e_bulletinHellenic Center for Disease Control and PreventionAgrafon 3-5, Marousi, 15123, Tel: +30 210 5212000November 2014Vol.46/ Year 4rthISSN 1792-9016http://www.keelpno.gr, info@keelpno.gr

MINISTRY OF HEALTH

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION (H.C.D.C.P.)

MINISTRY OF HEALTH

H.C.D.C.P.

Contents

Main article: Leptospirosis in Greece 2

Article 9

Surveillance data 11

Interesting activities 14

Recent bublications 18

Myths and truths 20

Outbreaks around the world 21

Quiz of the month 22

Leptospira and leptospirosis

Transmission of Leptospira bacteria is based on a multifactorial mecha-nism of a dynamic nature as the ge-nus comprises 14 pathogenic species divided further into a huge number (>300) of season-, place-, host- and ecosystem- dependent strains. Main hosts (rodents, small wild mammals, domestic animals), are chronic asymptomatic carriers, in-termittently or continuously shed-ding pathogenic Leptospira by urination, and so promoting and preserving the presence of Lepto-spira, particularly in high-risk envi-ronmental niches, such as stagnant water collections and moist soil.Humans contract the disease either directly, by contact with the animals’ main hosts, which is extremely rare, or indirectly, by contact with contam-inated food, water, soil or any other environmental, moisture-bearing sources in nature. Indirect transmis-sion can also occur through contact with soiled hands. The pathogen enters the human

body through broken skin, mucosal membranes or by inhalation of con-taminated aerosol or droplets. At the beginning, Leptospira are present in peripheral blood and then disappear from the blood and settle in certain organs and tissues of the organism. Humans are accidental hosts, since insufficient numbers of Leptospira are present in urine and are unable to propagate transmission to other humans or other main or accidental hosts. Clinical disease may vary from mild to grave, and mortality rate can reach 5–15% (Weil’s disease). Certain forms of pneumonic hem-orrhage have recently been attrib-uted to leptospirosis and present a mortality rate of 50%. Epidemiology and aspects of clini-cal disease are associated with the taxonomic classification of strains, which is a challenging and labori-ous task, considered unreliable by some. Molecular techniques are studied as a useful tool for identi-fication of Leptospira in the future.

Prof. Yannis Tselentis

Leptospirosis: path physiology, epidemiological data for Greece, leptospirosis in animals, prevention and recommendations to travellers.

Page 2

HCDCP’s Interventions at Zakynthos and Corfu islands for the epidemiological surveillance of leptospirosis cases.

Page 14

Professor Billinis from the University of Thessaly demystifies the Myths and reveals the Truths about leptospirosis, in the very popular Myths and Truths column.

Page 20 http://en.wikipedia.org

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Leptospirosis in Greece

IntroductionThe Leptospira genus includes several heterogenic groups of pathogenic (group I and II) and of non-pathogenic microorganisms. Taxonomy on a genetic basis, describes 14 different species of pathogens, grouped in 260 different serovars, classified in antigenically similar groups. The diversity of serovars is due to structural heterogenicity of the distal part (antigen 0) of the superficial lipopolysaccharides (LPS) and the variance of the biosynthetic apparel encoding antigen 0 (locus rfb) [1,2,3]. The transmission cycle includes main hosts, which play the role of natural reservoirs of the pathogen, and the incidental hosts. Main hosts are usually asymptomatic and include animals in which the disease is endemic. Leptospires in the main vectors present with well-adapted strains, escape the immunological response and establish chronic infection, colonizing the renal tubules. As a result, large numbers of the microorganism may be expelled through urine, in a continuous or intermittent way, contaminating the environment. By contrast, incidental hosts are infected by non-well-adapted strains which cause a massive immunological response and manifest mild or severe disease of a classical nature (Weil’s disease), or the newest types of manifestations (pneumonic hemorrhage), with potentially fatal outcomes. Animals appear to be the main hosts of certain serovars, and incidental hosts of others [4]. Most important main hosts are small mammals (chiefly rodents), but not exclusively, as domestic animals (bovines, small ruminants, dogs) may also play the role of main host. Animal species acting as main hosts may be different in certain areas. Adaptation of a serovar to a new animal species is favored by the fluctuation of the genes of locus rfb and is pertinent to the serovars of the specie (i.e. L. interrogans) which carry other mechanisms of gene adaptation, according to the pan-genomic and patho-genomic science. The spread of the disease depends on the frequency of contact between main and incidental hosts. Epidemiological investigation of the infection source and the

route of transmission in a given area is based on the knowledge of the dominant Leptospira serovars and the main hosts in that area [2]. Molecular mechanisms contributing to the pathogenicity of the disease remain largely unknown. Specific infective agents genetically described below, are an ompA-like superficial protein, encoded by the gene Loa22, a soluble adenylic cyclase resulting in increase of the cAMP of cells involved in the immunological response, and two paralog genes (PF07598) up-regulating expression of the superficial antigens of pathogens belonging to group I. Epidemiological data of transgenic lab rodents suggest that PF07598 genes reduce colonization of renal tubules and promote the hypothesis that leptospires cause different expressions of proteins and downregulation of superficial antigens. Apparently, a molecular mechanism evolved in leptospires, which enables them to avoid immunological attack, facilitates colonization of renal tissue, causes persistence of the microorganism in urine, and contributes to the pathogenesis of chronic interstitial nephritis [5]. The immune response is mainly of the antibody type, is directed against LPS, and is specific for a certain serologic group. The host response also seems to play an important role in the toll-like receptors TLR2 and TLR4 (producing many immune components and numerous cytokines) and the macrophages. Nevertheless, those two immune response mechanisms differ between rodents and humans, a fact compatible with the hypothesis that differences exist in those hosts and therefore in the cycle of transmission [4]. Ideal conditions for the survival of leptospires in the environment are the presence of water and an average temperature of around 22°C, with fluctuations of no more than ± 5°C [6]. The pathogen is susceptible to dry conditions, to UV radiation, to all antiseptics or detergents, and is quickly neutralized by exposure to temperatures ≥50°C (indicative temperature/time required for inactivation, 50°C/10¢, 60°C/10²) [7,8,9] . The incubation period is 2–30 days, more frequently 5–14 days [10]. The disease presents with a broad spectrum of clinical manifestations, ranging from sub-clinical infection in 90% of cases to severe disease with multi-organ failure (Weil’s dyndrome) and mortality that may be more than 15% [11,12].

