An Overview of Tick-Borne Encephalitis Epidemiology in Endemic Regions of Continental Croatia, 2017-2023.

Tick-borne encephalitis (TBE) represents an important public health problem in Europe. We analyzed the epidemiology of TBE based on data from humans, animals, and Ixodes ricinus ticks in endemic regions of continental Croatia. In the period from 2017 to 2023, cerebrospinal fluid (CSF) and serum samples of 684 patients with neuroinvasive diseases, 2240 horse serum samples, and 300 sheep serum samples were tested for TBEV. In addition, 8751 I. ricinus ticks were collected. CSF samples were tested using RT-PCR. Serological tests (serum, CSF) were performed using commercial ELISA, with confirmation of cross-reactive samples by a virus neutralization test. Eighty-four autochthonous human TBEV cases were confirmed. The majority of patients were in the age group of 40-69 years (58.3%) with a male predominance (70.2%). TBE showed a bimodal seasonality with a large peak in April-August and a small one in October-November. In addition to humans, TBEV IgG antibodies were found in 12.2% of horses and 9.7% of sheep. Seasonal tick abundance corresponds to the reported number of human infections. Continental Croatia is still an active natural focus of TBE. Continuous monitoring of infections in humans, sentinel animals, and ticks is needed for the implementation of preventive measures.

Coxiella burnetii (Q-fever) outbreak associated with non-occupational exposure in a semi-urban area of western Croatia in 2022.

In March 2022, an outbreak of Q fever (Coxiella burnetii) with non-occupational exposure was confirmed in a semi-urban area in Cavle, Croatia. Veterinary and human epidemiological investigations were conducted to identify the source of the outbreak and to implement appropriate control measures. Three farms were settled next to each other near the homes of the first human cases at the end of the street. The closest farm was less than 500 meters away. These farms contained 161 adult sheep and goats. Among the animal samples analysed, all 16 goats (100%) and 24/50 sheep (48%) tested positive for C. burnetii IgM/IgG antibodies, phase I and II. One out of five sheeps' vaginal swabs were C. burnetti DNA positive. Human testing revealed 20 confirmed and three probable cases (9/23 pneumonia, 2/23 hepatitis, 21/23 fever), with three hospitalizations, and one death. Twenty-seven cases were discarded following negative laboratory results. The epidemiological investigation revealed airborne transmission as the most likely route of transmission. Multiple logistic regression analyses were used to evaluate risk factors for Q fever infection. Persons who were near the farms (≤750 m) (OR 4.5; 95% CI = 1.1-18.3) and lived in the nearest street to the farms had the highest risk of contracting Q fever (OR 3.7; 95% CI = 1.1-13.6). Decreased rainfall compared to monthly averages was recorded in the months prior to the outbreak with several days of strong wind in January preceding the outbreak. This was the largest Q fever outbreak in the county in the last 16 years, which was unexpected due to its location and non-occupational exposure. To stop the outbreak, numerous intensive biosecurity measures were implemented. The outbreak highlights the importance of urban development strategies to limit the number of animal housing near residential areas while providing regular biosecurity measures to prevent infections in livestock.

Vaccination attitudes, beliefs and behaviours among primary health care workers in northern Croatia.

Primary health care workers (HCWs) provide almost all vaccine services in Croatia, so they play an essential role in vaccine recommendations and uptake. The aim of this study was to determine the level of vaccine hesitancy among primary HCWs, to identify differences between nurses and physicians in attitudes, beliefs and behaviours towards vaccination, and to determine predictors of vaccine hesitancy among HCWs. We conducted a cross-sectional study from July to December in 2018 among physicians and nurses employed in the services of epidemiology, public health, school medicine, pediatrics and general practice/family medicine in Primorje-Gorski Kotar County, a primarily urban region with a population around 300 000 in the northern part of Croatia. The list of primary HCWs offices was obtained from the Croatian Health Insurance Fond website. We used a self-administered questionnaire on their attitudes, beliefs and behaviours relative to vaccination. Obtained response rate was 65.5% (324/495) of eligible primary HCWs; 64.1% (143/223) of physicians and 66.5% (181/272) of nurses. Seventeen percent of HCWs were identified as vaccine hesitant, and in univariate analysis, we observed an association between HCWs occupation and their own vaccination against flu (p = 0.001), measles (p = 0.016) and HPV (p = 0.025). Nurses and physicians differed (p < 0.001) in their general attitude, beliefs and behaviours towards vaccination, with a higher level of hesitancy among nurses. In multiple logistic regression, those more likely to be vaccine-hesitant were nurses (AOR = 5.73, 95%CI = 2.48-13.24), those who were uncertain or would never receive a vaccine against measles (AOR=11.13; 95%CI=5.37-23.10) and HPV (AOR=5.02; 95%CI=2.60-9.74), as well as those who had encountered a serious adverse event following immunization (AOR=7.55; 95%CI=3.13-19.18). As personal hesitancy may have a negative impact on vaccination education and recommendations, and therefore vaccine coverage, it is necessary to implement interventions to increase vaccination knowledge and confidence among primary health care workers, especially nurses.

