Announcement

**Gert van der Hoek** · August 22, 2011, 03:01 AM

Re: Greece: autochthonous malaria reported

In this report from august 4 this year, Leonidas Grigorakis, a member of parliament from Laconia region, is complaining about the situation regarding malaria:

- no mosquito control;

- no or hardly any medicines available to treat malaria patients ;

- one malaria patient had to be transferred to Athens, is treated in ICU there;

- West Nile Virus infections also are a problem in this region.

The MP asks for immediate action.

**Gert van der Hoek** · August 22, 2011, 03:13 AM

Re: Greece: autochthonous malaria reported

Reading the local news, 3 factors are mentioned which are blamed for the current malaria outbreaks which started some years ago:

- (illegal) immigration (from Pakistan);

- some regions with marshes, a lot of stagnant water;

- authorities don't have money for mosquito control or waste the money.

For instance: http://www.notospress.gr/index.php?c_id=51&n_id=2621

**Gert van der Hoek** · August 23, 2011, 08:07 AM

Re: Greece: autochthonous malaria reported

ECDC - RISK ASSESSMENT

Autochthonous Plasmodium vivax malaria in Greece

23 August 2011

Main conclusions and recommendations

Greece reports six cases of Plasmodium vivax infection in Evrotas, Lakonia, Peloponnese region, and Chalkida
in Evoia since June 2011. The main risk related to the current event is to persons living in, visiting and working
in the particular area of Evrotas in the district of Lakonia (and potentially Chalkida in Evoia, though more
information is needed) in Greece. The local transmission of P. vivax malaria to humans is believed to have
occurred here over the last three years and is likely to continue producing annual clusters of human cases.
However, the risk for further extension of malaria transmission into the EU related to this event is considered
low at present.

Read more (map, references)

**Gert van der Hoek** · September 24, 2011, 02:27 PM

Re: Greece: autochthonous malaria reported

MALARIA, P. VIVAX - GREECE (04): AUTOCHTHONOUS
**********************************************

Date: Fri 23 Sep 2011

From: Corneliu Petru Popescu [edited]

cornel160@yahoo.com

New _Plasmodium vivax_ infected patient in Greece
-------------------------------------------------
I would like to announce that we had from 19 Sep 2011 a new case of
malaria with _P. vivax_ in a patient who lived in Greece for the last
3 years and returned 3 weeks ago. He worked in the south, in the same
region as the previous patient
(http://www.eurosurveillance.org/View...rticleId=19954),
in the Leimonas village, near Skala and Elos.

The traveler had no history of travel to any malaria-endemic areas.
The patient was a citizen from Romania and was admitted and diagnosed
at the Clinical Hospital of Infectious and Tropical Diseases Dr V
Babes in Bucharest.

--
Corneliu Petru Popescu <cornel160@yahoo.com
Simin Aysel Florescu <siminflorescu@yahoo.com
Dr V Babes Clinical Hospital of Infectious and Tropical Diseases
Bucharest Romania

[The last patient was reported from Romania on 1 Aug 2011, and the
present case adds up to 8 cases of _P. vivax_ infected in Greece since
June 2011. The patients were infected in 2 areas: Euboea and the
Evrotas river basin.

It is disturbing that new cases continue to appear. We speculated
earlier that the cases resulted from migrant workers from endemic
areas being asymptomatic gametocyte carriers, but as new cases
continue to be found, local reservoirs in these 2 regions must be
considered.

Surveys of blood films, perhaps seropositivity for malaria antibodies
and investigation of sporozoites in the local _Anopheles_ population
would help define the situation.

ProMed

**Gert van der Hoek** · September 26, 2011, 06:19 AM

Re: Greece: autochthonous malaria reported

Malaria in Greece, September 2011

26 Sep 2011

Since June 2011, sixteen cases of Plasmodium vivax malaria, without previous history of travel to an endemic country, have been reported from Greece. Ten of the cases are residing in the municipality of Evrotas (Lakonia Prefecture), two in Chalkida (Evoia Prefecture), two in Eastern Attiki Prefecture, one in Agia (Larissa Prefecture) and one in Orchomenos (Viotia Prefecture).

