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WEST NILE VIRUS - EURASIA (09): BELGIUM ex GREECE
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Date: Thu 20 Sep 2012
From: Lieselotte Cnops [edited]


We report about the 1st laboratory confirmed case of WNV [West Nile virus] encephalitis in a Belgian traveler returning from Greece.

A Belgian female of 73 years old traveled to Kavala in Macedonia (Greece). The woman developed fever and neurological symptoms. She was 1st hospitalized in Kavala and thereafter in a private hospital in Thessaloniki. A serum sample from the 9th day of illness was sent to the Aristotle University of Thessaloniki. IgM antibodies against WNV were detected in the serum by ELISA, IgG antibodies were absent. The patient was repatriated to Brussels (Belgium) on [30 Aug 2012]. CSF and serum samples from 3 and 6 Sep [2012] respectively were sent to our laboratory in the scope of our function as national reference center for WNV. Both IgM and IgG antibodies were detected in the serum and CSF by ELISA. Immunofluorescence assays on the serum sample revealed IgM antibodies against WNV only and IgG antibodies against WNV, DENV [dengue virus], YF [yellow fever], and JEV [Japanese encephalitis virus] with the strongest reaction against WNV. Real-time RT-PCR [adapted from Linke et al, 2007] on the serum demonstrated a weak positive signal. Repeated RNA extraction and RT-PCR on the serum were confirmative.

The patient was in a coma when she arrived in Brussels and her situation has not improved up to date.

Flemish, national and European health authorities were notified of the laboratory confirmed imported case of WNV.

--
Dr L Cnops
Dr M Van Esbroeck
National Reference Center for WNV
Department of Clinical Sciences, Institute of Tropical Medicine
Antwerp
Belgium

Dr A Papa
Hellenic Reference Lab for Arboviruses, University of Thessaloniki, Thessaloniki
Greece

Dr P Weyers
Head of intensive care, Hospital Brussels
Belgium

Lieselotte Cnops, PhD
Department Clinical Sciences
Central Laboratory for Clinical Biology (CLKB)
Kronenburgstraat 43/3
B-2000 Antwerp
Belgium


[The 6 Aug 2012 ProMED-mail post (archive no 20120810.1239031) reported that in Greece, 3 people died in July and August 2012. It is becoming increasingly clear that WNV has become endemic there, and probably in nearby countries as well. It is not surprising that individuals present in these areas are at risk of becoming infected by WNV and with illness upon return to their home countries. That indicates that diagnostic laboratories and health providers in the travelers' home countries need to be as well prepared to diagnose and treat these patients as the Belgian and Greek health professionals demonstrated in the situation above.

ProMED-mail thanks Dr Cnops and colleagues for sending this report. - Mod.TY

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/3tcV.]

MALARIA, P. VIVAX - GREECE (03)
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[1]

Date: Mon 17 Sep 2012
Source: ProMED-mail HealthMaps [edited]
http://healthmap.org/ln.php?1295616&u3392


Malaria in Greece - Travelers' Health - CDC
------------------------------------
As of 5 Aug 2012, 8 cases of malaria have been reported from the Attica and Laconia regions of Greece. Cases have occurred in the cities of Marathon, Markopoulo, and Evrotas. No cases have been reported in Athens.

The Hellenic (Greek) CDC and the European CDC are improving surveillance for malaria cases. In affected areas, mosquito control has been intensified; healthcare providers have been educated, and the public has been informed.

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[2]
Date: Sat 15 Sep 2012
Source: ECDC [edited]
http://ecdc.europa.eu/en/publications/P ... .15.12.pdf


Since June 2012, 8 autochthonous cases of malaria caused by _Plasmodium vivax_ infection have been reported from Greece. Local control measures have been implemented in accordance with national guidelines.

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******
[3]
Date: Fri 7 Sep 2012
Source: ECDC [edited]
http://ecdc.europa.eu/en/press/news/Lis ... sts%2FNews


On 22 Jun 2012, the Hellenic Centre for Disease Prevention and Control (KEELPNO) reported the 1st locally acquired case of _Plasmodium vivax_ (_P. vivax_) malaria, from the Marathon area in the Attica region, Greece.

As of 3 Sep 2012, KEELPNO has reported 50 cases of malaria since the beginning of 2012 in Greece. 42 of these concerned immigrants from malaria-endemic countries and were classified as imported cases, while 8 were classified as locally acquired. Of those 8 cases, 4 were reported from the municipality of Evrotas, Laconia and 4 from the department of East Attica in the Marathon area (2) and in Markopoulo (2). All samples were confirmed _P. vivax_ positive by the reference public health laboratory.

In 2011, 40 cases of _P. vivax_ infection were reported in Greece in patients without travel history to a malaria-endemic area from 5 different districts, namely Laconia (34), Attica (2), Evvoia (2), Viotia (1) and Larisa (1). A cluster involving 27 Greek resident cases and 7 immigrant cases from non-endemic countries was identified in the area of Evrotas, Laconia. In addition, 23 cases of _P. vivax_ in Lakonia were reported in migrant farm workers from malaria-endemic countries.

