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Introduction: Elevated particulate matter (PM) concentrations of anthropogenic and/or desert dust origin are associated with increased morbidity among children with asthma., Objective: The Mitigating the Health Effects of Desert Dust Storms Using Exposure-Reduction Approaches randomised controlled trial assessed the impact of exposure reduction recommendations, including indoor air filtration, on childhood asthma control during high desert dust storms (DDS) season in Cyprus and Greece., Design, Participants, Interventions and Setting: Primary school children with asthma were randomised into three parallel groups: (a) no intervention (controls); (b) outdoor intervention (early alerts notifications, recommendations to stay indoors and limit outdoor physical activity during DDS) and (c) combined intervention (same as (b) combined with indoor air purification with high efficiency particulate air filters in children's homes and school classrooms. Asthma symptom control was assessed using the childhood Asthma Control Test (c-ACT), spirometry (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC)) and fractional exhaled nitric oxide (FeNO)., Results: In total, 182 children with asthma (age; mean=9.5, SD=1.63) were evaluated during 2019 and 2021. After three follow-up months, the combined intervention group demonstrated a significant improvement in c-ACT in comparison to controls (β=2.63, 95% CI 0.72 to 4.54, p=0.007), which was more profound among atopic children (β=3.56, 95% CI 0.04 to 7.07, p=0.047). Similarly, FEV1% predicted (β=4.26, 95% CI 0.54 to 7.99, p=0.025), the need for any asthma medication and unscheduled clinician visits, but not FVC% and FeNO, were significantly improved in the combined intervention compared with controls., Conclusion: Recommendations to reduce exposure and use of indoor air filtration in areas with high PM pollution may improve symptom control and lung function in children with asthma., Trial Registration Number: NCT03503812., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Recent European-wide data place Cyprus and Greece in the highest positions of total antimicrobial consumption. While this level of consumption might be partly attributed to the high rates of infections due to MDR bacteria in these countries, several other reasons should be sought to help apply local measures, to decrease inappropriate and excess antimicrobial use. The present viewpoint aims to provide a roadmap for interventions, by briefly discussing the various factors that underlie antimicrobial use and prescribing practices in Greece and Cyprus., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

The present study investigated comprehensively the atmospheric occurrence and fate of an extensive range of polychlorinated biphenyls (PCBs; forty-two congeners), organochlorine pesticides (OCPs; twenty-seven emerging and legacy agrochemicals) and polycyclic aromatic hydrocarbons (PAHs; fifty parent and alkylated members, including the non USEPA-16 listed toxic ones), in both gas and particulate phase of the scarcely monitored atmosphere over Cyprus for the first time. Parent-metabolite concentration ratios suggested fresh application for dichlorodiphenyl-trichloroethanes (DDTs), dicofol, hexachlorocyclohexanes, endosulfan and chlorothalonil, particularly during spring (April-May). Regressions of logarithms of partial pressure against ambient temperature revealed that secondary recycling from contaminated terrestrial surfaces regulates the atmospheric level variability of PCBs, DDTs, aldrin, chlordane, dicofol, heptachlor and endosulfan. Enthalpies of surface-air exchange (∆H SA ) calculated from Clausius-Clapeyron equations were significantly correlated to vaporization enthalpies (∆H V ) determined by chromatographic techniques, corroborating presence of potential stockpile-contaminated sites around the study area. The Harner-Bidleman equilibrium model simulating urban areas, and the Li-Jia empirical model, predicted better the partitioning behavior of PAHs (P ) were inadequately predicted by the Li-Ma-Yang steady-state model, probably due to local human activities and regional transport in the study area., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objectives: To prospectively quantify at the community level changes in asthma symptom control and other morbidity indices, among asthmatic schoolchildren in response to coronavirus disease 2019 (COVID-19) lockdown measures., Methods: In Spring 2019 and Spring 2020, we prospectively assessed monthly changes in pediatric asthma control test (c-ACT), asthma medication usage, infections and unscheduled visits for asthma among schoolchildren with active asthma in Cyprus and Greece. We compared asthma symptom control and other morbidity indices before and during lockdown measures, while participants' time spent at home was objectively assessed by wearable sensors., Results: A total of 119 asthmatic children participated in the study during Spring 2020. Compared to a mean baseline (pre-COVID-19 lockdown) c-ACT score of 22.70, adjusted mean increases of 2.58 (95% confidence interval [CI]: 1.91, 3.26, p < 0.001) and 3.57 (95% CI: 2.88, 4.27, p < 0.001) in the 2nd and 3rd monthly assessments were observed after implementation of lockdown measures. A mean increase in c-ACT score of 0.32 (95% CI: 0.17, 0.47, p < 0.001) was noted per 10% increase in the time spent at home. Improvement was more profound in children with severe asthma, while significant reductions in infections, asthma medication usage and unscheduled visits for asthma were also observed. During Spring 2019, 39 children participated in the study in the absence of lockdown measures and no changes in c-ACT or other indices of disease severity were observed., Conclusions: Clinically meaningful improvements in asthma symptom control, among asthmatic schoolchildren were observed during the COVID-19 lockdown measures in Spring 2020. Improvements were independently associated with time spent at home and were more profound in the children with severe asthma., (© 2021 Wiley Periodicals LLC.)

