Epidemiological investigation of two parallel gastroenteritis outbreaks in school settings

BACKGROUND: Two parallel gastroenteritis outbreaks occurred in an elementary school and a neighboring kindergarten in Kilkis, Northern Greece in 2012. The aim of the study was the investigation of these two parallel outbreaks as well as their possible source. METHODS: Two retrospective cohort studies were performed to identify the mode and the vehicle of transmission as well as the possible connection between them. RESULTS: Elementary school and kindergarten populations of 79.9% (119/149) and 51.1% (23/45) respectively, participated in the study. Case definition was satisfied by 65 pupils from the elementary school and 14 from the kindergarten. For elementary school, 53 cases were considered primary cases of the outbreak and were included in the analysis. Based on the results of the multivariate analysis, consumption of tap water was the only statistically significant independent risk factor of gastroenteritis (RR = 2.34, 95% C.I.: 1.55-3.53).; a finding supported by the shape of the epidemic curve which referred to a common point source outbreak with secondary cases. For kindergarten, no statistically significant risk factor was identified, and the epidemic curve supported a person-to-person transmission according univariate analysis. Norovirus GI and GII and human Adenovirus were detected by Real Time PCR in stool samples from seven children of elementary school, but stool samples were not collected by children of the kindergarten. CONCLUSIONS: Even though the etiological agent of the outbreak was not verified, combined epidemiological and laboratory results were in favor of a waterborne viral gastroenteritis outbreak at the elementary school, followed by a person to person spread at the kindergarten

Initial assessment of the COVID-19 vaccination's impact on case numbers, hospitalisations and deaths in people aged 80 years and older, 15 EU/EEA countries, December 2020 to May 2021

Prioritisation of elderly people in COVID-19 vaccination campaigns aimed at reducing severe outcomes in this group. Using EU/EEA surveillance and vaccination uptake, we estimated the risk ratio of case, hospitalisation and death notifications in people 80 years and older compared with 25-59-year-olds. Highest impact was observed for full vaccination uptake 80% or higher with reductions in notification rates of cases up to 65% (IRR: 0.35; 95% CI: 0.13-0.99), hospitalisations up to 78% (IRR: 0.22; 95% CI: 0.13-0.37) and deaths up to 84% (IRR: 0.16; 95% CI: 0.13-0.20).S

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

Risk factors for death from invasive pneumococcal disease, europe, 2010

We studied the possible association between patient age and sex, clinical presentation, Streptococcus pneumoniae serotype, antimicrobial resistance, and death in invasive pneumococcal disease cases reported by 17 European countries during 2010. The study sample comprised 2,921 patients, of whom 56.8% were men and 38.2% were >65 years of age. Meningitis occurred in 18.5% of cases. Death was reported in 264 (9.0%) cases. Older age, meningitis, and nonsusceptibility to penicillin were signifcantly asso ciated with death. Non-pneumococcal conjugate vaccine (PCV) serotypes among children 65 years of age, risk did not differ by serotype. These fndings highlight differences in case-fatality rates between sero types and age; thus, continued epidemiologic surveillance across all ages is crucial to monitor the long-term effects of PCVs

Immunisation of migrants in EU/EEA countries: Policies and practices

In recent years various EU/EEA countries have experienced an influx of migrants from low and middle-income countries. In 2018, the “Vaccine European New Integrated Collaboration Effort (VENICE)” survey group conducted a survey among 30 EU/EEA countries to investigate immunisation policies and practices targeting irregular migrants, refugees and asylum seekers (later called “migrants” in this report). Twenty-nine countries participated in the survey. Twenty-eight countries reported having national policies targeting children/adolescent and adult migrants, however vaccinations offered to adult migrants are limited to specific conditions in seven countries. All the vaccinations included in the National Immunisation Programme (NIP) are offered to children/adolescents in 27/28 countries and to adults in 13/28 countries. In the 15 countries offering only certain vaccinations to adults, priority is given to diphtheria-tetanus, measles-mumps-rubella and polio vaccinations. Information about the vaccines given to child/adolescent migrants is recorded in 22 countries and to adult migrants in 19 countries with a large variation in recording methods found across countries. Individual and aggregated data are reportedly not shared with other centres/institutions in 13 and 15 countries, respectively. Twenty countries reported not collecting data on vaccination uptake among migrants; only three countries have these data at the national level. Procedures to guarantee migrants’ access to vaccinations at the community level are available in 13 countries. In conclusion, although diversified, strategies for migrant vaccination are in place in all countries except for one, and the strategies are generally in line with international recommendations. Efforts are needed to strengthen partnerships and implement initiatives across countries of origin, transit and destination to develop and better share documentation in order to guarantee a completion of vaccination series and to avoid unnecessary re-vaccination. Development of migrant-friendly strategies to facilitate migrants' access to vaccination and collection of vaccination uptake data among migrants is needed to meet existing gaps