Malaria is an infectious disease caused by _Plasmodium_ parasites and transmitted by _Anopheles_ mosquitoes. The incubation period varies between 7 and 15 days, but long incubation periods of several months (and years) have been observed for _P. vivax_ malaria.

According to ECDC's risk assessment, the risk to travellers is considered to be low since both areas are agricultural rather than tourist areas. The risk for further extension of malaria transmission into Europe in relation to this event is considered low at present. Taking account of the present malaria situation in Greece, ECDC, the consulted experts from EuroTravNet, and WHO do not recommend chemoprophylaxis for travellers to the agricultural areas of the Laconia region. The use of standard mosquito biting prevention measures continues to be recommended.

The KEELPNO, in collaboration with the Ministry of Health and Social Solidarity and all stakeholders, developed and are implementing the strategic plan of action for malaria control in the country, which defines the control activities to be undertaken during the _Anopheles_ season (spring-autumn 2012) in Greece. The main goal is to avoid the reestablishment of the disease in the country through coordinated actions, which are implemented nationally and locally in a systematic manner.

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[_P. vivax_ is found in a temperate climate variant and a tropical climate variant. The temperate climate _P. vivax_ variant has an incubation period of 8-9 months. To understand the present situation in Greece, it is important to type the _P. vivax_ isolates to know whether they belong to the temperate variant (long incubation period type) or tropical _P. vivax_ variant (short incubation type) in order to know whether the patients were infected in 2011 or 2012. - Mod.EP

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

WEST NILE VIRUS - EURASIA (10): CROATIA
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Date: 19 Sep 2012
Source: Epi South eWeb 235 [edited]
http://www.episouthnetwork.org/sites/de ... _09_12.pdf


Croatia
-----
This is the 1st time that WNV cases have been reported in humans in Croatia. In July and August 2012, WNV cases were reported in horses in Vukovar-Syrmia region. In 2011, a low intensity of WNV was found in horses through serological testing. A higher intensity of WNV was found through seroprevalence surveys in horses in the eastern and continental parts of the country.

On 17 Sep 2012, 5 probable West Nile cases in humans were reported by the Croatian National Institute of Public Health in the East of the country: 4 autochthonous WNV cases:
- One was in Slavonski Brod, and 3 were in Osijek-Baranja and Vukovar-Syrmia, at the border with Serbia.
- One imported WNV case from Serbia in Slavonski Brod. Seroneutralisation tests are in process.

Kosovo
-----
This is the 1st time that human WNV cases have been reported in Kosovo. No equine WNV case has ever been reported in the country. Considering that WNV is circulating in several Balkan countries neighbouring Kosovo since 2010, the occurrence of WNV human cases in Kosovo was not unexpected. A permanent, passive human WNV surveillance system has been implemented in Kosovo.

On 19 Sep 2012, one confirmed WNV case and 2 suspect cases were reported by the National Institute of Public Health of Kosovo in the country.

Italy
-----
On 13 Sep 2012, the National Centre for Epidemiology, Surveillance and Health Promotion reported 3 confirmed cases of WNV in Treviso province and 2 in Venice province.

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[WNV human infections continue to occur in small numbers around the Mediterranean Basin. Croatia and Kosovo reported their 1st WNV human infection cases this year [2012]. ProMED-mail posted a report on equine WNV infections earlier in 2012 (see archive no. 20120823.1258325) and human cases in Italy (archive no. 20120906.1283932).

Maps of the affected areas are shown in the above URL. - Mod.TY]

WEST NILE VIRUS - EURASIA (12): BALKANS
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Date: Thu 20 Sep 2012
Source: The Guadrian [edited]
http://www.guardian.co.uk/world/2012/se ... sfeed=true


At least 5 people in the Balkans have died from West Nile virus [infections] and several dozen others have been taken to hospital in the past 4 weeks, according to health authorities in Serbia, Kosovo, Macedonia and Croatia.

West Nile virus is a mosquito-borne disease usually found in temperate and tropical regions. While many cases are mild and have no symptoms, severe disease symptoms can include headaches, high fever, neck stiffness, coma, tremors, convulsions, muscle weakness and paralysis.

Kosovo confirmed its 1st death on Wednesday, saying the victim was a woman from central Kosovo who died on 14 Sep [2012]. Macedonia's health officials said on Thursday [20 Sep 2012] one woman had died and 2 other people were infected with the virus.

A spokesman for the Kosovo health ministry told Reuters 2 other people who died recently were also suspected of having the same virus, but the cases had not been confirmed with laboratory blood tests.

In Serbia, 3 people have died and 35 taken to hospital since mid-August.

"This is the 1st time the West Nile virus [WNV] has been officially registered in Serbia," the country's department for public health said in a statement.

