Kostas Danis

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.

Malaria in Greece: historical and current reflections on a re-emerging vector borne disease.

Between 2009 and September 2012, locally acquired cases of P. vivax infection were reported in Greece, mostly from the agricultural area of Evrotas, Lakonia (n = 48), but also sporadically from five other regions (n = 14), suggesting that conditions in these areas are favourable for local transmission of malaria. The risk of re-establishment of malaria in Greece will depend on whether the receptivity for disease transmission (presence of the mosquito vector and adequate ecological and climatic factors) and the vulnerability (importation of the parasite in human reservoirs or presence of infected mosquito vectors) continue to be present in the country. The continuous implementation of the integrated preparedness and response plan for malaria that covers all aspects from surveillance and laboratory diagnosis to vector control and the reorganization of public health infrastructures are necessary to prevent transmission and control the disease in the long term. However, the impact of the severe economic crisis on current health-care, public health infrastructures and vector control constitute a great challenge for the future. The current threat of renewed sustained local malaria transmission in Greece (and thus in continental Europe) merits an international response, including financial and technical support, from European and international stakeholders.

Fatal cases associated with pandemic influenza A (H1N1) reported in Greece.

ABSTRACT Between 18 May 2009 and 3 May 2010, a total of 149 fatal cases associated with pandemic influenza A (H1N1) were reported in Greece. Detailed case-based epidemiological information was available for the large majority of fatal cases. The time distribution follows an epidemic curve with a peak in the beginning of December 2009 and a second peak one month later. This is similar to that of laboratory confirmed cases and influenza-like illness cases from our sentinel surveillance system, with two weeks delay. The most commonly reported underlying conditions were chronic cardiovascular disease and immunosuppression, while the most frequently identified risk factor was obesity. These findings should be taken into consideration, when vaccination strategies are employed.

Successful Control of Ebola Virus Disease: Analysis of Service Based Data from Rural Sierra Leone.

Introduction The scale and geographical distribution of the current outbreak in West Africa raised doubts as to the effectiveness of established methods of control. Ebola Virus Disease (EVD) was first detected in Sierra Leone in May 2014 in Kailahun district. Despite high case numbers elsewhere in the country, transmission was eliminated in the district by December 2014. We describe interventions underpinning successful EVD control in Kailahun and implications for EVD control in other areas. Methods Internal service data and published reports from response agencies were analysed to describe the structure and type of response activities, EVD case numbers and epidemic characteristics. This included daily national situation reports and District-level data and reports of the Sierra Leone Ministry of Health and Sanitation, and Médecins Sans Frontières (MSF) patient data and internal epidemiological reports. We used EVD case definitions provided by the World Health Organisation over the course of the outbreak. Characteristics assessed included level of response activities and epidemiological features such as reported exposure (funeral-related or not), time interval between onset of illness and admission to the EVD Management Centre (EMC), work-related exposures (health worker or not) and mortality. We compared these characteristics between two time periods—June to July (the early period of response), and August to December (when coverage and quality of response had improved). A stochastic model was used to predict case numbers per generation with different numbers of beds and a varying percentage of community cases detected. Results There were 652 probable/confirmed EVD cases from June-December 2014 in Kailahun. An EMC providing patient care opened in June. By August 2014 an integrated detection, treatment, and prevention strategy was in place across the district catchment zone. From June-July to August-December 2014 surveillance and contact tracing staff increased from 1.0 to 8.8 per confirmed EVD case, EMC capacity increased from 32 to 100 beds, the number of burial teams doubled, and health promotion activities increased in coverage. These improvements in response were associated with the following changes between the same periods: the proportion of confirmed/probable cases admitted to the EMC increased from 35% to 83% (χ2 p-value<0·001), the proportion of confirmed patients admitted to the EMC <3 days of symptom onset increased from 19% to 37% (χ2 p-value <0·001), and reported funeral contact in those admitted decreased from 33% to 16% (χ2 p-value <0·001). Mathematical modelling confirmed the importance of both patient management capacity and surveillance and contact tracing for EVD control. Discussion Our findings demonstrate that control of EVD can be achieved using established interventions based on identification and appropriate management of those who are at risk of and develop EVD, including in the context of ongoing transmission in surrounding regions. Key attributes in achieving control were sufficient patient care capacity (including admission to specialist facilities of suspect and probable cases for assessment), integrated with adequate staffing and resourcing of community-based case detection and prevention activities. The response structure and coverage targets we present are of value in informing effective control in current and future EVD outbreaks.

