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e_bulletin HCDCP HELLENIC CENTER FOR DISEASE CONTROL & PREVENTION MINISTRY OF HEALTH

Hellenic Center for Disease Control and Prevention Agrafon 3- 5, Maroussi, 15123, Tel: +30 210 5212000, info@keelpno.gr, http://www.keelpno.gr October 2013

Vol. 32/ Year 3rd ISSN 1792-9016

VOL. 3 2

Blood safety Transfusion of blood and blood products represents the cornerstone of every health-care system, and is one of the most frequently used medical practices. However, transmission of hepatitis C and human immunodeficiency virus (HIV) in the 1980s led to the implementation of decisions and safety measures based predominantly on fear within the political, regulatory and medical-legal environments. The dominant principle of decision makers all over the world, regarding blood safety, is one of precaution, implying that scientific evidence of danger is not necessary to justify preventative measures (unless scientific evidence of a lack of danger is available). In the current era of economic crisis, transfusion services are facing two equally dangerous risks: the over-dramatization and the under-estimation of transfusion risks, sometimes leading to a further, unforgivable risk, that expensive technological investments absorb the available financial resources, in an effort to keep up with richer countries but leaving no money for essential investment in the promotion of voluntary non-remunerated blood donation, the education of donors, the training of transfusion medicine specialists and the rational and effective organization of blood transfusion services, which represent the basic requirements for building up a safe transfusion system. Efforts should be made to understand the real extent of transfusion risks, compared with other possible risks, not only the transmission of infection but all risks involved in the process of safe transfusion.

Contents Main article: Working group for the designation of areas affected by vector-borne diseases in Greece

2

Surveillance data

4

Invited articles

7

Recent publications

15

Interesting activities

16

Conferences and meetings

17

Interview

18

Myths and truths

22

Outbreaks around the world

24

News from the HCDCP’s administration

25

Quiz of the month

26

Konstantinos Stamoulis, Hematologist Scientific Director of EKEA MINISTRY OF HEALTH

Highlights In this issue, we first examine if and to what extent infection with malaria and West Nile virus affect the safety of blood transfusion, and then we look at the efforts made by institutions involved in the protection of public health.

More on pages 7, 9, 12

This month’s interviewee, Mrs Konstantina Politis, Responsible for the Co-ordinating Hemovigilance Center, explains the reasons why the level of blood and blood product safety is considered to be high in Greece, and talks about her career and experience.

More on page 18

http://www.keelpno.gr

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Main article

2 Working group for the designation of areas affected by vector-borne diseases in Greece The term ‘affected area’ is used internationally in the health sector to designate areas where a particular biological agent is in circulation, or to characterize areas affected by a natural phenomenon, usually in order to organize public health measures for that area. Regarding vector-borne diseases, e.g. West Nile virus (WNV) infection and malaria, the term affected area was introduced in West Nile Virus and Blood Safety, Introduction to a Preparedness Plan in Europe (June 2012), and is used by blood services in the European Union (EU) member states (MS) to decide on the relevant blood safety measures, in particular for screening travelers or residents from affected areas before blood donation. Following the report of each WNV infection, case staff from the Department of Epidemiological Surveillance of the Hellenic Center for Disease Control (CDC) conducts an investigation with the use of a structured questionnaire to identify the area of potential exposure. As well as this investigation and in order to designate the WNV affected area , it is necessary to take into account several more parameters, such as: • epidemiological data on human cases from the current and previous years • epidemiological data on animals (birds, equids, etc.) • entomological surveillance data • geophysical data for the area. Therefore, an interdisciplinary Working Group (WG) for the designation of affected areas by vector-borne diseases was established in Greece during the transmission period in 2012, as recommended in the EU West Nile Virus and Blood Safety Preparedness Plan 2012. The WG provides advice to the Ministry of Health (MoH) and the National Blood Donation Center (EKEA) on the affected areas regarding WNV and malaria. The WG includes epidemiologists and public health professionals from the Hellenic CDC, the University of Thessaly and the National School of Public Health (NSPH), and experts in blood donation and blood safety issues (the Hellenic Co-ordinating Hemovigilance Center, Hellenic CDC and EKEA), as well as entomologists, veterinarians and representatives of the MoH. Following each updated designation of affected areas, according to the strategy for the management of blood supplies, EKEA (www.ekea.gr) adopts the necessary blood safety measures and informs the blood banks across the country. During the transmission period 2012, the WG met 13 times, ​​initially establishing criteria for the designation of affected areas in Greece, followed by the designation of 40 different affected municipalities and, after week 40, proceeded to recommend reclassification criteria for the affected area to determine the end of circulation of WNV in a particular area. An area considered to be affected by WNV is any municipality with one laboratory-diagnosed human case of WNV infection. The criteria used for the reclassification of a municipality as unaffected by WNV include: i. an elapsed time equal to three maximum incubation periods for WNV infection (42 days), measured from the date of onset of symptoms of the last recorded WNV human case in that municipality ii. surveillance data of humans indicating only sporadic cases in the municipality iii. data from other surveillance systems, such as hemovigilance (blood-donor screening), entomological surveillance, equids and birds, that indicate a lack of continued WNV circulation in the municipality iv. non-proximity (border) to a municipality with recent evidence of virus circulation, taking into consideration all surveillance systems and the geomorphology of the area (mountains, etc.). Regarding WNV, at the WG meetings there was continuous exchange of information on surveillance data and results of humans, mosquito, equid and bird surveillance, as well as the ongoing screening of blood donations. In the transmission period 2013, the WG continued to work with the same criteria, meeting a http://www.keelpno.gr

total of 10 times until 14 November 2013 (Table 1). Regarding malaria, the WG worked on criteria for the designation of a malaria-affected area in Greece, where the disease is not endemic and only sporadic cases are detected. Based on the available data and following discussions at a European level, the definition of a malariaaffected area has been modified for the specific situation in Greece. In addition, when a locally acquired case of malaria is reported to the Hellenic CDC, the WG co-operates with the Department of Epidemiological Surveillance and Intervention to determine the focus and plan the subsequent active case detection procedure; this process has been applied successfully in the last two transmission periods. Table 1 presents a comparison of the last two transmission periods (2012 and 2013) regarding epidemiological surveillance and the WG’s work concerned with WNV and malaria. Table 1: Surveillance data and WG decisions on WNV- and malaria-affected areas, for the transmission periods 2012 and 2013 (until 14 November 2013), Greece

Characteristics of transmission periods and WG decisions

Vector-borne disease transmission period 2012

2013 (until 14 November 2013)

27 July 2012

10 May 2013

109

51

Total number of WNV-related deaths

18

10

Total number of municipalities affected by WNV

40

39

7

13

7 (100%)

9 (69%)

Days until the diagnosis of a human WNV case in municipalities designated in advance (median)

8 days

25 days

1st WG meeting for the re-assignment of WNV-affected areas

6 October 2012

18 October 2013

Day after which there was no evidence of WNV circulation in the country

10 November 2012

10 November 2013

Total imported cases

73

17

Total locally acquired cases

20

3

8

1 και 13 communities*

1st WG meeting Total number of WNV cases

Total number of municipalities designated as affected by WNV in advance WNV

Malaria

Number of municipalities designated in advance where human WNV cases were later diagnosed

Total number of malaria-affected municipalities

*The definition of the malaria-affected area changed during transmission period of 2013 and consequently smaller administrative entities were characterized.

