Dengue virus infection in Croatia: seroprevalence and entomological study.

During 2011-2012, a total of 1,180 sera samples were collected from residents of seven Croatian counties located on the Adriatic Coast and four counties in northeastern Croatia and tested for the presence of dengue virus (DENV) IgG antibodies using ELISA. Reactive samples were further tested by IFA. Seven samples (0.59%) tested positive for DENV antibodies. Seroprevalence rates by county varied from 0-2.21%. The highest seropositivity rate (2.21%) was found in the Dubrovnik-Neretva County where autochthonous dengue cases were recorded in 2010. Additionally,3,699 mosquitoes were collected from 126 localities along the Adriatic coast in August-September, 2011. Aedes albopictus was the most prevalent species (81.37%). No evidence of DENV RNA was detected by RT-PCR among 1,748 female mosquitoes.

Risk factors influencing non-use of condoms at sexual relations in populations under heightened risk.

To determine risk factors for non-use of condoms when engaging in sexual intercourse among high-risk population groups for acquiring HIV/STIs. We collected the data obtained by interviews in the period from 2005 to 2011 in the Voluntary Counseling and Testing Center for HIV/AIDS at the Institute of Public Health of Zadar County. Four hundred ninety four respondents were divided into risk and control groups. The majority of the respondents in our population does not consistently use condoms, in the risk group as much as 89.9%, and in the control group 65.7% of them (p< 0.001). Persons consuming alcohol when having sexual relations use condoms about 5x less often compared to those not consuming alcohol at all (OR=5.00; CI=1.69-14.29). There are significant differences among women and men in the risk group regarding reasons for non-use of condoms. The main reason with women is "I trust mypartners" 33.7% while men "do not like having sex with condoms, 53.6% of them (p < 0.001). The main risk factors for non-use of condoms are alcohol consumption at sexual relations, non-use of condoms in a casual relationship. Having in mind the non-use of condoms among populations of high-risk groups of acquiring HIV there are significant differences among genders.

Sexual behaviour and condom use as a protection against sexually transmitted infections in student population.

The aim of the study was to determine the differences in sexual behaviour and condom use as a protection against sexually transmitted infections (STI) between the first-year and the last-year students. Data were collected by filling anonymous and consented questionnaire in June of 2011 at University of Josip Juraj Strossmayer in Osijek, Croatia. Out of 857 students in the planned sample, 462 (53.9%) filled out the questionnaire, and 353/462 (76.4%) were sexually active. Data from sexually active students were processed and statistically significant results between first-year and the last-year students were presented. Studied sample consisted of 192/353 (54.4%) first-year students and 161/353 (45.6%) last-year students. Average age of sexual initiation for the first-year students was 17.28 +/- 1.29 years, a for the last-year students 18.45 +/- 2.14 years, and the difference is significant (Man-Whitney test = 10335.00, p < 0.01). First-year students have lower number of sexual partners (chi2 = 28.005, p < 0.01), during relationship they had lower number of intercourses with the third person (2 = 17.947, p < 0.01), and feel that lower number of their friends were already sexually active at the time of their own sexual initiation (chi2 = 18.350, p < 0.01). First-year students more often inform their partners about existing or previous STI (chi2 = 14.476, p < 0.01) and curiosity significantly influenced their decision regarding sexual initiation (chi2 = 8.689, p < 0.05). First-year students more often used condom at their first sexual intercourse (chi2 = 7.275, p < 0.01), and more rarely used withdrawal (chi2 = 6.380, p < 0.05). At their last sexual intercourse, first-year students more often used any kind of protection (chi2 = 3.853, p < 0.05),more often used condom (chi2 = 11.110, p < 0.01) and withdrawal (chi2 = 5.156, p < 0.05), and more rarely used contraceptive pills (chi2 = 4.405, p < 0.05). First-year students more often use condom in a permanent relationship (chi2 = 13.384, p < 0.05), and also plan to use it during following intercourse in the permanent relationship (chi2 = 17.575, p < 0.01). Growing condom use and decreasing risky sexual behaviour among students, as well as other adolescents and young adults needs to be maintained. Youth should learn before sexual initiation that only correct condom use at every sexual intercourse protects them against STI and human immunodeficiency virus (HIV). Sexual education and STI/HIV prevention programmes, positive role of media (television) and civil organisations that communicate with the youth can help that. Such changes among adolescents and young adults should have to be seen in student population as well.

