West Nile virus in humans, Greece, 2018: the largest seasonal number of cases, 9 years after its emergence in the country.

BackgroundHuman cases of West Nile virus (WNV) infection are recorded since 2010 in Greece, with seasonal outbreaks occurring almost annually. Enhanced surveillance has been implemented since 2010, to promptly characterise cases' temporal and geographical distribution and inform authorities for implementation of appropriate measures (mosquito control, health education, blood safety).AimWe describe the epidemiology of WNV human infections in Greece focusing on the 2018 season.MethodsThe National Public Health Organization advised physicians to test all suspect WNV infection cases and refer samples to reference laboratories. Laboratories notified diagnosed cases on a daily basis. Treating physicians, patients, and infected blood donors were interviewed within 48 hours after diagnosis and the probable infection location was identified. Hospitalised cases were followed up until discharge.ResultsA total of 317 autochthonous WNV infection cases were diagnosed in 2018. Among them, 243 cases had neuroinvasive disease (WNND), representing a 23% increase of WNND cases compared with 2010, the previous most intense season. There were 51 deaths. Cases started occurring from week 22, earlier than usual. Both rural and urban areas were affected, with 86 (26% of the total) municipalities belonging to seven (54% of the total) regions recording cases. Two major epicentres were identified in Attica and Central Macedonia regions.ConclusionsThe largest number of human cases of WNV infection ever recorded in Greece occurred in 2018, with a wide geographical distribution, suggesting intense virus circulation. Enhanced surveillance is vital for the early detection of human cases and the prompt implementation of response measures.

Infectious disease surveillance system descriptors: proposal for a comprehensive set.

To tailor a surveillance system to its objectives and to evaluate its fitness for purpose, an accurate description of its structural elements is essential. Existing recommendations for setting up a system seldom offer a comprehensive list of all surveillance elements to be considered. Moreover, there is sometimes confusion in the way terms describing these elements are interpreted. The objective of this paper is to propose a comprehensive set of surveillance system descriptors that can delineate the important elements and clarify the meaning of the terms used. We identified 20 descriptors that we classified in five categories: (i) surveillance scheme; (ii) population and cases; (iii) supplementary data; (iv) information flow; and (v) period of time. We tried to make the definitions of these descriptors as clear and simple as possible to avoid confusion or misinterpretation of the terms used. The relative importance of each element may vary depending on the objectives of the surveillance scheme. Surveillance descriptors should be reviewed periodically to document changes and to assess if the system continues to be fit for purpose. Together with the minimum requirements for variables and the planned outputs for disseminating the data, the surveillance descriptors can be used to define surveillance standards.

Increase of breast-feeding in the past decade in Greece, but still low uptake: cross-sectional studies in 2007 and 2017.

OBJECTIVE: To estimate breast-feeding prevalence in Greece in 2007 and 2017, compare breast-feeding indicators and maternity hospital practices between these years, and investigate breast-feeding determinants. DESIGN: Two national cross-sectional studies (2007 and 2017) using systematic cluster sampling of babies with the same sampling design, data collection and analysis methodology. SETTING: Telephone interview with babies' mothers or fathers. PARTICIPANTS: Representative sample of infants who participated in the national neonatal screening programme (n 549 in 2017, n 586 in 2007). RESULTS: We found that breast-feeding indicators were higher in 2017 compared with 10 years before. In 2017, 94 % of mothers initiated breast-feeding. Breast-feeding rates were 80, 56 and 45 % by the end of the 1st, 4th and 6th completed month of age, respectively. At the same ages, 40, 25 and <1 % of babies, respectively, were exclusively breast-feeding. We also found early introduction of solid foods (after the 4th month of age). Maternity hospital practices favouring breast-feeding were more prevalent in 2017, but still suboptimal (63 % experienced rooming-in; 51 % experienced skin-to-skin contact in the first hour after birth; 19 % received free sample of infant formula on discharge). CONCLUSIONS: We observed an increasing trend in all breast-feeding indicators in the past decade in Greece, but breast-feeding rates - particularly rates of exclusive breast-feeding - remain low. Systematic public health initiatives targeted to health professionals and mothers are needed in order to change the prevailing baby feeding 'culture' and successfully implement the WHO recommendations for exclusive breast-feeding during the first 6 months of life.