Background: The south-eastern Mediterranean experiences frequent desert dust storm events (DDS) that have been shown to be associated with adverse health effects., Aims: This study assessed the perceptions and practices towards DDS of local authorities and stakeholders from 3 countries in the region, Cyprus, Greece and Israel., Methods: Between October 2017 and April 2018, we administered a semi-structured questionnaire to regulatory authorities involved in public protection from DDS as well as social stakeholders in the 3 countries. The questionnaire addressed their knowledge regarding DDS, perceptions on the relationship between DDS and health effects and relevant actions taken towards public protection., Results: Out of 58 stakeholders contacted, 49 participated in the study (84.5% response rate). Fourteen (28.6%) were regulatory authorities and 35 (71.4%) were social stakeholders. All responders were familiar with DDS but several underestimated the frequency of events while the majority (73%) instinctively reported that elders, children and respiratory patients are susceptible subpopulations. Nevertheless, 71% were unaware of a national policy on DDS, or considered that this was lacking in their country. Although several stakeholders reportedly receive questions from the public regarding DDS effects, only few reply according to a pre-determined action plan., Conclusions: Regulatory authorities and social stakeholders in Cyprus, Greece and Israel are characterized by good knowledge of DDS and associated health effects, although implementation of pre-determined action plans for public protection is limited. Future efforts should concentrate on increasing awareness among stakeholders and the public and developing national policies, including effective measures to minimize DDS exposure., (Copyright © World Health Organization (WHO) 2021. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

We present two different approaches for modeling the spread of the COVID-19 pandemic. Both approaches are based on the population classes susceptible, exposed, infectious, quarantined, and recovered and allow for an arbitrary number of subgroups with different infection rates and different levels of testing. The first model is derived from a set of ordinary differential equations that incorporates the rates at which population transitions take place among classes. The other is a particle model, which is a specific case of crowd simulation model, in which the disease is transmitted through particle collisions and infection rates are varied by adjusting the particle velocities. The parameters of these two models are tuned using information on COVID-19 from the literature and country-specific data, including the effect of restrictions as they were imposed and lifted. We demonstrate the applicability of both models using data from Cyprus, for which we find that both models yield very similar results, giving confidence in the predictions., Competing Interests: The authors have declared that no competing interests exist.

Between March and April 2020, Cyprus and Greece health authorities enforced three escalated levels of public health interventions to control the COVID-19 pandemic. We quantified compliance of 108 asthmatic schoolchildren (53 from Cyprus, 55 from Greece, mean age 9.7 years) from both countries to intervention levels, using wearable sensors to continuously track personal location and physical activity. Changes in 'fraction time spent at home' and 'total steps/day' were assessed with a mixed-effects model adjusting for confounders. We observed significant mean increases in 'fraction time spent at home' in Cyprus and Greece, during each intervention level by 41.4% and 14.3% (level 1), 48.7% and 23.1% (level 2) and 45.2% and 32.0% (level 3), respectively. Physical activity in Cyprus and Greece demonstrated significant mean decreases by - 2,531 and - 1,191 (level 1), - 3,638 and - 2,337 (level 2) and - 3,644 and - 1,961 (level 3) total steps/day, respectively. Significant independent effects of weekends and age were found on 'fraction time spent at home'. Similarly, weekends, age, humidity and gender had an independent effect on physical activity. We suggest that wearable technology provides objective, continuous, real-time location and activity data making possible to inform in a timely manner public health officials on compliance to various tiers of public health interventions during a pandemic.

