Wüstenschiff

Griechenland - West Nile-Fieber
12.09.2011

Ende Juli ist der 1. Fall in diesem Jahr aufgetreten. Ein Mann aus der Region Karditsa (Thessalien, zentral) erkrankte mit Symptomen einer milden Enzephalitis. Bis zum 9. September wurden insgesamt 56 Fälle gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Für den Sommer und Herbst dieses Jahres werden noch mehr Erkrankungen erwartet. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

Griechenland - West Nile-Fieber
19.09.2011

Seit Ende Juli kommt es zu Erkrankungshäufungen. Bis zum 15. September wurden insgesamt 67 Erkrankungen gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Für den Herbst dieses Jahres wird eine weitere Zunahme der Fallzahlen erwartet. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

MALARIA, P. VIVAX - GREECE (04): AUTOCHTHONOUS
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Fri 23 Sep 2011
From: Corneliu Petru Popescu [edited]
<cornel160@yahoo.com>


New _Plasmodium vivax_ infected patient in Greece
-------------------------------------------------
I would like to announce that we had from 19 Sep 2011 a new case of
malaria with _P. vivax_ in a patient who lived in Greece for the last
3 years and returned 3 weeks ago. He worked in the south, in the same
region as the previous patient
(<http://www.eurosurveillance.org/ViewArt ... leId=19954>),
in the Leimonas village, near Skala and Elos.

The traveler had no history of travel to any malaria-endemic areas.
The patient was a citizen from Romania and was admitted and diagnosed
at the Clinical Hospital of Infectious and Tropical Diseases Dr V
XXXXXX in Bucharest.

--
Corneliu Petru Popescu <cornel160@yahoo.com>
Simin Aysel Florescu <siminflorescu@yahoo.com>
Dr V XXXXXX Clinical Hospital of Infectious and Tropical Diseases
Bucharest Romania

[The last patient was reported from Romania on 1 Aug 2011, and the
present case adds up to 8 cases of _P. vivax_ infected in Greece since
June 2011. The patients were infected in 2 areas: Euboea and the
Evrotas river basin.

It is disturbing that new cases continue to appear. We speculated
earlier that the cases resulted from migrant workers from endemic
areas being asymptomatic gametocyte carriers, but as new cases
continue to be found, local reservoirs in these 2 regions must be
considered.

Surveys of blood films, perhaps seropositivity for malaria antibodies
and investigation of sporozoites in the local _Anopheles_ population
would help define the situation.

ProMED-mail will be happy to publish further information. - Mod.EP]

[Leimonas, Skala, and Elos can be located via the
HealthMap/ProMED-mail interactive map of Greece at
<http://healthmap.org/r/1gW_>. - Sr.Tech.Ed.MJ]

MALARIA, P. VIVAX - GREECE (05): AUTOCHTHONOUS, COMMENT
*******************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Mon 26 Sep 2011
From: Corneliu Petru Popescu <cornel160@yahoo.com> [edited]


Further information concerning the 2nd patient diagnosed in Romania
-------------------------------------------------------------------
The 2nd patient had symptoms for 2 months before admission but did not
seek medical care before being back in Romania. He worked picking
oranges in Greece without insurance.

He told us that many people from other countries, especially Pakistan,
also worked on the farms.

--
Corneliu Petru Popescu
Dr V XXXXXX Clinical Hospital of Infectious and Tropical Diseases
Bucharest Romania
<cornel160@yahoo.com>

[The new information kindly provided by Dr Corneliu Popescu from
Bucharest, supports our previous hypothesis, that the cases were
infections transmitted from immigrants from _P. vivax_ endemic
countries. - Mod.EP]

[A HealthMap/ProMED-mail interactive map of Greece can be seen at
<http://healthmap.org/r/1gW_>. - Sr.Tech.Ed.MJ]

Griechenland - West Nile-Fieber
26.09.2011

Seit Ende Juli kommt es zu Erkrankungshäufungen. Bis zum 22. September wurden insgesamt 51 Erkrankungen gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Für den Herbst dieses Jahres wird eine weitere Zunahme der Fallzahlen erwartet. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm
_________________________

Griechenland - Malaria
26.09.2011

Bei einem zweiten Rumänen wurde am 19.09. eine Malaria durch Plasmodium vivax diagnostiziert. Auch er hatte zuvor kein Endemiegebiet bereist, sondern lebte und arbeitete in den letzten 3 Jahren in einer der Regionen auf dem Peleponnes, in der in diesem Jahr seit Juni autochthone Malaria-Fälle aufgetreten sind. Die Zahl der Erkrankten erhöht sich damit auf 8. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Anhand der verfügbaren Daten lässt sich noch nicht beurteilen, ob die Übertragungen in diesem Jahr über einen importierten Fall mittels eines lokalen Vektors erfolgten, oder ob bereits ein Erregerreservoir in Menschen in dieser Region existiert. Die Behörden haben die Infektionsüberwachung intensiviert und Aufklärungsmaßnahmen für die Bevölkerung laufen an. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

Gruß
Birgitt

Griechenland - West Nile-Fieber
10.10.2011

Seit Ende Juli kommt es zu Erkrankungshäufungen. Bis zum 6. Oktober wurden insgesamt 61 Erkrankungen gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

LEGIONELLOSIS - UK ex GREECE (02): TRAVELERS, REQUEST FOR INFORMATION
*********************************************************************

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http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Date: Sat 15 Oct 2011
Source: UK Press Association [edited]
http://www.google.com/hostednews/ukpres ... 609818986A



Another 3 cases of Legionnaires' disease have been confirmed in UK
residents who have visited Corfu, bringing the total number of cases
to 12, the Health Protection Agency (HPA) has said. The HPA said 3
other possible cases in people who travelled to the Greek island in
the past 3 months are still under investigation.

As a precautionary measure, the HPA is looking into the possibility of
a UK source, but a spokeswoman said preliminary investigations have so
far not found a common link between the patients -- whose ages range
from 39 to 79 -- other than they all visited Corfu, albeit different
parts of the island. Greek health authorities have sent 2 teams to
Corfu and over the past week water samples have been taken from hotels
and other venues.