On behalf of the WG, A. Baka (Office for Scientific Advisers) and D. Pervanidou (Office for Vector-Borne Diseases), HCDCP

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Surveillance data

4

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0 0 4 7 12 2 0 1 0 0

0 0 1 2 4 2 0 0 0 0

0 0 0 1 2 1 0 0 0 0

3 1 9 5 6 4 3 0 0 0

22 11 1 3 0 0 0 0 62 10 0 0 0 0 4 1

26 11 0 3 0 0 0 0 108 6 0 0 0 0 6 1

11 8 0 0 0 0 0 0 45 1 0 0 0 0 0 0

63 28 7 7 0 5 0 1 241 12 0 0 0 0 18 3

Brucellosis Malaria Echinococcosis Hepatitis Α Hepatitis B, acute & HBsAg(+) in infants <12 months Pertussis Legionellosis Leishmaniasis Leptospirosis EHEC infection Meningitis aseptic bacterial (except meningococcal disease) unknown etiology Meningococcal disease Salmonellosis (non-typhoid/ paratyphoid) Shigellosis Cluster of foodborne/waterborne disease cases Tetanus/neonatal tetanus Typhoid fever/paratyphoid Tuberculosis

Unknown

5

Crete

0

Southern Aegean

2

Northern Aegean

0

Peloponnese

18

Attica

0

Region

Number of notified cases

Sterea Greece

5

Disease

Western Greece

Hepatitis C, acute & confirmed anti-HCV positive (1st diagnosis) Measles Haemorrhagic fever Pertussis Legionellosis Leishmaniasis Leptospirosis Listeriosis EHEC infection Rabies Melioidosis/glanders Meningitis aseptic bacterial (except meningococcal disease) unknown etiology Meningococcal disease Plague Mumps Poliomyelitis Q fever Salmonellosis (non-typhoid/paratyphoid) Shigellosis Severe acute respiratory syndrome Congenital rubella Congenital syphilis Congenital toxoplasmosis Cluster of foodborne/waterborne disease cases Τetanus/neonatal tetanus

1

Table 2: Number of notified cases by place of residence (region) (place of residence is defined according to the home address of the patient), September 2013, Mandatory Notification System, Greece

Ionian islands

Hepatitis B, acute & HBsAg(+) in infants <12 months

0 0 0 6 0 0 3 0 0 2 22

0 0 4 80 0

Thessalia

Botulism Chickenpox with complications Anthrax Brucellosis Diphtheria Arbo-viral infections Malaria Rubella Smallpox Echinococcosis Hepatitis Α

0 0 0 29 0

Epirus

September 2013

Number of notified cases Median Min. number Max.number number September September September 2004-2012 2004-2012 2004−2012 0 0 0 0 0 2 0 0 1 11 6 15 0 0 0 0 0 0 3 2 33 0 0 0 0 0 0 2 0 5 9 2 37

0 0 1 49 0

Western Macedonia

Disease

0 0 1 38 0

Central Macedonia

Table 1: Number of notified cases in September 2013, median number and range of notified cases in September for the years 2004−2012, Mandatory Notification System, Greece

Tularaemia Trichinosis Typhoid fever/paratyphoid Tuberculosis Cholera

Eastern Macedonia and Thrace

SEPTEMBER 2013, GREECE

0 0 0 18

1 0 1 0

0 0 0 0

0 0 0 0

1 0 0 1

0 0 0 0

0 0 0 0

3 0 0 0

0 1 0 1

1 1 1 0

0 0 0 0

0 0 0 0

0 0 0 2

0 1 0 0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0 0 0 0 0

0 1 0 1 0

0 0 0 0 0

0 0 0 0 0

0 1 9 1 0

0 1 0 0 0

0 0 0 0 0

0 0 1 0 0

2 3 1 0 0

0 0 1 0 0

1 0 0 0 0

0 0 0 0 0

0 0 0 0 1

1 1 0 0 0

1

2

0

3

3

3

3

1

4

0

0

0

2

0

1

2

0

0

1

0

0

1

2

1

2

0

1

0

0 1

1 0

0 1

0 0

0 0

0 0

0 1

0 0

0 0

0 0

0 0

0 0

0 0

0 0

7

5

2

2

5

1

6

5

23

1

0

2

0

3

0

0

0

0

3

0

3

0

4

0

0

0

0

0

0

0

0

0

0

0

2

0

1

0

0

0

1

0

0 0 1

1 0 1

0 0 0

0 0 2

0 0 3

0 0 0

0 0 4

0 0 0

0 0 14

0 0 4

0 0 0

0 0 1

0 0 6

0 1 2

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Invited articles

6 Table 3: Number of notified cases by age group and gender (M, male F, female), September 2013, Mandatory Notification System, Greece Disease

Blood safety: a complex approach

Number of notified cases by age group (years) and gender <1

Brucellosis Malaria Echinococcosis Hepatitis Α Hepatitis B, acute & HBsAg(+) in infants <12 months Pertussis Legionellosis Leishmaniasis Leptospirosis EHEC infection Meningitis aseptic bacterial (except meningococcal disease) unknown etiology Meningococcal disease Salmonellosis (nontyphoid/paratyphoid) Shigellosis Tetanus/neonatal tetanus Typhoid fever/ paratyphoid Tuberculosis*

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

0 0 0 0

0 0 0 1

0 0 0 1

0 0 0 2

0 0 0 6

0 0 0 6

0 1 0 0

0 0 0 2

0 1 0 1

0 0 0 3

0 1 0 0

1 0 0 0

1 0 1 0

0 0 0 0

0 0 0 0

0 0 1 0

3 0 0 0

1 0 0 0

0 0 0 0

0 0 0 0

0

0

0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

1 0 0 0 0

1 1 0 0 0

1 0 1 0 0

1 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 1 0 1

0 1 1 1 0

0 0 1 0 0

0 0 0 1 0

0 0 0 0 0

0 1 3 0 0

0 0 1 0 0

0 3 1 0 0

0 1 3 0 0

0 0 0 0 0

0 0 0 0 0

3

0

2

1

2

2

0

1

1

3

1

2

2

1

0

0

1

0

0

0

0

0

0

0

0

2

0

0

2

1

0

0

4

0

1

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

1

0

0

1

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

6

5

10

6

7

4

1

0

0

0

2

1

1

2

0

2

10

4

0

1

1

2

3

1

2

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

3

1

3

1

4

1

8

2

3

0

6

4

0

0

*For two tuberculosis cases there was no information recorded regarding gender. The presented data 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 on HCDCP’s HCDCP (www.keelpno.gr). It should be noted that the data for September 2013 are provisional, and could be slightly modified/corrected 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

