[Delays in diagnosing and treating tuberculosis in Croatia]. / Izgubljeno vrijeme u otkrivanju i pocetku lijecenja tuberkuloze: sto treba napraviti?

The aim of this study was to determine factors causing delay in tuberculosis diagnosis and treatment in Croatia. It included 240 adults with pulmonary tuberculosis, who were interviewed for demographics, socioeconomic, lifestyle, and personal health data. Total delay was defined as a number of days from the onset of symptoms to the initiation of therapy. The median and the 75th percentile of the total delay were 68 and 120 days, respectively: 16.7 % of the patients initiated treatment within the first month, 23.8 % within the second month, 23.3 % within the third month, 12.9 % within the fourth month, and 23.3 % more than four months after the symptoms appeared. Long delay (exceeding median delay) was strongly associated with drug abuse (p=0.021). Extreme delay (75th percentile of delay) was significantly associated with the lowest level of education (p=0.021), below minimal income (p=0.039), minimal to average income (p=0.020), current smoking (p=0.050), and co-morbidity (p=0.048). In the multivariate model, long delay remained associated with drug abuse, while extreme delay was associated with the lowest level of education (p=0.033) and current (p=0.017) and ex-smoking (p=0.045).In a setting with decreasing TB incidence, the reported delay can be reduced by increasing health education, not only about tuberculosis per se, but about health in general and attitudes towards prevention and early care. It is also important to increase tuberculosis knowledge among healthcare workers as well as their diagnostic skills.

Predicting AH1N1 2009 influenza epidemic in Southeast Europe.

AIM: To use the data on the AH1N1 2009 influenza epidemic in the Southern hemisphere countries to predict the course and size of the upcoming influenza epidemic in South-Eastern Europe (SEE) countries and other regions of the World with temperate climate. METHOD: We used a comparative epidemiological method to evaluate accessible electronic data on laboratory-confirmed deaths from AH1N1 2009 influenza in the seasons 2009/2010 and 2010/2011. The studied SEE countries were Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Hungary, Kosovo, Macedonia, Montenegro, Romania, Serbia, and Slovenia, while Southern hemisphere countries were Argentina, Australia, Chile, New Zealand, Paraguay, Uruguay, and South Africa. RESULTS: In influenza season 2009/2010, Southern hemisphere countries with temperate climate reported 1187 laboratory-confirmed influenza AH1N1 2009 deaths (mortality rate 0.84/100000; 95% confidence interval [CI], 0.50-1.24). SEE countries with similar climatic conditions reported 659 deaths and similar mortality rates (0.86/100000, 95% CI, 0.83-1.10). In the whole Europe without the Commonwealth of Independent States countries (CIS, former Soviet Union), there were 3213 deaths (0.60/100000; 95% CI, 0.65-0.93). In 2010/2011, Southern hemisphere countries reported 94 laboratory-confirmed deaths (mortality rate 0.07/100000; 95% CI, 0.02-0.28) or only 7.9% of the previous season. SEE countries by the end of the 11th epidemiological week of 2010/2011 season reported 489 laboratory-confirmed deaths, with a mortality rate of 0.64/100000 (95% CI, 0.26-0.96) or 74.2% of the previous season, which was significantly higher than in the Southern hemisphere countries (χ(2) (1) =609.1, P<0.001). In Europe without CIS countries, there were 1836 deaths, with a mortality rate of 0.34/100000 (χ(2) =153.3, P<0.001 vs SEE countries). CONCLUSION: In the 2009/2010 season, SEE countries and Southern hemisphere countries had similar influenza AH1N1 2009 mortality rates. In the 2010/2011 season, the forecast of 10% increase in total mortality in SEE countries and Europe compared with the 2009/2010 season was significantly exceeded, while the expected impact of type-specific vaccines against influenza AH1N1 2009 was not achieved. Consumption of epidemic potential has greater importance for the prognosis of the course and size of influenza epidemic than the degree of vaccine immunity.

