Przegląd Epidemiologiczny Epidemiological Review

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1 Przegląd Epidemiologiczny Epidemiological Review QUARTERLY JOURNAL OF THE NATIONAL INSTITUTE OF PUBLIC HEALTH NATIONAL INSTITUTE OF HYGIENE AND THE POLISH SOCIETY OF EPIDEMIOLOGY AND INFECTIOUS DISEASES Index Copernicus 9 MNiSW 7 pkt VOLUME No 3 CONTENTS Full text: PROBLEMS OF INFECTIONS A A Zasada: Corynebacterium diphtheriae infections currently and in the past M Korzeniewska-Koseła, J Kuś, K Lewandowska, I Siemion-Szcześniak: Tuberculosis in homeless persons in Poland K Majewski, M Rybczyńska, K Wódz: Evaluation of detection and drug resistance of Mycobacterium tuberculosis in patients in Łódzkie voivodeship in K Madaliński, K Zakrzewska, A Kołakowska, P Godzik: Epidemiology of HCV infection in Central and Eastern Europe M Stępień, M Rosińska: Hepatitis C oubreaks in Poland in Medical procedures as a dominant route of HCV transmission P Grabarczyk, A Kopacz, E Sulkowska, D Kubicka-Russel, M Mikulska, E Brojer, M Łętowska: Blood donors screening for blood born viruses in Poland A Zajkowska, A Garkowski, P Czupryna, A Moniuszko, M E Król, J Szamatowicz, S Pancewicz: Seroprevalence of parvovirus B19 antibodies among young pregnant women or planning pregnancy, tested for toxoplasmosis K Kubiak, M Wrońska, E Dzika, M Dziedziech, H Poźniak, M Leokajtis, J Dzisko: The prevalence of intestinal parasites in children in preschools and orphanages in the Warmia-Masuria province (North-Eastern Poland) W Rożej-Bielicka,H Stypułkowska-Misiurewicz, E Gołąb: Human babesiosis HOSPITAL INFECTIONS A Różańska, J Wójkowska-Mach, M Bulanda, P B Heczko: Infection control in Polish medical wards data from the PROHIBIT project M Kołpa, A Grochowska, A Gniadek, B Jurkiewicz: Level of knowledge among medical personnel about infections transferred through direct contact results of questionnaire survey M Wałaszek: The analysis of the occurrence of nosocomial infections in the neurosurgical ward in the District Hospital from

2 RECOMMENDATIONS W Halota, R Flisiak, A Boroń-Kaczmarska, J Juszczyk, M Pawłowska, K Simon, K Tomasiewicz, P Małkowski: Recommendations for the treatment of hepatitis C Polish group of HCV Experts PUBLIC HEALTH A Kuziemski, K Frankowska, E Gonia, B Czerniak, O Bakhurynska, Z Sobociński: Evaluation of the efficiency of hospital antibiotic policy applied Dr Jan Biziel University Hospital No 2 in Bydgoszcz in A Schubert, M Czech, A Gębska-Kuczerowska: Evaluation of economic effects of population ageing - methodology of estimating indirect costs T Konopka, E Dembowska, M Pietruska, P Dymalski, R Górska: Periodontal status and selected parameters of oral condition of Poles aged 65 to 74 years G Kopeć,M Waligóra, M Brózda, K Jonas, A Sarnecka, M Podolec, B Sobień, A Pająk, P Podolec: Effectiveness of single medical advice on emergency phone numer knowledge in urban adult population Health, Alcohol and Psychosocial Factors in Eastern Europe substudy HISTORY OF MEDICINE B Cichy: Analysis of fatality due to cholera epidemics in Tuliszków parish in OBITUARY B Tobiasz-Adamczyk: Professor Wiesław Jędrychowski (15 th January, th May, 2015) INSTRUCTION FOR AUTHORS 559 CORRECTIONS Corrigendum, errata , 478

3 ARTICLES IN POLISH Przegląd Epidemiologiczny Epidemiological Review K W A R T A L N I K NARODOWEGO INSTYTUTU ZDROWIA PUBLICZNEGO PAŃSTWOWEGO ZAKŁADU HIGIENY I POLSKIEGO TOWARZYSTWA EPIDEMIOLOGÓW I LEKARZY CHORÓB ZAKAŹNYCH Index Copernicus 9 Punktacja MNiSW 7 TOM NR 3 TREŚĆ Pełne teksty: PROBLEMY ZAKAŻEŃ A A Zasada: Zakażenia Corynebacterium diphtheriae dawniej i dziś M Korzeniewska-Koseła, J Kuś, K Lewandowska, I Siemion-Szcześniak: Gruźlica u osób bezdomnych w Polsce K Majewski, M Rybczyńska, K Wódz: Ocena wykrywalności i lekooporności prątków gruźlicy u pacjentów w województwie łódzkim w latach K Madaliński, K Zakrzewska, A Kołakowska, P Godzik: Epidemiologia zakażeń HCV w Europie Środkowej i Południowo-Wschodniej M Stępień, M Rosińska: Ogniska wirusowego zapalenia wątroby typu C w Polsce w latach Procedury medyczne najczęstszą drogą przenoszenia zakażeń HCV P Grabarczyk, A Kopacz, E Sulkowska, D Kubicka-Russel, M Mikulska, E Brojer, M Łętowska: Badania wirusów przenoszonych przez krew u dawców krwi w Polsce A Zajkowska, A Garkowski, P Czupryna, A Moniuszko, M E Król, J Szamatowicz, S Pancewicz: Ocena częstości występowania przeciwciał przeciw parwowirusowi B19 u kobiet będących w ciąży lub planujących ciążę, badanych w kierunku toksoplazmozy K Kubiak, M Wrońska, E Dzika, M Dziedziech, H Poźniak, M Leokajtis, J Dzisko: Występowanie pasożytów jelitowych u dzieci w wieku przedszkolnym oraz wychowanków domów dziecka w województwie warmińsko-mazurskim (północno-wschodnia Polska) W Rożej-Bielicka,H Stypułkowska-Misiurewicz, E Gołąb: Babeszjoza u ludzi ZAKAŻENIA SZPITALNE ARóżańska, J Wójkowska-Mach, M Bulanda, P B Heczko: Zwalczanie zakażeń w polskich oddziałach niezabiegowych wyniki programu PROHIBIT M Kołpa, A Grochowska, A Gniadek, B Jurkiewicz: Poziom wiedzy personelu medycznego szpitala o przenoszeniu zakażeń drogą kontaktową wyniki badania ankietowego

4 M Wałaszek: Analiza występowania zakażeń szpitalnych w Oddziale Neurochirurgii w latach w Szpitalu Wojewódzkim REKOMENDACJE W Halota, R Flisiak, A Boroń-Kaczmarska, J Juszczyk, M Pawłowska, K Simon, K Tomasiewicz, P Małkowski: Rekomendacje leczenia wirusowych zapaleń wątroby typu C Polskiej Grupy Ekspertów HCV ZDROWIE PUBLICZNE A Kuziemski, K Frankowska, E Gonia, B Czerniak, O Bakhurynska, Z Sobociński: Ocena skuteczności szpitalnej polityki antybiotykowej stosowanej w latach w Szpitalu Uniwersyteckim Nr 2 w Bydgoszczy A Schubert, Marcin Czech, A Gębska-Kuczerowska: Metodologia szacowania kosztów pośrednich w ocenie ekonomicznej starzenia sie społeczeństwa - specyfika oceny T Konopka, E Dembowska, M Pietruska, P Dymalski, R Górska: Stan przyzębia i wybrane wykładniki stanu jamy ustnej Polaków w wieku od lat G Kopeć, M Waligóra, M Brózda, K Jonas, A Sarnecka, M Podolec, B Sobień, A Pająk, P Podolec: Skutecznośc pojedynczego pouczenia na znajomość numeru telefonu ratunkowego w populacji osób dorosłych podbadanie Health, Alcohol and Psychosocial Factors in Eastern Europe Study HISTORIA MEDYCYNY B Cichy: Analiza zgonów w parafii Tuliszków spowodowanych epidemią cholery w 1852 r WSPOMNIENIE POŚMIERTNE B Tobiasz-Adamczyk: Profesor zwycz.dr hab.med. Wiesław Jędrychowski 15 stycznia maja SPRAWOZDANIA T M Zielonka: Sprawozdanie z IX Konferencji z okazji Światowego dnia Gruźlicy, Warszawa, 21 marca 2015 roku INSTRUKCJA DLA AUTORÓW 663

5 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Aleksandra Anna Zasada CORYNEBACTERIUM DIPHTHERIAE INFECTIONS CURRENTLY AND IN THE PAST Department of Bacteriology, National Institute of Public Health National Institute of Hygiene, Warsaw, Poland ABSTRACT Along with the introduction of common obligatory vaccinations against diphtheria, the disease has been limited in developed countries. However, diphtheria is still endemic in developing countries. Due to a growing popularity of visiting these countries, there is a risk of importation of the disease to Europe. Studies revealed that over 60% of persons aged > 40 years in the Polish population do not have a protective level of antibodies against diphtheria. Furthermore, an access to diphtheria antitoxin, which is essential in diphtheria treatment, is now hardly accessible in Europe. On the other hand, in many countries, including Poland, new infections caused by non-toxigenic Corynebacterium diphtheriae have been emerged. Such infections are frequently manifested by bacteraemia and endocarditis with a high fatality rate, amounting even to 41%. Key words: diphtheria, Corynebacterium diphtheriae, invasive infection, vaccination PATHOGEN CHARACTERISTICS Corynebacterium diphtheriae is a Gram-positive, aerobic, pleomorphic coccobacillus, frequently with club-shaped edges. Based on the colony morphology and biochemical properties, four C. diphtheriae biotypes were described: gravis, mitis, intermedius and belfanti (1, 2). Until recently, strains capable of producing diphtheria toxin were exclusively considered to be pathogenic for humans. C. diphtheriae acquires the potential to produce diphtheria toxin through the lysogenization with corynebacteriophage carrying tox gene. Recently, severe infections caused by non-toxigenic strains are also reported. Its course is considerably different compared to diphtheria (3). Irrespective of the fact that pathogens belonging to Corynebacterium are prevalent in environment soil, plants, skin and mucosa of humans and animals - C. diphtheriae is present nearly only in humans. Recently, however, it was observed that horses and other domestic animals, including cats and dogs, may also be the carriers of this pathogen (4-6). INFECTIONS CAUSED BY TOXIGENIC CORYNEBACTERIUM DIPHTHERIAE STRAINS Toxigenic C. diphtheriae strains cause the disease called diphtheria. Depending on the anatomic site involved, there are the following manifestations of diphtheria: pharyngeal, laryngeal, aural, nasal, cutaneous, conjunctival, umbilical and genital. The disease is transmitted through respiratory droplets or direct contact with an infected person or carrier, their secretions or objects that were in contact with the infected person or carrier. During the course of diphtheria bacteria colonize locally the mucosa. Usually, they do not permeate the tissues, however, the toxin, which is produced by these bacteria, is absorbed into the bloodstream and distributed throughout the whole organism. Pharyngeal and laryngeal diphtheria are the most common manifestations of this disease. Following a short period of incubation, lasting for 2-5 days, fever and sore throat are present. At the site of colonization on the mucosa of the pharynx and larynx, necrotic membranes appear, i.e. pseudomembranes which are grey, translucent or black-coloured. Any efforts to remove it cause bleeding. Simultaneously, lymph nodes are enlarged. Neck s size is increased (called National Institute of Public Health National Institute of Hygiene

6 440 Aleksandra A Zasada No 3 bull neck, proconsul neck or Neron neck). Formation of pseudomembranes and considerable enlargement of lymph nodes result in the narrowing of the pharynx and larynx lumen. Consequently, it hinders swallowing and breathing. Toxin, which is produced by C. diphtheriae, permeates the bloodstream and all organs. It causes an early damage to the fibres of cardiac muscle and its inflammation, conduction disorders and, possibly, heart block as well as demyelination of nerves which leads to the paralysis of the palate and ocular muscles. Paralyses similar to those observed in case of the Guillain-Barré syndrome may also be present (7, 8). Nasal, aural, conjunctival, cutaneous, umbilical and genital diphtheria occures due to the colonization of toxigenic C. diphtheriae strains on localized areas such as wounds, abscesses, skin lesions. At these sites, inflammation is developed, accompanied by serosanguineous exudate, toxin production and formation of necrosis and pseudomembranes (7). Diphtheria toxin is a potent toxin whose lethal dose for susceptible species (i.a. human, monkeys, rabbits, guinea pigs) was determined at ng/kg of body mass (9). Thus, a basic therapy of diphtheria consists in the neutralization of diphtheria toxin circulating in organism by administering appropriate doses of antitoxin. It neutralizes only unbound toxin, i.e. toxin which has not fixed to the host organism cells, thus, early initiation of therapy with antitoxin is of importance (10). Unfortunately, diphtheria antitoxin is now hardly accessible in both Europe and America as the majority of producers stopped to manufacture it. Only few producers worldwide with examples being Microgen (Moscow, Russia) and Vins Bioproducts (Hyderabad, India) still produce diphtheria antitoxin (11, 12). DIPHTHERIA IN POLAND In , the number of diphtheria cases and deaths due to this disease ranged from 1815 to and 219 to 1 186, respectively. At the time of occupation, no unified register of infectious diseases was held on the territory of Poland. Immediately after the Second World War, i.e , the number of cases varied from to , including from 600 to deaths. In , a large diphtheria epidemic was present in Poland. During its peak, the number of cases ranged from more than to nearly , while the number of fatal cases varied from to more than annually (13, 14). The number of cases decreased considerably after introduction of common vaccinations against diphtheria in the whole country in 1954, (Figure 1). In , only single infections were reported. Since 2001 up to the present time, no diphtheria cases were reported in Poland (14, 15). It is worth to note that Poland was one of the first countries in Europe to introduce vaccinations against diphtheria. In 1930, diphtheria vaccinations were held in Warsaw, Łódź and Vilnius, and then, they were introduced to other regions of the country. During the Second World War, no diphtheria vaccinations were held. Following the WWII, vaccinations were not conducted in a systematic manner. Furthermore, only one dose of vaccine was mainly administered. It was not until the end of 1954, when the Ministry of Health commenced the mass vaccinations. All children aged 4 months to 7 years were subject to obligatory vaccinations. Primary immunization schedule included the administration of three doses of vaccine at specific intervals, and then, booster doses every 3-4 years (13). DIPHTHERIA WORLDWIDE A number of countries in Africa, South America, Asia, South Pacific, Middle East, Eastern Europe as well as Haiti and the Dominican Republic remain to be endemic areas for diphtheria (16). In Europe, the largest diphtheria epidemic in the recent time was reported in the countries of the former USSR in the 90s of the last NUMBER OF CASESI Fig. 1. Number of diphtheria cases in Poland in (Gałązka A) (14). YEAR Fig. 1. Number of diphtheria cases in Poland in (according to Gałązka A (14)).