Mycoplasma pneumoniae infections, 11 countries in Europe and Israel, 2011 to 2016

Background: Mycoplasma pneumoniae is a leading cause of community-acquired pneumonia, with large epidemics previously described to occur every 4 to 7 years. Aim: To better understand the diagnostic methods used to detect M. pneumoniae; to better understand M. pneumoniae testing and surveillance in use; to identify epidemics; to determine detection number per age group, age demographics for positive detections, concurrence of epidemics and annual peaks across geographical areas; and to determine the effect of geographical location on the timing of epidemics. Methods: A questionnaire was sent in May 2016 to Mycoplasma experts with national or regional responsibility within the ESCMID Study Group for Mycoplasma and Chlamydia Infections in 17 countries across Europe and Israel, retrospectively requesting details on M. pneumoniae-positive samples from January 2011 to April 2016. The Moving Epidemic Method was used to determine epidemic periods and effect of country latitude across the countries for the five periods under investigation. Results: Representatives from 12 countries provided data on M. pneumoniae infections, accounting for 95,666 positive samples. Two laboratories initiated routine macrolide resistance testing since 2013. Between 2011 and 2016, three epidemics were identified: 2011/12, 2014/15 and 2015/16. The distribution of patient ages for M. pneumoniae-positive samples showed three patterns. During epidemic years, an association between country latitude and calendar week when epidemic periods began was noted. Conclusions: An association between epidemics and latitude was observed. Differences were noted in the age distribution of positive cases and detection methods used and practice. A lack of macrolide resistance monitoring was noted

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

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

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

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

Frequency and severity of complications in greek β-thalassemia intermedia patients: phenotype - genotype correlation