[Does Croatia have hospital surplus?]. / Ima li Hrvatska visak bolnica?

BACKGROUND: In addition to human resources in health care, hospitals are unavoidable factor in international deliberations of development level of health systems. Besides education of health workers, equipped devices and efficiency of work in hospitals, it is important to compare the number of hospitals, their size, type of hospitals, their distribution and availability to users. These elements are essential to the overall quality and efficiency of health work of an area. AIM: To identify and analyze the hospital by the number, type and size, number and type of beds in them, and the disposition in relation to population and unit area (km2) in Croatia, County of Split-Dalmatia and other European countries in total and by groups of European countries by the gross national product per capita (GDP pc), in 2007. Based on the analysis, to answer the question whether Croatia has a sufficient number of hospitals, particularly in County of Split-Dalmatia and Dalmatia. METHOD: In this article are used methods of descriptive epidemiology based on available electronic data of the WHO Office for Europe. RESULTS: Of the 44 European countries, Croatia is in the 35th place with a total of 79 hospitals (1.7 hospitals/100,000 population; Europe 3.4/100,000). Without 10 hospital wards, and 6-of-hospital maternity, Croatian average is 1.4/100,000 which places Croatia in 41st place. By the number of acute hospitals with no out-patient clinic and maternity wards, Croatia is in the penultimate 43rd place with 36 hospitals (0.8/100,000; Europe 2.6/100,000). According to the average number of beds/100,000 population, Croatia is at the 23rd place (Europe: 489 beds/100,000 population; Croatia: 352 beds/100,000). By the size of the hospitals per average number of hospital beds per one acute hospital Croatia has no clinic and outpatient hospitals (446) which puts Croatia in the second place behind the Netherlands (541). According to the number of acute hospitals/1,000 km2 with no out-patient clinic and maternity wards, Croatia is at the 39th place (0.6/1,000 km2; European average without Russia: 2.3/1,000 km2). In Croatia, most hospitals/100,000 population has County of Pozega-Slavonia (3.5/100,000), while the least are in Split-Dalmatia County (0.4/100,000). The most acute hospitals are in County of Pozega-Slavonia (2.3/100,000), and the least in County of Split-Dalmatia (0.2/100,000) or 7 times less than the Croatian average, and 13 times less than the European average. By the number of acute hospitals with no out-patient clinic and maternity wards/1,000 km2 in Croatia, there are most hospitals together, in City of Zagreb and County of Zagreb (3/1000 km2), and the least in County of Lika-Senj and County of Split-Dalmatia (0.2/1,000 km2). DISCUSSION: Croatia is getting behind by the number of hospitals, compared to Europe, especially concerning acute hospitals. Given the density and area unit in the Southern Croatia there is a striking lack of acute hospitals, causing a disparity in the availability of hospital and specialist health care. To make hospital and specialist health care available to the 170,000 inhabitants of Dalmatia, who are more than an hour away from the hospital, it is necessary to replace outpatient-clinics and maternity hospitals with the general hospitals. CONCLUSION: Given the fact that Croatia is at the top of Europe by the size of the hospitals by the number of beds for acute patients, and there is the sufficient number of beds to population, but also a lack of spatial coverage of acute hospitals and therefore poor availability of hospital and specialist care for the advisory large population of south and east of the state and Istria. Croatia should achieve further necessary hospital facilities by planning and building small municipal/town/local hospitals for acute patients with the necessary agreed facilities at the headquarters of the former health centers where already exists specialist diagnostic and therapeutic activities of secondary level health care.

[Adverse health events and health hazards reflections of epidemiologists and environmentalists]. / Nezeljeni zdravstveni dogadaji--kako epidemiolozi i ekolozi razmislaju zajedno.

