ESCMID Online Lecture Library © by Author ESCMID Online Lecture Library Imported Malaria Mediterranean Region

• Greece endemic country in mid-20th century

• National malaria eradication programme: 1946 - 1960

• 1974: WHO declares© Greece by author malaria- free

• 1975ESCMID - 2010: 20 Online-50 imported Lecture malaria cases Library reported annually Malaria in Greece, 1960 - 2010

• Sporadic locally acquired cases

– in 1991, 1999, 2000, 2009, 2010

• 2004 - 2010: 255 malaria© by cases author (mean 36 cases/year) – 53 Greek (mostly travellers) ESCMID Online Lecture Library – 202 other nationality Place of exposure of locally acquired malaria cases, Greece, 2011

Number of malaria cases by week of onset and nationality status, affected areas, Greece, 2011

*3 asymptomatic cases in migrants from Pakistan are not included in the epi-curve. 2 cases in Romanian farm workers diagnosed in Romania are also not included Malaria cases, Greece, 2011

96 malaria cases recorded

• Imported cases: 54 - 49 in immigrants from malaria endemic countries - 36 P. vivax

• Locally acquired:© 42by author - 34 Greek, 5 Romanian, 2Moroccon, 1 Polish ESCMID - all P. vivax Online Lecture Library

Place of residence of malaria cases, Evrotas, Lakonia, 2011

Red dots: immigrants Yellow dots: Greek cases Clinical picture

 Fever, rigor, malaise, myalgias, jaundice

 Hepato-splenomegaly

 Anemia, thrombocytopenia © by author   ESCMID LDH, ind Online bil, Lecture Library

Georgantas MD. Personal communication, Sparta Hospital © by author ESCMID Online Lecture Library Plasmodium genotyping Courtesy of N. Vakalis, NSPH, unpublished data

Polymorfism at the membrane surface protein, Plasmodium vivax Active case finding, Evrotas, Laconia

T & Sxs c/w malaria 1. House visits Blood sample & RDT 2. Foci investigation Medical Evaluation © by author 3. Mass pre-Sx screening DOT Chloroquine (2d) + Primaquine ESCMID Online Lecture Library(14d)

Focus investigation radius of 100m Evrotas, Laconia

Map of village of Elos, Lakonia using Google Earth Active Case Detection (ACD), Evrotas, Lakonia, Oct 2011 - Oct 2012

• 3570 residences visited 130 immigrants residences

• 7731 individuals recorded ~ 800 - 1000 migrants, significant turn-over

• 377 RDTs performed in symptomatic patients • 480 microscopy © by author • 450 PCR ESCMID Online Lecture Library • 480 blood samples drawn in symptomatic patients Results of ACD, Evrotas, 2011-2012

• 25 malaria cases detected due to ACD - 10 cases in 2011 - 15 cases in 2012 (15/16 imported cases)

• Median time from onset of symptoms to diagnosis, 2012:© by author - Greeks: 3 days vs 7 fays in 2011 ESCMID - Migrants: Online 3 days vsLecture 5 days in Library 2011

• >50 DOT courses for malaria

Health professionals Public Presentations, Information material to: Presentations, Information material to:

• Local health centres and hospitals • Local communities (+ RDT donation-training) • Migrant communities with the • All private practicing physicians© inby authorassistance of mediators Lakonia • Internal Residual Spraying (IRS) • All pharmaciesESCMID in Lakonia Online Lecture risk communication Library Communication

o Study of the mosquito fauna, mapping and monitoring of mosquito populations in Greece, funded by HCDCP

o Integrated Surveillance and control programme for West Nile Virus and malaria in Greece, funded by National Strategic Reference Framework (NSRF) 2007- 2013

Mapping of Mosquitoes Breeding Sites

www.bioapplications .gr © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Mosquito species • Anophelinae • An. Sacharovi + • An. Claviger +

• Culicinae • Cx. pipiens • Cs. longiareolata • Cs. ann©ulata by author • Oc. caspius ESCMID• Oc. Online dentritus Lecture Library • Cx. tritaeniorynchus • Cq. richiardii Vector control

 Larvicidal efforts & for Anopheles spraying

 Air spraying (Χ 3 Vivari lake)

