ESCMID Online Lecture Library © by Author

P. vivax malaria: the experience of Greece

P. vivax in Europe: a re-emerging disease 23©rd ECCMIDby author 2013

ESCMID Online LectureAgoritsa Library Baka, MD On behalf of the Vectorborne Diseases team Hellenic CDC 1 Malaria in Greece, 1960 - 2010

• Greece endemic country in mid-20th century

• National malaria eradication programme: 1946 - 1960

• 1974: WHO declares Greece malaria-free

• 1975 - 2010: 20 - 50 imported malaria cases reported annually

• Reports of sporadic locally acquired cases in 1991, 1999, 2000, 2009, 2010 © by author • 2004 - 2010: 255 malaria cases (mean 36 cases/year) - 53 Greek nationality (mostly Greek travellers + known locally acquired cases) ESCMID- 202 other nationality Online Lecture Library

- 94% likely acquired the infection in malaria endemic country - 71.5% of all cases originated from endemic countries (94% of non-Greeks)

Place of exposure of locally acquired malaria cases, Greece, 2009

Cluster of 6 cases in 1 case in East Attiki Evrotas, Lakonia (Nea Makri)

3 Place of exposure of locally acquired malaria cases, Greece, 2010

2 cases in Thiva (Roma children)

1 case in Evrotas 1 case in East Attica Lakonia (Roma) (Marathon) © by author ESCMID Online Lecture Library Reported malaria cases, Greece, 2011

96 malaria cases recorded

• Imported cases: 54 - 45 in immigrants from malaria endemic countries - 36 P. vivax

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

Place of exposure of locally acquired malaria cases, Greece, 2011 (n=42) Viotia (Orchomenos): 40-50 yrs Roma Larisa (Omolio): 70 yrs

Evia: 2 cases 40-50 yrs

ESCMID Online Lecture Library Reported malaria cases, Greece, 2012

93 malaria cases reported

• Imported cases: 74 - 68 in immigrants from malaria endemic countries - 60 P. vivax

• Locally acquired:© 19by author - 13 Greek, 2 Moroccan, 3 Romanian, 1 Albanian ESCMID - all P. vivax Online Lecture Library

Place of exposure of locally acquired malaria cases, Greece, 2012 (n=18)

Karditsa: 2 cases (Romanian) 24 & 53 yrs Xanthi: 61 yrs

Viotia: 47 yrs

ESCMIDEvrotas: 10 cases Online Lecture EastLibrary Attiki (Markopoulo):

2 cases, 44 & 70 yrs

Reported malaria cases not attributed to 2012 transmission period, Greece, 2012

• 5 relapses in 2011 cases: 4 Greek, 1 Pakistani ⁻ relapses: after 7-12 months ⁻ inadequate Primaquine treatment ⁻ 19% (4/21) of cases treated with 8-week Primaquine scheme relapsed ⁻ no case treated with Primaquine 30mg x 14d relapsed

• 4 cases attributed to© past by transmission author periods: - 1 case (P.vivax), 30yro Moroccan male, Evrotas, onset: 03/04/2012 - 1 caseESCMID (P.vivax), 7yro Online Greek female, Lecture Evrotas, onset: Library 27/08/2012 - 2 cases of P.malariae (Greek): 78yrs, onset: 08/01/2012 85yrs, onset: 01/05/2012 9

Number of reported malaria cases by year of onset and case classification, Greece, 2009 - 2012

Case classification Year of symptom Total onset Imported cases Locally acquired cases

44 51 2009 7 40 44 2010 4 54 96 2011 © by author42 74 93 2012 19 ESCMID Online Lecture Library Distribution of locally acquired malaria cases by week of reported onset of symptoms, Greece, 2012 (n=18)

• Age: ranged from 24 - 82 yrs (median 52 yrs)

• Gender: 63% were male

• Plasmodium species: all cases P.vivax

• Hospitalization: 75% hospitalized, no case in ICU

• Treatment: © by author Chloroquine (13), Mefloquine (4), Atovaquone-Proguanile (1), ESCMID + Primaquine ( 17Online) Lecture Library no treatment (1)

• Outcome: No fatality 12 Evrotas, Lakonia

New active focus © by author ESCMID Online Lecture Library Malaria cases, Evrotas, Lakonia, 2011-2012

Malaria cases Evrotas, 2011 Number Malaria cases Evrotas, 2012 Number Greek nationality 28 Greek nationality 7

Immigrants from non-endemic Immigrants from non- 3 countries 8 endemic countries Romania 5* Morocco 2 Poland 1 Romania 1 Morocco 2 Total (locally acquired) 10 Total (locally acquired) 36** © by authorImmigrants from endemic Immigrants from endemic countries 17 countries 23 Pakistan 13 PakistanESCMID Online 21 Lecture Afghanistan Library 4 Afghanistan 2 Total 27 Total 59 * 2 cases diagnosed in Romania ** 2 cases had onset of symptoms in 2012

