e_bulletinHellenic Center for Disease Control and PreventionAgrafon 3-5, Marousi, 15123, Tel: +30 210 5212000March 2014Vol.38/ Year 4rthISSN 1792-9016http://www.keelpno.gr, info@keelpno.gr

MINISTRY OF HEALTH

HCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH

Contents

Main article: Air and maritime transport and public health 2

Surveillance data 7

Interesting activities 10

Public health meetings 13

Recent Publications 16

Myths and truths 18

Conferences and meetings 20

Outbreaks around the world 21

Quiz of the month 23

Transportation and Public health

Today, modern means of transport allow people to travel faster than ever. It has been said that no town is more than 24 hours away from another and that diseases do not respect borders. As a result, containing diseases within country borders is extremely difficult. The risks may vary depending on the means of transport. Airplanes move faster than other means of transport and can contribute to the transmission of disease

from country to country. On the other hand, travellers can stay a longer time on ships and have more opportunities for interaction. Biological, chemical and radiological hazards can affect the health of the population travelling by air or sea. The current issue of the newsletter presents epidemiological data on air and sea transport, as well as on prevention and control strategies.

Prof. Christos Hadjichristodoulou

Air and maritime transport and public health

Page 2

Final MALWEST workshop, Page 15

Myths and Truths on Transportation and Public Health

Page 18

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Main article

Air and maritime transport and public health

Introduction

As international travel has become increasingly easy and readily available, air travel has become ever more popular. More than half the world’s tourists travel by air; nearly three billion people and 47 million metric tons of cargo were transported safely by air in 2012. Strong economic growth in emerging markets has resulted in the expansion of passenger traffic and an increase in aviation connectivity with 65% of the growth in passenger numbers in international markets. Travel within Asia accounted for just over half of this growth. Passenger traffic (expressed in revenue passenger kilometres) grew by 5.3% in 2012. Another 23% of 2012’s international air travel growth was generated within Europe [1]. In Greece, during 2013, Athens International Airport’s passenger traffic was an estimated 12.5 million, which was lower by only 3.2% from the equivalent level of 2012. In 2013, domestic passengers accounted for 4.3 million and international passengers for 8.24 million, a 4.6% and 2.4% decrease, respectively [2].A large number of the world’s population travels by ship, while more than 90% of world trade (7.3 billion tons) is transported by sea [3]. In 2011, European ports recorded 1,900,000 ship visits and in 2012, 207 cruise ships of 65 cruise lines sailed in European waters [4]. About 6.26 million Europeans booked a cruise in 2012 and 60,608 European sailors work in cruise ships. Although there are various benefits from shipping, maritime transport can have an impact on public health. Ships provide accommodation for travellers,

and a workplace for sailors. They are isolated communities with particular environmental conditions, used to transport all kinds of goods from one place to another. The following paragraphs describe public health risks in maritime transport, measures for their prevention and control, as well as the legal framework for implementing those measures.

Epidemiological data

Although infrequently reported and difficult to assess, there is a risk of disease transmission during air travel, and the popularity of airline transportation and the growing mobility of people have increased the potential for transmitting disease among passengers before, during or after flights. The modes of disease transmission include droplet-borne and airborne (TB, SARS, the common cold, influenza, meningococcal disease, measles), food- or water-borne (salmonellosis, staphylococcus food poisoning, shigellosis, cholera, viral enteritis), and vector-borne (malaria, dengue, yellow fever). The risk of disease transmission within the confined space of the aircraft cabin is difficult to identify, and incomplete passenger manifests complicate risk assessment, causing bias in many of the available epidemiological studies. Risk of disease transmission within the aircraft cabin is associated with cabin ventilation and with sitting within two rows of a contagious passenger for a flight time of more than eight hours. Confined space, limited ventilation, prolonged exposure times and recirculating air, all common to air travel, create the potential to spread respiratory pathogens during flight. Also, the potential for the spread of bioterrorism agents by air travel exists. In-flight spread of smallpox has been documented, while viruses causing viral haemorrhagic fever (Ebola, Lassa) have been investigated for potential transmission [5,6,7].

The table shows the infectious diseases that have been transmitted on commercial airlines.

Number of reports CommentsAirborneTB 2 Positive TB skin test only. No active TB. SARS 4 No cases since WHO guidelines.Common cold 0 Difficult to investigate.Influenza 2 None since ventilation regulations.

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Main article

Public health events on ships may be caused by biological, chemical or radiological agents, and include communicable diseases. Ships can provide the place for person-to-person disease transmission, or transmission through contaminated surfaces. Moreover, food-borne, waterborne or airborne diseases may occur. Ships may disperse vectors from country to country or transfer contaminated or infested goods. Table 1 shows selected diseases that have been associated with maritime transport.

Table 1. Diseases that have been associated with maritime transport.

