Measles outbreak, Montenegro January-July 2018: Lessons learned.

In 2017, the Regional Verification Commission for Measles and Rubella Elimination (RVC) of the World Health Organization confirmed that measles elimination was sustained in Montenegro, and the previous endemic transmission remained interrupted. However, the RVC was extremely concerned over the continuing low vaccination coverage reported for this country. In this study, we describe the most recent measles epidemic in Montenegro using the epidemiological data collected from January 1 to July 31, 2018. The outbreak is largely attributable to a dangerous accumulation of susceptible subjects across the country and represents a high-risk factor for re-establishing endemic transmission in the Balkan area. This study showed how a vaccine-preventable communicable disease outbreak can have a dramatic impact and severe consequences on regional public health system performance in terms of the sanitary spending point of view. A detailed update is provided on the epidemiological situation in this Central European area, not available until now.

Severe acute respiratory infection surveillance in Montenegro, 2014-2017.

AIM: The study aim was to analyze the epidemiology and clinical characteristics of severe acute respiratory infection (SARI) cases and to compare demographic and clinical characteristics as well as outcomes of influenza-positive SARI cases to those of influenza-negative SARI cases in Montenegro. METHODS: SARI surveillance was established in 2014 in nine healthcare institutions. Retrospective analysis of case-based surveillance data pertaining to all reported SARI cases during three seasons was conducted. RESULTS: Among the 90 identified SARI cases, 64 (71%) were influenza positive. Death outcome was reported in 25 (28%) of all registered SARI cases. Cardiovascular disease was more prevalent among the patients in the influenza-positive SARI group (36% vs. 12%, p = .021), as was concurrence of two or more chronic medical conditions (57% vs. 30%, p = .042). These patients were also more likely to be immunocompromised (16% vs. 0%, p = .057) and have viral pneumonia (14.4% vs. 20.3%, p = .017), compared to those in the influenza-negative SARI group. Younger age, presence of cardiovascular disease and being immunocompromised were patient characteristics independently associated with SARI related to influenza. CONCLUSION: Continued and extended monitoring of SARI is necessary in order to fully assess the burden of flu disease, define risk groups and establish better control measures.

Haemorrhagic fever with renal syndrome in Montenegro, 2004-14.

From 2004 to 2014, 106 cases of Human haemorrhagic fever with renal syndrome were notified in Montenegro, with a peak in 2014. Most of the cases occurred in summer, in the North-east and Central Montenegro, a hilly/mountainous area, that provides suitable habitats for the main rodent carriers. Cases were mainly males (71) and exposures were often working outdoor or spending time visiting mountains and lakes. Incidence correlated with average annual temperature increase and average annual rainfalls decrease, but not with land cover. Environment and climate effects on HFRS in Montenegro need further investigation to get insight into future trends.

Hepatitis C virus genotype 3A in a population of injecting drug users in Montenegro: Bayesian and evolutionary analysis.

Few reports are available on HCV molecular epidemiology among IDUs in Eastern Europe, and none in Montenegro. The aim of this study was to investigate the HCV genotype distribution in Montenegro among IDUs and to perform Bayesian and evolutionary analysis of the most prevalent HCV genotype circulating in this population. Sixty-four HCV-positive IDUs in Montenegro were enrolled between 2013 and 2014, and the NS5B gene was sequenced. The Bayesian analysis showed that the most prevalent subtype was HCV-3a. Phylogenetic data showed that HCV-3a reached Montenegro in the late 1990s, causing an epidemic that exponentially grew between the 1995 and 2005. In the dated tree, four different entries, from 1990 (clade D), 1994 (clade A) to 1999 (clade B) and 2001 (clade C), were identified. In the NS5B protein model, the amino acids variations were located mainly in the palm domain, which contains most of the conserved structural elements of the active site. This study provides an analysis of the virus transmission pathway and the evolution of HCV genotype 3a among IDUs in Montenegro. These data could represent the basis for further strategies aimed to improve disease management and surveillance program development in high-risk populations.

Genetic diversity of the haemagglutinin (HA) of human influenza a (H1N1) virus in montenegro: Focus on its origin and evolution.

In 2009 an influenza A epidemic caused by a swine origin H1N1strain, unusual in human hosts, has been described. The present research is aimed to perform the first phylogenetic investigation on the influenza virus A (H1N1) strains circulating in Montenegro, from December 1, 2009, when the first case of death due to H1N1 was confirmed, and the epidemic began causing a total of four fatalities. The phylogenetic analysis of the strains circulating showed the absence of a pure Montenegrin cluster, suggesting the occurrence of multiple re-introductions in that population from different areas till as far as the early 2010. The time to most recent common ancestor (TMRCA) for the complete dataset has been dated in early 2008, pre-dating the first Montenegrin identification of H1N1 infection. These data suggest that virus was spreading undetected, may be as a consequence of unidentified infections in returning travelers. Anyhow, the estimated TMRCA of Montenegrin strains is fully consistent to that found in different areas. Compatibly with the time coverage of the study period here analyzed, molecular dynamic of Montenegrin strains follows similar trend as in other countries. J. Med. Virol. 88:1905-1913, 2016. © 2016 Wiley Periodicals, Inc.

