Need for orthodontic treatment and oral health-related quality of life in children and adolescents - A systematic review.

OBJECTIVES: To determine the relationship between the need for orthodontic treatment and OHRQoL in children and adolescents, and to identify potential modifying factors of this relationship. METHODS: Systematic review, starting with searches of PubMed, Scopus, and EBSCO Discovery Service. Observational studies which examined the relationship between the need for orthodontic treatment and OHRQoL, in children and adolescents, were considered eligible. RESULTS: Eighteen studies were included, of which, one was a prospective cohort study and 17 were cross-sectional. Twelve of 18 studies reported a relationship between the need for orthodontic treatment and OHRQoL, while the remainder failed to demonstrate a clear relationship. Gender and self-esteem were found to modify this relationship. CONCLUSIONS: Need for orthodontic treatment is associated with OHRQoL in children and adolescents. Gender and self-esteem are potential effect modifiers of this relationship.

A patient with respiratory toxigenic diphtheria in Greece after more than 30 years.

The introduction of treatment and systematic vaccination has significantly reduced diphtheria mortality; however, toxigenic strains continue to circulate worldwide. The emergence of an indigenous diphtheria case with fatal outcome in Greece, after 30 years, raised challenges for laboratory confirmation, clinical and public health management. Toxigenic Corynebacterium diphtheriae was isolated from an incompletely vaccinated 8-year-old boy with underlying conditions. The child passed away due to respiratory distress syndrome, before the administration of diphtheria antitoxin (DAT). All close contacts in family, school and hospital settings were investigated. Pharyngeal swabs were obtained to determine asymptomatic carriage. Chemoprophylaxis was given for 7 days to all close contacts and a booster dose to those incompletely vaccinated. Testing revealed a classmate, belonging to a subpopulation group (Roma), and incompletely vaccinated, as an asymptomatic carrier with an indistinguishable toxigenic strain (same novel multilocus sequence type, designated ST698). This case highlights the role of asymptomatic carriage, as the entry of toxigenic strains into susceptible populations can put individuals and their environment at risk. Maintenance of high-level epidemiological and microbiological surveillance, implementation of systematic vaccination in children and adults with primary and booster doses, availability of a DAT stockpile, and allowing timely administration are the cornerstone to prevent similar incidents in the future.

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.

Ongoing measles outbreak in Greece related to the recent European-wide epidemic.

We report an ongoing measles outbreak in Greece. The first cases were notified through the mandatory notification system on May 2017 in Northern Greece and concerned a cluster of three imported cases in unvaccinated Roma siblings. So far, 3150 cases have been reported in all 13 Regions. Initially, the outbreak mainly affected Greek Roma but as it progressed it spread to non-minority Greek nationals. The outbreak reached its ultimate peak on week 10/2018 but from week 15/2018 has been gradually declining. Most cases (60.6%) were Roma (especially children <10 year-old) followed by non-minority Greek nationals (29.3%; mostly young adults). The majority (80.4%) were unvaccinated. Interestingly, 129 (4.1%) cases were healthcare workers (HCWs). Genotype B3 was identified by molecular methods in all 87 cases tested. Overall, 61.3% of the cases were hospitalised. Complications were reported in 17.1% of the cases among which four deaths. The outbreak occurred after 3 years without local endemic measles transmission. Extensive vaccination implemented as the major public health measure managed to prevent the emergence of a large number of cases in refugee/migrant hosting sites. Mitigation efforts currently focus on raising awareness among HCWs and closing the immunisation gap in populations with suboptimal vaccination coverage.

Time trends in pediatric hospitalizations for hepatitis A in Greece (1999-2013): Assessment of the impact of universal infant immunization in 2008.

Hepatitis A vaccine was introduced in the Greek National Immunization Program in 2008. To estimate possible impact of the universal vaccination implementation, time trends of hospitalizations for hepatitis A at the Infectious Diseases Unit of a Tertiary Pediatric Hospital in Athens during 1999-2013 were analyzed. Hepatitis A hospitalizations were recorded from the discharge database and were expressed as frequencies and rate of annual departmental hospitalizations. Time series analysis (ARIMA) was used to explore trends and the impact of the vaccination. Moreover, changes in patient age, population group distribution and the duration of hospitalization were also examined. Hepatitis A hospitalizations rate significantly decreased between pre-vaccination (1999-2008) and post-vaccination (2009-2013) era from 50.5 to 20.8/1000 hospitalizations (p = 0.005). A 3-year periodicity and a trend of reduction on hepatitis A hospitalizations rates across years were noted. Roma children had significant higher rates of hepatitis A hospitalization, followed by immigrant children. Importantly, possibly due to preceding vaccine availability with considerable uptake in private market and unvaccinated group/pockets of children (Roma), overall vaccination effect was less apparent when compared to data from other countries that implemented universal vaccination. No significant change in patient age, population group distribution, or duration of hospitalization was observed. High risk groups such as Roma children should be targeted for vaccination to reduce future outbreaks.

