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Abstract Background Brucellosis is an endemic disease present in many countries worldwide, but it is rare in Europe and North America. Nevertheless brucella is included in the bacteria potentially used for bioterrorism. The aim of this study was the investigation of the antibiotic susceptibility profile of brucella isolates from areas of the eastern Mediterranean where it has been endemic. Methods The susceptibilities of 74 Brucella melitensis isolates derived from clinical samples (57) and animal products (17) were tested in vitro. The strains originate from Crete (59), Cyprus (10), and Syria (5). MICs of tetracycline, rifampicin, streptomycin, gentamicin, norfloxacin, ciprofloxacin, levofloxacin, trimethoprim/sulfamethoxazole, ampicillin, amoxicillin/clavulanic acid, and erythromycin were detected by E-test method. The NCCLS criteria for slow growing bacteria were considered to interpret the results. Results All the isolates were susceptible to tetracycline, streptomycin, gentamicin, ciprofloxacin, norfloxacin, and levofloxacin. Two isolates presented reduced susceptibility to rifampicin (MIC value: 1.5 mg/l) and eight to SXT (MIC values: 0.75–1.5 mg/l). Erythromycin had the highest (4 mg/l) MIC90value and both norfloxacin and erythromycin the highest (1.5 mg/l) MIC50 value. Conclusion Brucella isolates remain susceptible in vitro to most antibiotics used for treatment of brucellosis. The establishment of a standardized antibiotic susceptibility method for Brucella spp would be useful for resistance determination in these bacteria and possible evaluation of bioterorism risks.

Abstract Background A long-term active surveillance of Q fever was conducted in Cyprus organized in two phases. Methods Following serological tests and identification of seropositive humans and animals for C. burnetii in two villages (VIL1 and VIL2), all seronegative individuals were followed up for one year on a monthly basis by trained physicians to detect possible seroconversion for Q fever. In the second phase of the study, active surveillance for one year was conducted in the entire Cyprus. Physicians were following specific case definition criteria for Q fever. Standardized questionnaires, a geographical information system on a regional level, Immunofluorescence Assay (IFA) examinations and shell vial technique were used. Results Eighty-one seronegative humans and 239 seronegative animals from both villages participated in the first phase surveillance period of Q fever. Despite the small number of confirmed clinical cases (2 humans and 1 goat), a significant percentage of new seropositives for C. burnetii (44.4% of human participants and 13.8% of animals) was detected at the end of the year. During the second phase of surveillance, 82 humans, 100 goats, and 76 sheep were considered suspected cases of Q fever. However, only 9 human, 8 goat, and 4 sheep cases were serologically confirmed, while C. burnetii was isolated from three human and two animal samples. The human incidence rate was estimated at 1.2 per 100,000 population per year. Conclusion A small number of confirmed clinical cases of Q fever were observed despite the high seroprevalence for C. burnetii in human and animal population of Cyprus. Most of the cases in the local population of Cyprus appear to be subclinical. Moreover further studies should investigate the role of ticks in the epidemiology of Q fever and their relation to human seropositivity.

Abstract Background Nocardia brasiliensis is a rare human pathogen usually associated with localized cutaneous infections. Case Presentation We report a case of primary lymphocutaneous Nocardia brasiliensis infection developed after a bone fracture of the left hand of an otherwise healthy 32-year-old man. Treatment with trimethoprim-sulfamethoxazole given for a total of three months combined with surgical debridement resulted in complete resolution of the infection. Conclusion Nocardiosis should be part of the differential diagnosis in patients with sporotrichoid infection, particularly those with a history of outdoor injury. Culture of the affected tissue and antimicrobial susceptibility testing of the isolate should be performed for diagnosis and treatment.

The emergence and spread of vector-borne diseases (VBDs) is a function of biotic, abiotic and socio-economic drivers of disease while their economic and societal burden depends upon a number of time-varying factors. This work is concerned with the development of an early warning system that can act as a predictive tool for public health preparedness and response. We employ a host-vector model that combines entomological (mosquito data), social (immigration rate, demographic data), environmental (temperature) and geographical data (risk areas). The output consists of appropriate maps depicting suitable risk measures such as the basic reproduction number, R 0 , and the probability of getting infected by the disease. These tools consist of the backbone of a semi-automatic early warning system tool which can potentially aid the monitoring and control of VBDs in different settings. In addition, it can be used for optimizing the cost-effectiveness of distinct control measures and the integration of open geospatial and climatological data. The R code used to generate the risk indicators and the corresponding spatial maps along with the data is made available.