Impact and Lessons Learned from Mass Drug Administrations of Malaria Chemoprevention during the Ebola Outbreak in Monrovia, Liberia, 2014

Background In October 2014, during the Ebola outbreak in Liberia healthcare services were limited while malaria transmission continued. Médecins Sans Frontières (MSF) implemented a mass drug administration (MDA) of malaria chemoprevention (CP) in Monrovia to reduce malaria-associated morbidity. In order to inform future interventions, we described the scale of the MDA, evaluated its acceptance and estimated the effectiveness. Methods MSF carried out two rounds of MDA with artesunate/amodiaquine (ASAQ) targeting four neighbourhoods of Monrovia (October to December 2014). We systematically selected households in the distribution area and administered standardized questionnaires. We calculated incidence ratios (IR) of side effects using poisson regression and compared self-reported fever risk differences (RD) pre- and post-MDA using a z-test. Findings In total, 1,259,699 courses of ASAQ-CP were distributed. All households surveyed (n = 222; 1233 household members) attended the MDA in round 1 (r1) and 96% in round 2 (r2) (212/222 households; 1,154 household members). 52% (643/1233) initiated ASAQ-CP in r1 and 22% (256/1154) in r2. Of those not initiating ASAQ-CP, 29% (172/590) saved it for later in r1, 47% (423/898) in r2. Experiencing side effects in r1 was not associated with ASAQ-CP initiation in r2 (IR 1.0, 95%CI 0.49–2.1). The incidence of self-reported fever decreased from 4.2% (52/1229) in the month prior to r1 to 1.5% (18/1229) after r1 (p<0.001) and decrease was larger among household members completing ASAQ-CP (RD = 4.9%) compared to those not initiating ASAQ-CP (RD = 0.6%) in r1 (p<0.001). Conclusions The reduction in self-reported fever cases following the intervention suggests that MDAs may be effective in reducing cases of fever during Ebola outbreaks. Despite high coverage, initiation of ASAQ-CP was low. Combining MDAs with longer term interventions to prevent malaria and to improve access to healthcare may reduce both the incidence of malaria and the proportion of respondents saving their treatment for future malaria episodes.

Serogroup-specific Seasonality of Verotoxigenic Escherichia coli, Ireland.