Disease Viral gastroenteritis due to Norovirus Gastroenteritis due to Vibrio parahaemolyticusShigellosisSalmonellosisStaphylococcus poisoning TuberculosisLegionellosis RubellaMeasles Varicella Influenza Ciguatera Fish PoisoningMeningitisBotulismHepatitis E

Radiological and chemical hazards can also pose risks to travellers, mainly in cargo ships transporting dangerous goods. In addition, environmental pollution may affect travellers’ health. For example, after the nuclear accident in Fukushima, competent authorities and experts were asked to give their opinions with regard to possible consequences of and health measures for travellers sailing around the sea of Fukushima, as well as the possibility of onboard production of potable water by desalination of sea water. Vector dispersal is another potential public health risk. Worldwide dispersal of Aedes albopictus [8] by ship provides a characteristic example. In addition, autochthonus cases of port malaria have occurred in malaria-free port cities [9]. Cases of cargo ship ballast water contaminated with Vibrio cholerae have been documented [10]. Such water can contaminate bathing waters or oyster farms if the measures of international conventions are not implemented on ships.

Management/Guidelines Early recognition and appropriate infection control measures are necessary when passengers are exposed to an infectious or potentially infectious passenger. In 1969, the World Health Organization (WHO) published the International Health Regulations (IHR). The revised IHR, adopted in 2005, provide a legal framework for a more

Meningococcal disease

0 21 reports of ill passengers, no secondary cases

Measles 3 Imported cases and international adoptionsFood-borne Salmonellosis 15 No recent outbreaksStaphylococcus food poisoning

8 No recent outbreaks

Shigellosis 3 No recent outbreaksCholera 3 During cholera epidemic Viral enteritis 1 Common on other types of transportVector-borneMalaria 7 Probably underestimatedDengue 1 Likely to be airport, not aircraft transmissionYellow fever 0 No outbreaks since disinfection of aircraftBioterrorism agentsSmallpox 1 Before eradication

Mangili A, Gendreau MA. Transmission of infectious diseases during commercial air travel. Lancet. 2005, March 12–18;365(9463):989-96.

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effective coordinated international response to emergencies caused by outbreaks of infectious diseases [11].The WHO published guidelines for tuberculosis and air travel in 1998, defining the extent and potential risks of in-flight TB transmission and providing specific recommendations for passengers, air crews, physicians, health authorities and airline companies. More recently however, in 2006 and in 2008, WHO developed revised guidelines in collaboration with the International Civil Aviation Organization (ICAO), the International Air Transport Association (IATA), international experts in infectious diseases and leading authorities in public health and travel medicine [12]. In order to assist national authorities in the EU Member States in the assessment of risks associated with the transmission of various infectious agents on board airplanes, the European Centre for Disease Prevention and Control (ECDC) also published the ‘Risk Assessment Guidelines for Diseases transmitted on aircraft’ (RAGIDA) in 2009. These guidelines provide a detailed, systematic literature review, and operational guidance for evaluating the risk for transmission of disease [13].The US CDC has also developed their Airline Guidance, which includes protocols for reporting illness and death, disinfection, disease-specific information, and managing ill passengers/crew [14].Accordingly, ICAO sought the assistance of specialist organizations such as the WHO, CDC, Airports Council International (ACI) and IATA in order to formulate guidelines which would assist State Parties to develop their own, national preparedness plans. More detailed guidance, directed specifically towards airports and airlines, has also been developed [15].The Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation (CAPSCA) programme is available to help State Parties develop plans at a national and operational level [16].The AIRSAN Project (2013) aims to support EU Member States to ensure a well-organized and coherent response to public health threats in air transport by targeting national public health and civil aviation authorities, local public health authorities at airports,

airport management responsible for public health events, and airlines across EU Member States as potential members of the AIRSAN Network [17].European Commission DG SANCO funded three European projects:

• SHIPSAN (http://www.eushipsan.gr) which started in 2006,

• SHIPSAN TRAINET (http://www.shipsan.eu/trainet),

• and, in February 2012, the European SHIPSAN ACT Joint Action. The EU SHIPSAN ACT Joint Action deals with the impact on maritime transport of health threats caused by biological, chemical and radiological agents, including communicable diseases, and it supports the implementation of International Health Regulations 2005 in Europe.

With the adoption of the International Health Regulations (IHR), the World Health Organization (WHO) State Parties are obliged to develop and maintain core capacities at points of entry [18]. The following list provides guidelines that have been published in relation to public health at points of entry:

• Rapid Risk Assessment of Acute Public Health Events. Geneva: World Health Organization, 2012. [19]

• International Health Regulations (2005): A Guide for Public Health Emergency Contingency Planning at Designated Points of Entry [20].

• Manual for the Public Health Management of Chemical Incidents [21].

• Human Health Risk Assessment Toolkit: Chemical Hazards [22].

• Guide to Ship Sanitation [23]. • International Health Regulations (2005):

Handbook for inspection of ships and issuance of ship sanitation certificates [24].

The following guidelines and conventions exist for environmental and chemical hazards especially:

• International Convention for the Safety of Life at Sea (SOLAS) [25].

• International Maritime Dangerous Goods Code (IMDG) [26].

• International Convention for the Prevention of Pollution from Ships (MARPOL) [27].

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The WHO International Travel and Health [28] and the International Medical Guide for Ships (IMGS) [29] provide guidance on health measures for travellers.

