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

Clinical and molecular epidemiology of infection with Dientamoeba Fragilis in Greece

INTRODUCTION: Dientamoeba fragilis is a cosmopolitan but overlooked ameba-like flagellate. It may cause gastrointestinal symptoms similar to those of irritable bowel syndrome. So far, no clinical/epidemiological analysis has been conducted in Greece. This study aimed at describing the situation of D. fragilis infection in the country from 2010-2015.METHODOLOGY: Fecal samples from 1,361 Greek patients with possible intestinal parasitosis were tested for, inter alia, D. fragilis using microscopy and real-time PCR. Laboratory, clinical, and demographic characteristics of patients with D. fragilis-infection were compared to those of patients with Giardia lamblia- and Blastocystis sp.-infection and analyzed.RESULTS: D. fragilis was found in 4.6% patients with possible enteric parasitosis. It ranked third after Blastocystis sp. (8.4%). It ranked second after G. lamblia (4.9%) among pathogenic intestinal protozoa. D. fragilis-monoinfected patients were almost 50% less likely than G. lamblia-monoinfected patients to be hospitalized [OR=0.47 (0.29-0.77)]; and tolerated gastrointestinal symptoms well like Blastocystis sp.-monoinfected patients did. D. fragilis-infected women had a high peak at their forties (parental age). D. fragilis was more likely than G. lamblia [OR=4.70(1.68-13.14)] and Blastocystis sp. [OR=2.2 (1.07-4.90)] to be acquired in rural areas, in which young males (<40 years) were more likely than females to become infected with D. fragilis [MH-OR=5.76 (1.70-19.54)].CONCLUSIONS: D. fragilis was identified at a low rate among Greek patients with possible intestinal parasitosis. Primary care physicians, in rural areas in particular, should be aware of the possibility of D. fragilis infection in case of non-specific gastrointestinal symptoms that cannot be explained by other enteropathogens and request further laboratory testing.ΕΙΣΑΓΩΓΗ: Η Dientamoeba fragilis είναι ένα πρωτόζωο με παγκόσμια κατανομή το οποίο όμως συχνά παραγνωρίζεται. Πρόκειται για ένα μαστιγοφόρο το οποίο έχει προσαρμοσθεί και πλέον ομοιάζει με αμοιβάδα. Είναι δυνατό να προκαλέσει συμπτώματα από το γαστρεντερικό σύστημα τα οποία προσομοιάζον με εκείνα του συνδρόμου του ευερέθιστου εντέρου. Μέχρι σήμερα δεν έχει διενεργηθεί καμιά μελέτη κλινικού ή επιδημιολογικού περιεχομένου στη χώρα μας. Η παρούσα έρευνα εστιάζεται στην περιγραφή της λοίμωξης από D. fragilis στον Ελλαδικό χώρο την τελευταία εξαετία (2010-2015).ΥΛΙΚΟ ΚΑΙ ΜΕΘΟΔΟΙ: Εξετάσθηκαν δείγματα κοπράνων από 1.361 ασθενείς με υποψία παρασίτωσης του εντέρου, εκτός από τα λοιπά παράσιτα του εντέρου, και για D. fragilis με μικροσκόποηση και αλυσιδωτή αντίδραση πολυμεράσης πραγματικού χρόνου. Τα χαρακτηριστικά των ασθενών εκείνω που βρέθηκαν να παρασιτώνται από D. fragilis συγκρίθηκαν με εκείνα όσων είχαν διαγνωσθεί με λοίμωξη από Giardia lamblia ή Blastocystis sp και ακολούθησε στατιστική επεξεργασία και ανάλυσηΑΠΟΤΕΛΕΣΜΑΤΑ: Η D. fragilis βρέθηκε στο 4,6% των ασθενών με υποψία παρασίτωσης του εντέρου. Σε συχνότητα ερχόταν τρίτη μετά τη Blastocystis sp. (8,4%) και δεύτερη μετά τη G. lamblia (4,9%) ανάμεσα στα παθογόνα πρωτόζωα του εντέρου. Οι ασθενείς που είχαν μολυνθεί μόνο με D. fragilis νοσηλεύονταν κατά περίπου 50% λιγότερο από ότι όσοι είχαν μολύνθεί μόνο G. lamblia [OR=0,47 (0,29-0,77)], ενώ φάνηκε ότι ανέχονταν τη συμπτωματολογία που εκδηλωνόταν λόγω της λοίμωξής τους το ίδιο καλά με όσους είχαν μολυνθεί μόνο με Blastocystis sp. Αιχμή παρουσιάστηκε στην ηλικιακή ομάδα των γυναικών με μονοπαρασίτωση από D. fragilis που ήταν στην πέμπτη δεκαετία της ζωής τους, όταν ασκούσαν τον γονεϊκό τους ρόλο και έρχονταν σε στενή επαφή με μικρά παιδιά που βιβλιογραφικά θεωρουνται πιο ευάλωτα σε παρασιτώσεις. Διαπιστώθηκε επιπλέον ότι στις αγροτικές περιοχές ο πληθυσμός ήταν πιο επιρρεπής να υποστεί μόλυνση με D. fragilis από ότι με G. lamblia [OR=4,70 (1,68-13,14)] ή Blastocystis sp. [OR=2,2 (1,07-4,90)]. Είναι χαρακτηριστικό ότι οι νέοι άντρες κάτω των 40 ετών είχαν μεγαλύτερη πιθανότητα να μολυνθούν από ότι οι γυναίκες [MH-OR=5,76 (1,70-19,54)].ΣΥΜΠΕΡΑΣΜΑ: Η D. fragilis ταυτοποιήθηκε σε χαμηλό ποσοστό μεταξύ του ενήλικου πληθυσμό της Ελλάδας με υποψία παρασίτωσης του εντέρου. Οι οικογενειακοί ιατροί πρώτης γραμμής θα πρέπει να είναι ενημερωμένοι για την πιθανότητα λοίμωξης από D. fragilis στην περίπτωση που κληθούν να αντιμετωπίσουν άτυπη συμπτωματολογία από το γαστερντερικό σύστημα που δεν μπορεί να αποδοθεί σε κάποιο άλλο λοιμογόνο παράγοντα ώστε να παρεγγέλνουν τις κατάλληλες εργαστηριακές εξετάσεις

