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RABIES - ROMANIA: (MOLDAVIA) CANINE, HUMAN
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Date: Tue 6 Mar 2012
Source: NECM.com, Associated Press report [edited]
http://www.necn.com/03/06/12/5-year-old ... 00c1e76e74


Romanian doctors are being investigated for malpractice after a 5 year old girl in their care died of rabies. Health officials have said the girl was bitten by a stray dog in December [2011] in a village in eastern Romania and initially received an anti-tetanus jab from the doctors.

In February [2012], she was hospitalized at a unit that treats infectious diseases in the city of Iasi where she died on 27 Feb 2012. Veterinary health spokesman Gheorghita Vlad said on Tuesday [6 Mar 2012] that dogs were being examined for rabies in the village where the girl was bitten. Health official Marin Bustuc said the doctors are being investigated. Rabies is a deadly virus that spreads to humans from the saliva of infected animals. The disease affects the central nervous system and brain.

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[Rabies is prevalent in both domestic animals and wildlife throughout Romania.

The WHO Rabies-Bulletin-Europe on 20 Dec 2011 reported the tragic death of a young girl from Romania following the bite of a rabid cat. Post-exposure prophylaxis was not administered. The girl was hospitalized after the 1st signs of disease and treated according to the Milwaukee protocol, but without success http://www.who-rabies-bulletin.org/service/news.aspx. If the incident described in the above press report is indeed a different case, in view of this prior experience, it is surprising that the child in the incident described above did not receive post-exposure prophylaxis.

Iasi is one of the largest cities and a municipality in Romania, located in the north eastern region of Moldavia. A map of Romania showing the location of Iasi can be accessed at http://wwp.greenwichmeantime.com/time-z ... /index.htm. - Mod.CP

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

RABIES - ROMANIA (02): BACKGROUND
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Date: Thu 8 Mar 2012
Source: GIDEON (Global Infectious Disease & Epidemiology Network) [edited]
http://www.gideononline.com


[re: ProMED-mail Rabies - Romania: (MA) canine, human 20120308.1064096]
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Recent sporadic cases of rabies associated with a dog and a cat belie the fact that most animal rabies in Romania involves foxes [1,2]. See graph at http://www.gideononline.com/wp/wp-conte ... omania.png.

In fact, the incidence of fox rabies in Romania exceeds that reported by adjacent countries [2,3]. See graph at http://www.gideononline.com/wp/wp-conte ... omania.png.

References
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1. Berger SA: Infectious Diseases of Romania, 2012. 389 pp, 107 graphs, 349 references. Gideon e-books, http://www.gideononline.com/ebooks/coun ... f-romania/
2. Gideon graph tool at http://www.GIDEONonline.com/wp/wp-conte ... Graphs.pps
3. Berger SA: Rabies: Global Status, 2012. 376 pp, 546 graphs, 1375 references. Gideon e-books, http://www.gideononline.com/ebooks/dise ... al-status/

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[ProMED-mail thanks Steve Berger for extracting this interesting information from the Gideon database. - Mod.CP

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

Q FEVER - SERBIA: (VOJVODINA)
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Date: Thu 12 Apr 2012
Source: Eurosurveillance 2012, Volume 17, Issue 15 [edited]
http://www.eurosurveillance.org/ViewArt ... leId=20143


Q fever outbreak in Serbia, January to February 2012
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From 27 Jan 2012 to 10 Feb 2012, a total of 43 cases of Q fever were notified in the village of Nocaj, Srem county, Autonomous Province of Vojvodina, Republic of Serbia. Q fever was laboratory confirmed in 37 notified cases. Although, the outbreak is considered over, the outbreak investigation is still ongoing in order to identify aetiologic factors relevant for this outbreak.

On 27 Jan 2012 after 10 patients were hospitalised with atypical pneumonia, an outbreak of Q fever was discovered in Srem county, Vojvodina province, Serbia. Laboratory testing of some of the 1st patients for pathogens such as _Coxiella burnetii_, _Chlamydia pneumoniae_, _Mycoplasma pneumoniae_, influenza A and B, parainfluenza, and respiratory syncytial virus had all resulted negative, except for _C. burnetii_.

Between 27 Jan 2012 and 10 Feb 2012, 43 cases of Q fever were reported. The majority of patients (n=41) were residents of Nocaj, a village with 2120 inhabitants located in the vicinity of the city of Sremska Mitovica (Srem county) near the border between Serbia and Bosnia and Herzegovina. The attack rate in this period was 2 percent.

Hereby we describe the preliminary results of the ongoing outbreak investigations started on 30 Jan 2012, by the Center for Disease Control and Prevention of the Institute of Public Health, Sremska Mitrovica. The investigation was assisted by the World Health Organization (WHO), Regional Office for Europe.

Epidemiological investigation
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Specific notification criteria and case definitions adapted to the current situation were applied. A probable case of Q fever, according to the European Union criteria, which are used in Serbia [1], was not relevant in this investigation because the source of the current outbreak was not yet identified, and no epidemiological link could be established.

A "clinical case" was defined as having acute fever and one or more of the following: rigors, severe retrobulbar headache, acute hepatitis, pneumonia, or elevated liver enzymes' levels with onset of illness between 20 Jan 2012 and 10 Feb 2012, and no other likely cause for illness in a patient who either lived or visited Nocaj in the period from 1 to 20 Jan 2012. The risk period for exposure was estimated considering an average incubation period of 20 days [2] and time distribution of cases.

