Ultra-Processed Food vs. Fruit and Vegetable Consumption before and during the COVID-19 Pandemic among Greek and Swedish Students.

BACKGROUND: The COVID-19 pandemic has impacted children's lifestyles, including dietary behaviors. Of particular concern among these behaviors is the heightened prevalence of ultra-processed food (UPF) consumption, which has been linked to the development of obesity and related non-communicable diseases. The present study examines the changes in (1) UPF and (2) vegetable and/or fruit consumption among school-aged children in Greece and Sweden before and during the COVID-19 pandemic. METHODS: The analyzed dataset consisted of main meal pictures (breakfast, lunch, and dinner) captured by 226 Greek students (94 before the pandemic and 132 during the pandemic) and 421 Swedish students (293 before and 128 during the pandemic), aged 9-18, who voluntarily reported their meals using a mobile application. The meal pictures were collected over four-month periods over two consecutive years; namely, between the 20th of August and the 20th of December in 2019 (before the COVID-19 outbreak) and the same period in 2020 (during the COVID-19 outbreak). The collected pictures were annotated manually by a trained nutritionist. A chi-square test was performed to evaluate the differences in proportions before versus during the pandemic. RESULTS: In total, 10,770 pictures were collected, including 6474 pictures from before the pandemic and 4296 pictures collected during the pandemic. Out of those, 86 pictures were excluded due to poor image quality, and 10,684 pictures were included in the final analyses (4267 pictures from Greece and 6417 pictures from Sweden). The proportion of UPF significantly decreased during vs. before the pandemic in both populations (50% vs. 46%, p = 0.010 in Greece, and 71% vs. 66%, p < 0.001 in Sweden), while the proportion of vegetables and/or fruits significantly increased in both cases (28% vs. 35%, p < 0.001 in Greece, and 38% vs. 42%, p = 0.019 in Sweden). There was a proportional increase in meal pictures containing UPF among boys in both countries. In Greece, both genders showed an increase in vegetables and/or fruits, whereas, in Sweden, the increase in fruit and/or vegetable consumption was solely observed among boys. CONCLUSIONS: The proportion of UPF in the Greek and Swedish students' main meals decreased during the COVID-19 pandemic vs. before the pandemic, while the proportion of main meals with vegetables and/or fruits increased.

Implication of COVID-19 pandemic on the incidence of Clostridioides difficile infection in a Greek tertiary hospital.

Introduction. C. difficile infection (CDI) represents an important global threat. In the COVID-19 era, the multifactorial nature of CDI has emerged.Hypothesis - Aim. The aim was to assess the impact of COVID-19 pandemic on the incidence of CDI in a Greek hospital.Methodology. A retrospective study was performed throughout a 51 month period (January 2018 to March 2022), divided into two periods: pre-pandemic (January 2018 to February 2020) and COVID-19 pandemic (March 2020 to March 2022). The effects of the pandemic compared to the pre-pandemic period on the incidence of CDI [expressed as infections per 10 000 bed days (IBD)] were studied using interrupted time-series analysis.Results. Throughout the study, there was an increase in the monthly CDI incidence from 0.00 to 11.77 IBD (P<0.001). Interrupted time-series disclosed an increase in CDI incidence during the pre-pandemic period from 0.00 to 3.36 IBD (P<0.001). During the COVID-19 pandemic period the linear trend for monthly CDI rose from 2.65 to 13.93 IBD (P<0.001). The increase rate was higher during the COVID-19 pandemic period (r2 = +0.47) compared to the pre-pandemic period (r1 = +0.16).Conclusion. A significant increase of CDI incidence was observed, with the rate of the rise being more intense during the COVID-19 pandemic.

A new outbreak of HIV infection among people who inject drugs during the COVID-19 pandemic in Greece.

