History repeats itself: consumption of a local traditional roast pork meat recipe leads to Salmonella ser. Give cases in Greece.

INTRODUCTION: An outbreak of gastroenteritis due to Salmonella Give, a very rarely identified serotype in human isolates in Greece, occurred in participants of a religious festival in a rural area of southern Greece, in September 2022. The objectives of this study were to describe the outbreak in terms of epidemiology, identify the vehicle of transmission of the foodborne pathogen and recommend prevention measures. METHODS: The outbreak was linked to the consumption of a local traditional recipe of roasted pork meat served by a street food vendor. In 2018, the same food item, served in a restaurant in the same region, was implicated in another S. Give outbreak. RESULTS: Outbreak investigations revealed that outbreak-associated isolates, of food and human origin, belonged to the same S. Give strain. Significant deficiencies regarding food safety practices were identified. CONCLUSION: Technical knowledge about pathogen transmission paths is important in order for both food handlers and consumers to follow hygiene and sanitary measures, mainly in cases of mass gatherings, where large quantities of food are prepared, handled, cooked and served. Efficient official supervision, mainly during summer festivals, is required in order to avoid recurrence of foodborne infections by different combinations of pathogens/food commodities.

A Point Source Gastroenteritis Outbreak in a High School Putatively Due to Clostridium perfringens: Timely Investigation Is Everything.

On May 28, 2021, several gastroenteritis cases were reported among students and staff of a high school on a Greek island. Lunches were delivered daily at the school by a catering company. We conducted a retrospective cohort study. Cases were defined as students or school staff presenting with diarrhea and abdominal pain between May 27 and 29, 2021. We used a self-administered questionnaire to collect the data. In the univariate analysis, we calculated food-specific attack rates (ARs), relative risks (RRs), and confidence intervals (95% CIs). Statistically significant variables (p < 0.05) were included in the multivariable model. Stool samples were collected from students on the same day of notification and were tested for bacteria, viruses, and parasites. The local food safety authority also inspected the school and the catering company premises. The food samples were sent to the reference laboratory for analysis. We received 129 responses from 174 students and staff members (response rate: 74%). Thirty cases were identified (AR, 23%). Of the 11 significant food items in the univariate analysis, the consumption of spaghetti with minced meat on May 27 (odds ratio 53.40, 95% CI: 3.9-736.1, 97% of cases exposed) was independently associated with the onset of gastroenteritis. Clostridium perfringens was detected in two of the three students' stool samples. Six samples from spaghetti with minced meat were positive for C. perfringens and four of those also tested positive for Bacillus cereus. Environmental investigation revealed non-compliances concerning food personnel training and Hazard Analysis and Critical Control Points (HACCP) plan implementation in the food establishment. Timely investigation and samples collection allowed the identification of the probable source of the outbreak. Changes, regarding the reception and distribution of meals in the school, were applied. Recommendations were given to the catering establishment focusing on adequate personnel training and HACCP issues, especially regarding temperature/time controls during all production, handling, and distribution phases.

Public health and clinical implications of multidrug-resistant shigellosis cases in a reception centre for refugees/migrants, Greece, October-December 2019.

From October to December 2019, 18 shigellosis cases (median age: 4.3 years, range: 0-21) were identified in the Reception Center for refugees/migrants on the Greek island of Samos. Fifteen cases (83.3%) were Afghani. Median time from arrival to symptoms onset was 53 days (40-101). Isolates from 14 cases, serotyped as Shigella flexneri 1b, and from three cases, serotyped as S. sonnei phase S (I), presented a multidrug-resistant phenotype. S. flexneri 1b isolates also produced extended-spectrum ß-lactamases. Shigella flexneri 2a isolate from the remaining case was resistant to sulfomethoxazole, trimethoprim and pefloxacin. Improvement of hygiene and strengthening of laboratory investigation is needed.

Waterborne outbreak in a rural area in Greece during the COVID-19 pandemic: contribution of community pharmacies.

