Molecular Epidemiology of SARS-CoV-2 in Greece Reveals Low Rates of Onward Virus Transmission after Lifting of Travel Restrictions Based on Risk Assessment during Summer 2020.

The novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread rapidly during the first months of 2020 and continues to expand in multiple areas across the globe. Molecular epidemiology has provided an added value to traditional public health tools by identifying SARS-CoV-2 clusters or providing evidence that clusters based on virus sequences and contact tracing are highly concordant. Our aim was to infer the levels of virus importation and to estimate the impact of public health measures related to travel restrictions to local transmission in Greece. Our phylogenetic and phylogeographic analyses included 389 full-genome SARS-CoV-2 sequences collected during the first 7 months of the pandemic in Greece and a random collection in five replicates of 3,000 sequences sampled globally, as well as the best hits to our data set identified by BLAST. Phylogenetic trees were reconstructed by the maximum likelihood method, and the putative source of SARS-CoV-2 infections was inferred by phylogeographic analysis. Phylogenetic analyses revealed the presence of 89 genetically distinct viruses identified as independent introductions into Greece. The proportion of imported strains was 41%, 11.5%, and 8.8% during the three periods of sampling, namely, March (no travel restrictions), April to June (strict travel restrictions), and July to September (lifting of travel restrictions based on thorough risk assessment), respectively. The results of phylogeographic analysis were confirmed by a Bayesian approach. Our findings reveal low levels of onward transmission from imported cases during summer and underscore the importance of targeted public health measures that can increase the safety of international travel during a pandemic. IMPORTANCE Our study based on current state-of-the-art molecular epidemiology methods suggests that virus screening and public health measures after the lifting of travel restrictions prevented SARS-CoV-2 onward transmission from imported cases during summer 2020 in Greece. These findings provide important data on the efficacy of targeted public health measures and have important implications regarding the safety of international travel during a pandemic. Our results can provide a roadmap about prevention policy in the future regarding the reopening of borders in the presence of differences in vaccination coverage, the circulation of the virus, and the presence of newly emergent variants across the globe.

COVID-19 Outbreak on a Passenger Ship and Assessment of Response Measures, Greece, 2020.

We describe response measures to an outbreak involving 128 (33.4%) coronavirus disease cases (46.1% asymptomatic) among 383 persons onboard a passenger ship. Multivariate analysis indicated that dining in certain rooms and bar areas, nationality, working department (for crew members), and quarantining onboard the ship were significantly associated with infection.

Detection of imported COVID-19 cases worldwide: early assessment of airport entry screening, 24 January until 17 February 2020.

The purpose of this study was to provide an overview of entry screening measures applied at airports in response to the COVID-19 epidemic worldwide. Between 24 January and 17 February 2020, 5.2% (95% CI 3.1-8.5) of the 271 total imported COVID-19 cases worldwide (excluding imported cases arriving in China, Macao, and Hong Kong) with known detection location were captured through airport entry screening. The majority of imported COVID-19 cases (210) were identified by the health care system (77.5%). Efforts should focus on health care system preparedness for early case detection, since according to our and previous studies health care facilities are the actual point of entry of imported cases.

Economic Crisis Impact and Social Determinants of Perinatal Outcomes and Infant Mortality in Greece.

(1) Background: To explore the effects of the 2008 economic crisis on maternal, perinatal and infant mortality in Greece and the socio-economic determinants associated with them; (2) Methods: The annual rates of stillbirth (SBR), perinatal mortality (PMR), infant mortality (IMR), neonatal mortality (NNMR), post-neonatal mortality (PNMR), low birth weight (LBW), and maternal mortality (MMR) were calculated for the years 2000-2016. Average Annual Percent Changes (AAPC) were calculated by the period before and after 2008. The expected rates of 2009-2016 and the observed-to-expected rate ratios (RR) were calculated. Correlation and multiple linear regression analyses were used to test the impact of socio-economic variables on health outcomes; (3) Results: A reverse in downwards trends of PNM, IMR, and NNMR is observed since 2009. All observed values of 2009-2016 were found significantly higher than the expected ones by 12-34%. All indicators except SBR were found negatively correlated with GDP and DHI. A positive correlation was found between IMR, NNMR, and LBW and long-term unemployment, and no association with public health expenditure; (4) Conclusions: Economic crisis was associated with remarkable adverse effects on perinatal outcomes and infant mortality, mainly determined by long-term unemployment and income reduction. The findings stress a need for interventions to protect maternity and child health during crises.

