HCDCP e-bulletin January 2013

Hellenic Center for Disease Control and PreventionAgrafon 3- 5 Maroussi 15123 Tel +30 210 5212000infokeelpnogr httpwwwkeelpnogr

January 2013 ISSN 1792-9016Vol 23 Year 2nd

MINISTRY OF HEALTH

HCDCP

HELLENIC CENTER FORDISEASE CONTROL amp PREVENTION

MINISTRY OF HEALTH

Highlights

Dr Athanasios Tsakris Professor of Microbiology at the University of Athens is this monthrsquos interview-ee He provides in-depth answers regarding concerns about the viral gastroenteritis outbreaks and the challenges regarding their handling and prevention and provides es-sential comments on the role of the public health services during the current economic crisis

More on page 34

Main article Investigation of viral gastroenteritis outbreaks Greece 2004-2012 2

Surveillance data 6

Public health news 9

Invited articles 14

HCDCPrsquo s departments activities 29

Recent publications 30

Future conferences 32

Outbreaks around the world 33

Interview 34

Myths and truths 37

News from the HCDCPrsquos administration 39

Quiz of the month 40

Contents

Viral gastroenteritis is not just the main theme of the current e-bulletin but it is an issue that is currently high on the agenda for public health given its rising fre-quency Read about this issue and about the preventive measures that can be taken against these viral infections

More on page 2

The impact of viral gastroenteritis on public health in Greece

Infectious diarrhea is a major public health issue not only in the developing world where it causes high mortality especially among children but also in the developed world Moreover and in contrast to the developing world where bacterial infections (salmonellosis shigellosis cholera etc) are the main target of preventive efforts in the western world viruses and especially rota- noro- entero- and astroviruses are responsible for up to 70 of all diarrhea cases particularly among children

More specifically rotavirus is the main cause of gastroenteritis in children in both the developing and western worlds The main cause of gastroenteritis in the USA is norovirus which usually causes outbreaks in social gatherings such as occur on cruise ships and in hospitals and restaurants being responsible for up to 90 of the cases

In Greece not many epidemiological studies have tackled the issue of identifying the cause of non-bacterial gastroenteritis a fact possibly arising from the difficulty of routine laboratory diagnosis However it seems that norovirus is the main cause of community-acquired diarrhea in children in both sporadic cases as well as in outbreaks

In contrast the incidence of rotavirus infection although also a significant cause of disease in Greece seems to be declining (at least among children that seek hospital treatment) possibly as a result of increased vaccination rates

Water and food are the most common vehicles for outbreaks in this country making the study of non-bacterial infectious diarrhea an important public health priority

This issue of the monthly Hellenic Center for Disease Control and Prevention (HCDCP)rsquos e-bulletin is dedicated to the analysis of various aspects of infectious non-bacterial diarrhea

Professor Alikiviadis Vatopoulos

2 3

Main article Main article

Investigation of viral gastroenteritis outbreaks Greece 2004-2012

Introduction

Viral gastroenteritis is an intestinal infection characterized by watery diarrhea abdominal cramps nausea vomiting and sometimes fever [1] Except for infants elderly people and immunocompromised individuals that may experience severe illness patients usually recover without complications The disease is usually transmitted through the consumption of contaminated food or water and by person to person Viral gastroenteritis is generally more common during winter while bacterial gastroenteritis has a higher incidence during summer [1] As the majority of countries only include outbreaks of viral gastroenteritis in their surveillance systems and not sporadic cases the exact incidence of viral gastroenteritis is unknown

Norovirus rotavirus adenovirus and sapovirus are the most common etiological agents of viral gastroenteritis Mainly norovirus and secondarily rotavirus and adenovirus cause gastroenteritis outbreaks [2-4] Norovirus causes approximately 90 of non-bacterial outbreaks of gastroenteritis around the world and is responsible for many foodborne and waterborne outbreaks recorded in developed countries [3]

Viral gastroenteritis outbreaks recent epidemiological data

In recent years the reported incidence of viral gastroenteritis outbreaks has increased This increase reflects to some extent the improvement of laboratory techniques in detecting viruses in clinical and environmental samples At the same time the importance of investigating (by epidemiological laboratory and environmental means) these outbreaks which would lead to the implementation of appropriate control measures has been recognized [356] Nowadays the results of the investigation of such outbreaks are frequently presented in the literature [7-9]

According to the latest reported data of the European Food Safety Authority (EFSA) 697 foodborne viral outbreaks were reported by 18 European countries in 2008 [3] The overall notification rate was 014 outbreaks per 100000 population In 2008 the total number of foodborne outbreaks of viral etiology had increased by 33 compared with 2007 [3] In the USA almost half of the foodborne outbreaks that occurred between 2006 and 2010 were attributed to norovirus [10] and in 2009 and 2010 a total of 2259 outbreaks as a result of person to person transmission were recorded of which 89 were attributed to norovirus and only 04 to rotavirus [11]

Viral gastroenteritis outbreaks in Greece

In Greece foodbornewaterborne gastroenteritis outbreaks are included in the Mandatory Notification System (MNS) In total 36 viral gastroenteritis outbreaks were reported from 2004 to 2012 Table 1 summarizes the reported outbreaks with at least ten cases

Table 1 Reported outbreaks of viral etiology with at least 10 cases MNS Greece 2004-2012

Year Region Number of recorded

cases

Number of hospitalized

patients

Number of deaths

Causative agent

2005 Peloponnese 38 38 0 Norovirus

2005 Eastern Macedonia amp Thrace 702 0 0 Norovirus

2006 Eastern Macedonia amp Thrace 721 0 0 Norovirus2007 Thessaly 37 10 0 Norovirus2010 South Aegean 200 0 0 Norovirus2010 Thessaly 124 1 0 Norovirus2010 South Aegean 166 37 0 Norovirus

2010 North Aegean 64 0 0 Norovirus2011 Attica 36 18 0 Norovirus2012 Attica 63 - 0 Norovirus2012 Central Macedonia 80 1 0 Norovirus2012 Thessaly 986 - 0 Rotavirus2012 Western Macedonia 23 17 0 Rotavirus

Most of the above outbreaks were attributed to a specific causative agent after the laboratory testing of clinical samples In order to confirm that a particular pathogen is the etiological agent of an outbreak its detection both in clinical and foodwater samples is required

As shown in Table 1 the majority of the outbreaks were attributed to norovirus Some of the viral gastroenteritis outbreaks that have been investigated by the foodborne and waterborne diseases unit of HCDCP in the last few years are presented in detail below

a) Elassona March 2012 In total 986 gastroenteritis cases were recorded 552 by the health-care center of Elassona and 434 by private doctors in Elassona and adjacent areas It was estimated that in Elassona city alone there were more than 3600 cases (attack rate gt50) Symptoms were mild and compatible with viral gastroenteritis Thirty-eight out of 45 clinical samples that were tested were positive for rotavirus but the virus was not detected in water samples Based on the results of a case-control study that was conducted the consumption of tap water was a statistically significant risk factor [odds ratio (OR) 218 95 confidence interval (CI) 111-428)] for developing gastroenteritis symptoms Evidence such as a) the occurrence of heavy rainfall the week before the appearance of cases b) comments by several patients that a few hoursdays before they became ill the water of the public supply system was colored along with c) the results of laboratory testing of the water supported the hypothesis of a waterborne outbreak

b) Kilkis 2012 In January 2012 two parallel gastroenteritis outbreaks were investigated in Nea Santa Kilkis one in a primary school and one in an adjacent kindergarten Two retrospective cohort studies were conducted one in each school Regarding the primary school the consumption of water from the school taps was a statistically significant risk factor [relative risk (RR) 901 95 CI 333-2441] for developing gastroenteritis symptoms The hypothesis of a mixed (concerning the pathogens) viral common point source waterborne outbreak with secondary cases in the primary school was compatible with a) the shape of the epidemic curve and other descriptive data b) the results of the multivariate analysis and c) the detection of norovirus GI and GII in four clinical samples and adenovirus in four samples from primary school students Further information about the quality of the tap water was not acquired because its prompt laboratory testing was not possible

Regarding the kindergarten the shape of the epidemic curve was indicative of person-to-person transmission Univariate analysis did not reveal any statistically significant risk factor However adenovirus was detected in the water samples collected from the kindergartenrsquos taps The connection between the two outbreaks could not be confirmed

c) Athens Special Olympics 2011 [12] The 2011 Special Olympics World Summer Games were conducted in Greece from 25 June to 4 July During the Games a gastroenteritis outbreak was identified among members of the British delegation The case-control study that was carried out showed a statistically significant association between prior contact with a symptomatic person and the appearance of gastroenteritis symptoms (OR 146 95 CI 181-1181) Two stool samples were positive for norovirus Epidemiological and laboratory data were indicative of a common point source norovirus outbreak The source was probably the first athlete who developed symptoms exposing the other members to the virus during a trip from Skiathos to Athens before the Games began

d) Agios Efstratios 2010 [13] In February 2010 a concurrent increase in gastroenteritis cases was observed in Limnos Lesvos and Agios Efstratios (islands in the Northern Aegean) The retrospective cohort study held in Agios Efstratios revealed that the consumption of shellfish that had been introduced to the island from Kavala was statistically significantly

4 5


associated with the development of gastroenteritis symptoms (RR 215 95 CI 89-518) The fact that clinical and environmental samples were not collected meant there was no opportunity to link the Agios Efstratios outbreak with the increased gastroenteritis cases on Lemnos and Lesvos The causative agent of the outbreak based on Kaplan criteria was considered to be norovirus This investigation highlighted the importance of epidemiological investigation in remote areas of the country and revealed the challenges of laboratory testing

e) Kalambaka 2007 In a gastroenteritis outbreak among high school students during a school excursion to Kalambaka in 2007 although the retrospective cohort study did not reveal any statistically significant risk factor descriptive data were suggestive of a common point source outbreak followed by secondary cases The mild symptoms of patients along with the fact that the stool samples were negative for the common enteropathogens and that one sample was positive for norovirus GII were indicative of a viral outbreak

Challenges of the investigation of viral gastroenteritis outbreaks conclusions

Viral gastroenteritis is highly contagious and results in large-scale outbreaks with high direct (doctor consultations hospitalizations etc) and indirect (lost working hours disruption of social role etc) costs The main objective of the investigation of such outbreaks is the prompt implementation of control measures as well as assessment of the extent of the outbreak and the identification of the mode and vehicle of transmission and of the possible source of infection

A common problem for surveillance systems of many countries is that these outbreaks are not notified or are notified with delay usually after a lot of people have become ill This happens mainly because the symptoms are mild and self-limited therefore many patients do not visit the health-care services Additionally the general belief that in the case of viral gastroenteritis public health measures and further epidemiological investigation are not required contributes to the problem

Another limitation of the investigation is the lack of widely available reliable specialized diagnostic tests for the detection of viruses in clinical and environmental samples [14] In Europe in 2008 only 55 of the reported foodborne viral outbreaks were confirmed [9] In Greece there is no officially appointed reference center for viruses that cause gastroenteritis a fact that leads to incomplete investigation of many outbreaks

In a nutshell improvement of the detection and notification systems and of the laboratory investigations is required

Tips

In order to protect yourself against viral gastroenteritis you are advised to implement the following

A) Follow the basic hygiene rules

bull Wash hands thoroughly with soap and water (ie after toilet use changing diapers contact with ill people before during and after food handling) Make sure that children do the same

bull Clean surfaces used for meal preparation along with the utensils used thoroughly with soap and water before during and after food handling

bull Use household bleach for cleaning the kitchen and the toilet and carefully wash fabrics contaminated with feces or vomit (clothes underwear towels etc)

bull Avoid using the same utensils (cups plates etc) as other peopleB) Make sure that the food and water you consume are as safe as possible (remember that contaminated food may look and smell normal)

bull Wash all foodstuffs properly before cooking and before consumption (when they are consumed raw)

bull Use safe water (of known origin) for drinking and cooking

bull Avoid eating raw shellfishFinally if you develop symptoms of gastroenteritis it is recommended to prevent transmission of the disease to other people for as long as the symptoms last and for at least 2 days after they resolve to refrain from food handling and to avoid visiting crowded places or places that host vulnerable people such as kindergartens hospitals nursing homes etc

References

1 Heymann DL Control of Communicable Diseases Manual Washington DC American Public Health Association 2008

2 Cowden J Winter vomiting infections due to Norwalk-like viruses are underestimated Brit Med J 2002324249-250

3 Greig JD Lee MB A review of nosocomial norovirus outbreaks infection control interventions found effective Epidemiol Infect 201241-10

