REVIEW

Surveillance of wildlife zoonotic diseases in the Region

Mirsada Hukić1, Fatima Numanović2, Maida Šiširak1, Almedina Moro1, Edina Dervović1, Sanja Jakovac3, Irma Salimović Bešić1

1Institute of Clinical Microbiology, Clinical Center of the University of Sarajevo, 2Institute of Microbiology, Clinical Center of the Univer- sity of Tuzla, 3Institute of Microbiology, Clinical Center of the University of Mostar; Bosnia and Herzegovina

ABSTRACT

The countries of the Balkan Peninsula have become the region with frequent outbreaks of the emerging and re-emerging disea- ses during the last decade of the 20th and the first decade of the 21st century. The majority of outbreaks were wildlife zoonotic, and vector-borne diseases, such as brucellosis, leptospirosis, li- steriosis, tularemia, Q-, Lyme disease, anthrax, , viral hemorrhagic , fever, tick-borne encephalitis and le- ishmainiasis. Epidemiological factors determined by ecology of Corresponding author: causative agents are often the most useful diagnostic clues. The Mirsada Hukić recognition of evolving problems of emerging and re-emerging Institute of Clinical Microbiology, diseases emphasizes the need for the development of better la- Clinical Center University of Sarajevo, boratory diagnostic methods for the surveillance and tracking of the diseases, and for continued research of factors contributing to Bonička 25, 71000 Sarajevo, Bosnia and the transmission of the organisms. The continuous occurrence of Herzegovina previously unidentified infections requires prospective national Phone/fax: +387 33 440 447; strategies for timely recognition of the syndromes, causative agent E-mail: [email protected] identification, establishment of criteria and methods for the dia- gnosis, optimization of the treatment regime, and determination of successful approaches to prevention and control. Wildlife di- seases surveillance in the most of the Balkan countries has been coordinated by the WHO since 1992. Although new technology and communication have extremely improved in the last decade, there is a need for optimal communication lines among the Balkan Original submission: countries, better exploitation of communication technologies like 14 December 2009; the Internet and other media in the field of emerging diseases. Revised submission: Key words: surveillance, wildlife zoonotic diseases, Balkan Pe- 30 December 2009; nninsula Accepted: 05 January 2010

Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):96-105

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INTRODUCTION evidence of the disease absence or to determine pathogen prevalence. A is an animal disease that may be tran- smitted to humans in natural conditions. Almost To be successful in the understanding WZDs a ba- a half out of 1700 known pathogens affecting sic lack of integration between disciplines needs humans are estimated to be zoonotic (1). It has to be eliminated, the most noticeably between been reported that there are up to 335 pathogens human and veterinary medicine and also among which were associated with emerging infectious different branches within these fields. Although diseases (EID) in the global human population new technology and communications have extre- between 1940 and 2004, and majority of them mely advanced in the last decade, there is still a were caused by the wildlife zoonotic diseases, need for better exploitation of communication te- while vector-borne diseases were responsible for chnologies such as the Internet and other media up to 22.8% (1). in the field of EIDs (5-7). Many wildlife zoonotic disease (WZD) outbreaks WILDLIFE ZOONOSIS IN THE BALKANS REGION were reported in the area of the Balkan Peninsula during the last twenty years (2). The wartime pe- The epidemiological situation related to zoono- riod (1992-1995) was associated with socio-eco- ses in the Balkan countries is not well characteri- nomic, human demographics, behavioral, ecolo- zed due to the difficult circumstances prevailing gical and environmental (climate, ecosystems, during the previous decade. There is a lack of microbial adaptation) changes that had signifi- reporting and publishing system of the infection cant impact on public health and global economy, and/or health status of animal and human popula- as well as to wildlife zoonotic diseases (3). The tions. Although there were no readily accessible additional variables which mostly influence zo- data concerning epidemiology and epizootolo- onoses and vector borne diseases are human po- gy of WZDs, limited official and published data pulation density, human population growth, and were analyzed. wildlife and non-wildlife host species richness Anthrax (1, 3-5). Breaking of communications channels between the former Yugoslav countries during Anthrax is endemic in some regions of the Bal- the wartime and some years in post-war periods, kan Peninsula, but it is not a significant public and lack of political will to control the diseases health problem (2). However, in the past century have also greatly contributed to the appearance cutaneous anthrax cases with several clinical si- of WZD outbreaks in the Balkans area. gns of septicemia were recorded in Bulgaria, Bo- There is a need for different actions to be under- snia and Herzegovina (B&H) and Croatia, with a taken in order to recognize and control EIDs and low mortality rate (1.64%) (7-9). WZDs. First of all, it is important to improve Brucellosis the reporting system of infectious diseases at the state, regional and World Health Organization le- Brucellosis is a significant health problem among vel. It is also important to improve several tools animals and humans in the Balkan Peninsula. Bru- for controlling EIDs and WZDs such as epide- cellosis is spread in Greece, the former Yugoslav miologic field investigation, control, eliminati- Republic of Macedonia, Kosovo, Serbia and Croa- on and eradication, training, diagnostic develo- tia (10, 11). It is an endemic disease among animals pment, and basic and applied research activities and humans in the southern part of the Balkan Pe- including technology transfer. Surveillance of ninsula, Greece, the Former Yugoslav Republic of th infectious diseases and continuous systematic Macedonia and Kosovo at the end of 20 century, collection, collation, analysis and interpretation which was a consequence of the changes in politi- of data and the dissemination of information to cal situation in this area followed by the wartime. the authorities have to be established in order to Appearance of brucellosis represents a classical take any actions (4-7). The purpose of the disease example of spreading zoonosis as a result of the surveillance is to identify the changes of infecti- population and animal migration (9, 12, 13). on and/or health status of animal and human po- Brucellosis is an EID in B&H and it is still an pulations, and it is essential to provide rigorous increasing public health problem. Only one case