Reported cases of P.vivax infection by month of onset and case classification, Lakonia, Greece, 2011 (n=56*) and 2012 (n=27)

Orange trees

Irrigation &drainage channels (105 km)

Other cultivations

Coastal wetlands & lake under NATURA ESCMID Online Lecture Library Sea Ecological situation in Evrotas, Lakonia

Evrotas river © by author ESCMID Online LectureIrrigation channel Library near the orange plantations

Habitation inside the orchard Filia, Sofades, Karditsa

New© by active author focus Sofades Municipality population: 18.910 ESCMID Online Lecture Library Affected households, Filia, Sofades, Karditsa, 2012

Spring 2012: Hellenic CDC Action Plan for the Management of malaria 2012-2015  risk assessment  partnership to implement the national project: “Integrated surveillance and control programme for West Nile virus and malaria in Greece” (www.malwest.gr)  Greek section of Medecines sans Frontieres (MSF) from April-October 2012

I. Enhancement of malaria surveillance: • Early detection of cases and focus investigation • Active malaria case detection© inby the generalauthor and the migrant populations: - in Evrotas: 16/17 malaria cases in immigrants have been actively detected - improvement of timeliness of diagnosis • ScreeningESCMID of migrants Online for malaria Lecture Library

II. Treatment of immigrants in Evrotas, Lakonia - with positive malaria serology (up to 60%) Active case detection, Evrotas, Lakonia

III. Enhancement of laboratory diagnosis of malaria - training seminars, RDTs distribution to health units IV. Standardization of the malaria treatment V. Increase awareness amongst health professionals for the diagnosis of malaria (41 seminars all over the country) VI. Communication to the public (29 public meetings, 82 seminars in schools) VII. Communication with international public health stakeholders (ECDC, WHO) – expert meetings © by author VIII. Vector control activities- Entomologic Surveillance: - GuidanceESCMID to local authorities Online Lecture Library - Vector surveillance, mosquito mapping projects - Communication to the local level: training seminars Lessons learned

• Access to health care – free diagnosis and treatment for undocumented immigrants is crucial for the early detection of cases

• Multi-sectoral collaboration: challenging - essential • Blood safety measures • Local Public Health Authorities: critical role in case and focus investigation and management –reinforcement needed

• Awareness of health professionals in low risk areas should be continued intensively © by author • Local laboratory capacity should be enhanced

• ESCMIDRDT: useful tool, improvingOnline field Lecture and local diagnosis Library of malaria

• Full focus investigation for imported cases in areas with high receptivity should be continued Discussion

. Vulnerable areas for re-establishment of malaria exist in Greece, due to: . increased number of immigrants from endemic countries . competent vector circulation (Anopheles spp.) in many areas.

. Most affected areas are agricultural, non-touristic, close to wetlands, with large populations of migrant farm workers

. Fewer malaria cases recorded this year (vs.2011), although enhanced surveillance and active case© detectionby author are in place : - throughout Greece: 57% decrease of locally acquired cases - in Evrotas: 72% decrease of locally acquired cases - ESCMIDimprovement of timelinessOnline of diagnosis Lecture Library

Conclusions

. Conditions exist in Greece for local transmission of P. vivax, which is mainly responsible for sporadic cases and in certain cases small clusters.

. Provided that healthcare,© by author mosquito control and public health infrastructures remain intact, re-establishment is unlikely ESCMID Online Lecture Library

27 Transmission period 2013

. Establish proof for the transmission chain in Evrotas, Lakonia . Continue and enhance ACD in Evrotas . Provide one full antimalarial course to all immigrants in the “epi-centre” (chloroquine + primaquine, DOT) . Ensure IRS rounds are performed appropriately . Distribute LLINs . Continue capacity building at the local level BUT © by author • Hellenic CDC: decreased budget (by 40%) • ESCMIDLoss of staff (>20 Online PH doctors andLecture nurses) Library • Early spring (>15-20 days earlier than in 2011) • Delays in the local tenders for vector control activities 28 Acknowledgements:

• Office of vector borne diseases and all the Department of Surveillance and Response, Hellenic CDC (www.keelpno.gr) • Office of the President, Hellenic CDC • Maria Tseroni, RN and the Hellenic CDC field team • Prof Ch. Hadjichristodoulou and the staff of the project «Integrated Surveillance and control programme for West Nile Virus and malaria in Greece» (www.malwest.gr) • Prof Vakalis and the staff in the Malaria Reference Laboratory • Prof Tsakris, and the staff in the Dept of Microbiology, School of Medicine, University of Athens • Benakeion Fytopathological© by Institute author and the staff at the Entomology Laboratory

• ESCMIDMSF-Greece Online Lecture Library • Municipal authorities of Evrotas, hospital physicians in Sparti and local public health authorities who contribute to the surveillance & control of malaria in Greece 29

Thank you www.keelpno.gr www.malwest.gr