The European Commission’s Task Force on Bioterrorism

In response to the increased threat of bioterrorism, a task force on health security was established in the European Commission. Task force members address a broad range of issues related to preparedness for and response to bioterrorist events and seek to bring about a greater collaboration between the European Union member states

Estimating the Disease Burden of 2009 Pandemic Influenza A(H1N1) from Surveillance and Household Surveys in Greece

The aim of this study was to assess the disease burden of the 2009 pandemic influenza A(H1N1) in Greece.Data on influenza-like illness (ILI), collected through cross-sectional nationwide telephone surveys of 1,000 households in Greece repeated for 25 consecutive weeks, were combined with data from H1N1 virologic surveillance to estimate the incidence and the clinical attack rate (CAR) of influenza A(H1N1). Alternative definitions of ILI (cough or sore throat and fever>38°C [ILI-38] or fever 37.1-38°C [ILI-37]) were used to estimate the number of symptomatic infections. The infection attack rate (IAR) was approximated using estimates from published studies on the frequency of fever in infected individuals. Data on H1N1 morbidity and mortality were used to estimate ICU admission and case fatality (CFR) rates. The epidemic peaked on week 48/2009 with approximately 750-1,500 new cases/100,000 population per week, depending on ILI-38 or ILI-37 case definition, respectively. By week 6/2010, 7.1%-15.6% of the population in Greece was estimated to be symptomatically infected with H1N1. Children 5-19 years represented the most affected population group (CAR:27%-54%), whereas individuals older than 64 years were the least affected (CAR:0.6%-2.2%). The IAR (95% CI) of influenza A(H1N1) was estimated to be 19.7% (13.3%, 26.1%). Per 1,000 symptomatic cases, based on ILI-38 case definition, 416 attended health services, 108 visited hospital emergency departments and 15 were admitted to hospitals. ICU admission rate and CFR were 37 and 17.5 per 100,000 symptomatic cases or 13.4 and 6.3 per 100,000 infections, respectively.Influenza A(H1N1) infected one fifth and caused symptomatic infection in up to 15% of the Greek population. Although individuals older than 65 years were the least affected age group in terms of attack rate, they had 55 and 185 times higher risk of ICU admission and CFR, respectively

Outbreak of West Nile Virus Infection in Greece, 2010

During 2010, an outbreak of West Nile virus infection occurred in Greece. A total of 197 patients with neuroinvasive disease were reported, of whom 33 (17%) died. Advanced age and a history of heart disease were independently associated with death, emphasizing the need for prevention of this infection in persons with these risk factors

National immunization strategies targeting migrants in six European countries

Over the last three years an unprecedented flow of migrants arrived in Europe. There is evidence that vaccine preventable diseases have caused outbreaks in migrant holding centres. These outbreaks can be favored by a combination of factors including low immunization coverage, bad conditions that migrants face during their exhausting journey and overcrowding within holding facilities. In 2017, we conducted an online survey in Croatia, Greece, Italy, Malta, Portugal and Slovenia to explore the national immunization strategies targeting irregular migrants, refugees and asylum seekers. All countries stated that a national regulation supporting vaccination offer to migrants is available. Croatia, Italy, Portugal and Slovenia offer to migrant children and adolescents all vaccinations included in the National Immunization Plan; Greece and Malta offer only certain vaccinations, including those against diphtheria-tetanus-pertussis, poliomyelitis and measles-mumps-rubella. Croatia, Italy, Malta and Portugal also extend the vaccination offer to adults. All countries deliver vaccinations in holding centres and/or community health services, no one delivers vaccinations at entry site. Operating procedures that guarantee the migrants' access to vaccination at the community level are available only in Portugal. Data on administered vaccines is available at the national level in four countries: individual data in Malta and Croatia, aggregated data in Greece and Portugal. Data on vaccination uptake among migrants is available at national level only in Malta. Concluding, although diversified, strategies for migrant vaccination are in place in all the surveyed countries and generally in line with WHO and ECDC indications. Development of procedures to keep track of migrants' immunization data across countries, development of strategies to facilitate and monitor migrants' access to vaccinations at the community level and collection of data on vaccination uptake among migrants should be promoted to meet existing gaps. The study was conducted in the framework of the CARE (''Common Approach for REfugees and other migrants' health") project (717217/CARE) that received funding from the EU health Programme (2014–2020). info:eu-repo/semantics/publishedVersio