All the infected people were over 50 and had other chronic diseases, it said. Serbia's western neighbour Croatia has registered five probable cases of the virus but no deaths.

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[Yesterday's ProMED-mail post reported these cases in Serbia, Kosovo, and Croatia (see ProMED-mail archive no.20120920.1303163], but the report from Macedonia, above, is new. This just reinforces the evidence that WNV is broadly disseminated in the Balkans area, producing sporadic cases in humans and equine animals. - Mod.TY

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/240j.]

RABIES - ROMANIA: (DAMBOVITA) BEAR, HUMAN EXPOSURE
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Date: Wed 19 Sep 2012
Source: Reuters.com [edited]
http://www.reuters.com/article/2012/09/ ... 2E20120919


Police and hunters were tracking a brown bear which attacked and killed a man in the south of Romania on Wednesday [19 Sep 2012], just days after a bear infected with rabies was shot dead after it killed a man and injured 2 others in the same area.

Romania boasts roughly half of Europe's brown bears living in its largely unspoilt Carpathian Mountains, with an estimated 4000-7000 animals, according to environmentalists.

The bear, which killed the 64-year-old man on Wednesday [19 Sep 2012] in Dambovita county, northwest of Bucharest, had escaped from a poacher's trap before it attacked. It then disappeared into a forested area nearby.

"The bear was tangled in a trap and hurt. We do not know if the man who was attacked was just passing by or whether he had laid the trap himself," Dragos Rusu, prefect of Dambovita county, told local television station Realitatea TV.

The area around the scene of Saturday's [15 Sep 2012] bear attack, which killed a 71-year-old man in his orchard, has been placed under quarantine after preliminary autopsy results showed the animal had rabies. 2 other people were also injured.

Romania's mountains have been home to brown bears for centuries, and their numbers surged in the 1970s and 80s, when hunting had been banned.

Now the law limits bear hunting to a little under 350 animals a year, which officials said is needed to maintain their population, but poaching may lift the figure higher.

Bears are often seen foraging through trashcans in Romanian mountain towns, and there have been cases of bears breaking into apartment buildings, backyards, or pubs.

Several people, including foreign tourists, have been killed or injured by hungry or scared bears, and environmentalists have warned the animals' natural habitat is being destroyed by construction and food resources are becoming scarce.

[Byline: Luiza Ilie, Ioana Patran]

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[Growing numbers of people and a large bear population set the stage for an increasing human-wildlife interface that might result in increased pathogen circulation and spill-over. The dominant carnivore species of a given region usually plays an important role in the circulation and maintenance of rabies.

A picture of a Romanian black bear (_Ursus arctos_) can be seen at http://images.summitpost.org/medium/472292.jpg.

A map of the affected area can be accessed at http://healthmap.org/r/3v12. - Mod.PMB]

MALARIA, PLASMODIUM VIVAX - GREECE (04): (EAST MACEDONIA AND THRACE)
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Date: Thu 27 Sep 2012
Source: EpiSouth electronic Weekly Epidemiological Bulletin (eWEB), no 236 (19-25 Sep 2012) [edited]
http://www.episouthnetwork.org/sites/de ... _09_12.pdf


9th case of autochthonous _Plasmodium vivax_ malaria in Greece in 2012
----------------------------------------------------------------------
On 27 Sep 2012, The Hellenic Centre for Disease Control and Prevention (KEELPNO) reported one new [_P. vivax_ malaria autochthonous case] in Greece.

The case is located in Abdera city, Xanthi regional unit, part of the region of East Macedonia and Thrace (map 4 [available at the source URL above]). It is the 1st time that this area is reporting a _P. vivax_ malaria case.

On 3 Sep 2012, KEELPNO reported 2 additional cases in 2 areas already affected by _P. vivax_ malaria in 2012 (eWEB no 230 [http://www.episouthnetwork.org/sites/de ... _08_12.pdf]):
- One case in Evrotas municipality, Laconia regional unit (Peloponnese region).
- One case in Markopoulo Mesogaia municipality, East Attica regional unit (Attica region).

To date, a total of 9 autochthonous cases infected in 2012 have been reported in 3 different regions in Greece:
- 4 in East Attica regional unit. The 1st autochthonous malaria case was reported on 18 Jun 2012 (eWEB no 224 http://www.episouthnetwork.org/sites/de ... _06_12.pdf
- 4 in Evrotas municipality, Laconia regional unit, Peloponnese region.
- 1 in Xanthi regional unit, East Macedonia and Thrace region.

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[The present report brings the number of autochthonous vivax cases up to 9 in 2012. It is urgent to know whether the 2012 cases represent relapses in patients infected in 2011, or whether local transmission is occurring in the area where the patients live.

The new case reported here is the 1st case from the East Macedonia and Thrace Region, but if the case is a relapse of an infection acquired in 2011, it does not represent local transmission.

