Publications by authors named "Androula Pavli"

40 Publications

Post-COVID Syndrome: An Insight on Its Pathogenesis.

Vaccines (Basel) 2021 May 12;9(5). Epub 2021 May 12.

Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece.

Post-COVID syndrome is increasingly recognized as a new clinical entity in the context of SARS-CoV-2 infection. Symptoms persisting for more than three weeks after the diagnosis of COVID-19 characterize the post-COVID syndrome. Its incidence ranges from 10% to 35%, however, rates as high as 85% have been reported among patients with a history of hospitalization. Currently, there is no consensus on the classification of post-COVID syndrome. We reviewed the published information on post-COVID syndrome, putting emphasis on its pathogenesis. The pathogenesis of post-COVID syndrome is multi-factorial and more than one mechanism may be implicated in several clinical manifestations. Prolonged inflammation has a key role in its pathogenesis and may account for some neurological complications, cognitive dysfunction, and several other symptoms. A multisystem inflammatory syndrome in adults (MIS-A) of all ages has been also described recently, similarly to multisystem inflammatory syndrome in children (MIS-C). The post-infectious inflammatory pathogenetic mechanism of MIS-A is supported by the fact that its diagnosis is established through serology in up to one third of cases. Other pathogenetic mechanisms that are implicated in post-COVID syndrome include immune-mediated vascular dysfunction, thromboembolism, and nervous system dysfunction. Although the current data are indicating that the overwhelming majority of patients with post-COVID syndrome have a good prognosis, registries to actively follow them are needed in order to define the full clinical spectrum and its long-term outcome. A consensus-based classification of post-COVID syndrome is essential to guide clinical, diagnostic, and therapeutic management. Further research is also imperative to elucidate the pathogenesis of post-COVID syndrome.
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http://dx.doi.org/10.3390/vaccines9050497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8151752PMC
May 2021

COVID-19 vaccine passport for safe resumption of travel.

J Travel Med 2021 06;28(4)

Directorate of Research, Studies and Documentation, National Public Health Organization, Athens, Greece.

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http://dx.doi.org/10.1093/jtm/taab079DOI Listing
June 2021

COVID-19 Outbreak on a Passenger Ship and Assessment of Response Measures, Greece, 2020.

Emerg Infect Dis 2021 Jul 12;27(7):1927-1930. Epub 2021 May 12.

We describe response measures to an outbreak involving 128 (33.4%) coronavirus disease cases (46.1% asymptomatic) among 383 persons onboard a passenger ship. Multivariate analysis indicated that dining in certain rooms and bar areas, nationality, working department (for crew members), and quarantining onboard the ship were significantly associated with infection.
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http://dx.doi.org/10.3201/eid2707.210398DOI Listing
July 2021

Post-COVID syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals.

Arch Med Res 2021 May 4. Epub 2021 May 4.

Directorate of Research, Studies and Documentation, National Public Health Organization, Athens, Greece. Electronic address:

Post-COVID syndrome also known as long COVID refers to symptoms persisting for more than three weeks after the diagnosis of COVID-19. We reviewed the current evidence on post-COVID syndrome, focusing on its clinical manifestations and addressing the challenges for its management in primary healthcare. The incidence of post-COVID syndrome is estimated at 10-35%, while for hospitalized patients it may reach 85%. Fatigue is the most common symptom reported in 17.5-72% of post-COVID cases, followed by residual dyspnea with an incidence ranging from 10-40%. Mental problems, chest pain, and olfactory and gustatory dysfunction may affect up to 26%, 22% and 11% of patients, respectively. More than one third of patients with post-COVID syndrome have pre-existing comorbidities, hypertension and diabetes mellitus being the most common. Beyond the prolonged duration of symptoms, the scarce published data indicate that most patients with post-COVID syndrome have a good prognosis with no further complications or fatal outcomes reported. Given the clinical spectrum of patients with post-COVID syndrome, most of them will be managed by primary healthcare professionals, in conjunction with pre-existing or new co-morbidities, which, in turn, may increase the burden of COVID-19 on primary healthcare. In conclusion approximately 10% of patients with COVID-19 may have symptoms persisting beyond three weeks, fulfilling the criteria of post-COVID syndrome. Primary healthcare professionals have a key role in the management of patients with post-COVID syndrome. Research is needed to elucidate the pathogenesis, clinical spectrum, and prognosis of post-COVID syndrome.
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http://dx.doi.org/10.1016/j.arcmed.2021.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093949PMC
May 2021

Determinants of intention to get vaccinated against COVID-19 among healthcare personnel in hospitals in Greece.

Infect Dis Health 2021 Mar 31. Epub 2021 Mar 31.

Pathophysiology Department, Medical School, National and Kapodistrian University of Athens, 11527, Greece.

Background: To investigate intention rates to get vaccinated against COVID-19 among healthcare personnel (HCP) in Greece.

Methods: Cross-sectional survey.

