Malaria in Greece: epidemiological data and KEELPNO actions
Danai Pervanidou, MD, MPH, EPIET alumni Unit for Vector-borne Diseases Department of Surveillance and Intervention, Hellenic Centre for Disease Control and Prevention (KEELPNO) Malaria in Greece
• Until mid-20th century: endemic
• 1974: malaria-free
• 1975 - 2008: 20 - 50 imported cases reported annually Reports of sporadic locally acquired cases: 1991, 1999, 2000
• 2009 - 2013: 81% of imported cases were immigrants from endemic countries Since 2009: locally-acquired cases reported annually
2
Reported malaria cases, Greece, 2009 - 2013
Year of Imported cases Locally acquired cases* Total symptom onset Greece Greece
2009 44 7 51
2010 40 4 44
2011 54 42 96
2012 73 20 93
2013 22 3 25
* All P.vivax cases 3 Reported malaria cases, Greece, 2009 - 2013
Year of Imported cases Locally acquired cases* Total symptom onset Greece Evrotas Greece Evrotas
2009 44 0 7 6 51
2010 40 0 4 1 44
2011 54 21 42 36 96
2012 73 17 20 10 93
2013 22 0 3 0 25
* All P.vivax cases 4 Reported malaria cases, Greece, 2009 - 2013
Year of Imported cases Locally acquired cases* Total symptom onset Greece Evrotas Greece Evrotas
2009 44 0 7 6 51
2010 40 0 4 1 44
2011 54 21 42 36 96
2012 73 17 20 10 93
2013 22 0 3 0 25
* All P.vivax cases 5 Number of locally acquired malaria cases by year of symptom onset*, Greece, 2009 - 2013
*Two cases with symptom onset in 2012 are attributed in the 2011 transmission period Place of exposure of locally acquired malaria cases, Greece, 2009 (n=7)
Cluster of 6 cases in 1 case in East Attica Evrotas, Lakonia (Nea Makri)
7 Place of exposure of locally acquired malaria cases, Greece, 2010 (n=4)
2 cases (Roma children) in Viotia (Thiva)
1 case in Evrotas 1 case in East Attica Lakonia (Roma) (Marathon) Reported malaria cases, Greece, 2011
96 malaria cases recorded
• Imported cases: 54 - 45 in immigrants from malaria endemic countries - 36 P. vivax
• Locally acquired: 42 - 34 Greek, 5 Romanian, 2 Moroccan, 1 Polish - all P. vivax
Place of exposure of locally acquired malaria cases, Greece, 2011 (n=42)
yrs Viotia (Orchomenos): Larisa: >70 40-50 yrs Roma
Evia: 2 cases 40-50 yrs Lakonia, Evrotas: 36 cases
East Attica (Marathon, Kalivia): 2 cases >70 yrs Malaria cases, Evrotas, Lakonia, 2011
Case classification - Nationality Number
Locally - acquired cases 36** • Greek nationality 28 • Immigrants 8 Romania 5* Poland 1 Morocco 2
Immigrants from endemic countries 21 Pakistan Afghanistan 20 1
* 2 cases diagnosed in Romania ** 2 cases had onset of symptoms in 2012
Place of residence of malaria cases, Evrotas, Lakonia, 2011
Red dots: immigrants Yellow dots: Greek cases 12 Reported malaria cases, Greece, 2012
93 malaria cases reported
• Imported cases: 73 - 64 in immigrants from malaria endemic countries - 54 P. vivax, 15 P.falciparum, 1 P.vivax + P.falciparum
• Locally acquired: 20 - 14 Greek, 3 Romanian, 2 Moroccan, 1 Albanian - all P. vivax
Reported malaria cases not attributed to 2012 transmission period, Greece, 2012
• 5 relapses in 2011 cases: 4 Greek, 1 Pakistani - inadequate Primaquine treatment
• 4 cases infected in past transmission periods: - 1 case (P.vivax), 30yrs Moroccan male, Evrotas, onset: 03/04/2012 - 1 case (P.vivax), 7yrs Greek female, Evrotas, onset: 27/08/2012 - 2 cases of P.malariae (Greek): 78yrs, onset: 08/01/2012 85yrs, onset: 01/05/2012
14 Place of exposure of locally acquired malaria cases, Greece, 2012 (n=20)
Karditsa: 2 cases, 24 & 53 yrs Xanthi: 2 cases, 23 & 61 yrs
Viotia: 2 cases, 23 & 47 yrs
East Attica, Marathon: 2 cases, 52 & 78 yrs
Lakonia, Evrotas: 10 cases East Attica, Markopoulo: 2 cases, 44 & 70 yrs
Malaria cases, Evrotas, Lakonia, 2012
Case classification - Nationality Number
Locally-acquired cases 10 • Greek nationality 7 • Immigrants from non-endemic countries 3 Romania 1 Morocco 2
Immigrants from endemic countries 17 Pakistan 13 Afghanistan 4
Total 27 Place of residence of malaria cases, Evrotas, 2012
Red dots: immigrants Yellow dots: Greek cases Reported malaria cases, Greece, 2013
25 malaria cases reported
• Imported cases: 22 - 13 in immigrants from malaria endemic countries - 9 P. vivax, 12 P.falciparum, 1 P.ovale
• Locally acquired: 3 - all Greeks - all P. vivax
Place of exposure of locally acquired malaria cases, Greece, 2013 (n=3)
Karditsa: 1 case 67 yrs Evros: 2 cases, 40 & 48 yrs Locally-acquired malaria cases by week of symptom onset, Greece, 2011 (n=39*), 2012 (n=19**) and 2013 (n=3)