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Safe transfusion in combination with ensuring the availability of blood for transfusion is a priority for developed countries and depends equally on blood donors, the infrastructure of the blood donation services and doctors, as well as the public services that are involved. Unlike other medical specialties, blood donation is constantly under the scrutiny and control not only of the public and the media, but also of the relevant authorities of each country. As a result, every time there is an issue concerning the safety of blood, there are great social and emotional outbursts, which can result in decisions or measures that, under different circumstances, would be regarded as excessive or inefficient [1]. With regard to the transfusion of infectious diseases, all blood derivatives can potentially transmit pathogens such as viruses, bacteria and parasites. Today, the transfusion of blood and its derivatives is safer compared with earlier decades, due to the introduction of more sensitive detection techniques; in particular, in recent years the ‘window of opportunity’ for pathogens has been significantly reduced with the use of molecular techniques. However, the risk cannot be reduced to zero, for the following reasons [2]. • Most serological techniques cannot detect pathogens during the window of opportunity. • There is always the possibility that new pathogens, that we either do not know or have no suitable means of detection for, are transmitted. • The epidemiological characteristics of several European countries can become modified because of population changes, which stem from the ever-increasing number of economic migrants flowing into them; from the moment migrants are incorporated in the social network of the host country, they can instigate the need to integrate new blood security measures. • Bacteria and parasites constitute an additional threat to the safety of blood, particularly for unstable products. • We should not under-estimate the probability of transmission of diseases for which there is not yet an appropriate method of detection, as well as diseases such as malaria, Chagas disease, etc., which are not tested for during routine serology. Additionally, anticipation regarding the application of molecular testing is tempered by the increasing effort required to combine maximum sensitivity of the methods used without a significant increase in the cost of blood testing, which could become prohibitive for most national health systems. However, we are still looking for techniques that can be incorporated into the daily operation of blood banks with the fewest possible changes in the daily workflow. Despite the fact that the application of molecular techniques undoubtedly contributes to increasing the safety of blood, many questions are raised about the cost-effectiveness, and many studies have shown that this relationship is negative, taking into account the already small risk of transmission before even implementing molecular techniques. Currently, the cost per identified infection amounts to 1.7 x 10 6 $ when molecular control is applied to mini-pools and 2.7 x 10 6 $ when the testing is applied to a single-donor format. However, what is worrying those engaged in the safety of blood and its derivatives more and more is the ever-increasing incidence of newly emerging or the re-emergence of ‘forgotten’ pathogens. Many of these pathogens are considered to be particularly dangerous, because they seem to be resistant to the inactivation methods that are used and are characterized by prolonged incubation period. The American Association of Blood Banks (AABB) has identified 69 infectious agents whose transmission through transfusion is either suspected or has already been proven and for which no measures have yet been taken, at least in the USA and Canada. This group of pathogens includes factors such as Babesia, the dengue virus and new variant Creutzfeldt-Jakob (vCJD). For some of these factors there are schemes for the diagnosis and management of risk regarding the safety of blood, but they are still considered to be a threat to the blood-donation system, either because the implementation of control methods for the donors is relatively recent or there are gaps in further treatment, in particular regarding the info@keelpno.gr


Invited articles

8 impact of the control and consequent exclusion of donors from blood stocks and derivatives regarding infections such as West Nile virus (WNV), Parvus-virus B19 (parvoB19), HAV, etc. These viruses, such as parvoB19, and some newly emerging pathogens, such as WNV, require the development of preventive strategies, as well as a surveillance system of transfusion recipients, so that the donation system can be informed promptly about the possibility of a new threat and subsequently take appropriate measures. The development of user-friendly diagnostics that provide broad applicability for newly emerging pathogens continues to be an obstacle for the safety of blood, so careful monitoring of the epidemiological characteristics of blood, along with careful monitoring of the recipients of transfused blood, is one of the main defenses against infectious threats within transfusion. The basic principles on which a modern health system should be based in order to determine strategies for addressing the threats to blood donation from newly emerging or re-emerging pathogens are: • • • • •

precaution harmonization with strategies followed by the European Union (EU) cost-effectiveness compliance with other practices followed in the health sector responding to the expectations of patients and the public with regard to the safety of blood.

Before implementing any strategy regarding the safety of blood, we need to consider very seriously the effects of that strategy on the safety of blood and its derivatives. The philosophy of addressing the entire issue is expressed best by the World Health Organization, which emphasizes ‘Blood should be available when needed at affordable costs and used appropriately’. In conclusion, what is almost certain is that there can be no end to the problem of transfusiontransmitted diseases. However, safe transfusion can exist when: • the blood comes from systematic, appropriately chosen, volunteer non-remunerated donors • the absolute indications for the transfusion of blood and its derivatives are strictly observed • there is constant vigilance for unexpected threats throughout the chain of donation of blood and its derivatives.

References 1. Stein J, Besley J, Brook C, et al. 2011. Risk-based decision-making for blood safety: preliminary report for a consensus conference. Vox Sang 101:277-281. 2. Regan FAM, Hewitt P, Barbara JA, Contreras M. 2000. Prospective investigation of transfusion transmitted infection in recipients of over 20 000 units of blood. Br Med J 320:403-406. 3. Rachid Salmi L, McClelland B, AuBuchon JP. 2001. The myth of the ultimate blood safety wall. Transfusion 41:716. 4. Kitchen AD, Barbara JA. 2000. Which agents threaten blood safety in the future? Baillieres Best Pract Res Clin Haematol 13:601-614.

Konstantinos Stamoulis, Hematologist Scientific Director, EKEA

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Malaria and Sparti’s experience Introduction Malaria is a vector-borne disease and is rarely transmitted through infected blood. The disease currently exists in southern Africa and Asia. In Greece malaria was eradicated in 1974; since then in our country sporadic cases have been recorded related to travel or residence in countries with endemic malaria. Very few incidents without travelling history were documented in 1991, 1999, 2000 and 2010, while in 2009, 2011 and 2012 there are recorded concourse of incidents of malaria.

Recording caseloads From August to October 2009, in Lakonia and specifically in the municipalities of Skala and Elos, today the municipality Evrota, six cases of malaria transmitted domestically and two cases in immigrants from endemic countries were diagnosed. In all patients, the National School of Public Health (NSPH) laboratory confirmed infection with Plasmodium vivax. The area where the outbreak presented was: • rural, with large irrigation areas that were served by a dense complex of open canals and drains where there was standing water throughout the summer, along with constant soil humidity • the place of residence and work for immigrants from countries of south-east Asia, where malaria is endemic • populated with mosquitoes of the genus Anopheles, which are the natural vector of malaria. In the past few years, malaria has been a plague for the population of southern Laconia, even though it had been eliminated in 1950. However, the return and resettlement of malaria in the region was always possible.

Vigilance With the appearance of the first cases of malaria in August 2009, involving a Roma without a travel history, the blood donation department of Sparti advised the Co-ordinating Hemovigilance Center (SKAE), who in turn advised us to be vigilant. Another five cases were then recorded, involving Roma and non-Roma Greek citizens without a travel history, so SKAE, after the first few days, took measures to ensure the safety of blood and therefore the protection of transfusion patients. The measures included: • suspension of any scheduled blood collection in the area of Skala • temporary exclusion of blood donors who had come into contact with malaria patients • sending stored serum samples of blood donors from Skala and other nearby areas for retrospective testing for antimalarial antibodies from June 2009. The blood donation department of Sparti, in collaboration with the microbiology laboratory of Alexandra Hospital and after personal agreement with the Director, retrospectively tested 158 sera from blood donors using indirect immunofluorescence, and all were found to be negative. Five months after the last case of malaria and because of a serious need for blood, we asked SKAE to terminate the suspension for actual blood collection in the region in March 2010; we planned to test all the blood units collected for antimalarial antibodies  and, depending on the result, would then use the blood units for transfusion, or not. SKAE agreed with our proposal and lifted the ban. We collected 101 blood units that were all negative for antimalarial antibodies. We continued the blood collections, and kept donated blood serum units from the area of Skala in a deep freezer for future examination, because the laboratory of Alexandra Hospital was unable to test them at the time. Meanwhile there were intense reactions from the municipal authority of Skala because of the exclusion of local blood donors: they did not want their area to be ‘stigmatized’, believing that the problem concerned the whole of Laconia, because people travel daily into and out of Skala from the wider area. Local epidemiological investigation and action plan

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10 The Hellenic Center for Disease Control and Prevention (HCDCP), in co-operation with NSPH, carried out the following procedures. • An HCDCP unit went to the area twice to carry out local epidemiological investigations. • Suggested measures to prevent a cascade of disease transmission: a) early diagnosis and treatment of all patients with malaria b) enhanced epidemiological and laboratory surveillance c) a plan for mosquito control. • A document was provided to all physicians in Laconia outlining a ‘protocol of enhanced surveillance for malaria in Laconia and ways of protection against insects’, aimed at the prevention and early diagnosis and treatment of patients with malaria. • A proposal to continue active surveillance for malaria for a year, with re-assessment in the light of any new outbreaks. In August 2010 the only recorded case of indigenous malaria was a Greek-originated Roma, who lived in the same camp where in 2009 two cases had been recorded. For precautionary reasons, blood collections were suspended from Evrotas municipality until December 2010. The lack of incidents recorded in 2010 led to complacency within various departments. In the same year, there was no mosquito elimination program, as HCDCP had suggested, because the municipality and regional authorities could not agree on who’s responsibility the elimination program was.

