Changing trends and pretravel preparation of business travelers from Greece during the financial crisis.

OBJECTIVES: Unemployment in Greece has been increasing as a result of the financial crisis. The aim of this study was to assess the changing trends of business travelers and their pretravel preparation. STUDY DESIGN: Prospective, questionnaire-based study. METHODS: The study was conducted between 2008 and 2016 at all Regional Public Health Departments. All travelers seeking pretravel advice during the study period were invited to participate. RESULTS: A total of 12,379 travelers completed the questionnaire, 58% of whom were business travelers. Between 2008 and 2016, the proportion of business travelers increased from 33% to 80.7% and those travelling for recreational purposes decreased from 47.9% to 15.5%. Business travelers sought pretravel advice at a mean of 18.5 days before departure; 89.1% were men with a mean age of 34.4 years. The Middle East was the most common destination (47.8%) followed by Sub-Saharan Africa (28.3%). Most business travelers stayed in urban areas (77.6%) and for ≥ 1 month (68.6%). Yellow fever vaccine was administered to 75% of business travelers. A total of 76.2%, 26.9%, 15.5%, and 13.9% of those visiting Sub-Saharan Africa received yellow fever, typhoid fever, hepatitis A, and meningococcal vaccines, respectively. Malaria prophylaxis vaccine was administered to 26.8% of business travelers; including 46.5% of those traveling to Sub-Saharan Africa and 53.5% to those traveling to the Indian subcontinent. CONCLUSIONS: There is an increasing trend for business travel from Greece, especially to developing countries. Improving the knowledge of travel health consultants about the risks of business travel and the pretravel preparation of business travelers is crucial.

Parental concerns and vaccine hesitancy against COVID-19 vaccination for children in Greece: A cross-sectional survey.

INTRODUCTION: Parental hesitancy against children's COVID-19 vaccination remains a challenge globally. Although many studies have explored parental hesitancy, less is known about parental intentions towards COVID-19 vaccination of 6-month to 4-year-old children who were the last age group that became eligible for vaccination and for older children throughout the Omicron predominance period. METHODS: We conducted a nationwide cross-sectional survey from November to December 2022 in Greece. We aimed to explore parental COVID-19 vaccination intentions for their children, reasons against vaccination, and to estimate the association between parents' intentions and child and parental characteristics and parental attitudes towards COVID-19 vaccination. RESULTS: Of 431 parents, 243 (56.4 %) had not or did not intend to vaccinate their children against COVID-19. Most parents were vaccinated against COVID-19 (64.7 % no booster; 14.2 % at least one booster). Among parents with children under the age of 5, 13.0 % intended to vaccinate their children against COVID-19, while 47.3 % of parents with children 5 years of age or older reported intention or had already completed vaccination. The most common reasons against COVID-19 vaccination were fear of side effects (32.9 %), perceived short length of clinical trials (29.2 %), and the child having previously contracted COVID-19 (12.0 %). The strongest factors associated with intention or already completed vaccination were parental own vaccination against COVID-19, using a pediatrician or a healthcare professional as the main source of vaccine-related information for their children, agreeing with their pediatrician regarding COVID-19 vaccination, and trusting official healthcare guidelines. Stratified analyses by the two children's age groups (<5 and 5 to 17) yielded similar estimates. Among parents who had not or did not intend to vaccinate their children, 11.9 % would do so if recommended by a pediatrician. CONCLUSIONS: Our findings highlight the need to incentivize healthcare professionals and pediatricians to inform parents about vaccines, clarify misconceptions and address concerns.

Timing of last COVID-19 vaccine dose and SARS-CoV-2 breakthrough infections in fully (boosted) vaccinated healthcare personnel.

