Hellenic Center for Disease Control and PreventionAgrafon 3- 5, Maroussi, 15123, Tel: +30 210 5212000,info@keelpno.gr, http://www.keelpno.gr

May 2012 ISSN 1792-9016Vol. 15/ Year 2nd

HCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH &

SOCIAL SOLIDARITY

Highlights

The first European female Presi-dent of the General Assembly of the World Health Organization, Mrs M. Violaki-Paraskeva, is the guest interviewee in the current issue of HCDCP’s e-bulletin. A multi-award winner, Mrs Violaki, who has had a remarkable career in the field of public health, refers to the success of the anti-malaria campaign that has led to eradica-tion of the disease, and offers ad-vice for the present situation.

More on page 37

Editorial: Epidemiology and the prevention of malaria and WNV infection in Greece 2

Surveillance Data 8

Invited articles 11

HCDCP’ s Departments Activities 25

Recent publications 30

Interesting activities 32

Meet our editorial team 34

Future conferences 35

Outbreaks around the world 36

Interview 37

Myths and truths 40

News from the HCDCP’s administration 41

Quiz of the month 42

Contents:

Diseases transmitted by insects are now part of the daily agenda of public health in our country. Spe-cifically, for the last 2 years (2010-2011) Greece has dealt with clus-ters of West Nile virus infections, while another disease, malaria, which is also spread by insects, has emerged as a major public health problem. An article in this issue analyzes the epidemiologi-cal data and HCDCP’s action plan.

More on page 2

!

Prevention of sporadic malaria cases in Greece

The recent celebration of Malaria World Day, aimed to note the global effort for the sufficient control of the disease. Greece has painful memories from malaria. At the end of the 50’s and early 60’s, the disease was completely under control, but the WHO eradication acceptance, even informal, came later (1974). At the beginning of the 20th century, Greece was a malaria endemic country. Back in 1905, Sir R. Ross, during his visit to Kopaeda lake reported that in the village Moulki, childrens’ blood samples had such a high parasitaemia as in India and Africa. The coordinated actions by the Health Services in Greece, in cooperation with foreign experts, resulted in malaria eradication. Since then, Greece had only imported cases, seldom autochthonous malaria cases and an impressive elimination of blood transfer infections.

The recent occurrence of (imported) malaria cases in Lakonia region and a few sporadic cases in other areas, noted the fact that our country is receptive for malaria reintroduction and resettlement. The problems that are raised from the insufficient control of the illegal immigrants intensify that threat. A new effort is taking place now, organized by the Ministry of Health, the HCDCP, the local authorities and several educational institutions and aims to control the problem. The direct cooperation with global organizations (WHO, ECDC) contributed to effectively resolve the scientific and mainly the technical matters. It is a widespread belief, that despite any difficulties due to the ongoing situation, malaria will be entirely controlled and eradicated again.

Nikolas Vakalis

World Blood Donor Day

14June

14June

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Editorial Editorial

Epidemiology and the prevention of malaria and West Nile virus infection in Greece, during 2010 and 2011

Introduction

Vector-borne diseases are already on the agenda asmajor public health issues in our country. During the last 2years in particular, an outbreak of West Nile virus (WNV) infection has occurred and anothervector-borne disease, malaria, has emerged as a public health threat. The April 2011 issue of the HCDCP e-bulletin was devotedto the WNV infection, so in thisissue we will focus on malaria and present the surveillance data on the WNV infection for 2011.

WNV infection

Surveillance data for 2011A totalof 101 laboratory-confirmed cases of WNV infection wasidentified during 2011,76 of which showed symptoms of the central nervous system (CNS) (encephalitis or/and meningitis or/and acute flaccid paralysis) while25 cases showed milder symptoms (fever). Ninedeaths were reported, all of which were of patients who were more than65 years old with underlying disease. Oneof the 76 cases with CNS symptoms wasconsidered to have beenimported, becausethe patient had been stayingin Albania during the incubation period of the disease. Another one of these 76 cases concerned a French citizen, whose diagnosis was madein France, but the patient had stayed in Greece throughout the incubation period. The last of the 101 reported caseshad an onset date of18 October 2011. Since then, no other case has been reported. InFigure 1 we present the WNV infection cases by week of disease onset. The first reported case refers to week 28/2011 (11–17 July2011). The age of the patients ranged between 2 and 89 years (with a median age of 70 years).

Figure 1: Number of laboratory-confirmed WNV infection cases and CNS manifestations per week of symptom onset, Greece, 2011

*The dotted line represents the number of WNV cases with neuro-invasive manifestations reported in 2010. Each box represents one case reported in 2011.

InTable 1, the number and annual incidence of patients who werelaboratory-diagnosed with WNV infection with CNS manifestations per regional area of residence are presented for Greece in 2011. It should be noted that the residential area is a rough criterion for assessing the area of virus circulation.

Table 1: Number and annual incidence of patients with a laboratory diagnosis of WNV infection with CNS manifestations per area of residence, Greece, 2011

Regional area of residence Number of patients Patients per 100,000 population*

Karditsa 8 6.89Larissa 12 4.20Viotia 5 3.99Trikala 5 3.83Eastern Attica 15 3.71Pella 5 3.45Serres 5 2.65Imathia 3 2.08Chalkidiki 2 2.00Western Attica 2 1.32Kozani 1 0.65Thessaloniki 6 0.53Evoia 1 0.48Etoloakarnania 1 0.45Western sector of Attica 1 0.21South sector of Attica 1 0.19North sector of Attica 1 0.18Central sector of Attica 1 0.09

Total 75 0.67

*Calculation based on the population data provided by the National Statistical Service (2008 forecast)

Malaria

Epidemiological data for 2011Malaria is endemic in more than 100 countries around the world, mainly in subSaharan Africa and Asia. In Greece, the disease was eradicated in 1974, after an intensive malaria eradication program (1946–1960). Since then approximately 30–50 cases are reported annually, the majority of which are related with travel to or staying in a country with endemic malaria. Sporadic malaria cases without a reported travel history were recorded in 1991, 1999, 2000, 2009 and 2010.

In 2011, 40 laboratory-confirmed cases of malaria were reported with no history of travel to malaria-endemic countries. Thirty-fourof these cases resided in the municipality of Evrotas, Laconia, two in Evia, two in eastern Attica, one in Larissa and one in Viotia. All of the cases were confirmed to have Plasmodium vivax infection by the Department of Parasitology and Tropical Diseases of the National School of Public Health.

In the area of Laconia, 23 malaria cases occurred in migrants from malaria-endemic countries, althoughtheir travel history and date of arrival in Greeceare not clear.

Figure 2 shows the cases of malaria in the affectedareas ofGreece (the municipality of Evrotas Laconia and other areas with evidence of local transmission) per week of symptoms. The last incident was a Greek patient whose symptoms began on 18 October 2011. The ages of the

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Editorial Editorial

Greek cases without travel history to an endemic country ranged from 19 months to79 years old (with a median ageof 47 years);57.6% were men.

Figure 2: Malaria cases per week of symptom onset inaffected areas, Greece, 2011

Healthcare professionals and malaria

Malaria should be included in the differential diagnosis of patients with fever not attributable to anyapparent cause, especially if the patient has traveled to or come from a malaria-endemic area. A prompt and accurate parasitological diagnosisby the nearest microbiological laboratory capable of conducting a laboratory examination is essential in all suspected cases of malaria.

A ‘suspected’case of malaria is any incident with a clinical picture compatible with malaria, especially if the patient has a travel history concerning or resides in an area where local transmission of malaria has occurred.

For all laboratory-confirmed malaria cases, as well as all suspected cases where there is no possibility of laboratory confirmation at a local level,a sample of blood (complete blood vial) and/or the coating (tile) on which diagnosis was based should be sent for microscopy examination and polymerase chain reaction (PCR)at one of the following laboratories.

Department of Parasitology, Entomology and Tropical Diseases National School of Public Health 196 Alexandra Avenue 115 27 Athens Tel: 213 2010317, 213 2010318 Contact: Professor Nikolaos Vakalis

Microbiology Laboratory School of Medicine, University of Athens 75 Mikras Asias 115 27, Athens Tel:210 7462011, 210 7462133, 210 7462140 Contact: Professor Athanasios Chakris

Malaria is one of the mandatory notifiable diseases in our country. Each malaria case that has been laboratory-confirmed should be reported immediately to the Hellenic Center for Disease Control and Prevention (HCDCP). The relevant notification form for malaria can be found on HCDCP’swebsite. The form should besent by fax to the Department of Epidemiological Surveillance and Intervention of HCDCP

(tel: 210 8899000, fax: 210 8818868, 210 8842011).

Treatment

An early diagnosis and appropriate treatment is necessary to interrupt the chain of transmission of malaria. The recommended treatment is determined by the Plasmodium species, the disease severity, the risk factors of the patient (e.g. pregnancy), the possible resistance of Plasmodium to antimalarial drugs, and the patient’s country of origin or travel.

If someone is infected with P. vivax, itis not considered necessary for that person to be hospitalized, under the condition that his or her clinical symptomsaremild according to the assessment of the clinician. The recommended schedule for radical treatment of uncomplicated malarialP.vivax includes administration of chloroquine and primaquine. Administration of primaquine is needed to treat hypnozoites in the liver and prevent relapses. Guidelines for the treatment of malaria in Greece can be found onthe HCDCP’s website (www.keelpno.gr).

Actions by HCDCP for malaria

The Ministry of Health and HCDCP are in constant communication and co-operation with European and international public health centers and the World Health Organization (WHO) to assess the risk for our country and Europe generally. Moreover, HCDCP and the Ministry of Health, in co-operation with all stakeholders, have already developed a strategic action plan for the control of malaria in Greece, which defines the actions to be carried outduring the next period of increased movement of Anopheles(spring–autumn 2012).

According to WHO recommendations, as listed in the joint WHO-European Center for Disease Control and Prevention (ECDC) assessment mission in response to the 2011 malaria outbreak in Lakonia, Greece, 10–14 October 2011 (WHO travel report), and according to the working groups of the inaugural meeting of the Special Program for the Control of West Nile Virus and Malaria, Strengthening Surveillance inthe Greek Territory, which takes place under the operational program Human Resources of the NSRF (2007-2013), the following actions are carried out.

• Detection and treatment of malaria cases (case detection and management). In any suspected case of malaria, a laboratory examination is made. Confirmed cases receive the appropriate treatment either during their hospitalization or directly supervised (directly observed therapy) by HCDCP units.

• Reinforcing the capability of a rapid and early laboratory malaria diagnosis at a local level. A seminar was organized for laboratory personnel throughout the country by the National Malaria Reference Laboratory (National School of Public Health),andrapid diagnostic tests will be distributed at primary health care centers in order to enable an authoritative and timely control of any suspected case of malaria (within 24 hours of examination) and the immediate initiation of treatment.

• Investigation of the particular case andrisk factors (case investigation). Each confirmed case of malaria with evidence of local transmission is to be investigatedpromptly with a face-to-face interview using a structured questionnaire, in order to investigate the risk factors, identify the possible site of transmission and assess the risk of further transmission.

• Investigation of the case’s domicile (focus investigation) andan active search for other cases in the environment of the known case. Foreach confirmed case of malaria with evidence of local transmission, an outbreak investigation is carried out as quickly as possible, with anactive search for other cases in the environment of the known case, coveringan area of about 100 meters radius around the case’s domicile.

• Active laboratory surveillance. The goal is to identify and report newly diagnosed cases. An active laboratory surveillance was performed inLakonia on a daily basis during the summer and autumn of 2011, in co-operation with the microbiology laboratory of the Hospital of Sparta.

• Active searching for cases of malaria in the general population. Anactive search for cases hasbeenin place since October 2011 in the municipality of Evrotas in Lakonia. Periodic visits are made (every 15 days) toall residences/accommodation of the inhabitants incertain areas, permanent and occasional (such as migrants who work in seasonal agricultural works), in order to identify suspected cases with fever (temperature measurement, fever screening) or a febrile history,and carry out laboratory tests. Because ofthe alertness and awareness of the indigenous population tothe clinical aspects of malaria and the importance of early diagnosis, the active case search is only continuingin high-risk groups such as migrants and Roma, becauseaccess and referral to health services of suspected cases belonging to non-minority population groups is assured.