Influx of new cases and integrated action plan On 31 May 2011, the first case of malaria for 2011 was recorded in an 18-month-old Roma, who was living in the same camp where the other cases of malaria had been recorded in 2009 and 2010. Because there was a major need for blood, we asked SKAE to continue blood collections in the municipality of Evrotas, provided that all blood units collected were checked by polymerase chain reaction (PCR) in the Department of Parasitology at NSPH, after first consulting with the staff. They tested 86 blood units by PCR and the results were negative for Plasmodium spp. Since then, and specifically since the end of July in 2011, we have had an influx of malaria cases. Fiftyseven cases of malaria have been recorded, 34 of which indicate a ‘home unit’; 27 cases were Greek, seven were from non-endemic countries (Poland and Romania) and 23 were from endemic countries (Pakistan and Afghanistan). SKAE recommended the suspension of blood collections in the municipality of Evrotas to 19 April 2012. Meanwhile, the problem has now become extensive and the concern of citizens is growing. HCDCP, the National School of the Ministry of Health and representatives of the European Union (EU) and the World Health Organization (WHO) have visited the prefecture of Laconia and met with representatives of the region, the local authorities and health departments of Laconia. Following WHO recommendations, the HCDCP, in collaboration with the relevant agencies, has prepared a comprehensive action plan for: • the detection and treatment of malaria cases • support for rapid laboratory diagnosis of malaria at a local level • the investigation of actual cases and risk factors • the investigation of the patients’ domicile (focus investigation) • active laboratory surveillance • an active search for malaria cases in the general population, which has already been implemented since October 2011 in the area of the municipality Evrotas • massive health screening of people arriving from endemic countries and Roma living in the municipality of Evrotas • public awareness of means of personal protection from mosquitoes • mosquito elimination during spring and autumn.

transmission. From the beginning of 2013 until 21 October 2013, two malaria cases have been recorded, both of which were from endemic countries. Meanwhile the need for blood is great, the area was ruled for long periods of blood collections over the last three years, and there are strong protests and pressure from citizens and the municipal authority of Evrotas to find a solution for blood testing. Our blood donation department is in consultation with SKAE and NSPH, who have promoted our request to HCDCP. With the support of HCDCP, we have decided that the blood from donors in the wider region of Evrota’s municipality has to be checked as a precautionary measure for Plasmodium spp. by PCR and microscopy examination by the reference laboratories of NSPH and the University of Athens.

Conclusions The responsible authorities must be vigilant to prevent emergencies, carrying out immediate investigations, assessment and intervention plans. Complacency and failure to take immediate action just postpones the problem for later, with serious consequences for public health. Particularly important is the awareness of physicians to enable early diagnosis, treatment and declaration of the disease, and immigrant access to health services and timely implementation of measures to prevent transmission. Regarding the safety of blood, as a precautionary measure, from June 2009 until 20 October 2013 we have tested 877 blood units from donors in the wider area of west Evrotas, and all were found to be negative for Plasmodium spp.; so we have been able to transfuse our patients safely with this valuable product. The blood donation department must be vigilant and in readiness for emerging and re-emerging infections that threaten the safety and sufficiency of donated blood. There is also a need for solidarity among health departments, and blood donations in regions not affected should be encouraged to cover the blood shortage for areas in need.

References wwwkeelpno.gr

M. Kalkani, I. Kodonis, Blood Donation Department of General Hospital of Sparta

Also in 2012, HCDCP developed an action plan to tackle malaria from 2012–2015, with proposals defined according to the risk assessment of each area, and joined the ESPA program, with the aim of preventing the re-establishment of malaria in Greece. In 2012, 23 cases of malaria were recorded, 17 of which were from endemic countries and six had evidence of domestic

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Invited articles

12 Blood Safety for Diseases transmitted via Vectors: The Athens Experience of West Nile Virus General information Since 2010, the emergence of West Nile virus (WNV) in Greece has primarily affected the health authorities and secondarily the transfusion services of the country. Through its webpage, the Hellenic Center for Disease Control and Prevention (HCDCP) is providing valuable information on the registered annual number of outbreaks and deaths, mainly concerning the elderly population, and especially those with known co-morbidities. Infected vectors (mosquitoes) transmit WNV to humans when they bite them. Most people infected with WNV do not experience any signs or symptoms. About 20% of cases present with mild symptoms resembling common influenza (‘flu), and about 1% manifest with more serious symptoms, mainly of the central nervous system. Consequently, the target group of blood donors, i.e. healthy people who are 18-65 years old, might have been either a) infected and developed antibodies without knowing it or b) recently infected and developed ‘flu-like symptoms as a result of WNV after giving blood. For those blood donors belonging to groups a) and b), the transfusion department must follow certain guidelines in order to check that the collected blood is safe regarding the transmission of WNV. The co-ordination, supervision and writing of protocols followed by the transfusion departments of our country fall under the responsibility of the National Center for Blood Transfusion (EKEA).

Measures taken for blood safety Temporary exclusion of blood donors who live in areas characterized by qualified authorities as affected by the WNV. This characterization includes areas from which there has been a reported WNV outbreak, diagnosed with the appropriate laboratory tests. These areas change on a daily and annual basis, because the outbreak depends on multiple local factors, such as infected mosquitoes, water stagnation, default seasonal spraying and dense vegetation. Molecular control of WNV in blood donated in affected areas. The control of transfused blood starts when it is considered necessary by the relevant authorities. This test is not normally included in the obligatory set of tests performed on transfused blood according to guidelines provided by the Ministry of Health. Blood units that have been collected from areas that are afterwards characterized as affected are put into quarantine. This means that they are not transfused until they have undergone molecular control, and are then used or discarded.

Hemovigilance procedures retrospective control. Blood units collected from any blood donor who develops ‘flu-like symptoms within the next 15 days and WNV infection is diagnosed undergo molecular control. When tests are positive for WNV, the blood donor is informed and the blood units are withdrawn. If the blood units have already been used, then the patient(s) transfused with red blood cells, plasma or platelets need to be checked. All infected cases regarding blood donors and patients who have been transfused with WNVinfected blood are reported through a confidential written form to HCDCP’s Co-ordinating Hemovigilance Center (SKAE). Special measures are taken for blood donors that are not residents but have visited an affected area. These donors are excluded from giving blood for 28 days after they last visited an affected area. If the process of molecular control has already been started, the blood from such donors can be withdrawn and checked immediately. Blood donors that have been infected by WNV can donate blood 120 days after an established diagnosis and if they are healthy.

