Genetic Structure of Introduced Plasmodium vivax Malaria Isolates in Greece, 2015-2019.

Greece has been malaria-free since 1974, after an intense malaria control program. However, as Greece hosts migrant populations from P. vivax malaria-endemic countries, there is a risk of introducing the disease to specific vulnerable and receptive areas of the country. Knowledge of the genetic diversity of P. vivax populations is essential for understanding the dynamics of malaria disease transmission in a given region. We used nine highly polymorphic markers to genotype 124 P. vivax-infected archived DNA samples from human blood specimens referred to the NMRL from all over Greece throughout 2015-2019. The genotypic variability of the samples studied was noted, as they comprised several unique haplotypes, indicative of the importation of a large number of different P. vivax strains in the country. However, only a few events of local transmission were recorded. Genotyping revealed and confirmed the same clusters as those identified through epidemiological investigation. In only one introduction event was the index case found. No sustained/ongoing malaria transmissions in/between the studied regions or during consecutive years or additional foci of local transmission were observed. Genotyping is an important component in assisting malaria surveillance, as it provides information concerning the patterns of introduction and the effectiveness of implemented malaria control and elimination measures.

Evaluation of mpox contact tracing activities and data collection in EU/EEA countries during the 2022 multicountry outbreak in nonendemic countries.

To control human-to-human mpox transmission during the 2022 outbreak, European Union (EU)/European Economic Area (EEA) countries conducted case investigation and contact tracing (CT). We aimed to provide an overview of CT activities, describe CT data collection practices, and identify related facilitators, barriers, and potential opportunities for improvement. Between April 03, 2023 and May 12, 2023, a survey was distributed to CT stakeholders in 30 EU/EEA countries, asking about mpox CT activities and data collection and requesting to rank enablers, barriers, and improvements for CT on a five-point Likert scale. The 139 respondents from 27 countries indicated having performed case investigations (96%, n = 133), backward CT (88%, n = 122), forward CT (87%, n = 121), and follow-up on contacts' outcomes (77%, n = 107). Sixty percent (n = 80/134) used standardized data collection forms and 73% (n = 91/124) used databases. The highest-rated enablers were clear guidelines (mean = 3.9), quick access to laboratory results (3.6), and sufficient expertise (3.6). Highly rated barriers were inability to contact contacts (3.0) or cases (2.5) and lack of staff (2.4). The most needed improvements were availability of staff (3.5), expertise on affected populations (3.4) and data reporting tools and systems (3.3). To improve CT of mpox and diseases with similar transmission patterns, EU/EEA countries should increase workforce capacity in public and sexual health, offer training on CT operations and communication with affected communities, and use common CT data collection tools and systems.

Public health considerations for transitioning beyond the acute phase of the COVID-19 pandemic in the EU/EEA.

Many countries, including some within the EU/EEA, are in the process of transitioning from the acute pandemic phase. During this transition, it is crucial that countries' strategies and activities remain guided by clear COVID-19 control objectives, which increasingly will focus on preventing and managing severe outcomes. Therefore, attention must be given to the groups that are particularly vulnerable to severe outcomes of SARS-CoV-2 infection, including individuals in congregate and healthcare settings. In this phase of pandemic management, a strong focus must remain on transitioning testing approaches and systems for targeted surveillance of COVID-19, capitalising on and strengthening existing systems for respiratory virus surveillance. Furthermore, it will be crucial to focus on lessons learned from the pandemic to enhance preparedness and to enact robust systems for the preparedness, detection, rapid investigation and assessment of new and emerging SARS-CoV-2 variants. Filling existing knowledge gaps, including behavioural insights, can help guide the response to future resurgences of SARS-CoV-2 and/or the emergence of other pandemics. Finally, 'vaccine agility' will be needed to respond to changes in people's behaviours, changes in the virus, and changes in population immunity, all the while addressing issues of global health equity.

COVID-19 research priorities for non-pharmaceutical public health and social measures.

Europe is in the midst of a COVID-19 epidemic and a number of non-pharmaceutical public health and social measures have been implemented, in order to contain the transmission of severe acute respiratory syndrome coronavirus 2. These measures are fundamental elements of the public health approach to controlling transmission but have proven not to be sufficiently effective. Therefore, the European Centre for Disease Prevention and Control has conducted an assessment of research gaps that can help inform policy decisions regarding the COVID-19 response. We have identified research gaps in the area of non-pharmaceutical measures, physical distancing, contact tracing, transmission, communication, mental health, seasonality and environment/climate, surveillance and behavioural aspects of COVID-19. This prioritisation exercise is a step towards the global efforts of developing a coherent research road map in coping with the current epidemic but also developing preparedness measures for the next unexpected epidemic.