4 Centers for Disease Control and Prevention (CDC) Rotavirus surveillance worldwide 2001-2008 MMWR 2008571255-1257

5 Karagiannis I et al A waterborne Campylobacter jejuni outbreak on a Greek island Epidemiol Infect 2010 1381717-1726

6 Medici MC et al An outbreak of norovirus infection in an Italian residential-care facility for the elderly Clin Microbiol Infect 20091597-100

7 Koroglu M et al A waterborne outbreak of epidemic diarrhoea due to group A rotavirus in Malatya Turkey New Microbiol 20113417-24

8 Cardemil CV et al Two rotavirus outbreaks caused by genotype G2P[4] at large retirement communities cohort studies Ann Intern Med 2012157621-631

9 European Food Safety Authority (EFSA) The community summary report on trends and sources of zoonoses and zoonotic agents and food-borne outbreaks in the European Union in 2008 EFSA J 201081496-1864 Available at httpwwwefsaeuropaeuenefsajournaldoc1496pdf

10 CDC Norovirus trends and outbreaks Available at httpwwwcdcgovnorovirustrends-outbreakshtml

11 Wikswo ME et al Outbreaks of acute gastroenteritis transmitted by person-to-person contact United States 2009-2010 MMWR Surveill Summ 2012611-12

12 Mellou K et al Detection and management of a norovirus gastroenteritis outbreak Special Olympics World Summer Games Greece June 2011 Int J Public Health 2012120-24 Available at httpwwwinternationalscholarsjournalsorgjournalijphearchivenovember-2012-vol-1-28229

13 Karagiannis I et al An outbreak of gastroenteritis linked to seafood consumption in a remote Northern Aegean island February-March 2010 Rur Rem Health 2010101507 Available at httpwwwrrhorgaupublishedarticlesarticle_print_1507pdf

14 Kroneman A et al Analysis of integrated virological and epidemiological reports of norovirus outbreaks collected within the Foodborne Viruses in Europe network from 1 July 2001 to 30 June 2006 J Clin Microbiol 2008462959-2965

Kassiani Mellou Theologia Sideroglou Maria Potamiti-KomiFoodborne and Waterborne Diseases Unit

6 7

Surveillance data Surveillance data

Table 1 Number of notified cases in December 2012 median minimum and maximum number of notified cases in December 2004minus2011 Mandatory Notification System Greece

Disease Number of notified cases

December 2012

Median number December

2004minus2011

Min number December 2004-2011

Max number December 2004-2011

Botulism 0 0 0 0Chickenpox with complications 1 1 0 4Anthrax 0 0 0 2Brucellosis 5 7 3 15Diphtheria 0 0 0 0Arbo-viral infections 0 0 0 0Malaria 3 1 0 3Rubella 0 0 0 0Smallpox 0 0 0 0Echinococcosis 2 15 0 6Hepatitis Α 8 12 4 35Hepatitis B acute amp HBsAg(+) in infants lt12 months 3 5 1 18

Hepatitis C acute amp confirmed antiminusHCV positive (1st diagnosis) 1 05 0 6

Measles 0 0 0 107Haemorrhagic fever 0 0 0 0Pertussis 6 05 0 2Legionellosis 7 1 0 3Leishmaniasis 2 45 1 10Leptospirosis 1 15 0 4Listeriosis 0 0 0 1EHEC infection 0 0 0 0Rabies 0 0 0 0Melioidosisglanders 0 0 0 0Meningitis

aseptic 19 16 7 53bacterial (except meningococcal disease) 9 14 9 19unknown etiology 1 05 0 3

Meningococcal disease 9 8 2 15Plague 0 0 0 0Mumps 0 0 0 2Poliomyelitis 0 0 0 0Q Fever 2 0 0 1Salmonellosis (non-typhoidparatyphoid) 21 335 11 94Shigellosis 5 2 1 9Severe acute respiratory syndrome 0 0 0 0Congenital rubella 0 0 0 0Congenital syphilis 0 0 0 1Congenital toxoplasmosis 0 0 0 0Cluster of foodbornewaterborne disease cases 3 15 0 5

Τetanusneonatal tetanus 1 1 0 1Tularaemia 0 0 0 0Trichinosis 0 0 0 1Typhoid feverparatyphoid 1 0 0 4Tuberculosis 45 46 26 88Cholera 0 0 0 0

Table 2 Number of notified cases by place of residence (region) December 2012 Mandatory Notification System Greece (place of residence is defined according to the home address of patients)


Region

Eas

tern

Mac

edonia

an

d T

hra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n

Chickenpox with complications 0 0 0 0 1 0 0 0 0 0 0 0 0 0Brucellosis 0 1 0 0 1 0 1 2 0 0 0 0 0 0Malaria 0 0 0 0 0 0 0 0 1 1 0 0 1 0Echinococcosis 0 1 1 0 0 0 0 0 0 0 0 0 0 0Hepatitis Α 1 4 0 0 0 0 0 0 3 0 0 0 0 0Hepatitis B acute amp HBsAg(+) in infants lt12 months 0 3 0 0 0 0 0 0 0 0 0 0 0 0Hepatitis C acute amp confirmed anti-HCV positive (1st diagnosis)

0 0 0 0 1 0 0 0 0 0 0 0 0 0

Pertussis 0 0 0 0 0 0 0 0 6 0 0 0 0 0Legionellosis 1 0 0 1 0 0 1 1 2 0 0 0 0 1Leishmaniasis 0 1 0 0 0 0 0 0 1 0 0 0 0 0Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 1 0Meningitis

aseptic 0 2 1 0 2 0 6 1 6 0 0 0 1 0bacterial (except meningococcal disease) 2 2 1 1 1 0 1 0 1 0 0 0 0 0unknown etiology 0 1 0 0 0 0 0 0 0 0 0 0 0 0

Meningococcal disease 1 1 0 0 1 0 1 1 3 0 1 0 0 0Q Fever 0 0 0 0 2 0 0 0 0 0 0 0 0 0Salmonellosis (non-typhoidparatyphoid) 0 2 0 0 2 0 2 1 4 2 0 0 4 4Shigellosis 0 0 0 0 0 0 1 0 3 1 0 0 0 0Cluster of foodbornewaterborne disease cases 0 0 0 0 0 0 0 1 1 1 0 0 0 0Tetanusneonatal tetanus 0 0 0 0 0 1 0 0 0 0 0 0 0 0Typhoid fever paratyphoid 0 0 0 0 0 0 0 0 1 0 0 0 0 0Tuberculosis 4 8 0 0 1 0 5 1 15 5 2 0 2 2

Table 3 Number of notified cases by age group and gender December 2012 Mandatory Notification System Greece (M male F female)

Disease Number of notified cases by age group (years) and genderlt1 1minus4 5minus14 15minus24 25minus34 35minus44 45minus54 55minus64 65+ Un

M F M F M F M F M F M F M F M F M F M F

Chickenpox with complications 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0Brucellosis 0 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 1 0 0Malaria 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0Echinococcosis 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0Hepatitis Α 0 0 0 0 1 0 1 0 0 0 1 0 4 0 0 0 0 1 0 0Hepatitis B acute amp HBsAg(+) in infants lt12 months

0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0

Hepatitis C acute amp confirmed anti-HCV positive (1st diagnosis)

0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

Pertussis 4 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Legionellosis 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 2 1 1 0Leishmaniasis 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0Leptospirosis 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Meningitis

aseptic 2 0 2 2 4 5 0 2 1 1 0 0 0 0 0 0 0 0 0 0bacterial (except meningococcal disease) 0 1 2 0 0 0 1 0 0 1 0 0 0 0 1 1 1 1 0 0unknown etiology 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Meningococcal disease 0 0 0 2 1 4 1 0 0 0 0 0 1 0 0 0 0 0 0 0Q Fever 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0Salmonellosis (non-typhoidparatyphoid) 2 2 3 3 3 0 0 0 1 0 0 0 0 0 0 2 2 1 1 1Shigellosis 1 0 0 2 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0

Tetanusneonatal tetanus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0Typhoid fever paratyphoid 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0Tuberculosis 0 1 0 1 0 0 2 1 10 2 1 3 3 2 7 1 9 2 0 0

8 9

Surveillance data Public health news

The data presented are derived from the Mandatory Notification System (MNS) of the Hellenic Center for Disease Control and Prevention (HCDCP) Forty-five infectious diseases are included in the list of the mandatory notifiable diseases in Greece Notification forms and case definitions can be found at the website of HCDCP (wwwkeelpnogr)

It should be noted that the data for December 2012 are provisional and could be slightly modifiedcorrected in the future and also that data interpretation should be made with caution as there are indications of under-reporting in the system

Department of Epidemiological Surveillance and Intervention

The increasing incidence of norovirus gastroenteritis world-wide

According to a recent Eurosurveillance article [1] there are indications of world-wide increased norovirus activity during the past few months compared with previous years The United Kingdom the Netherlands and Japan are among the countries that have reported an increase [2-4] Given the limited surveillance of norovirus gastroenteritis in most countries it is difficult to come to a safe conclusion about whether this increase is real or suggests an early seasonal activity

During the last decade GII4 norovirus strains have been proven to be responsible for the majority of acute gastroenteritis outbreaks and sporadic cases Since 1995 epidemic GII4 norovirus strains which seem to appear every 2 or 3 years have been associated with an increased incidence of norovirus gastroenteritis [56-8]

Molecular data shared through the NoroNet network suggest that the late increase of norovirus activity is related to the emergence of a new norovirus genotype II4 variant This variant has evolved from previous norovirus GII4 variants and has a common ancestor with the dominant norovirus GII4 variants Apeldoorn_2007 and NewOrleans_2009 but it is phylogenetically distinct Changes in norovirus strains may have led to an escape from existing herd immunity and might explain the observed increased outbreak activity The first report of this variant was from Australia in March 2012 so it was named norovirus GII4 Sydney 2012 In the USA the variant was detected in September 2012 in five of 22 (23) laboratory-confirmed outbreaks and in November in 37 of 71 (52) laboratory-confirmed outbreaks [9] This new variant has also been found in outbreaks that have occurred in Belgium and Denmark

It is recommended that health services should be prepared for a high seasonal activity of norovirus gastroenteritis and probably for more severe cases this season Outbreak control measures such as strict implementation of hygiene rules and the isolation of symptomatic patients may help to reduce the size of outbreaks that may occur [1011]

Currently more data are needed to confirm the association between a higher norovirus incidence and the new norovirus GII4 2012 variant

References

1 van Beek J Ambert-Balay K Botteldoorn N et al Indications for worldwide increased norovirus activity associated with emergence of a new variant of genotype late 2012 Eurosurveill 201318pii=20345 Available at httpwwweurosurveillanceorgViewArticleaspxArticleId=20345

2 Rijksinstituut voor Volksgezondheid en Milieu (RIVM) Virologische weekstaten Bilthoven RIVM [in Dutch] Available at httpwwwrivmnlOnderwerpenOnderwerpenVVirologische_weekstaten [accessed 13 December 2012]

3 Health Protection Agency (HPA) Update on Seasonal Norovirus Activity London HPA 18 December 2012 Available at httpwwwhpaorgukwebwHPAwebampHPAwebStandardHPAweb_C1317137436431

4 National Institute of Infectious Diseases (NIID) Flash Report of Norovirus in Japan Tokyo NIID Available at httpwwwnihgojpniideniasr-noro-ehtml [accessed 13 Dec 2012]

5 Vega E Barclay L Gregoricus N et al Novel surveillance network for norovirus gastroenteritis outbreaks United States Emerg Infect Dis 2011171389-1395

6 Siebenga JJ Vennema H Renckens B et al Epochal evolution of GGII4 norovirus capsid proteins from 1995 to 2006 J Virol 2007819932-9941

7 Siebenga J Kroneman A Vennema H et al Food-borne viruses in Europe network report the norovirus GII4 2006b (for US named Minerva-like for Japan Kobe034-like for UK V6) variant now dominant in early seasonal surveillance Eurosurveill 200813pii=8009 Available at httpwwweurosurveillanceorgViewArticleaspxArticleId=8009

10 11

Public health news Public health news

8 Kroneman A Vennema H van Duijnhoven Y et al High number of norovirus outbreaks associated with a GGII4 variant in the Netherlands and elsewhere does this herald a worldwide increase Eurosurveill 20048pii=2606 Available at httpwwweurosurveillanceorgViewArticleaspxArticleId=2606

