Preservation status and microbial communities of vacuum-packed hot smoked rainbow trout fillets.

Vacuum-packed hot smoked rainbow trout fillets from two different smokehouses of Greece were stored at 2 and 7.9 °C. Microbiological, sensory, and physicochemical changes were monitored. Microbial communities grown on MRS of three different pHs (5.4, 6.4 and 7.4) were also classified and identified using Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Shelf-life was found to differ between products from the two smokehouses (A: 104 and 45 days, B: 100 and 45 days, at 2 and 7.9 °C, respectively). At the time point that sensory rejection was recorded, counts on MRS were found at higher population levels than the other microorganisms tested, almost in all cases. Out of the 567 colonies isolated from MRS of three different pHs, 71 classified as Enterococcus spp., 383 as Candida spp. and 113 as Lactobacillus spp.. Candida zeylanoides dominated exclusively in fillets from the smokehouse A during storage at 2 °C, while Lactobacillus sakei dominated clearly against C. zeylanoides at 7.9 °C, in all pH values. For the smokehouse B, C. zeylanoides or Enterococcus faecalis found to dominate initially in MRS of three pHs, C. zeylanoides, and/or Candida famata in the middle and/or the time point that sensory rejection was recorded at 2 °C, while Lactobacillus curvatus or E. faecalis at 7.9 °C. This study reveals the predominant cultivable spoilage microbiota of vacuum-packed hot smoked rainbow trout, and provides valuable information to the researcher and producers towards the production of more stable products with improved shelf-life.

Prevalence and characteristics of Listeria monocytogenes in meat, meat products, food handlers and the environment of the meat processing and the retail facilities of a company in Northern Greece.

In this study, we investigated the incidence of Listeria monocytogenes in the receiving meat, the meat products, the personnel and the environment of a vertically integrated company in Northern Greece owing a processing plant and three trading facilities. A total of 303 samples were examined from the receiving raw meat, raw meat preparations, ready-to-eat meat products, processing surfaces and the environment of these facilities as well as the food handlers' hands and nasal cavities. MALDI-TOF MS was used for Listeria identification; from the 22 (7·26%) positive to Listeria spp. isolates, 12 (3·96%) identified as L. monocytogenes, eight (2·64%) as Listeria innocua and two (0·66%) as Listeria welshimeri. Molecular serotyping of L. monocytogenes isolates by multiplex PCR revealed 11 strains belonging to serogroup IIa (1/2a and 3a) and one to IIc (1/2c and 3c). The assay for the detection of the virulence-associated genes revealed eight isolates carrying all the examined genes (inlA, inlB, inlC, plcA, prfA, actA, hlyA and iap) and four carrying all except the actA gene. Eleven (91·7%) of the isolates showed a strong ability to form biofilm. All isolates were multidrug resistant. The MALDI-TOF Main Spectrum Profile (MSPs), revealed three clusters: one with five isolates (four from environmental samples and one from a food handler), one with five isolates (all from environmental samples) and one with two isolates (both from raw meat products). MALDI-TOF MS seems to be a reliable tool for the identification of niches and contamination routes in processing plants, contributing also to the evaluation and improvement of the applied preventive measures to control L. monocytogenes.

Low seropositivity for SARS-CoV-2 antibodies among healthcare workers after the first COVID-19 pandemic wave in Greece.