AIM: To estimate the incidence, timing and severity of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) breakthrough infections in fully vaccinated healthcare personnel (HCP). METHODS: In total, 6496 fully vaccinated HCP were analysed prospectively from 15th November 2021 to 17th April 2022. Full coronavirus disease 2019 (COVID-19) vaccination was defined as a complete primary vaccination series followed by a booster dose at least 6 months later. RESULTS: Overall, 1845 SARS-CoV-2 breakthrough infections occurred (28.4 episodes per 100 HCP), of which 1493 (80.9%) were COVID-19 cases and 352 (19.1%) were asymptomatic infections. Of the 1493 HCP with COVID-19, four were hospitalized for 3-6 days (hospitalization rate among HCP with COVID-19: 0.3%). No intubations or deaths occurred. SARS-CoV-2 breakthrough infections occurred at a mean of 16.2 weeks after the last vaccine dose. Multi-variable regression analyses showed that among the 1845 HCP with a breakthrough infection, the administration of a COVID-19 vaccine dose ≥16.2 weeks before the infection was associated with increased likelihood of developing COVID-19 rather than asymptomatic SARS-CoV-2 infection [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.01-2.46; P=0.045] compared with administering a vaccine dose later. The likelihood of developing COVID-19 compared with asymptomatic infection increased by 7% weekly after the last COVID-19 vaccine dose (OR 1.07, 95% CI 1.03-1.11; P=0.001). CONCLUSION: SARS-CoV-2 breakthrough infections are common among fully (boosted) vaccinated HCP. However, full COVID-19 vaccination offered considerable protection against hospitalization. These findings may contribute to defining the optimal timing for booster vaccinations. More efficient COVID-19 vaccines that will also confer protection against SARS-CoV-2 infection are needed urgently.

Central-line-associated bloodstream infections, multi-drug-resistant bacteraemias and infection control interventions: a 6-year time-series analysis in a tertiary care hospital in Greece.

BACKGROUND: Central-line-associated bloodstream infections (CLABSIs) are serious healthcare-associated infections with substantial morbidity and hospital costs. AIM: To investigate the association between the incidence of CLABSIs, the implementation of specific infection control measures, and the incidence of multi-drug-resistant (MDR) bacteraemias in a tertiary care hospital in Greece from 2013 to 2018. METHODS: Analysis was applied for the following indices, calculated monthly: CLABSI rate; use of hand hygiene disinfectants; isolation rate of patients with MDR bacteria; and incidence of bacteraemias [total Gram-negative carbapenem-resistant Acinetobacter baumanii, carbapenem-resistant Pseudomonas aeruginosa and carbapenem-resistant Klebsiella pneumoniae; and Gram-positive meticillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci]. FINDINGS: The total number of bacteraemias from carbapenem-resistant Gram-negative pathogens was significantly correlated with an increased CLABSI rate for all (total) hospital departments [incidence rate ratio (IRR) 1.17, 95% confidence interval (CI) 1.05-1.31, P=0.006] and the adult intensive care unit (ICU) (IRR 1.37, 95% CI 1.07-1.75, P=0.013). In the adult ICU, every increase in the incidence of each resistant Gram-negative pathogen was significantly correlated with a decreased CLABSI rate (carbapenem-resistant A. baumanii: IRR 0.59, 95% CI 0.39-0.90, P=0.015; carbapenem-resistant K. pneumoniae: IRR 0.48, 95% CI 0.25-0.94, P=0.031; carbapenem-resistant P. aeruginosa: IRR 0.54, 95% CI 0.33-0.89, P=0.015). The use of hand disinfectants was correlated with a decreased CLABSI rate 1-3 months before the application of this intervention for all (total) hospital departments (IRR 0.80, 95% CI 0.69-0.93, P=0.005), and for scrub disinfectants in the current month for the adult ICU (IRR 0.34, 95% CI 0.11-1.03, P=0.057). Isolation of patients with MDR pathogens was not associated with the incidence of CLABSIs. CONCLUSION: Hand hygiene was associated with a significant reduction in the incidence of CLABSIs at the study hospital. Time-series analysis is an important tool to evaluate infection control interventions.