7 No 3 Corynebacterium diphtheriae infections currently and in the past 441 Fig. 2. Geometric mean of anti-diphtheria toxin antibody titre in Polish population by age groups (23). century. In the peak of the epidemic in 1995, a total of cases and nearly deaths were registered (17). Overall, in , more than infections and nearly fatal cases were noted (14). In the present time, diphtheria occurs sporadically in the developed countries. According to the data of the World Health Organization, a total of diphtheria infections were reported in 2013 worldwide. Based on the ECDC data, 20 diphtheria cases were notified in 2011 in Europe. These cases were reported in Latvia (6 cases), France (5 cases), Germany (4 cases), Sweden (4 cases), Great Britain (2 cases) and Lithuania (1 case). It is worth to note that the highest number of diphtheria cases in Europe in the recent years is reported in Latvia which is considered to be an endemic area for diphtheria, e.g. in 2007 and 2008 a total of 15 and 28 cases were registered there, respectively, while the total number of diphtheria infections in Europe was 21 in 2007 and 42 in 2008 (18). Epidemiological data suggest that a more common cause of diphtheria in developed countries is not C. diphtheriae, but C. ulcerans which also has the potential to produce diphtheria toxin. For example, in , 43 toxigenic Corynebacterium strains were isolated from patients in Great Britain. Of them, 27 (63%) were C. ulcerans (19). In France, 12 C. ulcerans strains (63%) were isolated from 19 cases infected with toxigenic Corynebacterium in (20). Having considered the ECDC data on diphtheria in Europe in 2011 presented above, 7 cases were caused by C. ulcerans. against diphtheria resulted not only in a decrease of incidence, but also a shift of incidence to the elder age groups as a lack of contact with this pathogen prevented from acquiring the active immunity through being repeatedly exposed to the infection with toxigenic C. diphtheriae (21). Current obligatory immunization schedule in Poland indicates to administer 7 doses of vaccine against diphtheria at the age of 2, 3-4, 5-6, months and then 6, 14 and 19 years (22). In case of adults, it is recommended to be given a booster dose every 10 years. According to the WHO data, 96-99% of children are given primary vaccinations against diphtheria in Poland. Study conducted by Zasada et al. (23), however, suggest that only 64% of children aged up to 5 years have a protective level of antibodies against diphtheria. Along with the administration of successive doses of vaccine, the percentage of immunized persons increases. Its value is the highest in the age group, i.e. following the administration of the last obligatory does of vaccine against diphtheria. In this group, nearly 83% of tested individuals had a protective level of antidiphtheria toxin antibody. A dramatic decrease in the anti-diphtheria toxin antibody titre was demonstrated in persons aged > 40 years, where only 36% had antibody titre which ensures a basic protection. None of them had antibody titre giving complete and long-term immunity against diphtheria (23). Figure 2 presents a geometric mean of anti-diphtheria toxin antibody titre in different age groups of the Polish population. Fig. 2. Geometric mean concentration of diphtheria toxoid antibodies in the Polish population according to the age groups (23). IMMUNITY TO DIPHTHERIA IN POLISH POPULATION In the past, diphtheria was considered to be a childhood disease as it was of the highest incidence and fatality in this group (14). Widespread vaccinations INFECTIONS CAUSED BY NON-TOXIGENIC CORYNEBACTERIUM DIPHTHERIAE STRAINS Until recently, non-toxigenic C. diphtheriae strains were not considered to be pathogenic. In Europe and

8 442 Aleksandra A Zasada No Toxigenic C. diphtheriae Fig. 3. Number of toxigenic and non-toxigenic C. diphtheriae strains isolated in England and Wales in (25). America, however, serious invasive infections caused by these pathogens began to be reported in the 90s of the last century. Such cases were reported, i.a. in France, Italy, Switzerland, Germany, Great Britain, Brazil, Canada as well as Poland (4, 24). The most spectacular increase in the number of infections caused by nontoxigenic C. diphtheriae was reported in England and Wales where 8 toxigenic strains and 1 non-toxigenic strain were isolated in Then, the number of isolated non-toxigenic strains began to increase dramatically in the 90s while in 2000 it amounted to 294. At that year, only one toxigenic strain was isolated (25, 26). Nowadays, the number of non-toxigenic C. diphtheriae strains isolated in England and Wales annually amounts to several dozens (Fig. 3). In Poland, the first case of bacteraemia and endocarditis due to non-toxigenic C. diphtheriae strain was reported in Since that time, such cases are noted every year (3, 27). Figure 4 shows non-toxigenic C. diphtheriae cases whose isolates were sent to the Non-toxigenic C. diphtheriae Department of Bacteriology of the NIPH-NIH for verification. There is no obligation to notify the infections caused by non-toxigenic C. diphtheriae strains, thus, it may be presumed that the number of such cases is higher. The phenomenon observed suggests that nontoxigenic C. diphtheriae strains acquired the potential to permeate the tissues. It is worth to note that diphtheria vaccine contains diphtheria toxoid, thus, it prevents from the action of diphtheria toxin, however, it does not protect against the infection with non-toxigenic strains. Studies demonstrate that the homeless, persons addicted to alcohol, people who inject drugs, individuals suffering from diabetes, cirrhosis and those having massive dental caries are at a risk of invasive infection with non-toxigenic C. diphtheriae strains. It is assumed that dental caries may be a portal of entry for invasive infection with C. diphtheriae (3). In cases of invasive infections with non-toxigenic C. diphtheriae strains, fatality rate is very high and amounts to 36-41% (28, 29). Fig. 3. Number of toxigenic and non-toxigenic C. diphtheriae in England and Wales in (25) Number of patients Age (years) Male Female Fig. 4. Number of non-toxigenic Corynebacterium diphtheriae infections in Poland in (excluding 5 cases for whom age is not available) (3). Fig. 4. Number of non-toxigenic Corynebacterium diphtheriae infections in Poland in Excluded are 5 cases for which no data a age were available (3).

9 No 3 Corynebacterium diphtheriae infections currently and in the past 443 SUMMARY Low antibody titre in persons aged > 40 years constitutes a risk of introduction of diphtheria from its endemic areas, which are becoming more popular tourist destinations. Simultaneously, current political situation in the eastern part of Europe, may result in an increased risk of the occurrence of diphtheria in Poland and Western European countries. Such situation was observed in the 90s of the 20 th century. It resulted from a collapse of the immunization system and increased migration of population. Thus, administration of diphtheria booster doses to adults is of importance. A special attention should be paid to persons caring for cats as they were identified to be a possible source of infection with toxigenic C. ulcerans and C. diphtheriae strains in the recent years. In order to facilitate the physicians and patients the process of diphtheria vaccination monitoring in adults, it should be considered to make the recommendations more precise by, e.g., indicating administration of booster doses at the age of 30, 40, 50 year etc. instead of general recommendations stating that booster doses should be given every 10 years. An attention should be also paid to the occurrence of invasive infections with non-toxigenic C. diphtheriae strains. Currently, little is know about the pathogenesis and epidemiology of such infections. Probably, infections caused by non-toxigenic C. diphtheriae strains should also be subject to obligatory notification. It would allow not only for determining the actual number of these infections, but also conducting reliable epidemiological studies. REFERENCES 1. Pleszczyńska E. Pałeczki Gram-dodatnie. In: Jabłoński J, ed. Podstawy Mikrobiologii Lekarskiej. Wyd 4. Warszawa: PZWL;1986: Efstratiou A, Maple PAC. 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10 444 Aleksandra A Zasada No Zasada AA, Rastawicki W, Rokosz N, et al. Seroprevalence of diphtheria toxoid IgG antibodies in children, adolescents and adults in Poland. BMC Infect Dis 2013;13: Zasada AA, Baczewska-Rej M, Wardak S. An increase in non-toxigenic Corynebacterium diphtheriae infections in Poland molecular epidemiology and antimicrobial susceptibility of strains isolated from past outbreaks and those currently circulating in Poland. Int J Infect Dis 2010;14:e Public Health England. Laboratory isolates of Corynebacterium diphtheriae and Corynebacterium ulcerans in England and Wales from 1986 to gov.uk/diphtheria-laboratory-isolates-of-c-diphtheriae-and-c-ulcerans. 26. Reacher M, Romsay M, White J, et al. Nontoxigenic Corynebacterium diphtheriae: an emerging pathogen in England and Wales? Emerg Infect Dis 2000;6: Zasada AA, Zaleska M, Podlasin RB, et al. The first case of septicemia due to nontoxigenic Corynebacterium diphtheriae in Poland: case report. Ann Clin Microbiol Antimicrob 2005;4: Patey O, Bimet F, Riegel P, et al. Clinical and molecular study of Corynebacterium diphtheriae systemic infections in France. J Clin Microbiol 1997;35: Hirata Jr.R, Pereira GA, Filardy AA, et al. Potential pathogenic role of aggregative-adhering Corynebacterium diphtheriae of different clonal groups in endocarditis. Braz. J Med Biol Res 2008; 41: Received: Accepted for publication: Address for correspondence: Aleksandra Anna Zasada National Institute of Public Health - National Institute of Hygiene Department of Bacteriology Chocimska 24, Warsaw Tel azasada@pzh.gov.pl

11 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Maria Korzeniewska- Koseła*, Jan Kuś**, Katarzyna Lewandowska**, Izabela Siemion- Szcześniak** TUBERCULOSIS IN HOMELESS PERSONS IN POLAND * National Tuberculosis and Lung Diseases Research Institute, Department of Tuberculosis Epidemiology and Surveillance ** National Tuberculosis and Lung Diseases Research Institute, I Department of Lung Diseases ABSTRACT The fall in rates of tuberculosis (TB) in many countries has been accompanied by the concentration of cases in the social risk groups including homeless persons. AIM. Comparison of TB features in homeless persons and in non-homeless patients. METHODS. TB cases reported to National TB Register in Poland in whom information about the social status was available (the data about the social status were collected obligatorily in the years only) were analysed. The results of DSTs were obtained from laboratory records and were available for the cases reported since Treatment outcome after 12 months was analysed for the cases registered between The significance (Si) of the differences in proportions was assessed with chi-square test. P<0.05 was regarded as statistically significant. Test F was used to evaluate the significance of differences of the means of age. The multivariate logistic regression models were applied to find out the independently operating determinants of not achieving of success of treatment. RESULTS. 2,349 homeless persons (HP) and 72,989 other patients (OP) with TB were included. In the group of HP, there was a greater proportion of males in comparison with OP (90.5% vs. 66.3%) (Si). The mean age of HP was 49.8 years (SD ± 10.9); of OP years (SD ± 17.5) (Si). 16.6% of HP and 10.4% of OP were previously treated for TB (Si). The previous treatment was adequate in 62.2% of HP and in 85.8% of OP (Si). Pulmonary TB was in 98.0%, extrapulmonary TB in 2.0% of HP and, respectively, in 92.5% and 7.5% of OP (Si). Pulmonary TB was confirmed by culture in 76.3% of HP and in 64.5% of OP (Si). Sputum smears were positive in 70.7% of HP and in 62.5% of OP (Si). Caseous pneumonia occurred in 2.7% of homeless subjects and in 1.1% of OP (Si); infiltrative TB in 95.5% of HP and in 97.5% of OP (Si). Resistance to isoniazid was observed in 2.9% of HP and in 3.1% of OP; to rifampicin in 0.0% of HP and in 0.2% of OP; to isoniazid and rifampicin in 0.4% of HP and in 0.8% of OP. These differences were not Si. Treatment success rate among HP was 44.1%; default rate 24.8%; 4.0% of HP died from tuberculosis; 3.2% died from other causes; 5.2% were transferred and their outcomes were unknown; 0.4% were still on treatment; 0.4% had treatment failure; in 17.9% of HP results of treatment were not available. Among other TB patients the rate of success was 66.8%; of default- 8.8%; 1.9% died from TB; 3.1% died from other causes; 2.6% were transferred; 0.5% were still treated; 0.2% had treatment failure; in 16.1% the results were not reported. Differences between both groups were Si, except for the category died from other causes, still on treatment and treatment failure. CONCLUSIONS. In the group of homeless persons with tuberculosis phenomena which indicate a delay in diagnosis of disease and in some cases the possibility of a recent infection and also unfavorable treatment outcomes occur in a greater proportion than among other patients. Targeted screening for TB and directly observed treatment could likely improve the epidemiological situation of tuberculosis in the population of homeless. Key words: tuberculosis, homeless persons, types of tuberculosis, smear and culture positive cases, drug resistance, treatment success, treatment default, death from tuberculosis National Institute of Public Health National Institute of Hygiene

