International travel increase and malaria importation in Romania, 2008-2009.

OBJECTIVES: This report aims to assess the epidemiological characteristics of imported malaria in Romania in the context of international travel increase, and to compare them with the data reported by other European countries. METHODS: Data on malaria cases were provided by the National Centre for Surveillance and Control of the Communicable Disease, whereas the data regarding international travels to and from Romania were retrieved from the Romanian Statistical Yearbook. RESULTS: The number of Romanian citizens who traveled to Africa in 2007 increased by over 600% as compared to the previous year. During the years 2008-2009, 25 cases of imported malaria were registered in Romania, with no fatalities. All patients were male and most of them (84%) acquired the infection in Africa. Plasmodium falciparum was involved in 68% of cases. The majority of the affected patients (41%) were aged 31 to 40 years. Labor was the main reason for traveling (72%), and 92% of cases took either partial or no chemoprophylaxis. CONCLUSION: The continuous growth of professional and leisure voyages to malaria-endemic regions may lead to a dramatic increase of imported cases, especially if prophylactic measures are not strictly followed.

Cystic echinococcosis in Romania: the pediatric approach.

Cystic echinococcosis (CE) has represented a leading parasitic disease in Romania since 1862 when the first case was detected. Following the extremely high number of human and animal cases registered in 1995, Romania was framed in the forefront of Europe and among the first countries worldwide. This review aims to overview and analyze important data concerning CE in Romania from a pediatric point of view. To fulfill these goals, we focused on information provided by major epidemiological studies and rare/unusual case presentations. CE represents a serious concern for both public health services and the society, mainly because of prolonged hospitalization and convalescence periods. Moreover, the situation is much more problematic in children because physical, psychical, or intellectual impairments may impact negatively on their developmental and educational progress. The management of the disease consumes considerable healthcare resources estimated at about 1500-2000 United States Dollar (USD) for each uncomplicated case and approximately double for the complicated ones. A systematic analysis of data framed important epidemiological characteristics that may be useful when assessing individuals at risk: children (0-19 years old) represented 22.1% of the total number of cases, patients aged 13 years were most frequently affected (p < 0.0001), male patients and rural inhabitants predominated (p = 0.01 and p < 0.0001, respectively), and pulmonary involvement was detected most frequently (p < 0.0001). Considering the immense burden of this disease in Romania, emphasis should be given to the wide-scale implementation of effective prophylactic measures toward its eradication. Among them, education of the population plays an important role and should begin in early childhood.

Epidemiology and history of human parasitic diseases in Romania.

Intestinal parasitic diseases such as enterobiasis, giardiasis, and ascariasis are detected most frequently in Romania, but their importance is definitely surpassed by trichinellosis, cystic echinococcosis, and toxoplasmosis. Malaria was common until its eradication in 1963, and only imported cases are reported nowadays. The aim of this review was to bring together essential data on the epidemiology and history of human parasitoses in Romania. Information on 43 parasitic diseases was collected from numerous sources, most of them unavailable abroad or inaccessible to the international scientific community. Over time, Romanian people of all ages have paid a significant tribute to the pathogenic influences exerted by the parasites. Sanitary and socio-economical consequences of the parasites diseases have great negative impact on the quality of life of affected individuals and the overall well-being of the population. Implementation of efficient public health measures and informative campaigns for the masses as well as changing the inadequate habits that are deeply rooted in the population are mandatory for cutting successfully this Gordian knot.

Intestinal nematode infections in Romania: an epidemiological study and brief review of literature.