Costs associated with COVID-19 in healthcare personnel in Greece: a cost-of-illness analysis.

BACKGROUND: Healthcare personnel (HCP) are at increased risk of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the aetiological agent of coronavirus disease 2019 (COVID-19). AIM: To estimate the costs related to SARS-CoV-2 exposure and infection among HCP in Greece. METHODS: Data were retrieved from the national database of SARS-CoV-2 infections and from the database of HCP exposed to patients with COVID-19. A cost-of-illness analysis was performed to estimate total, direct and indirect costs. RESULTS: In total, 254 HCP with COVID-19 and 3332 HCP exposed to patients with COVID-19 during the first epidemic wave were studied. Of the 254 HCP with COVID-19, 49 (19.3%) were hospitalized (mean length of hospitalization 11.6 days) and four were admitted to intensive care units (mean duration 10.8 days). Overall, 1332 (40%) exposed HCP had a mean duration of absenteeism of 7.5 days, and 252 (99.2%) HCP with COVID-19 had a mean duration of absenteeism of 25.8 days. The total costs for the management of the two groups were estimated at €1,735,830 (€772,890 Euros for HCP with COVID-19 and €962,940 for exposed HCP). Absenteeism accounted for a large proportion of the total costs (80.4% of all expenditures), followed by costs for reverse transcriptase polymerase chain reaction and hospitalization (10.2% and 6.5% of all expenditures, respectively). CONCLUSION: COVID-19 is associated with increased rates and duration of absenteeism among HCP. Indirect costs, particularly absenteeism, are the major driver of total costs among exposed HCP and HCP with COVID-19. The estimated total costs are conservative. Studies are needed to explore the impact of COVID-19 vaccination of HCP on absenteeism and COVID-19-associated costs.

Hospital factors associated with SARS-CoV-2 infection among healthcare personnel in Greece.

Healthcare workers (HCWs) have been recognized as a high-risk group for infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This study estimated their risk of infection based on hospital characteristics. Factors significantly associated with increased risk for SARS-CoV-2 infection were: working in a non-referral hospital compared with a coronavirus disease 2019 (COVID-19) referral hospital, working in a hospital with a high number of employees, and working in a hospital with an increased number of patients with COVID-19. This study revealed gaps in infection control in the non-referral hospitals. There is an urgent need for continuous training in infection control practices. Compliance of HCWs with the use of personal protective equipment should also be addressed.

Crimean-Congo hemorrhagic fever in Europe: current situation calls for preparedness.

During the last decade Crimean-Congo hemorrhagic fever (CCHF) emerged and/or re-emerged in several Balkan countries, Turkey, southwestern regions of the Russian Federation, and the Ukraine, with considerable high fatality rates. Reasons for re-emergence of CCHF include climate and anthropogenic factors such as changes in land use, agricultural practices or hunting activities, movement of livestock that may influence host-tick-virus dynamics. In order to be able to design prevention and control measures targeted at the disease, mapping of endemic areas and risk assessment for CCHF in Europe should be completed. Furthermore, areas at risk for further CCHF expansion should be identified and human, vector and animal surveillance be strengthened.

Costs associated with measles in healthcare personnel during the 2017-2018 epidemic in Greece: a real-world data cost-of-illness analysis.

Measles represents an occupational risk for healthcare personnel (HCP). A total of 117 cases of measles among HCP were notified in Greece during 2017-2018. We were able to contact 46 of them. Most of those contacted had a serious clinical course with complications, necessitating hospitalization in 67% of cases. All HCP reported absenteeism, for a mean duration of 21.2 working days (range: 3-60 days); 54.3% of HCP reported being at work while symptomatic for a mean duration of 2.3 working days (range: 1-7 days). The average total cost-of-illness was €4,739 per HCP. The total direct and indirect costs of the 117 notified cases among HCP amount to €554,494, which is likely to be an underestimate of the true cost.