The temperate variant of _P. vivax_ has an incubation period of 8-9 months. Genotyping can determine if the _P. vivax_ is of the temperate or tropical variant (Miao M et al. BMC Evol Biol. 2012; 12: 22), but this has to our knowledge not been done. Another possibility is a detailed travel history in Greece in 2011 of the 9 patients. If they were close to the 2011 hotspots in that year they may have been infected there, travelled to their present location, and experienced their 1st malaria attack 8-9 months later. - Mod.EP]

[Maps of Greece can be seen at http://www.sfakia-crete.com/sfakia-cret ... gions2.gif and http://healthmap.org/r/3ykG. - Sr.Tech.Ed.MJ]

Griechenland - Malaria
02.10.2012

Bis zum 27. September sind 9 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

MALARIA - ALBANIA: REQUEST FOR INFORMATION
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Date: Sun 7 Oct 2012
Source: FluTrackers, Makfax report [in Macedonian, machine trans., edited]
http://www.flutrackers.com/forum/showth ... p?t=193541


Seven cases of malaria in Albania
---------------------------------
The correspondent reports that 7 cases of malaria have been registered in Albania, for the 1st time since 1970.

According to Dimitar Kraja, head of infectious diseases of the State Hospital in Tirana, these cases have been registered recently.

This information was presented at a conference held in Tirana on "infectious diseases in Albania". According to Kraja, all the data indicate that the [increase in cases is a result of imported cases] from Greece and Italy.

The conference stated that Albania needs to take measures to strengthen border controls to detect people suffering from malaria, and in the 2 neighboring countries.

At the conference it was also reported that Albania has registered 4 cases of West Nile fever but all are in good health.

--
communicated by:
Gert van der Hoek
Senior Moderator
FluTrackers


[The report above states only that the cases were diagnosed in recent times without indicating whether this is within the last month or the last 5 years. The article makes the conjectural statement that the patients may have been infected in Italy, although there is no known malaria transmission in Italy.

Albania reported a malaria case in 2010 suspected infected in Greece (ProMED-mail posting Malaria - Albania: RFI: 20100518.1634). If this is true, it indicates that malaria transmission was present in Greece before the outbreak was reported in 2011.

The patients may have been infected in Greece, if the history shows that they have been in areas where _Plasmodium vivax_ transmission took place in 2011 and 2012. However, more information is needed to determine this.

The conclusion that border controls should be tightened seems unfounded and not based on facts. - Mod.EP

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

MALARIA - ALBANIA (02)
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Date: Tue 9 Oct 2012
From: Silvia Bino [edited]



Clarification about malaria cases in Albania
--------------------------------------------
The imported malaria case in Albania were 43 [not clear which period]. 5 Albanian citizens are among them.

The imported cases have been from Asia, China, India (57.15 per cent); in Africa (35.71 per cent); only 2.38 per cent from South America and 4.76 per cent cases (Albanian citizens) were infected traveling in Africa, Middle East and Asia.

Most of the cases were found during the period between 1964-1971 and have been mostly _Plasmodium vivax_.

Since 2010, 7 malaria imported cases were registered in Albania.

In 2010 a male, 17 years old, was diagnosed with _P. vivax_ and imported from Greece (illegal migrant with a 7 months travel history in Greece).

The other 6 cases were diagnosed in 2012 starting from February and were imported from Equatorial Guinea, all young males 19-36 years old, neglecting prophylaxis and working for an Albanian company working in different areas of Equatorial Guinea. They are all citizens of Vlora, a coastal city in Albania. 3 cases were diagnosed as _P. ovale_ and 3 other as _P. falciparum_. All cases were diagnosed at IPH laboratories in Tirana and treated at Tirana University Hospital Infectious Diseases Clinic. The diagnosis was confirmed for most of the cases at ISS, Rome, Italy.

Also 2 other probable cases came to our knowledge but not as current patients. One referred to have been treated in Italy (we cannot confirm this case as we did not find any record until now) and the other one reported about malaria treatment in Equatorial Guinea but was lacking written diagnosis.

--
Silvia Bino MD, PhD
Associate Professor of Infectious Diseases
Head, Control of Infectious Diseases Department
Institute of Public Health
Alexander Moisiu Str. 80
Tirana/Albania

[ProMED thanks Silvia Bino for the comments. The malaria case diagnosed in 2010 with _P. vivax_ malaria was reported by ProMED-mail (Malaria - Albania: RFI: 20100518.1634) in May 2010. Other cases diagnosed in Albania were infected in Equatorial Guinea and thus imported cases. The other 2 cases were not confirmed. If the decision by the Albanian authorities to strengthen control with travelers from Greece and Italy it appears that the decision is based on one case from May 2010. - Mod.EP

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

WEST NILE VIRUS - EURASIA (13): AUSTRIA ex SERBIA
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Date: 13 Oct 2012
From: Stephan Aberle [edited]



West Nile virus Lineage 2 infection in an Austrian traveller imported from Serbia
------------------------------------------------------------
An Austrian woman of 65 years travelled to Serbia to spend the summer with her relatives living close (28 km [17 mi]) to Beograd. Within the last 3 weeks before onset of disease she stayed only in this region, the surroundings of Beograd.