Long-lasting hyporesponsivenss induced by the 23-valent pneumococcal polysaccharide vaccine (PPV23) in asplenic patients with ß-thalassemia major.

We have previously shown that multiple vaccinations with 23-valent pneumococcal polysaccharide vaccine (PPV23s) resulted in attenuated antibody responses to subsequent 7-valent conjugate vaccine (PCV7) in asplenic adults with ß-thalassemia major (Orthopoulos et al. Vaccine 2009; 27:350). However, there is evidence that PPV23-induced immune hyporesponsiveness could be overcome with time (Papadatou et al. Clin Infect Dis 2014; 59:862). In the current study we investigate the duration of hyporesponsiveness in the same cohort seven years after the original study vaccinations. Patients received one dose of 13-valent conjugate vaccine (PCV13) and antibody levels were measured before and one month after vaccination. Antibodies increased significantly after vaccination with PCV13, but were lower than post-PCV7 seven years earlier. Lower pre-vaccination antibody levels were associated with more robust response to PCV13. Our findings suggest that PPV23 should be used cautiously in asplenic adults vaccinated with multiple PPV23s in the past. Measurement of anti-pneumococcal antibodies before and after vaccination could be used to optimise timing of vaccinations and certify vaccine immunogenicity in such individuals.

Antibiotic prescription practices for common infections and knowledge about antibiotic costs by private-practice pediatricians in Greece.

AIM: Greece is among the European countries with the highest antibiotic consumption in the community. We investigated the antibiotic prescription practices by private-practice paediatricians, using the 2007 national guidelines for antibiotic use as the gold standard. METHODS: A standardized questionnaire was distributed to 520 private-practice pediatricians. There were 6 scenarios about common infections. RESULTS: A total of 124 pediatricians participated (23.8% response rate). Compliance with the first recommended antibiotic was 48% for streptococcal pharyngitis, 30.6% for community-acquired pneumonia, 12.4% for urinary tract infection, 67.8% for bacterial skin infection, 48.8% for acute otitis media, and 18.2% for bacterial pneumonia. The highest variation in antibiotic prescription concerned the community-acquired pneumonia scenario (11 antibiotics, including 6 beyond the guidelines). The overall mean compliance rate with the first recommended antibiotic was 37.4%. The mean compliance rates were 49.2%, 36.4%, 35.8%, and 27.5% in the <40, 41-50, 51-60, and >60 years age groups, respectively (P value<0.001). CONCLUSION: Five years after the first guidelines about antibiotic use were issued in Greece, a wide range of antibiotic prescription practices by private-practice pediatricians was discovered, with only one every three pediatricians complying fully with them.

Nosocomial pertussis in neonatal units.

Pertussis remains a public health concern in many countries despite high vaccination coverage rates. Nosocomial outbreaks of pertussis continue to occur in neonatal units. Neonates and young infants admitted to neonatal intensive care units constitute a pool of susceptible high-risk patients given their prematurity, inadequate immune response and the fact that they are too young to have completed their primary vaccination series against pertussis. This article reviews nosocomial pertussis in neonates and infants, focusing on the role of healthcare workers (HCWs). Outbreaks in neonatal units are often traced to HCWs and are associated with serious morbidity or even a fatal outcome among susceptible young infants. A high index of suspicion is required for early recognition and isolation of patients admitted with suspected or proven pertussis, as well as for HCWs with a compatible clinical syndrome, regardless of vaccination status. Contact investigation is also essential in order to guide administration of post-exposure prophylaxis. Recommendations for a booster vaccination for HCWs are in place in several countries; however, the need of HCWs for lifelong immunity against pertussis cannot be fulfilled by the current vaccine.

Evaluation of viral co-infections in hospitalized and non-hospitalized children with respiratory infections using microarrays.