9 Kroneman A Vennema H Harris J et al Increase in norovirus activity reported in Europe Eurosurveill 200611pii=3093 Available at httpwwweurosurveillanceorgViewArticleaspxArticleId=3093

10 Division of Viral Diseases National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention Updated norovirus outbreak management and disease prevention guidelines MMWR Recomm Rep 2011601-18

11 Friesema IH Vennema H Heijne JC et al Norovirus outbreaks in nursing homes the evaluation of infection control measures Epidemiol Infect 20091371722-1733

Kassiani Mellou Foodborne and Waterborne Diseases Unit

Information regarding the prevention of viral gastroenteritis

What can we do to protect ourselves from viral gastroenteritis

In order to avoid getting sick from viral gastroenteritis you are advised to follow the recommendations below

Adhere to basic hygiene rules

Wash hands thoroughly with soap and water especially

before after

consumption of food toilet usechanging diapers

food preparation handling objects contaminated with vomit or feces

food handling handling fabrics contaminated with feces or vomit (clothes underwear towels etc)

contact with ill people

food handling

Make sure that children follow the hygiene rules as wellClean surfaces used for meal preparation along with the utensils used thoroughly with soap and water before during and after food handlingUse household bleach for cleaning the kitchen and the toiletAvoid using the same utensils (cups plates etc) as other people

Make sure that the food and water you consume are as safe as possible (remember that contaminated food may look and smell normal)Wash all foodstuffs properly before cooking and before consumption (when they are consumed raw)Use safe water (of known origin) for drinking and cookingAvoid eating raw shellfish

Make use of the vaccine available against rotavirus which causes viral gastroenteri-tis mainly for infants and young children

In Greece the vaccine against rotavirus is now included in the national immunization program for children and adolescents and should be completed by the age of 6 months at the latest For more information contact your pediatrician

Note that there is no available vaccine against other viruses that cause gastroenteritis

Prevention and Control Measures for gastroenteritis in a kindergarten

httpwwwkeelpnogrPortals0ΑρχείαΤροφιμογενήΓαστρεντερίτιδεςΒρε-φονηπιακοίσυγκεντρωτικό_3_pdf

What can a sick person do to prevent the transmission of gastroenteritis to other people

When someone develops gastroenteritis they should adhere to the following for as long as the symptoms last and for at least 2 days after they resolve

bull Refrain from food handling or providing health care to other people to limit direct contact with relatives

bull Refrain from attending kindergarten or school (both students and staff)bull Avoid visiting crowded places or places that host vulnerable people such as kindergartens

hospitals nursing homes etcbull Refrain from activities such as swimming in a pool spa visits and team sports

Maria Potamiti Komi Kassiani MellouFoodborne and Waterborne Diseases Unit HCDCP

12 13


World Cancer Day 4 February 2013

The message for 4 February 2013 can be seen at httpwwwworldcancerdayorg

One year of operation for the Hellenic Cancer Registry (HCR)

Within the framework of the development of the Hellenic Cancer Registry (HCR) and as described by the ministerial decisions with protocol numbers Y4αοικ1362169-12-2011 and 101012-2011 cancer notification is based on a network of health professionals the so-called lsquocancer registrarsrsquo all working in hospitals and private clinics in Greece

Cancer registrars mainly health visitors and nurses are part of the public hospital and private clinic personnel are directly linked to the HCR and are appointed to collect cancer data from patients diagnosed or treated at their institutions

In 2012 186 health professionals in 143 public and military general hospitals and private clinics throughout the country were appointed as cancer registrars (regular and substitutes)

The first short training course for the cancer registrars was carried out on 1 February 2012 in Athens as part of a 1-day conference entitled Cancer Prevention and Public Health Promotion From the HCR to Today A second series of courses was organized and supported by the Hellenic Center for Disease Control and Prevention (HCDCP) and took place in the cities of Athens Thessaloniki Heraklion and Patra during the period May to June 2012

In addition and with the aim of continuously training the appointed registrars HCDCP initiated and fully financed a 3-month collaboration with the Hellenic Society of Pathologists providing on-the-job training The program was designed to address primarily specialized cancer hospitals and those hospitals and private clinics with a pathology laboratory Forty-two public general hospitals and two specialized hospitals participated in the program

Furthermore to encourage and advance communication between registrars an intranet area was developed on HCDCPrsquos website accessible only to registrars holding a password given to them by HCR

With decision 59422-2-2012 of the Secretary General for Health of the Hellenic Ministry of Health Mr N Polyzosrsquo approval was gained officially for funding the development of the HCR as part of the National Strategic Reference Framework Program 2007-2013 for the next 2 years of operation and the project (lsquoDevelopment of the HCRrsquo) has commenced Despite this delay the sub-project lsquoProvision of laptopsrsquo to public hospitals participating in cancer notification for the exclusive use of cancer registrars was completed in 2012 The laptops will be sent to the hospitals as soon as their set-up is complete

In the next period the call for the sub-project lsquoIntegration of information systems for the electronic notification and codification of neoplasmsrsquo in accordance with the requirements of the Data Protection Act by the Hellenic Data Protection Authority will be announced The aim is to develop an information system for the collection electronic notification and codification of the collated cancer cases which will assist cancer registrars in their work and at the same time minimize data entry errors

With the decision of protocol number 95313-07-2012 of the Hellenic Data Protection Authority according to law number 24721997 the Hellenic Data Protection Authority has provided the terms for the lawful processing of personal data from cancer patients Because of the particular nature of such data the security measures taken in relation to the information systems and data storage and transmission must be reinforced and therefore strict procedures according to international standards such as user authentication and data encryption procedures through SSL protocols and the use of virtual private networks (VPN) have been incorporated The HCDCP Office for Informatics and Telecommunication has already completed the above actions and all laptops ready to be sent to the registrars have been parameterized accordingly

Despite the difficulties encountered during the first year of HCRrsquos operation because of the economic crisis and all the associated problems such as a lack of collaboration and support for the registrars by hospital administrations and the scientific community the registrarsrsquo overlapping tasks etc cancer notification did progress satisfactorily within 2012 A number of registrars have responded positively to our collaboration and support the operation of the HCR To all these people and colleagues we would like to express our sincere thanks The development of HCR is undoubtedly a huge and challenging project for our country that requires the support of all parties and stakeholders related to cancer including political support in order to evolve

HCR team HCDCP

14 15

Invited articles Invited articles

Norovirus on cruise ships SHIPSAN

Introduction

Gastroenteritis is the most common health problem for travelers (httpwwwwhointithen) When gastroenteritis caused by the highly persistent norovirus and travelers are brought together in closed or semi-closed accommodation facilities including cruise ships and land-based premises there is a high risk of an outbreak occurring

Floating accommodation facilities such as cruise ships can facilitate case-to-case norovirus transmission (hand-to-hand then hand-to-mouth) and transmission from surfaces to hand and then to mouth [1] This is relatively easy because of traveler interaction common activities self-service buffets use of communal toilets and other facilities and hand contact with commonly touched surfaces Infection after swallowing vomit-aerosolized particles containing the virus is also possible Even 18 virus particles can cause infection [2] and it is possible that the virus is spread to the environment from symptomatic and asymptomatic travelers if proper personal and environmental hygiene is not taking place [3] Consumption of contaminated food or water is also possible Consequently this infectious agent has the ability to spread quickly in the environment and there is the potential to affect a large number of travelers if control measures are not in place Implementation of control measures in order to stop further transmission and to prevent recurrent outbreaks should start as early as possible

A large number of people travel with cruise ships As indicated on the European Cruise Council website lsquo278 million passengers visited a European port in 2011 56 million passengers joined their cruise in Europe in the same year with the industry generating euro367 billion of goods and services and providing more than 300000 jobsrsquo In the same year lsquothere were at least 171 cruise ships active in the Mediterranean and 102 in Northern Europe ranging in size from 4200 passengers to less than 100rsquo (httpwwweuropeancruisecouncilcom)

The lsquokey playersrsquo in prevention ship companies travelers and authorities

There are three lsquokey playersrsquo in the prevention of gastroenteritis outbreaks the ship operators the travelers and the health authorities at ports Ship companies as well as public health authorities at ports need to be prepared to confront untoward public health events including norovirus outbreaks It is important for both cruise ship operators and public health authorities to be able to recognize when there is the potential for an outbreak to occur when it is occurring when it is under control and when it is not On the other hand effective prevention of outbreaks demands the education of travelers (both passengers and crew members) and their strict compliance with the prevention and control policies of ships including hand washing reporting of symptoms and isolation

To prevent the adverse consequences of outbreaks including health impacts that can be serious for susceptible travelers bad publicity and economic loss cruise ship companies and public health authorities have developed and implemented sophisticated and effective plans to prevent and control norovirus outbreaks

Centers for Disease Control and Prevention) Vessel Sanitation Program

The USArsquos Vessel Sanitation Program (VSP) has the longest experience in gastroenteritis surveillance conducting hygiene inspections based on the standards of the VSP operations manual (httpwwwcdcgovncehvspoperationsmanualopsmanual2011pdf) and investigating outbreaks on cruise ships since the 1970s The impact of the USArsquos VSP in preventing outbreaks has been evaluated in epidemiological studies from 1975 to 2006 After looking at incidents and gastroenteritis outbreaks on cruise ships over the last four decades published by Addiss et al [4] the World Health Organization [5] Cramer et al [6] Lawrence [7] and Cramer et al [8] one can assume that especially after 2000 outbreaks

with a bacterial etiology are rarely reported or published [9] Compliance with the Centers for Disease Control and Prevention (CDC)rsquos operations manual [10] has decreased bacterial gastroenteritis outbreaks among passengers and crew as described by Neri et al [11]

However norovirus outbreaks continue to occur sometimes to a greater extent because of genetic drifts in the virus resulting in epidemic strains [12] Two articles published recently in Eurosurveillance and CDC MMWR reported that the latest surveillance data in Europe and the USA demonstrate an increased activity of norovirus in late 2012 that relates to a new norovirus genotype II4 variant termed Sydney 2012 [1314] In the forthcoming months it will be interesting to explore the impact of this new strain on outbreaks in recreational accommodation facilities including cruise ships

European guidelines for the prevention and control of norovirus outbreaks on passenger ships EU SHIPSAN

Actions at a European Union (EU) level for the prevention of norovirus outbreaks on passenger ships were started in 2006 by the European Commission with the implementation of the SHIPSAN and SHIPSAN TRAINET projects (wwwshipsaneu) A manual was developed comprising a compilation of existing European legislation procedures and best practices for medical facilities food safety potable and recreational water safety pest management housekeeping and facilities hazardous substances waste management ballast water and surveillance of communicable diseases (wwwshipsaneu) Moreover it includes guidelines for the management of gastroenteritis and other infectious diseases on passenger ships In particular it provides guidance on how to differentiate viral and bacterial gastroenteritis outbreaks how to develop a plan for prevention and control every-day preventive measures and guidelines for outbreak management The manual provides a combination of measures to stop the chain of infection The prevention strategy begins before the embarkation of passengers by providing information leaflets advising about symptom identification personal hygiene and case management A key point in the prevention strategy is the determination of thresholds to trigger control measures which can be rates of gastroenteritis cases per hour or percentages of ill passengers (14)

In summary the required measures comprise the following isolation of all individuals reported symptoms until 48 hours after the last symptom of gastroenteritis with special attention to food-handling crew on-board surveillance and alertness of crew and medical personnel to identify new cases of gastroenteritis such as reporting vomiting episodes in public places or cabins and isolation of new cases as identified cleaning and disinfection of cabins commonly touched surfaces vomit medical and other facilities with effective products and in such a manner as to avoid cross contamination education of the crew on implementing measures communication to encourage immediate reporting of symptoms the importance frequency and method of hand washing encouragement of hand hygiene by all travelers waste management in a manner to avoid cross-contamination effective cleaning of linens at temperatures sufficient to destroy the virus and in a manner avoiding cross-contamination use of personal protective equipment (PPE) by people that clean areas after vomiting and diarrhea episodes stopping the self-service of food to eliminate possibilities for food contamination [101516]

