HCDCP NEWSLETTER

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

July 2011 ISSN 1792-9016Vol. 05/ Year 1stHCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH &

SOCIAL SOLIDARITY

Drinking water and water-borne diseases

In the middle of the bright, warm Greek summer, with a touch of the Aegean breeze, water issues are more pertinent than during any other season. Whatever the water is being used for, water quality assurance is necessary for our health and safety. According to the latest guidance from the World Health Organization, compliance with safety terms and conditions throughout the journey from natural source to the consumer, from the systematic monitoring of water quality to carrying out sampling and laboratory tests, and the immediate resolution of any problems that occur and redesign of the water supply system, are necessary steps.

In our country, water quality is monitored by relevant bodies (e.g. the local government authorities for water supply/sewerage) and inspected by territorial authorities (the Department of Health and Environment of the Regional Sections).

The data collected are conveyed to the European Union (EU) to show that management of the water quality in our country responds to the requirements laid down by European directives and Greek legislation. We should always bear in mind that water quality monitoring is a continuous process, to ensure unconditionally the health of users and consumers.

Karaouli Vassiliki

Chief Editor:

Ch. Hadjichristodoulou

Scientific Board:

Ν. VakalisΕ. VogiadjakisP. Gargalianos- KakolirisΜ. Daimonakou- VatopoulouΙ. LekakisC. LionisΑ. PantazopoulouV. PapaevagelouG. SaroglouΑ. Tsakris

Editorial Board:

M. Angelopoulou

R. VorouPh. KoukouritakisΑ. -Μ. LeoutsiΚ. MellouS. ParissisΤ. PatoucheasV. RoumeliotiV. SmetiV. TsatsareliCh. TsiaraΜ. FotineaΕ. Hadjipashali

Highlights

ContentsEditorial:Waterborne infections 2-5Surveillance Data 6-8Invited article 8HCDCP Departments Activities 9-15Recent publications 16Interesting activities 17-22Future conferences and meetings 22Quiz of the month 22Outbreaks around the world 23Letter to the Editor 24News from HCDCP Administration 25

The Foodborne Disease Depart-ment at the Hellenic Centre for Disease Control and Prevention (HCDCP) stresses the importance of conducting an analytical epide-miological study in order to classify an epidemic as ‘waterborne’. Ac-cording to the CDC, the epidemio-logical criteria are more important than the microbiological criteria re-garding water quality. For the time period 2004–2010, a total of 12 possible waterborne diseases were recorded. For nine epidemics, the causative agent was identified.

Read more on page 2

As well as mosquito bites (transmit-ting West Nile Virus), bites from the black widow spider, now endemic in Greece, should be avoided. Ac-cording to the Operational Centre of HCDCP, three serious cases of black widow spider bites were re-corded during July. Intensive care was required, and for two of the cases administration of the specific antiserum from HCDCP was neces-sary. Doctors should be aware of the correct diagnosis and impor-tance of timely management for such incidents.

Read more on page 14

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Editorial

Waterborne infections and water-related gastroenteritis outbreaks

Waterborne infections can occur as isolated sporadic cases; more commonly, however, they occur as large outbreaks affecting many people simultaneously. In order for an outbreak to be characterized as waterborne, two conditions need to be met: (a) the presence of two or more people with similar symptoms after ingestion of drinking water or after exposure to recreational water and (b) epidemiological and laboratory data implicating water as the possible source of the disease. Based on the epidemiological data provided and the presence or absence of water-quality data, waterborne outbreaks are classified into four categories (Table 1).Table 1: Classification of waterborne outbreaks based on the epidemiological data provided

(Source: Centre for Disease Control)

Class Epidemiological data Water-quality data

Ι

Adequatea) Data were provided about exposedand unexposed people; andb) the relative risk or odds ratio was ≥2,and the association was statistically significant

Provided and adequateCould be historical information orlaboratory data (e.g. it was documented that a chlorinator had malfunctioned or a water main had broken, there was no detectable free-chlorineresidual, or the presence of coliforms inthe water was noted)

ΙΙ

Adequatea) Data were provided about exposedand unexposed people; andb) the relative risk or odds ratio was ≥2,and the association was statistically significant

Not provided or inadequate(e.g. stating that a lake was crowded)

ΙΙΙ

Provided, but limiteda) Epidemiological data were providedthat did not meet the criteria for class I; orb) the claim was made that those who were ill had no other common exposure apart from water, but no data were provided

Provided and adequate Could be historical information orlaboratory data (e.g. it was documented that a chlorinator had malfunctioned or a water main had broken, there was no detectable free-chlorineresidual, or the presence of coliforms inthe water was noted)

ΙV

Provided, but limiteda) Epidemiological data were providedthat did not meet the criteria for class I; orb) the claim was made that those who were ill had no other common exposure apart from water, but no data were provided

Not provided or inadequate

The recent increase in incidence of waterborne infections can be attributed to various factors, such as the ageing of the water supply and sewage systems, the improvement of recording methods and the enhancement of laboratory detection of pathogens in water. The increase has also been attributed to overpopulation and urbanization, massive population displacement, population ageing, an increase in immunocompromised people, lifestyle changes (e.g. more travel for recreational and leisure purposes), climate change and other factors.

Waterborne infections can be transmitted through (a) direct contact with water, (b) ingestion of contaminated water, (c) inhalation of aerosol and (d) aspiration of contaminated water.In this article, infections transmitted by ingestion of contaminated water, which normally leads to symptoms of gastroenteritis, are discussed. Water can be polluted with bacteria (Campylobacter spp., Escherichia coli, Salmonella spp., Shigella spp., Vibrio cholera, Yersinia spp., etc.), viruses (Adenovirus, Astrovirus, Enterovirus, HAV & HEV, Norovirus, Rotavirus, Sapovirus, etc.), and

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protozoa and helminthes (Cryptosporidium parvum, Entamoeba histolytica, Giardia intestinalis, Toxoplasma gondii, etc.). The list of possible causative agents of waterborne infections is growing, as laboratory isolation techniques of pathogens become more advanced.

Internationally, waterborne outbreaks of gastroenteritis can be attributed to various micro-organisms. In recent years, according to the published data available, Campylobacter jejuni has caused the majority of outbreaks with bacterial aetiology in developed countries [1–3], while Norovirus is the most frequently detected virus [4–6]. Cryptosporidium [7] and Giardia lamblia [8, 9] are primarily responsible for protozoa infections that lead to waterborne outbreaks. Waterborne outbreaks have the potential to be large and of mixed aetiology [10–13].

According to data from the European Centre for Disease Control and Prevention (ECDC), although waterborne outbreaks from ingestion of contaminated drinking water are typically quite large, their actual incidence is probably underestimated [14]. In 2006, just five European countries reported 17 waterborne outbreaks. A number that small indicates that many waterborne outbreaks are not reported to surveillance systems. The outbreaks reported were caused by several causative agents, including Campylobacter spp., Norovirus, Giardia and Cryptosporidium [14].

Waterborne outbreaks of gastroenteritis in Greece

Notification of outbreaks (clusters of cases) related to consumption of contaminated water is included in the Mandatory Notification System. From 2004 to 2010, 12 waterborne outbreaks were reported. Six of them were caused by bacteria: four by Salmonella spp., one by Shigella flexneri and one by Campylobacter spp. Basic information on the reported bacterial outbreaks are presented in Table 2.