Conclusions IHR 2005 provides the legal framework for global public health preparedness and response. With the fulfillment of obligations of IHR 2005 by State Parties, the provision of advice and training to travelers, and the contribution of the shipping industry, the global community can be prepared to safeguard public health in maritime transport. Public health emergencies have always been a significant issue of concern during air-travel. However the increase in aviation

activity in recent decades and the potential risk of spreading communicable disease emphasises the importance of increasing public health awareness and of public health authorities developing national preparedness plans. Coordination with aviation authorities is crucial in order to prevent public health threats at international borders. Regional and international organizations have a major role to play in facilitating such coordination.Guidance, activities and information with regard to public health and maritime transport can be viewed at the EU SHIPSAN ACT Joint Action website (www.shipsan.eu). The WHO webpage, where guidance and information on alert, response, and capacity building under the IHR can be found is: http://www.who.int/ihr/ports_airports/pagnet/en/

References

1. International Air Transport Association (IATA). 2013 Annual review. At: http://www.iata.org/publications/Pages/annual-review.aspx [Accessed: 28 March 2014].

2. Athens International Airport. Passenger traffic development 2013. At: http://www.aia.gr/company-and-business/the-company/facts-and-figures [Accessed: 28 March 2014].

3. United Nations Conference on Trade and Development. Review of Maritime Transport 2011. Report by the UNCTAD secretariat, Chapter 2. United Nations. New York and Geneva, 2011. [Cited 2 October 2012]. Available from: http://unctad.org/en/Docs/rmt2011_en.pdf.

4. European Cruise Council. Contribution of Cruise Tourism to the Economies of Europe. 2013 edition.

5. Mangili A, Gendreau MA. Transmission of infectious diseases during commercial air travel. Lancet. 2005, March 12–18; 365(9463):989–96.

6. Abubakar I. Tuberculosis and air travel: a systematic review and analysis of policy. Lancet Infect Dis. 2010, March; 10(3):176–83.

7. Silverman D, Gendreau MA. Medical issues associated with commercial flights. Lancet. 2009 June 13;373(9680):2067–77.

8. Tatem, AJ, Hay, SI, and Rogers, DJ. “Global traffic and disease vector dispersal.” Proc. Natl. Acad. Sci. U.S.A. 103.16 (2006): 6242–47.

9. Anselmo, M, et al. “Port malaria caused by Plasmodium falciparum a case report.” Infez. Med 4.1 (1996): 45–47.

10. Lovell, SJ and Drake, LA. “Tiny stowaways: analyzing the economic benefits of a U.S. Environmental Protection Agency permit regulating ballast water discharges.” Environ. Manage. 43.3 (2009): 546–55.

11. World Health Organization (WHO). International Health Regulations (IHR). At: http://www.who.int/ihr/publications/9789241596664/en/ [Accessed: 28 March 2014].

12. World Health Organization (WHO). ‘Tuberculosis and Air Travel’. At: http://www.who.int/tb/features_archive/aviation_guidelines/en/ [Accessed: 28 March 2014].

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13. European Centre for Disease Prevention and Control (ECDC). Risk assessment guidelines for diseases transmitted on aircraft (RAGIDA). At: www.ecdc.europa. eu/../0906_ter_risk_assessment_guidelines_for_infectious_diseases_transmitted_on_aircraft.pdf [Accessed: 28 March 2014].

14. Centers for Disease Prevention and Control (CDC). Airline Guidance. At: http://www.cdc.gov/quarantine/air/index.html [Accessed: 28 March 2014].

15. International Civil Aviation Organization (ICAO). Public health and aviation. At: http://www.icao.int/safety/aviation-medicine/Pages/guidelines.aspx [Accessed: 28 March 2014].

16. Collaborative Arrangement for the Prevention and Management of public health events in Civil Aviation (CAPSCA). At : http://www.capsca.org/ [Accessed: 28 March 2014].

17. AIRSAN Project. At: http://www.airsan.eu/TheProject/Objectives.aspx [Accessed: 28 March 2014].

18. International Health Regulations (2005). 2nd edition. Switzerland, World Health Organization, 2008.

19. Rapid Risk Assessment of Acute Public Health Events. Geneva: World Health Organization, 2012.

20. International Health Regulations (2005): A Guide for Public Health Emergency Contingency Planning at Designated Points of Entry. World Health Organization Regional Office for the Western Pacific, 2012.

21. Manual for the Public Health Management of Chemical Incidents. Geneva: World Health Organization, 2009.

22. Sheffer, M. Human Health Risk Assessment Toolkit: Chemical Hazards. Geneva, World Health Organization, 2010.

23. Guide to Ship Sanitation. 3rd edition. Geneva: World Health Organization, 2011.24. International Health Regulations (2005) Handbook for inspection of ships and issuance

of ship sanitation certificates. World Health Organization, 2011.25. International Convention for the Safety of Life at Sea (SOLAS), 1974. International

Maritime Organization, 2013.26. International Maritime Dangerous Goods (IMDG) Code. International Maritime

Organization, 2010.27. International Convention for the Prevention of Pollution from Ships (MARPOL).

International Maritime Organization, 2013.28. International Travel and Health. Geneva: World Health Organization, 2012.29. International Medical Guide for Ships: Including the Ship’s Medicine Chest. 3rd edition.

Geneva: World Health Organization, 2007.

Paraskevi Smeti, Androula PavliTravel Medicine Office

Helena MaltezouDepartment for Interventions in Health-Care Facilities

Varvara MouchtouriPeripheral Public Health Laboratory, Thessaly, Greece

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Surveillance data

February 2014

Table 1. Number of notified cases in January 2014, median number of notified cases in February for the years 2004−2013 and range. Mandatory Notification System, Greece.