Risk behavior of customers in centers for free voluntary HIV counselling and testing in two Croatian cities--Osijek and Zadar.

The primary goal of this research is to compare risks and occurrence of HIV infection in Osijek-Baranja and Zadar County. Several chosen socioeconomic factors controlled by sex and age were investigated including level of education, employment and marital status of the free-of charge voluntary counseling and testing center (VCT) customers in the towns of Osijek and Zadar and their risk behaviors for acquiring HIV. Bivariate analysis of the differences between the customers from Osijek and Zadar showed statistically significant differences in the following variables: gender, education, number of VCT clients who use intravenous drugs (IDU), promiscuous behavior, number of homosexual clients, mode of receiving information on the VCT services, marital and partnership status, having children, inclination towards homosexual and bisexual relations, the main reasons for not using condoms, injecting drugs (IDU) needle sharing and the occurrence of hepatitis C. The analysis showed that significantly more males were counseled and tested in the city of Osijek, significantly less hepatitis C positive persons and promiscuity among all behavioral risk factors more often. A higher number of the customers of the VCT in the city of Osjek were "in permanent" relationship. Strategic management of health and health care, methods of comparing regional and national standardized indicators can provide valuable information about setting the focus, choosing priorities and establishing a good economic policy at the micro level. This study clearly established the dimensions of problems in HIV/AIDS prevention onto which it should be influenced through regional and local measures and actions. The indexes measured indicate which special initiatives and programs should be focused and set up as priorities in particular regions. The determined differences point to the need for a regional approach to HIV/AIDS prevention in purpose of improving preventive activities according to most common risk behaviors. Even though Croatia is a relatively small country, it has many regional and local features which need to be taken into consideration when developing prevention programs and activities.

Characteristics of hepatitis C infection in injecting drug users in Zadar County, Croatia.

The aim of the study was to determine additional risk factors that could increase the prevalence of hepatitis C (HCV) infection among injecting drug users (IDU). The study included 327 heroin addicts registered in Zadar County, Croatia. The participants were divided into two groups according to their HCV status. HCV-positive and HCV-negative study participants were compared. HCV-positive group started injecting heroin at earlier age (median 18.5 years) than HCV-negative group (median 20.0 years) (p = 0.032) and had been injecting heroin for a significantly longer period (median 5 years vs. median 4 years, respectively; p < 0.001). IDUs in HCV-positive group shared their injecting equipment significantly more often than IDUs in HCV-negative group (p < 0.001; chi2 = 32.7). The main reasons for starting drugs were curiosity, psychological reasons (depression and/or neurosis), and peer or partner pressure in HCV-positive group, and fun, curiosity, and peer pressure in HCV-negative group (p = 0.051; chi2 = 23.6). Earlier onset of heroin use, longer heroin use, sharing injection equipment, curiosity, and psychological problems as reasons for starting drugs were associated with higher prevalence of HCV infection among injecting heroin users in Zadar County.

[The outbreak of acute gastroenteritis caused by Norwalk like viruses in Zadar general hospital (2007)]. / Nozokomijalna epidemija akutnog gastroenteritisa uzrokovana norovirusima u opcoj bolnici Zadar 2007. Godine.