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Epidemiology of leptospirosis in GreeceIn Greece, leptospirosis is an obligatory notifiable disease. The yearly incidence (number of cases per 100,000 of population) for the period 2004–2013 ranged from 0.12 to 0.31 and the average annual incidence was 0.21, without a specific temporal pattern (Figure 1a). In remaining countries of the European Union (EU), according to available data of the years 2007–2011, the incidence ranged from 0.11–0.22 with a 0.15 average incidence for that period and a decreasing temporal trend13 (Figure 1b). Over the last year of available data (2011), the minimal incidence by country was 0.0 and maximum 0.46.

Figure 1a. Incidence of leptospirosis cases per year of notification, Greece, 2004–2013.

Figure 1b. Incidence of leptospirosis per year of notification, EU, 2007–2011.

Source: ECDC Annual Report 2013

The incidence shows a notable increase in the period August–October, as is the case in areas with a mild climate [1] and is believed to be

due to favorable conditions of temperature and moisture in the environment (Figure 2a). A similar monthly distribution of cases appears also in the EU (Figure 2b). The connection of the disease with environmental factors has been established and prognostic models have been proposed to link the frequency of cases with climatologic parameters, i.e. average monthly precipitation and average monthly temperature, [14] or with geophysical characteristics, i.e. the draining capacity of the soil, or hydrologic conditions of the area [15].

Figure 2a. Mean number of cases per month of notification, Greece, 2004–2013

Figure 2b. Mean number of cases per month of notification, EU, 2007–2011.

Source: ECDC Annual Report 2013

The mean age of cases was 53 years (95% CI: 50–55, minimum: 12, maximum: 84) (Figure 3a) and 84% were males. The high proportion of males among cases could be due to increased exposure resulting from high-risk professions or occupations usually associated with men [10]. The age group most affected was the 45–64 year-old group

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(41%). Similarly, in EU, 83% of cases were males and the age distribution shows the same pattern, but with younger ages being slightly more affected [13] (Figure 3b).

Figure 3a. Age distribution of leptospirosis cases, Greece, 2004–2013.

Figure 3b. Age distribution of leptospirosis cases, EU, 2007–2011.

Source: ECDC Annual Report 2013

Spatial distribution of cases is particularly interesting because, over the years, highly endemic areas have been identified, with a markedly higher incidence than the rest of Greece. The Ionian Islands Region has the highest incidence (0.35) while the Attica Region the lowest (0.03) (Table 1). At the Prefecture level, the highest case frequency appears in Zakynthos (2.21) while Heraklion has the lowest (0.30) (Map 1).

Table 1. Distribution of mean annual incidence of leptospirosis cases by Region of residence, Greece, 2004–2013.

Region MeanAnnual

Ionian Islands 1.35

Western Greece 0.59

Epirus 0.45

Thessaly 0.44

Central Macedonia 0.30

Central Greece 0.20

Crete 0.13

Western Maceconia 0.11

North Aegean 0.10

Peloponnese 0.10

Southern Aegean 0.10

Eastern Macedonia & Thrace 0.07

Attica 0.03

Map 1. Mean annual incidence of leptospirosis by Prefecture, Greece, 2004–2013.

The increased incidence in some areas probably reflects specific environmental characteristics that contribute to higher loads of pathogen for a longer duration [1,14]. Leptospirosis is traditionally connected to certain occupations which are regarded as increasing chances of exposure to the pathogen, e.g. farmers, animal stock holders, rice-field workers, hunters, mine-workers, sewage-workers, veterinarians or military personnel, especially during exercise in tropical areas [10]. Because of risky behavioral patterns, children may be in increased danger, especially when coming in contact with moist soil or mud in places where animals urinate. Recreational or sport activities, e.g. camping, trekking in nature, or canoe-kayaking, rafting, swimming in white water, or athletic events in environments with mud, ponds, rivers or lakes, or any non-

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salty water collection, may cause exposure to leptospires [16]. Group activities or mass events create conditions for large outbreaks with a point source and may even have an international character [16,17].In Greece, according to data from the notified cases, more frequent high-risk occupations connected with leptospirosis were farmers (46.7%) and animal stock holders (10.0%) (Figure 5). Sports activities in rivers or lakes (5.1%) and camping (5.1%) are the most frequently recorded high-risk activities (Figure 6).

Figure 5. Percentage % of high-risk occupations / professions in leptospirosis cases, Greece, 2004–2013.

Figure 6. Percentage % of high risk recreational /sport activity in leptospirosis cases, Greece, 2004-2013.

Remarkably, in a significant percentage of 37% of cases, there was no history of high-risk exposure, either occupational or activity-based. Admission to hospital was recorded in 97% of cases. The most frequent manifestation was renal insufficiency and jaundice (Table 2). Mortality, according to data from notification forms, which however does not include follow-up, was 7.4%.

Table 2. Clinical symptoms of leptospirosis based on data from Obligatory Notification System, Greece, 2004–2013.

Clinical symptom

Percentage %of cases

Renal Insufficiency 89.9Jaundice 89.5Hepatic Insufficiency 73.3Hemorrhagic rash 35.0Meningoencephalitis 20.3

The mean time for admission to hospital, from the date of onset of symptoms, was 5.04 days (CI 95%: 4.45–5.61, minimum: 0, maximum: 28) (Figure 7). Successful management of a patient depends on seeking medical help early and the prompt diagnosis by physician of leptospirosis, based on the history and clinical presentation. A course of antibiotics, starting as early as possible, and importantly, in the first 5 days after onset of symptoms, is crucial for an uncomplicated recovery [10].

Figure 7. Time interval (days) between onset of symptoms and admission of patient to a clinical setting, Greece, 2004–2013.

A small scale sero-epidemiological survey was performed in Greece, in 1980, examining circulating serovars of Leptospira spp. The population under study was high-risk workers (rice-field workers, sewage-workers) and the general population, and the most frequently isolated serovars were grippotyphosa, hebdomadis and icterohaemorrhagiae [18].