In this article we present management of water resources in Croatia as a model of integral approach in public health interventions. The links between provision of clean water, sanitation and good health are so strong that today management and water protection are deeply integrated in primary health care. This article is a follow up on topics presented on 2nd Croatian congress on preventive medicine and health promotion which gave us "state of art" in Croatian public health. We strongly believe that every system has its own advantages and downsides, and only by knowing the system well and continuous improvement we can protect ourselves in time of health, social or economic crisis. The model of water protection showed that to prevent and overcome the variety of water-related health risks, implementation of various activities that include general environmental protection, development of water management system, permanent water quality monitoring and control, and improvement of standards and legislative is needed. On the other hand if there is no holistic approach, to the public health problems, all the efforts in just one field will not result in health indicators improvement. Constant monitoring and uniform analysis of data could help to identify possible risks of adverse effects of various environmental factors and possible burden of disease as a consequence. That information could be a point of arguing with local governments and communities for public health interventions. It is important that epidemiological and environmental data do not remain in the domain of academic discussion or statistics, and never reach primary health care which could use them in direct health care providing. Information exchange in real time is important for the real time public health intervention. Primary health care is the front line in communication with patients and diagnostics of disease as well as prevention, and they need to have access to all relevant data.

Historic, demographic, and genetic evidence for increased population frequencies of CCR5Delta32 mutation in Croatian Island isolates after lethal 15th century epidemics.

AIM: To assess the frequency of 32 base pair deletion in CCR5 (CCR5Delta32), which has been shown to confer resistance to HIV infection in a homozygous form, in 10 isolated island communities of Dalmatia, Croatia, with different histories of exposure to epidemics during and since the medieval period. METHODS: In 2002, DNA analysis of 100 randomly selected individuals from each of the 10 isolated communities of 5 Croatian islands (Susak, Rab, Vis, Lastovo, and Mljet) showed high levels of 3-generational endogamy, indicating limited gene flow. Five of the communities were decimated by epidemics of unknown cause between 1449-1456, while the other 5 villages remained unaffected. Genotyping of the CCR5 gene was performed using the polymerase chain reaction method with primers flanking the region containing 32-bp deletion. RESULTS: The frequency of CCR5Delta32 in the 5 villages affected by the epidemic was 6.1-10.0%, and 1.0-3.8% in the 5 unaffected villages. The Delta32 mutation was found in 71 of 916 alleles among the individuals from the affected villages (7.5%), and in 24 of 968 alleles in unaffected villages (2.5%, chi(2)=27.3, P<10-6). A previous study in 303 random Croatian blood donors showed the frequency of the CCR5 Delta32 of 7.1% in the general population. The difference remained significant after correcting for population structure using both STRAT and STRUCTURE software and the genomic control test, to ensure results do not arise from the background genetic differences. CONCLUSION: Our results and historical evidence, suggest that the mid-15th century epidemic could have acted as a selection pressure for the CCR5Delta32 mutation.

Historic exposure to plague and present-day frequency of CCR5del32 in two isolated island communities of Dalmatia, Croatia.

AIM: To assess the frequency of deletion of 32 base pairs in a CCR5 gene, shown to confer resistance to HIV infection, in two isolated island communities of Dalmatia, Croatia, with different histories of exposure to (plague) during the medieval period and beyond. METHODS: Random samples of 100 individuals from highly isolated communities of Lopar (island of Rab) and Komiza (island of Vis) were selected in 2002 and their DNA was extracted. An extremely high level of 3-generational endogamy was found in both communities (98% and 91%, respectively), indicating very limited gene flow, which was confirmed by available historic records. The two settlements also differed in their historic exposure to plague: between 1449 and 1456, Lopar was decimated by plague, while Komiza remained unaffected. Genotyping of the CCR5 polymorphism was performed using the polymerase chain reaction (PCR) method with primers flanking the region containing 32-bp deletion. RESULTS: The frequency of CCR5del32 in Lopar was 6.0% and in Komiza 1.5% (P=0.037). A previous study in 303 random Croatian blood donors showed a frequency of CCR5 32bp deletion of 7.1%. CONCLUSION: This study does not rule out the possible role of plague in positive selection at CCR5del32. However, analyses of further neighboring isolated island communities need to be made in order to provide more substantial support for this hypothesis.