Despite considerable improvement in the management of anal cancer, there is a great deal of variation in the outcomes among European countries, and in particular among different hospital centres in Greece and Cyprus. The aim was to elaborate a consensus on the multidisciplinary management of anal cancer, based on European guidelines (European Society of Medical Oncologists-ESMO), considering local special characteristics of our healthcare system. Following discussion and online communication among members of an executive team, a consensus was developed. Guidelines are proposed along with algorithms of diagnosis and treatment. The importance of centralisation, care by a multidisciplinary team (MDT) and adherence to guidelines are emphasised.

The occurrence of a wide variety of regulated (four trihalomethanes (THM(4)), five haloacetic acids (HAA(5))) and unregulated (haloacetonitriles (HANs), halogenated ketones, chloropicrin, carbon tetrachloride, and other haloacetic acids) disinfection by-products (DBPs) was studied, in two hundred twenty-six finished drinking water samples collected in Barcelona (Spain, between 2008 and 2009), Athens (Greece, 2009-2010), Heraklion (Greece, 2009-2010), Nicosia (Cyprus, 2012-2013), and Limassol (Cyprus, 2011). The samples were analyzed by using liquid-liquid extraction, gas chromatography coupled with an electron capture detector or negative chemical ionization mass spectrometry. In addition, fourteen swimming pool water samples (from Heraklion and Athens) were also investigated regarding their DBPs content. The studied DBPs were determined concurrently with pH, total organic carbon (TOC), and bromide. Spearman's statistical analysis has shown statistically significant (p < 0.001) weak correlations between TOC, THM(4), HANs and HAA(5) but a strong correlation between THM(4) and HANs. Principal component analysis (PCA) on THM(4), HANs and HAA(5) provided a clear differentiation between the examined drinking waters, on the basis of their DBPs content. In the drinking water of coastal cities, the brominated DBPs dominated over the chlorinated ones, due to the higher bromide concentrations occurring in the corresponding raw waters. Lifetime cancer risk and hazard quotient by exposure to four THMs, dichlorocetic acid and trichloroacetic acid in drinking water and indoor swimming pools through multiple pathways were estimated. Total cancer unit risks in drinking water for Nicosia, Barcelona, Limassol and Athens exceeded in most cases the US EPA's regulatory threshold (1.0E-06). The total lifetime cancer risk evaluated for the studied indoor swimming pools was above the US EPA's negligible level for male, female, and junior swimmers., Competing Interests: Declaration of competing interest The authors declare no potential or actual competing financial interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Competing Interests: The authors have declared that no competing interests exist.

Sand flies are responsible for the transmission of leishmaniasis, a neglected tropical disease claiming more than 50,000 lives annually. Leishmaniasis is an emerging health risk in tropical and Mediterranean countries as well as temperate regions in North America and Europe. There is an increasing demand for predicting population dynamics and spreading of sand flies to support management and control, yet phenotypic diversity and complex environmental dependence hamper model development. Here, we present the principles for developing predictive species-specific population dynamics models for important disease vectors. Based on these principles, we developed a sand fly population dynamics model with a generic structure where model parameters are inferred using a surveillance dataset collected from Greece and Cyprus. The model incorporates distinct life stages and explicit dependence on a carefully selected set of environmental variables. The model successfully replicates the observations and demonstrates high predictive capacity on the validation dataset from Turkey. The surveillance datasets inform about biological processes, even in the absence of laboratory experiments. Our findings suggest that the methodology can be applied to other vector species to predict abundance, control dispersion, and help to manage the global burden of vector-borne diseases.