A "clinical case" who had not been serologically tested was defined as a possible case of Q fever.

A laboratory-confirmed case of acute Q fever was defined as a "clinical case" with serologic evidence of a positive IgM and/or IgG antibody result to phase II antigen _C. burnetii_, by enzyme-linked immunosorbent assay (ELISA). The results were interpreted in line with the manufacturer's guidance as follows: <9, negative; 9-11, equivocal; >11, positive (ELISA, NovaLisa). Paired sera samples tested at least 2 weeks apart were taken for 4 patients for whom the result of the first sera tests were equivocal or negative (2 sera samples were positive after the 2nd test).

All sera samples were tested in the Reference Laboratory for Q fever, Institute of Public Health, Zrenjanin, Serbia. Of 43 notified cases, 37 were laboratory confirmed and the rest were classified as possible cases. All laboratory-confirmed cases were classified as acute Q fever cases. All cases of acute Q fever with known preconditions for chronic disease were referred for laboratory follow-up in periods of 3, 6 and 12 months after onset of illness, in order to detect the development of chronic Q fever [3]. The majority of cases (n=41) reported illness onset between 20 Jan 2012 and 1 Feb 2012 (Figure).

Data about the age and sex of cases rates are shown in Table 1.

The clinical features of Q fever in this outbreak are presented in Table 2.

During the epidemiological investigation in the village households, all present family members were interviewed about symptoms of Q fever and possible preconditions for chronic Q fever. Efforts were made to conduct laboratory testing, in order to detect recent Q fever infection in asymptomatic people, with known preconditions for chronic Q fever or at risk for complications, like pregnant women (n=10) and newborns (n=2), people with heart valvular diseases (n=1) or immunosupression (n=2). Also exposed health care workers (n=9) were tested. The testing was done by ELISA in order to detect a _C. burnetii_ specific antibody response (IgG or IgM phase II), as previously described. By 26 Mar 2012, 8 additional cases of asymptomatic Q fever were discovered including 3 pregnant women, 4 exposed health care workers and one child with undefined symptoms. They were all referred to infectious disease specialists for review.

In exploratory interviews taken between 30 Jan 2012 and 16 Feb 2012, 28 of 43 patients denied direct contact with livestock, although most of them own livestock in their households. In Serbia, reporting on aborted pregnancy in domestic animals is mandatory and requires a standard number of tests including tests for _C. burnetii_. However in the previous few months, local farmers and veterinary services in Nocaj had not observed such cases.

Only 2 patients in the current outbreak were not residents of Nocaj. They visited their relatives in Nocaj for a few hours each on different days (8 and 16 Jan 2012). The time of the visits to Nocaj is compatible with the incubation period and onset of disease in these particular patients. Overall 30 of 43 patients mentioned that they had visited a football tournament in the village school sport hall, from 4 to 7 Jan 2012.

Environmental investigation and results
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As the large number of cases in a small area was suggestive of a point source, smear samples were taken from heating ventilators, seats and the floor of the sport hall. DNA extraction from swabs was performed using QIAamp DNA Mini Kit (Qiagen, Germany) in the Veterinary Specialized Institute Kraljevo, Serbia. 2 polymerase chain reaction (PCR) protocols were used for molecular detection of _C. burnetii_: The Real-Time PCR protocol published by Klee et al. [4] and the PCR protocol published by Berri et al. [5] The PCR assays for _C. burnetii_ were all negative.

The Veterinary Scientific Institute, Novi Sad, conducted an epizootiologic investigation in the households of patients and their neighbours by order of the Republic Veterinary Inspectorate. Of 207 tested sheep, goats and cattle, only one seropositive sheep in the village was found. Although seropositive, the vaginal swab sample of this seropositive sheep analysed by PCR was negative. Interestingly, this seropositive sheep was detected in a particular household in which 2 of 7 human cases were registered during an outbreak of Q fever in Nocaj in 2009.

Epidemiological situation in Serbia
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Q fever, a zoonosis distributed worldwide, was recognised as a specific disease in 1937 [6], and is caused by _C. burnetii_. A wide range of animals serves as a natural reservoir for the pathogen [7]. Inhaling aerosols that are contaminated by _C. burnetii_ is the most frequent route of transmission in large human outbreaks [8,9]. Q fever outbreaks are regularly reported throughout Europe as well as in other parts of the world [10].

In Serbia, Q fever is a notifiable disease since 1966. Notification of Q fever is made on the basis of clinical diagnosis, epidemiological link and laboratory confirmation. During the last 14 years notification is based on European Union case-definition criteria in the absence of criteria adopted at the national level [1].

The Autonomous Province of Vojvodina, (Northern Province of Serbia) including Srem county is considered as an endemic region for Q fever. The latest seroepidemiological investigation of Q fever, which was conducted in 1985 and included 5599 persons (representing 0.5 percent of the adult population of Vojvodina aged between 19 and 59 years), revealed a seroprevalence of _C. burnetii_ antibodies of 9.3 percent [11]. In the period from 2002 to 2011, the incidence rate of Q fever in Vojvodina varied between 0.1-2.3 per 100 000 population. The incidence rate in Srem county varied between 0 and 2.1 per 100 000 population, with 2 outbreaks reported in 2009 [12] and 2011 (unpublished data). In the 2009 outbreak, 7 human cases were notified in the village of Nocaj. Considering the high rate of mild cases and non-specific symptoms of Q fever [10], it is estimated that the actual incidences might be higher than presented above.