Professor Nick Phin, head of the HPA's Legionnaires' department, said
Legionnaires' was uncommon and cannot be spread from person to person
but warned residents to be aware of the risks. "As we are still seeing
cases of Legionnaires' in UK residents returning from Corfu, we want
them to be aware of this potential risk, but we are not suggesting
that people change their holiday plans," Mr Phin said. He said it was
difficult to pinpoint the cause behind the Legionnaires' cluster.
"Sometimes a source for the infection is never found, because the
bacteria can live in a very wide variety of types of water supply," he
said.

The HPA is working with the European Centre for Disease Prevention and
Control, UK colleagues, and the Greek Public Health authorities to
identify the source of the Legionnaires' cluster. People going on
holiday to Corfu are being told to be aware of the signs and symptoms
of Legionnaires' disease, which is a form of pneumonia which is spread
through water droplets. Symptoms may start between 2 and 14 days after
exposure to the bacterium, often with an initial flu-like illness
leading on to pneumonia.

--
Communicated by:
Denis Green


[HealthMap Alerts submitted a similar news release. These news
releases add 3 more cases to the 9 cases previously reported as having
developed Legionnaires' disease among British tourists following a
stay on the Greek island of Corfu. (See Legionellosis - UK ex Greece,
travelers, alert 20111008.3021). It would be useful for the HPA to say
if there are any towns, hotels, or other tourist destinations on Corfu
that were found to be in common among these 12 British tourists, or,
if nothing is in common on the island of Corfu itself, if there are
any common means by which these 12 British tourists traveled to
Corfu.

For a discussion of travel-associated Legionellosis see ProMED-mail
post Legionellosis - USA (03): (NV) hotel 20110716.2159.

Corfu, a popular tourist destination, is a Greek island northwest of
mainland Greece off the coast of Albania in the Ionian Sea
(http://en.wikipedia.org/wiki/Corfu). For a map of Corfu see
http://en.wikipedia.org/wiki/File:Corfu ... map-en.svg. A
HealthMap/ProMED-mail interactive map of Greece can be seen at
http://healthmap.org/r/1gW_. - Mod.ML]

Griechenland - West Nile-Fieber
17.10.2011

Seit Ende Juli kommt es zu Erkrankungshäufungen. Bis zum 13. Oktober wurden insgesamt 65 Erkrankungen gemeldet. Damit ist Griechenland das Land, in dem EU-weit die meisten Fälle auftreten (65 von insgesamt 85). Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

MALARIA, P. VIVAX - GREECE (06): AUTOCHTHONOUS
**********************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Date: Thu 20 Oct 2011
Source: Eurosurveillance edition 2011; 16(42) [edited]
http://www.eurosurveillance.org/ViewArt ... leId=19993


Autochthonous _Plasmodium vivax_ malaria in Greece, 2011
--------------------------------------------------------
[Authors: Danis K, Baka A, Lenglet A, et al.]

Between May and September 2011, 20 cases of _Plasmodium vivax_
infection were reported in Greek citizens without reported travel
history. The vast majority of those cases were confined to a delimited
agricultural area of Evrotas, Lakonia. Conditions favouring locally
acquired transmission of malaria, including the presence of competent
vectors and migrants from endemic countries exist in Greece,
underscoring the need for the development of an integrated
preparedness and response plan for malaria prevention.

In 2011, 20 malaria cases without reported travel history to endemic
countries have been notified as of 27 Sep 2011 from Evrotas, Lakonia
and other geographical areas in Greece. We conducted an investigation
to describe the geographical and temporal distribution of those cases,
determine the affected area(s) and identify the potential source of
infection, in order to better understand the transmission dynamics and
implement targeted control measures.

Malaria was officially eliminated from Greece in 1974, following an
intense national malaria eradication programme that was implemented
between 1946 and 1960 [1]. Between 1975 and 2005 approximately 50
cases of malaria were reported annually, the vast majority of whom
were imported cases from countries endemic for malaria. However,
sporadic cases of mosquito-transmitted malaria that could have been
acquired locally were reported in 1991, 1999, and 2000 [2].

Between 2005 and 2009, 171 cases of malaria were reported in Greece
with a mean number of 34 cases per year [3]. Of those, 98 per cent
were in people that likely acquired the infection in endemic countries
and 78 per cent of all cases were in migrants from those countries.

Between early August and October 2009, a cluster of 8 malaria cases
was notified to the Hellenic Centre for Disease Control and Prevention
(HCDCP) from the Evrotas area of Lakonia district, which is located in
the Peloponnese in southern Greece.

The 1st 2 cases were in migrant workers from Pakistan and Afghanistan
who reportedly arrived in Greece during the summer of 2009 and who
were working in the agricultural holdings in this particular area. 4
of the remaining 6 cases belonged to the local Roma community and the
other 2 were Greek citizens residing in the area. None of those 6
cases reported travel history to a malaria endemic country.

In 2010, another malaria case was notified from the same area in
Evrotas, who also belonged to the local Roma community. Additionally,
2 Roma children with malaria were notified in Viotia with disease
onset on 25 and 30 Aug 2010 and an unclear travel history.

Surveillance of malaria in Greece
---------------------------------
As part of the mandatory notification system, physicians in Greece are
asked to notify HCDCP of all cases of laboratory-confirmed malaria
infection.

Enhanced surveillance is implemented in areas where domestic
transmission is suspected (that is, where no clear recent travel
history to a malaria-endemic country can be established), by tracing
the reported cases, visiting their homes, and if possible conducting
face-to-face interviews. When this is not possible, telephone
interviews are conducted. Translators are used where appropriate. The
case investigation form for enhanced surveillance gathers information
on: detailed travel history, potential modes of transmission, clinical
manifestations and treatment, previous malaria clinical episodes,
possible onward transmission, and household characteristics.