INTRODUCTION: On 15 June 2020, the National Public Health Organization was informed about the identification of two cases of Escherichia coli Ο157 infection in a small town in the Peloponnese Region in Greece and we suspected an outbreak. METHODS: We asked the local pharmacist to assist us to verify the outbreak by providing the daily number of over-the-counter anti-diarrheal drugs sold from 20 May 2020 onwards. The pharmacist asked customers with gastroenteritis to submit stool samples at the local hospital. Samples were tested for 22 pathogens. We conducted a 1 : 1 case-control study. Cases and controls were retrieved from the pharmacy client list. Chlorination records of the water supply system were retrieved, and water samples were tested for microbiological indicators and viruses. RESULTS: The increased number of sales of anti-diarrheal drugs verified the outbreak. Overall, 58 cases and 57 controls were recruited for the study. Tap water consumption (odds ratio (OR)=10.9, 95% confidence interval (CI)=3.1-38.0, p<0.001) and consumption of ice cubes made from tap water (OR=39.3, 95%CI=10.3-150.9, p<0.001) were independently associated with gastroenteritis occurrence. Eleven stool samples were tested; one was positive for shigatoxin-producing E. coli, one for enteropathogenic E. coli, four for E. coli Ο157 and one for Salmonella spp. Four samples tested negative. Five water samples collected on 18 June tested negative. The residual chlorine on 5 and 14 June ranged from 0.12 mg/L to 0.14 mg/L. CONCLUSION: This was the first investigation of a waterborne outbreak in Greece performed with the collaboration of a local pharmacy. The COVID-19 pandemic favored the use of alternative resources and channels of communication with the local population, which can also be used in the future, especially in remote areas of the country.

First Data on WGS-Based Typing and Antimicrobial Resistance of Human Salmonella Enteritidis Isolates in Greece.

Salmonella enterica subsp. enterica serotype Enteritidis (S. Enteritidis) is one of the major causes of foodborne infections and is responsible for many national and multi-country foodborne outbreaks worldwide. In Greece, human salmonellosis is a mandatory notifiable disease, with laboratory surveillance being on a voluntary basis. This study aims to provide the first insights into the genetic characteristics and antimicrobial resistance profiles of 47 S. Enteritidis human isolates using whole-genome sequencing (WGS) technology. The S. Enteritidis population was mainly resistant to fluoroquinolones due to gyrA point mutations, whereas one isolate presented a multi-resistant plasmid-mediated phenotype. ST11 was the most frequent sequence type, and phylogenetic analysis through the cgMLST and SNP methods revealed considerable genetic diversity. Regarding virulence factors, 8 out of the 24 known SPIs and C63PI were detected. Due to the observed variability between countries, it is of utmost importance to record the circulating S. Enteritidis strains' structure and genomic epidemiology at the national level. WGS is a valuable tool that is revolutionizing our approach to Salmonella by providing a deeper understanding of these pathogens and their impact on human health.

Gastroenteritis Outbreaks after Contamination of Water Supply Systems: Public Health Response Gaps and Challenges, Greece, 2004-2023.

BACKGROUND: waterborne disease outbreaks (WGDOs) following the contamination of drinking water remain a public health concern. METHODS: The current study aims to assess the occurrence and identify gaps in the notification and investigation of WGDOs in Greece. Data for 2004-2023 were retrieved and summarized. RESULTS: Thirty-five outbreaks with 6128 recorded cases were identified. The median time from the date of onset in the first cases to reporting was 7 days (range: 1-26 days). Authorities were informed by health care services in thirty (85.7%) outbreaks and by the media in five (14.3%). The investigation methods used varied. An analytical study was conducted in nine (25.7%) outbreaks and the testing of clinical samples in twenty-seven (77.1%). In three (11.1%) outbreaks, clinical samples were simultaneously tested for multiple bacteria, viruses, and parasites. Water samples were collected in nineteen (54.3%) outbreaks (in three after chlorination) with a mean time lag of 5 days (range: 1-20 days) from the first cases. A pathogen in clinical samples was identified in 20 (57.1%) outbreaks and, in 1 (6.25%), the same microorganism was isolated in both clinical and water samples. CONCLUSIONS: delays in reporting and the heterogeneity of investigations depict that the surveillance of WGDOs and response practices should be strengthened, and operational procedures should be standardised.