Factors associated with inconsistent condom use with clients among female sex workers in Podgorica, Montenegro.

Introduction: Female sex workers (FSWs) are a group at increased risk for human immunodeficiency virus (HIV) infection, and inconsistent condom use with clients is a known risk factor for infection in this group. Objective: The aim of the study was to determine factors associated with inconsistent condom use with clients among female sex workers in Podgorica, Montenegro. Methods: We conducted an HIV bio-behavioral cross-sectional study in a sample of female sex workers recruited by snowball sampling. Results: A total of 142 FSWs were recruited. Eighty-one (57.0%) of them used condoms consistently with clients. HIV prevalence was 0.0%. In the multivariate analysis inconsistent condom use with clients in the previous month was associated with clients' negative personal attitude [age-adjusted odds ratio (AOR) = 22.7, 95% confidence interval (CI) = 2.3­228.0] or client's indifference (AOR = 13.0, 95% CI = 1.4­118.9) towards using condom during sex with sexual workers, decision making by clients or by mutual agreement with client about using a condom (AOR = 10.2, 95% CI = 3.7­28.0), and early age of first sex (AOR = 5.4, 95% CI = 1.6­18.5). Conclusion: Our results suggest not only the need for further promotion of condom use, information and education for FSW but also the need to strengthen negotiation skills of FSWs with clients on regular use of condoms, as well as the need to extend prevention programs to clients of FSWs.

Prevalence of HIV and other infections and correlates of needle and syringe sharing among people who inject drugs in Podgorica, Montenegro: a respondent-driven sampling survey.

BACKGROUND: People who inject drugs (PWID) have significantly higher rates of blood borne and sexually transmitted infections due to unsafe injecting practices and risky sexual behaviors. METHODS: We carried out an HIV bio-behavioral survey using respondent-driven sampling (RDS) in people who use drugs (PWID) in Podgorica, Montenegro in 2013 in order to determine the prevalence of HIV, hepatitis C (HCV), hepatitis B surface antigen (HBsAg) and risk behaviors. Data were analyzed using RDS Analyst and SPSS 12.0 to obtain prevalence estimates of key bio-behavioral indicators and assess correlates of needle and syringe sharing using multivariate logistic regression. RESULTS: A total of 402 PWID were recruited. HIV prevalence was 1.1%, while the prevalence of HCV and HBsAg was 53.0% and 1.4%, respectively. In the multivariate analysis, significant correlates of needle and syringe sharing in the past month were being older than 26 years, female, injecting drugs more than once per day, injecting in parks or on streets, not being able to obtaining free-of-charge sterile needles and syringes and reporting more than four partners in the past 12 months. CONCLUSIONS: The results indicate that the HIV epidemic in PWID in Montenegro might still be at a low level, though the HCV epidemic is well-established.

Hepatitis B virus genotype and subgenotype prevalence and distribution in Montenegro.

The Mediterranean area and the Balkans in particular show the highest level of genetic heterogeneity of HBV in Europe. Data about the circulation of HBV genotypes in Montenegro are lacking. It was studied the prevalence and distribution of HBV genot/subgenotypes in a total of 150 HBV infected patients living in Montenegro. Phylogenetic analysis of 136 successfully amplified P sequences showed a high degree of genetic heterogeneity of HBV in Montenegro. Subgenotype D2 (36.8%) and D3 (32.3%) were the most prevalent, followed by genotype A (subgenotype A2 in all of the cases-19.8%). Eight patients were infected with recombinant strains. HBV-D1 which is the most spread HBV subgenotype in the south-eastern Mediterranean countries, seems to be relatively rare in Montenegro, suggesting a penetration of HBV more probably from North-East or West than from Eastern Mediterranean countries. The relatively different prevalence of D3 and A2 among subjects infected through sexual route, seems to confirm the association of these subgenotypes with different route of transmissions (mainly parenteral for D3 and mainly sexual for A2) even in Montenegro. The low prevalence of D2 among children and its absence in perinatal transmission, suggests that this subgenotype circulated prevalently in the past. If this is due to changes in the most prevalent way of transmission and in the recent different contacts of Montenegro with other European countries, it remains to be established by other larger studies.

Reconstruction of the evolutionary dynamics of hepatitis C virus subtypes in Montenegro and the Balkan region.