In addition, active surveillance is implemented by maintaining weekly
communication with local laboratories to enquire about recent
diagnosed cases of malaria. Residents in the neighbourhoods
surrounding the homes of suspected locally-acquired cases are asked to
report febrile illnesses to the local public health office and to seek
health care promptly.

Laboratory investigation
------------------------
Light microscopic examination of Giemsa stained thick and thin blood
smears is used to identify malaria parasites in local laboratories.
Blood smears are routinely analysed when general blood count tests
identify anaemia, thrombocytopenia, or other abnormal findings.

All blood specimens positive for malaria and a number of negative ones
are forwarded to the National Malaria Reference Laboratory (MRL) at
the National School of Public Health in Athens to be validated with
both microscopy and polymerase chain reaction (PCR). Rapid diagnostic
antigen tests are not routinely used. 20 per cent of positive samples
are being genotyped at present.

Entomological investigation
---------------------------
Following the 2010 large outbreak of West Nile Virus infection in
Greece [4], a study on vector distribution and mapping of risk areas
was carried out. The adult mosquito population is monitored using CO2
or CO2-light traps at permanent sampling stations that are collected
every 14 days. Several additional traps were used at locations of
suspected malaria transmission in order to detect _Anopheles_
mosquitoes. Collected specimens were counted and morphologically
identified.

Situation in 2011
-----------------
Epidemiological and clinical findings
-------------------------------------
Up to 27 Sep 2011, the HCDCP has received reports of 20 cases of _P.
vivax_ infection in Greek citizens who did not report travel to an
endemic country. The majority of those cases (n=14) reside in the
agricultural area of Evrotas, Lakonia district (Table, Figure 1 [all
tables and figures are available at the source URL above]). The
remaining 6 Greek cases were reported from 4 other prefectures, namely
Eastern Attiki (n=2), Evia (n=2), Viotia (n=1), and Larissa (n=1).

>From the area of Evrotas were further reported 16 cases of _P. vivax_
infection in migrant workers from endemic countries (mainly from
Pakistan) for whom no clear malaria importation status can be
determined. In addition, 2 Romanian workers who had been working and
living in the area of Evrotas developed symptoms in July 2011 and were
diagnosed with _P. vivax_ infection upon their return to Romania [5].

These 2 cases are not included in further analysis because not all the
epidemiological information is available. All 36 cases have been
confirmed as _P. vivax_ infections, by both microscopy and PCR at the
MRL.

None of the cases had a history of recent blood transfusion or
tissue/organ transplantation. (table 1 and figure 1: see URL above).
The 1st case from Evrotas reported disease onset on 23 May 2011
(figure 2: see URL above).

An increasing number of cases residing in Evrotas area was observed
during September (weeks 35-37). At the time of publication of this
report, the outbreak is still ongoing. (Figure 2) Reported cases of
malaria by week of symptom onset and region of residence, Greece,
May-September 2011 (n=36)

The age distribution of the 36 reported cases ranged from 1.5-79 years
(median: 36 years). The median age of migrant cases (24 years; range
15-55 years) was significantly lower (p less than 0.001) than of Greek
cases (47 years; range 1.5-79 years), possibly reflecting the
different age distributions of the 2 population groups. 7 of the Greek
cases were female. As the majority of the migrant worker community is
male, women with _P. vivax_ infection were not reported among
migrants.

Fever was reported as the main symptom by all cases, followed by
splenomegaly (n=14) and anaemia (n=14). 3 cases had central nervous
symptom manifestations. All cases were hospitalised; one was admitted
to an intensive care unit and has recovered fully.

To date, there has been one fatality in an elderly male case from
Evrotas area who had several underlying medical conditions, including
cardiac insufficiency, arrhythmias, and chronic obstructive pulmonary
disease, and developed acute respiratory distress syndrome. This is
the 1st death associated with _P. vivax_ infection in the last 3 years
in Greece. All other cases have fully recovered.

Almost all cases but 3 who were prescribed mefloquine and primaquine,
received the current treatment regimen for uncomplicated _P. vivax_
infection according to the national guidelines [6], which is 3-day
chloroquine treatment followed by 14-day primaquine treatment. Some
cases in Lakonia received the alternative weekly primaquine outpatient
regimen (higher dose than the daily regimen) for 8 weeks, to achieve a
higher compliance rate. Only one case among the reported 36 cases had
glucose-6-phosphate dehydrogenase deficiency and did not receive
primaquine.

When comparing the date of onset of symptoms to the date of
hospitalisation (which is a proxy for receipt of anti-malaria
treatment in Greece), the time period for all cases ranged between 0
and 27 days (median: 4 days). The median delay between symptom onset
and treatment was shorter in the group of migrant workers (3 days;
range 0-19 days) compared to Greek patients (4 days; range 2-27 days).
However, this difference was not statistically significant (p=0.12).

Entomological findings
----------------------
Fifteen _Anopheles_ species occur in Greece, 5 of which are considered
as potential malaria vectors, namely _An. claviger_, _An. hyrcanus_,
_An. maculipennis_, _An. sacharovi_, and _An. superpictus_ [7-9]. In
the Evrotas area, _Anopheles_ larvae were found in rivers, reed beds,
the Vivari lake, and draining channels, but at very low densities.

>From 1 Jun to 15 Sep 2011, 23 adult _Anopheles_ specimens were
collected from 2 sampling stations in the area, most of them _An.
sacharovi_ (n=21). 2 specimens which were determined as _An. plumbeus_
need further confirmation as they were not intact.

In the wetland area of Schinias national park in, Eastern Attiki, 19
mosquito species were identified, with _An. claviger_ being the
dominant _Anopheles_ species in the area [9]. Other _Anopheles_
species that were collected in that area included: _An. algeriensis_,
_An. maculipennis s.s._, _An. pseudopictus_, and _An. sacharovi_.

In the remaining affected areas in Greece, _Anopheles_ species were
identified, but their reported densities were often low. The most
commonly identified species there were _An. sacharovi_ and _An.
claviger_.