A web-based communication platform has been developed by the SHIPSAN TRAINET project providing health authorities at ports or at national or European levels and ship captains with the ability to communicate public health information including outbreak management This communication platform has been used to facilitate authorities in gastroenteritis outbreak management The added value of the communication tool has been the rapid exchange of appropriate information between authorities the follow-up of outbreaks and the avoidance of duplication of effort in interventions

Conclusion

The occurrence of symptomatic or asymptomatic norovirus cases among passengers on

16 17


cruise ships is unavoidable because such a large number of people travel on them and the pathogen is endemic world-wide However outbreaks can be preventable and manageable with co-ordinated efforts by ship companies travelers and health authorities

References

1 Noah N Controlling communicable disease 2011

2 Teunis PF Moe CL Liu P et al Norwalk virus how infectious is it J Med Virol 2008801468-1476

3 Goodgame R Norovirus gastroenteritis Curr Gastroenterol Rep 20068401-408

4 Addiss DG Yashuk JC Clapp DE Blake PA Outbreaks of diarrhoeal illness on passenger cruise ships 1975-85 Epidemiol Infect 198910363-72

5 World Health Organization (WHO) Sustainable Development and Healthy Environments Sanitation on Ships Compendium of Outbreaks of Foodborne and Waterborne Disease and Legionnairersquos Disease Associated with Ships 1970ndash2000 Geneva WHO 2001

6 Cramer EH Gu DX Durbin RE Vessel Sanitation Program Environmental Health Inspection Team Diarrheal disease on cruise ships 1990-2000 the impact of environmental health programs Am J Prev Med 200324227-233

7 Lawrence DN Outbreaks of gastrointestinal diseases on cruise ships lessons from three decades of progress Curr Infect Dis Rep 20046115-123

8 Cramer EH Blanton CJ Otto C Shipshape sanitation inspections on cruise ships 1990-2005 Vessel Sanitation Program Centers for Disease Control and Prevention J Environ Health 20087015-21

9 Mouchtouri VA Bartlett CL Diskin A Hadjichristodoulou C Water safety plan on cruise ships a promising tool to prevent waterborne diseases Sci Total Environ 2012429199-205

10 CDC Vessel Sanitation Program Operations Manual Atlanta US Department of Human Services Public Health Services

11 Neri AJ Cramer EH Vaughan GH Vinjeacute J Mainzer HM Passenger behaviors during norovirus outbreaks on cruise ships J Travel Med 200815172-176

12 Lindesmith LC Costantini V Swanstrom J et al Norovirus GII4 strain emergence correlates with changes in evolving blockade epitopes J Virol 2012 [Epub ahead of print]

13 van Beek J Ambert-Balay K Botteldoorn N et al on behalf of NoroNet Indications for worldwide increased norovirus activity associated with emergence of a new variant of genotype II4 late 2012 Eurosurveill 201318

14 CDC EU ship sanitation training network Notes from the field emergence of new norovirus strain GII4 Sydney United States 2012 MMWR Morb Mortal Wkly Rep 20136255

15 Directorate General for Health and Consumers European Manual for Hygiene Standards and Communicable Diseases Surveillance on Passenger Ships European Commission Directorate General for Health and Consumers 2011

16 Health Protection Agency (HPA) Guidance for Management of Norovirus Infection in Cruise Ships HPA 2007

Varvara Mouhtouri

Viral gastroenteritis norovirus Prevention and control measures in health-care settings

Norovirus is the most frequent cause of outbreaks of adult and child viral gastroenteritis The incubation period is 24-48 hours and the symptoms develop suddenly and last from 12 to 60 hours Approximately 10 of patients will require medical care including hospitalization Attributable mortality mainly applies to specific categories of hospitalized patients and elderly patients in long-term care facilities Because of the prolonged survival of the virus on inanimate surfaces in closed and crowded places such as hospitals the spread of the virus rapidly affects the delicate hospital population and increases morbidity and mortality

Actions to control the spread of the virus effectively should focus on the following areas

bull Timely diagnosis of the first cases in a hospital settingbull Timely recognition of a potential influx of casesbull Documentation of the onset of an outbreak (pathogen possible source of transmission

time of onset mode of transmission high-risk departments)bull Increased awareness of inter-hospital structures (administration infection control

committees nursing departments)bull Information and training of employees on the proper implementation of the necessary

measuresbull Information for and co-operation with public health stakeholdersbull Communication with reference laboratories for the identification of specific pathogensbull Defining the end of an outbreak and removal of contact precautions

Timely diagnosis is primarily based on clinical symptoms and is documented by molecular and immunohistochemistry methods and from patient stools or vomit An increased incidence of gastroenteritis in the community helps in the early diagnosis of the disease because epidemic waves affecting both children and adults occur during the autumn and winter months The clinical criteria of Kaplan are used for the timely diagnosis of the disease and the identification of clusters in case the direct application of specific laboratory methods for detecting the pathogen are not available In the case of an outbreak efforts have to focus on controlling the spread of the pathogen and include the monitoring of

bull patientsbull health-care workers bull visitors bull the inanimate environmentbull potentially contaminated food and water

18 19


The basic principle of controlling an outbreak of norovirus is limiting the number of people who will be in contact with the virus The physical separation of infected patients from non-infected patients and limiting visitors to a clinical department who have been exposed to the virus and can become a vehicle for its transmission are the most important measures that must be implemented immediately Patients with disease should be isolated or cohorted

Hand hygiene is the most important measure for controlling the spread of norovirus in a health-care facility It should be performed by hand washing with soap (20 s) under running warm water before and after contact with a patient regardless of the use of gloves Studies have shown that antiseptics with ethanol (70) may be more effective against the virus compared with other antiseptics with or without alcohol Contact with a patient also demands the application of personal protective equipment particularly the use of gloves and cons

Health-care workers who develop symptoms should be removed from the workplace immediately and not return until at least 48 hours after the complete absence of clinical symptoms After their return to the workplace or in case they return earlier than 48 hours they should care for patients with gastroenteritis This should be intensified for health-care professionals who work in places that manufacture or distribute food in the hospital

Finally an important issue is the disinfection of a contaminated environment with emphasis on a patientrsquos ward even after their discharge from the hospital and also areas in which health professionals and visitors gather The decontamination process should be frequent starting with clean areas and ending up at the most contaminated Food and drink that are likely to be contaminated should be removed

Removal of contact precautions should be instigated 48 hours after the complete resolution of patient symptoms For special patient groups (patients with renal and cardiopulmonary failure or immunosuppression) and children (especially those that are lt2 years) who retain the virus for longer than other patients an extended application of the prevention measures is recommended usually for more than 48 hours (for children up to 5 days) The epidemiological end of an outbreak requires no new appearance of a case during a period of 7 days The proper application of the above recommendations requires daily monitoring for new cases as well as strict monitoring of the compliance of health-care workers (HCWs) for the implementation of contact precautions However the most effective training process is the updating of information for the staff and in general for all those who are involved in patient care (family dedicated nurses) as well as the patients themselves

Table 1 Prevention and control measures for a norovirus gastroenteritis outbreak in health-care settings

Α Contact precautious

Patient isolation This is highly recommended

Cohorting In case there are no rooms available for isolation

Personal protective equipment (PPE) for HCWs

Loading trolleys out of the patient room with PPE and frequent cleaning of the roller

Hand hygiene for HCWs who take care of patients Wash with soap and water after the removal of gloves

Hand hygiene for HCWs who visit clinical departments Wash hands or use antiseptic in accordance with instructions

HCWs cohorting for patients with gastroenteritis

This measure should be applied to all shifts and staff already infected must occupy wards with patients with gastroenteritis

Inanimate surfaces As few as possible

Β External visitors

Patient visitors They are not allowed

Ward visitors They are not allowed

Visitors in isolation

Only if they are required Updating and monitoring the implementation of contact precautions by visitors They must not circulate in public spaces especially in the hospital canteen

Dedicated nursesExclusive occupation with their patient Updating and monitoring the implementation of contact precautions

HCWs who visit the ward Updating and monitoring the implementation of contact precautions

Patient movement Movement restrictions only if they are absolutely necessary Information and immediate implementation of prevention measures cleaning equipment and surfaces that they have used

C Food and liquid transportation

Meals for patientsDisposable utensils have to be discarded prior to their exit from the patient room Equipment carried out on a special trolley that will be disinfected

WaitersThey must not be admitted into a patientrsquos room The transfer of meals into a patientrsquos room must be performed by the nursing staff

Staff Avoiding use of common refrigerator- freezers

D Management of the inanimate environment

Medical equipment (not critical) Exclusive for patients with gastroenteritis

Medical equipment (critical) Mechanical cleaning and disinfection after their use for patients with gastroenteritis

Medical equipment used by para-clinical departments

Avoid the use of common medical equipment After contact with a patient they should be cleaned and disinfected in the best possible way

Patient area

Cleaning and disinfection in accordance with the instructions of IC (frequency-shift water) Biological fluids must be removed first by dry cleaning and by using a bleach solution with a specific density (1000-5000 ppm) Final cleaning of rooms in which patients without gastroenteritis will be hospitalized

Surfaces of clinical wards Cleaning without using the same equipment as the rest of the clinical ward

Commonly used surfaces Frequent cleaning without using the same equipment as the rest of the clinical ward

Ε HCWs that are patientsImmediate removal from the workplace After their return it is recommended that they work with patients with gastroenteritis

F Removal of contact precautious

At least 48 hours after the symptoms have resolved In cases where a patient will be discharged continue applying contact precautious until after he or she leaves the hospital Extend this for special patient populations and children

G Public areas Active surveillance in public areas such as canteens dining rooms rest rooms for staff in order to identify new cases

20 21


References

1 Health Protection Agency British Infection Association Healthcare Infection Society Infection Prevention Society National Concern for Healthcare Infections National Health Service Confederation Guidelines for the Management of Norovirus Outbreaks in Acute and Community Health and Social Care Settings 2012

2 MacCannell T et al Healthcare Infection Control Practices Advisory Committee (HICPA) Guidelines for the Prevention and the Control of Norovirus Gastroenteritis Outbreak in Healthcare Settings HICPA 2011

3 Centers for Disease Control and Prevention Updated Norovirus Outbreak Management and Disease Prevention Guidelines Morb Mort Weekly Rep Recomm Rep 201160


Flora Kontopidou Helena Maltezou

Viral gastroenteritis

Viral gastroenteritis is one of the leading causes of morbidity and mortality globally [1] In western Europe and the rest of the industrialized world morbidity and mortality have increased in recent decades as a result of the acute clinical symptomatology of these infections mainly expressed as acute episodes of diarrheal stools Therefore the appearance of acute diarrhea is the most serious and more frequent factor for admission to hospital accompanied with increased morbidity especially in children under 5 years of age and elderly people over 60 years of age [2]

In recent decades the incidence of infectious gastroenteritis caused by bacteria and parasites has been reduced as a result of comprehensive public health surveillance in particular through monitoring maintenance and improvement of water and sanitation infrastructures However the incidence of viral gastroenteritis does not follow the same rate of decline More specifically in some developed countries an increase in the incidence of the disease is recorded [34]

Viral gastroenteritis is the second most frequent clinical entity after respiratory infections and the most frequent cause of diarrhea in children and adults The frequency depends on the age country and welfare of the patient In the developed world one to three episodes per person per year occur on average while in developing countries these figures increase to one to 18 According to the World Health Organization (WHO) in the developing world mortality from gastroenteritis amounts to 22 million deaths per year The distribution of viral gastroenteritis shows that the incidence rates peak during the winter months unlike bacterial or parasitic gastroenteritis which show exacerbation during the summer months and are more likely to be associated with improper maintenance of food and drink

Most studies focus on revealing the explanatory factors of acute diarrhea in children but also in adults [5] Rotaviruses are the leading cause of acute diarrhea in children world-wide (30-60) followed by noroviruses (8-30) astroviruses (6-9) and adenoviruses (group F) (6-9) [6] In particular rotaviruses are responsible for 50 of epidemic diarrheal syndromes in infants and children while in recent years noroviral infections have shown increasing trends in both children and adults Other viruses that cause gastroenteritis are the enteroviruses and coronaviruses

The clinical manifestations of acute viral gastroenteritis include diarrhea vomiting fever anorexia headache abdominal cramps and muscle aches None of the these symptoms is helpful for the differential diagnosis of viral from bacterial or parasitic causes of gastroenteritis

The age of the child and the accompanying symptoms the appearance of the stool seasonal variations or the knowledge of any exposure to causative factors may help differentiate viral from bacterial and parasitic gastroenteritis

