Epidemiological patterns of tuberculosis in Croatia in the period 1996-2005

The last comprehensive publication on tuberculosis in Croatia and the earliest impact of war, besides the yearly routine reports, was done in 1996 in Croatian. We were, therefore, interested to explore incidence trends and to highlight the early post-war tuberculosis epidemiological patterns in the next ten years period (1996-2005). A retrospective analysis of epidemiological data on all registered tuberculosis cases in Croatia searching the databases of 21 Croatian Public Health Institutes and the National Tuberculosis Registry was made. During the study period, the total tuberculosis incidence rates in Croatia dropped from 45 to 25.8/100 000 inhabitants. The average highest age-specific rates were recorded in the age group > or = 65 years being in decrease in all age groups. Paediatric cases (0-14 years) represented 4.5% of all cases. Tuberculosis cases among males were recorded in 64% cases, and 83.6% were indigenous population. Tuberculosis was bacteriologically confirmed in 67.7% cases. A low proportion of drug resistance (3.3%) was recorded. During 1985-2005, 56 tuberculosis cases among 242 AIDS cases were reported. Tuberculosis mortality showed a decreasing trend (p < 0.001). However, tuberculosis has still had the highest mortality rates among infectious diseases in Croatia. Despite the War chain of events and tuberculosis programmatic changes, tuberculosis incidence rates in Croatia have been decreasing but they are still far away from national target, incidence rate of 10/100 000 declared in 1998 and much higher than in European Union and Western Europe. Tuberculosis among children, resistance to tuberculosis drugs and HIV prevalence, significant problems in many European countries, have not caused problems in tuberculosis control in Croatia. This favourable epidemiological situation must be kept and improved through strengthened tuberculosis control measures.     

Descriptive epidemiology of cutaneous squamous cell carcinoma in Croatia

The aim of the study was to investigate the squamous cell carcinoma (SCC) incidence in Croatia in the 2003-2005 period. The cases of SCC were retrospectively studied. Data were collected from University Department of Dermatology and Venereology, Zagreb University Hospital Center and National Cancer Registry. In the study period, there were 1,860 cases of SCC (934 men and 926 women). The crude incidence rate for the Croatian population of 100,000 was 14.6 for men and 13.4 for women. The age-standardized incidence rate (adjusted for the world standard population) was 8.9 for men and 5.2 for women. The head was almost exclusive localization of SCC in both sexes. The highest SCC incidence was recorded in Zadar County. These results will serve for the SCC trend monitoring in Croatia and Europe in the forthcoming years.     

Dental evidence of exhumed human remains from the 1991 war in Croatia

The aim of this paper is to present the post mortem dental evidence and dental health of the victims exhumed throughout the territories of Croatia that was temporarily occupied during the war. A total number of 62,432 teeth out of 1,253 human bodies exhumed from 5 different counties were analyzed. The majority of victims inhabited those areas before 1991. Post mortem dental characteristics were analyzed according to the American Board of Forensic Odontology and WHO methodology. The results show the highest level of the dental health before 1991 in the Vukovarsko-Srijemska County. The decayed (D), missing (M), filling (F), teeth (T), DMFT of that County was at the lowest level i.e. at 5.2. In all of the other counties, it was always between 6 and 12. The material most frequently used for the dental fillings was amalgam. Its highest frequency level was recorded in the County 4 (8%) and lowest in the County 1 (1.5%), p<0.001. The most frequent prosthodontic appliances were acrylic dentures. Their frequency was lowest in the County 5 (1.3%) and highest in the County 3 (11.6%), p<0.001. Determination of sex and dental age showed that victims were mostly men (79%) of middle and elderly age (89%). Teeth were useful also for monitoring of the quality of exhumations--taking into consideration number of empty dental sockets. The highest number of empty dental sockets was recorded in the County 3 (40.4%) and lowest in the County 1 (13.5%), p<0.001. Even after many years in the soil, teeth proved to be the most preserved human organs and valuable indicators of identity as well as of the way of life before death.     

