Publications by authors named "Kostas Danis"

36 Publications

Global Landscape Review of Serotype-Specific Invasive Pneumococcal Disease Surveillance among Countries Using PCV10/13: The Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) Project.

Microorganisms 2021 Apr 2;9(4). Epub 2021 Apr 2.

National Public Health Organisation, 15123 Athens, Greece.

Serotype-specific surveillance for invasive pneumococcal disease (IPD) is essential for assessing the impact of 10- and 13-valent pneumococcal conjugate vaccines (PCV10/13). The Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) project aimed to evaluate the global evidence to estimate the impact of PCV10/13 by age, product, schedule, and syndrome. Here we systematically characterize and summarize the global landscape of routine serotype-specific IPD surveillance in PCV10/13-using countries and describe the subset that are included in PSERENADE. Of 138 countries using PCV10/13 as of 2018, we identified 109 with IPD surveillance systems, 76 of which met PSERENADE data collection eligibility criteria. PSERENADE received data from most (n = 63, 82.9%), yielding 240,639 post-PCV10/13 introduction IPD cases. Pediatric and adult surveillance was represented from all geographic regions but was limited from lower income and high-burden countries. In PSERENADE, 18 sites evaluated PCV10, 42 PCV13, and 17 both; 17 sites used a 3 + 0 schedule, 38 used 2 + 1, 13 used 3 + 1, and 9 used mixed schedules. With such a sizeable and generally representative dataset, PSERENADE will be able to conduct robust analyses to estimate PCV impact and inform policy at national and global levels regarding adult immunization, schedule, and product choice, including for higher valency PCVs on the horizon.
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http://dx.doi.org/10.3390/microorganisms9040742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066045PMC
April 2021

Recommendations for respiratory syncytial virus surveillance at national level.

Eur Respir J 2021 Apr 22. Epub 2021 Apr 22.

Statens Serum Institut, Copenhagen, Denmark.

Respiratory syncytial virus (RSV) is a common cause of acute lower respiratory tract infections (ALRI) and hospitalisations among young children and is globally responsible for many deaths in young children, especially in infants below 6 months of age. Furthermore, RSV is a common cause of severe respiratory disease and hospitalisation among the elderly. The development of new candidate vaccines and monoclonal antibodies highlights the need for reliable surveillance of RSV. In the European Union (EU), no up-to-date general recommendations on RSV surveillance are currently available. Based on outcomes of a workshop with 29 European experts in the field of RSV virology, epidemiology and public health, we provide recommendations to develop a feasible and sustainable national surveillance strategy for RSV that will enable harmonisation and data comparison at the European level. We discuss three surveillance components: active sentinel community surveillance, active sentinel hospital surveillance, and passive laboratory surveillance, using the EU acute respiratory infection (ARI) and WHO extended severe acute respiratory infection (SARI) case definitions. Furthermore, we recommend the use of quantitative reverse transcription polymerase chain reaction (qRT-PCR) based assays as the standard detection method for RSV and virus genetic characterisation, if possible, to monitor genetic evolution. These guidelines provide a basis for a good quality, feasible and affordable surveillance of RSV. Harmonisation of surveillance standards at European and global level will contribute to the wider availability of national level RSV surveillance data for regional and global analysis, and estimation of the RSV burden and impact of the future immunisation programmes.
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http://dx.doi.org/10.1183/13993003.03766-2020DOI Listing
April 2021

Coronavirus Disease 2019 in French Residential Care Facilities: A Nationwide Study.

J Am Med Dir Assoc 2021 Jun 20;22(6):1142-1145. Epub 2021 Mar 20.

Santé Publique France, the National Public Health Institute, Saint-Maurice, France.

Objectives: The Coronavirus 2019 (COVID-19) pandemic caused a considerable mortality in long-term care facilities (LTCFs), including residential care setting and nursing homes. This study aimed to estimate COVID-19 incidence and mortality in residential care facilities and to compare them with those recorded in nursing homes.

Design: Nationwide observational study conducted by French health authorities.

Settings And Participants: Since March 1, 2020, all LTCFs in France reported all COVID-19 cases and COVID-19-related deaths among their residents.

Methods: Possible cases were those with COVID-19-related symptoms without laboratory confirmation and confirmed cases those with a reverse transcriptase polymerase chain reaction test or serology positive for SARS-CoV-2. We included facilities with at least 1 confirmed case of COVID-19 and estimated the cumulative incidence of COVID-19 cases and mortality due to COVID-19 reported until June 30, 2020, using the maximum bed capacity as a denominator.

Results: Of the 2288 residential care facilities, 310 (14%) and, of the 7688 nursing homes, 3110 (40%) reported COVID-19 cases among residents (P < .001). The cumulative incidence of COVID-19 was significantly lower in residential care facilities as compared with nursing homes (1.10 vs 9.97 per 100 beds, P < .001). Mortality due to COVID-19 was also lower in residential care facilities compared with nursing homes (0.07 vs 1.29 per 100 beds, P < .001). Case fatality was lower in residential care facilities (6.49% vs 12.93%, P < .001).

Conclusion And Implications: French residential care facilities experienced a much lower burden from COVID-19 than nursing homes. Our findings may inform the implementation of better infection control practices in these settings.
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http://dx.doi.org/10.1016/j.jamda.2021.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980140PMC
June 2021

Changes in Invasive Pneumococcal Disease Caused by Serotype 1 Following Introduction of PCV10 and PCV13: Findings from the PSERENADE Project.

Microorganisms 2021 03 27;9(4). Epub 2021 Mar 27.

National Centre for Immunisation Research and Surveillance and Discipline of Child and Adolescent Health, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia.

serotype 1 (ST1) was an important cause of invasive pneumococcal disease (IPD) globally before the introduction of pneumococcal conjugate vaccines (PCVs) containing ST1 antigen. The Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) project gathered ST1 IPD surveillance data from sites globally and aimed to estimate PCV10/13 impact on ST1 IPD incidence. We estimated ST1 IPD incidence rate ratios (IRRs) comparing the pre-PCV10/13 period to each post-PCV10/13 year by site using a Bayesian multi-level, mixed-effects Poisson regression and all-site IRRs using a linear mixed-effects regression (N = 45 sites). Following PCV10/13 introduction, the incidence rate (IR) of ST1 IPD declined among all ages. After six years of PCV10/13 use, the all-site IRR was 0.05 (95% credibility interval 0.04-0.06) for all ages, 0.05 (0.04-0.05) for <5 years of age, 0.08 (0.06-0.09) for 5-17 years, 0.06 (0.05-0.08) for 18-49 years, 0.06 (0.05-0.07) for 50-64 years, and 0.05 (0.04-0.06) for ≥65 years. PCV10/13 use in infant immunization programs was followed by a 95% reduction in ST1 IPD in all ages after approximately 6 years. Limited data availability from the highest ST1 disease burden countries using a 3+0 schedule constrains generalizability and data from these settings are needed.
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http://dx.doi.org/10.3390/microorganisms9040696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066231PMC
March 2021

Invasive pneumococcal disease incidence in children and adults in France during the pneumococcal conjugate vaccine era: an interrupted time-series analysis of data from a 17-year national prospective surveillance study.