Prevalence and determinants of current cigarette smoking and secondhand smoking among Greek adolescents: the Global Youth Tobacco Survey (GYTS) 2013 study.

OBJECTIVES: Smoking prevalence in Greece is considered high within the European Union and the collection of evidence on tobacco use among adolescents is of vital importance in order to develop effective smoking prevention and cessation programmes. DESIGN: Cross-sectional. SETTING: Greece. PRIMARY AND SECONDARY OUTCOME MEASURES: Global Youth Tobacco Survey (GYTS) is a national representative, paper-and-pencil, cross-sectional, school-based study of students at ages 13-15 years. The survey employed a multistage cluster sample design with schools selected proportional to enrolment size. Finally, 4618/5127 students aged 13-15 years participated in the survey. The school response rate was 98.1%, the student response rate was 90.1% and the overall response rate was 88.4%. RESULTS: The prevalence of current cigarette smoking was estimated at 10.1% (10.4% in GYTS 2005) and of exposure to secondhand smoking in public places at 67.4% (94.1% in GYTS 2005). The vast majority of the adolescents (82.1%) supported the banning of smoking inside enclosed public places. Most of the current smokers (90.8%) were not prevented/refused purchase because of their age according to existing law. Multivariate analysis showed that peer influence (OR=48.32; 95% CI 36.2 to 64.48), pocket money (OR=2.63; 95% CI 1.28 to 3.41), increasing age (OR=2.35; 95% CI 1.63 to 3.39) and low educational level of father (OR=2.82; 95% CI 1.7 to 4.68) were risk factors independently associated with current cigarette smoking. CONCLUSIONS: Despite the existence of strict laws related to tobacco control, exposure to secondhand smoking among Greek students remained high even when compared with GYTS in 2005. This is likely a result of weak enforcement, what is really missing is the enforcement of the related legislation.

Hepatitis A outbreak disproportionately affecting men who have sex with men (MSM) in the European Union and European Economic Area, June 2016 to May 2017.

Between 1 June 2016 and 31 May 2017, 17 European Union (EU) and European Economic Area countries reported 4,096 cases associated with a multi-country hepatitis A (HA) outbreak. Molecular analysis identified three co-circulating hepatitis A virus (HAV) strains of genotype IA: VRD_521_2016, V16-25801 and RIVM-HAV16-090. We categorised cases as confirmed, probable or possible, according to the EU outbreak case definitions. Confirmed cases were infected with one of the three outbreak strains. We investigated case characteristics and strain-specific risk factors for transmission. A total of 1,400 (34%) cases were confirmed; VRD_521_2016 and RIVM-HAV16-090 accounted for 92% of these. Among confirmed cases with available epidemiological data, 92% (361/393) were unvaccinated, 43% (83/195) travelled to Spain during the incubation period and 84% (565/676) identified as men who have sex with men (MSM). Results depict an HA outbreak of multiple HAV strains, within a cross-European population, that was particularly driven by transmission between non-immune MSM engaging in high-risk sexual behaviour. The most effective preventive measure to curb this outbreak is HAV vaccination of MSM, supplemented by primary prevention campaigns that target the MSM population and promote protective sexual behaviour.

Assessment of the antioxidant and antimutagenic activity of extracts from goji berry of Greek cultivation.

The aim of this study was to assess the antioxidant and antimutagenic activities of ultrasound assisted aqueous extracts from dry goji berry fruits cultivated in Greece. The extracts' free radical scavenging activity was assessed by the DPPH• and ABTS•+ assays. The results from both assays demonstrated that the extracts exhibited strong radical scavenging activity with IC50 values ranging from 1.29 to 3.00 mg/ml for DPPH• and from 0.39 to 1.10 mg/mL for ABTS•+ assay. The investigated extracts also inhibited free radical-induced DNA damage induced by peroxyl (ROO•) radicals with IC50 ranging from 0.69 to 6.90 mg/mL. Τhe antioxidant activity of the goji berry extract exhibited the highest potency in the above assays was also examined in muscle cells. In particular, muscle C2C12 cells were treated with the selected extract at non cytotoxic concentrations for 24 h and four oxidative stress markers were measured: total reactive oxygen species (ROS), glutathione (GSH), lipid peroxidation and protein carbonyl levels. The results showed that the extract at 25 and 100 µg/mL increased GSH levels up to 189.5% and decreased lipid peroxidation and protein carbonyls by 21.8 and 29.1% respectively. The present study was the first on the antioxidant effects of ultrasound assisted aqueous extracts from goji berry fruits in muscle cells.

