The burden and epidemiology of hepatitis B and hepatitis D in Georgia: findings from the national seroprevalence survey.

OBJECTIVES: The burden of hepatitis B virus (HBV) and hepatitis D virus (HDV) infections is unknown in Georgia. This analysis describes the prevalence of hepatitis B and coinfection with HDV and the demographic characteristics and risk factors for persons with HBV infection in Georgia. STUDY DESIGN: This is a cross-sectional seroprevalence study. METHODS: A cross-sectional, nationwide survey to assess hepatitis B prevalence among the general adult Georgian population (age ≥18 years) was conducted in 2015. Demographic and risk behavior data were collected. Blood specimens were screened for anti-hepatitis B core total antibody (anti-HBc). Anti-HBc-positive specimens were tested for hepatitis B surface antigen (HBsAg). HBsAg-positive specimens were tested for HBV and HDV nucleic acid. Nationally weighted prevalence estimates and adjusted odds ratios (aORs) for potential risk factors were determined for anti-HBc and HBsAg positivity. RESULTS: The national prevalence of anti-HBc and HBsAg positivity among adults were 25.9% and 2.9%, respectively. Persons aged ≥70 years had the highest anti-HBc positivity (32.7%), but the lowest HBsAg positivity prevalence (1.3%). Anti-HBc positivity was associated with injection drug use (aOR = 2.34; 95% confidence interval [CI] = 1.46-3.74), receipt of a blood transfusion (aOR = 1.68; 95% CI = 1.32-2.15), and sex with a commercial sex worker (aOR = 1.46; 95% CI = 1.06-2.01). HBsAg positivity was associated with receipt of a blood transfusion (aOR = 2.72; 95% CI = 1.54-4.80) and past incarceration (aOR = 2.72; 95% CI = 1.25-5.93). Among HBsAg-positive persons, 0.9% (95% CI = 0.0-2.0) were HDV coinfected. CONCLUSIONS: Georgia has an intermediate to high burden of hepatitis B, and the prevalence of HDV coinfection among HBV-infected persons is low. Existing infrastructure for hepatitis C elimination could be leveraged to promote hepatitis B elimination.

Tularemia transmission to humans: a multifaceted surveillance approach.

Tularemia has sustained seroprevalence in Eurasia, with estimates as high as 15% in endemic regions. The purpose of this report is to characterise the current epidemiology of Francisella tularensis subspecies holarctica in Georgia. Three surveillance activities are summarised: (1) acute infections captured in Georgia's notifiable disease surveillance system, (2) infectious disease seroprevalence study of military volunteers, and (3) a study of seroprevalence and risk factors in endemic regions. Descriptive analyses of demographic, exposure and clinical factors were conducted for the surveillance studies; bivariate analyses were computed to identify risk factors of seropositivity using likelihood ratio χ2 tests or Fisher's exact tests. Of the 19 incident cases reported between 2014 and August 2017, 10 were confirmed and nine met the presumptive definition; the estimated annual incidence was 0.12/100 000. The first cases of tularemia in Western Georgia were reported. Seroprevalences of antibodies for F. tularensis were 2.0% for military volunteers and 5.0% for residents in endemic regions. Exposures correlated with seropositivity included work with hay and contact with multiple types of animals. Seroprevalence studies conducted periodically may enhance our understanding of tularemia in countries with dramatically underestimated incidence rates.

CORRELATION BETWEEN PERINATAL RISK FACTORS AND NEURODEVELOPMENTAL OUTCOMES IN CHILDREN AT 24 MONTHS OF AGE.