Development of a tool to assess evidence for causality in studies implicating sink drains as a reservoir for hospital-acquired gammaproteobacterial infection.

BACKGROUND: Decades of studies document an association between Gammaproteobacteria in sink drains and hospital-acquired infections, but the evidence for causality is unclear. AIM: We aimed to develop a tool to assess the quality of evidence for causality in research studies that implicate sink drains as reservoirs for hospital-acquired Gammaproteobacterial infections. METHODS: We used a modified Delphi process with recruited experts in hospital epidemiology to develop this tool from a pre-existing causal assessment application. FINDINGS: Through four rounds of feedback and revision we developed the 'Modified CADDIS Tool for Causality Assessment of Sink Drains as a Reservoir for Hospital-Acquired Gammaproteobacterial Infection or Colonization'. In tests of tool application to published literature during development, mean percent agreement ranged from 46.7% to 87.5%, and the Gwet's AC1 statistic (adjusting for chance agreement) ranged from 0.13 to 1.0 (median 68.1). Areas of disagreement were felt to result from lack of a priori knowledge of causal pathways from sink drains to patients and uncertain influence of co-interventions to prevent organism acquisition. Modifications were made until consensus was achieved that further iterations would not improve the tool. When the tool was applied to 44 articles by two independent reviewers in an ongoing systematic review, percent agreement ranged from 93% to 98%, and the Gwet's AC1 statistic was 0.91-0.97. CONCLUSION: The modified causality tool was useful for evaluating studies that implicate sink drains as reservoirs for hospital-acquired infections and may help guide the conduct and reporting of future research.

National hand hygiene campaigns in Europe, 2000-2009.

Hand hygiene represents the single most effective way to prevent healthcare-associated infections. The World Health Organization, as part of its First Global Patient Safety Challenge, recommends implementation of multi-faceted strategies to increase compliance with hand hygiene. A questionnaire was sent by the European Centre for Disease Prevention and Control to 30 European countries, regarding the availability and organisation of their national hand hygiene campaigns. All countries responded. Thirteen countries had organised at least one national campaign during the period 2000-2009 and three countries were in the process of organising a national campaign. Although the remaining countries did not have a national campaign, several reported regional and local hand hygiene activities or educational resources on national websites.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations.

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the 'European Network for HIDs' conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.

Vaccination of healthcare workers against influenza: does a day off make a difference?

This article presents the results of actions undertaken to increase influenza vaccine uptake by healthcare workers (HCWs) in Greece during the 2016-2017 influenza season. Influenza vaccination among HCWs increased from 10.9% in acute care hospitals and 24.3% in primary healthcare centres in 2015-2016 to 18% in acute care hospitals and 34.6% in primary healthcare centers in 2016-2017. Vaccination on site at the healthcare facility and use of reward systems were significantly associated with increased vaccination rates. Offering vaccinated HCWs one day off work was associated with the greatest increase in influenza vaccine uptake.

Nosocomial scabies.

Scabies is a parasitic dermatosis with a worldwide distribution. This infestation affects millions of people annually and may cause large nosocomial outbreaks with considerable morbidity among patients and healthcare workers. Immunocompromised or elderly institutionalized patients admitted with unrecognized crusted scabies are the main source of nosocomial transmission. Factors that facilitate the development of hospital-acquired scabies and nosocomial epidemics are: poor knowledge of scabies epidemiology, unfamiliarity of healthcare workers with atypical presentations, long incubation period, diagnostic delay and incomplete monitoring. Within hospitals, containment of an outbreak relies on the strict implementation of appropriate infection control measures and treatment administration to contacts. It is associated with a considerable working and economic burden.

Factors influencing influenza vaccination rates among healthcare workers in Greek hospitals.