OBJECTIVES: The main aim of this report was to present the epidemiological, clinical, laboratory, and therapeutic aspects of a series of patients admitted to a reference hospital from Romania and found to be infected with intestinal nematodes. Additionally, we attempted to overview, for the first time in the international literature, the most relevant data regarding diseases caused by these helminthes in Romania. PATIENTS AND METHODS: We have retrospectively investigated the medical records of patients admitted at Victor Babes Hospital of Infectious Diseases in Timisoara (Timis County) who presented infections with intestinal nematode helminthes between 1971 and 2007. RESULTS: Forty-two patients were found to be infected with intestinal nematode worms, with the predominance of Enterobius vermicularis (42.8%). The mean age of patients in this series was 23.5 ± 16.4 years. Women were affected in 66.7% of cases and inhabitants of urban regions in 71.4% of cases. Of this series, 57.2% of patients were adults and most of them were people with limited formal education belonging to the low social class. Overall, abdominal pain was most frequently detected (59.5%) and the mean eosinophil count was 8.2% ± 10.9% (range 1%-56%). Piperazine was administered in most of the cases (33.3%). CONCLUSIONS: Infections with intestinal nematodes are less frequently diagnosed in hospitalized patients despite that they are quite common in the Romanian population. To further limit their occurrence, public health measures and informative campaigns for the whole population should be implemented.

Reviews on trichinellosis (I): renal involvement.

Besides cardiac and neurological complications of trichinellosis, renal involvement is the most important as regards the cases published and discussed in literature and is generally characteristic of the severe forms of the disease. This article focuses exclusively on the renal disturbances that may occur in this parasitic illness and includes a synopsis of published cases. Our primary goal was to increase the awareness of infectious diseases specialists, nephrologists, and general practitioners about these complications with possible fatal outcome. To our knowledge, this is the first international review dedicated to this topic. Cases for which enough details were available have been analyzed, and the results indicated that the mean age of the affected patients was 31.6 years, with a slightly male predominance (56.2%). The fatality rate was 26.1%. Proteinuria was detected in 84.8% of cases, hematuria in 30.4%, and casts were observed in urine specimens from 23.9% of patients. Renal failure was evidenced in 8.7% of patients, whereas renal lesions were found by biopsy or necropsy in 43.5% of cases. Of the routine laboratory parameters that are relevant for trichinellosis, mean eosinophil count was 32.2% and mean leukocyte count was 17,312 cells/µL. Finally, we emphasize on the necessity of establishing an early and correct diagnosis of trichinellosis to avoid later and severe complications. Additionally, implementation of public health and food safety prophylactic measures against the disease must represent an immediate priority for the affected regions.

Malaria and the campaigns toward its eradication in Romania, 1923-1963.

Malaria was common in Romania until largely successful campaigns of the 20th century. Researchers Ioan Cantacuzino, George Zotta, and Mihai Ciuca carried out important early contributions to the understanding of malarial endemo-epidemic situation in Romania. The malarial endemy registered a peak in 1942 with an incidence of 1218 cases per 100,000 inhabitants as a result of the disastrous effects of the Second World War. In the following years the incidence increased from 421.5 cases per 100,000 inhabitants in 1944 to 735.1 cases per 100,000 inhabitants in 1946. A Malaria Commission was formed in February 1947 with the mission to reorganize the fight against malaria in Romania based on international guidelines. Following the adoption of proper malarial eradication methods, namely coverage of endemic areas by spraying of residual insecticides, associated with chemotherapy and, eventually, chemoprophylaxis with synthetic products, and by surveillance, indigenous cases disappeared rapidly, relapsing cases were much reduced, and imported and induced cases remained constant or even increased slightly, probably due to the increase in traffic and in the use of blood transfusions. No indigenous cases have been registered in Romania since 1962. In 1963 the Romanian authorities declared malarial eradication in the territory to the World Health Organization.

Reviews on trichinellosis (II): neurological involvement.

Neurological involvement may occur in 0.2%-52% of cases with trichinellosis, generally in the most severely affected patients. This review focuses on neurotrichinellosis and includes a brief overview of selected cases reported in the literature. Our primary goal was to increase the awareness of infectious diseases specialists, neurologists, and general practitioners about these major complications with possible fatal outcome. Seventy seven of the cases, for which enough details were available, have been pooled for statistical analysis. The mean age of the investigated group was 34.6 ± 16.8 years. Patients with both focal and diffuse manifestations predominated (55.8%), and they were significantly older (40 ± 15.5 years old) than those who presented solely focal (28.9 ± 17.8 years old; p = 0.03) or diffuse lesions (27.9 ± 15.3 years old; p = 0.007). In most of the cases (59.7%), complete recovery was reported, whereas 23.4% of cases had sequelae and 16.9% of the patients died. Patients who died had significantly lower eosinophil counts (13.8% ± 14%) when compared with those who made complete recovery (28.7% ± 18%; p = 0.015) and the cases with sequelae (35% ± 17.9%; p = 0.006). To sum up, trichinellosis must be considered in the differential diagnosis of any patient with encephalitis or other central nervous system malady of ambiguous etiology.

