Gastroenteritis Outbreaks after Contamination of Water Supply Systems: Public Health Response Gaps and Challenges, Greece, 2004-2023.

BACKGROUND: waterborne disease outbreaks (WGDOs) following the contamination of drinking water remain a public health concern. METHODS: The current study aims to assess the occurrence and identify gaps in the notification and investigation of WGDOs in Greece. Data for 2004-2023 were retrieved and summarized. RESULTS: Thirty-five outbreaks with 6128 recorded cases were identified. The median time from the date of onset in the first cases to reporting was 7 days (range: 1-26 days). Authorities were informed by health care services in thirty (85.7%) outbreaks and by the media in five (14.3%). The investigation methods used varied. An analytical study was conducted in nine (25.7%) outbreaks and the testing of clinical samples in twenty-seven (77.1%). In three (11.1%) outbreaks, clinical samples were simultaneously tested for multiple bacteria, viruses, and parasites. Water samples were collected in nineteen (54.3%) outbreaks (in three after chlorination) with a mean time lag of 5 days (range: 1-20 days) from the first cases. A pathogen in clinical samples was identified in 20 (57.1%) outbreaks and, in 1 (6.25%), the same microorganism was isolated in both clinical and water samples. CONCLUSIONS: delays in reporting and the heterogeneity of investigations depict that the surveillance of WGDOs and response practices should be strengthened, and operational procedures should be standardised.

Disentangling the contributions of initial heterogeneities and dynamic stress adaptation to nonlinearities in bacterial survival curves.

The deviations from log-linearity that are often observed in bacterial survivor curves can be explained using different arguments, both biological and experimental. In this study, we used Bacillus subtilis as a model organism to demonstrate that the generally accepted vitalistic arguments (initial heterogeneities in the stress resistance of the cells in the population) may fail to describe microbial inactivation in some situations. In this sense, we showed how dynamic stress acclimation during an isothermal treatment provides an alternative explanation for survivor curves with an upwards curvature. We also provided an innovative experimental approach based on preadaptation experiments to evaluate which hypothesis is more suitable for the bacterial response. Furthermore, we used our experimental results to define bounds for the possible stress acclimation that may take place during dynamic treatments, concluding that the magnitude of stress acclimation may be larger for dynamic treatments than for isothermal experiments. We also evaluated the contribution of the SigB general stress response system to heat resistance by comparing the heat survival of wt and the ΔsigB mutant. Both strains survived better in 51, 52.5 and 55 °C when cells were pre-adapted at 48 °C than non-pre-adapted cells. However, ΔsigB was less resistant to heat than wt due to the missing SigB general stress system. Although these conclusions were based on B. subtilis as a model organism, this study can be the first step towards the development of a novel methodology able to estimate dynamic effects using only isothermal experiments. This would improve the models developed within the predictive microbiology community, improving our ability to predict microbial inactivation during industrial treatments, which are most often dynamic.

Different model hypotheses are needed to account for qualitative variability in the response of two strains of Salmonella spp. under dynamic conditions.

In this article, the thermal inactivation of two Salmonella strains (Salmonella Enteritidis CECT4300 and Salmonella Senftenberg CECT4565) was studied under both isothermal and dynamic conditions. We observed large differences between these two strains, with S. Senftenberg being much more resistant than S. Enteritidis. Under isothermal conditions, S. Senftenberg had non-linear survivor curves, whereas the response of S. Enteritidis was log-linear. Therefore, weibullian inactivation models were used to describe the response of S. Senftenberg, with the Mafart model being the more suitable one. For S. Enteritidis, the Bigelow (log-linear) inactivation model was successful at describing the isothermal response. Under dynamic conditions, a combination of the Peleg and Mafart models (secondary model of Mafart; t* of Peleg) fitted to the isothermal data could predict the response of S. Senftenberg to the dynamic treatments tested (heating rates between 0.5 and 10 °C/min). This was not the case for S. Enteritidis, where the model predictions based on isothermal data underestimated the microbial concentrations. Therefore, a dynamic model that considers stress acclimation to one of the dynamic profiles was fitted, using the remaining profiles as validation. In light of this, besides its quantitative impact, variability between strains of bacterial species can also cause qualitative differences in microbial inactivation. This is demonstrated by S. Enteritidis being able to develop stress acclimation where S. Senftenbenberg could not. This has important implications for the development of microbial inactivation models to support process design, as every industrial treatment is dynamic. Consequently, it is crucial to consider different model hypotheses, and how they affect the model predictions both under isothermal and dynamic conditions.

Transmission Clusters, Predominantly Associated With Men Who Have Sex With Men, Play a Main Role in the Propagation of HIV-1 in Northern Spain (2013-2018).