Q Fever Risk Across a Dynamic,Heterogeneous Landscape in Laikipia County,Kenya

Two hundred fourteen serosamples were collected from four livestock species across five ranches in Laikipia County, Kenya. Serological analysis for Coxiella burnetii (the causative agent for Q fever) showed a distinct seroprevalence gradient: the lowest in cattle, higher in sheep and goats, and the highest in camels. Laikipia-wide aerial counts show a recent increase in the camel population. One hundred fifty-five stakeholder interviews revealed concern among veterinary, medical, ranching, and conservation professionals about Q fever. Local pastoralists and persons employed as livestock keepers, in contrast, revealed no knowledge of the disease. This work raises questions about emerging Q fever risk in Laikipia County and offers a framework for further integrative disease research in East African mixed-use systems.     

Epidemiological investigation and physician awareness regarding the diagnosis and management of Q fever in South Korea, 2011 to 2017

BackgroundIn South Korea, the number of Q fever cases has rapidly increased since 2015. Therefore, this study aimed to characterize the epidemiological and clinical features of Q fever in South Korea between 2011 and 2017.Methods/Principal findingsWe analyzed the epidemiological investigations and reviewed the medical records from all hospitals that had reported at least one case of Q fever from 2011 to 2017. We also conducted an online survey to investigate physicians’ awareness regarding how to appropriately diagnose and manage Q fever. The nationwide incidence rate of Q fever was annually 0.07 cases per 100,000 persons. However, there has been a sharp increase in its incidence, reaching up to 0.19 cases per 100,000 persons in 2017. Q fever sporadically occurred across the country, with the highest incidences in Chungbuk (0.53 cases per 100,000 persons per year) and Chungnam (0.27 cases per 100,000 persons per year) areas. Patients with acute Q fever primarily presented with mild illnesses such as hepatitis (64.5%) and isolated febrile illness (24.0%), whereas those with chronic Q fever were likely to undergo surgery (41.2%) and had a high mortality rate (23.5%). Follow-up for 6 months after acute Q fever was performed by 24.0% of the physician respondents, and only 22.3% of them reported that clinical and serological evaluations were required after acute Q fever diagnosis.ConclusionsQ fever is becoming an endemic disease in the midwestern area of South Korea. Given the clinical severity and mortality of chronic Q fever, physicians should be made aware of appropriate diagnosis and management strategies for Q fever.     

Effects of war aggression in Croatia on histopathological manifestations of breast cancer in defined population of one county

The aim of the present study was to determine the differences in epidemiological and clinical manifestations of breast cancer during the war in Croatia and in peacetime. 660 consecutive patients were recorded (656 female and 4 male patients) from Pozesko-Slavonska County. The changes in histopathological features were recorded in war period (1991-1995, 156 patients) and through two control periods, before the war (1981-1990, 282 patients) and after the war (1995-2000, first five months, 223 patients). The relative predictive value was calculated using chi 2-test. The survival was calculated according to Kaplan-Meier analysis of survival. The histopathological analysis showed an equal distribution of noninvasive cancer (in situ cancer) across periods. In the war period, the level of the most common invasive cancer, ductal breast cancer, was lower (57.7%), compared to control periods (71.2%:63.7%:68.2%). Opposite to that, invasive lobular cancer was more common in the war period (3.2%), compared to control periods (0.7%-1.3%). Furthermore, mixed cancer was also increased in the war period (7.1%) compared to control periods (0.7%-2.2%), as was medullar cancer (10.9% vs. 5.5%-5.9%). The study showed statistically significant differences in the survival of patients with different histopathological diagnoses (Log Rank = 47.49, df = 7, p < 0.0001), while the histological grade of tumor, as a predictive factor was not proved to be statistically significant (p > 0.05). This study confirmed the influence of war of war on histopathological incidence of some forms of breast cancer.     

