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Hellenic Center for Disease Control and Prevention Agrafon 3- 5, Maroussi, 15123, Tel: +30 210 5212000, info@keelpno.gr, http://www.keelpno.gr August 2012

Contents:

2

Surveillance Data

8 11

European program

23

Recent publications

26

Interesting activities

27

Future conferences

28

Outbreaks around the world 30 Interview

31

Myths and truths

33

World day

37

News from the HCDCP’s administration

39

Quiz of the month

40

HCDCP HELLENIC CENTER FOR DISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH & SOCIAL SOLIDARITY

ISSN 1792-9016

Sexually Transmitted Diseases (STDs)

Editorial: Sexually Transmitted Infections in Greece

Invited articles

Vol. 18/ Year 2nd

Over the last 30 years there has been a significant outbreak of sexually transmitted diseases (STDs) in developed countries, a fact that is recognized widely as a major public health problem. The increase in STDs started during the 1960s and intensified through the course of the 1980s because of the newly emerging human immunodeficiency virus (HIV) infection. More than 30 years after the first HIV-positive cases, and despite the tremendous efforts made by health authorities, there is still a need for better control of STDs in today’s society. Apart from the traditional medical specialties, such as dermatologists and venereologists, a large number of other medical and paramedical specialties (health providers) participate in the struggle against this type of disease, and a large amount of money is allocated to scientific research in the field of STDs, primarily for HIV infection. This determined fight and consistent research during the past few years has resulted in progress in our knowledge regarding STDs beyond all expectations. Modern technology has helped the investigation of these diseases, especially at molecular and cellular levels, and has revealed the complexity and variety of the infections. On occasions these investigations have overthrown and/or consolidated theories on the pathogenic mechanisms, immune response and therapy of these diseases. In this issue of the HCDCP’s e-bulletin, we present the actions and interventions, and their co-ordination, undertaken concerning the three mandatory notifiable sexually transmitted infections in Greece: syphilis, gonorrhea and chlamydia. Maria Hatzivasileiou Pappa Edited by Philip Koukouritakis

Highlights Epidemiological data regarding sexually transmitted infections (STIs) are presented in the main article: an attempt is being made to realize the size of the problem. In recent years there has been a relative increase in reported cases in Greece, but interpretation of this needs to take into account the changes in the surveillance system of STIs. The data indicate that efforts should be intensified for both better notification of STIs and the prevention and control of this type of disease by targeted actions. More on page 2

In this issue the European Center for Disease Prevention and Control (ECDC) presents its activities regarding the co-ordination and surveillance of STIs and HIV through European networks. More on page 28

This issue of the HCDCP’s ebulletin presents an interview with Mrs Antoniou, Professor of Dermatology at ‘Andreas Syggros’ Hospital, in which she describes STIs as being ‘far from forgotten’. She also emphasizes the importance of STI notification and underlines the need for a more intensified epidemiological surveillance. Special attention should be paid to prevention because there have been no new discoveries in the field of therapy. More on page 40


Editorial

Editorial

Sexually Transmitted Infections: Epidemiological Surveillance Sexually transmitted infections (STIs) remain a serious public health issue. The main diseases that can spread through sexual contact are syphilis, gonorrhea, chlamydia, HSV II, trichomaniasis, bacterial vaginosis, HPV, hepatitis and human immunodeficiency virus (HIV) infection. Often the term STI is used instead of sexually transmitted disease (STD) in order to incorporate asymptomatic cases. In order to prevent further transmission of STIs, a change in sexual behavior and adoption of safer sex practices is needed.

performed by 67/88 (76%) public hospitals.

Laboratory diagnosis of syphilis

For the year 2010, screening tests for syphilis were performed by 116/143 public hospitals (81.1%). Confirmation of syphilis infection using two treponemal tests could be performed by 11 public hospitals. Nine public hospitals had the capacity to confirm early syphilis infection by performing IgM Abs.

According to international guidelines, interventions should include: A. information campaigns and health promotion for the general public and populations at most risk B. proper clinical and laboratory diagnosis C. therapeutic guidelines laboratory guidelines guidelines for partner notification services epidemiological surveillance and reporting to relevant authorities. In this main article of the newsletter, the new surveillance system for Greece is presented. Further information on the diseases can be found on the organization’s website.

Epidemiological surveillance of STIs Reporting is compulsory in Greece for syphilis, gonorrhea, congenital syphilis and chlamydia infections, including LGV. The Hellenic Center for Disease Control and Prevention (HCDCP) is responsible under law for epidemiological surveillance in Greece. The new surveillance system for STIs, established in 2009, actively collects data (case-based and aggregated) on cases of chlamydia, gonorrhea, syphilis, congenital syphilis and LGV. Data are collected from clinicians, laboratories and hospitals, in the public and private sectors. European Union (EU) 2008 case definitions are used. The new system is intended to be comprehensive but does not yet provide national coverage. Thus significant underreporting may exist, mainly from the private sector. Case-based report questionnaires and case definitions can be found on the organization’s website.

Review of laboratory diagnoses

In order to review laboratory diagnoses and obtain data from laboratories, 143 questionnaires have been sent to all public hospitals in Greece and a further 28 in private hospitals in the main Athens area. Response rates from the public health sector have reached 100%. In the first 6 months of 2012, the survey was repeated. The 2011 data will be available soon.

Epidemiological data of early syphilis (primary, secondary and early latent) In 2010, the total number of early syphilis cases reported by case-based format was 241. It should be noted that these numbers do not represent the total number of cases diagnosed in the country. There were cases diagnosed that did not meet the laboratory case definition and also cases that had been laboratory diagnosed but no case-based report was submitted and the clinical stage was missing. The data presented in this report are subject to change if new evidence is provided by reporting centers. Because of the introduction of the new surveillance system, data from more centers are expected to be reported in future years. Data reported per hospital and year of diagnosis are presented in Table 1. Since the beginning of the pilot project in ‘Andreas Syngros’ Hospital in 2003, an increase of 38% in reported early syphilis cases has been noticed. However, in 2010 there was a decrease of 8% in reported cases compared with 2009 from this source.

Table 1: Early syphilis cases by reporting hospital and year of diagnosis Year of diagnosis

Pilot project on epidemiological surveillance ‘Andreas Syngros’ Hospital* STI clinic

Hospital for Venereology and Dermatology Diseases, Thessaloniki

116

116

2004

103

103

2005

139

139

2006

141

141

2007

197

197

2008

155

39

2009

174

53

32

259

2010

160

46

35

241

194

*The pilot project on STI surveillance was implemented by the A’ Venereology and Dermatology Clinic in ‘Andreas Syggros’ Hospital. The project was funded by the HCDCP.

Most cases in 2003-2010 were reported in men (Figure 1).

Laboratory diagnosis of gonorrhea infections

In 2010, laboratory diagnosis of gonorrhea infections was performed by 88/143 (61.5%) public hospitals; 21/88 public hospitals (24%) only used the Gram stain for diagnosis (it should be noted that the Gram stain met the case definition for confirmed cases only in an urethral male specimen). In 2010, laboratory diagnosis of gonorrhea by culture was 2

Total number of reported cases

2003

Laboratory diagnosis of chlamydia infections

Laboratory diagnosis of chlamydia infections was performed by 65/143 public hospitals (45%). Laboratory diagnosis using NAATs was performed by 8/65 public hospitals (12.3%). Laboratory diagnosis of chlamydia infections using DFA tests was performed by 13/65 public hospitals (20%). Laboratory diagnosis in the rest of the public hospitals, 44/65 (67.6%), was performed using other diagnostic tests, mainly EIAs.

Other sources

3


Editorial

Editorial

Figure 1: Reported cases of early syphilis from the STI clinic in ‘Andreas Syngros’ Hospital by gender and year of diagnosis

Dermatology Hospital in Thessaloniki were reported in a case-based format. Data from the laboratories of ‘Andreas Syngros’ Hospital and Tzaneio Hospital were reported in aggregated format and distributions by age, gender and transmission category. From the rest of the public hospital data, only the total number of cases with a distribution by gender were reported. Retrospective data for the years 1990-2009 were reported to NRCG mainly from the two venereology and dermatology hospitals in Athens and Thessaloniki; reporting remained low from other hospitals during that period. Data from NRCG were reported to HCDCP in an aggregated format with distribution by age, gender and transmission category. All cases reported from both NRCG and HCDCP met the EU 2008 case definitions that are used by the new surveillance system. As seen in Table 3, a total of 312 cases was reported in 2010, an increase in number of cases compared with those reported in previous years. This increase was due in part to the increased number of cases reported by the two venereology and dermatology hospitals but mainly to the increased number of cases reported to HCDCP from other sources, because HCDCP communicated actively with all public hospitals in order to increase reporting. In conclusion, the change in the surveillance system that was implemented by HCDCP in 2010 has led to an increased number of reported cases of gonorrhea. It should be mentioned, however, that as underreporting from the private sector exists, the true number of gonorrhea cases diagnosed in Greece might be higher than indicated.

In Table 2, the reported numbers of early syphilis cases in 2010 are presented by age, gender and transmission category. From the total of 241 cases, 209 were men (86.7%) and 32 women (13.3%). In male cases where the transmission category is known, 58.8% were MSM. The largest number of cases belonged to the age category 25-34 years for both genders.