Lancet Infect Dis 2021 01 20;21(1):137-147. Epub 2020 Jul 20.

Public health France, the French National Public Health agency, Saint Maurice, France.

Background: The long-term benefits of pneumococcal conjugate vaccines (PCVs) remain unknown because of serotype replacement. We aimed to estimate the effect of PCV implementation on invasive pneumococcal disease incidence in France.

Methods: We did a quasi-experimental interrupted time-series analysis using data from a French national prospective surveillance system. We included all invasive pneumococcal disease cases in children and adults from more than 250 participating hospitals between Jan 1, 2001, and Dec 31, 2017. The primary outcome was incidence of invasive pneumococcal disease (meningitis and non-meningitis) over time, analysed by segmented regression with autoregressive error. Isolates were serotyped by latex agglutination with antiserum samples.

Findings: We included 75 903 patients with invasive pneumococcal disease, including 4302 (5·7%) children younger than 2 years and 37 534 (49·4%) adults aged 65 years or older. Before PCV7 implementation, the estimated monthly incidence of invasive pneumococcal disease was 0·78 cases per 100 000 inhabitants, which did not change significantly up to May, 2010. PCV13 implementation in 2010 was followed by a significant decrease in the incidence of invasive pneumococcal disease (-1·5% per month, 95% CI -2·2 to -0·8), reaching an estimated monthly incidence of 0·52 cases per 100 000 inhabitants in December, 2014. From January, 2015, the incidence rebounded (1·8% per month, 95% CI 1·0 to 2·6), reaching an estimated monthly incidence of 0·73 cases per 100 000 inhabitants in December, 2017. The estimated monthly incidence increased from 0·93 cases per 100 000 in December, 2014, to 1·73 cases per 100 000 in December, 2017, for children younger than 2 years, and from 1·54 cases per 100 000 in December, 2014, to 2·08 cases per 100 000 in December, 2017, for adults aged 65 years or older. The main non-PCV13 serotypes involved in the increase were 24F in young children and 12F, 22F, 9N, and 8 in adults aged 65 years or older.

Interpretation: PCV13 implementation led to a major reduction in the incidence of invasive pneumococcal disease. However, a rebound in cases among children and adults since 2015, driven by several emerging non-PCV13 serotypes, jeopardises the long-term PCV benefits. These findings, if confirmed in the coming years, should be considered in the development of next-generation PCVs and might guide policy makers in the selection of future pneumococcal vaccines.

Funding: Foundation for Medical Research; Pfizer, BioMérieux, Sanofi for the Regional Observatory of Pneumococci.
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http://dx.doi.org/10.1016/S1473-3099(20)30165-1DOI Listing
January 2021

Emergence of Kawasaki disease related to SARS-CoV-2 infection in an epicentre of the French COVID-19 epidemic: a time-series analysis.

Lancet Child Adolesc Health 2020 09 2;4(9):662-668. Epub 2020 Jul 2.

Department of General Paediatrics, Paediatric Internal Medicine, Rheumatology and Infectious Diseases, National Referee Centre for Rheumatic, Autoimmune and Systemic Diseases in Children, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Université de Paris, UFR de Médecine Paris Nord, Paris, France; Center for Research on Inflammation, INSERM, UMR1149, Paris, France; Biology and Genetics of Bacterial Cell Wall Unit, Pasteur Institute, Paris, France. Electronic address:

Background: Kawasaki disease is an acute febrile systemic childhood vasculitis, which is suspected to be triggered by respiratory viral infections. We aimed to examine whether the ongoing COVID-19 epidemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with an increase in the incidence of Kawasaki disease.

Methods: We did a quasi-experimental interrupted time series analysis over the past 15 years in a tertiary paediatric centre in the Paris region, a French epicentre of the COVID-19 outbreak. The main outcome was the number of Kawasaki disease cases over time, estimated by quasi-Poisson regression. In the same centre, we recorded the number of hospital admissions from the emergency department (2005-2020) and the results of nasopharyngeal multiplex PCR to identify respiratory pathogens (2017-2020). These data were compared with daily hospital admissions due to confirmed COVID-19 in the same region, recorded by Public Health France.

Findings: Between Dec 1, 2005, and May 20, 2020, we included 230 patients with Kawasaki disease. The median number of Kawasaki disease hospitalisations estimated by the quasi-Poisson model was 1·2 per month (IQR 1·1-1·3). In April, 2020, we identified a rapid increase of Kawasaki disease that was related to SARS-CoV-2 (six cases per month; 497% increase [95% CI 72-1082]; p=0·0011), starting 2 weeks after the peak of the COVID-19 epidemic. SARS-CoV-2 was the only virus circulating intensely during this period, and was found in eight (80%) of ten patients with Kawasaki disease since April 15 (SARS-CoV-2-positive PCR or serology). A second peak of hospital admissions due to Kawasaki disease was observed in December, 2009 (six cases per month; 365% increase ([31-719]; p=0.0053), concomitant with the influenza A H1N1 pandemic.

Interpretation: Our study further suggests that viral respiratory infections, including SAR-CoV-2, could be triggers for Kawasaki disease and indicates the potential timing of an increase in incidence of the disease in COVID-19 epidemics. Health-care providers should be prepared to manage an influx of patients with severe Kawasaki disease, particularly in countries where the peak of COVID-19 has recently been reached.

Funding: French National Research Agency.
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http://dx.doi.org/10.1016/S2352-4642(20)30175-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332278PMC
September 2020

Clinical and epidemiological performance of WHO Ebola case definitions: a systematic review and meta-analysis.

Lancet Infect Dis 2020 11 25;20(11):1324-1338. Epub 2020 Jun 25.

The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.

Background: Ebola virus disease case definition is a crucial surveillance tool to detect suspected cases for referral and as a screening tool for clinicians to support admission and laboratory testing decisions at Ebola health facilities. We aimed to assess the performance of the WHO Ebola virus disease case definitions and other screening scores.