Results: The response rate was 14.5%. Of 1521 HCP with a known profession, 607 (39.9%) were nursing personnel, 480 (31.6%) physicians, 171 (11.2%) paramedical personnel, 72 (4.7%) supportive personnel, and 191 (12.6%) administrative personnel. Overall, 803 of 1571 HCP (51.1%) stated their intention to get vaccinated while 768 (48.9%) stated their intention to decline vaccination. Most HCP (71.3%) who reported intent to get vaccinated noted contributing to the control of the pandemic and protecting their families and themselves as their reasons, while the most common reason for reporting intent to decline vaccination was inadequate information about the vaccines (74.9%), followed by concerns about vaccine safety (36.2%). Logistic regression analysis revealed that the probability of intending to get vaccinated increased with male gender, being a physician, history of complete vaccination against hepatitis B, history of vaccination against pandemic A (H1N1) in 2009-2010, belief that COVID-19 vaccination should be mandatory for HCP, and increased confidence in vaccines in general during the COVID-19 pandemic. The following factors were associated with a lower intention to get vaccinated: no vaccination against influenza the past season, no intention to get vaccinated against influenza in 2020-2021, and no intention to recommend COVID-19 vaccination to high-risk patients.

Conclusion: There is an urgent need to built safety perception towards COVID-19 vaccines and raise vaccine uptake rates by HCP, and thus to protect the healthcare workforce and the healthcare services.
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http://dx.doi.org/10.1016/j.idh.2021.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011642PMC
March 2021

Infectious complications related to medical tourism.

J Travel Med 2021 01;28(1)

Directorate of Research, Studies and Documentation, National Public Health Organization, Athens, Greece.

Background: Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation.

Methods: A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews.

Results: The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications.

Conclusions: There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.
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http://dx.doi.org/10.1093/jtm/taaa210DOI Listing
January 2021

In-flight transmission of COVID-19 on flights to Greece: An epidemiological analysis.

Travel Med Infect Dis 2020 Nov - Dec;38:101882. Epub 2020 Sep 17.

Department of Research, Studies and Documentation, National Public Health Organization, 3-5 Agrafon Street, Athens, 15123, Greece. Electronic address:

Background: The emergence in China in late 2019 and subsequent progression of a pandemic of a respiratory disease named coronavirus disease 2019 (COVID-19) was highly facilitated by international travel. We present 5 cases of probable in-flight transmission in Greece.

Methods: We studied international passengers arriving to or departing from Greece from February 26 through March 9, 2020. Contact tracing extended up to 4 days before the onset of symptoms and focused on close contacts. Close contacts were defined as persons sitting within a distance of <2 m for >15 min, including passengers seated two seats around the index case and all crew members and persons who had close contact with the index case.

Results: We investigated 18 international flights with 2224 passengers and 110 crew members. Main countries of departure included Northern Italy, Israel and the United Kingdom. In accordance with the national surveillance investigation, in these flights there were 21 index cases and 891 contact traced cases. Six index cases were symptomatic during the flight. Of the 891 contact traced cases, 4 passengers and 1 crew member developed laboratory-confirmed infection (3 with COVID-19 and 2 with asymptomatic infection); they travelled on the same flight with two COVID-19 cases.

Conclusions: Air travel has played a central role in the progression of the COVID-19 pandemic. However, there are scarce data about in-flight transmission. Our extensive investigation showed five cases of probable in-flight transmission. Efforts should be placed in order to ensure the prompt implementation of appropriate infection control measures on board.
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http://dx.doi.org/10.1016/j.tmaid.2020.101882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494513PMC
January 2021

A cluster of COVID-19 in pilgrims to Israel.

J Travel Med 2020 Aug;27(5)

Directorate of Epidemiological Surveillance and Interventions for Infectious Diseases, National Public Health Organization, Athens, Greece.

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http://dx.doi.org/10.1093/jtm/taaa102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337872PMC
August 2020

A case of Crimean-Congo haemorrhagic fever imported in Greece: Contact tracing and management of exposed healthcare workers.

J Infect Prev 2019 Jul 6;20(4):171-178. Epub 2019 Jun 6.

Department of Infection Control, University Hospital of Alexandroupolis, Alexandroupolis, Greece.

Background: Nosocomial transmission is a major mode of infection of Crimean-Congo haemorrhagic fever (CCHF). In May 2018, a patient with CCHF was hospitalised in Greece.

Objective: Our aim was to present the management of healthcare workers (HCWs) to the CCHF case.

Methods: Contact tracing, risk assessment and follow-up of exposed HCWs were performed. Testing (RT-PCR and/or serology) was offered to contacts. Post-exposure prophylaxis (PEP) with ribavirin was considered for high-risk exposures.

Results: Ninety-one HCWs were exposed to the case. Sixty-six HCWs were grouped as high-risk exposures. Ribavirin PEP was offered to 29 HCWs; seven agreed to receive prophylaxis. Forty-one HCWs were tested for CCHF infection; none was found positive. Gaps in infection control occurred.

Discussion: CCHF should be considered in patients with compatible travel history and clinical and laboratory findings. Early clinical suspicion and laboratory confirmation are imperative for the implementation of appropriate infection control measures. Ribavirin should be considered for high-risk exposures. Infection control capacity for highly pathogenic agents should increase.
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http://dx.doi.org/10.1177/1757177419852666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683607PMC
July 2019

Vaccinations and Malaria Chemoprophylaxis of Adolescents Traveling From Greece to International Destinations: A Nine-Year Prospective Study.

Pediatr Infect Dis J 2018 05;37(5):e132-e135

First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece.

Background: There are few publications focusing on vaccination and malaria chemoprophylaxis in adolescent travelers. We assessed pretravel vaccinations and malaria chemoprophylaxis of adolescents 12-18 years old traveling from Greece to international destinations.

Methods: We prospectively studied 239 adolescents 12-18 years old during 2008-2016. A standard questionnaire was used to collect data.