Prevalence and determinants of smoking and secondhand smoke exposure in a rural population of central Greece: a cross-sectional study.

INTRODUCTION: Smoking is one of the most important risk factors for heart and lung disease and is responsible for many forms of cancer. The resulting morbidity and mortality weigh heavily upon countries with high prevalence, such as Greece. According to the Global Adult Tobacco Survey (GATS) Greece, 38.2% of Greeks aged ≥15 years, namely 51.2% of men and 25.7% of women, are smokers. Smoking is also common among the young and people of high education. Despite laws prohibiting smoking at indoor places, exposure to environmental tobacco is very high both in private and public places. The study goal was to estimate the prevalence and characteristics of smoking, the level of tobacco exposure and the factors that affect both in a rural population. METHODS: A cross-sectional household study was conducted using the GATS questionnaire in a rural borough of Thessaly, Greece. Eligible participants were permanent residents of the selected villages, aged ≥18 years and they were selected by a combination of stratified sampling with probability proportional to size, random sampling and convenience sampling. Population demographics, current smoking status and tobacco use patterns, exposure to secondhand smoke, attitudes and knowledge on smoking were recorded. Analyses were performed according to the GATS manuals using the SPSS complex samples module. RESULTS: A total of 330 adults participated in the study (168 men, 162 women). The mean age of the sample was 54.2±17.75 years (range 18.5-86.1 years). Smoking prevalence was 32.4%; 46.4% (95% confidence interval (CI) 37.8-55.3%) of men and 17.9% (95%CI 12.0-25.9%) of women were smokers. Smoking was also common among the young, people with secondary education and high school graduates. The manufactured cigarette was the most preferred tobacco product. Daily smokers consumed on average 20.6 (95%CI 17.67-23.52) cigarettes per day. Men smoked more cigarettes and started at an earlier age than women. Overall exposure to environmental tobacco smoke was high among the population. Men, individuals aged 18-24 years and 40-54 years were more exposed than their counterparts. Places where high exposure was recorded included restaurants (80.0%, 95%CI 76.0-83.5%), bars (87.8%, 95%CI 75.7-94.3%) and coffee shops (82.6%, 95%CI 68.4-91.3%). Six out of ten (62.1%, 95%CI 51.7-71.5%) workers were exposed at their workplace and nearly half were exposed on a daily basis. Prevalence of home exposure was 40.4% (95%CI 32.0-49.5%). The multivariate analysis showed that sex and age were independent predictors of current smoking status, while only sex was independently associated with exposure to secondhand smoke. CONCLUSIONS: There are very few studies studying the characteristics of smoking and tobacco exposure exclusively in rural populations in Greece, such as the present study. Both the high prevalence of smoking and the high levels of exposure to tobacco show a population at increased risk for tobacco-related disease. These call for immediate action to reduce smoking prevalence, help smokers quit and protect the health of non-smokers. The present study's conclusions provide the basis for designing local prevention programs and the baseline for monitoring of future trends in the area.

A cross-sectional vaccination coverage study in preschool children attending nurseries-kindergartens: Implications on economic crisis effect.

Vaccination coverage studies are important in determining a population's vaccination status and strategically adjusting national immunization programs. This study assessed full and timely vaccination coverage of preschool children aged 2-3 y attending nurseries-kindergartens (N-K) nationwide at the socioeconomic crisis onset. Geographically stratified cluster sampling was implemented considering prefectures as strata and N-K as clusters. The N-K were selected by simple random sampling from the sampling frame while their number was proportional to the stratum size. In total, 185 N-K (response rate 93.9%) and 2539 children (response rate 81.5%) participated. Coverage with traditional vaccines for diphtheria-tetanus-pertussis, polio and measles-mumps-rubella was very high (>95%), followed by Haemophilus influenzae type b and varicella vaccines. Despite very high final coverage, delayed vaccination was observed for hepatitis B (48.3% completed by 12 months). Significant delay was observed for the booster dose of pneumococcal conjugate vaccines (PCV) and meningococcal C conjugate vaccines (MCC). Of the total population studied, 82.3% received 3 PCV doses by 12 months, while 62.3% received the fourth dose by 24 months and 76.2% by 30 months. However, 89.6% received at least one MCC dose over 12 months. Timely vaccinated for hepatitis A with 2 doses by 24 months were 6.1%. Coverage was significantly low for Rotavirus (<20%) and influenza (23.1% one dose). High vaccination coverage is maintained for most vaccines at the beginning of the crisis in Greece. Coverage and timeliness show an increasing trend compared to previous studies. Sustained efforts are needed to support the preventive medicine system as socioeconomic instability continues.