Methods: In this systematic review and meta-analysis, we searched PubMed, Scopus, Embase, and Web of Science for studies published in English between June 13, 1978, and Jan 14, 2020. We included studies that estimated the sensitivity and specificity of WHO Ebola virus disease case definitions, clinical and epidemiological characteristics (symptoms at admission and contact history), and predictive risk scores against the reference standard (laboratory-confirmed Ebola virus disease). Summary estimates of sensitivity and specificity were calculated using bivariate and hierarchical summary receiver operating characteristic (when four or more studies provided data) or random-effects meta-analysis (fewer than four studies provided data).

Findings: We identified 2493 publications, of which 14 studies from four countries (Sierra Leone, Guinea, Liberia, and Angola) were included in the analysis. 12 021 people with suspected disease were included, of whom 4874 were confirmed as positive for Ebola virus infection. Six studies explored the performance of WHO case definitions in non-paediatric populations, and in all of these studies, suspected and probable cases were combined and could not be disaggregated for analysis. The pooled sensitivity of the WHO Ebola virus disease case definitions from these studies was 81·5% (95% CI 74·1-87·2) and pooled specificity was 35·7% (28·5-43·6). History of contact or epidemiological link was a key predictor for the WHO case definitions (seven studies) and for risk scores (six studies). The most sensitive symptom was intense fatigue (79·0% [95% CI 74·4-83·0]), assessed in seven studies, and the least sensitive symptom was pain behind the eyes (1·0% [0·0-7·0]), assessed in three studies. The performance of fever as a symptom varied depending on the cutoff used to define fever.

Interpretation: WHO Ebola virus disease case definitions perform suboptimally to identify cases at both community level and during triage at Ebola health facilities. Inclusion of intense fatigue as a key symptom and contact history could improve the performance of case definitions, but implementation of these changes will require effective collaboration with, and trust of, affected communities.

Funding: Médecins sans Frontières.
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http://dx.doi.org/10.1016/S1473-3099(20)30193-6DOI Listing
November 2020

High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020.

Euro Surveill 2020 06;25(22)

European Agency for Safety and Health at Work, Bilbao, Spain.

Residents in long-term care facilities (LTCF) are a vulnerable population group. Coronavirus disease (COVID-19)-related deaths in LTCF residents represent 30-60% of all COVID-19 deaths in many European countries. This situation demands that countries implement local and national testing, infection prevention and control, and monitoring programmes for COVID-19 in LTCF in order to identify clusters early, decrease the spread within and between facilities and reduce the size and severity of outbreaks.
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http://dx.doi.org/10.2807/1560-7917.ES.2020.25.22.2000956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336111PMC
June 2020

Cluster of Coronavirus Disease 2019 (COVID-19) in the French Alps, February 2020.

Clin Infect Dis 2020 07;71(15):825-832

French National Public Health Agency, Auvergne-Rhône-Alpes Regional Office, Lyon, France.

Background: On 7 February 2020, French Health authorities were informed of a confirmed case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in an Englishman infected in Singapore who had recently stayed in a chalet in the French Alps. We conducted an investigation to identify secondary cases and interrupt transmission.

Methods: We defined as a confirmed case a person linked to the chalet with a positive reverse-transcription polymerase chain reaction sample for SARS-CoV-2.

Results: The index case stayed 4 days in the chalet with 10 English tourists and a family of 5 French residents; SARS-CoV-2 was detected in 5 individuals in France, 6 in England (including the index case), and 1 in Spain (overall attack rate in the chalet: 75%). One pediatric case, with picornavirus and influenza A coinfection, visited 3 different schools while symptomatic. One case was asymptomatic, with similar viral load as that of a symptomatic case. Seven days after the first cases were diagnosed, 1 tertiary case was detected in a symptomatic patient with from the chalet a positive endotracheal aspirate; all previous and concurrent nasopharyngeal specimens were negative. Additionally, 172 contacts were monitored; all contacts tested for SARS-CoV-2 (N = 73) were negative.

Conclusions: The occurrence in this cluster of 1 asymptomatic case with similar viral load as a symptomatic patient suggests transmission potential of asymptomatic individuals. The fact that an infected child did not transmit the disease despite close interactions within schools suggests potential different transmission dynamics in children. Finally, the dissociation between upper and lower respiratory tract results underscores the need for close monitoring of the clinical evolution of suspected cases of coronavirus disease 2019.
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http://dx.doi.org/10.1093/cid/ciaa424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184384PMC
July 2020

Outbreak of pneumococcal pneumonia among shipyard workers in Marseille, France, January to February 2020.

Euro Surveill 2020 03;25(11)

Aix Marseille University, IRD, AP-HM, SSA, VITROME, Marseille, France.

We report the third outbreak of pneumococcal pneumonia within one year among workers in European shipyards. During January and February 2020, 37 cases of pneumonia were identified in a shipyard in Marseille, south-eastern France. Outbreak control measures were implemented, including a mass vaccination campaign with 23-valent pneumococcal polysaccharide vaccine targeting all shipyard workers. Given the high mobility of shipyard workers, coordinated responses between European public health institutes are necessary to avoid further outbreaks.
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http://dx.doi.org/10.2807/1560-7917.ES.2020.25.11.2000162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096773PMC
March 2020

Factors Associated With Severe Nonmeningitis Invasive Pneumococcal Disease in Adults in France.

Open Forum Infect Dis 2019 Dec 30;6(12):ofz510. Epub 2019 Nov 30.

Hospital Centre Annecy Genevois, Annecy, France.

Background: In France, pneumococcal vaccination in adults is recommended for risk groups (chronic conditions/immunosuppression). We conducted a study on invasive pneumococcal disease (IPD) in adults to identify factors associated with disease severity and death.

Methods: We included IPD cases, excluding meningitis, from 25 acute care hospitals in 6 regions. We defined severe cases as those with shock or severe sepsis or intensive care unit admission/mechanical ventilation. We included deaths occurring within 30 days of hospitalization. Infectious disease specialists collected clinical/microbiological data on cases.

Results: During 2014-2017, 908 nonmeningitis IPD cases were diagnosed; 48% were severe, 84% had comorbidities, 21% died. Ninety percent of cases with comorbidities who previously sought health care were not vaccinated against pneumococcus. Compared with previously healthy cases, the risk of severe IPD increased from 20% (adjusted risk ratio [aRR], 1.2; 95% confidence interval [CI], 1.0-1.4) in cases with 1-2 chronic diseases to 30% (aRR, 1.3; 95% CI, 1.0-7.0) in those with >2 chronic diseases. Among risk groups, 13-valent pneumococcal conjugate vaccine (PCV13) serotypes and 23-valent pneumococcal polysaccharide vaccine (PPSV23) nonPCV13 serotypes were more likely to induce severe IPD compared with nonvaccine serotypes (aRR, 1.5; 95% CI, 1.3-1.9; aRR, 1.3; 95% CI, 1.0-1.5, respectively).