2011 - 2012: 52% decrease of locally-acquired cases
2012 - 2013: 85% decrease of locally acquired cases
* Two cases with symptom onset in 2012 and one case with unknown week of onset are not included ** One case with symptom onset in 2013 is not included Locally-acquired malaria cases by week of symptom onset, Evrotas, 2011 (n=33*) and 2012 (n=10)
Evrotas, 2011 - 2012: 72% decrease of locally-acquired cases
* Two cases with symptom onset in 2012 and one case with unknown week of onset are not included Lakonia Regional Unit P.vivax malaria cases by week of symptom onset, Lakonia, Greece, 2011 (n=55*), 2012 (n=27)
*3 asymptomatic cases in migrants from Pakistan are not included as well as one case with unknown date of onset (diagnosed in Romania) Map of Evrotas (Land use)
Orange trees
Irrigation &drainage channels (105 km)
Other cultivations
Coastal wetlands & lake
Sea Map of Evrotas (Irrigation & drainage network) Ecological situation in Evrotas, Lakonia
Evrotas river
Irrigation channel near the orange plantations
Habitation inside the orchard
Place of residence of malaria cases, East Attica, 2009 - 2012
Place of residence of malaria cases, East Attica, 2009 - 2012 Evia Regional Unit Viotia Regional Unit Place of residence of locally acquired malaria cases, Viotia, 2010 - 2012
Xanthi Regional Unit Place of residence of locally acquired malaria cases, village of Xanthi, 2012 Karditsa Regional Unit Malaria cases, village of Sofades Municipality, Karditsa, 2012 - 2013
Sept-Oct 2012: 11 P.vivax cases in 2 residencies (170m) - 1st residency: 26 persons from Afganistan and Bagladesh - 2nd residency: 5 persons from Romania
• 9 cases in immigrants from endemic countries (1st residency): onset 03/09 - 11/10/2012, 1.5 - 11 months in Greece
• 2 introduced cases (2nd residency): Romanian Roma onset: 22/09, 30/09/2012
6/11 cases detected actively
Nov 2013: 1 locally-acquired case (Greek)
Place of residence of malaria cases, village of Karditsa, 2012 - 2013
Number of malaria cases by week of onset and case classification, village of Karditsa, 2012 Evros Regional Unit Place of residence of locally acquired malaria cases, town of Evros, 2013 Place of residence of locally acquired malaria cases, town of Evros, 2013
KEELPNO action plan for the management of malaria, 2012 - 2015
KEELPNO Working Group on vector-borne diseases
Risk assessment
Partnership to implement the national project: “Integrated surveillance and control programme for West Nile virus and malaria in Greece”
41 KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
42 KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
43 Enhanced malaria surveillance
• Enhancement of passive surveillance - test “suspected” cases (case definition)
• Case investigation - interviews with the patients and treating physicians - case classification, place of exposure, detailed travel history during the last 5 years, risk factors for ongoing transmission
• Environment investigation
• Active case detection
Active case detection, Greece, 2012 - 2013
To timely diagnose and treat malaria cases in order to prevent further transmission
1. Focus investigation of malaria cases: - all over Greece
2. Daily door - to - door ACD throughout the year: - in Evrotas
3. Screening of immigrants from endemic countries
45 Focus investigation of malaria cases, Greece, 2012 - 2013
It was conducted all over Greece: • following every new locally acquired case • following every imported case residing in rural area
In surroundings around case’s residence/ suspected place of exposure
46 Focus investigation of malaria cases, Greece
Door -to- door visits
Individual Individual from non - endemic country from endemic country
Fever screening
Fever (+): Fever (-): 1. RDT + microscopy
2. Fever screening 1. RDT + microscopy Fever screening weekly x 1 month 2. Fever screening weekly x 1 month weekly x 1 month 47 ACD, town of Evros, 12-14/10/2013
ACD, village of Karditsa, 13-15/11/2013 Door -to- door daily ACD, Evrotas, 2012- 2013 Mapping of all residences, Data base Initial visit: Provide information on malaria & protective measures
Fever screening every 7 - 15 days
Fever (+): RDT + microscopy
RDT (+): - Physician evaluation - Chloroquine
Microscopy (+) for P.vivax:
Primaquine (after G6PD test) 50 Cases detected actively, Greece, 2012
Cases detected by Cases detected by Total cases
focus investigation, daily ACD, detected actively, Cases Greece Evrotas Greece n / N (%) n / N (%) n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