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Leptospirosis in animalsMany of the 270 known serovars of Leptospira spp. infect animals, either clinically or sub-clinically, some of which become reservoirs of the pathogen in nature. Variable morbidity, which differs for each serovar and is related to adaptation in specific animal species, hinders epizootiological study of the microorganism in animals and the determination of the importance of each serovar for public health purposes. Continuous study of the distribution of serovars in nature may provide evidence of the significance of each serovar in susceptible animals, because serovars are in a dynamic state of change, altering the morbidity in animals as much as in humans. Recognition of serovars and therefore serovar prevalence in animals is performed with the Microscopic Agglutination Test (MAT). Based on this method, Leptospira prevalence in wild animals, regardless of serovar, is 13–52%, according to animal species, country and specific area, while in some districts, seroprevalence was zero. Globally, where climate promotes the survival of the pathogen in nature, prevalence is over 50% in bovines, small ruminants and swine; over 66% in dogs, and up to 35% in cats. Internationally, the most frequently identified serovars in bovines, depending on area, are autumnalis, bratislava, grippotyphosa, hardjo, castellonis, pomona, tarassovi και Wolffi. In small ruminants, they are autumnalis, castellonis, grippotyphosa, icterohaemorrhagiae, hardjo, sejroe, shermani; in swine, bratislava, hardjo-bovis, sejroe, pomona, shermani. In Greece, leptospirosis in animals was reported for the first time in 1932, followed by a second report in 1955 and a third in 1987. In 2002, a study carried out by the author and her team recorded high seropositivity in bovines connected to abortion cases (mean seroprevelence: 23.5%). Among clinically healthy bovines, sheep, goats, swine and dogs, positive animals were found in 2.6%, 5.7%, 16.2%, 17.8%, 11.4% respectively. Most common serovars in bovines, sheep and swine were bratislava and copenhageni, and in dogs was copenhageni, which is notably not included in the administered vaccines. Newer research in western Peloponnese revealed 24% seroprevalence in small ruminants.

Seropositivity is independent of morbidity of serovars. Consequently, a seropositive animal does not pose an immediate risk for humans. Connection of animal leptospirosis and human leptospirosis is only possible if infective serovars in human cases are investigated in relation with their occupational or other, especially high-risk, activities.Remarkably, a significant proportion of serovars copenhageni and tarassovi, considered to be highly pathogenic for humans, were identified in animals in Greece, but not as frequently in other countries.Differences in serovars are apparent in different geographic areas and animal species, and pathogens may be spilled in the environment by agricultural animals as well. Thus, asymptomatic rodent hosts are not solely responsible for maintaining environmental contamination. Climate change, such as global warming, may contribute to the spread of the microorganism to areas not significantly affected before, so leptospirosis is considered a re-emerging disease. Efforts for systematic molecular studies of Leptospira spp. are undertaken by international scientific teams, with the aim of using reliable molecular techniques to identify infective serovars promptly and to design effective vaccines against several serovars which cause disease in animals or humans. Lack of adequate antigenic affinity makes current vaccines for serovars ineffective for any other serovars than those contained in the vaccine. Furthermore, the vaccines protect from clinical disease against the specific serovars which are designed, but do not prevent renal colonization and subsequent excretion of live leptospires through the urine of animals.

Conclusions:• The spread of leptospira in the

environment is due not only to wild animals, or especially rodents.

• Domestic animals, among them agricultural, contribute significantly both as asymptomatic or clinically ill (i.e. excretion of pathogen through abortion products).

• An animal vaccinated against leptospirosis may present the risk of

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infection for the owner. • There is a need to establish a national

team for the epidemiological surveillance of circulating leptospires in the serovar levels in humans as much as in animals.

Prevention of leptospirosis Prevention measures focus on using appropriate protective equipment and applying rules of hygiene so that leptospires potentially present in the environment cannot enter the organism. Rodent control is also important as these animals are considered the most important hosts and transmitters. Finally, seeking medical help promptly is important if systematic symptoms occur, especially when there is history of high-risk exposure during previous weeks.

More specifically, prevention measures include:

• Using impermeable gloves, clothing and boots so that skin is protected during work in high-risk environments, such as stagnant waters, mud, moist vegetation, farms, or any environment which combines moisture and potential rodent activity.

• Covering open wounds with impermeable patches during farming activities or activity in a high-risk environment.

• Thorough washing or dipping in hot water (>50°C) of vegetables or other soiled

farming products that are intended to be consumed raw. Specifically, immediate consumption of produce directly from a farm should be avoided (e.g. grapes, if not thoroughly washed beforehand).

• Avoiding leaving food in places where rodents are potentially present. Food must be preserved in such a way that no contact with rodents is possible.

• Avoiding swimming or contact with potentially contaminated water (rivers, lakes) and using personal protective equipment when such activity cannot be avoided.

• Controlling rodents in inhabited places. Removing garbage, draining stagnant water and improving sanitary conditions around houses so that they are unattractive to rodents. Blocking rodents’ access in the residence (i.e. covering holes, cracks, etc. with metallic mesh).

• Avoiding direct, unprotected contact with urine of agricultural or domestic animals and complying with hygienic measures (using gloves, washing hands).

• Seeking medical help promptly in a case where fever, myalgia, shivering manifests. The patient must mention any contact with rodents or a high-risk environment, up to one month before onset of symptoms (usually 1–3 weeks previously).

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References

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six epidemic serogroups of Leptospira in China,BMC Microbiol.,2010,10,67-714. Manahan A. M. ,Host - Pathogen Interactions in the Kidney during.chronic

Leptospirois,Vet.Pathol.,2009,46,792-7995. Lehmaan J. S., Pathogenomics Inference of Virulence -Associated Genes in Leptospira

interrogans, PLoS Neglected Tropical Diseases,2013,7(10),e24686. World Health Organization. Guidelines for the prevention and control of leptospirosis.

Zoonosis Division, National Institute of Communicable Diseases, 22 Sham Nath Marg, Dehli-110 054; 2006

7. Spickler A.R., Leedom Larson K.R. Leptospirosis. August 2013. At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php

8. Parija Subhash Chandra et al, Emerging and Re-Emerging Infectious Diseases McGraw Hill, New York 2009

9. Pope V., Johnson R. (1991). Effect of heat or formalin treatment of leptospires on antibody response detected by immunoblotting. J. Clin. Microbiol. 29:1548-1550.