In addition to these autochthonous malaria cases, twelve cases have been reported from the Lakonia prefecture among migrant workers from Pakistan (10 cases), Morocco (1) and Romania (1). The Romanian case worked in Evrotas, Lakonia and was diagnosed after returning to his country. Even though most of these cases had been residing in Evrotas area for several years, they may have been infected outside of Greece.

Control measures implemented by the Hellenic Centre for Disease Control and Prevention (KEELPNO) include enhancing surveillance in the affected areas to rapidly identify cases, informing health care professionals on early malaria diagnosis and treatment, raising public awareness, and strengthening blood safety. Intensified mosquito control measures have also been carried out by local authorities.

Malaria was eradicated in Greece in 1974. Since then, Greece reported 30 to 50 cases annually, most of them with travel histories to endemic countries. However, sporadic cases without travel history were reported in 1991, 1999 and 2000. In 2009, eight laboratory-confirmed cases of P. vivax malaria were reported from Evrotas, Lakonia and one from the same area in 2010. All areas with reported cases have a large population of non-documented migrant farm workers from malaria-endemic countries (e.g. Pakistan, India). These areas are not touristic destinations.

Two ECDC experts are currently in Greece to assess the situation from a European perspective.

Read more: ECDC

Figure 1: Municipality of residence of malaria cases without travel history to an endemic country, Greece, 2011, as of 19 September

**Gert van der Hoek** · September 29, 2011, 10:11 AM

Re: Greece: autochthonous malaria reported

GREECE

 On 26th September 2011, the Hellenic Centre for Disease control and
Prevention (HCDCP) reported a total of 28 cases of Plasmodium vivax
malaria, 26 of them being very likely autochthonous.

 From June to end of August 2011, 6 cases were already reported in 2
localities (eWEB n° 179):

o Lakonia: 4 cases
o Evoia: 2 cases

 Since the end of August 2011, 22 additional cases have been notified
in 4 different localities:

o Lakonia: 18 cases (6 Greek nationals and 12 migrant
workers)
o Voiotia: 1 case
o East Attika: 2 cases
o Larissa: 1 case
In Lakonia, concerning the 12 cases reported in migrant workers:
o 10 cases haven’t travelled for the last 3 years (ie. likely to be
autochthonous cases)
o 2 cases arrived in Greece during the last month (among
which 1 has been exported to Romania, cf. eWEB n°179 and
below)

 Entomological studies showed the presence of several species of
anopheles in some areas of the country.

ROMANIA

 On 1st and 30th August 2011, 2 cases of P. Vivax malaria have been
diagnosed in Romania and have been both imported from Lakonia
locality (Greece):

o The 1st case came back from Lakonia around 3 weeks ago,
and used to work in Elos and Skala.

Investigation showed the absence of a recent travel in an
endemic country.

o The 2 nd case has been diagnosed in a Romanian worker,
coming back from Leimonas village (located close to Elos
and Skala) where he has lived for 3 years.

 The 2 cases have been diagnosed through a rapid test (PCR and blood
smear test).

Source: EpiSouth

EpiSouth comment:

The evolution of the epidemiological situation in Greece and Romania indicates:

 the persistence of an autochthonous transmission in Greece

 the geographical extension of the autochthonous transmission area in the country

 an exportation risk towards other countries in the EpiSouth area.

More information on the situation in Greece is available on the Hellenic Centre for Disease control and Prevention HCDCP) website.

.

**Gert van der Hoek** · October 10, 2011, 06:20 AM

Re: Greece: autochthonous malaria reported - 26 cases

Greece reports 4 more autochthonous malaria patients in Laconia

Patients with malaria, no history of travel to an endemic country in Greek patients. Greece, period 2011 (to 05/10/2011

Total autochthonous cases in Greece: 28

Source: KEELPNO Epidemiological report (in Greek) : KEELPNO

Note: The numbers from Greece can be confusing. The previous number of 26 found cases included 2 Romanian cases, infected in Greece.
The 28 in the report from oct 5 excludes those 2 cases.

**Gert van der Hoek** · October 18, 2011, 09:40 AM

Re: Greece: autochthonous malaria reported - 32 cases

KEELPNO

machinetranslation

UPDATE OCT 18, 2011

Epidemiological data, 2011

From the beginning of 2011 until the 17/10/2011, diagnosed a total of 32
malaria, to Greeks who did not report a history of travel to endemic for
malaria areas. The place of residence of the facts presented in Figure 1.