Conclusions: We observed a cumulative effect of concurrent comorbidities on severe IPD. Vaccine serotypes were more likely to induce severe IPD among risk groups. The missed opportunities for vaccination underscore the need to enhance vaccination in risk groups.
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http://dx.doi.org/10.1093/ofid/ofz510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918451PMC
December 2019

Maternal health after Ebola: unmet needs and barriers to healthcare in rural Sierra Leone.

Health Policy Plan 2020 Feb;35(1):78-90

Manson Unit, Médecins Sans Frontières (MSF), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London EC4A 1AB, UK.

Sierra Leone has the world's highest estimated maternal mortality. Following the 2014-16 Ebola outbreak, we described health outcomes and health-seeking behaviour amongst pregnant women to inform health policy. In October 2016-January 2017, we conducted a sequential mixed-methods study in urban and rural areas of Tonkolili District comprising: household survey targeting women who had given birth since onset of the Ebola outbreak; structured interviews at rural sites investigating maternal deaths and reporting; and in-depth interviews (IDIs) targeting mothers, community leaders and health workers. We selected 30 clusters in each area: by random GPS points (urban) and by random village selection stratified by population size (rural). We collected data on health-seeking behaviours, barriers to healthcare, childbirth and outcomes using structured questionnaires. IDIs exploring topics identified through the survey were conducted with a purposive sample and analysed thematically. We surveyed 608 women and conducted 29 structured and 72 IDIs. Barriers, including costs of healthcare and physical inaccessibility of healthcare facilities, delayed or prevented 90% [95% confidence interval (CI): 80-95] (rural) vs 59% (95% CI: 48-68) (urban) pregnant women from receiving healthcare. Despite a general preference for biomedical care, 48% of rural and 31% of urban women gave birth outside of a health facility; of those, just 4% and 34%, respectively received skilled assistance. Women expressed mistrust of healthcare workers (HCWs) primarily due to payment demanded for 'free' healthcare. HCWs described lack of pay and poor conditions precluding provision of quality care. Twenty percent of women reported labour complications. Twenty-eight percent of villages had materials to record maternal deaths. Pregnant women faced important barriers to care, particularly in rural areas, leading to high preventable mortality and morbidity. Women wanted to access healthcare, but services available were often costly, unreachable and poor quality. We recommend urgent interventions, including health promotion, free healthcare access and strengthening rural services to address barriers to maternal healthcare.
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http://dx.doi.org/10.1093/heapol/czz102DOI Listing
February 2020

Disentangling a complex nationwide Dublin outbreak associated with raw-milk cheese consumption, France, 2015 to 2016.

Euro Surveill 2019 Jan;24(3)

These authors contributed equally to this article and share last authorship.

On 18 January 2016, the French National Reference Centre for reported to Santé publique France an excess of serotype Dublin ( Dublin) infections. We investigated to identify the source of infection and implement control measures. Whole genome sequencing (WGS) and multilocus variable-number tandem repeat analysis (MLVA) were performed to identify microbiological clusters and links among cases, animal and food sources. Clusters were defined as isolates with less than 15 single nucleotide polymorphisms determined by WGS and/or with identical MLVA pattern. We compared different clusters of cases with other cases (case-case study) and controls recruited from a web-based cohort (case-control study) in terms of food consumption. We interviewed 63/83 (76%) cases; 2,914 controls completed a questionnaire. Both studies' findings indicated that successive Dublin outbreaks from different sources had occurred between November 2015 and March 2016. In the case-control study, cases of distinct WGS clusters were more likely to have consumed Morbier (adjusted odds ratio (aOR): 14; 95% confidence interval (CI): 4.8-42) or Vacherin Mont d'Or (aOR: 27; 95% CI: 6.8-105), two bovine raw-milk cheeses. Based on these results, the Ministry of Agriculture launched a reinforced control plan for processing plants of raw-milk cheeses in the production region, to prevent future outbreaks.
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http://dx.doi.org/10.2807/1560-7917.ES.2019.24.3.1700703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6344836PMC
January 2019

Socioeconomic disparities associated with 29 common infectious diseases in Sweden, 2005-14: an individually matched case-control study.

Lancet Infect Dis 2019 02 14;19(2):165-176. Epub 2018 Dec 14.

Public Health Agency of Sweden, Solna, Sweden; Department of Medical Sciences, Uppsala University, Uppsala, Sweden. Electronic address:

Background: Although the association between low socioeconomic status and non-communicable diseases is well established, the effect of socioeconomic factors on many infectious diseases is less clear, particularly in high-income countries. We examined the associations between socioeconomic characteristics and 29 infections in Sweden.

Methods: We did an individually matched case-control study in Sweden. We defined a case as a person aged 18-65 years who was notified with one of 29 infections between 2005 and 2014, in Sweden. Cases were individually matched with respect to sex, age, and county of residence with five randomly selected controls. We extracted the data on the 29 infectious diseases from the electronic national register of notified infections and infectious diseases (SmiNet). We extracted information on country of birth, educational and employment status, and income of cases and controls from Statistics Sweden's population registers. We calculated adjusted matched odds ratios (amOR) using conditional logistic regression to examine the association between infections or groups of infections and place of birth, education, employment, and income.

Findings: We included 173 729 cases notified between Jan 1, 2005, and Dec 31, 2014 and 868 645 controls. Patients with invasive bacterial diseases, blood-borne infectious diseases, tuberculosis, and antibiotic-resistant infections were more likely to be unemployed (amOR 1·59, 95% CI 1·49-1·70; amOR 3·62, 3·48-3·76; amOR 1·88, 1·65-2·14; and amOR 1·73, 1·67-1·79, respectively), to have a lower educational attainment (amOR 1·24, 1·15-1·34; amOR 3·63, 3·45-3·81; amOR 2·14, 1·85-2·47; and amOR 1·07, 1·03-1·12, respectively), and to have a lowest income (amOR 1·52, 1·39-1·66; amOR 3·64, 3·41-3·89; amOR 3·17, 2·49-4·04; and amOR 1·2, 1·14-1·25, respectively). By contrast, patients with food-borne and water-borne infections were less likely than controls to be unemployed (amOR 0·74, 95% CI 0·72-0·76), to have lower education (amOR 0·75, 0·73-0·77), and lowest income (amOR 0·59, 0·58-0·61).