Disease Number of notified cases

February 2014

Median number February

2004−2013

Min number February

2004–2013

Max number February

2004–2013Botulism 0 0 0 1Chickenpox with complications 0 2 0 4Anthrax 0 0 0 1Brucellosis 8 8.5 2 24Diphtheria 0 0 0 0Arbo-viral infections 0 0 0 0Malaria 0 0.5 0 3Rubella 0 0 0 3Smallpox 0 0 0 0Echinococcosis 0 1 0 3Hepatitis Α 5 12 3 27Hepatitis B, acute & HBsAg(+) in infants < 12 months 3 5.5 1 13

Hepatitis C, acute & confirmed anti−HCV positive (1st diagnosis) 0 1 0 7

Measles 0 0.5 0 75Haemorrhagic fever 0 0 0 0Pertussis 4 1 0 26Legionellosis 2 0.5 0 3Leishmaniasis 4 3 1 7Leptospirosis 1 0.5 0 3Listeriosis 1 0 0 1EHEC infection 0 0 0 1Rabies 0 0 0 0Melioidosis/Glanders 0 0 0 0Meningitis

aseptic 15 9 6 23bacterial (except meningococcal disease) 9 16 11 21unknown aetiology 0 0.5 0 4

Meningococcal disease 8 9.5 5 22Plague 0 0 0 0Mumps 0 0 0 4Poliomyelitis 0 0 0 0Q Fever 1 0 0 1Salmonellosis (non-typhoid/paratyphoid) 9 18.5 10 42Shigellosis 2 1 0 9Severe Acute Respiratory Syndrome 0 0 0 0Congenital rubella 0 0 0 0Congenital syphilis 0 0 0 0Congenital Toxoplasmosis 0 0 0 0Cluster of foodborne/waterborne disease cases 2 1 0 8

Τetanus / Neonatal tetanus 0 0 0 2Tularaemia 0 0 0 0Trichinosis 0 0 0 3

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Surveillance data

Typhoid fever/Paratyphoid 0 1 0 3Tuberculosis 43 46.5 31 61Cholera 0 0 0 0

Table 2. Number of notified cases by place of residence (region), Mandatory Notification System, February 2014 (place of residence is defined according to home address of cases).

Disease Number of notified cases

RegionEas

tern

Mac

edonia

and 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

Brucellosis 0 0 0 0 1 0 5 2 0 0 0 0 0 0Hepatitis Α 0 0 0 0 3 0 0 0 2 0 0 0 0 0Hepatitis B, acute & HBsAg(+) in infants < 12 months 0 0 0 0 0 0 0 0 3 0 0 0 0 0

Haemorrhagic fever 0 1 0 0 0 0 0 0 0 0 0 0 0 3Pertussis 0 0 0 0 0 0 1 1 2 0 0 0 0 0Legionellosis 0 1 0 0 0 0 0 1 0 0 0 0 0 0Leishmaniasis 0 1 0 0 0 0 0 1 1 1 0 0 0 0Leptospirosis 0 0 0 0 0 1 0 0 0 0 0 0 0 0Listeriosis 0 1 0 0 0 0 0 0 0 0 0 0 0 0Meningitis

aseptic 0 0 0 1 1 0 3 1 9 0 0 0 0 0bacterial (except meningococcal disease) 1 5 0 0 0 0 0 1 1 1 0 0 0 0

Meningococcal disease 1 0 0 0 1 1 0 0 5 0 0 0 0 0Q Fever 0 0 0 0 0 0 0 0 1 0 0 0 0 0Salmonellosis (non-typhoid/paratyphoid) 3 0 1 0 1 0 0 3 1 0 0 0 0 0Shigellosis 1 0 0 0 0 0 0 0 1 0 0 0 0 0Cluster of foodborne/waterborne disease cases 0 1 0 0 0 0 0 1 0 0 0 0 0 0

Tuberculosis 3 6 0 2 6 1 4 1 8 1 0 3 1 7

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Surveillance data

Table 3. Number of notified cases by age group and gender, Mandatory Notification System, Greece, February 2014 (M: male, F: female)

Disease Number of notified cases by age group (years) and gender

<1 1-4 5-14 15-24

25-34

35-44

45-54

55-64 65+ Un.

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

Brucellosis 0 0 0 0 0 0 2 0 2 0 0 0 0 0 0 1 1 2 0 0Hepatitis Α 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 1 0 0 0Hepatitis B, acute & HBsAg(+) in infants < 12 months

1 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Haemorrhagic fever 0 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 1 0Pertussis 1 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0Legionellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0Leishmaniasis 0 0 0 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0Listeriosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0Meningitis

aseptic 4 1 1 1 1 1 0 1 2 0 1 0 0 0 1 1 0 0 0 0bacterial (except meningococcal disease)

0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 1 3 0 0

Meningococcal disease 0 0 0 0 2 1 0 2 0 0 0 0 2 0 0 1 0 0 0 0Q Fever 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0Salmonellosis (non-typhoid/paratyphoid) 0 0 2 1 3 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0

Shigellosis* 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0Tuberculosis** 0 0 0 0 0 1 2 2 4 2 6 1 3 1 4 1 6 6 2 0

*An additional case notified in the age group 1–4; gender unknown

*An additional case notified in the age group 25–34, and another in the age group 35–44; gender unknown in either case.