Twenty-six (26) of these patients reside in the municipality euro Laconia, two on Evia
two in eastern Attica, one in San Francisco and one in Boeotia (Table 1). In all
laboratory confirmed patients infected with Plasmodium vivax, the Chair Parasitic
and Tropical Diseases, National School of Public Health (National School).

The regional section of Laconia, by the beginning of 2011 until the
17/10/2011, a total of 51 diagnosed cases of malaria, of which 26 in Greek
patients with no history of travel to endemic malaria countries (Figure 1). Of the 25
foreign patients reported, 18 from Pakistan, one from Morocco,
one from Afghanistan and three from Romania, while two other incidents in Romanian
patients associated with staying in the area, diagnosed in Romania. Four of
foreign patients came to Greece a year ago, two two years ago, while five
do not know the date of arrival in the country. The rest say they are in
Greece for ≥ 3 years and did not report a history of travel to an endemic country.

Note that in the same area occurred in 2009, 8 serial incidents, of which
six were Greeks with no history of travel to an endemic area. Three of these patients
were gypsies who lived in a camp near the stairs. In the same camp, lived in
unique event in Greek, no history of travel, declared in 2010 and first
incident (child) declared in 2011. These two cases had an epidemiological link
(Father-son).

The ages of Greek patients with no reported history of travel to endemic areas,
ranging from 19 months - 79 years (median age: 47 years). The 57.6% were male

Table 1. Place of residence of patients with malaria with no history of travel to endemic country in Greek patients.

Greece, period 2011 (until 10/17/2011)

Laconia 26

Evia 2

Boeotia 1

Eastern Attica 2

Larissa 1

Total country 32

More incl. map @ KEELPNO

**Gert van der Hoek** · October 28, 2011, 04:54 AM

Re: Greece: autochthonous malaria reported - 32 cases

Epidemiological update: Malaria in Greece, October 2011

28 Oct 2011

According to the available epidemiological and entomological information, and the arriving winter season, the intensity of malaria transmission in Evrotas, Lakonia in Greece is believed to be very low and is expected to cease shortly. For this reason, chemoprophylaxis for malaria is not recommended for visitors to the area. The use of standard mosquito biting prevention measures continues to be encouraged.

Between 21 May and 26 October, 2011, 61 cases of Plasmodium vivax infection have been reported in Greece. Thirty-three of these cases were Greek citizens without travel history to an endemic country. Twenty seven cases are reported from the area of Evrotas, a 20 km2 river delta area, located in the district of Lakonia in Pelloponese, southern Greece (see map). The remaining six cases are from the municipalities of Attiki (n=2), Evoia (n=2), Viotia (n=1) and Larissa (n=1). In addition, 28 cases of P. vivax infection in migrant workers have been reported from the area of Evrotas. Of the 28 malaria cases identified in immigrants in Evrotas, Lakonia, the majority (n=21) originated from malaria endemic countries even though a clear importation status could not be determined; 19 originated from Pakistan and two from Afghanistan. For the remaining seven immigrant cases, five were from Romania (two were diagnosed in Romania), one from Morocco, and one from Poland. It should be noted that all reported cases in immigrants (including the two cases diagnosed in Romania) are in persons that work in the agricultural areas in this part of Greece.

Map: Municipality of residence of Plasmodium vivax malaria cases, Greece, as of 17 October, 2011 (n=61)

Read more - ECDC

**Gert van der Hoek** · October 28, 2011, 06:43 AM

Re: Greece: autochthonous malaria reported - 33 cases

KEELPNO

EPIDEMIOLOGICAL SURVEILLANCE REPORT

MALARIA, 2011 (01/01/2011 - 27/10/2011)

Introduction

During the summer of 2011, a cluster of malaria cases was reported among residents of the Municipality of
Evrotas, Lakonia in Peloponnese, while sporadic cases with no reported history of travel in endemic
countries were reported in four more areas: Chalkida, Evia, Agia, Larissa, Kalivia and Marathon, Eastern
Attica and Orchomenos, Voiotia.