Table 2: Total number of early syphilis cases reported in 2010, by gender, age group and transmission category Age group

Men

Women Total

Table 3: Total number of cases reported in Greece between 1990 and 2011 by year of diagnosis and reporting center

Year of diagnosis

Pilot project on epidemiological surveillance, ‘Andreas Syngros’ Hospital* STI clinic

Hospital for Venereology and Dermatology Diseases, Thessaloniki

Other sources

Total number of reported cases

1990

85

23

0

108

1991

79

38

0

117

1992

94

48

1

143

1993

100

37

0

137

1994

76

56

1

133

1995

82

35

0

117

1996

68

28

0

96

1997

62

29

0

91

1998

100

46

1

147

Heterosexual contact

MSM

Unknown

Heterosexual contact

0-4

0

0

0

0

0

5-14

0

0

0

0

0

15-19

0

0

0

1

1

20-24

7

11

0

6

24

25-34

27

51

2

10

90

1999

95

29

0

124

35-44

23

32

0

7

62

2000

70

28

0

98

45-64

18

16

2

5

41

2001

135

42

0

177

65+

5

2

1

1

9

2002

118

26

0

144

Άγνωστο

0

2

10

2

14

2003

105

13

1

119

Total

80

114

15

32

241

2004

138

38

1

177

2005

164

28

5

197

2006

154

30

6

190

Epidemiological data on gonorrhea

2007

150

41

10

201

In Table 3, the data presented include a) 2010 gonorrhea cases reported directly to HCDCP and b) retrospective data for 1990-2009 reported to HCDCP by the National Reference Center for Gonorrhea (NRCG) where originally reported during that period.

2008

145

53

10

208

2009

150

6

8

164

2010

178

29

105

312

2010

The 2010 cases were reported from all public hospitals. Data from the Venereology and

4

5


Editorial

Editorial

Cases for 2010 were reported directly to HCDCP. 1990-2009 cases were reported to HCDCP by NRCG and the Hellenic Pasteur Institute. As mentioned, in 2010 the number of gonorrhea cases was 312. In 46 cases the gender was unknown. In the 266 cases where gender was known, 260 (97.7%) were men and only six cases were women. For male cases where the transmission category was known 74.5% were heterosexual men. The largest number of reported cases in men belonged to the age category of 25-34 years. (Table 4).

Table 4: Total number of gonorrhea cases by gender, age group and transmission category Men

Women

Heterosexual contact

MSM

Unknown

Heterosexual contact

Total*

0-4

0

0

0

0

0

5-14

0

0

0

0

0

15-19

2

0

0

0

2

20-24

27

10

0

0

37

25-34

58

30

1

0

89

35-44

36

10

0

0

46

45-64

28

2

0

1

31

65+

4

0

0

0

0

Unknown

0

1

51

5

103

Total

155

53

52

6

312

Age group

2010

Table 5: Aggregated data on cases that met the case definition, by reporting hospital and year of diagnosis ‘Elena Venizelou’ Hospital

Year of diagnosis

‘Andreas Syggros’ Hospital

2008

71

Total number of cases reported

2009

64

35

211

327

2010

72

44

541

657

71

Vasileia Konte, Ornella Gotzani, Maria Gouletsa, Dimitra Paraskeva, HIV & STI Office

*This value includes cases where the gender is unknown.

Epidemiological data on chlamydia infections The total number of chlamydia cases that met the case definition are presented in Table 5 by reporting hospital. The data were provided by laboratory surveillance. The data provided by the laboratories in ‘Andreas Syngros’ Hospital and ‘Elena Venizelou’ Hospital were reported in aggregate format with distributions by gender, age group and transmission category. The rest of the laboratories only reported the total number of cases diagnosed, with distribution by gender in some reports. The response rates from public hospitals reached 100%. The total number of cases in 2010 that met the case definition reached 657. Another 330 cases that did not meet the case definition for laboratory diagnosis were reported. It should be noted that the change in surveillance system led to an increase in the number of reported cases mainly because of inclusion of data from other sources. In 2010, from the 657 cases that met the case definition, gender was known for only 417 cases (63.4%). For cases where gender was known, 336 were women (80.6%). The age group was reported for only 117 cases (17.7%).

6

Other public hospitals

7


Surveillance data

Surveillance data

Cholera

1 0 3 3,5 3,5 5 0 0 0 0

0 0 1 0 1 1 0 0 0 0

18 2 9 9 10 9 2 0 0 0

38 14 0 2 0 0 0 0 73 12 0 0 0 0 10 0 0 0 0 46

28 16,5 1 3 0 0,5 0 0 149,5 5 0 0 0 0 11 0,5 0 0 1 51

20 8 0 1 0 0 0 0 40 0 0 0 0 0 6 0 0 0 0 28

62 30 5 7 0 2 0 1 326 21 0 0 1 1 22 5 0 0 9 121

0

0

0

0

8

3 0 0 3 3 0 1

9 5 0 16 0 2 13

1 1 0 1 0 1 1

2 1 0 1 0 0 1

2 1 1 1 1 0 1

0 12 0 1 0 0 2 3 0 2 1 1 2 2

Unknown

0 0 12 5 2 3 2 1 0 0

Crete

12

0 0 0 0 0 0 1 0 0 0 0

Southern Aegean

0

2 0 0 1 1 0 0 0 1 0 0

Northern Aegean

1,5

0 0 0 0 0 0 0 0 1 0 0

Peloponnese

0

6 0 0 0 0 0 0 0 0 0 1

Attica

20

4 0 0 1 0 2 0 0 1 0 0

Sterea Greece

1

0 0 0 1 0 1 0 0 0 0 0

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

Western Greece

4

Ionian islands

Hepatitis C, acute&confirmedanti− HCVpositive (1st diagnosis) Measles Haemorrhagic fever Pertussis Legionellosis Leishmaniasis Leptospirosis Listeriosis EHEC infection Rabies Melioidosis/Glanders Meningitis aseptic bacterial (except meningococcal disease) unknown aetiology 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 Tularaemia Trichinosis Typhoid fever/Paratyphoid Tuberculosis

2

Region

Thessalia

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

0 0 0 21 0 0 12 0 0 1 14

Number of notified cases

Epirus

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

Disease

Western Macedonia

August 2012

Number of notified cases Median Max Min number number number August August August 2004-2011 2004−2011 2004-2011 0 0 0 0 0 3 0 0 1 18 5 35 0 0 0 0 0 0 6 5 13 0 0 0 0 0 0 0,5 0 6 3,5 2 46

Central Macedonia

Disease

Table 2: Number of notified cases by place of residence (region)*, Mandatory Notification System, August 2012.

Eastern Macedonia and Thrace

Table 1: Number of notified cases in August 2012, media number of notified cases in August for the years 2004−2011 and range, Mandatory Notification System, Greece.

3 0 0 8 0 0 0 0 0 0 0

1 0 0 0 0 0 0 0 0 0 0

1 4 1 3 1 8 4 2 0 1 0

3 6 0 0 0 1 0 0 0 1 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 0

0 2 0 0 0 0 0 0 0 0 0

2 0 1 3 1 0 2

4 1 0 28 5 2 13

2 1 0 4 0 0 4

1 0 0 5 0 1 0

0 0 0 2 0 0 0

0 1 0 3 0 2 2

0 2 0 1 0 0 4

* place of residence is defined according to home address of cases

Table 3: Number ofnotified cases by age group and gender*,Mandatory Notification System, Greece, August 2012. Disease

Brucellosis Malaria Echinococcosis Hepatitis Α Hepatitis B, acute &HBsAg(+) in infants< 12 months Pertussis Legionellosis Leishmaniasis Leptospirosis Listeriosis EHEC infection Meningitis aseptic bacterial (except meningococcal disease) Meningococcal disease Salmonellosis (non typhoid/ paratyphoid) Shigellosis

Number of notified cases by age group (years) and gender <1 M F 0 0 0 0 0 0 0 0

1−4 M F 0 0 0 0 0 0 1 3

5−14 15−24 25−34 M F M F M F 1 2 0 0 6 0 0 0 5 0 4 0 0 0 0 0 0 0 3 3 0 0 1 1

35−44 45−54 55−64 65+ Unkn. M F M F M F M F M F 2 0 5 1 1 0 3 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 1 0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

1

0

0

0

0 0

3 0 0 0 0 0

8 0 0 0 0 0

0 0 1 0 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 1 0 0 0 0

0 0 0 1 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 1 0 0 0

0 1 0 0 0 0

0 0 0 1 0 0

0 0 0 0 0 0

0 2 0 1 1 1

0 1 0 0 1 0

0 0 0 0 0 0

1

0

4

0

10

5

3

5

2

2

1

2

0

2

0

0

1

0

0 0

2

0

0

0

1

1

1

0

1

0

1

1

0

0

0

1

3

2

0 0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

0 0

10

3

15

2

6

9

2

6

3

1

0

3

0

1

1

5

2

4

0 0

2

2

1

2

1

2

0

1

0

0

0

0

0

0

0

0

0

1

0 0

9

0 0 0 0 0 0


Surveillance data

Invited articles

Hellenic Center for Diseases Control and Prevention (HCDCP). Forty five (45) infectious diseases are included in the list of the mandatory notified diseases in Greece. Notification forms and case definitions can be found at the website of HCDCP (www.keelpno.gr). It should be noted that data for August 2012 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 under-reporting to the system.

West Nile Virus infection From the beginning of 2012 until 05/08/2012, 118 laboratory diagnosed cases of WN infection have been reported to KEELPNO and 7 deaths, of which 81 presented with neuro-invasive disease (encephalitis and/or meningitis and/or acute flaccid paralysis) and 37 cases with mild symptoms (febrile syndrome). One imported case of WNV infection was diagnosed in Greece in June 2012. It refers to a young boy from USA.