Trichinellosis in children and adults: a 10-year comparative study in Western Romania.

INTRODUCTION: This study aims to evaluate and compare the epidemiologic, laboratory, clinical, and therapeutic aspects of trichinellosis in child and adult populations residing in Western Romania. PATIENTS AND METHODS: We have retrospectively investigated the medical records of patients with trichinellosis hospitalized between 1996 and 2005 in 5 infectious diseases hospitals located in 4 Western Romanian counties. RESULTS: Trichinellosis was diagnosed in 1344 patients, of whom 348 were children (26%) and 996 were adults (74%). The annual average incidence was 8.4 cases per 100,000 in children and 7.7 cases per 100,000 in adults. The mean ages for the children and adults were 11 ± 4.4 years and 38.1 ± 14.2 years, respectively. Myalgias and complications of trichinellosis were detected less frequently in children who also had lower eosinophil counts, leukocyte counts, and erythrocyte sedimentation rates compared with those for adults. Albendazole and mebendazole had comparable efficacies in adult patients; however, albendazole proved to be a better choice than mebendazole for the treatment of children. CONCLUSIONS: Trichinellosis occurs commonly among inhabitants of Western Romania. Although the general trend of decline in the incidence of trichinellosis cases cannot be used as a statistical predictor of future improvement, it provides encouragement and demonstrates the need for the implementation of correct public health and educational measures to fully prevent and eradicate trichinellosis in Western Romania.

Malaria, a journey in time: in search of the lost myths and forgotten stories.

The saga of malaria parasites precedes the history of humans. Malaria has always been part of the rising and decline of nations, of wars and of upheavals. People of ancient times attributed the malarial manifestations to supernatural influences. Myths about demons responsible for fevers and efforts to bring them under control were often mentioned in ancient articles and attested archaeologically. More than 4 millennia were required until malaria was finally demystified. From the ancient Chinese Canon of Medicine to Ronald Ross' milestone discovery, the humanity struggled to face one of the most debilitating diseases of mankind. This essay assesses the history of malaria from ancient mysteries until it was demystified. Its sections describe the attempts of humans from different times to understand and defeat malaria through supernatural practices, religious rites and medicine, and also their efforts mirrored in art and literary masterpieces.

Cardiac involvement in patients with trichinosis hospitalized in western Romania.

OBJECTIVES: Cardiovascular disturbances are reported as major trichinosis complications, and myocarditis is the most frequent of them. Previous Romanian surveillances on prevalence of cardiac involvement indicated a rate of 30%­50%. The present study aimed to overview the clinical and the main epidemiological characteristics of persons from western Romania found to have trichinosis and cardiac involvement. PATIENTS AND METHODS: Hospitalization documents of individuals with trichinosis and cardiac complications admitted at the Hospital of Infectious Diseases in Timisoara, Romania, were retroactively investigated. Patients were residents of three Romanian counties and were hospitalized between 1990 and 2001. RESULTS: Twenty-eight patients, found to have trichinosis, presented cardiac involvement. Of the study group, six patients (21.4%) died during hospitalization and their necropsy revealed the diagnosis of myocarditis. For the remaining patients, myocarditis was only suspected and cardiac abnormalities were mainly evidenced by electrocardiography. The mean age of the patients was 38 years (range, 3­80 years) and there were 18 male patients (64.3%). Repolarization disturbances predominated and myalgia was the most common symptom. The mean eosinophil value of the study group was 16.9% (range, 2­70%). CONCLUSIONS: Cardiac involvement represented and still continues to be a major complication in Romanian patients. According to its potentially lethal outcome, myocarditis must be considered in such patients even when specific symptoms are missing. Prophylactic measures are also very important and should be based especially on health education programs for the masses.

Foodborne nematodal infections in hospitalized patients from a southwestern Romanian county.