Discussion
----------
As of 27 Sep 2011, 20 malaria cases were reported in Greece, affecting
Greek citizens who did not have any reported history of travel to a
country endemic for malaria.

The vast majority of those cases were confined to a delimited
geographical area in Evrotas, Lakonia, where a small number of malaria
cases had already occurred in the previous 2 years. All other areas
that reported cases were previously unaffected.

In addition, 16 cases in migrant farm workers with unclear malaria
importation status were notified in Evrotas. As none of these workers
were documented, it is difficult to ascertain when they first arrived
in Greece, where they travelled and worked and how long they had been
residing in the area.

Therefore, based on their self-reported travel, medical history, and
possibility of relapses, it cannot be determined conclusively whether
they were non-imported cases.

The affected area in Lakonia district is a plain agricultural area of
about 20 sq km [7.7 sq mi] in the delta of the Evrotas river. It was
one of the historical hot spots of malaria transmission before
elimination of the disease in Greece [10].

The area is characterised by freshwater springs, a complex network of
130 km [81 mi] of irrigation and drainage channels, the Evrotas river
delta, the brackish Vivari lake, which seasonally dries out, and
coastal wetlands.

All other affected sites are located in agricultural areas, often
closely associated with river deltas or wetland areas, providing
favourable conditions for the presence and reproduction of potential
malaria mosquito vectors. None of those areas are tourist
destinations.

The affected area of Evrotas has a population of 4485 and a large
community of migrant farm workers (estimated between 2000-4000
depending on the period of the year), most of whom are not registered
[11].

About 80 per cent of all migrant workers in the area come from
Pakistan, around 15 per cent from Romania, and the remaining from
Morocco. The other affected areas have high numbers of migrant
agricultural workers from malaria-endemic countries, predominantly
from the Indian subcontinent.

Following the reports of malaria in Greece, the following control
measures were introduced. Guidelines for the recognition, management,
and diagnosis of malaria were provided to healthcare professionals to
improve their awareness of the disease. Interviewed patients were
informed that people in their close environment presenting with fever
should get diagnosed as soon as possible.

Support was provided to strengthen the laboratory capacity of local
health centres in the affected areas to diagnose malaria. Surveillance
of mosquitoes was enhanced in the affected areas. Guidance for blood
and blood product safety according to European Union directives was
implemented, including deferral from blood donation for a period of 6
months of persons residing or working in the affected areas within a
radius of 10 km [6 mi].

Communication and health promotion activities were strengthened
encouraging personal protection against mosquito bites in the general
population. Intensified vector control activities were implemented
using larviciding in breeding sites, ultra-low volume spraying in the
affected villages, and outdoor residual spraying in a zone of 50
metres [55 yards] around the houses of the cases, including backyards,
neighbouring stockyards, and other installations favourable for the
resting of _Anopheles_ adults.

Furthermore, all households in the area have been visited fortnightly
since 30 Sep 2011 to detect people with fever and to ensure early
detection and prompt treatment of all malaria cases. During those
visits, multidisciplinary health teams screened blood smears from all
persons with fever of 37.5 deg C [99.5 deg F] or higher, current or
reported during the previous 15 days.

Since the malaria eradication in 1974 in Greece, sporadic cases of
probable local mosquitoborne transmission have occurred. Because of
its climate, proximity of human and mosquito populations, and the
increased number of migrants from malaria-endemic countries, Greece
and possibly other Mediterranean countries might be vulnerable to the
re-establishment of endemic malaria [12,13].

However, provided that current healthcare, mosquito control, and
public health infrastructures remain intact in Greece, the
re-establishment of endemic areas for malaria remains unlikely.

Nevertheless, conditions may exist for small clusters of locally
acquired mosquitoborne transmission to occur sporadically. The
development of an integrated preparedness and response plan for
malaria that covers all aspects from surveillance, clinical
management, laboratory diagnosis, entomological surveillance, vector
control, and communication is necessary to prevent transmission and
control the disease on the long term. Such a plan should not only
address the most affected area of Evrotas, Lakonia, but also other
parts of Greece where ecological parameters are favourable for malaria
transmission.

Acknowledgements
----------------
We would like to thank all hospital physicians and local public health
authorities who contributed to the surveillance of malaria infections
in Greece; the internists and microbiologists at the General Hospital
of Sparti; the personnel of the National Malaria Reference Laboratory
for technical support. We would like to thank Katrin Leitmeyer, Lara
Payne, and Herve Zeller at the European Centre for Disease Prevention
and Control for their continued support during this event.