The purpose of this research was to investigate the developmental follow-up of children of 24 months age, exposed to separate and combination impact of perinatal risk factors, compared with not exposed cases, within the prospective cohort study. Between January 2017 and January 2018, was conducted final stage of research, where were participated the medical centers in Tbilisi (capital of Republic of Georgia) and Mtskheta, Dusheti (districts of Georgia). Within postnatal follow-up, the children from whole population were assessed at 24 month of age by family doctors using the Denver Developmental Screening Test (Denver II). The association between the risk factors and neurodevelopmental outcomes was analyzed by Chi-square test of independence. Statistical analysis of these data was performed using the SPSS version 12.0.1 (SPSS Inc., Chicago, IL). A P value of less than 0.01 was considered as significant. Prevalence of abnormal development in whole population was revealed 2.9% or 30 cases at age of 24 month. Statistical analysis showed that an abnormal developmental outcomes were more frequent when researched risk factors, such as maternal age <17>35YY (OR-22.17, CI 95% - 8.91 to 55.15), pathologies of pregnancy (OR-13.79 CI 95% - 6.19 to30.71) and/or delivery (OR -7.74 CI 95% - 3.69 to 16.26), birth before 37 weeks of gestation (OR-29.30 CI 95% - 13.29 to 64.61), were exposed as well, as correlation of these risk factors with neurodevelopmental adverse outcomes was significant (p<0.0001). Neonatal pathologies, such as gestation age, neonatal sepsis with complication and combination with other risk factors and CNS malformation, combined with some perinatal risk factors were correlated strongly with adverse neurological disorders (p<0.0001) at age of 24 month. There was less significant correlation between Hypoxic-ischemic encephalopathy I-II stage of severity, as well as intracranial hemorrhage of I-II stages and neurodevelopmental outcomes (p<0.05). The most significant single risk factor for abnormal neurodevelopmental outcome was gestation age, maternal age and pathologies of pregnancy. High frequency of neurodevelopmental adverse outcomes were correlated with combined impact of risk factors and neonatal disorders, especially neonatal sepsis with complication and CNS malformation.

CLINICAL AND EPIDEMIOLOGICAL CHARACTERIZATION OF INFLUENZA A/H1N1PDM AND B AMONG HOSPITALIZED CHILDREN, GEORGIA, SEASON 2010-2011.

The aim of the study was to describe, analyze and compare clinical and epidemiological characteristics of laboratory confirmed influenza A(H1N1)pdm and B cases in hospitalized children during post pandemic season. Between 1st January and 1st May, 2011 retrospective observational study was conducted in M. Iashvili Children's Central Hospital. From 1028 patients with influenza like illness hospitalized at Children's Hospital 871 specimens were collected and 360 tested positive for influenza: A(H1N1)pdm - 139 and B - 221. Data were obtained for 290 cases: A(H1N1)pdm - 122 and B - 168. At the time of hospital admission, influenza A(H1N1)pdm and B cases had similar median age of 2 years. The median length of hospital stay was 5 days for both influenza types. Predominant clinical symptoms were fever (98.3%), cough (82.4%) and running nose (68.6%). 39.7% (115/290) of patients suffered with lower respiratory tract infection: A(H1N1)pdm - 41% (50/122) and B - 38.7% (65/168). 19% (55/290) developed pneumonia of which 12 with primary diagnosis of acute respiratory failure were admitted to ICU: A(H1N1)pdm - 4.9% (6/122) and B - 3.6% (6/168). Median length in ICU stay was 6 days. Only two patients with A(H1N1)pdm required artificial ventilation with one fatal outcome. Almost equally (31%) patients with influenza A or B viruses suffered with at least one pre-existing condition. Statistically significant association was revealed between neurological pre-existing conditions and developing pneumonia (OR=5.6; p=0.00) and ICU requirement (OR=17.5, p=0.00). Congenital malformations were also associated with sever course of disease (OR=9.1; p=0.01). Treatment with antiviral oseltamivir was prescribed to 29.5% (36/122) A(H1N1)pdm and 8.3% (14/168) B cases among whom only 24% cases received antiviral within 48 hours after symptoms onset. None of the patients was vaccinated against influenza. Our study revealed no significant difference between influenza A(H1N1)pdm and influenza B in terms of age distribution, clinical manifestation, hospital stay or complications in hospitalized children during post pandemic season. Pre-existing conditions such as neurological disorders and congenital malformations represented risk factors for severe course of influenza, therefore timely antiviral treatment and annual influenza vaccination is recommended to avoid complications.

The Middle East and Eastern Europe rabies Expert Bureau (MEEREB) third meeting: Lyon-France (7-8 April, 2015).

MEEREB is an inter-regional network of countries from North Africa, Europe, the Middle East and Central Asia that work together with the aim of improving rabies control and prevention at local, regional and global level. MEEREB members met for the third time in 2015 in France (Lyon) to review the current rabies situation within the network and to discuss the way forward the prospect of a One Health approach against rabies. Dogs were the main vector of transmission in all MEEREB countries except for Croatia and Serbia where foxes represented the primary source. The number of rabies animal cases reported in 2014 varied substantially between countries with Ukraine reporting the highest number of animal cases. Human cases still occur in North Africa and all Middle East and Eurasian countries while no cases of human rabies were reported in Croatia, Serbia and Romania, although cases of rabies were identified in both dogs and foxes in 2014. Participants concluded that MEEREB can act as a think-tank where countries can share data, information, experiences and best practices to jointly address challenges in rabies control and prevention. They called for elimination of dog-transmitted rabies through vaccine and rabies immunoglobulin stockpiles and implementation of a One Health approach to achieve rabies's eradication.