The impact of viral co-infections and recently discovered viruses on the epidemiology of respiratory infections in children is still unclear. To simultaneously detect viruses that are involved in the aetiology of respiratory infections, we used a DNA/RNA microarray assay that identifies 17 different viruses or viral subtypes. Rhinopharyngeal washes were taken from 611 children (aged 1 month to 14 years) who presented in the emergency department with respiratory infections from June 2010 to June 2011 and were treated as outpatients (299, 48.9%) or hospitalized (312, 51.1%). Lower respiratory tract infection was diagnosed more often in hospitalized children (68% versus 36%, p 0.001). Of 397 children in which microarrays detected viral infection (70.1%), a single virus was found in 228 (57.4%) and two or more viruses in 169 (42.5%). The most prevalent viruses among children with positive samples were respiratory syncytial virus (RSV) in 225 (56.6%), parainfluenza virus (PIV) in 118 (29.7%), rhinovirus (RV) in 73 (18.4%), followed by influenza in 56 (14.1%), adenoviruses in 31 (7.8%), bocavirus in 25 (6.3%), human metapneumovirus in 15 (3.7%) and enteroviruses in 12 (3%). Most common viral co-infections were RSVA-RSVB in 46 children (27.2%), RSV-Influenza in 20 (11.8%), RSV-RV in 18 (10.6%) and PIV-RV in 13 (7.7%). Multiple logistic regression analysis revealed that viral co-infections were associated with increased probability for hospitalization (OR 1.52, 95% CI 1.01-2.29, p 0.04), and previous pneumococcal vaccination was associated with decreased probability for hospitalization (OR 0.52, 95% CI 0.33-0.81, p 0.004). We conclude that viral co-infections are involved in a significant proportion of children with an acute respiratory infection and may increase the severity of clinical presentation and the risk for hospitalization.

Prospective study of human norovirus infection in children with acute gastroenteritis in Greece.

AIM: Noroviruses are considered as a major cause of acute gastroenteritis in childhood worldwide. This prospective study was undertaken to investigate the frequency and clinical features of norovirus infections in children aged less than 5 years with acute gastroenteritis in Greece. METHODS: Routine stool samples were obtained from 227 children, 119 boys and 108 girls, with acute gastroenteritis, who attended a tertiary paediatric hospital in Athens during the period November 2008 - October 2009. All specimens were tested for the presence of norovirus, rotavirus and adenovirus antigens using validated enzyme-linked immunoassays. RESULTS: Norovirus was detected in 8 (7.9%) out of 101 children during the period November 2008 to April 2009, while the respective rate during the period May 2009 to October 2009 was 1/126 (0.8%). In the total sample, rotavirus was detected in 56 (24.7%) children and adenovirus in 5 (2.2%) children. Three (1.3%) samples grew Campylobacter jejuni, while 6 (2.6%) samples grew Salmonella. In all cases, norovirus was detected as a unique viral pathogen. Among norovirus-positive children, who required hospitalization, the median duration of intravenous fluid administration was 3.5 days. The median duration of hospitalization was 4 days (range 3 days to 5 days) and did not differ from the duration of hospitalization of rotavirus-positive children. CONCLUSION: Our results suggest norovirus as the second most common cause of community-acquired acute gastroenteritis in children in Greece, following rotavirus. We highlight the need to implement norovirus detection assays for the clinical diagnosis and the prevention of viral gastroenteritis in paediatric departments.

Decrease of antibiotic consumption in children with upper respiratory tract infections after implementation of an intervention program in Cyprus.

To assess the impact of intervention on antibiotic misuse in children, parents' and pediatricians' knowledge, attitudes, and practices (KAP) concerning antibiotic use were evaluated pre- and postintervention in Larnaca (Cyprus) and Limassol (Cyprus). Concurrently, pediatricians documented upper respiratory tract infection (URTI) visits and pharmacists provided antibiotic consumption data. Intervention was implemented for parents and pediatricians residing in Larnaca. The consumption/URTI incidence index was significantly reduced in Larnaca but not in Limassol. Parental responses to a KAP questionnaire remained unchanged; therefore, antibiotic consumption reduction is attributable to pediatricians' education.

Human papilloma virus (HPV) vaccination in childhood: challenges and perspectives.

Vaccination against human papilloma virus (HPV) in childhood is a significant step forward in the reduction of HPV associated morbidity and mortality and a considerable scientific achievement. However, many challenges remain to be overcome if an effective HPV vaccine programme is to be successfully introduced worldwide. The aim of this review is to identify and summarize the new issues concerning HPV vaccination that have emerged since its introduction into clinical practice in school-aged girls. According to the literature, the overall impact of HPV vaccination on cervical cancer is unlikely to be apparent for the next decade. Cost-effectiveness is of particular importance, particularly in developing countries. Determining the age at which the vaccine should be administered, whether to include boys in addition to girls, the costs and the implications for cervical screening are issues that need to be addressed by conducting further research.

