Wüstenschiff

CRIMEAN-CONGO HEMORRHAGIC FEVER - GRIECHENLAND (05): (NORDOST)
**********************************************************
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ProMED-mail is a program of the
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Date: Sat 23 Aug 2008
Source: Kathimerini, International Herald Tribune [edited]
<http://www.ekathimerini.com/4dcgi/_w_ar ... 2008_99771>


A 61-year-old woman from Rhodope, northern Greece, who died last
Tuesday [19 Aug 2008] after suffering a high fever, had been bitten
by a tick carrying a [virus] that also led to the death of a
[46-year-old woman from Alexandroupolis -- also in Rhodope -- at the
end of June 2008], doctors said yesterday [22 Aug 2008]. The Rhodope
woman had been admitted to the hospital 3 times this month [August
2008] after suffering from insomnia, a heavy cough and high fever,
but had not told doctors about the tick bite. Doctors determined that
the woman had been infected by Crimean-Congo hemorrhagic fever (CCHF)
[virus] once they had been told about the bite by the victim's relative.

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

[This 2nd confirmed case of Crimean-Congo hemorrhagic fever in Greece
is also the 2nd death. Sequence analysis of a portion of the genome
of virus from the 1st patient has shown that the causative virus
strain is similar to other strains detected or isolated in the Balkan
Peninsula (Albania, Bulgaria, and Kosovo), Russia, and Turkey, which
have been associated with severe, and sometimes fatal, disease in
humans. The strain identified in Greece was similar to those found in
the Balkan Peninsula, Russia, and Turkey, but differed greatly from a
Greek strain AP92, isolated from ticks in 1976, which may have caused
inapparent infections in humans.

During March and April 2008, 6 probable CCHF cases have been reported
in a known endemic area in Bulgaria, close to the border with Greece.
In addition, many CCHF cases have been reported in Turkey this year
(2008), but none of them in the European part of the country.

For a more detailed account of the 1st case in Greece, see
A Papa et al: A recent case of Crimean-Congo hemorrhagic fever in
Greece, June 2008. Eurosurveillance 13(33); 14 Aug 2008, available at
<http://www.eurosurveillance.org/ViewArt ... leId=18952>.

Subsequent to the death of the woman in Alexandroupolis, residents
throughout Rhodope and the neighbouring prefectures of Drama, Kavala,
Xanthi, and Evros were informed about measures for tick bite
prevention and about the importance to refer as soon as possible to
the closest hospital or general practitioner for tick removal. At the
same time guidelines were disseminated to health-care workers for
proper removal of attached ticks. Tragically, the 2nd victim seems to
have escaped this surveillance by failing to disclose a tick bite.

A map and description of Rhodope are available at
<http://en.wikipedia.org/wiki/Rhodope_Prefecture>. - Mod.CP]

Griechenland - West Nile-Fieber
05.10.2010

Seit Anfang August sind im Norden Griechenlands (Zentralmakedonien) 200 Patienten mit West Nile-Fieber registriert worden. 24 Patienten sind verstorben. In der betroffenen Region sind Blutspenden eingestellt worden, Transfusionen werden auf ein Minimum beschränkt. Das West Nile-Virus verursacht eine Enzephalitis bei Pferden und Menschen. Eine Impfung existiert nicht. Touristengebiete sind nicht betroffen. Trotzdem verstärkt Mückenschutz beachten, insbesondere nachts. / Quelle: crm

Gruß
Birgitt

WEST NILE VIRUS - EURASIA (02): ROMANIA
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ProMED-mail is a program of the
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<http://www.isid.org>

Date: Sun 24 Jul 2011
Source: MediaFax.ro [edited]
<http://www.mediafax.ro/english/romania- ... ar-8512693>


Romania's Health Ministry said Thursday [21 Jul 2011] it has
confirmed this year's [2011] 1st case of infection with the
mosquito-borne West Nile virus. The case was confirmed in the eastern
Galati County [in eastern Romania], which is crossed by the Danube
River. The patient is a 37-year-old woman, whose health condition is
good. Last year [2010], 4 people died in Romania from West Nile
[virus] infections and 38 others were infected. All 4 people who died
were aged over 60 and had chronic illnesses.

West Nile virus infections have affected the whole of Europe last
summer [2010]. The virus is transmitted in humans through
mosquito-bites and is not transmitted directly between humans. There
is no vaccine against the virus.

While infections are often without any symptoms, people are advised
to see a doctor immediately if they suffer from fever, intense
headaches, nausea, or abdominal, muscular, or joint pain.

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

[This case has occurred early in the transmission season. One would
usually expect the 1st cases to be reported in late summer. One hopes
that this does not portend an outbreak situation in Romania or other
neighboring countries similar to the outbreak last year (2010).

Maps of Romania can be accessed at
<http://www.mapsofworld.com/romania/maps/romania-map.jpg> and
<http://healthmap.org/r/14BD>. - Mod.TY]

WEST NILE VIRUS - EURASIA (03): GREECE
***************************************
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Date: Tue 2 Aug 2011
From: Anna Papa <annap.med@gmail.com> [edited]


As of 31 Jul 2011 (epidemiological week 30), 3 human cases of West
Nile infection had been reported to the Hellenic CDC (KEELPNO)
(<http://www.keelpno.gr>; in Greek). These are the 1st cases of 2011.

The onset of illness of the 1st case was 16 Jul 2011. All 3 cases were
neuroinvasive. WNV-specific IgM antibodies have been detected in
patient's serum and CSF [cerebrospinal fluid]. The location of cases
is Thessaly.

KEELPNO, in cooperation with the Ministry of Health, is closely
monitoring the events and information is given on a weekly basis in
Greek through its website.

--
Asst. Prof. Anna Papa, MD, PhD
Head of the National Reference Centre for Arboviruses
Aristotle University of Thessaloniki, Greece
<annap.med@gmail.com>

[ProMED-mail thanks Dr Papa for this 1st hand report.

