ZOONOSES – EPIDEMIOLOGICAL SITUATION IN HUMANS IN R.MACEDONIA Institute of Public Health of R. Macedonia Dr.Kristina Stavridis, Snezana Cvetkovic Bansko, Bulgaria, 23.04.2015

LEGISLATION The surveillance of zoonoses in the R. Macedonia is conducted according: Law on Protection of Population from communicable diseases (Off. Gazette 66/2004; 139/2008; 99/2009; 149/2014) – Law for public health (Off. Gazette 22/2010) Law for evidence in the health system (Off. Gazette 20/2009) Rulebook for reporting and forms for reporting infectious diseases and microbiological isolates(Off. Gazette 46/2009; 149/2014) Annual program of the preventive activities, adopted and financed by the Government

KEY ELEMENTS OF THE SURRVEILLANCE SYSTEM Mandatory notification of 64 communicable diseases and 56 infectious disease agents Within 24 hours the medical doctors are obligated to report mandatory notifiable diseases to Centers for Public Health (CPH) Centers for Public Health (CPH) are obligated to report mandatory notifiable zoonoses to responsible institutions in veterinary sector also the responsible institutions in veterinary sector are obligated to report to CPH any case of zoonoses in animals. The Law on population protection of communicable diseases (Offitial Gazette 66/2004) Within 48 hours the laboratories are obligated to report laboratory confirmed agents to CPH, MoH, SSHI or AFV

NATIONAL COMMUNICABLE DISEASE SURVEILLANCE SYSTEM - FLOW CHART GP’s / Hospitals Patients Laboratories 64 diseases 56 infectious disease agent Centers for Public Health (regional level) MoH SSHI AFV (18 agents) Institute for Pubic Health (national level) International institutions (international level) WHO ECDC Epi South etc. Ministry of Health State Sanitary and Health Inspectorate Agency for food and veterinary

List of 64 communicable diseases that are mandatory for reporting 1.Anthrax 2.Toxiinfectio alimentaris 3.Bacterial meningitis 4.Rabies 5.Botulismus 6.Brucellosis 7.Encephalitis virosa 8.Meningitis virosa 9.Hepatitis virosa A 10.Hepatitis virosa B 11.Hepatitis virosa C 12.Hepatitis virosa D, E 13.Hepatitis virosa 14.Pertussis 15.Variolla 16.Gonorrhoea 17.Influenza 18.Typhus exanthematicus 19.Polyomielitis 20.Dyphtheria 21.Enterocolitis 22.Echinococcosis 23.Yellow fever 24.Parotitis 25.Mononucleosis infective 26.Chlamidya infection 27.E. coli infection 28.Haemophillus influenzae type B infection 29.Yersiniosis 30.Q fever 31.Campylobacteriosis 32.Cholera 33.Cryptosporidiosis 34.Lyme boreliosis 35.Leishmaniosis 36.Legionellosis 37.Leptospirosis 38.Listeriosis 39.Malaria 40.Morbili 41.Meningitis epidemica 42.Varicella 43.Pneumococcus infection 44.Prion deceases 45.AFP (acute flaccid paralysis) 46.Salmonellosis 47.SARS 48.AIDS 49.Syphilis 50.Scarlatina 51.Tetanus 52.Typhus abdominalis,Paratyphus 53.Toxoplasmosis 54.Trichinellosis 55.Tuberculosis 56.Tularemia 57.Crimae hemorrhagic fever 58.Hemorragic fevers 59.Hemorrhagic fever with renal syndrome 60.Rubeola 61.Pestis 62.Giardiasis, Lambliasis 63.Dysenteria bacillaris 64.Scabies

Morbidity and number of cases of zoonosis, 2004 - 2014

Morbidity / 100.000 inhabitants of the main zoonosis, 2009 - 2014 Year/ disease 2010 2011 2012 2013 2014 Brucellosis 8.2 4.7 4.0 1.8 1.9 Echinococcosis 1.6 0.9 1.3 1.0 Leishmaniasis 0.6 0.1 0.5 Q fever 0.2 0.4 Lyme fever 0.7 Leptospirosis 0.0 Anthrax 0.05 Tetanus Tularemia Trichinelosis Prion disess Rabies Pestis