12 446 Maria Korzeniewska-Koseła, Jan Kuś et al. No 3 INTRODUCTION In the countries with a low incidence of TB, new cases are concentrated in the social risk groups. Groups at increased risk of TB include migrants from the countries with high prevalence of TB, poor people, prisoners, homeless persons, those who abuse alcohol, drug addicts and HIV-infected persons. In 2013, in 18 countries from the European Union and European Economic Area, TB incidence was below 10 cases per 100,000 population. Poland with the incidence of 18.8 cases per 100,000 population in 2013 (17.4 in 2014), does not belong to the mentioned group of countries with the best epidemiological situation of TB, but, according to the WHO and ECDC criteria, it is already the low-incidence country. Epidemiological trends observed in low-incidence countries are also found in Poland. The Polish group of patients with TB includes a larger proportion of unemployed and homeless people, compared to the entire population (1, 2). Homeless persons, due to their lifestyle, are particularly exposed to infection with M. tuberculosis and, according to data collected in numerous countries, they start treatment while being at advanced stage of disease, so they constitute the source of infection for a long time. Treatment in homeless persons rarely ends with success (3). THE OBJECTIVE OF THE STUDY The objective of the study was to compare TB phenomena in homeless persons to other patients. The comparison concerned demographic data (sex and age), the occurrence of treatment of TB in the past, the results of bacteriological examination, drug-resistance to isoniazid (INH) and rifampicin (RMP) and to isoniazid and rifampicin simultaneously (multidrug-resistant tuberculosis - MDR-TB), form of TB (pulmonary and extrapulmonary), type of radiological changes in case of pulmonary TB (disseminated TB, caseous pneumonia, infiltrative TB, fibrocavernous TB) and treatment results. The objective of the study was also to learn whether the homelessness has an independent impact to nonsuccess of treatment. Another objective was to reveal the full set of independent causal factors of not achieving treatment success. The knowledge of characteristics of tuberculosis in homeless persons will help to increase efficiency in the fight against TB in this social group. MATERIAL AND METHODS The data concerning TB cases registered between in the National TB Register maintained by the National Tuberculosis and Lung Diseases Research Institute in Warsaw were evaluated. Information used in the analysis was included in TB (suspected TB) case report forms. The years were chosen because only then information about the social status of the patient in a TB (suspected TB) case report form was required. Solely the cases with available information about the social status of the patient were evaluated. We compared the group of people that in the TB (suspected TB) case report form in the point 3 of additional information regarding social status were marked homeless, with the cases who in the same point were marked schoolgoer/student, worker/farmer, whitecollar worker, unemployed, retired person/pensioner. The results of drug susceptibility testing (DST) in the registered cases were obtained from laboratory records. DST results have been collected since 2010, therefore, the results concerning the patients registered between were analysed. The data regarding treatment results after 12 months from reporting the disease concerned the cases registered between Treatment results were classified in accordance with commonly used guidelines (4). Reporting of treatment results was not mandatary and treatment outcomes were made available on a voluntary basis. Statistical analyses included observation units that did not lack data necessary for the analysed variable. Statistical calculations were performed using the SPSS software, version 21. The significance of the differences in proportions was evaluated using chi-square test. P<0.05 was regarded as statistically significant. The differences in the mean age were analysed with the help of MEANS procedure from the SPSS. Test F was used to evaluate the significance of differences of the means of age. The multivariate logistic regression models were applied to find out the independently operating determinants of not achieving of success of treatment. RESULTS The group of 2,349 homeless persons included 2,126 males (90.5%) and 223 females (9.5%). The group of 72,989 remaining patients with TB comprised 48,374 males (66.3%) and 24,615 females (33.7%). The difference in proportions of both sexes between the group of homeless subjects and other patients was statistically significant (p < 0.001). The mean age of homeless patients (2,349) was 49.8 years (SD ± 10.9), of the remaining subjects (72,974) years (SD ± 17.5). The difference was statistically significant (p < 0.001) (Table I).

13 No 3 Tuberculosis in homeless persons in Poland 447 Table I. Demographics of TB cases in the group of homeless persons and in the group of other patients Gender and age of patients* Homeless persons Non-homless patients Nc** N*** % Nc N % Significance Males in the group of patients % % p<0.001 Age 2349 mean 49.8 SD ± mean 52.9 SD ±17.5 p<0.001 * Only cases with data on a given characteristic (presence or absence) were included in the individual analyzes ** The number of cases in which analyzed characteristic was present *** The total number of cases with available information on the presence or absence of a given characteristic Explanations apply to all tables. 325 out of 1,959 (16.6%) homeless persons and 6,436 out of 62,130 (10.4%) remaining patients were treated due to TB in the past. The difference was statistically significant (p < 0.001). The previous treatment took its normal course in 202 out of 325 (62.2%) homeless persons and in 5,520 out of 6,436 (85.8%) remaining patients (statistically significant difference; p < 0.001). Among the homeless subjects, pulmonary TB occurred in 2,303 out of 2,349 (98.0%) patients; and extrapulmonary TB - in 46 (2.0%) persons. Solely pulmonary TB was found in 67,484 out of 72,989 other patients (92.5%), extrapulmonary - in 5,505 (7.5%) subjects. The difference was statistically significant (p < 0.001). Pulmonary TB was confirmed by culture in 1,757 out of 2,303 homeless patients (76.3%) and in 43,542 out of 67,484 remaining subjects (64.5%). The difference was statistically significant (p < 0.001). In the group of homeless persons, positive results of sputum smears were found in 70.7% of subjects with known result of the examination (1,198/1,695). The result of sputum bacterioscopy was known in 42,398 remaining patients with bacteriologically confirmed pulmonary TB, and the outcome was positive in 26,492 (62.5%). The difference was statistically significant (p < 0.001). In the group of homeless patients with pulmonary TB, in whom the form of TB was known, miliary tuberculosis occurred in 6 out of 2,291 cases (0.3%) and in the same proportion in the remaining patients with a known form of pulmonary TB (185/67,041). The difference was not statistically significant. Fibrocavernous TB occurred in 34 out of 2,291 (1.5%) homeless persons and in 773 individuals out of 67,041 (1.2%) other patients with pulmonary TB, with a known form of disease. The difference was not statistically significant. Caseous pneumonia was diagnosed in 62 out of 2,291 (2.7%) homeless persons and in 714 out of 67,041 (1.1%) remaining subjects with pulmonary TB and a known form of disease (p < 0.001). Infiltrative TB was found in 2,189 persons out of 2,291 homeless patients (95.5%) and in 65,369 out of 67,041 (97.5%) remaining subjects with pulmonary TB and a known form of disease (p < 0.001). The results of DST were known in 716 homeless persons and in 14,398 other patients. The resistance to isoniazid was found in 21 homeless subjects (2.9%) and in 446 other patients (3.1%), whereas resistance to rifampicin was observed in 27 (0.2%) other patients and in none of the homeless, resistance to INH and RMP was noticed in 3 (0.4%) homeless persons and in 110 (0.8%) other patients. The differences were not statistically significant (Table II). In the group of homeless persons, treatment success was achieved in 927 (44.1% out of 2,104 patients). 522 Table II. Clinical characteristics of TB cases in the group of homeless persons and in the group of other TB patients Clinical characteristics Homeless persons Non-homeless patients Nc N % Nc N % Significance Tb treatment in the past -yes % % p<0.001 The previous TB treatment was adequate -yes % % P<0.001 Pulmonary TB % % p<0.001 Extrapulmonary TB % % p<0.001 Sputum smears + (in pulmonary TB) % % p<0.001 Culture % % p<0.001 Culture + (in pulmonary TB) % % p<0.001 Resistance to INH % % ****NS Resistance to RMP % % NS MDR-TB % % NS Miliary TB % % NS Caseous pneumonia % % p<0.001 Infiltrative pulmonary TB % % p<0.001 Fibrocavernous TB % % NS ****NS- not significant

14 448 Maria Korzeniewska-Koseła, Jan Kuś et al. No 3 Table III. Results of treatment in the group of homeless persons and in the group of other TB patients Results of treatment Homeless persons Non-homeless patients Nc N % Nc N % Significance Success of treatment % % p<0.001 Treatment failure % % NS Treatment default % % p<0.001 Transferred to % % p<0.001 Death % % NS Death because of TB % % p<0.001 Still on treatment % % NS Results not reported % % p<0.02 (24.8%) patients defaulted from treatment, 84 (4.0%) died due to TB, 68 (3.2%) died from other causes, 110 subjects (5.2%) were transferred out, in 8 patients (0.4%) the result was classified as still on treatment, in 8 (0.4%) - as treatment failure, the results of 377 (17.9%) patients were not available. The differences between homeless and other patients were statistically significant apart from the subjects who died due to other causes, were still on treatment or were classified as treatment failure. Treatment success was achieved in 45,789 other patients (non-homeless) (66.8% out of 68,511 patients), 6,007 (8.8%) subjects defaulted from treatment, 1,304 (1.9%) persons died due to TB, 2,109 (3.1%) died due to other causes. In 153 patients (0.2%) treatment failure was observed; 371 (0.5%) subjects - after 12 months were still treated, 1,767 (2.6%) belonged to the category transferred out - and their treatment results remained unknown. In 11,010 cases (16.1%) the results were not available (Tab. III). Treatment results could not be evaluated (not available, patients transferred to another centre, still on treatment) in 495 out of 2,104 (23.5%) homeless persons and in 13,148 out of 68,511 remaining patients (19.2%). The difference was statistically significant (p < 0.001). The dependent variable in the multinomial logistic regression model was the non-success of treatment. The explaining variables (determinants) in this model were: age, gender, resistance to INH, resistance to RMP, MDR-TB, type of TB- pulmonary and extrapulmonary, previous treatment of TB, culture confirmation, microscopy result, and homelessness. It turned out that the only significant factors (p<0,001) explaining the non-success of treatment were (in decreasing value of standardized regression coefficients): being male, positive result of culture, the resistance to RMP, resistance to INH and MDR-TB and homelessness. DISCUSSION Due to biological, social and environmental factors, the risk of TB is higher in some groups of society than in the entire population. The homeless constitute such a high-risk group of development of TB. They stay in overcrowded shelters, live next to other homeless people, which exposes them to infection with M. tuberculosis. Commonly met among the homeless problems, such as malnutrition, alcoholism, cigarette smoking and in some countries drug addiction, are the factors that promote reactivation of an acquired TB infection (5-7). TB incidence among the homeless is several times higher compared to the remaining population (8-11). In Poland, approximately twofold predominance of men among TB patients is observed over the years. In the group of homeless TB patients, the predominance of men in relation to women was 9.5 : 1, in the group of remaining patients : 1. In the entire population of the homeless, the predominance of men in 2013 was 4 : 1 (in 2013, they constituted 80% of all counted homeless persons) (12). A substantial proportion of men among homeless patients with TB was also found in other countries (13). Homeless persons with TB were statistically significantly younger than other patients, which may be related to the fact that in Poland, the majority of the homeless are under 60 years of age (12). Furthermore, younger age of homeless TB patients may indicate in this group a bigger proportion of cases that were infected recently, and not the cases with infection that had been acquired many years ago, and then was reactivated. Such possibility is supported by frequent occurrence of caseous pneumonia among the homeless, which is attributed to primary TB (statistically significant differences). The proportion of homeless persons with typical for post-primary disease infiltrative form of pulmonary TB, was lower than the remaining patients. Epidemiological - conventional and molecular examinations that were carried out in various countries, indicate the current transmission of infection with M. tuberculosis among the homeless. The homeless get infected in shelters, hostels, also in emergency rooms in hospitals, where they are waiting for medical care, e.g. due to complications related to alcoholism. Poorly ventilated and overcrowded rooms where homeless people live, facilitate infection. In Poland, homeless people are also more exposed to M.tuberculosis than other groups. The study conducted in Cracow showed that homeless persons had positive tuberculin skin test

15 No 3 Tuberculosis in homeless persons in Poland 449 results and positive IGRA test results more frequently than the persons who seemed to be most exposed to infection, i.e. those who had close contact with TB patients (14-16). The proportion of homeless patients with resistance to isoniazid, rifampicin and the two drugs simultaneously was in the present analysis not statistically significantly lower, compared to other subjects. Earlier conducted examinations allowed to identify the risk factors for MDR-TB. The highest risk factor for MDR-TB that is repeated in the studies is previous treatment. It seems that it is not the fact of previous treatment alone that counts but its regularity and the use of drugs adequate for drug-sensitiveness of Mycobacterium tuberculosis (17). In the present study, a larger proportion of homeless persons were treated for TB in the past, compared to the remaining patients. However, it did not result in a larger proportion of disease caused by drug-resistant bacilli. It may be caused by the fact that when homeless people stop treatment they do it completely. They do not take a single drug, which results in selection of resistant strains. They often abandon treatment definitely, usually at its initial stage, during their stay in hospital (17, 18). In the literature, homelessness is not considered to be a risk factor for MDR-TB. According to information included in the TB case report forms, previous treatment was appropriate merely in 62.2% of homeless subjects (in other patients %). So it is very probable that a wide group of homeless patients stopped treatment. Early termination of properly matched treatment results in the higher risk of recurrence of the disease but not in drug-resistance (17). A lower proportion of homeless persons had extrapulmonary TB, compared to other patients. The difference may be explained by more frequent among the homeless alcohol abuse and cigarette smoking, which are the factors that promote pulmonary TB, reducing the probability of the occurrence of extrapulmonary forms of TB (19-21). The persons living on the margins of society: homeless, unemployed, abusing alcohol, living alone, have TB diagnosed at more advanced stage, compared to other patients (13, 21, 22). Due to late diagnosis of TB (in the American study, TB was treated in homeless people on average after 10 months of infectivity) homeless persons are the source of new cases of the disease (23, 24). One reason for such situation may lie in poor functioning of health care system. It occurs that homeless persons inform their doctors about symptoms typical of TB, and despite the fact that they are commonly considered the risk group for TB, they are not examined for TB (25). In the present paper, it was shown that among homeless patients, pulmonary TB was confirmed bacteriologically in a statistically significantly larger proportion. A statistically significantly larger proportion of homeless patients, compared to other patients, had positive results of sputum bacterioscopy and fibrocavernous TB (insignificant difference). It indicates more advanced TB at diagnosis, so, indirectly, late diagnosis. In Poland, treatment results of tuberculosis are worse than average results in the European Union countries. The most crucial cause may be a voluntary character of reporting them by doctors. A large proportion of patients whose treatment results are unknown, reduces the proportion of cases with treatment success in a cohort analysis. The proportion of patients registered in Poland in 2012 who achieved treatment success amounted to 58.2%, whereas in the European Union - 74% (4). Reporting the results of treatment of tuberculosis should be obligatory in Poland as it is in most countries. Knowledge of treatment results enables effective supervision of tuberculosis In the present study, treatment results of homeless persons were worse compared to other patients; the proportion of patients who achieved treatment success, in the group of homeless subjects, was statistically significantly lower. The homelessness was revealed in regression analysis the independent causal factor operating on non-success of treatment. Therefore, the smaller chances of homeless people to achieve the success of treatment are not the simple consequence of the fact that majority of homeless people are men who as a rule have worse outcome of treatment (2). Homelessness determines chances of treatment success independently to other variables. The positive culture which is also more common among homeless people operates similarly to homelessness and is an independent factor determining the non-success of treatment. Also resistance to the first-line anti-tb drugs which is less common among homeless people has and independent causal impact that decreases the probability of success of treatment. A statistically significantly larger proportion of homeless patients defaulted from treatment or were transferred to another centre, and their treatment results were unknown at the place of previous stay. A statistically significantly larger proportion of homeless persons died due to TB, which is also indicative of delayed both diagnosis and treatment. Defaulting from treatment by homeless patients with TB and poor treatment outcome are common phenomena (18, 26-28). In the group of homeless subjects described between by the Japanese authors, a large proportion of deaths due to TB were also observed (13) The actions aimed at reducing the number of TB incidence among the homeless are undertaken in many countries. The use of directly observed therapy (DOT) in this group of patients is likely to improve treatment