On 7 Sep 2012 she developed fever with general malaise and because of neurological symptoms -- that is, seizures and altered mental status, she was hospitalized on 14 Sep 2012 in Beograd, Serbia (Klinika za infektivne i tropske bolesti). Clinical and laboratory findings (CSF 290 cells/microliter, 99 per cent lymphocytes) indicated a viral meningoencephalitis and infection with West Nile virus (WNV) was suspected.

On 21 Sep 2012 the patient was transferred to the Kaiser Franz Josef Hospital in Vienna, Austria. A blood sample taken on 23 Sep 2012 (16 days after onset of symptoms) was highly WNV IgM and IgG antibody positive (InBios ELISA). The infection with WNV was confirmed by detection of WNV RNA in blood as well as in urine taken on 25 Sep 2012 (18 days after onset of symptoms) using both real time and nested PCR. The sequence analyses of a 408bp long PCR fragment from the structural protein region revealed an infection with WNV lineage 2, closely related to published strains from Greece in 2010 and Italy in 2011. The neurological condition of the patient improved significantly and she will be discharged from hospital within the next days.

This imported case of WNV lineage 2 was reported to the Austrian and European health authorities.

--
Dr Stephan W Aberle, Dr Karin Stiasny, Dr Franz X Heinz
Department of Virology, Medical University of Vienna, Austria
National Reference Center for Flaviviruses

Dr Hermann Laferl, Dr Marton Szoll, Dr Gertrude Seiberl, Dr Christoph Wenisch
Fourth Medical Department (Infectious Diseases and Tropical Medicine),
Kaiser Franz Josef Hospital, Vienna, Austria

Dr Stephan Aberle
Department of Virology, Medical University of Vienna, Austria
Kinderspitalgasse 15
A-1095 Vienna, Austria


[West Nile virus (WNV) has been actively transmitted this summer in the Balkans, including Serbia, with several human cases reported (see ProMED-mail archives below). As of 20 Sep 2012, 35 individuals were hospitalized with 3 deaths due to WNV infection in Serbia.

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."

ProMED-mail thanks Dr Aberle and colleagues for this interesting, detailed report. It provides an excellent example of the need for health facilities and providers to be prepared to diagnose and treat patients for diseases that do not usually occur in their geographic area.

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

HEPATITIS A - BULGARIA: SOFIA
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Date: Sat 20 Oct 2012
Source: Standart [edited]
http://paper.standartnews.com/en/articl ... icle=40325


There is an outbreak of hepatitis A in Sofia, and GPs are alarmed. Statistics from the Regional Health Inspection Service show that the morbidity rate has increased dramatically during the past week; 58 patients were hospitalized with a diagnosis of hepatitis A.

Hepatitis A is a liver disease caused by hepatitis A virus, and it can affect anyone, the Health Ministry stated, while pointing out that the last hepatitis A outbreak was recorded in 1999. Back then, a total of 7269 Bulgarians were [diagnosed] with the disease.

Good personal hygiene and proper sanitation can help prevent hepatitis A, Tatayana Chervenkova, a national consultant in contagious diseases, said. Hepatitis A virus is [easily] spread from person to person. For this reason, the virus is more easily transmitted in places with poor sanitary conditions or in places where people are not careful about washing their hands.

[Byline: Rumiana Mileva]

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[Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic recurrences. According to the World Health Organisation, every year there are an estimated 1.4 million cases of hepatitis A worldwide. Hepatitis A virus is one of the most frequent causes of foodborne infection. Epidemics related to contaminated food or water can erupt explosively, and hepatitis A viruses can persist in the environment. Hepatitis A virus is transmitted primarily by the faecal-oral route. Waterborne outbreaks, though infrequent, are usually associated with sewage-contaminated or inadequately treated water. The current report indicates that there has been a resurgence of hepatitis A virus infection in Sofia, the capital city of Bulgaria. The number of cases remains low, and the outbreak should be containable by improvements in environmental conditions and attention to personal hygiene.

According to the Gideon Database, the incidence of hepatitis A virus infection in Bulgaria has been decreasing in recent years, but nonetheless, the rates in Bulgaria remain slightly higher than those in neighbouring countries. See ProMED-mail Hepatitis A - Bulgaria (02): background 20110826.2600. In extremes, hepatitis A can be controlled by the deployment of a cheap and effective vaccine. Travellers to Bulgaria should be aware of the current situation in Sofia and consider the possibility of vaccination.

