The Importance of an Active Case Detection (ACD) Programme for Malaria among Migrants from Malaria Endemic Countries: The Greek Experience in a Receptive and Vulnerable Area.

Greece has been malaria-free since 1974. In October 2011, following an outbreak of 36 locally acquired malaria (LAM) cases in Evrotas Municipality, a Pro-Active Case Detection (PACD) program for malaria was implemented among migrants from malaria-endemic countries, to support early diagnosis and treatment of cases. We evaluated the PACD program for the years 2012-2017 using indicators such as the number of locally acquired cases, the detection rate/sensitivity and the timeliness of diagnosis and treatment. We visited each migrant home every 7-15 days to screen migrants for malaria symptoms, performing Rapid Diagnostic Tests (RDTs) and blood smears on symptomatic patients. We estimated: (i) the number of malaria cases detected by the PACD, divided by the total number of reported malaria cases during the same period among the same population; (ii) the time between onset of symptoms, diagnosis and initiation of treatment. The total number of migrants who were screened for malaria symptoms for the years 2012-2017 was 5057 with 84,169 fever screenings conducted, while 2288 RDTs and 1736 blood smears were performed. During the same period, 53 imported P. vivax malaria cases were detected, while incidence of malaria among migrants was estimated at 1.8% annually. Ten and one LAM cases were also reported in 2012 and 2015, respectively. Sensitivity of PACD ranged from 86% to 100%; median timeliness between onset of symptoms and diagnosis decreased from 72 h in 2012 to 12 h in 2017 (83% decrease), while timeliness between diagnosis and treatment initiation was 0 h. The implementation of PACD could be considered an effective prevention and response tool against malaria re-introduction.

Phylogenetic Analysis of Bird-Virulent West Nile Virus Strain, Greece.

We report the full polyprotein genomic sequence of a West Nile virus strain isolated from Eurasian magpies dying with neurologic signs in Greece. Our findings demonstrate the local genetic evolution of the West Nile virus strain responsible for a human disease outbreak in the country that began in 2010.

Detection of West Nile Virus - Lineage 2 in Culex pipiens mosquitoes, associated with disease outbreak in Greece, 2017.

During July-October 2017 a WNV outbreak took place in the Peloponnese, Southern Greece with five confirmed deaths. During routine monitoring survey in the Peloponnese, supported by the local Prefecture, we have confirmed the presence of all three Culex pipiens biotypes in the region, with a high percentage of Culex pipiens/molestus hybrids (37.0%) which are considered a highly competent vector of WNV. Kdr mutations related to pyrethroid resistance were found at relatively low levels (14.3% homozygosity) while no mosquitoes harboring the recently identified chitin synthase diflubenzuron-resistance mutations were detected in the region. As an immediate action, following the disease outbreak (within days), we collected a large number of mosquitoes using CO2 CDC traps from the villages in the Argolis area of the Peloponnese, where high incidence of WNV human infections were reported. WNV lineage 2 was detected in 3 out of 47 Cx. pipiens mosquito pools (detection rate = 6.38%). The virus was not detected in any other mosquito species, such as Aedes albopictus, sampled from the region at the time of the disease outbreak. Our results show that detection of WNV lineage 2 in Cx. pipiens pools is spatially and chronologically associated with human clinical cases, thus implicating Cx. pipiens mosquitoes as the most likely WNV vector. The absence of diflubenzuron resistance mutations and the low frequency of pyrethroid (kdr) resistance mutations indicates the suitability of these insecticides for Cx. pipiens control, in the format of larvicides and/or residual spraying applications respectively, which was indeed the main (evidence based) response, following the disease outbreak.

Prevention of Malaria Resurgence in Greece through the Association of Mass Drug Administration (MDA) to Immigrants from Malaria-Endemic Regions and Standard Control Measures.

Greece was declared malaria-free in 1974 after a long antimalarial fight. In 2011-2012, an outbreak of P. vivax malaria was reported in Evrotas, an agricultural area in Southern Greece, where a large number of immigrants from endemic countries live and work. A total of 46 locally acquired and 38 imported malaria cases were detected. Despite a significant decrease of the number of malaria cases in 2012, a mass drug administration (MDA) program was considered as an additional measure to prevent reestablishment of the disease in the area. During 2013 and 2014, a combination of 3-day chloroquine and 14-day primaquine treatment was administered under direct observation to immigrants living in the epicenter of the 2011 outbreak in Evrotas. Adverse events were managed and recorded on a daily basis. The control measures implemented since 2011 continued during the period of 2013-2014 as a part of a national integrated malaria control program that included active case detection (ACD), vector control measures and community education. The MDA program was started prior to the transmission periods (from May to December). One thousand ninety four (1094) immigrants successfully completed the treatment, corresponding to 87.3% coverage of the target population. A total of 688 adverse events were recorded in 397 (36.2%, 95% C.I.: 33.4-39.1) persons, the vast majority minor, predominantly dizziness and headache for chloroquine (284 events) and abdominal pain (85 events) for primaquine. A single case of primaquine-induced hemolysis was recorded in a person whose initial G6PD test proved incorrect. No malaria cases were recorded in Evrotas, Laconia, in 2013 and 2014, though three locally acquired malaria cases were recorded in other regions of Greece in 2013. Preventive antimalarial MDA to a high-risk population in a low transmission setting appears to have synergized with the usual antimalarial activities to achieve malaria elimination. This study suggests that judicious use of MDA can be a useful addition to the antimalarial armamentarium in areas threatened with the reintroduction of the disease.