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Epidemiological data In Athens in 2010, there were no outbreaks of WNV diagnosed by laboratory tests. Therefore the impact on the transfusion departments in Athens was attributed to the fact that many blood units had been collected from the rest of the country where outbreaks had been recorded. This occurs because of the greater needs of Athenian hospitals for blood units. In 2010, the first year that WNV emerged in the country, EKEA sent relevant instructions to all the transfusion departments in Athens regarding blood units collected in affected areas (Central Macedonia and Larissa). If blood units had already been transfused, patients were put under surveillance. The instructions also covered blood collection from donors that had visited an affected area outside Athens. The Consulting Committee of Blood Transfusion sent EKEA a plan of suggested measures to prevent the transmission of WNV infection through blood transfusion. The plan also included measures to ensure a sufficient blood reserve. In general, Athens was not overburdened by the WNV infection in 2010, unlike Larissa and Central Macedonia prefectures. No WNV transmission via blood or blood products transfusion and no blood donor positive for WNV antibodies was registered in the municipality of Athens. In May 2011, the supervised services received instructions concerning WNV from the relevant health authorities. At the same time, molecular control of WNV in each area with a registered outbreak was initiated. In August 2011, nucleic acid technology (NAT) molecular control for WNV was started in the three corresponding control centers of Laiko and G. Gennimatas hospitals and EKEA, because of an outbreak in the Marathonas area. No WNV transmission via blood or blood product transfusion and no blood donor positive for WNV antibodies was registered in the municipality of Athens in 2011. Because of very early recordings of outbreaks in Athens at the beginning of 2012, many blood donors that were inhabitants or worked in the area were excluded. EKEA reported that blood units collected after 1 July 2012 from Nea Smyrni, Palaio Faliro, Agios Dimitrios, Alimos, Elliniko and Argyroupoli had to be retained and sent to EKEA. These measures led to a shortage of blood and blood products, especially platelets, in Athenian hospitals. The management and handling of blood came under the complete jurisdiction of EKEA, with daily recording of blood reserves in the country, in order to cover the country’s needs. The safety measures taken during blood collection were detailed history taking, the exclusion of a blood donor who worked or lived in an affected area and reporting to the transfusion department any case where the donor developed ‘flu-like clinical symptoms after donating. On 3 August 2012, new areas of Athens were added to the list of affected areas, namely Neos Kosmos, Kynos Argous, METS, Pagrati, Ag. Ioannis (Gouva) and Moschato. On 4 August, Ilioupoli, Amarousio and Chalandri were registered. Under these circumstances, the ability to cover the blood needs of the hospitals of Athens became extremely difficult. NAT molecular control for WNV started on 21 August at blood centers at EKEA for Athens and AHEPA for Thessaloniki and Alexandroupolis. The municipalities of Piraeus and Oropos were also added to the list of affected areas, minimizing even further the choices for possible donation campaigns and blood collection. On September 2012, due to an extended period of high temperatures, new outbreaks were recorded in the municipalities of Vari, Voula and Vouliagmeni. On 16 November, the safety measures against WNV regarding blood transfusion were withdrawn, without causing serious problems of blood shortage for any patient. On 2 August 2013, the first registered outbreaks occurred in the outskirts of Athens, in Amarousio, Heraklio, Vrilissia, Pendeli and Chalandri. The exclusion of people living or working in the above mentioned areas immediately created a much greater shortage of blood than the usual shortage that occurs during the summer months in Athens. A week later, on 7 and 9 August, Markopoulo Mesogaias, Rafina and Pikermi were added to the list of affected areas. On 12 August, Agia Paraskevi followed. The shortage of blood started to become apparent, as most campaigns for blood donation in these areas were cancelled. By the end of August blood collection was also restricted from the municipalities of Galatsi, Filothei, Psichiko, Papagou, Cholargos and Glyfada. At the beginning of September, NAT molecular control for WNV started at three centers in Athens, providing a means of coping with the immense need for blood because of the exclusion info@keelpno.gr


Recent publications

14 of many areas of the capital. After starting the molecular control, Voula, Vari, Vouliagmeni, Lykovrisi and Pefki were added to the affected areas. On 27 September, a gradual withdrawal of safety measures was started, while on 3 October two more areas were affected, Filadelfia and Chalkidona municipalities. Continuing high temperatures in Athens could lead to new outbreaks of WNV infection in the city. During the 4 years since the emergence of WNV in Greece, the knowledge and experience gained has made it possible to develop and execute an annual plan for the country’s transfusion departments. The target is to supply the country’s need for blood safely.

Conclusions The provision of timely updated reports by HCDCP (Department of Epidemiologic Surveillance and Intervention) triggers the implementation of safety measures in the country‘s transfusion departments. The selection of blood donors following the epidemiologic reports of HCDCP and the guidelines of EKEA leads to the collection of safe blood despite the temporary exclusion of people from affected areas. NAT molecular testing of blood units from affected areas ensures the safe transfusion of blood and blood products. The sooner NAT molecular control of blood units is applied, the easier the work of the transfusion departments becomes. Blood units and especially platelets are rapidly released without being put into quarantine. Blood transport from unaffected areas during exacerbated periods of WNV infection partly covers the need for red blood cells in Athens. Multi-transfused thalassemia patients are transfused sparsely and with older blood units. Conversely, platelet units become unavailable when molecular control has not been performed on time, and blood donors from affected areas are excluded. Overall, hemovigilance promotes safe transfusion.

Recent publications Possible transfusion-related lethal WNV infection, Colorado USA 2012 Kelly S, Le TN, Brown JA, Lawaczek EW, Kuehnert M , Rabe IB, Staples JE, Fischer M MMWR 2013; 62(31):622-624 This case report refers to a fatal case of possible transfusion-related West Nile virus (WNV) infection through transfusion of platelets collected from an asymptomatic donor. In August 2012, a man with non-Hodgkin’s lymphoma was admitted to hospital for chemotherapy and autologous stem cell transplant. The patient died 43 days after admission with a clinical presentation of severe encephalitis. Postmortem evaluation showed diffuse encephalitis. WNV IgM antibodies were identified in serum collected on hospital day 43. WNV RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) on brain and spinal cord tissues collected at autopsy. During his hospital stay the patient had received transfusion of various blood products from a total of 10 donors, of which one was found to be positive for WNV IgM and for WNV neutralizing antibodies within the framework of the investigation of this case. The investigation also showed that the blood donation unit from which the platelets were derived had been tested initially by mini-pool nucleic acid technology (NAT) (MP-NAT) together with five more units. The minipool had tested positive; however, all of the units comprising the mini-pool were non-reactive when tested by ID-NAT and were released into the blood supply. Cases of transfusion-related WNV infections had been reported in the literature frequently until the instigation of routine blood screening in the USA. Nevertheless, clinicians should include WNV infection in the differential of immune-compromised patients who are at higher risk of WNV neuro-invasive disease (WNND). The protocol for releasing donation units to the blood supply in the USA was modified after the reporting of this case. In a similar scenario, where the initial MP-NAT is positive but the ID-NAT of the individual units in the mini-pool is negative, all blood units are discarded.

M. Moschou Parara, MD, PhD, Hematologist, Head of Department, Blood Transfusion Establishment, Evaggelismos General Hospital

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Conferences and meetings

16 Greece participated in the EpiSouth-Plus Nautilus Simulation Exercise Greece participated in the EpiSouth-Plus Nautilus Simulation Exercise, which was carried out successfully on 2-3 October 2013 at the National Health Operation Center of the Ministry of Health (MoH), in Athens, Greece, with the active participation and support of the MoH, the National Health Operation Center, the Hellenic Center for Disease Control and Prevention (HCDCP) and the Directorate of Public Hygiene of the MoH. The EpiSouth Network includes 27 countries: nine European Union (EU) and 18 non-EU countries. It is therefore the biggest inter-country collaborative effort of this kind in the region. Since October 2010, with the approval of a new project phase (EpiSouth-Plus), the network has focused on increasing health security in the Mediterranean area and south-east Europe by enhancing and strengthening preparedness to common health threats and bio-security risks at national and regional levels in the contributing countries. The Nautilus Simulation Exercise (SE) is the final stage of a capacity-building process that started with a capacity-needs assessment aimed at identifying the aspects to be strengthened in the Mediterranean and Balkan regions. The Nautilus SE simulated a public health event of international concern affecting several EpiSouth countries, with the possibility of spread all over the Mediterranean basin and even further. The objectives were: • testing the availability and use of the national emergency preparedness and response plans • testing the communication, co-ordination and decision-making process in emergency situations • testing the co-ordination between national public health services and points of entry • identifying different levels in communication and decision-making processes (national and international) in the EpiSouth region (using the EPIS/EpiSouth platform tool) • testing the diagnostic confirmation procedures in the EpiSouth Mediterranean regional laboratory network (MRLN) • testing the timeliness of the process • 7.identifying needs and assessing availability of stockpiles and funds for facing outbreaks. EpiSouth Plus is co-financed by the EU DG-EAHC/SANCO and Europe Aid/DEVCO for an amount of 3.9 million Euro together with the contributing public health institutes and ministries of health. The financial support of the Italian Ministry of Health and the European Centre for Disease Prevention and Control (ECDC) is also acknowledged.