Metabolic syndrome in a metapopulation of Croatian island isolates.

AIM: To investigate the prevalence and factors associated with the metabolic syndrome in 9 isolated populations on Adriatic islands, Croatia, and in the group of immigrants to these islands. METHODS: Random samples of 100 inhabitants from each village and 101 immigrants were collected during 2002 and 2003. Bivariate and multivariate methods were used in data analysis. Age, gender, village, diet, smoking habits, physical activity, education, occupational class, and personal genetic history (a pedigree-based estimate of the individual genome-wide heterozygosity level) were used as independent variables in logistic regression. RESULTS: A total of 343 (34%) examinees met criteria of the metabolic syndrome diagnosis, with significant differences in the prevalence among villages (P=0.002). Metabolic syndrome was most frequently detected on Mljet island (53%), where all examinees exhibited fasting plasma glucose over 6.1 mmol/L. Examinees with metabolic syndrome were significantly older than those without it (median age 60.0 vs 53.0; P<0.001). Women were more frequently diagnosed than men (39% vs 28%; P<0.001). The highest prevalence of the metabolic syndrome was found in the autochthonous group, whereas the lowest proportion was recorded in the admixed group (39% vs 21%, respectively, P=0.017). However, only age (odds ratio [OR], 1.06; 95% confidence intervals [CI], 1.03-1.08) and having a university degree (OR, 0.18; 95% CI 0.04-0.92) were significantly associated with metabolic syndrome in the regression model. CONCLUSION: Metabolic syndrome was not associated with pedigree-based individual genome-wide heterozygosity estimate, after controlling for a number of confounding factors. More precise marker based genomic measures are needed to provide a clear answer whether metabolic syndrome development is influenced by the population genetic structure.

[Epidemiologic characteristic of hepatitis B in the Splitsko-Dalmatinska County]. / Epidemioloske karakteristike hepatitisa B u Splitsko-Dalmatinskoj zupaniji.

Epidemiologic characteristics of hepatitis B virus (HBV) infection in the Split-Dalmatia County and in Croatia as a whole from January 1, 1994 till December 31, 2003 were analyzed. The mean number of hepatitis B cases was 28 (morbidity rate 6.03 per thousand) in the Split-Dalmatia County and 208 (morbidity rate 4.68 per thousand) in Croatia. Over the last five years, there was a marked decrease in the incidence of hepatits B in the Split-Dalmatia County (morbidity rate 1.55 per thousand), whereas its incidence at the national level showed a stable pattern (morbidity rate 4.49 per thousand). In the Split-Dalmatia County, the majority of patients (57.51%) were aged 15-29, which could be attributed to risky sexual contacts and intravenous drug use. The male to female ratio was 2.1(188:93). There was no major incidence fluctuation according to months of year. The hepatitis B mortality rate was 0.24% (5/2079) in Croatia as a whole, whereas no case of HBV lethality was recorded in the Split-Dalmatia County. The significant decrease in the hepatitis B morbidity rate in the Split-Dalmatia County most probably resulted from the comprehensive measures of prevention, especially vaccination, the early introduction of the needle exchange program (1955-1996).

An outbreak of Yersinia enterocolitica O:3 infections on an oil tanker.

In January 2002, an outbreak of Yersinia enterocolitica O:3 infections occured on 'Asirat', an oil tanker, during its return test voyage from Split, Croatia to Trieste, Italy. Of the 120 crewmembers and workers 22 (18%) suffered from gastrointestinal symptoms. In 17 patients Y. enterocolitica O:3 was isolated from stool samples. All available food and water samples were negative and the source of infection was not determined. Probably a foodborne transmission was involved, although person to person transmission could not be excluded.