Department of Epidemiological Surveillance and Intervention

Surveillance of gonococcal resistance to antimicrobials: the National Reference Center for Neisseria gonorrhoeae Neisseria gonorrhoeae is prone to developing antibiotic resistance because of its genetic properties, mainly its natural competence for genetic transformation and homologous recombination. DNA exchange with other neisseriae through this process generates genetic diversity for many gonococcal characteristics, including susceptibility to antimicrobial agents [1]. The gonococcus is therefore a prominent example among bacterial species that, although endogenously susceptible, has rapidly developed resistance to all clinically available antibiotics. Genetic determinants of resistance are localized on the chromosome, conjugative transposons or plasmids, originating from either mutations on the gonococcal genome or the acquisition of exogenous genetic material through horizontal DNA transfer (bacterial conjugation or transformation). Among the mechanisms responsible for gonococcal resistance, some affect one class of antibiotics specifically (e.g. penicillinase production), while others, such as the impaired permeability of the outer membrane and the derepression of the gonococcal efflux pump, are non-specific, affecting different antibiotic classes. Moreover, distinct mechanisms of specific and non-specific resistance are likely to coexist [2,3]. The various mechanisms of resistance already described in N. gonorrhoeae are summarized in Table 1. Table 1: Antibiotic resistance mechanisms in N. gonorrhoeae* Genetic mechanism

Biochemical mechanism

Penicillin G  Acquisition of penicillin-resistance Production of ΤΕΜ-1 plasmids penicillinase

 Mutation on penA gene on the chromosome

Structural modification of penicillin-binding protein 2 (PBP-2), reducing its affinity for penicillins

Resistance phenotype

PPNG strains, Pen MIC as high as >256 mg/L

CMR strains, Pen MIC 2–8 mg/L

Tetracycline  Acquisition of the conjugative Tet-M plasmid harboring the tetM gene

Ribosome (30S-50S) protection TRNG strains, from tetracyclines Tet MIC 4–128 mg/L

Macrolides  Acquisition of conjugative transposons carrying ermF or ermB genes  Acquisition of conjugative transposons carrying mef

23S rRNA protection through the production of erythromycin ERNG strains, high-level methylase resistance to Ery (MIC up to 128 mg/L) Activation of a macrolidespecific efflux pump

Spectinomycin  Chromosomal mutations

Structural modification of the ribosome (30S)

Spe MIC ≥128 mg/L

Structural modification of the fluoroquinolone targets (gyrase A and topoisomerase IV)

QRNG strains, Nal MIC >128 mg/L, Cip MIC ³1–>32 mg/L

Fluoroquinolones  Mutations in gyrA and parC genes on the chromosome

10

11


Invited articles

Invited articles

 Recombination of penA genes with homologous genes from other neisseriae

Synthesis of mosaic-structured CDS strains, PBP-2s with reduced affinities decreased susceptibility for 3GC to Ctx, Cfx, Cro

Non-specific chromosomal resistance  Mutations on por (penB) gene

Reduced permeability of the outer membrane impeding the entrance of antibiotics in the cell

 Mutations on the mtrR-mtrCDE operon

Derepression of the gonococcal CMR strains, Pen, Tet, Ery, MTR efflux pump Chl MIC 1–8 mg/L

CMR strains, Pen, Tet MIC 1–8 mg/L

Abbreviations: Pen, penicillin; Tet, tetracycline; Ery, erythromycin; Spe, spectino-mycin; Nal, nalidixic acid; Cip, ciprofloxacin, Ctx, Cfx, Cro, cefotaxime, cefixime, ceftriaxone, respectively; Chl, chloramphenicol. For the international abbreviations of resistance phenotypes, see Figure 1. *The content of this table originates from a literature review [2].

Epidemiologic control of gonorrhea requires rapid diagnosis and immediate administration of therapy, in order to minimize disease transmissibility. As a consequence, in symptomatic and easily diagnosed cases, such as those of male gonococcal urethritis, empirical treatment is usually given, relying on available epidemiological data concerning the resistance of gonococci circulating in the community. This information should be provided continuously through monitoring antimicrobial susceptibility trends in N. gonorrhoeae. Surveillance programs that detect drift in susceptibility and the emergence of resistance are then imperative and should be organized at international and, most importantly, regional and local levels [4,5].

In Greece, surveillance of gonococcal susceptibility is conducted by the National Reference Center for N. gonorrhoeae (NRCNG), implemented in the Laboratory of Bacteriology of the Hellenic Pasteur Institute in 1987 (http://www.pasteur.gr). In 2002, the NRCNG was linked to the European Network for Surveillance of Sexually Transmitted Diseases (ESSTI) and since 2009 has been nominated to represent Greece in the gonococcal microbiology project guided by the ECDC. The activities of the NRCNG include the following.

• •

• • • •

Keeping the Greek medical community up to date regarding the antimicrobial susceptibility trends of N. gonorrhoeae in Greece through presentations and publications and the website of the Hellenic Pasteur Institute. • Laboratory training of scientists and technologists, as well as supervision of PhD students, in the field of gonococcal resistance to antibiotics. •

Third-generation cephalosporins (3GC)

Receiving gonococcal isolates and/or patient data from gonococcal infections or even simple reports of gonorrhea cases diagnosed in Greek hospitals and other health care units. Patients’ data are received in a standardized questionnaire provided by NRCNG for collecting demographic and disease-associated information that facilitate monitoring resistant strains in the population. The gonococcal isolates are registered in the consecutive strain collection maintained by the NRCNG, which today holds approximately 5,000 characterized isolates. Typing of gonococcal strains by using conventional and molecular methods (serotyping, auxotyping, plasmid content analysis, PFGE and, when indicated, NG-MAST and MLST). Antimicrobial susceptibility testing by the determination of minimal inhibitory concentrations (MIC) of currently recommended and other antibiotics used in gonorrhea therapy (thirdgeneration cephalosporins, fluoroquinolones, spectinomycin, macrolides, penicillin G, tetracycline, chloramphenicol). Characterization of emerging or widely spread resistance mechanisms identified among gonococci circulating in Greece. Maintenance of a database including microbiological and epidemiological data for gonococcal isolates and the respective gonorrhea infections. Reporting to the Greek Ministry of Health annually. Providing ECDC with microbiologic and epidemiological data on gonococcal susceptibility in Greece.

12

Table 2: presents the results of antimicrobial susceptibility testing of gonococci received by NRCNG during the year 2011.

Antibiotics (number of strains tested) Penicillin G (n=144)

Cefotaxime (n=89)

Cefixime (n=95)

Ceftriaxone (n=105)

Susceptibility categories (classification criteria)*

Plasmid-mediated resistance –PPNG (penicillinase production) Chromosomal resistance (ΜIC >1 mg/L) Intermediate susceptibility Susceptibility (MIC £0.064 mg/L) Decreased susceptibility –CDS (MIC >0.125 mg/L) Susceptibility (MIC £0.125 mg/L) Decreased susceptibility –CDS (MIC >0.125 mg/L) Susceptibility (MIC £0.125 mg/L)

No. (%) of strains

Etest MIC values (mg/L)

13 (9.0)

3->32

38 (26.4)

1.5-4

80 (55.6) 12 (8.3)

0.094-1 ≤0.008-0.047

31 (34.8)

0.19-0.75

58 (65.2)

≤0.002-0.125

3 (3.1)

0.19

92 (96.8)

≤0.016-0.125

Decreased susceptibility –CDS (MIC >0.125 mg/L) Susceptibility (MIC £0.125 mg/L)

0

105 (100)

≤0.002-0.125

Spectinomycin (n=144)

Resistance (MIC >64 mg/L) Susceptibility (MIC £64 mg/L)

0 144 (100)

– 2-24

Tetracycline (n=144)

Plasmid-mediated resistance –TRNG (detection of the tetM gene) Chromosomal resistance (MIC >1 mg/L) Intermediate susceptibility Ευαισθησία (MIC £0.25 mg/L)

27 (18.8)

6-24

46 (31.9)

1.5-4

49 (34.0) 22 (15.3)

0.38-1 ≤0.016-0.25

Erythromycin (n=113)

Resistance –CMR (MIC >1 mg/L) Intermediate susceptibility Susceptibility (MIC £0.25 mg/L)

40 (35.4) 47 (41.6) 26 (23.0)

1.5-4 0.38-1 ≤0.016-0.25

Azithromycin (n=68)

Resistance –CMR (MIC >0.5 mg/L) Intermediate susceptibility Susceptibility (MIC £0.25 mg/L)

6 (8.8) 24 (35.3) 38 (55.9)

0.75 0.38-0.5 ≤0.016-0.25

Chloramphenicol (n=144)

Resistance –CMR (MIC >1 mg/L) Intermediate susceptibility

94 (65.3) 41 (28.5)

1.5-12 0.38-1

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Ευαισθησία (MIC £0.25 mg/L)

9 (6.2)

≤0.016-0.25

Norfloxacin (n=144)

Resistance –QRNG (MIC >0.5 mg/L) Susceptibility (MIC £0.25 mg/L)

113 (78.5) 31 (21.5)

2-64 £0.016-0.047

Ciprofloxacin (n=144)

Resistance –QRNG (MIC >0.5 mg/L) Intermediate susceptibility –QRNG Susceptibility (MIC £0.064 mg/L)

112 (77.8) 1 (0.7) 31 (21.5)

0.75->32 0.5 £0.002-0.023

*Susceptibility categorization of the isolates was based on EUCAST breakpoints for penicillin, cephalosporins, spectinomycin and azithromycin, on CLSI for tetracycline and ciprofloxacin, and on generally accepted criteria for erythromycin, norfloxacin and chloramphenicol.

For most of the antibiotics examined, including fluoroquinolones, the isolation frequencies of resistant gonococci in the Greek community greatly exceed the 5% percentage that is globally acceptable as a ‘cut-off’ for the safe prescription of an antibiotic in empirical gonorrhea therapy [3,5]. Antibiotics meeting this criterion were spectinomycin, although this is not commercially available in Greece, and, among the third-generation cephalosporins (3GC) examined, ceftriaxone and cefixime. However, concerning 3GC it should be noted that their effectiveness in the future could be jeopardized by the wide dissemination of strains with decreased susceptibility to cephalosporins (CDS). The reduced susceptibility of these strains is not equally obvious in all 3GC but reveals the presence of the underlying mechanism of resistance to all cephalosporins, including those that are nowadays recommended as firstline therapy for gonorrhea. As shown in Figure 1, presenting the full susceptibility patterns of isolates, CDS strains exhibited multiresistant phenotypes and were the most frequently isolated gonococcal strain types during the year 2011. Figure 1: Distribution of gonococci isolated during 2011 (n=144) into susceptibility phenotypes. Resistance patterns of the isolates Susceptibility Phenotypes of Gonococci isolated in Greece during the year 2011 Q-CMR-CDS 42%

QR 2%

Q-CMR 16%

PP 2%

CMR 3.5%

I/S 13%

TR/QR 12%

S 3%

With a few exceptions, CDS gonococci isolated in Greece have been allocated to the same serovar (Bpyut), while those that have been genotyped up to now have shared similar molecular types (NG-MAST ST3127 and ST3128, MLST ST1901 and ST 1900, respectively), with those that emerged first in Greece (two isolates in Thessaloniki, December 2006) indicating that the high isolation frequencies of CDS gonococci during the subsequent years is mainly the result of the spread of clonally related strains [6-8]. The situation depicted by the above susceptibility data is not restricted to Greece; in fact, it reflects global resistance trends of N. gonorrhoeae and is a cause of concern

throughout the world. The emergence and spread of multiresistant CDS gonococci during the last decade raises the alarm for the risk that gonorrhea will become an untreatable disease in the near future. Of the possible solutions discussed, the re-evaluation of current regimens by recording treatment failures or the return to previous therapeutic choices, such as spectinomycin and gentamicin, seem to be the most realistic. In the meantime, enhanced surveillance of the gonococcal susceptibility trends, as well as informed management of the antibiotics that are still effective against gonorrhea, is unanimously advised [3-5].