The presented data derive from the Mandatory Notification System (MNS) of the Hellenic Centre for Diseases Control and Prevention (HCDCP). Forty-five (45) infectious diseases are included in the list of the mandatory notified diseases on Greece. Notification forms and case definitions can be found at the website of HCDCP (www.keelpno.gr).It should be noted that data for February 2014 are provisional, and can be slightly modified/corrected in the future and also that data interpretation should be made with caution, as there are indications of underreporting to the system.

Department of Epidemiological Surveillance and Intervention

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Interesting activities

Dr Stathis Avramidis HCDCP

Sport lifesaving introduced in Greeceto benefit public health; assisted by the Hellenic CDCP

On 23–23 March 2014, the Hellenic Federation of Underwater Activity (EOYDA), under the auspices of the Hellenic Centre for Disease Control & Prevention (HCDCP), made history in Greek sports and lifesaving as it promoted public health by organizing a seminar of sport lifesaving.EOYDA was founded in 1952 and is approved by the General Secretariat for Sports. In terms of its constitution it is responsible for governing the sport of lifesaving in Greece (sportlifesaving.blogspot.gr). By participating in this seminar, the HCDCP fulfilled one of its commitments towards the Ministry of Health, based on the National Strategic Plan for Accidents (in the water), for prevention, education and intervention.After permission was granted by the Ministry of National Defence, the seminar took place in the auditorium of the historic Hellenic Naval Academy. The organizations that supported the event were represented by Dimitris Diamantis (Ministry of Health), Niki Dandoulaki (Ministry of Mercantile & Aegean),

Eleonora Hatjipashali (HCDCP), Dr Nikos Tripodis (Pan-Hellenic Union of Educational Professionals in Physical Education), Nikos Kraounakis (Swimming Federation of Greece), Charalampos Papanikolaou (Union of Greek Athletes with Extraordinary Achievements), Dr Garyfallia Ntziouni (International Awards Giuseppe Sciacca) and Dr Manolis Velonakis (National School of Public Health). Sport lifesaving has existed for several decades at a world level. The seminar was attended by 150 coaches, judges, athletes and volunteers. The program contained introductory speeches, the screening of the award-winning documentary “Ode to Lifesaving Joy”, an awards ceremony and oral presentations on the hygiene of water, resuscitation, lifesaving, training, judging and the rules of the sport. Both Stylianos Xenakis and Dr Irene Anagnostou were honored for their contributions to the sport. The participants were very enthusiastic and highly commended the organization of the event. As far as the HCDCP was concerned, Dr Stathis Avramidis, director of the event, made three oral presentations about the historical evolution and the rules of sport lifesaving. Dr Manolis Velonakis presented the rules of hygiene and safety in the water. Eleonora Hadjipashali’s opening speech underlined the importance of this new sport for public health. Master of Ceremonies was Garyfallia Antoniou and camera-man was Stamatis Parissis.

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Interesting activities

Viral Hepatitis Office March 2014

• On Thursday, 13 March 2014, a Doctor of the Viral Hepatitis Office, Anastasia Zisouli, provided health coverage to 55 guests at the Immigration Detention Centre of Amygdaleza.

• On Monday, 17 March 2014, a Doctor of the Viral Hepatitis Office, Anastasia Zisouli, gave an informative speech on Viral Hepatitis to the staff of the Annex of Rehabilitation of Children with Disabilities.

• On Wednesday, 19 and Thursday, 20 March 2014, two doctors of the Viral Hepatitis Office, Anastasia Zisouli and Georgia Nikolopoulou, participated in an meeting of ECDC-KEELPNO experts on the advantages for the Public Health of screening for infectious diseases in newly-arrived immigrants in the European Union (EU) / European Economic Area countries.

Training seminar on HIV/AIDS issues for the executives of the Rehabilitation Unit “18 Ano”.

On March 19, the Office for Psychosocial Support and Psychotherapeutic Interventions of KEELPNO, Department for Interventions in the Community, successfully implemented a training seminar for executives of the Rehabilitation Unit “18 Ano” of the Psychiatric Hospital of Athens, at their request. Those trained were social workers and psychologists.The seminar was dedicated to social services’ management of seropositivity issues. Special emphasis was placed on managing topics concerning social benefits and issues related to access to health services. Lectures on specialized topics and case studies were used as educational tools.

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Interesting activities

Expansion of the Official Scope for the Implementation of the Accreditation and its Maintenance, for the Regional Public Health Laboratory of Thessaly, according to the ELOT EN ISO/IEC 17025 standard.

After a successful assessment from the National Accreditation Body (ESYD), the

Regional Public Health Laboratory of Thessaly received approval for the expansion of its Official Scope for the Implementation of the Accreditation, and for its maintenance, also according to the ELOT EN ISO/IEC 17025 standard, from 13 March 2014. Specifically, the Official Scope for the Implementation of the Accreditation was expanded to include 12 new tests. At present the Public Health Laboratory of Thessaly is systematically preparing for the next assessment by the National Accreditation Body in order to expand its Official Scope for the Implementation of the Accreditation in new methods.

