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VOL. 35

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

January 2014 ISSN 1792-9016Vol. 35/ Year 4rth

MINISTRY OF HEALTH

HCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH

In the context of updating the Sentinel Surveillance System, a proposal submitted in January 2013 for co-financing by the European Social Fund (NSRF 2007-2013) was approved and integrated in May 2013 as a project of the NSRF Operational Plan “Human Resources Development”.

More on pages 2

This month’s interviewee, Professor of Hygiene and Epidemiology and Chief Editor of our e-bulletin, Christos Hadjichristodoulou, explains to us the importance of the epidemiological surveillance, its’ current international trends and shares with us some of the advise he gives to his students and younger colleagues.

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Contents

Main article: Epidemiological surveillance systems of infectious diseases in Greece: actions and goals for the near future 2

Surveillance data 6

Invited articles 9

Interesting activities 21

Recent Publications 22

Conferences and meetings 23

Interview 24

Myths and truths 26

Outbreaks around the world 28

News from the HCDCP’s administration 29

Quiz of the month 31

Highlights

Epidemiological surveillance

Worldwide, epidemiological surveillance is anessential public health tool.Public health surveillance is the continuous, systematic collection, analysis and interpretation of the health-related data needed to plan, implement and evaluate public health practice (WHO). Such surveillance can:serve as an early-warning system for impending public health emergencies,document the impact of an intervention, or track progress towards specified goals, and monitor and clarify the epidemiology of health problems, to allow priorities to be set and to plan public health policy and strategies. One key prerequisite for the success of such a system is,inter alia, the feedback to scientists of results from the primary collection points.Internationally, epidemiologicalsurveillancehas improved, acquiring new tools and specialized methods both for recordingand analysing data.The HCDCP is involved in multiplepublic health activities, and epidemiological surveillance has always been at the centre of them. Despite the difficult economic situation, during the last few years there has been a great effort to rehabilitate and modernize allsurveillance systems.The HCDCP Department of Epidemiological Surveillance and Intervention is primarily responsible for the epidemiological surveillance of infectious diseases in Greece. The Department’s main fields of actions include:1. the mandatory notifiable disease system,2. the sentinel system, and 3. the laboratory surveillance system.Forvery serious diseases,such as tuberculosis, additionalsurveillance networksare being developed and combinedwithmonitoringthe treatment’s completion. Finally, a specific methodology has been developed and appliedto evaluate the vaccination programme according to WHO guidelinesby recording vaccination coverage of children, usually 2 and 3 years of age.This issuesummarizesthe relatedactionsaimed atunderstanding the importance, the capabilities, and the difficultiesinvolvedin the systems operating in our country.I would like totake this opportunity to thank all health professionals involvedinepidemiologicalsurveillancenetworks. Their work is very important and,without them,no primary data would exist.In addition,I would like to thank the staff of HCDCP Department of Epidemiological Surveillance and Intervention, who work with untiring scientific integrity and cooperation for the treatment of both minor and major crises in the field of Public Health.

Professor Jenny Kourea KremastinouHCDCP President

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Epidemiological surveillance systems of infectious diseases in Greece: actions and goals

for the near future

The term ‘epidemiological surveillance’ refers to the systematic collection, analysis and interpretation of epidemiological data, aimed at taking public health protection measures. Countries need effective epidemiological surveillance systems in place in order to know precisely the disease epidemiology in their population, to detect in a timely manner outbreaks of diseases, to locate sporadic cases and take public health measures in their environment, to evaluate interventions and public health strategies, to monitor the progress of goals, and finally, to be able to better understand the natural course of the diseases. Simultaneously, every system targets a different point in the epidemiological pyramid of infectious diseases: clinical diagnosis, laboratory confirmation, hospitalization, and reporting. In Greece, epidemiological surveillance is performed mainly via three surveillance systems:

• Mandatory Notification System • Primary Health Care Sentinel Surveillance System, and • Laboratory Surveillance System.

The existence of multiple surveillance systems is necessary for two reasons: first, no surveillance system is capable on its own of achieving all the surveillance goals; and secondly, it helps in verifying the conclusions drawn from each system.Given the fact that public health risks are not static but change over time, countries need to review their surveillance priorities periodically. The World Health Organization states (2006):

• Some diseases remain on the national lists of mandatory notifiable diseases, although they have stopped being a public health threat for the countries that monitor them. On the other hand, emerging or re-emerging diseases that may represent substantial public health threats have not been included in the national surveillance systems.

• The disease profile evolves as antigenic variants expand their host or geographical range, or as antibiotic resistance develops. The role of surveillance in the fight against these diseases has increased.

• Technological development and the progress in scientific knowledge also affect surveillance strategies and methods. The availability, for example, of rapid diagnostic tests or molecular typing methods and the progress of information technology open new possibilities in the surveillance field, reducing its cost and increasing its scope.

• The introduction of new vaccines and control programs can affect and modify surveillance goals or methods.

• Demographic changes, for example due to longer life expectancy or lower birth rates, can impact the nosological spectrum of populations. Similarly, an increase in the number of immuno-compromised people can lead to an increase in the frequency of diseases that were previously under control.

Within the goals of the Department of Epidemiological Surveillance and Intervention of the Hellenic Center for Disease Control and Prevention, lie the evolution, update and improvement of epidemiological surveillance systems in order to meet the changing public health needs. In this context, the Office for Coordination of Surveillance Systems of the Department of Epidemiological Surveillance and Intervention is planning the following actions:

Restructuring the Mandatory Notification SystemThe Hellenic mandatory notification system was revised for the last time back in 2003, both to make it compatible with the European Union surveillance framework and in preparing to host the 2004 Olympic Games in Greece. In the context of this revision, the mandatory notifiable diseases list was updated, and a total of 45 infectious diseases were included in the list. In 2014 the mandatory notification system will be reformed, dictated by public health changes that have taken place during the last decade, both at national and international level. These changes include:

• the emergence of new diseases worldwide (i.e. bird flu, pandemic influenza Α(Η1Ν1) 2009),• the re-emergence of eliminated diseases (i.e. poliomyelitis in Syria and in China),• changes in infectious diseases surveillance in Europe (establishment of the European

Center for Disease Prevention and Control), the emergence in Greece of diseases non-endemic in the country (i.e. emergence of West Nile virus infection),

• the re-emergence in Greece of eliminated diseases (i.e. malaria cases locally acquired, laboratory confirmed rabies cases in animals),

• Changes in the national vaccination strategy in Greece (i.e. changes in chickenpox vaccination, hepatitis A, diphtheria, tetanus, pertussis),

• Changes regarding the regional and local government system. One of the main components of the reform will be the update of the mandatory notifiable diseases list, which will be performed by prioritizing epidemiological surveillance needs. Prioritizing diseases for surveillance involves complex value judgments about the relative importance of monitoring diseases with different characteristics. Several methodological approaches have been used in order to standardize this procedure, based on combining quantifiable epidemiological, clinical, and financial data with interpretive assessments of a group of informed participants (World Health Organization, 2006). The documents prepared for the process of prioritizing epidemiological surveillance needs include:

• A preliminary list of the diseases that will be evaluated. The list includes mandatory notifiable diseases in Greece, diseases pertaining to the network for the epidemiological surveillance and control of communicable diseases in the European Community, diseases that are considered priorities according to the International Health Regulation, and diseases listed in internationally recognized infectious diseases manuals.

• A preliminary table (Table 1) with the evaluation criteria for the diseases, along with their grading, which was based on the available literature review (Balabanova et al., 2011; Doherty, 2000; WHO/CDS/EPR/LYO/2006.3).