Viruses of HIV-1-infected individuals whose transmission is related group phylogenetically in transmission clusters (TCs). The study of the phylogenetic relations of these viruses and the factors associated with these individuals is essential to analyze the HIV-1 epidemic. In this study, we examine the role of TCs in the epidemiology of HIV-1 infection in Galicia and the Basque County, two regions of northern Spain. A total of 1,158 HIV-1-infected patients from both regions with new diagnoses (NDs) in 2013-2018 were included in the study. Partial HIV-1 pol sequences were analyzed phylogenetically by approximately maximum-likelihood with FastTree 2. In this analysis, 10,687 additional sequences from samples from HIV-1-infected individuals collected in Spain in 1999-2019 were also included to assign TC membership and to determine TCs' sizes. TCs were defined as those which included viruses from ≥4 individuals, at least 50% of them Spaniards, and with ≥0.95 Shimodaira-Hasegawa-like node support in the phylogenetic tree. Factors associated to TCs were evaluated using odds ratios (OR) and their 95% CI. Fifty-one percent of NDs grouped in 162 TCs. Male patients (OR: 2.6; 95% CI: 1.5-4.7) and men having sex with men (MSM; OR: 2.1; 95% CI: 1.4-3.2) had higher odds of belonging to a TC compared to female and heterosexual patients, respectively. Individuals from Latin America (OR: 0.3; 95% CI: 0.2-0.4), North Africa (OR: 0.4; 95% CI: 0.2-1.0), and especially Sub-Saharan Africa (OR: 0.02; 95% CI: 0.003-0.2) were inversely associated to belonging to TCs compared to native Spaniards. Our results show that TCs are important components of the HIV-1 epidemics in the two Spanish regions studied, where transmission between MSM is predominant. The majority of migrants were infected with viruses not belonging to TCs that expand in Spain. Molecular epidemiology is essential to identify local peculiarities of HIV-1 propagation. The early detection of TCs and prevention of their expansion, implementing effective control measures, could reduce HIV-1 infections.

Severity of the clinical presentation of hepatitis A in five European countries from 1995 to 2014.

OBJECTIVES: We analysed hepatitis A (HepA) notifications and hospitalisations in Italy, the Netherlands, Norway, Spain, and Sweden for available periods between 1995 and 2014. We aimed to investigate whether decreasing HepA incidence is associated with increasing age at infection and worsening HepA presentation and to identify groups at risk of severe disease. METHODS: We performed a retrospective cohort study including 36 734 notified and 36 849 hospitalised patients. We used negative binomial regressions to identify over time: i) trends in hospitalisation and notification rates; ii) proportion of hospitalised and notified patients aged ≥40 years; iii) proportion of "severe hospitalisations"; and iv) risk factors for severe hospitalisation. RESULTS: During the study period both HepA notifications and hospitalisations decreased, with notification rates decreasing faster, patients aged ≥40 years increased, however, the proportion of severe HepA hospitalisations remained stable. Older patients and patients with comorbidities, particularly liver diseases, were more likely to experience severe disease. CONCLUSIONS: We used digitalised health information to confirm decreasing trends in HepA hospitalisations and notifications, and the increasing age of patients with HepA in Europe. We did not identify an increase in the severity of the clinical presentation of patients with HepA. Older patients with liver diseases are at increased risk of severe disease and should be prioritised for vaccination.

Epidemiology of Escherichia coli Bacteremia: A Systematic Literature Review.

BACKGROUND: Escherichia coli is the most common cause of bacteremia in high-income countries. To enable the development and implementation of effective prevention strategies, a better understanding of the current epidemiology of invasive E. coli infections is needed. METHODS: A systematic review of literature published between 1 January 2007 and 31 March 2018 on the burden and epidemiology of E. coli bacteremia in populations that include adults in high-income countries was conducted. Meta-analysis was performed for descriptive purposes. RESULTS: During the studied time interval, the estimated incidence rate of E. coli bacteremia was 48 per 100 000 person-years, but this increased considerably with age: rates per 100 000 person-years were >100 in 55-to-75-year-olds and >300 in 75-to-85-year-olds. Overall, E. coli accounted for 27% of documented bacteremia episodes: 18% if hospital acquired, 32% if community-onset healthcare associated, and 33% if community acquired. The estimated case fatality rate was 12%. Approximately 44% of episodes were community acquired, 27% community-onset healthcare associated, and 27% hospital acquired. Urinary tract infection (UTI) was the primary source for 53% of episodes. CONCLUSIONS: This systematic review confirms the substantial burden of E. coli bacteremia in older adults and justifies the implementation of community-level programs to prevent E. coli bacteremia and ideally UTI in this age group.

Training in tools to develop Quantitative Risk Assessment using Spanish ready-to-eat food examples.