Outbreak control measures
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The Center for Disease Control and Prevention of the Institute of Public Health Sremska Mitrovica proposed to the management of the Nocaj elementary school to improve hygiene and proceed to a desinfection of the sport hall, and these measures were applied by order of the Provincial Sanitary Inspectorate.

General practitioners in the area and the nearest health care centre in Bosnia and Herzegovina were informed about the outbreak in order to make sure that any new arising cases of Q fever would be notified. All authorised institutions were informed, including the WHO, Regional Office for Europe following obligations included in the International Health Regulations (IHR) [13].

Efficient data sharing with the veterinary services was ensured in order to identify potential source(s) of the outbreak and to conduct veterinary control measures. Livestock trading, slaughter and use of unpasteurised milk and products from unpasteurised milk were temporarily prohibited in the investigated households until the serology results of tested animals were obtained.

Exclusion of blood donors (rather than screening) from the affected region was done. Health promotion campaigns to educate citizens on how to prevent possible Q fever infection took place in the village in the form of interviews, lectures and the delivering of information leaflets. Appropriate hygiene practices when dealing with livestock by-products of birth and manure and safe procedures for clothing and footwear were the key messages in the health education campaign for farmers. People at high risk for severe Q fever infection or complications were advised not to visit or stay in the livestock holding areas or barns.

In order to investigate potential factors for airborne spread of the bacteria, official meteorological data were analysed. Epidemiological reports were updated and published on the website of the Institute of Public Health of Sremska Mitrovica providing authoritative and accurate information regarding the outbreak and reducing fear and panic in the village and area.

In order to prevent hospital-acquired _C. burnetii_ infections among health care workers and patients, the commission for the prevention of hospital infections in the general hospital Sremska Mitrovica proposed implementation of enhanced standard precautionary measures, such as monitoring compliance with hand hygiene, the use of gloves for contact with blood or body fluids, excretions and secretions, as well as anticipating the need for use of personal protective equipment (gowns, masks) according to the patient condition and type of procedure.

Discussion and conclusions
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Considering the unusual high rate of hospitalisations and atypical pneumonia in this outbreak, we can assume that the number of cases is far higher than reported. The predominance of male sex among patients is not surprising, because the infection may be asymptomatic in 60 percent of Q fever infections, especially among women and children aged 15 years and younger [14-16].

Although a single animal source can cause many human Q fever cases [17], compared to 2009, the larger geographic area in which cases occurred in 2012 may indicate a multiple sources or possible airborne spread of _C. burnetii_. The low annual number of cases of Q fever in Nocaj registered during past few decades was due to direct contact with animal placenta and/or birth products. The sudden and unusual acute presentation of the large outbreak in the current situation, required the consideration of other routes of Q fever infection. Although many cases in the village of Nocaj had attended the same football tournament in a school sport hall, the environmental investigation yielded negative results. Moreover, there were no registered cases of Q fever among residents of other villages who attended the tournament, nor among school children/staff where the tournament took place, which argues against the school sport hall as being the source of the outbreak. Until now, no common exposure has been identified among patients who did not attend the football tournament.

The data obtained from the epidemiological investigation were not indicative of a food-borne route of infection. The presumable route of infection in this outbreak is airborne by inhalation of contaminated dust and aerosol in the period around the orthodox Christmas. During January the weather in Nocaj was unusually dry and windy so the conditions to transmit _C. burnetii_ were present. The heavy snowfall during February possibly reduced the further spread of this outbreak and limited its duration. We cannot rule out other possible causes via direct contact with livestock or by other possible exposures. Epidemiological investigation of infection sources and routes of transmission is ongoing. With this report, we would like to inform of this outbreak and raise awareness in neighbouring countries.

[For Tables, Figure, and References, see the URL for this article above.]

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[Q fever is due to _Coxiella burnetii_, an obligate intracellular rickettsia-like bacterial pathogen. It is highly resistant to drying and heat, attributed to a small cell variant of the organism that is part of a biphasic developmental cycle. Q fever is a zoonosis. Domestic ungulates such as sheep, cattle, and goats serve as the reservoir of infection for humans. The organism is shed in urine, feces, milk, and especially in birth products.

Humans usually become infected by inhaling aerosolized organisms. Acute symptoms of a 'flu-like illness usually develop within 2-3 weeks of exposure, although as many as half of humans infected with _C. burnetii_ do not show symptoms (http://www.cdc.gov/qfever/symptoms/index.html). Although most persons with acute Q fever infection recover, others may experience serious illness with complications that may include pneumonia, granulomatous hepatitis, endocarditis, myocarditis, and central nervous system involvement. Pregnant women who are infected may be at risk for pre-term delivery or miscarriage.