Table 1: Suggested criteria for the prioritization of surveillance needs, Greece, 2014

αα Criteria Grades

–1 0 +1

Burden of disease

1 Incidence <0.05/100.000 0.05–0.75/100.000 >0.75/100.000

2 Case fatality rate Low Medium High

Epidemiological features

3 Epidemic potentialNo epidemic potential or low epidemic potential

Possibility for epidemics in local level

Possibility for epidemics at national or international level

4 Changing pattern/emerging potential

No changes* in the disease’s epidemiology during the last 5–10 years and the conditions† are not met in order for them to occur †

No changes in the disease’s epidemiology during the last 5–10 years, but the conditions for changes to occur are met

There have been changes in the disease’s epidemiology during the last 5–10 years

5 Trend Decreasing (without peaks)

Decreasing with peaks or stable Increasing

Disease severity

6 Severity Short and mild disease Medium to severe Very severe/life threatening

7 Chronicity of illness or sequelae

No chronicity or sequelae

Mild to moderate chronicity or sequelae

A large amount of chronicity or persistent sequelae

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Social dimensions

8 Social and economic impact

Low socio-economic cost (direct and indirect) ‡

Moderate socio-economic cost (direct and indirect)

High socio-economic cost (direct and indirect)

9 Public perception

Risk perception by the general public is low and no priority in the socio- political agenda

Risk perception by the general public is moderate; medium priority in the socio-political agenda

The disease implies international duties or its risk perception by general public is high or it is explicitly high on political agenda

Possibilities for confrontation/benefit for public health

10 Prevention possibilities and needs

Preventive potential is low or the disease does not require prevention or effective prevention strategies are established (there is no need for significant strategy modification)

Measures for prevention are established but their effectiveness needs improvement

Need for prevention is established but currently no effective prevention measures are available

11 Treatment possibilities and needs

No need for treatment (or treatment is rarely necessary) or effective regimens are well established (no need for significant modifications)

Medical treatment regimens are established but their effectiveness needs improvement

Need for treatment is established but currently no effective treatment is available or AMR limits treatment options

Special criteria

12 International considerations

Not included in international networks or included in international networks, but not in the EC network or in the IHR

Included in the EC network Included in the IHR

* Changes in the disease’s epidemiology include changes in its epidemiological features, such as more severe clinical picture, new high-risk groups, increase in incidence, appearance of a new type/subtype, emergence of an eliminated disease, etc. † Conditions for changes in the epidemiology of a disease include changes in environmental parameters, changes in the distribution of vectors, etc. ‡ Direct and indirect cost: direct cost represents the amount of resources spent on the prevention, diagnosis, treatment and rehabilitation of a disease, whereas the indirect cost reflects the worth of all productive, financial and social goods or services lost due to illness.

The next steps include:• A critical review of the diseases list and the evaluation criteria by a team of experts.• Weighting the criteria according to their importance for defining epidemiological

surveillance priorities via a standardized procedure, which involves the participation of representatives from different scientific disciplines from the public health sector, to ensure the broadest possible acceptance of the result by the scientific community.

• Public health experts scoring the diseases, aiming at producing a ranked list of diseases, which will be used as a basic tool for updating the mandatory notifiable diseases list.

At the same time, the notification forms will be redesigned according to relevant suggestions from the Offices of the Department of Epidemiological Surveillance and Intervention and the disease categories critically reviewed by groups of experts.

Update of the Primary Health Care Sentinel Surveillance System In the context of updating the Sentinel Surveillance System, a proposal was submitted in January 2013 for co-financing by the European Social Fund (NSRF 2007-2013). The proposal was approved and integrated in May 2013 as a project of the NSRF Operational Plan “Human Resources Development”. The main components of the system’s update that are proposed in the project include:

• adapting the currently functioning system to population changes and primary health care reforms taking place in Greece,

• simplifying data entry procedure through a web-based application, • updating and improving the statistical analysis,• adapting and standardizing the system with the revised WHO guidance on sentinel

surveillance,• implementing a set of incentives for participating physicians in order to ensure the

continued, consistent operation of the system, • developing a standardized mechanism for evaluating the system,• expanding the accreditation of laboratory methods used in the National Laboratory

Reference Centers for Influenza. The duration of the project is 22 months and the system will operate on a pilot basis from October 2014 to March 2015.The Laboratory-based Surveillance System started operation in 2004 with a small number of participating hospitals. In September 2011 a decision was taken to reform the system in order to improve data completeness and quality, and the pilot operation of the reformed system started in February 2012. The Laboratory-based Epidemiological Surveillance Office of the Department of Epidemiological Surveillance and Intervention coordinates the pilot operation of the reformed Laboratory-based Surveillance System. The System monitors the laboratory results of clinical specimens taken from cases of infectious diseases or syndromes. Hospital laboratories, laboratory reference centers and private diagnostic centers participate in the network. Data collection and analysis is performed using Epi-info software. Data are sent via e-mail to the Hellenic Center for Disease Control and Prevention, where the analysis takes place. The future goal is to fully automate the data collection and analysis procedure through a dedicated web-based application, to expand the operation of the system to more surveillance sites, and to update the list of pathogens to align with the changes in the public health field and with international surveillance requirements.

References

1. Balabanova Y, Gilsdorf A, Buda S, Burger R et al. Communicable diseases prioritized for surveillance and epidemiological research: results of a standardized prioritization procedure in Germany, 2011. PLoS One. 2011;6(10):e25691. doi: 10.1371/journal.pone.0025691. Epub 2011 Oct 4.

2. Doherty JA. Establishing priorities for national communicable disease surveillance. Can J Infect Dis. 2000 Jan;11(1):21-4.

3. WHO/CDS/EPR/LYO/2006.3. Setting priorities in communicable disease surveillance. Available from: http://www.who.int/csr/resources/publications/surveillance/WHO_CDS_EPR_LYO_2006_3/en/

Gkolfinopoulou Kassiani, RN, MPH, PhDOffice for Coordination of Surveillance Systems

Lambrou Angeliki, RN, MPH, ScDOffice for Laboratory Epidemiological Surveillance

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December 2013, Greece

Table 1. Number of notified cases in December 2013; median number of notified cases in December for the years 2004−2012 and range; Mandatory Notification

System, Greece.

Disease Number of notified cases

December 2013

Median number December

2004−2012

Min number December 2004–2012

Max number December 2004–2012

Botulism 0 0 0 0Chickenpox with complications 1 1 0 4Anthrax 0 0 0 2Brucellosis 3 7 3 15Diphtheria 0 0 0 0Arbo-viral infections 0 0 0 0Malaria 0 1 0 8Rubella 0 0 0 0Smallpox 0 0 0 0Echinococcosis 0 2 0 6Hepatitis Α 18 12 4 35Hepatitis B, acute & HBsAg(+) in infants < 12 months 2 5 1 18

Hepatitis C, acute & confirmed anti−HCV positive (1st diagnosis) 2 1 0 20

Measles 0 0 0 107Haemorrhagic fever 0 0 0 0Pertussis 0 1 0 6Legionellosis 4 1 0 7Leishmaniasis 7 5 1 10Leptospirosis 1 1 0 4Listeriosis 1 0 0 1EHEC infection 0 0 0 0Rabies 0 0 0 0Melioidosis/glanders 0 0 0 0Meningitis

aseptic 21 16 7 53bacterial (except meningococcal disease) 12 14 9 19

unknown aetiology 0 1 0 3Meningococcal disease 10 9 2 15Plague 0 0 0 0Mumps 0 0 0 2Poliomyelitis 0 0 0 0Q Fever 0 0 0 2Salmonellosis (non-typhoid/paratyphoid) 17 31 11 92

Shigellosis 6 3 1 9Severe Acute Respiratory Syndrome 0 0 0 0Congenital rubella 0 0 0 0Congenital syphilis 0 0 0 1Congenital Toxoplasmosis 0 0 0 0Cluster of food-borne / waterborne disease cases 1 1 0 5

Τetanus / neonatal tetanus 0 1 0 1Tularaemia 0 0 0 0Trichinosis 0 0 0 1Typhoid fever/paratyphoid 0 0 0 4Tuberculosis 22 49 26 88Cholera 0 0 0 0

Table 2. Number of notified cases by place of residence (region); Mandatory Notification System, December 2013 (place of residence is defined according to

home address of cases).

Disease Number of notified cases

Region

Eas

tern

Mac

edonia

and T

hra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n

Chickenpox with complications 0 0 0 0 0 0 0 0 0 0 1 0 0 0Brucellosis 0 0 0 2 0 0 0 0 0 1 0 0 0 0Hepatitis Α 4 3 0 0 5 0 0 0 5 0 0 0 1 0

Hepatitis B, acute & HBsAg(+) in infants < 12 months 0 1 0 0 1 0 0 0 0 0 0 0 0 0

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

Legionellosis 0 0 0 0 0 0 0 0 4 0 0 0 0 0Leishmaniasis 0 0 0 1 5 0 0 0 0 1 0 0 0 0Leptospirosis 0 1 0 0 0 0 0 0 0 0 0 0 0 0Listeriosis 0 0 0 0 0 0 0 0 1 0 0 0 0 0Meningitis

aseptic 1 1 0 2 2 0 2 0 0 0 0 1 0bacterial (except meningococcal disease) 0 2 1 0 1 2 2 0 4 0 0 0 0 0

Meningococcal disease 0 2 0 0 0 2 0 0 5 0 0 0 1 0Salmonellosis (non typhoid/paratyphoid) 5 3 0 0 1 2 2 1 3 0 0 0 0 0Shigellosis 0 0 0 0 0 0 1 1 4 0 0 0 0 0Cluster of food-borne / waterborne disease cases 1 0 0 0 0 0 0 0 0 0 0 0 0 0

Tuberculosis 2 6 0 1 1 2 1 2 5 1 0 1 0 0

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Table 3. Number of notified cases by age group and gender; Mandatory Notification System, Greece, December 2013 (M: male, F: female)