Influenza vaccination rates are generally low among healthcare workers (HCWs) worldwide. In September 2005, the Hellenic Center for Disease Control and Prevention conducted a nationwide campaign to promote influenza vaccination in hospital HCWs. During the 2005-2006 influenza season, the overall vaccination rate among HCWs was 16.36% (range: 0-85.96%). The self-reported vaccination rate during the previous season was 1.72%, indicating a 9.5-fold increase. Compared with physicians, significantly fewer technical personnel were vaccinated, whereas administrative personnel were more likely to receive the vaccine. Among clinicians, rates for internal medicine departments exceeded those of surgical departments by a factor of 2.71 and laboratory medicine departments by a factor of 2.36. Multivariate analysis showed lower vaccination rates in large hospitals (>200 beds) than in smaller hospitals and lower rates in hospitals with specialist services (intensive care unit, psychiatry or dermatology) than in general hospitals. Factors associated with higher rates included working in northern Greece, in a paediatric or an oncology hospital, or in a prefecture with avian influenza H5N1 activity. In conclusion, in Greece influenza vaccination rates among HCWs remain low, but the implementation of a nationwide campaign had a considerable impact. Efforts should focus on hospital- and HCW-associated factors to increase vaccination uptake.

Nontuberculous mycobacterial lymphadenitis in children.

OBJECTIVES: To describe the clinical and epidemiologic features, management and outcome associated with the development of nontuberculous mycobacterial (NTM) superficial lymphadenitis in children. METHODS: The medical records of all children 0 to 14 years of age with NTM superficial lymphadenitis who were diagnosed at P. and A. Kyriakou Children's Hospital between January, 1982, and December, 1997, were reviewed. RESULTS: Forty-seven children were identified, 76.5% during the second half of the study period. Mycobacterium avium complex was the predominant isolate. Children with NTM lymphadenitis noted satisfactory aesthetic results when total excision was performed within 1 month after its onset. CONCLUSIONS: NTM superficial lymphadenitis in children has been increasingly recognized during the last decade. Prompt total excision of the involved lymph node is required in such patients.

Lack of association between Kawasaki syndrome and infection with Rickettsia conorii, Rickettsia typhi, Coxiella burnetii or Ehrlichia phagocytophila group.

BACKGROUND: The etiology of Kawasaki syndrome (KS) is unknown. Rickettsiae, intracellular microorganisms that invade the vascular endothelium, might cause KS. OBJECTIVES: To investigate whether there is an association between KS and infection with Rickettsia conorii, Rickettsia typhi, Coxiella burnetii or Ehrlichia phagocytophila group. METHODS: All children who were diagnosed with KS at the University of Athens Second Department of Pediatrics from December, 1999, through November, 2000, were prospectively studied. Paired serum specimens were obtained from all patients and antibody titers against R. conorii, R. typhi, C. burnetii and E. phagocytophila group were assessed by microimmunofluorescence assay. RESULTS: Eleven children with a median age of 2.5 years were included in the study. A 15-month-old child had a 4-fold rise of antibody titers against C. burnetii, which is indicative of acute Q fever. The patient had a history of recent exposure to possible sources of C. burnetii. The remaining patients tested negative for the presence of antibodies against R. conorii, R. typhi, C. burnetii and E. phagocytophila group. CONCLUSIONS: Our study does not provide serologic evidence that KS is the result of infection with R. conorii, R. typhi, C. burnetii or E. phagocytophila group. It is suggested that C. burnetii may cause a KS-like illness in young children.

Hemolytic-uremic syndrome associated with Coxiella burnetii infection.

Acute Q fever most commonly manifests as a self-limited febrile illness, pneumonia or hepatitis. We report the case of a 12-year-old child with documented exposure to sources of Coxiella burnetii who was admitted to our hospital because of hemolytic-uremic syndrome. Serologic tests established the diagnosis of acute Q fever.

Viral infections in children undergoing hematopoietic stem cell transplant.

