malaria in greece: epidemiological data and keelpno actions · malaria in greece • until mid-20th...
TRANSCRIPT
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Malaria in Greece:
epidemiological data and
KEELPNO actions
Danai Pervanidou, MD, MPH, EPIET alumni
Unit for Vector-borne Diseases
Department of Surveillance and Intervention,
Hellenic Centre for Disease Control and Prevention (KEELPNO)
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Malaria in Greece
• Until mid-20th century: endemic
• 1974: malaria-free
• 1975 - 2008:
20 - 50 imported cases reported annually
Reports of sporadic locally acquired cases: 1991, 1999, 2000
• 2009 - 2013:
81% of imported cases were immigrants from endemic
countries
Since 2009: locally-acquired cases reported annually
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Reported malaria cases, Greece, 2009 - 2013
Year of
symptom onset
Imported cases Locally acquired cases*
Total
Greece Greece
2009 44 7 51
2010 40 4 44
2011 54 42 96
2012 73 20 93
2013 22 3 25
* All P.vivax cases 3
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Reported malaria cases, Greece, 2009 - 2013
Year of
symptom onset
Imported cases Locally acquired cases*
Total
Greece Evrotas Greece Evrotas
2009 44 0 7 6 51
2010 40 0 4 1 44
2011 54 21 42 36 96
2012 73 17 20 10 93
2013 22 0 3 0 25
* All P.vivax cases 4
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Reported malaria cases, Greece, 2009 - 2013
Year of
symptom onset
Imported cases Locally acquired cases*
Total
Greece Evrotas Greece Evrotas
2009 44 0 7 6 51
2010 40 0 4 1 44
2011 54 21 42 36 96
2012 73 17 20 10 93
2013 22 0 3 0 25
* All P.vivax cases 5
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Number of locally acquired malaria cases by
year of symptom onset*, Greece, 2009 - 2013
*Two cases with symptom onset in 2012 are attributed in the 2011 transmission period
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7
1 case in East Attica (Nea Makri)
Place of exposure of locally acquired malaria cases,
Greece, 2009 (n=7)
Cluster of 6 cases in Evrotas, Lakonia
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Place of exposure of locally acquired malaria cases,
Greece, 2010 (n=4)
2 cases (Roma children) in Viotia (Thiva)
1 case in Evrotas Lakonia (Roma)
1 case in East Attica (Marathon)
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Reported malaria cases, Greece, 2011
96 malaria cases recorded
• Imported cases: 54
- 45 in immigrants from malaria endemic countries
- 36 P. vivax
• Locally acquired: 42
- 34 Greek, 5 Romanian, 2 Moroccan, 1 Polish
- all P. vivax
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Larisa: >70 yrs
East Attica (Marathon, Kalivia): 2 cases >70 yrs
Viotia (Orchomenos): 40-50 yrs Roma
Place of exposure of locally acquired malaria cases,
Greece, 2011 (n=42)
Evia: 2 cases 40-50 yrs
Lakonia, Evrotas: 36 cases
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Malaria cases, Evrotas, Lakonia, 2011
* 2 cases diagnosed in Romania ** 2 cases had onset of symptoms in 2012
Case classification - Nationality Number
Locally - acquired cases
• Greek nationality
• Immigrants
Romania
Poland
Morocco
Immigrants from endemic countries
Pakistan
Afghanistan
36**
28
8
5*
1
2
21
20
1
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Place of residence of malaria cases,
Evrotas, Lakonia, 2011
Red dots: immigrants Yellow dots: Greek cases 12
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Reported malaria cases, Greece, 2012
93 malaria cases reported
• Imported cases: 73
- 64 in immigrants from malaria endemic countries
- 54 P. vivax, 15 P.falciparum, 1 P.vivax + P.falciparum
• Locally acquired: 20
- 14 Greek, 3 Romanian, 2 Moroccan, 1 Albanian
- all P. vivax
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Reported malaria cases not attributed to
2012 transmission period, Greece, 2012
• 5 relapses in 2011 cases: 4 Greek, 1 Pakistani
- inadequate Primaquine treatment
• 4 cases infected in past transmission periods:
- 1 case (P.vivax), 30yrs Moroccan male, Evrotas, onset: 03/04/2012
- 1 case (P.vivax), 7yrs Greek female, Evrotas, onset: 27/08/2012
- 2 cases of P.malariae (Greek): 78yrs, onset: 08/01/2012
85yrs, onset: 01/05/2012
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Place of exposure of locally acquired malaria cases,
Greece, 2012 (n=20)
East Attica, Marathon: 2 cases, 52 & 78 yrs
Xanthi: 2 cases, 23 & 61 yrs
Viotia: 2 cases, 23 & 47 yrs
Karditsa: 2 cases, 24 & 53 yrs
Lakonia, Evrotas: 10 cases East Attica, Markopoulo:
2 cases, 44 & 70 yrs
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Malaria cases, Evrotas, Lakonia, 2012
Case classification - Nationality Number
Locally-acquired cases
• Greek nationality
• Immigrants from non-endemic countries
Romania
Morocco
Immigrants from endemic countries
Pakistan
Afghanistan
Total
10
7
3
1
2
17
13
4
27
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Place of residence of malaria cases, Evrotas, 2012
Red dots: immigrants Yellow dots: Greek cases
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Reported malaria cases, Greece, 2013
25 malaria cases reported
• Imported cases: 22
- 13 in immigrants from malaria endemic countries
- 9 P. vivax, 12 P.falciparum, 1 P.ovale
• Locally acquired: 3
- all Greeks
- all P. vivax
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Place of exposure of locally acquired malaria cases,
Greece, 2013 (n=3)
Karditsa: 1 case 67 yrs