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Editorial Editorial

Tips for protection against mosquitoes

Prevent mosquito bites and reduce the insect populations by:

• applying insect repellents to skin and clothing when you are outdoors• putting on appropriate clothing whenever possible that will minimize

the area of exposed skin (e.g. wearing long-sleeved tops, socks and long pants)

• taking baths regularly to remove sweat• using bed nets while sleeping• applying screens to windows• using cooling fans or/and air conditioning• using yellow lamps for outdoor lighting• using insect repellents• removing or draining anything around an area that can hold water,

such as bird baths, wheelbarrows, wading pools and plant containers, and being aware that mosquitoes lay their eggs in any standing water

• mowing the grass and pruning bushes and foliage where adult mosquitoes could find shelter

• removing water from plantations.

• Screening migrants from malaria-endemic countries. A mass screening for malaria control wasstarted formigrants from endemic countries inthe municipality of Evrotas, Lakonia, in April 2012. The aim is laboratory testing for malaria with RDTs of all migrants from endemic countries. The screening is carried outonce for asymptomatic migrants as well as of all suspected cases of malaria, i.e. symptomatic individualswith a compatible clinical picture or history of fever during the last 15 days.

Screening is also carried out of people who are considered to be at high-risk because of exposure to mosquitoes or reduced access to health services, such as Roma.

• Informing the public about malaria and protection measures. An informationleaflet has beenproduced,describing protection against mosquitoes,thatis available fromthe HCDCP website (www.keelpno.gr) and has been distributed to municipalities, hospitals and healthcare centers, tolls (Elefsina and Afidnes), post office branches and churches. More than 1.5 million brochures and 50,000 posters have been distributed. In 2011, home visits were made to all villages inthe municipality of Evrotas where cases of malaria were reported, in order to inform the local residents about the symptoms and precautions that can be taken against malaria. In 2012, information workshops have been organized inall villages and forspecial population groups (e.g. Roma) in the municipality of Evrotas, and are still ongoing.

Informationsessions have been carried outforstudents, teachers, parents and clubs inthe area.

• Increasing awareness and training forhealth professionals. HCDCP, onceacase has been reported without a travel historyto an endemic country, as a first priority notifies the Ministry of Health and the Department of Public Health of the relevant region. HCDCP also alertsclinicians in the region (public hospital,health centers and private doctors) tothe need for prompt diagnosis and appropriate malaria treatment. In addition, the Co-ordinating Center for Hemovigilance takes all the necessary measures for blood safety. In the area of the municipality of Evrotas, Lakonia, the awareness of healthcare professionals inall public health services has been increased through information days at the General Hospital of Sparti, the General Hospital–Health Center of Molaoi and at the health centers of Githio, Areopolis, Vlachioti, Kastoriou and Neapoli.

Health professionals and private doctors who could not attend the workshops, especially physicians, pediatricians, general practitioners, microbiologists, hematology and pulmologists, have been informed individually.

During the summer of 2012, another information workshop will be organized at the municipality of Evrotas and its neighboring regions, in order to remind people and increase awareness of the need for prompt malaria diagnosis.

• Educational seminars. Alongside all the above-mentioned activities, training seminars are being conducted forrelevant bodies on the procedures forchecking mosquito control programs and action evaluation.

• HCDCP is collaboratingwith the University of Thessaly onthe Special Program for the Control of West Nile Virus and Malaria, Strengthening the Surveillance in the Greek territory, which is takingplace under the operational program Human Resource Development of the NSRF (2007-2013). Different arms of the program include the development of geographical information systems (GIS), the strengthening of epidemiological surveillance for both diseases, the mapping of mosquito habitats and mosquito sampling from high-risk areas, the strengthening of bird and horse monitoring for WNV transmission, informative campaigns addressingthe public, especially high-risk groups, and health professionals who are involved directly withthe control and treatment of both diseases, as well as the screening of immigrants at the borders, mainly those from endemic countries.

Discussion

WNV InfectionIn 2011, fewer cases of WNV infection were reported in Greece compared with 2010, but there was a spread to the south and within the urban area of Attica. Thisphenomenon is similar to that observed in California in 2003. The resurgence and spread of WNV proves the existence of the virus in Greece and its circulation is expected to continue in coming years.

Malaria

WHOhas declared Greece malaria-freesince1974. However, the potential re-establishmentof the disease is a real threat because ofthe following factors.(a) The country is a place of residence and work for immigrants from endemic countries. (b) In many areas there are mosquitoes of the genus Anopheles, a malaria vector. (c) A change in environmental conditions has been noted, with a consequent increase in mosquito populations and activity. The reoccurrence and possible relocation of malaria in Greece is a major national problem with serious economic repercussions. This underlines the necessity of developing a wider strategy to combatthe disease, which includes intensification of the mosquito control program and increasing public and doctorawareness ofprompt malaria diagnosis and case treatment. HCDCP has prepared an action plan for managingmalaria for 2012–2015, which is presented in this issue.

The most appropriate measures for managingmalaria and WNV infectionsareenhanced epidemiological surveillance, systematic mosquito control measures as well as personal protection measures againstmosquitoes, medical practitioner awareness, laboratory preparedness, measures forblood safety and public awareness of the protection measures against mosquitoes.

M. Detsis, E. Papanikolaou, D. Pervanidou, M. Tseroni, E. Terzaki, G. Dougas, Department of Epidemiological Surveillance and Intervention

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Surveillance data Surveillance data

Table 1: Number of notified cases in Αpril 2012, median number of notified cases in April for the years 2004−2011 and range, Mandatory Notification System, Greece.

Disease Number of notified cases April

2012

Median number April 2004−2011 Range

Botulism 0 0 0-1Chickenpox with complications 0 1 0-5Anthrax 0 0 0-0Brucellosis 6 14 7-46Diphtheria 0 0 0-0Arbo-viral infections 0 0 0-0Malaria 5 1 0-3Rubella 0 0 0-1Smallpox 0 0 0-0Echinococcosis 0 1 0-4Hepatitis Α 6 7 3-12

Hepatitis B, acute & HBsAg(+) in infants < 12 months 5 5 2-13

Hepatitis C, acute & confirmed anti−HCV positive (1st diagnosis) 0 2 0-9

Measles 0 0 0-105Haemorrhagic fever 0 0 0-0Pertussis 0 0,5 0-4Legionellosis 0 1 0-3Leishmaniasis 5 2,5 2-7Leptospirosis 1 1 0-4Listeriosis 0 1 0-2EHEC infection 0 0 0-0Rabies 0 0 0-0Melioidosis/Glanders 0 0 0-0Meningitis aseptic 5 10,5 6-18 bacterial (except meningococcal disease) 7 11,5 10-26 unknown aetiology 0 3 0-6Meningococcal disease 5 10 4-14Plague 0 0 0-0Mumps 0 0 0-3Poliomyelitis 0 0 0-0Q Fever 0 0 0-1Salmonellosis (non typhoid/paratyphoid) 13 33 9-42Shigellosis 5 0 0-2Severe Acute Respiratory Syndrome 0 0 0-0Congenital rubella 0 0 0-0Congenital syphilis 0 0 0-0Congenital Toxoplasmosis 0 0 0-0Cluster of foodborne / waterborne disease cases

1 2.5 1-5

Τetanus / Neonatal tetanus 2 0,5 0-1Tularaemia 0 0 0-0Trichinosis 0 0 0-0Typhoid fever/Paratyphoid 0 0,5 0-3Tuberculosis 45 51 39-72Cholera 0 0 0-0

Table 2: Number of notified cases by place of residence (region)*, Mandatory Notification System, April 2012.

Disease Number of notified cases

Region

Eas

tern

Mac

edonia

and

Thra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n

Brucellosis 0 0 0 0 4 0 1 1 0 0 0 0 0 0Malaria 0 1 0 0 0 0 0 0 2 2 0 0 0 0Hepatitis Α 0 0 0 0 0 0 0 5 0 1 0 0 0 0Hepatitis B, acute & HBsAg(+) in infants < 12 months 0 0 0 0 1 0 0 0 2 1 1 0 0 0

Leishmaniasis 0 1 0 1 2 0 1 0 0 0 0 0 0 0Leptospirosis 0 1 0 0 0 0 0 0 0 0 0 0 0 0Meningitis aseptic 0 2 1 1 0 0 1 0 0 0 0 0 0 0 bacterial (except meningococcal

disease) 1 2 0 0 0 0 1 0 1 0 1 0 0 1

Meningococcal disease 0 0 1 0 2 0 2 0 0 0 0 0 0 0Salmonellosis (non typhoid/paratyphoid) 0 6 0 1 1 0 1 0 3 0 1 0 0 0Shigellosis 0 0 0 0 1 1 0 0 3 0 0 0 0 0Cluster of foodborne / waterborne disease cases 0 0 0 0 0 0 0 0 1 0 0 0 0 0

Τetanus / Neonatal tetanus 0 0 0 1 0 0 0 0 0 0 0 1 0 0Tuberculosis 1 7 1 4 3 0 0 2 19 2 0 0 5 1

* place of residence is defined according to home address of cases

Table 3: Number of notified cases by age group and gender*, Mandatory Notification System, Greece, April 2012.

Disease Number of notified cases by age group (years) and gender

<1 1−4 5−14 15−24 25−34 35−44 45−54 55−64 65+ Un.M F M F M F M F M F M F M F M F M F M F

Brucellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 4 1 0 0

Malaria 0 0 0 0 0 0 1 0 2 0 1 1 0 0 0 0 0 0 0 0

Hepatitis Α 0 0 0 0 0 0 1 0 2 0 1 0 1 0 0 1 0 0 0 0

Hepatitis B, acute & HBsAg(+) in infants < 12 months

0 0 0 0 0 0 0 0 2 0 0 2 0 0 1 0 0 0 0 0

Leishmaniasis 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 0 0 0 1 0

Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0

Meningitis aseptic 0 0 0 0 0 2 2 0 0 0 0 0 0 1 0 0 0 0 0 0 bacterial (except

meningococcal disease)

1 0 0 0 0 1 0 0 1 0 0 0 0 0 2 1 0 1 0 0

Meningococcal disease 0 0 2 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0

Salmonellosis (non typhoid/paratyphoid) 1 2 3 2 0 1 1 0 0 0 0 0 0 1 1 0 0 1 0 0

Shigellosis 0 0 0 1 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0Τetanus / Neonatal tetanus 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0

Tuberculosis 1 0 0 0 0 2 2 1 11 2 5 2 2 1 1 0 6 5 2 2

*M: male, F: female

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Invited articlesSurveillance data

Malaria: clinical picture, diagnosis and therapy

The recent autochthonous cases of malaria in Laconia show the increased risk of recurrence of malaria in our country. Thus a clinical doctor should be able to diagnose and treat malaria promptly in order to break the transmission chain of the disease.

Doctors should include malaria in the differential diagnosis of all patients with fever if they cannot exclude any other disease. This is especially true if the patient has a travel history to a malaria-endemic region. Updated information on malaria epidemiology in Greece can be found on the Hellenic Center for Disease Control and Prevention (HCDCP)’s webpage (www.keelpno.gr).

From the five species of the Plasmodium that have been described globally, P. vivax was detected recently as the cause of cases with transmission within Greece. However, usually in Greece P. falciparum is the species detected in travelers or foreigners that have come from regions where the parasite is endemic.

The clinical picture of malaria varies from an asymptomatic infection to severe disease and death (Table 1). Severe infection is usually associated with P. falciparum. Fever may occasionally appear periodically (‘tertian’ or ‘quartan’ fever), depending on the species of the parasite, but this is not usually the case. The clinical picture is not specific, especially during disease onset, when the symptoms resemble those of common infections (e.g. ’flu-like symptoms, a dry cough, abdominal pains). Individuals with partial immunity (i.e. immigrants) can have asymptomatic infection or an atypical clinical picture. Malaria during pregnancy can cause severe disease in the mother and may lead to premature labor or an underweight fetus.