51 Cases detected actively, Greece, 2012
Cases detected by Cases detected by Total cases
focus investigation, daily ACD, detected actively, Cases Greece Evrotas Greece n / N (%) n / N (%) n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
52 Cases detected actively, Greece, 2012
Cases detected by Cases detected by Total cases
focus investigation, daily ACD, detected actively, Cases Greece Evrotas Greece n / N (%) n / N (%) n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
53 Cases detected actively, Greece, 2012
Cases detected by Cases detected by Total cases
focus investigation, daily ACD, detected actively, Cases Greece Evrotas Greece n / N (%) n / N (%) n / N (%)
Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)
Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)
Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)
54 Screening of immigrants from endemic countries, Greece, 2012 - 2013 RDT in immigrants from endemic countries
2012: • affected areas (Evrotas, East Attica): 1,450 immigrants • 8 detention centres (5 in greek-turkish borders): 1,015 immigrants
2013: • recommended in health units in North Aegean and Dodecanese islands (immigrants’ entry points) • 554 immigrants in Chios and Limnos islands
55 Antimalarial drug administration to immigrants from endemic countries, Evrotas, 2012 - 2013
• 2012: immigrants with positive malaria serology
• 2013: mass drug administration
KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
57 Enhancing laboratory diagnosis of malaria
• Training seminars for lab personnel (from NSPH), 2012
• RDTs distribution to hospitals and health centres in: - affected areas - areas with immigration detention centres - large urban areas - entry points (greek-turkish borders, islands)
• Free of charge testing for malaria in the reference laboratories
• Support genotyping of the P. strains - NSPH / ECDC 58 KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
59 Case management - Standardization of the malaria treatment
• KEELPNO treatment guidelines
• Guidance to physicians for proper case management
• Protocol for following-up the treatment efficacy
• All 2011 improperly treated malaria cases were treated with a 2nd course in 2012
• Availability of anti-malarial drugs for radical P.vivax treatment (primaquine) and severe cases (artesunate)
60 KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
61 Communication
• Health professionals: - informative material disseminated every spring - seminars (41 in 2012,15 in 2013)
• Public: - educational material in website, leaflets - TV spot - public meetings (29 in 2012, 82 in schools in 2012)
• National stakeholders: MoH, regional and local public health authorities, blood safety authorities
• International public health stakeholders (WHO, ECDC, CDC)
62 KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
63 Blood safety measures
• Multisector Working Group on the definition of affected areas by vector borne diseases: characterization of affected areas for the implementation of blood safety measures
• National Centre for Blood Donations
• Donor deferral from affected areas
64 KEELPNO action plan for the management of malaria, 2012 - 2015
1. Enhanced malaria surveillance - early detection of cases
2. Enhancing laboratory diagnosis of malaria
3. Case management - Standardization of the malaria treatment
4. Communication
5. Blood safety measures
6. Vector surveillance and control activities
65 Vector surveillance and control activities
• Technical guidance for regional, local authorities, for timely organizing vector control activities • Individual reports with entomological and epidemiological data for each region • Training seminars for local authorities (2012) • Vector surveillance: 2012 mosquito mapping projects, around the country • Entomological activities in the framework of the project MALWEST
In Evrotas: - Distribution of LLINs (2013) - IRS
Conclusions I
• Conditions may exist for locally acquired transmission to occur sporadically or in small clusters in vulnerable areas: - increased number of immigrants from endemic countries - competent vector circulation in many areas
• Most affected areas are agricultural, non-touristic, close to wetlands, with large populations of migrant farm workers
Conclusions II
• Decrease of locally-acquired cases in 2012 and 2013 - impact of public health actions - decreased immigrants’ entry - fewer imported cases? - under-notification unlikely - under-diagnosis?