In general bacterial infections are associated more with older children and are often accompanied by the appearance of mucous with the stool or a bloody stool characteristics that are not consistent with a viral attack Epidemiological data on rotavirus infections show that their impact is at around 10 of incidents with episodes of diarrhea requiring medical intervention and progressing to severe disease in children Children with rotavirus infection show more vomiting and high fever (gt398degC) than those with other causes of acute gastroenteritis [78]

Gastroenteritis caused by rotaviruses

Rotaviruses owe their name to their appearance which simulates a trolley wheel (rota) and is transmitted by the oral-enteric pathway while transmission is independent of hygienic conditions because they are highly resistant RNA viruses and can remain for weeks in water on hands and on other surfaces They are transferred to the gastrointestinal tract through consumption of contaminated food (most frequently vegetables) which in turn is contaminated after washing with contaminated water

After an incubation time of 2-4 days the disease manifests abruptly with aqueous stools fever vomiting and abdominal pain The duration of symptoms varies from 3 to 7 days The most serious complication and cause of high mortality is dehydration this being the biggest threat for infants and children aged from 6 to 24 months The outcome is worse in developing countries while in the developed world patients can be treated in a hospital setting and the results are better There is no special antiviral treatment and the main concern is the prevention of dehydration of the patient In the late 1990s the first vaccine against rotaviruses (Rotashieldreg) was released which was associated with elevated rates of intussusception and withdrawn quickly In the mid-2000s two more vaccines were released (Rotarixreg and Rotateqreg) which are safe and co-administered with other infantile vaccinations at the ages of 2 4 and 6 months [9ndash11]

Gastroenteritis caused by noroviruses

These viruses acquired their name from an outbreak at a school in the city of Norwalk Ohio USA in 1968 which not only affected 50 of children but also a large number of their relatives Originally all viruses that were isolated from that incident were named Norwalk viruses Studies using electron microscopy revealed other Norwalk-like viruses and the whole genus was named Norovirus Modern classification places the norovirus group along with the Sapovirus family of Calicivirus Noroviruses affect mainly adults while sapoviruses affect mainly children

Trey are both transmitted by the oral-enteric route and are particularly virulent because they are excreted in large numbers from the feces and vomit of patients they can still be detected 2 weeks after the easing of symptoms Transmission can be from person to person but it is more common from contaminated food or water More rarely mentioned is airborne transmission

The incubation time is usually 1-2 days and symptoms include nausea vomiting non-bloody diarrhea malaise muscle pain abdominal pain and fever Similar to rotavirus infections the disease appears more frequently in the winter months and the duration of symptoms is 24ndash48 hours The most frequent complication is dehydration although its severity is less than the dehydration that occurs with rotavirus-caused gastroenteritis

Therapeutic actions are limited to avoiding transmission of the virus and preventive measures involving good hand washing isolation of patients and the recommendation to avoid work for 3-4 days after withdrawal of the symptoms [1213]

22 23


Laboratory diagnosis

Most of the viruses that cause gastroenteritis cannot multiply in cell cultures In contrast they can be easily distinguished by electron microscopy (EM) on the basis of their diverse morphology However the sensitivity of the method is very low (requiring at least 106 viral particlesmL solution) Detection of rotaviruses is easier because they are excreted in high numbers at the time of outbreak in diarrheal stools (up to 1011 viral particlesmL feces) Astroviruses are also present in large numbers in the feces and are detected easily

Other viruses especially caliciviruses multiply in small quantities and are very difficult to trace by EM The use of EM is therefore generally difficult for clinical diagnosis of viral infections The same is true for PPAT methods because they show extremely low sensitivity In recent years molecular methods and more specifically polymerase chain reaction (PCR) with reverse transcription (RT-PCR) have provided excellent specificity (999) and sensitivity (up to 20ndash100 viral particles per reaction) Therefore RT-PCR combined with serological techniques [detection of antibody in the serum of patients using enzyme-linked immunosorbent assay (ELISA) methods] is used for laboratory diagnosis and epidemiological surveillance of viral gastroenteritis [14] (Table 1)

Table 1 Diagnostic methods for the detection of viruses that cause acute gastroenteritis

Virus EM ELISA PPAT PCR

Rotavirus + ++ + +++ (RT)

Adenovirus + ++ - +++

N o r o v i r u s (calicivirus) +- ++ - +++ (RT)

Astrovirus + + - +++ (RT)

Sensitivity EM 105ndash106 viral particlesmL

ELISA 105 molecules of antigen or antibodymL

PPAT 105 molecules of antigen or antibodymL

PCRRT-PCR 101ndash102 viral particlesmL

The scale of (-)ndash(+++) indicates the relative levels of sensitivity and relative diagnostic value of the method

References

1 Musher DM Musher BL Contagious acute gastrointestinal infections N Engl J Med 20043512417-2427

2 Gangarosa RE Glass RI Lew JF Boring JR Hospitalizations involving gastroenteritis in the United States 1985 the special burden of the disease among the elderly Am J Epidemiol 1992135281ndash290

3 Parashar UD Gibson CJ Bresse JS Glass RI Rotavirus and severe childhood diarrhea Emerg Infect Dis 200612304ndash306

4 Robert Koch Institut (RKI) Epidemiologisches Bulletin Berlin RKI 2009

5 Jansen A Stark K Kunkel J et al Aetiology of community-acquired acute gastroenteritis in hospitalised adults a prospective cohort study BMC Infect Dis 20088143

6 Glass RI Bresee J Jiang B Gentsch J et al Gastroenteritis viruses an overview Novartis Found Symp 20012385ndash25

7 Rodriguez WJ Kim HW Arrobio JO et al Clinical features of acute gastroenteritis associated with human reovirus-like agent in infants and young children J Pediatr 197791188ndash193

8 Staat MA Azimi PH Berke T et al Clinical presentations of rotavirus infection among hospitalized

children Pediatr Infect Dis J 200221221ndash227

9 Anderson Ej Weber SG Rotavirus infection in adults Lancet Infect Dis 2004491-99

10 Parashar UD Bresse JS Gentsch JR et al Rotavirus Emerg Infect Dis 19984561-570

11 Santos N Hospino Y Global distribution of rotavirus serotypesgenotypes and its implication for the development and implementation of an effective rotavirus vaccine Rev Med Virol 20051529-56

12 Trivedi TK Desai R Hall AJ et al Clinical characteristics of norovirus-associated deaths a systematic literature review Am J Infect Control 2012

13 Kroneman A Verhoef L Harris J et al Analysis of integrated virological and epidemiological reports of norovirus outbreaks collected within the Foodborne Viruses in Europe network from 1 July 2001 to 30 June 2006 J Clin Microbiol 2008462959-2965

14 Zuckerman A Banatvala J Pattison J et al Principles and Practice of Clinical Virology 5th edn John Wiley amp Sons 2004

Nikolaos Spanakis Athanasios Tsakris Athens Medical School UoA

Laboratory investigation of environmental samples for viral gastroenteritis

Environmental factors that have a known or potential impact on public health can be physical mechanical chemical and biological Examples of such environmental factors are pesticides (chemical agents) ionizing radiation (physical agents) and micro-organisms such as waterborne pathogens (bacteria and viruses) Some of these factors can be detected in the air others in food in water or in the soil

Many environmental factors mainly microbial agents can cause viral gastroenteritis These factors may be waterborne or foodborne Exposure to these factors can happen at home school the workplace and health-care facilities and is often associated with the type of food consumed and the type of food production and processing Among the important factors that could cause outbreaks are viruses that cause viral gastroenteritis such as noroviruses hepatitis A virus enteroviruses rotaviruses and adenoviruses Laboratory investigation of the presence of viruses that cause viral gastroenteritis can be carried out using molecular cultural and immunological techniques The development of molecular techniques in the mid-1980s has provided a major tool for the detection and identification of pathogenic viruses Although initially these techniques were primarily qualitative further development of these technologies over the past two decades has greatly increased the ability for rapid identification standardization and quantification in environmental samples This significant progress has helped substantially in the treatment and control of epidemic viral gastroenteritis

Molecular techniques provide high sensitivity and specificity if planned carefully They have the ability to detect very small numbers of viruses in a variety of different environmental samples In most cases the isolation of DNA by various methods automated or not does not affect them and careful design of molecular reactions allows for accurate identification of a large variety of different micro-organisms in samples of different origins Besides their detection sensitivity the speed and specificity of molecular techniques have improved significantly especially regarding public health issues such as gastroenteritis

Despite their advantages molecular techniques have a greater cost than traditional culturing

24 25


methods However in the case of slow-growing bacteria and viruses the long incubation period that is needed to identify the pathogen can significantly delay the appropriate preventive measures for the protection of public health In these cases molecular identification significantly reduces the time needed for identification of the micro-organism and thus to implement appropriate measures The reduction in time helps to reduce costs significantly by avoiding the use of inappropriate measures while reducing the stay of patients in the hospital

In the control of outbreaks particularly of waterborne and foodborne outbreaks molecular techniques play an important role in the rapid detection and identification of the micro-organism responsible especially in food and water samples and in the correlation of the virus isolated from a clinical sample and thus in the full epidemiological investigation This allows for rapid reliable and appropriate measures to address an outbreak such as interrupting the production of food and water disinfection Because of their significant sensitivity (in many cases lt10) molecular techniques allow the the detection and identification of a small number of viruses in environmental samples which contributes significantly to the protection of public health against viruses for which hitherto reliable and sensitive detection methods did not exist In addition molecular techniques by determining the sequence (microbial sequence typing) have provided great opportunities for the standardization (genotype determination) and creation of appropriate phylogenetic trees for micro-organisms greatly improving our knowledge in the field of molecular epidemiology

For the laboratory testing of food and water samples during the investigation of a foodborne or waterborne outbreak of viral gastroenteritis the process comprises the following steps concentrating and isolating micro-organisms from the sample purifying the micro-organism and detecting the micro-organism If molecular techniques are to be performed the last step requires isolation of nucleic acids Some of the molecular techniques that are most frequently used in the testing of environmental samples and thus outbreaks are the polymerase chain reaction (PCR) and its applications (such as RT-PCR nested-PCR RFLP and AFLP) hybridization microbial sequence typing real-time PCR and new systems of genome sequencing (metagenomics systems) and chip-DNA techniques These techniques have shown a very high specificity and sensitivity Also they have been applied to a large group of viruses and the results are easy to read With the development of real-time PCR the role and importance of human error in the results has decreased significantly (usually false positives as a result of contamination) and quantification of the results has been achieved In environmental samples the techniques based on PCR have been applied extensively in the detection of viruses replacing time-consuming culture techniques

The importance of the use of molecular techniques has been demonstrated by the fact that the European Union (EU) through the European Organization for Standardization (CEN) has begun the process of standardization of molecular techniques for monitoring viruses in the environment and food samples The use of molecular techniques clearly has a dominant role to play in public health as we move into the 21st century giving a major boost to the improvement of the protection of the human population from major health problems

The capacity for rapid identification of pathogens during an emerging outbreak significantly increases the chances of success of any intervention measures Many countries with the help of global organizations (the World Health Organization and the European Center for Disease Prevention and Control) or through research projects have made great efforts in developing integrated surveillance networks to monitor foodborne and waterborne pathogens such as noroviruses rotaviruses and enteroviruses They have also made systematic efforts to identify the genetic structure geographical distribution and presence in food or water of viruses involved in outbreaks The environmental surveillance of pathogenic viruses is an important sector in the control of a viral gastroenteritis

References

1 Centers for Disease Control and Prevention (CDC) Updated guidelines for evaluating public health surveillance systems recommendations from the guidelines working group MMWR 200150

2 Panackal AA Mrsquoikanatha NM Tsui FC et al Automatic electronic laboratory-based reporting of notifiable infectious diseases at a large health system Emerg Infect Dis 20028685-691

3 Smolinski MS Hamburg MA Lederberg J Microbial Threats to Health Emergence Detection and Response Washington DC National Academies Press 2003

4 Teutsch SM Churchill RE Principles and Practice of Public Health Surveillance 2nd edn New York Oxford University Press 2000

5 Wagner MM Tsui FC Espino JU et al The emerging science of very early detection of disease outbreaks J Pub Health Mgmt Pract 2001651-59

6 Zeng X Wagner M Modelling the effects of epidemics on routinely collected data Proc AMIA Ann Symp 2001781-785

7 Rodriacuteguez-Laacutezaro D Cook N Ruggeri FM et al Virus hazards from food water and other contaminated environments 2011 FEMS Microbiol Rev 201236786-814

