Date Published: November 19, 2015
Publisher: Public Library of Science
Author(s): Maria Tseroni, Agoritsa Baka, Christina Kapizioni, Georges Snounou, Sotirios Tsiodras, Maria Charvalakou, Maria Georgitsou, Maria Panoutsakou, Ioanna Psinaki, Maria Tsoromokou, George Karakitsos, Danai Pervanidou, Annita Vakali, Varvara Mouchtouri, Theano Georgakopoulou, Zissis Mamuris, Nikos Papadopoulos, George Koliopoulos, Evangelos Badieritakis, Vasilis Diamantopoulos, Athanasios Tsakris, Jenny Kremastinou, Christos Hadjichristodoulou, Photini Sinnis. http://doi.org/10.1371/journal.pntd.0004215
Abstract: Greece was declared malaria-free in 1974 after a long antimalarial fight. In 2011–2012, an outbreak of P. vivax malaria was reported in Evrotas, an agricultural area in Southern Greece, where a large number of immigrants from endemic countries live and work. A total of 46 locally acquired and 38 imported malaria cases were detected. Despite a significant decrease of the number of malaria cases in 2012, a mass drug administration (MDA) program was considered as an additional measure to prevent reestablishment of the disease in the area. During 2013 and 2014, a combination of 3-day chloroquine and 14-day primaquine treatment was administered under direct observation to immigrants living in the epicenter of the 2011 outbreak in Evrotas. Adverse events were managed and recorded on a daily basis. The control measures implemented since 2011 continued during the period of 2013–2014 as a part of a national integrated malaria control program that included active case detection (ACD), vector control measures and community education. The MDA program was started prior to the transmission periods (from May to December). One thousand ninety four (1094) immigrants successfully completed the treatment, corresponding to 87.3% coverage of the target population. A total of 688 adverse events were recorded in 397 (36.2%, 95% C.I.: 33.4–39.1) persons, the vast majority minor, predominantly dizziness and headache for chloroquine (284 events) and abdominal pain (85 events) for primaquine. A single case of primaquine-induced hemolysis was recorded in a person whose initial G6PD test proved incorrect. No malaria cases were recorded in Evrotas, Laconia, in 2013 and 2014, though three locally acquired malaria cases were recorded in other regions of Greece in 2013. Preventive antimalarial MDA to a high-risk population in a low transmission setting appears to have synergized with the usual antimalarial activities to achieve malaria elimination. This study suggests that judicious use of MDA can be a useful addition to the antimalarial armamentarium in areas threatened with the reintroduction of the disease.
Partial Text: Greece was declared free of malaria in the year 1974 after many years of intense public health efforts . Since then, a small number of imported cases have been reported annually , though rare sporadic cases raising the possibility of local transmission were also detected from time to time . In 2009 and 2010 cases of P. vivax malaria (n = 6 and n = 1, respectively) most probably locally acquired were recorded in the agricultural area of Evrotas, Laconia in Peloponnese in Southern Greece . In 2011, an outbreak of 36 confirmed locally acquired P. vivax cases were recorded in Greek citizens with no history of travel, and 21 imported cases in immigrants from non-endemic countries in the same area . After the 2011 outbreak, a multidisciplinary strategy with a variety of intensive response activities, was adopted and implemented in Evrotas . Nonetheless, in 2012, 10 locally acquired cases and 17 imported cases were again recorded . The geographic distribution of malaria cases (imported and locally acquired) in Greece during 2011–2012 is shown in Fig 1.
One thousand two hundred seventy (1270) immigrants were eligible to participate in the intervention in the years 2013 and 2014. Seventeen (17) immigrants, who had been diagnosed with malaria in the 2012 transmission period and had received therapy, were excluded. A total of 1094 immigrants from malaria-endemic countries received MDA during the transmission periods 2013 and 2014 (862 in 2013 and 232 in 2014). The vast majority of immigrants were from Pakistan or Afghanistan (Table 1), with a smaller number from Bangladesh and other Asian countries. The immigrants often resided outside settlements close to mosquito breeding sites in poor housing conditions, principally sheds, outhouses and other makeshift housing without proper doors or windows to reduce man-mosquito contact. The immigrant target population was not stable during the transmission period, with significant turnover where about 30% moved in or out of the area depending on work availability. All eligible immigrants were initially checked for G6PD, while 75 of them left the area despite having initially agreed to participate in the MDA intervention and they were excluded. Testing for G6PD levels identified 22 immigrants with moderate or severe deficiency, who were also excluded. The majority of the target population (950, 75.8%) underwent DOT with the antimalarial regimen as described above, while the remaining 144 received SOT (Fig 2), bringing the total treatment coverage to 87.3% of the target population. Initiation and completion of treatments before the end of July and the peak of the transmission period was ensured for the majority of immigrants who were present in the particular area, while for the newly arriving immigrants the treatment was initiated within two weeks of their arrival. The monthly distribution of completed treatments is shown in Fig 3.
This article describes the first mass administration of antimalarial treatment in Greece several decades after the malaria elimination programs that led to the declaration of the country as malaria free in 1974. The choice to deploy an MDA scheme in Evrotas was dictated by the failure of the extensive control measures implemented in 2011 and 2012 to stem the occurrence of locally acquired malaria in the 2012 transmission period. It is highly likely that the implementation of the MDA scheme led to the sustainable interruption of transmission in 2013 and 2014, during which no malaria cases were recorded in Evrotas.