There was a total of 261 laboratory confirmed cases of West Nile virus
(WNV) infections in humans reported in central Macedonia as well as in
the district of Larissa (Northern Greece) in 2010 (see ProMED-mail
archive no 20110313.0809). One hopes that this year (2011) there will
be fewer cases.

A HealthMap/ProMED-mail interactive map showing the location of
Thessaly can be accessed at <http://healthmap.org/r/15*H>. - Mod.TY]

WEST NILE VIRUS - EURASIA (04): GREECE
**************************************
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International Society for Infectious Diseases
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Date: Thu 4 Aug 2011
Source: Eurosurveillance Edition 2011; 16 (31) [edited]
<http://www.eurosurveillance.org/ViewArt ... leId=19933>


Evidence of enzootic circulation of West Nile virus (Nea
Santa-Greece-2010, lineage 2), Greece, May to July 2011
-------------------------------------------------------------------------------------
Abstract
--------
A West Nile virus (WNV) surveillance network including sentinel
chickens was deployed in Thessaloniki county, Greece, from May - July
2011. For the 1st time in summer 2011, a chicken WNV isolate from 6
Jul 2011 was identified molecularly. The partial NS3 sequence was
identical to that of the Nea Santa-Greece-2010 WNV lineage 2, detected
in central Macedonia [region] in 2010. This suggests that WNV is
actively circulating in central Macedonia and that it may have
overwintered in northern Greece.

Background
----------
During 2010, Greece underwent the 2nd largest West Nile virus (WNV)
epidemic in Europe in the last 2 decades, with 262 clinical human
cases and 35 fatalities. WNV lineage 2 was identified in 2 pools of
_Culex_ mosquitoes (Nea Santa-Greece-2010 virus) and in wild birds
that were sampled during the epidemic season of 2010 from areas in
close proximity to human cases. No active vector and arbovirus
surveillance system was in place in Greece before the epidemic in
2010. We initiated a monitoring programme in 2011.

Results
-------
Seroconversion of the 1st sentinel chicken was detected in the
agricultural area of west Thessaloniki in the city of Chalastra on 29
Jun [2011]. On 13 Jul [2011], a 2nd chicken seroconversion was
detected in the city of Agios Athanasios, followed by a 3rd chicken
seroconversion on 20 Jul [2011] in the same area.

Discussion
----------
Transmission in the sentinel chickens occurred immediately after the
1st significant _Culex_ population peak, as has been observed in
[other] WNV outbreaks. [The] 2 principal WNV vectors in Europe, _Cx.
pipiens- and _Cx. modestus_, are highly abundant in the agricultural
area of Thessaloniki and both species may be associated with the
transmission of the virus.

[Byline: A Chaskopoulou, C I Dovas, S C Chaintoutis, I Bouzala, G Ara,
M Papanastassopoulou]

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


[It is encouraging to learn that a prospective West Nile virus
monitoring system has been put in place and is producing results than
can be useful for animal and human health authorities. This
information can be helpful in directing mosquito control and equine
vaccination efforts to the right places in a timely way. Ongoing
surveillance may be necessary in future years if the virus is
overwintering in Greece and may have become endemic there.

The full article, with references and geographic locations, is
available at the above URL.

A HealthMap/ProMED-mail interactive map showing the location of
Thessaloniki in central Greece can be accessed at
<http://healthmap.org/r/16yp>. - Mod.TY]

******
[2]
Date: Fri 29 Jul 2011
Source: Greece Greek Reporter [edited]
<http://greece.greekreporter.com/2011/07 ... ns-greece/>


A case of West Nile encephalitis has been recorded in an adult in the
area of Karditsa, Greece. Local authorities are acting immediately to
launch prevention and control programs to minimize the spread of the
disease [virus]. The Hellenic Centers for Disease Control confirmed
the disease to be epidemic, with 257 cases confirmed last year [2010],
most of them in Central Macedonia [region] and Thessalia, of which 191
were severe encephalitis.

The president of the Hellenic Centers of Disease Control, TzenI
Kremastinou, stated that the West Nile virus still exists after 10
years in the USA, spreading now as a type of seasonal epidemic that
flares up during the summer period and continues into the fall, and
that more human cases are expected to be reported this summer in
Greece. Cases have already been recorded during the present summer
period in other European countries.

For the prevention and control of the West Nile virus threat in Greece
this year, a national network for epidemiological observation has been
[deployed] in the country that continuously conducts risk assessment
and [sends alarms to] the authorities for possible emerging risks.
Focusing especially in Central Macedonia, the measures for prevention
and control that are so far activated by the Hellenic Centers for
Disease Control include detecting bird carrier index, thriving [sic]
mosquito collection on 100 spots around Greece, along with recording
cases of human infection.

Official reports announced from the Hellenic Centers for Disease
Control to the Greek Reporter/News up to the weekend 23/24 Jul [2011]
referred to only 6 infections in pigeons and no human infection. On
Monday [24 Jul 2011], the Hellenic CDC announced the 1st human case of
the summer period 2011, clinically characterized as mild
encephalitis.

The Hellenic Centers for Disease Control and Prevention remind the
public that systematic personal precautions will reduce chances of
infection, and emphasize measures that need to be taken on a local
level, such as spraying methods and the elimination of stagnant
water.

[Byline: John Papagiannidis]

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

[Curiously, this report does not mention the sentinel chicken results
presented in the Eurosurveillance report, above, from 29 June to 20
July.