Assessment of antibody responses in local and immigrant residents of areas with autochthonous malaria transmission in Greece.

Greece has been officially malaria free since 1974. However, from 2009 to 2012, several locally acquired, cases of Plasmodium vivax malaria were detected, in immigrants and in Greek citizens. In this study, the antibody (Ab) response of Greeks and immigrants with documented malaria was initially assessed, followed by an Ab screening of Greeks and immigrant residents of local transmission areas. Of the 38 patients tested, 10.5% of Greeks and 15.7% of immigrants were positive 5-7 months after infection. Of the 1,019 individuals from various areas of Greece, including those of autochthonous transmission, 85 of the 721 (11.8%) immigrants were positive, whereas all 298 Greeks were negative. The rapid Ab titer decline observed is reasonable, given the non-endemic epidemiological setting. The seroepidemiological findings indicate that the local Greek population remains malaria naive and that at this point Greeks are unlikely to serve as reservoir for the infection of local mosquitoes.

Field application of SD bioline malaria Ag Pf/Pan rapid diagnostic test for malaria in Greece.

Greece, a malaria-free country since 1974, has experienced re-emergence of Plasmodium vivax autochthonous malaria cases in some agriculture areas over the last three years. In early 2012, an integrated control programme (MALWEST Project) was launched in order to prevent re-establishment of the disease. In the context of this project, the rapid diagnostic tests (RDT) of SD Bioline Malaria Ag Pf/Pan that detects hrp-2 and pan-LDH antigens were used. The aim of this study was to assess the field application of the RDT for the P. vivax diagnosis in comparison to light microscopy and polymerase chain reaction (PCR). A total of 955 samples were tested with all three diagnostic tools. Agreement of RDT against microscopy and PCR for the diagnosis of P. vivax was satisfactory (K value: 0.849 and 0.976, respectively). The sensitivity, specificity and positive predictive value of RDT against PCR was 95.6% (95% C.I.: 84.8-99.3), 100% (95% C.I.: 99.6-100.0) and 100% (95% CI: 91.7-100.0) respectively, while the sensitivity, specificity and positive predictive value of RDT against microscopic examination was 97.4% (95% C.I.: 86.1-99.6), 99.4% (95% C.I.: 98.6-99.8) and 86.1% (95% CI: 72.1-94.7), respectively. Our results indicate that RDT performed satisfactory in a non-endemic country and therefore is recommended for malaria diagnosis, especially in areas where health professionals lack experience on light microscopy.

What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012).

OBJECTIVES: There is a controversy about the impact of economic crisis on suicide rates in Greece. We analysed recent suicide data to identify who has been most affected and the relationships to economic and labour market indicators. SETTING: Greece. PRIMARY AND SECONDARY OUTCOME MEASURES: Age-specific and sex-specific suicide rates in Greece for the period 2003-2012 were calculated using data provided by the Hellenic Statistical Authority. We performed a join-point analysis to identify discontinuities in suicide trends between 2003 and 2010, prior to austerity, and in 2011-2012, during the period of austerity. Regression models were used to assess relationships between unemployment, Gross Domestic Product (GDP) and suicide rates for the entire period by age and sex. RESULTS: The mean suicide rate overall rose by 35% between 2010 and 2012, from 3.37 to 4.56/100,000 population. The suicide mortality rate for men increased from 5.75 (2003-2010) to 7.43/100,000 (2011-2012; p<0.01). Among women, the suicide rate also rose, albeit less markedly, from 1.17 to 1.55 (p=0.03). When differentiated by age group, suicide mortality increased among both sexes in the age groups 20-59 and >60 years. We found that each additional percentage point of unemployment was associated with a 0.19/100,000 population rise in suicides (95% CI 0.11 to 0.26) among working age men. CONCLUSIONS: We found a clear increase in suicides among persons of working age, coinciding with austerity measures. These findings corroborate concerns that increased suicide risk in Greece is a health hazard associated with austerity measures.