The impacts of vascular wilt disease of the takamaka tree Calophyllum inophyllum on conservation value of islands in the granite Seychelles

The takamaka tree Calophyllum inophyllum is animportant component of indigenous coastal forests in the granitic Seychelles,found on most islands of the archipelago. In 1994, a fungal pathogen previouslyunrecorded in the Seychelles (Leptographium calophylli) wasdetected on takamaka. Since the first cases of the disease were observed, spreadof the disease has been rapid, both within and between islands. Attempts tocontrol the disease, involving both legislation and forest management, appear tohave had little impact in controlling the spread. In the six yearssince the disease was first recorded in the Seychelles, it has reached10 islands, including most of the large islands of the archipelago. Mortality ratesand rates of spread between trees appear to vary in different islands andsituations, but in some cases both appear to be high. This paper describes thedistribution of the disease in the granitic Seychelles six yearsafter it was first recorded, reviews the potential impact of the disease onconservation value and discusses management strategies to minimise the impact ofthe disease on endemic vertebrates.     

Neonatal birth weight variations between inland and littoral Croatia

The aim of the study was to assess neonatal birth weight (BW) differences between inland and littoral Croatia, to identify BW groups with most pronounced differences, and possible variations in the rate of BW > or = 4000 g between Sibenik area and the rest of littoral (counties with access to the Adriatic Sea) and inland Croatia. The study included data on 99.42% of 200,740 live births recorded in 37 Croatian maternity hospitals during the 2001-2005 period. Distribution of 500-g BW groups was analyzed irrespective of neonatal sex and gestational age. Differences were found between the inland and littoral parts of Croatia according to distribution of the BW groups of < 2500 g (5.4% vs. 4.4%), 2500-3999 g (84% vs. 80.2%) and > or = 4000 g (10.6% vs. 15.4%) (chi2 = 882; p < 0.001).The highest rate of BW > or = 4000 g was recorded in Sibenik-Knin County (5-year mean 18.32%) and was greater throughout the littoral as compared with inland Croatia (5-year mean 14.99% vs. 9.58%). A shift towards higher BWgroups recorded throughout littoral as compared with inland Croatia supports the hypothesis on variation in anthropologic characteristics in the respective populations to be pronounced as early as at birth. Study results confirmed fetal macrosomia not to be exclusively characteristic of Sibenik-Knin County, since the rate of neonatal BW > or =4000 g was significantly higher in the entire littoral as compared with inland Croatia.     

Effects of war aggression in Croatia on some forms and manifestations of breast cancer

The aim of this study was to determine the differences in epidemiological and clinical manifestations of breast cancer in time of war in Croatia and in peacetime before and after the war, in the defined population of Pozesko-Slavonska County. The methods used in this study were the evaluation of relative predictive value of variables by means of chi 2-test and the analysis of variance, while the survival studies were tested by Long Rank test according to Kaplan-Meier analysis of survival. This work encompasses 660 patients who had breast cancer. The differences between three time periods were evaluated: the war period (1991-1995), and two control periods: before the war (1981-1990) and after the war (1996-2000). The patients were grouped by age, localization of tumor and survival. During the war period the patients were, on the average, 4.2 years younger than those who acquired the disease in control periods, and the mean age of patients was between 50 and 59 years (36.5% of patients). Although the difference in tumor distribution by sides (left or right breast) and quadrants was statistically significant (war period vs. control periods; p < 0.001), there was no statistically significant difference in the survival of patients according to the results of Kaplan-Meier analysis of localization of tumor (p > 0.05). The length of survival in terms of age of patients in time of surgical procedure was significantly different (p < 0.001). This study confirms the effects of war on some epidemiological and clinical manifestation of breast cancer in the defined population of Pozesko-Slavonska County.     

Epidemiology of monosymptomatic optic neuritis in Rijeka County, Croatia: meteorological aspects

In order to analyze the meteorological factors possibly influencing the monosymptomatic optic neuritis in Rijeka County, northwestern part of Croatia, retrospective analysis of all cases diagnosed in Rijeka County in period from 1977 to 2001, was done. Meteorological data on monthly and yearly temperature, humidity, insolation in Rijeka County were collected from Croatian Meteorological and Hydrological Service. In the observed period there were 173 cases of monosymptomatic optic neuritis, female/male ratio was 1.66, and overall incidence was 2.18/100,000 inhabitants. There was no correlation of incidence with average yearly and monthly temperature, humidity, insolation, or month of birth. This is the first study on meteorological factors and optic neuritis in Croatia.     