Nocaj is a village in northern Serbia, with a population of 2120 people in 2002. For a map showing the location of Nocaj, see http://en.wikipedia.org/wiki/Nocaj. A HealthMap/ProMED-mail interactive map of Serbia can be seen at http://healthmap.org/r/1BY0. - Mod.ML]

MUMPS - SERBIA: (VOJVODINA)
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Date: Thu 10 May 2012
Source: Eurosurveillance Edition 2012, 17(19) 10 May 2012 [edited]
http://www.eurosurveillance.org/ViewArt ... leId=20169


Ongoing mumps outbreak in Novi Sad, the Autonomous Province of Vojvodina, January to April 2012
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[Authors: Rajcevic S, Seguljev Z, Petrovic V, et al]

Background
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From 16 Jan to 30 Apr 2012, a total of 119 cases of mumps were notified in Novi Sad, Serbia. Of these cases, 89 (75 percent), were among students. The average age of cases was 22 years old (range 3-37). The outbreak is still ongoing in Novi Sad and is spreading to other parts of the Vojvodina province. As of 30 Apr 2012, 209 cases have been notified in the province among those 119 from Novi Sad.

Resurgent outbreaks of mumps have recently been reported from several European Union and neighbouring countries [1-7]. Here we report on an ongoing mumps outbreak in Novi Sad, capital of the Autonomous Province of Vojvodina, Serbia. Similarly to outbreaks in England, Netherlands and Israel in recent years, the present one affects mainly young adults [8-10].

Mumps is a vaccine-preventable disease caused by a paramyxovirus. The typical clinical picture comprises fever, headache, malaise, painful unilateral or bilateral parotid swelling and complications such as orchitis, meningitis and encephalitis occur. Mumps is a notifiable disease in Serbia.

Outbreak description
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On 16 Jan 2012, the Institute for Student Health Care in Novi Sad reported 2 cases of mumps among students who study at University of Novi Sad, to the Institute of Public Health of Vojvodina. These students had spent the Christmas and New Year holidays [2011] in Bosnia and Herzegovina, where a large outbreak of mumps is ongoing [7,11,12].

Novi Sad is the 2nd largest city in Serbia, capital of the northern Serbian province of Vojvodina, and the administrative centre of the South Backa district. The urban area has a population of 221 854, while its municipal area has a population of 335 701 [13].

Since 25 Jan 2012, the Public Health Service in Novi Sad has been registering further cases of mumps among students and residents of the town. These had not travelled during the maximum length of the incubation period, 25 days. Here we provide detailed information about cases up to 30 Apr 2012.

Case definition
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An imported case of mumps is defined as any person in Novi Sad with a history of painful swelling of one or both parotid glands without any other apparent cause, epidemiologically linked with a case of mumps in Bosnia and Herzegovina within the maximum length of the incubation period.

A possible case is defined as a case with a clinical picture compatible with mumps diagnosed by a physician after 16 Jan 2012, in Novi Sad.

An epidemiologically linked case is defined as any person in Novi Sad meeting the clinical criteria and epidemiologically linked with a confirmed or imported case of mumps.

A confirmed case is defined as a case with symptoms compatible with mumps and with serological confirmation of IgM mumps antibodies and/or verification by PCR from throat swabs in any person not vaccinated in the previous 2 months.

By 30 Apr 2012, a total of 119 cases had been reported from Novi Sad to the Institute of Public Health of Vojvodina of which 25 were considered as imported. In total, 32 cases were laboratory-confirmed (IgM or PCR-positive), genotyping was not performed. 87 cases were clinically diagnosed as either possible cases (n=45) or epidemiologically linked cases (n=42).

The average age of cases was 22 years. The youngest case was three years old and the oldest was 37 years of age. Cases occurred most frequently in the 20 to 29-year-old age group (n=91; 76 percent). There were more male (n=70) than female (n=49) cases. 13 cases were hospitalised with complications, 9 with orchitis, and 4 with pancreatitis. In total 13 percent of males over 15 years old contracted orchitis. For 86 cases, there was no information or data about previous mumps vaccination. The remaining 33 cases were vaccinated, among which 29 had received 2 doses of measles-mumps-rubella (MMR) vaccine. 4 were vaccinated with only one dose of MMR.

Public health response
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The public health authorities of Vojvodina, advised the paediatric health services to revisit immunisation records of all children between one and 14 years of age and to call-in and vaccinate children who had not received the recommended MMR vaccine for temporary reasons, as soon as possible.

Other epidemic control measures include, disseminating information to health services and the general public about the mumps outbreak by the public health authorities, isolating infected persons and limiting contact with them. Furthermore, persons who had been in contact with those infected, are placed under medical surveillance and receive information about the disease.

Discussion and conclusion
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Immunisation against mumps was introduced in Serbia in 1986. Between 1996 and 2006, a combined MMR vaccine was administered according to a 2-dose schedule at the ages of 12 months and 12 years but no later than 14 years of age. In 2006, the schedule was changed and the 2nd dose is now administered at the age of 7.

In Serbia, before vaccination against mumps became part of the Serbian childhood vaccination schedule, mumps occurred frequently among children 5 to 9 years of age. Since the introduction of mumps vaccine into the routine childhood immunisation schedule, the number of cases has declined dramatically from 240 in 1982, to 30 in 1994 [14-16].

In Novi Sad, after introduction of the MMR vaccine into the national schedule in 1996, a total of 36 cases of mumps were registered between 1996 and 2011. The incidence rate was low and ranged from zero per 100 000 population in the period from 2007 to 2009 to 3.3 per 100 000 population in 2003 [17].