OBJECTIVES: To estimate the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity among healthcare workers (HCWs) in Greece and to identify high-risk groups in healthcare facilities. STUDY DESIGN: The study design used in this study is a nationwide cross-sectional study. METHODS: Data were collected from 1 June to 9 July 2020. HCWs in the Greek National Health System were offered a free SARS-CoV-2 IgG antibody test, regardless of symptoms. RESULTS: Overall, 379 of 57,418 HCWs (0.66%, 95% confidence interval [CI]: 0.59-0.73) were positive for SARS-CoV-2 antibodies. The adjusted overall seroprevalence was 0.43% (95% CI: 0.35-0.51). We found that HCWs in non-reference hospitals for COVID-19 (odds ratio [OR]: 1.81, 95% CI: 1.23-2.64; P = 0.002) and reference hospitals for COVID-19 (OR: 1.66, 95% CI: 1.06-2.58; P = 0.03) were more likely to be seropositive than HCWs in primary care centres. Regarding professions, nurses (OR: 1.45, 95% CI: 1.07-1.98; P = 0.02), physicians (OR: 1.43, 95% CI: 1.06-1.93; P = 0.02), and administrative, cleaning and security staff (OR: 1.50, 95% CI: 1.09-2.06; P = 0.01) had a statistically higher chance of having a positive serology than laboratory employees. CONCLUSIONS: The adjusted overall seroprevalence found in this study indicates a very low prevalence of SARS-CoV-2 among HCWs in Greece. This result is in line with the low incidence of COVID-19 during the first wave of the pandemic and is a direct benefit from the early implementation of lockdown.

'Evidence for waterborne origin of an extended mixed gastroenteritis outbreak in a town in Northern Greece, 2019'.

We investigated a large gastroenteritis outbreak that occurred in Northern Greece in 2019. A case was defined as anyone presenting with diarrhoea and/or vomiting from 24 January 2019 to 04 February 2019. We conducted a case-control study (CCS) using random selection of participants >16 years of age, residents of town X, who visited the health care centre between 25 and 28 January 2019. Moreover, we conducted a retrospective cohort study (CS) at the four elementary schools of the town. We collected clinical and water samples and the water supply system was inspected. In total, we recorded 638 cases (53% female; median age was 44 years (range 0-93)). Forty-eight cases and 52 controls participated in the CCS and 236 students in the CS. Both CCS and CS indicated tap water as the most likely source (OR 10, 95% CI 2.09-93.4, explaining 95.7% of cases; RR = 2.22, 95% CI 1.42-3.46, respectively). More than one pathogen was detected from stool samples of 6 of the 11 cases tested (norovirus, Campylobacter jejuni, Enterohemorrhagic E. coli (EHEC) and Enteropathogenic E. coli (EPEC)). Water samples, collected after ad-hoc chlorination, tested negative. Technical failures of the water tanks' status were identified. Our results suggested a waterborne outbreak. We recommended regular monitoring of the water supply system and immediate repair of technical failures.

Epidemiology of hepatitis A in Greece in the last decade: management of reported cases and outbreaks and lessons learned.

Hepatitis A is a mandatory notifiable disease in Greece. Here, we present the epidemiological data for 2009-2018 and the results of outbreak investigations performed, and discuss future public health priorities.Overall, 1193 cases were reported; 320 migrants/refugees, 240 Roma, 112 travellers and 521 from the general population. The median age of the affected general population (37 years) had an increasing trend (from 30.8 years in 2009 to 40.5 in 2018, P < 0.001) and was significantly higher than that among Roma and migrants (7 and 8 years, respectively, P < 0.001). Twenty-two cases (2.2%) were unvaccinated patients with a chronic liver disease. Fifty clusters with 2-12 cases each were recorded; 44 were attributed to person-to-person transmission and six to food consumption. Three outbreaks accounting for 32.3% of the total number of recorded cases were identified; in 2013 among Roma (112 cases), in 2016 among refugees (188 cases) and in 2017 among men having sex with men (96 cases; 33 of them (34.4%) HIV-positive). The epidemiological data depict that improving living conditions and vaccination coverage of deprived populations, and informing adults on the disease focusing at faecal-oral transmission during sexual intercourse and travel should be the future public health priorities.

Norovirus waterborne outbreak in Chalkidiki, Greece, 2015: detection of GI.P2_GI.2 and GII.P16_GII.13 unusual strains.