The importance of an active case detection (Acd) programme for malaria among migrants from malaria endemic countries: The greek experience in a receptive and vulnerable area

Greecehasbeenmalaria-freesince1974. InOctober2011,followinganoutbreakof36locally acquired malaria (LAM) cases in Evrotas Municipality, a Pro-Active Case Detection (PACD) program for malaria was implemented among migrants from malaria-endemic countries, to support early diagnosis and treatment of cases. We evaluated the PACD program for the years 2012–2017 using indicatorssuchasthenumberoflocallyacquiredcases,thedetectionrate/sensitivityandthetimeliness of diagnosis and treatment. We visited each migrant home every 7–15 days to screen migrants for malaria symptoms, performing Rapid Diagnostic Tests (RDTs) and blood smears on symptomatic patients. We estimated: (i) the number of malaria cases detected by the PACD, divided by the total number of reported malaria cases during the same period among the same population; (ii) the time betweenonsetofsymptoms,diagnosisandinitiationoftreatment. Thetotalnumberofmigrantswho were screened for malaria symptoms for the years 2012–2017 was 5057 with 84,169 fever screenings conducted, while 2288 RDTs and 1736 blood smears were performed. During the same period, 53 imported P. vivax malaria cases were detected, while incidence of malaria among migrants was estimated at 1.8% annually. Ten and one LAM cases were also reportedin 2012 and 2015, respectively. Sensitivity of PACD ranged from 86% to 100%; median timeliness between onset of symptoms and diagnosis decreased from 72 h in 2012 to 12 h in 2017 (83% decrease), while timeliness betweendiagnosis and treatment initiation was 0 h. The implementation of PACD could be considered an effective prevention and response tool against malaria re-introduction

Use of wild bird surveillance, human case data and GIS spatial analysis for predicting spatial distributions of West Nile Virus in Greece

West Nile Virus (WNV) is the causative agent of a vector-borne, zoonotic disease with a worldwide distribution. Recent expansion and introduction of WNV into new areas, including southern Europe, has been associated with severe disease in humans and equids, and has increased concerns regarding the need to prevent and control future WNV outbreaks. Since 2010, 524 confirmed human cases of the disease have been reported in Greece with greater than 10% mortality. Infected mosquitoes, wild birds, equids, and chickens have been detected and associated with human disease. The aim of our study was to establish a monitoring system with wild birds and reported human cases data using Geographical Information System (GIS). Potential distribution of WNV was modelled by combining wild bird serological surveillance data with environmental factors (e.g. elevation, slope, land use, vegetation density, temperature, precipitation indices, and population density). Local factors including areas of low altitude and proximity to water were important predictors of appearance of both human and wild bird cases (Odds Ratio = 1,001 95%CI = 0,723–1,386). Using GIS analysis, the identified risk factors were applied across Greece identifying the northern part of Greece (Macedonia, Thrace) western Greece and a number of Greek islands as being at highest risk of future outbreaks. The results of the analysis were evaluated and confirmed using the 161 reported human cases of the 2012 outbreak predicting correctly (Odds = 130/31 = 4,194 95%CI = 2,841–6,189) and more areas were identified for potential dispersion in the following years. Our approach verified that WNV risk can be modelled in a fast cost-effective way indicating high risk areas where prevention measures should be implemented in order to reduce the disease incidence

Σύστημα επιτήρησης σοβαρών περιστατικών γρίπης: πανδημία γρίπης 2009 σε σύγκριση με τις μεταπανδημικές περιόδους γρίπης 2010 - 2016