Rengina Vorou, FP EpiSouth-Plus, HCDCP

Conferences and meetings November 2013 8-10 November 2013 Title: 1st Pan-Hellenic Conference on Crisis Management in Health Care Country: Greece City: Athens Venue: Divani Caravel Contact Number: 210-6827405, 6839690-1 Website: http://crisis-management-congress.eu/

19 November 2013 Title: CDC Public Health Grand Rounds: Antibiotic Use Country: USA City: Atlanta Venue: Centers for Disease Control and Prevention, Tom Harkin Global Communications Center, Building 19, Auditorium A Website: http://www.cdc.gov/about/grand-rounds/

19-22 November 2013 Title: 8th World Congress of the World Society for Pediatric Infectious Diseases Country: South Africa City: Cape Town Venue: Cape Town International Convention Centre (CTICC) Contact Number: +41 22 908 0488 Website: http://www2.kenes.com/wspid/Pages/home.aspx

22-24 November 2013 Title: 4th Pan-Hellenic Conference of the Forum on Public Health & Social Medicine Country: Greece City: Athens Venue: Royal Olympic Contact Number: 210 6827405, 210 6839690-1 Website: http://www.tmg.gr/4thforum-phsm

26-27 November 2013 Title: Strategic Approaches to Healthcare Infection Prevention Country: Australia City: Sydney Venue: Mercure Sydney Contact Number: +61 (2) 9239 5700 Website: http://confreg.criterionconferences.com/register/?c=99#regFormTopAnc

Office for Public and International relations, HCDCP

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Interview

18 Dr Konstantina Politis, Head of EKEA

The safety of blood and blood products has been a highly debated issue as far as public health is concerned, and has always been the focus of attention for both the public and the media. Why do you think this is? The safety of blood and blood products is the real focus of attention for the public and the media, as one of the most ‘sensitive’ matters in medical science. This is largely due to the intense emotional reaction associated with cultural, religious and metaphysical preconceptions about the ‘red liquid tissue’ that flows in our veins. Back in ancient times, the dual power of blood was highlighted by Euripides in the scene where Athena gave Asclepius, the god of medicine, two drops of Medusa the Gorgon’s blood: one drop would treat all diseases and preserve life, while the other was lethal. Scientific discoveries in immunohematology in the 20th century established blood transfusion as part of the treatment for a variety of diseases and opened the way for surgical and other operations on millions of people every year, thereby responding to the issue of blood safety and also dispelling the contradictory images of blood as a carrier of life and suffering at the same time. What was the status of blood donation and safety 20-30 years ago and what is it today? Have we actually made significant progress? As regards the microbiological and virological safety of blood, up until 1980 blood was screened for syphilis and hepatitis B, and the review of the potential donor’s medical history formed the basis for the selection of donors. It was the emergence of acquired immune deficiency syndrome (AIDS) in the early 1980s that upset established practices regarding blood transfusions and undermined the confidence of the public, patients and the medical community in the safety of transfusion of blood components. From then on, the focus of attention turned to blood safety, with the aim of minimizing the risks of transfusion and preventing the transmission of infectious diseases through blood. There was a worldwide effort to protect blood transfusions by establishing appropriate health policies and institutionalizing blood safety measures. As far as Europe is concerned, blood safety is the subject of the European Union (EU)’s first law (Directive) in an effort to implement Article 152 on public health of the Treaty of Amsterdam. At the same time, the Council of Europe and the World Health Organization (WHO) have established standards and principles for every procedure within donor selection and blood collection, processing, testing, storage and distribution, taking into account the scientific advances and the epidemiological data for each country. To achieve blood safety, the first and foremost condition is the consensus of a competent government and the establishment of the appropriate organizational and legislative framework for blood donation in each country.

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Dr Politis, you are the most competent person to tell us whether we have succeeded as a country and as a health system in this particular domain. Are we considered to be one of the successful countries today? Yes, we have been successful for the following reasons. • We have had no remunerated blood donation since March 1979. • Greece was among the first countries in Europe to enact Law 1820 on Blood Transfusion in 1988, based on the recommendations of the Council of Europe and WHO, and later Law 3402/2005 in line with the European Directive 2002/98/EC. • The legal toolkit in blood transfusion comprises a multitude of presidential decrees, ministerial decisions and circulars that, based on the recommendations of the Blood Transfusion Committee, provide guidelines for the scientific and organizational framework of blood donation and transfusion. • The National Blood Center was established in 2005 and is gradually becoming a blood supervisory and control authority. • We have increased blood collection considerably and we have institutionalized all regulations on blood safety and quality, in line with the European Directives 2004/33, 2005/ 61 and 2005/62. • The ongoing collaboration between our services and the volunteer donors’ associations and groups has contributed decisively to the development of voluntary blood donation. • Together with France and the United Kingdom, our country has established a system of hemovigilance overseen by the Co-ordinating Hemovigilance Center (SKAE), which functions as a department of the Hellenic Center for Disease Control and Prevention (HCDCP). • We have made significant advancements in immunohematology, in the serological testing of blood and the molecular control of blood-transmitted infections using nucleic acid technology (NAT). In this way, the safety of blood has improved considerably. • We have contributed to a rationalized use of blood and blood components. • Blood donation has contributed decisively to improving the ‘picture’ of patients with thalassemia and the treatment of people with hemophilia and other bleeding disorders. • We have introduced methods of leukapheresis, irradiation and pathogen inactivation in plasma, and we have also increased the collection of platelets with automated aphaeresis procedures. • There have been several more achievements for blood donation in Greece, the most important of which is the creation of a sense of family for all blood transfusion services, which have common objectives and apply common technical practices. • There are several shortcomings, however, and much remains to be done in restructuring our blood system in order to achieve a more efficient blood supply and better blooddonor management, and to increase quality assurance for our services. The nationwide implementation of computerized systems and the operation of our services within a centralized scheme will accelerate progress in blood safety and quality, and it will also save resources that could be reallocated to improving public education and information to promote further regular voluntary blood donation. It is also necessary for all blood services to obtain a quality certificate and to improve the overall performance of transfusion according to the requirements of the inspections. • The development of a valid national plasma fractionation program for the production of albumin and immunoglobulins remains to be accomplished, while much of the collected plasma is overtransfused. Let us now focus on vector-borne diseases. Has the emergence of West Nile virus (WNV) infections in 2010 as well as the resurgence (at a local level) of malaria in 2011 complicated matters for blood banks, and to what extent? What problems have they caused? Safety measures had to be taken against WNV infections in affected areas in 2010 and against malaria in the region of Eurotas in Laconia and several areas in Attica. These measures affected the blood supply adversely during the summer months, when there is usually a decrease in blood collection at the same time as the demand for blood increases because info@keelpno.gr