Background: Ticks are considered to be a natural reservoir of Coxiella burnetii and are responsible for the spread of infection in wild animals and for the transmission to domestic animals. More than 40 tick species are naturally infected with C. burnetii. In Cyprus, few studies have been carried out on the distribution and incidence of C. burnetii infection in wildlife and the threat that infected wild animals pose to humans and domestic animals remains uncertain., Methods: During 3 studies in Cyprus, lasting 7 years (2000-2006), ticks were collected from rats (98 Rattus norvegicus and 38 R. rattus), 74 mouflons (Ovis orientalis ophion), 32 foxes (Vulpes vulpes indutus), 247 hares (Lepus europaeus), 557 birds (endemic and migratory) and 10 different tick species. All samples were tested for the presence of Coxiella burnetii using molecular assays., Results: In total, 31% (23/74) of mouflons, 28% (9/32) of foxes, 48% (15/31) of hares and 31% (41/131) of birds were positive for C. burnetii. We tested 1315 ticks (195 pools) and C. burnetii was detected in 28.9% (56/195) of them. Forty percent (24/60) of ticks collected from hares and 25.2% (27/107) of tick pools collected from mouflons were positive for C. burnetii. However, C. burnetii was detected in only one tick from foxes and one from birds. Positive samples were prevalent all over the island and did not show a specific geographic distribution pattern., Conclusions: Several animal and tick species collected from wildlife are potential sources of C. burnetii in Cyprus. These species are abundant in the area and may represent a risk for domestic livestock that share grazing environments., (© The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Over 40 tick species are naturally infected by Coxiella burnetii. However, little is known about the presence of C. burnetii in other ectoparasites such as fleas. During a 6-year (2000-2006) study, 1147 fleas were collected from 652 animals (252 rats, 118 foxes, and 282 hares) captured from different areas of Cyprus. Three flea species-Xenopsylla cheopis, Ctenocephalides felis, and C. canis-were identified. Fleas were pooled (153 pools) and tested by PCR for the presence of C. burnetii. The pathogen was identified in 25 (16.3%) pools. None of the fleas parasitizing hares was positive for C. burnetii, as opposed to fleas collected from rats (12% pool positivity) and foxes (47.6% pool positivity). The highest prevalence of positive pools was recorded in C. canis (38%) compared to C. felis (16.6%) and X. cheopis (10.8%). All pools of C. canis positive for C. burnetii were removed from foxes (44.4%), whereas all positive X. cheopis (10.8%) were removed from rats. The role of fleas in the maintenance and transmission of C. burnetii among wild vertebrates remains to be determined.

Climatic, environmental, and demographic changes favor the emergence of neglected vector-borne diseases like leishmaniasis, which is spreading through dogs, the principle host of the protozoan Leishmania infantum. Surveillance of the disease in dogs is important, because the number of infected animals in an area determines the local risk of human infection. However, dog epidemiological studies are costly. Our aim was to evaluate the Emerging Diseases in a Changing European Environment (EDEN) veterinary questionnaire as a cost-effective tool in providing reliable, spatially explicit indicators of canine leishmaniasis prevalence. For this purpose, the data from the questionnaire were compared with data from two epidemiological studies on leishmaniasis carried out in Greece and Cyprus at the same time using statistical methods and spatial statistics. Although the questionnaire data cannot provide a quantitative measure of leishmaniasis in an area, it indicates the dynamic of the disease; information is obtained in a short period of time at low cost., (© The American Society of Tropical Medicine and Hygiene.)

The paper presents an annotated catalogue of the millipedes (Diplopoda) of Cyprus, based on literature scrutiny and on hitherto unpublished material. A total of 21 species belonging to 14 genera, 9 families and 7 orders are recorded from the island. Three species are regarded as new to science, but are not formally described, and the status of another three is yet to be clarified. Pachyiulus cyprius Brölemann, 1896 and Strongylosoma (Tetrarthrosoma) cyprium Verhoeff, 1902 are established as junior subjective synonyms of Amblyiulus barroisi (Porat, 1893) and T. syriacum (Humbert & DeSaussure, 1869), respectively, both syn. nov. The present-day diversity of the Cypriotic millipede fauna is analysed in the light of past geological events. It is presumed that the fauna originated from the late Miocene, when Cyprus was formed as a result of uplift of the sea floor. During the Messinian salinity crisis, some 6-5.3 mya, land bridges existed between the island and the neighbouring Taurus Mts. (Turkey) and the region of Latakia (Syria), which are supposed to have served as migratory pathways for various millipede taxa.

Cyprus does not have a National Food Safety Authority (NFSA), but a multi-level, fragmented system with responsibilities divided among different ministries and governmental agencies, frequently impeding efforts to effectively manage food risks by duplication and overlapping of responsibilities. A population-based survey was carried out to determine the beliefs and attitudes of interested parties concerning the establishment of a NFSA in Cyprus. Information was collected using a random stratified sampling design and a structured questionnaire. A total of 868 questionnaires were collected (704 from regular consumers, 154 from food businesses' representatives, and 10 from public services' directors or acting head officers). About 11% of food businesses' representatives and 45% of consumers reported that they did not know which public authorities are responsible for food control. Moreover, 2 out of 10 (17%) of responders from public agencies, 70% from food businesses and 91% from consumers, although not aware of ongoing efforts to establish a food safety authority in Cyprus (currently under consideration), were supportive of the idea [8 out of 10 (83%) of responders from public services, 93% from food businesses, and 89% of consumers]. Finally, 7 out of 10 (67%) from the public agencies and 84% of representatives from food businesses agreed with the separation of risk assessment from risk management activities. Public opinion in Cyprus as well as public agencies and food businesses' representatives support the establishment of a single independent national food safety authority in Cyprus based on the European paradigm including the division of risk activities., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

