of P. falciparum to these patients will be discussed. From a public health perspective, international collaboration is crucial when potential cases of European autochthonous P. falciparum malaria in Europe re considered.Plasmodium falciparum malaria is an important cause of morbidity and mortality worldwide.1 It is not endemic to Europe, and reported cases in Europe are almost exclusively in travelers returning from malaria-endemic areas.2 Imported infections with P. falciparum (P. falciparum malaria) account for most malaria-related morbidity and mortality in Europe. 3The Netherlands was declared malaria free by the World Health Organization in 1970.The incubation period of P. falciparum malaria is 12-14 days, but longer incubation periods can occur in semi-immune persons and persons taking ineffective malaria prophylaxis, but is typically less than one month.4,5 Importantly, diagnosis of P. falciparum malaria may be missed or delayed in patients who have malaria years after leaving a malaria-endemic area or who do not report recent visits to malaria-endemic countries. 6 However, early detection of apparently non-imported cases of P. falciparum malaria in Europe is of major public health importance because it enables effective response activities to prevent outbreaks. We describe two patients who had not been in malaria-endemic areas for years, but had P. falciparum malaria shortly after returning from countries in southern Europe. Informed consent was obtained from the patients for publication of this report. CASE-PATIENT 1A 23-year-old man from Liberia was seen at an emergency department in the Netherlands because of abdominal pain for three days and a fever of 40 C. Besides an episode of malaria in the past (before 2008), he had no medical history. His travel history indicated a visit to a malaria-endemic country, Liberia, in 2008. Nine days before admission to our hospital, he returned from a four-week holiday in Barcelona, Spain and Treviso, Italy, where he traveled by car. During his travel, he stayed with immigrants who recently returned from Africa, some of whom were sick and had fevers. The patient reported that in both places the living conditions were poor, and many indoor insects, including mosquitoes, were present. No other risk factors for transmission of malaria (e.g., intravenous drug use, blood transfusion, surgical interventions, airport visit) were reported.At a physical examination, he did not appear acutely ill. His blood pressure was 108/55 mm of Hg, his pulse rate was 84 beats/ minute and his temperature was 40 C. He had abdominal tenderness. There were no other abnormalities. Laboratory test results showed hemoglobin level of 8.3 mmol/L, a thrombocyte count of 56 cells/ L and a normal different...

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