8 Kokkinos PA Ziros PG Meri D et al Environmental surveillance An additionalalternative approach for the virological surveillance in Greece Int J Environ Res Public Health 201181914-1922

A Vantarakis Assist Professor Medical School University of Patras

Vaccines for rotavirus gastroenteritis

Prevention of rotavirus gastroenteritis among infants and young children is important Rotavirus infection is responsible for approximately half a million deaths among children aged less than 5 years old mainly in low-income countries Moreover in all countries rotavirus is the causative agent of 10 of acute gastroenteritis episodes in children under 5 years Nearly 80 of children are affected by rotavirus by the age of 5 years Infants and young children with rotavirus gastroenteritis have more severe symptoms than infants and young children with gastroenteritis caused by other pathogens Among these symptoms rotavirus gastroenteritis may cause severe dehydration in children aged 4-23 months Rotavirus is responsible for 30-50 of diarrheal hospitalizations in children less than 5 years old and 70 during the seasonal peaks Of note after the first rotavirus infection there is a partial protection from other episodes and a reduction in the severity of subsequent infections

A rotavirus vaccine was studied in the 1990s and a tetravalent rotavirus vaccine was introduced in the USA in 1998 This was a Rhesus-based tetravalent rotavirus vaccine (RRV-TV Wyeth Rotashieldreg) It was recommended to be administered in three doses given at the ages of 2 4 and 6 months However a year after its introduction it was withdrawn because of its association with an increased frequency of intussusception

Today there are two live oral vaccines recommended by the World Health Organization (WHO) for the prevention of rotavirus infection globally including Greece

1) A monovalent vaccine containing a human rotavirus (RV1 GSK Rotarixreg) This is an oral vaccine administered in a two-dose series (1 mL per dose)

2) A pentavalent vaccine containing reassortant rotaviruses developed from human and

26 27


bovine parent strains (RV5 Merck Rotateqreg) This is an oral vaccine administered in a three-dose series (2 mL per dose)

The characteristics and administration schedules of these two vaccines are shown in Table 1

Table 1 Characteristics of rotavirus vaccines

Rotarixreg Rotateqreg

Characteristic Monovalent Pentavalent

Parent strain Human strain 89-12 Bovine strain WC3

Vaccine composition G1P1A[8] G1x WC3 G2x WC3 G3x WC3 G4x WC3 P1A[8]x WC3

Vaccine titer gt106 2-28 times 106

Formulation Lyophilized vaccine with a liquid diluent Liquid requiring no reconstitution

Pivotal phase III clinical trial

Countries USA and Finland Latin America and Finland

Total number of 70301 63225

Efficacy versus rotavirus gastroenteritis

98 versus severe rota gastroenteritis

85-100 versus severe rota gastroenteritis

Efficacy versus all causes of severe gastroenteritis

59 hospitalization for diarrhea of any cause


Administration schedule

Number of doses in series 2 3

Recommended ages 2 and 4 months 2 4 and 6 months

Minimum age for first dose 6 months 6 months

Maximum age for first dose 15 weeks 15 weeks

Minimum interval between doses 4 weeks 4 weeks

Maximum age for last dose 8 months 8 months

Recommendations for rotavirus vaccines in Europe and USA include the following

bull Rotavirus vaccines can be administered together with all other vaccines given in infancy Available data suggest that rotavirus vaccines do not interfere with the immune response to other vaccines

bull Infants with a history of rotavirus gastroenteritis should be vaccinated according to the administration schedule An initial acute gastroenteritis caused by rotavirus m i g h t provide only partial protection against subsequent rotavirus infections

bull Infants with mild acute illness with or without fever can be vaccinatedbull Pre-term infants can be vaccinated according to their chronological age (minimum

chronological age for the first dose is the sixth week of life)bull Both breast-fed and non-breast-fed infants should be vaccinatedbull Rotavirus vaccines may be administered at any time before concurrent with and after

administration of any blood product This recommendation is the same for antibody-containing products including gamma globulin

bull During hospitalization of vaccinated infants no precautions in addition to standard precautions are needed

bull The presence of a pregnant woman in an infantrsquos household is not a contraindication for rotavirus vaccination Most of the women at this age have pre-existing immunity to rotavirus

bull The presence of an immunocompromised person in an infantrsquos household is not a contraindication for rotavirus vaccination However although the risk is low hand hygiene is always recommended after diaper changing

bull In the case of vomiting or regurgitation during or after administration of rotavirus vaccine this dose should not be re-administered Vaccination should follow the routine schedule

bull Vaccination should be completed with the same product (RV1 or RV5) If one vaccine product is not available vaccination should be completed with the available product

bull During vaccination if the previous vaccine product is unknown a total of three doses should be administered

Evidence suggests that the efficacy of the rotavirus vaccine correlates with mortality quartiles in various countries While the efficacy of rotavirus vaccine is reduced in countries with high mortality rates in children aged less than 5 years old the absolute benefits are higher in these countries Table 2 depicts the efficacy of rotavirus vaccines in countries according to WHO mortality strata

Table 2 Efficacy of rotavirus vaccines according to WHO mortality strata

WHO mortality strata

Percentile mortality in children lt5 years

Estimated vaccine efficacy ()

Countries

High Highest(gt75th percentile) 50-64 Ghana Kenya

Mali Malawi

Intermediate High mid(50thndash75th percentile) 46-72 Bangladesh South

Africa

Intermediate Low mid(25thndash50th percentile) 72-85 Vietnam Region of

the Americas

Low Least(lt25th percentile) 85-100

Region of the Americas Europe and Western Pacific

The impact of rotavirus vaccines on mortality rates as a result of acute gastroenteritis has been studied in Brazil and Mexico The impact of rotavirus vaccine on deaths for all causes of acute gastroenteritis among children aged less than 5 years is depicted in Table 3

Table 3 Annual reduction of mortality after the introduction of rotavirus vaccine

Country (nationwide) Vaccine Annual reduction of mortality as a result of acute

gastroenteritis of all causes ()

Brazil Rotarix 30-39

Brazil Rotarix 22

Mexico Rotarix 4

Administration of rotavirus vaccines is contraindicated in the following situations

bull Infants with a severe allergic reaction (eg anaphylaxis) after a previous dose of vaccine or to a vaccine component Latex rubber is contained in Rotarixreg and should not be administered to infants with severe allergy to latex

bull Infants with severe combined immunodeficiency Gastroenteritis with severe diarrhea and long-term viral shedding in the stools has been reported in children vaccinated with rotavirus vaccine and then diagnosed with severe combined immunodeficiency

bull Infants with a history of intussusception

28 29

Invited articles

Special precautions for rotavirus vaccination should be taken in the following circumstances

bull Altered immunocompetence (other than severe combined immunodeficiency) moderate or severe illness (including acute gastroenteritis) and pre-existing chronic gastrointestinal disease

bull Infants with spina bifida or bladder exstrophy who are at risk of acquiring latex allergy should be vaccinated with Rotateqreg instead of Rotarixreg If Rotarixreg is the only available vaccine it should be administered because the benefit of vaccination is considered to be greater than the risk of sensitization

Post-marketing studies have documented a small increase in the incidence of intussusception in Mexico and Australia in 2010 More specifically it was estimated that there was an excess of one to two cases of intussusception per 100000 vaccinations Based on the available evidence WHO reported in 2012 that rotavirus vaccination has been associated with a small (5-fold) increase in risk of intussusception in some populations This risk is lower than the risk of intussusception associated with Rotashieldreg which was withdrawn However the benefits of rotavirus vaccination are substantial and outweigh any small increase of the risk of intussusception

In 2010 DNA from a porcine circovirus was detected in both rotavirus vaccines Available evidence suggests that this porcine circovirus poses no risk in humans and that these viruses have not been associated with human infection

References

1 American Academy of Pediatrics Committee on Infectious Diseases Prevention of rotavirus disease update guidelines for use of rotavirus vaccine Pediatrics 20091231412-1420

2 Centers for Disease Control and Prevention Prevention of rotavirus gastroenteritis among infants and children Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2009581-25

3 Centers for Disease Control and Prevention Addition of severe combined immunodeficiency as a contraindication for administration of rotavirus vaccine MMWR Weekly 201059687-688

4 World Health Organization Rotavirus vaccines an update Weekly Epidemiol Record 200984533-540

5 Vesikari T European Society for Pediatric Infectious Diseases Evidence-based recommendations for rotavirus vaccination in Europe J Pediatr Gastroenterol Nutr 200846S38-S48

6 USA Food and Drug Administration 2010 Available at wwwfdagovNewsEventsNewsroomPressAnnouncementsucm212149htm [accessed at 21 December 2012]

7 World Health Organization Global Vaccine Safety Statement on Rotarix and Rotateq Vaccines and Intussusception 2010 Available at wwwwhointvaccine_safetycommitteetopicsrotavirusrotateqintussesception_sep2010en [accessed at 21 December 2012]

8 PATH Rotavirus Vaccine Access and Delivery 2011 Available at httpsitespathorgrotavirusvaccineabout-rotavirusrotavirus-vaccines [accessed at 21 December 2012]

9 Desai R et al Potential intussusception risk versus benefits of rotavirus vaccination in the United States Ped Infect Dis J 2013321-7

E Iosifidis and E Roilides Infectious Disease Unit 3rd Pediatric Department Aristotle University Hippokration

Hospital Thessaloniki

HCDCPrsquos departments activities

Hellenic Cancer Registry and Office for Rare Diseases December 2012 Activities concerning rare diseases

1 A congress in the context of EUROPLAN II the European program on national planning for rare diseases was held on Saturday 1 December at the Eugenides Foundation This activity was co-ordinated by EURORDIS (the European organization for rare diseases) national patient organizations are responsible for the organization of the congress in the member states For Greece PESPA (the Greek alliance for rare diseases) prepared and organized the congress Antoni Montserrat Moliner policy officer for rare diseases and neurodevelopmental disorders the Directorate of Public Health (SANCO C-2) and the European Commission also participated

The Hellenic Center for Disease Control and Prevention (HCDCP) as a relevant stakeholder in the field of rare diseases participated in the congress as well as the two preparatory meetings that took place at the Ministry of Health Dr Lia Tzala Head of the Hellenic Cancer Registry and Office for Rare Diseases and Dr Ioanna Laina the pediatrician for the office represented HCDCP

2 The 3rd National Conference of the Public Health and Social Medicine Forum was held at the Royal Olympic Hotel in Athens from 30 November 2012 to 1 December 2012 On Saturday 1 December a roundtable discussion with the theme lsquoHCDCP registries and their role in public healthrsquo took place with the following lectures

bull Diseases registries and their usefulness by Professor Tz Kourea-Kremastinou President of HCDCP

bull Hellenic Cancer Registry at HCDCP by L Tzala Head of the Hellenic Cancer Registry and Office for Rare Diseases

bull Rare Diseases Registry at HCDCP by I Laina Pediatrician of the Hellenic Cancer Registry and Office for Rare Diseases

3 The 8th Pan-Hellenic Congress on Health Management Economics and Policy took place in the amphitheater of the National School of Public Health from 13 December 2012 to 15 December 2012 Lia Tzala Head of the Hellenic Cancer Registry and Office for Rare Diseases gave a lecture on lsquoRare diseases actions for harmonization of Greece with European Union policyrsquo

L Tzala I Laina Hellenic Cancer Registry and Office for Rare Diseases HCDCP

30 31

Recent publications Recent publications

The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States 1999-2007 Hall AJ Curns AT McDonald LC et al Clin Infect Dis 201255216-223

Gastroenteritis is a well-known contributor to mortality among children world-wide but there are limited data regarding adult mortality The researchers aimed to describe trends in gastroenteritis deaths across all ages in the USA and specifically estimate the contributions of Clostridium difficile and norovirus

Gastroenteritis-associated deaths in the USA during 1999-2007 were identified from the National Center for Health Statistics multiple-cause-of-death mortality data All deaths in which the underlying cause or any of the contributing causes was listed as gastroenteritis were included

Gastroenteritis mortality averaged 391000000 person-years (11255 deaths per year) during the study period increasing from 251000000 in 1999-2000 to 571000000 in 2006-2007 (Plt0001) Adults aged ge65 years accounted for 83 of gastroenteritis deaths (2581000000 person-years)

Norovirus contributed to an estimated 797 deaths annually (31000000 person-years)