Anaplasma phagocytophilum, transmitted by Ixodes ticks, is an intracellular pathogen of zoonotic interest. Regarding animals of veterinary importance, infection by this agent has been linked mainly to high fever, neutropenia, reduced milk production, but hemorrhagic diathesis, abortion and impaired spermatogenesis have also sporadically been reported. In Greece, A. phagocytophilum has been detected in dogs, ticks and humans, while so far only A. ovis had been detected in farm animals. Following the occurrence of multiple abortions in two goat farms in Northern Greece, samples were collected from aborted animals. Stomach contents and placental tissue from aborted animals tested positive for A. phagocytophilum by molecular assays and negative for other infectious and parasitic agents. Treatment with oxytetracycline LA stopped the abortions. In tick risk areas clinicians should consider A. phagocytophilum as a cause of abortion in goats.

This retrospective study investigates the potential benefits from the introduction of point-of-care tests for rapid diagnosis of infectious diseases. We analysed a sample of 441 hospitalized patients who had received a final diagnosis related to 18 pathogenic agents. These pathogens were mostly detected by standard tests but were also detectable by point-of-care testing. The length of hospital stay was partitioned into pre- and post-laboratory diagnosis stages. Regression analysis and elementary queueing theory were applied to estimate the impact of quick diagnosis on the mean length of stay and the utilization of healthcare resources. The analysis suggests that eliminating the pre-diagnosis times through point-of-care testing could shorten the mean length of hospital stay for infectious diseases by up to 34 per cent and result in an equal reduction in bed occupancy and other resources. Regression and other more sophisticated models can aid the financing decision-making of pilot point-of-care laboratories in healthcare systems.

Visceral Leishmaniasis (VL) is endemic to the Attica region of Greece. The geographical distribution of VL cases was analyzed employing methods of spatial analysis in a GIS environment. A geographic database was constructed including data for the disease cases and environmental factors, such as land cover types, stray dog population, and socioeconomic factors. Classic and spatial regression models are presented that suggest the factors contributing most to the incidence of leishmaniasis are green urban areas and the population of stray dogs in the municipalities of Attica region. The results of the spatial regression model were more accurate, thus were used to produce a disease risk map. This map indicates the high-risk municipalities in which surveillance for the control of leishmaniasis is necessary.

Several Travel-associated Legionnaires' disease (TALD) cases occur annually in Europe. Except from the most obvious sites (cooling towers and hot water systems), infections can also be associated with recreational, water feature, and garden areas of hotels. This argument is of great interest to better comprehend the colonization and to calculate the risk to human health of these sites. From July 2000-November 2017, the public health authorities of the Island of Crete (Greece) inspected 119 hotels associated with TALD, as reported through the European Legionnaires' Disease Surveillance Network. Five hundred and eighteen samples were collected from decorative fountain ponds, showers near pools and spas, swimming pools, spa pools, garden sprinklers, drip irrigation systems (reclaimed water) and soil. Of those, 67 (12.93%), originating from 43 (35.83%) hotels, tested positive for Legionella ( Legionella pneumophila serogroups 1, 2, 3, 6, 7, 8, 13, 14, 15 and non-pneumophila species ( L. anisa , L. erythra , L. taurinensis , L. birminghamensis , L. rubrilucens ). A Relative Risk (R.R.) > 1 ( p < 0.0001) was calculated for chlorine concentrations of less than 0.2 mg/L (R.R.: 54.78), star classification (<4) (R.R.: 4.75) and absence of Water Safety Plan implementation (R.R.: 3.96). High risk (≥10⁴ CFU/L) was estimated for pool showers (16.42%), garden sprinklers (7.46%) and pool water (5.97%)., Competing Interests: The authors have declared no conflicts of interest.