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of human brucellosis was reported in 1999, while and icterohaemorrhagiae. A strong correlation in 2008 there were 988 cases reported (14). The between serovars in bears and serovars previou- current animal health situation in B&H shows sly isolated from small mammals in Croatia was an increase in the number of reported outbreaks noted (25). in ruminants. The number of seropositive cases as compared with the number of processed se- Listeriosis rums in last four years has ranged from 0.047% Listeriosis is present in the area of the Balkan Pe- to 1.09% (11). ninsula, but it is not a considerable public health In Greece, cattle are also affected either by B. problem. However, occasional cases of different melitensis or B. abortus. Wild boars (Sus scro- clinical forms of leptospirosis have been recor- fa) were found to be carriers and reservoirs of ded recently (26, 27). The analysis of the conta- Brucella suis biovar 2 in Croatia (15), whereas mination level of different kinds of raw meat (raw Brucella suis biovar 3 was isolated from horses beef, pork and chicken) in B&H showed overall in Croatia (16). presence of Listeria spp. in 49.4% samples; L. Due to the dimension of the disease-related pro- monocytogenes detected in 23.3%, L. innocua in blems, there is a need to establish cooperation 22.2% and L. welshimeri in 3.9% analyzed row in the elimination and prevention of brucellosis meat samples (28). Both beef and pork were among all countries in the region, supported by mostly contaminated by L. monocytogenes, in World Health Organization. 34.3% and 25.7%, respectively. Chicken had the lowest level of contamination amounting to Leptospirosis 10.0% (28). In a study conducted in Serbia, 45% of all pigs examined harboured L. monocytogenes Leptospirosis is an endemic zoonosis existing in their tonsils, and 3% were intestinal carriers. Croatia and B&H (17-20). This is a widely spre- L. monocytogenes was detected in 29% of swabs ad disease with frequent epidemic occurrence, from retropharyngeal nodes and in 19% of fecal especially among miners in B&H and foresters in samples of cattle. L. monocytogenes was found in Croatia (18, 21, 22). Serological testing conduc- 69% of minced meat (mixed pork and beef) sam- ted in 1983 revealed antibodies to Leptospira se- ples, in 19% of raw dry sausages, and in 21% of rovares pomona, grippotyphosa, sejroe, australis vacuum-packaged hot smoked sausages. Howe- and bataviae (21) in 10.08% of the B&H miners ver, L. monocytogenes was not detected in the hot population. Leptospiroisis outbreak among mi- smoked sausages heated to internal temperature ners in B&H occurred 25 years later (2005) but of 70-75 °C after the fumigation process (29). caused by new serovars: L. ballum, L. ictroha- emorrhagiae, L. sejroe and L. tarassovi (22). Tularemia Serological tests in patients from Croatia have shown 18 different serovars of Leptospira, with Francisella tularensis has been recognized as a the highest prevalence of L. sejroe, L.pomona, L. human pathogen for almost 100 years and it is the australis and L. icterohaemorrhagiae (23). etiological agent of the zoonotic disease, tulare- mia. The organism has been isolated from over Leptospira seroprevalence among small rodents 250 different species, including fish, birds, amp- captured in shafts of the lignite mines in B&H of hibians, rabbits, squirrels, hares, voles, ticks and 37.5% was noted in 1983 (21). flies. An important aspect of F. tularensis patho- An analysis of Leptospira sp. among small ro- genesis is the transmission via arthropod vectors dents in Croatia revealed three different spe- into mammalian host. Chrysops spp. and Taba- cies: L. borgpetersenii, L. kirschneri and L. in- nus spp. also designated as deer fly and horsefly, terrogans. Mus musculus exhibited the highest respectively, are common arthropod vectors of infection level which was confirmed as a major Francisella transmission to humans, resulting in reservoir of the serogroup Sejroë (23). Leptos- initial clinical presentation with ulceroglandular pira infection was also found among European form of the disease (30, 31) brown bears (Ursus arctos) in Croatia (24), and Due to its easy dissemination, multiple routes based on the antibody titers, several serovars fo- and low dose infection, morbidity and mortali- und were implicated: australis, sejroe, canicola