Results: Adolescents sought pretravel services at a mean of 24.1 days before departure. Their main destinations were sub-Saharan Africa (79 adolescents; 33.1%), Latin America (56; 23.5%) and North America (26; 10.9%). Almost half (46.1%) of them planned to stay abroad for at least 3 months. Sixteen (7.4%) adolescents planned to visit friends and relatives. The yellow fever vaccine and the typhoid vaccine were the most frequently administered vaccines (74.1% and 20.5%, respectively), while the hepatitis A vaccine and the tetanus-diphtheria vaccine accounted for most routine vaccinations (18% and 14.2%, respectively). The rabies and the typhoid fever vaccines were administered inadequately to adolescents traveling to endemic areas. Malaria chemoprophylaxis should have been prescribed in many cases traveling to sub-Saharan Africa and the Indian subcontinent.

Conclusions: Only a small number of adolescents from Greece traveling abroad seek pretravel counseling. We found significant gaps in typhoid fever and rabies vaccinations of adolescents traveling to endemic areas. We also found gaps in prescription of malaria chemoprophylaxis for those traveling to high-risk areas. There is a need to develop communication strategies to access adolescent travelers and improve appropriate vaccination and use of malaria chemoprophylaxis.
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http://dx.doi.org/10.1097/INF.0000000000001782DOI Listing
May 2018

Preparedness of adolescents departing from Athens International Airport to Africa or Asia: A five-year airport-based prospective study.

Travel Med Infect Dis 2018 Jan - Feb;21:69-73. Epub 2017 Aug 1.

University of Athens First Department of Pediatrics, "Aghia Sophia" Children's Hospital, Athens, Greece.

Background: The number of adolescents who travel has increased. We estimated the preparedness of adolescents (12-18 years) departing from Athens to Africa and Asia.

Methods: An airport-based survey was conducted from 2011 to 2015.

Results: Sixty-eight adolescents participated; 27/68 (40%) had the Greek nationality. Their main destinations were the Indian subcontinent (37%) and South-East Asia (32%). Most adolescents planned to stay for <1 month (69%) or for 1-3 months (22%). Their main purpose for travel was to visit friends and relatives (VFRs) (60%). Compared to non-VFR adolescents, VFRs more frequently travelled to sub-Saharan Africa and Southeast Asia, stayed in local residences and for longer periods. Twenty-one (31%) adolescents sought pre-travel counseling (in 57% of cases 8-14 days before departure). Having the Greek nationality was the only significant factor associated with an increased probability for seeking pre-travel counseling. Vaccination against rabies, typhoid fever, Japanese encephalitis and meningococcus was highly inadequate for adolescents travelling to endemic areas. Significant gaps in malaria chemoprophylaxis were found in those travelling to the Indian subcontinent.

Conclusions: Less than one third of adolescents travelling to Africa and Asia seek counseling. There is a need to access adolescent travellers in Greece and improve pre-travel vaccinations and malaria chemoprophylaxis.
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http://dx.doi.org/10.1016/j.tmaid.2017.07.011DOI Listing
May 2018

Meningococcal disease awareness and meningoccocal vaccination among Greek students planning to travel abroad.

Int J Adolesc Med Health 2017 Jun 9;31(3). Epub 2017 Jun 9.

Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, 3-5 Agrafon Street, Athens, 15123 Greece, Phone: 30-210-5212-175.

Objective Students living in dormitories are at increased risk for meningococcal disease. Our aim was to evaluate Greek students planning to study abroad about their level of meningococcal disease awareness and attitudes and practices towards meningococcal vaccination. Methods We studied 231 Greek ERASMUS students using a questionnaire. Results Students had a mean number of 4.1 correct answers out of six questions. In particular 66.5% 79.3%, 72.3% and 82.3% of them answered correctly about the etiology, transmission, epidemiology and treatment of meningococcal disease, respectively. Only 23.4% were vaccinated, whereas 14.7% were planning to do so in the near future. Students who answered correctly ≥5 questions were more likely to be male, vaccinated against meningococcal meningitis and science students. Conclusion We found an overall good level of knowledge about meningococcal disease among Greek students planning to study or already studying abroad. Knowledge about meningococcal disease was associated with vaccine uptake. However, vaccination rate against meningococcal disease was low.
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http://dx.doi.org/10.1515/ijamh-2017-0016DOI Listing
June 2017

Health problems of newly arrived migrants and refugees in Europe.

J Travel Med 2017 07;24(4)

Travel Medicine Office, Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, Marousi, Greece.

Background: The number of migrants and refugees in Europe in the past few years has increased dramatically due to war, violence or prosecutions in their homeland. Migration may affect physical, mental and social health. The objective of this article is to assess migrants and refugees' health problems, and to recommend appropriate interventions.

Methods: A PubMed search of published articles on health problems of newly arrived migrants and refugees was conducted from 2003 through 2016, focusing on the current refugee crisis in Europe.

Results: In addition to communicable diseases, such as respiratory, gastrointestinal and dermatologic infections, non-communicable diseases, including chronic conditions, mental and social problems, account for a significant morbidity burden in newly arrived migrants and refugees. Vaccine-preventable diseases are also of outmost importance. The appropriate management of newly arrived refugees and migrants' health problems is affected by barriers to access to health care including legal, communication, cultural and bureaucratic difficulties. There is diversity and lack of integration regarding health care provision across Europe due to policy differences between health care systems and social services.