Η γρίπη προκαλεί τόσο ετήσιες επιδημίες, όσο και πανδημίες. Έχει σημαντική νοσηρότητα και θνησιμότητα κάθε χρόνο, και συνοδεύεται από κοινωνικές και οικονομικές επιπτώσεις. Η πανδημία γρίπης 2009 (Α(Η1Ν1)pdm09) προκάλεσε περίπου 200 εκατομμύρια κρούσματα στον κόσμο και κόστισε περίπου 300.000 θανάτους. Θεωρείται μία πανδημία ήπιας νοσηρότητας, η οποία επηρέασε κατά κύριο λόγο παιδιά και νεώτερα άτομα. Η εργασία αυτή είναι μελέτη παρατήρησης παρελθόντος 1865 σοβαρών κρουσμάτων γρίπης που χρειάστηκαν νοσηλεία σε Μονάδα Εντατικής Θεραπείας (ΜΕΘ) κατά την διάρκεια της πανδημίας γρίπης 2009 και έξι επόμενωνν περιόδων εποχικής γρίπης. Η συλλογή των δεδομένων έγινε μέσω του συστήματος επιτήρησης σοβαρών κρουσμάτων γρίπης. Εκτός από περιγραφική στατιστική, έγιναν μονοπαραγοντική και πολυπαραγοντική ανάλυση με δίτιμη λογιστική παλινδρόμηση, και αναλύσεις επιβίωσης. Η διάμεση ηλικία των κρουσμάτων είναι 54 έτη (SD19.8), και το 58% είναι άνδρες. 82% των κρουσμάτων είχαν τουλάχιστον ένα υποκείμενο νόσημα, με τα συχνότερα τη παχυσαρκία (33%), τα χρόνια καρδιαγγειακά, μεταβολικά (25%) και αναπνευστικά (22%) νοσήματα, και την ανοσοκαταστολή (21%). 88% των σοβαρών κρουσμάτων γρίπης δεν είχαν εμβολιαστεί κατά της εποχικής γρίπης. Η θνητότητα των κρουσμάτων στη μελέτη ανέρχεται σε 41%, ενώ η διάμεση ηλικία των θανόντων ήταν 57 έτη. Τα σοβαρά κρούσματα είχαν μεγάλα ποσοστά ARDS (82%) και διασωλήνωσης. Ο διάμεσος χρόνος από την έναρξη συμπτωμάτων έως την διασωλήνωση, την εισαγωγή σε ΜΕΘ και την έναρξη αντι-ϊικής αγωγής ήταν 4-5 ημέρες. Η διάμεση διάρκεια μηχανικού αερισμού κυμαίνεται 5-12 ημέρες, και η διάμεση νοσηλεία σε ΜΕΘ από 7-12 ημέρες. Η μονοπαραγοντική ανάλυση ανέδειξε σημαντικούς παράγοντες κινδύνου για κακή έκβαση την ηλικία, το ανδρικό φύλο, και τη χρόνια νεφροπάθεια, ηπατοπάθεια, ανοσοκαταστολή και νοσογόνο παχυσαρκία. Η πολυοργανική ανεπάρκεια φέρει 11 φορές μεγαλύτερο κίνδυνο θανάτου. Ο αντιγριπικός εμβολιασμός αναδεικνύεται προστατευτικός για την «διασωλήνωση», όπως και η έγκαιρη χορήγηση αντι-ϊικής αγωγής, προστατεύοντας με έμμεσο τρόπο από το θάνατο. Η θνητότητα των σοβαρών κρουσμάτων γρίπης το 2009 (42%) είναι υψηλότερη από την μέση εκτιμώμενη θνητότητα της Ευρώπης (31%) και συμβαδίζει με τη θνητότητα ασθενών με ARDS (41%). Η περιορισμένη διαθεσιμότητα κλινών ΜΕΘ (6 κλίνες/100.000 κατοίκους (2011)) φαίνεται ότι αποτελεί κομβικό σημείο στην αντιμετώπιση των σοβαρών κρουσμάτων γρίπης. Ειδικές ομάδες ασθενών, όπως οι ασθενείς με ενδονοσοκομειακή γρίπη και τα παιδιά με υποκείμενα νοσήματα εμφανίζουν υψηλά ποσοστά θνητότητας. Οι ασθενείς με ενδονοσοκομειακή μετάδοση γρίπης με γρίπη Α έχουν 26 φορές μεγαλύτερο κίνδυνο θανάτου από αυτούς με γρίπη Β. Ο αντιγριπικός εμβολιασμός χρειάζεται ενίσχυση της στρατηγικής και επικοινωνίας. Τέλος, το σύστημα επιτήρησης σοβαρών κρουσμάτων, που δημιουργήθηκε για την διαχείρηση της πανδημίας γρίπης 2009, χρήζει αξιολόγησης και εκσυγχρονισμού. Τα αποτελέσματα της μελέτης αυτής μπορούν να αποτελέσουν