Table 1: Malaria clinical picture

Symptoms

Mild disease Severe disease with complications

• Fever/low grade/chills • Fever/low grade/chills

• Headache • Decreased consciousness, seizures, coma or other neurological complications

• Arthralgias/myalgias/fatigue/malaise/sweats/nausea/vomiting • Can co-exist in severe form

Organs

• No respiratory distress • Acute respiratory distress syndrome

• Hepatosplenomegaly/mild jaundice • Hepatosplenomegaly/mild jaundice, splenic rupture

• No shock • Shock

Laboratory discoveries

• Mild anemia and/or leucopenia-thrombocytopeia, ESR /CRP

• Severe anemia as a result of hemolysis, LDH, bilirubin, leucopenia, ESR/CRP

• Minor coagulation defects • Major coagulation defects, DIC

• transaminases • transaminases

• Minor increase in urea/creatinine • Acute renal insufficiency, metabolic acidosis, hemoglobinuria

• Hypoglycemia in children, pregnant women after treatment with quinine • Hypoglycemia

• Low parasitemia (in microscopy <5,000 parasites/mL of blood or <0.1% of the red cells infected)

• High parasitemia (in microscopy >5% of red cells infected by parasites)

The presented data derive from the Mandatory Notification System (MNS) of the Hellenic Centre for Diseases Control and Prevention (HCDCP). Forty five (45) infectious diseases are included in the list of the mandatory notified diseases in Greece. Notification forms and case definitions can be found at the website of HCDCP (www.keelpno.gr).

It should be noted that data for April 2012 are provisional, and can be slightly modified/corrected in the future and also that data interpretation should be made with caution, as there are indications of under0reporting to the system.

Department of epidemiological surveillance and intervention

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invited articles Invited articles

Diagnosis

Diagnosis is based on the microscopic examination of peripheral blood (Giemsa stain, ‘thin’ or ‘thick’ blood smear). This examination determines the infection, calculates the degree of parasitemia and identifies the specific Plasmodium species. Molecular confirmation of the findings can be performed at the National Reference Laboratory (National School of Public Health, Professor Vakalis). Rapid diagnostic antigen tests (RDTs) detect specific parasite antigens using immunochromatography and can differentiate between P. falciparum and non-falciparum species.

Treatment

Treatment is prescribed according to the species of Plasmodium, the severity of the infection, the risk factors of the individual patient for severe disease (e.g. pregnancy) and the possible resistance of the Plasmodium (depending on the epi data, e.g. country of origin or visit of the affected patient). Administration of medications such as quinine, chloroquine, mefloquine, atovaquone-proguanil, doxycycline and artemisin derivatives (Table 2) should be immediate. For infection caused by P. vivax, hospitalization is usually not necessary given the mild clinical picture. For P. vivax treatment, in addition to chloroquine it is essential to use primaquine in order to eradicate the hypnozoite stage of the parasite (in the liver) and prevent relapses. When using primaquine, G6PD testing is essential and, if a deficiency is present, consultation with an expert should be sought. Respiratory support and hospitalization in an intensive care unit (ICU) is necessary for severe forms of malaria (usually caused by P. falciparum). More information on the use and dosing of therapeutic regimens is provided on HCDCP’s website .

Table 2: Therapeutic treatment of malaria (more information and dosage schemes available on www.keelpno.gr)

Clinical diagnosis/Plasmodium species Recommended treatment

Non-complicated malaria

P. falciparum or non-identified Plasmodium

• Atovaquone-proguanil (malarone)

• Quinine sulfate + doxycycline or tetracycline or clindamycin

• Mefloquine (lariam)

Non-complicated malaria

P. vivax

• Chloroquine-phosphate plus primaquine

• Hydroxychloroquine (Plaquenil©) + primaquine

Complicated malaria (all Plasmodium species)

• Artesunate (available HCDCP) + doxycycline or clindamycin

• Quinidine gluconate (if available, otherwise quinine sulfate via nasogastric tube) + doxycycline or oxytetracycline or clindamycin

• ICU support for severe complications and clinical follow-up

Prognosis: relapses

The infection caused by P. falciparum can be fatal if not treated in a timely fashion. With appropriate treatment, mortality is approximately 10–20%. Severe disease associated with P. vivax is rare but has been described recently in the area of south-east Asia. In Greece, during the 2011 outbreak in Laconia, one patient with significant co-morbidities died. Children under the age of 5, patients with immunosuppression and pregnant women are considered to be at increased risk of severe disease and complications, especially in areas with high endemicity of the disease. In areas with low endemicity, all age groups are in danger.

Relapses months and up to 5 years after the original infection have been noted in infections by P. vivax and P. ovale, especially when no hypnozoite eradication treatment (primaquine) was administered. With infections caused by P. malariae, the recrudescence can appear after decades (Table 3).

Table 3: Malaria incubation period per Plasmodium species and relapses

Plasmodium sp. Incubation period Relapses

P. vivax 12-18 days* Yes

P. falciparum 7-14 days No

P. ovale 12-18 days Yes

P. malariae 18-40 days No

*Especially for P. vivax this can last much longer (up to 6-12 months in certain cases).

References:1. http://www.keelpno.gr/el-gr/malariaworldday.aspx2. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/

malaria.htmhttp://www.rbm.who.int/endemiccountries.html3. World Health Organization (WHO) guidelines for the treatment of malaria, second edition. http://

whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf4. European Center for Disease Control and Prevention (ECDC) factsheet for health professionals. http://

ecdc.europa.eu/en/healthtopics/malaria/basic_facts/Pages/factsheet_health_professionals.aspx

S. Tsiodras, G. Saroglou

Malaria

Malaria (from the Italian mala aria, which means bad air, thought to be associated with the vapors over swamps and marshlands) is an infectious febrile disease caused by the protozoan parasite Plasmodium and transmitted by Anopheles mosquitoes, which are more active from dusk till dawn [1,2].

Malaria remains a huge global health issue; it has been estimated to cause more than one million deaths per year world-wide (Table 1). More than 100 (109) tropical and subtropical countries are highly malaria endemic, with those of subSaharan Africa have the largest proportion (Figure 1). Eighty countries are now in a phase of malaria control, 23 with elimination programs and six following measures in order to prevent re-introduction of the disease [3].

Figure 1: Country categorization by malaria control status and burden [3]

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Table 1: Numbers of cases and estimated deaths in 2010 [3]

History and science

Malaria has been documented for more than 4,000 years. The first description of symptoms comes from around 2,700 BC in China. The principal symptoms were even described by Hippocrates in the 4th century BC [2].

The discovery of the malaria parasite was made by a French army surgeon, Charles Louis Alphonse Laveran, who, in November 1880, noticed, for the first time, parasites in the blood; however, his observations were met with skepticism. In 1886, an Italian neurophysiologist, Camillo Golgi, discovered merozoites (a specific stage in the lifecycle of Plasmodium). The Italian investigators Giovanni Batista Grassi and Raimond Filetti introduced the names Plasmodium vivax and Plasmodium malariae in 1890. 1897 was the year that the American William H. Welch named the tertian malaria parasite Plasmodium falciparum, followed by the description of Plasmodium ovale in 1922 by John William Watson Stephen. Robert Knowles and Biraj Mohan Das Gupta described Plasmodium knowlesi in a macaque, and finally, in 1897, a British officer, Ronald Ross, discovered that mosquitoes transmit malaria.

The first medicine against malaria, chloroquine, was invented in 1934, and the first insecticide was formulated in 1939 [2].

Plasmodium species and routes of transmission

There are four species of malaria parasite that infect humans: P. falciparum, P. vivax, P. ovale and P. malariae. In 2008, P. knowlesi was recognized by the World Health Organization (WHO) as a fifth species responsible for malaria in humans (a zoonotic malaria), although it normally infects animals (macaques) [3].

The main mode of transmission of the disease is by bites from infected Anopheles mosquitos that have previously had a blood meal from an individual with parasitemia. Less common routes of transmission are via infected blood transfusion, transplantation, infected needles, and from a mother to her fetus during pregnancy [4].

Plasmodium lifecycle and incubation period:

The lifecycle of Plasmodium follows three different stages: stage I, infection of a human with sporozoites; stage II (asexual reproduction), development in the liver and blood of the infected person; stage III (sexual reproduction), further development of the parasite in the human’s blood and then the lifecycle is completed in a mosquito (Figure 2).

The female Anopheles mosquito injects the infective sporozoite stages of a Plasmodium directly into the blood stream of a host; after 30-60 minutes, sporozoites invade the liver cells, where

they develop and multiply, creating merozoites (the exo-erythrocytic stage). Merozoites are released into the bloodstream and penetrate the red cells (RBCs, or erythrocytes), where they evolve into trophozoites and mature schizonts; thereafter, the infected RBCs are ruptured and parasitemia presents.

Some of the Plasmodium in the RBCs may differentiate into sexual forms (gametocytes). When these forms are taken up by the Anopheles mosquito when it is feeding on blood, a new cycle begins but this time in the digestive system of the vector (the mosquito); this procedure ends with the development of sporozoites that migrate to the salivary glands of the mosquito and can be transmitted to humans with another bite.

It is worth mentioning that, regarding P. vivax and P. ovale, some of the sporozoites do not divide immediately but instead remain dormant in the liver (hypnozoites); maturation of hypnozoites weeks or months later may lead to a disease relapse [1].

Figure 2: Plasmodium lifecycle [4] (source: Open Course Ware)

Incubation and infectious period of the disease

The incubation period is the time between exposure to the pathogenic organism and clinical manifestations of the disease. In malaria, this is the time between sporozoites entering the bloodstream and the eruption of infected RBCs. It is different for each vector species, as shown in the Table 2 [1].

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Table 2: Incubation period [1]

Plasmodium species Incubation period (days)

P. vivax 12-17 or up to 6-12 months

P. ovale 16-18 or longer

P. malariae 18-40 or longer

P. falciparum 9-14

Mosquitoes can be infected if they feeding on an infected human’s blood during the period that gametocytes are circulating in the human’s blood. The duration of this period varies greatly, from weeks to months, depending on a region’s endemicity, the parasite species and the possibility of medication being taken [2].

References:

1. Warrell D, Gilles H. Essential Malariology, 4th edn. Boston: Oxford University Press; 2002.

2. CDC. www.cdc.gov

3. WHO. www.who.int

4. Malaria Site. www.malariasite.com

Andriani Marka, MD, University of Thessaly

The role of vaccine in the prevention of malaria

The first attempts in developing a malaria vaccine

After the discovery of malaria Plasmodium by the French military surgeon Charles Louis Alphonse Laveran in 1880 [1, 2], Angelo Celli, an Italian physician and zoologist, made the first attempt at immunization with dried red blood cells and transfer of serum to prevent fever, but without success [3].

Despite the efforts of many scientists to produce a malaria vaccine, especially in the last 50 years, currently there is no licensed vaccine available.

What are the difficulties in producing a malaria vaccine?

Plasmodium has a complicated lifecycle that takes place in a host and in the Anopheles mosquito. When an infected mosquito bites an individual, it releases sporozoites that circulate in the blood stream for about 30 minutes [1]. This short period of time may be not enough for an immune response. The mechanism by which sporozoites enter the hepatocytes is not completely known and therefore it is difficult for researchers to identify a way to prevent the entry of sporozoites into hepatocytes [4]. Plasmodia are complex organisms. The Plasmodium falciparum genome is large, consisting of 14 chromosomes with about 5000 genes [1]. Each stage of the lifecycle of P. falciparum expresses different proteins. A vaccine should target the right antigens that will cause immunity, and it is possible that these antigens have not yet been properly selected [4]. The parasite rapidly passes from stage to stage, so when an immune response has been developed for a specific lifestage it cannot be recognized [1].

Malaria vaccines trials

Malaria vaccines in development are targeting the pre-erythrocytic stages, blood stages and sexual stages of P. falciparum. The World Health Organization (WHO) website lists the malaria vaccine projects at advanced pre-clinical and clinical stages [5].

a) Fourteen candidate vaccines targeting the pre-erythrocytic stage [5]. The RTS,S/AS01E is under this category and includes the surface protein of sporozoites (circumsporozoite protein). Field trials in Africa have shown a 50.4% efficacy in about 15,500 young vaccinated children [6]. Vaccines belonging to this category will reduce infection rates and, if the effectiveness is improved, they will prevent infection [7].

b) Eighteen candidate vaccines targeting the blood stages [5]. These vaccines will reduce the disease intensity and mortality [7].

c) One candidate vaccine targeting the sexual stage of the parasite [5], which will reduce and interrupt the malaria transmission [7].