10. Human Leptospirosis: Guidance for diagnosis, Surveillance and Control, WHO 200311. Mandell G.L., Bennet J.E., Dolin R. Principles & Practice of Infectious Diseases, 6th

edition, Vol 2. Elsevier/Churchill Livingstone, Philadelphia, 200512. Marotto P.C., Nascimento C.M., ElufNeto J., et al. Acute lung injury in leptospirosis:

clinical and laboratory features, outcome, and factors associated with mortality. Clin Infect Dis 1999;29:1561-3

13. European Centre for Disease Prevention and Control. Annual Epidemiological Report 2013. Reporting on 2011 surveillance data and 2012 epidemic intelligence data.Stockholm: ECDC; 2013.

14. Desvars A. et al. 2011. Seasonality of human leptospirosis in La Réunion island (Indian ocean) and its association with meteorological data. PLoS One 6: e20377.

15. Vega-Corredor M.C., Jacob O. Earth Perspectives February 2014, 1:3, Open Access Date: 12 Feb 2014 Hydrology and public health: linking human leptospirosis and local hydrological dynamics in Trinidad, West Indies

16. Bharti A.R. Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis. 2003 Dec;3(12):757-71.

17. Suneth Agampodi et al The Lancet Infectious Diseases, The potential emergence of leptospirosis in Sri Lanka Volume 9, Issue 9, Pages 524 - 526, September 2009 doi:10.1016/S1473-3099(09)70211-7.

18. Tselentis Y., Mailloux Μ., Stathakakis V., Cordossis Th., Melissinos K., Archives Institute Pasteur Hellenic, 1980, τ. 26 σελ.:72-78

Georgios Dougas, DVM, Zoonoses Office, Department of Epidemiological Surveillance, and Intervention , HCDCP

Aggeliki Rodi-Burriel DVM, MSc, MSc, PhD, Prof. of Veterinary Microbiology, Faculty of Veterinary Science, University of Thessaly

Yannis Tselentis, Prof. of Bacteriology, Parasitology, Zoonoses , and Geographical Medicine,Faculty of Medicine, University of Crete

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Article

Leptospirosis in travellers

International travel is growing rapidly worldwide. It has been estimated that international travellers will reach nearly 1.6 billion by 2020, with the highest rise in tropical and subtropical areas [1]. Leptospirosis is considered the most widespread zoonosis, occurring worldwide except in polar regions. During the past decade, leptospirosis has been increasingly recognized among adventure travellers in temperate and tropical areas. Protean manifestations of leptospirosis and unawareness of this illness as a cause of fever in the returning traveller may lead to many unrecognized cases [2,3]. Because the outcome of the disease is potentially fatal, physicians should consider leptospirosis in febrile travellers with compatible epidemiological history, and promptly administer treatment.Transmission of leptospirosis may occur worldwide in both rural and urban areas; however, the incidence of infection is significantly higher in tropical areas [4,5,8–12]. Traditionally, leptospirosis has been considered an occupational hazard among professionals in contact with urine of infected animals [9,13]. However, outbreaks are increasingly reported among adventure travellers and athletes participating in freshwater sports [10,11,14–20]. Information regarding prophylactic measures should be targeted at this group of travellers and leptospirosis should be considered in febrile travellers returning with a compatible epidemiologic association [7,9,21]. The precise incidence of leptospirosis remains unknown because of the worldwide lack of awareness or systemic investigation for this illness. Estimates of annual incidence rates range from 0.02 to 1/100,000 persons in temperate areas and from 10 to 100/100,000 persons in humid tropics. During outbreaks, and in high-risk exposure groups, incidence may reach 100/100,000 persons [6,22]. Climate and rainfall influence the incidence and seasonality of leptospirosis. The higher incidence in the tropics is related to the longer survival of leptospires in the warm and humid environment, and in tropical areas to the presence of stagnant waters and poor sanitary conditions [22]. Although an increasing number of imported leptospirosis cases and

outbreaks following international travel and adventure activities has been published during the last decade [5,10,11,15,17,20,24–26], most leptospiral infections in this group probably remain unrecognized. Reasons for this include the non-specific symptoms commonly encountered in leptospirosis, the lack of awareness of this illness as a cause of fever among returning travellers, and the relative unavailability of testing. However, given the increasing popularity of travel and eco-tourism in tropical areas, it appears that the risk and thus the incidence of leptospirosis among travellers will increase. Examples of leptospirosis outbreaks include the outbreak in Springfield, Illinois in 1998, at an international triathlon athletic event, where the attack rate was 12% among 834 participants [11], and the outbreak that occurred among 304 athletes from 27 countries in the ‘Eco-Challenge’ multisport race in Malaysia in 2000 with an attack rate of 62% of all athletes [10].Adventure travellers, athletes participating in freshwater sports, and military recruits travelling in areas endemic for leptospirosis should be informed about the risk of infection during high-risk activities and advised about preventive measures: wearing protective waterproof clothes and boots, avoiding submersion and consumption of river water, and covering cuts and abrasions with waterproof dressings in order to minimize exposure to a contaminated environment. Special attention should be paid to travellers travelling to areas recently affected by floods. Drinking water should be purified by boiling and treating with chlorine. Filtration of water might not be effective because of the size of the organism which can pass through 0.45 µM filters [9]. Pre-travel counselling should focus on preventive measures, including the administration of prophylactic doxycycline for travellers engaged in freshwater activities in endemic areas. Pre-exposure doxycycline chemoprophylaxis at 200 mg/week p.o. should be considered for high-risk travellers. High-risk activities include fresh water swimming, rafting, kayaking, canoeing, fishing, hunting, and trail biking. Health-care providers should be aware of the possibility of imported leptospirosis among febrile returning travellers with a compatible epidemiological history, and administer appropriate treatment.

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References

1. World Tourism Organization. Tourism 2020 vision, last accessed: June 18, 2008, at: www.world-tourism.org

2. Travel Industry Association. Travel Market segments, last accessed: June 18, 2008, at: www.tia.org/researchpubs/travel_market_segments.html

3. Wilson ME, Freedman DO. Etiology of travel-related fever. Curr Opin Infect Dis 2007;20:449-4534. Meites E, Jay MT, Deresinski S, et al. Reemerging leptospirosis, California. Emerg Infect Dis

2004; 10:406-4125. Jansen A, Schneberg I, Frank C, et al. Leptospirosis in Germany, 1962-2003. Emerg Infect Dis

2005;11:1048-10546. Katz AR, Ansdell VE, Effler PV, et al. Leptospirosis in Hawaii, 1974-1998: epidemiologic analysis

of 353 laboratory confirmed cases. Am J Trop Med Hyg 2002;66:61-707. Meslin FX. Global aspects of emerging and potential zoonoses: a WHO perspective. Emerg

Infect Dis 1997;3:223-2288. Ellis RD, Fukuda MM, McDaniel P, et al. Causes of fever in adults in the Thai-Myanmar border.