Correction to: West Nile virus in Europe: after action reviews of preparedness and response to the 2018 transmission season in Italy, Slovenia, Serbia and Greece.

An amendment to this paper has been published and can be accessed via the original article.

The Importance of an Active Case Detection (ACD) Programme for Malaria among Migrants from Malaria Endemic Countries: The Greek Experience in a Receptive and Vulnerable Area.

Greece has been malaria-free since 1974. In October 2011, following an outbreak of 36 locally acquired malaria (LAM) cases in Evrotas Municipality, a Pro-Active Case Detection (PACD) program for malaria was implemented among migrants from malaria-endemic countries, to support early diagnosis and treatment of cases. We evaluated the PACD program for the years 2012-2017 using indicators such as the number of locally acquired cases, the detection rate/sensitivity and the timeliness of diagnosis and treatment. We visited each migrant home every 7-15 days to screen migrants for malaria symptoms, performing Rapid Diagnostic Tests (RDTs) and blood smears on symptomatic patients. We estimated: (i) the number of malaria cases detected by the PACD, divided by the total number of reported malaria cases during the same period among the same population; (ii) the time between onset of symptoms, diagnosis and initiation of treatment. The total number of migrants who were screened for malaria symptoms for the years 2012-2017 was 5057 with 84,169 fever screenings conducted, while 2288 RDTs and 1736 blood smears were performed. During the same period, 53 imported P. vivax malaria cases were detected, while incidence of malaria among migrants was estimated at 1.8% annually. Ten and one LAM cases were also reported in 2012 and 2015, respectively. Sensitivity of PACD ranged from 86% to 100%; median timeliness between onset of symptoms and diagnosis decreased from 72 h in 2012 to 12 h in 2017 (83% decrease), while timeliness between diagnosis and treatment initiation was 0 h. The implementation of PACD could be considered an effective prevention and response tool against malaria re-introduction.

West Nile virus in Europe: after action reviews of preparedness and response to the 2018 transmission season in Italy, Slovenia, Serbia and Greece.

BACKGROUND: After Action Reviews (AAR) with a One Health perspective were performed in Slovenia, Italy, Serbia and Greece following a severe West Nile virus (WNV) transmission season in 2018. A protocol combining traditional techniques and organizational process analysis was developed and then implemented in each country. RESULTS: In 2018, response to the unusually intense transmission season of WNV in Slovenia, Italy, Serbia and Greece took place through routine response mechanisms. None of the four countries declared a national or subnational emergency. We found a very strong consensus on the strengths identified in responding to this event. All countries indicated the availability of One Health Plans for surveillance and response; very high laboratory diagnostic capacity in the human, veterinary and entomology sectors and strong inter-sectoral collaboration with strong commitment of engaged institutions as critical in the management of the event. Finally, countries implementing One Health surveillance for WNV (in terms of early warning and early activation of prevention measures) consistently reported a positive impact on their activities, in particular when combining mosquito and bird surveillance with surveillance of cases in humans and equids. Recurring priority areas for improvement included: increasing knowledge on vector-control measures, ensuring the sustainability of vector monitoring and surveillance, and improving capacity to manage media pressure. CONCLUSIONS: The AARs presented here demonstrate the benefit of cross-sectoral and cross-disciplinary approaches to preparedness for West Nile virus outbreaks in Europe. In the coming years, priorities include fostering and strengthening arrangements that: enable coordinated One Health surveillance and response during WNV transmission seasons; ensure adequate laboratory capacities; strengthen risk communication; and fund longer-term research to address the knowledge gaps identified in this study.

Antibody Response Following Pre-Exposure Immunization Against Rabies in High-Risk Professionals.