A Community Waterborne Salmonella Bovismorbificans Outbreak in Greece.

BACKGROUND: In August 2022, the Hellenic National Public Health Organisation was notified about a gastroenteritis outbreak in town A in Southern Greece. Investigations aimed to identify the source and implement control measures. METHODS: Case definition categories were used in a 1:3 case-control study. Cases and controls were interviewed about various exposures. Cases' stool samples were cultured on agar plates and characterised by serotyping, antimicrobial susceptibility testing and Pulse Field Gel Electrophoresis (PFGE). Environmental investigations included tap water sampling for microbiological and chemical analysis in town A and inspection of the water supply system. RESULTS: We identified 33 cases (median age: 17 years). Tap water consumption was the only significant risk factor for gastroenteritis (OR = 5.46, 95% CI = 1.02-53.95). Salmonella (S.) Bovismorbificans isolated from eight stool and one tap water samples had identical PFGE profiles. No resistant isolates were identified. Residual chlorine levels were lower than the acceptable limits before and during the outbreak. We advised consumption of bottled water and adherence to strict hand hygiene rules until tap water was declared suitable for drinking. CONCLUSIONS: Epidemiological and molecular data revealed a waterborne S. Bovismorbificans outbreak in town A. We recommend local water safety authorities to ensure that residual chlorine levels comply with the legislation towards water safety planning, to mitigate risks.

Parental presence and distraction during painful childhood procedures.

AIM: To investigate the effect of parental presence and the distraction of the attention by a toy in children undergoing a painful procedure. METHODS: A randomised study with two experimental groups and one control group-130 children (64 girls and 66 boys), mean age 8.3 years (range 7-10 years) were randomly assigned to one of the three groups from September 2006 to March 2007: the parent presence group, the toy group, the control group. The verbal rating scale of pain, the assessment of vital signs before and after the procedure and the State-Trait Anxiety Inventory for Children were used. RESULTS: Children who had their parent close to them showed a reduction in breaths (95% confidence interval (CI) for gradient of regression line): -4.20 to -2.80, p<0.001), mean blood pressure (95% CI: -4.88 to -2.99, p<0.001) and pulse (95% CI: -8.76 to -5.68, p<0.001) compared to the children whose parents were absent. They also felt less pain (95% CI: -4.40 to -2.71, p<0.001) and they were less distressed (95% confidence interval for A-State tool (CIA-State): -10.46 to -6.49, p<0.001 and 95% confidence interval for A-Trait tool (CIA-Trait): -5.71 to -2.13, p<0.001). CONCLUSION: Parental presence is considered to be important in decreasing children's pain, stress and their negative behaviour in general during invasive procedures.

Impact of Salmonella Control Programmes in Poultry on Human Salmonellosis Burden in Greece.

Since 2008, veterinary authorities in Greece have implemented national control programmes (NSCPs) targeting S. Enteritidis (SE) and S. Typhimurium (ST) in poultry. We assessed the effect of the programs on the reported number of human isolates. Using monthly data for 2006-2017, we defined two groups (SE, ST) and one control group with serotypes unrelated to poultry or eggs. For SE we also analysed data for 2006-2015 due to a multi-county SE outbreak in 2016. We performed an interrupted time series analysis and used a negative binominal regression model. For both SE and ST, there was no significant trend of the isolation rate before or after NSCPs' introduction. After the NSCPs' introduction there was an increasing rate (IRR: 1.005, 95% CI: 1.001-1.008) for control serotypes and a decreasing one for SE (IRR: 0.990, 95% CI: 0.986-0.995) (for 2009 to 2015 analysis). From 2006 to 2017, NSCPs had a statistically significant impact on the number of SE isolates that decreased by 49% (IRR:0.511, 95% CI: 0.353-0.739). No impact was shown on the number of ST (p-value = 0.741) and control isolates (p = 0.069). As a conclusion, NSCP's implementation was associated with decreased SE isolates and overall burden of salmonellosis; however further measures aiming at human salmonellosis due to ST, should be considered.