16 450 Maria Korzeniewska-Koseła, Jan Kuś et al. No 3 results and reduce the proportion of disease recurrences. Better effects of DOT may be obtained with the help of awards and incentives (11,29). Screening programmes aimed at TB detection among the homeless are being conducted in countries at the forefront in fighting with tuberculosis but data on the outcomes of such actions are sparse. For example, the British National Institute for Health and Care Excellence (NICE) recommends that screening radiological examinations are performed in shelters for the homeless (30). The activities should be supported by directed social care. In the United States coercive measures in the fight against tuberculosis are applied. In New York, the patients who avoid treatment are subject to law on public health and by court decision are incarcerated. Then most patients achieve good treatment results (29). For actions aimed at improving the epidemiological situation of tuberculosis in the group of homeless persons it is necessary to know who is homeless among patients with tuberculosis and what is the scale of the co-occurrence of homelessness and tuberculosis. Information about the social status of the patient should find its place on the notification form of TB cases. SUMMARY A larger proportion of homeless persons with TB were males, they were also younger, compared with the remaining patients. In comparison with other patients, a larger proportion of homeless subjects were treated for TB in the past and the treatment course in most cases was incorrect. A smaller proportion of homeless subjects had extrapulmonary TB, compared to other patients. Homeless persons had more advanced TB at diagnosis than the remaining patients, which has been confirmed by a larger proportion of persons with positive sputum smears and culture results. A larger proportion of homeless patients, compared to other subjects, had caseous pneumonia, which may be indicative of recent infection. The mentioned differences in proportions were statistically significant. A lower proportion of homeless persons with TB, although statistically insignificantly, had resistance to isoniazid and/or rifampicin. A smaller proportion of homeless patients, compared to other subjects, achieved treatment success, a larger proportion defaulted from treatment and died due to TB. CONCLUSIONS The phenomena that are indicative of late diagnosis of the disease, and in some cases, of the possibility of recent infection and poor treatment results occur more frequently in the group of homeless persons with TB, compared to other patients. Screening tests targeted at TB and DOT could improve epidemiological situation of TB among the homeless. REFERENCES 1. Korzeniewska-Koseła M. Gruźlica w Polsce w 2012 roku. Przegl Epidemiol 2014;68: Korzeniewska-Koseła M. Gruźlica w Polsce-czynniki sukcesu leczenia. Pneumonol Alergol Pol 2007;75 (Suppl.2): Abubakar I, Aldridge R. Control of tuberculosis in low-incidence countries. In: Clinical tuberculosis, 5 th edition. ed. Davies PDO, Gordon SB, Davies G, 2014 by CRC Press; Taylor and Francis Group, Boca Raton, London, New York: European Centre for Disease Prevention and Control/ WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe Stockholm: European Centre for Disease Prevention and Control, Loennroth K, Williams BG, Stadlin S, et al. Alcohol use as a risk factor for tuberculosis- a systemic review. BMC Public Health 2008;14(8): Cegielski P, McMurray DN. The relationship between malnutrition and tuberculosis: evidence from studies in humans and experimental animals. Int J Tuberc Lung Dis 2004;8; Lung CC, Yew WW, Chan CK, et al. Smoking adversely affects treatment response, outcome and relapse in tuberculosis. Eur Respir J 2015;45: Nardell E, McInnis B, Thomas B, et al. Exogenous reinfection with tuberculosis in a shelter for the homeless. N Engl J Med 1986;315: Haddad MB, Wilson TW, Ijaz K, et al. Tuberculosis and homelessness in the United States, JAMA 2005;293: Romaszko J, Buciński A, Wasiński R, et al. Incidence and risk factors for pulmonary tuberculosis among the poor in the northern region of Poland. Int J Tuberc Lung Dis 2008;12(4): van Hest NA, Aldrige RW, de Vries G, et al. Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement. Euro Surveill 2014,19(9): pii= Ogólnopolskie Badanie Liczby Osób Bezdomnych w 2013 roku; Min. Pracy i Polityki Społecznej 13. Uchimura K, Ngamvithayapong-Yanai J, Kawatsu L, et al. Characteristics and treatment outcomes of tuberculosis cases by risk groups, Japan, WPSAR 2013;4(1): Morbidity and Mortality Weekly Report (MMWR), Centers for Diseases Control and Prevention. Notes from the field: outbreak of tuberculosis associated with a newly identified mycobacterium tuberculosis genotype- New York City, November 15,2013; 62(45):

17 No 3 Tuberculosis in homeless persons in Poland Lukacs J, Tubak V, Mester J, et al. Conventional and molecular epidemiology of tuberculosis in homeless patients in Budapest, Hungary. J Clin Microbiol 2004;42(12): Kruczak K, Duplaga M, Sanak M, et al. Comparison of IGRA tests and TST in the diagnosis of latent tuberculosis infection and predicting tuberculosis in risk groups in Krakow, Poland. Scand J Infect Dis 2014;46(9): Lange Ch, Abubakar I, Alffenaar J-WC, et al. Management of patients with multidrug-resistant/extensively drug-resistant tuberculosis in Europe: a TBNET consensus statement. Eur Respir J 2014;44: Matsumoto K, Komukai J, Kasai S. Medication support and treatment outcomes in homeless patients with tuberculosis. Kekkaku 2013;88(9): Przybylski G, Nowakowska- Arendt A, Pilaczynska-Cemel M, Gołda R. 10 years comparative clinico-epidemiological analysis of smoking and alcohol consumption in TB patients (M. tuberculosis) and with mycobacteriosis (M. kansasii). Przegl Lek 2014;71(11): Garcia- Rodriguez JF, Alvarez- Diaz H, Lorenzo- Garcia MV. Extrapulmonary tuberculosis: epidemiology and risk factors. Enferm Infecc Microbiol Clin 2011;29(7): Jagodziński J, Zielonka TM, Błachnio M. Socio-economic status and duration of TB symptoms in males treated at the Mazovian Treatment Centre of Tuberculosis and Lung Diseases in Otwock. Pneumonol Alergol Pol 2012;80(6): Wallace RM, Kammerer JS, Iademarco MF, et al. Increasing proportion of advanced pulmonary tuberculosis reported in the United States; are delays in diagnosis on the rise? Am J Respir Crit Care Med 2009;180(10): Mitruka K, Oeltmann JE, Ljaz K, Haddad MB. Tuberculosis outbreak investigations in the United States, Emerg Infect Dis 2011;17(3): Haddad M, Mitruka K, Oeltmann JE, et al. Characteristics of tuberculosis cases that started outbreaks in the United States, Emerg Infect Dis 2015;21(3): Geyer BC, Godwin P, Powell TJ, et al. Patients factors associated with failure to diagnose tuberculosis in the emergency department. J Emerg Med 2013;45(5): Shimouchi A, Ohkado A, Matsumo K, et al. Strengthened tuberculosis control programme and trend of multidrug resistant tuberculosis rate in Osaka City, Japan. Western Pac Surveill Response J 2013;4(1): Jenkins HE, Ciobanu A, Plesca V, et al. Risk factors and timing of default from treatment of non-multidrug-resistant tuberculosis in Moldavia. Int J Tuberc Lung Dis 2013;17(3): Borgdorff MW, Veen J, Kalisvaart NA, et al. Defaulting from tuberculosis treatment in the Netherlands; rates, risk factors and trend in the period Eur Respir J 2000;16: Pursnani S, Srivastava S, Ali S, Leibert E, et al. Risk factors for and outcomes of detention of patients with TB in New York City: an update: Chest 2014;145(1): National Institute for National Health and Care Excellence (NICE). NICE public health guidance 37: identifying and managing tuberculosis among hard-to-rich groups. London: NICE; 2012 Received: Accepted for publication: Address for correspondence: Prof. nadzw. dr hab. n. med. Maria Korzeniewska-Koseła National Tuberculosis and Lung Diseases Research Institute ul. Plocka 26, Warszawa m.korzeniewska@igichp.edu.pl tel

18 CORRIGENDUM: In the article entitled Chickenpox in Poland in 2013 authored by M. R. Korczyńska and J. Rogalska which was published in the Przegląd Epidemiologiczny Epidemiological Review 2015;69(2):p.219, incorrect term was used in the summary part of the abstract i.e. smallpox instead of chickenpox ERRATA: In the article entitled Measles in Poland in 2013 authored by J. Rogalska, which was published in the Przegląd Epidemiologiczny Epidemiological Review 2015;69(2):pp , tables and figure were not inserted. Omitted tables and figure are presented below (page 452 and page 478). Table I. Measles in Poland during Number of suspected and confirmed cases and incidence per population by voivodeship Voivodeship Median suspected cases confirmed cases suspected cases confirmed cases suspected cases confirmed cases number incidence per number incidence per number incidence per number incidence per number incidence per POLAND Dolnośląskie Kujawsko-pomorskie Lubelskie Lubuskie Łódzkie Małopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Śląskie Świętokrzyskie Warmińsko-mazurskie Wielkopolskie Zachodniopomorskie number incidence per Table II. Number and percentage of children vaccinated against measles in Poland according to birth year (primary and booster vaccinations)* Year of birth As of 31th December 2010 As of 31th December 2011 As of 31th December 2012 As of 31th December 2013 number % of children vaccinated number % of children vaccinated number % of children vaccinated number % of children vaccinated Primary dose x x x x x x x x x x x x Booster dose x x x x x x x x x x x x x x x x * vaccination against measles. rubella and mumps - MMR (based on Vaccinations in Poland in 2013, NIPH-NIH, Warsaw 2014)

19 PRZEGL EPIDEMIOL 2015; 69: Problems of infections 1,2 Karol Majewski, 2 Małgorzata Rybczyńska, 1 Karolina Wódz EVALUATION OF DETECTION AND DRUG RESISTANCE OF MYCOBACTERIUM TUBERCULOSIS IN PATIENTS IN THE ŁÓDZKIE VOIVODSHIP IN Department of Experimental Immunology, Medical University of Lodz 2 dr n. med. Teresa Fryda Medical Laboratory Sp. z o.o. ABSTRACT STUDY AIM. Evaluation of detection and drug resistance of Mycobacterium tuberculosis in patients from the Łódzkie Voivodship in the period MATERIAL AND METHODS. The data presented in the study include information obtained while diagnosing patients from the Łódzkie Voivodship in order to detect infections with Mycobacterium tuberculosis in the period RESULTS. In we analyzed clinical specimens for the purpose of detection of Mycobacterium tuberculosis. Tubercle bacilli were confirmed in 5621 specimens in 2196 patients; positive bacterioscopy results were observed in 1724 clinical specimens. In the study period 18 clinical specimens obtained from children contained tubercle bacilli. In the period we noted multi-drug resistant (MDR) strain in 41 clinical specimens, which made up 1.8 % of strains with known results of drug-sensitivity. In 5 clinical specimens we observed extensively-drug resistant (XDR) strain, which made up 0.2 % of strains with known results of drugsensitiveness. 12 clinical specimens appeared to contain pre-xdr strain, which constituted 0.6 % of strains with known results of drug-sensitivity. SUMMARY AND CONCLUSIONS. Despite advances in the diagnostics and treatment of tuberculosis (TB) this diseases still poses a serious medical problem. The detection level in the period is relatively unchanged, with regards to both bacterioscopy and culture methods. Thus, the laboratory detection of tuberculosis bacilli is similar. It directly results from the enforcement of strict procedures regarding the quality of specimens collected for microbiological purposes and the control of the performed tests, which contributes to a greater number of confirmed cases of TB. In the study period the number of new cases of the infectious diseases is variable. Only in children this number remains stable over the years. Researchers observe that tubercle bacilli are resistant to basic first-line treatment drugs. They also note the occurrence of MDR, pre-xdr and XDR strains. Hence, it is important to regularly and carefully monitor the sensitivity of Mycobacterium tuberculosis to antibiotics administered in a long-term anti-tuberculosis therapy. Key words: Mycobacterium tuberculosis, TB, bacteriological confirmation, drug-resistance INTRODUCTION Tuberculosis is a contagious disease caused by intracellular pathogens, bacilli of Mycobacterium tuberculosis. It usually develops in lungs but it can also occur in other organs (extrapulmonary tuberculosis). It is worth pointing out that a relatively small percentage of people infected with the bacteria develop full-blown tuberculosis. TB is the second most serious contagious disease. It follows the human immunodeficiency virus (HIV), which contributes to the highest number of deaths due to contagious diseases all around the world. According to WHO estimates, 9 million people were infected with TB and of that number 1.5 million died. It is estimated that mainly due to making proper diagnoses and introducing effective therapies in it was possible to prevent 37 million people from death (1, 2). A crucial breakthrough in combating TB occurred in the second part of the 20 th century after discovering many anti-tuberculosis drugs and introducing them into National Institute of Public Health National Institute of Hygiene