In a previous study conducted in Cyprus, various spotted fever group Rickettsia species were detected and identified in ticks by molecular analysis. Among them, a partially characterized Rickettsia species was detected in Hyalomma anatolicum excavatum and Rhipicephalus turanicus ticks. We report characterization of this rickettsial strain by using polymerase chain reaction sequencing analysis of partial citrate synthase A, outer membrane protein A, outer membrane protein B, and 17-kD protein genes. We propose a provisional name Rickettsia sp. strain Tselenti for this strain until it is isolated and further characterized.

Epidemiological and clinical data of 193 human cases of murine typhus in Cyprus were recorded and analysed during a 9-year period (2000-2008). The incidence rate was estimated at 24.5 cases/100,000 population/year. The incidence rate varied considerably between rural, urban and semi-urban areas, with residents in rural areas accounting for 79.3% of the total cases. Most (72.5%) of the cases occurred in late summer (July and August) and early autumn (September to October) with a peak in September. Well-established persistent endemic foci with clusters of cases were identified and characterised as 'high risk' areas. Presence of or contact with rats and fleas, presence of domestic/peridomestic animals and residence in rural areas, especially locations near the 'green line' (a narrow zone patrolled by UN forces that separates the northern and southern parts of the island), increased the possibility of murine typhus infection. The results of the current study enhance the belief that murine typhus is a serious public health problem in Cyprus., (Copyright © 2012 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.)

In two surveys conducted from March 1999 to March 2001 and from January 2004 to December 2006, a total of 3,950 ticks (belonging to ten different species) were collected from seven domestic and wild animals (goat, sheep, cattle, dog, fox, hare, and mouflon) from different localities throughout Cyprus. In order to establish their infection rate with Spotted Fever Rickettsiae (SFG), ticks were pooled and tested by polymerase chain reaction targeting gltA and ompA genes, followed by sequencing analysis. When tick pools tested positive, individual ticks were then tested one by one, and of the 3,950 ticks screened, rickettsial DNA was identified in 315 ticks (infection rate, 8%). Five SFG Rickettsiae were identified: Rickettsia aeschlimannii in Hyalomma marginatum marginatum, Rickettsia massiliae in Rhipicephalus turanicus and Rhipicephalus sanguineus, Rickettsia sibirica mongolotimonae in Hyalomma anatolicum excavatum, and a Rickettsia endosymbiont of Haemaphysalis sulcata (later described as Rickettsia hoogstraalii) in Haemaphysalis punctata. Two additional genes, 17 kDa and ompB, were targeted to characterize a new genotype of "Candidatus Rickettsia barbariae" genotype in R. turanicus, designated here as "Candidatus Rickettsia barbariae" Cretocypriensis. These results confirm the presence of a spectrum of SFG Rickettsiae on the island. Further studies are necessary to gain better knowledge on the epidemiology of SFG Rickettsiae in Cyprus.

Fleas collected from rats during a three-year period (2000-2003) in 51 areas of all provinces of Cyprus were tested by molecular analysis to characterize the prevalence and identity of fleaborne rickettsiae. Rickettsia typhi, the causative agent of murine typhus, was detected in Xenopsylla cheopis (4%) and in Leptopsylla segnis (6.6%). Rickettsia felis was detected in X. cheopis (1%). This is the first report of R. typhi in X. cheopis and L. segnis from rats, in Cyprus, and the first report of R. felis in X. cheopis in Europe. The role of fleas (mainly X. cheopis) was confirmed in the epidemiologic cycle of murine typhus in Cyprus by interrelation of current results with those of previous studies. The geographic distribution of fleas coincided with the geographic distribution of the pathogen they can harbor, which emphasizes the potential risk of flea-transmitted infections in Cyprus.