A HealthMap/ProMED-mail interactive map of Greece showing the location
of Kardista can be accessed at
<http://healthmap.org/r/16yq>. - Mod.TY]

Griechenland - West Nile-Fieber
22.08.2011

Ende Juli ist der 1. Fall in diesem Jahr aufgetreten. Ein Mann aus der Region Karditsa (Thessalien, zentral) erkrankte mit Symptomen einer milden Enzephalitis. Bis zum 18. August wurden insgesamt 26 Erkrankungen gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Für den Sommer und Herbst dieses Jahres werden noch mehr Erkrankungen erwartet. Mückenschutz beachten. / Quelle: crm
______________

Griechenland - Malaria
22.08.2011

Ein Rumäne, der sich Ende Juli im südlichen Griechenland (Peleponnes) aufgehalten hat, ist an Malaria (Plasmodium vivax) erkrankt. Er hatte zuvor kein Malaria-Endemiegebiet bereist, so dass man davon ausgehen muss, dass er sich in Griechenland infiziert hat. Griechenland ist seit 1974 malariafrei, nach Angaben der griechischen Gesundheitsbehörden sind bereits seit Juni 2011 insgesamt 6 Personen ohne Reiseanamnese in ein Endemiegebiet an Malaria erkrankt. Alle Fälle ereigneten sich auf der Peleponnes-Halbinsel. Die Behörden haben die Infektionsüberwachung intensiviert und Aufklärungsmaßnahmen für die Bevölkerung laufen an. Reisende sollten gewissenhaft Expositionsprophylaxe durchführen. / Quelle: crm

HEPATITIS A - BULGARIA: (PLOVDIV), ROMA
***************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Thu 25 Aug 2011
Source: Novinite.com [edited]
<http://www.novinite.com/view_news.php?id=131474>


The Regional Health Inspectorate in Bulgaria's southern city of
Plovdiv has registered a total of 144 cases of hepatitis in August
2011. According to the report, 34 of the 144 cases were located in the
city's Roma ghetto, Stolipinovo. The majority of patients were of Roma
ethnic origin and [were] children, the watchdog announced. Most of the
cases were of hepatitis A infection, but 10 of the probes raised
suspicions of hepatitis B and C.

According to Doctor Milena Kolarova, head of the Epidemiological
Control Department at the Plovdiv Regional Health Inspectorate, the
cases of infection are epidemiologically unrelated. Doctor Kolarova
told journalists on Thursday [24 Aug 2011] that extra preventive
measures had been taken, such as frequent garbage collection from
Stolipinovo and other residential districts as well as regular
disinfection of the areas surrounding garbage containers.

Apart from that, Kolarova stated that meetings had been held with Roma
non-governmental organizations to educate the population about the
causes and symptoms of the contagious liver disease. She also
explained that it was too early to speak of a hepatitis boom, but the
situation was pre-epidemiological, and steps had been taken to ensure
adequate medical service in case of an emergency.

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

[Hepatitis A is a viral liver disease that can cause mild to severe
illness. It is spread by faecal-oral transmission when a person
ingests food or drink contaminated by an infected person's faeces. The
disease is closely associated with poor sanitation and a lack of
personal hygiene habits. An estimated 1.4 million cases of hepatitis A
occur annually. Improved sanitation and the hepatitis A vaccine are
the most effective ways to combat the disease
<http://www.who.int/mediacentre/factshee ... index.html>.

With respect to the outbreak of hepatitis A virus infection in the
Roma population of Plovdiv, a general improvement in personal hygiene,
coupled with provision of hepatitis A vaccine, might be a more
effective strategy than enhancement of garbage collection.

The Romani people are an ethnic group with origins in India who are
widely dispersed, with their largest concentrated populations in
Europe, especially Central and Eastern Europe. The Roma are a subgroup
of the Romani people who live primarily in Central and Eastern Europe.
Romani people constitute the 3rd largest ethnic group (after
Bulgarians and Turks) in Bulga. According to the 2001 census, there
were 370 908 Roma in Bulgaria, equivalent to 4.7 percent of the
country's total population
<http://en.wikipedia.org/wiki/Romani_peo ... y#Bulgaria>.

The city of Plovdiv is the 2nd-largest city in Bulgaria after Sofia
(the capital), with a population of 338 153 [1]. Plovdiv is in the
southern part of the Plovdiv Plain on the 2 banks of the Maritsa
River. It can be located in the map of Bulgaria at:
<http://www.alexandertour.com/bulgarian_map.htm>. - Mod.CP]

WEST NILE VIRUS - EURASIA (08): GREECE, HUMAN, EQUINE
*****************************************************
A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Thu 25 Aug 2011
Source: Eurosurveillance [edited]
<http://www.eurosurveillance.org/ViewArt ... leId=19951>


Ongoing outbreak of West Nile virus infection in humans, Greece, July
- August 2011. [Reported by: K Danis (<daniscosta@ yahoo.com>)1, A
Papa, E Papanikolaou, G Dougas, I Terzaki, A Baka, G Vrioni, V
Kapsimali, A Tsakris, A Kansouzidou, S Tsiodras, N Vakalis, S Bonovas,
J Kremastinou]
----------------------------------------
Abstract:

Between 16 Jul and 21 Aug 2011, 31 cases of West Nile neuroinvasive
disease were reported from 4 regions in Greece. Of these, 17 occurred
in districts that had not been affected in 2010. The reoccurrence of
human cases in 2 consecutive years (following the large 2010 outbreak)
and the spread of the virus in new areas suggest that West Nile virus
is established in Greece, and its transmission may continue to occur
in the future.

Background:

Since July 2011, an outbreak of West Nile virus (WNV) infection has
been ongoing in regions in Greece that had already been affected in
2010 and in regions that had never reported human cases before. During
2010, Greece experienced the 2nd largest outbreak of WNV infections in
Europe since the one that had occurred in Romania in 1996. Overall,
262 cases of WNV infection in humans were notified mainly in northern
Greece. In the Central Macedonia region, all 7 districts had reported
cases, and in the adjacent Thessalia region, one of the 4 districts
was affected. Among reported cases, 197 presented with WNND, and 33 of
these died, indicating a case fatality rate of 17 per cent among WNND
cases. WNV lineage 2 sequences were obtained from 3 pools of _Culex_
mosquitoes (strain Nea Santa-Greece-2010), from 2 blood donors and
from wild birds. This was the 1st time that WNV infection was
documented in humans in Greece, although serosurveys in the early
1960's, 1980's and 2007 identified WNV antibodies in approximately one
per cent of the human population, suggesting that WNV, or a related
flavivirus, was circulating in Greece.