The aim of this report is to present in short the epidemiological data
concerning the aforementioned malaria cases in Greece and it is going to be periodically updated.
Malaria is a parasitic infection, transmitted through the bite of the infected female Anopheles mosquito.
Four types of plasmodia cause disease to humans: Plasmodium falciparum, Plasmodium vivax, Plasmodium
ovale and Plasmodium malariae.

The most common symptoms of malaria (chills, high fever, sweating,
malaise, headache and muscle aches) manifest 1-4 weeks after infection with the parasite, while relapses of
the disease are usually observed in short intervals but up to 5 and in extreme cases up to 8 years after P.
vivax infections. A number of effective anti-malarial drugs are available to treat the infection; starting the
treatment promptly is essential in avoiding complications.

Malaria is endemic in more than 100 countries around the world, mainly in sub-Saharan Africa and Asia.
Greece was declared malaria-free in 1974, after an intense malaria eradication program between the years
1946-1960. Since then, approximately 30-50 cases are reported annually to the Hellenic CDC, the majority
of which are travel-related. Sporadic malaria cases without reported travel history were recorded in 1991,
1999, 2000, 2009 and 2010.

Epidemiologic data, 2011

Since the beginning of 2011 up to 27/10/2011, 33 laboratory confirmed cases of malaria were reported in
Greek patients with no history of travel to malaria-endemic areas. The place of residence of each case is
depicted in the spot map of Figure 1.

Twenty-seven of these cases reside in the Municipality of Evrotas,
Lakonia, two in Evia, two in Eastern Attica, one in Larissa and one in Viotia.
All of the cases were confirmed to have Pl. vivax infection by the Department of Parasitology and Tropical
Diseases of the National School of Public Health.

As of 27/10/11, in the Evrotas area of Lakonia district, 27 cases of malaria have been reported in Greek
citizens without travel history in malaria-endemic regions. In the same area, 28 malaria cases occurred in
migrant farm workers, the majority of whom non-documented. Of those, 19 originated from Pakistan, one
from Morocco, two from Afghanistan, one from Polland and three from Romania, while two more
Romanian cases that were working in the area were diagnosed after they had returned back to Romania.
The malaria importation status of many of those migrant cases remains unclear.

The first reported cases in Evrotas had symptom onsets in epidemiological week 21 (23-29 May) and the
last two cases had reported symptom onset during week 42 (17 – 23 October). A peak in reported
symptom onset occurred during weeks 36 and 37 (5 – 18 September). Since then, a steady decline in
reported cases has been observed despite the ongoing active case finding in the area. All cases were mild,
apart from one fatal case in a male aged over 70 years who had pulmonary co-infection and underlying
medical conditions.

It must be noted that a cluster of 8 cases was reported in 2009 in Evrotas area, Lakonia, of which 6 were
Greeks with no travel history to an endemic area. Three were Roma, residing in a camp near Skala, Lakonia.
The same camp was the place of residence of the single Greek malaria case with no travel history, which
was reported in 2010 and the first case (child) reported in 2011. These two cases were epidemiologically
linked (father-son).

The age of the Greek cases without travel history ranged between 19 months-79 years (median age: 47
years). Of those, 57.6% were male.

For the above reasons the Hellenic CDC in coordination with the ECDC and WHO, maintain that the
main risk for malaria infection in Greece is to persons residing, and working in the affected areas of
Greece, particularly that of Evrotas, Lakonia. Due to the low intensity of transmission and the reduction
of mosquito vector activity (due to the season), this risk will decrease even further in the near future.
For this reason, chemoprophylaxis for malaria is not recommended for visitors to the area of Evrotas
in Lakonia or any other areas in Greece. The use of standard mosquito biting prevention measures
continues to be encouraged.

Read more - KEELPNO

**Gert van der Hoek** · December 6, 2011, 01:24 PM

Re: Greece: autochthonous malaria reported - 40 cases

EPIDEMIOLOGICAL SURVEILLANCE REPORT

MALARIA, 2011 (01/01/2011 - 05/12/2011)

Key Points

• The last detected domestic case of malaria in Lakonia had onset of symptoms on October 18, 2011.
Approximately 45 days have elapsed from the date of symptom onset of this last case and given the
enhanced surveillance and extensive active case finding in the area, suggesting that local transmission
of malaria in the area is discontinued.