The Rising Burden of Salmonellosis Caused by Monophasic Salmonella Typhimurium (1,4,[5],12:i:-) in Greece and New Food Vehicles.

Monophasic Salmonella typhimurium is of increasing importance worldwide. Here we present the available data regarding monophasic S. typhimurium from 2007 to 2019 in Greece, in order to assess its public health impact. Surveillance data, data on antimicrobial resistance, molecular typing by pulsed-field gel electrophoresis (PFGE), and results of the investigation of monophasic S. typhimurium outbreaks were analyzed. Overall, 403 cases were identified; 329 (81.6%) sporadic and 74 (18.4%) related to two community outbreaks in 2017. A total of 305 isolates from sporadic cases tested for antimicrobial resistance revealed resistance to ampicillin, streptomycin, sulphamethoxazole, and tetracycline (41.3%). Some 23.3% were further resistant to trimethoprim and 5.2% were also resistant to chloramphenicol. Outbreak 1 in 2017 with 37 identified cases was attributed to the consumption of raw milk from a vending machine and isolates were resistant to ampicillin, streptomycin, sulphamethoxazole, tetracycline, and trimethoprim. Outbreak 2 also with 37 cases was attributed to the consumption of pork and isolates were resistant to the five above mentioned antibiotics plus chloramphenicol. The number of human monophasic S. typhimurium isolates is low; however, since 2009, it has been among the five most frequently identified serotypes in Greece. Investigation of the outbreaks revealed that other vehicles apart from pork may be implicated in the occurrence of outbreaks.

Clostridium perfringens Foodborne Outbreak during an Athletic Event in Northern Greece, June 2019.

BACKGROUND: Food safety is a major public health consideration during athletic events. On 27 June 2019, the Hellenic National Public Health Organization was notified of a cluster of gastroenteritis cases among athletes of four of the 47 teams participating at the Panhellenic Handball Championship for children. METHODS: A retrospective cohort study among the members of the four teams was performed. The local public health authority visited the restaurants where common meals took place, amassed information on the preparation of meals, and collected samples of leftovers. Stool samples were tested for Salmonella spp. and Shigella spp. RESULTS: Consumption of minced beef had a statistically significant association with disease occurrence [RR:8.29 (95%CI 1,31-52,7)]. Samples of meat were found positive for Clostridium perfringens. It was documented that the meat was not stored and re-heated as indicated. Stool samples were negative for Salmonella spp. and Shigella spp. and were not tested for the Clostridium perfringens toxin. CONCLUSION: Specific standards should be kept to prevent outbreaks during athletic events. This was the first time that a foodborne outbreak due to Clostridium perfringens was investigated in the country. Laboratory investigation for toxins should be enhanced, especially in foodborne outbreaks where clinical manifestations of cases are found to be compatible with infection caused by a toxin.

Parents' satisfaction concerning their child's hospital care.

AIM: To explore parents' satisfaction concerning their child's care during hospitalization and its determinants. METHODS: A descriptive, non-experimental correlational design was used. The data collection was based on interviews using a 63 item questionnaire, the Swedish Pyramid Questionnaire. The parents of 206 children (hospitalized in two pediatric and two surgical units) participated in the study. RESULTS: The independent t-test results demonstrated that the parents showed greater satisfaction with staff attitudes and medical treatment, whereas they were less satisfied with the information concerning routines and the staff work environment. The stepwise multiple regression analysis revealed that adequacy of care, adequate pain management, parents' involvement in care, a trusting relationship, and staff attitudes were the most important determinants of parental satisfaction. CONCLUSION: Interventions in pediatric care should include measurements of parental and child satisfaction as a tool to assess the quality of care.