References
----------
1. World Health Organization (WHO). Malaria elimination: a field
manual for low and moderate endemic countries. Geneva: WHO; 2007.
Available from
http://whqlibdoc.who.int/publications/2 ... 84_eng.pdf
2. Kampen H, Proft J, Etti S, et al. Individual cases of autochthonous
malaria in Evros Province, northern Greece: entomological aspects.
Parasitol Res. 2003; 89(4): 252-8. [Abstract available from
http://www.ncbi.nlm.nih.gov/pubmed/12632161]
3. Hellenic Centre for Disease Control and Prevention (HCDCP),
Department of Epidemiological Surveillance and Intervention.
Epidemiological data for malaria in Greece, 2005 to 2009. Athens:
HCDPC. [Accessed. 23 Sep 2011]. Available from
http://www.keelpno.gr/images/stories/ke ... 09_eng.pdf
4. Danis K, Papa A, Theocharopoulos G, et al. Outbreak of West Nile
virus infection in Greece, 2010. Emerg Infect Dis. 2011; 17(10):
1868-72. [Available from
http://wwwnc.cdc.gov/eid/article/17/10/ ... rticle.htm]
5. Florescu SA, Popescu CP, Calistru P, et al. _Plasmodium vivax_
malaria in a Romanian traveller returning from Greece, August 2011.
Euro Surveill. 2011; 16(35): pii=19954. Available from
http://www.eurosurveillance.org/ViewArt ... leId=19954
6. Hellenic Centre for Disease Control and Prevention (HCDCP).
[Guidelines for the treatment of malaria]. [Accessed 23 Oct 2011].
Available from [Greek]
http://www.keelpno.gr/images/stories/ke ... 102011.pdf
7. Darsie RF Jr, Samanidou-Voyadjoglou A. Keys for the identification
of the mosquitoes of Greece. J Am Mosq Control Assoc. 1997; 13(3):
247-54. [Available from
http://wrbu.si.edu/keys/darsiesamanidou97a.pdf]
8. Samanidou-Voyadjoglou A, Darsie RF jr. An annotated checklist and
bibliography of the mosquitoes of Greece (Diptera: Culicidae). Mosq
Syst. 1993; 25(3): 177-85. [Available from
http://www.mosquitocatalog.org/files/pd ... 03P177.PDF
9. Patsoula E, Samanidou-Voyadjoglou A, Spanakos G, et al. Molecular
characterization of the _Anopheles maculipennis_ complex during
surveillance for the 2004 Olympic Games in Athens. Med Vet Entomol.
2007; 21(1): 36-43. [Abstract available from
http://www.ncbi.nlm.nih.gov/pubmed/17373945]
10. Vine MJ. The anti-malaria campaign in Greece (1946). Bull World
Health Organ. 1948; 1(1): 197-204. [Available from
http://whqlibdoc.who.int/bulletin/1947- ... 97-204.pdf]
11. Hellenic Statistical Authority (EL. STAT.). Mid-year estimated
population by 5-year age groups level NUTS III (NOMOS). Population by
usual residence. Pireus: EL. STAT. [Accessed 26 Sep 2011]. Available
from
http://www.statistics.gr/portal/page/po ... 8_F_EN.pdf
12. Sabatinelli G, Ejov M, Joergensen P. Malaria in the WHO European
Region (1971-1999) . Euro Surveill. 2001; 6(4): pii=213. Available
from http://www.eurosurveillance.org/ViewArt ... icleId=213
13. Santa-Olalla Peralta P, Vazquez-Torres MC, et al. First
autochthonous malaria case due to _Plasmodium vivax_ since
eradication, Spain, October 2010. Euro Surveill. 2010; 15(41):
pii=19684. Available from
http://www.eurosurveillance.org/ViewArt ... leId=19684

--
communicated by:
ProMED-mail from HealthMap alerts


[The paper in a thorough review of the outbreak of _P. vivax_ malaria
in Greece in 2011. 20 Greek citizens and 16 immigrants from Pakistan,
Morocco, and Romania were diagnosed with _P. vivax_ infestation.

An increasing number of cases residing in Evrotas area was observed
during September (weeks 35-37), and the report concludes that "At the
time of publication of this report, the outbreak is still ongoing."

In our earlier comment to the outbreak we speculated that the only
explanation for the cases was migrant labor from _P. vivax_ endemic
countries, and the information provided in the report that
"approximately 80 per cent of all migrant workers in the area come
from Pakistan‚" strongly supports that the vivax was indeed
introduced by carriers from the Indian subcontinent.

The Greek authorities has implemented active case detection in the
affected areas as well as mosquito control with using larviciding in
breeding sites, ultra-low volume spraying in the affected villages,
and outdoor residual spraying.

Malaria prophylaxis is in our view not needed for visitors to Greece.
- Mod.EP

A HealthMap/ProMED-mail interactive map of Greece can be seen at
http://healthmap.org/r/1mfV. - Sr.Tech.Ed.MJ]

MALARIA, P. VIVAX - GREECE (07): AUTOCHTHONOUS
**********************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Mon 26 Oct 2011 Source: CDC [edited]
http://www.cdc.gov/malaria/malariagreece.htm


New Malaria Recommendations for Greece
--------------------------------------
Malaria prophylaxis is now indicated for Lakonia region of Greece. A
travel notice titled "New Malaria Recommendations for Greece" has been
added to the site. New recommendations for Greece are also reflected
in the Yellow Book's country-specific malaria information and the
Greece destination page.

The Centers for Disease Control and Prevention (CDC) has received
updated information on malaria cases in Greece. According to a recent
publication by Greek health authorities [K Danis, A Baka, A Lenglet, W
Van Bortel, et al. Autochthonous Plasmodium vivax malaria in Greece,
2011. Eurosurveillance. 2011 Oct 20, 16(42)], since 27 Sep 2011, a
total of 20 malaria cases have been reported in persons with no
history of travel to a malaria-endemic area. An additional 16 cases
have been identified in persons from malaria endemic countries in whom
importation versus local transmission of malaria could not be
determined. All cases were confirmed to be _P. vivax_. The majority
(20 cases) occurred in the southern region of the country,
specifically in the Laconia district in the south. Other cases
occurred in the Evia/Euboea (island east of the Central Greece
region), Eastern Attiki, Voitia, and Larissa districts (see map on:
http://www.cdc.gov/malaria/malariagreece.htm).

The Hellenic CDC of Greece continues to work with the European CDC and
has responded by enhancing its surveillance system and intensifying
mosquito control in affected areas, raising awareness among health
care providers and hospitals about early malaria diagnosis and
treatment, and educating the public about prevention of mosquito
bites.

Because of the ongoing evidence of malaria transmission in Laconia
district, CDC is recommending that travelers to Laconia district in
Greece take anti-malarial medicines to prevent malaria. Recommended
antimalarials include one of the following: atovaquone-proguanil
(Malarone TM), chloroquine, doxycycline, mefloquine, or primaquine.
Note that primaquine is contraindicated in people with
glucose-6-phosphate dehydrogenase (G6PD) deficiency. If primaquine is
chosen, the traveler must be screened for G6PD deficiency prior to
use.

For the districts of Evia/Euboea, Eastern Attiki, Voitia, and Larissa,
anti-malarials are not recommended at this time because there have
only been a limited number of cases.

Measures to prevent mosquito bites should also be taken for all of
these districts with malaria. These measures include using insect
repellent when outdoors, and staying in an air-conditioned or
well-screened area, or sleeping under an insecticide treated bed net
during the peak biting period for mosquitoes (dusk and dawn).