βάση για την σύγκριση της απόκρισης του συστήματος υγείας σε άλλες κρίσεις όπως αυτή της πανδημίας COVID-19 αλλά και για τον καλύτερο σχεδιασμό προετοιμασίας της δημόσιας υγείας για μελλοντικές απειλές.Influenza causes annual outbreaks and unpredictable pandemics. It carries substantial annual morbidity and mortality and has social and financial effects. The 2009 influenza pandemic (Α(Η1Ν1)pdm09) caused an estimated 200 million cases worldwide and at least 300 000 deaths. It is considered a mild pandemic affecting mostly children and young adults. This is a retrospective observational study of 1865 reported severe influenza cases requiring intensive care (ICU) during the 2009 influenza pandemic and the subsequent six seasons in Greece. Data collection was performed through the severe influenza surveillance system. In addition to descriptive statistics, univariate and multivariate analysis and survival analysis were performed. The mean age of severe influenza cases is 54 years (SD 19.8) and 58% were men. 82% of cases had at least one underlying condition; the most common being obesity (33%), cardiovascular and metabolic diseases (25% each), chronic respiratory (22%) and immune suppression (21%). 88% of cases were not vaccinated against influenza. Case fatality rate (CFR) is 41%, while median age of lethal cases is 57 years. Severe cases had high rates of ARDS (82%) and intubation (>80%). Median interval between symptom onset and intubation, ICU admission and starting antiviral treatment was 4-5 days. Median duration of mechanical ventilation ranged between 5-12 days and median ICU stay between 7-12 days. Univariate analysis indicated that age, male sex, chronic renal and hepatic disease, as well as immune suppression and morbid obesity (BMI>40kg/m2) are significant risk factors for death. Multiorgan failure carries an OR of 11 for death. Influenza vaccination and prompt antiviral treatment were protective against intubation indirectly protecting against death. CFR of severe influenza cases in Greece in 2009 (42%) is higher than the estimated average for Europe (31%), similar to CFR of ARDS (41%). The ICU bed capacity (avg. 6 ICU beds /100 000 population) is a limiting factor in the definitive management of severe influenza cases. Patients with nosocomial influenza and children with underlying conditions have high fatality rates. Patients with nosocomial influenza A have 26 times worse risk of death than influenza B. Influenza vaccination strategy in Greece needs new strategy and better communicated. Finally, the severe influenza surveillance system, which functions with the same principles developed in 2009, needs evaluation and renovation to fulfil its role in the future. This study results can serve as the basis for the evaluation of the response to other public health crises, like the currently ongoing COVID-19 pandemic, and include important information for public health preparedness planning for similar future health threats