A map of Bulgaria showing the location of Sofia in the west of the country can be accessed at: http://www.geographicguide.net/europe/m ... lgaria.htm. - Mod.CP

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

MALARIA, PLASMODIUM VIVAX - GREECE (05): UPDATE
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[1]

Date: 19 Oct 2012
Source: CDC [edited]
http://wwwnc.cdc.gov/travel/notices/out ... t-2012.htm


Cases of malaria continue to be reported in Greece. Some new cases have occurred in areas of Greece where malaria had not been previously reported. Cases of malaria have been reported from the Attica, Karditsa, Laconia, Viotia, and Xanthi regions of Greece. Cases have occurred in the cities of Evrotas, Marathon, Markopoulo, and Selino. No cases have been reported in Athens. The Hellenic (Greek) CDC and the European CDC are improving surveillance for malaria cases. In affected areas, mosquito control has been intensified; health care providers have been educated, and the public has been informed.

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[2]
Date: 28 Sep 2012
Source: European CDC [edited]
http://ecdc.europa.eu/en/publications/P ... week42.pdf


Since June 2012, 11 autochthonous cases of malaria caused by _Plasmodium vivax_ infection have been reported from Greece. Local control measures have been implemented in accordance with national guidelines. No new cases have been reported since the last update.

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[The latest issue of EpiSouth (http://www.episouthnetwork.org/sites/de ... _10_12.pdf) reports 11 autochthonous _P. vivax_ cases in Greece this year [2012], which are also reported by the ECDC [2]; however, 12 cases are reported by a newspaper citing the CDC (http://www.examiner.com/article/cdc-iss ... for-greece), and the number of cases are not mentioned in the CDC news posing cited above [1].

The CDC recommends that travelers to the agricultural areas of Evrotas take prescription medicine to prevent malaria, but the European authorities (ECDC] do not recommend malaria prophylaxis to any parts of Greece at present.

As ProMED-mail has pointed out before, the incubation time of temperate climate _P. vivax_ can be 8 to 9 months or even longer, and a _P. vivax_ case in some part of Greece does not, therefore, necessarily indicate local transmission this year (2012). This has been thoroughly discussed in our previous postings on the subject, but as far as we know, genotyping has not yet been performed.

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

MALARIA, PLASMODIUM VIVAX - GREECE (06): UPDATE
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Date: Wed 31 Oct 2012
Source: EpiSouth Weekly Eli Bulletin [edited]
http://www.episouthnetwork.org/sites/de ... _10_12.pdf


On 22 Oct 2012, the Hellenic Centre for Disease Control and Prevention (KEELPNO) reported 5 new malaria _Plasmodium vivax_ autochthonous cases in Greece.

- 2 cases are located in Karditsa regional unit, Thessaly region (cf. map 1 [available at the source URL above]). It is the 1st time that this area is reporting autochthonous malaria _P. vivax_ cases. According to KEELPNO, these cases are considered to have a direct epidemiological relation with a cluster of 8 imported cases.

- 3 other cases were reported in Laconia regional unit, Peloponnese region. These 5 cases had onset of symptoms between weeks 38 and 42 (between 17 Sep and 21 Oct 2012).

- To date, a total of 16 autochthonous cases infected in 2012 has been reported in 4 different regions in Greece:
4 in East Attica regional unit. The 1st autochthonous malaria case was reported on 18 Jun 2012 (cf. eWEB no. 224; [http://www.episouthnetwork.org/sites/de ... _06_12.pdf]). 8 in Laconia regional unit, Peloponnese region. 1 in Xanthi regional unit, East of Macedonia and Thrace region. 2 in Karditsa regional unit, Thessaly region.

Comment
-------
The occurrence of new cases in Laconia regional unit was not unexpected considering the establishment of a local transmission cycle of _P. vivax_ malaria in this area.
On 1 Oct 2010, one case was reported in Xanthi regional unit. It was the 1st time that this area reported _P. vivax_ autochthonous cases.
The report of a _P. vivax_ malaria case in the new area of Karditsa regional unit strongly suggests an extension of the circulation of malaria in other areas in Greece.

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

[The 5 reported cases bring the total number autochthonous _P. vivax_ cases in Greece this year [2012] to 16. We have previously pointed out that genotyping is mandatory to understand the transmission and ProMED-mail will be happy to post these data when available.

The present report underlines that the outbreak is not under control despite the increased surveillance and active case detection in the vicinity of the cases.

With the incubation period as long as 8 to 9 months it can be difficult to determine exactly where the patient was infected, and this makes active case detection less effective. - Mod.EP

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

RABIES - GREECE: (NORTH) RE-EMERGENCE, HUMAN EXPOSURE
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Date: Thu 2 May 2013
Source: Eurosurveillance, Volume 18, Issue 18, 02 May 2013 [Abridged & edited]
http://www.eurosurveillance.org/ViewArt ... leId=20474

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 - March 2013.
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(By: Tsiodras S, Dougas G, Baka A, Billinis C, Doudounakis S, Balaska A, Georgakopoulou T, Rigakos G, Kontos V, Efstathiou P, Tsakris A, Hadjichristodoulou C, Kremastinou)

Summary
--------
Greece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.