References:

PP/TR/QR 7%

PMR 21%

PMR, plasmid-mediated resistance PP, plasmid-mediated resistance to penicillin –PPNG (penicillinase-producing N. gonorrhoeae) strains TR, plasmid-mediated resistance to tetracycline –TRNG strains QR, resistance to fluoroquinolones –QRNG strains CMR, chromosomally mediated resistance to one or more of the antibiotics penicillin, tetracycline, erythromycin or azithromycin, and chloramphenicol Q-CMR, multiresistant phenotypes combining QR and CMR resistance μη-ειδικής χρωμοσωματικής αντοχής και αντοχής στις νεότερες κινολόνες Q-CMR-CDS, multiresistant phenotypes also exhibiting decreased susceptibility to the newer cephalosporins –CDS strains I/S, intermediate susceptibility to one or more antibiotics/susceptibility to the rest S, susceptibility to all antibiotics tested Note: The percentage of 42%, corresponding to the isolation frequency of multiresistant CDS strains, includes a few isolates that exhibited marginal MIC of 3GC (0.125 mg/L) and should not have been considered as CDS according to the current breakpoints set by EUCAST for this phenotype (MIC >0.125 mg/L); however, these isolates were included because they shared identical pheno- and genotypes with those of the main CDC clone gathered in this sector of the graph.

1. Hamilton HL, Dillard JP. Natural transformation of Neisseria gonorrhoeae: from DNA donation to homologous recombination. Mol Microbiol 2006;59:376-385. 2. “Τζελέπη Ε. Αντοχή στα αντιβιοτικά στη Neisseria gonorrhoeae. Κλινικά Φροντιστήρια τόμος 17 (τεύχος 3), σελ. 91–115, Εκδόσεις Ιατρικής Εταιρείας Αθηνών, Αθήνα 2005.” 3. Tapsall JW, Ndowa F, Lewis DA, Unemo M. Meeting the public health challenge of multidrug and extensively drug-resistant Neisseria gonorrhoeae. Expert Rev Anti Infect Ther 2009;7:821-384. 4. Dillon JR. Sustainable antimicrobial surveillance programs essential for controlling Neisseria gonorrhoeae super bug. Sex Transm Dis 2011;38:899-901. 5. Ison CA. Antimicrobial resistance in sexually transmitted infections in the developed world: implications for rational treatment. Curr Opin Infect Dis 2012;25:73-78. 6. Tzelepi E, Daniilidou M, Miriagou V, et al. Cluster of multidrug-resistant Neisseria gonorrhoeae with reduced susceptibility to the newer cephalosporins in Northern Greece. J Antimicrob Chemother 2008;62:637-639. 7. Tzelepi E, Avgerinou H, Flemetakis A, et al. Changing figures of antimicrobial susceptibility and

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serovar distribution in Neisseria gonorrhoeae isolated in Greece. Sex Transm Dis 2010;37:115120. 8. Mavroidi A, Tzelepi E, Siatravani E, et al. Analysis of emergence of quinolone-resistant gonococci in Greece by combined use of Neisseria gonorrhoeae multiantigen sequence typing and multilocus sequence typing. J Clin Microbiol 2011;49:1196-1201.

Eva Tzelepi, National Reference Center for Neisseria gonorrhoeae, Laboratory of Bacteriology of the Hellenic Pasteur Institute, Athens

Laboratory diagnosis of gonorrhea, syphilis and Chlamydia trachomatis infections Gonorrhea Gonorrhea is caused by Neisseria gonorrhoeae. Samples are taken from the anterior portion of the male urethra and the endocervix of the uterus, or the posterior pharynx, the tonsils and the rectum in cases of orogenital or anal intercourse. Laboratory diagnosis is based on the following. 1. Microscopy of a direct smear of the discharge stained with Gram stain reveals Gramnegative diplococci within polymorphonuclear leucocytes. The sensitivity of the microscopy is highest in urethral samples in men, reaching 90–95%, whereas for endocervical smears sensitivity drops to 30–50%. In asymptomatic patients sensitivity is extremely low (20%). 2. Culture of N. gonorrhoeae requires the use of agar enriched with blood or hemoglobin and several agents such as glucose, amino acids and antibiotics (colistin, vancomycin, nystatin, etc.), to suppress the growth of commensal neisseriae, and Gram-positive and Gram-negative bacteria and fungi. These selective media are modified Thayer Martin medium, New York City medium (NYC), GC-Lect medium and Martin Lews (ML) medium. Plates should be incubated at 35° to 37°C with 3–7% CO2 in a moist atmosphere for 24–48 hours. Identification of the growing colonies is based on the oxidase test and carbohydrate utilization assays. Identified colonies can be tested for antibiotic susceptibility and typing. 3. Enzyme immunoassays (EIAs) can be used for quick identification of gonococcal urethritis with good sensitivity and specificity. These tests lack sensitivity and specificity when used for cervical, pharyngeal and rectal samples. 4. Nucleic acid detection methods enable the detection of N. gonorrhoeae from clinical samples without the requirement of bacterial viability. These are the nucleic acid amplification tests (NAATs) that are used in pharyngeal and rectal samples, with greater sensitivity than cultures.

Syphilis Syphilis is an infectious systemic illness caused by Treponema pallidum subspecies pallidum. It is sexually transmitted or acquired by passage through the placenta (congenital syphilis). Laboratory diagnosis is based on: (a) direct examination of mucocutaneous lesions of the genitalia or lymph nodes for the detection of T. pallidum, and (b) serologic tests for the detection of non-treponemal and specific treponemal antibodies in serum and cerebrospinal fluid (CSF).

Direct examination Treponema pallidum can be demonstrated in serous transudate from moist lesions (primary chancre, condylomata latum or lymph nodes) with dark-field microscopy; the characteristic corkscrew appearance and spiraling motion of T. pallidum differentiates it from commensal treponemas found on lesions. With dark-field microscopy it is impossible to differentiate T. pallidum from subspecies of the same family, such as T. perternue, T. endemicum and T. carateum. When looking for T. pallidum in oral lesions it should be noted that it is impossible to differentiate it from T. denticola. The direct fluorescent antibody test for T. pallidum (DFATp) requires the same methods of sampling and uses fluorescein isothiocyanate (FITC)conjugated monoclonal or polyclonal antibodies. This method is recommended for oral and rectal lesions. The sensitivity of DFA-Tp reaches 100% when lesions are recent. Recent technology is based on conventional or real-time polymerase chain reactions (PCR and RTPCR) for detecting T. pallidum DNA, but these methods are only used by selected reference laboratories. 16

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Serological tests Serological tests for syphilis are subdivided into (a) non-treponemal and (b) treponemal assays. Both can be applied to serum and CSF if there is central nervous system (CNS) involvement. All these assays are diagnostic of the stages of syphilis (except for the first 30-35 days of infection) and are useful for determining the efficacy of treatment. The standard non-treponemal tests used today are: VDRL (venereal disease research laboratory) RPR (rapid plasma reagin) USR (unheated serum reagin) TRUST (toluidin red unheated serum test). Non-treponemal tests use a cardiolipin-based antigen to detect antibodies against lipoidal antigens that are secreted by the destruction of the cells of the infected subject, and the cardiolipin that is secreted by the treponema. Non-treponemal tests are easy to perform in a large number of samples and are essential for determining the efficacy of treatment.

• • • •

(4) Nucleic acid amplification methods (NAATs) are the most sensitive tests today and can be used for large groups of symptomatic and asymptomatic patients. NAATs that are approved for diagnostic use are: Roche Amplicor Aptima, Gen Probe BD Probe Tec SDA Gobas TaqMan ABBOTT m 2000 BD ProbeTec These methods have a sensitivity of between 90.3% and 97% and a specificity between 98% and 99.1%. The diagnosis of lymphogranuloma venereum is based on in-house NAATs. The method of choice is Quadriplex RTPCR, which detects Chlamydia trachomatis serovars L1-L3 and D-K because co-infection is very often encountered.

Treponemal serological tests use Nichol’s antigen to detect specific antibodies. The commercially available treponemal tests today are as follows. 1. FTA-Abs (fluorescent treponemal antibody-absorption) and the related FTA-Abs-Ds (fluorescent treponemal antibody absorption - double staining) −FITC-conjugated antihuman immunoglobulin is used to detect antibody-labeled organisms. 2. TPHA (Treponema pallidum hemagglutination assay) and the modified passive hemagglutination tests MHA-Tp (micro-hemagglutination assay for antibodies to Treponema pallidum) as well as the TPPA (Treponema pallidum agglutination test). 3. Enzyme immunoassays (EIA) for the detection of IgG and IgM antibodies. All the treponemal tests confirm the findings of the non-treponemal methods and confirm the diagnosis of late latent syphilis. These tests are not treatment dependent and remain reactive for a lifetime despite the course of the illness. References:

Chlamydia infections The genus Chlamydia includes Chlamydia trachomatis:

1. Elias J, Frosch M, Bogel N. Neisseria gonorrhoeae. In: Manual of Clinical Microbiology, 10th edn, Chapter 32. ASM, 2012;559-571.

a. serovars A,B,B1,C, the cause of trachoma

2. Martin IM, Ison CA, Aanensen DM, et al. J Infect Dis 2004;189:1497-1505.

b. serovars D–K, the agent that causes urogenital infections

3. Tramont EC. Treponema pallidum (Syphilis). In: Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, Vol. 2, 7th edn. Churchill Livingstone, 2010;3035-3053

c. serovars L1, L2, L3, which cause lymphogranuloma venereum. Laboratory diagnosis is based on the detection of intracellular Chlamydia in the epithelial cells of the host with the following methods.