Table 2: Notified bacterial waterborne outbreaks, Mandatory Notification System, 2004–2010

Year Region Number of cases

Number of hospital

admissions

Number of deaths Causative agent

2004 Western Greece 526 13 0 Salmonella spp.

2004 Attica 2 2 0 Salmonella spp.

2004 Crete 37 0 0 Salmonella typhimurium

2004 Thessaly 125 43 0 Shigella flexneri

2009 Peloponnese 3 1 0 Salmonella spp.

2009 Crete 54 14 0 Campylobacter jejuni

In 2009, a case-control study was conducted as part of the epidemiological investigation of a C. jejuni outbreak that caused gastroenteritis in children who lived close to Chania city, Crete. According to the results, consumption of water from the local water supply system had a statistically significant association with the outbreak [odds ratio (OR) 4.39, 95% confidence interval (CI) 1.30 to 14.8] [15].

Despite the fact that water samples from the water supply system were negative for bacteria, there was epidemiological evidence that the water from the supply system was the source of the outbreak. Cases like this highlight the importance of conducting an analytical epidemiological study for waterborne diseases.

The remaining six of the reported outbreaks are presented in Table 3.

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Table 3: Possible waterborne outbreaks of viral or unknown aetiology reported to the Mandatory Notification System, 2004–2010.

Year Region Number of cases

Number of hospital

admissions

Number of deaths

Causative agent

2004 Central Greece 22 7 0 Unknown

2005 E. Macedonia and Thrace 365 0 0 Unknown

2005 E. Macedonia and Thrace 702 0 0 Norovirus

2006 Central Greece 43 9 0 Unknown

2006 E. Macedonia and Thrace 721 0 0 Norovirus

2010 S. Aegean 166 37 0 Norovirus

The causative agent remained unknown in three of the six outbreaks, because stool and water samples were only tested for bacteria and not for viruses, even though the epidemiological characteristics and the patients’ symptoms were consistent with viral infection.

In 2006, a large outbreak, with 721 reported cases, was detected in Xanthi town (33 stool samples positive for Norovirus). The majority of the cases had mild symptoms consistent with viral gastroenteritis (mainly vomiting and diarrhoea of short duration). Water examination was positive for E. coli, but no viruses were detected [16].

Similarly, at the latest reported Norovirus outbreak in Rhodes in 2010, among the residents of a hotel, five stool samples were positive for Norovirus, according to virological testing performed by the Laboratory of Microbiology of the Medical School of Athens. Microbiological testing of water samples performed by the State Chemical Service identified the presence of E. coli at the restaurant’s water supply system and isolated pseudomonas to both the municipality’s aquifer and the restaurant’s reservoir. Water samples were not tested for viruses. The assumption that the vehicle of infection may be the water was based on the descriptive data collected.

These outbreaks are classified as class III waterborne outbreaks (Table 1).

Conclusion

The discussion above emphasizes the importance of epidemiological investigation of waterborne gastroenteritis outbreaks. Laboratory confirmation is not always possible because of: (a) the inability to collect water samples or the delayed collection of samples after measures (e.g. chlorination) have been implemented regarding the water supply system, (b) inadequate testing of samples, particularly when it comes to viruses. Epidemiological investigation provides useful information regarding the size and characteristics of an outbreak as well as the potential risk factors of the disease.

It is essential that comprehensive laboratory testing of clinical and environmental samples collected from the site of any outbreak is continued.

References

1. Jakopanec I, Borgen K, Vold L, et al. A large waterborne outbreak of campylobacteriosis in Norway: the need to focus on distribution system safety. BMC Infect Dis 2008;24(8):128.

2. Furtado C, Adak GK, Stuart JM, et al. Outbreaks of waterborne infectious intestinal disease in England and Wales, 1992–5. Epidemiol Infect 1998;121:109–119.

3. Stern-Green J, Nicholls C, McEwan S, et al. Waterborne outbreak of Campylobacter jejuni in Christchurch: the importance of a combined epidemiologic and microbiologic investigation. NZ Med J 1991;104:356–358.

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4. Riera-Montes M, Brus Sjölander K, Allestam G, et al. Waterborne norovirus outbreak in a municipal drinking-water supply in Sweden. Epidemiol Infect 2011;20:1–8.

5. Hewitt J, Bell D, Simmons GC, et al. Gastroenteritis outbreak caused by waterborne norovirus at a New Zealand ski resort. Appl Environ Microbiol 2007;73(24):7853–7857.

6. Anderson AD, Heryford AG, Sarisky JP, et al. A waterborne outbreak of Norwalk-like virus among snowmobilers—Wyoming, 2001. J Infect Dis 2003;187:303–306.

7. MacKenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the public water supply. N Engl J Med 1994;21, 331(3):161–167.

8. Nygård K, Schimmer B, Søbstad Ø, et al. A large community outbreak of waterborne giardiasis-delayed detection in a non-endemic urban area. BMC Public Health 2006;25(6):141.

9. Daly ER, Roy SJ, Blaney DD, et al. Outbreak of giardiasis associated with a community drinking-water source. Epidemiol Infect 2010;138(4):491–500.

10. Bopp DJ, Sauders BD, Waring AL, et al. Detection, isolation, and molecular subtyping of Escherichia coli O157:H7 and Campylobacter jejuni associated with a large waterborne outbreak. J Clin Microbiol 2003;41(1):174–180.

11. Kopilović B, Ucakar V, Koren N, et al. Waterborne outbreak of acute gastroenteritis in a coastal area in Slovenia in June and July 2008. Euro Surveill 2008;13(34). Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18957 12. Gallay A, De Valk H, Cournot M, et al. A large multi-pathogen waterborne community outbreak linked to faecal contamination of a groundwater system, France, 2000. Clin Microbiol Infect 2006;12(6):561–570.

12. O’Reilly CE, Bowen AB, Perez NE, et al. A waterborne outbreak of gastroenteritis with multiple etiologies among resort island visitors and residents: Ohio, 2004. Clin Infect Dis 2007;15, 44(4):506–512.

13. http://www.ecdc.europa.eu/en/healthtopics/climate_change/health_effects/pages/water_borne_diseases.aspx

14. Karagiannis I, Sideroglou T, Gkolfinopoulou K, et al. A waterborne Campylobacter jejuni outbreak on a Greek island. Epidemiol Infect 2010;138(12):1726–1734.

15. Parasidis T, Vorou E, Mellou K, et al. Outbreak of gastroenteritis occurred in north-eastern Greece associated with several waterborne strains of noroviruses. Int J Inf Dis 2008;12(1):104–105 (Abstract)

Kassiani Mellou, Maria Potamiti-Komi, Athina Kallimani, Theologia SideroglouFoodborne and Waterborne Diseases Section

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Surveillance Data

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Data

Table 1: Number of notified cases in June 2011, median number and range of notified cases in June for the years 2004–2010, Mandatory Notification System, Greece

Disease Number of notified cases

June 2011

Median number June 2004−2010 Range

Botulism 0 0 0–1

Chickenpox with complications 0 5 0–11

Anthrax 0 0 0–1

Brucellosis 17 24 6–59

Diphtheria 0 0 0–0

Arbo-viral infections 0 0 0–0

West Nile Virus infection 0 0 0–0

Malaria 1 3 1–5

Rubella 0 0 0–0

Smallpox 0 0 0–0

Echinococcosis 0 2 0–4

Hepatitis Α 4 6 1–14

Hepatitis B, acute & HBsAg(+) in infants <12 months 4 6 1–20

Hepatitis C, acute & confirmed anti-HCV positive (1st diagnosis) 0 3 0–8

Measles 3 0 0–52Haemorrhagic fever 0 0 0–2Pertussis 0 3 1–12Legionellosis 1 2 0–4Leishmaniasis 2 5 2–9Leptospirosis 0 0 0–2Listeriosis 2 0 0–2EHEC infection 2 0 0–1Rabies 0 0 0–0Melioidosis/glanders 0 0 0–0Meningitis (bacterial, aseptic) 14 50 32–262Meningococcal disease 1 5 0–14Plague 0 0 0–0Mumps 1 1 0–6Poliomyelitis 0 0 0–0Q Fever 1 0 0–2Salmonellosis (non-typhoid/paratyphoid) 51 84 23–138Shigellosis 2 2 0–6Severe acute respiratory syndrome 0 0 0–0Congenital rubella 0 0 0–0Congenital syphilis 1 0 0Congenital toxoplasmosis 0 0 0–1