Considerations on the current universal vaccination policy against hepatitis A in Greece after recent outbreaks.

Greece is the only European Union member state that in 2008 included hepatitis A (HAV) vaccine in the routine national childhood immunization program (NCIP). Given that the resources allocated to public health have dramatically decreased since 2008 and that Greece is a low endemicity country for the disease, the benefit from universal vaccination has been questioned. The aim of this paper is to summarize the available epidemiological data of the disease for 1982-2013, and discuss the effects of universal vaccination on disease morbidity. Descriptive analysis, ARIMA modeling and time series intervention analysis were conducted using surveillance data of acute HAV. A decreasing trend of HAV notification rate over the years was identified (p<0.001). However, universal vaccination (~ 80% vaccine coverage of children) had no significant effect on the annual number of reported cases (p = 0.261) and has resulted to a progressive increase of the average age of infection in the general population. The mean age of cases before the inclusion of the vaccine to NCIP (24.1 years, SD = 1.5) was significantly lower than the mean age of cases after 2008 (31.7 years, SD = 2.1) (p<0.001). In the last decade, one third of all reported cases were Roma (a population accounting for 1.5% of the country's total population) and in 2013 three outbreaks with 16, 9 and 25 Roma cases respectively, were recorded, indicating the decreased effectiveness of the current immunization strategy in this group. Data suggest that universal vaccination may need to be re-considered. Probably a more cost effective approach would be to implement a program that will include: a) vaccination of high risk groups, b) universal vaccination of Roma children and improving conditions at Roma camps, c) education of the population and travel advice, and d) enhancement of the control measures to increase safety of shellfish and other foods.

Organ donation knowledge and attitudes among health science students in Greece: emerging interprofessional needs.

BACKGROUND: The impact of presumed consent on donation rates has been widely debated. In June 2013 Greece adopted a 'soft' presumed consent law for organ and tissue donation, where relatives' approval is sought prior to organ removal. AIMS: To report on the knowledge, attitudes and concerns of undergraduate students, enrolled in three health science disciplines, in regards to organ donation and presumed consent. METHODS: Undergraduate junior and senior health science students [medical (MS), nursing (NS) and medical laboratory students (MLS)] were recruited from higher education settings in Thessaly, Greece. Dichotomous questions, previously used, were adopted to assess knowledge, attitudes and concerns towards organ donation, together with questions regarding the recent presumed consent legislation. RESULTS: Three hundred seventy-one out of 510 students participated in the study (response rate: 72.7%). Only 3.6% of NS, 8.7% of MS and 3.2% of MLS carried a donor card. Although over 78% in all groups knew that it was possible to leave kidneys for transplant after death, only 10% to 39% considered themselves well-informed. NS were more likely to consider opting-out (21.5%), followed by MLS (17.9%) and MS (10.9%). Respondents were more likely to refuse organ removal upon death when expressing one of the following views: a) opposing a system making it lawful to take kidneys from an adult who has just died, unless forbidden while alive [Odds ratio (OR) 95% Confidence Interval (CI): 2.96 (1.48-5.93), p=0.002], b) worrying about their kidneys being removed after death [OR, 95% CI: 3.37 (1.75-6.49), p=<0.001] and c) believing that an intact body was needed after death [OR, 95% CI: 4.23 (2.15-8.31), p<0.001]. CONCLUSION: Health science students, soon to become healthcare professionals, demonstrated limited awareness in regards to the newly reformed organ donation system. Identified knowledge deficits and concerns could have far-reaching implications in terms of conveying a clear message and shaping the public's stand. The feasibility and effectiveness of a joint inter-professional curriculum on organ and tissue donation issues across all three health science disciplines, addressing common themes and concerns deserves further study.

Medical supplies shortages and burnout among greek health care workers during economic crisis: a pilot study.