 Indoor residual sprays

 21-27 July & 14-17 September 2012  12 inhabited areas© -by 147 authorbuildings/spaces  Non inhabited places, warehouses, stables, ESCMIDbasements Online etc Lecture Library

Evrotas - landscape

Evrotas – the river !!! © by author ESCMID Online LectureIrrigation channel Library next to orange orchard

Migrants living outdoors Evrotas delta –land use

Orange orchards

Irrigation channels (105 km) Other cultivating farms

River delta ESCMID Online Lecture LibraryNational park Small geographical area Sea Total surface 25km Environmental interventions

Vegetation removal from irrigation or drainage canals

© by author2011 - 2012: 59% decrease in total n of cases ESCMID Online Lecture78% decrease Library in locally acquired cases Place of exposure of locally acquired malaria cases, Greece, 2012 (until 26/10/2012)

Foci classification Markopoulo, East Attiki

Selino, Avdira, Xanthi Filia, Sofades, Karditsa New active Lake Paralimni, Viotia Evrotas, Lakonia Marathon, East Attiki Omolio, Agia, Larisa © by author Kalivia, East Attiki Residual non-active ESCMID OnlineChalkida Lecture (Faros & Filla), Library Evia Orchomenos, Viotia

Thiva, Viotia Reported malaria cases, Greece, 2012 (until 15/11/2012)

81 malaria cases reported

• Imported cases: 65 - 58 in immigrants from malaria endemic countries - 52 P. vivax

• Locally acquired:© 16by author - 13 Greek, 1 Moroccan, 2 Romanian ESCMID - all P. vivax Online Lecture Library

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: © by author Chloroquine (11), Mefloquine (3), Atovaquone-Proguanile (1), ESCMID no treatment (1) Online Lecture Library + Primaquine (15)

• Outcome: No fatality

High risk areas based on Anopheles captures

www.bioapplications .gr Immigrant-based Ro (Ro results from the introduction of an infected host into a fully susceptible population)

www.bioapplications .gr Immigrant and Anopheles-based Ro (Ro results from the additional introduction of Cv)

www.bioapplications .gr CDC 05 Σεπτ 2012 16-12-2011

…recommends preventive antimalarial © by author drugs for travel to the agricultural areas ESCMID Online Lecture Library of Evrotas in the Laconia region… WHO 2012 – Greece/malaria

…recommended© by preventionauthor in risk ESCMID Online Lecture Library areas: I (mosquito bite prevention) MALARIA FREE WORLD

© by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Artemisinin combination therapy for vivax malaria? Nicholas M. Douglas, Nicholas M. Anstey, Brian J. Angus, Francois Nosten and Ric N. Price Lancet Infect Dis. 2010 June 10(6):405-416.

1999

Reports of chloroquine-resistant Plasmodium vivax by 1999 (a) and 2009 (b). Red stars = >10% recurrence (and greater than 5 absolute failures) by day 28 with or without chloroquine levels; orange diamonds = <10% recurrence (or less than 5 absolute failures) by day 28, with chloroquine levels; yellow circles = <10% recurrence (or less than 5 absolute failures) by day 28, without chloroquine levels.

Schlagenhauf P et al., Expert Rev. Anti Infect. Ther. 2012; 10(5): 537–546 Insecticide resistance

 Vulnerable areas for re-establishment exist

.  influx of migrants from endemic countries . Appropriate mosquito vector

 Most affected areas are agricultural, non-touristic, close to wetlands, w large populations of migrants © by author  Fewer malaria cases recorded in 2012, ESCMID. Enhanced surveillanceOnline Lecture & ACD helped Library

Conclusions-Malaria Greece

 Goal to prevent re-establishment

. Need intact healthcare, mosquito control & PH infrastructures

.ESCMIDmay occur sporadically Online or in Lecture small clusters Library

Conclusions-Malaria Greece/ World

 Multi-sector control strategy - surveillance

- clinical management

- laboratory diagnosis

- entomological© surveillance by author - vector control, bite prevention, ? vaccine ESCMID Online Lecture Library - communication Greece, Ntl Malaria Plan, 2012-15 © by author ESCMID Online Lecture Library