Rodents play an active role in the transmission of a number of zoonoses by harboring and disseminating the pathogens involved, either through their biological materials or via their ectoparasites. Hence, the spatial and seasonal distribution of potential agents of zoonoses may be studied by examining their distribution in the rodent vectors and their ectoparasites. A surveillance was conducted in wild rodents in 51 different areas of Cyprus, an island ecosystem, to monitor the reemergence of Echinococcus granulosus and Encephalomyocarditis virus (pathogens that have been eradicated from Cyprus), to study the presence and dispersal of Salmonella spp. (a bacterium found in patients and poultry in the island), as well as to investigate the presence of helminth parasites and rodent ectoparasites. Biological material collected from 625 rodents, examined macroscopically, microscopically, and after culture, showed that the most widespread pathogens encountered in wild rats (Rattus rattus and Rattus norvegicus) were helminth parasites, found in 92 animals (three helminth species found for the first time in Cyprus: Cysticercus fasciolaris, Hymenolepis diminuta, and Physalloptera spp.), and Salmonella spp., detected in the intestine of 56 rats (12 different Salmonella spp. and serotypes). None of the rodents were found infected with the cestode Echinococcus or Encephalomyocarditis virus, indicating that the control measures taken by the Veterinary Services on the island prevented its reestablishment despite changing conditions. The rodents were also free of the nematode Trichinella. Over 40% of the rats collected were infested with fleas, mainly Xenopsylla cheopis. The results, analyzed using the Geographical Information System technology, revealed two of the areas studied as high risk for public health.

A total of 622 rats (402 Rattus norvegicus and 220 R. rattus frugivorus) were collected in 51 different areas in Cyprus during 2000-2003 and used as indicators of the presence and dispersal of six zoonotic microbial agents. IgG antibodies against Rickettsia typhi (241/496, 48.6%), R. conorii (209/500, 41.8%), Toxoplasma sp. (138/494, 27.9%), Coxiella burnetti (63/494, 12.8%), Bartonella henselae (52/494, 10.5%) and Leishmania infantum (36/494, 7.3%) were detected by indirect immunofluorescence test. There was variation in the association between the seropositivity of the six microbial agents and other factors. Rat species affected R. typhi and R. conorii seropositivity, the prefecture where the rats were caught affected R. typhi, C. burnetii, B. henselae, T. gondii and L. infantum, the sampling season impacted on R. typhi, R. conorii, T. gondii and L. infantum, and the flea species affected R. typhi, R. conorii and B. henselae. These results were analysed using geographical information system (GIS) technology and the seropositivity in rats against the pathogens tested appeared to follow the occurrence of these pathogens in humans. This suggests that rats could be used as disease sentinels and, together with GIS technology, they could be a useful tool for the identification of endemic foci and high-risk areas for each pathogen., (Copyright © 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.)

Background: The achievement of quality of care constitutes a priority for modern health care systems. The objective of our study was to evaluate a quality improvement intervention in primary care of Cyprus., Methods: In a two-arm non-randomized controlled study in primary care centres in Cyprus, all patients with hypertension (HTN) and diabetes (n = 539) were invited. In one urban and one rural centre, a quality improvement programme was implemented; two other centres (one urban and one rural) served as control practices. The intervention mainly consisted of the introduction of clinical disease management guidelines and an electronic medical record system. The primary outcome measurement was improvement of specific clinical indicators for HTN and diabetes. Patients' satisfaction was evaluated using the European Task Force on Patient Evaluations of General Practice (EUROPEP) questionnaire over an 18-month follow-up period., Results: Five hundred and four patients completed the study, 278 patients in the intervention practices and 226 patients in the control practices. Mean results for blood pressure, total cholesterol and low density lipoprotein-cholesterol and three annual performance measures (urine protein testing, dilated eye and foot examination) had improved at 18-month follow-up in the intervention as compared to the control group. There was no improvement of HbA1c levels. Patients' satisfaction improved in the intervention practices (improvement of 10/23 EUROPEP items) but decreased in the control group (decline of 20/23 items)., Conclusions: A pilot multifaceted quality improvement intervention programme for patients with diabetes and HTN implemented in primary care settings in Cyprus showed promising results. Future studies need to involve a broader number of practices and patient populations.

A seroprevalence study of Anaplasma infection was conducted in a stratified random sample of goats and sheep in Cyprus in which the sample locations were recorded using a geographical information system (GIS). The aim of the study was to estimate the prevalence of Anaplasma phagocytophilum and other Anaplasma species in sheep and goats, and to identify high-risk regions. A total of 689 serum samples (343 from sheep and 346 from goats) were randomly collected and tested for the detection of antibodies against A. phagocytophilum antigen using an indirect immunofluorescent assay. The polymerase chain reaction followed by sequencing analysis was used for the detection and molecular characterization of Anaplasma sp DNA in the blood samples. The prevalence of IgG antibodies against A. phagocytophilum antigen was 18% for goats, and 31% for sheep. Six new genotypes were detected in goats and sheep; by sequence analysis one was identified as A. phagocytophilum, one as Anaplasma platys and the remaining four as Anaplasma species. The results provide evidence for the presence of A. phagocytophilum and Anaplasma species in sheep and goats in Cyprus.