20 454 Karol Majewski, Małgorzata Rybczyńska, Karolina Wódz No 3 therapies. Within two years following the introduction of streptomycin in 1943 and rifampicin in 1963 into therapies a significant decrease in the death rate due to TB was observed and the spread of tubercle bacilli was substantially reduced. Current treatment of drugresistant TB involves a six-month application of four first-line anti-tuberculosis drugs: isonizaid, rifampicin, ethambutol, and pyrazinamide. Unfortunately, improper application of anti-tuberculosis drugs in the 1980s resulted in the occurrence of strains which do not respond to treatment, so called MDR (Multi-Drug Resistans). Treatment of this type of TB takes more time (about 20 months). It requires administering more expensive and more toxic drugs and it might be less effective. MICROBIOLOGICAL METHODS OF DIAGNOSING TUBERCULOSIS Microbiological tests (microscopic tests and culture on diagnostics media) are a referential method for detection of TB and are performed if any cases of the disease are suspected. In order to diagnose TB a lot of methods of various sensitivity and specificity is use and in which they obtain results after various periods of time. It must be pointed out that bacteriological tests for TB can be performed only in laboratories supervised by the Polish National Reference Tuberculosis Laboratory. The Laboratory for Diagnostics of Tuberculosis Medical Laboratory, dr n.med. Teresa Fryda Sp. z o.o. at the Provincial Health Care Centre Network, the Centre for the Treatment of Lung Diseases and Medical Rehabilitation in Lodz meets the above requirements (3). The first and the most basic method for diagnosing TB is bacterioscopy of smears from samples obtained from a patient (except for urine), where, under a microscope, the bacteria stained with the application of the Ziehl- Neelsena method are observed. Further selection of diagnostic methods depends on the result of the bacterioscopy test (3, 4). Its result can be a ground neither for confirming nor for ruling out TB because positive smear can contain dead tubercle bacilli or MOTT bacilli (Mycobacterium other than tuberculosis). Thus, in order to confirm bacilli, a culture test on solid and liquid media is performed. After obtaining results of the bacteriological test the cultured bacilli are identified each time and a drug-resistance test is performed. The molecular tests with the application of probes specific for Mycobacterium tuberculosis are also carried out. Despite their high specificity and sensitivity genetic methods cannot replace the traditional culture method, which is a reference method. They only serve as supplementary methods. In laboratories mycobacte rioses induced by MOTT bacilli are also diagnosed. They are cultivated on media used for growing tubercle bacilli. Thus, in each culture, it is essential to differentiate Mycobacterium tuberculosis complex from MOTT. An integral procedure in the diagnostics of TB, after tubercle bacilli have been confirmed in the culture, is a test, evaluating the drug-resistance to four basic drugs, i.e. isonizaid (INH), streptomycin (SM), rifampicin (RMP) and PZA in determining of drug resistance by automated methods, ethambutol (EMB) (in all new tuberculosis patients who developed bacilli) and to other drugs, if the patients have appeared to demonstrate MDR or XDR resistance (5). In most cases the occurrence of the disease can be clinically confirmed with laboratory tests. The percentage is lower for bacterioscopy (around 40%); with regards to inoculation it is about 70%. In the year 2008 in 40.7% of cases of pulmonary tuberculosis the results of the bacterioscopy tests turned out positive (6). In 2009 such results were observed in 40.0% cases (7), in in 40.1% (8), in 2011 in 37% (9), in in 39.6% (10), in % (11). In 2008 the occurrence of pulmonary tuberculosis was confirmed in bacteriological tests in 65.4% of cases (6), in 2009 the result was positive in 65.8% (7), in 2010 in 65.6% (8), in 2011 in 67.6% (bacteriological confirmation of the incidence of pulmonary tuberculosis 13.9) (9), in 2012 in 69.4%, in % (11). In 2008 the incidence of bacteriologically confirmed TB was 13.4 per 100,000 population. In subsequent years ( ) the incidence rate of bacteriologically confirmed TB fluctuated significantly: +2.23% (2008 vs. 2009); -8.76% (2009 vs. 2010); % (2010 vs. 2011); -9.59% (2011 vs. 2012); -5.30% (2012 vs. 2013). In a diagnostic process in 2013 the incidence rate of bacteriologically confirmed TB was 12.5, which made up 66.6% of the total number of patients. TB therapy has to be conducted in compliance with certain guidelines. These procedures should be observed prior to the initiation of the therapy as well as during the therapy. In order to bacteriologically confirm the infection with tubercle bacilli it is recommended to perform a smear test and prepare a culture test from three consecutive sputum specimens collected from a patient, at best, on three consecutive days. Both the stages of the therapy, the intensive one and the eradicating treatment are regularly monitored bacteriologically. In the event of new cases of TB the first test is conducted prior to the commencement of the therapy. Patients with pulmonary tuberculosis caused by bacilli resistant to basic drugs undergo a bacterioscopy test and a sputum culture two months after the commencement of the treatment. After three months of the treatment the bacteriological test is conducted again. If the patient still demonstrates active TB, the drug-sensitivity is re-evaluated. A final test is carried out after completion of the therapy, i.e. after 6 months. If pulmonary tuberculosis has been caused by multi-drug resistant bacilli, a bacterioscopy test

21 No 3 Mycobacterium tuberculosis in patients in Łodzkie voivodeship 455 and a sputum culture are performed every month until the disease turns into non-active and then, every three months until the completion of the therapy. Previously treated patients, who are being administered another TB therapy, are supposed to have bacteriological tests done at the end of the 3 rd, 5 th, and 8 th month of the therapy. It must be emphasized that while treating the patient again, one should not use the resistance profile applied in the previous episode of the infection (4, 5). EPIDEMIOLOGY OF TUBERCULOSIS IN POLAND The Polish legislature has introduced a lot of regulations which enable to monitor TB. According to the Act of 5 December 2008 on prevention and control of infections and infectious diseases in humans, the Act of 13 July 2012 amending the above Act and the Act on the State Sanitary Inspection, doctors are required to report all cases of TB within 24 hours following the detection. The cases are first reported to district and then to provincial sanitary and epidemiological stations and these send quarterly reports to the National Tuberculosis and Lung Diseases Research Institute. In cooperation with the Chief Sanitary Inspectorate the institute prepares reports on the number of cases of TB registered in Poland. The National TB Register has been kept in the institute, in the Department of Tuberculosis Epidemiology and Surveillance for 55 years. The Laboratory for Diagnostics of Tuberculosis Medical Laboratory, dr n.med. Teresa Fryda Sp. z o.o. at the Provincial Health Care Centre Network, the Centre for the Treatment of Lung Diseases and Medical Rehabilitation in Lodz plays an important laboratory role by monitoring TB in the Łódzkie Voivodship. The laboratory is required to report any occurrence of tubercle bacilli detected in samples obtained from a patient to the Provincial Sanitary and Epidemiological Station. The procedure applies to each new case of infection, an infection which re-occurred and the occurrence of multi-drug resistant strains. A new case of an infection refers to patients who were not administered an anti-tuberculosis therapy for longer than one month (2). In 2008 new cases of the disease made (7) up 87.3% of all registered cases (6), in % (7) in % (8), in % (9), in %, in % (11). The Laboratory Studio for Diagnostics of Tuberculosis Medical Laboratory, dr n.med. Teresa Fryda Sp. z o.o. at the Provincial Health Care Centre Network, the Centre for the Treatment of Lung Diseases and Medical Rehabilitation in Lodz reports cases of an infection detected in all hospitals, outpatient clinics and prisons in the Łódzkie Voivodship. Obtained results allow to report all new cases of TB in the region. In 2008 the incidence of TB (all types) in Poland was 21.2 per 100,000 population. In subsequent years ( ) the incidence rate fluctuated significantly: +1.88% (2008 vs. 2009); -8.79% (2009 vs. 2010); % (2010 vs. 2011); % (2011 vs. 2012); -4.08% (2012 vs. 2013). In the above period we observed an average decrease in the incidence of TB, i.e. 2%. In 2013 the incidence rate for TB was significantly different in different voivodships. Figure 1 presents current data on the incidence of TB in Poland in The most serious epidemiological situation was observed in the Lubelskie voivodship ( per 100,000 population), the Świętokrzyskie voivodship ( per 100,000 population) and the Śląskie voivodship ( per 100,000 population). Despite the above fact, we have been observing a constant decrease in the number of TB cases in Poland for a decade. The lowest incidence of TB was noted in the Wielkopolskie voivodship ( per 100,000 population), the Warmińsko-mazurskie voivodship ( per 100,000 population), the Podlaskie voivodship ( per 100,000 population), the Podkarpackie voivodship ( per 100,000 population). Table 1 presents the incidence rate of TB, including the rate for the Łódzkie voivodship. MATERIAL AND METHODS The first and the most basic method for diagnosing TB is bacterioscopy of smears from samples obtained from a patient (except for urine), where, under a microscope, the bacteria stained with the application of the Ziehl-Neelsena method were observed. Further selection of diagnostic methods depends on the result of the bacterioscopy test [3, 4]. It should be pointed out that its result can be a ground neither for confirming nor for ruling out TB because the positive smear can contain dead tubercle bacilli or MOTT bacilli (Mycobacterium other than tuberculosis). Bacteriological methods, apart from a microscopic examination, also include culture on diagnostic media. They are a referential method for detection of TB and are performed if any cases of the disease are suspected. For the purpose of detecting tubercle bacilli, in the Laboratory for Diagnostics of Tuberculosis Medical Laboratory, we applied two methods, as recommended by WHO; the first one was a conventional (traditional) method, i.e. inoculation on the Löewenstein-Jensen and Stonenbrink solid media and the other one was an automatic (fluorescence) method, i.e. inoculation on the Middlebrook media with the application of the MGIT

22 456 Karol Majewski, Małgorzata Rybczyńska, Karolina Wódz No 3 Table I. Incidence of tuberculosis per 100,000 population in Comparison of the Łódzkie voivodship with the whole population of Poland Incidence rate Incidence in total Incidence confirmed microbiologically Poland Łódzkie voivodship In total Pulmonary tuberculosis Extrapulmonary tuberculosis In total Pulmonary tuberculosis Extrapulmonary tuberculosis automated system (Becton Dickinson). The cultivated bacterial strains were classified into the proper group: TB complex (Mycobacterium tuberculosis) and MOTT (Mycobacterium other than tuberculosis). In order to identify the culture we performed two tests: niacin test for cultures grown on solid media or MGIT identification test for cultures grown on solid and liquid media. An integral procedure in the diagnostics of TB, after tubercle bacilli have been confirmed in the culture, is a test, evaluating the drug-resistance to four basic drugs, i.e. INH, SM, EMB, RMP and PZA in determining of drug resistance by automated methods ethambutol (EMB) (in all new tuberculosis patients who developed bacilli) and to other drugs, if the patients have appeared to demonstrate MDR or XDR resistance. Thus, in further stages of the diagnostics, drug-resistance tests with the application of the traditional method on the Löewenstein-Jensen solid media, for evaluation of the resistance to first-line anti-tuberculosis drugs (INH, SM, EMB, RMP) were performed. With regards to MDR strains the resistance to second-line anti-tuberculosis drugs (cycloserine, capreomycin, para-aminosalicylic acid, ofloxacin) and third-line anti-tuberculosis drugs (amikacin, trimethoprin, sulfamethoxazole, clofazimine, erythromycin) was also evaluated. For strains cultured with the fluorescence method drug-resistance tests with the application of the automatic method on the Middlebrook liquid media in the BACTEC MGIT 960 apparatus were performed. The test allowed to evaluate resistance to the following drugs: isonizaid, streptomycin, ethambutol, rifampicin, pyrazinamide. In order to bacteriologically confirm the infection with tubercle bacilli a smear test and prepared a culture test from at least three consecutive sputum specimens collected from a patient, on three consecutive days were performed. Moreover, in the stage of intensive treatment a microbiological examination was carried out, as ordered by the doctor in charge. The number of ordered tests correlates with the degree of the disease and clinical observation. With regards to patients with highly active TB the number of specimens sent for analysis is bigger. On average, it is usually 5 10 samples. After completing the treatment a mi crobiological test was we performed twice in order to confirm the eradica tion of the patients and the effectiveness of the therapy. A final test is carried out after completion of the therapy, i.e. after 6 months for bacilli resistant to basic drugs. RESULTS DETECTION OF ACID-FAST BACILLI Types of studied samples. The most common clinical sample sent to analysis for the diagnostics of Mycobacterium tuberculosis was sputum, then bronchoaspirate, pleural fluid, laryngeal swab, gastric washings and urine. Other specimen constituted 1.1% of all the studied specimens. They included: bioptates, peritoneal fluid, cerebrospinal fluid, fistula swab, ear swab, scrapings from the uterine cavity. Bacterioscopy results. We obtained positive results in 1724 clinical specimens, which confirmed the occurrence of acid-fast bacilli. In 2009 we received 319 positive bacterioscopy results, in , in , in , in Positive results in cultures were observed in 28.52% of all the studied specimens. In 2009 positive bacterioscopy results were noted in 28.15% of samples, in in 21.99%, in 2011 in 21.97%, in %, in in 41.16% of samples. Bacteriological confirmation of tubercle bacilli. We bacteriologically confirmed the occurrence of Mycobacterium tuberculosis in 5621 studied clinical specimens, in 2196 patients. In 2009 we obtained 1133 positive cultures of acid-fast bacilli. This number included 1096 tubercle bacilli isolated from 451 adult patients and 3 children. In 2010 we obtained positive cultures of acidfast bacilli. This number included 1082 tubercle bacilli