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 F

Chickenpox with complications 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

Brucellosis 0 0 0 0 0 0 0 0 2 0 0 0 0 1 0 0 0 0 0 0

Hepatitis Α 0 2 2 0 4 6 3 0 0 1 0 0 0 0 0 0 0 0 0 0

Hepatitis B, acute & HBsAg(+) in infants < 12 months

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

Hepatitis C, acute & confirmed anti-HCV positive (1st diagnosis)

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

Legionellosis 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 1 0 0 0 0

Leishmaniasis 0 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0 1 2 0 0

Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0

Listeriosis 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Meningitis

aseptic 3 1 4 1 7 2 0 1 0 0 0 0 0 0 0 0 1 1 0 0

bacterial (except meningococcal disease)

0 1 0 0 1 1 1 0 0 0 0 0 1 1 2 3 0 1 0 0

Meningococcal disease 0 0 1 2 1 1 1 1 1 0 0 0 0 1 0 1 0 0 0 0

Salmonellosis (non-typhoid/paratyphoid) 0 1 2 0 4 2 0 0 0 1 1 3 0 0 1 0 1 1 0 0

Shigellosis 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Tuberculosis* 0 0 0 0 0 0 3 0 0 1 2 0 2 1 5 1 3 3 1 0

The data presented derive from the Mandatory Notification System (MNS) of the Hellenic Centre for Diseases Control and Prevention (HCDCP). Forty-five (45) infectious diseases are included in the list of the mandatory notifiable diseases in Greece. Notification forms and case definitions can be found at the website of HCDCP (www.keelpno.gr).It should be noted that data for December 2013 are provisional, and may be slightly modified/corrected in the future and also that data interpretation should be made with caution, as there are indications of underreporting to the system.

Department of Epidemiological Surveillance and Intervention

Increased number of hepatitis A reported cases among Roma in 2013 and January 2014, Greece

Hepatitis A is one of the most frequent vaccine-preventable diseases worldwide [1]. It is distributed globally and geographical areas can be characterized by high, intermediate, low or very low levels of endemicity [2]. The hepatitis A endemicity level is determined by seroprevalence studies which measure the proportion of people in each age group of the population with immunity (through infection/vaccination) based on the presence of IgG anti-HAV antibodies in the serum [3].The available epidemiological data for the years 2004–2012 have been summarized in a previous issue of the HCDCP newsletter [4].Since the beginning of 2013, an increased number of hepatitis A cases has been reported among Roma. Reported outbreaks and clusters of cases mainly affect camps in the regional units of Western Macedonia and Thrace. The occurrence of new cases among Roma has continued in 2014. We present here the available epidemiological data of the Department of Epidemiological Surveillance and Intervention for hepatitis A for 2013 and the first 2 weeks of 2014.

HAV epidemiological dataIn 2013, 164 HAV cases were reported to the Mandatory Notification System (MNS), 101 (62%) were Roma, 53 belonged to the general population (32.3%), two (1.2%) were migrants, while eight (4.9%) were travel-related. The number of notified cases in the general population was within the expected ranges, based on the background data for 2004–20121. Regarding the Roma population:

• In January-February 2013, an outbreak of 16 cases in a Roma camp in the prefecture of Korinthos (Peloponnese region) was recorded. The median age of cases was 6.6 years (interquartile range (IQR): 3–8).

• In July–December 2013, nine cases in a Roma camp in the prefecture of Xanthi (Western Macedonia and Thrace region) with a median age of 19 years (IQR:17–26) were recorded.

• A larger outbreak was also identified in the prefecture of Xanthi (Western Macedonia and Thrace region) between 12 July and 30 September in another camp. Twenty-five cases with a median age of 6 years (IQR: 3.6–7.0) were identified.

• In December 2013, two hepatitis A cases among Roma children in the prefecture of Kavala (Western Macedonia and Thrace region) were reported, followed by another four cases among the Roma residents of the same area in the beginning of 2014.

No community cases were recognized in the context of the above outbreaks.Hepatitis A sporadic cases were also reported in the Roma population of some of the aforementioned prefectures, as well as of other prefectures of the country (Table 1). Based on the background data of MNS, there was no significant increase in the number of reported cases in other prefectures.

1 The expected number of cases was calculated based on the formula: mean annual number of reported cases for 2004-2012 ± 2 standard deviations.

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Table 1. Number of reported hepatitis A cases among Roma, by region and prefecture of residence, Mandatory Notification System, Greece, 2013.

Region and prefecture of residence Number of notified cases

Western Macedonia and Thrace

Evros 6Rodopi 6Kavala 2Central Macedonia

Imathia 1Thessaloniki 4Thessaly

Karditsa 4Larissa 3Magnesia 2Trikalon 1Western Greece

Ahaia 5

Central GreeceViotia Evoia

11

Peloponnese 1Argolida 1

AtticaAthens 5

Total 42

ConclusionThe increase in the number of notified hepatitis A cases so far affects the Roma population. It is obvious that it is imperative to implement measures targeted at this specific population to control this increase. The importance of vaccinating Roma children and of following up the completion of the recommended scheme with the two doses of the vaccine should be stressed. An important limitation that has been emphasized by the public health directorates of several prefectures is a lack of vaccines against HAV.

References

1. Centers for Diseases Control and Prevention (CDC). The Pink Book. Epidemiology & Prevention of Vaccine-Preventable Diseases 2012. Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/ downloads/hepa.pdf

2. World Health Organization (WHO/CDS/CSR/EDC/2000.7). Hepatitis A. Available from: http://www.who. int/csr/disease/hepatitis/HepatitisA_whocdscsredc2000_7.pdf

3. World Health Organization (WHO). Hepatitis A vaccines: WHO position paper. Wkly Epidemiol Rec. 2000;75:38–44.

4. T Sideroglou, M Potamiti-Komi, K Mellou. Epidemiology of hepatitis A in Greece. Newsletter HCDCP, April 2013, Issue 26. Available from: http://www.keelpno.gr/Portals/0/Newsletter/2013/E-bulletin_HCDCP _APRIL_2013.pdf

Κ. Mellou, T. Sideroglou, Food-borne Diseases Section, HCDCP

Laboratory-based surveillance

IntroductionLaboratory-based surveillance is one of the pillars of infectious diseases epidemiological surveillance. Data collected and analyzed by laboratory-based surveillance systems include laboratory results from patients with infectious diseases that can be laboratory confirmed. These systems, along with notifiable diseases surveillance systems and sentinel primary health care systems, provide important epidemiological information for public health actions and for evaluating prevention and control measures. The existence of multiple surveillance systems allows each system to complement the other while it enables crossover conclusions drawn from the analysis of the information collected by each system separately. Lab-based surveillance is used for a wide range of food-borne and waterborne diseases, blood-transmitted diseases, diseases that are transmitted through the respiratory system and zoonoses (Niesters, et al. 2013). The main aims of lab-based surveillance are: (i) assessing temporal trends in the frequency of detection of the pathogens under surveillance; (ii) detecting early pathogens with an increased probability of spreading; (iii) the detecting and confirming outbreaks, and (iv) strengthening other surveillance systems (Teutsch & Churchill 1994).

HCDCP Laboratory-based Surveillance SystemThe Laboratory-based Surveillance System (Lab-SS) of the Hellenic Center for Disease Control and Prevention (HCDCP) started operating in 1999 (with some modifications in 2004) with a small number of participating hospitals throughout the region, mainly in the Attica region. The evaluation of the system showed that data was incomplete and quality was low. To improve the system, and in the context of our country’s participation in European networks of laboratory-based surveillance, in September 2011 it was decided to re-organise the system. The pilot phase of the new Lab-SS started in February 2012 and has been coordinated by the Laboratory-based Epidemiological Surveillance Office of the Department of Epidemiological Surveillance and Intervention.

Pathogens under surveillanceThe pathogens that are currently under surveillance through the HCDCP Lab-SS are the following: Salmonella spp. Shigella spp., STEC, Campylobacter spp., Yersinia enterocolitica, Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica, Streptococcus pneumoniae, Brucella spp., Legionella pneumophila, Rotavirus, Adenovirus, Norovirus, rubella virus, hepatitis A virus, measles virus and Toxoplasma gondii.

Surveillance sitesPotential surveillance sites are invited to participate in the Lab-SS and, upon acceptance of the invitation, HCDCP staff members visit the sites, which include hospitals, reference centers and diagnostic centers, and train health professionals in the implementation of the system.So far, the sites that have participated in the system are the microbiology laboratories of eight public hospitals, one reference center and two branches of a large private diagnostic center. Other surveillance sites are gradually being added until the goal of a sufficient number of participating sites representative of the geographic and population distribution of the target population of the whole country is achieved.