Interview

20 of increased traveling and tourism resulting in a greater number of accidents and other emergencies. In particular, the donor deferral measures and the cancellation of blood sessions caused dysfunction in major hospitals in Attica, where a large supply of blood is necessary to accommodate surgical, orthopedic and other operations, as well as to treat multi-transfused, oncology and other patients. The implementation of NAT blood screening for WNV provided significant support for the blood transfusion services and allowed sufficiency as well as safety of the blood supply. We must stress the significant efforts made by the National Blood Center and the donors’ associations with regard to the effective management of the blood supply at a national level and the transportation of blood to the areas particularly affected by the WNV epidemic and the resurgence of malaria. We should also mention the efforts and collaboration between the National Blood Center and the Co-ordinating Hemovigilance Center with public health professionals, HCDCP services and scientists of other specialties to determine the affected areas in accordance with the recommendations of the European Centre for Disease Prevention and Control. Let us now move on to our own matters. What role does the HCCH/HCDCP play in blood safety and hemovigilance? Give us a brief outline of its activities and their significance. In our country, the relevant authority for hemovigilance is SKAE, which was founded by the Hellenic Center for Infectious Diseases Control (Board decision, during the 23rd meeting 1995, OG 831/29 June 2001 - Internal Regulation CCID) and institutionalized as the agency that is responsible for hemovigilance in our country by virtue of OG 261/17-02-2011. Since January 2008, SKAE has been located in HCDCP’s headquarters and has operated using personnel qualified in medical issues such as transfusion, public health, laboratory blood screening, counselling, statistical analysis, training and organization. It was established in line with European efforts to implement quality and safety standards in blood donation and transfusion, and particularly to limit the risks that arise in this area of public health, thus improving the safety of the blood transfusion chain from donor to patient. To achieve this, we have developed a reliable epidemiological surveillance system for adverse reactions and events associated with blood donation and transfusion at local (hospital), regional (six locations) and national (SKAE) levels. This is a support mechanism for blood transfusion and public health using the infrastructure of HCDCP and the Ministry of Health. SKAE notifies the results of epidemiological surveillance to HCDCP and the National Blood Center. The Greek efforts in hemovigilance are based on voluntary participation, confidentiality and protection of personal data, education and an ongoing dialogue between the blood services and clinical departments as well as all stakeholders in blood donation and transfusion therapy. SKAE is a founding member of the European (and now International) Hemovigilance Network, and co-ordinates and administers the international surveillance database for adverse reactions associated with transfusion and donation (International Surveillance of Transfusion Associated Reactions; ISTARE). SKAE has worked systematically to present the epidemiological situation of blood-transmitted infections and has recommended corrective and preventive measures in order to improve blood safety. In particular, it has highlighted the value of analysis of chronological trends in the prevalence of infections depending on the frequency of blood donation and the quality indicators of the blood services. Hemovigilance for all unforeseen and adverse reactions and events associated with transfusion has led to recommendations for the assignment of a unique code to each patient admitted to a hospital and its use for patient identification in all medical procedures and blood transfusion. Moreover, SKAE recommends that a blood order form be completed and the patient’s details be confirmed prior to transfusion at the clinic, as well as the use of computerized methods to prevent errors, both those leading to events (an incidence rate of 1:8,787 blood components) and to ‘near miss’ events (1:2,114). According to data collected by SKAE, human errors and failure of equipment account for 39% and 20%, respectively, of adverse events.

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Although this question is considered to be a routine one, please tell us how difficult it is (if it is) to maintain high levels of blood safety in a period of economic crisis? Have the general budget cuts in the public sector threatened or are they still threatening this sensitive domain of public health? Yes, the safety of blood has occasionally been threatened by shortages in reagents and consumables. Also, a reduced number of staff in the blood services for various reasons (voluntary retirement, early retirement, suspension, minimum recruitment, etc.), and a general feeling of insecurity about the future have sometimes had a negative effect on the efficiency of blood donation and transfusion. Concessions on matters of quality have sometimes been made, while blood centers have occasionally felt that the management is not as supportive as it should be. In these difficult times, what has saved the day is the solidarity among blood centers and the assistance of blood donors and the National Blood Center. Above all, the driving force has been the care for the patient who needs blood. Would you please allow us a personal question? With all the distinctions you have achieved, both in Greece and abroad, during your long career, what have you remembered most vividly? • Participation in the struggle for multi-transfused patients with thalassemia, who are trying to survive and to improve their health and their quality of life in collaboration with health professionals in treatment units and blood centers. • The long battle for the recruitment of blood donors. The recognition of my contribution in this domain by the associations of voluntary blood donors and my appointment as chairperson of the Organizing and Scientific Committee of the 14th Amphictyony in Zappeion in 2000 were a great honor and valuable experience. • The shock of AIDS in relation to blood safety. • My first time as a national representative for blood at the Council of Europe and the feeling that my name was directly linked with my country. • The 1995 meeting in Strasbourg for the provision of scientific and technical assistance to eastern and central European countries to restructure the blood donation system in those countries in order to ensure blood supply and safety. My appointment as head of the task force was a great responsibility for me. • The emotions felt by my colleagues and my husband when I received an award from the International Hemovigilance Network (IHN) in Brussels for my contribution to the work of blood safety nationally and internationally.

Edited by Philip Koukouritakis

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Myths and truths

22 Myths and truths about blood donation and transfusion Myths Blood donation can harm the body and make the donor weak.

Truths

Every healthy man or woman aged 18-65 years can safely give blood 2-4 times a year. Before each donation, a physician from the blood collection team examines the donor. There is a brief medical check-up by means of a questionnaire on the medical history, general health and lifestyle of the donor. The level of hemoglobin is checked (to rule out anemia), as well as blood pressure and heart rate. The general appearance of the individual is also taken into consideration, together with temperature and auscultation if necessary. If following this assessment they are considered to be fit to give blood, a sample of their blood will be tested for hepatitis B and C (HBV, HCV), acquired immune deficiency syndrome (AIDS; human immunodeficiency virus, HIV), T-lymphotropic virus (HTLV) and syphilis. A donor who is found to be positive for any of these infectious agents will be referred to specialists for further investigation and treatment. Therefore, blood donation is not only life saving for those who need blood but it can also be beneficial to the donor’s health if it leads to the early diagnosis of any infection or other diseases. Moreover, recent studies have shown that regular blood donors aged 43-61 years have a lower risk of developing heart disease, hypertension, diabetes, hypercholesterolemia and embolic episodes compared with non-regular donors. To replenish The donation of 450 mL of blood corresponds to removing 1/20 of the the volume and total volume of the donor’s blood. The body responds by activating a components of chain of natural mechanisms to restore it promptly. The replenishment blood given by the process begins immediately upon donation but takes a different length donor in a donation of time for each component. The blood volume is the first to be restored requires a long (usually within 10 minutes), with the aid of liquids consumed by the time, even months donor (usually a glass of orange juice). Plasma requires 24 hours for or years. complete restitution, platelets 72 hours and red blood cells 2-4 weeks, while iron requires 12 weeks in men and 16 weeks in women. Hence the recommendation to allow at least 3 months to elapse between two successive donations. By donating blood, The days when inadequately sterilized syringes and glass bottles were it is possible to used in blood collection are long gone. Today, all the materials that are contract AIDS or used in blood collection (syringes, needles, plastic bags, skin cleansers hepatitis or some and dressings) are sterile and disposable. Therefore, there is no risk of other contagious someone being infected by giving blood. disease through the syringes and needles that are used to collect the blood. Not every blood Blood transfusion services are prohibited by law from issuing blood for donation given by transfusion unless it has passed all the required control procedures. a donor is tested. Regulations for blood banks are very strict and apply to all European Some blood banks Union (EU) countries. Moreover, clinical departments in hospitals are allow blood to be prohibited from carrying out transfusions in the absence of the required transfused without data, which includes labels, determination of blood groups (ABO and the necessary RhD) and the results of testing for infections (HIV, HBV, HCV, syphilis testing. and HTLV).