BACKGROUND: Multiple HIV outbreaks have been recorded among people who inject drugs (PWID) since 2010. During an intervention for PWID in 2019-2021 in Thessaloniki, Greece, an increasing number of HIV cases was documented. Here, we provide an analysis of this new outbreak. METHODS: ALEXANDROS was a community-based program and participation included interviewing, rapid HIV/HCV tests, counselling and linkage to care. PWID were recruited through Respondent-Driven Sampling (RDS) in five sampling rounds. Crude and RDS-weighted HIV prevalence estimates were obtained. HIV incidence was estimated from data on 380 initially seronegative PWID with at least two tests. Multivariable Cox proportional hazards model was used to assess risk factors for HIV seroconversion. RESULTS: In total, 1,101 PWID were recruited. At first participation, 53.7% were current PWID, 20.1% homeless, 20.3% on opioid substitution treatment and 4.8% had received syringes in the past 12 months. HIV prevalence (95% CI) was 7.0% (5.6-8.7%) and an increasing trend was observed over 2019-2021 (p = 0.002). Two-thirds of the cases (67.5%) were new diagnoses. HIV incidence was 7.0 new infections/100 person-years (95% CI:4.8-10.2). Homelessness in the past 12 months (HR:2.68; 95% CI:1.24-5.81) and receptive syringe sharing (HR:3.86; 95% CI:1.75-8.51) were independently associated with increased risk of seroconversion. By the end of the program, 67.3% of the newly diagnosed cases initiated antiretroviral treatment. CONCLUSIONS: A new HIV outbreak among PWID was documented in Greece during the COVID-19 pandemic with homelessness and syringe sharing being associated with increased risk of HIV acquisition. Peer-driven programs targeting the population of high-risk underserved PWID can be used to early identify emerging outbreaks and to improve linkage to HIV care.

Efficacy of Tocilizumab in Severely Ill COVID-19 Patients With Rapid Respiratory Deterioration: A Single Center Experience During the Third Pandemic Wave in Greece.

BACKGROUND/AIM: Immunomodulatory therapy with Tocilizumab (TCZ), a monoclonal antibody against interleukin-6 receptor-alpha, has been endorsed by the World Health Organization and other major regulatory bodies, as part of the standard-of-care therapy for severe or critical COVID-19 cases despite discordant trial outcomes. The aim of the present study was to report the experience of our center regarding TCZ routine use in severely ill COVID-19 patients who were hospitalized during the third pandemic wave in Greece. PATIENTS AND METHODS: From March 2021 to December 2021, we retrospectively analyzed COVID-19 patients with radiological findings of pneumonia and signs of rapid respiratory deterioration that were treated with TCZ. The primary outcome included the risk of intubation or/and death in TCZ-treated patients compared to matched controls. RESULTS: TCZ administration was neither predictive of intubation and/or death [OR=17.5 (95% CI=0.47-652.2; p=0.12)] or associated with fewer events (p=0.92) in multivariate analysis. CONCLUSION: Our single-center real-life experience is in line with recently published research, revealing no benefit from TCZ routine use in severely or critically ill patients with COVID-19.

Wastewater Levels of Respiratory Syncytial Virus Associated with Influenza-like Illness Rates in Children-A Case Study in Larissa, Greece (October 2022-January 2023).

The emergence of the COVID-19 pandemic has led to significant progress in the field of wastewater-based surveillance (WBS) of respiratory pathogens and highlighted its potential for a wider application in public health surveillance. This study aimed to evaluate whether monitoring of respiratory syncytial virus (RSV) in wastewater can provide a comprehensive picture of disease transmission at the community level. The study was conducted in Larissa (Central Greece) between October 2022 and January 2023. Forty-six wastewater samples were collected from the inlet of the wastewater treatment plant of Larissa and analyzed with a real-time reverse transcription polymerase chain reaction (RT-PCR) based method. RSV and SARS-CoV-2 wastewater viral loads (genome copies/100,000 inhabitants) were analyzed against sentinel surveillance data on influenza-like illness (ILI) to identify potential associations. Univariate linear regression analysis revealed that RSV wastewater viral load (lagged by one week) and ILI notification rates in children up to 14 years old were strongly associated (std. Beta: 0.73 (95% CI: 0.31-1.14), p = 0.002, R2 = 0.308). A weaker association was found between SARS-CoV-2 viral load and ILI rates in the 15+ age group (std. Beta: 0.56 (95% CI: 0.06-1.05), p = 0.032, R2 = 0.527). The results support the incorporation of RSV monitoring into existing wastewater-based surveillance systems.

The Use of Dietary Supplements and Their Association with COVID-19-Related Anxiety among Non-Institutionalized Elderly in Northern Greece.