Brucellosis in humans: why is it so elusive?

Brucella spp. are small, slow-growing, Gram-negative coccobacilli that are responsible for brucellosis, the most common zoonotic disease worldwide. Brucellosis is a notifiable disease in most countries. Brucellosis is also considered as an occupational, laboratory and travel-acquired disease. Brucella spp. are transmitted through consumption of raw animal products (food-borne brucellosis) and animal contact. They may be spread through droplets in the air; they are traditionally classified as a class B bioterrorism agent. Brucellosis incidents have been reported in relation to domestic animals. Brucella strains have been isolated from terrestrial and marine mammals. Brucella melitensis, B. suis and B. abortus differ in host range, pathogenicity and virulence. B. canis infections have rarely been reported. Current global trends on the incidence of brucellosis are reviewed. Brucellosis is often overlooked and can mimic other conditions; it may be acute, subacute or chronic in presentation, and may involve various body sites. Recent studies on endocarditis, osteoarticular, haematological, neurological and other involvements are reviewed. Relapses in brucellosis should also be considered. Collaboration between the microbiologist and the clinician is important for diagnosis, since diagnosis of brucellosis is based on laboratory testing by serology and, ultimately by culture, in the context of clinical presentation and history of recent or past exposure. Advanced PCR-based techniques may also be used to diagnose brucellosis. Today a combination of antibiotics are recommended in treatment, whereas further therapeutic approaches are possible. New challenges posed by international travel, animal trade, animal movement, and occupational migration to/from endemic countries may increase incidence of human cases and the risk of re-emergence of brucellosis in previously brucellosis free regions such as Northern and Central Europe. Animals are considered to be lifelong carriers of Brucella spp. providing a large continuous source of human infection. A lower incidence of human brucellosis is likely to result from a decrease in incidence of animal brucellosis. Control and surveillance strategies may depend on the level of healthcare development and the prevalence of reservoir hosts in the affected region. (C) 2009 Wolters Kluwer Health | Lippincott Williams &amp; Wilkin

Assessment of a commercially available multiplex real-time PCR kit against direct immunofluorescence and nested PCRs for the detection of Giardia lamblia, Cryptosporidium spp., and Entamoeba histolytica in sewage