More than 20 million hepatitis C virus (HCV) carriers live in the countries of the Eastern Mediterranean. We determined HCV genotype distribution among chronically infected patients in Montenegro and investigated the phylodynamics and phylogeography of the most represented HCV subtypes. The HCV-NS5b sequences of the Montenegrin patients were compared with sequences isolated in different known localities of the Mediterranean area, Europe and Asia. A Bayesian approach was used in order to allow the simultaneous estimate of the evolutionary rate, time-scaled phylogeny, demography and ancestral spatial status. The most frequent HCV subtypes among the Montenegrin patients, were 1b (34.7%) and 3a (24.7%), but there was also a significant prevalence of 1a and 4d (19.5%). Subtype 3a was significantly more frequent among younger patients and intravenous drug users (IDUs), whereas subtype 1b was more frequently associated with iatrogenic exposure and older ages. The spatio-temporal analysis of the epidemic suggested that HCV-1b penetrated Europe at the beginning of the XX century, probably through Greece and Cyprus and in the 1920s reached Montenegro, where there was an exponential increase in the effective number of infections between the 1950s and 1970s. The phylogeographic and phylodynamic analysis of HCV 3a showed that its most probable origin was in the Indian sub-continent (Pakistan in our reconstruction) about 300years ago. The evolutionary dynamics analysis showed that HCV-3a reached Montenegro more recently in the late 1970s and underwent multi-phasic growth still persisting. Our data suggest multiple introduction of HCV subtypes in the area, supported by different causes of dispersion: adverse social conditions and unsafe medical practices for HCV-1b and i.v. drug use for HCV-3a.

Hepatitis C virus infection and related risk factors among injection drug users in Montenegro.

BACKGROUND: In Southeastern Europe, similar to other postsocialist regions on the continent, injection drug users (IDU) are exposed to a high risk of blood-borne infections. In this paper, we report the prevalence of HIV, hepatitis C (HCV) and hepatitis B (HBV) among IDUs in Montenegro. We also examine the risk factors associated with HCV diagnosis. METHODS: In 2008, 322 IDUs in Montenegro participated in a respondent-driven sampling survey. Blood specimens were collected and tested for HIV, HCV and HBV. Behavioral data were collected with self-administered questionnaires. RESULTS: In comparison to 2005, HCV prevalence had increased from an estimated 22 to 53.7%. Only one HIV and no HBV cases were detected. Anti-HCV positivity was associated with the region of origin, income, sharing injection equipment and frequency of injecting drugs. CONCLUSION: The increasing HCV prevalence among IDUs in Montenegro calls for increased and better designed programs to prevent its further spread and a potential HIV outbreak.

Phylogeographic reconstruction of HIV type 1B in Montenegro and the Balkan region.

Human immunodeficiency virus (HIV) is one of the most genetically variable human viruses as it is characterized by high rates of mutation, viral replication, and recombination. Phylodynamics is a powerful means of describing the behavior of an infection as a combination of evolutionary and ecological processes. Only a few studies of HIV-1 molecular epidemiology have so far been carried out in the Balkans. In this study, we used Bayesian methods to reconstruct the phylogeography and phylodynamics of HIV-1B in Montenegro and some other Balkan countries on the basis of pol gene sequences retrieved from a public database. The phylogenetic analysis showed that 43% of the isolates grouped in accordance with their geographic area, whereas the majority were interspersed in the tree, thus confirming the multiple introductions of HIV-1B in the Balkans. The Bayesian phylogeographic analysis suggested that HIV-1B entered the Balkans in the early 1970s probably through Greece and other Mediterranean tourist/travel destinations (such as Slovenia). Other Balkan countries, such as Bulgaria and Serbia, may have played an important role in spreading the infection to the entire Eastern Mediterranean area, and possibly to Northeast Europe. This suggests that the Balkans may have played a role as a "gateway" between Western and Eastern Europe.

Genetic diversity of HIV type 1 in Montenegro.

Human immunodeficiency virus type 1 (HIV-1) is characterized by high genetic variability due to its high replication rate and the lack of proofreading activity of the reverse transcriptase enzyme. On the basis of phylogenetic analysis performed on numerous isolates from all over the world, HIV-1 is subdivided into types, subtypes, subsubtypes, circulating recombinant forms, and unique recombinant forms. No data are currently available about the circulation of HIV-1 types in Montenegro. Here, we describe the genetic variability of HIV-1 strains identified in plasma samples of patients from Montenegro. Phylogenetic analysis on 32 HIV-1 sequences was carried out. The prevalent circulating HIV-1 subtype is B. The strains were interspersed within the tree. Two main clades (I and II) may suggest independent introductions of HIV-1 subtype B into Montenegro, although other epidemiological evidence will be needed to assume a small number of introductions. No obvious evidence of clustering by residence, age, or sex was found (data not shown). Nelfinavir resistance was found, though lopinavir is the only PI administered. Continuous monitoring of HIV-1-infected individuals is crucial to a better understand of the epidemiology of the B subtype in Montenegro.