ASSESSMENT OF NEURODEVELOPMENTAL OUTCOMES IN INFANTS 6-12 MONTHS OF AGE ACCORDING TO IMPACT OF PERINATAL RISK FACTORS.

The purpose of this research was to investigate the developmental follow-up of infants (at age of 6 month and 12 month), exposed to separate and combination impact of perinatal risk factors, compared with not exposed cases, within the prospective cohort study. Between January 2015 and January 2017, in this research we prospectively enrolled 1018 live-born infants from the medical reports of the participating clinics in Tbilisi (capital of Republic of Georgia) and Mtskheta, Dusheti (districts of Georgia). Within postnatal follow-up, the children from whole population were assessed at 6 and 12 months of age by family doctors using the Denver Developmental Screening Test (Denver II). The association between the risk factors and neurodevelopmental outcomes was analyzed by Chi-square test of independence. Statistical analysis of these data was performed using the SPSS version 12. (SPSS Inc., Chicago, IL). A P value of less than 0.05 was considered as significant. Prevalence of abnormal development in whole population was revealed 9.0% or 92 cases at age of 6 month and 36 cases or 3.5% at age of 12 month. Point prevalence of farther neurodevelopmental adversities for healthy born children not influenced by studied risk factors was 0.1% and for infants with impact of the risk factors - 1.5%; on the other hand, prevalence of observed abnormal development in infant's population who had neonatal pathologies was 2.3% if risk factors were not exposed and 21.6% under influence of risk factors. Statistical analysis showed that an abnormal developmental outcomes were more frequent when researched risk factors were exposed (OR-23.18, CI 95% - 11.83 to 45.41 - at age of 6 month; OR - 26.12, CI 95% - 7.95 to 85.85 - at age of 12 month) as well, as correlation of these risk factors with neurodevelopmental adverse outcomes was significant (p<0.001). Significant correlations were identified for separate risk factors, such as maternal age (<17Y>35Y), pathologies of pregnancy and delivery as well as gestation age (<37 weeks). Coexistence of revealed risk factors increased probability of adverse neurological outcomes in infants at age of 6 month as well as at age of 12 month. There was a statistically important association between infant's 1-year neurological outcomes and these perinatal risk factors.

[ANTIBIOTIC SENSITIVITY/RESISTANCE OF MICROBIAL STRAINS ISOLATED IN TRAUMATOLOGICAL DEPARTMENT].

In this article, there are given data of study for antibiotic sensitivity/resistance of gram-positive and gram-negative representatives of different microbial species, isolated from patients after primary hip replacement and osteosynthesis of long bones, which had post operative infectious complications, and also isolated from samples of traumatology department environment. Identification of sensitivity/resistance to antibiotics was performed with use of two methods - disc diffusion and serial dilution on solid nutrient media. It was found, that gram-positive, as well as gram-negative microorganisms had high level of resistance to several penicillins and aminoglycosides. Gram-positive microorganisms had high level of sensitivity to vancomycin, ciprofloxacin, amikacin, amoxiclav, cefazoline, cefuroxim, cefotaxim and cefepim. Gram-negative microorganisms had high level of sensitivity to representatives of ftorhinolones, carbapenems and several cephalosporins. Strains of Candida albicans, showed 100% resistance to nistatine and comparatively high level of sensitivity to such antifungal drugs as diflucan, ketakonasol and amphotericin B. Performed studies once more confirmed significance of microbiological laboratories, which have to be main components of infectious control to dial with infectious complications - performance of permanent microbiological monitoring in separately taken hospitals, that in particular enables effective rotation of antibacterial drugs in that hospitals.

Human anthrax outbreak associated with livestock exposure: Georgia, 2012.