23 No 3 Mycobacterium tuberculosis in patients in Łodzkie voivodeship 457 Table II. Summary of the results obtained from growth and bacterioscopy of acid-fast bacilli in % positive smear % positive culture % cultivated tubercle bacilli isolated from 412 adult patients and 3 children. In 2011 we obtained 1365 positive cultures of acid-fast bacilli. This number included 1264 tubercle bacilli isolated from 541 adult patients and 3 children. In 2012 we obtained 1342 positive cultures of acid-fast bacilli. This number included 1218 tubercle bacilli isolated from 473 adult patients and 3 children. In 2013 we obtained 1064 positive cultures of acid-fast bacilli. This number included 961 tubercle bacilli isolated from 319 adult patients and 6 children (Table II). New cases of TB in the Łódzkie voivodship in In the period we noted 2070 new cases of TB. In 2009 we bacteriologically confirmed the occurrence of 400 new cases of tuberculosis, in , in , in , in In the number of new cases of infection with Mycobacterium tuberculosis fluctuated: -4.25% (2009 vs. 2010); +34.7% (2010 vs. 2011); -8.3% (2011 vs. 2012); -58.7% (2012 vs. 2013). DRUG-RESISTANCE The number of tubercle bacilli sensitive to all antituberculosis first-line drugs made up 93.11%. In 2009 we confirmed that 417 strains were sensitive to all anti-tuberculosis first-line drugs. In 2010 there were 383 such strains, in strains, in strains and in strains. In we isolated MDR strains (resistance to INH + RMP, also in combination with resistance to other drugs) from 41 clinical specimens, which made up 1.8% of strains with known results of drug-sensitivity. In 2009 we isolated 5 MDR strains, in strains, in strains, in strains, in strains. In the analyzed period we detected XDR strain (resistance to MDR + fluoroquinolone, amikacin, kanamycin, capreomycin) in 5 clinical specimens, which made up 0.2% of strains with known drug-sensitivity results. In 2009 we isolated 2 XDR strains, in strain, in strains. In 2010 and 2013 we did not isolate any strains. 12 clinical specimens appeared to contain pre-xdr strain, which made up 0.6% strains with known results of drugsensitivity. In 2010 we isolated 4 pre-xdr strains, in pre-xdr strains, in pre-xdr strains, in pre-xdr strains. In 2009 we did not isolate any pre-xdr strains. Table III presents detailed information on drug-resistance of the isolated tubercle bacillus. DISCUSSION Although the number of microbiologically confirmed cases of TB has increased the detection level in various regions in Poland is much different. The percentage of patients with pulmonary tuberculosis confirmed in bacteriological tests was 65.4% in 2008 and ranged from 54.2% to 91.8% (6), in 2009 it was 65.8% and in 40% of all TB patients tubercle bacilli were detected as early as in bacterioscopy. The percentage of patients who were diagnosed with TB after performing a sputum culture ranged from 48.3% to 85.6% (7). In 2010 there were still differences among voivodships with regards to pulmonary tuberculosis. The percentage of bacteriologically confirmed cases ranged from 57.6% to 90.4% (8). Similar differences among voivodships were observed in 2011 and the percentage ranged from 57.2% to 90.0 (9). In 2012 it ranged from 60.8% to 89.7% (10) and in from 60.4% to 90.5% (11). Such huge differences might result from a poor quality of bacteriological tests in some areas and a improper diagnosis of active tuberculosis (7). In the study period, positive results of culture obtained in the Laboratory for Diagnostics of Tuberculosis were noted in almost 90% of cases, which is a high percentage if we take Table III. Drug resistance of Mycobacterium tuberculosis isolated from clinical samples % strains sensitive to first-line drugs % strains resistant to INH % strains resistant to SM % strains resistant to EMB % strains resistant to RMP % strains resistant to INH+SM % MDR % XDR % pre-xdr

24 458 Karol Majewski, Małgorzata Rybczyńska, Karolina Wódz No 3 the whole country into consideration. Moreover, since 2009 the number of bacteriologically confirmed TB cases, i.e. with positive culture results, has been stable. A similar percentage of bacteriologically confirmed TB cases can be also observed in the European Union (6). With regards to positive results of sputum culture there are huge differences in Poland, too. In the study period positive results of culture obtained in the Laboratory for Diagnostics of Tuberculosis were noted in 28.52% of all analyzed clinical specimens. Concluding, the enforcement of strict procedures regarding the quality of specimens collected for microbiological purposes and conducted tests as well as a better control of the tests result in the stable percentage of the detected and confirmed occurrence of tubercle bacilli in the Laboratory for Diagnostics of Tuberculosis. Besides, an implementation of molecular biology methods will reduce the time needed for obtaining results and increase the number of confirmed cases of TB. CONCLUSIONS Despite advances in the diagnostics and treatment of tuberculosis (TB) this diseases still poses a serious clinical problem. In the studied period the number of positive bacterioscopy results remains stable and observed fluctuations are directly connected with the number of analyzed samples. The number of bacteriologically confirmed positive results of bacterioscopy remains stable so does the number of diagnosed cases of TB in laboratory conditions. In , in the Łódzkie Voivodship the number of new diagnosed cases of TB fluctuated. Some cases were noted in children. In 2013 we observed the greatest number of new cases in this age group. However, this observance is not identified with an increase in the number of cases but results from statistical variability. A small percentage of the patients studied for TB demonstrated drug-resistance. However, we noted resistance to basic first-line drugs and occurrence of MDR, pre-xdr and XDR strains. REFERENCES 1. WHO. Global Tuberculosis Report World Health Organization, Geneva European Centre for Disease Prevention and Control/ WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe Stockholm. European Centre for Disease Prevention and Control, Zalecenia Polskiego Towarzystwa Chorób Płuc dotyczące rozpoznawania, leczenia i zapobiegania gruźlicy u dorosłych i dzieci. Pneumonologia i Alergologia Polska 2013, tom 81, nr 4, WHO. Treatment of tuberculosis: guidelines. 4th ed. WHO/HTM//TB/ World Health Organization, Geneva Guidelines for the programmatic management of drug-resistant tuberculosis update. WHO/HTM/ TB/ World Health Organization Geneva Maria Korzeniewska- Koseła. Gruźlica w Polsce w 2008 roku. Przegl Epidemiol 2010; 64: Maria Korzeniewska- Koseła. Gruźlica w Polsce w 2009 roku. Przegl Epidemiol 2011; 65: Maria Korzeniewska- Koseła. Gruźlica w Polsce w 2010 roku. Przegl Epidemiol 2012; 66: Maria Korzeniewska- Koseła. Gruźlica w Polsce w 2011 roku. Przegl Epidemiol 2013; 67: Maria Korzeniewska- Koseła. Gruźlica w Polsce w 2012 roku. Przegl Epidemiol 2014; 68: Korzeniewska- Koseła. Gruźlica i choroby układu oddechowego w Polsce w 2013roku. Instytut Gruźlicy i Chorób Płuc 2014; Zakład Epidemiologii i Organizacji Walki z Gruźlicą Konferencja naukowo-szkoleniowa specjalistów chorób płuc w Zakopanem, VI.2014 r. Received: Accepted for publication: Address for correspondence: Karol Majewski Department of Experimental Immunology Medical University of Łódź Pomorska 251 street, Łódź Phone: karol_majewski@op.pl

25 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Kazimierz Madaliński 1, Karolina Zakrzewska 1,2, Agnieszka Kołakowska 1, Paulina Godzik 1 EPIDEMIOLOGY OF HCV INFECTION IN CENTRAL AND EASTERN EUROPE 1 Department of Virology, Laboratory of Immunopathology of Hepatotropic Infections National Institute of Public Health - National Institute of Hygiene in Warsaw 2 Department of Epidemiology, Medical University of Warsaw ABSTRACT AIM OF STUDY is the estimation of prevalence of HCV infection in fourteen Central and Eastern European countries (CEEC). MATERIAL AND METHODS. This review describes the comparative data of persons possessing anti-hcv antibodies and persons with HCV viremia (% of population and number) in fourteen Central and Eastern European countries (CEEC). The study was performed according to data on the 15 years of age populations obtained from the Statistical Offices of the countries. RESULTS. The prevalence of anti-hcv in populations varied between 0.27 and 3.5%. The lowest values were reported from Kosovo, Hungary, Germany and the Czech Republic; %. The highest values of anti-hcv antibodies were noted in Latvia, Lithuania and Romania; 2.4, 2.85 and 3.5%, respectively. From eight countries the percentages of persons with HCV viremia were available ( %). CONCLUSIONS. The paper gives an estimate of the number of people infected with HCV in the general population of 8 countries from the CSEEC region. This number is approximately ~1.16 million. Key words: Hepatitis C, anti-hcv antibodies, HCV-RNA, prevalence in general population and first-time blood donors; countries of Central and Eastern Europe INTRODUCTION Hepatitis C infection is an important problem of public health, recognized by the WHO (1). Due to the long-term asymptomatic HCV breakthrough, the disease is very dangerous. The consequences of unrecognized infection, in most cases, are liver cirrhosis and hepatocellular carcinoma. It is estimated that 10-40% of Europeans are not aware of their disease, and they are a potential source of infection for other persons (2). The prevalence of anti HCV antibodies in Europe is uneven and fluctuates between 0.4% and 6%, but in some regions of Italy they reach up to 20% (3). An estimation of the number of people infected with HCV in the population is very important for the health policy of the given country. This allows planning of preventive and therapeutic interventions, and also allows determination of the need for treatment of infected persons. According to recent exact determinations, there are 115 mln persons with anti-hcv, a number which is lower than that quoted by the WHO ( million people with hepatitis C); and 80 mln HCV viremic individuals in the world; this number has not been reported before (4). Several papers have appeared recently, with the aim of comparing the prevalence of anti-hcv antibodies between different countries, but they do not deal specifically with CEEC region (4-7). According to Wikipedia and data from the World Bank this region is composed of 18 countries (8-9). The countries are: Estonia, Lithuania, Latvia, Germany, Poland, Czech Republic, Slovakia, Hungary, Romania, Bulgaria, Slovenia, Croatia, Albania, Bosnia and Herzegovina, Kosovo, Macedonia, Montenegro, Serbia and Belarus, in some descriptions. (Fig. 1.) The purpose of this review was to estimate: 1) the number of adults who had contact with the virus (anti-hcv positive), and 2) the number of persons actually infected with HCV (presence of HCV RNA) in 14 European countries of the Central and Eastern European region, for which the data were available, but which had not been studied systematically yet. Central and Eastern Europe includes countries which share common National Institute of Public Health National Institute of Hygiene

26 460 Kazimierz Madaliński, Karolina Zakrzewska et al. No 3 Suorce: Figure 1. Map of Central and Eastern Europe

27 No 3 Epidemiology of HCV infection in Central and Eastern Europe 461 cultural and historical roots, especially sharing a past as a buffer to socialist republics of the Soviet Union, or as a component part of the Soviet Union. METHODS The following terms were used for the PubMed search: hepatitis C AND (name of the country) AND prevalence AND viremia. The papers selected represented unique data for the particular countries. Full original papers were obtained for 11 countries. However, in the Table I letter to the editor containing original results was also included, as well as conference material with the original data (Romania and Slovakia respectively). No original data were found for Belarus and Czech Republic, thus review papers were the source of data. Papers rejected did not contain data on the prevalence of HCV, but concerned only HCV genotypes in the country (Macedonia). In the present study, the prevalences of anti-hcv and/or HCV RNA were estimated on the basis of published data, compared with the number of the adult population. The population of each country was taken from Statistical Office: the Main Statistical Office of Poland, the Czech Statistical Office, the Statistical Office of the Slovak Republic, the Hungarian Central Statistical Office, the National Institute of Statistics of Romania, the National Statistical Institute of the Republic of Bulgaria, the Croatian Bureau of Statistics, the Statistical Office of the Republic of Serbia, the Federal Office of Statistics of Bosnia and Herzegovina, the Kosovo Agency of Statistics, the Department of Statistics of Lithuania, the Central Statistical Bureau of Latvia, the Federal Statistical Office of Germany and the Ministry of Statistics and Analysis of Belarus. The number of the adult population ( 18 years) were not available for all the countries analyzed in this study, and therefore we adjusted the obtained values to give the population from 15+ years. Therefore, the data on the prevalence of anti-hcv and / or HCV RNA was related to a population of persons 15 years of age. Adolescents between 15 and 17 years of age, as the population of adults under take actions and social behavior, which may contribute to an increased risk of HCV infection. In Kosovo the total population was taken, because a value for the population from 15+ years was not found in Kosovo Agency of Statistics for The following methods were used to detect anti- HCV antibodies: immunochemical (ELISA, EIA, CMIA), immunochromatography tests or Western Blot. The genetic material of the virus (HCV RNA) determination was performed by PCR Cobas Amplicor ver 2.0 and Real Time PCR. RESULTS The results of this study are presented in the Table 1. The prevalence of anti-hcv in the populations of countries within CSEEC varied from 0.27 to 3.5%, the range expected for Europe. The percentages of persons with HCV viremia amounted to %. The following studies were performed on the adult general population: Germany, Czech Republic, Croatia, Romania, Belarus, Lithuania and Latvia. The exceptional country which estimated values obtained from blood donors in the general population was Bosnia and Herzegovina. Two countries reported the prevalence of anti-hcv antibodies in voluntary blood donors: Kosovo and Hungary. Two countries performed their studies on patients who were admitted to hospital because of diseases other than viral hepatitis: Slovakia and Bulgaria. The results obtained in the study of patients from emergency wards in Poland, were standardized to general population 18+ years old. DISCUSSION The original HCV prevalence in the general population was not available for two countries: the Czech Republic and Belarus. In the Czech Republic there were no population studies, nor a national screening programme for hepatitis C. However, an expert panel defined the prevalence of anti-hcv in the population as 0.6% and the percentage of persons with viremia as 0.4% (5-6). The next difficult country is Belarus, for which we did not have original data, but values taken from the review paper (4). Data described for the seroepidemiology of HCV in Germany showed the prevalence of antibodies in 0.3% and HCV-RNA in 0.2% of the big group of ~7000 persons tested (13). However, there are also two review papers available with show higher percentages of anti- HCV: 0.4% and 0.5% among studied individuals (5-6); and HCV RNA in 0.3% (6). As a source of data for the Table 1 the original paper from Robert Koch Institute in Berlin was chosen (13). As a comment to Table 1, we have to add that there are two papers from Poland (3,23); one was included in the Table 1. The first study was undertaken on 4822 subjects from orthopedic and traumatic wards which were chosen at random (3). Study was performed with double-step ELISA for anti-hcv, i.e. positive sample was repeated twice to obtain the second positive result (3). The second study investigated patients (suffering from diseases other than viral hepatitis) and health care workers; the study group was not randomized. Single-step EIA was used in this study and gave

