Malaria in Greece:

epidemiological data and

KEELPNO actions

Danai Pervanidou, MD, MPH, EPIET alumni

Unit for Vector-borne Diseases

Department of Surveillance and Intervention,

Hellenic Centre for Disease Control and Prevention (KEELPNO)

Malaria in Greece

• Until mid-20th century: endemic

• 1974: malaria-free

• 1975 - 2008:

20 - 50 imported cases reported annually

Reports of sporadic locally acquired cases: 1991, 1999, 2000

• 2009 - 2013:

81% of imported cases were immigrants from endemic

countries

Since 2009: locally-acquired cases reported annually

2

Reported malaria cases, Greece, 2009 - 2013

Year of

symptom onset

Imported cases Locally acquired cases*

Total

Greece Greece

2009 44 7 51

2010 40 4 44

2011 54 42 96

2012 73 20 93

2013 22 3 25

* All P.vivax cases 3

Reported malaria cases, Greece, 2009 - 2013

Year of

symptom onset

Imported cases Locally acquired cases*

Total

Greece Evrotas Greece Evrotas

2009 44 0 7 6 51

2010 40 0 4 1 44

2011 54 21 42 36 96

2012 73 17 20 10 93

2013 22 0 3 0 25

* All P.vivax cases 4

Reported malaria cases, Greece, 2009 - 2013

Year of

symptom onset

Imported cases Locally acquired cases*

Total

Greece Evrotas Greece Evrotas

2009 44 0 7 6 51

2010 40 0 4 1 44

2011 54 21 42 36 96

2012 73 17 20 10 93

2013 22 0 3 0 25

* All P.vivax cases 5

Number of locally acquired malaria cases by

year of symptom onset*, Greece, 2009 - 2013

*Two cases with symptom onset in 2012 are attributed in the 2011 transmission period

7

1 case in East Attica (Nea Makri)

Place of exposure of locally acquired malaria cases,

Greece, 2009 (n=7)

Cluster of 6 cases in Evrotas, Lakonia

Place of exposure of locally acquired malaria cases,

Greece, 2010 (n=4)

2 cases (Roma children) in Viotia (Thiva)

1 case in Evrotas Lakonia (Roma)

1 case in East Attica (Marathon)

Reported malaria cases, Greece, 2011

96 malaria cases recorded

• Imported cases: 54

- 45 in immigrants from malaria endemic countries

- 36 P. vivax

• Locally acquired: 42

- 34 Greek, 5 Romanian, 2 Moroccan, 1 Polish

- all P. vivax

Larisa: >70 yrs

East Attica (Marathon, Kalivia): 2 cases >70 yrs

Viotia (Orchomenos): 40-50 yrs Roma

Place of exposure of locally acquired malaria cases,

Greece, 2011 (n=42)

Evia: 2 cases 40-50 yrs

Lakonia, Evrotas: 36 cases

Malaria cases, Evrotas, Lakonia, 2011

* 2 cases diagnosed in Romania ** 2 cases had onset of symptoms in 2012

Case classification - Nationality Number

Locally - acquired cases

• Greek nationality

• Immigrants

Romania

Poland

Morocco

Immigrants from endemic countries

Pakistan

Afghanistan

36**

28

8

5*

1

2

21

20

1

Place of residence of malaria cases,

Evrotas, Lakonia, 2011

Red dots: immigrants Yellow dots: Greek cases 12

Reported malaria cases, Greece, 2012

93 malaria cases reported

• Imported cases: 73

- 64 in immigrants from malaria endemic countries

- 54 P. vivax, 15 P.falciparum, 1 P.vivax + P.falciparum

• Locally acquired: 20

- 14 Greek, 3 Romanian, 2 Moroccan, 1 Albanian

- all P. vivax

Reported malaria cases not attributed to

2012 transmission period, Greece, 2012

• 5 relapses in 2011 cases: 4 Greek, 1 Pakistani

- inadequate Primaquine treatment

• 4 cases infected in past transmission periods:

- 1 case (P.vivax), 30yrs Moroccan male, Evrotas, onset: 03/04/2012

- 1 case (P.vivax), 7yrs Greek female, Evrotas, onset: 27/08/2012

- 2 cases of P.malariae (Greek): 78yrs, onset: 08/01/2012

85yrs, onset: 01/05/2012

14

Place of exposure of locally acquired malaria cases,

Greece, 2012 (n=20)