• Managing malaria remains a challenge (continuing entrance of new migrants from malaria endemic countries)
• Need for a multi-sector control strategy: entomological surveillance, intensifying mosquito control measures, communication to the public and health professionals
Number of immigrants arrested for illegal entry and residence at the Greek-Turkish land and sea borders and Crete, Greece, 2009 - 2013
69 Source: Hellenic Police website (www.astynomia.gr) Number of immigrants from 6 malaria endemic countries* arrested for illegal entry and residence, Greece, 2009 - 2013
*Pakistan, Afganistan, Bangladesh, Somalia, Erithrea, Irak 70 Source: Hellenic Police website (www.astynomia.gr) Priority actions - Recommendations, 2014
• Continue ACD in Evrotas. In Karditsa?
• Involve local public health authorities to achieve sustainability
• Local laboratory capacity should be enhanced
• Vector control programmes (+ IRS, LLINs)
• Assess in health care - free diagnosis and treatment for undocumented immigrants
Need to address for undocumented immigrants: • poor living conditions • long-term health care access
Thank you Malaria cases by month and case classification, Lakonia, 2009-2012
Malaria cases by month Years Number of cases by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
2012 Imported 0 0 1 0 1 2 6 4 0 1 0 0 15
Locally 0 0 0 0 0 1 3 0 1 3 0 0 8 acquired 2011 Imported 0 0 0 0 0 1 0 2 12 4 1 0 20
Locally 0 0 0 0 1 0 4 4 17 8 0 0 34 acquired 2010 Imported 0 0 0 0 0 0 1 0 0 0 0 0 1
Locally 0 0 0 0 0 0 1 0 0 0 0 0 1 acquired 2009 Imported 0 0 0 0 0 0 0 2 0 0 0 0 2
Locally 0 0 0 0 0 0 0 1 4 1 0 0 6 acquired Malaria cases by age and case classification, Lakonia, 2009-2012
Malaria cases by age Years Number of cases by age in years 0-19 20-29 30-39 40-49 50-59 >=60
2012 Imported 3 9 1 2 0 0
Locally 0 1 1 3 2 1 acquired 2011 Imported 3 16 2 1 1 0
Locally 5 4 5 9 5 7 acquired 2010 Imported 0 0 0 0 1 0
Locally 0 1 0 0 0 0 acquired 2009 Imported 0 2 0 0 0 0
Locally 0 1 0 1 3 1 acquired Malaria cases by social and high risk group, Evrotas, Lakonia, 2011 - 2012
Years Number of malaria cases by category Children- Agricultural Labourers Office House- Pensioners - Student workers workers wives Other 2012 Imported 1 14 0 0 0 0
Locally 0 2 0 2 3 1 acquired 2011 Imported 0 18 1 0 0 0
Locally 4 14 5 4 3 5 acquired Characteristics of locally acquired cases, Greece, 2012 (n=16)
• Age: ranged from 24 - 82 yrs (median 52 yrs)
• Gender: 62.5% were male
• Plasmodium species: all cases P.vivax
• Hospitalization: 75% hospitalized, no case in ICU
• Treatment: Chloroquine (11), Mefloquine (3), Atovaquone-Proguanile (1), no treatment (1) + Primaquine (15)
• Outcome: No fatality 76
Reported cases of P.vivax infection by month of onset and case classification, Lakonia, Greece, 2011 (n=56*) and 2012 (n=27)
Evrotas, 2011-2012: 72% decrease of locally-acquired cases
77