Adverse effect of the financial crisis in Greece on perinatal factors.

Background: Starting in 2008 recession affected many European countries and especially Greece. Previous studies have reported increases in low birth weight, preterm birth and stillbirth rates in Greece during early crisis. In our study we used data on births from 1980 to 2014 that allowed us to distinguish recent changes, which could possibly be attributed to the financial crisis, from long term trends, and controlled for maternal age and country of origin as potential confounders. Our study covered a longer period (up to 2014) than what has been studied before and looked separately at the effect of early and established crisis. Methods: We used national vital statistics data from 1980 to 2014. We performed age standardization and calculated age standardized rates and standardized rate ratios (SRRs) for perinatal factors for three time periods (pre-crisis, early crisis and established crisis) for Greek and non-Greek women. Results: We found an increase in low birth weight deliveries independent of maternal age and origin and an increased stillbirth rate in Greek women younger than 25 in early (RR = 1.42 95%CI: 1.12-1.80) and established crisis periods (RR = 1.36 95%CI: 1.07-1.72) compared with pre-crisis. Non-Greek women have also been affected, with their advantage regarding birth outcomes becoming less profound in the established crisis period (low birth weight: established crisis SRR = 0.84 95%CI: 0.82-0.87, pre-crisis SRR = 0.79 95% CI: 0.76- 0.81). Conclusions: The financial crisis has possibly adversely affected perinatal factors in Greece. Our results highlight the need of appropriate public health interventions and family support policies, especially for younger people, unemployed and immigrants.

Clinical assessment is a neglected component of outbreak preparedness: evidence from refugee camps in Greece.

BACKGROUND: Refugees may have an increased vulnerability to infectious diseases, and the consequences of an outbreak are more severe in a refugee camp. When an outbreak is suspected, access to clinical information is critical for investigators to verify that an outbreak is occurring, to determine the cause and to select interventions to control it. Experience from previous outbreaks suggests that the accuracy and completeness of this information is poor. This study is the first to assess the adequacy of clinical characterisation of acute medical illnesses in refugee camps. The objective is to direct improvements in outbreak identification and management in this vulnerable setting. METHODS: We collected prospective data in 13 refugee camps in Greece. We passively observed consultations where patients presented with syndromes that might warrant inclusion into an existing syndromic surveillance system and then undertook a structured assessment of routine clinical data collection to examine the extent to which key clinical parameters required for an outbreak response were ascertained and then documented. RESULTS: A total of 528 patient consultations were included. The most common presenting condition was an acute respiratory illness. Clinicians often made a comprehensive clinical assessment, especially for common syndromes of respiratory and gastrointestinal conditions, but documented their findings less frequently. For fewer than 5% of patients were a full set of vital signs ascertained and so the severity of patient illnesses was largely unknown. In only 11% of consultations was it verified that a patient who met the case criteria for syndromic surveillance reporting based on an independent assessment was reported into the system. DISCUSSION: Opportunities exist to strengthen clinical data capture and recording in refugee camps, which will produce a better calibrated and directed public health response. CONCLUSION: Information of significant utility for outbreak response is collected at the clinical interface and we recommend improving how this information is recorded and linked into surveillance systems.

Low vaccination coverage of Greek Roma children amid economic crisis: national survey using stratified cluster sampling.