Process – Evaluation For the purpose of data collection, a special form of notification of laboratory results was designed. The form includes information on the number of positive test results for the pathogens under surveillance, information on serotypes, as well as basic demographic information of patients with specific positive test results. Data is collected on a weekly basis and recorded in an electronic database that was designed based on the notification form and created using the Epi-Info software of the USA Centre for Disease Control and Prevention. The data is then encrypted and sent via email to HCDCP headquarters where it is decrypted and checked for quality and completeness. This check initiates the necessary corrective actions after which the

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data is imported into the central HCDCP database for analysis.The pilot phase of the Lab-SS involves continuous and regular evaluation and restructuring of the notification forms along with the necessary database changes. As a result of the evaluation process, there might be changes in the information flow to facilitate the unhindered participation of the surveillance sites and to improve the effectiveness of the surveillance.

Data analysisCurrently, statistical analysis focuses on descriptive statistics for the purpose of checking data quality. Once the goal of having a sufficient number of participating sites is achieved, the aim is to analyze the data on a weekly basis. The analysis will include: (a) time trends in the frequency of detection of the pathogens under surveillance, (b) geographical depiction of their frequency, (c) analysis by age, gender, nationality and other factors included in the notification forms. Data from the current participating surveillance sites is available for a different number of epidemiological weeks due to different times of entry to the Lab-SS system. The absolute number of positive test results for the pathogens under surveillance from the four surveillance sites with the largest number of available epidemiological weeks is shown in Table 1. Figure 1 shows the relative frequency of positive test results of pathogens under surveillance that were detected by stool cultures in the four surveillance sites for a total of 52 epidemiological weeks (27th week of 2012–26th week of 2013, July 2, 2012–June 30, 2013).

Table 1. Absolute number of positive test results for the pathogens under laboratory surveillance from four surveillance sites for a total of 52 epidemiological weeks

(27th week of 2012–26th week of 2013, July 2, 2012–June 30, 2013)

PATHOGEN “P. & Α. KYRIAKOY”GENERAL

CHILDREN’S HOSPITAL

“AGIA SOFIA” CHILDREN’S HOSPITAL*

THESSALONIKI SPECIAL

DISEASES’ HOSPITAL

BIOMEDICINE OF ATHENS

(VIOIATRIKI)

Stool culture

Salmonella spp. 43 38 54 10

Shigella spp. 14 26 1 0

STEC 0 0 0Test not

performed

Campylobacter spp.

19 75 121 18

Yersinia enterocolitica

9 1 1 0

Stool parasitological test

Giardia lamblia 1 1 11 9

Cryptosporidium parvum

0 0 6 0

Entamoeba histolytica

0 0 8 0

Culture of clinical specimen

Streptococcus pneumoniae

0 8 0 0

Brucella spp. 1 1 5 0

Detection of antigen in urine

Legionella pneumophila

Test not performed

0 0 0

Detection of antigen in stool

Rotavirus 66 227 152 6

Adenovirus 39 201 0 20

Norovirus 57 15** 0 0

Recent infection antibodies

Rubella virus 0 1 1 2

Hepatitis A 10 20 4 0

Detection of IgM or PCR

Τoxoplasma gondii*** 1 0 4 0

*The data for the 26th week of 2013 (June 24–June 30) is not available for the “Agia Sofia” Children’s Hospital. ** The detection of Norovirus antigens in stool started to being performed in the “Agia Sofia” Children’s Hospital in January 2013.***Detection of antibodies or PCR for Τoxoplasma gondii in specimens from infants <1 year\s

Figure 1. Relative frequency of positive test results for the pathogens under surveillance that were detected through stool culture for the four surveillance sites

for a total of 52 epidemiological weeks (27th week of 2012–26th week of 2013, July 2, 2012–June 30, 2013)

Next stepsThe ultimate aim of a laboratory-based surveillance system is to implement it in a sufficient number of sites so the collected data will depict the frequency of occurrence of the pathogens under surveillance in the target population of the whole country. Therefore, the implementation of the system is gradually being extended to additional surveillance sites. When the goal of a representative number of participating sites is achieved, the data will be analyzed on a regular basis and the results will be communicated in the form of a report to the surveillance sites and other involved agencies. In addition, the range of pathogens under surveillance will be extended to accommodate the changing demands that arise in the field of public health as well as the requirements of the international surveillance systems. For example, in 2011 the European Centre for Disease Prevention and Control suggested a change in the hepatitis B and C case definition and notification of the chronic hepatitis cases in order to estimate the prevalence and the changes in the epidemiology of viral hepatitis. The new European case definitions for hepatitis B and C to be used for the purposes of surveillance are based solely on laboratory criteria, which make it imperative to integrate hepatitis B and C viruses (and other immunological markers of the viruses) in the laboratory-based surveillance system. To accommodate this need, we structured a laboratory notification form for hepatitis B and C and we designed and built the respective electronic database in order to include hepatitis B and C viruses in the Lab-SS. Another aim of the Lab-SS is to automate the procedure of collecting, sending, processing and analyzing the laboratory data. In this context, there was a NSRF proposal for the design and implementation of a web-based application for the entry, management, statistical analysis and geographical depiction of the data collected by the Lab-SS.

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Conclusions Surveillance systems of laboratory test results provide important epidemiological information for timely confirmation of infectious disease case occurrence or outbreaks and estimation of time trends in the frequency of detection of the pathogens under surveillance. The scientific and technological advances in diagnostic methods and the use of information systems require the synchronization of laboratory-based surveillance; automating the procedure of data collection and process allows not only greater flexibility and adaptation to the continuously changing public health needs, but also more efficient actions for the benefit of public health.

References

1. Niesters, H.G., Rossen, J.W., van der Avoort, H., Baas, D., Benschop, K., Claas, E.C., Kroneman, A., van Maarseveen, N., Pas, S., van Pelt, W., Rahamat-Langendoen, J.C., Schuurman, R., Vennema, H., Verhoef, L., Wolthers, K., Koopmans, M., 2013. Laboratory-based surveillance in the molecular era: the TYPENED model, a joint data-sharing platform for clinical and public health laboratories. Euro Surveill, 18(4):pii=20387. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20387

2. Teutsch, S.M. & Churchill, R.E., 1994. Principles and Practice of Public Health Surveillance, 2nd edn. Oxford University Press, New York, pp.18-9.

Angeliki Lambrou, RN, MPH, ScD, Laboratory-based Epidemiological Surveillance Office, HCDCP.

Ioanna Kokkali, Administrative officer, Laboratory-based Epidemiological Surveillance Office, HCDCP.

Nikolaos Bitsolas, Informaticist, Regional Public Health Laboratory of Thessaly.

The Laboratory-based Epidemiological Surveillance Office of HCDCP would like to express our deepest thanks to the personnel of the participating surveillance sites for their voluntary participation and valuable help in the laboratory-based surveillance. The list of the participating sites and the names of their personnel contact points follows:

SURVEILLANCE SITES Names

Biomedicine of Athens (Vioiatriki) Ioanna Dimopoulou

Biomedicine of Thessaloniki (Vioiatriki) Antreas KampalonisDimitris VasiloglouKonstantinos Christoglou

National Reference Laboratory for Measles-Rubella, Hellenic Pasteur Institute Andreas MentisElina Horefti

Kalamata General Hospital Erieta Vernardaki

Lamia General Hospital Dimitra Astrecha

Larissa General Hospital Ioanna Voulgaridi

“Agios Panteleimon” General Hospital of Nikaia, Piraeus Nikolaos Zachos

«Panagioti and Aglaias Kyriakou» General Children’s Hospital of Athens Nikoleta Palaiologou