In conclusion gastroenteritis-associated mortality has more than doubled during the past decade primarily affecting the elderly population Clostridium difficile is the main contributor to gastroenteritis-associated deaths and norovirus is probably the second leading infectious cause These findings can help guide appropriate clinical management strategies and vaccine development

Prospective study of human norovirus infection in children with acute gastroenteritis in Greece Mammas IN Koutsaftiki C Nika E et al Minerva Pediatr 201264333-339

Norovirus is considered to be a major cause of acute gastroenteritis in children world-wide 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

Routine stool samples were obtained from 227 children with acute gastroenteritis who attended a tertiary pediatric hospital in Athens during the period November 2008-October 2009 All specimens were tested for the presence of norovirus rotavirus and adenovirus antigens by enzyme-linked immunosorbent assay (ELISA)

In the total sample norovirus was detected in nine (41) rotavirus in 56 (247) and adenovirus in five (22) children Three (13) samples grew Campylobacter jejuni while six (26) samples grew Salmonella In all cases norovirus was detected as a unique viral pathogen In norovirus-positive children who required hospitalization the median duration of intravenous fluid administration was 35 days and the median duration of hospitalization was 4 days as in rotavirus-positive children

These results suggest that norovirus is 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 prevention of viral gastroenteritis in pediatric departments

Effectiveness of rotavirus vaccination in prevention of hospital admissions for rotavirus gastroenteritis among young children in Belgium case-control study Braeckman T Van Herck K Meyer N et al Br Med J (Online) 20123457872

In order to evaluate the effectiveness of rotavirus vaccination among young children in Belgium researchers designed a prospective case-control study using a random sample from 39 Belgian

hospitals The study population consisted of 215 children admitted to hospital (February 2008 to June 2010) with rotavirus gastroenteritis confirmed by polymerase chain reaction (PCR) and 276 age- and hospital-matched controls All children were aged ge14 weeks

Ninety-nine children (48) admitted with rotavirus gastroenteritis and 244 (91) controls had received at least one dose of a rotavirus vaccine (Plt0001) Regarding hospital admissions the unadjusted effectiveness of two doses of the monovalent rotavirus vaccine was 90 overall The G2P[4] genotype accounted for 52 of cases confirmed by PCR Vaccine effectiveness was 85 against G2P[4] and 95 against G1P[8] In 25 of cases confirmed by PCR there was reported co-infection with adenovirus astrovirus andor norovirus Vaccine effectiveness against co-infected cases was 86 Effectiveness of at least one dose of any rotavirus vaccine was 91

In conclusion rotavirus vaccination is effective in preventing hospital admissions of rotavirus gastroenteritis among young children in Belgium despite the high prevalence of G2P[4] and viral co-infection

Incidence of post-infectious irritable bowel syndrome and functional intestinal disorders following a water-borne viral gastroenteritis outbreak Zanini B Ricci C Bandera F et al Am J Gastroenterol 2012107891-899

Post-infectious irritable bowel syndrome (PI-IBS) may develop in 4-31 of affected patients following bacterial gastroenteritis (GE) but limited information is available on the long-term outcome of viral GE During summer 2009 a massive outbreak of viral GE associated with contamination of municipal drinking water (norovirus) occurred in San Felice del Benaco (Italy) To investigate the natural history of a community outbreak of viral GE and to assess the incidence of PI-IBS and functional gastrointestinal disorders the scientists carried out a prospective population-based cohort study with a control group

Baseline questionnaires were administered to the resident community within 1 month of the outbreak Follow-up questionnaires of the Italian version of the Gastrointestinal Symptom Rating Scale (GSRS) were mailed to all patients responding to a baseline questionnaire at 3 and 6 months and to a cohort of unaffected controls living in the same geographical area 6 months after the outbreak The GSRS items were grouped into five areas abdominal pain reflux indigestion diarrhea and constipation At month 12 all patients and controls were interviewed by a health assistant to verify Rome III criteria of IBS

The study group consisted of 348 patients with a mean age 45 plusmn 22 years 53 female During the outbreak the most common symptoms were nausea vomiting and diarrhea (66 60 and 77 respectively) On follow-up surveys returned at month 6 by 186 patients and 198 controls the mean GSRS score was significantly higher in patients than in controls for abdominal pain diarrhea and constipation At month 12 40 patients were identified with a new diagnosis of IBS in comparison with three in the control cohort (Plt00001)

In conclusion this study provides evidence that norovirus GE leads to the development of PI-IBS in a substantial proportion of patients similar to that reported after bacterial GE

Dimitrios Kassimos University of Thrace Christina Tsigaglou General University Hospital of Alexandroupolis

32 33

Future conferences and meeting Outbreaks around the world

February 2012

22-24 February 2013

Title 13th Pan-Hellenic Congress of the Hellenic Society for Infectious Diseases

Country Greece City AthensVenue Divani CaravelPhone +30 210 7223046Website httpwwwinfections2013gr

25-28 February 2013

Title Legionnairesrsquo disease risk assessment outbreak investigation and control

Country HungaryCity BudapestVenue Health Protection AgencyPhone +46 (0)8 586 010 00Website httpwwwecdceuropaeuenPageshomeaspx

27 February-1 March 2013

Title 6th National Congress of Clinical Microbiology amp Hospital Infections

Country GreeceCity AthensVenue Royal Olympic HotelPhone +30 210 7213225Website httpwwwhmsorggrupdocumentsAFISA-2013-sitepdf

Office for Public and International relations HCDCP

Outbreak news January 2013

Cholera

Cuba [1]As of 6 January 2013 there was an increase in acute diarrheal disease in the municipality of Cerro and other municipalities of Havana related to food handling As of 14 January 2013 51 cholera cases had been confirmed all of which were characterized as Vibrio cholerae toxigenic serogroup O1 serotype Ogawa biotype El Tor

Dominican Republic [1]Since the beginning of the epidemic in 2012 the total number of suspected cholera cases has reached 29433 of which have 422 died At the end of December 2012 cases were reported in the provinces of Duarte Espaillat La Romana La Vega Puerto Plata San Pedro de Macoris Monte Plata Santa Domingo and the National District

Haiti [2]Since the beginning of the epidemic (October 2010) to 31 December 2012 the total number of cholera cases has reached 635980 with 7512 deaths Cases have been reported officially in all 10 departments of Haiti In Port-au-Prince the countryrsquos capital 173485 cases have been reported since the beginning of the outbreak Cases in Port-au-Prince have been reported from the following neighborhoods Carrefour Cite Soleil Delmas Kenscoff Petion Ville Port-au-Prince and Tabarre

References

1 National Travel Health Network and Center (NaTHNaC) Available at httpwwwnathnacorgDiseaseReport [accessed 31 January 2013]

2 Centers for Disease Control and Prevention (CDC) Available at httpwwwnccdcgovtravel noticesoutbreak-noticehaiti-cholera [accessed 31 January 2013]

Travel Medicine OfficeDepartment for Interventions in Health-Care Facilities

34 35

Interview Interview

Professor Athanasios Tsakris

At this time of year we worry even more about viral epidemics especially of the gastroenteric system What do you think is the best public health policy to combat this

What you have mentioned regarding the increasing pre-occupation with viral gastroenteritis is quite justified Over the past few years in developed countries we have noted an increase in viral gastroenteric epidemics even more for those caused by caliciviruses especially the noroviruses This has mainly to do with epidemics that appear mid-winter up until the beginning of summer and attack all age groups Nevertheless their clinical symptoms appear stronger in children and elderly people who often need hospitalization

The main characteristic of such epidemics is that they often alarm society because they mostly appear in public places such as hospitals schools restaurants cruise ships and generally in places of mass use and gathering Furthermore quite often we implicate comestibles in their transmission food that is produced and packaged in a standardized way (industrialized methods) and not cooked

In order to confront such epidemics it is of the outmost importance to diagnose them in time Thus hospitals and clinical doctors should inform the Hellenic Center for Disease Control and Prevention (HCDCP) promptly when they come across cases that need further epidemiological research Examples are multiple cases of gastroenteritis in a hospital the simultaneous appearance of gastroenteric symptoms in cases that are linked cases labeled as lsquofood poisoningrsquo and multiple cases of gastroenteritis in the same area

Simultaneously the public health authorities must research all the evidence co-ordinate epidemiologic and clinical controls and offer their conclusions in time informing the public regarding the prevention measures that should be taken Surveillance should not be interrupted during the epidemic and the medical community and the public should be informed upon cessation of the epidemic

The measures that should be taken can be divided into the generally preventive ie hand sanitation use of gloves frequent check-ups for those who work in the food industry etc and the particular preventive measures that apply to those who work in hospitals ie the use of special protective outfitrobes and use of chemicals in order to clean surfaces and utensils

For this reason according to the standards set by different state authorities in public health there should be a specific epidemic control plan for viral gastroenteritis which should include all the steps to be taken in order to confront any type of epidemic large or small

What are the challenges today as far as prevention of viral gastroenteritis is concerned

As in many other sectors of public health for the prevention of viral gastroenteritis it is of great importance to apply general hygiene measures ie careful cleaning of hands and the use of protective methods within the food industry or in places where processed pre-cooked meals are prepared The use of the afore-mentioned measures should be an integral part of the procedure for food preparation and dispatch and we must not forget that in this way we avoid many infections not only viral gastroenteritis Given that there is no vaccine for the prevention of noroviral gastroenteritis the use of preventive measures becomes of even greater importance

What is the role of HCDCP especially when it comes to research confrontation and prevention of viral epidemics

HCDCP plays a very important role when it comes to confronting all epidemics regardless of origin or cause I remind you of the motivation for and the significant implication of confronting and diminishing epidemics and serious problems in public health such as influenza malaria and West Nile infection But the role of HCDCP should not and is not restrained to large climax epidemics It should co-ordinate all the efforts to monitor research and carry out surveillance of smaller climax epidemics such as viral gastroenteritis epidemics and it should have a strategic plan for every pathogen that could cause small or large climax infections

Letrsquos expand the subject a little bit Do you consider it is possible to defend public health effectively now during this economic crisis

I believe that particularly during such difficult times the defense of public health is even more important because personal income is reduced and the government has cut back on expenses in public health These cutbacks have to do mainly with expensive medication and hospitalization In contrast preventive measures for public health should be re-enforced For this reason we should inform the public more regarding the preventive measures that are indicated for serious health problems problems that can prove to be more expensive and difficult We should all learn that prevention apart from anything else is cheaper than the cure Imagine the cost of a seat belt in your car and compare that with the cost of the consequences if you donrsquot use it and have a serious car accident Maybe the economic crisis is a chance for us to start using the much cheaper preventive measures that unfortunately we have forgotten all about

How significantly can HCDCP and the university medical schools contribute in the above-mentioned move

HCDCP as we all know has a mission among other things to co-ordinate all the authorities involved in order to prevent monitor and confront infections and other diseases that can spread in the population Its role in times of economic crisis should be re-enforced so that the diminished resources given for public health are divided better thus stressing the application of preventive measures The university medical schools could cover the gaps that could arise in the remit of public hospitals Furthermore they can provide the know-how and train health professionals in new methods and techniques that can be applied to prevention diagnosis and control as far as infections and other epidemics are concerned

What are the challenges do you think in these times of economic crisis for health professionals and those who work in the field of public health

The challenge is to be trained so that we can provide good-quality health services with less financial resources We can definitely find cost-effective ways to confront disease without

36 37

having to cut down on the quality of the health services Within this framework it is important to re-enforce prevention effectively and the health services as well as the health professionals should inform the public about that direction

Finally as we thank you for your time could you please share with us some thoughts about the future What would you advise the younger scientists in the field of microbiology and public health

Microbiology in Greece has expanded especially in laboratories I wish and hope that this continues especially now that everything is automated and there is a stronger need to approach problems more efficiently via clinical and diagnostic paths I would urge young microbiologists to become very well educated regarding the requirements of laboratory medicine and to maintain a continuous co-operation with all clinical doctors and other scientists in the field of public health This would benefit the patient as they could opt for the best health controls and the best evaluation of the results Thus the laboratory doctor can be more efficient in the prevention diagnosis and surveillance of any disease

Interview Myths and truths

Myths and Truths

Myths Truths

Viral gastroenteritis is usually caused by enteroviruses

There are different types of viruses that can cause gastroenteritis We most commonly come across rotavirus (especially type A) norovirus adenovirus (especially for serotypes 40 and 41) and astrovirus