Evros: 2 cases, 40 & 48 yrs
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Locally-acquired malaria cases by week of symptom onset,
Greece, 2011 (n=39*), 2012 (n=19**) and 2013 (n=3)
* Two cases with symptom onset in 2012 and one case with unknown week of onset are not included
** One case with symptom onset in 2013 is not included
2011 - 2012:
52% decrease
of locally-acquired cases
2012 - 2013:
85% decrease
of locally acquired cases
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Locally-acquired malaria cases by week of symptom onset,
Evrotas, 2011 (n=33*) and 2012 (n=10)
* Two cases with symptom onset in 2012 and one case with unknown week of onset are not included
Evrotas, 2011 - 2012:
72% decrease
of locally-acquired cases
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Lakonia Regional Unit
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P.vivax malaria cases by week of symptom onset,
Lakonia, Greece, 2011 (n=55*), 2012 (n=27)
*3 asymptomatic cases in migrants from Pakistan are not included as well as one case with unknown date of
onset (diagnosed in Romania)
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Map of Evrotas (Land use)
Orange trees
Coastal wetlands & lake
Irrigation &drainage channels (105 km)
Other cultivations
Sea
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Map of Evrotas (Irrigation & drainage network)
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Irrigation channel near the orange plantations
Habitation inside the orchard
Ecological situation in Evrotas, Lakonia
Evrotas river
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Place of residence of malaria cases,
East Attica, 2009 - 2012
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Place of residence of malaria cases,
East Attica, 2009 - 2012
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Evia Regional Unit
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Viotia Regional Unit
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Place of residence of locally acquired malaria cases,
Viotia, 2010 - 2012
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Xanthi Regional Unit
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Place of residence of locally acquired malaria cases,
village of Xanthi, 2012
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Karditsa Regional Unit
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Malaria cases, village of Sofades Municipality, Karditsa,
2012 - 2013
Sept-Oct 2012: 11 P.vivax cases in 2 residencies (170m)
- 1st residency: 26 persons from Afganistan and Bagladesh
- 2nd residency: 5 persons from Romania
• 9 cases in immigrants from endemic countries (1st residency):
onset 03/09 - 11/10/2012, 1.5 - 11 months in Greece
• 2 introduced cases (2nd residency): Romanian Roma
onset: 22/09, 30/09/2012
6/11 cases detected actively
Nov 2013: 1 locally-acquired case (Greek)
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Place of residence of malaria cases,
village of Karditsa, 2012 - 2013
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Number of malaria cases by week of onset and
case classification, village of Karditsa, 2012
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Evros Regional Unit
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Place of residence of locally acquired malaria cases,
town of Evros, 2013
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Place of residence of locally acquired malaria cases,
town of Evros, 2013
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KEELPNO action plan for the management of malaria, 2012 - 2015
KEELPNO Working Group on vector-borne diseases
Risk assessment
Partnership to implement the national project: “Integrated
surveillance and control programme for West Nile virus and malaria in Greece”
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
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Enhanced malaria surveillance
• Enhancement of passive surveillance
- test “suspected” cases (case definition)
• Case investigation
- interviews with the patients and treating physicians
- case classification, place of exposure, detailed travel history
during the last 5 years, risk factors for ongoing transmission
• Environment investigation
• Active case detection
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Active case detection, Greece, 2012 - 2013
To timely diagnose and treat malaria cases
in order to prevent further transmission
1. Focus investigation of malaria cases:
- all over Greece
2. Daily door - to - door ACD throughout the year:
- in Evrotas
3. Screening of immigrants from endemic countries
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Focus investigation of malaria cases,
Greece, 2012 - 2013
It was conducted all over Greece:
• following every new locally acquired case
• following every imported case residing in rural area
In surroundings
around case’s residence/ suspected place of exposure
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Focus investigation of malaria cases, Greece
Door -to- door visits
Individual
from non - endemic country
Fever screening
Fever (+):
1. RDT + microscopy
2. Fever screening
weekly x 1 month
Fever (-):
Fever screening
weekly x 1 month
Individual
from endemic country
1. RDT + microscopy
2. Fever screening
weekly x 1 month
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ACD, town of Evros, 12-14/10/2013