OBJECTIVES: Caras-Severin County presented the highest incidence of human trichinellosis (108.5 cases per 100,000 inhabitants) throughout Romania in 1993. This study aimed at providing an overview of the epidemiological and clinical characteristics of persons from this county hospitalized with nematodal infections between 1996 and 2008. PATIENTS AND METHODS: Data were collected from the medical records of 269 patients admitted to two infectious diseases hospitals and found to have nematode helminthic infections. RESULTS: Of the study group, 250 patients (92.9%) presented with trichinellosis, 10 (3.7%) with ascariasis, 7 (2.6%) with trichuriasis, and 2 (0.8%) with ascariasis and trichuriasis coinfections. Geohelminthic infections prevailed in children (68.4%). Giardiasis, a protozoan parasitic disease, was also found in 21 patients (7.8%). CONCLUSIONS: Although trichinellosis cases decreased in this county, public health authorities must remain aware because new outbreaks may occur at any time as it happened in the neighboring counties. Regarding geohelminthiasis, parents must be aware of the potential risk of acquiring these infections and the major complications that may follow.

Evidence of Trichinella spiralis in Timis County, Romania: a report of a winter trichinellosis outbreak in 2008 due to consumption of contaminated pork.

A trichinellosis outbreak occurred in early 2008 in two villages in Timis County, Romania, due to consumption of pork from an infected animal. The infective species, detected by multiplex polymerase chain reaction, was Trichinella spiralis (Isolate Code ISS 1951). This report presents an extensive characterization of the outbreak using the documents of the epidemiological investigation and the medical charts of the hospitalized patients. Fifteen people consumed pork from the same backyard pig, which was slaughtered in the household without veterinary inspection of the meat. Among them, five patients presented clinical forms of the disease and were hospitalized. The analysis within this report includes only the hospitalized cases that were serologically confirmed. The mean age of the patients was 33.4 years. The common symptoms presented by these patients included headache, eyelid and lower limb edema, myalgia, fever, diarrhea, and nausea. Eosinophil counts ranged between 5.5% and 52%. Favorable outcomes were achieved for the patients using antihelminthic therapy. As an important public health concern, trichinellosis outbreaks reinforce the need to urgently implement veterinary and educational programs. Identification of T. spiralis in this case strengthens the supposition that it is one of the most frequently spread species in Romania.

Trichinellosis and poverty in a Romanian industrial area: an epidemiological study and brief review of literature.

OBJECTIVE: Trichinellosis is a foodborne parasitic disease that is acquired by humans through ingestion of raw or inadequately cooked meat containing larvae of different Trichinella species. During a high endemic year, Hunedoara County, part of Transylvania region, was the second most affected Romanian county, with an incidence of 84.8 cases per 100,000 inhabitants. The objective of this study was to bring new epidemiological and clinical data on human trichinellosis from an endemic former industrial area characterized by high rates of poverty and unemployment. PATIENTS AND METHODS: Data have been collected from the medical charts of 492 patients (mean age, 27.6 years) found to have trichinellosis and admitted between 1996 and 2005 in two infectious disease hospitals. A brief review of relevant epidemiological and epizoological information regarding the evolution of the infection in this region was also considered. RESULTS: Women (55.1%, n = 271), townsfolk (77.0%, n = 379), and unemployed (40.1%, n = 126) were the most affected categories. The clinical symptoms included myalgia (64.6%, n = 118), edema (45.3%, n = 223), and headache (38.6%, n = 190). Eosinophilia ranged between 10% and 19.99% in 28.0% (n = 138) of the cases. For 47.8% (n = 235) of the patients, the hospitalization period ranged from 1 to 7 days. Thiabendazole was administered in 72.0% (n = 329) of the cases. CONCLUSIONS: For a long period of time, trichinellosis represented a serious public health and ecological concern because of the favorable social, economic, cultural, and geographic conditions of this territory. Despite rich history, an overall decrease in the number of human trichinellosis cases over the 10-year study period was revealed and the decline might have been favored by the following positive aspects: improvement of sanitary conditions, implementation of a more reliable collaboration between veterinarians and pig breeders/consumers, education of the population, and a more careful supervision of the public health services.