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Because of all the tests that are performed, blood is absolutely safe for the patient to whom it is transfused.

It doesn’t matter whether or not one takes precautions, because the blood bank will always test the blood. Therefore the patient who receives the blood transfusion will not be endangered. Giving blood for a relative or friend means that the blood you give will be transfused to that particular patient.

During blood collection, the donor feels a constant pain from the prick of the needle.

It is true that, with the advancement of science and the implementation of blood screening, transfused blood is today safer than ever before. Unfortunately, it is impossible to eliminate all risks of transfusion, because hazards so far unknown to science may be present, such as a new virus, or another infectious agent that has not caused overt clinical symptoms in the donor (he or she may simply be a carrier) but may cause disease in the recipient. In some very rare cases, there could be inadvertent mistakes or unforeseen errors in the blood bank or the clinical department where the patient receives transfusion. Such adverse events can occur in any medical or other procedure that is subject to human error. For this reason, a new system of supervision and vigilance at all stages of the so-called ‘blood chain’, from the donor’s vein to the recipient’s vein, has been established in our country and elsewhere in the past 20 years. Blood donation is a very responsible act. The laboratory tests performed on blood donors are not sufficient to ensure the absolute safety of the blood transfused. For this reason, information and guidance is provided to prospective donors before they give blood. Donors should be rested, should not have smoked or eaten heavy fatty food, drunk alcohol or taken medicine, and they must read carefully the questions contained in the donor information sheet about their medical history and lifestyle. Of all the blood safety measures taken in our country and worldwide, the ‘safe and healthy’ behavior of the donor is considered to be the most important one. Issuing donors’ blood for transfusion is the sole responsibility of the blood transfusion services. Following regulations, the issuing of the existing blood supply is based on the patients’ need for blood. For this, the availability of the various blood groups plays an important role. Before each transfusion, blood group compatibility tests are run. Only when the compatibility of the donor’s and patient’s blood has been established may the blood be transfused. The Council of Europe and the World Health Organization (WHO) do not permit the transfusion of blood from a specific donor to a particular patient, partly because it presents organizational difficulties in blood banks but also for ethical and psychological reasons. People who are giving blood for the first time often feel somewhat anxious, but the prick of the needle only hurts during the first 2-3 seconds. People with difficult veins are rare exceptions to this. International surveys of blood donation and the reasons why one does or does not give blood demonstrate that those who regularly give blood do not mention the needle or the few minutes of time that they give up in order to donate blood. Rather, they attest that donation is good for them. They feel assured about their good health and are confident that the frequent check-ups that they undergo help to prevent diseases. But mainly, they talk about the mental well-being they feel because they are doing the ‘right’ thing by saving two or three patients who will receive the blood cells, plasma and platelets obtained from just the single unit of blood that they offer each time.

Dr Konstantina Politis, Head of EKEA

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News from the HCDCP’s administration

24 Outbreak news, October 2013 Middle East respiratory syndrome coronavirus (MERS-CoV) [1] Globally, from September 2012 to 4 November 2013, the World Health Organization (WHO) has been informed of a total of 150 laboratory-confirmed cases of infection with MERS-CoV, including 64 deaths. Affected countries in the Middle East include Jordan, Qatar, Saudi Arabia and the United Arab Emirates (UAE). France, Germany, Italy, Tunisia and the United Kingdom have also reported laboratory-confirmed cases; the patients were either transferred there for care of the disease or returned from the Middle East and subsequently became ill. In France, Italy, Tunisia and the United Kingdom, there has been limited local transmission among patients who had not been to the Middle East but had been in close contact with the laboratory-confirmed or probable cases. 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.

Polio [1, 2] As of 29 October 2013, following reports of a cluster of 22 acute flaccid paralysis (AFP) cases on 17 October 2013 in the Syrian Arab Republic, wild poliovirus type 1 (WPV1) has been isolated from 10 of the cases under investigation. Wild poliovirus had not been detected in the Syrian Arab Republic since 1999. Most of the patients are very young (below 2 years of age) and were un- or under-immunized. As of 1 October 2013, 175 cases of polio have been reported from Somalia since April 2013; these are the first wild poliovirus cases reported in Somalia since 2007. Fourteen polio cases have been reported from Kenya; these are the first wild poliovirus cases confirmed in Kenya since July 2011. Four cases have been reported from the Somali Region of Ethiopia; these are the first wild poliovirus cases reported in Ethiopia since 2008. Three cases have been reported in South Sudan.

Cholera [1] From 9 September to 28 October 2013, a total of 176 confirmed cases, including one death, of infection with Vibrio cholerae O1 Ogawa toxigen has been reported in Mexico. Of these, two are from the Federal District, 157 from the state of Hidalgo, nine from the state of Mexico, two from the state of San Luis Potosi and six from the state of Veracruz. This is the first local transmission of cholera recorded since the 1991-2001 cholera epidemic in Mexico. WHO does not recommend any travel or trade restrictions be applied to Mexico with respect to this event.

First meeting of ECDC National Focal Points (NFPS) Stockholm, 15-17 october 2013 The first meeting of the European Centre for Disease Prevention and Control (ECDC) National Focal Points (NFPs) for Communication took place from 15 to 17 October 2013, at ECDC in Stockholm, Sweden, and is planned to be held on a biennial basis. The meeting’s agenda was divided into three thematic areas, according to ECDC’s activities and its liaisons with European Union (EU) member states, and emphasis was given mainly to health communication. More specifically, the meeting focused on: • research for efficient/proper health communication practices • availability of tools and resources • development/strengthening of skills and expertise. Each topic was presented by both rapporteurs and ECDC staff, including working group activities/exercises and assessment reports. The aim of the meeting was to set a common ground for future co-operation between ECDC and new NFPs for Communication, emphasizing the needs of EU member states and, at the same time, the best ways of dealing with them. The results of this first meeting were productive, as specific objectives were defined. Among others: • to discuss the process of working together • to identify areas for mutual co-operation in the promotion of European public health in support of the goals set by the new EU initiative regarding serious cross-border threats to health, by strengthening core capacities, in particular risk/crisis communication as preparedness to respond to (public health) emergencies • to clarify the role of NFPs in co-operation with ECDC and the European Commission, under the Health Security Communications Network • to clarify the role of the NFPs.

References 1. World Health Organization (WHO). Available at: http://www.who.int/csr/don/ [accessed 5 November 2013] 2. Centers for Disease Control and Prevention (CDC). Available at: http://wwwnc.cdc.gov/ travel/ notices/outbreak-notices/ [accessed 5 November 2013]

Travel Medicine Office, Department for Interventions in Health Care Facilities

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26 Chief Editor:

Quiz of the month, November 2013 When was the first case of transmission of West Nile virus through blood transfusion published?

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

Associate Editors:

Ch. Hadjichristodoulou

P. Koukouritakis Μ. Fotinea

Scientific Board:

Editorial Board:

Ν. Vakalis Ε. Vogiatzakis P. Gargalianos- Kakoliris Μ. Daimonakou- Vatopoulou Ι. Lekakis C. Lionis Α. Pantazopoulou V. Papaevagelou G. Saroglou Α. Tsakris

R. Vorou E. Karatampani P. Koukouritakis Κ. Mellou D. Papaventsis Τ. Patoucheas V. Roumelioti V. Smeti Ch. Tsiara Μ. Fotinea Ε. Hadjipashali

Editors:

Graphic Design:

Τ. Kourea- Kremastinou HCDCP President T. Papadimitriou HCDCP Director

Ε. Lazana

Copy Editor:

P. Koukouritakis

HCDCP HELLENIC CENTER FOR DISEASE CONTROL & PREVENTION MINISTRY OF HEALTH

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MINISTRY OF HEALTH

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E bulletin HCDCP October 2013