4. IUSTI/WHO European STD Guidelines Editorial Board. 2008 European Guideline on the Management of Syphilis. IUSTI/WHO, 2008.

(1) Isolation in cell culture, which was the reference diagnostic method until 1980. Today it is the only method for confirming child abuse.

5. Carder C, Mercey D, Benn P. Chlamydia trachomatis. Sex Trans Infect 2006;82(suppl 4):10-12.

Chlamydiae are grown in the yolk sac of embryonated hen eggs and cell lines such as McCoy, BGMK, HeLa, etc. Sensitivity is dependent on the quality of the clinical samples and the preservation of the Chlamydia in a live form until they reach the laboratory (stable temperature at 4°-8°C for 24 hours). (2) Enzyme immunoassay (EIA), which uses polyclonal antibodies to detect chlamydial lipopolysaccharide (LPS). This is the first method for testing a large number of people, such as pregnant women, sexual contacts and young adolescents. (3) Direct cytological examination of smears using fluorescein (FITC)-conjugated monoclonal antibodies directed against OMP1. This method can be used for large groups of patients with 88% sensitivity and 98-99% specificity. 18

6. Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005;142:914925. 7. Jensen IP, Fogh H, Prag J. Diagnosis of Chlamydia trachomatis infections in a sexually transmitted disease clinic: evaluation of a urine sample tested by enzyme immunoassay and polymerase chain reaction in comparison with a cervical and/or a urethral swab tested by culture and polymerase chain reaction. Clin Microbiol Infect 2003;9:194-201.

E. Papadogeorgaki, MD, PhD, Microbiology Laboratory and STDs & HIV-AIDS Reference Laboratory, ‘A. Syggros’ Hospital, Athens

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ECDC activities in the field of sexually transmitted infections Program on sexually transmitted infections including HIV/AIDS and blood-borne infections. European Center for Disease Prevention and Control The European Center for Disease Prevention and Control (ECDC) co-ordinates the European networks on sexually transmitted infections (STI) and human immunodeficiency virus (HIV). Through these networks, ECDC performs enhanced surveillance for STI and HIV across Europe and addresses key intervention and prevention issues through a number of projects. Responding to the threat of multidrug-resistant Neisseria gonorrhoeae

Union (EU)/European Economic Area (EEA) member states to inform national treatment guidelines. Ensuring that a minimum capacity for culture and susceptibility testing at a national level in EU/EEA member states is either available or developed. Establishing a strategy to detect rapidly patients diagnosed with gonorrhea who experience a clinical treatment failure following treatment with recommended cephalosporins, including the clinical management of affected patients and their sexual partners. Outlining a set of recommended public health actions to be implemented at a national level, following the detection of MDR NG cases. Increasing the awareness of policy makers, clinicians, patients and key populations through a sound communication strategy. These objectives will be reached through different components of the plan, which address multidisciplinary sectors including all key stakeholders in the control of multidrug-resistant N. gonorrhoeae. The plan is available at http://www.ecdc.europa.eu/en/publications/Publications/1206-ECDC-MDRgonorrhoea-response-plan.pdf

The European Gonococcal Antimicrobial Surveillance Program (Euro-GASP) has been established as a sentinel surveillance system for antimicrobial-resistant gonococci across Europe to inform public health and treatment guidelines. Results from Euro-GASP for 2010 [1] are particularly alarming. Decreased susceptibility to cefixime (>0.125 mg/L) has increased from 4% in 2009 to 9% in 2010 and has now been reported from 17 countries. Rates of ciprofloxacin and azithromycin resistance are high across Europe (53% and 7%, respectively), and these antimicrobials should therefore not be used for treatment unless isolates are known to be susceptible or local resistance rates are known to be less than 5%. Although decreased susceptibility to ceftriaxone has not been noted, the continual upward drift in the MIC needs to be monitored carefully. These results add to the concern that gonorrhea may become untreatable in the future and susceptibility testing of Neisseria gonorrhoeae in Europe should be prioritized. Reports of third-generation cephalosporin treatment failures are increasing: cefixime treatment failure in Europe has been described in a number of publications [2â&#x20AC;&#x201C;5]. Ceftriaxone treatment failure was first described in Japan [6] but, in recent months, there have also been reports from France and probably Spain [7,8].

Surveillance of STIs in Europe ECDC co-ordinates surveillance of sexually transmitted infections in Europe. This involves the annual collection of surveillance data from all EU/EEA member states for chlamydia, gonorrhea, syphilis, lymphogranuloma venereum and congenital syphilis using standardized case definitions. The data reported by countries are analyzed and published in surveillance reports. The second STI surveillance report has been published recently. This report covers the years 1990 to 2010 and aims to describe the basic trends and epidemiological features of the five STIs under EU surveillance.

Strengthening the surveillance of gonococcal antimicrobial susceptibility in the European

The report identifies marked differences in trends across the EU member states. While trends for chlamydia in Europe are mainly increasing, the overall trend in gonorrhea and syphilis across the EU/EEA over the past decade appears to be slightly decreasing and shows two patterns: 1) a decreasing trend in countries that had previously reported very high rates, and, for the time being, a continuous decline or stabilization; 2) continuous increases observed in other countries over time. The increasing chlamydia rates reflect the increase in testing and screening practices in a number of countries. These trends must be interpreted with caution because of the heterogeneity in reporting and health care systems. A further limitation to the interpretation of the epidemiological situation of STI in the EU/EEA is that many cases are either not diagnosed or not reported.

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Decreased susceptibility to cefixime is extremely concerning because it is a recommended therapy for gonorrhea across Europe, together with ceftriaxone. Loss of cefixime as an oral treatment option across Europe may have major cost and compliance implications if parenterally administered ceftriaxone becomes the only viable option. As part of the response to the threat of multidrug-resistant N. gonorrhoeae, a meeting of experts in gonorrhea antimicrobial resistance was organized by ECDC to discuss the development of a response plan for multidrug-resistant N. gonorrhoeae in Europe. The plan aims to address the following.


European program

Invited articles The full report is available at http://www.ecdc.europa.eu/en/publications/Publications/201206Sexually-Transmitted-Infections-Europe-2010.pdf Other ECDC activities Current projects on STIs include the following. Chlamydia control in Europe: ECDC has published guidance on chlamydia control (http:// ecdc.europa.eu/en/publications/Publications/0906_GUI_Chlamydia_Control_in_Europe.pdf). The current project aims to review critically the scientific evidence for the epidemiology and natural history of chlamydia infection, in order to evaluate and estimate better the impact and cost-effectiveness of public health interventions targeted at chlamydia. ECDC aims to monitor the progress and track changes in chlamydia control and prevention policies across the EU since 2007, and to revise guidance on chlamydia control accordingly. Guidance on a comprehensive approach to disease prevention for HIV, STIs and hepatitis among men who have sex with men (MSM): this project aims to collect evidence on effective behavioral, psychosocial and biomedical interventions, review EU/EEA national policies and consult key experts in the field. This information will be used to produce guidance on a comprehensive approach to disease prevention among MSM in the context of sexual health and health promotion. HIV and STI prevention among MSM: this project was launched to look closely at prevention interventions for MSM, reviewing increased trends and outbreaks of STI and HIV in MSM and assessing the effectiveness of prevention interventions targeted at MSM, to update current knowledge and identify knowledge gaps to be able to initiate future activities. More information on ECDC activities and projects is available on the ECDC disease-specific program pages: http://ecdc.europa.eu/en/activities/diseaseprogramme s/hash/Pages/index.aspx References: 1. ECDC. Gonococcal antimicrobial susceptibility surveillance in Europe 2010. Stockholm: ECDC, 2012. Available at http://www.ecdc.europa.eu/en/publications/Publications/1206-GonococcalAMR.pdf

Implementation of actions in the region of Evros supporting the medical and psychosocial needs of third-country immigrants without legal documents who may also need international protection On 31 August, this program was completed under the Emergency Measures of the European Refugee Fund for the Business Year 2011. The program was implemented by the Hellenic Center for Disease Control and Prevention (HCDCP) in partnership with the 4th YPE. The program was carried out at the border guard service centers of Kyprinos, Soufli, Ferres, Venna and Tychero, all in the region of Evros. The funding was provided by a contribution from the European Refugee Fund of up to 80% and the participation of the Ministry of Health of up to 20%. The Administrative Co-ordinator of the program was Mrs E. Hadjipaschali, Deputy Director of HCDCP, the Administrative Manager was Mr G. Olmpasalis, from 4th YPE, and the Head of Psychosocial Support was Mrs E. Xanthopoulou, also from HCDCP. The project employed about 30 people in total. Purpose of the program • Supervision of public health • Creating a network of local stakeholders • Supplying primary health providers • Supplying psychosocial services • Covering inventory data needs • Supplying other supporting services Preliminary results of the program Total number of people examined by doctors: 11,325

2. Unemo M, Golparian D, Stary A, Eigentler A. First Neisseria gonorrhoeae strain with resistance to cefixime causing gonorrhoea treatment failure in Austria, 2011. Euro Surveill 2011;16:pii=19998. Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=199 98 3. Unemo M, Golparian D, Syversen G, et al. Two cases of verified clinical failures using internationally recommended first-line cefixime for gonorrhoea treatment, Norway, 2010. Euro Surveill 2010;15:pii=19721. Available at http://www.eurosurveillance.org/ViewArticle. aspx?ArticleId=197 21 4. Ison CA, Hussey J, Sankar KN, et al. Gonorrhoea treatment failures to cefixime and azithromycin in England, 2010. Euro Surveill 2011;16:pii:19833. Available at http://www.eurosurveillance.org/ ViewArticle.aspx?ArticleId=198 33 5. Forsyth S, Penney P, Rooney G. Cefixime-resistant Neisseria gonorrhoeae in the UK: a time to reflect on practice and recommendations. Int J STD AIDS 2011;22:296-297. 6. Ohnishi M, Golparian D, Shimuta K, et al. Is Neisseria gonorrhoeae initiating a future era of untreatable gonorrhea? Detailed characterization of the first strain with high-level resistance to ceftriaxone. Antimicrob Agents Chemother 2011;55:3538-3545 7. Unemo M, Golparian D, Nicholas R, et al. High-level cefixime- and ceftriaxone resistant N. gonorrhoeae in Europe (France): novel penA mosaic allele in a successful international clone causes treatment failure. Antimicrob Agents Chemother 2011. 8. Carnicer-Pont D, Smithson A, Fina-Homar E, Bastida MT. First cases of Neisseria gonorrhoeae resistant to ceftriaxone in Catalonia, Spain, May 2011. Enferm Infec Microbiol Clin 2012.