This notice will be updated as new information becomes available.

--
Communicated by:
ProMED-Mail
promed@promedmail.org

[The situation in Greece has been thoroughly investigated and the data
presented in Eurosurveillance edition 2011; 16(42)
(http://www.eurosurveillance.org/ViewArt ... leId=19993).


When recommending malaria prophylaxis to a given area the risk of
infection should be balanced to the risk of serious side effects from
the drugs used for malaria prophylaxis.

Laconia region is in the Southern part of the Peleponnes peninsula and
a popular tourist destination during summer. Of the 20 cases reported,
16 came from malaria endemic countries in Southeast Asia and are most
probably infected before arriving in Greece. The four patients
infected in Greece worked in close relation with the patients
presumably infected outside Greece.
Thus the risk of infection at present seems very limited to tourist in
the area.

The CDC recommended "antimalarials include one of the following:
atovaquone-proguanil (Malarone TM), chloroquine, doxycycline,
mefloquine, or primaquine. Note that primaquine is contraindicated in
people with glucose-6-phosphate dehydrogenase (G6PD) deficiency. If
primaquine is chosen, the traveler must be screened for G6PD
deficiency prior to use."

HealthMap location: http://healthmap.org/r/1nLG. - Mod.EP]

MALARIA, P. VIVAX - GREECE (08): AUTOCHTHONOUS, COMMENTS
********************************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Comments on _P. vivax_ malaria in Greece
----------------------------------------
[1]
Date: Mon 31 Oct 2011
From: Tony Ellam [edited]


The posting Malaria, P. vivax - Greece (07) autochthonous
20111030.3226 misinterprets the data contained in the original
article, and in doing so understates the potential risk of ongoing
transmission to local residents and tourists. The ProMED post states:

"Of the 20 cases reported, 16 came from malaria endemic countries in
Southeast Asia and are most probably infected before arriving in
Greece. The 4 patients infected in Greece worked in close relation
with the patients presumably infected outside Greece. Thus the risk of
infection at present seems very limited to tourist in the area."

This is not so, however. There were in fact a total of 36 cases
reported from this region. While 16 were in migrant workers from
endemic countries, and as ProMED correctly notes, may well have been
infected in their country of origin -- mainly Pakistan -- there were
20 other cases reported which were NOT in migrant workers.

"As of 27 Sep 2011, 20 malaria cases were reported in Greece,
affecting Greek citizens who did not have any reported history of
travel to a country endemic for malaria."

The ProMED report thus implies there were only 4 people infected in
Greece, an incorrect statement which significantly underplays the real
risk, which is represented by a total of 20 infections.


--
Dr Tony Ellam
Consultant in Communicable Disease Control (retired)
London

******
[2]
Date: Mon 31 Oct 2011
From: Denis Coulombier [edited]

Regarding ProMED-mail post Malaria, P. vivax - Greece (07)
autochthonous 20111030.3226, ECDC has updated on 28 Oct 2011 its
epidemiological assessment. It can be found at
http://ecdc.europa.eu/en/press/news/Lis ... 29a&ID=511.

On the basis of this assessment, ECDC is currently "not recommending
chemoprophylaxis for malaria for visitors to the area. The use of
standard mosquito biting prevention measures continues to be
encouraged."

--
Denis Coulombier
Head of Unit for Surveillance and Response Support
European Centre for Disease Prevention and Control (ECDC)
Tomtebodavagen 11A
171 83 Stockholm, Sweden

http://www.ecdc.europa.eu

[ProMED-mail thanks Dr Tony Ellam and Dr Denis Coulombier for their
comments. We agree that the report in Eurosurveillance reported 36
cases of which 20 had never travelled outside Greece, and we apologize
(http://www.eurosurveillance.org/ViewArt ... leId=19993).
The Eurosurveillance report concludes:

Up to 27 Sep 2011, the HCDCP (Hellenic Centre for Disease Control and
Prevention) has received reports of 20 cases of _Plasmodium vivax_
infection in Greek citizens who did not report travel to an endemic
country. The majority of those cases (n=14) reside in the agricultural
area of Evrotas, Lakonia district (Table, Figure 1; available at the
URL above). The remaining 6 Greek cases were reported from 4 other
prefectures, namely Eastern Attiki (n=2), Evia (n=2), Viotia (n=1),
and Larissa (n=1). From the area of Evrotas were further reported 16
cases of _P. vivax_ infection in migrant workers from endemic
countries (mainly from Pakistan) for whom no clear malaria importation
status can be determined. In addition, 2 Romanian workers who had been
working and living in the area of Evrotas developed symptoms in July
2011 and were diagnosed with _P. vivax_ infection upon their return to
Romania. These 2 cases are not included in further analysis because
not all the epidemiological information is available. All 36 cases
have been confirmed as _P. vivax_ infections, by both microscopy and
PCR at the MRL (National Malaria Reference Laboratory). None of the
cases had a history of recent blood transfusion or tissue/organ
transplantation.

A HealthMap/ProMED-mail interactive map of Greece can be seen at
http://healthmap.org/r/1nLG. - Mod.EP]

Griechenland - West Nile-Fieber
31.10.2011

Seit Ende Juli kommt es zu Erkrankungshäufungen. Bis zum 27. Oktober wurden insgesamt 67 Erkrankungen gemeldet. Damit ist Griechenland das Land, in dem EU-weit die meisten Fälle auftreten (67 von insgesamt 90). Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Als Vektor dienen Mücken; Mückenschutz beachten.
___________________

Griechenland - Malaria
31.10.2011

Zwischen Mai und Ende Oktober 2011 sind insgesamt 61 Fälle von Malaria verursacht durch Plasmodium vivax aufgetreten. Davon waren 33 sog. autochthone Fälle, also bei Personen, die zuvor kein Malariaendemiegebiet bereist hatten. Die übrigen Fälle betrafen Migranten u.a. aus Pakistan. Hauptsächlich betroffen ist die Region Evrotas. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Vektoren, die die Erkrankung übertragen könnten, sind in Griechenland vorhanden, außerdem arbeiten dort zahlreiche Migranten aus Endemiegebieten, über die der Erreger importiert werden kann. Die Behörden haben die Infektionsüberwachung intensiviert und Aufklärungsmaßnahmen für die Bevölkerung laufen an. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen.