Vaccination against rabies and routine antibody testing of subjects participating in programs for the surveillance and control of rabies in animals is strongly recommended. The scope of this study is to describe the antibody level as measured by a commercial enzyme-linked immunosorbent assay (ELISA) after primary and booster intramuscular vaccination with a purified vero-cell rabies vaccine (PVRV) in high-risk professionals and to determine the influence of an array of factors on antibody level, that is, time elapsed since primary immunization series and booster dose, sex, age, pathologic conditions, high-risk occupation, and peak antibody level after initial scheme and booster dose. A primary series of three doses of PVRV was administered and a commercial ELISA was recommended 14 days postimmunization with continuous repetition at 6 months and yearly intervals for the laboratory personnel and the rest of the professionals, respectively. The protective antibody titer was defined as a minimum of 0.5 equivalent units/mL (EU/mL) (seroconvertion) and a booster dose was applied if the titer was determined nonprotective. The seroconversion rate (SCR) after primary vaccination was 100%, with a geometric mean titer (GMT) of 2.90 EU/mL (interquartile range [IQR]: 1.85-3.45). After booster vaccination due to nonprotective titer, the SCR was 100% and the GMT increased by 678% (95% confidence interval [CI]: 514-887) reaching 4.25 EU/mL (IQR: 4.00-4.60), 2.5 times higher than the GMT elicited by the primary vaccine scheme in the respective recipients. The titer dropped by 1.20% per month (95% CI: 0.52-1.89) regardless of booster administration or any other factor. Women had 51% higher titer compared with men (95% CI: 6-116). High-risk professionals should be verified for adequate antibody titers, but routine administration of a single booster dose of PVRV 1 year after the primary series could be considered; more evidence is needed to support the benefit in terms of immunity and logistics.

Biosecurity Threat Posed by Botulinum Toxin.

The deliberate release of biological agents with terrorist or criminal intent continues to pose concerns in the current geopolitical situation. Therefore, attention is still needed to ensure preparedness against the potential use of pathogens as unconventional weapons. Botulinum neurotoxin (BoNT) is one such biological threat, characterized by an extremely low lethal dose, high morbidity and mortality when appropriately disseminated, and the capacity to cause panic and social disruption. This paper addresses the risks of a potential release of the botulinum neurotoxin and summarizes the relevant aspects of the threat.

Immunization related behaviour among healthcare workers in Europe: Results of the HProImmune survey.

OBJECTIVES: Vaccine preventable diseases (VPDs) continue to pose a significant threat to healthcare workers (HCWs) while immunization among this group remains low. HCWs' behaviours as well as facilitators and barriers towards their vaccination for a number of VPDs were explored through an EU-wide survey. METHODS: HCWs across the EU answered online survey that explored attitudes and behaviours towards vaccination for a number of VPDs. Response data were adjusted based on weights estimated by HCWs' country and working profession according to WHO statistics. The survey was delivered between October 2012 and April 2014. RESULTS: Analysis was based on responses from 5,424 HCWs from 14 European countries. The majority (86.7%) had a positive attitude regarding immunizations. HCWs considered influenza (86.4%), viral hepatitis type B (71.9%) and tuberculosis (59.1%) as higher risk diseases for occupational exposure in the workplace. However, 43.8% reported not receiving a seasonal influenza vaccine in the last 10 years and 65.6% reported not receiving the pandemic influenza vaccine in 2009. Main enablers towards immunizations included believing in vaccine protection and easy, free of charge access to vaccines in the workplace. Barriers to up-to-date immunizations differed according to disease but included concerns about short- and long-term effects. CONCLUSION: Although the concept of mandatory vaccination seems to be favoured by many health professionals in Europe, it remains a controversial subject both among HCWs' profession categories and also among different countries. Interventions to increase vaccination among HCWs would benefit by tailoring their approach according to disease and target group.

National immunization strategies targeting migrants in six European countries.