Interpretation: These findings indicate persistent socioeconomic inequalities in infectious diseases in an egalitarian high-income country with universal health care. We recommend using these findings to identify priority interventions and as a baseline to monitor programmes addressing socioeconomic inequalities in health.

Funding: The Public Health Agency of Sweden.
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http://dx.doi.org/10.1016/S1473-3099(18)30485-7DOI Listing
February 2019

Emerging Shiga-toxin-producing Escherichia coli serogroup O80 associated hemolytic and uremic syndrome in France, 2013-2016: Differences with other serogroups.

PLoS One 2018 12;13(11):e0207492. Epub 2018 Nov 12.

Santé Publique France, Saint-Maurice, France.

To generate hypotheses on possible sources of Shiga toxin-producing Escherichia coli (STEC) serogroup O80 associated hemolytic-uremic syndrome (HUS), we explored differences in factors associated with STEC O80 associated HUS, compared with STEC O157 or STEC of other serogroups, in France during 2013-16. STEC was isolated from 153/521 (30%) reported HUS cases: 45 serogroup O80, 46 O157 and 62 other serogroups. Median ages were 1.1 years, 4.0 years and 1.8 years, respectively. O80 infected patients were less likely to report ground beef consumption (aOR [adjusted Odds Ratio] 0.14 95% CI [Confidence Interval] 0.02-0.80) or previous contact with a person with diarrhea or HUS (aOR 0.13 95%CI 0.02-0.78) than patients infected with STEC O157. They were also less likely to report previous contact with a person presenting with diarrhea/HUS than patients infected with other serogroups (aOR 0.13 95%CI 0.02-0.78). STEC O80 spread all over France among young children less exposed to known risk factors of O157 or other STEC infections, suggesting the existence of different reservoirs and transmission patterns.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207492PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231688PMC
April 2019

Large outbreak of mumps virus genotype G among vaccinated students in Norway, 2015 to 2016.

Euro Surveill 2018 09;23(38)

Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway.

From 6 September 2015-May 2016, a large mumps outbreak occurred among vaccinated students in Norway. A case was defined as a person presenting with a clinical mumps infection, notified between 1 September 2015 and 30 June 2016. Confirmed cases had positive laboratory confirmation and probable cases had an epidemiological link; PCR-positive specimens were genotyped. A total of 232 cases were notified (230 confirmed) with median age of 23 years (range 4-81) and 61% were male. Of 68 (30%) confirmed cases that were genotyped, 66 were genotype G and associated with the outbreak. Cases that had received two doses of the measles-mumps-rubella (MMR) vaccine had reduced risk of hospitalisation (adjusted relative risk (aRR): 0.14; 95%CI: 0.03-0.57), mumps-related orchitis (aRR: 0.21; 95% CI: 0.08-0.55) and severe outcome (aRR: 0.25; 95% CI: 0.10-0.62) compared with those unvaccinated. A third dose of the vaccine was offered to approximately 1,300 fully vaccinated close contacts and subsequently reported cases decreased. This large outbreak, occurring among predominately vaccinated students, suggests the current genotype A vaccine offers suboptimal protection against mumps genotype G. We recommend maintaining high vaccination coverage and offering the vaccine to all unvaccinated individuals.
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http://dx.doi.org/10.2807/1560-7917.ES.2018.23.38.1700642DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157090PMC
September 2018

Improving mapping for Ebola response through mobilising a local community with self-owned smartphones: Tonkolili District, Sierra Leone, January 2015.

PLoS One 2018 3;13(1):e0189959. Epub 2018 Jan 3.

Manson Unit, Médecins Sans Frontières, London, United Kingdom.

Background: During the 2014-16 Ebola virus disease (EVD) outbreak, the Magburaka Ebola Management Centre (EMC) operated by Médecins Sans Frontières (MSF) in Tonkolili District, Sierra Leone, identified that available district maps lacked up-to-date village information to facilitate timely implementation of EVD control strategies. In January 2015, we undertook a survey in chiefdoms within the MSF EMC catchment area to collect mapping and village data. We explore the feasibility and cost to mobilise a local community for this survey, describe validation against existing mapping sources and use of the data to prioritise areas for interventions, and lessons learned.

Methods: We recruited local people with self-owned Android smartphones installed with open-source survey software (OpenDataKit (ODK)) and open-source navigation software (OpenStreetMap Automated Navigation Directions (OsmAnd)). Surveyors were paired with local motorbike drivers to travel to eligible villages. The collected mapping data were validated by checking for duplication and comparing the village names against a pre-existing village name and location list using a geographic distance and text string-matching algorithm.

Results: The survey teams gained sufficient familiarity with the ODK and OsmAnd software within 1-2 hours. Nine chiefdoms in Tonkolili District and three in Bombali District were surveyed within two weeks. Following de-duplication, the surveyors collected data from 891 villages with an estimated 127,021 households. The overall survey cost was €3,395; €3.80 per village surveyed. The MSF GIS team (MSF-OCG) created improved maps for the MSF Magburaka EMC team which were used to support surveillance, investigation of suspect EVD cases, hygiene-kit distribution and EVD survivor support. We shared the mapping data with OpenStreetMap, the local Ministry of Health and Sanitation and Sierra Leone District and National Ebola Response Centres.

Conclusions: Involving local community and using accessible technology allowed rapid implementation, at moderate cost, of a survey to collect geographic and essential village information, and creation of updated maps. These methods could be used for future emergencies to facilitate response.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189959PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752033PMC
January 2018

Ebola management centre proximity associated with reduced delays of healthcare of Ebola Virus Disease (EVD) patients, Tonkolili, Sierra Leone, 2014-15.

PLoS One 2017 1;12(5):e0176692. Epub 2017 May 1.

Manson Unit, Médecins Sans Frontières, London, United Kingdom.