The importation of mumps cases from Bosnia and Herzegovina contributes to the epidemic spread of mumps in 2012 in Novi Sad and further on in Vojvodina. Ill students infected in Novi Sad probably represent a source for the further spread of the outbreak to other towns, all over Vojvodina Province, where there are a number of susceptible people in age groups that were not targeted for mumps vaccination as children and adolescents. In total, from 16 Jan to 30 Apr 2012, 209 cases of mumps were registered in Vojvodina among those 119 from Novi Sad, with the majority of cases in 20 to 29 year olds.

The fact that new outbreaks of mumps take place decades after vaccine introduction, and the occurrence of cases among young adults and previously immunised persons, indicate the need for further improvement of prevention strategies. The complication rate early in this outbreak of 13 percent is slightly higher than that in the literature and also highlights the need for attention [18,19].

[Interested readers should access the full text at the source URL above to obtain the full list of references cited. - Mod.CP]

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[The Autonomous Province of Vojvodina is an autonomous province of Serbia, located in the northern part of the country, in the Pannonian Plain of Central Europe. Its capital and largest city is Novi Sad. Vojvodina has a population of about 2 million (approximately 27 percent of Serbia's total).

Superficially it would appear that the current outbreak in Vojvodina may be an extension of the ongoing mumps epidemic in Bosnia and Herzegovina coupled with less than comprehensive MMR vaccination throughout Serbia. However, other factors may be important and further analysis is awaited.

The autonomous province of Vojvodina can be found on the map at http://mappery.com/maps/Serbia-and-surr ... mthumb.png. The HealthMap/ProMED-mail interactive map of Serbia can be seen at http://healthmap.org/r/2lf*. - Mod.CP]

WEST NILE VIRUS - EURASIA: GREECE
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Date: Fri 13 Jul 2012
Source: Ekathimerini [edited]
http://www.ekathimerini.com/4dcgi/_w_ar ... 012_451929

According the Center for Disease Control and Prevention (KEELPNO), 5 people in Greece have contracted the West Nile virus [WNV], which is carried by mosquitoes.

The 1st case reported this year in Greece was on Sunday [8 Jul 2012], when a pensioner in Palaio Faliro, southern Athens, was taken ill. Another resident of a nearby district was confirmed as having the disease the next day.

However, KEELPNO says 3 more cases had been confirmed by Thursday evening [12 Jul 2012]. They were in Elliniko, Palaio Faliro and Piraeus, all neighbourhoods of southern Athens.

KEELPNO said that it expects more cases in this part of the capital, which has never been considered a high risk area for West Nile virus, to appear over the next few days.

The West Nile virus, which can cause encephalitis, was discovered in 1937 in Uganda. Sporadic cases of the disease in humans have occurred in Europe since the 1960s. It was first detected in Greece in 2010, when 262 people contracted the disease, 35 of whom died.

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[There was active transmission and human cases of WNV infection in Greece in 2011. In a 12 Sep 2011 ProMED-mail post (archive no. 0110912.2775) Dr. Anna Papa reported WNV lineage 2 sequences were obtained from patients' sera taken during the acute phase of the illness. Sequences of the NS3 gene were identical to those obtained in 2010 from _Culex_ mosquitoes and blood donors, thus, similar to the Hungarian WNV strain. With the WNV transmission season starting this year (2012) more cases can be expected. It will be interesting to learn if lineage 2 is present again.

A HealthMap/ProMED-mail map showing the location of Athens and vicinity can be accessed at
http://healthmap.org/r/2K53. - Mod.TY]

MALARIA, P. VIVAX - GREECE: AUTOCHTHONOUS (ATTICA)
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Date: Tue 17 Jul 2012
Source: ECDC [edited]
http://ecdc.europa.eu/en/press/news/Lis ... 29a&ID=660


Epidemiological update: Local case of malaria in Greece
-------------------------------------------------------
The Greek Centre for Disease Control and Prevention (KEELPNO) has informed about a recent case of autochthonous _Plasmodium vivax_ malaria.

On 22 Jun 2012, a case of locally acquired malaria infection was reported in Greece. The case is a 78-year-old Greek citizen who presumably acquired the infection close to Marathon, Attica region; onset of symptoms was around 7 Jun 2012.

Laboratory investigation revealed _Plasmodium vivax_, confirmed by molecular biology (PCR). The case reported no travel to an endemic country in the past 5 years.

The Marathon area is a historical place of malaria transmission, combining humid zones and intensive agricultural activities. Climatic conditions are now considered favourable for local vector development. In 2011, an autochthonous case occurred in a nearby location.

According to Greek authorities, active screenings of neighbours and seasonal immigrants is carried out to detect malarial infection, and vector control measures are being implemented.

ECDC is currently reviewing the epidemiological and background information of this case in order to assess the level of risk for travellers. ECDC is consulting relevant international partners, in particular the Greek Health Authorities, WHO-EURO IHR team and US CDC, for a coordinated assessment.

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[Last year (2011) Greece reported an outbreak with 20 autochthonous and 16 imported cases of _P. vivax_ (Eurosurveillance edition 2011; 16(42)
http://www.eurosurveillance.org/ViewArt ... leId=19993).

2 forms of _P. vivax_ exist, temperate zone _P. vivax_ which may have an incubation period of 9 months or longer and tropical zone P. vivax with a short incubation period (reviewed by White NJ. Malaria J 2011;10:297). The 2 types can also be distinguished by genetic markers (Miao M et al. BMC Evol Biol. 2012;12:22).