Moreover, the WHO table lists three vaccines that are a combination of categories (a), (b) and (c) and two with a whole organism. All vaccines target P. falciparum, except one that targets Plasmodium vivax.

Vaccines and currently available means for controlling and preventing malaria

It is interesting to examine the contribution of a vaccine in relation to the currently available means of preventing and controlling malaria. These measures are aimed at reducing the Anopheles mosquito population and the human reservoir, as well as preventing mosquito bites. Antimalarial drugs are used to prevent and cure malaria. A malaria vaccine targeting the pre-erythrocytic stage would prevent infection and at the same time produce long-term immunity. Mosquito control measures involve the elimination of breading sites, indoor residual spraying, and use of insecticide-treated nets. Vaccine use could be synergetic with the application of currently available means.

It is important to consider the effect of each preventive and control measure in the transmission cycle of malaria. The factors taking part in the transmission of malaria have been expressed using mathematical formulas. Macdonald’s model has been used for calculating the basic case reproduction rate (R0). This rate expresses the number of secondary cases arising from a single primary case, in a fully susceptible human population (R0):

Macdonald model [8]

ma represents the human-biting rate, p is the probability of the mosquito surviving 1 day, n is the incubation period to infectivity in the mosquito, b is the percentage of biting from infected mosquitoes that will result in human infection, h is the proportion of infected humans that are actually infectious, and r is the proportion of cases recovering in 1 day [1].

Considering the above-mentioned factors in relation to the prevention and control measures against malaria, we can conclude that each measure affects a different factor or factors [9]. Taking into account that it is impossible to achieve 100% vaccine efficacy and uptake, vaccination alone could not eradicate malaria. Instead, a vaccination program should be implemented in parallel with the other prevention and control measures available.

Designing future vaccination programs

Mortality is high in infants and children, and therefore future vaccination programs should target those populations. A high vaccine uptake would be difficult to achieve, especially in countries that do not have a well-organized health system. Before a vaccination program starts, resources should be secured to guarantee long-term continuing implementation and surveillance during and after the program is implemented. Failure to achieve this would have adverse health consequences, as the population would then be vulnerable to the parasite

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without natural or acquired immunity.

Conclusions

A vaccine could definitely contribute to the prevention and control of malaria in endemic counties, as well as those countries experiencing epidemics or even to prevent malaria cases among travelers. Parallel application of the currently available measures would be important, including early diagnosis and treatment, mosquito control measures and prevention of mosquito bites. Based on the published data, vaccines under trials are not highly effective and cannot provide long-lasting immunity. Before vaccination programs are put in place in the future, political commitment, continued funding and a health system able to support uninterrupted implementation should be ensured. Until all these criteria are fulfilled, the tools currently available should be implemented carefully and improved continuously.

References:

1. Warrel DA, Gilles HM. Essential Malariology, 4th edn. Arnold; 2002.

2. Laveran CL. Classics in infectious diseases: a newly discovered parasite in the blood of patients suffering from malaria. Parasitic etiology of attacks of malaria: Charles Louis Alphonse Laveran (1845-1922). Rev Infect Dis 1982;4:908-911.

3. Saleh JA, Yusuph H, Zailani SB, Aji B. Malaria vaccine: the pros and cons. Niger J Med 2010;19:8-13.

4. London School of Hygiene and Tropical Medicine. University London International Programmes. MSc Postgraduate Diploma in Infectious Diseases. Malaria. Training material in CD format. London: London School of Hygiene and Tropical Medicine; 2011.

5. WHO. Malaria Vaccine Rainbow Tables. Available at: http://www.who.int/vaccine_research/links/Rainbow/en/index.html [accessed November 2011].

6. Agnandji ST, Lell B, Soulanoudjingar SS, et al. First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children. N Engl J Med 2011;365:1863-1875.

7. WHO. Malaria report shows rapid progress towards international targets. News release. WHO; 2010.

8. MacDonald G. The epidemiology and control of malaria. Oxford: Oxford University Press; 1957.

9. Chilengi R, Gitaka J. Is vaccine the magic bullet for malaria elimination? A reality check. Malar J 2010;9(Suppl 3):S1.

Varvara Mouchtouri, RPHL of Thessaly

Control of malaria and West Nile virus vectors

Numerous medically important parasites and pathogens, such as viruses, bacteria, protists and nematode worms, that cause serious diseases in humans are transmitted by mosquitoes. Malaria, a disease caused by parasitic protists belonging to the genus Plasmodium, and West Nile virus (WNV), an arbo-virus classified within the Japanese Encephalitis serological complex, rank among the most important of them.

Human malaria continues to be one of the most important global health problems, with an estimated number of 216 million annual cases and 655,000 deaths in 2010 [1]. Greece was declared malaria-free in 1974; however, 40 cases of Plasmodium vivax infection with an endemic configuration were reported in 2011, mostly in Eurotas, Lakonia [2]. Human malaria represents a typical example of a single-cycle disease that includes one single host (Homo sapiens), one parasite (Plasmodium species) and one insect vector (Anopheles mosquitoes). Only 30–40 species of Anopheles mosquitoes (out of 400 identified) are considered to be important vectors of the four Plasmodium species (P. falciparum, P. vivax, P. ovale and P. malariae) causing human malaria [5, 6]. At least two blood meals, one to gain the pathogen and a second to transmit the disease, are required for a female mosquito to act as a vector. The transmission cycle of Plasmodium species involves sexual replication in mosquito vectors and asexual replication in humans. Malaria transmission is mainly regulated by vector distribution, abundance, life expectancy, host feeding preference, feeding rate and competence [6].

Since 1994 WNV, the most widely distributed arbo-virus in the world, has started to become frequent in Mediterranean regions [3]. WNV cases in humans were documented in Greece for the first time in 2010 in central Macedonia, northern Greece [4]. The persistence of WNV in nature is achieved through an enzootic transmission cycle involving mainly ornithophilic (‘amplification vector’) mosquitoes (primarily Culex spp.) and birds. Mosquitoes with mixed feeding preferences (both humans and birds) carry the virus from infected birds to secondary, incidental and usually dead-end hosts, such as humans, horses and other non-avian vertebrates. Although WNV has been isolated in >60 species of mosquitoes, only members of the genus Culex are considered to be major amplification vectors [3].

The most efficient way to keep populations of mosquito vectors of malaria and WNV at low levels is through an integrated mosquito management (IMM) program that combines all available control methods in the most effective, economical and safe way [5].

A consistent surveillance program (including both larvae and adults) determining mosquito species composition, relative abundance and population dynamics in relation to climatic conditions, and mapping of seasonal breeding sites, is a prerequisite for an effective control program and evaluation of its success.

Larval mosquito sampling in aquatic habitats usually serves as a tool for estimating the relative abundance of a vector species, and assessing its population density before and after the application of larvicidal insecticides.

Adult mosquito surveillance verifies the presence of a mosquito vector species, assesses its relative abundance, sets action thresholds for control activities, and assesses the success of control actions [7]. A wide array of sampling techniques, including netting, collection with aspirators, direct human bait catches, suction traps and traps utilizing attractants (e.g. CO2 traps), are used for adult mosquito sampling.

Altering or eliminating mosquito larval habitats represents a permanent, effective and economical method of mosquito control [7]. This strategy, which may significantly reduce breeding sites, includes single sanitation measures, such as proper disposal of used tires, cleaning up of illegal dump sites and rain gutters, as well as more complicated water management projects carried out at a regional scale, such as impoundment and open marsh water management.

When reduction of larval habitats fails to maintain populations of mosquito vector species below a threshold level, implementation of larvicidal activities is necessary. Larviciding aims to keep the transmission risk low by suppressing the target mosquito population before it

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reaches adulthood and has the ability to disperse [7]. Because mosquito larvae are often concentrated in limited habitats, the application of larvicides is restricted to smaller areas compared with adulticides. Mapping breeding habitats represents a valuable tool for effective larviciding, because habitats of even limited size may result in large mosquito broods.

Adulticiding is recommended when accurate surveillance data show that the risk of disease transmission is high and that therefore a significant proportion of the adult mosquitos needs to be eliminated. Indoor residual spray (IRS) and insecticide-treated nets (ITNs) represent two of the most important tools for controlling malaria vectors. IRS involves the application of stable insecticide formulations to the interior sprayable surfaces (walls, roofs and ceilings) of houses, and remains the most effective way of interrupting malaria transmission, especially in epidemiological settings (recently also in malaria-endemic areas) with seasonal transmission where mosquito vectors mainly rest indoors [8]. A prerequisite for the success of IRS is the co-operation of the inhabitants so that complete coverage of their houses is achieved. ITNs (which only recently became widely used) impregnated with pyrethroids decrease the physical contact between humans and mosquito vectors and kill some of the endophagic nocturnal-biting Anopheles mosquitoes [8].

Adulticiding operations against mosquito vectors of WNV should be determined according to the (1) general ecology and topography of the region, (2) relative abundance, distribution, flight range and age structure of the target mosquito population, (3) time period since the mosquito species was found to be infected with WNV, (4) flight range of bird WNV-amplifying hosts, (5) human demographic profile, and (6) persistence of WNV [7]; (7) accurate knowledge of the daily pattern of activity of the mosquito species is also necessary to achieve maximum control benefits. Finally, a strategy to manage resistance of mosquito vectors to insecticides is necessary in IMM programs.

The use of predators, parasites, pathogens, competitors and toxins from micro-organisms to suppress mosquito populations while avoiding toxicological effects in non-target organisms could play an important role as part of an IMM program. Numerous organisms (aquatic insects, entomopathogenic nematodes, entomopathogenic fungi and mosquitocidal bacteria such as Bacillus thurigensis) have been used as biological control agents; however, the larvivorous fish Gambusia affinis represents the best-known aquatic predator [5].

Evaluation of control efforts is a necessary component of an effective operational program against adult mosquitoes, while similar approaches (when feasible) may be followed for the evaluation of larvicide operations [7].

Control of both malaria and WNV vectors is a multidimensional, continuous process involving long-term planning, high levels of co-ordination, adoption of novel technologies, public awareness and the availability of funds.

References:1. World Health Organization (WHO). World Malaria Report 2011. Geneva: WHO; 2011.2. European Center for Disease Control and Prevention (ECDC) and WHO. Mission Report.

Joint ECDC/WHO mission related to local malaria transmission in Greece in 2011. Summary September/October 2011. Stockholm: ECDC/WHO; 2012.

3. Blitvich BJ. Transmission dynamics and changing epidemiology of West Nile virus. Animal Health Res Rev 2008;9:71-86.

4. Papa A, Danis K, Baka A, et al. Ongoing outbreak of West Nile virus infections in humans in Greece, July–August 2010. Euro Surveill 2010;15:pii:19644.

5. Becker N, Petric D, Zgomba M, et al. Mosquitoes and Their Control, 2nd edn. Berlin and Heidelberg: Springer-Verlag; 2010.

6. Gullan PJ, Cranston PS. The Insects: An Outline of Entomology, 4th edn. Hoboken, NJ: Wiley-Blackwell; 2010. 7. CDC. Epidemic/Epizootic West Nile Virus in the United States: Guidelines for Surveillance,

Prevention, and Control, 3rd revision. CDC; 2003. Available at: http://www.cdc.gov/ncidod/dvbid/westnile/resources/wnv-guidelines-aug-2003.pdf.

8. Karunamoorthi K. Vector control: a cornerstone in the malaria elimination campaign. Clin Microbiol Infect 2011;17:1608–1616.

Alexandros D. Diamantidis and Nikos T. Papadopoulos, Laboratory of Entomology and Agricultural Zoology, University of Thessaly, Greece

The laboratory diagnosis of malaria

Apart from the importance of the clinical diagnosis of malaria, the common clinical symptoms cause diagnostic problems and reinforce the need for the laboratory confirmation. This will take place mostly with the following laboratory methods

• Microscopic examination of the peripheral blood (1,2)Until nowadays it remains the gold standard. The test is done in thick film and in thin film. The thick film testing helps detecting the plasmodium and the thin film helps identifying the parasite. For the blood examination, experience is required. During the preparation, the technical details should be always taken into consideration, to avoid any changes at the parasite morphology and characteristics. The plasmodium identification is based on their special characteristics and the appearance of the blood cell that they have infected. (Pictures 1 and 2)

In thick film preparations 200- 300 fields should be examined (x100). In low parasitaemia, larger number of fields is required. Ideally, all preparations are examined by two microscopists (where the second one should have great experience). When there are clinical signs of malaria and preparations are negative, examination of new samples should be repeated every 12 hours, at least. One negative result does not exclude malaria. Thrombocytopenia or suspicious findings in some hematology analyzers increase the malaria suspicion and new examination is required.