The elderly constitute a vulnerable group for increased anxiety and poor diet during the COVID-19 pandemic. There is limited research on the levels of COVID-19-related anxiety and dietary habits including dietary supplementation practices among the elderly and very elderly in Greece. A cross-sectional survey was conducted in 364 non-institutionalized elderly (65-74 y) and very elderly (≥75 y) living in northern Greece, with the aim to investigate the use of dietary supplements and their association with other factors, particularly the COVID-19-related anxiety. Levels of anxiety were assessed with the use of the Coronavirus Anxiety Scale (CAS-5). The percentage of dietary supplement users was 62.6%. The most popular dietary supplements used were vitamin D followed by vitamin C and multivitamin and mineral supplements. Multivariate analysis showed that the very elderly and overweight individuals were less likely to consume vitamin D supplements. Approximately a third of the participants (33.8%) exhibited signs of COVID-19-related anxiety but only 8% showed dysfunctional levels of anxiety. Regression analysis indicated that women, former smokers, and people exhibiting any sign of COVID-19 anxiety were approximately two times more likely to consume dietary supplements of any kind (Gender: OR 2.34, 95% CI 1.30-4.19; Smoking: OR 2.15, 95% CI: 1.08-4.26; COVID-19 anxiety: OR 2.16, 95 % CI: 1.20-3.91). Our results provide useful insights into the current practices of dietary supplement use in this population group and could be used by dietetic and medical associations as well as public authorities in the formulation of targeted, safe, and effective interventions for the protection of public health.

Impact of the COVID-19 lockdown on the oral health status of paediatric dental patients in Greece.

BACKGROUND: Limited evidence regarding the post-COVID-19 dental status of paediatric patients is available, with most studies assessing only children's oral health habits. AIM: To evaluate the effect of the COVID-19 lockdown on the oral health of paediatric dental patients in Greece. DESIGN: This was a retrospective cohort study that included a questionnaire on children's oral health behavior and a clinical examination assessing dental caries and dental treatment needs using the International Caries Detection and Assessment System criteria, dmft/DMFT, and Treatment Need Index. The Wilcoxon signed-rank test was used for a statistical comparison between questionnaire and clinical data before, during, and after the lockdown. RESULTS: A total of 102 children with a median age of 9 years were recruited from the current cohort of patients that had their last dental examination 6 months prior to the lockdown. Results from the questionnaire showed decreased brushing frequency with increased eating frequency and sugar consumption during the lockdown period (p < .001). Moreover, 16.5% had to visit the dentist for urgent care during the lockdown, 13.6% experienced dental pain, and 51.5% did not experience any dental emergencies. Clinical examination, after the lockdown, recorded significantly increased mean dmft/DMFT scores by 0.63 units in the primary dentition (p = .01) and 0.52 units in the permanent teeth (p = .002). Significantly higher treatment needs, with more carious lesions requiring extensive treatment after the lockdown, were recorded (p < .001). CONCLUSION: The COVID-19 lockdown negatively affected children's oral health behavior: caries prevalence increased and more complex dental treatments were required.

Impact of COVID-19 Pandemic on Mental Health and Socioeconomic Aspects in Greece.

The global outbreak of the COVID-19 pandemic has spread worldwide, affecting almost all countries and territories. COVID-19 continues to impact various spheres of our life, such as the economy, industries, global market, agriculture, human health, health care, and many others. The aim of this study was to investigate the impact of the COVID-lockdowns on people's mental health in Greece. A descriptive, cross-sectional study was conducted in several urban, semi-urban and rural areas. The survey of 252 Greek people was conducted in spring 2022, and 46.8% of them were female and the other 53.2% were male. Ages were between 19 and 60 years old. Some of the main findings were that most of the participants feel their mental health got worse than before (about 80%), participants with kids were more affected than those who did not have any kids because they had bigger responsibilities and the pandemic might have caused them a lot of problems to deal with. The higher the income, the less they are affected, and people whose jobs did not change dramatically were also less likely to not be much mentally affected. Moreover, the percentage of smokers whose mental health became worse was greater than that among those who did not smoke. The same happened with those who consumed alcohol. Finally, we used the GBM algorithm to find three important predictors and we applied k-means to have a clear picture of the different clusters and how a number of participants are connected according to their answers.

Behavioral and Cultural Insights, a Nationwide Study Based on Repetitive Surveys of WHO Behavioral Insights Tool in Greece Regarding COVID-19 Pandemic and Vaccine Acceptance.