Sparta General Hospital Dimitra Rempelou Spuridon Fokas

Thessaloniki Special Diseases’ Hospital (NEPTH) Anthoula Kandili

“Agia Sofia” Children’s Hospital Kleopatra Kalogriopoulou

Methodology of Greek nationwide study on vaccination coverage in children aged 2–3

years: preliminary results on vaccination against poliomyelitis

Systematic monitoring of vaccination coverage according to the National Immunization Program, is an indicator of the health level in a country. In many developed countries, systematic monitoring of the vaccination status of the child population is performed in order to draw conclusions on the configuration, application and periodic adjustment of vaccination strategies in each country.To date in our country, several studies for the assessment of childhood vaccination have been conducted, out of which four nationwide, the latest is a national sample of pupils in the first grade of primary school, aimed to update information concerning Greek childhood immunization.The Office for Vaccine Preventable Diseases of HCDCP, in cooperation with the Department of Hygiene and Epidemiology, University of Thessaly, conducted a nationwide study in 2013 on vaccination coverage of children born between January 2010 and January 2011. The target population was children aged 2–3 years old living in Greece, as most of the childhood vaccinations have been completed by this age. The sampling population was children at day care centers (nurseries-kindergartens). For this purpose, a complete record of all day care centers in the country was created.Stratified cluster sampling per geographical area was applied. The prefectures in the country were considered as strata, based on the NUTS-3 (Nomenclature of Territorial Units for Statistics) classification. Day care centers were the primary sampling units consisting of “clusters” of children, who were the final sampling units. The day care centers of each strata were selected by simple random sampling from the list of day care centers in each prefecture, which was the sampling frame of the study.Based on the births in 2010, it was calculated that the required sample size was approximately 2500 children, taking into consideration that the expected full vaccination coverage would be 80% with an accuracy ±2.5%, the sampling design effect would be equal to 2, and the study response rate estimated at 80%. The number of children required in the sample from each stratum was proportional to the number of births in 2010 at the corresponding stratum, and it was calculated that 197 nurseries-kindergartens were needed to participate in the study, estimating that nurseries-kindergartens in Attica, Thessaloniki and the rest of Greece have an average of 20, 15 and 10 children aged 23 years old, respectively. The number of day care centers selected from each geographic stratum was calculated by dividing the required sample size of each stratum by the estimated average number of children per day care center in the corresponding stratum/prefecture, selected by simple random sampling.In the final study, 185 day care centers out of the 197 participated (response rate 81.5%) and 2539 out of the 3114 children (response rate 93.9%).A study protocol on vaccination coverage was created as well as a specially designed database in the statistical program Epi-Info. In order to confirm the validity of the data, several tests were made before the analysis, to detect and correct any logical inconsistencies (consistency and range checks). The analysis was performed with the statistical package SPSS (ver. 19). The preliminary results on vaccination coverage against poliomyelitis with IPV vaccine are presented (95% confidence interval) below.

Table 1. Selected indicators on vaccination coverage against poliomyelitis (IPV) – Greece

Doses n / N % 95% CI

1 2538 / 2539 100.0 99.7-100.0 2 2537 / 2539 99.9 99.7-100.0 3 2526 / 2539 99.5 98.9-99.8

4 2420 / 2539 95.3 94.3-96.2

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2 doses up to 6 months 2370 / 2539 93.3 92.0-94.4

2 doses up to 12 months 2515 / 2539 99.1 98.6-99.4

3 doses up to 24 months(with 2 doses up to 12 months) 2505 / 2539 98.7 97.9-99.2

3 doses up to 36 months(with 2 doses up to 12 months) 2511 / 2539 98.9 98.3-99.3

The vaccination coverage against poliomyelitis with 3 doses of vaccine was ≥99.5% and for the 4th dose was 95.3%. Children’s vaccination with 2 doses of polio vaccine during the first year of life (up to 12 months old) was almost universal (99.1 %) although there was a slight delay in its achievement as 93.3% of children were vaccinated with 2 doses by 6 months old. The percentage of complete vaccination with 3 doses by 24 months of age (of which 2 doses up to 12 months old) was very high (98.7%) while some children who were late in getting vaccinated completed the schedule by 36 months (98.9%) of age.Table 2 shows the above selected indicators for major geographical areas according to NUTS-1. Vaccination with 2 doses up to 12 months as well as the complete vaccination with 3 doses up to 24 or 36 months (of which the first 2 up to 12 months) seems to lag statistically significantly in Central Greece compared with other areas, despite the fact that vaccination coverage remains very high.

Table 2. Selected indicators on vaccination coverage against poliomyelitis (IPV) per major geographical areas NUTS1 –Greece

Vaccine doses NUTS1 n / Ν % 95% CI p-value

Dose 1

North Greece 851 / 852 99.9 99.2–100

0.777Central Greece 473 / 473 100.0 –Attica 867 / 867 100.0 –Aegean Islands and Crete 347 / 347 100.0 –

Dose 2

North Greece 851 / 852 99.9 99.2–100.0

0.682Central Greece 472 / 473 99.8 98.5–100.0Attica 867 / 867 100.0 –Aegean Islands and Crete 347 / 347 100.0 –

Dose 3

North Greece 850 / 852 99.8 99.0–99.9

0.072Central Greece 466 / 473 98.5 95.2–99.6Attica 863 / 867 99.5 98.8–99.8Aegean Islands and Crete 347 / 347 100.0 –

Dose 4

North Greece 822 / 852 96.5 94.6–97.7

0.123Central Greece 441 / 473 93.2 89.1–95.9Attica 827 / 867 95.4 93.9–96.5Aegean Islands and Crete 330 / 347 95.1 93.5–96.3

2 doses up to 6 months

North Greece 808 /852 94.8 92.7–96.4

0.590Central Greece 435 /473 92.0 87.1–95.1Attica 795 / 867 91.7 89.5–93.5Aegean Islands and Crete 332 / 347 95.7 93.6–97.1

2 doses up to 12 months

North Greece 850 /852 99.8 99.1–99.9

0.023Central Greece 464 / 473 98.1 95.7–99.2Attica 857 / 867 98.8 98.0–99.3Aegean Islands and Crete 344 / 347 99.1 97.9–99.6

3 doses up to 24 months (with 2 doses up to 12

months)

North Greece 849 / 852 99.6 98.9–99.9

0.032Central Greece 460 / 473 97.3 92.6–99.0Attica 854 / 867 98.5 97.5–99.1Aegean Islands and Crete 342 / 347 98.6 97.2–99.3

3 doses up to 36 months (with 2 doses up to 12

months)

North Greece 849 / 852 99.6 98.9–99.9

0.021Central Greece 462 / 473 97.7 94.4–99.0Attica 856 / 867 98.7 97.9–99.2Aegean Islands and Crete 344 / 347 99.1 97.9–99.6

As shown in Table 3, the vaccination coverage of immigrant children is very high, almost identical, with the children of Greek families belonging to the general population. The exception to this seems to be vaccination with 2 doses of up to 6 months remaining statistically significantly low in immigrant children. This delay in vaccination of immigrants disappears by the age of 12 months.

Table 3. Selected indicators on vaccination coverage against poliomyelitis (IPV) per population group –Greece

Vaccine doses Population groups n / Ν % 95% CI p-value

Dose 1General population 2400 /

2401 100.0 –0.824

Immigrants 119 / 119 100.0 –

Dose 2General population 2399 /

2401 99.9 99.7–100.00.755

Immigrants 119 / 119 100.0 –

Dose 3General population 2391 /

2401 99.6 99.2–99.80.487

Immigrants 119 / 119 100.0 –

Dose 4General population 2295 /

2401 95.6 94.7–96.30.729

Immigrants 113 / 119 95.0 89.7–97.6

2 doses up to 6 monthsGeneral population 2255 /

2401 93.9 92.8–94.90.041

Immigrants 106 / 119 89.1 81.4–93.8

2 doses up to 12 monthsGeneral population 2380 /

2401 99.1 98.7–99.40.969

Immigrants 118 / 119 99.2 94.1–99.9

3 doses up to 24 months (with 2 doses up to 12

months)

General population 2373 / 2401 98.8 98.3–99.2

0.749Immigrants 118 / 119 99.2 94.1–99.9

3 doses up to 36 months (with 2 doses up to 12

months)

General population 2377 / 2401 99.0 98.5–99.3

0.866Immigrants 118 / 119 99.2 94.1–99.9

After completing the analysis for all vaccines, the results will be communicated and will only be used for purposes serving the public health and contributing to the development of vaccination policies and concrete measures.

Georgakopoulou Theano, Katsioulis Antonis, Vernardaki Alexandra, Paza Efi, Markotsis Filippos, Mavraganis Pantelis, Katsaounos Panagiotis,

Chatzichristodoulou ChristosOffice for Vaccine Preventable Diseases

Department of Epidemiological Surveillance and Intervention, H.C.D.C.P.Department of Hygiene and Epidemiology, University of Thessaly

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Changes in the epidemiological surveillance of viral hepatitis B and C

In2011, the European Centre for Disease Prevention (ECDC) proposed changing the case definitions for hepatitis B and C, reporting chronic cases of viral hepatitis and remodeling the case-based report to include new variables. At that stage, only cases of acute hepatitis were reported. The objective was to have uniform data from all the countries, data that would be collected from the European system of surveillance (TESSy) in order to make it possible to estimate the prevalence and the changes of epidemiology of viral hepatitis.