Epidemiology and epizootology of cystic echinococcosis in Romania 1862-2007.

Infections with cestodes from genus Echinococcus are usually acquired by oral ingestion of eggs, direct contact with carriers, and contaminated food (especially vegetables) or water. Echinococcosis, previously characterized as a malady of medical importance only, depends upon veterinary solutions and faces political obstacles; it is considered the most important zoonotic disease in Romania. As a result of the increased number of human and animal cases, Romania was framed in the forefront of the European countries and among the first countries worldwide in 1995. The present paper is the first international systematized review concerning echinococcosis in Romania. It covers a period of 146 years, beginning in 1862, when the first case of human hydatid disease was mentioned in medical annals, until 2007 and aims at overviewing and analyzing data provided by major studies from different fields of human and veterinary medicine. Authors also present unpublished data of a 37-year surveillance performed in a reference infectious disease hospital. During the period 1979-1988, 8557 patients were hospitalized for hydatid disease requiring 210,057 days of health care, and 516 fatalities (6.03%) were registered. The prevalence of the disease in livestock during the period 1983-1994 varied between 24.3% and 92.9% in sheep, 31.2% and 43.6% in cattle, and 20.4% and 73.8% in swine. The economic losses in animals are very high due not only to increased mortality rates but also to weight loss and decreased productivity. Epidemiological data available showed that at least one person from 45.5% of Romanian localities underwent surgery for cystic echinococcosis. The information presented outlines the severity of the situation from human- and livestock-associated cystic echinococcosis in Romania. Control programs based on combinations of animal vaccination, dehelmintization of dogs, and education programs should be implemented to achieve effective prevention of disease transmission.

Human taeniasis in western Romania and its relationship to multicultural food habits and influences.

OBJECTIVES: Taeniasis, an intestinal infection produced by adult tapeworms of the genus Taenia, is acquired by the consumption of raw or undercooked beef or pork containing the infective cysticerci. The symptoms are generally mild and include abdominal pain, nausea, dizziness, headache, weight loss, anorexia, and allergic syndromes. In Romania, the morbidity of taeniasis ranges between 0.4% and 0.75% with higher rates in Moldavia and Banat regions as a consequence of regional gastronomic customs. This study aimed to overview the epidemiological, clinical, and therapeutic characteristics of taeniasis cases diagnosed in Timis County, part of Banat region, during a 37-year period (1971-2007). PATIENTS AND METHODS: The authors have retrospectively analyzed the medical charts of 26 adult patients (mean age 38.3 years) admitted to the reference hospital for infectious diseases in southwestern Romania. RESULTS: Females (77.0%, n = 20), inhabitants of urban areas (65.4%, n = 17), and laborers (46.2%, n = 12) were the most affected categories. The clinical symptoms included abdominal pain (57.7%, n = 15), asthenia (26.9%, n = 7), and loss of appetite (15.4%, n = 4). Eosinophilia was evidenced in 38.5% (n = 10) of the cases. For 80.8% (n = 21) of the patients, the hospitalization period ranged from 1 to 7 days. Niclosamide was administered in 61.5% (n = 16) of the cases. CONCLUSIONS: The disease might be more frequently diagnosed in patients with mild symptomatology or asymptomatic ones who usually consult general practitioners and hence the low number of cases treated in hospitals. As a consequence, specific prophylactic measures oriented mainly to sanitary education of the masses must be considered for its eradication. Collaboration between family physicians and veterinary doctors must be strengthened especially in the countryside regions where humans live in close proximity to animals on which they rely mostly for their food resources.

Epidemiology and epizootology of trichinellosis in Romania 1868-2007.

According to the International Commission on Trichinellosis, Romania accounted for the most cases of trichinellosis reported worldwide in 2004. The following report summarizes the evolution of trichinellosis in Romania over a 140-year period (1868-2007). The sylvatic cycle, such as the consumption of meat from wild boar and bear, has been implicated in human cases. However, 95% of human trichinellosis cases originate from specific cultural food practices involving pork consumption. The first report of human and pig trichinellosis in Romania dates back to 1868. After the political changes of 1989, the annual incidence increased from between 0.1 and 4.1 cases per 100,000 inhabitants during the communist period (1963-1989) to 6.2 cases per 100,000 inhabitants, with a range of 2-15.9 per 100,000 between 1990 and 2007. Trichinellosis is a major public health issue in Romania that requires that policies be put forth to advance efficient prevention and control strategies.