Pott's disease in a two-year-old girl.

Fractures in children require a specific treatment depending on age. While obstetric fractures usually heal well even in case of significant dislocations and conservative therapy, the proportion of operative interventions among all pediatric fractures is increasing with age. Though the vast majority of fractures in childhood are still treated non-operatively, a trend towards early operative interventions and cast-free mobilization has been noticeable in the recent years. The methods of operative stabilization differ between the respective age groups: While K-wire osteosynthesis and a minimal invasive approach using elastic stable intramedullary nailing (ESIN) are common in the group of school aged children, the use of external fixation and plate osteosynthesis has been accepted for the treatment of fractures in adolescents. Bioresorbable implants do not yet play a decisive role in the management of pediatric fractures. This review is focusing on the current indications and concepts for stabilization of frequent pediatric fractures.

Seroepidemiology of hepatitis B in Greek children 6 years after the implementation of universal vaccination.

The seroepidemiology of hepatitis B in children living in Greece 6 years post-implementation of universal infant immunization (1998) was studied. We collected 90-100 sera/year of age, stratified by geographic region. The prevalence of HbsAg(+) was 0.6% (95% CI 0.3-1.3) whereas 4.5% (95% CI 3.4-5.9%) of children over 12 months of age had evidence of past HBV infection. A significant decline in the prevalence of past infection between children born before and after 1998 (5.5% vs 2.9%; RR = 1.9, 95% CI 1.03-3.5) was noted. Conversely, the prevalence of past HBV infection did not change significantly among immigrant children. Reinforcement of early vaccination of immigrant population is necessary.

Pertussis outbreak detected by active surveillance in Cyprus in 2003.

Pertussis is a disease of substantial public health importance that still lacks an efficient surveillance system. It has been a notifiable disease in Cyprus since 1930, and has had an incidence rate of 1 per 100,000 persons during the last 10 years. In 2001, the Greece-Cyprus Paediatric Surveillance Unit (GCPSU) was established with the aim of active surveillance for rare paediatric diseases, including weekly data reporting, zero reporting, and obligatory laboratory tests. From November 2002, pertussis has been included in the active surveillance scheme of GCPSU, resulting in a very early detection of an outbreak in June 2003 that led to immediate and successful action.

Changes in leptin serum levels in HIV-infected children receiving highly active antiretroviral therapy.

Highly active antiretroviral therapy (HAART) has significantly improved the prognosis of HIV(+) in children. Human immunodeficiency-associated lipodystrophy syndrome (HALS) is a side effect of HAART seen predominantly in adults and less often in children. Leptin is a protein thought to play an important role in body composition and has been shown to have immunomodulatory effects. We retrospectively studied serum levels of leptin in a cohort of eight HIV-infected children followed prospectively before and during HAART and investigated whether there is a correlation of these levels with the clinical, immunological, viral or nutritional changes observed during treatment in these children. None of our children developed HALS. In this small cohort of children, we found that serum leptin levels were appropriate to the nutritional status of the patient and that leptin/BMI increased in patients who responded to HAART. In conclusion, in HIV(+) children during HAART, leptin levels are related to the nutritional status of the child.

Invasive meningococcal disease in children in Greece: comparison of serogroup A disease with disease caused by other serogroups.

Although invasive meningococcal disease caused by serogroup A is not prevalent in developed countries, a considerable number of cases were recently recorded in Greece. In this study, serogroup A meningococcal disease was compared prospectively with meningococcal disease caused by other serogroups, using similar settings of testing and management during a 5-year period between 1999 and 2003. The Neisseria meningitidis serogroup was determined in 262 cases. Serogroup B predominated, accounting for 158 (60%) of the cases. Serogroup A was second most frequent (19%), followed by serogroups W135 (11%), C (8%), and Y (2%). No cases due to serogroup C were recorded during the last year of the study. Patients with serogroup A disease were older and had a milder course compared to patients infected with serogroups B or C. Toxic appearance, purpura, thrombocytopenia, abnormal coagulation tests, and the need for admission to the intensive care unit, fluid resuscitation, inotropic drugs, and mechanical ventilation were less common. Although morbidity and mortality were lower in these patients, the differences were not significant. Serogroup B is predominant in our area, and the introduction of an effective vaccine against it is a priority. Serogroup A has emerged as the second most common serogroup, but the illness associated with it is milder.