Medical data: Total 6,711 5,334 1,745 818 76 136 1 100 14 11,325

New arrivals Examined (new) Vaccinated Mantoux tests performed Positive Mantoux test cases Examinations for precautionary reasons Cultivations Referrals Emergencies Total examined Psychosocial data:

Total 734 125 10

Number of sessions Need for monitoring Need for referral

Gianfranco Spiteri, STI expert, Marita van de Laar, senior expert and head of program

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European program

European program

European Territorial Co-operation Program Greece-Bulgaria 2007-2013

Vaccines: Total Τetanus

1,692

MMR

53

Malaria test August

Total

RDT test

154

Benefits provided by the program • Provision of cleaning services • Providing technical maintenance at border centers • Providing decontamination at border centers • Providing sanitation • Providing layers • Providing blankets • Provision of medical consumables and small equipment • Supplying clothing • Supplying insect lotion • Provision of first aid • Providing sleeping bags • Providing medical supplies

The Peripheral Laboratory of Public Health East Macedonia-Thrace, as a decentralized unit of the Hellenic Center for Disease Prevention and Control (HCDCP), contributes to the European Territorial Co-operation Program Greece-Bulgaria 2007-2013, entitled Cross-Border Research Center for Environment and Health (RCEH). The main input from the Bulgarian side is the Regional Health Inspectorate (RΗΙ) from Kardzhali county, Bulgaria. The main goal of this program is to create common actions within the sector of environmental health and to promote public health specifically at the cross-border territory. The program is pursuing a course of actions such as the creation of an information exchange network, mutual transfer of technical knowledge and field research with the aim of enhancing interdisciplinary co-operation. In the context of this co-operation, on 30 July 2012 an opening of the Cross-Border Research Center for Environment and Health took place. From HCDCP, the Alternate Director of the Network of Public Health Laboratories, E. Chatzipashali, and the Responsible Scientist of the Peripheral Laboratory of Public Health East Macedonia-Thrace, Mrs Konstantinidis, attended. The ceremony was also attended by the Greek Consul in Bulgaria, the Kardzhali city mayor, the president of the Bulgarian parliament and other local officials.

In conclusion, the program was considered to have been successful by both stakeholders and the general public, and especially by people who had received medical and psychosocial services.

E. Hadjipaschali, Deputy Director of HCDCP-PHLN

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Peripheral Laboratory of Public Health East Macedonia-Thrace

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Recent publications

Interesting activities

The annual meeting of EPAAC in Athens

1. Euro Surveill 2012;17:pii=20225 Increasing trends of gonorrhoea and syphilis and the threat of drug-resistant gonorrhoea in Europe Van de Laar M, Spiteri G. Available online at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20225 In the editorial of Eurosurveillance, Volume 17, Issue 29, 19 July 2012, M. Van de Laar and G. Spiteri from the European Center for Disease Prevention and Control (ECDC) try to provide an explanation for the increase in sexually transmitted infection (STI) notifications in several European

countries since the early 2000s. The authors suggest that this rise is most likely due to multiple factors, such as increased screening, the use of more sensitive diagnostics, improved reporting and also high levels of unsafe sexual behavior among certain subpopulations. The authors conclude that the increasing rates of gonorrhea and syphilis need to be closely monitored and public health interventions need to be targeted at the affected groups. These intervention programs need to be evidence-based and monitored rigorously and systematically to ensure a high quality. Multidrug-resistant Neisseria gonorrhoeae is a serious public health threat that could result in the loss of the last remaining options for effective treatment in the near future. The spread of strains with reduced antimicrobial susceptibility to thirdgeneration cephalosporins across Europe needs to be investigated further using tools such as molecular typing. Public health experts and clinicians need to be informed about the current critical situation and should be vigilant in looking for treatment failures.

The Steering Committee of the European Partnership for Action against Cancer (EPAAC) will take place in Athens on 24–26 September 2012. Greece is participating in the partnership through the Hellenic Center for Disease Control and Prevention’s (HCDCP) Head of the Department for Education and National Registries and Head of the Office of the Hellenic Cancer Registry and Rare Diseases, Dr Evagelia Tzala, Epidemiologist–Biostatistician (PhD). The partnership’s work is planned to be completed by January 2014. Its primary objective is to exchange experiences and advance cancer control and prevention methods and practices, by addressing stakeholders with various and different backgrounds (researchers, groups of patients, industry and national authorities throughout the European Union). The collaboration of different groups will minimize duplication of effort and repetition and reduce unnecessary expenditure. More information can be found at www.keelpno.gr or www.epaac.eu/home.

The partnership supports and brings forward the development of cancer plans at national and European levels as well as actions for cancer control and prevention, such as population-based cancer registries, screening programs for the types of cancer indicated, etc. For more information, visit http://www.epaac.eu/home.

National Cancer Registry, HCDCP

2. Antimicrob Agents Chemother 2012;56:1273-1280 High-level cefixime- and ceftriaxone- resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a successful international clone causes treatment failure Unemo M, Golparian D, Nicholas R, Ohnishi M, Gallay A, Sednaoui P. The first Neisseria gonorrhoeae strain (H041) highly resistant to the expanded-spectrum cephalosporins (ESCs) ceftriaxone and cefixime, which are the last remaining options for first-line gonorrhea treatment, was isolated in Japan. In this article the authors confirm and characterize a second strain (F89) with high-level cefixime and ceftriaxone resistance that was isolated in France and most probably caused a treatment failure with cefixime. As the authors mention, N. gonorrhoeae appears to be emerging as a superbug, and in certain circumstances and settings gonorrhea may become untreatable. Investigations into the biological fitness and enhanced understanding and monitoring of the ESC-resistant clones and their international transmission are required. Enhanced disease control activities, antimicrobial resistance control and surveillance worldwide, and public health response plans with global (and national) perspectives, are also crucial. Nevertheless, new treatment strategies and/or drugs and, ideally, a vaccine are essential to develop efficacious gonorrhea management.

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Future conferences and meeting

Future conferences and meeting

September 2012 4-5 September, 2012

15, September, 2012 Title: National Hepatitis B & C Training Program and Treatment Update

Title: 3rd Annual meeting of the European Legionnaires’ Disease Surveillance Network (ELDSNet) Country: Germany City: Dresden Venue: Faculty of Medicine Carl Gustav Carus Contact Number: +49 3514586580 Website: http://esgli2012.konsiliarlabor-legionella.de/ 4-6 September, 2012

Country: USA City: Seattle Venue: Seattle Marriott Waterfront Contact Number: + 206-443-5000 Website: http://www.scripps.org/ 17-21, September, 2012 Title: Epidemiology and Microbiology for Facilitators

Title: Inform, Protect, Immunize: Engaging Underserved Populations Country: Ireland City: Dublin Venue: Contact Number: + 46 (0)8 586 010 00 Website: http://www.ecdc.europa.eu/

Country: Spain City: Menorca Venue: Contact Number:  +46 (0)8 586 010 00 Website: http://www.ecdc.europa.eu/en/press/events/ 22, September, 2012

5-7 September, 2012 Title: Nordic Vaccine Meeting

Title: Emerging and Re-emerging Epidemics Affecting Global Health

Country: Denmark City: Copenhagen Venue: Eigtveds Pakuhs Contact Number: +45 3311 3061 Website: http://www.conferencemanager.dk/NVM2012

Country: Italy City: Orvieta Venue: Palazzo del Popolo Contact Number: +39 06 49902980 Website: http://globalhealth2012.weebly.com/index.html

7 September, 2012

24 September- 12 October, 2012

Title: The Viral Hepatitis Congress

Title: Introduction to Intervention Epidemiology and Microbiology

Country: Germany City: Frankfurt Venue: Johann Wolfgang Goethe University Contact Number: +44 (0) 1625 664392 Website: http://www.viral-hep.org/default.aspx

Country: Spain City: Menorca Venue: Contact Number:  +46 (0)8 586 010 00 Website: http://www.ecdc.europa.eu/en/press/events/

14-16, September, 2012

26-27, September, 2012

Title: 5th Congress of the Hellenic Organization of Research and Treatment of HPV Country: Greece City: Salonica Venue: Hyatt Regency Hotel Contact Number: +30 2106074200 Website: http://5hpv.mdcongress.gr/47fls/site_sub.asp?catid=601&l=1

Title: Thirty-first meeting of the ECDC Advisory Forum Country: Sweden City: Stockholm Venue: ECDC Contact Number:  +46 (0)8 586 010 00 Website: http://www.ecdc.europa.eu/en/press/events/ International relations office

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Outbreaks around the world

Interview

Outbreak news, August 2012 Avian influenza [1]

Christina Antoniou Professor of Dermatology, ’A. Syggros‘ Hospital, Athens, Greece

The Ministry of Health of Indonesia has notified a new case of human infection with avian influenza A(H5N1) virus. To date, a total of 191 cases has been confirmed in Indonesia, of which 159 have been fatal.