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ty rates, F. tularensis subsp. tularensis has been pathogens, unfed adult Ixodes ricinus ticks were classified as a category A bioterrorism agent by collected from vegetation at 18 localities throu- the CDC (32). ghout Serbia in 2001, 2003, and 2004, a total of Tularemia is an emergent infectious disease in 287 ticks were examined by PCR technique for several countries at the Balkan Peninsula. The the presence of Borrelia burgdorferi sensu lato; first outbreak of tularemia occurred in B&H in prevalence rate for B. burgdorferi sensu lato was 1995, during the wartime (33). A large tulare- 42.5% (36, 39). The presence of five B. burgdor- mia outbreak occurred in Kosovo in the early feri sensu lato genospecies, namely B. burgdorfe- postwar period, 1999-2000 (34). Only sporadic ri sensu stricto, B. afzelii, B. garinii, B. lusitani- cases of tularemia have been recognized and re- ae, and B. valaisiana was identified by restriction ported since the first epidemic in Kosovo (32, fragment length polymorphism (RFLP) analysis 34). There are no data about tularemia seropre- (39). The most frequent B. burgdorferi sensu lato valence in general population or in the high risk genospecies was B. lusitaniae, followed by B. groups, e.g. foresters, hunters, veterinarians, or burgdorferi sensu stricto. These findings indicate soldiers. a public health threat in Serbia related to tick- borne diseases caused by B. burgdorferi sensu Epidemiological and environmental investigati- lato (39). ons were conducted to identify sources of infec- tion, modes of transmission, and household risk Q-fever factors in Kosovo. The results suggested that the infection was transmitted through contaminated Q-fever has been present in the region of the food or water and that the source of the infection Balkan Peninsula since it was first recorded as were rodents (34). Environmental circumstances ‘’the Balkans flu’’ (1941–1942), and it occurs in in the war-torn Kosovo led to epizootic rodent the form of small-scale epidemics and epizooti- tularemia and its spread to displaced rural popu- es (8, 40). Across the ex-Yugoslavia territories lations living under circumstances of substandard Q fever was discovered rather early – in Za- housing, hygiene, and sanitation (34). greb (1948), Banat (1950), Bosnia (1951, 1953), Sandzak (1953), Serbia (1953, 1956 – the Pirot Tularemia outbreak areas in 1962 and 1997-2006 strain), Dalmatia (1957), Vojvodina (1957), Gac- periods in Bulgaria were different. The first case ko (1959), Croatia (1962), B&H (1964), Pula of tularemia was reported in 1997. Starting from (1972), Vojvodina (1983), Croatia (1984), Vojvo- 1998 to 2008, 296 cases were registered. Ampli- dina (1984), Bosnia (1985), Kosovo and Metohi- fied fragment length polymorphism (AFLP) and ja, Cacak (1985), Vojvodina (1991, 1992, 1993, multiple-locus variable number of tandem-repe- 1994, 1995), Macva (in sheep from Kosovo ats analysis (MLVA) typing, confirmed epidemic 1998), Montenegro (1999), Serbia (2003), B&H spread and evolution, and comparison of strains (1998., 2000., 2002., 2004) (41,42). isolated from different regions in Bulgaria and Turkey resulted in the finding of the common Analyzing the available epizootiological and epi- “Balkan” genovar of Francisella. In addition, demiological data on the incidence of Q fever several novel genotypes of endosymbionts of in the region, it could be concluded that beside Francisella-like organisms have been found in classical locally focused character of the disease, Hyalomma and Dermacentor ticks (9). incidence of new epidemics was also influenced by uncontrolled dislocation of animals, mostly Lyme disease sheep and goats (41- 44). Although some experts deny the significance of Q fever from the view- Lyme boreliosis is an emergent disease in many point of veterinary medicine, the latent forms of Balkan countries: Bosnia and Herzegovina, Cro- this disease in domestic animals and abortions atia, Slovenia, Serbia and Bulgaria (35-39). It is in sheep and goats result in huge economic lo- a zoonosis transmitted from animals to humans sses, thus confirming the importance of Q fever by ticks of Ixodes ricinus complex. Lyme borreli- as a problem of the veterinary practice (39. 41). osis is caused by Borelia burgdorferi sensu lato, Moreover, having also in mind the fact that ve- which has four different species (36). In order to terinarians together with other professionals are evaluate prevalence rate of tick-borne bacterial