Human anthrax cases reported in the country of Georgia increased 75% from 2011 (n = 81) to 2012 (n = 142). This increase prompted a case-control investigation using 67 culture- or PCR-confirmed cases and 134 controls matched by residence and gender to investigate risk factor(s) for infection during the month before case onset. Independent predictors most strongly associated with disease in the multivariable modelling were slaughtering animals [odds ratio (OR) 7·3, 95% confidence interval (CI) 2·9-18·1, P 1 km; 15 (12%) of 125 had sick livestock; and 11 (9%) of 128 respondents reported finding dead livestock. We recommend joint public health and veterinary anthrax case investigations to identify areas of increased risk for livestock anthrax outbreaks, annual anthrax vaccination of livestock in those areas, and public awareness education.

THE INFLUENCE OF SOURCES OF INFORMATION ON CONTRACEPTION USE IN GEORGIA.

Along with socio-economic, cultural-traditional and other factors reliability of sources of information have an important influence on contraception use decision-making. The aims of study were to determine the significant sources of information about contraceptive methods and their influence on contraception use in Georgia. Secondary data analysis of women reproductive health survey 2010 was done. Descriptive statistics and multinomial logistic regression was used to establish statistically significant association of reliable sources of information with contraceptive methods use for selected group of women (n=4487). Friends frequently source of information about contraception, could not influence on contraception use decision (p>0.05). A reliable source of information are doctors, along with husband or partner. Doctors have an impact on modern, effective contraception choice (pill: OR =9.040, 95%CI 2.148-38.049 P=0.003, IUD: OR =14.248, 95%CI 1.886-107.664 P=0.010)) and on traditional methods (withdrawal, rhythm/calendar) choice as well (p<0.05). Information obtained from men/partner are associated with male condom use (OR =6.553, 95%CI 2.958-14.518 P=0.000 and traditional methods (withdrawal) use too (p<0.05). Since women consider doctors as a reliable source of information and information obtained from them influence on contraception use, it is necessary to improve doctors' knowledge about modern methods of contraception, acquiring necessary skills for conducting good counseling and work with pairs to help women to make well informed decision about high effective contraceptive choice. That increase modern effective contraception use prevalence and decrease the number of unintended pregnancies.

[ETHIOLOGY OF LEPTOSPIROSIS IN GEORGIA].

Investigation of leptospirosis was initiated in 1950s, when the first cases in humans were detected in Gudauta rayon. Serology test confirmed the diagnose. High level of antibodies to serogroup Pomona was revealed in all cases. Later on the infection encountered as sporadic cases, the exception was 1986, when a large outbreak was reported in Sukhumi. At present leptospirosis is widely spread in the country, especially in Ajara region, where indicators of morbidity recently reached 11.4 per 100 thousand population. It is likely that warm humid climate creates exceptionally favorite conditions for spreading of Leptospira. In order to determine the true magnitude of the infection in the country a seroprevalence study was carried out in 50-60-ies of the past century in humans, agricultural animals and rodents. It was found that serotgroups Pomona, Icteroheamorrhagiae and Grippothypos prevailed in humans, Serogroup L. Pomona - dominated in animals, while in rodents the dominated serotgrouo was L. Icteroheamorrhagiae. Similar study, conducted by us in 1990-2005 showed that L.Pomona and L. Icteroheamorrhagiae prevailed in humans and rodents while L. Icteroheamorrhagiae was the only serogroup isolated in gray rats, trapped in Tbilisi. Infectivity of rodants composed 70%. Currently lesptosirosis is caused by a new serogroups of Leptospira - L. Sejroe, namely by serotypes Wolfii and Hardjo, L. Australis (serotype Bratislava) and L. Autumnalis along with the previously occurring serogroups L. Icteroheamorrhagiae, L. Bataviae, L. Hebdomadis. In our opinion the recent increase in leptospirosis in the country is attributable to the improvements in diagnostics of the infection as well as to the emergence of new serogroups of Leptospira, which in turn is a result of intensive migration processes in the country.

Regional variations in home canning practices and the risk of foodborne botulism in the Republic of Georgia, 2003.

