Brucellosis underreporting in Greece: assessment based on aggregated laborato-ry data of culture-confirmed cases from public hospitals.

BACKGROUND: Brucella spp. isolation is one of the mainstays of brucellosis diagnosis. Simultaneously, the true brucellosis disease rate may be underrepresented in notification systems. This study aims at assessing the nosocomial capacity for Brucella spp. isolation and the underreporting rate of brucellosis cases in Greece. METHODS: Data for Brucella spp. culture capacity and the number of isolations were collected annually from public hospitals nationwide, during 2015-2018. The number of unreported cases was estimated after subtracting the National Mandatory Notification System cases from the survey-captured isolations, matched by hospital and year. RESULTS: Feedback was provided by 112 public hospitals (response rate: 97.4 %). Brucella spp. isolation capacity was completely absent in 27.7 % of hospitals; during the four years of the study, 11.3 %, 13.9 %, 20.0 %, and 25.2 % of the hospitals had isolation competence for one, two, three, or four years, respectively. Underreporting assessment was possible in hospitals that declared at least one Brucella spp. isolation (n =35) and unreported cases were identified in 19 (54 %). Α mean underreporting of 28.9 % of total cases was estimated for the whole period of the study ranging annually from 24.1 % to 35.0 %. The number of unreported cases per hospital ranged from one to 12 per year (median: 2, IQR: 5). CONCLUSIONS: Interventions for improving diagnosis and reporting of the disease are recommended. Assessment of brucellosis underreporting by comparing raw numerical data of survey-captured isolations and officially notified cases lacks the case by case specificity, however, keeping required data to a minimum achieves high feedback rate from hospitals and provides a tentative estimation of the notification deficit. HIPPOKRATIA 2019, 23(3): 106-110.

Rabies outbreak in Greece during 2012-2014: use of Geographical Information System for analysis, risk assessment and control.

The objectives of this work were (i) geographical analysis of the 2012-2014 outbreak of rabies in Greece using GIS and (ii) comparative analysis of animal cases with data of potential human exposure to rabies together with environmental data, in order to provide information for risk assessment, effective monitoring and control. Most animal cases (40/48) involved red foxes, while domestic animals were also diagnosed with rabies. Overall, 80% of the cases were diagnosed in central northern Greece; 75% of the cases were diagnosed in low altitudes (<343·5 m), within a distance of 1 km from human settlements. Median distance from livestock farms was 201·25 m. Most people potentially exposed to rabies (889/1060) presented with dog bite injuries. Maximum entropy analysis revealed that distance from farms contributed the highest percentage in defining environmental niche profiles for rabid foxes. Oral vaccination programmes were implemented in 24 administrative units of the country during 2013 and 2014, covering a total surface area of ~60 000 km2. Rabies re-occurrence in Greece emphasizes the need for ongoing surveillance in cross-border areas and in areas with intense human activity.

Epidemiology of human leishmaniasis in Greece, 1981-2011.

Leishmaniasis is endemic and mandatorily notifiable in Greece. Epidemiological surveillance data for leishmaniasis in Greece between 1981 and 2011 are presented. In 1998, the notification system began distinguishing between visceral and cutaneous leishmaniasis. The mean annual incidence of reported leishmaniasis cases between 1998 and 2011 was 0.36 per 100,000 population. Of a total 563 leishmaniasis cases reported after 1998, 523 (93%) were visceral leishmaniasis cases. Incidence of reported visceral leishmaniasis cases fluctuated during this period, generally decreasing after 2007, with a small re-increase in 2011. The mean annual incidence rate of reported visceral leishmaniasis cases was significantly higher in less than four year-olds (p <0.001). Leishmaniasis cases occurred both in the country mainland and islands. Between 1998 and 2011, Attica concentrated almost half of the reported visceral leishmaniasis cases, with incidence rates in western Attica and western Athens above 12.00 per 100,000 population. Compared to visceral leishmaniasis, cutaneous leishmaniasis had a rather sporadic distribution, with many prefectures appearing free of cases. From 2004, the notification also included risk factors and of 287 cases with known immune status, 44 (15%) were immunocompromised. Moreover having a dog at home was reported by 209 of 312 leishmaniasis cases (67%), whereas 229 of 307 cases (75%) reported the presence of stray dogs near their residence. Linking clinical surveillance data with laboratory data and improving collaboration with the veterinary public health sector are some of the future challenges for leishmaniasis surveillance in Greece.

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 - March 2013.

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.

Outbreak investigation of brucellosis in Thassos, Greece, 2008.

In spring 2008, the Hellenic Center for Disease Control and Prevention was notified about human brucellosis cases in Thassos, a Greek island that had been up to that point under a brucellosis eradication programme. Following the verification of the outbreak a 1:1 case­ control study was conducted in the island. The study revealed that consumption of locally produced raw cheese was a risk factor for Brucella melitensis infection (odds ratio (OR): 15.1, 95% confidence interval (CI): 6.56­34.7). Brucella melitensis biotype 3 was identified in two clinical samples. As a result of the outbreak, the island is no longer officially considered as an area with farms free of brucellosis and is currently under a brucellosis control programme. The investigation of this outbreak demonstrated that control and eradication of brucellosis is not only a question of designing a strategy, but rather of ensuring its continuous, strict implementation. Furthermore, it revealed the lack of appropriate education of the public regarding the risks associated with raw, non heat-treated cheese consumption.

Autochthonous Plasmodium vivax malaria in Greece, 2011.

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

Ongoing outbreak of West Nile virus infection in humans, Greece, July to August 2011.

Between 16 July and 21 August 2011, 31 cases of West Nile neuroinvasive disease were reported from four regions in Greece. Of these, 17 occurred in districts that had not been affected in 2010. The reoccurrence of human cases in two 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.