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very exposed to this infection, it is obvious that Rabies Q fever must not remain marginalized in the ve- Rabies remains endemic within a number of co- terinary science. The frequent incidence of this untries in Southeast Europe including Romania, disease in humans should be followed by syste- Bulgaria, B&H and Turkey (7, 44, 55, 56). With matic investigations of the infections in animals the exception of Turkey, the red fox (Vulpes vul- and natural reservoirs (42, 43). pes) is the principal disease reservoir in Southeast Hantavirus infections Europe. However, cases of rabies in dog (Canis familiaris) are regularly reported. In contrast to The Balkan Peninsula has been known as a hig- Northern Europe, the raccoon dog (Nyctereutes hly endemic region for hantavirus infections. So procyonoides) does not appear to be a vector in far our research has shown that at least two dif- the south. In Bulgaria, dogs are the main vectors ferent Hantaviruses (HTV) (the murine Dobrava bringing rabies into contact with humans and li- (DOBV) and the avricoline Puumala (PUUV) vi- vestock. Foxes are the principal reservoir species ruses), each carried by a different rodent species, for rabies in Romania although cases in dogs are have been circulating in the area (44,45). regularly reported. Despite a gradual decline in So far two viruses, Puumala and Dobrava have dog rabies, urban pockets of the disease remain been identified as causative agents of hemorrha- in many regions of Turkey. Furthermore, there is gic fever with renal syndrome in Albania, B&H, some evidence that the foxes have been a signi- Greece, Croatia, Kosovo, Montenegro, Slove- ficant vector for rabies and might be responsible nia and Serbia (45-50). Additionally, Tula virus, for increased rabies in cattle. Rabies in Croatia which is considered a non-pathogenic hantavirus has been registered in wild animals (mostly foxes) was detected in small mammals (51). However, and sporadically in domestic animals (dogs, cats). Clethrionomys glareolus, Apodemus agrarius and The last human case was described in 1964. The Apodemus flavicollis are the main reservoirs of fox and dogs are the principal reservoir species hantaviruses in the region (46). The incidence of for rabies in B&H. Throughout the region there is haemorrhagic fever with renal syndrome (HFRS) evidence of cross-border movement of rabies by varies in a cyclic fashion, with peaks occurring both wildlife and canine vectors (55,56). every three to four years, coinciding with peaks in The lyssaviruses currently consist of 7 esta- rodents population (45). Several HFRS outbreaks blished genotypes or lineaages of rabies(-like) vi- were registered in the area of the Balkan Penin- ruses (56) of which classical is found sula in: 1967, 1986, 1987, 1989, 1995 (45, 51), throughout the world and associated with terre- and 2002 with more than 1000 HFRS cases. Dual strial mammalian hosts and American bats forms infections with hantaviruses and leptospira were genotype 1. Phylogenetic relationships among also detected in humans as well as in rodents (52). sequences of five viruses isolated in B&H have In the Balkan states where PUU and DOB viruses shown the presence of two phylogenetic lines, co-circulate, seroprevalence in general population one which is present in the Northwestern part and is between 1.6% (Slovenia) up to 5.18% in B&H, the other, which is present in the Northeastern which has been recognized as a highly endemic part of the country. Viruses are closely related to region for hantavirus infections for over 56 years Western European isolates of rabies virus (56). (45,51,53). As early as in 1952 the first ‘’proba- ble’’ HFRS case was described in the region - the Tick-borne encephalitis victim was a soldier and infection occurred near Tick-borne encephalitis virus is the causative Fojnica city, B&H. The first documented HFRS agent of the most prevalent arboviral human outbreak was reported in 1967, followed by five infections in Europe. Three subtypes have been outbreaks in the region and the majority of the af- identified: European (TBEV-Eu), Far Eastern fected population was located in B&H. The total (TBV-FE) and Siberian (TBEV-Sib). The vector number of HFRS reported cases was 1242, but of TBEV-Eu transmission is the tick Ixodes rici- the real number of HFRS cases is probably higher nus, whereas I. persulcatus is the vector of other because the surveillance of infectious disease had two subtypes. The virus is maintained in nature not been regular until 1992 (53). through cycles involving tick and wild vertebra-