• Mosquito activity has decreased substantially in the previous weeks as the weather has become colder,
reducing the likelihood of human and mosquito contact. Entomological surveillance has not identified
adult malaria vectors or Anopheles larvae in the potential breeding sites during the previous weeks. This
is expected to continue during the winter months and early spring.

• Enhanced surveillance and active case finding in the area of Evrotas, Lakonia (house-to-house visits) will
continue during the winter months.

Epidemiologic data, 2011

Since the beginning of 2011 up to 05/12/2011, 40 laboratory confirmed cases of malaria were reported in
patients with no history of travel to a malaria-endemic country. The place of residence of each case is
depicted in the spot map of Figure 1.

Thirty four of these cases reside in the Municipality of Evrotas,
Lakonia, two in Evia, two in Eastern Attica, one in Larissa and one in Viotia.
All of the cases were confirmed to have Pl. vivax infection by the Department of Parasitology and Tropical
Diseases of the National School of Public Health.

As of 05/12/11, in the Evrotas area of Lakonia district, 27 cases of malaria have been reported in Greek
citizens without travel history in malaria-endemic regions and 7 in migrant farm workers from non-endemic
countries (i.e. one from Morocco, one from Poland and five from Romania, two of whom were diagnosed
after they returned back to Romania).

In the same area, 23 malaria cases occurred in migrant farm workers
from endemic countries, the majority of whom non-documented. Of those, 21 originated from Pakistan,
and two from Afghanistan. The malaria importation status of many of those migrant cases from endemic
countries remains unclear.

Read more - KEELPNO

**Gert van der Hoek** · December 7, 2011, 03:12 AM

Re: Greece: autochthonous malaria reported - 40 cases

ECDC is following the situation closely:

Epidemiological update: Malaria in Greece, 6 December 2011

06 Dec 2011

ECDC
Between 21 May and 5 December, 2011, 63 cases of Plasmodium vivax infection have been reported in Greece. The majority of cases (n=57) are reported from the area of Evrotas in Lakonia district, Peloponnese in southern Greece. The last detected domestic case of malaria in Lakonia had onset of symptoms on October 18, 2011.

More than 45 days have elapsed from the date of symptom onset of this last case and mosquito vector activity has ceased. Given the enhanced surveillance and extensive active case finding in the area, the epidemiological and entomological evidence suggests that local transmission of malaria in the area is discontinued at present.

The Greek Centre for Disease Control and Prevention (KEELPNO) has posted an update on their website regarding the outbreak of Plasmodium vivax that has been reported in Greece.

Between 21 May and 5 December 2011, 63 cases of Plasmodium vivax infection have been reported in Greece. Fifty-seven of these cases are reported from the area of Evrotas, a 20 km2 river delta area, located in the district of Lakonia in Peloponese, southern Greece (see map).

Of these, 27 are in Greek citizens without travel history to malaria-endemic regions, 23 malaria cases occurred in migrant farm workers from endemic countries (mostly Pakistan and Afghanistan) and seven cases in migrant farm workers from non-endemic countries (i.e. one from Morocco, one from Poland and five from Romania, two of whom were diagnosed after they returned back to Romania). The remaining six cases in other municipalities are in Greek citizens with no travel history to malaria endemic areas from the municipalities of Attiki (n=2), Evia (n=2), Viotia (n=1) and Larissa (n=1).
The last reported case in a Greek citizen was on 18 October.

The last reported case in a migrant worker, occurred during week 44 (31 October-6 November) in a man from Pakistan who arrived in Greece recently.
Given the enhanced surveillance and extensive active case finding in the area, the epidemiological and entomological evidence suggests that local transmission of malaria in the area is discontinued at present.

The Greek authorities will continue active case finding in Evrotas, Lakonia, during the winter months in order to carefully monitor the situation. Chemoprophylaxis for malaria is not recommended for visitors to this area. The use of standard mosquito biting prevention measures continues to be encouraged.

Read more ECDC

Announcement

Greece: autochthonous malaria reported - 63 cases

Greece: autochthonous malaria reported - 63 cases

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