The secular trend in the incidence of hemorrhagic stroke in the region of Osijek,Eastern Croatia in the period 1988-2000--a hospital based study

The purpose of the study was to establish the possible environmental influences in the observed peculiar rising and falling oscillations in the numbers of hemorrhagic stroke (HS) in Eastern Croatia (region of Osijek) during the last thirteen-years' period (1988-2000). In this period 1,222 HS were registered and treated. A constant increase in the incidence of HS was observed, from 60 (in 1988) to 139 (in 1998), with an average annual proportion of 16.5% of all stroke cases. A sharp increase in proportion of HS in total stroke incidence was recorded during the war in Croatia (1991-1995), with a peak incidence of 27.4% in 1993. Typical hypertensive intracerebral hemorrhage (ICH) was the most common (57.1%), atypical ICH occurred in 26.4%, subarachnoid hemorrhage (SAH) in 16.5%. Analysis of the annual number of hypertensive-ICH and SAH disclosed peculiar rising and falling oscillations. These variations were in correlation with heavy living conditions. During the war-period the SAH incidence sharply rose. Immediately after the war it suddenly decreased. The authors named this phenomenon a "pool depletion", supposing the relatively stable proportion of the bearers of aneurysms in population. The observed variations seem to be the consequence of the war stress and other negative psychosocial and economic factors in post-war period, which increases the risk for SAH and typical hypertensive-ICH through complex pathophysiological mechanisms.     

First case of Q fever endocarditis in Croatia and a short review

We present a 70-year-old man from Dalmatia, Croatia, with a history of prolonged high fever diagnosed as Q fever endocarditis. As far as we know, this is the first case of chronic Q fever in Croatia. The treatment was started as for culture-negative endocarditis, but was without clinical response. After significantly high anti-phase I IgG plus IgA antibodies titers to Coxiella burnetii were shown, the initial treatment with doxycycline was changed and ciprofloxacin was started with good clinical response.     

Q fever in maritime Canada.

Only nine cases of Q fever were recorded in Canada in the 20 years prior to 1978. In the 18 months from August 1979 to January 1981 the disease was diagnosed serologically in six patients from the Maritime provinces. All were epidemiologically unrelated and none had been exposed to animals. Five had pneumonia and one had chronic Q fever with probable prosthetic valve endocarditis. Three of the five pneumonia patients presented with signs and symptoms of an acute lower respiratory tract infection and were indistinguishable clinically from other patients with atypical pneumonias. The other two with pneumonia presented with nonresolving pulmonary infiltrates and complained of decreased energy. Four of the five pneumonia patients responded well to treatment with erythromycin; the fifth required two courses of tetracycline. The patient with chronic Q fever had a large amount of cryoglobulins in his serum and evidence of immune complex disease. These cases indicate that Q fever should be considered as a possible cause of atypical pneumonia in Canada.     

Surgical scientific publication and the 1991-1995 war in Croatia

The aim of this study was to evaluate surgical scientific publication in relation to the 1991-1995 war in Croatia, based on the articles indexed in Medline database that were published in 1980-2005 period. The number of articles was extracted from PubMed and analysed with trend analysis, which is preferred analytic approach over calculation of crude publication rates. The results indicate sporadic pre-war output, which was almost completely reduced by the onset of war. During wartime, a significant increasing trend in the number of published surgical articles that were related to warfare was detected (p = 0.003). During the post-war period a gradual shift towards surgical articles that were not related to warfare was detected, also marked by the significant increasing trend (p = 0.027). Both trends were significantly steeper than the overall Croatian biomedical output, suggesting that surgical scientific articles were being published more dynamically than in other biomedical areas in Croatia. The results suggest that war in Croatia has had a strong modifying effect on the surgical scientific output.     

Clinical Characteristics of Q Fever and Etiology of Community-Acquired Pneumonia in a Tropical Region of Southern Taiwan: A Prospective Observational Study

Background

The clinical characteristics of Q fever are poorly identified in the tropics. Fever with pneumonia or hepatitis are the dominant presentations of acute Q fever, which exhibits geographic variability. In southern Taiwan, which is located in a tropical region, the role of Q fever in community-acquired pneumonia (CAP) has never been investigated.