Background: Research on Roma health is fragmentary as major methodological obstacles often exist. Reliable estimates on vaccination coverage of Roma children at a national level and identification of risk factors for low coverage could play an instrumental role in developing evidence-based policies to promote vaccination in this marginalized population group. Methods: We carried out a national vaccination coverage survey of Roma children. Thirty Roma settlements, stratified by geographical region and settlement type, were included; 7-10 children aged 24-77 months were selected from each settlement using systematic sampling. Information on children's vaccination coverage was collected from multiple sources. In the analysis we applied weights for each stratum, identified through a consensus process. Results: A total of 251 Roma children participated in the study. A vaccination document was presented for the large majority (86%). We found very low vaccination coverage for all vaccines. In 35-39% of children 'minimum vaccination' (DTP3 and IPV2 and MMR1) was administered, while 34-38% had received HepB3 and 31-35% Hib3; no child was vaccinated against tuberculosis in the first year of life. Better living conditions and primary care services close to Roma settlements were associated with higher vaccination indices. Conclusions: Our study showed inadequate vaccination coverage of Roma children in Greece, much lower than that of the non-minority child population. This serious public health challenge should be systematically addressed, or, amid continuing economic recession, the gap may widen. Valid national estimates on important characteristics of the Roma population can contribute to planning inclusion policies.

Socioeconomical Factors Associated With Pediculosis (Phthiraptera: Pediculidae) in Athens, Greece.

Pediculosis in humans and especially in children is a very common dermatological disorder caused by the ectoparasite Pediculus humanus capitis De Geer. We investigated the socioeconomic factors affecting the prevalence of pediculosis in the Greek urban area of Athens during 2004-2006. The target population consisted of children from kindergartens. In total, 434 children from single- or two-parent families were investigated with respect to socioeconomic factors such as education, income and family composition, and the prevalence of pediculosis. The overall pediculosis rate was 5.30%. Head louse infestations were significantly higher in female children and in two-parent families. Lice infestations peaked in low- and medium-income families. Head louse infestation rates were influenced by income, parents' education, and nationality.

Cluster of late preterm and term neonates with necrotizing enterocolitis symptomatology: descriptive and case-control study.

OBJECTIVE: To investigate a necrotizing enterocolitis (NEC) cluster of late preterm and term neonates (gestational age ≥34 weeks). METHODS: We conducted a descriptive and a case-control study. Medical records of neonates with modified Bell stage ≥ IB NEC and matched controls were reviewed, in addition to microbiological and environmental investigation. Study variables included maternal/delivery and neonatal factors, medications, procedures and feeding practices. Univariable/multivariable logistic regression analyses were performed for all and for stage ≥ II cases. RESULTS: Out of 1841 late preterm and term neonates, 10 stage IB and 10 stage ≥ II [mean(SD) birthweight 2529.3 (493.04) g, gestational age 36.96 (1.48) weeks] presented with NEC symptomatology at mean 4.6 (range 2-8) days. Nearly all (19/20) resulted from high-risk pregnancies and received postpartum intermediate care. All were exclusively or partly formula fed. Most (14/20) were born by cesarean delivery. Eight underwent surgery, with no fatality. Intermediate care (p = 0.006), transient tachypnea (p = 0.049), not receiving breast milk (p = 0.019) and in addition intrauterine growth restriction (IUGR) (p = 0.017) for stage ≥ II cases were independently associated with NEC. CONCLUSIONS: Late preterm and term neonates in need of intermediate care, with IUGR and transient tachypnea were susceptible to NEC; feeding with breast milk was an important protective factor.

Evaluation of a West Nile virus surveillance and early warning system in Greece, based on domestic pigeons.