Foodborne botulism is a severe, paralytic illness caused by ingestion of preformed neurotoxins produced by Clostridium botulinum. In 2003, we conducted a population-based household survey of home canning practices to explore marked regional variations in botulism incidence in the Republic of Georgia (ROG). We designed a cluster sampling scheme and subdivided each of the 10 regions of the ROG into a variable number of strata. Households were selected from each stratum using a two-step cluster sampling methodology. We administered a questionnaire about home canning practices to household members responsible for food preparation. Using multivariate logistic regression analysis, we modeled high (eastern ROG) against low (western ROG) incidence areas. Overall, we surveyed 2,742 households nationwide. Home canning with a capping device hermetically sealing the lid covering the jar was practiced by 1,909 households (65.9%; 95% confidence interval [CI]: 59.8 to 72.1%). Canning was more prevalent in regions of low botulism incidence (34 versus 32%; P < 0.01). When compared with low-botulism areas, the following practices were associated with an increased risk in high-botulism areas: ≥ 6 months between canning vegetables and consuming them (adjusted odds ratio [aOR] = 2.1; 95% CI: 1.3 to 3.5) and adding any of the following ingredients to the jar at time of preparation: >1 tablespoon of salt per liter (aOR = 5.1; 95% CI: 1.2 to 22.6); vinegar (aOR = 2.2; 95% CI: 1.3 to 3.7), and greens (aOR = 5.6; 95% CI: 1.7 to 18.2). The following practices were associated with a decreased risk in high-botulism areas: >57 jars canned per household annually (aOR = 0.5; 95% CI: 0.3 to 0.9), covering or immersing vegetables in boiling water before placing them into the jar (aOR = 0.3 95% CI: 0.2 to 0.6), covering or immersing vegetables in boiling water after placing them into the jar (aOR = 0.4; 95% CI: 0.2 to 0.9), or adding garlic (aOR = 0.2; 95% CI: 0.1 to 0.5) or aspirin (aOR = 0.1; 95% CI: 0.1 to 0.2) to the jar at the time of preparation.

[Leptospirosis in Georgia].

The aim of the article was to study epidemiological patterns of leptospirosis in Georgia from 2001 to 2011. The investigation revealed that formal registration of the infection began in 1950s. Single cases were reported annually in the country with the exception of 1986, when water-borne outbreak broke out in Sukhumi with 21 detected cases. Low morbidity level of disease was reported during 2001-2005. Since 2006 significant increase of leptospirosis has been observed. The highest incidence was reported in 2011-1.81 per 100 000 population. The increase is likely to be mainly attributed to the improvements in diagnostics of the infection. Young and middle-age persons are more frequently vulnerable to leptospirosis in Georgia, 54.8% of the cases are reported among age group of 30-59. Incidence of the infection is the highest in males - 60-65% of the detected cases. In addition, leptospirosis is characterized by high case-fatality rate - 8.7 ± 3.6% (95% CI=5.7-11.7). Case fatality is especially high in persons over 60 and over reaching 24.3 ± 8.1%. Only single cases are observed in children under 14. In 21st century ethiological structure of leptospirosis has being changed somehow. By contrast, in the earlier period the disease was mainly caused by L. icterohaemorrhagiae and L.grippotyphosa, nowadays we encounter such causative agents which were not observed in 20th century - L. autunnalis, L. mankarso, L. wolffii and others. Water is mainly implicated as a risk factor in the infection transmission. Finally, to study of epidemiological characteristics of leptospirosis in Georgia, identified that, the infection is widely distributed in the country, has an increasing tendency and duration of the disease frequently is a severe.

Fighting rabies in Eastern Europe, the Middle East and Central Asia--experts call for a regional initiative for rabies elimination.

MEEREB is an informal network of rabies experts from the Middle East, Eastern Europe and Central Asia, seeking to eliminate rabies from the region. They met for the second time to review the current rabies situation, both globally and in their respective countries, highlighting current rabies control problems and potential solutions. Success stories in Latin America, in Western Europe, in some Asian countries, as well as in Croatia and Serbia prove that elimination of human rabies is achievable in the MEEREB region. It requires political willingness and cooperation of all stakeholders, including Ministries of Health and of Agriculture; adequate management of animal bites through post-exposure prophylaxis; pre-exposure prophylaxis for populations at high risk of rabies exposure, animal vaccination and humane control of stray dog populations. MEEREB members called for a regional initiative for rabies elimination in Eastern Europe and the Middle East. They are confident that the elimination of human rabies of canine origin can be achieved in the region through adopting a One Health approach, and that campaigns for rabies elimination will have significant benefit for public health, including strengthening the structure for control of other zoonoses.

Risk factors associated with human brucellosis in the country of Georgia: a case-control study.