Cholera [1, 2] Cuba

The Cuban Ministry of Health has confirmed the first cholera outbreak in Cuba in more than a century. As of 31 July 2012, 236 confirmed cases and three deaths have been reported in the cities of Manzanillo, Bayamo, Yara and Campechuela Niquero in Granma Province. Currently, the cases are limited to Granma Province, mostly in Manzanillo.

Sierra Leone

Since the beginning of the year, Sierra Leone has recorded 13,934 cases of cholera, with 232 deaths (a case fatality rate of 1.7). The rate of new cases has accelerated rapidly since the beginning of August. Eleven of the country’s 13 districts are now registering cases, with Western Area and Port Loko being the most affected. The most recently affected district is Kenema.

How did you decide to become a dermatologist?

Ebola haemorrhagic fever [1] Uganda

The Ministry of Health of Uganda has notified an outbreak of Ebola haemorrhagic fever in Kibaale district in the western part of the country. As of 3 September, 24 probable and confirmed cases, including 16 deaths, have been reported. Eleven cases have been laboratory confirmed.

Democratic Republic of Congo

On 17 August 2012, the Ministry of Health of the Democratic Republic of Congo notified an outbreak of Ebola haemorrhagic fever. As of 28 August, a total of 24 (six probable, six confirmed and 12 suspected) cases and 11 deaths have been reported from Province Orientale. The reported cases and deaths occurred in three health zones as follows: 17 cases and nine deaths in Isiro; six cases and two deaths in Viadana; one case and no deaths in Dungu. The fatal cases in Isiro include three health-care workers. There has been no Ebola suspected or confirmed case reported from outside Province Orientale. References: 1. World Health Organization (WHO). Available at http://www.who.int/csr/don [accessed 3 September 2012] 2. Centers for Disease Control and Prevention (CDC). Available at http://wwwnc.cdc.gov /travel/ notices/outbreak-notice/ [accessed 31 August 2012]

Travel Medicine Office Department for Interventions in Health Care Facilities

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My tutors in medical school and their love and devotion to dermatology have been my greatest inspiration. After deciding to follow this specialty later on, I, in turn, became fascinated by the field and have never regretted my decision.

What do you think is the significance of the problem of sexually transmitted infections in our country? Sexually transmitted infections, as much globally as in Greece, are anything but ‘long forgotten’. The fact that the fear of human immunodeficiency (HIV) infection has greatly declined over the past few years, because of the very effective treatment regimens, has led to people becoming lax in the use of condoms during sexual contact. Changes that we have seen at social and financial levels, as well as globalization, have facilitated the population’s interactions, whether for work or pleasure. These facts, in combination with the simplicity of establishing new contacts through the internet, have contributed to the increasing repercussion of sexually transmitted diseases in Europe and of course in Greece as well.

What are the emerging problems regarding sexually transmitted infections? Gonococcal infection is the second most frequent sexually transmitted disease with a bacterial cause, with 700,000 new incidents per year in the USA and increasing ramifications over the last decade within the European Union (EU) and Greece. Even though Neisseria gonorrhoeae stems, resistant to cinolones, are widespread nowadays, only one type of antibiotics, third-generation cephalosporins, is recommended for the treatment of gonococcal infection. Gonococcal resistance has been recorded in Greece as well, thus demonstrating a high percentage of resistance to penicillin, tetracycline, erythromycin, norfloxacin and ciprofloxacin. Since 2007 it has not been recommended to use cinolon to treat infections caused by N. gonorrhoeae and related cases (i.e. inflammatory disease of the pelvis), while in the past few years we have noted a worrying incidence of resistance and reduced sensitivity to cephalosporins, especially in countries of the Far East. For this reason, in case the treatment fails to react, we advise further cultivation and susceptibility testing with an antibiogram.

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Interview

Myths and truths

Myths and truths

What are considered to be the main risk factors for the transmission of a sexually transmitted infection? Risk factors for sexually transmitted diseases (STDs) are multiple sexual partners, a low social–financial level and a promiscuous sex life, which is especially frequent in high-risk groups (e.g. homosexual men, users of intravenous substances and prostitutes).

What changes have you noted as far as the epidemiological data are concerned? In the past few years, given the increasing trend of economic immigration, especially in larger cities, a great number of the patients that come to the Department of Venereal Diseases at the ‘A. Syggros’ Hospital belong to this group. Furthermore, a diagnosis of syphilis in pregnant women who come from former eastern Europe countries is also frequent.

Myths

Truths

Sexually transmitted diseases (STDs) concern very few people. They are rare diseases that do not cause serious health problems.

STDs are indeed a serious public health problem. These diseases are mainly transmitted through sexual contact and include, among others, human papillomavirus infections, i.e. Condyloma acuminata (warts), genital herpes, syphilis, gonorrhea, chlamydia infections, urethritis, non-specific or bacterial vaginitis, vaginal trichomoniasis, various types of hepatitis, the particularly significant human immunodeficiency virus (HIV) infection, etc. We often use the term sexually transmitted infections (STIs) instead of diseases in order to include asymptomatic cases.

What can we expect in the future for the treatment and prevention of STDs? Since there have been no new discoveries in the field of treatment (i.e. new antibiotics), we should give greater emphasis to prevention. This could be achieved by educational projects for the public, starting in schools, as well as targeted interventions in high-risk populations. The recording and epidemiological surveillance of STDs are of great importance because they facilitate a prompt alarm in the case of an outbreak as well as localizing the source of the infection in order to manage and confine its transmission. This is a common course of action amongst developed countries and it would be good for this to flourish in Greece as well. Moreover, it is important to adhere to the STD vaccination programs, vaccinations for hepatitis B and recently for human papilloma virus (HPV).

For gonorrhea, syphilis and chlamydia infections there are no vaccines for now. Do you believe that the HPV vaccine, against the human papilloma virus, plays a role in the prevention of the genital warts? Condyloma acuminata (genital warts) is the most common STD and appears mainly in teenagers and young adults up to 25 years of age. In recent years the vaccine against cervical cancer and papilloma has become available world-wide, including in Greece. The vaccine is provided for free to girls and women between the ages of 9 and 26 by the National Insurance Services and appears to be very effective with a good safety profile. In countries where the vaccination program is followed up properly and the percentage of population covered is high, as in Australia for example, there are already records of the first positive results, with a precipitous decrease in the appearance of papilloma in both men and women up to the age of 21, just 4 years after the commencement of the vaccine program. It is therefore important to encourage girls and young women to get vaccinated.

What advice would you give new dermatologists? Over the past few years it has been noted that many dermatologists have turned towards cosmetic dermatology techniques on the basis of new lifestyle influences. My view has always been that the main work of a dermatologist is traditional dermatology- and venereologyprescribed treatments. The financial situation we all live in has proven how important is for all dermatologists, especially those who are younger and upcoming, to build their careers upon the solid foundations of traditional dermatology and venereology. Edited by Eleni Karatabani and Philip Koukouritakis

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STDs can be treated successfully, although sometimes the treatment is tricky because of asymptomatic infection, as for example with genital herpes and warts. Furthermore, several studies have indicated that the existence of an STD facilitates the new transmission of another, for example HIV, through unprotected sexual contact. As medical science continuously evolves, there is no reason to worry about STDs. These diseases are treated with antibiotics.

It is true that syphilis, gonorrhea, various types of urethritis and vaginitis can be treated properly with antibiotics. That is why laboratory testing should be performed when there is a suspicion of an STI. But we have to take into consideration that many STDs do not show any symptoms, particularly in women. If they are not treated properly they can cause serious health problems.

It is not true that an antimicrobialresistant gonococci problem exists.

Gonorrhea can be treated successfully with the proper administration of antibiotics. But across Europe and throughout the world there is widespread concern over multidrug-resistant gonococci. According to the results of a European study on the cefixime-resistant gonococcus (cefixime has been a recommended antibiotic against gonococcal infections), the resistance has risen from 4% in 2009 to 9% in 2010 over the 17 European countries of the study. This fact has resulted in an amendment to the therapeutic guidelines. For these reasons, if, after the completion of a treatment regimen, the symptoms persist, a patient should contact his/her doctor again for a reassessment of the disease’s progress.

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Myths and truths

Condoms protect against all STDs.

Myths and truths

The systematic use of condoms for oral, vaginal and anal sex protects against the transmission of urethritis, chlamydia infections, syphilis, gonorrhea, hepatitis and HIV infection.

STDs are not transmitted by a pregnant mother to her fetus.

Both syphilis and gonorrhea, and also chlamydia infections, can be transmitted to the fetus or an infant from the mother, causing serious health problems for the fetus or infant.

Although condoms do not protect completely against the transmission of all STDs, for instance against warts located in the perigenital area, their use remains the best choice for protection against STDs. The use of other contraceptives only protects against unwanted pregnancy and not against any STD.

Using two condoms at the same time is safer than using only one.

The use of two condoms is not recommended. Use one new condom during every sexual contact.

STDs are not transmitted via oral sex.

STDs can be transmitted via any vaginal, anal or oral sexual contact.

STDs are mainly a concern for adults.

According to the data from the European STIs Surveillance Program (in which Greece is participating), more than 70% of the notified chlamydia cases, about 40% of the gonorrhea cases and 17% of the syphilis cases concern young people between the ages of 15 and 24. In addition, a large percentage of HPV newly infected people (causing warts) are teenagers.

Using condoms is the only way to protect yourself against STDs.

The use of condoms is a very good way to protect yourself against an STI, but not the only one. Vaccination against hepatitis B virus (HBV) and human papillomavirus (HPV) plays a very important protective role too.

Only people with unusual or weird behavior suffer from STDs.

STDs do not discriminate. They concern every sexually active person, and any person who is having unprotected sex could be infected.