Greece has been seriously affected by the economic crisis. In 2011 there were reports of 40% reduction to public hospital budgets. Occasional shortages of medical supplies have been reported in mass media. We attempted to pivotally investigate the frequency of medical supplies shortages in two Greek hospital units of the National Health System and to also assess their possible impact on burnout risk of health care workers. We conducted a cross-sectional study (n=303) of health care workers in two Greek hospitals who were present at the workplace during a casually selected working day (morning shift work). The Maslach Burnout Inventory (MBI) was used as the measure of burnout. An additional questionnaire was used about demographics, and working conditions (duration of employment, cumulative night shifts, type of hospital including medical supplies shortages and their impact on quality of healthcare. The prevalence of emotional exhaustion, depersonalization and low personal accomplishment was 44.5%, 43.2% and 51.5%, respectively. Medical supply shortages were significantly associated with emotional exhaustion and depersonalization. This finding provides preliminary evidence that austerity has affected health care in Greece. Moreover, the medical supply shortages in Greek hospitals may reflect the unfolding humanitarian crisis of the country.

Application of chemometric methods for assessment and modelling of microbiological quality data concerning coastal bathing water in Greece.

BACKGROUND: Worldwide, the aim of managing water is to safeguard human health whilst maintaining sustainable aquatic and associated terrestrial, ecosystems. Because human enteric viruses are the most likely pathogens responsible for waterborne diseases from recreational water use, but detection methods are complex and costly for routine monitoring, it is of great interest to determine the quality of coastal bathing water with a minimum cost and maximum safety. DESIGN AND METHODS: This study handles the assessment and modelling of the microbiological quality data of 2149 seawater bathing areas in Greece over 10-year period (1997-2006) by chemometric methods. RESULTS: Cluster analysis results indicated that the studied bathing beaches are classified in accordance with the seasonality in three groups. Factor analysis was applied to investigate possible determining factors in the groups resulted from the cluster analysis, and also two new parameters were created in each group; VF1 includes E. coli, faecal coliforms and total coliforms and VF2 includes faecal streptococci/enterococci. By applying the cluster analysis in each seasonal group, three new groups of coasts were generated, group A (ultraclean), group B (clean) and group C (contaminated). CONCLUSIONS: The above analysis is confirmed by the application of discriminant analysis, and proves that chemometric methods are useful tools for assessment and modeling microbiological quality data of coastal bathing water on a large scale, and thus could attribute to effective and economical monitoring of the quality of coastal bathing water in a country with a big number of bathing coasts, like Greece. Significance for public healthThe microbiological protection of coastal bathing water quality is of great interest for the public health authorities as well as for the economy. The present study proves that this protection can be achieved by monitoring only two microbiological parameters, E. coli and faecal streptococci/enterococci instead four microbiological parameters (the two mentioned above plus Total coliforms and Faecal coliforms) that are usually monitored today. As a consequence, countries, especially those with large quantities of coastal bathing sites, can perform microbiological monitoring of their bathing waters by checking only the mentioned two parameters, thus ensuring economies of scale. Thus, funds can be used in other actions to preserve the quality of coastal water and human health. This in turn, would aid in the assessment of the quality of coastal bathing waters and provide a more timely indication of bathing water quality, hence contributing to the immediate health protection of bathers.

Assessment of hygiene standards and Hazard Analysis Critical Control Points implementation on passenger ships.

The level of hygiene on ferries can have impact on travellers' health. The aim of this study was to assess the hygiene standards of ferries in Greece and to investigate whether Hazard Analysis Critical Control Points (HACCP) implementation contributes to the hygiene status and particularly food safety aboard passenger ships. Hygiene inspections on 17 ferries in Greece were performed using a standardized inspection form, with a 135-point scale. Thirty-four water and 17 food samples were collected and analysed. About 65% (11/17) of ferries were scored with >100 points. Ferries with HACCP received higher scores during inspection compared to those without HACCP (p value <0.001). All 34 microbiological water test results were found negative and, from the 17 food samples, only one was found positive for Salmonella spp. Implementation of management systems including HACCP principles can help to raise the level of hygiene aboard passenger ships.

A dedicated surveillance network for congenital toxoplasmosis in Greece, 2006-2009: assessment of the results.