Most gastroenteritis iscaused by bacteria and parasites

Most iscaused by viruses

Adults aremostly infected by viral gastroenteritis

People of all ages can beinfected by viral gastroenteritis but some viruses attack certain age groups Rotavirus usually causes gastroenteritis inchildren under the age of 5 adeno- and astrovirusesinchildren and adults Noroviruses can attack all ages most often in the form of an epidemic

Patients with viral gastroenteritisonly suffer from diarrhea

Patients do have diarrhea which is usually accompanied by abdominal pain vomiting and fever Usually the symptoms present1-2 days after infection and normally last a few days

Viral gastroenteritis is a serious health-threatening disease

For most people it is not a serious disease It does not require treatment or hospitalizationPatientsusually self-heal However olderpeople children and some immunosuppressed patients are in danger of dehydration which is the most commoncomplication

It is not contagious Viral gastroenteritis is a contagious disease It spreads directly from one patient to another through the entero-oralroute Furthermore it can spread through infected food and water

Gastroenteritis appears more often during the summer period and usually in quite warm climates

Viral gastroenteritis spreads world-wide but each virus has its own seasonal distribution In mild climates during winter months mostcasesare caused by rota-andastroviruses whereas infections byadenoviruses appear the whole year round On the other hand gastroenteritis caused by noroviruses does not seem to have a seasonal distribution

Diagnosis of viral gastroenteritis is carried outby aclinical doctor

The suspicion ofgastroenteritis is raisedby the clinical doctor Confirmation of a viral causecomes from microbiological laboratories via methods ofinstant detection of the virus in patient excrement

We do not have to take anysteps towards its prevention

Observingrules ofpersonal hygiene and sterilizing infected surfacesare the main factorsinthe elimination of gastroenteritis infection

For the prevention of infections caused by rotavirus inchildrenthere is a vaccine

38 39

News from the HCDCPrsquos administration

The customary lsquocutting of vasilopitarsquo in HCDCP

The traditional celebration of the cutting of vasilopita associated with the feast of New Yearrsquos Day was held on 18 January 2013 at the conference center of the Hellenic Center for Disease Control and Prevention (HCDCP) The event was attended by the President of HCDCP Mrs J Kremastinou the General Secretary of the Ministry of Health Mrs Ch Papanikolaou members of the board and numerous associates

References

1 Posfay-Barbe KMInfections in pediatrics old and new diseases Swiss Med Wkly 2012142w13654

2 Wiegering V Kaiser J Tappe D et alGastroenteritis in childhood a retrospective study of 650 hospitalized pediatric patients Int J Infect Dis 201115e401-407

3 Eckardt AJ Baumgart DC Viral gastroenteritis in adults Recent Pat Antiinfect Drug Discov 2011654-63

4 Dennehy PH Viral gastroenteritis in children Pediatr Infect Dis J 20113063-64

5 Khan MA Bass DM Viral infections new and emerging Curr Opin Gastroenterol 20102626-30

6 Ramani S Kang G Viruses causing childhood diarrhoea in the developing world Curr Opin Infect Dis 200922477-482

S Levidiotou-Stefanou Professor of Microbiology University of Ioannina

Myths and truths

40

Quiz of the month

How did norovirus come by its name and when was it detected

Send your answer to the following e-mail info-quizkeelpnogr

The answer to Decemberrsquos quiz was The question referred to fatality and many of our readers gave influenza as the answer However influenza has a low fatality but a high mortality because of its high morbidity The disease with the highest fatality rate is pneumococcal pneumonia

One person answered correctly

Chief EditorCh Hadjichristodoulou

Scientific BoardΝ VakalisΕ VogiatzakisP Gargalianos- KakolirisΜ Daimonakou- VatopoulouΙ LekakisC LionisΑ PantazopoulouV PapaevagelouG SaroglouΑ Tsakris

EditorsΤ Kourea- KremastinouHCDCP President

T PapadimitriouHCDCP Director

Editorial Board

R VorouE KaratampaniP KoukouritakisΚ MellouD PapaventsisΤ PatoucheasV RoumeliotiV SmetiCh TsiaraΜ FotineaΕ Hadjipashali

Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors

P KoukouritakisΜ Fotinea

2 3


Investigation of viral gastroenteritis outbreaks Greece 2004-2012

Introduction

Viral gastroenteritis is an intestinal infection characterized by watery diarrhea abdominal cramps nausea vomiting and sometimes fever [1] Except for infants elderly people and immunocompromised individuals that may experience severe illness patients usually recover without complications The disease is usually transmitted through the consumption of contaminated food or water and by person to person Viral gastroenteritis is generally more common during winter while bacterial gastroenteritis has a higher incidence during summer [1] As the majority of countries only include outbreaks of viral gastroenteritis in their surveillance systems and not sporadic cases the exact incidence of viral gastroenteritis is unknown

Norovirus rotavirus adenovirus and sapovirus are the most common etiological agents of viral gastroenteritis Mainly norovirus and secondarily rotavirus and adenovirus cause gastroenteritis outbreaks [2-4] Norovirus causes approximately 90 of non-bacterial outbreaks of gastroenteritis around the world and is responsible for many foodborne and waterborne outbreaks recorded in developed countries [3]

Viral gastroenteritis outbreaks recent epidemiological data

In recent years the reported incidence of viral gastroenteritis outbreaks has increased This increase reflects to some extent the improvement of laboratory techniques in detecting viruses in clinical and environmental samples At the same time the importance of investigating (by epidemiological laboratory and environmental means) these outbreaks which would lead to the implementation of appropriate control measures has been recognized [356] Nowadays the results of the investigation of such outbreaks are frequently presented in the literature [7-9]

According to the latest reported data of the European Food Safety Authority (EFSA) 697 foodborne viral outbreaks were reported by 18 European countries in 2008 [3] The overall notification rate was 014 outbreaks per 100000 population In 2008 the total number of foodborne outbreaks of viral etiology had increased by 33 compared with 2007 [3] In the USA almost half of the foodborne outbreaks that occurred between 2006 and 2010 were attributed to norovirus [10] and in 2009 and 2010 a total of 2259 outbreaks as a result of person to person transmission were recorded of which 89 were attributed to norovirus and only 04 to rotavirus [11]

Viral gastroenteritis outbreaks in Greece

In Greece foodbornewaterborne gastroenteritis outbreaks are included in the Mandatory Notification System (MNS) In total 36 viral gastroenteritis outbreaks were reported from 2004 to 2012 Table 1 summarizes the reported outbreaks with at least ten cases

Table 1 Reported outbreaks of viral etiology with at least 10 cases MNS Greece 2004-2012

Year Region Number of recorded

cases

Number of hospitalized

patients

Number of deaths

Causative agent

2005 Peloponnese 38 38 0 Norovirus

2005 Eastern Macedonia amp Thrace 702 0 0 Norovirus

2006 Eastern Macedonia amp Thrace 721 0 0 Norovirus2007 Thessaly 37 10 0 Norovirus2010 South Aegean 200 0 0 Norovirus2010 Thessaly 124 1 0 Norovirus2010 South Aegean 166 37 0 Norovirus

2010 North Aegean 64 0 0 Norovirus2011 Attica 36 18 0 Norovirus2012 Attica 63 - 0 Norovirus2012 Central Macedonia 80 1 0 Norovirus2012 Thessaly 986 - 0 Rotavirus2012 Western Macedonia 23 17 0 Rotavirus

Most of the above outbreaks were attributed to a specific causative agent after the laboratory testing of clinical samples In order to confirm that a particular pathogen is the etiological agent of an outbreak its detection both in clinical and foodwater samples is required

As shown in Table 1 the majority of the outbreaks were attributed to norovirus Some of the viral gastroenteritis outbreaks that have been investigated by the foodborne and waterborne diseases unit of HCDCP in the last few years are presented in detail below

a) Elassona March 2012 In total 986 gastroenteritis cases were recorded 552 by the health-care center of Elassona and 434 by private doctors in Elassona and adjacent areas It was estimated that in Elassona city alone there were more than 3600 cases (attack rate gt50) Symptoms were mild and compatible with viral gastroenteritis Thirty-eight out of 45 clinical samples that were tested were positive for rotavirus but the virus was not detected in water samples Based on the results of a case-control study that was conducted the consumption of tap water was a statistically significant risk factor [odds ratio (OR) 218 95 confidence interval (CI) 111-428)] for developing gastroenteritis symptoms Evidence such as a) the occurrence of heavy rainfall the week before the appearance of cases b) comments by several patients that a few hoursdays before they became ill the water of the public supply system was colored along with c) the results of laboratory testing of the water supported the hypothesis of a waterborne outbreak

b) Kilkis 2012 In January 2012 two parallel gastroenteritis outbreaks were investigated in Nea Santa Kilkis one in a primary school and one in an adjacent kindergarten Two retrospective cohort studies were conducted one in each school Regarding the primary school the consumption of water from the school taps was a statistically significant risk factor [relative risk (RR) 901 95 CI 333-2441] for developing gastroenteritis symptoms The hypothesis of a mixed (concerning the pathogens) viral common point source waterborne outbreak with secondary cases in the primary school was compatible with a) the shape of the epidemic curve and other descriptive data b) the results of the multivariate analysis and c) the detection of norovirus GI and GII in four clinical samples and adenovirus in four samples from primary school students Further information about the quality of the tap water was not acquired because its prompt laboratory testing was not possible

Regarding the kindergarten the shape of the epidemic curve was indicative of person-to-person transmission Univariate analysis did not reveal any statistically significant risk factor However adenovirus was detected in the water samples collected from the kindergartenrsquos taps The connection between the two outbreaks could not be confirmed

c) Athens Special Olympics 2011 [12] The 2011 Special Olympics World Summer Games were conducted in Greece from 25 June to 4 July During the Games a gastroenteritis outbreak was identified among members of the British delegation The case-control study that was carried out showed a statistically significant association between prior contact with a symptomatic person and the appearance of gastroenteritis symptoms (OR 146 95 CI 181-1181) Two stool samples were positive for norovirus Epidemiological and laboratory data were indicative of a common point source norovirus outbreak The source was probably the first athlete who developed symptoms exposing the other members to the virus during a trip from Skiathos to Athens before the Games began

d) Agios Efstratios 2010 [13] In February 2010 a concurrent increase in gastroenteritis cases was observed in Limnos Lesvos and Agios Efstratios (islands in the Northern Aegean) The retrospective cohort study held in Agios Efstratios revealed that the consumption of shellfish that had been introduced to the island from Kavala was statistically significantly

4 5









Tips










References
















6 7




December 2012


2004minus2011











Region

Eas

tern

Mac

edonia

an

d T

hra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n


0 0 0 0 1 0 0 0 0 0 0 0 0 0








0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0


0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0





8 9











References








10 11












before after





food handling














12 13















HCR team HCDCP

14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


4 5









Tips










References
















6 7




December 2012


2004minus2011











Region

Eas

tern

Mac

edonia

an

d T

hra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n


0 0 0 0 1 0 0 0 0 0 0 0 0 0








0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0


0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0





8 9











References








10 11












before after





food handling














12 13















HCR team HCDCP

14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


6 7




December 2012


2004minus2011











Region

Eas

tern

Mac

edonia

an

d T

hra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n


0 0 0 0 1 0 0 0 0 0 0 0 0 0








0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0


0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0





8 9











References








10 11












before after





food handling














12 13















HCR team HCDCP

14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


8 9











References








10 11












before after





food handling














12 13















HCR team HCDCP

14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


10 11












before after





food handling














12 13















HCR team HCDCP

14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


12 13















HCR team HCDCP

14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


14 15



Introduction















Conclusion


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


16 17



References

















Varvara Mouhtouri










18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


18 19



































Patient area








20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


20 21


References






















22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


22 23
















References






















24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


24 25







References
















26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


26 27












































Countries


Mali Malawi


Africa


the Americas








Brazil Rotarix 22

Mexico Rotarix 4





28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


28 29

Invited articles






References






















30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


30 31
























32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


32 33


February 2012

22-24 February 2013



25-28 February 2013








Cholera




References




34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


34 35

Interview Interview



















36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


36 37





Myths and Truths

Myths Truths



















38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


38 39




References








Myths and truths

40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


40

Quiz of the month









Editorial Board


Graphic Design

Ε Lazana

Copy Editor

P Koukouritakis

Associate Editors


HCDCP e-bulletin January 2013

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Transcript of HCDCP e-bulletin January 2013