If I get infected with an STD, for example chlamydia, I will realize it because I will have obvious symptoms.

Many chlamydia infections can stay undiagnosed because of the high percentage of asymptomatic cases (70% of women and more than 50% of men infected). Without any laboratory diagnosis, these asymptomatic cases will probably transmit the infection to their sexual partners.

Chlamydia infections never have any complications.

Both symptomatic and asymptomatic cases with Chlamydia trachomatis infection could have complications if not treated properly. Possible inflammation following upper genital tract infection could lead to tubal obstruction and subsequent infertility. Moreover, tubal obstruction as a result of a chlamydia infection or other STI is a significant risk factor for ectopic pregnancy, which is a situation that could threaten the life of the pregnant woman.

The PAP test indicates any STD.

The PAP test is not specific for any STD. In the case of a possible STI it is highly recommended that the person contacts her/his doctor and undergoes a proper diagnostic test.

I cannot use a condom. I am allergic to it/I cannot find a suitable size.

There is a variety of sizes and types of condoms, to fulfill the different preferences and needs of all users. There are also latex-free condoms for those people allergic to latex. Not using a condom could lead to an STI.

Once you are infected with an STI you become immune, meaning you will not get infected again.

You can get infected with an STD more than once, by either a non-treated partner or a new, infected partner. A treated infection of chlamydia, gonorrhea or syphilis does not protect a patient against a new infection.

If I am diagnosed with an STD there is no need to undergo tests for other STDs.

You might get infected with more than one STD. When an STD is diagnosed, it is very important to undergo tests for all the other common STDs, in order to get the proper care and treatment. It is also very important that the sexual partner undergoes the same tests and gets treatment if needed.

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There are two vaccines against HPV: the quadrivalent Gardasil and the bivalent Cervarix. Starting the immunization regimen for teenage girls at the age of 11-12, with one of these two vaccines, offers protection against HPV infection and subsequently against possible cervical cancer in the future. The quadrivalent vaccine offers some protection against Condyloma acuminata (genital warts) for both girls and boys. The vaccination against HBV should be given to people of any age who have never been infected by this virus. It protects against hepatitis B and subsequently against hepatocellular carcinoma. The diagnostic test for an STI can be performed at any time after the ‘suspicious’ sexual contact.

An STI diagnostic test can be performed at any time, as a preventive health measure. But in the case of a suspicious sexual contact, a test should always be performed bearing in mind that there is a ‘window’ during which some STIs cannot be diagnosed. For example, HIV antibodies can usually be traced only 3 months after the infection. The fluorescent treponemal antibody-absorption test (FTA-Abs) is an indirect fluorescent antibody technique that can be used as a confirmatory test for syphilis at least 21 days after the infection.

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Myths and truths

World day

It is not necessary for anybody to undergo a laboratory test for an STI because they could be a blood donor and any possible disease will be detected through the donation process.

This point of view is absolutely wrong for many reasons, some of which have been described above. If the blood donation happens during the wrong ‘window’, some STIs cannot be diagnosed by the blood laboratory tests. There could therefore be a serious threat to the health of the many people who might receive the donated blood.

Genital herpes and HPV can only be transmitted when there are obvious clinical symptoms on the genital organs.

Many patients do not know that, in the case of an infection with herpes simplex virus (HSV), an asymptomatic apoptosis of the virus occurs in the infected cells. Given this fact, the possibility of transmission from a carrier to his/her sexual partner cannot be excluded, even if no typical rash develops. However, the infectivity is much lower when the symptoms are absent. The same effect occurs in the case of an HPV infection.

STDs infect only the genital organs.

All rashes on genital organs indicate an STD.

Almost every STD (HIV, syphilis, etc.) has nongenital manifestations. In most of these cases the patients do not associate the symptoms with the STD, resulting in a delayed diagnosis and treatment. Manifestations can occur in the oral cavity, eyes and joints and sometimes in the cardiovascular and nervous systems. Many skin disorders, not related with an STD, such as psoriasis, lichen planus, vitiligo and contact dermatitis, may present as rashes on the genital organs or round them.

World Tourism Day 2012

World Tourism Day (WTD) is held annually on 27 September. The World Tourism Organization (UNWTO) General Assembly decided to establish WTD at its third session, beginning in 1980. This date was chosen to coincide with the anniversary of the adoption of the UNWTO statutes on 27 September 1970. The timing of WTD is particularly appropriate because it comes at the end of the tourism season in the northern hemisphere and the beginning of the season in the southern hemisphere, when tourism is on the minds of millions of people world-wide. Its purpose is to foster awareness among the international community of the importance of tourism and its social, cultural, political and economic value. After suffering a decline in 2009 as a result of the global economic crisis, international tourism recovered strongly in 2010, faster than expected. International tourism continued to grow in 2011, despite an increasingly uncertain global economy, political changes in the Middle East and North Africa and natural disasters around the world. International tourist arrivals reached 50 million in 1950, 150 million in 1970, and 693 million in 2001; there was an increase of 300% and 480% in 20 and 30 years, respectively. In 2011 international tourist arrivals reached 982 million and they are expected to reach close to 1.4 billion in 2020.

References:

1. Centers for Disease Control and Prevention (CDC). 2012 Update to CDC’s sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. Morbidity and Mortality Weekly Report 2012; 61:590-594.

International tourist arrivals, UNWTO

2. Workoswki KA, Berman S. Sexually transmitted diseases treatment guidelines 2010. Morbidity and Mortality Weekly Report 2010;59/RR-12. 3. Chuh AT, Wong CW, Lee A. 2006. Sexually transmitted infections. Ten common myths. Australian Family Physician 3:127-129. Vasileia Konte, MD, HCDCP – Office for HIV and Sexually Transmitted Diseases Demetrius Ioannidis, Professor of Dermato-venereology, Medical School of the AUT, Director of the 1st University Clinic, Hospital for Skin and Venereal Diseases of Thessaloniki Edited by Philip Koukouritakis

In Greece, international tourist arrivals have shown a continuous growth between 1990 and 2011.

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World day

News from the HCDCP Administraion

International tourist arrivals in Greece (*1000) Year Arrivals

1990

1995

2000

2003

2004

2005

2009

2010

2011

8,873

10,130

13,096

13,969

13,313

13,276

14,915

15,007

16,427

An upward trend has been noticed in Greek travel abroad, with the exception of the autumn of 2009, according to data from the Greek National Statistical Service, as shown in Table 1. Travelling abroad for 4 or more nights (*1000) Year

2004

Total

795,716

2005 995,233

2006

2007

945,783

954,999

2008 1102,161

2009

HCDCP participation in a meeting regarding the immigrant issue in Korinthos At the invitation of the Police Union of Employees and Union Officers of the Corinth and Peloponnese Region, the Hellenic Center for Disease Control and Prevention (HCDCP) attended the meeting held at the Chamber of Corinth on Wednesday 29 August 2012, on the establishment and operation of an illegal immigrants detention center. The Bureau of the Panhellenic Federation of Police Officers, the heads of the police union of the Peloponnese region and the medical doctor of the HCDCP, S. Sapounas, who participated in the meeting, stressed the necessity of contributing to the presence of the HCDCP to safeguard public health and the health of both prisoners and police.

802,164

In conclusion, international travel is growing as more and more people travel for business, social or humanitarian reasons, for recreation or for migration. Also, the rapid development of technology has enabled travelers to cover vast distances quickly. Population movement is one of the most important factors in the epidemiology of infectious and non-infectious diseases associated with travel. The relationship between the spread of disease and travel is known through time. A typical example is the recent pandemic of influenza A/H1N1 virus. It is important that travelers, before departure, are informed of the risks that could affect their health in the country or countries they will be visiting, and take appropriate precautions. It is also important to have an awareness of being a ‘responsible traveler’ who respects and protects the environment, people, infrastructure and culture in the country visited. References: 1. World Tourism Organization (UNWTO). Available at http://wtd.unwto.org/en [accessed 3/9/2012]

Emergency Operation XENIOS ZEUS: HCDCP’s participation On 3 August 2012, a special police operation in Athens called XENIOS ZEUS commenced in order to move undocumented immigrants away from the center of the capital. Within the framework of this project, it was decided to use the facilities of police colleges in Komotini and Xanthi as sites for the temporary housing of illegal immigrants, where they will stay for further management. A total of 1,300 undocumented immigrants has already been transferred and housed. The Hellenic Center for Disease Control and Prevention (HCDCP) was invited to contribute to this operation and was asked to provide two bases, one in Komotini and one in Xanthi, for the provision of care. HCDCP responded immediately by sending specially equipped mobile units to the above areas. Moreover, preventive medical screening and primary care of the immigrants has already begun. Basic necessities have also been distributed to the immigrants.

2. UNWTO Tourism Highlights, 2012 edition. Available at http://mkt.unwto.org/en/ barometer [accessed 3/9/2012] 3. Code of Ethics for Tourists. Available at http://ethics.unwto.org/en/content/background-globalcode-ethics-tourism [accessed 3/9/2012]

Travel Medicine Office Department for Interventions in Health Care Facilities

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?

Quiz of the month Which of the following famous composers died of syphilis? A. Franz Shubert B. Robert Schumann C. Johann Georg Leopold Mozart D. Kurt Weill E. Igor Stravinsky Send your answer to the following e-mail: info-quiz@keelpno.gr The answer to the June quiz was: c) Traffic Accidents

For further information see: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter2-the-pre-travel-consultation/injuries-andsafety.htm

Three people answered correctly.

Worlda day

27 September World Tourism Day

!

Chief Editor:

Editorial Board:

Ch. Hadjichristodoulou

M. Angelopoulou R. Vorou Ph. Koukouritakis Κ. Mellou D. Papaventsis Τ. Patoucheas V. Roumelioti V. Smeti Ch. Tsiara Μ. Fotinea Ε. Hadjipashali

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

Graphic Design: Ε. Lazana

Editors:

Editing:

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

E. Karatampani P. Koukouritakis 40


HCDCP E-bulletin August 2012