Gruß
Birgitt

Griechenland - West Nile-Fieber
07.11.2011

Seit Ende Juli kommt es zu Erkrankungshäufungen. Bis zum 3. November wurden insgesamt 69 Erkrankungen gemeldet. Damit ist Griechenland das Land, in dem EU-weit die meisten Fälle auftreten (69 von insgesamt 93). Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

Griechenland - West Nile-Fieber
21.11.2011

Die diesjährige Übertragungssaison neigt sich ihrem Ende zu. Bis zum 17. November wurden insgesamt 69 Erkrankungen gemeldet. Damit ist Griechenland das Land, in dem EU-weit die meisten Fälle aufgetreten sind (69 von insgesamt 93). Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm
____________

Griechenland - Malaria
21.11.2011

Zwischen dem 21. Mai und dem 15. November 2011 sind insgesamt 63 Fälle von Malaria, verursacht durch Plasmodium vivax, aufgetreten. Davon waren 33 sog. autochthone Fälle, also bei Personen, die zuvor kein Malariaendemiegebiet bereist hatten. Die übrigen Fälle betrafen Migranten u.a. aus Pakistan. Hauptsächlich betroffen ist die Region Evrotas. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Vektoren, die die Erkrankung übertragen könnten, sind in Griechenland vorhanden, außerdem arbeiten dort zahlreiche Migranten aus Endemiegebieten, über die der Erreger importiert werden kann. Die Behörden haben die Infektionsüberwachung intensiviert und Aufklärungsmaßnahmen für die Bevölkerung laufen an. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

Gruß
Birgitt

RUBELLA - ROMANIA: (SALAJ) ADOLESCENTS
**************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


Date: Thu 16 Feb 2012
Source: Eurosurveillance 2012; 17(7) [abbreviated & edited]
http://www.eurosurveillance.org/ViewArt ... leId=20089


Ongoing rubella outbreak among adolescents in Salaj, Romania, Sep 2011 to Jan 2012
-------------------------------------
By: Janta D, Stanescu A, Lupulescu E, Molnar G, Pistol A. At: National Institute of Public Health, National Centre for Communicable Diseases Surveillance and Control, Bucharest, Romania, European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden, National Institute of Research and Development for Microbiology and Immunology, Cantacuzino Reference Laboratory for Measles and Rubella, Bucharest, Romania, and Ministry of Health, Bucharest, Romania

Introduction
----------
A rubella outbreak has been ongoing in Salaj, Romania since September 2011 involving 1840 probable and confirmed cases among mainly unvaccinated adolescents. The index case became ill on 6 Sep 2011. The highest number of cases was recorded among 10-14 year olds and 15-19 year olds. Complications were recorded for 11 cases and included meningitis and arthritis. Although the peak has passed, surveillance is being maintained in the region.

An outbreak of rubella with more than 1800 cases was identified in Salaj, north western Romania, a district with 241 014 inhabitants in 2010. The European Union (EU) case definition [1] was used in the outbreak investigation, and 69 of the 1873 possible cases (3.6 per cent) were classified as laboratory-confirmed and 1771 (94.6 per cent) as probable, defined according to clinical criteria and epidemiological links with a confirmed case; 33 (1.8 per cent) were discarded. Of the 69 laboratory-confirmed cases, 2 were pregnant women, but no case of congenital rubella infection (CRI) has been reported so far.

Background
----------
Rubella has been a statutorily notifiable disease in Romania since 1978 [2]. Until 2010, data were reported in aggregated format by age group. In 2010, case-based reporting with mandatory laboratory confirmation was introduced. Since December 2002, as part of the measles surveillance system, clusters of febrile rash are investigated by the local public health authorities and, in order to confirm the clinical diagnosis, it is recommended to take samples from 5-10 cases in each cluster for serological testing for measles and, if the results are negative, for rubella. If rubella transmission is confirmed, pregnant women who are epidemiologically linked to a laboratory-confirmed case or who meet the clinical criteria are given priority for testing and are informed about the potential risks of congenital rubella syndrome (CRS) to the foetus. Although rubella is usually a mild febrile rash illness, infection during pregnancy can lead to miscarriage, stillbirth, and birth defects associated with CRS, such as heart disease, blindness, deafness, and mental retardation.

A national surveillance system for CRS was initiated in Romania in 2000. Newborns of rubella positive mothers have a rubella-specific IgM blood test tested for CRI and are reported in the CRI/CRS surveillance system according to the methodology in place [3]. Rubella is a vaccine preventable disease targeted for elimination in the WHO European Region by 2015 along with measles. Countries in the region have also committed to the prevention of CRS by the same year [4].

A rubella-containing vaccine was 1st available in Romania in 1998 (bivalent measles-rubella), and it was offered to girls aged between 15 and 18 years (birth cohorts 1980-1983) as part of a mass vaccination campaign following a nationwide measles outbreak [5]. After a large rubella outbreak in 2002 to 2003, a rubella-containing vaccine was offered to girls aged between 13 and 14 years until 2008 (birth cohort 1994). In 2004, the measles-mumps-rubella (MMR) vaccine was introduced in the national immunisation schedule for children aged 12-15 months. Since 2004, MMR vaccination has also been offered to children aged 7 years.

In 2002 to 2003, a large rubella outbreak occurred in Romania, with more than 115 000 cases reported nationwide, and the highest incidence was reported in children of school age (2564 per 100 000 population aged 5-9 years and 2446 per 100 000 population aged 10-14 years) [6]. By 2010, rubella incidence dropped to 1.6 per 100 000 population (2009: 2.9/100 000; 2008: 8.1/100 000) [7,8].