28 462 Kazimierz Madaliński, Karolina Zakrzewska et al. No 3 Table I. Demographic data and hepatitis C infection indices in Central and Eastern European countries Country and year(s) of study Population studied Presence of anti-hcv antibodies [%] Presence of HCV RNA [%] References Number of persons with anti-hcv Number of persons with viremia 1 Belarus (2013) general adult population 1,3 0,9 (4) Bosnia and Herzegovina (2009) (general adult population - estimated) 0,89) 17240) voluntary first time blood donors 0,27 (0, (5618- nd (10) nd 3 Bulgaria ( ) patients (for causes other than viral hepatitis) 0,7 0,35 (11) Croatian ( ) general adult population 0,9 nd (12) nd 5 Czech Republic (2012) general adult population - estimated 0,6 0,4 (6) Germany ( ) general adult population 0,3 0,2 (13) Hungary ( ) prison`s staff 0,5 nd (14) nd 8 Kosovo ( ), part of Serbia; independent voluntary first time blood donors 0,3 nd (15) 6048* nd Latvia (2010) general adult population 2,4 1,7 (16) Lithuania (2010) general population; cross-sectional survey of random anonymous volunteers 2,85 nd (17) nd 11 Poland (2010) patients hospitalized in emergency wards, for causes other than viral hepatitis (standardized to general adult 0,91 (0,86) 0,6 (0,59) (3,18) population) 12 Romania ( ) healthy adults 3,5 3,5 (19) Serbia (2005) patients, blood donors and healthcare staff of a hospital 0,5 nd (20) nd 14 Slovakia ( ) patients >=15y.old (cause other than viral hepatitis) 1,41 0,7 (21) * population, total; nd - not done a relatively higher level of anti-hcv antibodies in the studied group 1.9%; while HCV RNA was found in 0.6% of subjects who completed a questionnaire (23). The lowest values of anti-hcv prevalence were reported from Germany, Kosovo, Hungary, Serbia and the Czech Republic, i.e %. Bosnia and Herzegovina had a low value of anti-hcv in voluntary blood donors (0.27%), but the estimate for the adult population ranges from %. However, the study of Kosovo was performed on voluntary first time blood donors, which is not representative of the general population (15). There is another study from Kosovo, performed on a sample of the general population and health care workers, which reported 0.5% of anti-hcv in the studied group (20). In Hungary, unique studied group, the members of prison staff were investigated (value for anti-hcv equaled 0.5%); this value, according to the authors, reflects the situation in the general population (14,24). Earlier, another study was performed on voluntary first time blood donors - anti-hcv was found in 0.4% of them (25). A serological survey performed in 2001 in the Czech Republic showed a low prevalence of anti-hcv antibodies (0.2%), but the data were published 11 years ago (26). The data for the Czech Republic: prevalence of anti-hcv antibodies and HCV RNA in the population were taken from two review papers (5-6). In our study, we have obtained for the Czech Republic the absolute numbers of adult persons with anti-hcv: ~53,700 and persons with HCV RNA: ~35,800; while the respective numbers in the Bruggmann paper were: 60,000 and 42,000 (6). This example shows the importance of adjustment of the national prevalence of HCV indices obtained in the adult population into those for the real adult population as registered in the Statistics Office. At this point, the other difficulty appeared, that age groups which suited our demographic data, start from 15 years in the Statistics Offices, but not from 18 years (considered as the beginning of adulthood). The lower numbers obtained by us in comparison to the Bruggmann study originate from adjusting the HCV prevalence for the national population aged 15+. In some countries the prevalence of anti-hcv in the general population was converted from values in blood donors, but no mathematical formula was introduced for counting; that is why these data should be treated with caution (7,10,11). Data from Bosnia and Herzegovina are examples of such estimations of values from blood donors to the general adult population (10). The highest values of anti-hcv antibodies in the population, noted in this review, were in Latvia, Lithuania and Romania ( %). This last country is one of these for which we have two values, although not very different. The study quoted in the paper of Gower

29 No 3 Epidemiology of HCV infection in Central and Eastern Europe 463 et al., gives two values: 3.2% for anti-hcv in the adult population, and 2.9% as the adult viremic population (4). However, the original Romanian study quoted in the Table 1 determined the presence of anti-hcv in 3.5% of adult population, while the presence of HCV RNA also in 3.5% of adults, which was rather unexpected, because all the individuals with anti-hcv appeared as viremic (19). Such a situation was not observed in other countries studied so far. Romania has a relatively high emigration rate; thus, Romanian authors express the view that emigration from this country may cause HCV disease to be a burden in the immigrants destination (19). Certainly, there are many known factors which may influence the increased prevalence of the anti- HCV/viremic state in a population, including hygiene of medical units (nosocomial causes of infection), intravenous drug use, frequency of tattooing, acupuncture and piercing, etc. In contrast, while discussing the Kosovo results the authors concluded that there are few people living in a high-risk environment for HCV infection in this country (15). Moreover, only the adult layer of the society was evaluated here in terms on hepatitis C antibody positivity and infection. Pediatric studies should be reviewed separately. We are aware that the proper diagnosis of HCV should include serological anti-hcv testing, followed by HCV RNA determination (1), with a sensitivity of 25 IU/ml (27). The presence of HCV RNA indicates that the person with anti-hcv antibodies is currently infected with hepatitis C virus. The second step of diagnosis (detection of HCV RNA) was performed only in 8 countries. The estimation of the number of infected persons determines the treatment policy of the country. As can be approximated from Table 1, the number of adult people infected with HCV from 8 countries (which performed HCV RNA determination) amounts to 1.16 mln. The range of HCV infected persons to persons possessing anti-hcv is usually between 31 to 67%. This is a broad range which does not allow counting the number of persons who should be treated in countries where the HCV RNA determination was not done. The difficulty of this kind of review originates from the fact that data from different countries concerned various groups of the population. Also, a different epidemiological approach and diagnostic methods were used by authors (2), but standardization of methods is constantly conducted by WHO. To this end, WHO undertook efforts and created guidelines to unify the methodology of HCV determination screening and treatment (28). The report gives examples of countries, like Scotland, where HCV diagnostics is very effective and penetrates groups with a high risk of infection (28). In the present review we summarized data of the prevalence of HCV in 14 counties of CEEC. However, data from Albania, Estonia, Macedonia, Montenegro and Slovenia were not available. REFERENCES 1. Hepatitis C. Fact sheet N 164 Updated April Merkinaite S, Lazarus JV, Gore C. Addressing HCV infection in Europe: reported, estimated and undiagnosed cases. Cent Eur J Public Health. 2008; 16: Godzik P, Kolakowska A, Madalinski K, et al. [Prevalence of anti-hcv antibodies among adults in Poland--results of cross-sectional study in general population]. Przegl Epidemiol. 2012; 66: Gower E, Estes C, Blach S, et al. Global epidemiology and genotype distribution of the hepatitis C virus infection. J Hepatol. 2014; 30: Cornberg M, Razavi HA, Alberti A et al. A systematic review of hepatitis C virus epidemiology in Europe, Canada and Israel. Liver Int. 2011; 31: Bruggmann P, Berg T, Øvrehus AL, et al. Historical epidemiology of hepatitis C virus (HCV) in selected countries. J Viral Hepat 2014; 21: Hope VD, Eramova I, Capurro D, et al. Prevalence and estimation of hepatitis B and C infections in the WHO European Region: a review of data focusing on the countries outside the European Union and the European Free Trade Association. Epidemiol Infect 2014; 142: Central and Eastern Europe: Wikipedia, the free Encyclopedia. 9. Unleashing Prosperity: Productivity Growth in Eastern Europe and the Former Soviet Union, World Bank, Washington (2008), p Petrovic J, Salkic NN, Ahmetagic S, et al. Prevalence of chronic hepatitis B and hepatitis C among first time blood donors in Northeast Bosnia and Herzegovina: an estimate of prevalence in general population. Hepat Mon. 2011; 11: Kevorkyan A, Teoharov P, Lernout T, et al. Prevalence of HBV and HCV among outpatients in the Plovdiv region of Bulgaria, J Med Virol 2014; 27. doi: /jmv Vilibić-Cavlek T, Kucinar J, Ljubin-Sternak S, et al. Prevalence of viral hepatitis in Croatian adult population undergoing routine check-up, Cent Eur J Public Health 2014; 22: Poethko-Müller C, Zimmermann R, Hamouda O, et al. Epidemiology of hepatitis A, B, and C among adults in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2013, 56: Tresó B, Barcsay E, Tarján A, et al. Prevalence and correlates of HCV, HBV, and HIV infection among prison inmates and staff, Hungary. J Urban Health 2012; 89:

30 464 Kazimierz Madaliński, Karolina Zakrzewska et al. No Fejza H, Telaku S. Prevalence of HBV and HCV among blood donors in Kosovo. Virol J 2009; 13: Tolmane I, Rozentale B, Keiss J, et al. The prevalence of viral hepatitis C in Latvia: a population-based study. Medicina (Kaunas) 2011; 47: Liakina V, Valantinas J. Anti-HCV prevalence in the general population of Lithuania. Med Sci Monit 2012; 18: Godzik P. [Prevalence of hepatitis C infection in the Polish general population on the basis of cross-sectional studies performed between ]. Doctor`s thesis, National Institute of Public Health - National Institute of Hygiene, Warsaw Gheorghe L, Iacob S, Csiki IE. Prevalence of hepatitis C in Romania: Different from European rates? Letter to the Editor. J Hepatol 2008; 49: Quaglio G, Ramadani N, Pattaro C, et al. Prevalence and risk factors for viral hepatitis in the Kosovarian population: implications for health policy. J Med Virol. 2008; 80: Schréter I. [Epidemiologicke aspekty vyskytu virusovej hepatitidy B a C na Slovensku - Epid Project ]. XXIII Conference SSVPL SLS Stary Smokovec WHO European Region: Serbia [in:] Global policy report on the prevention and control of viral hepatitis. WHO Flisiak R, Halota W, Horban A, et al. Prevalence and risk factors of HCV infection in Poland. Eur J Gastroenterol Hepatol. 2011; 23: Takacs M, personal communication 25. Müller Z, Deák J, Horányi M, et al. The detection of hepatitis C virus in South Hungary. J Clin Virol 2001; 20: Nemecek V, Cástková J, Fritz P, et al. The 2001 serological survey in the Czech Republic--viral hepatitis. Cent Eur J Public Health. 2003; 11: Madaliński K, Flisiak R, Halota W, et al. [Laboratory diagnostics of HCV infections. Polish Guidelines 2012/2013]. J Labor Diagn 2013, 49: Global Hepatitis Programme. Guideline Development for Hepatitis C virus Screening, Care and Treatment in low- and middle- income countries. WHO 2014 Received:: Accepted for publication: Address for correspondence: Prof. dr med. Kazimierz Madaliński Dept. Virology, Laboratory of Immunopathology of Hepatotropic Infections National Institute of Public Health - National Institute of Hygiene Chocimska 24, Warsaw, Poland kmadalinski@pzh.gov.pl kom

31 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Małgorzata Stępień, Magdalena Rosińska HEPATITIS C OUTBREAKS IN POLAND IN MEDICAL PROCEDURES AS A DOMINANT ROUTE OF HCV TRANSMISSION 1. Department of Epidemiology National Institute of Public Health-National Institute of Hygiene in Warsaw ABSTRACT BACKGROUND. According to the data from routine epidemiological surveillance in Poland, over 70% of patients diagnosed with HCV infection report exclusively medical exposure which suggests that infection was probably associated with procedures performed in health care settings. To a large extent, neither the source nor the mechanism of transmission, however, may be determined. Infections detected in an acute phase, accounting for ca 2-3% of registered hepatitis C cases per year, better reflect the actual routes of HCV transmission. Epidemiological investigations of acute hepatitis C outbreaks allow for identifying the procedures in which the virus is transmitted. OBJECTIVE. To identify mechanisms and breaches of safety procedures, which are most frequently associated with HCV infection, based on a review of recent hepatitis C outbreaks in health care settings in Poland. METHODS. A systematic review of reports on acute hepatitis C cases registered in routine surveillance in and literature review in PubMed and SCOPUS. RESULTS. A total of six outbreaks were documented in which 116 cases were detected. Of them, four outbreaks were identified based on surveillance data, including one unconfirmed outbreak, and information on two outbreaks was retrieved from publications. Five of the described outbreaks were acquired in health care settings, including two outbreaks which occurred in dialysis units and one outbreak was associated with alternative medicine procedures. Probably, infections were most commonly transmitted due to mistakes of medical personnel resulting from negligence or ignorance of procedures, i.e. multiple use of disposable equipment and improper use of personal protective equipment (failure to change disposable gloves). In one case, neither breaches of procedure nor actions which could lead to HCV infection were determined. CONCLUSIONS. A detailed epidemiological investigation should be conducted in each registered case of acute hepatitis C as detected symptomatic cases allow for identifying the outbreaks. Epidemiological investigations of outbreaks should be improved by inclusion of molecular tests. Identification of breaches of binding procedures indicates a necessity of continuing training of personnel and enhanced control of compliance with binding recommendations, especially with regard to injection safety. Key words: hepatitis C, acute hepatitis C, outbreak, route of transmission, Poland BACKGROUND Irrespective of a substantial progress in the treatment of chronic hepatitis C, HCV infections still constitute one of the major health problems worldwide. An estimated million individuals are chronically infected globally and ,000 die each year due to long-term sequelae of hepatitis C, i.e. cirrhosis and liver cancer (1). Injecting equipment sharing in persons who inject drugs is considered to be the most effective route of HCV transmission as well as some medical procedures, especially hemodialysis, invasive medical procedures, and transfusions of blood or blood products in the past (2-5). Less frequently, the infections are acquired through sexual contacts, vertical transmission and nonmedical procedures - tattooing, piercing, beauty treatments accompanied by skin injury or acupuncture (3, 5, 1 Article was written under the task No.6/EM.1/2015 National Institute of Public Health National Institute of Hygiene