Parasitaemia determination is something that is asked from the clinical doctors. From the existed data (with objective X100) it is considered that 1-2 plasmodium per field corresponds to 0.1% parasitized red blood cells, while 1-2 plasmodium per 10 fields corresponds to 0.01% parasitized red blood cells. In high parasitaemia with 10-20 plasmodium per field, the percentage of parasitized red blood cells is 1%. These percentages differ according the plasmodium species and the researcher.

• Rapid antigen detection (RDT) (2,3). Immune-chromatographic method that detects the plasmodium antigen in the blood in a small amount of blood (5-15μl) in 5- 20 minutes.

The method is very useful for P. falciparum detection. In other plasmodium species, due to lower parasitaemia, the detection percentages are lower. Its’ usage is additional when there is absence of primary health care structure and no experienced microscopists. There are two approaches. The first one, uses the protein HRP-2, rich in histidine which specialises in P. falciparum but with insufficient antigen time limits detection after the treatment (antigen detection has been reported until two weeks after the end of the antimalarial treatment). The second one uses monoclonal antibodies against special plasmodium lactate dehydrogenase (pLDH). It detects plasmodium that are only inside the red blood cells. It detects P. falciparum but it can’t differentiate the rest of the species. Recently, two new antigens have been licensed for RDT test, SD FK70 Malaria antigen Pv test, and SD FK80 P.f/P.v antigen that can be used for RDT that detects P.vivax or P.vivax/P.falciparum. The first results are very satisfying. The antigen detection testing of plasmodium is being characterized by its simplicity and the its flexibility to be performed by people with low experience. The disadvantage is the lack of the percentage expression of the parasitaemia. A rapid procedure in order to be useful should have sensitivity above 95%. This is achieved for P. falciparum detection but not always for the rest of the plasmodium species. The last years there are RDT reagents from many companies and a great number of comparative surveys with many variances in the results.

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False positive results, in small percentages, are reported from the presence of the rheumatoid factor or heterophile antibodies. In contrast, the presence of anti-HRP-2 antibodies can be implicated for false negative results in high parasitaemia. The RDT performance depends on construction and environmental factors. The temperature and the humidity in our country do not affect the quality of the reagents.

• Molecular Biology methods (4)Polymerase Chain Reaction (PCR) has been well established. The disadvantages of the other methods (need for microscopy experience, high cost and sometimes the low sensitivity of the antigen detection methods) resulted in the Polymerase chain reaction development for the plasmodium detection. The method is simple. In the reference laboratory of the National School of Public Health, a multiplex method that detects at the same time P.vivax (266 bp) and P.falciparum (346 bp) (Picture 3) is being successfully applied for years. The detection limit is 1 parasite/μl for P.falciparum and 3 parasites/μl for P.vivax. Various modifications of PCR have been described for malaria diagnosis. PCR is equivelant to microscopic blood examination, however, presupposes the existence of such infrastructure

• FluorescentDescribed as a quick preliminary screening of Plasmodium detection whichwill lead to further Plasmodium recognition-identification.Of the 3 techniques that have been described, the best known is the QBC system (Quantitative buffy coat). The blood is collected in special capillary tubes bearing internal acridine orange. The capillaries are centrifuged and the white layers, where plasmodium is found, are examined under fluorescent microscope. Despite the simplicity and sensitivity of the method it requires the supply of special equipment, which results in high cost. Newer approaches based on this methodology are under evaluation.

• Search for antibodies against Plasmodium (6)The detection of antibodies against Plasmodium does not distinguish between recent or old infection and is of a limited value for treating patients. In case of a negative result, it helps to rule out malaria. The antibodies are detected a few days after the entry of the merozoites in the red blood cells. It could be useful for blood donors screening or to an examination of a traveler who underwent antimalarial treatment without a previous laboratory confirmation.

References:

1. “Βακάλης Ν. Ιατρική Παρασιτολογία,2003,Eκδ ΖΗΤΑ , Αθήνα”.

2. Wongsrichanalai C, Barcus MJ, Muth S, Sutamihardja A, Wernsdorfer. A review of Malaria of Malaria Tools: Microscopy and Rapid Diagnostic Test (RDT). Am J Trop Med Hyg (Suppl 6) ,2007,pp 119-127

3. Gillet P. Malaria Rapid diagnostic Tests. Laboratory aspects in the diagnostic setting. School for Public Health and Primary Care. Dissertation, p12,2011.

4. Patsoula E, Spanacos G, Sofianatou D, Parara M, Vakalis NC: A single step PCR method for the detection and differentiation of P.vivax and P.faalciparum. Ann Trop Med & Parasitol 2003,97:15-21.

5. CDC. Malaria diagnosis (US) Serology, 2010.

Nikolaos Vakalis, Professor of Parasitology-Entomology and Tropical Diseases, National School of Public Health

The HCDCP’s action plan 2012-2015 to battle malaria

During the summer period of 2011, 40 incidents of malaria were reported in Greece, caused by Plasmodium vivax with signs of ‘in-country transmission’ (i.e. in individuals that had not come from malaria-endemic regions nor traveled to such countries).

The majority of those incidents were in the Prefecture of Evrota/Lakonia, with scattered incidences, without a travel history in endemic countries, reported from another four regions of Greece (Chalkida/Evoia, Agia/Larissa, Kalivia and Marathonas/East Attica and Orchomenos/Voiotia).

Greece has officially been considered free from malaria since 1974. Taking into consideration the malaria incidents appearing within its inhabitants in 2009 (n = 6), 2010 (n = 3) and 2011 (n = 40) without a previous travel history to malaria-endemic countries, there is a chance that the disease will relapse because of the following factors.

(a) Greece is a place where immigrants from endemic countries work and live. Furthermore, there is a significant number of immigrants that come from malaria-endemic countries who cross the borders (mainly via land and sea) without undergoing any health checks.

(b) Mosquitoes of the species Anopheles, which are responsible for the transmission of malaria, exist in several regions of our country.

(c) We have noted alterations in climatic conditions (an increase in the average temperature and/or number of warm days per year), with an associated increase in the mosquito population and activity.

All the above stress the imminent need to draw up a national strategy in order to deal with this public health (PH) problem and lay out a complete action plan to combat malaria in Greece. The Hellenic Center for Disease Control and Prevention (HCDCP), in collaboration with a work team on vector-borne diseases, has developed a plan that includes a description of the actions to be taken to combat malaria. This action plan has been submitted to MOHAW, which is also preparing a strategic action plan for malaria in Greece, which they plan to publish as a common ministerial decree of the Ministers of Health, Internal Affairs and Agriculture.

Main scope of the action plan

The main scope of the current action plan is to avoid a malaria relapse in Greece.

Specific scopes of the action plan• To improve the organization and function of epidemiological surveillance for malaria by

the HCDCP across the whole of the country, strengthening it in high-risk areas.• To detect early and treat effectively incidences of malaria in Greece (clinical and non-

clinical types) in order to interrupt in time the transmission of malarial Plasmodium.• To co-ordinate and inform on time all the institutions involved regarding the necessary

actions to be taken for malaria control (health and public health professionals, local and regional authorities, other institutions, etc.).

• To co-ordinate and organize briefing activities for the public in high-risk areas regarding protection measures.

• To follow-up the course and effectiveness of completed projects on insect surveillance and insecticide, focusing on high-risk areas, by exchanging information between the prefectures.

• To create tools for the evaluation of risk assessment on malaria relapse in the whole of the country, by participating in study projects with the collaboration of other European public health authorities.

• To protect the country’s tourism, by not getting to the point where instructions have to be published by international organizations regarding necessary medication for travelers.

• To conform with the objective of the European Department of the World Health Organization (WHO) as far as the eradication of malaria in Europe by 2015 is concerned.

Since the last malaria transmission period in 2011 (November 2011), HCDCP has been collecting climatological, environmental, social and historical data regarding malaria in order to inform a risk assessment tool for better preparation for 2012. Based on the existing facts and in accordance with specialists’ opinions, there are four levels of risk for in-country transmission.

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Invited articles HCDCP’s departments activities

The Hellenic cancer registry and the office for rare diseases; activities May 2012

Activities concerning the hellenic cancer registry• A 2-day workshop on ‘Training on the cancer registry’. As part of EAN actions on

21 and 22 May 2012, in the auditorium of the National School of Public Health (NSPH), training on the cancer registry took place for the first group of trainees, working in public/state hospitals and private clinics of Attika, as well as the public hospitals of Lamia, Karpenisi, Livadia, Chalkida, Karistos, Thiva, Kimi, Tripoli, Argos, Nauplio, Sparti, Molai, Siros, Rodes and Mitilini. The aim of the workshop was to educate the cancer registrars on how to fill in the forms for malignant or borderline tumors.

• A workshop on ‘Training on the cancer registry’. Held on 29 May 2012 by the Hellenic Center for Disease Control and Prevention (HCDCP) of Thessaloniki in order to train the second group of trainees, working in public hospitals and private clinics of Thessaloniki as well as hospitals of Florina, Kastoria, Grvena, Kozani, Ptolemaida, Verroia, Νaousa, Edessa, Giannitsa, Katerini, Kilkis, Serres, Κavala, Drama, Xanthi, Κomotini, Αlexandroupoli, Chalkidiki, Goumenisa, Didimotiho, Larissa, Volo, Τrikala and Karditsa. The aim of the workshop was to educate the participants on how to fill in the forms for malignant or borderline tumors.

Activities concerning rare diseases

Lia Tzala, Head of the Department of Education and National Registries and Head of the Hellenic Cancer Registry and Office for Rare Diseases, represented Greece at the following meetings.

• Orphanet Europe Joint Action annual meeting in Brussels, 23 May 2012. Dr Michelakaki Eleni, representative of Orphanet Hellas, Director of the Department of Enzymology and Cellular Function, Institute of Child Health, President of the Hellenic Society for the Study of Inborn Errors of Metabolism and Vice-President of the European Working Group on Gaucher Disease (EWGGD), also represented our country at this meeting. During the meeting, each partner presented its activities and work plan for the next year. Greece is aiming to upload to the Orphanet site the centers of expertise (Ces) for rare diseases in our country and a Greek translation of the ‘encyclopedia’ for patients and professionals, in order to facilitate access and information dissemination on rare diseases for patients and health professionals.

• The 2nd EPIRARE meeting in Brussels on 23 May 2012. During the meeting the results of a survey on European Union (EU) registration activities were presented. The survey had collected information on a set of operational features for the performance of patient registries but also legal requirements regarding how to identify and inform patients (informed consent).

Future conferences and meetings, June 2012 • A workshop on ‘Training on the cancer registry’ will be held on 7 June 2012 in the

conference hall of the Heraklion General University Hospital, in Heraklion Crete, for the training of the third group of trainees, from public hospitals and private clinics of Crete. The aim of the workshop is to educate the cancer registrars on how to fill in the forms for malignant or borderline tumors.

• A workshop on ‘Training on the cancer registry’ will be held on 14 June 2012 in the University General Hospital of Patras for the training of the fourth group of trainees, from public hospitals and private clinics of Patras, and also the public hospitals of Ioannina, Kalamata, Korinthos, Aigio, Kalavrita, Filiates, Αgrinio, Κrestena, Preveza, Leukada, Μesologgi, Ζakinthos, Κeffalonia, Corfu, Pirgos, Αmaliada, Kiparissia and Arta. The aim of the workshop is to educate the participants on how to fill in the forms for malignant or borderline tumors.

• The 5th Meeting of the European Union Committee of Experts for Rare Diseases (EUCERD),

Specifically, the risk levels are as follows.

1. Risk level 0: regions without any risk factors regarding in-country transmission AND without such a history for the last 3 years, including those areas where malaria parasites are only seen in humans (who have come from malaria-endemic countries, i.e. infected immigrants and travelers), OR where there are only vectors (mosquitoes) of the Anopheles species (or environmental factors that encourage their growth).