OBJECTIVE: Early detection of clinical signs and symptoms of acute gastroenteritis and appropriate preventive measures to stop the spread of infection. METHODS: Epidemiological inspection, clinical examination of hospitalized patients followed by standard bacteriologic and virologic analysis. Norovirus antigen was detected in stool specimen by enzyme immunoassay (EIA). RESULTS: An epidemic of acute gastroenteritis caused by Norwalk like viruses lasted for two weeks (January 26-February 9, 2007). A total of 39 cases were recorded, including 22 (56.4%) inpatients and 17 (43.6%) healthcare workers with disease symptoms. All patients (n = 22; 100%) were hospitalized at Department of Internal Medicine, Cardiology Ward; 11 (64.7%) healthcare workers were working at Cardiology Ward, 3 (17.6%) at Diagnostic Cardiology Laboratory where patients underwent their diagnostic procedures, and 1 (5.9%) healthcare worker at Department of Anesthesiology and Intensive Care was patient consultant at Cardiac Intensive Care Unit. Other healthcare workers, 1 (5.9%) from Department of Neurosurgery and Department of Pathology each, were in family contact with two health care workers employed at Cardiology Ward. DISCUSSION: The Hospital Infection Control Committee was informed about the outbreak of acute gastroenteritis on day 8 of the outbreak. Anti-epidemic measures (according to the source of infection detected and to the mechanisms of transmission) were implemented after epidemiological inspection on day 1 of event recording and continued for two more weeks after the occurrence of the disease clinical symptoms in the last patient involved. CONCLUSION: It is necessary to promptly inform the Hospital Infection Control Committee on the epidemic outbreak for effective and timely anti-epidemic measures to stop the spread of acute gastroenteritis caused by Norwalk like viruses.

[Mediterranean spotted fever in north Dalmatia: is there a problem?]. / Mediteranska pjegava groznica u sjevernoj dalmaciji: postoji li problem?

We analyzed clinical and therapeutic characteristics of Mediterranean spotted fever (MSF) in north Dalmatia. Analysis was conducted in 93 patients hospitalized with MSF at Zadar General Hospital during the 1988-2000 period. The most frequently found signs of the disease were high fever (91; 97.8%), maculopapular rash (89; 95.7%), headaches (84; 90.3%), arthralgia (75; 80.6%), exhaustion (75; 80.6%) and nausea (65; 69.9%). Tache noire, as a pathognomonic sign of MSF, was found in 22 (23.7%) patients. The most frequently indicated diagnoses were febris cum exanthemate (43; 46.2), rickettsiosis suspecta (21; 22.6%) and exanthema maculopapulosum (15; 16.1%). Early therapeutic efficiency was achieved by doxycycline in 34/43 (79.1%), and by ciprofloxacin in 10/14 (71.4%) treated adult patients, and by azithromycin in 7/9 (77.8%) children. The identification of MSF endemic rickettsiosis in north Dalmatia, serious clinical forms of the disease and the success of early and adequate anti-rickettsial antibiotic therapy are a clear warning that our physicians must be very familiar with this disease and include this rickettsial disease in differential diagnosis of acute febrile diseases accompanied by rash.

[Rash and purulent lymphadenitis in cat scratch disease]. / Osip i purulentni limfadenitis u bolesti macjeg ogreba.

We present a case of a cat-scratch disease (CSD) presenting with typical (primary lesion and regional lymphadenitis) and rare (purulent lymphadenitis and maculopapular rash) symptoms and positive epidemiological data. Laboratory blood test showed normal values for routine parameters, except for mild leukocytosis (L 12.4 x 10(9)), elevated erythrocyte sedimentation rate (SE 65/h) and moderately elevated asparta e-aminotransferase and alanine-aminotransferase values (AST/ALT 48/90), fibrinogen (5.3 g/L) and C-reactive protein (CRP 85 mg/L). Cytological analysis of lymph node content revealed granulomatous inflammation in the first sample, and purulent inflammation in the second sample. In paired serum samples, collected on the 15th and 29th day from the onset of disease, antibodies IgG (titre 4096/8192) and IgM (titre 80/40) to Bartonella henselae were detected by using an indirect immunofluorescence assay (IFA). Antibiotic therapy with azithromycin (1 x 500 mg per os/5 days) was administered. Purulent lymphadenitis and rash, although a rare clinical manifestation in CSD, are significant clinical findings in differentiating CSD from other febrile illnesses accompanied with rash and lymphadenitis.