In the summer of 2010 an epidemic of West Nile virus (WNV) occurred in Central Macedonia, Greece, with 197 human neuroinvasive disease (WNND) cases. In the following years the virus spread to new areas, with a total of 76 WNND cases in 2011, and 109 WNND cases in 2012 (14 and 12 WNND cases, respectively, in Central Macedonia). We established a surveillance system based on serological testing of domestic pigeons, using cELISA confirmed by serum neutralization test. In Central Macedonia, pigeon seroprevalence was 54% (95% CI: 49-59%) and 31% (95% CI: 24-37%) at the end of the 2010 and 2011 epidemic seasons, respectively. One serum was positive for neutralizing antibodies directed against Usutu virus. Pigeon WNV seroprevalence and incidence rates of human WNND after the 2010 epidemic were positively correlated (ρ=0.94, at the regional unit level), while in 2011 the correlation (ρ=0.56) was not statistically significant, possibly due to small number of human WNND cases recorded. To evaluate the efficacy of the system at alerting upon WNV enzootic circulation before the onset of human cases, we tested 270 pigeons in 2011 and 240 pigeons in 2012. In Central Macedonia, the first seroconversions in pigeons were recorded 44 and 47 days, respectively, before the first human WNND cases. Pigeon surveillance was used successfully for identification of areas with WNV enzootic transmission and for early warning. Timely diffusion of information to health authorities facilitated the implementation of preparedness plans to protect public health.

Population seroprevalence study after a West Nile virus lineage 2 epidemic, Greece, 2010.

INTRODUCTION: During summer 2010, 262 human cases including 35 deaths from West Nile virus (WNV) infection were reported from Central Macedonia, Greece. Evidence from mosquitoes, birds and blood donors demonstrated that the epidemic was caused by WNV lineage 2, which until recently was considered of low virulence. We conducted a household seroprevalence study to estimate the spread of infection in the population during the epidemic, ascertain the relationship of infection to clinical disease, and identify risk factors for infection. METHODS: We used a two-stage cluster design to select a random sample of residents aged ≥18 years in the outbreak epicentre. We collected demographic, medical, and risk factor data using standard questionnaires and environmental checklists, and tested serum samples for presence of WNV IgG and IgM antibodies using ELISA. RESULTS: Overall, 723 individuals participated in the study, and 644 blood samples were available. Weighted seropositivity for IgG antibodies was 5.8% (95% CI: 3.8-8.6; n=41). We estimated that about 1 in 130 (1:141 to 1:124) infected individuals developed WNV neuroinvasive disease, and approximately 18% had clinical manifestations attributable to their infection. Risk factors for infection reflected high exposure to mosquitoes; rural residents were particularly at risk (prevalence ratio: 8.2, 95% CI: 1.1-58.7). DISCUSSION: This study adds to the evidence that WNV lineage 2 strains can cause significant illness, demonstrating ratios of infection to clinical disease similar to those found previously for WNV lineage 1.

Evaluation of tuberculosis underreporting in Greece through comparison with anti-tuberculosis drug consumption.

Surveillance is an integral part of tuberculosis (TB) control. Greece has a low TB notification rate, but there are doubts about underreporting. Examining anti-TB drug consumption is a way to validate the results of surveillance and estimate TB burden in the country. We used surveillance data from 2004 to 2008 to calculate the average prescribed treatment duration with the first-line anti-TB drugs isoniazid, rifampicin, ethambutol and pyrazinamide. We then obtained the best available data on consumption of these drugs, and calculated the number of treated cases to which these quantities correspond. We thus estimated underreporting at around 80% (77-81%), and annual TB incidence at about 30 cases per 100,000 population, five times over the notification rate. Underreporting was found to be constant over the study period, while incidence followed a decreasing trend. In addition we estimated that one person receives chemoprophylaxis for latent tuberculosis infection (LTBI) for every three TB cases. These results indicate the need for a comprehensive plan to improve TB surveillance and TB contact tracing in Greece, especially in light of the economic crisis affecting the country since 2009.

Outbreak of West Nile virus infection in Greece, 2010.

During 2010, an outbreak of West Nile virus infection occurred in Greece. A total of 197 patients with neuroinvasive disease were reported, of whom 33 (17%) died. Advanced age and a history of heart disease were independently associated with death, emphasizing the need for prevention of this infection in persons with these risk factors.

Respiratory viruses involved in influenza-like illness in a Greek pediatric population during the winter period of the years 2005-2008.