100 Hukić et al Wildlife zoonoses in the Balkans Region

te hosts and also by transovarial and transstadial between 1886 and 1962 (66-68), but there was no transmission in its vector. Many different verte- published data about the SFV infection between brates have been implicated in the maintenances 1971 and 2006. The recent infection was found in and circulation of the TBE virus. The major ca- 9.38% to 12.50% of patients during the period of usative role in Central Europe seems to belong three years (2006-2008) (68). to Apodemus flavicollis and Myodes glareolus, The first extensive serological investigations of not only because they are abundant in the regions the prevalence of the infection were where TBE incidence is high and they are exce- reported in 1975-1982 (64, 68-70). The results llent hosts for both nymphal and larval stages of indicated a high prevalence of the antibodies to the tick, but also because they promote transmi- Naples and Sicilian sandfly fever viruses in Dal- ssion by co-feeding (44,57,58). matian population, North Croatia and Kosovo. The distribution of TBEV is well coordinated On the island of Brač, 57.6% of the population with its vector distribution. There is a lack of data had antibodies for the Naples virus and 15.6% for related to TBEV seroprevalence among the wild the Sicilian virus, in Kosovo- 27.9% and 9.6%, animals in the Balkan region. Data from Slovenia respectively. The prevalence of the Naples virus have shown that the infection prevalence in ro- infection reached 62.1% in the inhabitants of dents sampled in Slovenia in the period between B&H in 1962 (69). These results indicated the 1990 and 2008 entirely varied based on the ro- continuous circulation of Naples virus in nature. dent species, from 14% in Myodes glareolus to Finding the TOSV positive results in clinical 2-4% in Apodemus species (57-59). samples after more than forty years (66), means Tick-borne encephalitis (TBE) in Slovenia repre- that the virus has been circulating in this region, sents a serious public health problem with hun- but has not been the point of interest of local rese- dred official reported cases (58). In Croatia TBE archers. It is very important to direct the attention was first discovered in 1953. The only really do- of clinicians to sandfly fever (papatasi fever) be- cumented natural focus of tick-borne encephalitis cause the disease was unrecognized in the region was the northern part of the country, between the until recently. Sava and Drava rivers. Alleged cases from other parts of Croatia still have to be confirmed and Leishmainiasis analyzed, and additional research and collabora- Leishmainiasis is widespread on the Balkan Pe- tion between different professionals is required ninsula. It is a protozoan parasitic infection cau- (44, 57, 59). Official data show no occurrence of sed by Leishmania infantum that is transmitted TBE in Albania, Bosnia and Herzegovina, Bulga- to human beings through the bite of an infected ria, the Former Yugoslav Republic of Macedonia female sadfly (71). The disease occurs in urban and Turkey (57). centers and rural highland villages in Albania, B&H, Croatia, Greece, Montenegro, Serbia, Ro- Sandfly fever mania and Slovenia (71-76). Zoonotic visceral Sandfly fever viruses (SFV) are moderately ende- leishmaniasis (VL) is a re-emerging disease in mic along the Adriatic coast of Albania, Croatia, the Balkan area (1, 3-5, 73, 74). The re-emerging B&H, Slovenia and landlocked Serbia, and fo- is probably due to a combination of factors inclu- cally distributed throughout Greece and the for- ding increased monitoring, intensified research, mer Yugoslav Republic Macedonia (44, 60-65). demographic change, land-use/land cover chan- Historical data of the sandfly fever (Pappataci ges that create new habitants and/or changes in fever) indicate its origin in B&H at the end of the microclimate, and changes in seasonal climate 19th century (62, 63). Before the World War II, (2). Some human cases are usually detected in the pappataci fever in the former Yugoslavia was the area every year (74-76). Visceral leishmani- mainly detected in Herzegovina, Dalmatia, Mon- asis in 50 children was reported from Albania in tenegro and especially in Macedonia, where its 2009 (72). prevalence coincided with that of Phlebotomus Leishmaniasis is mostly a problem in veterinary papatasi (64, 66). Most of the clinical and epi- medicine. The investigation of 272 dogs sera demiologic studies had been conducted in B&H originating from different regions in Albania