Rickettsiae and rickettsial diseases in Croatia: Implications for travel medicine.

AIM: To review the current state of knowledge concerning rickettsiae and rickettsioses in Croatia and to discuss their implications for travellers. METHODS: The PubMed database was searched from 1991 to 2015 by combining the words "rickettsia," "rickettsiosis", "travellers" and "Croatia". RESULTS: Since 1969, Croatia appears to be free of epidemic typhus (ET) caused by Rickettsia prowazekii and the last case of Brill-Zinsser disease was recorded in 2008. Mediterranean spotted fever (MSF) caused by Rickettsia conorii is the most frequent human rickettsial infection in Croatia, followed by murine typhus caused by Rickettsia typhi. Human cases of MSF and murine typhus have been predominantly observed along the eastern Adriatic coast from Zadar to Dubrovnik and between Zadar and Split, respectively. Rickettsia akari, etiologic agent of rickettsialpox, was isolated from blood of a patient diagnosed with MSF in Zadar, but no cases of rickettsialpox were reported. Several species of pathogenic (Rickettsia slovaca, Rickettsia aeschlimannii, Ricketsia helvetica, and Ricketsia raoultii) and species of undetermined pathogenicity (Ricketsia hoogstraalii sp. nov.) rickettsiae were identified in ticks collected in different ecological regions of Croatia. A search of the literature revealed no evidence of rickettsial infection in travellers visiting Croatia. Three imported cases of Rickettsia africae were observed in travellers returning from South Africa. CONCLUSION: Rickettsiae and rickettsial diseases continue to be present in Croatia. As they can be acquired while travelling, physicians should consider rickettsial infection in the differential diagnosis of patients returning from Croatia and presenting with febrile illness.

A case of Mediterranean spotted fever associated with severe respiratory distress syndrome.

Mediterranean spotted fever (MSF) is usually a mild endemic rickettsial disease occurring in southern Croatia. We have reported the clinical and epidemiological characteristics of an acute MSF case associated with severe respiratory distress syndrome and hemodynamical instability. The patient recovered completely after antimicrobial treatment. Indirect immunofluorescence assay (FOCUS Diagnostics Inc.) was performed to detect IgM and IgG antibodies to Rickettsia conorii. A significant increase of both IgM and IgG antibody titres found in paired acute- and convalescent-phase serum confirmed the diagnosis of acute MSF.

Seroprevalence and entomological study on Chikungunya virus at the Croatian littoral.

During 2011-2012, a total of 1008 serum samples from randomly selected inhabitants of seven Croatian counties located on the Adriatic Coast were tested for the presence of chikungunya virus (CHIKV) IgG antibodies using indirect immunofluorescence assay. Nine participants (0.9%) from four counties were found to be seropositive to CHIKV. Seroprevalence varied from 0.5% to 1.8% between counties. Additionally, a total of 3,699 mosquitoes were captured in 126 localities from August 16 to September 24, 2011. Three mosquito species were found: Ae. albopictus (3010/81.4%), Cx. pipiens (688/18.6%) and only one specimen of the Cs. longiareolata. Female mosquitoes (N = 1,748) were pooled. All pools tested negative for CHIKV RNA using a real-time RT-PCR.

[Hemorrhagic fever with renal syndrome: imported or native disease in the Zadar region]. / Hemoragijska vrucica s bubreznim sindromom: importirana i/iLi autohtona bolest u zadarskoj regiji.