East Attica, Marathon: 2 cases, 52 & 78 yrs

Xanthi: 2 cases, 23 & 61 yrs

Viotia: 2 cases, 23 & 47 yrs

Karditsa: 2 cases, 24 & 53 yrs

Lakonia, Evrotas: 10 cases East Attica, Markopoulo:

2 cases, 44 & 70 yrs

Malaria cases, Evrotas, Lakonia, 2012

Case classification - Nationality Number

Locally-acquired cases

• Greek nationality

• Immigrants from non-endemic countries

Romania

Morocco

Immigrants from endemic countries

Pakistan

Afghanistan

Total

10

7

3

1

2

17

13

4

27

Place of residence of malaria cases, Evrotas, 2012

Red dots: immigrants Yellow dots: Greek cases

Reported malaria cases, Greece, 2013

25 malaria cases reported

• Imported cases: 22

- 13 in immigrants from malaria endemic countries

- 9 P. vivax, 12 P.falciparum, 1 P.ovale

• Locally acquired: 3

- all Greeks

- all P. vivax

Place of exposure of locally acquired malaria cases,

Greece, 2013 (n=3)

Karditsa: 1 case 67 yrs

Evros: 2 cases, 40 & 48 yrs

Locally-acquired malaria cases by week of symptom onset,

Greece, 2011 (n=39*), 2012 (n=19**) and 2013 (n=3)

* Two cases with symptom onset in 2012 and one case with unknown week of onset are not included

** One case with symptom onset in 2013 is not included

2011 - 2012:

52% decrease

of locally-acquired cases

2012 - 2013:

85% decrease

of locally acquired cases

Locally-acquired malaria cases by week of symptom onset,

Evrotas, 2011 (n=33*) and 2012 (n=10)

* Two cases with symptom onset in 2012 and one case with unknown week of onset are not included

Evrotas, 2011 - 2012:

72% decrease

of locally-acquired cases

Lakonia Regional Unit

P.vivax malaria cases by week of symptom onset,

Lakonia, Greece, 2011 (n=55*), 2012 (n=27)

*3 asymptomatic cases in migrants from Pakistan are not included as well as one case with unknown date of

onset (diagnosed in Romania)

Map of Evrotas (Land use)

Orange trees

Coastal wetlands & lake

Irrigation &drainage channels (105 km)

Other cultivations

Sea

Map of Evrotas (Irrigation & drainage network)

Irrigation channel near the orange plantations

Habitation inside the orchard

Ecological situation in Evrotas, Lakonia

Evrotas river

Place of residence of malaria cases,

East Attica, 2009 - 2012

Place of residence of malaria cases,

East Attica, 2009 - 2012

Evia Regional Unit

Viotia Regional Unit

Place of residence of locally acquired malaria cases,

Viotia, 2010 - 2012

Xanthi Regional Unit

Place of residence of locally acquired malaria cases,

village of Xanthi, 2012

Karditsa Regional Unit

Malaria cases, village of Sofades Municipality, Karditsa,

2012 - 2013

Sept-Oct 2012: 11 P.vivax cases in 2 residencies (170m)

- 1st residency: 26 persons from Afganistan and Bagladesh

- 2nd residency: 5 persons from Romania

• 9 cases in immigrants from endemic countries (1st residency):

onset 03/09 - 11/10/2012, 1.5 - 11 months in Greece

• 2 introduced cases (2nd residency): Romanian Roma

onset: 22/09, 30/09/2012

6/11 cases detected actively

Nov 2013: 1 locally-acquired case (Greek)

Place of residence of malaria cases,

village of Karditsa, 2012 - 2013

Number of malaria cases by week of onset and

case classification, village of Karditsa, 2012

Evros Regional Unit

Place of residence of locally acquired malaria cases,

town of Evros, 2013

Place of residence of locally acquired malaria cases,

town of Evros, 2013

KEELPNO action plan for the management of malaria, 2012 - 2015

KEELPNO Working Group on vector-borne diseases

Risk assessment

Partnership to implement the national project: “Integrated

surveillance and control programme for West Nile virus and malaria in Greece”

41

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

42

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

43

Enhanced malaria surveillance

• Enhancement of passive surveillance

- test “suspected” cases (case definition)

• Case investigation

- interviews with the patients and treating physicians

- case classification, place of exposure, detailed travel history

during the last 5 years, risk factors for ongoing transmission

• Environment investigation

• Active case detection

Active case detection, Greece, 2012 - 2013

To timely diagnose and treat malaria cases

in order to prevent further transmission

1. Focus investigation of malaria cases:

- all over Greece

2. Daily door - to - door ACD throughout the year:

- in Evrotas

3. Screening of immigrants from endemic countries

45

Focus investigation of malaria cases,

Greece, 2012 - 2013

It was conducted all over Greece:

• following every new locally acquired case

• following every imported case residing in rural area

In surroundings

around case’s residence/ suspected place of exposure

46

Focus investigation of malaria cases, Greece

Door -to- door visits

Individual

from non - endemic country

Fever screening

Fever (+):

1. RDT + microscopy

2. Fever screening

weekly x 1 month

Fever (-):

Fever screening

weekly x 1 month

Individual

from endemic country

1. RDT + microscopy

2. Fever screening

weekly x 1 month

47

ACD, town of Evros, 12-14/10/2013

ACD, village of Karditsa, 13-15/11/2013

Door -to- door daily ACD, Evrotas, 2012- 2013

Mapping of all residences, Data base

Initial visit: Provide information on malaria & protective measures

Fever screening

every 7 - 15 days

Fever (+):

RDT + microscopy

RDT (+):

- Physician evaluation

- Chloroquine

Microscopy (+) for P.vivax:

Primaquine (after G6PD test) 50

Cases detected actively, Greece, 2012

Cases

Cases detected by

focus investigation,

Greece

n / N (%)

Cases detected by

daily ACD,

Evrotas

n / N (%)

Total cases

detected actively,

Greece

n / N (%)

Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)

Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)

Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)

51

Cases detected actively, Greece, 2012

Cases

Cases detected by

focus investigation,

Greece

n / N (%)

Cases detected by

daily ACD,

Evrotas

n / N (%)

Total cases

detected actively,

Greece

n / N (%)

Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)

Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)

Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)

52

Cases detected actively, Greece, 2012

Cases

Cases detected by

focus investigation,

Greece

n / N (%)

Cases detected by

daily ACD,

Evrotas

n / N (%)

Total cases

detected actively,

Greece

n / N (%)

Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)

Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)

Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)

53

Cases detected actively, Greece, 2012

Cases

Cases detected by

focus investigation,

Greece

n / N (%)

Cases detected by

daily ACD,

Evrotas

n / N (%)

Total cases

detected actively,

Greece

n / N (%)

Imported 6 / 73 (8%) 16 / 17 (94%) 22 / 73 (30%)

Locally-acquired 1 / 20 (5%) 2 / 10 (20%) 3 / 20 (15%)

Total 7 / 93 (8%) 18 / 27 (67%) 25 / 93 (27%)

54

Screening of immigrants from endemic

countries, Greece, 2012 - 2013

RDT in immigrants from endemic countries

2012:

• affected areas (Evrotas, East Attica): 1,450 immigrants

• 8 detention centres (5 in greek-turkish borders):

1,015 immigrants

2013:

• recommended in health units in North Aegean and

Dodecanese islands (immigrants’ entry points)

• 554 immigrants in Chios and Limnos islands

55

Antimalarial drug administration to immigrants

from endemic countries, Evrotas, 2012 - 2013

• 2012: immigrants with positive malaria serology

• 2013: mass drug administration

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

57

Enhancing laboratory diagnosis of malaria

• Training seminars for lab personnel (from NSPH), 2012

• RDTs distribution to hospitals and health centres in:

- affected areas

- areas with immigration detention centres

- large urban areas

- entry points (greek-turkish borders, islands)

• Free of charge testing for malaria in the reference

laboratories

• Support genotyping of the P. strains - NSPH / ECDC 58

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

59

Case management - Standardization of

the malaria treatment

• KEELPNO treatment guidelines

• Guidance to physicians for proper case management

• Protocol for following-up the treatment efficacy

• All 2011 improperly treated malaria cases were treated

with a 2nd course in 2012

• Availability of anti-malarial drugs for radical P.vivax

treatment (primaquine) and severe cases (artesunate)

60

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

61

Communication

• Health professionals:

- informative material disseminated every spring

- seminars (41 in 2012,15 in 2013)

• Public:

- educational material in website, leaflets

- TV spot

- public meetings (29 in 2012, 82 in schools in 2012)

• National stakeholders: MoH, regional and local public health

authorities, blood safety authorities

• International public health stakeholders (WHO, ECDC, CDC)