Human brucellosis occurs when humans ingest or contact Brucella spp. from shedding animals or contaminated environments and food. In Georgia animal and human brucellosis is endemic, but the epidemiology has not been fully characterized. A case-control study was conducted in 2010 to identify risk factors for human brucellosis. Using multivariable logistic regression, the following risk factors were identified: animal-related work [odds ratio (OR) 77·8, 90% confidence interval (CI) 4·7-1278], non-animal-related work (OR 12·7, 90% CI 1·1-149), being unemployed or a pensioner (OR 13·1, 90% CI 1·7, 101), sheep ownership (OR 19·3, 90% CI 5·1-72·6), making dairy products (OR 12·4, 90% CI 1·4-113), living in eastern Georgia (Kakheti) (OR 278·1, 90% CI 9·5-8100), and being aged >44 years (OR 9·3, 90% CI 1·02-84·4). Education of at-risk groups about risk factors and control of disease in sheep may reduce the human disease risk. This is the first study of its kind in Georgia since the collapse of the Soviet Union.

Comparison of total antibody and interferon-γ T-cell responses in patients following infection with brucellosis in Georgia.

Brucellosis is an ancient disease that still remains a significant threat to humans and is typically linked to exposure to infected animals and/or consumption of unpasteurized animal products. Despite this history, we have a relatively limited understanding of the host characteristics of this disease; consequently, further research is necessary. In this study, we examined the humoral immune response in 43 Georgian individuals that had been diagnosed with brucellosis 3-12 months before enrollment in the study, many of whom still had symptoms after the completion of antibiotic therapy. In total, 35 of 43 (83%) of the patients had antibodies that bound to Brucella lipopolysaccharide (LPS) by COMPELISA, and 34 of 38 (89%) patients had demonstrable specific antibodies to Brucellergene™ antigens; the results from the two ELISAs were highly correlated (p=0.031, r=0.851). We also studied the cellular immune responses in 15 patients. All of the patients generated interferon (IFN)-γ in response to ex vivo stimulation with Brucella protein antigens, and the majority of the patients maintained measurable humoral responses to both LPS and protein antigens. From this initial study, we conclude that measurement of antibody and of cellular (IFN-γ) responses to brucellergene OCB protein epitopes may be worthy of further investigation as an alternative or adjunct to current diagnostics.

[Epidemiology of meningococcal infection in Georgia].

Epidemiology of meningococcal infection in Georgia was studied for 2009-2011. As the official surveillance data shows, morbidity with the infection is characterized by a downward trend. During the analyzed period the morbidity level declined by 2,4 times. The average incidence rate for the period composed 0,95 ± 0,12 per 100 000 population. The infection is unequally spread throughout the country. High incidence is indicated in Tbilisi city and the regions: Ajara and Kvemo Kartli. Children are the most vulnerable population. 81,3% of all the cases fell on the children' population. High incidence rate in children of the age under 1 year is especially alarming, composing 11,52 per 100 000 population. Irrespective of the downward trend meningococcal infection in Georgia remains as a severe disease, high level of lethal outcome (lethality 18,6±3,0%) is the confirmation of that. Lethality is even higher in small children under 1 year - 27,7 ± 7,4%. The study of the isolated N. meningitides from patients with meningococcal meningitides as well as with meningococcemia showed that N. meningitides of the serosgoups B and C are being circulated in Georgia. Epidemiological investigation of the infection foci in terms of medical examination of contact persons of the cases indicated that the causative agents of the same serogroups are also widely circulated among contact subjects. Along of the passive surveillance data on the meningococcal disease, results of active investigation of epidemiological foci of the infection may serve as valuable information for planning of specific prevention measures against the infection.

Impact of unfounded vaccine safety concerns on the nationwide measles-rubella immunization campaign, Georgia, 2008.

Vaccine safety fears following media reports of adverse events led to low (50.3%) coverage in a supplementary measles-rubella immunization campaign in Georgia in 2008. Review of adverse events associated with the campaign identified 432 reports (<0.1% of ∼ 493,000 vaccinees) including 338 (78.2%) cases of syncope. There were no deaths. Causality assessment was performed for 79 cases perceived by providers as severe and with clinical details available. Conditions likely caused by the vaccine were identified in 13 (16.5%) cases (allergic and local reactions, thrombocytopenia). Thirty-seven (46.8%) cases had symptoms consistent with syncope or anxiety attack; 36 (97.3%) of them were initially misdiagnosed as anaphylactic shock/allergies/"postvaccinal reactions". Twenty-nine (36.7%) cases had coincidental illnesses. Safety fears were unfounded and exaggerated by media reports and providers' difficulties in recognizing syncope/anxiety attacks. Risk communication strategies to address perceived vaccine safety concerns are urgently needed to ensure that the goal of measles and rubella elimination in the European Region of the World Health Organization is met.