Noroviruses, along with rotaviruses, are among the leading causes of gastroenteritis worldwide and novel strains are periodically emerging. In August 2015, an unusual increase of gastroenteritis cases occurred in a touristic district in Kassandra peninsula, Chalkidiki, Northern Greece. Seven stool specimens from cases were tested positive for norovirus. Molecular investigation and phylogenetic analysis identified that there was co-circulation of norovirus GI.P2_GI.2 and the recombinant strain GII.P16_GII.13. A 1:1 case-control study conducted and showed that tap water consumption significantly associated with developing symptoms of gastroenteritis (odds ratio = 36.9, P = 0.018). The results of the epidemiological investigation, the co-circulation of two different norovirus strains, the information of a pipeline breakage at the water supply system before the onset of cases, and reports on flooded wells and sewage overflow, indicated the possibility of water contamination by sewage during the pipeline breakage leading to a large outbreak with a peak at 10 August and a possible secondary person-to-person transmission after the 16th of August. Norovirus GI.P2_GI.2 strains are rarely reported in Europe, while it is the first time that infection from the recombinant strain GII.P16_GII.13 is recorded in Greece.

Spatial and temporal distribution of p,p'-DDE (1­dichloro­2,2­bis (p­chlorophenyl) ethylene) blood levels across the globe. A systematic review and meta-analysis.

BACKGROUND: Although p,p'­DDT (1,1,1­trichloro-2,2­bis (p­chlorophenyl)­ethane) has been banned for decades in most countries, its major metabolite p,p'-DDE (1­dichloro­2,2­bis (p­chlorophenyl) ethylene) is still detected in the vast majority of human blood samples. OBJECTIVES: The purpose of this study was to quantitatively estimate the geographical distribution of DDE blood levels and record time-trends for specific countries and continents, exploiting available data from the scientific literature. METHODS: A literature search was performed in SCOPUS and PUBMED databases. Studies were screened at 2 levels applying different sets of inclusion/exclusion criteria. Blood levels of DDE along with other variables of interest were extracted, and a meta-analysis of random effects was conducted, by using the package metafor within the statistical programming language R. Results were expressed as pooled geometric means (GM [95% confidence intervals, CIs]). RESULTS: A total of 418 papers were included in the quantitative synthesis that contained data for 854 population subgroups, and analyzed a total of 195,595 samples. Overall global DDE concentrations dropped from 5207 (95% CI: 3616-7499) ng/g lipids during 1951-1969 to 207 (95% CI: 159-269) ng/g lipids for studies reporting sampling after 2000. Analyses for studies published from 2001 and onward revealed geographical differences regarding DDE burden. DISCUSSION: The significant decline in DDE blood levels after its restriction is demonstrated in our results. Differences in decrease trends were observed in different parts of the globe, which can be explained by deferred implementation of environmental policies. In some countries DDE concentrations remain high, and systematic biomonitoring is proposed.

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.

Complete exon 2 sequence of the HLA-DPA1*03:01 allele by sequence-based typing.

Completion of the first 20 nucleotides of exon 2 of DPA1*03:01 allele.

Time trends in pediatric hospitalizations for hepatitis A in Greece (1999-2013): Assessment of the impact of universal infant immunization in 2008.

Hepatitis A vaccine was introduced in the Greek National Immunization Program in 2008. To estimate possible impact of the universal vaccination implementation, time trends of hospitalizations for hepatitis A at the Infectious Diseases Unit of a Tertiary Pediatric Hospital in Athens during 1999-2013 were analyzed. Hepatitis A hospitalizations were recorded from the discharge database and were expressed as frequencies and rate of annual departmental hospitalizations. Time series analysis (ARIMA) was used to explore trends and the impact of the vaccination. Moreover, changes in patient age, population group distribution and the duration of hospitalization were also examined. Hepatitis A hospitalizations rate significantly decreased between pre-vaccination (1999-2008) and post-vaccination (2009-2013) era from 50.5 to 20.8/1000 hospitalizations (p = 0.005). A 3-year periodicity and a trend of reduction on hepatitis A hospitalizations rates across years were noted. Roma children had significant higher rates of hepatitis A hospitalization, followed by immigrant children. Importantly, possibly due to preceding vaccine availability with considerable uptake in private market and unvaccinated group/pockets of children (Roma), overall vaccination effect was less apparent when compared to data from other countries that implemented universal vaccination. No significant change in patient age, population group distribution, or duration of hospitalization was observed. High risk groups such as Roma children should be targeted for vaccination to reduce future outbreaks.