Proposal: new EU case definition for hepatitis BClinical criteriaNot relevant for surveillance purposes

Epidemiological criteria Not relevant for surveillance purposes

Laboratory CriteriaPositive results of at least one or more of the following tests or combination of tests:

• IgM Hepatitis B core antibody (anti-HBc IgM)• Hepatitis B surface antigen (HBsAg)• Hepatitis B e antigen (HBeAg)• Hepatitis B nucleic acid in serum (HBV-DNA)

Case classification • Possible case:NA• Probable case: NA• Confirmed case: Any person meeting the laboratory criteria

Implementation of hepatitis B case definition with specific variables:

Variable Codes Description

StageHEP(mandatory) Acute

Detection of IgM antigen specific antibody(anti-HBc IgMorDetection of hepatitis surface antigen (HBsAg) and previous negative HBV markers less than 6 months agoor Detection of hepatitis B nucleic acid ( HBV-DNA) and previous negative HBV markers less than 6 months agoor Any of the above with or without symptoms and signs ( e.g. jaundice, elevated serum aminotransferase levels, fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting, fever)

Chronic

Detection of HBsAg or HBeAg or HBVDNAandNo detection of anti-HBc IgM (negative results)orDetection of HBsAg or HBeAg or HBV-DNA on two occasions that are 6 months apart

UNK Any newly diagnosed case which cannot be classified according the above description of acute or chronic infection.

Proposal : new EU case definition for hepatitis CClinical criteriaNot relevant for surveillance purposes

Epidemiological criteria Not relevant for surveillance purposes

Laboratory CriteriaAt least one of the following three:

• Detection of hepatitis C virus nucleic acid (HCV RNA)• Detection of hepatitis C virus core antigen (HCV-core)• Hepatitis C virus antibody (anti-HCV Ab) confirmed by a confirmatory (e.g. immunoblot)

antibody test in person older than 18 months without the evidence of resolved infection.

Case classification • A. Possible case:NA• B. Probable case: NA• C. Confirmed case: Any person meeting the laboratory criteria

NOTE: The following combination of lab tests shall not be included or reported:Resolved infection: Detection of hepatitis C virus antibody and no detection of Hepatitis C virus nucleic acid (HCV-core negative result) in serum/plasma.

Implementation of hepatitis C case definition with specific variables

Variable Codes Description

StageHEP(mandatory) Acute

Recent HCV seroconversion (prior negative test for hepatitis C in last 12 months )or Detection of hepatitis C virus nucleic acid (HCV RNA) or Hepatitis C virus core antigen (HCV-core) in serum/plasma and no detection of hepatitis C virus antibody(negative result)

Chronic Detection of hepatitis C virus nucleic acid ( HCR RNA) OR HEPATITIS C core antigen ( HCV-core) in serum/plasma in two samples taken at least 12 months apart

UNK Any newly diagnosed case which cannot be classified according the above description of acute or chronic infection.

The set of variables which applies to Hepatitis case-based reporting consists of 34 variables for Hepatitis B and 30 variables for Hepatitis C. These variables can be divided in core-set and disease-specific variables. The variables are designed to allow the distinction between acute and chronic cases through the variable ‘StageHEP’. Further information on cases can be provided through non-mandatory fields.An aggregated format will also be implemented and will include Gender,Age, Class, StageHEP, Transmission Date used for statistics, Reporting Countryand the number of cases. The hierarchy for aggregate reporting is as follows: (1) gender,(2) age class,(3) StageHEP,(4) Transmission.ECDC strongly recommends case-based reporting.The variables are described in more detail, including the validation rules, in Annexure 1.Datasources will need to be appropriately configured for each member state and disease, where these do not already exist. Datasources provide information on the surveillance system, sending the data to ECDC, and are essential in interpreting reported data correctly.

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Table 1. Overview of enhanced set of variables for Hepatitis surveillance

Type Variable name Mandatory Hepatitis B Hepatitis C

Core-set Record ID Y V VRecord type Y V VRecord type version Y V VSubject Y V VStatus Y V VData source Y V VAge (years) Y V VGender Y V VOutcome V VDateofonset V VDate of diagnosis Y V VDate of notification V VDate used forstatistics Y V VReporting country Y V VPlace of residence V VPlace of notification V VClassification Y V V

Disease-specific StageHEP Y V VResultHBeAg N V NAViral load N V NAALTLevel N V VCountry of birth N V VCountry ofnationality N V VImported N V VProbable country of infection N V VCountry of birthparents N V NATransmission N V VHCW N V VHIV status N V VHBV status N NA VHCVstatus N V NAPrison N V VVaccination status N V NAComplications N V VGenotype N V V

Many countries expressed their fears about the reporting of chronic cases as there is already a problem of underreporting of acute cases and, with an additional burden, the system will collapse.The Viral Hepatitis Office of HCDCP, in cooperation with the Department of Epidemiological Surveillance and members of the Scientific Committee on Viral Hepatitis of HCDCP, studied the recommendations of the ECDC. Since the new case definitions are based solely on laboratory findings,it was decided to create the laboratory system reportof those diseases.The laboratory report form hasalready been prepared according tothe instructions of ECDC and will soon be implemented as apilot project. The laboratory report will be createdelectronically and will be sent to HCDCP.We hope that we will soon be able to implement the laboratory reportsystem in all hospitals and private laboratories that perform tests for viral hepatitis B and C.The report of viral hepatitis through the mandatory reportsystem will be maintained and operate in tandem so that the two systems complement each other.Some of the changes of the mandatory reporting of chronic and acute infectious diseases are related to risk factors, clinical features and laboratory findings.The success of the epidemiological surveillance will depend on the involvement of clinicians and laboratory physicians and we hope that their cooperation with the HCDCP will provide reliable information, in accordance with the instructions of the ECDC.

Dr G. Nikolopoulou, Head of Viral Hepatitis Office,HCDCP

Interesting activities“Prometheus”

The first association of patients with liver diseases, the Hellenic Liver Patient Association, “Prometheus”, was founded in 2012 and has been operating ever since. Through our experience as patients, we provide support to people living with viral hepatitis B and C and other liver diseases. This is our first and main objective and it involves defending the rights of chronically ill people, especially the right to unfettered access to diagnostic tests and drugs, which in recent years encountered serious obstacles. We represent and advocate for patients when such fundamental rights are violated, if necessary by applying pressure at a political level.Our second key objective and focus of action is to raise awareness among the general public and individual social actors and groups about the growing problem of viral hepatitis, its prevention and how to respond to the disease. To achieve the above, we simultaneously strive to eliminate the stigma and social exclusion of patients.As an association focusing on the patient and his or her needs, our agenda includes psychological support for patients when receiving difficult and painful medication, so that they continue to receive it properly and the treatment is successful. At the same time, we aim to promote new, patient-friendly, clinically-approved treatment schedules.Through the awareness campaign: “C-concerns you. Do not ignore it. Have a medical exam”, “Prometheus” seeks to raise public awareness about hepatitis C in a different and original way. Under the motto “C-concerns”, the volunteers of the association “rushed” in different corners of Athens, arousing the curiosity of passersby and inviting them to be informed. In October, large yellow ‘C’s were placed in central locations in Athens (at Monastiraki, Kerameikos and Korai Square, at Boukourestiou Street and at Maroussi Railway Station). The posters bore the message: “Approximately 200,000 Greeks have this disease. 80% of them do not know it.” At the same time, with the help of the mobile unit, we offered free and fast saliva testing for the disease to those who wished it. In the places where the advertising ‘C’ had been placed (a construction of about 2 metres, which certainly aroused and will again arouse the interest of passersby) the volunteers of the association distributed the relevant informative material. At the same time, for one month (29 October–29 November 2013), major TV stations in the country screened this social message, emphasizing the importance of information about this not-so-rare-disease.The main objective of the campaign is to inform and, at the same time, encourage the general public to be medically checked for Hepatitis C.The campaign was launched with great success in Athens (29 October–5 November) and by the end of 2014, “Prometheus” hopes to visit at least five other major cities in Greece, among them Thessaloniki, Larisa, Patras and Heraklion.

Contact details19, Perikleous Street, 15561, Holargos

Tel:2110122102Email: hlpaprometheus@gmail.com

Website: http://helpa-prometheus.gr/

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Recent Publications

Influenza vaccine effectiveness in the 2011–2012 season: Protection against each circulating virus and the effect of prior vaccination on estimates

Ohmit SE, Thompson MG, Petrie JG, Thaker SN, Jackson ML, Belongia EA, Zimmerman RK, Gaglani M, Lamerato L, Spencer SM, Jackson L, Meece JK, Nowalk MP, Song J, Zervos M, Cheng PY, Rinaldo CR, Clipper L, Shay DK, Piedra P, Monto AS.Clin Infect Dis. 2013; Nov 22. doi: 10.1093/cid/cit736 [Epub ahead of print].Each year, the US Influenza Vaccine Effectiveness Network examines the effectiveness of influenza vaccines in preventing medically-attended acute respiratory illnesses caused by influenza. Patients with acute respiratory illnesses of ≤7 days’ duration were enrolled at ambulatory care facilities in five communities. Specimens were collected and tested for influenza by real-time reverse-transcriptase polymerase chain reaction. Receipt of influenza vaccine was defined based on documented evidence of vaccination in medical records or immunization registries. Vaccine effectiveness was estimated in adjusted logistic regression models by comparing the vaccination coverage in those who tested positive for influenza with those who tested negative. The 2011–2012 season was mild and peaked late, with circulation of both type A viruses and both lineages of type B. Overall adjusted vaccine effectiveness was 47% (95% confidence interval [CI], 36–56) in preventing medically attended influenza; vaccine effectiveness was 65% (95% CI, 44–79) against type A (H1N1) pdm09 but only 39% (95% CI, 23–52) against type A (H3N2). Estimates of vaccine effectiveness against both type B lineages were similar (overall, 58%; 95% CI, 35–73). An apparent negative effect of prior year vaccination on current year effectiveness estimates was noted, particularly for A (H3N2) outcomes. Vaccine effectiveness in the 2011–2012 season was modest overall, with lower effectiveness against the predominant A (H3N2) virus. This may be related to antigenic drift, but past history of vaccination might also play a role.