Following the large WNV outbreak in 2010, WNV human infections are
notified in Greece for a 2nd consecutive year. As of 21 Aug [2011], 31
WNND were reported from 4 regions in Greece. The temporal distribution
of cases shows that the 1st human cases in 2011 occurred approximately
2 weeks later compared to 2010.

Comparing the magnitude of the current outbreak [2011] in Central
Macedonia to the outbreak in the previous year, the current one
remains lower to date, suggesting decreased or delayed WNV
transmission in humans. Due to the high visibility of the 2010
outbreak and the subsequent raised awareness to the infection among
physicians, it is unlikely to be due to delayed recognition of the
disease or under-reporting. However, as this is an ongoing outbreak,
the number of 2011 cases corresponding to previous weeks may increase
as more cases are confirmed retrospectively.

Regarding equidae, 5 horses from East Attiki presented with clinical
WNV disease manifestation, as well as one horse from Serres (Central
Macedonia) with antibodies against WNV that demonstrated a recent
infection (IgM positive). The 1st 2 cases in horses were identified
before human cases had been reported in Attiki and thus functioned as
an early warning signal.

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

[Evidence of West Nile virus circulation in Greece in sentinel
chickens was reported on 4 Aug 2011 (see ProMED-mail archive no.
20110805.2359), and now there are human and equine cases.
Unfortunately, there are cases in areas that were not affected by the
WNV outbreak last year (2010).

MALARIA, PLASMODIUM VIVAX - GREECE (02): AUTOCHTHONOUS, TRAVEL ADVICE
**********************************************************************
A ProMED-mail post
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ProMED-mail is a program of the
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<http://www.isid.org>

Date: Wed 24 Aug 2011
Source: The Telegraph, UK [edited]
<http://www.telegraph.co.uk/travel/trave ... rning.html>


Travellers to Greece have been warned to take precautions against
mosquito bites following 6 reported cases of malaria since June
[2011].

None of the victims -- 5 Greek adults and a Roma child -- had any
history of travel to a country where the disease is commonplace.

The cases occurred in the Laconia region of the southern Peloponnesus
and on Euboea, a large island north of Athens. Greek authorities have
responded with enhanced surveillance of malaria in the 2 areas, and
intensified mosquito control programmes. Awareness has also been
raised among doctors and local residents.

Professor David Hill, director of the Health Protection Agency's
National Travel Health Network and Centre, said: "The risk to
holidaymakers of catching malaria while in Greece remains extremely
low, so there is no need to take anti-malarial medication when
visiting this country, but travellers should take measures to prevent
being bitten.

"We already advise people travelling to Greece to prevent insect bites
to protect against another mosquito-borne infection caused by West
Nile virus," he added. "This can cause a nervous system disease and
over 200 cases were reported in Greece last year [2010]. The recent
cases of malaria in Greece reinforce the importance of taking
precautions against being bitten while on holiday."

Holidaymakers returning from the affected areas who experience
symptoms of malaria -- which include fever, headache, and muscle pains
-- should seek immediate medical advice.

[Byline: Oliver Smith]

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

[We agree with the Health Protection Agency that the risk of malaria
in travellers is extremely low in Greece. If no further cases are
reported, the most likely explanation is still limited transmission by
local mosquitoes infected from asymptomatic gametocyte carriers
infected outside Greece.

This occurs frequently as illustrated by such cases reported by
ProMED-mail listed below. Except for Jamaica, these cases never
resulted in sustained local transmission.

A map of Greece showing the location of Laconia and Euboea (Evia) can
be seen at <http://www.domatia65000.eu/images/greece_map.gif>. The
HealthMap/ProMED-mail interactive map of Greece can be seen at
<http://healthmap.org/r/19JI>. - Mod.EP]

HEPATITIS A - BULGARIA (02): BACKGROUND
***************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Fri 26 Aug 2011
Source: GIDEON (Global Infectious Disease & Epidemiology Network)
[edited]
<http://www.gideononline.com>


Comment on hepatitis A in Bulgaria
-----------------------------------
The incidence of viral hepatitis in Bulgaria has actually decreased in
recent years [1-3]. See graph at
<http://www.gideononline.com/wp/wp-conte ... lgaria.png>.

Nevertheless, disease rates in Bulgaria remain slightly higher than
those in neighboring countries. See graphs at
<http://www.gideononline.com/wp/wp-conte ... lgaria.png>
and
<http://www.gideononline.com/wp/wp-conte ... lgaria.png>.

(These graphs were generated using an interactive online system; see
<http://www.gideononline.com/wp/wp-conte ... Graphs.pps>.)

References
----------
1. Berger SA: Infectious Diseases of Bulgaria, 2011. 368 pp, 101
graphs, 967 references. Gideon e-books series.
<http://www.gideononline.com/ebooks/coun ... -bulgaria/>.
2. Berger SA: Hepatitis A: Global Status, 2011. 163 pp, 180 graphs,
1073 references. Gideon e-books series.
<http://www.gideononline.com/ebooks/dise ... al-status/>.
3. Berger SA: Hepatitis B: Global Status, 2011. 327 pp, 405 graphs,
1517 references. Gideon e-books series.
<http://www.gideononline.com/ebooks/dise ... bal-status>.