If the _P. vivax_ seen in Greece in 2011 behaves as the temperate zone _P. vivax_ with a long incubation period, there should be _P. vivax_ cases that appear this autumn which were infected in the 2011 transmission season.

Public health measures for malaria control in Greece can be found here: http://www.keelpno.gr/Portals/0/Files/E ... 6-2012.pdf. The measures include screening of immigrants from endemic areas and a few cases have been found.

The public health surveillance with active case detection in the areas reporting P. vivax in 2011 therefore is needed and cases infected in 2011 will be expected.

HealthMap/ProMED location: http://healthmap.org/r/2L1i. - Mod.EP]

Griechenland - Malaria
20.07.2012

Anfang Juni erkrankte ein 78-jähriger Mann an Malaria tertiana (Plasmodium vivax). Die Infektion erfolgte in der Nähe von Marathon (Region Attika). Im vergangenen Jahr gab es zwischen Mai und Dezember 63 Malaria-Fälle, alle verursacht durch P. vivax. Etwa die Hälfte der Erkrankungen waren sog. autochthone Fälle, also Infektionen bei Personen, die zuvor kein Malaria-Endemiegebiet bereist hatten. Die übrigen Fälle betrafen Migranten, u.a. aus Pakistan. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Mücken, die die Erkrankung übertragen könnten, sind in Griechenland vorhanden, außerdem arbeiten dort zahlreiche Migranten aus Endemiegebieten, über die der Erreger importiert werden kann. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

Gruß
Birgitt

Griechenland - Malaria
23.07.2012

Im Juni sind zwei Fälle von autochthoner Malaria, verursacht durch Plasmodium vivax, aufgetreten, also bei Personen, die zuvor kein Malaria-Endemiegebiet bereist hatten. Ende Juni erkrankte eine 48-Jährige aus Evrotas, in der Region Lakonia. Bereits Anfang Juni war ein 78-jähriger Mann in der Nähe von Marathon (Region Attika) erkrankt. Im vergangenen Jahr gab es zwischen Mai und Dezember 63 Malaria-Fälle, alle verursacht durch P. vivax. Etwa die Hälfte der Erkrankungen waren sog. autochthone Fälle, also Infektionen bei Personen, die zuvor kein Malaria-Endemiegebiet bereist hatten. Die übrigen Fälle betrafen Migranten, u.a. aus Pakistan. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Mücken, die die Erkrankung übertragen könnten, sind in Griechenland vorhanden, außerdem arbeiten dort zahlreiche Migranten aus Endemiegebieten, über die der Erreger importiert werden kann. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

Gruß
Birgitt

WEST NILE VIRUS - EURASIA (04): GREECE
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Date: Thu 6 Aug 2012
Source: Le VIF [In French, transl. Corr.SB]
http://www.levif.be/info/belga-generiqu ... 566800.htm


In Greece, 3 people died in July and August [2012], as a result of being bitten by mosquitoes carrying the West Nile fever virus. According to Greek health care services 44 others are also infected. Most cases were reported in the suburbs east and south of Athens and in the north, near the town of Naoussa.

"The number of people infected may be even higher," said Dr Giorgos Tagaris. "The patients complain of slight ailments such as cranial or joint pain, or show no symptoms."

The inhabitants of the regions concerned were advised to protect themselves against insect bites.

The West Nile virus is largely widespread, particularly in Africa, Asia and North America. More more cases have also been recorded in southern and eastern Europe.

According to the German Robert Koch Institute, about 20 per cent of patients infected develop a feverish flu-like illness, while one in 150 may incur more severe disease, including meningitis.

--
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[As was suggested in a comment in the 14 Jul 2012 ProMED-mail post (archive number 20120714.1202042) reporting the 1st human WNV encephalitis case in Greece this year (2012), the early appearance of clinical encephalitis cases suggested that more human, and perhaps equine, cases were to be expected. That is happening, with new cases occurring in August 2012. One hopes that residents in the areas where the cases occurred will take the precautions mentioned above to avoid mosquito bites, and that owners of equine animals have their animals already vaccinated.

A HealthMap/ProMED-mail map showing the location of Athens and vicinity can be accessed at
http://healthmap.org/r/2K53 and a map showing the location of Naoussa in northern Greece at http://en.wikipedia.org/wiki/Naousa,_Imathia. - Mod.TY]

Griechenland - Malaria
17.08.2012

Anfang August sind 4 weitere Malaria tertiana-Fälle aufgetreten, so dass es jetzt bisher insgesamt 6 Fälle gibt in diesem Sommer. Bereits Ende Juni erkrankte eine 48-Jährige aus Evrotas, in der Region Lakonia, sie war zuvor nicht in Malaria-Endemiegebiet gereist. Anfang Juni war ein 78-jähriger Mann in der Nähe von Marathon (Region Attika) erkrankt. Im vergangenen Jahr gab es zwischen Mai und Dezember 63 Malaria-Fälle, alle verursacht durch P. vivax. Etwa die Hälfte der Erkrankungen waren sog. autochthone Fälle, also Infektionen bei Personen, die zuvor kein Malaria-Endemiegebiet bereist hatten. Die übrigen Fälle betrafen Migranten, u.a. aus Pakistan. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Mücken, die die Erkrankung übertragen könnten, sind in Griechenland vorhanden, außerdem arbeiten dort zahlreiche Migranten aus Endemiegebieten, über die der Erreger importiert werden kann. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

Gruß
Birgitt

MALARIA, P. VIVAX - GREECE (02)
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Date: Mon 20 Aug 2012
Source: ANSAmed [edited]
http://www.ansamed.info/ansamed/en/news ... 58560.html


The Greek Center for Disease Control and Prevention (KEELPNO) has warned that malaria could be making a comeback in Greece, 38 years after the country was officially deemed free of the disease.