Τhe clinical course and complications of β-thalassemia intermedia in the Greek population and their correlation with the molecular and hematological data was studied in 98 β-thalassemia intermedia patients. Of them 94 (95.9%) had two βthal or δβ mutations and 4 (4.1%) were β-thalassemia heterozygotes with triplicated a gene (ααα/αα) or (ααα/ααα). Based on clinical and haematological data, patients were classified into two clinical phenotypes (I1 severe, I2 mild). Τhe age at diagnosis ranged from childhood to adulthood, the age of final evaluation was 27.3±11,5 years and the follow up period lasted for 25 years. Molecular analysis identified that the major factor contributing to the clinical expression of homozygous β-thalassemia intermedia in Greece is the inheritance of mild β-thalassemia mutations. The great majority of mutations 61.8% were β+ (silent, β++ and β+) mutations with sufficient production of β chain. The most prevalent mutation was IVSI-6 (17.8%). Other common mutations were IVSI-110 (14.1%), -101 (9.4%), CD39 (9.4%), IVSI-1 (8.4%) and IVSII-1 (6.3%). An important differentiation exists in the type and frequency of mutations between patients with the two clinical phenotypes of β-thalassemia intermedia. Silent and very mild mutations (-101, +6, IVSI-6, -87, polyA, -28) prevail in mild β-thalassemia intermedia I2 and account for 45.6% of I2 mutations. In severe β-thalassemia intermedia, β+ mutations are more prevalent and especially mutations that induce the production of γ chain and HbF like IVSII-1, (δβ)0 and δ0β+ Corfu. The coinheritance of α-thalassemia in 6.4% of our patients did not have any significant contribution in amelioration of clinical expression of β-thalassemia intermedia with the exception of one patient with the rare case of coinheritance of a severe form of β-thalassemia and hemoglobinopathy H who was diagnosed at the age of 50 years. An exacerbation of clinical severity was notified in 4 β-thalassemia heterozygous patients with triplicated a gene (ααα/αα) or (ααα/ααα). Mean hemoglobin at diagnosis was 8.0±1.5 gr/dl for type I1 patients and 9.0±1.5 gr/dl for type I2 (p<0.01). Patients preserved hemoglobin levels around 9.0 gr/dl at the final hematological check up. On regular transfusions were 26.5% patients. Most of them discontinued transfusions after splenectomy and at present only 8.2% are transfused. Splenomegaly was one of the most frequent clinical and ultrasound finding and was present in 89.1% patients; the majority (62.2%) was splenectomized. Osteoporosis was present in 89.8% and extramedullary hematopoiesis consisted of paravertebral masses in the posterior mediastinum in 18.4%. Iron overload was assessed with ferritin levels. Patients without transfusions and chelation had mean ferritin 466.4±687.1 μg/L (16.0-3097.0), those with sporadic transfusions without chelation 723.8±588.3 μg/L (112.0-2489.0) and those on regular transfusions and chelation 1130.7±637.7 (412.0-3441.0). On final evaluation 36.7% patients were on chelation. Endocrinopathies were not as frequent as in thalassemia major. Short stature (<3rd percentile) was found in only 6.1% patients. Subclinical hypothyroidism was present in 22.8%, hypogonadism in 18.8% and glucose intolerance in 9.2% patients. Gallstones were present in 39.8% of patients and 45.9% had undergone cholocystectomy at a mean age of 21.1±8.8 years. Echocardiography of the heart disclosed systolic left ventricular dysfunction (ejection fraction <55% or shortening fraction <30%) in 7.4% patients. In conclusion, in the Greek population, β-thalassemia intermedia presents broad clinical, hematological and molecular heterogeneity. The inheritance of mild β-thalassemia mutations is the major factor contributing to the mild clinical expression. The characterization of genotype in β-thalassemia is most valuable to the evaluation of prognosis and the implementation of appropriate treatment in Greek β-thalassemia intermedia children.