Monitoring behavioral and cultural insights during the pandemic is a useful tool to identify factors related to COVID-19 vaccine acceptance and confront the pandemic's vast impact. Data were collected using a questionnaire designed according to the "survey tool and guidance" provided by the World Health Organization (WHO). Surveys were conducted by a market research company for five consecutive months, with a sample of 1000 individuals recruited per survey. Vaccination acceptance increased from 55.2% to 67.2%, while the percentage of undecisive individuals decreased from 16.3% to 10.6%. The proportion of vaccine resistant participants remained relatively steady (25−30%). Knowledge about the pandemic and compliance with preventive measures was high (>90%). Factors associated with vaccination included: Increased age, male gender, influenza vaccination, following authorities' recommendations, being informed by HCWs or formal information sources, care for others, concern about the country's economic recession and health system overload. Pandemic fatigue was reflected across the surveys, indicated by a decrease in the intention to self-isolate and remain at home when ill. Despite the decrease of undecisive individuals, a firm core of vaccine resistant individuals may be responsible for the relatively lower vaccine coverage compared to northern EU countries. Study results could be useful for developing approaches tailored to a reluctant population.

Perspectives on Emergency Remote Teaching during COVID-19 Pandemic in a Sample of Greek Undergraduate Students: The Role of Self-Image.

Emergency remote teaching replaced the in-person education in academic institutions as a result of the COVID-19 pandemic. Students with different personality traits experienced this abrupt change to distance learning in different ways. Thus, this research aims to examine the interplay between several facets of the students' experience of emergency remote teaching, such as concerns about, tiredness with, and lack of communication during the first Greek lockdown, and their self-image through their core self-evaluations. The study sample consisted of 341 undergraduate students derived from 13 Greek universities, that completed a self-report questionnaire concerning students' experiences with distance education, as well as the Core Self-Evaluation Scale measuring self-image components. A cross-section design was used and multiple regression and mediation analyses were applied. The results showed that self-image has an effect on students' feeling of tiredness with distance learning, while female students demonstrated higher tiredness with distance learning and lack of communication. Moreover, except for gender and disability, all other variables along with self-image significantly predicted perspectives on distance learning. On the other hand, only gender, concerns about, and lack of communication significantly predicted students' e-attendance of theoretical courses. In this transformative era, it is a challenge for universities to create effective online courses concerning students' self-image. Finally, limitations and future directions are discussed.

The COVID-19 Pandemic Enhanced Virology Research in Greece.

The emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presented an unprecedented public health threat, being the cause of one of the most devastating pandemics in history [...].

Effectiveness of full (booster) COVID-19 vaccination against severe outcomes and work absenteeism in hospitalized patients with COVID-19 during the Delta and Omicron waves in Greece.

AIM: We estimated vaccine effectiveness (VE) of full (booster) vaccination against severe outcomes in hospitalized COVID-19 patients during the Delta and Omicron waves. METHODS: The study extended from November 15, 2021 to April 17, 2022. Full vaccination was defined as a primary vaccination plus a booster ≥ 6 months later. RESULTS: We studied 1138 patients (mean age: 66.6 years), of whom 826 (72.6 %) had ≥ 1 comorbidity. Of the 1138 patients, 75 (6.6 %) were admitted to intensive care unit (ICU), 64 (5.6 %) received mechanical ventilation, and 172 (15.1 %) died. There were 386 (33.9 %) fully vaccinated, 172 (15.1 %) partially vaccinated, and 580 (51 %) unvaccinated patients. Unvaccinated patients were absent from work for longer periods compared to partially or fully vaccinated patients (mean absence of 20.1 days versus 12.3 and 17.3 days, respectively; p-value = 0.03). Compared to unvaccinated patients, fully vaccinated patients were less likely to be admitted to ICU [adjusted relative risk (ARR: 0.49; 95 % CI: 0.29-0.84)], mechanically ventilated (ARR: 0.43; 95 % CI: 0.23-0.80), and die (ARR: 0.57; 95 % CI: 0.42-0.78), while they were hospitalized for significantly shorter periods (ARR: 0.79; 95 % CI: 0.70-0.89). The adjusted full VE was 48.8 % (95 % CI: 42.7 %-54.9 %) against ICU admission, 55.4 % (95 % CI: 52.0 %-56.2 %) against mechanical ventilation, and 22.6 % (95 % CI: 7.4 %-34.8 %) against death. For patients with ≥ 3 comorbidities, VE was 56.2 % (95 % CI: 43.9 %-67.1 %) against ICU admission, 60.2 % (95 % CI: 53.7 %-65.4 %) against mechanical ventilation, and 43.9 % (95 % CI: 19.9 %-59.7 %) against death. CONCLUSIONS: Full (booster) COVID-19 vaccination conferred protection against severe outcomes, prolonged hospitalization, and prolonged work absenteeism.