Measles outbreak in Dubrovnik-Neretva County, Croatia, May to June 2018.

In May 2018, measles was introduced in the Dubrovnik region by an adult who recently travelled to Kosovo*. Control measures and an outbreak investigation were implemented: 15 epidemiologically-linked cases met the outbreak case definition of a visitor/resident of Dubrovnik-Neretva County with laboratory-confirmed measles and symptom onset beginning on May 19. New cases were identified through hospitals and primary care physicians. Throat swabs, urine and/or serum samples were collected from outbreak cases. RT-PCR detection of viral RNA and IgM/IgG was used to confirm infection. The median age of cases was 33 years, with one 8 month-old infant. Vaccination status was unknown for 9 cases, three were unvaccinated, one case had history of one dose and two cases reported receiving two doses of measles-containing vaccine. There were 11 hospitalisations and one person developed pneumonia. Control teams undertook an extensive search of contacts and implemented a range of control measures. Despite the outbreak occurring at the beginning of the summer tourism season, it was contained and did not spread to neighbouring regions. With continuing measles transmission in Europe, even small outbreaks create a burden on the health system in countries which have eliminated measles, and illustrate the importance of maintaining high immunisation coverage.

Seroepidemiology of hepatitis E in patients on haemodialysis in Croatia.

PURPOSE: Data on the seroprevalence of hepatitis E virus (HEV) in heamodialysis (HD) patients are conflicting, ranging from 0 to 44%. The aim of this study was to determine the HEV seroprevalence and risk factors among HD patients in Croatia. METHODS: A total of 394 HD patients from six medical facilities in five Croatian cities (three sites in the continental and three sites in the coastal region) were tested for HEV IgM/IgG antibodies using an enzyme-linked immunosorbent assay. Additionally, all samples were tested for HEV RNA by RT-PCR. Sociodemographic data and risk factors were collected using a questionnaire. RESULTS: HEV IgG antibodies were detected in 110 (27.9%) patients. The seroprevalence varied significantly between dialysis centres, ranging from 5.2 to 43.4% (p = 0.001). HEV IgM antibodies were found in 0.04% of IgG positive patients. All patients tested negative for HEV RNA. Factors associated with HEV IgG seropositivity were age > 60 years (OR 8.17; 95% CI 1.08-62.14), living in the continental parts of the country (OR 2.58; 95% CI 1.55-4.30), and transfusion of blood products (OR 1.66; 95% CI 1.01-2.73). After adjusting for age and gender, patients from continental regions had higher odds of HEV seropositivity compared to patients from coastal regions (OR 2.88; 95% CI 1.71-4.85) and those who had RBC transfusions (OR 1.70, 95% CI 1.02-2.69) compared to those who did not. CONCLUSION: The study showed a high HEV seropositivity among HD patients in Croatia, with significant variations between geographical regions. Continental area of residence and RBC transfusion were the most significant risk factors for HEV seropositivity. Due to the high seroprevalence, routine HEV screening among HD patients, especially in transplant candidates should be considered.

Mortality Characteristics of Two Populations in the Northern Mediterranean (Croatia) in the Period 1960⁻2012: An Ecological Study.