Surveillance of severe influenza cases: influenza pandemic 2009 compared to the post pandemic influenza seasons 2010 – 2016, in Greece

Influenza causes annual outbreaks and unpredictable pandemics. It carries substantial annual morbidity and mortality and has social and financial effects. The 2009 influenza pandemic (Α(Η1Ν1)pdm09) caused an estimated 200 million cases worldwide and at least 300 000 deaths. It is considered a mild pandemic affecting mostly children and young adults.This is a retrospective observational study of 1865 reported severe influenza cases requiring intensive care (ICU) during the 2009 influenza pandemic and the subsequent six seasons in Greece. Data collection was performed through the severe influenza surveillance system. In addition to descriptive statistics, univariate and multivariate analysis and survival analysis were performed. The mean age of severe influenza cases is 54 years (SD 19.8) and 58% were men. 82% of cases had at least one underlying condition; the most common being obesity (33%), cardiovascular and metabolic diseases (25% each), chronic respiratory (22%) and immune suppression (21%). 88% of cases were not vaccinated against influenza. Case fatality rate (CFR) is 41%, while median age of lethal cases is 57 years. Severe cases had high rates of ARDS (82%) and intubation (>80%). Median interval between symptom onset and intubation, ICU admission and starting antiviral treatment was 4-5 days. Median duration of mechanical ventilation ranged between 5-12 days and median ICU stay between 7-12 days. Univariate analysis indicated that age, male sex, chronic renal and hepatic disease, as well as immune suppression and morbid obesity (BMI>40kg/m2) are significant risk factors for death. Multiorgan failure carries an OR of 11 for death. Influenza vaccination and prompt antiviral treatment were protective against intubation indirectly protecting against death. CFR of severe influenza cases in Greece in 2009 (42%) is higher than the estimated average for Europe (31%), similar to CFR of ARDS (41%). The ICU bed capacity (avg. 6 ICU beds /100 000 population) is a limiting factor in the definitive management of severe influenza cases. Patients with nosocomial influenza and children with underlying conditions have high fatality rates. Patients with nosocomial influenza A have 26 times worse risk of death than influenza B.Influenza vaccination strategy in Greece needs new strategy and better communicated. Finally, the severe influenza surveillance system, which functions with the same principles developed in 2009, needs evaluation and renovation to fulfill its role in the future.This study results can serve as the basis for the evaluation of the response to other public health crises, like the currently ongoing COVID-19 pandemic, and include important information for public health preparedness planning for similar future health threats.