Introduction
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The last animal rabies case in Greece, dates back to 1987 while the last human case was reported in 1970. Here we describe the re-emergence of rabies in both wild and domestic animals during October 2012 to end March 2013 in northern and central Greece that was associated with human exposure.

Rabid fox:

On 15 Oct 2012, a red fox (_Vulpes vulpes_) exhibited aggressive behavior during daytime, threatening inhabitants of a west Macedonian village in the area of Kozani. The animal was destroyed and transported to the National Reference Laboratory (NRL) for Animal Rabies at the Centre of Athens Veterinary Institutions Virus Department, of the Ministry of Rural Development and Food as part of a wild animal surveillance program for rabies organised and implemented by the Ministry of Rural Development since April 2012 because of documented presence of lyssavirus in neighbouring Balkan countries. Four days later on 19 October, the brain samples tested positive for lyssavirus by fluorescence antibody test (FAT) and molecular techniques i.e. real-time RT-PCR and RT-PCR followed by sequencing.

Rabid shepherd dog and exposure of humans and domestic animals:

On 10 November 2012, in west Macedonia, near the Greek-Albanian border in the area of Ieropigi, Kastoria, a shepherd dog, belonging to a herdsman, bit the thigh of a passing-by hunter unprovoked. Two days later, on 12 November, the dog developed an aggressive behaviour attacking other dogs and sheep of the herd. It was consequently destroyed and brain tissue samples investigated at the NRL in Athens were positive for lyssavirus both by FAT and molecular techniques on 16 November.

Tracing of exposed humans and animals and first control measures:

An epidemiological investigation was initiated on 16 Nov 2012 by the Emergency Response Center of the Hellenic Centre for Diseases Control and Prevention (KEELPNO), Athens, in order to identify all individuals who had had contact with the dog and possible exposure to the lyssa virus. Seven people possibly exposed were interviewed. Besides the hunter and the shepherd, three relatives of the latter reported close exposure according to the World Health Organization exposure category III i.e. dog bite and/or mucous membrane exposure to the rabid dog. All five including the veterinarian who had sampled the animal received human rabies immunoglobulin along with rabies immunisation series. None of the exposed individuals has developed any symptoms of human rabies so far.

Results from regular rabies surveillance November to March 2013:

In addition to the two animal cases described, and through the enhanced surveillance instituted by the veterinarian authorities, since November 2012 until end March 2013 we have identified additional 13 red foxes, one shepherd dog (20 December 2012) and one domestic cat (28 February 2013) with laboratory confirmed rabies. In total 104 human exposures (category I: 1; 1%; category II: 21; 20%; category III: 75; 72% and 7; 7% unknown) have been reported to KEELPNO resulting in the administration of post-exposure prophylaxis according to the WHO criteria.

Rabies situation in the Balkans countries:

Although Greece was declared rabies-free in 1987, reports of rabies in wildand domestic animals exist for the neighboring countries. In fact rabies appears to be prevalent in a number of reservoir species in southeastern Europe and in countries north and east of Greece. Recent phylogenetic analyses have shown a westward movement of rabies via the movement of wild animals from Bulgaria to other Balkan countries suggesting that this is a local event unrelated to the circulation of phylogenetically distinct viral strains in Turkey. In addition, in a previous study a distinct group of viruses identified in foxes in Serbia provided evidence for southward movement of rabies from Hungary, Serbia and Romania into Bulgaria . In another report that compared the nucleoprotein sequence among animal rabies isolates from three Balkan countries, including recent isolates from the years 2011-12, all strains belonged to the eastern European group implicating wildlife movement in the transmission of rabies across the region. However, more information is necessary regarding the circulation of the virus and more genotypic data will assist in establishing a pattern for the spread of disease. Only one autochthonous human rabies case was reported in 2009 in the European Union, in Romania, a person bitten by a fox.

Discussion
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The reported cases of confirmed and possible human rabies exposure after domestic or stray animal contact raise important public health concerns: first, there is an urgent need for a prevalence estimate of the virus circulation in wild animals in the area of northern Greece. Such information will help guide immediate vaccination efforts targeting wild animals that are reservoirs for the virus. It is likely that the virus circulates largely in populations of red foxes as red foxes are considered as the most important wild animal reservoir. Second, there is an urgent need for an immunisation program for wild animals. Experience from other countries has shown that rabies elimination cannot solely rely on measures that include farm animals or domestic pets such as compulsory vaccination and/or the control of stray animal population. Reducing population density through culling or sterilisation of the main wildlife reservoirs such as foxes has been the most important factor in rabies elimination in these countries.