In the second half of the 20th century, the town of Bakar (Primorje-Gorski Kotar County, Croatia), where a coking plant was operational 1978⁻1994, experienced intensive industrialisation. The town of Mali Losinj (Primorje-Gorski Kotar County, Croatia) in this period based its economy on non-industrial sectors. The study goal was comparing mortality characteristics of these populations in the northern Mediterranean for 1960⁻2012. An ecological study design was used. Data were analysed for 1960⁻2012 for the deceased with recorded place of residence in the study area. Data on the deceased for 1960⁻1993 were taken from death reports, for 1994⁻2012 from digital archives of the Teaching Institute of Public Health, Primorje-Gorski Kotar County. Data on causes of death for 1960⁻1994 were recoded to the three-digit code of underlying cause of death according to the International Classification of Diseases (ICD⁻10). Among studied populations significant difference was found among the causes of deaths coded within ICD⁻10 chapters: neoplasms (particularly stomach carcinoma), mental and behavioural disorders and diseases of the respiratory system (particularly chronic obstructive pulmonary disease, (COPD)). Increase in mortality from neoplasms, increase in respiratory diseases for the area exposed to industrial pollution, also stomach carcinoma and COPD particularly in the town Bakar require further research.

Attitudes and beliefs related to childhood vaccinations among parents of 6 years old children in Zagreb, Croatia.

The Croatian Immunization Programme is a mandatory prevention programme in which vaccines are offered free of charge and little is known about parental vaccine-related beliefs and attitudes. We aimed to describe beliefs and attitudes towards childhood vaccination of parents in Zagreb, estimate the proportion of parents with positive attitudes towards vaccination, and to identify the possible predictors of positive attitudes. Using a self-administered questionnaire, we performed a cluster sampling survey among parents of 6-years-old children in Zagreb. In total 542 questionnaires were collected, 80% (n = 430/542) of respondents were mothers. Even though 72.6% (n = 385/531; 95%CI: 69-76) respondents feel that childhood vaccination should remain mandatory, 36.3% (n = 192/528; 95%CI: 58.3-65.3) considered that simultaneous administration of vaccines can have negative effect to their child's health. In addition, 38% (n = 202/532; 95%CI: 33.2-43.1%) feared that vaccines may harm their child. Of total, parents mostly reported positive attitude towards vaccination (61.8%; 95% CI: 34.7-42). Parents with positive attitudes were more likely to state their child experienced mild or no adverse reaction after vaccination, report not delaying vaccination and provide additional non-mandatory vaccines to their child (p < 0.05). Gender, age, education and marital status of parent were not significantly associated with the positive attitude towards vaccination. Our results suggest the need for educational interventions and communication strategies that could foster better knowledge on immunization with a focus on parental misconceptions, perceived constraints and safety issues about vaccine.

Stress, depression and burnout among hospital physicians in Rijeka, Croatia.

BACKGROUND: Six years of recent ongoing economic and structural crisis in Croatia have brought to a significant decrease of socioeconomic standard in our country, and had an important impact on the health care system. In this background we examined the prevalence of depression and burnout and their association with work stressors. SUBJECTS AND METHODS: Cross sectional survey was conducted with self reported questionnaires in 459 hospital physicians in Rijeka, Croatia. Physicians were divided into three groups: surgical, nonsurgical and diagnostic group. Socio-demographic and work-related characteristics questionnaire, Occupational Stress Assessment Questionnaire (OSAQ), Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and Beck Depression Inventory II (BDI-II) were used. Sperman correlation and logistic regression were calculated to rank association between stressors at work with depression and burnout syndrome. RESULTS: Response rate was 62.3%, (286/459). Every fifth doctor experienced all examined stressors in the workplace as stressful. The prevalence of moderate and severe depression was 12.2%. High levels of emotional exhaustion were 43.6%, depersonalization 33.5%, and lack of personal accomplishment 49.1%. There was no statistical difference in surgical, nonsurgical and diagnostic groups in depression and all domains of MBI-HSS. Almost all stressors were correlated with depression and burnout syndrome. Most of the perceived stressors were significant predictors of burnout syndrome and depression. CONCLUSIONS: High levels of burnout domain compared to overall results from similar studies from other countries, placed the results in our sample on the higher end of the range, while results for depression after adjustment with lower cutoff point would be similar to those usually found in research literature. Our study showed that burnout is highly prevalent among Croatian physicians. Target interventions at the workplace should be considered as one of the strategies to reduce negative impact of work stress on physicians' mental health.