Resistant Shigella strains in refugees, August-October 2015, Greece.

Shigellosis is endemic in most developing countries and thus a known risk in refugees and internally displaced persons. In 2015, a massive influx of refugees into Greece, due to the political crisis in the Middle East, led to the development of appropriate conditions for outbreaks of communicable diseases as shigellosis. We present a cluster of 16 shigellosis cases in refugees, detected by the implementation of a syndromic notification system in one transit centre in Athens, between 20 August and 7 October 2015. Both Shigella flexneri (n = 8) and S. sonnei (n = 8) were identified, distributed in various serotypes. All tested isolates (n = 13) were multidrug resistant; seven were CTX-M-type extended-spectrum ß-lactamase producers. Our results indicate lack of a potential common source, although pulsed-field gel electrophoresis typing results revealed small clusters in isolates of the same serotype indicating possible limited person-to-person transmission without identifying secondary community cases related to the refugees. To prevent the spread of shigellosis, empirical antibiotic treatment as well as environmental hygiene measures were implemented. The detection of multi-drug resistance is important for determining the appropriate empirical antibiotic treatment for the more severe cases, while at the same time real-time typing is useful for epidemiological investigation and control measures.

First evidence of Leishmania infection in European brown hare (Lepus europaeus) in Greece: GIS analysis and phylogenetic position within the Leishmania spp.

Although the existence of a sylvatic transmission cycle of Leishmania spp., independent from the domestic cycle, has been proposed, data are scarce on Leishmania infection in wild mammals in Greece. In this study, we aimed to investigate the presence of Leishmania infection in the European brown hare in Greece, to infer the phylogenetic position of the Leishmania parasites detected in hares in Greece, and to identify any possible correlation between Leishmania infection in hares with environmental parameters, using the geographical information system (GIS). Spleen samples from 166 hares were tested by internal transcribed spacer-1 (ITS-1)-nested PCR for the detection of Leishmania DNA. Phylogenetic analysis was performed on Leishmania sequences from hares in Greece in conjunction with Leishmania sequences from dogs in Greece and 46 Leishmania sequences retrieved from GenBank. The Leishmania DNA prevalence in hares was found to be 23.49 % (95 % confidence interval (CI) 17.27-30.69). The phylogenetic analysis confirmed that the Leishmania sequences from hares in Greece belong in the Leishmania donovani complex. The widespread Leishmania infection in hares should be taken into consideration because under specific circumstances, this species can act as a reservoir host. This study suggests that the role of wild animals, including hares, in the epidemiology of Leishmania spp. in Greece deserves further elucidation.

Economic appraisal of the public control and prevention strategy against the 2010 West Nile Virus outbreak in Central Macedonia, Greece.