Cluster of foodborne/waterborne disease cases 7 5 2–8

Τetanus/neonatal tetanus 0 0 0–1Tularaemia 0 0 0–0Trichinosis 0 0 0–1Typhoid fever/paratyphoid 1 0 0–1Tuberculosis 35 71 42–92Cholera 0 0 0–0

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Data

Table 2: Number of notified cases by place of residence (region)*, June 2011, Mandatory Notification System, Greece

Disease Number of notified cases

Region

East

ern

Mace

do

nia

an

d T

hra

ce

Cen

tral

Mace

do

nia

West

ern

Mace

do

nia

Ep

iru

s

Th

ess

ali

a

Ion

ian

isl

an

ds

West

ern

Gre

ece

Ste

rea G

reece

Att

ica

Pelo

po

nn

ese

No

rth

ern

Aeg

ean

So

uth

ern

Aeg

ean

Cre

te

Un

kn

ow

n

Brucellosis 0 4 1 1 8 0 0 1 0 1 0 0 0 1Malaria 0 0 0 0 0 0 0 0 0 1 0 0 0 0Hepatitis A 0 0 0 1 0 0 0 1 2 0 0 0 0 0Hepatitis B, acute & HBsAg(+) in infants <12 months

0 0 0 0 0 0 0 0 3 0 1 0 0 0

Measles 0 0 0 0 0 0 0 0 2 0 0 0 1 0Legionellosis 0 0 0 0 0 0 0 0 1 0 0 0 0 0Leishmaniasis 0 1 0 0 0 0 1 0 0 0 0 0 0 0Listeriosis 0 0 0 0 0 0 0 0 1 1 0 0 0 0EHEC infection 0 0 0 0 0 1 0 0 1 0 0 0 0 0Mumps 0 0 0 0 0 0 0 0 0 0 0 0 1 0Q Fever 0 0 0 0 0 0 0 0 1 0 0 0 0 0Salmonellosis (non-typhoid/paratyphoid) 2 0 0 2 23 0 2 2 17 2 0 1 0 0Shigellosis 0 0 0 0 0 0 0 0 2 0 0 0 0 0Congenital syphilis 0 0 0 0 0 0 2 0 1 0 0 0 0 0Typhoid fever/paratyphoid 0 0 0 0 0 0 0 0 1 0 0 0 0 0Meningitis (bacterial, aseptic) 0 1 0 1 1 0 1 1 5 2 0 1 1 0Meningococcal disease 0 0 0 0 0 0 0 0 1 0 0 0 0 0Cluster of foodborne/waterborne disease cases 1 0 0 0 1 1 0 0 4 0 0 0 0 0Tuberculosis 6 3 4 1 0 1 2 2 12 1 0 0 2 1

* Place of residence is defined as the home address of the patient.

Table 3: Number of notified cases by age group and gender*, June 2011, Mandatory Notification System, Greece

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 FBrucellosis 0 0 0 0 0 1 2 0 2 1 3 2 1 0 1 0 2 2 0 0Malaria 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0Hepatitis A 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0Hepatitis B, acute & HBsAg(+) in infants <12 months

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

Measles 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0Legionellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0Leishmaniasis 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0Listeriosis 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0EHEC infection 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0Mumps 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0Q Fever 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0Salmonellosis (non-typhoid/paratyphoid)

1 3 6 6 9 1 0 0 2 1 1 1 0 0 3 2 0 0 0

Shigellosis 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Congenital syphilis 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0

Typhoid fever/paratyphoid

0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

Meningitis (bacterial, aseptic)

0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 9 1

Meningococcal disease 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0Tuberculosis 0 0 0 2 2 1 4 1 3 1 3 3 3 0 3 2 5 2 0 0

*M: male, F: female.

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Notification forms and case definitions of the diseases can be found at the website of the Hellenic Centre for Disease Control and Prevention (HCDCP) (www.keelpno.gr). It should be noted that the data for June 2011 are provisional and could be slightly modified in the future, and that data interpretation should be made with caution because there are indications of under-reporting in the system. We would like to thank warmly the physicians who, despite their daily work load, systematically notify infectious diseases to the Department of Epidemiological Surveillance and Intervention of the HCDCP.

Department of Epidemiological Surveillance and Intervention

Invited article

Division of Sanitary Engineering and Environmental Hygiene of Ministry of Health and Social Solidarity

• The Sanitary Engineering and Environmental Hygiene Division of the Health Ministry has been an institution of historical importance since its establishment in 1949 as the Department of Sanitary Engineering (Law 1037/1949), when it set the foundations for environmental law regarding the protection of public health.

• The Division’s responsibilities extend across many areas at the interface between environment and health. These areas expand daily with the development of technology and the increase in risks to human health caused by pollution (genetically modified organisms, electromagnetic waves, etc.)

In summary, the Division’s areas of responsibility and action regarding water quality comprise the following.

Co-ordination of follow-up action plans for applications of sanitary provision, regulation and guidelines, as well as action plans in the sectors of: • quality of drinking water; • bathing water; • quality of swimming pool water; • natural mineral water, spring water and table water; • surface water, groundwater and marine water; • urban sewage, industrial waste, toxic waste; • repercussions of major natural and industrial disasters.

One of the main responsibilities of the Division is the monitoring of drinking water quality in order to ensure public health. Within the framework of the application of relevant legislation, the Division of Sanitary Engineering and Environmental Hygiene:

• regularly sends guidance circulars to the water suppliers and regional health departments, referring to the essential measures for protecting water sources, the maintenance of water supply distribution systems and the application of audits according to the legislation;

• collects data regarding drinking water quality from the water suppliers, composes a tri-annual report and informs the European Union regarding the quality of drinking water in Greece.

V. Karaouli, Head of the Division of Sanitary Engineering & Environmental Hygiene, Ministry of Health and Social Solidarity

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HCDCP Departments Activities

Water Safety Plan

The guidelines for drinking water quality that were published by the World Health Organization (WHO) in 2004 introduced a new methodological approach for ensuring potable water quality, the Water Safety Plan (WSP) [3]. This plan is characterized as ‘the most appropriate means to guarantee safe water supply’ and is based on the systematic organization of methodologies used in the past, as well as on hazard analysis approaches such as HACCP. Since then, many guidelines, books and training materials have been published related to this subject and the WSP has been developed for municipality water supplies, hospitals and water reuse schemes.

WSP provides an integrated approach for assessing the risks from source to consumer in order to ensure drinking water is of appropriate quality. It is a multivariate approach that aims to produce water that meets the standards of legislation. It requires a detailed description of the water supply, identification of the risks, hazard analysis and implementation of control measures, and definition of operational limits and corrective actions. The basic steps for developing a WSP are presented in Figure 1 [1,4,5].