Viruses are the major cause of pediatric respiratory tract infection and yet many suspected cases of illness remain uncharacterized. This study aimed to determine the distribution of several respiratory viruses in children diagnosed as having influenza-like illness, over the winter period of 2005-2008. Molecular assays including conventional and real time PCR protocols, were employed to screen respiratory specimens, collected by clinicians of the Influenza sentinel system and of outpatient pediatric clinics, for identification of several respiratory viruses. Of 1,272 specimens tested, 814 (64%) were positive for at least one virus and included 387 influenza viruses, 160 rhinoviruses, 155 respiratory syncytial viruses, 95 adenoviruses, 81 bocaviruses, 47 parainfluenza viruses, 44 metapneumoviruses, and 30 coronaviruses. Simultaneous presence of two or three viruses was observed in 173 of the above positive cases, 21% of which included influenza virus and rhinovirus. The majority of positive cases occurred during January and February. Influenza virus predominated in children older than 1 year old, with type B being the dominant type for the first season and subtypes A/H3N2 and A/H1N1 the following two winter seasons, respectively. Respiratory syncytial virus prevailed in children younger than 2 years old, with subtypes A and B alternating from year to year. This is the most comprehensive study of the epidemiology of respiratory viruses in Greece, indicating influenza, rhinovirus and respiratory syncytial virus as major contributors to influenza-like illness in children.

Persistence of West Nile virus immunoglobulin M antibodies, Greece.

A major outbreak of West Nile virus (WNV) lineage 2 infections was observed in 2010 in Greece. In order to check the persistence of WNV IgM antibodies, a second serum sample taken 75-180 days after onset of the illness from 29 patients with WNV infection was tested. A third sample was obtained 181-270 days after onset of the illness from 8 of the 12 patients with IgM-positive second sample. Mixed effects linear regression analysis indicated that the approximate time at which IgM index became negative was 164 (95% confidence interval, 95% CI 99-236) days after the symptoms' onset. Persistence of IgM antibodies was observed in 12% of patients at 181-270 days of follow-up. A sharp decrease in the IgM levels was observed, mainly in patients who had high IgM index value in the acute phase. All patients were WNV IgG positive at the follow-up.

Estimating the disease burden of 2009 pandemic influenza A(H1N1) from surveillance and household surveys in Greece.

BACKGROUND: The aim of this study was to assess the disease burden of the 2009 pandemic influenza A(H1N1) in Greece. METHODOLOGY/PRINCIPAL FINDINGS: Data on influenza-like illness (ILI), collected through cross-sectional nationwide telephone surveys of 1,000 households in Greece repeated for 25 consecutive weeks, were combined with data from H1N1 virologic surveillance to estimate the incidence and the clinical attack rate (CAR) of influenza A(H1N1). Alternative definitions of ILI (cough or sore throat and fever>38°C [ILI-38] or fever 37.1-38°C [ILI-37]) were used to estimate the number of symptomatic infections. The infection attack rate (IAR) was approximated using estimates from published studies on the frequency of fever in infected individuals. Data on H1N1 morbidity and mortality were used to estimate ICU admission and case fatality (CFR) rates. The epidemic peaked on week 48/2009 with approximately 750-1,500 new cases/100,000 population per week, depending on ILI-38 or ILI-37 case definition, respectively. By week 6/2010, 7.1%-15.6% of the population in Greece was estimated to be symptomatically infected with H1N1. Children 5-19 years represented the most affected population group (CAR:27%-54%), whereas individuals older than 64 years were the least affected (CAR:0.6%-2.2%). The IAR (95% CI) of influenza A(H1N1) was estimated to be 19.7% (13.3%, 26.1%). Per 1,000 symptomatic cases, based on ILI-38 case definition, 416 attended health services, 108 visited hospital emergency departments and 15 were admitted to hospitals. ICU admission rate and CFR were 37 and 17.5 per 100,000 symptomatic cases or 13.4 and 6.3 per 100,000 infections, respectively. CONCLUSIONS/SIGNIFICANCE: Influenza A(H1N1) infected one fifth and caused symptomatic infection in up to 15% of the Greek population. Although individuals older than 65 years were the least affected age group in terms of attack rate, they had 55 and 185 times higher risk of ICU admission and CFR, respectively.