Η γρίπη προκαλεί τόσο ετήσιες επιδημίες, όσο και πανδημίες. Έχει σημαντική νοσηρότητα και θνησιμότητα κάθε χρόνο, και συνοδεύεται από κοινωνικές και οικονομικές επιπτώσεις. Η πανδημία γρίπης 2009 (Α(Η1Ν1)pdm09) προκάλεσε περίπου 200 εκατομμύρια κρούσματα στον κόσμο και κόστισε περίπου 300.000 θανάτους. Θεωρείται μία πανδημία ήπιας νοσηρότητας, η οποία επηρέασε κατά κύριο λόγο παιδιά και νεώτερα άτομα. Η εργασία αυτή είναι μελέτη παρατήρησης παρελθόντος 1865 σοβαρών κρουσμάτων γρίπης που χρειάστηκαν νοσηλεία σε Μονάδα Εντατικής Θεραπείας (ΜΕΘ) κατά την διάρκεια της πανδημίας γρίπης 2009 και έξι επόμενωνν περιόδων εποχικής γρίπης. Η συλλογή των δεδομένων έγινε μέσω του συστήματος επιτήρησης σοβαρών κρουσμάτων γρίπης. Εκτός από περιγραφική στατιστική, έγιναν μονοπαραγοντική και πολυπαραγοντική ανάλυση με δίτιμη λογιστική παλινδρόμηση, και αναλύσεις επιβίωσης. Η διάμεση ηλικία των κρουσμάτων είναι 54 έτη (SD19.8), και το 58% είναι άνδρες. 82% των κρουσμάτων είχαν τουλάχιστον ένα υποκείμενο νόσημα, με τα συχνότερα τη παχυσαρκία (33%), τα χρόνια καρδιαγγειακά, μεταβολικά (25%) και αναπνευστικά (22%) νοσήματα, και την ανοσοκαταστολή (21%). 88% των σοβαρών κρουσμάτων γρίπης δεν είχαν εμβολιαστεί κατά της εποχικής γρίπης. Η θνητότητα των κρουσμάτων στη μελέτη ανέρχεται σε 41%, ενώ η διάμεση ηλικία των θανόντων ήταν 57 έτη. Τα σοβαρά κρούσματα είχαν μεγάλα ποσοστά ARDS (82%) και διασωλήνωσης. Ο διάμεσος χρόνος από την έναρξη συμπτωμάτων έως την διασωλήνωση, την εισαγωγή σε ΜΕΘ και την έναρξη αντι-ϊικής αγωγής ήταν 4-5 ημέρες. Η διάμεση διάρκεια μηχανικού αερισμού κυμαίνεται 5-12 ημέρες, και η διάμεση νοσηλεία σε ΜΕΘ από 7-12 ημέρες. Η μονοπαραγοντική ανάλυση ανέδειξε σημαντικούς παράγοντες κινδύνου για κακή έκβαση την ηλικία, το ανδρικό φύλο, και τη χρόνια νεφροπάθεια, ηπατοπάθεια, ανοσοκαταστολή και νοσογόνο παχυσαρκία. Η πολυοργανική ανεπάρκεια φέρει 11 φορές μεγαλύτερο κίνδυνο θανάτου. Ο αντιγριπικός εμβολιασμός αναδεικνύεται προστατευτικός για την «διασωλήνωση», όπως και η έγκαιρη χορήγηση αντι-ϊικής αγωγής, προστατεύοντας με έμμεσο τρόπο από το θάνατο. Η θνητότητα των σοβαρών κρουσμάτων γρίπης το 2009 (42%) είναι υψηλότερη από την μέση εκτιμώμενη θνητότητα της Ευρώπης (31%) και συμβαδίζει με τη θνητότητα ασθενών με ARDS (41%). Η περιορισμένη διαθεσιμότητα κλινών ΜΕΘ (6 κλίνες/100.000 κατοίκους (2011)) φαίνεται ότι αποτελεί κομβικό σημείο στην αντιμετώπιση των σοβαρών κρουσμάτων γρίπης. Ειδικές ομάδες ασθενών, όπως οι ασθενείς με ενδονοσοκομειακή γρίπη και τα παιδιά με υποκείμενα νοσήματα εμφανίζουν υψηλά ποσοστά θνητότητας. Οι ασθενείς με ενδονοσοκομειακή μετάδοση γρίπης με γρίπη Α έχουν 26 φορές μεγαλύτερο κίνδυνο θανάτου από αυτούς με γρίπη Β.Ο αντιγριπικός εμβολιασμός χρειάζεται ενίσχυση της στρατηγικής και επικοινωνίας. Τέλος, το σύστημα επιτήρησης σοβαρών κρουσμάτων, που δημιουργήθηκε για την διαχείρηση της πανδημίας γρίπης 2009, χρήζει αξιολόγησης και εκσυγχρονισμού.Τα αποτελέσματα της μελέτης αυτής μπορούν να αποτελέσουν βάση για την σύγκριση της απόκρισης του συστήματος υγείας σε άλλες κρίσεις όπως αυτή της πανδημίας COVID-19 αλλά και για τον καλύτερο σχεδιασμό προετοιμασίας της δημόσιας υγείας για μελλοντικές απειλές

Biosecurity Threat Posed by Botulinum Toxin

The deliberate release of biological agents with terrorist or criminal intent continues to pose concerns in the current geopolitical situation. Therefore, attention is still needed to ensure preparedness against the potential use of pathogens as unconventional weapons. Botulinum neurotoxin (BoNT) is one such biological threat, characterized by an extremely low lethal dose, high morbidity and mortality when appropriately disseminated, and the capacity to cause panic and social disruption. This paper addresses the risks of a potential release of the botulinum neurotoxin and summarizes the relevant aspects of the threat