Number of cases of zoonoses and brucellosis, 2004 - 2014 Cases of zoonosis Cases of brucellosis

Leishmaniasis in R. Macedonia

Lyme borreliosis in R. Macedonia

Brucellosis in R. Macedonia Since 1988, every year the government approves a special program for prevention and eradication of brucellosis in the human population in the Republic of Macedonia First individual human cases in Macedonia - 1962 (3 cases) First time in epidemic form -1980 (102 cases) The largest number of registered cases -1992 (922 cases) The lowest number of cases (n=36) and the lowest morbidity (MB 1.8/ 100,000) was registered in 2013 The trend of the registered number of people infected with brucellosis in the period 2004-2013 is declining.

Brucellosis in R. Macedonia, trend, 2004-2014

Brucellosis in 2014, Macedonia Legend Number of cases

KEY FACTS ON BRUCELLOSIS 2014: Reduced number of cases and number of affected areas. The largest number of cases and the highest Mb is registered in older groups (95% - over 20 years). Males are more affected than females (trend in the last 30 years). Correlation between the profession and disease - usually affects people who have direct contact with cattle, their products, secretions/ excretions Clear seasonality - the peak in 2014 is in April, like in the past few years. The disease is more often registered in residents of rural areas than in urban

animal products (milk, meat products); RECCOMENDED CONTROL MEASURES: Rigorous implementation of veterinary and health control in animal products (milk, meat products); Conducting systematic health control for people who work professionally or come into contact with animals; Using protective clothing and other safety equipment when handling animals, their bodies, products, secretions and excretions; Early detection of person with brucellosis, mandatory laboratory confirmation of the diagnosis and adequate treatment; Continuous health education and information the population; Continuous medical education and awareness of brucellosis among the health workers. Continuous cooperation and coordination of field activities between health and veterinary sector.

Outbreak of tularemia in 2015

Current situation As of 17.04.2015 – 31 cases (МB 1,5/100.000) Geographical distribution: CPH Skopje(14 cases), CPH Veles/ LU Sveti Nikole (14 cases), CPH Kumanovo (3 cases). Tularemia, cumulative incidence, Macedonia, 2004-2015 Legend Tularemia 2004-2015 Incidence/100.000

Current situation (2) Distribution by month of onset of symptoms Distribution by week of onset of symptoms

Current situation (3) Distribution by age: Distribution by gender: Most affected age group - 20-29 years Distribution by gender: 17(55%) males and 14(45%) females cases

RECOMMANDED CONTROL MEASURES Reporting of all confirmed cases and collecting samples for confirmation of suspected cases; Epidemiological survey for every confirmed case; Update the existing data for the field situation and dissemination of data; Increasing awareness of tularemia among physicians; Continuous activities and taking measures on field: Control of the drinking water and recommendations for continuous disinfection of it. Establishment and maintenance of protective zones around springs and reservoirs / tanks of drinking water by all regulations and standards Pest control in affected areas where the disease has occurred and conducting regular pest control Education and information of the population for the ways of protection from tularemia.

CONCLUSIONS : Elimination and eradication of the epizooty among animals is a main activity for elimination of the disease in the human population. Measures and activities undertaken by the health sector are not enough, it is necessary those measures and activities to be taken primarily by the veterinarians, BUT cooperation, information and coordination of activities is of strong importance so that the disease can be put under control.  

CHALLANGES Integrated information system between human and veterinary sector for better communication Strengthening the collaboration between human and veterinary sector Strengthening the capacity of laboratories with new referent methods to confirm zoonotic diseases To achieve an effective surveillance, prevention and control of newly evolving threats from animal reservoirs is to have established and institutionalized strong links between the different sectors involved.

THANKS FOR YOUR ATTENTION