Conclusion: There is a notable burden of communicable and non-communicable diseases among newly arrived migrants and refugees. Provision of health care at reception and temporary centres should be integrated and provided by a multidisciplinary team Appropriate health care of migrants and refugees could greatly enhance their health and social status which will benefit also the host countries at large.
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http://dx.doi.org/10.1093/jtm/tax016DOI Listing
July 2017

Aseptic abscess syndrome associated with traveler's diarrhea after a trip to Malaysia.

IDCases 2016 15;6:23-5. Epub 2016 Sep 15.

4th Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, University General Hospital "Attikon", Athens, Greece.

The first, to our knowledge, case of the aseptic abscesses syndrome as a complication of traveler's diarrhea after a trip to Malaysia is presented. The patient failed to respond to several antimicrobials. The diagnosis was histologically confirmed and the patient only responded to immunomodulatory therapy with corticosteroids and methotrexate. Travel physicians should be aware of this entity reviewed herein in the context of traveler's diarrhea.
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http://dx.doi.org/10.1016/j.idcr.2016.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5035335PMC
September 2016

Respiratory infections and gastrointestinal illness on a cruise ship: A three-year prospective study.

Travel Med Infect Dis 2016 Jul-Aug;14(4):389-97. Epub 2016 Jun 15.

4th Department of Internal Medicine, Attikon University Hospital, National Kapodistrian University of Athens Medical School, Athens, Greece.

Background: Cruise ships carry a large number of people in confined spaces providing an environment for transmission of infections. The aim of this study is to estimate the incidence of and describe the spectrum of respiratory infections and gastrointestinal illness among passengers and crew of cruise Ship A.

Material And Methods: The study was carried out from January 2011 to December 2013 on cruise Ship A, including passengers and crew who presented with symptoms suggestive of acute respiratory infection (ARI), influenza-like illness (ILI) and gastrointestinal illness (GI). Advice about preventive measures of respiratory and gastrointestinal infections and influenza vaccination was given to passengers and crew. Data were collected by using one standardized form per patient.

Results: The most common destination was Northern Europe (90.7%). The mean duration of cruise was 10.6 days; 440 passengers and 421 crew members who sought medical attention were studied (mean age 72.6 ± 9.5 and 33 ± 7 years, respectively). ILI, ARI and GI were diagnosed in 32.7%, 15.9%, 17% and 10.9%, 80%, 0.2% of ill passengers and crew, respectively. The association of ARI, ILI and GI incidence in passengers was statistically significant with season, destination and duration of travel; the incidence for all illnesses was higher during winter, for travel to South America and for >14 days (p-value<0.001).

Conclusion: ARI, ILI and GI continue to pose a burden on cruise travel; therefore pre-travel advice is crucial for passengers and crew regarding respiratory and gastrointestinal infections. Surveillance and implementation of control measures are important for outbreak prevention.
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http://dx.doi.org/10.1016/j.tmaid.2016.05.019DOI Listing
April 2017

Migrant screening: Lessons learned from the migrant holding level at the Greek-Turkish borders.

J Infect Public Health 2017 Mar - Apr;10(2):177-184. Epub 2016 May 6.

4th Department of Internal Medicine, Attikon, University Hospital, National Kapodistrian University of Athens Medical School, Greece.

In March 2011, a migrant health project became operational that aimed to provide medical and psychosocial support to migrants at the Greek-Turkish border. The aim of this study is to describe common syndromes, the communicable disease profile and vaccination patterns in newly arrived migrants through a surveillance system that was based on medical records data as well as screening procedures. Data were collected prospectively using one standardized form per patient including demographic information, civil status, and medical and vaccination history. A tuberculin screening test (TST) and serological testing for HIV, hepatitis B and hepatitis C were performed after obtaining informed consent. A total of 6899 migrants were screened, the majority of whom were male (91%) and 18-31 years old (85%), with a mean age of 25.3 years. Of all patients, 2.5% received secondary care. Common complaints and diagnoses included respiratory infections (23%) and myalgia (18%). The tuberculin screening test (TST) was positive in 7.8% out of 1132 patients tested. Out of 632 migrants, 0.3%, 3.2% and 0.8% tested positive for HIV, hepatitis B and hepatitis C, respectively. Overall, 22.3% of adults were vaccinated against poliomyelitis. Irregular migrants that enter Greek borders are generally in good health. Nevertheless, the risk of spreading communicable diseases is an important issue to consider among migrants at the holding level due to severe overcrowding conditions. Therefore, there is a need to strengthen surveillance and implement harmonized screening procedures with the aim of providing sustainable and good quality services that are focused on prevention and early treatment.
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http://dx.doi.org/10.1016/j.jiph.2016.04.012DOI Listing
March 2017

Imported Chikungunya fever case in Greece in June 2014 and public health response.

Pathog Glob Health 2016 Mar 9;110(2):68-73. Epub 2016 May 9.

c A' Department of Microbiology, Medical School, National Reference Centre for Arboviruses and Hemorrhagic Fever Viruses , Aristotle University of Thessaloniki , Thessaloniki , Greece.