--
Communicated by:
Dr Steve Berger
Geographic Medicine
Tel Aviv Medical Center
Israel
<mberger@post.tau.ac.il>

[ProMED-mail thanks Professor Berger for providing these statistics on
hepatitis A and hepatitis B virus infection in Bulgaria and
neighboring countries. - Mod.CP]

Griechenland - West Nile-Fieber
28.08.2011

Ende Juli ist der 1. Fall in diesem Jahr aufgetreten. Ein Mann aus der Region Karditsa (Thessalien, zentral) erkrankte mit Symptomen einer milden Enzephalitis. Bis zum 26. August wurden insgesamt 39 Fälle gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Für den Sommer und Herbst dieses Jahres werden noch mehr Erkrankungen erwartet. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

MUMPS - BOSNIA AND HERZEGOVINA: ONGOING OUTBREAK
************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Thu 1 Sep 2011
Source: Eurosurveillance 2011; 16(35) [abridged, edited]
<http://www.eurosurveillance.org/ViewArt ... leId=19959>


Ongoing large mumps outbreak in the Federation of Bosnia and
Herzegovina. Dec 2010 to Jul 2011
----------------------------------------------
[abridged from: Hukic M, Ravlija J, Dedeic Ljubovic A, Moro A, Arapcic
S, Muller CP, et al. Ongoing large mumps outbreak in the Federation of
Bosnia and Herzegovina, Bosnia and Herzegovina, December 2010 to July
2011]

Summary
-------
From December 2010 until the end of July 2011, 5261 mumps cases were
recorded in the Federation of Bosnia and Herzegovina, leading to an
incidence of 225.8 per 100 000. 15 to 19 year olds (43 per cent) were
most affected, and 62 per cent of cases were male. Mumps-specific IgM
antibodies were found in about 70 per cent of sera investigated,
complications were reported in 41 per cent of 81 hospitalised
patients. The outbreak affected mainly those unvaccinated or unaware
of their vaccination status and is probably due to vaccination
failures during the war and post-war period (1992-1998).

In December 2010, the cantons of Zenica-Doboj (n=40) and Central
Bosnia (n=34) reported an increased number of mumps cases to the
Ministry of Health of Bosnia and Herzegovina. Subsequently, the number
of mumps patients continued to rise, and more cantons reported cases.
By the end of July 2011, a total of 5261 cases were reported to the
Ministry of Health.

Background
----------
Immunisation against mumps was introduced in Bosnia and Herzegovina in
1980 in the form of a combined vaccine against measles, mumps, and
rubella (MMR) [1]. Until 1992, it was recommended to vaccinate
children between one and 14 years of age without documented history of
mumps with one dose of MMR vaccine. Between 1992 and 1995, the war
caused disruptions to the routine immunisation programme in the
country, and these disruptions continued also during the post-war
period (1996-1998). In 2001, a 2-dose schedule with MMR vaccine was
implemented throughout the country, with the 1st dose given at the age
of 12 months and the 2nd dose at the age of 7 years and no later than
14 years. The MMR vaccine produced by the Institute of Immunology
Zagreb was used until 2009 and contained the L-Zagreb strain as the
component, and since 2010, the Glaxo SmithKline MMR vaccine containing
the Jeryl Lynn strain has been employed [1,2]. The average coverage
with MMR vaccine for the Federation of Bosnia and Herzegovina between
1998 and 2009 ranged from 84-92 per cent for the 1st dose, and from
53-92 per cent for the 2nd dose (figure 1).

Mumps is a notifiable disease in Bosnia and Herzegovina and is
reported on the basis of clinical symptoms and epidemiological data.
Reporting of mumps is normally done by the doctors to the Institute
for Public Health, which looks for epidemic evidence and provides
information to the Ministry of Health.

The 1st reports on mumps in Bosnia and Herzegovina date back to 1956
[3]. In the period before 1980, when vaccination against mumps was
introduced, morbidity was high with an incidence ranging from 189 to
253 cases per 100 000 inhabitants per year (figure 2). After
introduction of the vaccine, incidence decreased from 123 in 1981 to
3.5 in 1992. During the war from 1992 to 1995, the reported incidence
of mumps was between 7.8 and 5.1, but reporting was irregular, and
underreporting is likely. Between 1999 and 2002, 25 smaller outbreaks
were reported with a total of 2743 cases. The last outbreak of mumps
in Bosnia and Herzegovina occurred in 2002 with a total of 410
reported cases, and until December 2010 only few cases were notified
[4].

At the beginning of December 2010, a mumps outbreak started in the
Federation of Bosnia and Herzegovina and is still currently ongoing.
This report describes the mumps outbreak in the country and includes
data from December 2010 until the end of July 2011.

Description of the outbreak
---------------------------
Since the start of the outbreak in December 2010, 5261 cases have
occurred in 9 of the 10 cantons of the country; however, cantons are
affected to a different extent. In December 2010, 85 cases were
reported, and the peak of the outbreak was in April 2011 with 1240
cases reported (figure 3).

The most severely affected cantons are Central Bosnia Canton (n=2156
cases), Zenica-Doboj Canton (n=1695), Sarajevo Canton (n=1035), and
Herzegovina-Neretva Canton (n=326). Together, they account for about
99 per cent of all cases. Only a few cases have been reported in
Una-Sana, Tuzla, Bosnian Podrinje, West Herzegovina, and West Bosnia
cantons, and no cases from Posavina Canton (figure 4).

For 5219 patients, data on age and sex are available. The majority
(3255/5219; 62 per cent) are male, and the most affected age groups
include the 15 to 19 year olds (2232/5219; 43 per cent), followed by
20 to 29 year olds (1254/5219; 24 per cent) (figure 5).

Patients with serious clinical symptoms such as fever, temperature
above 38.5 C, swelling of the parotid and/or salivary glands, and
fatigue were hospitalised. A total of 81 patients were admitted to the
Clinical Centre University of Sarajevo, but we have no data for other
hospitals. The vast majority were male (67/81, 83 per cent), and 30 of
them had orchitis (30/67, 45 per cent). One female and 2 male patients
had meningitis (3/81, 4 per cent).

Vaccination status of cases
---------------------------
For 34 per cent of the cases (1774/5219) vaccination status was
unknown. About 33 per cent of cases (1722/5219) were unvaccinated, 18
per cent (939/5219) were vaccinated with one dose of a
mumps-containing vaccine, and only 15 per cent (784/5219) had received
2 doses (figure 6).