2. Risk level 1: regions with risk factors for in-country transmission of malaria, i.e. areas where there is an increased presence of malaria parasites in humans (who come from malaria-endemic countries, i.e. infected migrants and travelers) AND presence of vectors (mosquitoes) of the Anopheles species (or environmental factors that encourage their growth).

3. Risk level 2: regions with a record of at least one sporadic malaria incident showing signs of in-country transmission in the last 3 years.

4. Risk level 3: regions with consecutive malaria incidents with in-country transmission signs in the past 3 years OR consecutive transmission of the disease from year to year (appearance of new incidents in the area for at least 2 consecutive years). It is considered that in these areas the right transmission conditions exist for signs of a possible relapse in the transmission of malaria to appear.

The actions to be taken in order to combat malaria according to the plan are within the framework of the following points.

• Aid actions for epidemiological surveillance of malariaWe describe the malaria surveillance system, the active laboratory surveillance and the focused investigation in the environment of a confirmed case, as well as the investigation of malaria incidents, via screening, amongst newly arrived immigrants.

• Aid actions for laboratory detection of malariaWe describe all the actions to be taken in order to reinforce laboratory surveillance of the disease, in collaboration with the laboratories that study vector insects.

• Clinical confrontation of malaria, in accordance with guidelines on diagnosis and treatment• Communication actionsCommunication actions are fundamental to the implementation and success of the action plan, because they aim to provide information on malaria to health professionals and the public. Their objectives are, on the one hand, to communicate the need for early diagnosis and treatment of the disease and, on the other hand, to provide information on individual protection measures against mosquitoes.

• Malaria vector surveillance and controlWe describe the basic principles of insect surveillance and the two main methods of malaria vector control: larvacide and residual spraying of interior spaces.

• Inter-sectorial collaboration of HCDCP with implicated authorities.Malaria confrontation and control, as well as avoidance of its relapse in Greece, includes multiple actions and competences of many implicated authorities, such as health authorities, central and regional public health authorities, and environmental and agricultural development monitoring authorities. The HCDCP has developed communication and collaboration networks among every institution (public and private) to improve their co-ordination.

Agoritsa Baka, HCDCP President Collaborators’ Office

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HCDCP’ s departments activities

20-21 June 2012. Luxembourg. The office will be represented by Dr Christos Kattamis, Emeritus Professor of Pediatrics and National EUCERD representative. The agenda of the meeting includes numerous presentations focusing on cross-border health care directives and European reference networks (ERN), EUCERD joint actions, the clinical added-value of orphan drugs (CAVOD), Horizon 2020 and a presentation by the Scientific Secretariat of IRDiRC.

Lia Tzala, Head of the Department of Education and National Registries (Cancer and Rare Disease Registries), HCDCP

Hygiene, Safety and Lifesaving in Water

On 20 April 2012, at the Municipality of Palaio Faliro, the Mayor, Mr Dionisis Hatzidakis, and the Deputy Mayor, Vassiliki Andrikopoulou, organized a very successful event that was attended by more than 200 people.

The meeting was the final part of the pilot program Hygiene, Safety and Lifesaving in Water, and included practical experience at the municipality’s swimming pool, in association with its Director, Mr Dinos Nikolaidis, and Dr Stathis Avramidis, on behalf of the Hellenic Center for Disease Control and Prevention (HCDCP).

Α number of HCDCP public statements were announced regarding ’flu, smoking, mosquitoes and drowning. Mrs Eleonora Hatjipashali (Deputy Director HCDCP-NLPH) presented the aims and activities of the organization. She underlined the fact that the HCDCP aims to provide its services to the general public and hopes to expand its activities to other municipalities.

Dr Stathis Avramidis referred to drowning episodes reported in mythology, antiquity, history and Hollywood films. He then presented injury epidemiology data, the causes and consequences of drowning, and various rescue methods, and answered frequently asked questions about lifeguarding, lifesaving, hygiene and resuscitation.

Mr Hatzidakis, on behalf of the town and the event’s attendees, welcomed and commended the activities of the HCDCP. In addition, he commended its staff members and responded positively to the ‘present’ of Mrs Hatjipashali, when she suggested the expansion of this training initiative to the primary schools of the town.

Dr Stathis Avramidis, Central Public Health Laboratory, HCDCP

HCDCP’s departments activities

Malaria world-wide

Malaria is a common and life-threatening disease in many tropical and subtropical areas, where climatic factors (temperature, humidity and rainfall) influence malaria transmission.

Malaria causes 350–500 million infections world-wide and approximately 1 million deaths annually. According to the World Health Organization (WHO)’s World Malaria Report 2010, there were 216 million cases of malaria and an estimated 3.3 billion people were at risk. Specifically there were 174 million cases reported in the African region, 128 million cases in the south-east region, 10 million cases in the eastern Mediterranean region, 2 million cases in the western Pacific region, 1 million cases in the Central and South America region and 200 cases in the European region. An estimated 655,000 people died of malaria, 91% of them in Africa. Approximately 86% of the victims were children under 5 years of age. Imported malaria was reported by 91 countries between 2001 and 2010; the largest total numbers of cases were in the USA (12,701), the United Arab Emirates (20,452), France (48,580), United Kingdom (17,063) and Australia (3,355). Travelers with the highest estimated relative risk of infection were those going to West Africa and Oceania, followed by those going to other parts of subSaharan Africa, South Asia, South America, Central America and other areas of Asia. The increasing number of international travelers in association with the considerable influx of immigrants from malaria-endemic countries has had a significant impact on imported malaria cases. Currently malaria-endemic countries are visited by more than 125 million international travelers each year, and more than 30,000 malaria cases occur in European and North American travelers each year. Travelers visiting friends and relatives (VFRs) account for up to 50% of international travelers from developed countries. VFRs are emerging as the most significant group of travelers for the introduction of malaria into non-endemic countries.

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Geographical distribution of plasmodia• Plasmodium falciparum predominates, especially in Africa. • Plasmodium vivax is found mostly in Asia, Central and South America and some parts of Africa. • Plasmodium ovale is found mostly in Africa (especially west Africa) and the islands of the

western Pacific. • Plasmodium malariae is found world-wide.• Plasmodium knowlesi is found throughout south-east Asia (Malaysia).

Multidrug-resistant malaria

Multidrug-resistant malaria has been reported from south-east Asia (Cambodia, Myanmar, Thailand and Vietnam) and the Amazon basin of South America (parts of Brazil, French Guiana and Suriname).

In border areas between Cambodia, Myanmar and Thailand, P. falciparum infections do not respond to treatment with chloroquine or sulfadoxine-pyrimethamine, sensitivity to quinine is reduced and treatment failures in excess of 50% with mefloquine are being reported, and in south-western provinces of Cambodia on the border with Thailand resistance to artesunate has emerged. In these situations, malaria prevention consists of personal protection measures in combination with atovaquone-proguanil or doxycycline as a chemoprophylaxis. The emergence of artemisinin resistance on the Cambodia–Thailand border has implications for the management of malaria in international travelers for the following parts of south-east Asia: the border between eastern Thailand and western Cambodia, the border between western Thailand and south-eastern Myanmar, and the Binc Phuc province of Vietnam.

References:

1. World Health Organization (WHO). Available at http://www.who.int/malaria/ world_malaria_report_2011/en/index.html/ [accessed 21 May 2012].

2. Centers for Disease Control and Prevention (CDC). Available at http://www.cdc.gov/malaria/about [accessed 21 May 2012].

3. Bacaner N, Stauffer B, Boulware DR, et al. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004;291:2856-2864.

4. Pavli A, Smeti P, Spilioti A, et al. Descriptive analysis of malaria prophylaxis for travellers from Greece visiting malaria-endemic countries. Travel Med Infect Dis 2011;9:284-288.

Paraskevi Smeti, Androula Pavli, Maltezou Elena, Travel Medicine Office Department for Interventions in Health Care Facilities

HCDCP’ s departments activities

The progress on the project «Procroustes»

Within the context of the national action plan to combat infections caused by multidrug-resistant Gram-negative pathogens in health care facilities, called Procrustes, four workshops have been organized by the Hellenic Center for Disease Control and Prevention (HCDCP) in collaboration with the administrators of the health districts, in order to promote interventional activities through the implementation of infection control measures in hospitals.

Specifically, the following meetings took place in:

• Thessaloniki, for hospitals of the 3rd and 4th HRG on 5 March 2012• Patras, for hospitals of the 6th HRG on 24 April 2012• Heraklion-Crete, for hospitals of the 7th HRG on 25 April 2012• Larissa, for hospitals of the 5th HRG on 26 April 2012.

We would like to thank warmly the administrations of the health districts mentioned, as well as the members of the nosocomial infection control committees and all the health care professionals who participated, for their support in promoting intervention measures in hospitals, targeting the reduction of health care-associated infections.

Papadima Popi, office of nosocomial infections

HCDCP’s departments activities

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Recent publications

Rapid diagnostic tests as a source of DNA for Plasmodium species- specific real-time polymerase chain reactions Cnops L, Voderie M, Gillet P, Van Esbroeck M, Jacobs J Malaria J 2011;10:67

The World Health Organization (WHO) recommends wide implementation of rapid diagnostic tests (RDTs) as an antigen-based diagnosis in areas where other diagnostic tools, such as microscopy, are not available, mainly in endemic regions. However, until now there has not been a means of evaluating RDT efficacy.

This article demonstrates the possibility of using the blood samples from the RDTs for a real-time polymerase chain reaction (PCR) application that could be more efficient and convenient than PCR of whole blood samples.

Twelve different RDT brands were used; each brand was seeded with two blood samples with different parasite (Plasmodium falciparum) densities. Different components of the devices were used for DNA extraction (elution method), and it was shown that better extraction with lower CT values (the best results in PCR) was achieved with the proximal part of the nitrocellulose strip.

PCR on the two RDT brands used on clinical samples showed a detection limit identical to the same PCR on whole blood. Ct values were 27.25 (17.48–40.43) for PCR on whole blood, 30.24 (20.37–44.14) for PCR on the OptiMAL RDT and 31.05 (20.60–46.30) for PCR on the SDFK60.

Possible applications include quality assessment of RDTs in the field and confirmation of malaria in reference settings without the additional need for blood collection and storage.

Pyronaridine-artesunate versus mefloquine plus artesunate for malaria Rueangweerayut R, Pyae Phyo A, Uthaisin C, Poravuth Y, Quang Binh T, Tinto H, Pιnali LK, Valecha N, Thi Tien N, Abdulla S, Borghini-Fuhrer I, Duparc S, Shin C-S, Fleckenstein L New Engl J Med 2012;366:1298–1309

Artemisinin-based combination therapies (ACTs) belong to the first-line option according to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) guidelines for Plasmodium falciparum malaria therapy.

This article shows the results of a comparison between a new ACT (pyronaridine- artesunate) and an already known and widely used regimen (artesunate plus mefloquine). One-thousand two-hundred and seventy-one patients of all ages (81.3% from Asia and 18.7% from Africa), with microscopically proven uncomplicated falciparum monoinfection, underwent randomization and were assigned a 3-day regimen of pyronaridine-artesunate combination (848 patients) or mefloquine plus artesunate (423 patients).

The efficacy evaluation of each regimen was based on parasitological (e.g. aparasitemia) and clinical (e.g. apyrexia) response assessments on days 28 and 42.

Pyronaridine-artesunate efficacy [99.2%, 85% confidence interval (CI) 98.3–99.7 on day 28, and 83.1%, 95% CI 80.4–85.6 on day 42) was not inferior to that of mefloquine plus artesunate (97.8%, 95% CI 95.8–99.1 on day 28, and 83.9%, 95% CI 80.1–87.3 on day 42). There were no significant differences between the two groups for parasite and gametocyte clearance time, or fever clearance time.

Although artemisinin resistance arises in many endemic regions, this new ACT seems to be quite effective for uncomplicated falciparum malaria.

Recent publications

First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children The RTS,S Clinical Trials Partnership New Engl J Med 2011;365:1863-1875.

Malaria vaccines are an area of intensive research. A completely effective malaria vaccine is not yet available, although several vaccines are under development. The most advanced malaria vaccine is RTS,S/AS01. In 2011, the RTS,S clinical trials partnership reported the first findings from a phase III trial of RTS,S/AS01 that was conducted in children at 11 centers in seven African countries.