Methodology/Principal Findings

During the study period, May 2012 to April 2013, 166 cases of adult CAP and 15 cases of acute Q fever were prospectively investigated. Cultures of clinical specimens, urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila, and paired serologic assessments for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Q fever (Coxiella burnetii) were used for identifying pathogens associated with CAP. From April 2004 to April 2013 (the pre-study period), 122 cases of acute Q fever were also included retrospectively for analysis. The geographic distribution of Q fever and CAP cases was similar. Q fever cases were identified in warmer seasons and younger ages than CAP. Based on multivariate analysis, male gender, chills, thrombocytopenia, and elevated liver enzymes were independent characteristics associated with Q fever. In patients with Q fever, 95% and 13.5% of cases presented with hepatitis and pneumonia, respectively. Twelve (7.2%) cases of CAP were seropositive for C. burnetii antibodies, but none of them had acute Q fever. Among CAP cases, 22.9% had a CURB-65 score ≧2, and 45.8% had identifiable pathogens. Haemophilus parainfluenzae (14.5%), S. pneumoniae (6.6%), Pseudomonas aeruginosa (4.8%), and Klebsiella pneumoniae (3.0%) were the most common pathogens identified by cultures or urine antigen tests. Moreover, M. pneumoniae, C. pneumoniae, and co-infection with 2 pathogens accounted for 9.0%, 7.8%, and 1.8%, respectively.

Conclusions

In southern Taiwan, Q fever is an endemic disease with hepatitis as the major presentation and is not a common etiology of CAP.     

Q fever in the Ukraine

Q fever occurs in all geographical landscape zones and in most administrative regions of the Ukrainian SSR. The disease was diagnosed in those areas where no such cases had ever been registered. In the Kharkov region the examination of 425 fever patients with unclear diagnosis resulted in diagnosing 5 cases of Q fever. The proportion of seropositive persons among different professional groups of the population in the eastern part of the republic was determined (6.9% among workers of meat-packing factories, 8.7% among workers of fur- and wool-treating establishments, 5.2% among stock breeders). At the farms of the Kharkov, Poltava and Sumy regions the spread of infection among large cattle was 2.3% and among small cattle 5.6%. Rickettsial carriership revealed in hard ticks collected in the Kharkov region indicated the possibility of the existence of the natural focus of Q fever in this zone and increased the available information on the presence of the territories with the natural foci of this infection in the Ukraine.     

Diverse and atypical manifestations of Q fever in a metropolitan city hospital: Emerging role of next-generation sequencing for laboratory diagnosis of Coxiella burnetii

Although Q fever has been widely reported in the rural areas of China, there is a paucity of data on the epidemiology and clinical characteristics of this disease in large metropolitan cities. In this study, we profile the epidemiology and clinical manifestations of Q fever from a tertiary hospital in Shenzhen, a Southern Chinese metropolitan city with a large immigrant population from other parts of China. A total of 14 patients were confirmed to have Q fever during a nine-year-and-six-month period, five of whom were retrospectively diagnosed during case review or incidentally picked up because of another research project on unexplained fever without localizing features. Some patients had the typical exposure histories and clinical features, while a few other patients had rare manifestations of Q fever, including one with heart failure and diffuse intracapillary proliferative glomerulonephritis, a patient presenting with a spontaneous bacterial peritonitis-like syndrome, and another one with concomitant Q fever and brucellosis. Using a combination of clinical manifestation, inflammatory marker levels, echocardiographic findings and serological or molecular test results, nine, three and two patients were diagnosed to have acute, chronic and convalescent Q fever, respectively. Seven, five and two patients were diagnosed to have Q fever by serological test, nested real-time PCR and next-generation sequencing respectively. Diverse and atypical manifestations are associated with Q fever. The incidence of Q fever is likely to be underestimated. Next-generation sequencing is becoming an important diagnostic modality for culture-negative infections, particularly those that the physicians fail to recognize clinically, such as Q fever.     