The impact of seasonal influenza vaccination uptake on COVID-19 vaccination attitudes in a rural area in Greece.

INTRODUCTION: Promoting vaccination for coronavirus disease 2019 (COVID-19), especially for high-risk groups such as the elderly and persons with comorbidities, is important for reducing the incidence of severe disease and death. METHODS: Retrospective cross-sectional study of factors associated with COVID-19 vaccination, including previous influenza vaccination, among all persons who received medical services in a rural area in Crete, Greece, between October 2020-May 2021. RESULTS: Among 3129 participants, receipt of influenza vaccination in 2020-21 was strongly associated with COVID-19 vaccination, as was influenza vaccination in 2019-20, albeit to a lesser extent. In addition, persons older than 59 years (with exception of those 90 + years old) and those who lived closer to the hospital/health center, were more likely to vaccinate for COVID-19. Persons younger than 40 years of age, females, persons with mental illness or neurologic disease, were also less likely to vaccinate for COVID-19 (all p < 0.001). CONCLUSIONS: COVID-19 vaccination was more likely among those who were vaccinated for influenza before and during the pandemic. Access to healthcare services and specific comorbidities, were important influencers for vaccination, underlying the importance of tailored interventions to enforce vaccination in high-risk groups.

Work place and prevalence of COVID-19 in a rural population in Greece.

INTRODUCTION: Coronavirus disease-19 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic, giving rise to a serious global health threat. Many countries including Greece have seen a two-wave pattern of reported cases, with a first wave in spring and a second in autumn of 2020. METHODS: A cross-sectional seroprevalence study was designed to measure the prevalence of IgG antibodies with a quantitative SARS-CoV-2 IgG lab-based serology test, chemiluminescent microparticle immunoassay, against novel coronavirus in rural areas in Greece after the second pandemic wave. The study was conducted on 29 January 2021 in a rural semi-closed area, the municipality of Deskati, prefecture of western Macedonia in Greece after the second pandemic wave. RESULTS: Sixty-nine participants were included in this study. The present study demonstrated a high prevalence of COVID-19 infection (31 of 69 total participants; 45%) and those who were working in the public sector were at higher risk of COVID-19 infection in comparison to their counterparts in private sector (p=0.05364), (relative risk 2.64; 95% confidence interval 1.001-7.086). CONCLUSION: The study presents data showing a high prevalence of herd immunity for COVID-19 in a semi-closed area in Greece. These findings might help to understand the characteristics of this second wave, the behaviour and danger of SARS-CoV-2 in rural areas in Greece and Europe generally.

Evaluating the COVID-19 Containment Protocol in Greek Universities for the Academic Year 2021-2022.

The COVID-19 pandemic severely disrupted European universities' educational process. With the vaccination rollout, in-class instruction broadly resumed beginning in September 2021. In order to mitigate the risks of SARS-CoV-2 transmission, European universities apply COVID-19 containment protocols. The aim of this paper is to evaluate the COVID-19 containment protocol that Greek universities implemented in order to fully reopen in the fall of 2021 and for the entire academic year 2021-2022. A case study was conducted at the Department of Industrial Management and Technology, University of Piraeus (Athens' port), Greece. Data were collected from November 2021 to July 2022 and a quantitative statistical analysis (descriptive and inferential) was performed. A total of 330 unique (and 43 reinfections) COVID-19 cases were confirmed, including 241 undergraduate students, 73 postgraduate, and 2 doctoral students, 10 faculty, and 4 administrative personnel. Contact tracing reported four confirmed and eight potential cases of in-classroom transmission. The person in charge of implementing the COVID-19 containment protocol in the department ordered more than 6000 rapid tests during this period. The Department of Industrial Management and Technology at the University of Piraeus used a rigorously monitored and coordinated strategy of vaccine promotion, screening/testing, contact tracing, isolation, and quarantine in order to control COVID-19 transmission. The results show, on one hand, that the protocol's implementation is effective and leads to in-classroom transmission minimization and, on the other hand, verify the hypothesis that the department's confirmed COVID-19 cases are less (with a mean percentage difference of 50%) than the community's respective 18-39 age group.