The trial was conducted from March 2009 to January 2011 and included children of two age categories: 6-12 weeks of age and 5-17 months of age at enrollment. The trial included three different study groups in each age category: (1) children who received three doses of the vaccine administered at 1-month intervals and who were planned to receive a booster dose 18 months after the third one; (2) children who received the RTS,S/AS01 primary vaccination series without booster; and (3) a control group who received a non-malaria comparator vaccine.

Fourteen months after the first dose of vaccine, the incidence in the older age group was 0.32 episodes per person-year and in the control group 0.55 episodes per person-year, with an efficacy of 50.4% [95% confidence interval (CI), 45.8–54.6] in the intention-to-treat population and 55.8% (97.5% CI, 50.6–60.4) in the per-protocol population.

The authors concluded that the RTS,S/AS01 vaccine provided protection against both uncomplicated and severe malaria in African children.

P. Tserkezou, A. Marka

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Interesting activities

Environmental surveillance of sewage for the detection of wild polio virus in Greece

The World Health Organization (WHO) European region was declared a ‘polio-free area’ in June 2002, as a result of routine immunization and enhanced epidemiological surveillance of poliomyelitis.

Because of certain features of Greece, such as the existence of population groups with low immunization coverage (Roma) and the arrival of immigrants and refugees from endemic areas, as well as the recent outbreaks of wild polio virus type 1 in four endemic countries (Kazakhstan, the Russian Federation, Tajikistan and Turkmenistan), intensive epidemiological surveillance of poliomyelitis is required in our country in order to maintain a polio-free status.

For this reason, in addition to the existing epidemiological surveillance of acute flaccid paralysis (AFP) cases in children aged <15 years, it has been decided that environmental surveillance will be carried out to detect wild polio virus.

The Office of Vaccine-Preventable Diseases of the Department of Epidemiological Surveillance and Interventiond in collaboration with the Public Health Laboratory Network (KEDY/PEDY), has organized the collection of sewage samples, primarily from the biological sewage treatment plants of areas where immigrants and Romas reside, according to the area of responsibility of each laboratory. Samples are sent to the National Reference Laboratory for Enteroviruses/Polioviruse –Hellenic Pasteur Institute to be examined for the presence of wild polio virus.

Vernardaki Alexandra, Poufta Sofia, Mavraganis Pantelis, Pipa Efthalia, Georgakopoulou Theano, Hadjichristodoulou Christos

Office of Vaccine-Preventable Diseases, Department of Epidemiological Surveillance and Intervention

Interesting activities

14 June: World Blood Donor Day

With the slogan ‘Every blood donor is a hero’, World Blood Donor Day will be celebrated on 14 June.

The World Health Organization (WHO) and its partners chose this slogan to highlight the fact that every one of us can become a hero simply by giving blood. Blood donors respond to the urgent need for blood for transfusion, whatever the circumstances, putting the needs of others before their own. Voluntary donors of all ages come forward from all walks of life, all regions and all religions. By choosing to donate blood, they demonstrate the power of human solidarity that saves lives.

Events

As part of the celebration, events will be organized world-wide to spread the message of voluntary blood donation. There will be lectures, concerts, dances, sporting events and, of course, blood donation sessions. The central global celebration for 2012 will be held in Korea. On this day in our country, volunteer blood donor associations will organize various events and voluntary donation sessions.

The Hellenic Center for Co-ordinating Hemovigilance (SKAE) is participating by posting material on voluntary blood donation and blood safety on the official website of KEELPNO and through the participation of its staff in organizing voluntary blood collection.

Background

14 June was established as World Blood Donor Day by WHO, the International Federation of Red Cross and Red Crescent Societies, the International Federation of Blood Donor Organizations and the International Society of Blood Transfusion (ISBT).

The date was chosen in honor of the German doctor Karl Landsteiner, born on this day. Landsteiner discovered blood groups in 1900 and was given with the Nobel Prize for his work. On 14 June, we honor the anonymous volunteer blood donors and the altruism that they display in not seeking a reward for contributing 10 minutes of their time and 450 cubic centimeters of their 5-6 liters of blood, a gift so vital for suffering fellow humans.

Message

The message of the celebration of World Blood Donor Day is not only to inform, in order to eliminate the prejudice, fear and ignorance that surrounds blood donation, but above all to:

• attract new volunteer donors• encourage as many people as possible to become regular volunteer donors• transfuse into a new generation of blood donors the idea of voluntary unpaid blood donation.

Current situation

The transfusion of blood and blood products helps save millions of lives every year. Transfusion can help improve the life expectancy and quality of life of patients suffering from life-threatening conditions, and it supports complex medical and surgical procedures. Today, in 62 countries, national blood supplies are based on voluntary unpaid blood donation. However, in 40 countries a deposit of blood from family and friends of patients remains a prerequisite for ensuring the adequacy of blood, and paid blood donation remains a very real situation in some countries that face serious social problems.

The goal of WHO is for all countries to obtain their blood supplies entirely from voluntary unpaid donors by 2020.

Dr Constantina Politi, Assistant Professor, University of Athens, Head of the SKAE-Hellenic Center for Co-ordinating Hemovigilance, HCDCP

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Meet our editorial team

Papadima Popi I was born in Larissa Thessaly and grew up in Athens. I graduated from the 28th Lyceum in Pagrati in 1985 and shortly afterwards I started studying at the Medical School of Athens, from which I graduated in 1991. I specialized in respiratory medicine at the University Clinic of ‘Sotiria’ Hospital. For the following 2 years, I worked in the university intensive care unit of ‘Evagelismos’ Hospital. Since 2004 I have been working at KEELPNO, for the last 3 years in the Office of Nosocomial Infections, Antimicrobial Resistance and Strategic Use of Antibiotics. I spend most of my free time with my lovely 2-year-old daughter Christina.

Gavala Athina I am very pleased to have grown up in a small but very beautiful part of Greece, Epidaurus. In 2001, I graduated from the Department of Local Government-School of Management and Economics-Technological Educational Institute of Kalamata. Then, as a result of various circumstances, I worked for 4 years in a press office and at the Secretariat General of Mass Media, which was my first contact with this professional sector and a very interesting experience for me.

In 2005, I joined the workforce of the Center for Disease Prevention and Control, specifically at the Central Laboratory of Public Health, which since September 2009 has been situated at Vari City-Athens. At various times,sas required, I have served in many different positions at the Central Laboratory of Public Health, such as the Supply and Finance Division an, Division of Vaccinate, but for the last 2 years my responsibility has been in the Office Staff Division. I consider the HCDCP’s e-bulletin, in which I actively participate, to be a very creative part of our organization and I enjoy my collaboration with the rest of the editorial team . As well as enjoying my job, I adore the environment and am in good personal physical shape, I have always been excited by anything to do with the arts and aesthetics.

Future conferences and meeting

June 2012June 1-3, 2012

Title: 50th Pan-Hellenic Pediatric CongressCountry: Greece City: IoanninaVenue: Du Lac Contact Number: +30 210 3249242Website: http://www.ped-congress.gr/info/

June 4, 2012

Title: First International Congress on Narrative Medicine and Rare DiseasesCountry: ItalyCity: RomeVenue: Istituto Superiore di SanitàContact Number: +39 (0)6 4990 4017Website: http://www.iss.it/cnmr

June 15-17, 2012

Title: 10th Pan-Hellenic Congress on General Practice and Primary CareCountry: Greece City: Skafidia, IliaVenue: Aldemar Olympian VillageContact Number: +30 2107210052Website: http://www.congressworld.gr

International relations office

36 37

Outbreaks around the world

Outbreak news, May 2012

Avian influenza [1]

The Indonesian Ministry of Health has notified a new case of human infection with avian influenza A (H5N1) virus. Of the 189 cases reported in Indonesia, 157 have been fatal.

The Ministry of Health of the Kingdom of Cambodia has announced a confirmed case of human infection with avian influenza A (H5N1) virus.

Leptospirosis [2]

Flooding has caused an outbreak of leptospirosis in Peru, especially in the Loreto region. This is the worst flooding seen in this area for more than 20 years. Peru has reported more than 300 cases and three deaths associated with leptospirosis so far in 2012.

References:

1. World Health Organization (WHO). Available at http://www.who.int/csr/don [accessed 30 May 2012]

2. Centers for Disease Control and Prevention (CDC). Available at http://wwwnc.cdc.gov/travel/notices/outbreak-notice/leptospirosis-in-peru.htm [accessed 30 May 2012]

Travel Medicine Office, Department for Interventions in Health Care Facilities

Interview

Meropi Violaki-Paraskeva

Meropi Violaki-Paraskeva was born in Istanbul and moved to Athens after the Minor Asia disaster, with her father, sisters and grandmother. In 1940 she graduated from the Medical School of Athens, and during the third year of her studies she worked for free as a senior assistant in the pathology section of Ipokratio Hospital, which at that time was called Prosfighiko (Migrants’ Hospital). In 1943 she obtained her diploma from the Hygiene School of Athens and continued with post-doctoral studies on public health abroad. Upon finishing her studies she started her career at the State Hygiene Service where, after many months of delay, in 1971 she was granted the highest rank of General Hygiene Director. In 1948 she received a scholarship from the Danish Red Cross and carried out a special educational program on the campaign against tuberculosis in Denmark, Sweden and Norway. In 1949 she received a scholarship from the Rockefeller Institute and studied at the School for Public Health at Harvard University, becoming the first Greek female doctor to obtain a postgraduate degree in public health. Furthermore, in 1952, with a scholarship from the World Health Organization (WHO), she was educated at the Colindale Central Public Health Laboratory (United Kingdom) under the supervision of Alexander Fleming. Mrs Violaki has been honored several times, as much abroad as in Greece, for her contribution to public health. She has been a founding member, chairman and member of the administrative council of many different institutions and scientific companies, such as the National Center for Epidemiological Control and Intervention, the Hellenic Association for the Study and Confrontation of AIDS and the Gerontology Association. In 1981, Mrs Violaki was the first woman in Europe to be elected chairman of the WHO General Assembly. WHO has honored her twice: in 1988 with the Leon Bernard prize and in 1994 with a Health for All gold medal. Since 1977, when she officially retired, she has been offering her services as a consultant on public health issues, free of charge, to the Ministry of Health and Welfare.

1) Would you like to recall a good memory from the battle against malaria?

The memory that I recall is how we dealt with the period of malaria eradication. The eradication of malaria was carried out using simple methods and without many committees, because the people involved, the triad of doctor–nurse–nursing care practitioner, really believed in what they were doing. The same goes for the people who sprayed premises to kill the mosquitoes; they were proud of their contribution to the battle. The campaign against malaria was completed, and WHO adopted it and used Greek scientists abroad because they

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Interview

had the knowledge. Greece was a pioneer and was recognized by WHO.

2) Would you like to mention anything from the campaign against malaria that left you with bitter memories?

The fact that WHO embraced our project and we were asked to educate other countries, sharing our experience and knowledge because we were pioneers in that battle, was so positive that it has left me with no bitter memories.

3) What can you tell us regarding the relapse of the disease today?

Malaria is not new to us, and in Greece it had been a plague for years, and the only cure back then was quinine. At that time, especially in northern Greece, the doctors were informed no matter what their specialty was. The doctors, especially in villages, were not paid with money; people used to reimburse them with products like eggs, meat, anything they could offer, and that really surprised me. There was a project for the campaign against malaria that was completed by a department of the Hygiene School, by Professor Belios. The main issue was exactly what we ignore nowadays: door-to-door confrontation of the problem. The service that fought the mosquito species played a huge role by visiting every premise with a sprinkler: they did their research and then they sprayed. Door-to-door management. That is to say, in those days they confronted malaria with simple means. Now we are glad that we have all the modern means at our disposal, and we cannot expect the issue to be solved only by air-spraying. But it is not possible to have a clear image of the true situation if we do not go door-to-door, without knowing where the houses are, in what environment, whether it is a rural environment, and whether there are any hearths nearby, inside or outside.

4) What is the role of the Hygiene School in confronting the problem?

The Hygiene School has a mission to educate. That’s where some professionals are trained, such as the health supervisors. In the old days they used to call them the mosquito people, and they used to go door-to-door with the sprinklers on their backs. We ought not to forget that role.

5) In the Minutes of the Association for the Reduction of Marsh Diseases, we found a letter addressed to the Ministry in which they ask for 12 motorcycles to be used in the battle against malaria. Do you think that today, in the battle against the relapse of the disease, we face better conditions?