Internet-based surveillance systems for monitoring emerging infectious diseases

Gabriel J Milinovich, Gail M Williams, Archie C A Clements, Wenbiao HuLancet Infect Dis. 2013 Nov 27. pii: S1473-3099(13)70244-5. doi: 10.1016/S1473-3099(13)70244-5. [Epub ahead of print]Emerging infectious diseases present a complex challenge to public health officials and governments; these challenges have been compounded by rapidly shifting patterns of human behaviour and globalisation. The increase in emerging infectious diseases has led to calls for new technologies and approaches for detection, tracking, reporting, and response. Internet-based surveillance systems offer a novel and developing means of monitoring conditions of public health concern, including emerging infectious diseases. In this article, the writers review studies that have exploited internet use and search trends to monitor two such diseases: influenza and dengue. Internet-based surveillance systems have good congruence with traditional surveillance approaches. Additionally, internet-based approaches are logistically and economically appealing. However, they do not have the capacity to replace traditional surveillance systems; they should not be viewed as an alternative, but rather an extension of existing systems. Future research should focus on using data generated through internet-based surveillance and response systems to bolster the capacity of traditional surveillance systems for emerging infectious diseases.

Theano Georgakopoulou, MD, PhD, Head of the Department for Surveillance and Intervention HCDCP

Conferences and meetingsFEBRUARY 2014

2–7 FEBRUARY 2014

Title: Keystone Symposia: The Science of Malaria Eradication

Country: MexicoCity: MéridaVenue: Fiesta Americana Contact Number: +1-970-262-1230Website: http://www.keystonesymposia.org/14F1

21–23 FEBRUARY 2014

Title: 6th Conference of the Greek Society for Research and Treatment of Papilloma Virus (HPV)

Country: GreeceCity: ThessalonikiVenue: Hyatt Regency Contact Number: +30-210-607-4205Website: www.6hpv.mdcongress.gr

Office for Public and International relations, HCDCP

Interview

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Hadjichristodoulou Christos Professor of Hygiene and Epidemiology,

University of ThessalyScientific Coordinator of the Peripheral Public

Health Laboratory of ThessalyScientific Consultant for the Hellenic Centre for

Disease Control & Prevention, (HCDCP)

What is the definition of epidemiological surveillance? In a few words, what would you say is its importance to Public Health?According to the definition given by the World Health Organization for epidemiological surveillance, there are two aspects that are very important: first, that data are collected systematically and routinely rather than occasionally, and secondly, that the data are analyzed and are available for competent authorities to take action. Therefore, one cannot consider epidemiological surveillance without combining it with control measures or actions.

Does epidemiological surveillance apply only to infectious diseases? Certainly not to infectious diseases only. Epidemiological surveillance is also used for chronic non-infectious diseases, even habits such as smoking, as long as the conditions mentioned above are met.

It is generally accepted that in our country the collection of data and reliable information is inadequate. Can this be interpreted as systematic underreporting as far as the surveillance tools are concerned?Many believe that the main purpose of epidemiological surveillance is recording the actual incidence and impact of an infectious disease, which is very difficult to achieve. We must bear in mind that, regardless how well organized the epidemiological surveillance system is, the epidemiological pyramid applies. We collect data from the tip of the pyramid and it is extremely difficult to reach the base. Although there are several ways to estimate the impact of a disease in the community, it is far more useful to depict the trend over time, so as to evaluate preventive measures (e.g. vaccinations), and to detect clusters or outbreaks using the epidemiological surveillance tools and systems.

How could this underreporting be addressed? Underreporting is a phenomenon observed in all countries of the world, but to a different extent in different countries and for various diseases. We have to admit that the rate of underreporting of meningitis differs from that of flu. A good way to reduce underreporting is by providing feedback information to the doctors who participate in the surveillance system to increase their commitment. This important function is achieved in Greece through the HCDCP’s newsletter and the website. Moreover, the format and the content of the notification forms and the way of reporting are very important in order to avoid time-consuming procedures and to exclude the collection of information that is not required. In many foreign countries the information collected on a systematic basis is very limited. For diseases of particular interest (e.g. tuberculosis, meningitis), every 4 years an enhanced surveillance is organised by using

special reporting forms in which detailed, useful information is included. In Greece a group of experts is currently reforming the compulsory notification system of HCDCP through a documented assessment process using specific criteria.

Several people, including you, argue that there have been tremendous advances in laboratory support of epidemiological surveillance over the recent years. Is that true and if so, what is the role of HCDCP in this area? Indeed, in recent years microbiology has progressed greatly in identifying and typing pathogens. We are now in the phase of analysing the whole genome. Many countries, such as the United Kingdom, have started to use the whole genome analysis for enteropathogen typing. As you can understand, this increases the specificity of the surveillance system and enables the detection of food-borne and waterborne epidemics. The HCDCP, in collaboration with the reference laboratories, should also proceed with integrating what the technology offers today to the epidemiological surveillance of these diseases.

Could you tell us about any new universal trends regarding epidemiological surveillance. What are the new “tools” that have been developed? As mentioned above, the specificity of the system has already increased in many countries, but parallel efforts have been made to increase the sensitivity of epidemiological surveillance as well. In many countries and in international organizations, attempts are made to collect information from sources outside the conventional epidemiological surveillance system, such as the internet, newspapers and other media. It is known that journalists are the first to know when an epidemic occurs. Also, some countries have developed, especially for influenza, volunteer networks of people who report their symptoms in order for the flu to be detected before they seek medical help.

Let us put aside for a moment the epidemiological surveillance and let us focus on you. How were you engaged and how did you build a career in Public Health? What were your motives, or who were the people who inspired you in making this choice?I must say that I was very lucky because, as a medical student, one of my teachers was the Professor of Epidemiology, Dimitris Trichopoulos. The way he taught his courses, his whole presence, inspired me and made me love Epidemiology. In the course of my career I was fortunate to work with many professors like Mr Kattami, Mrs Theodoridou, Mr Tselenti, Mrs Kremastinou, Mr Papaevangelou, Mrs Kalapothaki, from whom I gained a great deal, and I would like to thank them. It is difficult for a doctor to leave clinical medicine and to get involved with Public Health. It is even more difficult to get students to think about this possibility. Allow me once again to refer to Great Britain, where the specialty of public health exists as a specialization and a large number of doctors are choosing this specialty. In our country this is not yet feasible for many reasons.

As a university professor and an active trainer, what advice would you give to your students and younger colleagues?Recently I was invited to speak on a High School Career Day together with other “successful” (whatever that means) fellow citizens. I told the children that I’m not Einstein and definitely I am not going to win a Nobel Prize, but nevertheless I have achieved some things in my life. When I was asked how I achieved these things, I replied with work, patience and perseverance. In other countries all you have to do is work; unfortunately in Greece, patience and perseverance are also required. Also, it is very important to have team spirit. Nobody achieves anything alone. It is very important to love your colleagues, to promote and share with them both successes and failures. We don’t step on other people in order to get what we want, nor do we believe the saying “the end justifies the means”. We must always proceed with caution and morals and with God’s help, to create things, bearing in mind that sometimes we may make mistakes. We are not infallible; we should recognize that and try to improve ourselves.

Thank you for giving me the opportunity to say a few things to the readers of this newsletter.

Myths and truths

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Myths and truths about Public Health Surveillance

Myths TruthsPublic health surveillance is the occasional collection of cases of some diseases.

According to the World Health Organization (W.H.O.), public health surveillance is the continuous and systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practices. Such surveillance can

a) serve as an early warning system for impending public health emergencies;

b) document the impact of an intervention, or track progress towards specified goals; and

c) monitor and clarify the epidemiology of health problems to allow priorities to be set and to inform public health policy and strategies.

(http://www.who.int/topics/public_health_surveillance/en/)Epidemiologic surveillance of infectious communicable diseases should raise concerns only at a national level.