BACKGROUND: Although viral infection is a major clinical problem for hematopoietic stem cell transplant recipients, there are few large series reporting on these infections in the pediatric population. We performed a retrospective analysis of the impact of viral infections in this patient population in our center, managed by a uniform antiviral prophylaxis protocol. METHOD: We reviewed the medical records of consecutive children and adolescents who received hematopoietic stem cell transplantation at the Division of Pediatrics, The University of Texas M. D. Anderson Cancer Center in Houston, TX, from July, 1992 to August, 1996. RESULTS: During the study period there were 70 episodes of viral infections in 96 transplants. The viruses most commonly encountered were cytomegalovirus (24), varicella-zoster (21) and herpes simplex (10). Fifty of these episodes resulted in clinically apparent diseases, affecting 39 patients. The Kaplan-Meier estimated probability for the development of viral diseases was 62%. Ten percent of these patients died as a direct result of the infectious process, all within 4 months of transplant. Significant factors for development of viral disease were the development of acute graft-vs.-host disease and the duration of preengraftment neutropenia. CONCLUSIONS: Viruses are common pathogens after hematopoietic stem cell transplantation in the pediatric population. Despite routine antiviral prophylaxis the morbidity and mortality of viral infections remain high. Enhancement of immune recovery after hematopoietic stem cell transplantation together with the development of new classes of antiviral agents may impact the incidence and prognosis of viral infections in this setting.

Dapsone for Pneumocystis carinii prophylaxis in children undergoing bone marrow transplantation.

Children who undergo bone marrow transplantation (BMT) are at risk for Pneumocystis carinii pneumonia (PCP). Prophylaxis using trimethoprim/sulfamethoxazole (TMP/SMX) is highly effective but the incidence of adverse drug reactions is significant. We retrospectively reviewed 33 pediatric BMT (25 allogeneic and eight autologous) in whom dapsone was used for PCP prophylaxis because patients were unable to receive TMP/SMX. Dapsone was administered at 50 mg/m2 p.o. once a week from engraftment to 180 days post-autologous BMT, and to 1 year or throughout the duration of immunosuppressive treatment post-allogeneic BMT. With a total of 7268 patient days of dapsone prophylaxis and a median follow-up of 353 days post-BMT, no proven PCP was diagnosed. Sixteen cases of chest radiograph abnormalities were noted in this patient population but none was attributed to PCP. Dapsone was well tolerated by all children with no serious adverse effects; however, one patient developed Toxoplasma gondii encephalitis during dapsone prophylaxis. Dapsone warrants further evaluation as an alternative for PCP prophylaxis in pediatric BMT patients intolerant of TMP/SMX. Additional prophylaxis should be considered for patients at high risk for T. gondii encephalitis.

Tuberculosis during infancy.

SETTING: A worldwide re-emergence of tuberculosis has been observed during the last decade. However, few studies of infants with tuberculosis appear in the literature. OBJECTIVE: To describe tuberculosis during infancy. DESIGN: The records of all infants diagnosed with tuberculosis at a tertiary care hospital from 1982 to 1998 were reviewed. RESULTS: Thirty-nine infants with a median age of 10 months were identified, 59% of whom presented during the second half of the study period. Diagnoses included endothoracic tuberculosis (33 patients), meningitis (3), miliary tuberculosis (2) and cervical lymphadenitis (1). Reasons for medical evaluation were the onset of symptoms (25 patients), contact investigation (12) and tuberculin skin test screening (2). Common signs and symptoms included fever (22 patients), cough (7), appetite loss (4) and wheezing/rales (4). Chest X-ray revealed hilar adenopathy (22 patients), infiltrates (16), atelectases (3) and miliary pattern (2). Cultures were attempted in nine patients and were positive in seven. All patients responded promptly to treatment. No complications or deaths occurred. CONCLUSION: Tuberculosis in infants has been diagnosed increasingly during the last decade. Endothoracic tuberculosis predominates. One third of the patients were diagnosed due to contact investigation. As early diagnosis and treatment appears to prevent complications and reduce mortality, pediatricians should be alert for tuberculosis in an infant with an atypical picture suggestive of infection.