WSP was initially introduced to be applied to drinking water supplies, but WHO guidelines for the prevention of legionellosis suggested that WSP can be developed to ensure safe water quality in swimming pools, hot tubs, cooling towers, hotels, spas and ships.

The Peripheral Public Health Laboratory of Thessaly developed a WSP for a water supply after investigating an outbreak of Legionnaires’ disease, and so far the results have been satisfactory.

The success of a WSP depends on many factors, such as appropriate and systematic risk analysis [2], the support of the senior management of the water supply company, the involvement of everyone who will be responsible for implementing the WSP from the beginning of the process, and the support of a team approach. WSP can be a useful tool in ensuring water safety, provided that all the necessary steps have been followed.

Figure 1: Principal stages of WSP

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References

1. Vieira JM. A strategic approach for Water Safety Plan implementation in Portugal. J Water Health 2011;9(1):107–116.

2. Dominguez-Chicas A, Scrimshaw MD. Hazard and risk assessment for indirect potable reuse schemes: an approach for use in developing Water Safety Plans. Water Res 2010;44(20):6115–6123.

3. World Health Organization. Guidelines for Drinking-Water Quality. Volume 1. Recommendations, 3rd edn. Geneva: World Health Organization; 2004.

4. World Health Organization–International Water Association. Water Safety Plan Manual. Step-by-Step Risk Management for Drinking-Water Suppliers. World Health Organization–International Water Association; 2009.

5. World Health Organization. Water Safety Plans. Managing Drinking Water-Water Quality from Catchment to Consumer. WHO/SDE/WSH/05.06. Geneva: World Health Organization; 2005

Barbara Mouchtouri, Environmental Health Officer, Peripheral Public Health Laboratory of Thessaly

World Hepatitis Day, 28 July 2011

World Hepatitis Day, 28 July 2011, is being held to increase awareness and understanding that viral hepatitis is a major public health problem all over the world.

The aims of the day are to emphasise co-ordinated action at an international level for the prevention and control of the disease, by increasing the prevention, screening and control of viral hepatitis and its related diseases, increasing vaccination and, in particular, increasing vaccine coverage against hepatitis B.

The Hellenic Centre for Disease Prevention and Control (HCDCP) invests a lot of effort in preventing the transmission of viral hepatitis, improving clinical care and safeguarding the rights of patients infected with viral hepatitis, HBV and HCV.

- There are blood tests for detecting hepatitis viruses.

- Taking a simple blood test can resolve any doubts.

The official Greek poster for Hepatitis Day

For further information call 0030.210.5212179-210, 0030.210.5212183.Dr Georgia Nikolopoulou

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Office of Environmental Health

“Environmental health addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments.”

The definition given by the World Health Organization (WHO), during the 2nd European Conference on Environment and Health, in Helsinki in 1994, reflects the prime importance of environmental hygiene in public health. The role of environmental health is evident as much in the natural environment as in man-made environments, and its fundamental facets are:

• waste management (solid, liquid and gaseous waste)• municipal• industrial• hospital• radioactive/hazardous;

• prevention and risk assessment;

• drinking-water quality assurance;

• hygiene and job security.The Hellenic Centre for Disease Control and Prevention (HCDCP) is an organization that advocates public health and thus it established the Office of Environmental Health in June 2011. The Office is staffed by:

1. Sambatakakis Stefanos (Head), Chemist and sanitarian engineer, MSc2. Dr Zagganas Panagiotis, Chemist, PhD3. Kefaloudi Chrysovallandou, Environmentalist4. Remboutsika Georgia, Administrative employee5. Vasileiou Georgia, Administrative employee

Initially, a communication network was launched among health administrations within the districts and prefectures of Greece, aiming to prevent and deal on time with any environmental hazards that may occur. Specifically, the Office contributed technical assistance to the Inspectorate of Health and Welfare (SEYYP) in Northern Greece in order to control, investigate and present their findings on the reasonable management and disposal of medical waste in hospitals, in the presence of a prefectural representative.

In co-operation with the infection control nurses in charge of the management of hospital waste, advisory services are provided to ensure their reasonable management. The Office of Environmental Health had an active role in Central Macedonia overseeing the West Nile Virus control programme in the summer of 2010 and is willing to participate again this year.

Having already created an environmental legislation file regarding waste management (municipal, industrial and medical), at regular intervals, we offer advisory services to public and private organizations in the field of health. Moreover, the Office of Environmental Health is obligated to answer punctually and appropriately to any appeals submitted by parliament that are relevant to its purview.

In conclusion, it is worth mentioning that the Office has future goals, to solve more environmental health issues such as:

- the listing of unsafe water resources within the Greek territory to enable timely prevention as well as risk assessments regarding public health;

- the creation of a database of the total amount of waste produced by industrial activities;

- the launch of an authorized body for the training of medical and nursing staff, regarding the collection, separation, storage and disposal of waste produced from hospital units;

- further technical provision within regional bodies concerned with public health, wherever necessary.

S. Sambatakakis, Head of the Office of Environmental Health

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Public health importance of water microbiological quality

Introduction

Drinking water is one of the key factors for human development and preservation of life. The human body mass consists of more than 60% water and it is well known that water is essential for blood circulation and conservation of electrolytic equilibrium [1]. The daily intake of water for a human ranges between 850 mL and 2500 mL, depending on the environmental temperature and how active a person is. But as every person should also have adequate quantities of water for preparing food and personal and domestic hygiene, the daily need for water can be up to 200 L [2]. Unfortunately not all people have access to an adequate and safe water supply [3]. Nowadays, 884 million people (approximately 1 in 8) lack access to a clean and healthy water supply, and 3.575 million people die every year from diseases related to poor quality water and associated bad hygiene [4]. About 0.5% of the total water reserves on the planet (surface and underground water) are used for human consumption. This water should be, in every aspect, harmless, absolutely clean, and smell and taste perfect, with no pathogenic germs and no substances that could possibly threat human health [1].

Quality test of water for human consumption

Water for human consumption is considered to be:

• any kind of natural or processed water that is meant for drinking, cooking, food preparation or any other domestic usage, regardless of its origin and regardless of whether it is provided by the water grid system, water tank, bottles or cans;

• the water used by the food industry, including for the preparation, processing, preservation and dispensing of products and substances that are for human consumption [5, 6].

The quality of water for human consumption is tested by:

• on-site health control;• chemical testing;• biological testing;• microbiological testing;• the evaluation and analysis of test results.

On-site health control

This is performed by a specialized scientist at the area of water intake, in order to evaluate the general conditions, the possible existence of any contamination or pollution areas and the technical infrastructure [2].

Chemical tests

These provide valuable information regarding the water hardness and the concentration of particular chemical substances, such as toxic metals (lead and cadmium), radioactive substances and other possibly harmful substances [1].

Biological tests

Water samples are tested for algae and protozoa that could establish in the water system as a result of damage or failure of the pest control system [1].

Microbiological tests

These are important tests because they use very sensitive methods for estimating whether water is contaminated. More than one test is needed for evaluating water quality, and these kinds of tests should be performed often and systematically. It is often preferable to take samples from mains water and perform frequent microbiological tests using simple methods rather than perform occasional, more complicated tests. One single test on any water sample, even if the results are negative and the water sample is clean, is not enough to conclude that the mains water is suitable and safe for human consumption is safe. Contamination can often H

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be intermittent and so would not be detected by testing one single sample.