To the Editor: Globally, an increasing number of serogroups of verotoxigenic Escherichia coli (VTEC) have been reportedly associated with human illness. The best known is serogroup O157; the World Health Organization also recognizes VTEC O103, O111, O145, and O26 as having the potential to cause severe disease (1). The increasing number of non-O157 VTEC infections is cause for concern. In general, human infections with VTEC are reportedly more common in late summer; the European Centre for Disease Control and Prevention reported that the number of cases across the European Union peaks each year during July–September (2). Similarly, the United States reported that the number of VTEC O157 cases peaks in late summer (3). Ireland is now one of the countries with the highest incidence of VTEC infection (2). In Ireland, statutory notification of VTEC infection became mandatory in 2004. In common with surveillance internationally, the focus was initially on VTEC O157; since then, testing and surveillance for non-O157 VTEC have improved substantially as a result of increased awareness and availability of diagnostic methods for non-O157 detection. Non-O157 VTEC were first reported in Ireland in 1999 (4), and surveillance data indicated that only 14% of VTEC notifications in 2004 compared with 75% in 2014 were caused by non-O157 VTEC. In the notification dataset for Ireland, the 2 primary VTEC serogroups (O26 and O157) over many years have seemed to differ in their seasonality; VTEC O26 notifications generally peaked ≈2 months earlier than VTEC O157 notifications (Figure, panel A). This earlier incidence peak for VTEC O26 has become progressively more consistent as the number of reported VTEC O26 notifications has risen. A study by Rivero et al. also suggested that non-O157 human infections may not exhibit the same seasonal variation observed for VTEC O157 (5). Figure Verotoxigenic Escherichia coli (VTEC) O157 and VTEC O26, Ireland, 2004–2014. A) Seasonal distribution of notifications. B) Predicted seasonal distribution. Data source: Computerised Infectious Disease Reporting System (https://www.hpsc.ie/NotifiableDiseases ... In this study, we compared the seasonality of the 2 strains by using national notification data for 2004–2014 (n = 2,569 notifications for O157 and O26). We estimated the timing of the seasonal peaks (phase of seasonality) for each of the serogroups, and the difference between the 2 phases, by using times series quasi-Poisson regression, fitting terms for temporal trend, and a sine wave with a period of 12 months for seasonality and for interaction by serogroup. We compared the phase shifts of the 2 serogroups by using the Wald test. To rule out the possibility that the observed distributions were influenced by the occurrence of a limited number of outbreaks, we reanalyzed the data for sporadic cases alone and, because risk factors for VTEC infection have been shown to vary by age (6), separately for patients <5 years of age and for older child and adult patients. The number of predicted cases peaked in July for VTEC O26 and in September for VTEC O157; the 2-month difference in phase (seasonality) by serogroup was significant (p 5 years of age (predicted difference in phase 1 month, p<0.0001). A significant increasing annual trend was also observed, in particular for VTEC O26. However, this increase is probably, at least in part, artifactual because of increased availability and more widespread use of clinical diagnostic tests for non-O157 VTEC in later years. One possible explanation for the difference in seasonality is that the primary animal reservoirs for the 2 serogroups could differ. Cattle and sheep have been identified as carriers of O157 and O26 strains in Ireland (7,8). In Germany, cattle density has been shown to be significantly associated with human VTEC O157 incidence but only marginally associated with O26 incidence (9); the same study showed no association between cattle density and VTEC O91 infection, indicating that not all serogroups necessarily share the same reservoirs. Alternatively, animals of the same species may be preferentially colonized with different serogroups at different times of the year or at different developmental ages. Other possible explanations could be variation in survival characteristics between the 2 strains, which results in a different seasonal distribution in the environment, or specific human behavior (e.g., seasonal food) resulting in more frequent exposure to sources of VTEC O157 and VTEC O26 at different times of the year. The consistent differences in seasonality identified here between the 2 most common VTEC serogroups suggest the existence of noteworthy underlying differences in disease etiology between the strains. Further exploration is recommended.

Improving mapping for Ebola response through mobilising a local community with self-owned smartphones: Tonkolili District, Sierra Leone, January 2015

Background During the 2014–16 Ebola virus disease (EVD) outbreak, the Magburaka Ebola Management Centre (EMC) operated by Médecins Sans Frontières (MSF) in Tonkolili District, Sierra Leone, identified that available district maps lacked up-to-date village information to facilitate timely implementation of EVD control strategies. In January 2015, we undertook a survey in chiefdoms within the MSF EMC catchment area to collect mapping and village data. We explore the feasibility and cost to mobilise a local community for this survey, describe validation against existing mapping sources and use of the data to prioritise areas for interventions, and lessons learned. Methods We recruited local people with self-owned Android smartphones installed with open-source survey software (OpenDataKit (ODK)) and open-source navigation software (OpenStreetMap Automated Navigation Directions (OsmAnd)). Surveyors were paired with local motorbike drivers to travel to eligible villages. The collected mapping data were validated by checking for duplication and comparing the village names against a pre-existing village name and location list using a geographic distance and text string-matching algorithm. Results The survey teams gained sufficient familiarity with the ODK and OsmAnd software within 1–2 hours. Nine chiefdoms in Tonkolili District and three in Bombali District were surveyed within two weeks. Following de-duplication, the surveyors collected data from 891 villages with an estimated 127,021 households. The overall survey cost was €3,395; €3.80 per village surveyed. The MSF GIS team (MSF-OCG) created improved maps for the MSF Magburaka EMC team which were used to support surveillance, investigation of suspect EVD cases, hygiene-kit distribution and EVD survivor support. We shared the mapping data with OpenStreetMap, the local Ministry of Health and Sanitation and Sierra Leone District and National Ebola Response Centres. Conclusions Involving local community and using accessible technology allowed rapid implementation, at moderate cost, of a survey to collect geographic and essential village information, and creation of updated maps. These methods could be used for future emergencies to facilitate response.