According to KEELPNO, as daily Kathimerini reports, 40 cases of malaria were detected in Greece in the 1st 7 months of this year [2012]. In 6 of those cases, those infected had no history of travel to countries where the potentially deadly disease is still endemic. The numbers are so far similar to last year [2011], when there was a spike in September. In previous years, there had been a total of 30-50 cases recorded but almost exclusively among people who had traveled to Greece from countries where malaria is still prevalent.

KEELPNO attributed the rise in malaria cases to climate conditions, the activity of mosquitoes, and a greater influx of immigrants. This prompted the watchdog to warn of a "real prospect" of the disease re-establishing itself in Greece.

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[In a report dated 13 Aug 2012, the European Centre for Disease Control states, "6 autochthonous cases of _Plasmodium vivax_ malaria have been reported from Greece since June 2012. According to the Greek authorities, active screening of neighbours and seasonal immigrants is being carried out to detect malarial infection, and vector control measures are being implemented." (see http://ecdc.europa.eu/en/press/news/Lis ... 29a&ID=703.)

The previous report on malaria from the Hellenic Center for Disease Control and Prevention (KEELPNO), dated 29 Jun 2012 (http://www.keelpno.gr/Portals/0/Files/E ... 6-2012.pdf), mentions one case in 2012, reported by ProMED-mail on 17 Jul 2012 (Malaria, P. vivax - Greece: autochthonous (AT) 20120717.1205005).

The 6 autochthonous cases reported by the ECDC in 2012 could have been infected in 2011. This would fit very well with a temperate zone _P. vivax_ and it is therefore very important to genotype the _P. vivax_ isolates. - Mod.EP

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

WEST NILE VIRUS - EURASIA (06): SERBIA
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Date: Tue 4 Sep 2012
Source: Medical Xpress, Agence France-Presse (AFP) report [edited]
http://medicalxpress.com/news/2012-09-d ... virus.html


An outbreak of the West Nile virus in Serbia has killed an elderly woman and infected 20 other people with the mosquito-borne disease [virus], health officials said Tuesday [4 Sep 2012].

The woman was from Pancevo [Vojvodina province], a town 20 km (15 mi) northeast of Belgrade. Health officials said the other infected people were from Belgrade and elsewhere in the country. "The presence of the virus was established in 21 people in the course of July and August [2012]," Olga Dulovic, deputy director of Serbia's clinic for infectious and tropical disease, said on national radio. About 20 other people have been hospitalised with symptoms that suggest a possible West Nile [virus] infection, and are awaiting lab test results, she added. Dulovic said the infected people were aged between 52 and 82 and had not recently travelled to countries with known outbreaks of West Nile virus.

Serbia's Health Minister Slavica Djukic Dejanovic told the Tanjug news agency there was no danger of a West Nile virus epidemic in Serbia.

Jelena Obrenovic, an official with Serbia's public health institute, called on residents to protect themselves from mosquito bites, notably by avoiding places infested with the bug [mosquitoes] and by placing mosquito screens on windows. Authorities have not announced if they will spray insecticides in a bid to reduce mosquito numbers.

West Nile virus [infections] can cause symptoms similar to those of the flu, but in extreme cases can result in trembling, fever, coma, and a lethal swelling of the brain tissue, known as encephalitis. It can also cause meningitis.

The virus, 1st discovered in Uganda in 1937, is carried by birds and spread to humans by mosquitoes.

There is no known cure for the disease but 80 per cent of those infected will not develop any symptoms at all. The virus is responsible for more than 60 deaths in the United States so far this year [2012].

--
Communicated by:
ProMED-mail Rapporteur George A Robertson

[There have been scattered human cases of West Nile virus neurological infections in southern and central Europe and adjoining countries this year (2012). As Mod. AS commented on the 23 Aug 2012 ProMED-mail post (archive no. 20120823.1258325), "...the European Centre for Disease Prevention and Control (ECDC), dated 16 Aug 2012, 58 human cases of West Nile fever have been reported in the EU during 2012, 57 of them in Greece and 1 in Italy. 97 additional cases have been reported from "neighbouring counties": 4 in Israel, 1 in the Palestinian territory, 91 in the Russian Federation, and 1 in Tunisia. The update, with a map, is available at http://ecdc.europa.eu/en/healthtopics/w ... index.aspx.

The HealthMap/ProMED-mail interactive map of Serbia can be seen at http://healthmap.org/r/3jGD. - Mod.TY]

DENGUE - GREECE: (WEST GREECE) SUSPECTED
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Date: Tue 4 Sep 2012
Source: BBC News [edited]
http://www.bbc.co.uk/news/world-europe-19481127


An elderly man has died in Greece in what officials believe to be the country's 1st case of dengue fever since the 1920s. The man, in his 80s, died in hospital on 30 Aug [2012] after contracting fever [virus] in the western village of Agrinio. Blood tests are being carried out to check whether villagers or members of his family also have the viral disease.