Laboratory findings
-------------------
Samples were collected for laboratory analysis from 104 cases: throat
swabs from 32, throat swabs and serum from 48, and only serum from 24
of them. The cases' age ranged from 7-48 years (median: 22.15 ±
7.47), and 83 per cent were male. All 72 serum samples were tested
with the Siemens Enzygnost anti-parotitis virus kit for mumps-specific
IgG and IgM antibodies. 68 samples were IgG positive (94 per cent), 3
were borderline, and one was negative. A total of 50 samples were
positive for IgM (69 per cent), 8 were borderline, and 14 were
negative. The results of PCR and sequence analysis from throat swabs
are pending.

Control measures
----------------
In March 2011, the federal minister of health declared a mumps
epidemic. It was recommended to increase the vaccination coverage with
2 doses of MMR vaccine in children between one and 14 years of age,
and some schools with increased case numbers were temporarily closed.
Other epidemic control measures by public health authorities,
supported by doctors and/or teachers in the schools included: (i)
health education, (ii) disseminating information about general and
personal sanitary and hygienic measures to take, (iii) isolating
infected persons and limiting contact with them, (iv) disinfection of
articles of general use, and (v) frequent hand washing in order to
limit further spread of the disease. The control measures were in
accordance with protocols for prevention and infection control.

Discussion and conclusions
--------------------------
In recent years, mumps outbreaks were reported from many countries all
over the world [5-8]. In Bosnia and Herzegovina, disruption in the
immunisation program during the war (1992-1995) and in the post-war
period (1996-1998) left considerable numbers of children susceptible
to measles, rubella, and mumps [9]. The children, who were supposed to
get their 1st vaccination between 1992 and 1998 are now between 14 and
20 years old and constitute a large proportion of the people affected
by the current outbreak. Our data also show that most cases in the
current outbreak (85 per cent) either did not know their vaccination
status or reported being not or incompletely vaccinated.

The geographical regions with the highest case numbers in the current
mumps outbreak largely concur with the areas that were most severely
affected during previously reported rubella and measles epidemics
[10,11]. Also, during the war from 1992 to 1995, immunisation was not
fully implemented across the entire territory of Bosnia and
Herzegovina. The program of immunisation was not the same across the
Cantons. Two doses of vaccine were used in the Posavina,
Herzegovina-Neretva and West Herzegovina cantons, while in other
cantons, only one dose was implemented. Some small outbreaks occurred
in Una-Sana Canton and Tuzla Canton, and they had additional
vaccination with monovalent parotitis vaccine, and that is the
probable reason for the smaller number of cases in these cantons in
the current outbreak.

Similar to the rubella outbreak in 2010 [10], more males contracted
the disease (62 per cent), and the most severely affected age group
were young adolescents (15 to 19 years of age, 43 per cent). High
numbers of mumps cases in male adolescents were reported recently from
several countries, such as Israel, the United Kingdom, the
Netherlands, and the United States [5,12-14].

The majority of cases reported during the current outbreak were
diagnosed based on clinical symptoms, sometimes supported by
epidemiological data. Only a few samples were collected from
non-hospitalised patients for laboratory confirmation, as the clinical
picture was considered typical. In about 70 percent of the serum
samples, mumps-specific IgM antibodies were detected, confirming the
clinical diagnosis.

Information about complications and hospitalisations related to the
outbreak is incomplete. The available data point to complications in
about 7 per cent of the female (meningitis) and 48 per cent of the
male (meningitis and orchitis) hospitalised patients, however, total
numbers of cases are low. Symptomatic meningitis has been reported to
occur in up to 15 per cent of patients and orchitis in as many as 50
per cent of post-pubertal males in other studies [12].

In conclusion, Bosnia and Herzegovina is currently facing a large
outbreak of mumps with an incidence of 225.8 in the Federation of
Bosnia and Herzegovna in the 1st half of 2011. The outbreak is
probably related to failures to vaccinate during the war and post-war
period between 1992 and 1998. Monitoring of the immunisation status
and vaccine effectiveness, high vaccination coverage rates with 2
doses, and catch-up campaigns are necessary to avoid measles, mumps,
or rubella outbreaks in the future.

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

[The figures and references have been omitted from this posting, and
interested readers should consult the original document via the source
URL.

Formerly one of the 6 federal units constituting the Socialist Federal
Republic of Yugoslavia, Bosnia and Herzegovina gained its independence
during the Yugoslav Wars of the 1990s. A map of Bosnia and Herzegovina
can be accessed at
<http://en.wikipedia.org/wiki/Bosnia_and ... .931995.29>.

The level of immunisation achieved in Bosnia and Herzegovina, despite
a decline in cases between 2002 and 2010, has not been sufficient to
interrupt the transmission of mumps virus infection. As the triple MMR
vaccine has been in use since 1980, it would be interesting to have
information on the incidence of measles and rubella during the same
period.

The MMR vaccine produced by the Institute of Immunology Zagreb was
used until 2009 and contained the L-Zagreb strain as component, and
since 2010, the Glaxo SmithKline MMR vaccine containing the Jeryl Lynn
strain has been employed. Was there a reason for this? - Mod.CP]

MALARIA, P. VIVAX - GREECE (03): AUTOCHTHONOUS
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Fri 2 Sep 2011
Source: Eurosurveillance 2011;16(35): 1 Sep 2011
<http://www.eurosurveillance.org/ViewArt ... leId=19954>


_Plasmodium vivax_ malaria in a Romanian traveler returning from
Greece, Aug 2011
----------------------------------------------------------------
In August 2011, a _Plasmodium vivax_ malaria infection was diagnosed
in a Romanian traveller returning from Greece. This case together with
several reports over the past decade of autochthonous cases in Greece
highlight that malaria should be considered as differential diagnosis
in symptomatic travellers returning from this country. Travellers may
serve as sentinels of emerging vectorborne diseases.