The microbiological parameters that are tested in order to estimate whether dispensed water is suitable and complies with the standard requirements (Joint Ministerial Decision Y2/2600/2001) are:

• mandatory parameters – presence and counts of Escherichia coli and enterococcus;

• suggested parameters – presence and counts of all coli forms, counts of colonies at 22°C and 37°C and presence and counts of Clostridium perfringens, including their seeds (when the water is superficial or is affected by superficial agents);• parameters for tentative monitoring – presence of Salmonella spp., pathogenic Staphylococcus, E. coli O157:Η7, Campylobacter spp. [5,6].The acknowledged value for mandatory parameters is strictly specified to 0/100 mL, as these parameters are directly related to the protection of human health and any positive value could mean the presence or potential presence of pathogenic germs.The suggested parameters do not imply any danger for human health; however, they can demonstrate a distinct change in water quality and therefore the need for corrective intervention. As a result, the suggested value for all coli forms and C. perfringens (which is estimated only when the water is superficial or is affected by superficial agents) is also 0/100 mL and colony counts at 22°C and 37°C should be stable.The acceptable value for parameters of tentative monitoring is null [5, 6].

The importance of all the above parameters lies in the demonstration of a particular kind of contamination in the water from which the tested sample is taken.

The results of the laboratory tests and especially the microbiological tests should always be interpreted in conjunction with reports from on-site health control. That is why the laboratory tests are considered to be complementary and not decisive. The laboratory tests alone can never provide the basis upon which a water supply system is disapproved unless they are confirmed by health control findings. For example, when a health control is performed on a water intake and there is a risk of contamination because the artesian well is near a waste matter tank, even if the microbiological test is negative the water is not considered suitable for use. On the other hand, when the result of a microbiological test is positive but there is no noticeable source of contamination, the water intake is not disapproved but additional investigations are carried out in order to explain the discrepancy between the laboratory and on-site control findings.

The Public Health Laboratory Network (CLPH–PLPH) conducts chemical and microbiological tests in water samples from all over Greece, to monitor the control of water quality by the peripheral public health services.

References

1. ‘Water Microbiology’, P. George Boufa (22-23 March 2010 Workshop in CPHL, Athens)

2. www.waterinfo.gr/eedyp/Paros_papers/velonakis_e.pdf

3. www.who.int/water_sanitation_health

4. http://water.org/learn-about-the-water-crisis/facts/

5. Joint Ministerial Dicision Υ2/2600/2001, Greek Government Gazette 892Β/11-7-2001

6. Official Guidelines: ‘Monitoring the quality of drinking water, the infrastructures of water supply system and taking measures for protecting public health.’Ministry of Health, Department of Sanitary Engineering and Environmental Health (DΥC2/ 94097/19.7.07)

Antonia Theofilou & Konstantina Aivalioti, Medical Lab Technologists, CPHL-HCDCP

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Incidents of black widow spider bites

During the first half of July, three possible incidents of black widow spider (Latrodectus mactans tredecimguttatus) bites occurred in Greece. The victims were all adult males. Two of the incidents happened in the area of Pyrgos and the other in the area of Alexandroupolis. The victims were aged 24, 64 and 66 years, respectively. All the victims reported having an insect bite 0.5–2 hours before they attended a hospital outpatient clinic, presenting with sweating, intense pain in the area around the bite, in the loins or legs, cardiovascular symptoms and an acute abdomen. All had increased levels of creatininephosphokinase (CPK). The antiserum ARACMYN PLUS was administered to two patients at the request of physicians to the Emergency Operation Centre of the Hellenic Centre for Disease Control and Prevention (HCDCP). All victims recovered fully and were able to leave hospital. One victim had to be admitted to the Intensive Care Unit (for 4 days), where he recovered before he was administered an antidote.

The insects or spiders that caused the bites were not found, so it was not possible to check definitely whether the bites were caused by a black widow spider. However, there is a strong likelihood that the bites were from black widow spiders because of the patients’ symptoms, the characteristics of the bites according to the medical personnel and the positive response to antivenom administration (ARACMYN PLUS). This antivenom is about to undergo phase 3 clinical trials in the USA by the Food and Drug Administration (FDA), and has not yet been approved for general use. It is preferred to existing antivenoms because it may be associated with less risk of allergic reaction. Its administration was agreed between the Hellenic Poison Treatment Centre and the medical personnel involved.

Widow spiders belong to the genus Latrodectus and include the black widow spider (L. mactans mactans). The term widow spider is used because not all species in the genus Latrodectus are black. Other widow spiders in North America include the brown widow (Latrodectus geometricus), the red-legged widow (Latrodectus bishopi), Latrodectus variolus and Latrodectus hesperus. The redback spider (Latrodectus hasselti) is endemic to Australia. Latrodectus mactans tredecimguttatus and Latrodectus pallidus are found in Europe and South America, and the button spider (Latrodectus indistinctus) is found in South Africa.

The adult female black widow spider is approximately 2 cm in length and shiny black with a red–orange hourglass or spot on the ventral abdomen. The male is smaller, brown and incapable of poisoning humans. Juvenile females are also brown but have the general body morphology of the adult. The female sometimes eats the male during or after copulation. Webs are irregular, low-lying and commonly seen in garages, barns, outhouses and foliage.

The venom produced by a black widow spider is called alpha-latrotoxin and causes the toxic effects observed in humans by opening cation channels (including calcium channels) presynaptically, causing an increased release of multiple neurotransmitters. This results in excess stimulation of motor endplates, with resultant clinical manifestations. Clinically, the predominant effects are neurological and autonomic. Symptoms of spider venom bites can include initial pain at the bite site, but generally this is trivial and may go unnoticed; it is commonly described as a pinch or pinprick, while infants may present with unexplained crying. Within about 1 h, systemic symptoms begin and may last for a few days. Victims may suffer muscle cramping locally, around the area bitten, but this may also extend into the large muscle groups, such as the abdomen, back, chest and thighs, and smooth muscles, such as bronchial and endometrial muscles. Nausea and vomiting, headache and anxiety may appear.

Physical findings may include abnormal vital signs, such as hypertension, tachycardia and diaphoresis. Tiny fang marks may be visible and local effects are usually limited to a small circle of redness and/or induration around the immediate bite site. A central reddened fang puncture site surrounded by an area of blanching and an outer halo of redness is described as a having a target appearance. Abdominal rigidity may mimic an acute abdomen, and neurological effects, including mild weakness, fasciculations and ptosis, have been described; latrodectus facies, characterized by spasm of the facial muscles, edematous eyelids and lacrimation, may occur. This can be mistaken for an allergic reaction. Finally, bronchorrhea and pulmonary oedema have been described in Europe and South Africa.

Most widow spider bites can be managed with opioid analgesics and sedative-hypnotics. HC

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Antivenom may be indicated for patients who have severe poisoning with pain refractory to these measures. Antivenom should be considered when the poisoning seriously threatens pregnancy or precipitates potentially limb- or life-threatening effects. On average, antivenom administration results in resolution of most symptoms half an hour after administration, and it has been shown to decrease the need for hospitalization. Studies suggest benzodiazepines are more effective than muscle relaxants for the treatment of muscle pain related to widow spider bites. Antibiotics are not indicated.

References

1. Gonzalez Valverde FM, Gomez Ramos MJ, Menarguez Pina F, Vazquez Rojas JL. [Fatal latrodectism in an elderly man]. Med Clin (Barc). Sep 22 2001;117(8):319. [Medline].

2. Pneumatikos IA, Galiatsou E, Goe D, Kitsakos A, Nakos G, Vougiouklakis TG. Acute fatal toxic myocarditis after black widow spider envenomation. Ann Emerg Med. Jan 2003;41(1):158. [Medline].