This report describes the case of an infant suffering from Kawasaki disease with a concomitant Anaplasma sp. infection. Further studies are required to demonstrate a possible association between Kawasaki disease and bacterial infections.

Background: Quality Improvement Interventions require significant financial investments, and therefore demand careful consideration in their design in order to maximize potential benefits. In this correspondence we present the methodological approach of a multifaceted quality improvement intervention aiming to improve quality of care in primary care, properly tailored for a country such as Cyprus where general practice is currently seeking recognition., Methods: Our methodological approach was focused on the design of an open label, community-based intervention controlled trial using all patients from two urban and two rural public primary care centers diagnosed with hypertension and type II diabetes mellitus. The design of our intervention was grounded on a strong theoretical framework that included the Unified Theory of Acceptance and Use of Technology, and the Chronic Care Model, which synthesize evidence-based system changes in accordance with the Theory of Planned Behavior and the Theory of Reasoned Action. The primary outcome measure was improvement in the quality of care for two chronic diseases evaluated through specific clinical indicators, as well as the patient satisfaction assessed by the EUROPEP questionnaire and additional personal interviews., Results: We designed a multifaceted quality improvement intervention model, supported by a varying degree of scientific evidence, tailored to local needs and specific country characteristics. Overall, the main components of the intervention were the development and adoption of an electronic medical record and the introduction of clinical guidelines for the management of the targeted chronic diseases facilitated by the necessary model of organizational changes., Conclusion: Health planners and policy makers need to be aware of the potential use of certain theoretical models and applied methodology as well as inexpensive tools that may be suitably tailored to the local needs, in order to effectively design quality improvement interventions in primary care settings.

Molecular genotyping has been used to characterize Toxoplasma gondii strains into the three clonal lineages known as types I, II, and III. To characterize T. gondii strains from Greece and Cyprus, polymerase chain reaction-restriction fragment length polymorphism analysis on the GRA6 gene was performed directly on 20 clinical samples from 18 humans (11 pregnant women, six patients with lymphadenopathy, and one patient positive for human immunodeficiency virus) and two rats. Characterization of T. gondii types was performed after digestion of amplified products with Mse I. The 20 strains were characterized as type II (20%) and type III (80%). Of these strains, 19 originated from the island of Crete (4 strains type II and 15 strains type III), and 1 from the island of Cyprus (type III). Although both type II and type III strains were found, type III was the most prevalent in Crete.

Objective: To examine the effect of heterogeneous case mix for a benchmarking analysis and interhospital comparison of the prevalence rates of nosocomial infection., Design: Cross-sectional survey., Setting: Eleven hospitals located in Cyprus and in the region of Crete in Greece., Methods: The survey included all inpatients in the medical, surgical, pediatric, and gynecology-obstetrics wards, as well as those in intensive care units. Centers for Disease Control and Prevention criteria were used to define nosocomial infection. The information collected for all patients included demographic characteristics, primary admission diagnosis, Karnofsky functional status index, Charlson comorbidity index, McCabe-Jackson severity of illness classification, use of antibiotics, and prior exposures to medical and surgical risk factors. Outcome data were also recorded for all patients. Case mix-adjusted rates were calculated by using a multivariate logistic regression model for nosocomial infection risk and an indirect standardization method.Results. The overall prevalence rate of nosocomial infection was 7.0% (95% confidence interval, 5.9%-8.3%) among 1,832 screened patients. Significant variation in nosocomial infection rates was observed across hospitals (range, 2.2%-9.6%). Logistic regression analysis indicated that the mean predicted risk of nosocomial infection across hospitals ranged from 3.7% to 10.3%, suggesting considerable variation in patient risk. Case mix-adjusted rates ranged from 2.6% to 12.4%, and the relative ranking of hospitals was affected by case-mix adjustment in 8 cases (72.8%). Nosocomial infection was significantly and independently associated with mortality (adjusted odds ratio, 3.6 [95% confidence interval, 2.1-6.1])., Conclusion: The first attempt to rank the risk of nosocomial infection in these regions demonstrated the importance of accounting for heterogeneous case mix before attempting interhospital comparisons.