Over the last three years an unprecedented flow of migrants arrived in Europe. There is evidence that vaccine preventable diseases have caused outbreaks in migrant holding centres. These outbreaks can be favored by a combination of factors including low immunization coverage, bad conditions that migrants face during their exhausting journey and overcrowding within holding facilities. In 2017, we conducted an online survey in Croatia, Greece, Italy, Malta, Portugal and Slovenia to explore the national immunization strategies targeting irregular migrants, refugees and asylum seekers. All countries stated that a national regulation supporting vaccination offer to migrants is available. Croatia, Italy, Portugal and Slovenia offer to migrant children and adolescents all vaccinations included in the National Immunization Plan; Greece and Malta offer only certain vaccinations, including those against diphtheria-tetanus-pertussis, poliomyelitis and measles-mumps-rubella. Croatia, Italy, Malta and Portugal also extend the vaccination offer to adults. All countries deliver vaccinations in holding centres and/or community health services, no one delivers vaccinations at entry site. Operating procedures that guarantee the migrants' access to vaccination at the community level are available only in Portugal. Data on administered vaccines is available at the national level in four countries: individual data in Malta and Croatia, aggregated data in Greece and Portugal. Data on vaccination uptake among migrants is available at national level only in Malta. Concluding, although diversified, strategies for migrant vaccination are in place in all the surveyed countries and generally in line with WHO and ECDC indications. Development of procedures to keep track of migrants' immunization data across countries, development of strategies to facilitate and monitor migrants' access to vaccinations at the community level and collection of data on vaccination uptake among migrants should be promoted to meet existing gaps.

Surveillance of Rabies Postexposure Prophylaxis in Greece: 4 Years Experience.

Rabies reemerged in Greek fauna during October 2012, 25 years after the last report in animals and 42 after the last human case. This study examined the administration of rabies postexposure prophylaxis (PEP) in humans over the period 2012-2016. A total of 1,454 individuals (62.6% males) received PEP. The vast majority (92.3%) of regimens was initiated in high risk for animal rabies areas (11.1 PEP per 100,000 residents per year). Among the exposed, 77.0% presented at a healthcare setting during the first 24 h after the incident; more severe injuries were associated with faster presentation (p < 0.05). A vaccine series was administered in 54.5% of exposed persons whereas 43.7% received both vaccine and immunoglobulin and 1.7% immunoglobulin only. Exposure to stray dogs represented 68.4% of all incidents. In exposures occurring in nonhigh risk for rabies areas, bat was the second most frequently involved animal (13.4% of incidents). All dogs and cats evaluated by a veterinarian and laboratory-confirmed rabid were initially deemed suspect for rabies during clinical examination or according to history. No human rabies cases were recorded during the period of the study. Surveillance of PEP represents a valuable tool for aiding assessment of present and future demands in prophylaxis biologicals, outlining the epidemiological profile of exposures and planning effective policies for the management of exposure incidents.

Amino acid signatures in the HLA class II peptide-binding region associated with protection/susceptibility to the severe West Nile Virus disease.

The MHC class II region in humans is highly polymorphic. Each MHC molecule is formed by an α and a ß chain, produced by different genes, creating an antigen-binding groove. In the groove there are several pockets into which antigens anchor and fit. The affinity of this fitting determines the recognition specificity of a given peptide. Here, based on our previous results about the association of MHC class II with the WNV disease, we examined the role of the binding pockets of HLA-DPA1, -DQA1 and-DRB1 in the severe form of the disease. In HLA-DQA1, variants in all pockets 1, 6 and 9 were found to be associated with either protection and/or susceptibility to neuroinvasion caused by WNV. Similarly, pockets 7, 9 and 10 in HLA-DRB1 were associated with severe disease. Protein modeling of these molecules revealed structural and functional differences among alleles with opposite roles concerning the development of the disease. Different amino acids in positions α52 and α66 (HLA-DQA1) significantly influenced the peptide binding while DYWLR/EFA combination (HLA-DRB1) was associated with neuronal damage. Further studies could help us understand the selectivity of pocket variants in order to create suitable peptides for an effective response.

Genetic Spatiotemporal Anatomy of Plasmodium vivax Malaria Episodes in Greece, 2009-2013.

An influx of immigrants is contributing to the reemergence of Plasmodium vivax malaria in Greece; 1 persistent focus of transmission is in Laconia, Pelopónnese. We genotyped archived blood samples from a substantial proportion of malaria cases recorded in Greece in 2009-2013 using 8 microsatellite markers and a PvMSP-3α gene fragment and plotted their spatiotemporal distribution. High parasite genetic diversity with low multiplicity of infection was observed. A subset of genetically identical/related parasites was restricted to 3 areas in migrants and Greek residents, with some persisting over 2 consecutive transmission periods. We identified 2 hitherto unsuspected additional foci of local transmission: Kardhítsa and Attica. Furthermore, this analysis indicates that several cases in migrants initially classified as imported malaria were actually locally acquired. This study shows the potential for P. vivax to reestablish transmission and counsels public health authorities about the need for vigilance to achieve or maintain sustainable malaria elimination.