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and Kosovo have shown specific antibodies for human trichinellosis is sporadic (83). A re-emer- Leishmania in 3.3% of animals. All leishmania- gence of trichinellosis is connected with the chan- positive animals were stray dogs (74, 75). Those ges in the social and political systems in Bulgaria animals contribute to the maintenance of Leish- and Romania (81, 84). In B&H, Kosovo, Serbia mania transmission in endemic areas, and a con- as well in Croatia, however, the re-emergence of trol of the canine stray population should be con- trichinellosis did not only happen due to political sidered (74-78). A historical review on human and and social changes, but also due to the war that canine leishmaniasis in Croatia documents the took place in these countries during the last years presence of stable disease foci in coastal and in- of the 20th century (84). sular territories of central and southern Dalmatia There are some other zoonoses and vector-bor- since the beginning of the 20th century (71,74). ne diseases with more or less documented evi- Among the species which may act as Leishmania dence on epidemiological, clinical or etiological infantum vectors in Croatia, Phlebotomus tobbi features (1, 8, 44, 85, 86). The special attention and P. neglectus were the most abundant (74). deserves tuberculosis and rickettiosis, because the outbreaks affected the history of the Balkan Echinococcosis Peninsula. Echinococcosis remains a very serious public health problem in Southeast Europe, although a THE SURVEILLANCE OF WILDLIFE ZOONOSIS decrease in incidence has been observed in some DISEASES endemic areas during the last decades (77-80). The last outbreaks of avian A (H5N1) and swine However, in some non-endemic areas an increase influenza A (H1N1) showed the importance of in infected cases and new foci of animal echino- greater collaboration between physicians and ve- coccosis were registered during the same time terinarians as well as for the disease surveillance (77). The disease is very common in the Balkan in humans, domestic animals and wild animals Peninsula, with the former republics of Yugosla- (5). The surveillance of diseases in wild animals via having one of the highest prevalence rates is a relatively new activity compared to the sur- (77-80). Echinococcosis is zoonosis transmitted veillance of diseases in humans or domestic ani- by dogs in livestock-raising areas and acciden- mals (5, 7). At the moment, there is no Balkan- tally affects men. The most frequent site of hyda- wide network of health surveillance. Since 1992, tid cysts is in the liver (78%), followed by lungs the disease surveillance in most Balkan countri- (17%), and less frequently, spleen, kidneys, he- es is irregular and coordinated by the WHO. A art, bones, central nervous system, and elsewhere number of new zoonotic infections emerged or (80). re-emerged during the past 17 years, caused by Trichinelosis social, political, climate and environmental chan- ges in the area. The communication channels In the majority of Southeast European countries among Balkan countries were broken, so preven- cases of trichinellosis among the human and ani- tive action has not been done. There is an urgent mal populations were described in the late 19th need for building of a European health survei- or early 20th century (80-81). Trichinella infec- llance network. It should include the following tions among wildlife were also described in the elements: national surveillance programs that aforementioned countries (5, 80). Today, the pre- cover the whole country; human diseases, dome- valence of trichinellosis between the Balkans and stic animal diseases, all wildlife species, and all bordering countries is different (81-83). A high diseases; comparable methodology among surve- prevalence of trichinellosis in domestic animals illance programs, so that it is valid to compare and humans has been reported in Bulgaria, Serbia results; strong interaction among surveillance and Montenegro, Romania and Croatia (80-84), programs, so that new information and knowled- and a moderate prevalence was found in B&H. ge is rapidly and efficiently shared. Trichinellosis has not been found among dome- Recent initiative called One Health, which sup- stic animals and humans in Greece and Macedo- ports the unique approach to zoonoses, is a con- nia in recent years, while in Turkey and Slovenia cept of the worldwide strategy for expanding

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interdisciplinary collaborations and communica- ACKNOWLEDGEMENTS/DISCLOSURES tions in all aspects of health care for humans and Competing interests: none declared. animals (86).

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