3. Boyer Hassen LV, McNally JT, Binford GJ. Spider bites. In: Auerbach PS, ed. Wilderness Medicine, 4th edn. St Louis: Mosby-Year Book; 2001:807–838.

4. Cohen J, Bush S. Case report: compartment syndrome after a suspected black widow spider bite. Ann Emerg Med. Apr 2005;45(4):414–416. [Medline].

5. Clark RF, Wethern-Kestner S, Vance MV, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med. Jul 1992;21(7):782–787. [Medline].

G. Antoniou, D. Iliopoulos, HCDCP Emergency Operation Centre

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J Hosp Infect 2011;77:47–51Effectiveness of different methods to control legionella in the water supply: ten-year experience in an Italian university hospitalMarchesi I, Marchegiano P, Bargellini A, et al.

The authors report their 10-year experience of hyperchlorination, thermal shock, chlorine dioxide, monochloramine, boilers and point-of-use filters for controlling legionella contamination in a hospital hot water distribution system. Shock disinfections were associated with a return to pre-treatment contamination levels within 1 or 2 months. They found that chlorine dioxide successfully maintained levels at <100 cfu/L, while preliminary experiments gave satisfactory results with monochloramine. No contamination was observed applying point-of-use filters and electric boilers at temperatures of >58°C and no cases of nosocomial legionellosis were detected in the 10-year observation period. The performance ranking in reducing legionella contamination was filter, boiler, chlorine dioxide, hyperchlorination and thermal shock. Chlorine dioxide was the least expensive procedure followed by thermal shock, hyperchlorination, boiler and filter. The authors suggest adopting chlorine dioxide and electric boilers in parallel.

Chest 2010;138:989–991Legionnaires’ disease in cannabis smokersNguyen LT, Picard-Bernard V, Perriot J

Tobacco smoking is a well-recognized risk factor for Legionnaires’ disease. However, it may be potentiated by cannabis use, as there is strong evidence that Δ(9)-tetrahydrocannabinol impairs immune functions in vitro and in vivo. The authors report two out of three cases of severe Legionnaires’ disease in three men with no overt comorbid illnesses, aged 38, 28, and 48 years, respectively. All of them were heavy cigarette and cannabis smokers.

Dr Helena Maltezou, Department for Interventions in Health-Care Facilities

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Interesting activities

Special Olympics, Athens 2011

The World Summer Special Olympics (WSGSO) Athens 2011 was a significant international event, organized in our country between 25 June and 6 July 2011. More than 6000 athletes and more than 35000 participants in total contributed to the successful organization of the Games.

The Hellenic Centre for Disease Prevention and Control (HCDCP) supported the organization in the area of public health (PH). During the preparation for the games, a group of HCDCP staff participated in a series of meetings with the Ministry of Health and the Medical Services team of the Organizing Committee of the Games.

The Hellenic Centre for Disease Control and Prevention (HCDCP) supported the event with three major PH activities.

Epidemiologic surveillance

The epidemiologic surveillance for the Athens 2011 Special Olympics included a system focusing on three syndromes: respiratory infection with fever, acute gastroenteritis, and fever with a rash. Daily reports were sent to the Medical Operations Centre (MedOC) of the Organizing Committee from each medical treatment centre in all the competition and accommodation venues, staffed by volunteer medical personnel. The data were collected and entered into a database by HCDCP liaison staff, who volunteered in the MedOC in 24-h shifts. Daily analysis was performed by the Department of Epidemiologic Surveillance and Intervention of the HCDCP, and the daily report also took into consideration reports to the national Notifiable Disease System of communicable diseases.

PH laboratory testing

The PH Laboratory Network (central and regional PH laboratories) received samples for microbiological and chemical testing during the preparation phase and until the delegations departed Greece. Laboratory testing was performed on samples of water (drinking water, swimming pools and beaches), foodstuff and waste from competition and accommodation venues. The total number of samples tested by the PH Laboratory Network was more than 1500.

Table 1 presents the water and food samples analysed by type, the number of samples and the percentages of those that complied or not to the terms of existing national and European legislation.

In Figure 1 the number of samples analysed by the laboratories is shown .

Table 1: Water and food samples analysed (microbiological and chemical testing) and characterized (based on legislation and standard protocols)

Type of sample

Number of samples Qualified Not qualified

Drinking water 170 145 (85.3%) 25 (14.7%) Swimming pool water 153 149 (97.4%) 4 (2.6%) Water in bathing beaches 30 30 (100%) 0 (0%) Water for Legionella spp. detection 831 759 (91.3%) 72 (8.7%) Water for chemical analysis 6 6 (100%) 0 (0%) Food 393 348 (88.5%) 45 (11.5%) Total 1583 1337 146

Based on the results, we could conclude that the majority of the samples analysed complied with the terms of the legislation. Controls were re-implemented on samples that did not comply with the legislation terms, after the required corrective actions had been carried out by the appropriate authorities.

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Figure 1: Number of samples analysed by the Laboratory of the Regional Public Health Laboratories (RPHL)–Central Public Health Laboratory (CPHL)Network

Διάγραµµα 2.Αριθµός δειγµάτων ανα Εργαστήριο του Δικτύου ΠΕΔΥ-ΚΕΔΥ

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ΚΕΔΥ ΠΕΔΥ ΘΕΣΣΑΛΙΑΣ ΠΕΔΥ ΑΜΘ ΠΕΔΥ ΚΡΗΤΗΣ

CPHLRPHL of Thessaly RPHL of E. Macedonia-Thrace RPHL of Crete

Management of PH incidents/crises

The Co-ordination Centre of the HCDCP functions 24 h/day, 7 days/week, and is staffed by medical personnel experienced in PH. A three-member team of PH professionals was also available to respond to any PH incident. One such example was the investigation of an acute gastroenteritis outbreak detected in members of the British Delegation on 25/6/2011, the day of the opening ceremony of the WSGSO Athens 2011. The response team was dispatched to the accommodation venue of the delegation in order to perform an initial assessment of the situation, to communicate the necessary control measures to the team and medical staff at the venue and to assist in a case-control survey study to identify the cause of the outbreak. Analysis of the data collected indicated that consumption of a particular dish (green salad) during a trip by the delegation outside Athens had the highest relative risk for developing gastroenteritis symptoms, while microbiological analysis of biological samples from hospitalized patients identified the causative agent as Norovirus.

All HCDCP activity and data analysis referring to the previous 24 h were presented in a daily report prepared by the HCDCP staff, which was communicated to the MedOC and the Organizing Committee as well as the Ministry of Health hierarchy.

PH preparedness for a large international gathering always pays off, because it enables prompt and effective responses and appropriate crisis management. The gastroenteritis outbreak managed during the WSGSO Athens 2011 is a classic, and relatively common, example of an incident that may put the response mechanisms of a PH authority to the test during such events.

Dr Agoritsa Baka, MD. HCDCP President’s Office Vasiliki Rousia, Technologist in Medical Laboratories, MSc Quality Assurance, Quality Manager, CPHL–

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European Programme Intervention Epidemiology Training (EPIET) in Greece for the first time

The Department of Surveillance of the Hellenic Centre of Disease Control and Prevention (HCDCP) will become a training site for the European Programme Intervention Epidemiology Training (EPIET) for the first time in September 2011. EPIET started in 1995, with the aim of creating a network of well-trained field epidemiologists and enhancing intervention epidemiology at both European and national levels.