Promotion of Immunizations for Health Professionals in Europe: A Qualitative Study in Seven European Member States.

Health Care Workers (HCWs) are a high-risk group for contracting Vaccine-Preventable Diseases who, despite legislation and guidance, remain undervaccinated. In order to understand their barriers and needs, focus groups were formed with 278 physicians, nurses, infection-control personnel, and policy-makers in 7 EU MS. Several implications for the development of promotional initiatives were identified including the need to overcome organizational barriers, to sensitize HCWs about the importance of immunization and to provide specific up-to-date information about vaccinations covering prevalence of diseases, protection years, side effects, administration times, antibody examinations, costs and immunization settings.

Genetic Contribution of MHC Class II Genes in Susceptibility to West Nile Virus Infection.

WNV is a zoonotic neurotropic flavivirus that has recently emerged globally as a significant cause of viral encephalitis. The last five years, 624 incidents of WNV infection have been reported in Greece. The risk for severe WNV disease increases among immunosuppressed individuals implying thus the contribution of the MHC locus to the control of WNV infection. In order to investigate a possible association of MHC class II genes, especially HLA-DPA1, HLA-DQA1, HLA-DRB1, we examined 105 WNV patients, including 68 cases with neuroinvasive disease and 37 cases with mild clinical phenotype, collected during the period from 2010 to2013, and 100 control individuals selected form the Greek population. Typing was performed for exon 2 for all three genes. DQA1*01:01 was considered to be "protective" against WNV infection (25.4% vs 40.1%, P = 0.004) while DQA1*01:02 was associated with increased susceptibility (48.0% vs 32.1%, P = 0.003). Protection against neuroinvasion was associated with the presence of DRB1*11:02 (4.99% vs 0.0%, P = 0.018). DRB1*16:02 was also absent from the control cohort (P = 0.016). Three additional population control groups were used in order to validate our results. No statistically significant association with the disease was found for HLA-DPA alleles. The results of the present study provide some evidence that MHC class II is involved in the response to WNV infection, outlining infection "susceptibility" and "CNS-high-risk" candidates. Furthermore, three new alleles were identified while the frequency of all alleles in the study was compared with worldwide data. The characterization of the MHC locus could help to estimate the risk for severe WNV cases in a country.

Identification of Climatic Factors Affecting the Epidemiology of Human West Nile Virus Infections in Northern Greece.

Climate can affect the geographic and seasonal patterns of vector-borne disease incidence such as West Nile Virus (WNV) infections. We explore the association between climatic factors and the occurrence of West Nile fever (WNF) or West Nile neuro-invasive disease (WNND) in humans in Northern Greece over the years 2010-2014. Time series over a period of 30 years (1979-2008) of climatic data of air temperature, relative humidity, soil temperature, volumetric soil water content, wind speed, and precipitation representing average climate were obtained utilising the ECMWF's (European Centre for Medium-Range Weather Forecasts) Re-Analysis (ERA-Interim) system allowing for a homogeneous set of data in time and space. We analysed data of reported human cases of WNF/WNND and Culex mosquitoes in Northern Greece. Quantitative assessment resulted in identifying associations between the above climatic variables and reported human cases of WNF/WNND. A substantial fraction of the cases was linked to the upper percentiles of the distribution of air and soil temperature for the period 1979-2008 and the lower percentiles of relative humidity and soil water content. A statistically relevant relationship between the mean weekly value climatic anomalies of wind speed (negative association), relative humidity (negative association) and air temperature (positive association) over 30 years, and reported human cases of WNF/WNND during the period 2010-2014 could be shown. A negative association between the presence of WNV infected Culex mosquitoes and wind speed could be identified. The statistically significant associations could also be confirmed for the week the WNF/WNND human cases appear and when a time lag of up to three weeks was considered. Similar statistically significant associations were identified with the weekly anomalies of the maximum and minimum values of the above climatic factors. Utilising the ERA-Interim re-analysis methodology it could be shown that besides air temperature, climatic factors such as soil temperature, relative humidity, soil water content and wind speed may affect the epidemiology of WNV.

West Nile Virus Circulation in Mosquitoes in Greece (2010-2013).