We report about the first imported case of Chikungunya fever in Greece in a Greek traveler returning from the Dominican Republic and the associated public health response. We investigated the case and performed focused epidemiological and entomological investigation in all areas the patient visited during the infectious period, to identify the targeted interventions needed. Entomological investigation revealed the occurrence of the competent vector Aedes albopictus (Diptera: Culicidae) in the environment surrounding the hospital where the patient was admitted and in her workplace. All captured mosquitoes tested negative for Chikungunya virus. We further conducted clinical and laboratory examination of the patient's co-travelers, gave advice on appropriate personal preventive measures against mosquito bites to the patient and co-travelers and on vector control, and raised awareness among health professionals throughout Greece. The risk of introduction and local transmission of Chikungunya and other arboviruses in Greece and other European countries is present, as the competent vector exists in many parts of Europe. Public health professionals, travel medicine specialists and clinicians should maintain awareness regarding this possibility of importation of arbovirus cases in order to provide the appropriate advice, seek the prompt diagnosis, and implement appropriate interventions. Mobilization of various stakeholders will lead to enhanced epidemiological and entomological surveillance that will allow for improved risk assessment in each area.
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http://dx.doi.org/10.1080/20477724.2016.1176311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4894267PMC
March 2016

Meningococcal vaccination for international travellers from Greece visiting developing countries.

Travel Med Infect Dis 2016 May-Jun;14(3):261-6. Epub 2016 Mar 10.

Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece. Electronic address:

Background: Meningococcal meningitis is a serious disease. Travel-associated infection for the general traveller is low; however regular epidemics in indigenous population, particularly in sub-Saharan Africa are responsible for significant morbidity and mortality. Our aim was to assess meningococcal vaccination for international travellers from Greece.

Methods: A prospective questionnaire-based study was conducted during 2009-2013.

Results: A total of 5283 travellers were studied (median age: 39.2 years); Meningococcal tetravalent vaccine (A,C,W135,Y) was delivered to 1150 (21.8%) of them. Of those who travelled to the Middle East and sub-Saharan Africa, 73.1% and 21.2% received meningococcal vaccine, respectively. Of those travellers who travelled to sub-Saharan Africa from November to June and from July to October, 22.1% and 20.6% were vaccinated with meningococcal vaccine, respectively. Of all travellers who travelled for <1 month and ≥1 month, 23.3%, and 20.5%, were vaccinated, respectively. Meningococcal vaccine was administered to 95.3% of pilgrims, 17.4% of those visiting friends and relatives (VFRs), 16.7% of those who travelled for recreation, and 13.8% of those who travelled for work. Of travellers who stayed in urban, in rural, and in urban and rural areas, 32%, 11.6% and 12.7% were vaccinated, respectively. Meningococcal vaccine was delivered to 29.2%, 21.1%, 19.4% and 5.1% of those who stayed in hotels, at local people's home, in camps, and on ships, respectively. The association of meningococcal vaccine administration with the destination, duration and purpose of travel, area of stay and type of accommodation was statistically significant.

Conclusion: There is a need to improve meningococcal vaccine recommendations for travellers from Greece, particularly for high risk populations, such as VFRs, business travellers and those visiting sub-Saharan Africa especially during the dry season.
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http://dx.doi.org/10.1016/j.tmaid.2016.03.001DOI Listing
April 2017

Travel-acquired Japanese encephalitis and vaccination considerations.

J Infect Dev Ctries 2015 Sep 27;9(9):917-24. Epub 2015 Sep 27.

Hellenic Center for Disease Control and Prevention, Athens, Greece.

Japanese encephalitis (JE) is a serious arboviral disease caused by a virus of the genus Flavivirus. Japanese encephalitis is the most common vaccine-preventable virus causing encephalitis in Asia, affecting more than 50,000 persons and leading to 15,000 fatalities per year in endemic countries. For most travelers to Asia, the risk of Japanese encephalitis infection is extremely low and depends on destination, duration of travel, season, and activities. This article reviews travel-acquired Japanese encephalitis with a focus on epidemiology and prevention in the light of the newly available options for active immunization against Japanese encephalitis which have become available, and of the increasing popularity of travels to Japanese encephalitis endemic countries.
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http://dx.doi.org/10.3855/jidc.5108DOI Listing
September 2015

Middle East respiratory syndrome coronavirus (MERS-CoV): prevention in travelers.

Travel Med Infect Dis 2014 Nov-Dec;12(6 Pt A):602-8. Epub 2014 Oct 19.

Department for Interventions in Health Care Facilities, Athens, Greece. Electronic address:

Middle East respiratory syndrome coronavirus (MERS-CoV), a novel coronavirus that causes a severe lower respiratory tract infection in humans, emerged in the Middle East in 2012. Since then, MERS-CoV has caused an ongoing epidemic in the Arabian Peninsula with sporadic cases imported in Europe, North Africa, Southeast Asia, and the United States of America. As of 28th May 2014, 636 laboratory-confirmed cases of infection with MERS-CoV have been reported to World Health Organization including 14 cases imported by travelers. The epicenter of the current MERS-CoV epidemic is located in Saudi Arabia, where millions of pilgrims travel for two mass gatherings annually. In this review we summarize MERS-CoV cases in relation to travel with focus on the epidemiology and prevention in travelers. It is important to increase awareness of travelers about the risks and appropriate preventive measures and for health professionals to be on alert if a patient with severe respiratory symptoms reports a recent history of travel to the region affected with MERS-CoV. Measures should be taken by local health authorities of the affected countries in order to improve hospital hygiene. Finally, it is crucial to investigate the reasons for travelers' poor compliance with rules and recommendations issued by Saudi officials and to take appropriate measures in order to improve them.
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http://dx.doi.org/10.1016/j.tmaid.2014.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110598PMC
August 2015

Vaccination and malaria prophylaxis among Greek international travelers to Asian destinations.

J Infect Public Health 2015 Jan-Feb;8(1):47-54. Epub 2014 Aug 14.

Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece. Electronic address:

Background: International travel is rapidly increasing worldwide, and the greatest increases have occurred in tropical and subtropical areas. The aim of the survey was to investigate the pre-travel health-seeking practices of travelers to Asian destinations.

Methods: A questionnaire-based survey was conducted at the Athens International Airport between the 1st of November 2011 and the 30th of April 2013.

Results: A total of 1666 adult travelers participated in the study, and 69.7% were men. The mean age of the participants was 39 years. Previous travel to tropical countries was reported by 69% of the participants. The most frequent destination was the Indian subcontinent (45.0%). The main reasons for travel were visiting friends and relatives (VFRs; 36.5%) and business (32.4%). Most of the participants traveled for <1 month (51.4%). Only 24.5% pursued pre-travel consultations. Vaccinations were administered to 14.4% of the participants, and of those, 77%, 73%, and 32.5% received hepatitis A, tetanus/diphtheria, and typhoid vaccines, respectively. Malaria prophylaxis was given to 12.2% of the participants. Logistic regression analysis revealed that being male and unemployed, having an elementary level of education, traveling to visiting friends and relatives, and short durations of travel were significant determinants of not seeking pre-travel consultations.

Conclusion: Significant gaps were revealed in the vaccinations and malaria prophylaxes of travelers departing to Asia. Specific educational tools should be developed to improve the awareness of travelers to high-risk destinations.
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http://dx.doi.org/10.1016/j.jiph.2014.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102727PMC
September 2015

Vaccinations and malaria prophylaxis for long-term travellers travelling from Greece: a prospective, questionnaire-based analysis.

Travel Med Infect Dis 2014 Nov-Dec;12(6 Pt B):764-70. Epub 2014 May 23.

Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece. Electronic address:

The purpose of this prospective, questionnaire-based study is to assess pre-travel vaccinations and malaria prophylaxis for long-term travellers who receive pre-travel advice in Greece. A total of 4721 travellers were studied from January 1, 2009 through December 31, 2012. Travellers sought pre-travel advice at a mean of 19.7 days (range: 0-349 days) before departure. Long-term travellers (≥ 1 month) accounted for 2205 (46.7%) of all travellers. Long-term travellers had a mean age of 34.5 years. The majority of them were men (79.8%). In terms of destinations, 84% were visiting malaria-endemic countries and sub-Saharan Africa was the most common destination (17.7%). Most long-term travellers pursued trips for work purposes (70%), visited urban areas (79.6%) and stayed in hotels (29.2%). Yellow fever, typhoid fever, hepatitis A and tetanus/diphtheria vaccines were administered to 1647 (74.7%), 741 (33.6%), 652 (29.5%), and 589 (26.7%) travellers, respectively. Yellow fever vaccine was administered to 339 (87%) and 132 (71%) of long-term travellers to sub-Saharan Africa and South America respectively, whereas typhoid vaccine to 119 (90.8%) and 330 (84.6%) of those travelling to the Indian subcontinent and sub-Saharan Africa respectively. Rabies vaccine was administered to 14 (0.6%) of them. Malaria prophylaxis was recommended to 446 (20%) of long-term travellers. Mefloquine was the most commonly (49%) prescribed agent, and was prescribed to 26.7% of long-term travellers to sub-Sahara Africa. In conclusion, this study revealed that recommendations for vaccine and malaria prophylaxis for long-term travellers to developing countries should be more selective, based on the assessment of all travellers' and travel characteristics, in order to provide adequate pre-travel preparation for this high risk group of travellers. More focused studies are suggested in order to understand the particular needs of long-term travellers. Increasing awareness of travellers and travel health consultants is very important.
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http://dx.doi.org/10.1016/j.tmaid.2014.05.003DOI Listing
September 2015

Vaccination and Malaria Prevention among International Travelers Departing from Athens International Airport to African Destinations.

J Trop Med 2014 2;2014:563030. Epub 2014 Mar 2.

Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, 3-5 Agrafon Street, 15123 Athens, Greece.

Background. International travel to Africa has grown dramatically over the last decade along with an increasing need to understand the health issues for travelers. The current survey aimed to assess vaccination and malaria prevention of travelers visiting Africa. Methods. A questionnaire-based survey was conducted from of November 1, 2011 to of April 30, 2013 at Athens International Airport. Results. A total of 360 travelers were studied; 68% were men. Their mean age was 39.9 years. Previous travel to tropical countries was reported by 71.9% of them. Most frequent destination was sub-Saharan Africa (60%). Most of them traveled for ≥1 month (62%). The main reason for travel was work (39.7%). Only 47% sought pretravel consultation. Hepatitis A, typhoid, and meningococcal vaccines were administered to 49.8%, 28%, and 26.6%, respectively, and malaria chemoprophylaxis to 66.8% of those who visited sub-Saharan Africa. A history of previous travel to a tropical country, elementary level of education, and traveling for visiting friends and relatives, and for short duration were significant determinants for not pursuing pretravel consultation. Conclusions. The current survey revealed important inadequacies in vaccine and malaria prophylaxis of travelers departing to Africa. Educational tools should be developed in order to improve awareness of travelers to risk destinations.
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http://dx.doi.org/10.1155/2014/563030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955583PMC
April 2014

Pre-travel preparation practices among business travellers to tropical and subtropical destinations: results from the Athens International Airport Survey.

Travel Med Infect Dis 2014 Jul-Aug;12(4):364-9. Epub 2013 Dec 24.

Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece. Electronic address:

Background: The number of business travellers from Greece to tropical and subtropical areas has recently increased. The study aimed to assess travel health preparation practices of business travellers departing to Africa, the Middle East and Asia.

Method: A questionnaire-based survey was conducted at Athens International Airport, from 1st of November 2011 to 30th of April 2013.

Results: A total of 684 business travellers participated in the study; the majority were men (86.1%), of Greek nationality (95.3%), with tertiary education (90.8%) and employed (98%). Their mean age was 40 years; 62% and 26% of them were 35-49 and 19-34 years of age respectively. 84.8% were travelling alone. Most frequent destinations were the Middle East (46.8%) and sub-Saharan Africa (16%). For 23.5% of the travellers it was their first trip to a tropical or subtropical country. Only 58.8% pursued pre-travel health consultation; vaccination and malaria chemoprophylaxis were administered to 24.7% and 25.7% of the travellers, respectively. Hepatitis A and typhoid vaccination rates were lower than expected (70% and 35%, respectively). Nearly half of the travellers who visited malaria endemic areas did not receive any chemoprophylaxis. Having elementary education level, travelling to the Middle East or North Africa, travelling for less than 1 month duration, and staying in a house or a hotel were associated with a higher probability of not pursuing health consultation.

Conclusions: Significant gaps were found in pre-travel health practices of business travellers departing to Africa, the Middle East and Asia. Strategies should be developed in order to improve awareness of business travellers.
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http://dx.doi.org/10.1016/j.tmaid.2013.12.004DOI Listing
March 2015

Preparedness of paediatric international travellers departing from Athens, Greece: an 18-month airport-based survey.

Acta Paediatr 2014 Apr 27;103(4):e161-4. Epub 2013 Dec 27.

Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece.

Aim: The number of children who travel to tropical and subtropical areas has increased. This study aimed to assess the preparedness of children departing from Greece to Africa and Asia, in terms of vaccination and malaria chemoprophylaxis.

Methods: An 18-month airport-based study was conducted in Athens between November 2011 and April 2013.

Results: Of the 183 children studied, 122 (66.7%) had a foreign nationality. Their main destinations were the Indian subcontinent (43.2%), South-East Asia (30.6%) and sub-Saharan Africa (14.2%). Just under three-quarters (73.2%) of the children were travelling to visit friends and relatives. Forty (21.9%) children had received pretravel services. Children visiting friends and relatives sought pretravel services less frequently than those who were not (17.9% versus 32.7%; p = 0.033). Female children and Greek nationals were significantly more likely to seeking pretravel services than males and foreign nationals (p = 0.007 and <0.001, respectively). The rabies and the typhoid fever vaccines were administered inadequately to children travelling to endemic areas, but malaria chemoprophylaxis was generally justified.

Conclusion: Travel medicine services for children in Greece should be improved. There is a particular need to communicate with the parents of children visiting friends and relatives.
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http://dx.doi.org/10.1111/apa.12531DOI Listing
April 2014

Typhoid vaccination for international travelers from Greece visiting developing countries.

J Travel Med 2014 Mar-Apr;21(2):99-103. Epub 2013 Nov 19.

Travel Medicine Office; Department for Interventions in Health Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece.

Background: Typhoid fever is one of the most common diagnoses in returned international travelers. Our aim was to study the typhoid vaccine prescription practices for travelers from Greece visiting developing countries.

Methods: A prospective questionnaire-based study was conducted during 2009-2012 in 57 Public Health Departments, which are the only sources of typhoid vaccine in Greece.

Results: A total of 3,680 travelers were studied (median age: 38.1 years). Typhoid vaccine was delivered to 1,108 (30.1%) of them. Of those who traveled to sub-Saharan Africa, South America, the Middle East, the Indian subcontinent, Southeast Asia, South Africa, East Asia, North Africa, and Central America, 31.6, 17.1, 35, 44.2, 36.9, 31, 17.7, 31.6, and 36.8% received typhoid vaccine, respectively. Of travelers who stayed <1 month, 1 to <3 months, 3 to <6 months, and ≥6 months, 21.4, 63.1, 32.3, and 34.9% were vaccinated, respectively. According to the purpose of travel, typhoid vaccine was administered to 32.7% of those who traveled for leisure, to 28.8% of those who traveled for business, and to 24.1% of those visiting friends and relatives (VFRs). Of travelers who stayed in urban areas, rural areas, and urban and rural areas, 36.3, 30.1, and 26.8% were vaccinated, respectively. The majority of travelers who received the typhoid vaccine stayed in camps (62.9%) or at local residences (41%). Typhoid vaccine administration was statistically significantly associated with destination, duration of travel, purpose of travel, area of stay, and type of accommodation.

Discussion: There is a need to increase awareness of travelers and public health professionals for typhoid vaccination and particularly for high-risk groups of travelers, such as travelers to the Indian subcontinent and VFRs. Strategies for continuing professional education should be developed for travel health professionals.
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http://dx.doi.org/10.1111/jtm.12076DOI Listing
November 2014

Ηepatitis A and enteric fever in Greece, 2004-2011: a cross-sectional analysis.

Travel Med Infect Dis 2014 Mar-Apr;12(2):143-8. Epub 2013 Oct 23.

Department for Epidemiological Surveillance, Hellenic Center for Disease Control and Prevention, Athens, Greece.

Background: In Greece the number of international travellers has increased significantly the past decade.