The major waterborne protozoan diseases are those caused by Giardia lamblia, Cryptosporidium spp., and Entamoeba histolytica. We studied the performance of a commercial multiplex real-time polymerase chain reaction (MRT-PCR) kit - applied in fecal samples - for the detection of intestinal protozoa in sewage. The MRT-PCR was assessed against direct immunofluorescence assay (DFA); and separate, nested PCRs (nPCRs) for the detection of G. lamblia, Cryptosporidium spp., and E. histolytica. MRT-PCR proved to be highly specific, enabling the detection of E. histolytica and a subset of Cryptosporidium spp. including those mainly responsible for human infections. MRT-PCR was also highly sensitive, finding 10 times more samples contaminated with G. lamblia than DFA. Compared with nPCR for G. lamblia, MRT-PCR was highly accurate. At a cutoff cycle threshold value of 37.6, it showed high sensitivity and specificity in detecting G. lamblia, while reaching substantial agreement with nPCR. Despite variable sensitivity by target DNA, its high specificity made the test a suitable alternative for fast, simultaneous screening for intestinal protozoa of public health importance, revealing co-contamination in five sewage samples. Its high throughput capacity may facilitate informed decision-making for drawing up a sewage monitoring plan and taking appropriate public health measures to minimize the public health risk posed by sewage reuse

Genetic Spatiotemporal Anatomy of Plasmodium vivax Malaria Episodes in Greece, 2009–2013

An influx of immigrants is contributing to the reemergence of Plasmodium vivax malaria in Greece; 1 persistent focus of transmission is in Laconia, Pelopónnese. We genotyped archived blood samples from a substantial proportion of malaria cases recorded in Greece in 2009–2013 using 8 microsatellite markers and a PvMSP-3α gene fragment and plotted their spatiotemporal distribution. High parasite genetic diversity with low multiplicity of infection was observed. A subset of genetically identical/related parasites was restricted to 3 areas in migrants and Greek residents, with some persisting over 2 consecutive transmission periods. We identified 2 hitherto unsuspected additional foci of local transmission: Kardhítsa and Attica. Furthermore, this analysis indicates that several cases in migrants initially classified as imported malaria were actually locally acquired. This study shows the potential for P. vivax to reestablish transmission and counsels public health authorities about the need for vigilance to achieve or maintain sustainable malaria elimination

Genetic Spatiotemporal Anatomy of Plasmodium vivax Malaria Episodes in Greece, 2009-2013

An influx of immigrants is contributing to the reemergence of Plasmodium vivax malaria in Greece; 1 persistent focus of transmission is in Laconia, Peloponnese. We genotyped archived blood samples from a substantial proportion of malaria cases recorded in Greece in 2009-2013 using 8 microsatellite markers and a PvMSP-3 alpha gene fragment and plotted their spatiotemporal distribution. High parasite genetic diversity with low multiplicity of infection was observed. A subset of genetically identical/related parasites was restricted to 3 areas in migrants and Greek residents, with some persisting over 2 consecutive transmission periods. We identified 2 hitherto unsuspected additional foci of local transmission: Kardhitsa and Attica. Furthermore, this analysis indicates that several cases in migrants initially classified as imported malaria were actually locally acquired. This study shows the potential for P. vivax to reestablish transmission and counsels public health authorities about the need for vigilance to achieve or maintain sustainable malaria elimination

Field Application of SD Bioline Malaria Ag Pf/ Pan Rapid Diagnostic Test for Malaria in Greece Field Application of SD Bioline Malaria Ag Pf/ Pan Rapid Diagnostic Test for Malaria in Greece

Abstract Greece, a malaria-free country since 1974, has experienced re-emergence of Plasmodium vivax autochthonous malaria cases in some agriculture areas over the last three years. In early 2012, an integrated control programme (MALWEST Project) was launched in order to prevent re-establishment of the disease. In the context of this project, the rapid diagnostic tests (RDT) of SD Bioline Malaria Ag Pf/Pan that detects hrp-2 and pan-LDH antigens were used. The aim of this study was to assess the field application of the RDT for the P. vivax diagnosis in comparison to light microscopy and polymerase chain reaction (PCR). A total of 955 samples were tested with all three diagnostic tools. Agreement of RDT against microscopy and PCR for the diagnosis of P. vivax was satisfactory (K value: 0.849 and 0.976, respectively). The sensitivity, specificity and positive predictive value of RDT against PCR was 95.6% (95% C.I.: 84.8-99.3), 100% (95% C.I.: 99.6-100.0) and 100% (95% CI: 91.7-100.0) respectively, while the sensitivity, specificity and positive predictive value of RDT against microscopic examination was 97.4% (95% C.I.: 86.1-99.6), 99.4% (95% C.I.: 98.6-99.8) and 86.1% (95% CI: 72.1-94.7), respectively. Our results indicate that RDT performed satisfactory in a non-endemic country and therefore is recommended for malaria diagnosis, especially in areas where health professionals lack experience on light microscopy