New Year Pie event

Cutting the New Year Pie was celebrated in the Central Public Health Laboratory in Vari on Friday, 21 February 2014. The Deputy Minister of Health, Ms Z. Makri, the Director of HCDCP, Mr T. Papadimitriou, the General Inspector of Control of Inspectors in Health Services Body, Mr M. Sabatakakis, the member of HCDCP Board of Directors, Mr St.

Spinis attended the event. In her speech, the Deputy Minister of Health wished the new Head of the Public Health Laboratory Network and all the personnel of the Laboratory good luck. She focused on the importance of the Central Public Health Laboratory services and the consequent added value for society. The event was closed with Mr. Sabatakakis’ speech in which he focused in the efficient operation of the Central Public Health Laboratory, which he wished to see continue, and he looked forward to the further development and empowerment of the Laboratory.

Baltsiotis Spiros, Economist, M.B.A.-T.Q.M. Department of Accreditation & Qualitative Sufficiency, P.H.L.N.-

H.C.D.C.P.

S. Baltsiotis, Economist, M.B.A.Total Quality Management, Department of Accreditation and Qualitative

Sufficiency of Public Health Laboratory Network, HCDCP

13

Public health meetings

Public health benefits of screening for infectious diseases among newly arrived migrants to the EU/EEA

Athens, 19–20 March 2014

In collaboration with the European Centre for Disease Prevention and Control (ECDC), the Hellenic Centre for Disease Control and Prevention (KEELPNO), under the auspices of the Greek Presidency of the EU Council 2014, organised a workshop on the “Public health benefits of screening for infectious diseases among newly arrived migrants to the EU/EEA” in Athens, 19–20 March 2014. This workshop provided an opportunity for European and international public health experts (WHO, IOM, CDC-USA) and representatives of civil society to exchange experiences on a variety of issues, such as screening practices for infectious diseases that are used in various countries, the existing data, as well as

challenges and best practices. Migration flows to and within Europe are having an increasing effect on demographic change in European societies. In 2011 there were an estimated 48.9 million foreign-born residents in the countries of the European Union (EU), amounting to 9.7% of the total population; 32.4 million were born outside the EU, and 16.5 million born in a different EU member state. Epidemiologic surveillance shows higher percentages of tuberculosis, HIV infection, Hepatitis B and other preventable infectious diseases in the migrant population. However, these findings are influenced by various factors such as high incidence in the country of origin, migration hardship and socio-economic inequalities in the hosting countries. Some of the main points of discussion during the meeting were:

• Migrants are a diverse population and appropriate risk assessment for each group is necessary before specific screening policies are adopted.

• More scientific data is needed to make appropriate policy decisions for migrant screening (e.g. prevalence in the country of origin, burden of disease). Sharing data was advocated as well as continuous evaluation of the results and cost-effectiveness of data.

14

Public health meetings

• Epidemiological data and statistics on migrant health should be carefully interpreted, in order to avoid stigmatization and discrimination.

• Screening should be comprehensive and not restricted to infectious diseases only, although resources may play a critical role in its implementation.

• Screening should benefit the individual as well as public health and should be connected to access to treatment for the particular diseases/conditions.

• Public health professionals should advocate the benefits of non-

discriminatory screening and close the gap with other involved stakeholders (e.g. ministries of interior, law enforcement, border control. etc).

• Current screening practices in the various EU member states vary significantly and there seems to no systematic approach to the diseases of concern, or to the methodology used.

• Further discussion at the EU level on an evidence-based approach to the public health benefits of screening for infectious diseases among migrants is needed.

Agoritsa Baka, Maria Fotinea, HCDCP

PRESS CONFERENCE10th PanHellenic conference on Public Health and Health Services: The Road to Development

The Press Conference for the 10th PanHellenic Conference on Public Health and Health Services was held in Athens at Divani Caravel Hotel, on 26 May 2014. The Conference was co-organized by HCDCP and the National School of Public Health (NSPH). The Deputy Minister of Health, Mrs Zetta Makri, together with HCDCP President and NSPH Professor, Mrs Jenny Kremastinou, Mrs Anastasia Barbouni, Supervisor of Public and Hygiene Department of NSPH, and Mrs Agoritsa Baka, Pediatrician at the Scientific Advisor’s Office of HCDCP, presented some of the current and most important public health issues, such as flu, tuberculosis (TB), smoking and vaccination.

Maria Fotinea, HCDCP

15

Public health meetings

Final MALWEST workshop

The final workshop of the “Integrated surveillance and control programme for West Nile Virus and malaria in Greece (MALWEST)” took place on 24–25 February 2014 in Athens (Greece). The main objectives were:

• To present the final results of the MALWEST project

• To discuss and plan the actions related to malaria and WNV for 2014–2018

• To receive updates from European and American experts on the latest developments on issues related to malaria and WNV.

A total of 116 experts participated, including MALWEST collaborating partners, the Ministry of Health, the Ministry of Rural Development and Food, and representatives of Public Health Departments of Greek Regional Unions. Seven experts were also invited from Europe (WHO, ECDC, Joint Research Centre European Commission, Médecins Sans Frontières) and USA (CDC) in order to present the latest developments on malaria and WNV.The workshop lasted two days. On 24 February, the final results of WNV were presented. At the end of the day, the participants were divided into four working groups to discuss future actions regarding WNV. The working groups proposed the following:

• Data regarding WNV collected by MALWEST project should be published;

• Continued mosquito surveillance was important and a demographic survey on mosquito species related to WNV transmission should be carried out;

• New areas in surveillance of wild and domestic birds and equines should be added;

• Changes in active case detection should be made;

• Risk assessment models based on mathematical models and existing data should be developed.