62

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

63

Blood safety measures

• Multisector Working Group on the definition of

affected areas by vector borne diseases:

characterization of affected areas for the implementation

of blood safety measures

• National Centre for Blood Donations

• Donor deferral from affected areas

64

KEELPNO action plan for the management of malaria, 2012 - 2015

1. Enhanced malaria surveillance - early detection of cases

2. Enhancing laboratory diagnosis of malaria

3. Case management - Standardization of the malaria treatment

4. Communication

5. Blood safety measures

6. Vector surveillance and control activities

65

Vector surveillance and control activities

• Technical guidance for regional, local authorities, for timely organizing

vector control activities

• Individual reports with entomological and epidemiological data for each

region

• Training seminars for local authorities (2012)

• Vector surveillance: 2012 mosquito mapping projects, around the country

• Entomological activities in the framework of the project MALWEST

In Evrotas:

- Distribution of LLINs (2013)

- IRS

• Conditions may exist for locally acquired transmission to

occur sporadically or in small clusters in vulnerable areas:

- increased number of immigrants from endemic countries

- competent vector circulation in many areas

• Most affected areas are agricultural, non-touristic,

close to wetlands, with large populations of migrant farm

workers

Conclusions I

• Decrease of locally-acquired cases in 2012 and 2013

- impact of public health actions

- decreased immigrants’ entry - fewer imported cases?

- under-notification unlikely

- under-diagnosis?

• Managing malaria remains a challenge (continuing

entrance of new migrants from malaria endemic countries)

• Need for a multi-sector control strategy: entomological

surveillance, intensifying mosquito control measures,

communication to the public and health professionals

Conclusions II

Number of immigrants arrested for illegal entry and

residence at the Greek-Turkish land and sea borders

and Crete, Greece, 2009 - 2013

69

Source: Hellenic Police website (www.astynomia.gr)

Number of immigrants from 6 malaria endemic countries*

arrested for illegal entry and residence, Greece, 2009 - 2013

70

Source: Hellenic Police website (www.astynomia.gr)

*Pakistan, Afganistan, Bangladesh, Somalia, Erithrea, Irak

Priority actions - Recommendations, 2014

• Continue ACD in Evrotas. In Karditsa?

• Involve local public health authorities to achieve sustainability

• Local laboratory capacity should be enhanced

• Vector control programmes (+ IRS, LLINs)

• Assess in health care - free diagnosis and treatment for

undocumented immigrants

Need to address for undocumented immigrants:

• poor living conditions

• long-term health care access

Thank you

Malaria cases by month and case classification, Lakonia, 2009-2012

Malaria cases by month

Years Number of cases by month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

2012 Imported 0 0 1 0 1 2 6 4 0 1 0 0 15

Locally

acquired

0 0 0 0 0 1 3 0 1 3 0 0 8

2011 Imported 0 0 0 0 0 1 0 2 12 4 1 0 20

Locally

acquired

0 0 0 0 1 0 4 4 17 8 0 0 34

2010 Imported 0 0 0 0 0 0 1 0 0 0 0 0 1

Locally

acquired

0 0 0 0 0 0 1 0 0 0 0 0 1

2009 Imported 0 0 0 0 0 0 0 2 0 0 0 0 2

Locally

acquired

0 0 0 0 0 0 0 1 4 1 0 0 6

Malaria cases by age and case classification, Lakonia, 2009-2012

Malaria cases by age

Years Number of cases by age in years

0-19 20-29 30-39 40-49 50-59 >=60

2012 Imported 3 9 1 2 0 0

Locally

acquired

0 1 1 3 2 1

2011 Imported 3 16 2 1 1 0

Locally

acquired

5 4 5 9 5 7

2010 Imported 0 0 0 0 1 0

Locally

acquired

0 1 0 0 0 0

2009 Imported 0 2 0 0 0 0

Locally

acquired

0 1 0 1 3 1

Malaria cases by social and high risk group, Evrotas, Lakonia, 2011 - 2012

Years Number of malaria cases by category

Children-Student

Agricultural workers

Labourers Office workers

House-wives

Pensioners -Other

2012 Imported 1 14 0 0 0 0

Locally

acquired

0 2 0 2 3 1

2011 Imported 0 18 1 0 0 0

Locally

acquired

4 14 5 4 3 5

Characteristics of locally acquired cases, Greece, 2012 (n=16)

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

• Gender: 62.5% were male

• Plasmodium species: all cases P.vivax

• Hospitalization: 75% hospitalized, no case in ICU

• Treatment: Chloroquine (11), Mefloquine (3), Atovaquone-Proguanile (1), no treatment (1) + Primaquine (15) • Outcome: No fatality

76

Reported cases of P.vivax infection by month of onset and case

classification, Lakonia, Greece, 2011 (n=56*) and 2012 (n=27)

Evrotas, 2011-2012: 72% decrease of

locally-acquired cases

77