The programme provides training and practical experience in intervention epidemiology (outbreak investigation, surveillance, applied research), with the main emphasis on learning-by-doing activities. EPIET is aimed at European Union (EU) medical practitioners, public-health nurses, microbiologists, veterinarians and other health-care professionals with previous experience in public health and a keen interest in epidemiology. For the first time it is possible for fellows to train in their own country (EPIET Member State Track). The Department of Surveillance of KEELPNO has been selected as a training site for Member State Track fellows.

Training methods and objectives

The programme lasts 2 years. A fellow will work full time at the Department of Surveillance at HCDCP. His or her work will be supervised by a local, chief supervisor at the training site and by an EPIET scientific co-ordinator (from a distance). Specific research or other projects may be supervised by other supervisors.

By the end of the 2 years, fellows should have:

• conducted outbreak investigations; • analysed, designed or implemented a surveillance system; • planned, developed and/or conducted a research project on a relevant public health issue; • presented and published the results of their work to the scientific community; • taught epidemiology.

At the beginning of the fellowship, fellows are required to participate in a 3-week introductory course, which provides basic knowledge of intervention epidemiology and aims to inspire a strong motivation for the field investigation. In addition to the 3-week introductory course, seven 1-week modules offer more specialized training relevant to the field of epidemiology. All modules are in English.

To participate in the programme, candidates should meet all of the following eligibility criteria:

• a level of post-secondary education attested by a diploma in public health or a related subject, at the level of a Masters degree;

• at least 1 year of practice in public health or epidemiology; • a thorough oral and written knowledge of Greek and English; • be either a national of an EU/European Economic Area/European Free Trade Association

country or have lived in the country for at least 3 years (with a working permit and permanent residency).

You may find more information at the EPIET website: http://ecdc.europa.eu/en/epiet/Pages/HomeEpiet.aspx

Department of Surveillance and Intervention, HCDCP

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21st European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) and 27th International Congress of Chemotherapy (ICC), Milan, Italy, 7-10 May 2011

Τhe 21st European Congress of Clinical Microbiology and Infectious Diseases (ECCMID)–27th International Congress of Chemotherapy (ICC) took place in Milan, Italy, 7-10 May 2011. It was well organised, with a wide range of seminars, lectures and symposia, and a large number of participants; many scientific bulletins were posted, providing new and significant knowledge regarding the fields of clinical microbiology and infection.

During the 21st ECCMID, six scientific papers (posters) were displayed officially, regarding the products of collaboration between our laboratory and the laboratories of several hospitals. All abstract submissions and poster presentations can be viewed via the online library of the congress, through the link ‘abstract and poster online library’ at the website http://www.eccmid-icc2011.org/. I was in charge of presenting the first and the second (replacing Mr Polemis) of the six posters.

• P1240 Consecutive outbreaks of Serratia marcescens infections in a neonatal ICU are due to the repeated introduction of new clones

K. Tryfinopoulou*, O. Pappa, M. Polemis, H. Prifti, K. Vatzeli, L. Ftika, H. C. Maltezou, K. Tzanetou, A. Vatopoulos (Athens, GR)

http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=125494&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900

• P1491 Bacteraemia and antibiotic resistance of its pathogens reported in Greece between 2000 and 2009: trend analysis

M. Polemis*, K. Tryfinopoulou, S. Chrisochoidou, M. Panopoulou, E. Platsouka, K. Tzanetou, V. Galanopoulou, E. Skouteli, C. Koutsia-Carouzou, K. Poulopoulos, M. Anagnostopoulou, M. Toutouza, K. Aveliodi, A. Pasxali, K. Dimarogona, P. Karampogia, A. Petridis, A. Mavridis, E. Tsorlini, E.M. Fakiri, S. Nikolaou, E. Kaitsa-Tsiopoulou, G. Stamatopoulou, A. Vatopoulos (Vari, Thessaloniki, Alexandroupolis, Athens, Corfu, Ioannina, Xanthi, GR)

http://registration.akm.ch/einsicht_iframe.php?XNABSTRACT_ID=128138&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900

• P1348 Surveillance of beta-lactamase production in a recent sample of Klebsiella pneumoniae isolated in Greek hospitals

C. C. Papagiannitsis*, K. Tryfinopoulou, P. Giakkoupi, O. Pappa, M. Polemis, E. Malamou-Lada, M. Orfanidou, S. Tsiplakou, V. Papaioannou, H. Fakiri, K. Stamoulos, D. Kairis, H. Papoutsidou, H. Katsifa, F. Kesidou, E. Tsafaraki, A. Tsouri, E. Platsouka, Z. Roussou, H. Kaitsa-Tsiopoulou, P. Kazila, E. Tzelepi, A. Vatopoulos (Athens, Thessaloniki, Chania, GR)

http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=126434&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900

• P1322 Epidemiology of Serratia marcescens colonisations and infections in a neonatal intensive care unit

M. Papadimitriou*, K. Tryfinopoulou, D. Kyriakou, A. Doudoulakakis, O. Pappa, J. Kapetanakis, A. Vatopulos, E. Lebessi (Athens, GR)

http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=127203&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900

• P1238 Outbreak of Pseudomonas (Flavimonas) oryzihabitans bacteraemia in a neonatal intensive care unit

H. Prifti*, D. Oikonomidou, O. Pappa, K. Tryfinopoulou, K. Vatzeli, K. Karaiskos, E. Kostis, A. Vatopoulos, K. Tzanetou (Athens, GR)

http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=125629&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900

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• P1332 Outbreak of Burkholderia cenocepacia bacteraemia in an intensive care unit: an epidemiologic and molecular study

M. Katsiari*, Z. Roussou, A. Xydaki, K. Tryfinopoulou, A. Vatopoulos, E. Platsouka, A. Maguina (Athens, GR)

http://registration.akm.ch/einsicht_iframe.php?XNABSTRACT_ID=125226&XNSPRACHE_ID=2&XNKONGRESS_ID=136&XNMASKEN_ID=900

Kiki Trifynopoulou, MD, Biopathologist, Central Public Health Laboratory (CPHL)

Participation of SKAE personnel at the voluntary blood donation session at Syntagma Metro Station, 7 July 2011

The Hellenic Co-ordinating Haemovigilance Centre (SKAE) is a support mechanism for blood donation and public health that operates through the Hellenic Centre for Disease Control and Prevention (HCDCP) and the Ministry of Health & Social Solidarity. SKAE compiles and disseminates surveillance data to HCDCP and the National Centre for Blood Donation (EKEA), and co-operates with the national authorities regarding crisis management, covering all aspects of the donation–transfusion chain.

SKAE personnel participated in a voluntary donation, organized by the Blood Donation Department of ‘Evangelismos’ General Hospital, on 7 July 2011, in the very functional multi-use Metro space at Syntagma. The donation session was successful: a large number of blood units was collected, and hundreds of people were informed regarding the health benefits facilitated by blood donation.

The official Greek poster for the World Blood Donor Day

Constantina Politis, MDAssociate Professor at the University of Athens, Scientific Advisor of HCDCP, Head of SKAE

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Workshop on cancer registries of south-east Europe within the framework of WP8 of the Eurocourse Project, Iasio Romania, 12–13 May 2011

Eurocourse is a European project (ERA-NET) aiming to build and strengthen an infrastructure for population-based cancer registries across Europe. It also aims to establish requirements for cancer registration and provide a basis for stable financing in the future. The workshop was part of work package 8 (WP8) and focused on cancer registries in south-east Europe.

The aim of the workshop was to:

• present the cancer registries of the participating countries• determine factors that will contribute to improving the cancer registry’s function • present

1. the need to create a common European cancer database2. the need to link the cancer registry with screening programmes and biobanks3. CanReg, a software package that can be used by cancer registries4. the data portal via which cancer registries can submit data.