On 25 February, the final results of malaria were presented. Three working groups were divided and suggested the following:

• Continuing the survey on behaviour of Anopheles spp.;

• Assessing the sensitivity and specificity of a rapid diagnostic test for malaria and evaluating methods used during screening in the last two years;

• Continuing the actions in the Municipality of Evrotas (Lakonia) and developing actions in Filia (Regional Union of Karditsa) where malaria cases were recorded the last two years;

• Continuing action in risk areas level 1 and 2.

Persa Tserkezou, Malwest Program, University of Thessalia

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Recent publications

Transmission of infectious diseases during commercial air travelA. Mangili, MA GendreauLancet, 2005 March 12–18;365(9463):989–96.

Because of the increasing ease and affordability of air travel and the mobility of people, airborne, food-borne, vector-borne, and zoonotic infectious diseases transmitted during commercial air travel are important public health issues. Heightened fear of bioterrorism agents has caused health officials to re-examine the potential of these agents being spread by air travel. The severe acute respiratory syndrome outbreak of 2002 showed how air travel can play an important role in rapidly spreading newly emerging infections, and could potentially even start pandemics.In conclusion, commercial airlines provide a favourable environment for the spread of pathogens carried by passengers or crew. The environmental control system used in commercial aircraft may restrict the spread of airborne pathogens, and the perceived risk is greater than the actual risk. The International Health Regulations adopted worldwide in 1969 to limit the international spread of disease are being revised to provide the means for immediate notification of all disease outbreaks of international importance. These new regulations, together with continued vigilance by countries, health authorities, airlines, and passengers will keep to a minimum, but not eliminate, the risk of disease spread by aircraft. In addition to the flight crew, public health officials and health care professionals play an important role in the management of infectious diseases transmitted on airlines and should be familiar with guidelines provided by local and international authorities.

Travel Medicine OfficeDepartment for Interventions in Healthcare Facilities

Self-reported stomach upset in travellers on cruise-based and land-based package holidays

ΑbstractBackgroundInternational travellers are at risk of infectious diseases not seen in their home country. Stomach upsets are common in travellers, including those on cruise ships. This study compares the incidence of stomach upsets on land- and cruise-based holidays.

MethodsOver many years, a major British tour operator has administered a Customer Satisfaction Questionnaire (CSQ) to UK resident travellers aged 16 or more on return flights from their holiday abroad. Data extracted from the CSQ was used to measure self-reported stomach upset in returning travellers.

ResultsFrom summer 2000 through winter 2008, 6,863,092 questionnaires were completed; 6.6% were from cruise passengers. A higher percentage of land-based holiday-makers (7.2%) reported stomach upset than cruise passengers (4.7%) (RR = 1.5, p<0.0005). Reported stomach upset on cruises declined over the study period (7.1% in 2000 to 3.1% in 2008, p<0.0005). Over 25% of travellers on land-based holidays to Egypt and the Dominican

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Recent publications

Republic reported stomach upset. In comparison, the highest proportion of stomach upset among cruise ship travellers was reported following cruises departing from Egypt (14.8%) and Turkey (8.8%).

ConclusionsIn this large study of self-reported illness, both demographic and holiday choice factors were shown to play a part in determining the likelihood of developing stomach upset while abroad. There is a lower cumulative incidence and declining rates of stomach upset in cruise passengers which suggest that the cruise industry has adopted practices (e.g. hygiene standards) that have reduced illness over recent years.

Varvara Mouchtouri, EU SHIPSAN ACT Joint Action Manager, University of Thessalia

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Myths and truths

Transportation and Public Health

Myths Truths

The competent authorities at the points of entry to countries have the right to apply public health measures to the means of transport travelling on an international voyage, without considering possible delays in arrivals and departure times of conveyances or travellers.

Competent authorities at points of entry of countries have the obligation to provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.A State Party implementing additional health measures which significantly interfere with international traffic (‘significant interference’ generally means refusal of entry or departure of international travellers, baggage, cargo, containers, conveyances, goods, and the like, or their delay, for more than 24 hours), shall inform WHO, within 48 hours of implementation, of such measures and their health rationale unless these are covered by a temporary or standing recommendation (IHR article 43).

The main public health hazards in air and sea transport are biological agents and communicable diseases.

Public health risks in population movements concern all types of hazards including biological, chemical and radiological agents.

The only criterion used in the decision-making process with regard to travellers is their health status at the time of arrival.

If a traveller develops symptoms of a communicable disease while travelling, the factors that need to be taken into consideration are whether the disease is endemic in the country of arrival.

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Myths and truths

Epidemiological investigation of a case or a conveyance should include possible exposure at the place of departure and at the place of arrival.

Epidemiological investigation of a case or a conveyance should include possible exposure at the place of departure, at the intermediate destinations, and at the place of arrival.

Public health events in air and sea transportation do not differ.

Airplanes move faster than other means of transport and can contribute to the rapid transmission of disease from country to country. However, travellers spend a longer time on ships and have more opportunity for interaction.