Outbreak description
--------------------
The index case (laboratory-confirmed) was reported on 6 Sep 2011 to the Salaj Public Health Authority in an unvaccinated 16 year old student attending a local high school. Between 1 Sep 2011 and 23 Jan 2012, 1840 confirmed and probable rubella cases were reported by Salaj Public Health Authority.

Of the 1840 cases 1069 were male, and 771 were female, showing a male:female ratio of 1.4:1. The highest number of cases was recorded in people aged between 10 and 19 years (n=1693). Of these, 1206 cases were registered among 15-19 year olds (58.6 per cent male and 41.4 per cent female) with a male:female ratio of 1.4:1. The rest of 487 cases were registered among 10-14 year olds (55.4 per cent male and 44.6 per cent female) with a male:female ratio of 1.2:1. Taking into account the fertile age, we registered 1341 cases in people aged between 15 and 44 years with a male:female ratio of 1.3:1. Among these 1341 cases, 59.1 per cent were male, and 40.9 per cent were female, giving a male:female ratio of 1.3:1. Of all outbreak cases, 23.3 per cent (428/1840) were registered among children born in 1996.

The incidence of rubella in Salaj was 763 per 100 000 population, with the highest incidence among high school teenagers aged between 15 and 19 years (9555 per 100 000 population for males and 7067 for females) followed by 10-14 year olds (3854 per 100 000 population for males, 3281 per 100 000 population for females). The 3rd most affected age group was the age group of 20-24 year olds with an incidence of 647 per 100 000 population among males and 154 per 100 000 population among females.

Complications included meningitis (n=2 cases) and arthritis (n=9 cases). 35 cases required hospitalisation, and the median length of hospital stay was 4 days (minimum one, maximum 9). A total of 98 samples were tested for rubella IgM antibodies, and 69 of these were confirmed as positive. In clinical specimens from 2 cases, rubella virus genotype 2B was identified.

Vaccination coverage among the reported cases was low: 38 (2.1 per cent) of the total number of cases were vaccinated with one dose of rubella-containing vaccine. Taking into account the eligible birth cohorts for vaccination against rubella and the number of rubella cases reported during the outbreak, we calculated the proportion of rubella cases occurring in birth cohorts from 1989 to 2002. The highest proportion of cases was registered among people born from 1994 to 1997.

We looked at the rubella vaccination coverage for Romania and Salaj district in the eligible birth cohorts for MMR vaccination at 12-15 months (birth cohort 2004-2008), for MMR vaccination at 7 years (birth cohort 1998-2002), and the rubella dose administered only to girls in birth cohort 1989-2003. The rubella vaccination coverage of the 13 to 14 year old females in Salaj district during 2003 to 2008 is higher, with 3.8 per cent on average, than the coverage in the whole country for the same period. For 2005 to 2009, the MMR vaccination coverage in Salaj was below the country average, except for 7 year old children vaccinated with MMR in 2008 and 2010, when the district coverage was higher than the country average.

Control measures
----------------
Since the identification of the outbreak, several control measures have been implemented by the local health authorities. The most important one was the initiation of a MMR vaccination campaign in the district of Salaj targeting all children and adolescents aged between 10 and 19 years, irrespective of their vaccination status. The MMR vaccine is supplied by the Ministry of Health and is offered free of charge through routine immunisation services (family physicians) and special outreach teams. As a result of this special campaign, 210 persons were vaccinated until 31 Dec 2011, but many parents still refused to have their children vaccinated. Local health care workers (doctors and nurses) were recommended to get vaccinated and to try to inform and increase awareness among their patients on the risk of this disease, especially among women of childbearing age.

In addition, the local public health authorities have initiated rubella screening among pregnant women epidemiologically linked to a probable or a confirmed case. While the general recommendations for MMR vaccination are maintained at national level, some districts bordering Salaj (Alba, Bihor, and Cluj) -- which were also affected by rubella, but to a lesser extent -- have issued vaccination recommendations among teenagers to avoid other potential outbreaks.

Discussion and conclusions
--------------------------
The results of the investigation revealed that of the total number of rubella [cases] described above, 98 per cent had never been vaccinated against rubella infection. The index case was an unvaccinated teenager, and 1206 of the rubella cases (65.5 per cent) occurred among teenagers aged between 15 and 19 years (born between 1992 and 1996). Taking into account the historical MMR vaccination schedule in Romania, 770 children born between 1995 and 1996 (15-16 year olds in 2011) were not eligible for rubella vaccination and represent 41.8 per cent of all cases. In the birth cohort 1992-1994, only girls were eligible for rubella vaccine at the age of 14 years.

Measures such as catch up campaigns are important to close existing gaps in vaccination and prevent further spread of the outbreak. Educating the general public on modes of rubella transmission and stressing the need for rubella vaccination is the most important way to prevent further spread of the disease in other districts and to prevent congenital infection.

Although the outbreak has passed its peak and is subsiding, surveillance for rubella will be maintained for a least 2 incubation periods (46 days) following onset of rash of the last case [9]. Moreover, active surveillance for infants with CRS will be carried out until the age of 9 months after the last reported rubella case [10].

[Interested readers can view the references cited and the figures and tables by accessing the original text via the source URL. - Mod.CP]

--
communicated by:
ProMED-mail <promed@promedmail.org>

[It is clear that rubella virus infection remains a problem worldwide despite the existence of a secure vaccine and its generally cost-free availability. This appears to be due in part to continuing ignorance of the consequences of rubella infection in women of child-bearing age, and prejudice against the currently offered MMR (measles, mumps and rubella) triple vaccine. It might be beneficial to offer the alternative of a single component rubella vaccine where there is irreconcilable resistance to the MMR vaccine.

The Romanian county of Salaj lies in the area between the Apuseni Mountains and the Eastern Carpathians known as the Somes River Platform. It is located in the historical regions of Crisana and Transylvania, with the capital city at Zalau. A map of Salaj county can be accessed at http://www.aboutromania.com/maps39.html. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1HU1.]