Fatal cases associated with pandemic influenza A (H1N1) reported in Greece.

Between 18 May 2009 and 3 May 2010, a total of 149 fatal cases associated with pandemic influenza A (H1N1) were reported in Greece. Detailed case-based epidemiological information was available for the large majority of fatal cases. The time distribution follows an epidemic curve with a peak in the beginning of December 2009 and a second peak one month later. This is similar to that of laboratory confirmed cases and influenza-like illness cases from our sentinel surveillance system, with two weeks delay. The most commonly reported underlying conditions were chronic cardiovascular disease and immunosuppression, while the most frequently identified risk factor was obesity. These findings should be taken into consideration, when vaccination strategies are employed.

An outbreak of gastroenteritis linked to seafood consumption in a remote Northern Aegean island, February-March 2010.

INTRODUCTION: Raw seafood consumption has frequently been linked to gastroenteritis and Norovirus is a common cause. In February and March 2010, there was an increase cases of gastroenteritis on the remote island of Agios Efstratios in the Northern Aegean Sea, Greece. A massive increase in seafood consumption associated with a religious festival a few days prior to the outbreak suggested seafood as the vehicle of transmission. METHODS: An outbreak investigation team visited the island in order to document the outbreak and find epidemiological evidence for its source. The whole island was used as a cohort in the retrospective cohort study that was conducted. RESULTS: Sixty-four of the 181 participants reported having had symptoms of gastroenteritis, of which 34 were considered primary cases. People who consumed any raw seafood imported to the island were 21.5 times (95% CI: 8.95-51.8) more likely to develop symptoms of gastroenteritis in the 72 hours following exposure. Consumption of local seafood was not found to be a risk factor. CONCLUSION: Despite the lack of laboratory evidence, all four Kaplan's criteria were met and the outbreak was thought to have been caused by Norovirus. The outbreak investigation demonstrates epidemiological methods for use in a remote setting, where the means for laboratory and environmental investigation may be absent or limited.

Predictive value of increased nuchal translucency as a screening test for the detection of fetal chromosomal abnormalities.

OBJECTIVE: The study aimed to estimate the incidence of increased nuchal translucency in the first trimester ultrasound scan results (cut-off limit 2.5 mm) and to evaluate the predictive value of increased nuchal translucency as a screening test for the detection of fetal chromosomal abnormalities. METHODS: We used the ultrasound scan results of nuchal translucency evaluation and the results of chromosomal analysis of the invasive prenatal control performed as a result of increased nuchal translucency. RESULTS: We collected 2183 nuchal translucency ultrasound scans in which we detected 21 embryos with a pathologic value (0.96%). We collected the data of 168 cases of invasive prenatal control due to increased nuchal translucency from which 122 cases were found. A total of 122 cases of pregnant women undergone an invasive prenatal diagnostic method due to increased nuchal translucency, of which 11 fetuses were found with trisomy 21 (Down syndrome) (9%), 3 fetuses with trisomy 13 (Patau syndrome) (2.45%), 3 fetuses with monosomy 45XO (Turner syndrome) (2.45%) and 1 fetus with translocation (0.8%). CONCLUSIONS: The positive predictive value of the increased fetal nuchal translucency as a screening test for the detection of fetal chromosomal abnormalities based on the results of the chromosomal-genetic analysis of the invasive prenatal diagnostic procedures is 14.8%.

Social paediatrics.

Social paediatrics is an approach to child health that focuses on the child, in illness and in health, within the context of their society, environment, school, and family. The glossary clarifies the range of terms used to describe aspects of paediatric practice that overlap or are subsumed under social paediatrics and defines key social paediatric concepts. The glossary was compiled by a process of consultation and consensus building among the authors who are all members of the European Society for Social Paediatrics. Social paediatricians from outside Europe were included giving a more international perspective.