OBJECTIVES: The aim of the present paper is to evaluate the economic efficiency of the public control and prevention strategies to tackle the 2010 West Nile Virus (WNV) outbreak in the Region of Central Macedonia, Greece. Efficiency is examined on the basis of the public prevention costs incurred and their potential in justifying the costs arising from health and nuisance impacts in the succeeding years. STUDY DESIGN: Economic appraisal of public health management interventions. METHODS: Prevention and control cost categories including control programmes, contingency planning and blood safety testing, are analyzed based on market prices. A separate cost of illness approach is conducted for the estimation of medical costs and productivity losses from 2010 to 2013 and for the calculation of averted health impacts. The averted mosquito nuisance costs to households are estimated on the basis of a contingent valuation study. Based on these findings, a limited cost-benefit analysis is employed in order to evaluate the economic efficiency of these strategies in 2010-2013. RESULTS: Results indicate that cost of illness and prevention costs fell significantly in the years following the 2010 outbreak, also as a result of the epidemic coming under control. According to the contingent valuation survey, the annual average willingness to pay to eliminate the mosquito problem in the study area ranged between 22 and 27 € per household. Cost-benefit analysis indicates that the aggregate benefit of implementing the previous 3-year strategy creates a net socio-economic benefit in 2013. However the spread of the WNV epidemic and the overall socio-economic consequences, had the various costs not been employed, remain unpredictable and extremely difficult to calculate. CONCLUSIONS: The application of a post epidemic strategy appears to be of utmost importance for public health safety. An updated well designed survey is needed for a more precise definition of the optimum prevention policies and levels and for the establishment of the various cost/benefit parameters.

Surveillance and Early Warning of West Nile Virus Lineage 2 Using Backyard Chickens and Correlation to Human Neuroinvasive Cases.

In 2010, a West Nile virus (WNV) epidemic was reported in Central Macedonia, Northern Greece, with 197 neuroinvasive disease (WNND) cases in humans. The following 3 years, WNV spreads to new areas of Greece and human cases reoccurred during the transmission periods. After the initial outbreak, a WNV surveillance system using juvenile backyard chickens was established in Central Macedonia (after the 2011 outbreak) and Eastern Macedonia-Thrace (after the 2012 outbreak). Sera were screened for the presence of antibodies against WNV using cELISA and serum neutralization test, to monitor the spread of WNV and to assess the correlation between the WNV point seroprevalence in chickens and the incidence rates of human WNND cases in the aforementioned areas. WNV seroprevalence in chickens was 10.4% (95% CI: 7-15) in Central Macedonia (2011) and 18.1% (95% CI: 14-23) in Eastern Macedonia-Thrace (2012). Seroprevalence in chickens and incidence rates of human WNND cases in Eastern Macedonia-Thrace were strongly positively correlated (ρ = 0.98, P = 0.005) at the regional unit level, with the incidence of WNND in humans increasing with increasing WNV point seroprevalence in chickens. In Central Macedonia, the correlation was weaker (ρ = 0.68, P = 0.20), apparently due to small number of reported human WNND cases. Another study was also conducted using juvenile backyard chickens in Central Macedonia, aiming to detect early WNV enzootic circulation, before the onset of human cases during 2011 and 2013. The first seroconverted chickens were detected about 1.5 months before the laboratory diagnosis of any human WNND cases in Central Macedonia, for both years. WNV surveillance, using juvenile backyard chickens, was reliable for the identification of areas with WNV enzootic and silent transmission, and for early warning. Timely diffusion of information to public health authorities facilitated the successful implementation of preparedness plans to protect public health.

A large waterborne gastroenteritis outbreak in central Greece, March 2012: challenges for the investigation and management.

In March 2012, there was an unusual increase of gastroenteritis cases in a district with 37,264 inhabitants in central Greece. It was estimated that more than 3600 people developed symptoms. A 1:1 case-control study showed that consumption of tap water was a risk factor for acquiring infection [odds ratio (OR) 2.18, 95% confidence interval (CI) 1.11-4.28]. Descriptive data, low gastroenteritis incidence in adjacent areas with different water supply systems, and water-quality data further supported the hypothesis of a waterborne outbreak. Thirty-eight stool samples were positive for rotavirus. Bacterial indicators of recent faecal contamination were detected in samples from the water source and ice cubes from a local production enterprise. Molecular epidemiology of rotavirus strains, apart from the common strain, G3[P8], identified the unusual G/P combination G2P[8]. Water sanitation measures contributed to the control of the outbreak. This outbreak demonstrated the need for the cooperation of laboratories with different expertise and the importance of early notification of waterborne gastroenteritis outbreaks.

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.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference.

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.