The emergence of enterovirus D68 in England in autumn 2014 and the necessity for reinforcing enterovirus respiratory screening.

In autumn 2014, enterovirus D68 (EV-D68) cases presenting with severe respiratory or neurological disease were described in countries worldwide. To describe the epidemiology and virological characteristics of EV-D68 in England, we collected clinical information on laboratory-confirmed EV-D68 cases detected in secondary care (hospitals), between September 2014 and January 2015. In primary care (general practitioners), respiratory swabs collected (September 2013-January 2015) from patients presenting with influenza-like illness were tested for EV-D68. In secondary care 55 EV-D68 cases were detected. Among those, 45 cases had clinical information available and 89% (40/45) presented with severe respiratory symptoms. Detection of EV-D68 among patients in primary care increased from 0.4% (4/1074; 95% CI 0.1-1.0) (September 2013-January 2014) to 0.8% (11/1359; 95% CI 0.4-1.5) (September 2014-January 2015). Characterization of EV-D68 strains circulating in England since 2012 and up to winter 2014/2015 indicated that those strains were genetically similar to those detected in 2014 in USA. We recommend reinforcing enterovirus surveillance through screening respiratory samples of suspected cases.

Ebola Management Centre Proximity Associated With Reduced Delays of Healthcare of Ebola Virus Disease (EVD) Patients, Tonkolili, Sierra Leone, 2014-15

Between August-December 2014, Ebola Virus Disease (EVD) patients from Tonkolili District were referred for care to two Médecins Sans Frontières (MSF) Ebola Management Centres (EMCs) outside the district (distant EMCs). In December 2014, MSF opened an EMC in Tonkolili District (district EMC). We examined the effect of opening a district-based EMC on time to admission and number of suspect cases dead on arrival (DOA), and identified factors associated with fatality in EVD patients, residents in Tonkolili District. Residents of Tonkolili district who presented between 12 September 2014 and 23 February 2015 to the district EMC and the two distant EMCs were identified from EMC line-lists. EVD cases were confirmed by a positive Ebola PCR test. We calculated time to admission since the onset of symptoms, case-fatality and adjusted Risk Ratios (aRR) using Binomial regression. Of 249 confirmed Ebola cases, 206 (83%) were admitted to the distant EMCs and 43 (17%) to the district EMC. Of them 110 (45%) have died. Confirmed cases dead on arrival (n = 10) were observed only in the distant EMCs. The median time from symptom onset to admission was 6 days (IQR 4,8) in distant EMCs and 3 days (IQR 2,7) in the district EMC (p<0.001). Cases were 2.0 (95%CI 1.4–2.9) times more likely to have delayed admission (>3 days after symptom onset) in the distant compared with the district EMC, but were less likely (aRR = 0.8; 95%CI 0.6–1.0) to have a high viral load (cycle threshold ≤22). A fatal outcome was associated with a high viral load (aRR 2.6; 95%CI 1.8–3.6) and vomiting at first presentation (aRR 1.4; 95%CI 1.0–2.0). The opening of a district EMC was associated with earlier admission of cases to appropriate care facilities, an essential component of reducing EVD transmission. High viral load and vomiting at admission predicted fatality. Healthcare providers should consider the location of EMCs to ensure equitable access during Ebola outbreaks.