The numerous opportunities for rapid and easy travelling (mainly by airplane), the expansion of international trade in food and medicinal biological products, the social and environmental changes linked to urbanization, are some of the characteristics of the rapidly changing global community that facilitate the spread of infectious communicable diseases. For all those reasons, detecting threats of communicable diseases in one country raises concerns at an international level.

Epidemiologic surveillance of infectious diseases is less important nowadays because of the many available vaccines and antibiotics.

Epidemiologic surveillance of infectious diseases nowadays is more important than ever before. The developping resistance of microorganisms due to excessive use of antibiotics and chemotherapeutics, and emerging virus mutations are expected to complicate the prevention and treatment of infectious diseases in the near future. Furthermore, the observed descrease of mandatory vaccination in childhood, due to the economic crisis, is also expected to have consequences for Public Health.

Public health surveillance is important only for developing countries.

According to W.H.O., in most industrialized countries where communicable disease mortality has greatly decreased, the concern is focused on preventing diseases from entering and leading to an outbreak or re-emergence. In developing countries, the concern is detecting communicable disease outbreaks early and stopping their mortality and spread. Surveillance systems are extremely important in evaluating the control of communicable diseases in both industrialized and developing countries.

(Global infectious disease surveillance, http://www.who.int/mediacentre/factsheets/fs200/en/)

W.H.O. is not involved if a communicable disease outbreak is confirmed by the public health surveillance system of a single country.

Once a communicable disease outbreak has been confirmed, relevant information is placed on the internet, so that it and can be accessed by the public (http:http://www.who.int/csr/don/en/). A WHO team arrives on site within 24 hours of the outbreak confirmation in order to make an initial assessment, start immediate control measures and prepare a larger international response, if necessary. Linking the international response to systematic global surveillance, a worldwide «network of networks» is available from which any country that confronts an outbreak can solicit support, both on a technical or an humanitarian level.

(WHO’s epidemic preparedness and response, http://www.who.int/mediacentre/factsheets/fs200/en/)

Public health surveillance is applicable only to infectious communicable diseases.

According to the Centers for Disease Control and Prevention (CDCs) Vision for Public Health Surveillance in the 21st Century, changes in the scope of Public health surveillance are expected, so that it is not limited to infectious communicable diseases. In the United States it has already evolved to tracking the occurrence of many non-infectious conditions, such as injuries, birth defects, chronic conditions, environmental and occupational exposure to health risks.(CDC’s Vision for Public Health Surveillance in the 21st Century. Morbidity and Mortality Weekly Report. Suppl./vol 61, July 27, 2012)

The best way to report surveillance data is by fax or email.

According to the Centers for Disease Control and Prevention (CDC’s) Vision for Public Health Surveillance in the 21st Century, changes in methods of data collection are expected. With the mass adoption of electronic health records, new opportunities for strengthening surveillance capacities are emerging. Electronic health records offer an opportunity to improve links between health-care providers and public health departments, making surveillance more effective and timely.(CDC’s Vision for Public Health Surveillance in the 21st Century. Morbidity and Mortality Weekly Report. Suppl./vol 61, July 27, 2012)

Malamatenia Arvanitidou-Vagiona, Professor of Hygiene, School of Medicine, Faculty of Health Sciences of Aristotle University of Thessaloniki

Zoi Tsimtsiou, Research Fellow in Hygiene, School of Medicine, Faculty of Health Sciences of Aristotle University of Thessaloniki

News from the HCDCP’s administration

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Outbreak news, January 2014

Chikungunya fever [1]

Chikungunya cases have been reported from several islands in the Caribbean. As of 20 January 2014, the following number of cases has been reported:

• 294 probable or confirmed cases in Saint Martin (FR);• 2 confirmed cases in Saint Martin (NL); • 127 probable or confirmed cases in Martinique; • 31 probable or confirmed cases in Saint Barthélemy; • 27 probable or confirmed cases, including one imported case from Saint Martin in

Guadeloupe; • 1 confirmed case imported from Martinique in French Guiana;• 3 confirmed cases on Jost Van Dyke islands in the British Virgin Islands.

Human infection with influenza A (H7N9) virus [1,2]

As of 27 January 2014, 251 laboratory confirmed cases have been reported in China from Zhejiang (102 cases), Shanghai (42), Jiangsu (31), Guangdong (32), Fujian (15), Jiangxi (5), Henan (4), Anhui (4), Hunan (4), Hong Kong (3), Beijing (3), Shandong (2), Taiwan (2), Hebei (1) and Guizhou (1), including 56 deaths. So far, there is no evidence of sustained human-to-human transmission. WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.

Middle East respiratory syndrome coronavirus (MERS-CoV) [2]

Globally, from September 2012 to 27 January 2014, WHO has been informed of a total of 180 laboratory-confirmed cases of infection with MERS-CoV, including 77 deaths. WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.

References

1. European Centre for Disease Prevention and Control. Epidemiological update. At: http://www.ecdc.europa.eu/en/press/news/_layouts/forms/ [Accessed 29 January 2014]

2. World Health Organization (WHO). At: http://www.who.int/csr/don/ [Accessed 29 January 2014]

Travel Medicine Office, Department for Interventions in Health Care Facilities

Professor Jenny Kremastinou, HCDCP President, visits Ath Checkpoint

In the Christmas holiday spirit, the HCDCP President, Professor Jenny Kremastinou, visited the Ath Checkpoint in downtown Athens, on December 23, 2013. The President, along with Mrs Calliope Giannopoulou, Deputy Mayor of Athens for Solidarity & Social Affairs, were given a tour of Checkpoint’s offices by the President of “Positive Voice”, Mr Nikos Dedes, and Centre’s scientific staff who gave them in-depth information about the Centre’s activities and operation to date. Ath Checkpoint is located in Monastiraki neighborhood (4, Pittaki Street) and operates as a Centre for HIV/AIDS Prevention, for the sexually active population. It offers information on safe-sex practices, rapid HIV testing, and collaborates with Health Units in the case of positive results. It is open Monday to Saturday from 12.00 to 20.00, and appointments can be booked by phone at +210 33 10 400.

HCDCP New Year’s cake-cutting event

In January 2014, we finally got our act together and had the traditional New Year’s cake-cutting event at HCDCP headquarters. The event was attended by the Minister of Health, Mr Adonis Georgiadis, and Deputy Minister Mrs Zetta Makri – who both expressed their support of the Organization’s difficult work – along with Dr Panos Efstathiou, Chief of EKEPY, and Mr Georgios Patoulis, Mayor of Amarousio and President of Athens Medical Association (ISA).

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Quiz of the month

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Protypo Centre for Urban Healthat Municipality of Peristeri

New Year’s cake-cutting event

On 15 January 2014, another festive event took place at the Protypo Centre for Urban Health (which is supervised by the HCDCP), at Peristeri Municipality: the Centre’s New Year’s cake-cutting with HCDCP President, Professor Jenny Kremastinou. The event was attended by Mr Ch. Karathanos, Advisor of the Minister of Health; Mr A. Theodorakos, Deputy Mayor of Peristeri, and Mrs E. Chatzipaschali, Chief of KEDY, together with the latter’s personnel. Mrs E. Giannakakou, Manager of Attikon Hospital, sent her greetings and good wishes.

1135 Helpline for Kefalonia earthquake victims

A special 24-hour Helpline “1135”, located at HCDCP headquarters, was created for the support of the victims of the recent Kefalonia earthquake. The “1135” opening ceremony was attended by Mrs Zetta Makri, Deputy Minister of Health, accompanied by Secretary General of Information & Communication, Mr A. Katsaniotis, and Secretary General of Governmental Coordination, Mr D. Vartzopoulos, who were all thoroughly informed about how the “1135” Helpline operates.

Quiz of the month, January 2014

When was the Mandatory Notification of Diseases firstly established by Law, in Greece?

A) 1943

B) 1953

C) 1963

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

The answer to December’s Quiz was: “the genetic background”.

Four people answered correctly.

Chief Editor:Ch. Hadjichristodoulou

Associate Editors:P. Koukouritakis

Μ. Fotinea

Scientific Board:Ν. Vakalis

Ε. VogiatzakisP. Gargalianos- Kakoliris

Μ. Daimonakou- VatopoulouΙ. LekakisC. Lionis

Α. PantazopoulouV. Papaevagelou

G. SaroglouΑ. Tsakris

Editorial Board:R. Vorou

E. KaratampaniP. Koukouritakis

Κ. MellouD. PapaventsisΤ. PatoucheasV. Roumelioti

V. SmetiCh. TsiaraΜ. Fotinea

Ε. Hadjipashali

Editors:Τ. Kourea- Kremastinou

HCDCP President

T. PapadimitriouHCDCP Director

Graphic Design:Ε. Lazana

Copy Editor:P. Koukouritakis

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