Am J Trop Med Hyg 2006;74:108-113 9. Bharti AR, Nally JE, Ricaldi JN, et al. Leptospirosis: a zoonotic disease of global importance.

Lancet Infect Dis 2003; 3:757-771 10. Sejvar J, Bancrift E, Winthrop K, et al. Leptospirosis in “Eco-Challenge” athletes, Malaysian

Borneo. Emerg Infect Dis 2000;9:702-70711. Morgan J, Bornstein SL, Karpati AM, et al. Outbreak of leptospirosis among Triathlon participants

and community residents in Springfield, Illinois 1998. Clin Infect Dis 2002;34:1593-159912. Perra A, Servas V, Terrier G, et al. Clustered cases of leptospirosis in Rochefort, France, June

2001. Euro Surveill 2002;7:131-13613. Jena AB, Mohanty KC, Devadasan N. An outbreak of leptospirosis in Orissa, India: the importance

of surveillance. Trop Med Int 2004;9:1016-102114. Narita M, Fujitani S, Haake DA Paterson DL. Leptospirosis after recreational exposure to water

in the Yaeyma islands, Japan. Am J Trop Med Hyg 2005;73:652-65615. Haake DA, Dundoo M, Cader R, et al. Leptospirosis, water sports, and chemoprophylaxis. Clin

Infect Dis 2002;34:40-4316. Abb J. Acute leptospirosis in a triathlete. Wilderness Environ Med 2002;13:45-47 17. Centers for Disease Control and Prevention (CDC). Outbreak of leptospirosis among white-

water rafters – Costa Rica 1996. MMWR Morb Mortal Wkly 1997;46:577-579 18. Shaw RD. Kayaking as a risk factor for leptospirosis. Mo Med 1992;89:354-35719. Koay TK, Nirmal S, Noitie L, Tan E. An epidemiological investigation of an outbreak of leptospirosis

associated with swimming, Beaufort Sabah. Med J Malaysia. 2004;59:455-45920. Nardone A, Capek I, Baranton G, et al. Risk factors for leptospirosis in metropolitan France: results

of a national case-control study, 1999-2000. Clin Infect Dis 2004;39:751-753 21. Levett PN. Leptospirosis. Clin Microbiol Rev 2001;14: 296-32622. World Health Organization. Human leptospirosis: guidance for diagnosis, surveillance and

control, last accessed: June 18, 2008, at: http://whqlibdoc.who.int/hq/2003/WHO_CDS_CSR_EPH_2002.23.pdf

23. Antony SJ. Leptospirosis – An emerging pathogen in Travel Medicine: a review of its clinical manifestations and management. J Travel Med 1996;3: 113-118

24. Gelman SS, Gundlapalli AV, Hale D, et al. Spotting the spirochete: rapid diagnosis of leptospirosis in two returned travelers. J Travel Med 2002;9:165-167

25. Van Crevel R, Speelman P, Gravekamp C, et al. Leptospirosis in travelers. Clin Infect Dis 1994;19:132-134

26. Haddock RL, Gilmore JW, Pimentel F. A leptospirosis outbreak on Guam associated with an athletic event. Pac Health Dialog 2002;9:186-189

Androula Pavli, Travel Medicine OfficeHelena Maltezou, Department for Interventions in Health-Care Facilities

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Surveillance data

OCTOBER 2014

Table 1. Number of notified cases in October 2014, median number of notified cases in October for the years 2004−2013 and range, Mandatory Notification System, Greece.

Disease Number of notified cases

October 2014

Median number October

2004−2013

Min number October 2004-

2013

Max number October

2004-2013Botulism 0 0 0 0Chickenpox with complications 1 0 0 1Anthrax 0 0 0 2Brucellosis 8 9 3 16Diphtheria 0 0 0 0Arbo-viral infections 0 0 0 0Malaria 6 5 1 27Rubella 0 0 0 1Smallpox 0 0 0 0Echinococcosis 0 1 0 3Hepatitis Α 0 9 3 44Hepatitis B, acute & HBsAg(+) in infants < 12 months 4 4,5 0 9

Hepatitis C, acute & confirmed anti−HCV positive (1st diagnosis) 4 1 0 6

Measles 0 0 0 1Haemorrhagic fever 1 0 0 1Pertussis 1 2 0 9Legionellosis 2 2 1 5Leishmaniasis 5 3 1 11Leptospirosis 5 2 0 7Listeriosis 1 0 0 1EHEC infection 0 0 0 0Rabies 0 0 0 0Melioidosis/Glanders 0 0 0 0Meningitis

aseptic 10 23 7 53bacterial (except meningococcal disease) 5 14 7 27unknown aetiology 0 1,5 0 10

Meningococcal disease 2 5,5 4 12Plague 0 0 0 0Mumps 0 0 0 1Poliomyelitis 0 0 0 0Q Fever 2 0 0 3Salmonellosis (non typhoid/paratyphoid) 30 70 27 132Shigellosis 6 4,5 2 20Severe Acute Respiratory Syndrome 0 0 0 0Congenital rubella 0 0 0 0Congenital syphilis 0 0 0 1Congenital Toxoplasmosis 0 0 0 0Cluster of foodborne / waterborne disease cases 3 2 0 7Τetanus / Neonatal tetanus 0 0,5 0 3Tularaemia 0 0 0 0Trichinosis 0 0 0 0

Typhoid fever/Paratyphoid 0 2 0 3

Tuberculosis 33 57,5 35 73Cholera 0 0 0 0

12

Surveillance data

Table 2. Number of notified cases by place of residence (region), Mandatory Notification System, October 2014 (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 1 0 0 0 0 0Brucellosis 0 0 0 1 2 0 1 0 1 3 0 0 0 0Malaria 0 0 0 0 0 0 0 0 4 1 0 0 1 0