Results of a Web-based survey of 2105 Greek migraine patients in 2020: demographics, clinical characteristics, burden and the effects of the COVID-19 pandemic on the course of migraine.

The Greek Society of Migraine and Headache Patients (GSMHP), maintaining a strong commitment to research and information, conducted its second web-based online survey named "Migraine in Greece-2020", following its first one conducted in 2018. The 2020 study included 2,105 migraine patients who were called to answer 151 questions. The purposes of the current research were to record the demographic and clinical characteristics of migraine patients in Greece, including the severity and effects of migraine on respondents' quality of life, as well as to survey the effects of the coronavirus pandemic on the course of migraine. Our population, internet-based study provides data that will hopefully contribute to better comprehend the clinical phenotype and course of migraine during the COVID-19 pandemic.

Effect of the first and second COVID-19 associated lockdown on the metabolic control of patients with type 2 diabetes in Greece.

The aim of this study was to assess the effect of the COVID-19 lockdown periods on the metabolic control of patients with type 2 diabetes (T2D) in three academic diabetes centers in Greece. There was a slight improvement in BMI, blood pressure and lipid values while the remaining parameters remained stable.

A qualitative study of nursing practitioners' experiences with COVID-19 patients dying alone in Greece.

Background: In Greece, there is still limited research on death in isolation due to COVID-19. This deserves attention because of the recent financial crisis, which profoundly impacted public health, and the high relevance of the Hippocratic tradition to the moral values of clinical practice. Methods: A prospective qualitative study using in-depth interviews with 15 frontline nursing practitioners working in a COVID-19 ward or intensive care unit (ICU) was conducted from July 2021 to December 2021. Results: The inability of family members to say a final goodbye before, during, or after death by performing proper mourning rituals is extremely inhuman and profoundly impacts the mental health status of patients, family members, and nursing practitioners. Patients and their family members strongly desire to see each other. Epidemiology, liability, and proper nursing performance emerged as reasons for the enforced strict visitation restrictions. Participants emphasized that visitations should be allowed on an individual basis and highlighted the need for the effective use of remote communication technology, which, however, does not substitute for in-person contact. Importantly, physicians allowed "clandestine" visits on an individual basis. Nursing practitioners had a strong empathic attitude toward both patients and their families, and a strong willingness to provide holistic care and pay respect to dead bodies. However, they also experienced moral distress. Witnessing heartbreaking scenes with patients and/or their families causes nursing practitioners to experience intense psychological distress, which affects their family life rather than nursing performance. Ultimately, there was a shift from a patient-centered care model to a population-centered care model. Furthermore, we identified a range of policy- and culture-related factors that exaggerate the negative consequences of dying alone of COVID-19. Conclusion: These results reinforce the existing literature on several fronts. However, we identified some nuances related to political decisions and, most importantly, convictions that are deeply rooted in Greek culture. These findings are of great importance in planning tailored interventions to mitigate the problem of interest and have implications for other similar national contexts.

Re-Starting the Cruise Sector during the COVID-19 Pandemic in Greece: Assessing Effectiveness of Port Contingency Planning.

Coronavirus disease (COVID-19) outbreaks on board cruise ships early in the pandemic highlighted gaps worldwide in public health emergency contingency plans (PHECPs) for responding to unknown threats. To restart cruise operations in 2021 and respond to potential COVID-19 outbreaks, a major tourist-based Greek island port (Port A) developed a COVID-19 PHECP. We assessed plan effectiveness by reviewing epidemiological data and monitoring outcomes, followed by an intra-action review (IAR) analyzing three event responses. From May to December 2021, 118 calls from 23 cruise ships with 119,930 passengers were recorded, with 29 COVID-19 cases in 11 cruises on board 7 ships. No outbreak was recorded during the study period. Strengths of the introduced PHECP included commitment of senior management; a core multi-disciplinary team of local authorities/ship agents involved in design and execution; interoperability agreements for port and ships' PHECPs; cruise industry commitment to compliance; and pre-existing scenarios considering capacity needs. Central government coordination for preparedness planning at local ports is essential for successful responses. Monitoring local and country level response capacities is critical to inform planning, risk assessment, and decision-making. Immediately recording ports' response actions provides the basis to capture lessons and improve contingency plans. To facilitate communication and common response protocols between European and non-European ports, IARs should be conducted between countries.