Unsafe food poses global health threats, potentially endangering consumers. The great majority of people will experience a food-borne disease at some point in their lives. Ready-to-eat (RTE) food is the one intended by the producer or the manufacturer for direct human consumption without the need for cooking or other processing effective to eliminate or reduce the concentration of pathogenic microorganisms. Prepared foods are often complex and may contain multiple components that make them vulnerable for growth of pathogenic microorganisms. Among all the pathogenic microorganisms that may be present in RTE foods, Listeria monocytogenes is of special interest because it is the causative agent of listeriosis and it has the ability to survive and replicate at refrigeration and low pH conditions. We performed a quantitative microbial risk assessment (QMRA) in RTE dry-fermented sausage to measure the risk of listeriosis associated to the consumption of this product. The starting point of our investigation was the storage at the factory, after the end-product was produced and before distribution to retail. The stochastic model was implemented in MicroHibro, an online tool for QMRA. Because L. monocytogenes concentration and prevalence can vary greatly between different studies and different types of fermented sausages, we tested different scenarios to show the importance of low prevalence and concentration of the pathogen at the final product. Our results show that the risk estimates are very sensitive to the modelling hypotheses used to describe this process. Therefore, the development of accurate probabilistic models describing the initial concentration of L. monocytogenes shall largely reduce the uncertainty associated to the QMRA of listeriosis in this type of product.

Species composition, distribution, ecological preference and host association of ticks in Cyprus.

Tick population and species depend on the effect of biotic and abiotic factors, especially vegetation, climate and host density; Cyprus, due to the mild climate, favors the appearance and spread of tick-borne infections. Our objective was to identify the tick species present in the island, to investigate their geographical distribution and their epidemiological implications. During a three-year study (2004-2006) we collected ticks from domestic and wild animals over the island of Cyprus. Data on temperature, humidity, altitude and vegetation, were also recorded. Each tick was identified by species using existing taxonomic keys. The results were mapped on a county level. During the current study 3057 ticks belonging to 11 tick species and four genera were collected from 441 (24.6%) infested animals. Rhipicephalus sanguineus was the predominant species (38.5%), followed by R. turanicus (21.3%) and R. bursa (17.8%). Most infestations occurred in May (24.0%), followed by March (13.6%) and June (12.2%). Rhipicephalus sanguineus had a positive correlation with humidity and temperature, R. bursa and Ixodes gibbosus had a positive correlation with altitude and a negative correlation with temperature. Contrary, Hyalomma excavatum had a negative correlation with altitude. Climate and the availability of hosts are among the major factors influencing ticks.

An outbreak of a possibly new Salmonella enterica subspecies enterica serovar with the antigenic formula 11:z41:e,n,z15, Greece, March to May 2016: preliminary results.

Eleven Salmonella spp. isolates with the antigenic type 11:z41:e,n,z15 - not referred to in the 9th edition of the White-Kauffman-Le Minor Scheme - were identified at the National Reference Laboratory for Salmonella in Greece. Their pulsed-field gel electrophoresis profiles were indistinguishable. No apparent epidemiological link has yet been identified; the results of a case-case study are pending.

Present and future of cervical cancer prevention in Spain: a cost-effectiveness analysis.

Human papillomavirus (HPV) vaccination within a nonorganized setting creates a poor cost-effectiveness scenario. However, framed within an organized screening including primary HPV DNA testing with lengthening intervals may provide the best health value for invested money. To compare the effectiveness and cost-effectiveness of different cervical cancer (CC) prevention strategies, including current status and new proposed screening practices, to inform health decision-makers in Spain, a Markov model was developed to simulate the natural history of HPV and CC. Outcomes included cases averted, life expectancy, reduction in the lifetime risk of CC, life years saved, quality-adjusted life years (QALYs), net health benefits, lifetime costs, and incremental cost-effectiveness ratios. The willingness-to-pay threshold is defined at 20 000&OV0556;/QALY. Both costs and health outcomes were discounted at an annual rate of 3%. A strategy of 5-year organized HPV testing has similar effectiveness, but higher efficiency than 3-year cytology. Screening alone and vaccination combined with cytology are dominated by vaccination followed by 5-year HPV testing with cytology triage (12 214&OV0556;/QALY). The optimal age for both ending screening and switching age from cytology to HPV testing in older women is 5 years later for unvaccinated than for vaccinated women. Net health benefits decrease faster with diminishing vaccination coverage than screening coverage. Primary HPV DNA testing is more effective and cost-effective than current cytological screening. Vaccination uptake improvements and a gradual change toward an organized screening practice are critical components for achieving higher effectiveness and efficiency in the prevention of CC in Spain.

Murine typhus in Cyprus: a 9-year survey.

Epidemiological and clinical data of 193 human cases of murine typhus in Cyprus were recorded and analysed during a 9-year period (2000-2008). The incidence rate was estimated at 24.5 cases/100,000 population/year. The incidence rate varied considerably between rural, urban and semi-urban areas, with residents in rural areas accounting for 79.3% of the total cases. Most (72.5%) of the cases occurred in late summer (July and August) and early autumn (September to October) with a peak in September. Well-established persistent endemic foci with clusters of cases were identified and characterised as 'high risk' areas. Presence of or contact with rats and fleas, presence of domestic/peridomestic animals and residence in rural areas, especially locations near the 'green line' (a narrow zone patrolled by UN forces that separates the northern and southern parts of the island), increased the possibility of murine typhus infection. The results of the current study enhance the belief that murine typhus is a serious public health problem in Cyprus.