Between August-December 2014, Ebola Virus Disease (EVD) patients from Tonkolili District were referred for care to two Médecins Sans Frontières (MSF) Ebola Management Centres (EMCs) outside the district (distant EMCs). In December 2014, MSF opened an EMC in Tonkolili District (district EMC). We examined the effect of opening a district-based EMC on time to admission and number of suspect cases dead on arrival (DOA), and identified factors associated with fatality in EVD patients, residents in Tonkolili District. Residents of Tonkolili district who presented between 12 September 2014 and 23 February 2015 to the district EMC and the two distant EMCs were identified from EMC line-lists. EVD cases were confirmed by a positive Ebola PCR test. We calculated time to admission since the onset of symptoms, case-fatality and adjusted Risk Ratios (aRR) using Binomial regression. Of 249 confirmed Ebola cases, 206 (83%) were admitted to the distant EMCs and 43 (17%) to the district EMC. Of them 110 (45%) have died. Confirmed cases dead on arrival (n = 10) were observed only in the distant EMCs. The median time from symptom onset to admission was 6 days (IQR 4,8) in distant EMCs and 3 days (IQR 2,7) in the district EMC (p<0.001). Cases were 2.0 (95%CI 1.4-2.9) times more likely to have delayed admission (>3 days after symptom onset) in the distant compared with the district EMC, but were less likely (aRR = 0.8; 95%CI 0.6-1.0) to have a high viral load (cycle threshold ≤22). A fatal outcome was associated with a high viral load (aRR 2.6; 95%CI 1.8-3.6) and vomiting at first presentation (aRR 1.4; 95%CI 1.0-2.0). The opening of a district EMC was associated with earlier admission of cases to appropriate care facilities, an essential component of reducing EVD transmission. High viral load and vomiting at admission predicted fatality. Healthcare providers should consider the location of EMCs to ensure equitable access during Ebola outbreaks.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0176692PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411047PMC
September 2017

Impact and Lessons Learned from Mass Drug Administrations of Malaria Chemoprevention during the Ebola Outbreak in Monrovia, Liberia, 2014.

PLoS One 2016 31;11(8):e0161311. Epub 2016 Aug 31.

Epicentre, Paris, France.

Background: In October 2014, during the Ebola outbreak in Liberia healthcare services were limited while malaria transmission continued. Médecins Sans Frontières (MSF) implemented a mass drug administration (MDA) of malaria chemoprevention (CP) in Monrovia to reduce malaria-associated morbidity. In order to inform future interventions, we described the scale of the MDA, evaluated its acceptance and estimated the effectiveness.

Methods: MSF carried out two rounds of MDA with artesunate/amodiaquine (ASAQ) targeting four neighbourhoods of Monrovia (October to December 2014). We systematically selected households in the distribution area and administered standardized questionnaires. We calculated incidence ratios (IR) of side effects using poisson regression and compared self-reported fever risk differences (RD) pre- and post-MDA using a z-test.

Findings: In total, 1,259,699 courses of ASAQ-CP were distributed. All households surveyed (n = 222; 1233 household members) attended the MDA in round 1 (r1) and 96% in round 2 (r2) (212/222 households; 1,154 household members). 52% (643/1233) initiated ASAQ-CP in r1 and 22% (256/1154) in r2. Of those not initiating ASAQ-CP, 29% (172/590) saved it for later in r1, 47% (423/898) in r2. Experiencing side effects in r1 was not associated with ASAQ-CP initiation in r2 (IR 1.0, 95%CI 0.49-2.1). The incidence of self-reported fever decreased from 4.2% (52/1229) in the month prior to r1 to 1.5% (18/1229) after r1 (p<0.001) and decrease was larger among household members completing ASAQ-CP (RD = 4.9%) compared to those not initiating ASAQ-CP (RD = 0.6%) in r1 (p<0.001).

Conclusions: The reduction in self-reported fever cases following the intervention suggests that MDAs may be effective in reducing cases of fever during Ebola outbreaks. Despite high coverage, initiation of ASAQ-CP was low. Combining MDAs with longer term interventions to prevent malaria and to improve access to healthcare may reduce both the incidence of malaria and the proportion of respondents saving their treatment for future malaria episodes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161311PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007029PMC
July 2017

Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination.

Vaccine 2016 07 7;34(32):3657-62. Epub 2016 Jun 7.

HSE Health Protection Surveillance Centre, Dublin, Ireland. Electronic address:

The World Health Organization (WHO), and European Agencies recommend influenza vaccination for individuals at-risk due to age (≥65 years), underlying diseases, pregnancy and for health care workers (HCWs) in Europe. Pneumococcal vaccine is recommended for those at-risk of pneumococcal disease. In Ireland, vaccination uptake among at-risk adults is not routinely available. In 2013, we conducted a national survey among Irish residents ≥18 years of age, to estimate size and vaccination coverage of at-risk groups, and identify predictive factors for influenza vaccination. We used computer assisted telephone interviews to collect self-reported information on health, vaccination status, attitudes towards vaccination. We calculated prevalence and prevalence ratios (PR) using binomial regression. Overall, 1770 individuals participated. For influenza, among those aged 18-64 years, 22% (325/1485) [95%CI: 17%-20%] were at-risk; 28% [95%CI: 23%-33%] were vaccinated. Among those aged ≥65 years, 60% [95%CI: 54%-66%] were vaccinated. Influenza vaccine uptake among HCWs was 28% [95%CI: 21%-35%]. For pneumococcal disease, among those aged 18-64 years, 18% [95%CI: 16%-20%] were at-risk; 16% [95%CI: 12%-21%] reported ever-vaccination; among those aged ≥65 years, 36% [95%CI: 30%-42%] reported ever-vaccination. Main reasons for not receiving influenza vaccine were perceptions of not being at-risk, or not thinking of it; and among HCWs thinking that vaccination was not necessary or they were not at-risk. At-risk individuals were more likely to be vaccinated if their doctor had recommended it (PR 3.2; [95%CI: 2.4%-4.4%]) or they had access to free medical care or free vaccination services (PR 2.0; [95%CI: 1.5%-2.8%]). Vaccination coverage for both influenza and pneumococcal vaccines in at-risk individuals aged 18-64 years was very low. Influenza vaccination coverage among individuals ≥65 years was moderate. Influenza vaccination status was associated with GP vaccination recommendation and free access to vaccination services. Doctors should identify and recommend vaccination to at-risk patients to improve uptake.
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http://dx.doi.org/10.1016/j.vaccine.2016.05.028DOI Listing
July 2016

Successful Control of Ebola Virus Disease: Analysis of Service Based Data from Rural Sierra Leone.

PLoS Negl Trop Dis 2016 Mar 9;10(3):e0004498. Epub 2016 Mar 9.

National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia.

Introduction: The scale and geographical distribution of the current outbreak in West Africa raised doubts as to the effectiveness of established methods of control. Ebola Virus Disease (EVD) was first detected in Sierra Leone in May 2014 in Kailahun district. Despite high case numbers elsewhere in the country, transmission was eliminated in the district by December 2014. We describe interventions underpinning successful EVD control in Kailahun and implications for EVD control in other areas.