Background: The computer-based electronic medical record (EMR) is an essential new technology in health care, contributing to high-quality patient care and efficient patient management. The majority of southern European countries, however, have not yet implemented universal EMR systems and many efforts are still ongoing. We describe the development of an EMR system and its pilot implementation and evaluation in two previously computer-naïve public primary care centres in Cyprus., Methods: One urban and one rural primary care centre along with their personnel (physicians and nurses) were selected to participate. Both qualitative and quantitative evaluation tools were used during the implementation phase. Qualitative data analysis was based on the framework approach, whereas quantitative assessment was based on a nine-item questionnaire and EMR usage parameters., Results: Two public primary care centres participated, and a total often health professionals served as EMR system evaluators. Physicians and nurses rated EMR relatively highly, while patients were the most enthusiastic supporters for the new information system. Major implementation impediments were the physicians' perceptions that EMR usage negatively affected their workflow, physicians' legal concerns, lack of incentives, system breakdowns, software design problems, transition difficulties and lack of familiarity with electronic equipment., Conclusion: The importance of combining qualitative and quantitative evaluation tools is highlighted. More efforts are needed for the universal adoption and routine use of EMR in the primary care system of Cyprus as several barriers to adoption exist; however, none is insurmountable. Computerised systems could improve efficiency and quality of care in Cyprus, benefiting the entire population.

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.

A cross-sectional study of Q fever was conducted in a representative sample of the human and animal population in Cyprus in order to assess the seroprevalence of Q fever and the prevalence of related risk factors. A total of 583 human and 974 ruminant animal serum samples were collected and tested for the detection of antibodies against Coxiella burnetii phase II antigen using an indirect immunofluorescent assay. One hundred forty-one ticks were collected from the infested animals examined; the polymerase chain reaction and the shell-vial technique were used to detect and isolate C. burnetii. Standardized questionnaires were used to obtain information concerning inhabitants and their animals. A geographical information system was used to identify high-risk regions. The prevalence of IgG antibodies against C. burnetii phase II antigen was estimated at 52.7% for humans, 48.2% for goats, 18.9% for sheep, and 24% for bovines. C. burnetii was detected in 11 (7.8%) ticks. Using the geographical information system, two villages were identified as high-risk regions on the basis of high seroprevalence rates of IgG antibodies in humans and animals. Risk factors related to Q fever seropositivity were identified by logistic regression analysis and included age, residence, occupation, use of manure in the garden, ownership of animals (especially goats), and the presence of tick-infested or aborting animals. Q fever poses an occupational hazard to humans living in close contact with sheep and/or goats. In parallel, ticks should be considered an important aspect in the epidemiology of Q fever and should be further studied to better elucidate their role.

Rickettsia felis was identified by polymerase chain reaction amplification and DNA sequencing analysis in Ctenocephalides felis fleas parasitizing rats in Cyprus. Murine typhus caused by R. typhi was believed to be the only flea-transmitted rickettsiosis on the island. This is the first report of this pathogen in southeastern Europe.

Ticks are the principal vectors and reservoirs of Coxiella burnetii. The identification of isolates is necessary for understanding the clinical diversity of Q fever in different geographic areas. This is the first report of isolation of C. burnetii from ticks by the shell-vial assay and by nested polymerase chain reaction (PCR) assay for the detection of this pathogen in ticks. Of 141 ticks collected in Cyprus (Rhipicephalus sanguineus and Hyalloma spp.), 10% were found to be infected with C. burnetii. Three ticks were positive by hemolymph test, and 11 triturated ticks were positive by nested PCR. Three isolates were obtained by the centrifugation shell-vial technique. Analysis by PCR, then restriction fragment length polymorphism showed that the 3 Cyprus isolates had identical restriction profiles to reference strains Nine Mile and Q212. The methods described are useful in studying the epidemiology and ecology of C. burnetii.

A simple and reliable technique was developed to distinguish Phlebotomine sandflies by restriction fragment length polymorphism of PCR-amplified (PCR-RFLP) 18S rDNAs. Seven morphologically identified sandflies species from several localities of Greece and Cyprus were studied, and specific patterns were developed by double digesting amplified 18S rDNAs with HpaII and RsaI. Three additional species of the subgenus Larroussius were distinguished by a second double digestion with AccI and BanI. We have successfully applied the method on samples in which morphological characters were badly distinguished due to poor storage conditions and in larval stages.