Successive oral vaccination campaigns (supported by the European Community) using bait vaccines have been successful in this regard in recent elimination efforts in some European countries for example Estonia but not in others e.g. Latvia and Lithuania. Third, all domestic and stray animals especially in areas where sylvatic rabies is prevalent should be vaccinated; since the majority of the bites originated from stray dogs they should be targeted first. Unofficial information about illegal importation of unimmunised hunting dogs justify the implementation of strict border control, hygiene and immunisation checks and appropriate quarantine during the importation process of such animals according to relevant EU legislation. In Greece, all imported dogs are checked for rabies immunisation with appropriate documentation together with antibody titers and if negative, entry to the country is not permitted. Other strategies pertaining to hunting animals such as the prohibition of hunting with dogs have not been discussed yet; nevertheless, the obligation to keep dogs on a leash is recommended. Fourth, the public needs to be aware about the potential for rabies exposures in areas where the virus circulates in wild animals. Pre-exposure vaccination for high risk groups is a priority in our targeted initial interventions.

The travel health department of KEELPNO is advising for preventive measures e.g. avoiding contact with wild and domestic animals, special attention for children exposure and pre-exposure prophylaxis only for high risk groups (e.g. game wardens, hunters, veterinarians working in the field) travelling to the affected areas; it also encourages the use of post-exposure prophylaxis according to the WHO guidelines. Currently, the risk of rabies to travellers to Greece remains extremely low and so far only the northern part of the country is affected. Fifth, healthcare workers need to carefully evaluate each human exposure from a potentially rabid animal and take the appropriate actions. Since the human rabies immunoglobulin is expensive, a risk assessment as proposed by WHO should guide a cost-effective approach in its administration.

Last but not least and since the disease was likely introduced to Greece by rabid wild foxes crossing borders in the north of the country, close collaboration with the neighboring countries is of paramount importance especially with regards to control measures in wild animals.

--
Communicated by:
ProMED-mail correspondent Susan Baekelnd

[Rabies remains an infectious disease with almost 100% fatality. The reappearance of rabies in Greece highlights the importance of rabies control measures not only in Greece and its neighbours, but throughout Europe. Italy recently reported the reappearance of rabies in wild animals and implemented an extensive array of control measures. The institution of appropriate measures through collaboration between veterinary and human health authorities, together with an educational campaign for the public, will be crucial and potentially effective in preventing the re-emergence of human cases in Greece and other European countries.

This report is accompanied by a map indicating the locations and types of the animals that have been confirmed to be rabies virus infected. Interested readers should access the original text at the above URL to view this map and the relevant references cited in the text. Although the locations where rabid animals haven been identified are remote from tourist areas, visors to the country nevertheless should be made aware of the potential hazard of encountering rabid wild and domestic animals. - Mod.CP


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

RABIES - GREECE (02): (CENTRAL MACEDONIA) CANINE, HUMAN EXPOSURE, OIE
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Date: Thu 27 Jun 2013
Source: OIE, WAHID (World Animal Health Information Database), weekly disease information 2013; 26(26) [summ., edited]
http://www.oie.int/wahis_2/public/wahid ... rtid=13677


Rabies, Greece
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Information received on 27 Jun 2013 from Mr Spiros Doudounakis, Director, Animal Health Directorate, Directorate General of Veterinary Services/Animal Health Directorare, Ministry of Rural Development and Food, Athens, Greece

Summary
Report type: Follow-up report no. 15
Date of start of the event: 15 Oct 2012
Date of pre-confirmation of the event: 18 Oct 2012
Report date: 27 Jun 2013
Date submitted to OIE: 27 Jun 2013
Reason for notification: Reoccurrence of a listed disease
Date of previous occurrence: 1987
Manifestation of disease: Clinical disease
Causal agent: Lyssavirus
Serotype: Not sampled
Nature of diagnosis: Clinical, laboratory (basic), laboratory (advanced)
This event pertains to a defined zone within the country

New outbreaks (1)
Outbreak 1: Periohi Emmanouil Pappa, Serres, Kentriki Makedonia
Date of start of the outbreak: 14 Jun 2013
Outbreak status: Continuing (or date resolved not provided)
Epidemiological unit: Village
Affected animals
Species / Susceptible / Cases / Deaths / Destroyed / Slaughtered
Dogs / - / 1 / 0 / 1 / 0

Affected population: A stray dog attacked an adult person and some other stray dogs.

Epidemiology
Source of the outbreak(s) or origin of infection: Contact with wild species

Control measures
Measures applied: Zoning, no vaccination, no treatment of affected animals
Measures to be applied: No other measures

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[This is the 24th reported case of rabies in northern Greece since 15 Oct 2012, when the surveillance was launched. So far, 20 red foxes, 3 dogs (including the one reported in the current notification) and one cat have been found rabid.

An accumulated report, including a map indicating the locations and affected animal species in each event, is available at http://www.oie.int/wahis_2/temp/reports ... 155427.pdf.

Control of the disease in Greece, which has been regarded free of rabies for decades, will be feasible only if coordinated with neighbouring, rabies-endemic countries. - Mod.AS

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/4AOg.]