Human granulocytic anaplasmosis (HGA) is a tick-borne disease caused by Anaplasma phagocytophilum that has the potential to spread in new geographical areas. The first fatal case of HGA in Greece is presented. Fever of unknown origin, renal and respiratory insufficiency and development of macrophage activation syndrome characterized the clinical presentation. Amplification and sequencing of a fragment of the groEL gene revealed the presence of A. phagocytophilum. The epidemiological and clinical features were collected during an epidemiological investigation. Public health measures were instituted by the Hellenic Centre for Disease Control and Prevention. The Public Health intervention required the collaboration of epidemiologists, veterinarians and microbiologists. Emphasis was given to communication activities and misconceptions concerning canines and their role in the disease. The emergence of human anaplasmosis in a new geographical area highlights the importance of disease awareness and of the need for continued support for tick and tick-borne disease surveillance networks., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Although a number of human Legionnaires' disease in tourists are recorded annually in Europe, there are few cases where a direct link can be made between the infected person and the source of infection (hotel or other accommodation). We present a scheme followed in order to track down and identify the source of infection in a tourist suffering from L. pneumophila sg 5 infection, who was accommodated in seven different hotels during his holidays in the island of Crete, and we comment on various difficulties and draw-backs of the process., Method: Water samples were collected from the seven hotels where the patient had resided and analyzed at the regional public health laboratory using cultivation and molecular tests., Results: Of 103 water samples analyzed, 19 (18.4%) were positive for Legionella non-pneumophila and 8 (7.8%) were positive for L. pneumophila. A successful L. pneumophila sg 5 match was found between the clinical and environmental sample, which led us to the final identification of the liable hotel., Conclusion: Timely notification of the case, within the the European Legionnaires' Disease Surveillance Network (ELDSNet) of the partners involved, is crucial during a course of travel associated with Legionella case investigation. Moreover, the urinary antigen test alone cannot provide sufficient information for the source identification. However, acquiring clinical as well as environmental isolates for serogroup and SBT identification is highly important for the successful matching., (Copyright© by the National Institute of Public Health, Prague 2017)

Malaria constitutes an important cause of human mortality. After 2009 Greece experienced a resurgence of malaria. Here, we develop a model-based framework that integrates entomological, geographical, social and environmental evidence in order to guide the mosquito control efforts and apply this framework to data from an entomological survey study conducted in Central Greece. Our results indicate that malaria transmission risk in Greece is potentially substantial. In addition, specific districts such as seaside, lakeside and rice field regions appear to represent potential malaria hotspots in Central Greece. We found that appropriate maps depicting the basic reproduction number, R0, are useful tools for informing policy makers on the risk of malaria resurgence and can serve as a guide to inform recommendations regarding control measures.

This article has been retracted by the authors under the agreement between the Editor-in-Chief, Masayuki Saijo and authors.

Although tick-borne rickettsiosis is endemic in Greece, until recently, human samples arriving at the National Reference Centre under suspicion of rickettsial infection were routinely tested only for Rickettsia typhi and R. conorii. However, identification of additional rickettsia species in ticks prompted revision of the protocol in 2010. Until that year, all human samples received by the laboratory were tested for antibodies against R. conorii and R. typhi only. Now, tests for R. slovaca, R. felis, and R. mongolotimonae are all included in routine analysis. The current description of a human R. slovaca case is possible as a result of these changes in routine testing.

Tick-borne rickettsioses are endemic in Greece; however, until recently, only Rickettsia typhi and R. conorii were tested routinely in human samples arriving at the National Reference Center. During the last few years, the identification of different rickettsia species in ticks led to the introduction of other spotted fever group rickettsiae in routine analysis. Under the new scheme, R. massiliae is now tested routinely in human samples; herein, we describe a human case of this infection.

This study investigates the seroprevalence of Greek adult cattle against West Nile virus, Anaplasma ovis and Lehismania infantum. In total, 156 serum samples were examined, drawn from cattle between 2-4 years old. All the examined cattle originated from slaughterhouses of 4 prefectures in Northern Greece (Thessaloniki, Pella, Chalkidiki, Kilkis), in 2 of which (Thessaloniki, Pella) human cases of West Nile virus had been recorded some months before. Thirty out of the 156 (18.6%) samples have tested positive for West Nile virus and fifty-five (35.9%) samples for Anaplasma ovis. All the examined samples tested negative for Leishmania infantum. The prefectures with positive samples against West Nile virus also showed human cases of West Nile virus infections. This should raise questions whether cattle could become markers for West Nile virus activity in high risk areas.