Hepatitis B, acute & HBsAg(+) in infants < 12 months 0 0 0 0 1 0 0 0 2 1 0 0 0 0

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

Haemorrhagic fever 0 1 0 0 0 0 0 0 0 0 0 0 0 0Pertussis 0 1 0 0 0 0 0 0 0 0 0 0 0 0Legionellosis 0 0 0 0 0 0 0 0 1 0 0 0 0 1Leishmaniasis 0 1 0 0 2 0 0 0 0 0 1 0 1 0Leptospirosis 1 0 0 0 1 3 0 0 0 0 0 0 0 0Listeriosis 0 0 0 0 0 0 0 0 1 0 0 0 0 0Meningitis

aseptic 0 2 0 1 3 0 1 0 0 1 0 0 2 0bacterial (except meningococcal disease) 0 0 0 0 0 2 1 0 2 0 0 0 0 0Unknown aetiology 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Meningococcal disease 0 1 0 0 0 0 0 0 0 1 0 0 0 0Q Fever 0 0 0 0 0 0 0 0 1 1 0 0 0 0Salmonellosis (non typhoid/paratyphoid) 1 2 0 0 7 2 3 3 5 2 4 0 1 0Shigellosis 0 0 0 0 4 0 1 0 1 0 0 0 0 0Cluster of foodborne / waterborne disease cases 0 0 0 0 1 0 1 0 0 0 0 0 1 0

Tuberculosis 0 4 0 1 2 2 1 4 13 1 0 0 2 3

13

Surveillance data

Table 3. Number of notified cases by age group and gender, Mandatory Notification System, Greece, October 2014 (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 FChickenpox with complications 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0

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

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

0 0 0 0 0 0 2 0 0 1 0 0 0 1 0 0 0 0 0 0

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

0 0 0 0 0 0 0 0 1 0 3 0 0 0 0 0 0 0 0 0

Haemorrhagic fever 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0Pertussis 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Legionellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0Leishmaniasis 0 0 0 1 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 0Leptospirosis 0 0 0 0 0 0 0 0 1 0 1 0 0 0 2 0 1 0 0 0Listeriosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0Meningitis

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

bacterial (except meningococcal disease)

0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 2 0 0 0 0

Unknown aetiology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Meningococcal disease 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0Q Fever 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0

Salmonellosis (non typhoid/paratyphoid) 0 3 2 5 8 5 0 0 0 0 0 0 1 0 2 2 2 0 0 0

Shigellosis 0 0 3 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0Tuberculosis 0 0 0 0 0 0 6 0 6 4 4 1 2 0 3 0 5 2 0 0

The presented data 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 notified 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 October 2014 are provisional, and can 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

14

Interesting activities

Intervention in Zakynthos: existing record of leptospirosis cases

HCDCP appointed a working group involving Dr. G. Rigakos of the Office of Animal Diseases, Department of Epidemiological Surveillance and Intervention, Mr. B. Paraskevopoulos, Agronomist in the Office of Environmental Health, and led by Emeritus Professor of Bacteriology, Parasitology, Animal Diseases and Geographical Medicine, Prof. John Tselentis, to investigate the existing record of leptospirosis cases in Zakynthos.The team of experts visited Zakynthos from 22–26 September 2014. The intervention was organized and implemented by the above offices in collaboration with the Directorate of Public Health and Social Welfare of Zakynthos. The purpose of the visit was

1. to organize surveillance, prevention and control of leptospirosis in Zakynthos,

2. to investigate sources of infection, modes of transmission and host diseases,

3. to contribute to the development of a disease control protocol in Zakynthos. Professor Tselentis, in meetings with local au-

thorities and interviews with the local media, informed them about the extent of the pro-liferation of the disease on the island, con-cluded that the transmission of the disease involved other animals (sheep, cattle, dogs, horses) in addition to rodents, and suggested organizing a voluntary network for epidemio-logical surveillance in animals by volunteer veterinarians. He also stressed the impor-tance of information campaigns at Primary and Secondary Education Institutions as well as for the authorities of the local community and the broader public, in order to promote appropriate disease control measures. During the team’s stay, informative interven-tions took place in the Courtroom Region-al Council of Zakynthos Regional Unity for health professionals, veterinarians and the public. The team also visited many cases.It was found that the disease is transmitted during agricultural work and the areas of oc-currence of cases are in the same geomor-phological basin of surface water. It is nec-essary to complete an epidemiological study, to perform a systematic surveillance of the disease in animals, and to conduct compre-hensive rodent control programs. It is also very important that both health professionals and the public on the island are alerted to and aware of the disease.

Paraskevopoulos Bill, Agronomist, Office of Environmental Health, HCDCP

15

Interesting activities

HCDCP response to Corfu leptospirosis cases

Following previous actions, and in response to the increased incidence of leptospirosis in the Region of Ionian Islands, HCDCP appoint-ed a working group consisting of members of the Office of Animal Diseases, Department of Epidemiological Surveillance and Interven-tion; members of the Office of Environmental Health, and the Emeritus Professor of Bac-teriology, Parasitology, Animal Diseases and Geographical Medicine, Dr. John Tselentis.

Prof. I. Tselentis, doctor of the Office of Ani-mal Diseases, Department of Epidemiologi-cal Surveillance and Intervention; Dr. G. Rigakos, and the agriculturist of the Environ-mental Health Office, Mr. B. Paraskevopou-los, visited Corfu from 17–23 October 2014. Members of these two offices organized the intervention in collaboration with the Munici-pality of Corfu and the General Directorate of Public Health and Social Care of the Region of Ionian Islands.The purpose of the visit was(1) to organize surveillance, prevention and control of leptospirosis in Corfu,(2) to investigate infection sources, modes of transmission and host disease,(3) to contribute to the development of α dis-ease control protocol in Corfu.During the team’s stay on the island of Corfu, epidemiological and environmental investiga-tion of reported cases took place, as well as a series of meetings with the local authorities. An information campaign was also held for

the health professionals and for all the public authorities of the island.

On 20 October, a group of HCDCP met in the Region Building with the Regional Direc-tor of the Ionian Islands, the Vice-Regional Director of Corfu, the Vice-Regional Director of Zakynthos, the Vice-Regional Director of Kefalonia, Ithaca; the Vice-Regional Director of Lefkada, and the Executive Director of the Ionian Islands on Health Issues.On 21 October, the group met the Mayor of Corfu at his office. The meeting was also at-tended by the Deputy Mayor of Corfu, Head of the Department of Primary Production Is-sues, and the Director of Social Protection, Education and Culture.On the same day, an informative intervention took place, organized with the assistance of the Municipality of Corfu. At this meeting, the speaker, Mr. B. Paraskevopoulos, stressed the importance of disease prevention.