Malaria is considered to be eradicated in several European countries
since 1975, although _Anopheles_ spp. mosquito vectors remain
prevalent in parts of southern and central Europe [1]. A few cases of
autochthonous transmission of malaria to local residents have been
reported over the last 10 years in areas where the disease has been
declared eradicated (Bulgaria, France, Germany, Greece, Italy, and
Spain), including the so-called airport malaria, but there has not
been sustained local transmission in any specific location [2].

In this report, we describe a case of malaria in a Romanian traveller
returning from Greece.

Case report
-----------
On 1 Aug 2011, a 25 year old Romanian man developed an acute febrile
illness with chills, myalgia, fever, and left abdominal flank pain. He
had returned from Greece on 30 Jul 2011. His past medical history
included a splenectomy 14 years earlier. As the symptoms persisted, on
3 Aug 2011, the patient visited the family doctor who suspected a
respiratory infection and prescribed a symptomatic and antibiotic
treatment (amoxicillin-clavulanate). On 9 Aug 2011, as there was no
improvement in his symptoms, as the fever persisted and he felt an
increased pain in the left flank, and after an episode of near
syncope, he was admitted to the local hospital in his area of
residence.

Abdominal ultrasound showed a hematoma in the splenic bed (5.5 by 6.6
cm). The hematoma was surgically drained. On 11 Aug 2011 laboratory
results revealed thrombocytopenia (57 000/mm3; norm: 150 000-400 000),
anaemia (Hb: 8.7 g/dl; norm 11.5-15), and leukocytosis (16 600/mm3;
norm: 4000-10 000) with normal white blood cell differential count.
Blood cultures taken upon each hospital admission remained negative.
Thin blood smear revealed _Plasmodium_ spp. trophozoites and
schizonts. On the same day, the patient was transferred to Victor
XXXXXX Hospital for Infectious and Tropical Diseases in Bucharest. On
arrival, physical examination revealed a reduced general condition, a
temperature of 37.8 deg C [100 deg F], abdomen with diffuse
sensitivity to palpation, and moderate hepatomegaly. Thin and thick
films revealed _Plasmodium vivax_ parasitaemia of 0.05 per cent with
mature trophozoites, young schizonts, and gametocytes of _P. vivax_.
Whole blood DNA quantification using a LightScanner 32 (Idaho
Technology, USA) demonstrated _P. vivax_ (1500 copies/mul) and was
negative for the other _Plasmodium_ species.

The patient responded quickly to the 7-day treatment of oral quinine
combined with doxycycline. The clinical response was good (fever
ceased after 48 hours of treatment) and the parasite clearance
appropriate (negative thin and thick smear after 72 hours of
antiparasitic treatment). After this treatment, the patient was given
primaquine for 14 days to prevent relapses. Patient history revealed
that he had worked intermittently in agriculture in Greece, for about
6 years (in 2005 in Argos region and then every October to February
from 2006 to 2010 in Lakonia region, in Skala and Elos localities of
the Evrotas river basin). More recently, from November 2010 to 30 July
2011 he worked in the same regions (Skala and Elos) in agriculture. He
had no history of travel to any malaria-endemic areas and his only
other travel abroad was a 2-month trip to Italy (Sicily) from
September to October 2010. He had never travelled by plane, he does
not live in the proximity of any international airport and there have
been no reports of imported malaria cases within his residence area in
Romania. Malaria tests in the patient's relatives with whom he had
travelled and worked in Greece were negative.

Epidemiological situation in Greece
-----------------------------------
Several anopheline vector species are known to breed in Greece,
including some of the historically most important vectors in Europe
including _A. atroparvus_, _A. sacharovi_, and _A. superpictus_ that
are competent for _P. vivax_ [3]. As early as 1994 and 1995 4
autochthonous malaria cases (_P. falciparum_, _P. malariae_, and 2 _P.
vivax_) were diagnosed in Evros, northern Greece, in native residents
from rural areas who stated that they had never left Greece or visited
an international airport [4]. In the summer of 1998 2 additional
malaria cases (_P. vivax_) were diagnosed in the same region in 2
patients who had been living for 4 years in Feres (in the Evros
peripheral area, East Macedonia and Thrace, Greece) after they had
immigrated from southern Albania [5]. Later, an autochthonous cluster
of _P. vivax_malaria occurred in the Evrotas river basin, Lakonia,
southern Greece, from August to October 2009, with 8 patients
hospitalised in Sparta General Hospital, including 2 immigrants from
Pakistan and Afghanistan and 6 patients, natives of Lakonia and living
in different areas from the 1st 2 [6]. More recently, between June and
18 Aug 2011, 6 cases of locally-acquired _P. vivax_ malaria have been
notified to the Hellenic Centre for Disease Control and Prevention
through the mandatory notification system in Greece: 4 cases from the
same agricultural wetland area of the Evrotas river basin, Lakonia, in
the Peloponnese, southern Greece and 2 cases who reside near the city
of Chalkida, Evoia, in the eastern part of Greece [7]. All cases were
local residents with no history of travel to a malaria endemic area.

Epidemiological situation in Romania
------------------------------------
The _P. vivax_ malaria case in Romania was reported to the National
Institute of Public Health within the National Malaria Surveillance
Programme. In Romania, there is a national programme for surveillance
and rapid communication of malaria cases. In 1948, a total of 333 198
cases of malaria were reported, but starting with 1968 Romania was
declared a malaria-free country. No local transmission of malaria has
been reported in Romania since then. Nevertheless, malaria remains a
possible re-emerging disease especially in the southern and
south-eastern part of the country, where vector-competent Anopheles
species are prevalent [8]. In the past 10 years, 107 cases of malaria
were diagnosed in the Victor XXXXXX Hospital of Infectious and Tropical
Diseases in Bucharest and all of them were in travellers who had
returned from malaria endemic areas, mostly from Africa [9,10].