Aim: To study the impact of international travels on the epidemiology of hepatitis A and enteric fever in Greece.

Methods: We studied cases of hepatitis A and enteric fever notified through the National Surveillance System from January 1, 2004 through December 31, 2011.

Results: A total of 921 cases of hepatitis A and 106 cases of enteric fever were notified; of them, 88 (9.5%) and 46 (43.4%) were travel-associated, respectively. Travellers returning from Eastern Europe and the Middle East accounted for most imported cases of hepatitis A (37 (43.5%) and 14 (16.5%) cases, respectively). The Indian subcontinent was the prevalent area of acquisition of travel-associated enteric fever, followed by the Middle East (35 (83.3%) and 4 (9.5%) cases, respectively). Foreign-born travellers accounted for 43 (48.8%) and 39 (86.6%) cases of travel-associated hepatitis A and enteric fever, respectively. Children <15 years accounted for 65.1% of hepatitis A cases and 7.7% among foreign-born travellers. Greek Roma accounted for 270 (29.3%) of all hepatitis A cases notified.

Conclusions: International travels have a significant impact on the epidemiology of enteric fever in Greece, affecting mainly foreign travellers. Hepatitis A carries a significant burden of morbidity among Greek travellers and children of foreign nationality. There is a need to improve travel medicine services for travellers travelling to developing countries.
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http://dx.doi.org/10.1016/j.tmaid.2013.10.004DOI Listing
December 2014

Vaccinations for international travellers travelling from Greece.

Travel Med Infect Dis 2013 Jul-Aug;11(4):225-30. Epub 2013 Feb 20.

Travel Medicine Office, Hellenic Center for Disease Control and Prevention, Athens, Greece.

The aim of this prospective, questionnaire-based study is to assess pre-travel vaccinations for international travellers who receive pre-travel advice in Greece. A total of 2494 travellers were studied from January 1, 2009 through December 31, 2010. Travellers sought pre-travel advice at a median of 16 days (range: 0-349 days) before departure. Sub-Saharan Africa was the most common destination (34.7%). Most travellers (60.8%) travelled for <1 month, for recreation purposes (58.9%), stayed in hotels (65.3%), and in urban areas (53.6%). Yellow fever, tetravalent meningococcal, typhoid fever, cholera, and rabies vaccines were administered to 1629 (65.3%), 666 (26.7%), 615 (24.7%), 28 (1.1%), and/or 12 (0.5%) travellers, respectively. Of those who received Yellow fever vaccine, 737 (45.2%) travelled to sub-Saharan Africa, 332 (20.4%) travelled to South America, 949 (58.3%) stayed for short term, and 762 (46.8%) stayed in urban areas. Of the 1629 travellers vaccinated against Yellow fever, 150 (9.2%) and 226 (13.8%) travelled to areas of sub-Saharan Africa and South America respectively, where the vaccine is not or generally not recommended. Of those travellers who received meningococcal vaccine, 327 (49.1%) travelled to the Middle East for the Hajj, 251 (29%) travelled to sub-Saharan Africa, 410 (61.6%) for short term, and 540 (64.4%) stayed in urban areas. Of those travellers who received typhoid vaccine, 241 (39.2%) travelled to sub-Saharan Africa, 78 (12.7%) to the Indian subcontinent, 234 (38%) for short term, and 419 (68.1%) stayed in urban areas. Regarding routine vaccines, tetanus-diphtheria, poliomyelitis, and measles-mumps-rubella vaccines were administered to 707 (28.3%), 639 (25.6%) and/or 149 (6%) travellers, respectively. Of those to whom poliomyelitis vaccine was recommended, 295 (46.2%) and 137 (21.4%) travelled to sub-Saharan Africa and the Middle East, respectively, and 362 (56.7%) travelled for short term. In conclusion, this study revealed that there is a need for more selective vaccine recommendations for travellers to developing countries, taking under consideration travellers and travel characteristics as well. Strategies to target travel health consultants should be developed in order to increase awareness in travel health issues.
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http://dx.doi.org/10.1016/j.tmaid.2012.11.007DOI Listing
April 2015

Knowledge and practice of malaria prophylaxis among travel medicine consultants in Greece.

Travel Med Infect Dis 2012 Sep 9;10(5-6):224-9. Epub 2012 Nov 9.

Travel Medicine Office, Hellenic Centre for Disease Control and Prevention, Athens, Greece.

Malaria is among the most significant travel-related infections encountered by travellers to endemic countries in terms of morbidity and mortality. The aim of this study is to assess the knowledge and practices about malaria prophylaxis of travel medicine consultants in Greece. A standardized questionnaire was sent to travel medicine consultants in all 57 Regional Departments of Public Health which are the official travel medicine services in Greece. Seventy (66% response rate) travel medicine consultants participated in the survey. Of them, 34.3%, 17.1%, and 44.3% delivered >20, 6-20, and ≤5 consultations per month, respectively. The average score of correct answers was 60% about malaria general knowledge and prophylaxis, and 60% about case scenarios. Linear regression revealed that being a physician and previous training in travel medicine were factors statistically significantly associated with higher rates of correct answers. Our results show inadequacies in knowledge and practices on malaria prophylaxis of travel medicine consultants in Greece. Continuing training and usage of credible information resources about malaria transmission and malaria prophylaxis in travellers will improve the quality of pre-travel advice provided by travel medicine consultants in Greece.
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http://dx.doi.org/10.1016/j.tmaid.2012.09.006DOI Listing
September 2012