Background of the Study. Following a large West Nile virus (WNV) epidemic in Northern Greece in 2010, an active mosquito surveillance system was implemented, for a 3-year period (2011, 2012, and 2013). Description of the Study Site and Methodology. Using mainly CO2 mosquito traps, mosquito collections were performed. Samples were pooled by date of collection, location, and species and examined for the presence of WNV. Results. Positive pools were detected in different areas of the country. In 2010, MIR and MLE values of 1.92 (95% CI: 0.00-4.57) and 2.30 (95% CI: 0.38-7.49) were calculated for the Serres Regional Unit in Central Macedonia Region. In 2011, the highest MIR value of 3.71(95% CI: 1.52-5.91) was recorded in the Regions of Central Greece and Thessaly. In 2012, MIR and MLE values for the whole country were 2.03 (95% CI: 1.73-2.33) and 2.15 (95% CI: 1.86-2.48), respectively, for Cx. pipiens. In 2013, in the Regional Unit of Attica, the one outbreak epicenter, MIR and MLE values for Cx. pipiens were 10.75 (95% CI: 7.52-13.99) and 15.76 (95% CI: 11.66-20.65), respectively. Significance of Results/Conclusions. The contribution of a mosquito-based surveillance system targeting WNV transmission is highlighted through the obtained data, as in most regions positive mosquito pools were detected prior to the date of symptom onset of human cases. Dissemination of the results on time to Public Health Authorities resulted in planning and application of public health interventions in local level.

Associations of ABO, D, and Lewis blood groups and HLA Class I and Class II alleles with West Nile virus Lineage 2 disease outcome in Greece, 2010 to 2013.

BACKGROUND: West Nile virus (WNV) infection, commonly asymptomatic, may cause mild West Nile fever (WNF) or potentially fatal neuroinvasive disease (WNND). An outbreak of 262 cases of the new Lineage 2 strain in Greece in 2010 continued with high mortality (17%) in WNND. The objective was to investigate ABO, D, and Lewis blood groups, as well as HLA Class I and Class II alleles, in relation to WNV Lineage 2 disease morbidity. STUDY DESIGN AND METHODS: A cohort of 132 Greek WNV cases in 2010 to 2013 (65% male; mean age 64 years; 41% WNF, 59% WNND) was compared to 51,339 healthy WNV-negative blood donors and 246 healthy subjects. RESULTS: Blood group A was more common in WNV cases (51%) than blood donors (39%) and group O less common (32% vs. 42%). D negativity within group A was higher in WNV than in blood donors (18% vs. 10%, p = 0.044). The frequency of secretors (Lewis(a-b+)) was 60% in WNV and 68% in donors (p = 0.16). HLA alleles C*08, DRB1*O4:O5, and DQB1*O2 occurred significantly less frequently in WNV than controls (p < 0.05 unadjusted for multiple testing) and DRB1*10:O1 more frequently (p = 0.039). CONCLUSION: This first study of symptomatic WNV Lineage 2 suggests A/D negativity as a new risk factor associated with WNV infection and level of morbidity. Further studies are required of the possibility that HLA C*08, DRB1*O4:O5, and DQB1*O2 are protective alleles and DRB1*10:O1 a "susceptible" allele to WNV infection and the role of secretor status in relation to WNV infection.

Imported Chikungunya fever case in Greece in June 2014 and public health response.

We report about the first imported case of Chikungunya fever in Greece in a Greek traveler returning from the Dominican Republic and the associated public health response. We investigated the case and performed focused epidemiological and entomological investigation in all areas the patient visited during the infectious period, to identify the targeted interventions needed. Entomological investigation revealed the occurrence of the competent vector Aedes albopictus (Diptera: Culicidae) in the environment surrounding the hospital where the patient was admitted and in her workplace. All captured mosquitoes tested negative for Chikungunya virus. We further conducted clinical and laboratory examination of the patient's co-travelers, gave advice on appropriate personal preventive measures against mosquito bites to the patient and co-travelers and on vector control, and raised awareness among health professionals throughout Greece. The risk of introduction and local transmission of Chikungunya and other arboviruses in Greece and other European countries is present, as the competent vector exists in many parts of Europe. Public health professionals, travel medicine specialists and clinicians should maintain awareness regarding this possibility of importation of arbovirus cases in order to provide the appropriate advice, seek the prompt diagnosis, and implement appropriate interventions. Mobilization of various stakeholders will lead to enhanced epidemiological and entomological surveillance that will allow for improved risk assessment in each area.