The Hellenic Centre for Disease Control and Prevention (HCDCP) was represented by Mrs Anthi Chrisostomou of the Hellenic Cancer Registry and Rare Diseases Office in the Department of Educational Development and National Registries.

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Future conferences and meetings

August 20117-11 August 2011

Title: World Congress of Epidemiology

Country: ScotlandCity: EdinburghVenue: International Conference Centre of EdinburghPhone: + 44 (0) 131 339 9235Website: http://www.epidemiology2011.com

International Relations Office, Hellenic Centre for Disease Control and Prevention (HCDCP)

Quiz Newsletter

It is the 8th Wonder of the Ancient World and it owes its fame to the Greek historian Herodotus. It is dated from the 6th century BC and is known in history as one of the greatest achievements of ancient engineering. The construction lasted for 10 years.

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

The June quiz answer: Hilary ListerFor more information: http://www.hilarylister.com

Six readers answered correctly

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Outbreak news, July 2011

Poliomyelitis

Pakistan has reported one case of wild poliovirus type 3 (WPV3), from a conflict-affected, inaccessible area of Khyber Agency, Federally Administered Tribal Areas (FATA). This is the only case of WPV3 detected in Asia in 2011 [1].

Pertussis

Between 1 January and 11 July 2011, there have been 18299 notifications of pertussis (whooping cough) in Australia. This represents an increase in cases compared with the same period in 2010. The majority of cases have occurred in three states: New South Wales (6427), Queensland (4349) and Victoria (4556) [2].

References

1. World Health Organization (WHO). Available at http://www.who.int/csr/don/ [accessed 22 July 2011].

2. National Travel Health Network and Center (NATHNAC). Available at http://www.nathnac.org/pro/clinical_updates / pertussisaustralia _120711.htm [accessed 22 July 2011].

Travel Medicine Office, Department for Interventions in Healthcare Facilities

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Letter to the Editor

Subject: Operation of swimming pools in Greece

Following the June issue of the Hellenic Centre for Disease Control and Prevention (HCDCP) newsletter, in relation to a study conducted to (a) assess the health status of public swimming pools in Greece, (b) evaluate the degree of compliance with relevant legislation and (c) evaluate the implementation of best practices within their operation, the Division of Sanitary Engineering and Environmental Hygiene needs to point out the following.

1. For the safe operation of swimming pools and to ensure the health of bathers, all provisions of the G1/443/73 (Official Gazette 87B) Sanitary Provision, as amended and applicable including all relevant circulars, should be abided by.

2. Our Ministry is constantly vigilant and co-operates with the relevant directorates of regional health units to ensure the fullest possible implementation of the terms and conditions of the above-mentioned relevant Sanitary Provision.

3. In 2010, the Division of Sanitary Engineering and Environmental Hygiene carried out research on the operation of swimming pools, using data collected by the relevant directorates of the regional sections. After the collection, processing and analysis of the data sent, the results generated diverged considerably from those of the study mentioned above. Details of the research conducted by our office are presented in Table 1.

Table 1: Research conducted by the Division of Sanitary Engineering and Environmental Hygiene

Swimming pools* With license Without license Under approval

2.092 1498 526 60

72% 25% 3%

72% of all swimming pools had been authorized, 25% had no license and 3% were under the approval process.Problems of construction and operation were recorded for 22% of all swimming poolsReduced and inadequate safety measures were recorded for 18% of all swimming pools42% of the audits that were recorded were carried out on an annual basis and a further 3% had control measures that were carried out more than once a year. 22% were carried out after complaints or for licensing, while control measures were recorded by relevant authorities because of a lack of staff.Perchlorination problems were recorded in 12% of the swimming pools and ypochloriosis and perchlorination problems were recorded in 14%.

*The swimming pools involved were public swimming pools of all categories (entertainment centres, hotels, sport centres, etc.)

Looking at the data from both studies shows that inferences should be made carefully, taking into consideration the conditions and limitations of the studies involved, the range of data, confidence intervals and the methodology of the statistical analyses used.

Our Division, within its remit of ensuring public health, is willing to consider any proposals to amend the existing institutional framework, bearing in mind that the legislation is already rigorous and highly detailed. The key priority is systematic monitoring of the implementation of the terms of the legislation, with full and integrated recording, processing and evaluation of reliable data, in order to protect the health and safety of bathers.

Bibliographic reference:

1. Boulougoura Α. & Partnes, Investigation of the health status of the Greek public swimming pools, HCDCP Newsletter No. 04, 2011.

V. Karaouli, Head of Division of Sanitary Engineering & Environmental Hygiene, Ministry of Health and Social Solidarity

HCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

ÊÅÍÔÑÏ ÅËÅÃ×ÏÕ & ÐÑÏËÇØÇÓÍÏÓÇÌÁÔÙÍ (ÊÅ.ÅË.Ð.ÍÏ.)

Graphic Design:Ε. Lazana

Editors:Τ. Kourea- KremastinouHCDCP President

T. PapadimitriouHCDCP Director

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News from the HCDCP Administration

West Nile Meeting

On Wednesday 20 July 2011, a meeting regarding West Nile was held in Thessaloniki; participants included the Deputy Minister of Health, the Ministry of Health & Social Solidarity, the Aristotle University of Thessaloniki, the Peripheral and Regional Administrative Divisions, the Decentralized Administrations, the 3rd and 4th Health Region (YPE) and the Development Companies of the Greek regions, as well as the Hellenic Centre for Disease Control and Prevention (HCDCP). The main subject of the meeting was implementation of the mosquito control programmes in Central Macedonia because of suspected human cases of infection with West Nile Virus. Following the meeting, a press conference was held by scientific personnel of HCDCP and the Aristotle University of Thessaloniki to inform journalists regarding mosquito control issues.

Transplants

The first conference of the new board of directors of the National Transplant Organization took place at Zappeion on Thursday 7 July 2011, in the presence of the Minister of Health & Social Solidarity, Mr A. Loverdos.

During the conference, Mrs Kremastinou, President of HCDCP and Professor of Public Health Administration at the National School of Public Health, presented the organization’s action plan aimed at enhancing the National Transplant Organization, including the realization of an operational algorithm, in association with competent authorities, as well as the realization of a training course and information programme, involving health professionals and the general public.

According to Mrs Kremastinou, initial results regarding public opinion of the new legislation show a positive feedback, portraying organ donation as an ‘act of humanity and altruistic behaviour’. However, there are considerable concerns regarding organ donation, including a lack of trust in authorities regarding their ability to perform the task.

Dr Agoritsa Baka, Paediatrician, HCDCP President’s Office

Giannopoulos’ visit to the HCDCP facilities, Vari, Attika

On Monday 11 July 2011, Mr Athanasios Giannopoulos, Head of the Health and Welfare Sector of the New Democracy (ND) political party and Medical Professor of the University of Athens, visited the HCDCP facilities in Vari, Attika, accompanied by political representatives from the ND party. During their visit they were shown around the Central Public Health Laboratory (CPHL) facilities and had the chance to hold discussions with the heads of departments. In a statement, Mr A. Giannopoulos congratulated the first laboratory modules for their commendable work. The ND political party fully endorses the development of the CPHL.

Public recognition of the HCDCP’s newsletter

HCDCP’s newsletter is widely accepted by health professionals. In the last 2 months more than 1600 new recipients have signed up. Thank you for your positive feedback! Your kind remarks encourage us to continue our work.