The following day, the doctor of Animal Diseases Office, Dr. G. Rigakos, briefed all healthcare professionals from National Corfu Hospital,

16

Interesting activities

local health units, and health professionals from the private sector on the prevention, diagnosis and treatment of leptospirosis. The discussion covered the epidemiological data on leptospirosis in Greece, especially in Corfu. Special emphasis was placed on the importance of early diagnosis and initiation of treatment of the disease, as well as on the details of laboratory tests.

On 23 October, the group met the Director of Veterinary Medicine of Corfu. This meeting

was attended by veterinarians of the Veterinary Authority, and the President of the Chamber of Corfu Private Veterinarians.It was decided to carry out an epidemiological study and a systematic surveillance of the disease in animals, and to implement a number of comprehensive rodent control programs. It is also very important that the health professionals and the general population of the island are made aware of the disease.

Paraskevopoulos Bill, Agronomist, MSc, Office of Environmental Health, HCDCP

Rigakos George, Office of Animal Diseases, HCDCP

17

Interesting activities

Brazilian “Vive la Grèce” for Dr. Stathis Avramidis at the Symposium and Sport Lifesaving Championship

Two medals were presented to Dr. Stathis Avramidis (Associate HCDCP Director Sport Lifesaving of the Hellenic Federation of Un-derwater Activity, HFUA) for his participation in and contribution to the Sport Lifesaving Championship and the International Sympo-sium of Aquatic Rescue in Brazil. In the spirit of ‘fair play’, the announcer and the spec-tators cheered “Vive la Grèce!” during the events, for the Greek athlete who won their respect for his participation and scientific contributions. The events took place in Vitoria, Brazil, under the auspices of the organizations SOBRASA and CBMES. Four hundred athletes, officials, coaches and other authorities participated. Dr. Avramidis competed in four open water and swimming pool events in the Category E for Masters (aged 40–45 years). In the International Symposium of Aquatic Rescue, Floods & Pools, Dr. Avramidis gave two presentations on Greek Lifeguard Legis-lation, and “Near-Death Experiences of the Drowning Victim” based on his in-press book with Prof. Janice M. Holden. The first presen-tation surprised the participants with its ac-count of the level of the Greek lifeguard legis-lation. At the end of the second presentation, four attendees gave personal accounts of near-death experiences caused by drowning, open-heart surgery, and a sailing accident. SOBRASA’s President, Joel Prates Pedroso, said: “Greek, your contribution to the success of the symposium was very important. We are very happy to have you with us.” The leader of the event, Dr. David Szpilman (SOBRASA Medical Advisor and International Life Saving Federation’s distinguished member), commented: “Stathi, we thank you

for everything you did while you were here. When everybody believed the Earth was flat, whoever dared to say that it was round was taking a risk. In the field in which we serve, you are doing the same thing, offering us new insights and understanding.” Dr. Avramidis, added: “Sport Lifesaving is the only sport that is related so closely to the preservation of public health from aquatic accidents. In the Symposium, we learned that for every 1 euro not spent on prevention, we will later need to spend 7 euro on intervention to save a human life. The HCDCP and the HFUA that I serve play a key role that I hope will be enhanced by the Ministry of Health with improved legislation. My participation in these sporting and scientific events represents the planting of a modest seed. I thank the HCDCP President, Prof. Kremastinou, the HCDCP General Director, Dr. Papadimitriou the CPHL Technical Director, Dr. Velonakis, and my family”.

Soon the HCDCP, in association with the HFUA, will launch a free program on ‘Water Safety and Sport Lifesaving’ for the general public in swimming pools.

Stathis Avramidis, PhD, CPHL/ HCDCP

18

Recent publications

Leptospirosis in humansHaake DA, Levett PN, 2015, Current topics in microbiology and immunology 387:169–85.

Leptospirosis is a widespread and potentially fatal zoonosis that is endemic in many tropical regions and causes large epidemics after heavy rainfall and flooding. Infection results from direct or indirect exposure to infected reservoir host animals that carry the pathogen in their renal tubules and shed pathogenic leptospires in their urine. Although many wild and domestic animals can serve as reservoir hosts, the brown rat (Rattus norvegicus) is the most important source of human infections. Individuals living in urban slum environments characterized by inadequate sanitation and poor housing are at high risk of rat exposure and leptospirosis. The global burden of leptospirosis is expected to rise with demographic shifts that favour increases in the number of urban poor in tropical regions subject to worsening storms and urban flooding due to climate change. Data emerging from prospective surveillance studies suggest that most human leptospiral infections in endemic areas are mild or asymptomatic. Development of more severe outcomes probably depends on three factors: epidemiological conditions, host susceptibility, and pathogen virulence. Mortality increases with age, particularly in patients older than 60 years of age. High levels of bacteremia are associated with poor clinical outcomes and, based on animal models and in vitro studies, are related in part to poor recognition of leptospiral LPS by human TLR4. Patients with severe leptospirosis experience a cytokine storm characterized by high levels of IL-6, TNF-alpha, and IL-10. Patients with the HLA DQ6 allele are at higher risk of disease, suggesting a role for lymphocyte stimulation by a leptospiral superantigen. Leptospirosis typically presents as a non-specific, acute febrile illness characterized by fever, myalgia, and headache and may be confused with other entities such as influenza and dengue fever. Newer diagnostic methods facilitate early diagnosis and antibiotic treatment. Patients may progress to multi-system organ failure with widespread haematogenous dissemination of pathogens. Non-oliguric (high output) renal dysfunction should be supported with fluids and electrolytes. When oliguric renal failure occurs, prompt initiation of dialysis can be life saving. Elevated bilirubin levels are due to hepatocellular damage and disruption of intercellular junctions between hepatocytes, resulting in leaking of bilirubin out of bile canaliculi. Haemorrhagic complications are common and are associated with coagulation abnormalities. Severe pulmonary haemorrhage syndrome, due to extensive alveolar haemorrhage, has a fatality rate of >50%. Readers are referred to earlier, excellent summaries related to this subject.