Foodborne botulism in southwest Romania during the post-communism period 1990-2007.

OBJECTIVES: This study was a retrospective investigation of botulism cases over a period of 18 years following major political and economic changes, addressing the question of whether this disease is still an important health concern in southwest Romania. METHODS: The medical records of botulism cases were used as the source of data. Patients from five southwest Romanian counties were hospitalized at Victor Babes Hospital of Infectious Diseases in Timisoara during the period 1990-2007. RESULTS: The median annual incidence of botulism cases in southwest Romania decreased from 0.1 per 100 000 persons during 1990-1998, to 0.05 per 100 000 persons during 1999-2007. Most of the cases (18.6%) were diagnosed in 1990, immediately following the communism period. The median age of the patients was 38 years (range 16-73 years); 24 (55.8%) were male; the case fatality rate was 2.3%. A significantly higher incidence rate of 2.7 cases per 100 000 persons occurred in rural areas, even though most of the cases (53.5%) were inhabitants of urban areas. The clinical pattern included: difficulty swallowing (79.1%), double and/or blurred vision (69.8%), dry mouth (60.5%), drooping eyelids (51.2%), vomiting (39.5%), mydriasis (37.2%), constipation (27.9%), abdominal pain (23.3%), and slurred speech (18.6%). All cases were attributed to contaminated food sources, mainly home-prepared traditional pork products. CONCLUSIONS: Although the botulism cases decreased over the study period in southwest Romania, this life-threatening disease continues to be an important concern. A strategy addressing individual behaviors in the home is needed to improve food safety.

Trichinellosis, a threatening and re-emerging disease in a Romanian western county.

INTRODUCTION: Trichinellosis is frequently reported in east European countries like Romania, where the yearly incidence during 1990-1999 was 5.5 cases/100,000 inhabitants. Arad, a western Romanian county, is known as one of the most endemic regions of trichinellosis. A major and unforgettable epidemic of trichinellosis has developed at the beginning of 1973 in this county. The present study focuses on human trichinellosis patients from Arad County, emphasizing on epidemiological, clinical, laboratory, and therapeutic aspects. PATIENTS AND METHODS: Retrospective analysis of the medical records of 335 patients found to have trichinellosis during 1996-2006 and hospitalized in Arad County. The mean age of the trichinellosis patients was 33.6 years, and majority (64.8%) were inhabitants of the rural areas. RESULTS: Winter was the season with the highest number of cases (71.6%). Fever was the most frequent manifestation of the disease (85.4%), followed by myalgia (83%). Eosinophilia ranged predominantly between 20% and 20.99% (19.4%). Albendazole was the specific drug administered in 49.4% of the patients. CONCLUSIONS: Trichinellosis still remains a concern and a major issue of public health in Arad County. Implementation of strict hygienic measures, especially in the rural areas, must be a priority.

Importation of visceral leishmaniasis in returning Romanian workers from Spain.

BACKGROUND: Over the past two decades visceral leishmaniasis cases and foci have increased in Romania, where the disease has also become a medical concern. The following study aimed to provide essential knowledge on early diagnosis and management of visceral leishmaniasis cases in Romania acquired especially by traveling and working in the Mediterranean countries. METHOD: Retrospective analysis of the medical records of the patients diagnosed with imported visceral leishmaniasis in a western Romanian county. RESULTS: Three patients with visceral leishmaniasis imported from Spain were admitted to hospital in Timisoara in 2005. Detailed case histories along with clinical and laboratory features are presented. In all the patients the final laboratory confirmation of the disease was by Giemsa-stained blood smears obtained by bone marrow biopsy. CONCLUSIONS: Since 2004, many Romanian citizens left their homeland looking for a better job in the Mediterranean region. Unaware of the risks of outdoor labor in warm climatic conditions, they accepted to live and work in improper sanitary conditions. Late identification of the disease resulted mainly from failure of the physicians to diagnose and associate the syndrome with travel.