Discussion and conclusions
--------------------------
The occurrence of presumably vector-competent Anopheles species,
together with increasingly favourable climatic conditions and the
frequent availability of reservoirs of infection such as imported
cases, produce an ongoing probability of autochthonous malaria
appearing time and again. This case report presented epidemiological
evidence and patient history point to an infection in the Skala and
Elos areas Greece. Prior to 2011, the patient had not been exposed in
Greece during summer, or during periods when autochthonous cases were
reported in Greece. However, it is unclear whether the reservoir of
infection for this case was from migrant workers in Greece coming from
South Asia or from the local population.

To the best of our knowledge, this is the 2nd case of malaria reported
recently in an international traveller who acquired the infection in
an European Union (EU) country. In 2000, a German couple was diagnosed
almost simultaneously with _P. vivax_ malaria after a one-week holiday
in Kassandra, Chalkidiki, a Greek tourist resort [11]. No local cases
had been reported at that time but it seems that sporadic local
transmission must have been occurring. Since Greece is a frequent
destination for people visiting or working, any re-emergence of
malaria will be of concern. Furthermore, the occurrence of malaria
cases in areas considered to be malaria-free may lead to delay in
diagnosis raising the possibility of exposure to vectors and even the
risk of incidence of local malaria cases.

To date, there has been no recommendation for travellers to the
affected areas in Greece to take any anti-malarial chemoprophylactic
drug. However, advice has been issued on avoidance measures regarding
insect bites particularly during the evening and at night [12,13]. In
the authors' opinion, the Greek interventions with the current cases
should be followed closely so that Romania and other formerly malaria
endemic countries in the EU remain malaria-free. Both local health
authorities and practicing clinicians need to be aware that they
should also include malaria in the differential diagnosis in
travellers and temporary residents returning from Greece and maybe
also other southern European countries. However, according to a risk
assessment related to the 6 autochthonous cases of _P. vivax_ malaria
in Greece, published by the European Centre for Disease Prevention and
Control, the risk for further extension of malaria transmission into
the EU is considered low at present [7].

Acknowledgements
----------------
We are grateful to Prof David O Freedman from GeoSentinel and Eskild
Petersen for helpful discussions.

References
----------
See the URL above.

--
communicated by:
Florescu SA, Popescu CP, Calistru P, Ceausu E, Nica M, Toderan A, et
al [see URL above for affiliations]

[The report nicely summarizes autochthonous malaria cases in Greece
over the past 15 years. The number of cases are small with several
years apart and in different locations (Evros, 1994-5; East Macedonia
and Thrace 1998; Lakonia 2009; Lakonia and Chalkida, Evoia 2011),
pointing to asymptomatic gametocyte carriers as the source.

A sustained reservoir in Greece would require a certain number of
cases each year in the same region. The population are not immune so
cases are likely to be clinical and should be picked up by the local
health care system. The reporting of the cases this summer show that
new malaria cases will identified by the Greek surveillance system, so
unreported cases are unlikely.

The areas where the cases were reported from are agricultural areas
and the most likely explanation is migrant labor from endemic areas
being asymptomatic gametocyte carriers. These agricultural areas often
grow vegetables in greenhouses and the production is labor intensive.

The local vectors are able to transmit malaria and thus a small number
of infections are seen from these asymptomatic carriers, but there is
no sustained reservoir.

It would be interesting to have data on imported migrant labor --
legal and illegal -- in the areas reporting cases. It is likely that
there are migrant laborers from malaria endemic areas.

HealthMap location: <http://healthmap.org/r/1cZu>. - Mod.EP]

Bosnien & Herzegowina - Mumps
05.09.2011

Seit Dezember 2010 gibt es einen noch immer andauernden Ausbruch, bis Ende Juli 2011 wurden landesweit 5.261 Fälle registriert, betroffen sind überwiegend junge Erwachsene zwischen 15 und 19 Jahren. Die meisten Erkrankten haben keinen ausreichenden Impfschutz aufgrund von Unterbrechungen der Impfprogramme zu Zeiten des Krieges (1992-1995). Es traten mindestens 80 komplizierte Verläufe auf, eine stationäre Behandlung wurde erforderlich. Reisenden sollten auf einen ausreichenden Impfschutz gemäß STIKO-Empfehlungen achten. / Quelle: crm
______________________

Griechenland - West Nile-Fieber
05.09.2011

Ende Juli ist der 1. Fall in diesem Jahr aufgetreten. Ein Mann aus der Region Karditsa (Thessalien, zentral) erkrankte mit Symptomen einer milden Enzephalitis. Bis zum 1. September wurden insgesamt 47 Fälle gemeldet. Im Jahr 2010 gab es 257 bestätigte Fälle. Da nun in zwei aufeinanderfolgenden Jahren menschliche Erkrankungen auftreten und neue Regionen betroffen sind, ist davon auszugehen, dass WNV in Griechenland endemisch ist. Für den Sommer und Herbst dieses Jahres werden noch mehr Erkrankungen erwartet. Als Vektor dienen Mücken; Mückenschutz beachten. / Quelle: crm

Gruß
Birgitt

WEST NILE VIRUS - EURASIA (10): GREECE
***************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Mon 12 Sep 2011
From: Anna Papa <annap@med.auth.gr> [edited]


[re: ProMED-mail West Nile virus - Eurasia (08): Greece, human, equine
20110825.2595]
----------------------------------------------------------------------
Following the ProMED-mail report concerning the ongoing outbreak of
West Nile virus (WNV) infections in Greece, I would like to inform you
that WNV lineage 2 sequences were obtained from patients' sera taken
during the acute phase of the illness. Sequences of the NS3 gene are
identical to those obtained in 2010 from _Culex_ mosquitoes and blood
donors, thus, similar to the Hungarian WNV strain.

--
Anna Papa
Head, National Reference Centre for Arboviruses
Medical School, Aristotle University of Thessaloniki
Greece
<annap@med.auth.gr>

[ProMED-mail thanks Dr Papa for this update on WNV lineages in Greece.
It is interesting that the sequences of this year (2011) are the same
as last year.

A HealthMap/ProMED-mail map of Greece can be accessed at
<http://healthmap.org/r/01Pm>. - Mod.TY]