Methods: Internal service data and published reports from response agencies were analysed to describe the structure and type of response activities, EVD case numbers and epidemic characteristics. This included daily national situation reports and District-level data and reports of the Sierra Leone Ministry of Health and Sanitation, and Médecins Sans Frontières (MSF) patient data and internal epidemiological reports. We used EVD case definitions provided by the World Health Organisation over the course of the outbreak. Characteristics assessed included level of response activities and epidemiological features such as reported exposure (funeral-related or not), time interval between onset of illness and admission to the EVD Management Centre (EMC), work-related exposures (health worker or not) and mortality. We compared these characteristics between two time periods--June to July (the early period of response), and August to December (when coverage and quality of response had improved). A stochastic model was used to predict case numbers per generation with different numbers of beds and a varying percentage of community cases detected.

Results: There were 652 probable/confirmed EVD cases from June-December 2014 in Kailahun. An EMC providing patient care opened in June. By August 2014 an integrated detection, treatment, and prevention strategy was in place across the district catchment zone. From June-July to August-December 2014 surveillance and contact tracing staff increased from 1.0 to 8.8 per confirmed EVD case, EMC capacity increased from 32 to 100 beds, the number of burial teams doubled, and health promotion activities increased in coverage. These improvements in response were associated with the following changes between the same periods: the proportion of confirmed/probable cases admitted to the EMC increased from 35% to 83% (χ(2) p-value<0·001), the proportion of confirmed patients admitted to the EMC <3 days of symptom onset increased from 19% to 37% (χ(2) p-value <0·001), and reported funeral contact in those admitted decreased from 33% to 16% (χ(2) p-value <0·001). Mathematical modelling confirmed the importance of both patient management capacity and surveillance and contact tracing for EVD control.

Discussion: Our findings demonstrate that control of EVD can be achieved using established interventions based on identification and appropriate management of those who are at risk of and develop EVD, including in the context of ongoing transmission in surrounding regions. Key attributes in achieving control were sufficient patient care capacity (including admission to specialist facilities of suspect and probable cases for assessment), integrated with adequate staffing and resourcing of community-based case detection and prevention activities. The response structure and coverage targets we present are of value in informing effective control in current and future EVD outbreaks.
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http://dx.doi.org/10.1371/journal.pntd.0004498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784943PMC
March 2016

Injection of new psychoactive substance snow blow associated with recently acquired HIV infections among homeless people who inject drugs in Dublin, Ireland, 2015.

Euro Surveill 2015 ;20(40)

European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden.

In February 2015, an outbreak of recently acquired HIV infections among people who inject drugs (PWID) was identified in Dublin, following similar outbreaks in Greece and Romania in 2011. We compared drug and risk behaviours among 15 HIV cases and 39 controls. Injecting a synthetic cathinone, snow blow, was associated with recent HIV infection (AOR: 49; p=0.003). Prevention and control efforts are underway among PWID in Dublin, but may also be needed elsewhere in Europe.
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http://dx.doi.org/10.2807/1560-7917.ES.2015.20.40.30036DOI Listing
April 2016

Low measles vaccination coverage among medical residents in Marseille, France: reasons for non-vaccination, March 2013.

Eur J Public Health 2015 Jun 11;25(3):512-7. Epub 2015 Feb 11.

2 Regional Office of the French Institute for Public Health Surveillance (Institut de Veille Sanitaire, InVS), Marseille, France.

Background: During 2008-12, France and Europe experienced large measles outbreaks, involving also healthcare workers (HCW). We aimed to estimate the vaccination coverage (VC) of measles among medical residents of the University of Aix/Marseille, in South-Eastern France.

Methods: In March 2013, we conducted a cross-sectional study among all medical residents of the Medical Faculty of Aix/Marseille. We used a self-administered questionnaire to collect information on self-reported VC and reasons for vaccination and non-vaccination. We compared proportions, using the chi-squared test and prevalence ratios (PRs) with 95% confidence intervals (95% CIs).

Results: Of 1152 eligible residents, 703 (61%) participated in the study and 95 (14%; 95% CI: 12-17%) reported having had measles in the past. Of all participants, 613 (93%; 95% CI: 91-95%) reported having been vaccinated against measles and 389 (76%; 95% CI: 73-80%) received two doses. Only 268 (38%) reported having visited an occupational health physician. Vaccinated individuals were more likely to report easy access to vaccination as the main motivation for measles vaccination, compared with unvaccinated residents (435; 71% and 21; 45%; P < 0.001, respectively).

Conclusions: VC among the medical residents of the University of Aix/Marseille was well below the recommended 95% coverage for two doses of measles vaccination. The majority of the study participants had not visited an occupational health doctor. Lack of easy access seems to represent major barriers to measles vaccination. We recommend that the student union, occupational health services and hospitals co-operate and address these problems in order to improve VC in this group.
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http://dx.doi.org/10.1093/eurpub/cku254DOI Listing
June 2015

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

Comp Immunol Microbiol Infect Dis 2014 Mar 16;37(2):131-41. Epub 2014 Jan 16.

Laboratory of Microbiology and Infectious Diseases, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.

In the summer of 2010 an epidemic of West Nile virus (WNV) occurred in Central Macedonia, Greece, with 197 human neuroinvasive disease (WNND) cases. In the following years the virus spread to new areas, with a total of 76 WNND cases in 2011, and 109 WNND cases in 2012 (14 and 12 WNND cases, respectively, in Central Macedonia). We established a surveillance system based on serological testing of domestic pigeons, using cELISA confirmed by serum neutralization test. In Central Macedonia, pigeon seroprevalence was 54% (95% CI: 49-59%) and 31% (95% CI: 24-37%) at the end of the 2010 and 2011 epidemic seasons, respectively. One serum was positive for neutralizing antibodies directed against Usutu virus. Pigeon WNV seroprevalence and incidence rates of human WNND after the 2010 epidemic were positively correlated (ρ=0.94, at the regional unit level), while in 2011 the correlation (ρ=0.56) was not statistically significant, possibly due to small number of human WNND cases recorded. To evaluate the efficacy of the system at alerting upon WNV enzootic circulation before the onset of human cases, we tested 270 pigeons in 2011 and 240 pigeons in 2012. In Central Macedonia, the first seroconversions in pigeons were recorded 44 and 47 days, respectively, before the first human WNND cases. Pigeon surveillance was used successfully for identification of areas with WNV enzootic transmission and for early warning. Timely diffusion of information to health authorities facilitated the implementation of preparedness plans to protect public health.
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http://dx.doi.org/10.1016/j.cimid.2014.01.004DOI Listing
March 2014

Laboratory and clinical characteristics of human West Nile virus infections during 2011 outbreak in southern Greece.