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ACD, village of Karditsa, 13-15/11/2013
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Door -to- door daily ACD, Evrotas, 2012- 2013
Mapping of all residences, Data base
Initial visit: Provide information on malaria & protective measures
Fever screening
every 7 - 15 days
Fever (+):
RDT + microscopy
RDT (+):
- Physician evaluation
- Chloroquine
Microscopy (+) for P.vivax:
Primaquine (after G6PD test) 50
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Cases detected actively, Greece, 2012
Cases
Cases detected by
focus investigation,
Greece
n / N (%)
Cases detected by
daily ACD,
Evrotas
n / N (%)
Total cases
detected actively,
Greece
n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
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Cases detected actively, Greece, 2012
Cases
Cases detected by
focus investigation,
Greece
n / N (%)
Cases detected by
daily ACD,
Evrotas
n / N (%)
Total cases
detected actively,
Greece
n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
52
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Cases detected actively, Greece, 2012
Cases
Cases detected by
focus investigation,
Greece
n / N (%)
Cases detected by
daily ACD,
Evrotas
n / N (%)
Total cases
detected actively,
Greece
n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
53
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Cases detected actively, Greece, 2012
Cases
Cases detected by
focus investigation,
Greece
n / N (%)
Cases detected by
daily ACD,
Evrotas
n / N (%)
Total cases
detected actively,
Greece
n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
54
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Screening of immigrants from endemic
countries, Greece, 2012 - 2013
RDT in immigrants from endemic countries
2012:
• affected areas (Evrotas, East Attica): 1,450 immigrants
• 8 detention centres (5 in greek-turkish borders):
1,015 immigrants
2013:
• recommended in health units in North Aegean and
Dodecanese islands (immigrants’ entry points)
• 554 immigrants in Chios and Limnos islands
55
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Antimalarial drug administration to immigrants
from endemic countries, Evrotas, 2012 - 2013
• 2012: immigrants with positive malaria serology
• 2013: mass drug administration
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
57
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Enhancing laboratory diagnosis of malaria
• Training seminars for lab personnel (from NSPH), 2012
• RDTs distribution to hospitals and health centres in:
- affected areas
- areas with immigration detention centres
- large urban areas
- entry points (greek-turkish borders, islands)
• Free of charge testing for malaria in the reference
laboratories
• Support genotyping of the P. strains - NSPH / ECDC 58
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
59
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Case management - Standardization of
the malaria treatment
• KEELPNO treatment guidelines
• Guidance to physicians for proper case management
• Protocol for following-up the treatment efficacy
• All 2011 improperly treated malaria cases were treated
with a 2nd course in 2012
• Availability of anti-malarial drugs for radical P.vivax
treatment (primaquine) and severe cases (artesunate)
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
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Communication
• Health professionals:
- informative material disseminated every spring
- seminars (41 in 2012,15 in 2013)
• Public:
- educational material in website, leaflets
- TV spot
- public meetings (29 in 2012, 82 in schools in 2012)
• National stakeholders: MoH, regional and local public health
authorities, blood safety authorities
• International public health stakeholders (WHO, ECDC, CDC)
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
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Blood safety measures
• Multisector Working Group on the definition of
affected areas by vector borne diseases:
characterization of affected areas for the implementation
of blood safety measures
• National Centre for Blood Donations
• Donor deferral from affected areas
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KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
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Vector surveillance and control activities
• Technical guidance for regional, local authorities, for timely organizing
vector control activities
• Individual reports with entomological and epidemiological data for each
region
• Training seminars for local authorities (2012)
• Vector surveillance: 2012 mosquito mapping projects, around the country
• Entomological activities in the framework of the project MALWEST
In Evrotas:
- Distribution of LLINs (2013)
- IRS
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• Conditions may exist for locally acquired transmission to
occur sporadically or in small clusters in vulnerable areas:
- increased number of immigrants from endemic countries
- competent vector circulation in many areas
• Most affected areas are agricultural, non-touristic,
close to wetlands, with large populations of migrant farm
workers
Conclusions I
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• Decrease of locally-acquired cases in 2012 and 2013
- impact of public health actions
- decreased immigrants’ entry - fewer imported cases?