AIM: The aim of the study is to warn of the need of clinical hemorrhagic fever with renal syndrome (HFRS) recognition and determination, and of the risk of its spread from a new focus of this natural zoonosis near Zadar (north Dalmatia), i.e., in the northern part (Lika) of the Zadar County. METHOD: Clinical and epidemiologic characteristics of HFRS were analyzed in four patients. Patient sera were analyzed for Puumala (PUU) and Hantaan (HTN) viruses by immunofluorescence test (IFT) and immunoenzyme test (ELISA). RESULTS: Epidemiologic studies confirmed the source of infection to be out of the area in three patients, whereas in one patient it was near Zadar area. Mild symptoms pointed to the disease. Pathologic findings showed pathologic leukocyte values (leukocytosis), two- to four-fold alanine aminotransferase, aspartate aminotransferase and creatinine increase in serum, proteinuria and erythrocyturia. A significant PUU antibody titer was found by serum IF and ELISA. CONCLUSION: The occurrence of HFRS in the Zadar area was confirmed by clinical description and laboratory evidence. The newly identified focus was in the vicinity of this area could imply a risk for the disease epidemic in the Zadar area.

Q fever epidemic among employees in a factory in the suburb of Zadar, Croatia.

AIM: To examine the role of wind in the spread of Q fever (Coxiella burnetii) from the source of infection (sheep on the pastures) to the factory where there was an outbreak of Q fever among the employees. METHODS: We performed clinical (fever, coughing, myalgias, arthralgias), laboratory (complete blood test, aminotransferases, antibodies to Coxiella burnetii), radiographic (chest X-ray), and epidemiological (questionnaire) analysis on 47 of 110 employees of the plant in a suburb of Zadar. Sera of 182 sheep were tested for antibody to C. burnetii by complement fixation reaction. RESULTS: During the first half of March 2004, 14 of 110 employees of a factory in a suburb of Zadar were diagnosed with Q fever on the basis of clinical and laboratory findings. In three sections of the plant, directly exposed to the north wind, a diagnosis of Q fever was confirmed in 14 of 110 employees by clinical, laboratory, and X-ray analysis, whereas there were no sick employees in the other four sections. North of the plant there were pastures where many flocks of sheep grazed. Antibodies to C. burnetii were found in 20 out of 182 sheep sera. Employees who were exposed to the north wind, had a significantly higher possibility of acquiring Q fever than did those working in sections protected from the wind. CONCLUSION: North wind (bura) containing the aerosolized C. burnetii likely influenced the Q fever outbreak in persons far from the source of the infection.

Latrodectus bites in northern Dalmatia, Croatia: clinical, laboratory, epidemiological, and therapeutical aspects.

AIM: To analyze clinical and epidemiological characteristics of the black widow spider (Latrodectus tredecimguttatus) bites and asses the impact of antitoxin administration after the bite on the intensity and duration of pain. METHOD: Retrospective analysis of clinical appearance, laboratory findings, and clinical assessment of the antitoxin administration efficacy in 32 patients with latrodectism treated at Zadar General Hospital between 1992 and 2002. RESULTS: All patients presented with generalized pain, profound perspiration, and burning in the sole of the foot. Laboratory findings revealed moderately increased serum glucose concentrations in half of the patients, concentrations of aspartate aminotransferase and alanine aminotransferase 2 to 3 times higher than normal in 8 of 32 patients, moderate leukocytosis in 16 of 32 patients, mature neutrophilia in 15 of 32 patients, and immature forms of leukocytes in 4 of 32 patients. In 21 patients who received the antitoxin, severe pain lasted 1-4 h (median, 1.2 h) after the antitoxin administration, moderate pain 1-5 h (median, 2.4 h), and hospitalization 1-5 days (median, 4 days). In patients who did not receive antitoxin, there was a statistically significant increase in duration of severe pain (median, 50 h; range, 24-72 h), moderate pain (median, 36 h; range, 24-48 h), and hospitalization (median, 6 days; range, 4-12 days) (p<0.05 for all, Kruskal-Wallis H test). Men were more often bitten by the venomous spider (20 men vs 12 women); adults more often than children (30 vs 2, respectively), domestic population more often than tourists (30 vs 2, respectively), and rural mainland inhabitants more often than islanders (21 vs 11, respectively). All biting incidents occurred between June and September, most often in July (17 patients). CONCLUSION: Latrodectism in Northern Dalmatia presents with severe clinical symptoms. Administration of the antitoxin is advisable in the treatment of all afflicted patients.