The molecular basis of leptospiral pathogenesis, 2015Murray GL, Current topics in microbiology and immunology, 387: 139-185

The mechanisms of disease pathogenesis in leptospirosis are poorly defined. Recent developments in the application of genetic tools in the study of Leptospira have advanced our understanding by allowing the assessment of mutants in animal models. As a result, a small number of essential virulence factors have been identified, though most do not have a clearly defined function. Significant advances have also been made in the in vitro characterization of leptospiral interaction with host structures, including extracellular matrix proteins (such as laminin, elastin, fibronectin, collagens), proteins related to haemostasis (fibrinogen, plasmin), and soluble mediators of complement resistance (factor H, C4b-binding protein), although none of these in vitro findings has been translated to the host animal. Binding to host structures may permit colonization of the host, prevention of blood clotting may contribute to haemorrhage, while interaction with complement resistance

19

Recent publications

mediators may contribute to survival in serum. While not a classical intracellular pathogen, the interaction of leptospires and phagocytic cells appears complex, with bacteria surviving uptake and promoting apoptosis; mutants relating to these processes (such as cell invasion and oxidative stress resistance) are attenuated in vivo. Another feature of leptospiral biology is the high degree of functional redundancy and the surprising lack of attenuation of mutants in what appear to be certain virulence factors, such as LipL32 and LigB. While many advances have been made, there remains a lack of understanding of how Leptospira causes tissue pathology. It is likely that leptospires have many novel pathogenesis mechanisms that are yet to be identified.

Chrisovalanto Kefaloudi, President’s Office, HCDCP

20

Myths and truths

Myths & Truths about Leptospirosis

Myths Truths

Leptospirosis in humans is caused only by direct contact with the secretions of wild animals like rodents.

Many animal species like cattle, sheep, horses and dogs can be infected by leptospires. The organism settles in the kidneys and is excreted with their secretions (mainly urine). Transmission of leptospires takes place through direct contact with urine or tissue from an infected animal, or through indirect contact with an environment contaminated with urine or secretions.

Owners who have their pets vaccinated are not at risk of being infected by them.

The lack of antigenic relatedness between serotypes of leptospires means the vaccines are not able to protect the animals against serotypes not included in them. Moreover, vaccines may prevent the manifestation of clinical disease but they cannot prevent the installation of leptospires in the kidneys of the animal. Therefore, it is possible that vaccinated animals may excrete both homologous and heterologous serotypes of leptospires.

All serotypes of leptospires are pathogenic.

There is a large number of serotypes of genus Leptospira that are non-pathogenic to humans. These serotypes are saprophytic, abundant in the environment, and create problems in the laboratory diagnosis of the disease.

Symptoms of leptospirosis are characteristic of the disease and the diagnosis based on these is relatively easy.

Leptospirosis occurs in humans in a mild or severe form, causing a wide range of symptoms. Therefore, many of the symptoms associated with leptospirosis can be attributed to other diseases, indicating possible under-diagnosis of the disease.

Serotyping of leptospires which are detected in humans and animals has no practical value.

The identification of the serotype of leptospires responsible for clinical disease of a patient/animal has great epidemiological importance. In animals, the epidemiological picture is very complex, and the co-existence of different animal species implies the co-existence of different natural and accidental hosts, which can lead to different disease states. The above demonstrates the need for constant and thorough monitoring of circulating serotypes of leptospires in animals which come into direct or indirect contact with humans, in order to reflect clearly the current epidemiological situation, and recognize early each new possible source of infection in humans and animals. Additionally, developing and using vaccines requires the identification of serotypes in each case, as the vaccines stimulate an immune response only against serotypes contained in them.

G. Valiakos, C. Bill;inis, Laboratory of Microbiology & Parasitology, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly

21

Outbreaks around the world

November 2014

Ebola virus disease (EVD) [1]As of 3 December 2014, 17,145 (probable, confirmed and suspected) cases and 6070 deaths have been reported in Guinea, Liberia, Mali, Spain, USA, Sierra Leone and in two previously affected countries (Nigeria, Senegal). WHO does not recommend any travel or trade restrictions be applied, except in cases where individuals have been confirmed or are suspected of being infected with EVD, or where individuals have had contact with cases of EVD. Contacts do not include properly-protected health-care workers and laboratory staff.

Chikungunya fever [2]As of 21 November 2014, more than 30,000 new chikungunya cases have been reported in Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Bolivia, Brazil, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, El Salvador, French Guiana, Grenada, Guadeloupe, Guatemala, Guyana, Haiti, Martinique, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Barthélemy, Saint Kitts & Nevis, Saint Lucia, Saint Martin (FR), Saint Vincent & Grenadines, Sint Maarten (NL), Suriname, Trinidad & Tobago, Turks & Caicos Islands, Venezuela, Virgin Islands (UK), and Virgin Islands (US).

References

1. World Health Organization (WHO). Global Alert and Response (GAR). At: http://www.who.int/csr/disease/ebola/en/ [accessed 5 December 2014]

2. European Centre for Disease Control and Prevention (ECDC). Communicable disease threats report. At : http://ecdc.europa.eu/en/publications/_layouts/forms/ [accessed 5 December 2014]

Travel Medicine OfficeDepartment for Interventions in Healthcare Facilities

Chief Editor:Ch. Hadjichristodoulou

Scientific Board:Ν. Vakalis

Ε. VogiatzakisP. Gargalianos- Kakoliris

Μ. Daimonakou- VatopoulouΙ. LekakisC. Lionis

Α. PantazopoulouV. Papaevagelou

G. SaroglouΑ. Tsakris

Associate Editors:P. Koukouritakis

Μ. Fotinea

Editorial Board:S. Baltsiotis

Μ. FotineaE. KaratampaniP. Koukouritakis

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Graphic Design:Ε. Lazana

Copy Editor:P. Koukouritakis

Editors:Τ. Kourea- Kremastinou

HCDCP President

T. PapadimitriouHCDCP Director

Quiz of the month

http://www.keelpno.gr info@keelpno.gr

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

The answer to the previous issue’s quiz was: In Mississippi in the United States.References

• Persaud D, Gay H, Ziemniak C, et al. Absence of Detectable HIV-1 Viremia after Treatment Cessation in an Infant. N Engl J Med 2013; 369: 1828–1835.

• NIH News. «Mississippi Baby» Now Has Detectable HIV, Researchers Find (Last Updated July 10, 2014) http://www.niaid.nih.gov/news/newsreleases/2014/pages/mississippibabyhiv.aspx

Two (2) people answered correctly.

Which of the following animals is not a ‘reservoir’ of Leptospira?

a) Catb) Pigeonc) Chickend) Lambe) Dog