- under-notification unlikely
- under-diagnosis?
• Managing malaria remains a challenge (continuing
entrance of new migrants from malaria endemic countries)
• Need for a multi-sector control strategy: entomological
surveillance, intensifying mosquito control measures,
communication to the public and health professionals
Conclusions II
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Number of immigrants arrested for illegal entry and
residence at the Greek-Turkish land and sea borders
and Crete, Greece, 2009 - 2013
69
Source: Hellenic Police website (www.astynomia.gr)
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Number of immigrants from 6 malaria endemic countries*
arrested for illegal entry and residence, Greece, 2009 - 2013
70
Source: Hellenic Police website (www.astynomia.gr)
*Pakistan, Afganistan, Bangladesh, Somalia, Erithrea, Irak
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Priority actions - Recommendations, 2014
• Continue ACD in Evrotas. In Karditsa?
• Involve local public health authorities to achieve sustainability
• Local laboratory capacity should be enhanced
• Vector control programmes (+ IRS, LLINs)
• Assess in health care - free diagnosis and treatment for
undocumented immigrants
Need to address for undocumented immigrants:
• poor living conditions
• long-term health care access
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Thank you
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Malaria cases by month and case classification, Lakonia, 2009-2012
Malaria cases by month
Years Number of cases by month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
2012 Imported 0 0 1 0 1 2 6 4 0 1 0 0 15
Locally
acquired
0 0 0 0 0 1 3 0 1 3 0 0 8
2011 Imported 0 0 0 0 0 1 0 2 12 4 1 0 20
Locally
acquired
0 0 0 0 1 0 4 4 17 8 0 0 34
2010 Imported 0 0 0 0 0 0 1 0 0 0 0 0 1
Locally
acquired
0 0 0 0 0 0 1 0 0 0 0 0 1
2009 Imported 0 0 0 0 0 0 0 2 0 0 0 0 2
Locally
acquired
0 0 0 0 0 0 0 1 4 1 0 0 6
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Malaria cases by age and case classification, Lakonia, 2009-2012
Malaria cases by age
Years Number of cases by age in years
0-19 20-29 30-39 40-49 50-59 >=60
2012 Imported 3 9 1 2 0 0
Locally
acquired
0 1 1 3 2 1
2011 Imported 3 16 2 1 1 0
Locally
acquired
5 4 5 9 5 7
2010 Imported 0 0 0 0 1 0
Locally
acquired
0 1 0 0 0 0
2009 Imported 0 2 0 0 0 0
Locally
acquired
0 1 0 1 3 1
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Malaria cases by social and high risk group, Evrotas, Lakonia, 2011 - 2012
Years Number of malaria cases by category
Children-Student
Agricultural workers
Labourers Office workers
House-wives
Pensioners -Other
2012 Imported 1 14 0 0 0 0
Locally
acquired
0 2 0 2 3 1
2011 Imported 0 18 1 0 0 0
Locally
acquired
4 14 5 4 3 5
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Characteristics of locally acquired cases, Greece, 2012 (n=16)
• Age: ranged from 24 - 82 yrs (median 52 yrs)
• Gender: 62.5% were male
• Plasmodium species: all cases P.vivax
• Hospitalization: 75% hospitalized, no case in ICU
• Treatment: Chloroquine (11), Mefloquine (3), Atovaquone-Proguanile (1), no treatment (1) + Primaquine (15) • Outcome: No fatality
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Reported cases of P.vivax infection by month of onset and case
classification, Lakonia, Greece, 2011 (n=56*) and 2012 (n=27)
Evrotas, 2011-2012: 72% decrease of
locally-acquired cases
77