The incidence of optic neuritis in Split-Dalmatia county, Croatia

The aim of the study was to determine the incidence of monosymptomatic optic neuritis (MON) in residents of Split-Dalmatia County, Croatia. The 127 cases (83 female, aged 26.2+/-9.9 and 44 male aged 26.9+/-11.2) with MON presented between January 1985 and December 2001 were analyzed from hospital data. The annual incidence was 1.6 per 100,000 (95% CI, 0-3). The incidence among females was 2.2 (95% CI, 0-4.6) cases / 100,000 per year and 1.1 (95% CI, 0-3) among males. The difference in incidence rates for women vs. men was not significant (chi2=0.41; p=0.52), although it is more likely that a true difference exists. The peak incidence in both sexes observed in the group 20-29 years of age was 4.2 (95% CI, 0-10). The highest incidence of MON was found in spring (46 cases). In summary, the incidence of MON in Split-Dalmatia County during the 17 years period is relatively low.     

The 2007–2010 Q fever epidemic in The Netherlands: characteristics of notified acute Q fever patients and the association with dairy goat farming

We describe the Q fever epidemic in the Netherlands with emphasis on the epidemiological characteristics of acute Q fever patients and the association with veterinary factors. Data from 3264 notifications for acute Q fever in the period from 2007 through 2009 were analysed. The patients most affected were men, smokers and persons aged 40–60 years. Pneumonia was the most common clinical presentation (62% in 2007 and 2008). Only 3.2% of the patients were working in the agriculture sector and 0.5% in the meat-processing industry including abattoirs. Dairy goat farms with Coxiella burnetii-induced abortion waves were mainly located in the same area where human cases occurred. Airborne transmission of contaminated dust particles from commercial dairy goat farms in densely populated areas has probably caused this epidemic. In 2010, there was a sharp decline in the number of notified cases following the implementation of control measures on dairy goat and sheep farms such as vaccination, hygiene measures and culling of pregnant animals on infected farms. In combination with a rise in the human population with antibodies against C. burnetii, these have most likely ended the outbreak. Development of chronic Q fever in infected patients remains an important problem for years to come.     

Anti-Anisakis IgE Seroprevalence in the Healthy Croatian Coastal Population and Associated Risk Factors

Background

The main objective of the study was to determine the degree of sensitization to Anisakis spp. antigens in healthy coastal population of Dalmatia given the high thermally unprocessed fish intake rate present in this area, suggested as a significant risk factor for anisakiasis. We performed a monocenter, cross-sectional pilot study stratified by geographic area of residence, conducted at the County secondary healthcare provider Medicine-biochemical Laboratory in Split (Croatia), from November 2010 till December 2011, on 500 unpaid volunteer subjects undergoing routine blood analysis and belonging to the south coast of the Adriatic Sea.

Methodology/Principal Findings

We studied the IgE seroprevalence to Anisakis spp. Ani s l and Ani s 7 allergens by indirect ELISA in healthy subjects, which were selected at random in the region of Dalmatia (Southern Croatia), among islands, coastal urban and inland rural populations. In order to detect possible cross-reactivity to other human helminthes, serum samples were tested also for the presence of IgG antibodies to Ascaris lumbricoides and Toxocara canis. The overall and coastal Anisakis seroprevalences for the sampled population were 2% and 2.5%, respectively. The logistic univariate regression analysis confirmed that regarding anti-Anisakis IgE seroprevalence, raw fish intake, daily fish intake, homemade origin of fish dish and occupational contact (professional, artisanal or hobby contact with fishery or fish industry) were risk factors associated to Anisakis spp. sensitization, but neither of the variables was exclusive for a particular seropositive population. Also, a significant difference was observed between seropositive and seronegative subjects that had stated allergy or symptoms associated with allergy (atopic dermatitis, asthma or rhinitis) in their previous history.

Conclusions/Significance

Being the first in Croatia, our study underlines the necessity of incorporating Anisakis spp. allergens in routine hypersensitivity testing of coastal population.