Fortunately, our country has been erased from the malaria map of WHO and we have been free of malaria since 1974. If we accept that technical means are not enough and that human motivation is also needed, then, of course, the disease will be eradicated. We need to stress prevention, which is not a secondary priority. If the municipalities, prefectures and regional authorities applied the directives given in time by the Ministry of Health, then we wouldn’t be facing any problem.

6) In the hard times that our country is going through, we recall the words of Mr Kardamatis (one of the founders of the Association for the Reduction of Marsh Diseases): that the battle against malaria is no less important than any other national fight. What are your thoughts on the battle with the disease during these times?

We need to truly believe that this is not just about malaria; there are other things, along with malaria, that we have to consider and for which we have to take action. Education–information –prevention: this is a significant triad that we should never forget.

7) Which moments stand out during your personal career in the field?

So much before and after my retirement: there are many moments that you could say have affected my career. It’s not only malaria, we have seen many other programs for public health, such as the vaccination program, which is still ongoing, and the fact that we have eradicated polio, which is quite a victory. But we need to be alert, for example in case polio shows up again, and because tuberculosis is changing form because of migrants. In the old days tuberculosis used to be the number one priority, and health education about tuberculosis was

Interview

of great importance. Back then, when I started to work in public health, people were even afraid to pass outside the house of someone with consumption. As a matter of fact, I recall that there were signs saying ‘it is forbidden to spit’ because tuberculosis could be transmitted that way. Fortunately now these signs have disappeared, but of course people do not spit any more in the streets. Education plays a great role regarding health matters. We should not stick to the theory of a norm, we should apply it. For instance, we should not ignore the national vaccination program. Of course, this does not ensure that certain diseases will not re-appear (e.g. diphtheria or even measles). All the programs under the General Directorate for Public Health, which is the official authority of MOHOW, should be applied, as well as all the programs that the Ministry mandates. Circulars should be taken seriously; they are not just bureaucracy or naive documents. They have two main thrusts: medical and administrative. They are to be sent out and applied. Furthermore, we must realize that it’s not only malaria that we should be concerned with, but every disease transmitted by insects. I cannot understand why we pay so much attention to this particular matter, given that the incidences of malaria are very few. If there is a program, it should not be limited to only confronting malaria but other diseases as well, at least those transmitted by insects, such as dengue fever and West Nile virus. There should be a complete program for diseases transmitted by insects.

8) What would you advise practitioners of public health today?

Correct education, in every sector, should be carried out in time; we shouldn’t wait until the last minute. At every level, those working in public health must bear this in in mind. When we deal with malaria, we ought to give priority to matters of public health. What I always repeat and new professionals also know: every euro spent on eradication and public health contributes to multiple positive outcomes. We reduce hospitalization periods. The damage caused by malaria, if not treated early, has many consequences. But, most importantly, practitioners should like what they’re doing. They should emphasize the human factor, which is missing nowadays. In the old days, every sector had its doctor, a hygiene professional and a visiting nurse. In Attica, where I worked, we used to have hygiene centers, which we then called multi-surgeries, which had a doctor, a visiting nurse and a supervisor. Now we don’t. We shouldn’t be discouraged when we realize that as long as we only work with modern technology we can actually go backwards. Yes, modern technology has helped, but the briefings are carried out at a very theoretical level and not everyone can get a profit out of it. And then we have eliminated certain roles, for example that of the visiting nurse. People need to understand what the professionals have to say. Scientific language should be simple in order to convince the masses. It is very important that specialists change their style so that people can understand what they have to convey. Health education should be carried out with simple language for every level of the population.

Thank you for your time.

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Myths and truths

Myths and truths about Malaria

Myths Truths

Malaria is restricted to humans and malaria zoonosis does not exist

Apart from the Plasmodium species that have humans as reservoirs (P. falciparum, P. vivax, P. malariae and P. ovale), the genus Plasmodium includes several other species that can use monkeys and apes as reservoirs (P. knowlesi, P. cynomolgi, P. inui and others). In 1965 the first case of zoonotic malaria caused by P. knowlesi was reported in humans, and in 1965 the first caused by P. cynomolgi (laboratory-acquired). Since then it is usually accepted that P. knowlesi is a common agent of zoonotic malaria in south-west Asia (Malaysia, Singapore, Thailand, Myanmar and the Philippines). In these countries 5% of patients that had been diagnosed as positive for malaria as a result of P. falciparum, and 69% of patients diagnosed as P. malariae-positive, have been proven to be infected with P. knowlesi.

Today, as far as the western world is concerned, zoonotic malaria caused by P. knowlesi or potentially other Plasmodium species is a travel medicine issue [2].

Infection in patients is caused by only one strain of P. falciparum or P. vivax (monoclonal infection)

The monoclonal infection dogma has been questioned since 1980 [3] and was later resolved with the development and use of new molecular methods [4]. Multiclonal infections caused by P. vivax are up to five times more likely than those caused by P. falciparum. The high proportion of multi-strain infections caused by P. vivax has been found in areas of low transmission. It has been proven that heterologous hypnozoites (hypnozoites of every strain) are activated in multi-strain infections, with the consequent occurrence of new, genetically different, genotypes (different from the primary infection) with every relapse. In Canada, six new genotypes occurred during relapses from one primary infection, in Brazil 10 genotypes from two primary infections, and in Thailand five from two [5]. Multi-strain infections are identified by genotype analysis of Pvcs and Pvmsp1 genes with microsatellite markers.

Myths and truths

P. vivax malaria is a benign disease Before 2008 there was no reference of any severe (malignant) malaria case (brain, lung, kidney or hepatic syndrome, severe anemia, shock or ARDS) caused by P. vivax.

In the last 10 years, however, many cases of severe (malignant) malaria caused by P. vivax have been reported in south-east Asia, the Middle East and South America. Among the list of these cases, one case of malignant malaria caused by P. ovale is included. The prevalence of these severe forms is unknown because of a lack of prior population information. The increased virulence of P. vivax has been attributed to the existence of multiclonal, genetically distinct strains in the same patient [7].

There are no antimalarial resistance problems regarding P. vivax; P. vivax is chloroquine/primaquine sensitive

The importance of P. vivax malaria in public health has risen after the appearance and rapid dispersion of strains resistant to chloroquine and sulfadoxine-pyrimethamine, and P. vivax tolerance to primaquine.

Initially, rare cases of resistance appeared in Indonesia and Papua-New Guinea. It was quickly proven that the prevalence of chloroquine-resistant cases had increased, with high rates, in south and south-east Asia [8, 9] and South America [10]. Recent clinical trials have demonstrated that in the Indonesian archipelago chloroquine-sensitive parasites account for <50% of cases. In the Malay peninsula, Myanmar and south-east Vietnam, the percentage of sensitive strains is 85-90%. In southern Turkey the percentage is 78%, and in South America it is 95%.

Regarding public health, the fact that P. vivax has acquired a tolerance mechanism against primaquine [11] is far more important. The tolerance of P. vivax to primaquine does not decrease the percentage of multi-strain infections, resulting in an increase in antagonism between the genetically distinct strains that exist. This results in the selection of strains with high virulence, transmission and/or drug resistance [12].

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Myths and truths

Anopheles mosquitoes are infected during the clinical and post-clinical asymptomatic phases of the disease

Until recently, this knowledge was incomplete because it was unknown whether patients with a low parasite burden and gametocytes were capable of infecting the mosquitoes. Furthermore, the studies available had indicated that the percentage of infected mosquitoes was insignificant when low numbers of oocysts were developed.

Experimental infection of volunteers with P. vivax, and the experimental biting of volunteer patients by infected Anopheles mosquitoes, has been used to address any discrepancies in this myth.

These studies have shown the following.

1) During the primary phase of malaria, the number of gametocytes increases day by day between days 7 and 12. The number then decreases until day 14, and by day 18 the gametocytes have already disappeared or are very scarce.

2) During relapses of the disease, gametocytes are present and are fully capable of effectively infecting mosquitoes during all three phases of the disease, namely asymptomatic/pre-clinical, clinical and asymptomatic/post-clinical phases.

These studies have indicated that the asymptomatic phases of the disease (pre-clinical and post-clinical) have a noticeably longer duration compared with the clinical phase, which lasts for 3 days. The infected mosquitoes are able to produce larger numbers of oocysts during the asymptomatic periods compared with the oocyst numbers produced during the clinical phase.

Myths and truths

The classic control strategies for malaria are not always sufficient

The emergence of resistance against antimalarial drugs and the presence of severe clinical forms of P. vivax malaria indicate that Plasmodium populations undergo evolutionary and adaptive effects. These phenomena can be analyzed in the context of population genetics and evolutionary biology.

F statistics are the most commonly used tools for describing the gene flow and breeding structure of a population. They generally express deviations from panmixia (from the Hardy-Weinberg equilibrium).

We can also measure the presence of linkage disequilibrium (LD) and the occurrence of ‘bottlenecks’ and the ‘founder effect’. The consequences of variable rates of clonal reproduction on population genetics can also be explored through a computer program for population genetic simulation.

The application of population genetic studies provides useful information for preventing and limiting the spread of drug resistance.

Population genetic studies indicate that knowledge of the population structure provides valuable information for disease control, principally at the topical level, where classic methods have proved to be unsuccessful. Their application also provides useful information for preventing and limiting the spread of drug resistance.

References:

1. Cox Sinhg J, Singh B. Trends Parasitol 2008;24:406-410.

2. Baird KJ. Travel Med 2009;7:269-277.

3. Rosario V. Science 1981;212:1037-1038.

4. Udomsangpetch R, et al. Trends Parasitol 2008;24:85-88.

5. Havrylink T, Ferreira MU. Mem Inst Oswaldo Cruz, Rio de Janeiro 2009;104:67-73.

6. Imwong, et al. J Infect Dis 2007;195:927-933.

7. Mackinnon MJ, Read AF. Phil Trans Royal Soc London B 2003;359:965-986.

8. Price RN, et al. Am J Trop Med Hyg 2007;64:97-106.

9. Baird JK. Antimicrob Agents Chemother 2004;48:4075-4083.

10. Santos-Ciminera PD. Brazil Emerg Infect Diseases 2007;13:1597-1600.

11. Board JK, Rickmann KH. Trends Parasitol 2003;19:115-120.

12. Galvani AP. Trends Ecol Evol 2003;18:132-139.

13. Shute PG, Maryon M. Trans Royal Soc Tropical Med Hyg 1957;51:403-410.

14. Shute PG, Maryon M. WHO/Ma1/233. 1959.

Professor Ioannis Tselentis, University of Crete

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Administration News

Within the framework of the continuing activities of the HCDCP-PHLN to assist the local health authority regional unity of Corfu, a team from the HCDCP–RPHL of Thessaly carried out sampling in tourist accommodation on the island of Corfu. The target was preventive intervention, before the peak tourist season on the island, looking for any positive presence or absence of the bacterium Legionella spp. in tourist businesses on the island.

Another target was to increase awareness of this issue, protecting the health of both tourists and employees who use these services, and the whole population and public health in general.

News from the HCDCP Administraion Quiz of the month

?How many Plasmodium species are linked with malaria in humans? a) 3, b) 4, c) 5

Send your answer to the following e-mail: info-quiz@keelpno.gr

The answers to the April quiz were: Malta Fever, Naples Fever, Cypriot Fever, Gibraltar Fever, Melitian Fever. For further information see Bruce D, 1889

Five people answered correctly.

Chief Editor:Ch. Hadjichristodoulou

Scientific Board:Ν. VakalisΕ. VogiatzakisP. Gargalianos- KakolirisΜ. Daimonakou- VatopoulouΙ. LekakisC. LionisΑ. PantazopoulouV. PapaevagelouG. SaroglouΑ. Tsakris

Editors:Τ. Kourea- KremastinouHCDCP President

T. PapadimitriouHCDCP Director

Editorial Board:

M. AngelopoulouR. VorouPh. KoukouritakisΚ. MellouD. PapaventsisΤ. PatoucheasV. RoumeliotiV. SmetiCh. TsiaraΜ. FotineaΕ. Hadjipashali

Graphic Design:

Ε. Lazana

Editing:

E. KaratampaniP. Koukouritakis

!World Blood Donor Day

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