Vector Borne Zoonotic Dis 2014 Jan 20;14(1):52-8. Epub 2013 Dec 20.

1 Department of Microbiology, Medical School, University of Athens , Athens, Greece .

During the summer-autumn of 2011, a human outbreak of West Nile virus (WNV) infection occurred in southern Greece, following the first outbreak during 2010 in northern Greece. An investigation was performed to analyze laboratory diagnosis, geographic distribution, and clinical features of WNV cases in southern Greece. Serum and cerebrospinal fluid (CSF) specimens from all patients seeking laboratory diagnosis for suspected WNV infection were tested for the presence of specific WNV immunoglobulin M (IgM) and IgG antibodies. Detection of WNV RNA in CSF and whole blood samples was accomplished by real-time PCR. During August-October of 2011, 31 confirmed or probable cases of WNV infection were identified. In 25 of them, individuals experienced severe neurological manifestations and were classified as WNV neuroinvasive disease cases. Risk factors such as advanced age, hypertension, and diabetes mellitus were identified in most cases with neurological complications. As many as 25 of the WNV cases occurred in the broader region of Athens; the majority of them (17 cases) were identified in municipalities of Eastern Attica, located almost 40 km from the metropolitan area of Athens and 500 km from Central Macedonia, where the 2010 WNV outbreak occurred. The spread of the virus in a newly affected area of the country suggests that WNV has been established in Greece and disease transmission will be continued in the future.
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http://dx.doi.org/10.1089/vbz.2013.1369DOI Listing
January 2014

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

PLoS One 2013 18;8(11):e80432. Epub 2013 Nov 18.

European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden ; Dutch National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.

Introduction: During summer 2010, 262 human cases including 35 deaths from West Nile virus (WNV) infection were reported from Central Macedonia, Greece. Evidence from mosquitoes, birds and blood donors demonstrated that the epidemic was caused by WNV lineage 2, which until recently was considered of low virulence. We conducted a household seroprevalence study to estimate the spread of infection in the population during the epidemic, ascertain the relationship of infection to clinical disease, and identify risk factors for infection.

Methods: We used a two-stage cluster design to select a random sample of residents aged ≥18 years in the outbreak epicentre. We collected demographic, medical, and risk factor data using standard questionnaires and environmental checklists, and tested serum samples for presence of WNV IgG and IgM antibodies using ELISA.

Results: Overall, 723 individuals participated in the study, and 644 blood samples were available. Weighted seropositivity for IgG antibodies was 5.8% (95% CI: 3.8-8.6; n=41). We estimated that about 1 in 130 (1:141 to 1:124) infected individuals developed WNV neuroinvasive disease, and approximately 18% had clinical manifestations attributable to their infection. Risk factors for infection reflected high exposure to mosquitoes; rural residents were particularly at risk (prevalence ratio: 8.2, 95% CI: 1.1-58.7).

Discussion: This study adds to the evidence that WNV lineage 2 strains can cause significant illness, demonstrating ratios of infection to clinical disease similar to those found previously for WNV lineage 1.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0080432PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832368PMC
July 2014

Mapping environmental suitability for malaria transmission, Greece.

Emerg Infect Dis 2013 May;19(5):784-6

European Centre for Disease Prevention and Control, Stockholm, Sweden.

During 2009-2012, Greece experienced a resurgence of domestic malaria transmission. To help guide malaria response efforts, we used spatial modeling to characterize environmental signatures of areas suitable for transmission. Nonlinear discriminant analysis indicated that sea-level altitude and land-surface temperature parameters are predictive in this regard.
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http://dx.doi.org/10.3201/eid1905.120811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647495PMC
May 2013

Malaria in Greece: historical and current reflections on a re-emerging vector borne disease.

Travel Med Infect Dis 2013 Jan-Feb;11(1):8-14. Epub 2013 Feb 22.

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

Between 2009 and September 2012, locally acquired cases of P. vivax infection were reported in Greece, mostly from the agricultural area of Evrotas, Lakonia (n = 48), but also sporadically from five other regions (n = 14), suggesting that conditions in these areas are favourable for local transmission of malaria. The risk of re-establishment of malaria in Greece will depend on whether the receptivity for disease transmission (presence of the mosquito vector and adequate ecological and climatic factors) and the vulnerability (importation of the parasite in human reservoirs or presence of infected mosquito vectors) continue to be present in the country. The continuous implementation of the integrated preparedness and response plan for malaria that covers all aspects from surveillance and laboratory diagnosis to vector control and the reorganization of public health infrastructures are necessary to prevent transmission and control the disease in the long term. However, the impact of the severe economic crisis on current health-care, public health infrastructures and vector control constitute a great challenge for the future. The current threat of renewed sustained local malaria transmission in Greece (and thus in continental Europe) merits an international response, including financial and technical support, from European and international stakeholders.
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http://dx.doi.org/10.1016/j.tmaid.2013.01.001DOI Listing
September 2013

Permissive summer temperatures of the 2010 European West Nile fever upsurge.

PLoS One 2013 19;8(2):e56398. Epub 2013 Feb 19.

Department of Geography and Environmental Studies, University of Haifa, Haifa, Israel.

Background: In the summer of 2010, Europe experienced outbreaks of West Nile Fever (WNF) in humans, which was preceded by hot spells. The objective of this study was to identify potential drivers of these outbreaks, such as spring and summer temperatures, relative humidity (RH), and precipitation.

Methods: Pearson and lag correlations, binary and multinomial logistic regressions were used to assess the relationship between the climatic parameters and these outbreaks.

Results: For human morbidity, significant (<0.05) positive correlations were observed between a number of WNF cases and temperature, with a geographic latitude gradient: northern ("colder") countries displayed strong correlations with a lag of up to four weeks, in contrast to southern ("warmer") countries, where the response was immediate. The correlations with RH were weaker, while the association with precipitation was not consistent. Horse morbidity started three weeks later than in humans where integrated surveillance was conducted, and no significant associations with temperature or RH were found for lags of 0 to 4 weeks.

Conclusions: Significant temperature deviations during summer months might be considered environmental precursors of WNF outbreaks in humans, particularly at more northern latitudes. These insights can guide vector abatement strategies by health practitioners in areas at risk for persistent transmission cycles.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0056398PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576399PMC
August 2013