BACKGROUND: Toxoplasmosis is caused by infection with the protozoan parasite Toxoplasma gondii. Acute infections in pregnant women may be transmitted to the fetus and cause severe illness. The purpose of this study was to establish a dedicated surveillance network (DSN) for congenital toxoplasmosis (CT) in Greece, in order to assess the birth prevalence of CT. METHODS: A DSN of thirty clinicians was established for reporting CT cases from hospitals throughout Greece. The clinicians were selected on the basis that there was a high possibility the suspected cases would be referred to them from district hospitals or private clinics. Suspected cases of CT were reported on a monthly basis with a zero reporting card during a surveillance period from April 2006 to December 2009. A questionnaire was sent for any suspected case to record information including demographic parameters, clinical signs and symptoms and laboratory results. Serological and molecular confirmation of cases was performed by the Pasteur Hellenic Institute. All newborns suspected of CT received treatment and were serologically and clinically followed up for one year. RESULTS: The monthly response rate reached 100%, although only after reminders sent to 65% of the participant physicians. Sixty-three suspected CT cases were recorded by the DSN during the study period including fourteen confirmed and seven probable cases. Ten cases (47.6%) presented with symptoms at birth. Chorioretinitis was the most prominent manifestation, occurring in five symptomatic CT cases (50%). No other symptoms appeared by the end of the one year clinical follow up. No case was recorded by the existing surveillance system of the Hellenic Center of Disease Control and Prevention (HCDCP) during the same time period. Birth prevalence was estimated at 0.45, 0.51 and 0.51 per 10,000 births for 2007, 2008 and 2009 respectively. The incidence rate of symptomatic CT at birth was estimated at 0.10 cases per 10,000 births per year in Greece (for the period 2007-2009). CONCLUSION: The DSN for CT proved to be more sensitive than the classical notification system, easy in application and very efficient in reporting rare diseases such as CT. Similar DSNs could be used to provide useful information on other rare diseases.

Surveillance and control of communicable diseases related to passenger ships in Europe.

This study was conducted within the European SHIPSAN (ship sanitation) project and aims at exploring the legislative framework and current practices related to surveillance of communicable diseases and response aboard passenger ships in Europe. A detailed questionnaire was disseminated and completed by 59 competent authorities in 27 European countries. The majority of competent authorities used national legislation without special provisions for passenger ships. Only 20% had specific provisions for ships regarding quarantine, while a smaller proportion of new Member States (MS) have specific legislation in comparison with old MS (p = 0.01). The Maritime Declaration of Health (MDH) was the main reporting tool used. About 30.5% of the competent authorities declared that they require submission of MDH by all arriving ships, but 28.8% only from affected areas, and 11.9% never require MDH. A total of 45 outbreaks or incidents (36 gastrointestinal, 1 incident of legionellosis, 3 respiratory, and 1 influenza-like illness outbreak, occupational tuberculosis, varicella, scabies, and meningitis) were reported to EU competent authorities during 2006. About 75% of the responders stated that there are gaps in the surveillance and control of communicable diseases. A diversity of approaches in EU countries, and gaps regarding surveillance and response and training needs of personnel were identified.

Application of multivariate statistical methods for groundwater physicochemical and biological quality assessment in the context of public health.

Three representative areas (lowland, semi-mountainous, and coastal) have been selected for the collection of drinking water samples, and a total number of 28 physical, chemical, and biological parameters per water sample have been determined and analyzed. The mean values of the physical and chemical parameters were found to be within the limits mentioned in the 98/83/EEC directive. The analysis of biological parameters shows that many of the water samples are inadequate for human consumption because of the presence of bacteria. Cluster analysis (CA) first was used to classify sample sites with similar properties and results in three groups of sites; discriminant analysis (DA) was used to construct the best discriminant functions to confirm the clusters determined by CA and evaluate the spatial variations in water quality. The standard mode discriminant functions, using 17 parameters, yielded classification matrix correctly assigning 96.97% of the cases. In the stepwise mode, the DA produced a classification matrix with 96.36% correct assignments using only ten parameters (EC, Cl-, NO3-, HCO3-, CO3(-2), Ca+2, Na+, Zn, Mn, and Pb). CA and factor analysis (FA) are used to characterize water quality and assist in water quality monitoring planning. CA proved that two major groups of similarity (six subclusters) between 17 physicochemical parameters are formed, and FA extracts six factors that account for 66.478% of the total water quality variation, when all samples' physicochemical data set is considered. It is noteworthy that the classification scheme obtained by CA is completely confirmed by principal component analysis.