Water-borne outbreak of oropharyngeal and glandular tularemia in Georgia: investigation and follow-up.

BACKGROUND: In November 2006, an outbreak of waterborne tularemia occurred in an eastern region in the Republic of Georgia. Outbreak investigation revealed 26 cases: 21 oropharyngeal and 5 glandular tularemia cases. METHODS: The presentation of the index case triggered an outbreak investigation involving the collection of clinical/ epidemiological data, application of tularine skin test, and laboratory confirmation of the possible cases using the tube agglutination test and polymerase chain reaction (PCR) testing. Serology results were verified by enzyme-linked immunosorbent assay (ELISA) and Western blot. A case- control study along with follow-up was conducted 4 months after the index case presentation. RESULTS: Exudative pharyngitis, predominantly laterocervical adenitis, fever, and headache were the most prevalent clinical signs/symptoms observed. Depressed mood, concentration difficulties, and sleep disturbance were also detected. Bubo aspirates tested by PCR were positive in 4/4 cases and pharyngeal swabs also tested by PCR were positive in 2/3 cases. Francisella tularensis was isolated from the water samples. Comparison of the cases and controls did not reveal any statistically significant risk factors. A follow-up investigation revealed cases with protracted symptoms of fatigue, headache, and sleep disturbance. Additionally, 8/26 cases still had cervical adenopathy of prominent size. A delay in diagnosis was associated with persistent lymphadenopathy on follow-up examination (p = 0.05). CONCLUSION: We observed unique features of persistent neuropsychiatric symptoms and lymphadenopathy 5 months after tularemia infection which were associated with delayed diagnosis and the lack of prompt response to therapy. This outbreak of oropharyngeal tularemia emphasizes the importance of a rapid diagnostic and investigative response to tularemia. This type of response can prevent ongoing exposure, as well as provide expeditious treatment to mitigate persistent symptoms.

[Malaria mosquitoes of the Anopheles maculipennis (Diptera, Culicidae) complex in Georgia].

Malaria mosquito larvae and imagoes underwent morphological, cytogenetic, and molecular genetic analyses in West and East Georgia. In the areas under study, the authors identified three related types of malaria mosquitoes of the maculipennis complex: An. maculipennis Meigen, 1818; An. melanoon Hacket, 1934; An. sacharovi Favre, 1903. The authors revealed the types An. maculipennis and An. melanoon in the Kolkhida cavity (West Georgia) and An. maculipennis and An. sacharovi in the Iveria cavity (East Georgia). The morphology of eggs was defined in the study types of mosquitoes. An. melanoon ovipositions similar in the exochorion pattern with An. messeae eggs were found in West Georgia.

Rabies control and prevention in Georgia: current status and perspectives.

The incidence of rabies post-exposure prophylaxis (PEP) is very high in Georgia, at 876/100,000 persons in 2006. Data from the National Centre for Disease Control on rabies surveillance for 2004, 2005 and 2006 was analysed, with the objective of improving postexposure policy and practice, as well as identifying priorities for national surveillance and control. For the base period 1986-1995, a total of 40 rabies cases in humans were reported in Georgia. In 2004, 2005 and 2006 there were 12, 10 and 7 reported cases, respectively, representing a significant increase in overall incidence for this period. Ninety-three percent (93%) of cases were caused by dog bites. The large population of stray dogs and unvaccinated pets in Georgia is recognized as the main risk factor. In 2006, 38,569 patients received PEP following bites by an animal with suspected rabies, compared to 23,712 in 2004, and 30,254 in 2005 (representing a 1/3 increase annually). Of the total number of PEP treatments initiated in 2004, 16,568(69.9%) were discontinued due to the fact that the biting animal remained healthy during the observation period; 23,106 (76.4%) were discontinued in 2005; and 30,254 (78.4%) were discontinued in 2006. Concerns regarding the safety of available immunoglobulins, uncertainty regarding the use of vaccines and immunoglobulins from different manufacturers, and the inconsistency of national guidelines with international recommendations are cited as obstacles to an improved delivery of PEP. For the effective control of rabies, the national veterinary programmes need to be improved, stray dog population control measures need to be updated according to international standards, and clear national guidelines regarding the use of rabies vaccines and immunoglobulins for PEP should be developed and implemented.