Dengue fever [virus] is spread particularly by the Asian tiger mosquito [_Aedes albopictus_], which has increasingly been seen in Europe.

Although health officials believe the elderly man in western Greece had contracted dengue fever, they are describing it as a probable rather than a definite infection, because of the complications of his case.

There was evidence of West Nile virus in his blood [antibodies or virus?] when he died in hospital in Patras, but the dengue fever [reaction] was stronger. He also had an infection and low platelets (thrombocytopenia) -- both of them symptoms of the dengue viral disease.

"We are dealing with a disease we haven't seen for several decades," said Dr Sotirios Tsiodras of the Greek Centre for Disease Control and Prevention. "It might be an isolated case but we want to make sure there are no further cases. We need to take it very seriously," he said.

As well as blood tests, mosquito traps have been set up in Agrinio as part of an entomological investigation.

In 2010, cases of dengue fever were reported in Croatia and France and the spread of viruses by the Asian tiger mosquito in Europe has been linked to travellers and migrants.

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[It will be of considerable interest to know if other people in the same village have clinical or serological evidence of dengue virus infection, and if dengue viruses are found in any of the collected mosquitoes.

The classification of this case as probable is prudent if the diagnosis is based on serological results, due to the extensive cross-reactions among the flaviviruses, the family to which the dengue and West Nile viruses belong. As the report above mentions, _Ae. albopictus_ has expanded its range into southern Europe and local dengue transmission has occurred in southern France and Croatia. In areas where this mosquito has become relatively abundant, all that is needed to initiate a dengue outbreak is the arrival of a viremic individual, similar to what occurred in Italy and southern France with chikungunya virus. Arrival of individuals from dengue-endemic areas into dengue virus free areas is not an uncommon event.

More outbreaks such as these can be expected in the future where competent dengue virus vectors are present, and underscores the need for ongoing surveillance to detect local transmission early on. - Mod.TY]

[A HealthMap/ProMED-mail interactive map of Greece can be seen at http://healthmap.org/r/3khk. - Sr.Tech.Ed.MJ]

WEST NILE VIRUS - EURASIA (08): SERBIA
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Date: Thu 6 Sep 2012
Source: UB Alert [edited]
http://www.ubalert.com/Qn1


Deputy director Olga Dulovic of Belgrade's Clinic for Infectious and Tropical Diseases reported on Thursday [6 Sep 2012] that the West Nile virus [WNV] has claimed the lives of 3 elderly people in Serbia. The deaths occurred last month [August 2012], and Dulovic said doctors confirmed that the cause was viral encephalitis, although the patients had other medical complications.

On Wednesday [5 Sep 2012], Dulovic said that 16 more people were infected with West Nile virus, which is transmitted by the tiger mosquito [_Culex_ spp. are more likely vectors. - Mod.TY]. As of Wednesday, the total number of infected people in Serbia rose to 37. She added that the number represented the total by the end of August 2012, and there could be an increase in West Nile patients, depending on the level of activity of the mosquitoes in the succeeding days.

Earlier, Dulovic said about 20 patients had been admitted to hospitals with symptoms that indicated a possible encephalitis infection. It turned out that 2 of the patients were indeed infected with the dreaded virus, as it can sometimes take as long as 2 weeks to get the laboratory test results. However, the deputy director stressed that the public has no reason for concern since several types of viral encephalitis can be mild and even pass unnoticed. Meanwhile, Health Minister Slavica Djukic Dejanovic also stated that there is no risk of a West Nile virus epidemic in the country.

--
Communicated by:
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[The number of cases has increased from 20 cases with one death reported 3 days ago (4 Sep 2012, ProMED-mail archive no. 20120905.1281223) to 37 cases with 3 deaths yesterday (6 Sep 2012) reported here. It would be of interest to know whether the increase is due to laboratory results becoming available or whether these are new, recently acquired cases. It would also be of interest to know whether there are any equine WNV infections in this area. With several weeks of the WNV transmission season remaining, one wonders whether the increase in human WNV infections noted recently will continue and perhaps accelerate.

The HealthMap/ProMED-mail interactive map of Serbia can be seen at http://healthmap.org/r/3jGD. - Mod.TY]

Griechenland - Malaria
18.09.2012

Bis zum 5. August sind 8 Malaria tertiana-Fälle aufgetreten. Bereits Ende Juni erkrankte eine 48-Jährige aus Evrotas, in der Region Lakonia, sie war zuvor nicht in ein Malaria-Endemiegebiet gereist. Anfang Juni war ein 78-jähriger Mann in der Nähe von Marathon (Region Attika) erkrankt. Im vergangenen Jahr gab es zwischen Mai und Dezember 63 Malaria-Fälle, alle verursacht durch P. vivax. Etwa die Hälfte der Erkrankungen waren sog. autochthone Fälle, also Infektionen bei Personen, die zuvor kein Malaria-Endemiegebiet bereist hatten. Die übrigen Fälle betrafen Migranten, u.a. aus Pakistan. Griechenland ist seit 1974 malariafrei, in den letzten Jahren traten einzelne Fälle mit vermutetem Zusammenhang zu importierten Erkrankungen auf. Mücken, die die Erkrankung übertragen könnten, sind in Griechenland vorhanden, außerdem arbeiten dort zahlreiche Migranten aus Endemiegebieten, über die der Erreger importiert werden kann. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

Gruß
Birgitt