Vivi Smeti, Travel Medicine Office, HCDCPVarvara Mouchtouri, EU SHIPSAN ACT Joint Action Manager, University

of Thessalia

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Conferences and meetings

April 2014

23–25 APRIL 2014

Title: 22nd International HPH Conference

Country: Spain City: BarcelonaVenue: Hotel Fira PalaceWebsite: http://www.hphconferences.org/barcelona2014.html

23–26 APRIL 2014

Title: 26th Pan-Hellenic Conference on General Medicine

Country: Greece City: CorfuVenue: Grecotel Imperial Corfu ResortContact Number: +30 210 72 54 360Website: http://www.elegeia.gr/pdf_archive/anakoinosi_26th.pdf

24–27 APRIL 2014

Title: World Conference on Health Sciences

Country: TurkeyCity: AntalyaVenue: Zeynep Sentido Hotel Convention Center Website: http://www.h-sci.org/

Office for Public and International relations, HCDCP

21

Outbreaks around the world

March 2014

Ebola haemorrhagic fever [1]The Ministry of Health (MoH) of Guinea has notified WHO of a rapidly evolving outbreak of Ebola haemorrhagic fever in forested areas of south-eastern Guinea (Guekedou, Macenta, and Kissidougou districts). As of 26 March 2014, a total of 86 cases including 62 deaths (case fatality ratio: 72%) had been reported. Investigations on reported cases in Liberia and Sierra Leone along the border with Guinea are ongoing.

Middle East respiratory syndrome coronavirus (MERS-CoV) [1, 2]Globally, from September 2012 to 23 March 2014, WHO has been informed of a total of 200 laboratory-confirmed cases of infection with MERS-CoV, including 85 deaths. WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.

Zika virus infection [2]An outbreak of Zika virus (ZIKAV) infection has been ongoing since the beginning of October 2013 in all islands of French Polynesia. As of 14 March 2014, 8647 suspected cases have been reported. As of 18 March 2014, a total of 276 cases have been reported in New Caledonia, of which 244 are autochthonous. By 13 March 2014, 188 cases with Zika-like symptoms had been reported on the Cook Island, including 19 confirmed cases. An additional 40 suspected cases of ZIKAV infection have been reported on Easter Island.

Chikungunya fever [2]As of 21 March 2014, there have been more than 15,000 probable and confirmed cases in the following locations:

• Saint Martin (FR): 2640 suspected and 782 confirmed or probable cases, 3 deaths.• Sint Maarten (NL): 115 confirmed autochthonous cases.• Saint Barthélemy: 420 suspected and 134 confirmed or probable cases.• Martinique: 7630 suspected and 1141 confirmed or probable cases, 2 deaths.• Guadeloupe: 1960 suspected and 586 confirmed or probable cases.• Virgin Islands (UK): 7 confirmed cases.• Dominica: 56 confirmed and 394 suspected cases.• Anguilla: 14 confirmed cases including one imported case from Saint Martin.• Aruba: one confirmed imported case from Sint Maarten.• Saint Kitts & Nevis: one confirmed case.• French Guiana: 22 confirmed autochthonous cases and 10 imported cases.

Human infection with influenza A (H7N9) virus [2]As of 20 March 2014, 394 laboratory-confirmed cases have been reported in China from Zhejiang (138), Guangdong (92), Shanghai (42), Jiangsu (42), Fujian (21), Hunan (18),

22

Outbreaks around the world

Anhui (10), Hong Kong (6), Jiangxi (5), Henan (4), Beijing (4), Guangxi (4), Shandong (2), Taiwan (2), Hebei (1), Jilin (1) and Guizhou (1), including 121 deaths. So far, there is no evidence of sustained human-to-human transmission. WHO does not advise special screening at points of entry with regard to this event, nor does it recommend that any travel or trade restrictions be applied.

References

1. World Health Organization (WHO). Disease outbreak news. At: http://www.who.int/csr/ don/ [Accessed 28 March 2014]

2. European Centre for Disease Prevention and Control (ECDC). Epidemiological updates. At: http://www.ecdc.europa.eu/en/press/news/Pages/News.aspx [Accessed 28 March 2014]

Travel Medicine OfficeDepartment for Interventions in Healthcare Facilities

Chief Editor:Ch. Hadjichristodoulou

Scientific Board:Ν. Vakalis

Ε. VogiatzakisP. Gargalianos- Kakoliris

Μ. Daimonakou- VatopoulouΙ. LekakisC. Lionis

Α. PantazopoulouV. Papaevagelou

G. SaroglouΑ. Tsakris

Associate Editors:P. Koukouritakis

Μ. Fotinea

Editorial Board:R. Vorou

E. KaratampaniP. Koukouritakis

Κ. MellouD. PapaventsisΤ. PatoucheasV. Roumelioti

V. SmetiCh. TsiaraΜ. Fotinea

Ε. Hadjipashali

Graphic Design:Ε. Lazana

Copy Editor:P. Koukouritakis

Editors:Τ. Kourea- Kremastinou

HCDCP President

T. PapadimitriouHCDCP Director

Quiz of the month

http://www.keelpno.gr info@keelpno.gr

Send your answer to the following e-mail: info-quiz@keelpno.gr

The answer to February’s quiz was: Shanghai, China.

For more information see: HCDCP e-bulletin, No. 36.

Three (3) people answered correctly.

“How many countries have signed the World Health Regulations of 2005?”