Με σκοπό τη μελέτη της κλινικής εικόνας και των επιπλοκών της ενδιάμεσης β-ΜΑ στον Ελληνικό πληθυσμό και τη συσχέτισή τους με τα μοριακά και αιματολογικά ευρήματα, μελετήσαμε 98 ασθενείς με κλινική εικόνα ενδιάμεσης β-ΜΑ, 94 (95,9%) από τους οποίους είχαν δύο μεταλλάξεις για βthal ή δβ γονίδια ενώ 4 (4,1%) ήταν ετεροζυγώτες β-ΜΑ με συνύπαρξη τριπλασιασμένου α γονιδίου (ααα/αα ή ααα/ααα). Η ηλικία διάγνωσης κυμάνθηκε από τη βρεφική ως την ενήλικη ζωή, η παρούσα μέση ηλικία ήταν 27,3±11,5 έτη και οι ασθενείς παρακολουθήθηκαν για μεγάλο χρονικό διάστημα ως και 25 χρόνια. Οι ασθενείς ταξινομήθηκαν με βάση τα κριτήρια που χρησιμοποιεί η Κλινική μας σε δυο κλινικούς φαινοτύπους (Ι1 βαρύς, Ι2 ήπιος) με διακριτή τη διαφορά τους στην κλινική βαρύτητα. Η ταξινόμηση υποβοήθησε σημαντικά τη σύγκριση των κλινικών, αιματολογικών και μοριακών ευρημάτων. Η ηλικιακή σύνθεση των δυο ομάδων ασθενών ήταν συγκρίσιμη. Από τη συσχέτιση με τα μοριακά ευρήματα των ασθενών μας καταδεικνύεται ότι η βαρύτητα του κλινικού φαινότυπου σχετίζεται κυρίως με το είδος και τη βαρύτητα των μεταλλάξεων και του β-γονότυπου και την ακολουθούμενη διαταραχή της βιοσύνθεσης των αιμοσφαιρινικών αλυσίδων. Η μεγάλη πλειοψηφία των μεταλλάξεων 61,8% είναι β+ (σιωπηρές, β++ και β+) μεταλλάξεις με ικανό βαθμό σύνθεσης της β αλυσίδας. Η συχνότερη μετάλλαξη είναι η IVSI-6 (17,8%) και ακολουθούν οι IVSI-110 (14,1%), -101 (9,4%), CD39 (9,4%), IVSI-1 (8,4%) και IVSII-1 (6,3%). Χαρακτηριστική είναι η διαφοροποίηση του τύπου και της συχνότητας των μεταλλάξεων μεταξύ των ασθενών με ήπια (Ι2) και βαριά (Ι1) ενδιάμεση β-ΜΑ. Στην ήπια ενδιάμεση β-ΜΑ επικρατούν οι σιωπηρές και πολύ ήπιες μεταλλάξεις (-101, +6, IVSI-6, -87, polyA, -28) που καλύπτουν το 45,6% των μεταλλάξεων στην ομάδα Ι2. Στη βαριά ενδιάμεση β-ΜΑ (Ι1) επικρατούν β+ μεταλλάξεις και κυρίως μεταλλάξεις που επάγουν τη σύνθεση γ αλυσίδας και προάγουν τη σύνθεση εμβρυϊκής αιμοσφαιρίνης όπως η μετάλλαξη IVSII-1 και κυρίως οι μεταλλάξεις της (δβ)0 ΜΑ και η δ0β+ Corfu. Στη μελέτη μας η επίδραση της συνύπαρξης της α-ΜΑ που βρέθηκε σε ποσοστό 6,4% των ασθενών, στην βελτίωση της βαρύτητας της κλινικής τους εικόνας δεν φαίνεται να είναι ουσιαστική εκτός από τη σπάνια περίπτωση ασθενούς με συνύπαρξη ομόζυγης β-ΜΑ και αιμοσφαιρινοπάθειας Η. Σε 4 ετεροζυγώτες β-ΜΑ ασθενείς, η επιβάρυνση του κλινικού φαινοτύπου οφείλονταν σε συνύπαρξη τριπλασιασμένου α γόνου σε ετερόζυγη (ααα/αα) ή ομόζυγη κατάσταση (ααα/ααα). Στη διάγνωση οι ασθενείς διατηρούσαν ικανοποιητικά επίπεδα αιμοσφαιρίνης με μέση τιμή αιμοσφαιρίνης 8,0±1,5 gr/dl για τους ασθενείς Ι1 και 9,0±1,5 gr/dl για τους ασθενείς Ι2 (p<0,01). Την αιμοσφαιρίνη διάγνωσης διατήρησαν οι περισσότεροι μέχρι τον τελευταίο έλεγχο. Σε πρόγραμμα συστηματικών μεταγγίσεων μπήκε 26,5% των ασθενών. Οι περισσότεροι διέκοψαν τις μεταγγίσεις μετά τη σπληνεκτομή και σήμερα μεταγγίζεται συστηματικά το 8,2%. Ένα από τα συχνότερα κλινικά και υπερηχογραφικά ευρήματα ήταν η σπληνομεγαλία (89,1%). Σε σπληνεκτομή υποβλήθηκε 62,2% των ασθενών. Η οστεοπόρωση ήταν το σημαντικότερο κλινικό εύρημα (89,8%). Εξωμυελική αιμοποίηση βρέθηκε σε 18,4% των ασθενών με κύρια εντόπιση παρασπονδυλικά και αμφοτερόπλευρα στην θωρακική μοίρα της σπονδυλικής στήλης. Ο βαθμός αιμοσιδήρωσης εκτιμήθηκε με την τιμή της φερριτίνης. Οι αμετάγγιστοι χωρίς αποσιδήρωση ασθενείς είχαν μέση τιμή φερριτίνης 466,4±687,1 μg/L (16,0-3097,0), οι ευκαιριακά μεταγγιζόμενοι χωρίς αποσιδήρωση 723,8±588,3 μg/L (112,0-2489,0) και οι ασθενείς με τακτικές μεταγγίσεις και αποσιδήρωση 1130,7±637,7 μg/L (412,0-3441,0). Σε υποδόρια αποσιδήρωση υποβάλλονταν το 36,7% των ασθενών. Το 73,5% των ασθενών είχε ήπιο ίκτερο, το 16,3% μέτριο και 10,2% βαρύ. Η σωματική ανάπτυξη των ασθενών ήταν στην πλειοψηφία φυσιολογική και μόνο 6,1% είχε ύψος <3η Ε.Θ. Η συχνότερη ενδοκρινική διαταραχή ήταν ο υποκλινικός υποθυρεοειδισμός με ποσοστό 22,8% ενώ ακολουθούσε ο υπογοναδισμός 18,8% και η διαταραχή του μεταβολισμού της γλυκόζης με 9,2%. Χολολιθίαση παρουσίασε το 39,8% των ασθενών ενώ σε χολοκυστεκτομή υποβλήθηκε το 45,9% σε μέση ηλικία 21,1±8,8 έτη. Από τον υπερηχοκαρδιογραφικό έλεγχο, διαταραχή της συσταλτικότητας της αριστερής κοιλίας (κλάσμα εξώθησης <55% ή κλάσμα βράχυνσης <30%) διαπιστώθηκε σε 7,4% ασθενείς. Συμπερασματικά η ενδιάμεση β-ΜΑ παρουσιάζει μια μεγάλη κλινική, αιματολογική και μοριακή ετερογένεια στον Ελληνικό πληθυσμό και οφείλει την καλοήθη κλινική της πορεία κυρίως στην ύπαρξη ήπιων β+ μεταλλάξεων. Ο γονοτυπικός χαρακτηρισμός αποτελεί προϋπόθεση ολοκληρωμένης διάγνωσης και συμβάλλει στην πρόγνωση, την πρόληψη και τον καθορισμό θεραπείας σε παιδιά που πάσχουν από ενδιάμεση β-ΜΑ

A modified chain binomial model to analyse the ongoing measles epidemic in Greece, July 2017 to February 2018

Greece is currently experiencing a large measles outbreak, in the context of multiple similar outbreaks across Europe. We devised and applied a modified chain-binomial epidemic model, requiring very simple data, to estimate the transmission parameters of this outbreak. Model results indicate sustained measles transmission among the Greek Roma population, necessitating a targeted mass vaccination campaign to halt further spread of the epidemic. Our model may be useful for other countries facing similar measles outbreaks