32 466 Małgorzata Stępień, Magdalena Rosińska No 3 6). In case of a number of patients, exposure/risk factor which could be associated with HCV infection cannot be established (4, 7). In particular, in the majority of chronic cases of long asymptomatic course a probable route of infection may be determined by considering an individual history of exposures throughout life. Identification of dominant route of transmission in a given population and on a defined territory is of paramount importance for planning and undertaking hepatitis C preventive and control measures, both in terms of safety of procedures accompanied by skin injury as well as the behavior and lifestyle of people. In the EU countries, over 75% of detected HCV cases (out of those with known route of infection, in acute, chronic and unknown phases considered altogether) were acquired through injection drug use and only 4% through medical procedures (8). In addition, the majority of healthcare-associated infections are linked with transfusions or invasive procedures performed in the past. Such route of transmission, however, was rarely indicated in newly diagnosed acute cases. Documented acute hepatitis C cases can provide more reliable data on the actual routes of HCV transmission. Acute cases, however, account only for a small percentage of confirmed HCV infections registered annually due to frequent asymptomatic course - 1.7% based on the ECDC (8). In order to improve the safety of medical procedures (and safety of each hospitalization which is not associated with invasive procedures), it is necessary to determine which procedures most often lead to new HCV infections and strengthen the weak points in the existing safety standards. The aim of this study was to identify and describe the procedures most often leading to HCV infections in Poland based on the analysis of documented outbreaks of acute hepatitis C in recent years. MATERIAL AND METHODS A retrospective analysis of individual reports on hepatitis C registered in routine surveillance system in was performed, with a particular attention paid to acute hepatitis C cases. Individual reports on hepatitis C cases are available in the epidemiological surveillance system in Poland since Cases who meet the criteria of hepatitis C definition adopted by the European Commission by means of the Decision 2002/253/EC, and since 2009 the decision 2008/426/ EC) are subject to registration (9). Detailed information on risk factors is collected since 2009, following the modification of the report form, and was available for Hepatitis C case definition used for the purpose of surveillance: all laboratory-confirmed cases (confirmed presence of antibodies or detection of virus nucleic acid), regardless of the clinical picture (2009 case definition), in previous years (2005 case definition): cases with clinical symptoms or cases with elevated transaminase activity in the course of HCV infection confirmed by the detection of anti-hcv or HCV nucleic acid in clinical samples. Hepatitis C case definition used did not allow for differentiating acute and chronic cases. Classification of stage was based on a diagnosis made by the reporting physician using the following criteria of acute hepatitis C: case with documented anti-hcv seroconversion within the last 12 months OR symptomatic hepatitis C case (according to the case definition used in surveillance) who present with jaundice or elevated alanine transaminase activity (ALT>350 IU/mL or ALT>10N) OR case with HCV RNA and undetected anti-hcv with a known exposure to HCV infection within the last 6 months Cases with markers of hepatitis of different etiology (hepatitis A, hepatitis B, EBV, CMV), alcoholic or toxic hepatitis or a history of liver diseases were excluded. In each case notified as acute hepatitis C, the following variables were verified: - exposure to HCV infection within six months prior to the first detection of HCV - link with the outbreak (according to the information provided by District Sanitary-Epidemiological Stations, DSES) - if the case occurred in the outbreak, data from outbreak investigations were analyzed. Regardless of the surveillance data analysis, MED- LINE/PubMed and SCOPUS databases were searched using the keywords: ((acute hepatitis C OR hepatitis C OR HCV infection) AND outbreak AND Poland) to identify studies describing acute hepatitis C outbreaks in Poland, with particular attention paid to the mechanism of HCV transmission. RESULTS According to the epidemiological surveillance data, a total of 19,328 hepatitis C cases were reported in in Poland, including 6,690 in As a result of analysis of case-based reports, a total of 577 acute hepatitis C cases were identified (155 in ) (Tab. I). Out of hepatitis C cases (acute and chronic altogether) registered in , 67-75% reported medical procedures as the most likely route of transmission while injection drug use was indicated only in 6-7.5%

33 No 3 Hepatitis C outbreaks in Poland 467 Table I. Number of hepatitis C cases recorded in surveillance in in Poland Total number of hepatitis C cases Number of acute hepatitis C cases Number of hepatitis C outbreaks % Transfusion, invasive medical procedures, dialysis Minor medical procedures PWID Tattooing/piercing or beauty treatments Occupational exposure HCV-infected sexual partner or householder Vertical transmission Other Unknown Fig 1. Hepatitis C in Poland in Percentage of probable routes of transmission of HCV in the total number Fig of 1. cases. Hepatitis C in Poland in Percentage of probable routes of transmission Source: Case-based reports collected in routine mandatory surveillance system of HCV in the total number of cases. Source: Case-based reports collected in routine mandatory surveillance system of cases. Having considered only the cases with probable route of transmission specified, the percentage of infections which were probably acquired via medical procedures exceeded 80% (Fig. 1). Based on the routine surveillance data, three outbreaks and one suspicion of outbreak were identified in , in which a total of 75 persons were infected. All the outbreaks occurred in health care settings, including two in dialysis units, one in the diagnostic center medical procedures performed. Two outbreaks occurred in dialysis units, one was detected in the department of computed tomography (CT) and the suspected outbreak 2010 concerned 2011 patients 2012 hospitalized Total on HepC hematology Transfusion, invasive medical procedures, dialysis ward. 48 Infections 52 in the outbreak 51 unrelated to healthcare Minor medical procedures settings (10), was also associated with the procedures PWID 6 7,2 7,5 considered to be medical i.e. intravenous infusions carried out without compliance with the safety standards Tattooing/piercing or beauty treatments 2 3,5 3 Occupational exposure 0,6 2,5 2,2 in alternative medicine settings. HCV-infected sexual partner or householder 0,8 2,5 1,7 in the department Vertical of transmission computed tomography and magnetic resonance imaging and one suspected outbreak, ual cases based on various criteria. In the outbreaks 0,1 Acute 0,5 hepatitis 0,4 C was recognized in individ- finally recognized as unconfirmed, on the hospital ward. detected in dialysis units, diagnosis was based on Having searched the PubMed and SCOPUS, a anti-hcv seroconversion in patients which were regularly examined due to chronic dialysis. None of the total of 28 publications were identified. Following the exclusion of duplicates and non-relevant articles, two infected dialysis patients presented perceptible symptoms of viral hepatitis. Detection of outbreaks asso- publications describing two HCV outbreaks in Poland in 2003 were included in the analysis (10, 11). No publication describing hepatitis C outbreaks identified based on linking the first symptomatic patients hospitalized on ciated with CT and chelation therapy resulted from the surveillance data, i.e was found. infectious diseases wards with a common exposure A total of 6 outbreaks from were analyzed. Table II presents a detailed description of these by active searching for cases in the remaining persons within the incubation period of the disease and then outbreaks. As molecular studies confirming the link between strains isolated from patients were not performed tion could occur. being the patients/clients at the time when the infec- in any of the registered outbreaks, a cluster of cases on Outbreak of hepatitis C in patients hospitalized on a hospital ward, which was considered as unconfirmed, gynecological ward was confirmed in epidemiological was also included. investigation which was by means of civil court request All detected outbreaks, except for one from 2003, after the infected patients brought the legal action occurred in healthcare settings and were associated with against the hospital (11). Diagnosis of acute hepatitis

34 468 Małgorzata Stępień, Magdalena Rosińska No 3 Tab. II. Characteristics of acute hepatitis C outbreaks in Poland in by settings Year Location/setting 2003 Alternative medicine center (chelation therapy with unknown agent) Number of individuals infected 15 Number of individuals tested all individuals treated in the center during Jul-Aug 2003, number unknown Age, range and median Sex M:F HCV genotype Known or suspected route of transmission and contributing factors: Intravenous infusions of unknown agent - unsafe injection practices 2003 Department of Gynecology, Obstetrics and Oncology 26 (22 had major gynecological surgeries) Symptomatic cases (including jaundice) ALT (IU/l) Source 48-72; mean 61 12:3 1b 40% unk unk :26 not determined not specified 1 (few patients) not available unk Known or suspected route of transmission and contributing factors: Major gynecological procedures; breaches in sterilization procedures: using a dry air sterilizer, using expired biological tests, incorrect transportation of equipment and incorrect packaging of material, no control of packaging seals, using decommissioned sterilization equipment. Failure to comply with the basic sanitary rules and hygiene standards: washing hands, instruments and newborns in the same washbasin, medical equipment dried with hand towels, using non-sterile materials (swabs), instruments and equipment, no separation of sterile and non-sterile areas. Lack of written crucial procedures Dialysis unit on dialysis, 121 householders, 15 personnel members 32-88; 64 29:24 unk 1 0% not available Probably one of 12 patients previously infected HCV Known or suspected route of transmission and contributing factors: Dialysis and/or injections from multiple vials; numerous breaches of procedures, the most important: multiple use of disposable needles, syringes and capillary tubes for ionometer, use of non-sterile minor medical equipment, lack of changing of dialyzer for each patient, use of erythropoietin in multi-dose vials for >1 patient. Lack of written crucial procedures Dialysis unit 5 76 patients on dialysis and all medical personnel (number unk) Detailed route of transmission was not identified. There were no breaches of procedures Department of Hematology and Oncology 8 unk 27-73; 63 4:4 Outbreak unconfirmed - Hepatitis C detected in patients receiving chemotherapy on the same hospital ward 2013 CT&MRI diagnostic center 9 22 out of 28 patients examined on the same day 34-69; 64 4:1 2 0% unk 34-75; 66 5:4 1b (in one patient, in the rest unk 1 ) 1 subtype undetermined 37% unk 67% Probably patient HCV(+) examined on the same shift Known or suspected route of transmission and contributing factors: Via set for contrast media for CT & MRI injector - multiple use of disposable sets. Failure to change gloves between patients, lack of compliance with essential procedures at worksites. 1 HCV-RNA was positive in all patients in whom HCV genotype was not determined or unknown for authors

35 No 3 Hepatitis C outbreaks in Poland 469 C (acute or recent hepatitis C) was made on a basis of symptoms or elevated transaminase activity and detection of HCV RNA (in all 26 infected women). Suspicion of hepatitis C outbreak on hematology and oncology ward was made following the detection of anti- HCV in 8 patients of this ward receiving chemotherapy within a few months preceding the detection of HCV, in most cases on the same ward. As many as three patients presented with the symptoms of acute hepatitis or significantly elevated transaminase activity which allowed for the initial diagnosis of acute hepatitis C. Presence of other exposures reported in the incubation period of the disease, the lack of molecular confirmation of infection with the same strain of the virus, the absence of information on genotype in the majority of patients and detection of anti-hcv prior to the initiation of chemotherapy in one patient (a possible source of infections) however, did not allow for confirming the outbreak. Sequencing of HCV to confirm the infection with the same strain was not performed in any of the described outbreaks. In three outbreaks, all patients were infected with the same HCV genotype (G1 or G2) and other exposures to infection within the incubation period were excluded. The source of infection was indicated only in one outbreak (chronically infected patient). Sequencing of virus allowing for confirming a common source of infection for all infected persons in the outbreak, however, was not performed. Chronically infected patients, whose status was known previously (12 HCV positive persons in one unit, no data on the number of infected dialysis patients in the second unit), were also a probable source of infection in outbreaks reported in dialysis units. In none of these outbreaks, a common source of new infections was identified. In case of two outbreaks, a probable mechanism of infection transmission was specified, i.e. in CT department and dialysis unit in 2006 (Tab. II). In dialysis station, however, a number of breaches were established (multiple use of disposable needles, syringes and capillary tubes for ionometer, failure to change dialyzers between patients, use of erythropoietin in multi-dose vials for more than one patient and injecting the remaining blood used to test the electrolyte back to the line, no separate stands for patients previously infected with HCV) which could lead to infection transmission between patients. In the chelation therapy-related outbreak, intravenous infusions of an unknown agent was the only exposure identified. Neither the exact mechanism of transmission (e.g. use of multi-dose packages for several patients, multiple use of disposable equipment etc.) nor the source of infection (lack of access to the investigation report), however, could be determined. In all outbreaks reported in healthcare settings except for one (dialysis unit, 2011), numerous breaches of standards were identified which could lead to infection transmission between patients. DISCUSSION All of the identified acute hepatitis C outbreaks were related to medical procedures, including the outbreak reported in alternative medicine center, in which intravenous infusions were administered without adherence to safety standards. Results of inspections carried out in healthcare settings reported to be the places of exposure showed, to a large extent, the lack of developed procedures or lapses in existing procedures which confirms the possibility of HCV patient-patient transmission. Although the precise determination of the mechanism of transmission is not possible, collected data allow for making some hypotheses. According to the available information, the infections probably occurred most frequently due to human error resulting from the lack of adequate training of the personnel to operate specialist equipment (dialysis station, 2006) or deliberate omission of known procedures (Gyn. ward, CT). The latter may occur particularly with regard to the use of disposable equipment which does not have a visible contact with the patients blood (e.g. contrast administration set, syringes, gloves). Only in one case (dialysis station, 2011), no breaches in existing procedures was established. Outbreaks described were associated with procedures of documented risk of HCV infection - in dialysis units, in connection with invasive surgical procedures or injections performed without compliance with safety standards (12-17). Both registered outbreaks in healthcare settings as well as the percentage of acute cases reporting medical procedures as a route of transmission in the surveillance (over 60%) indicate that problem of healthcare-related HCV infections in Poland remains still unresolved. In the recent years, publications appear which indicate that the number of healthcare-acquired HCV infections in the European countries may be considerably higher (4, 7, 18-20) compared to the above-cited ECDC data. Having considered underestimated European data, however, Poland still stands out negatively against other EU countries. Due to the risk of HCV infection which is present even in case of minor procedures accompanied by skin or mucous injury, there is a necessity to remind of the strict compliance with the existing safety standards in all medical and non-medical settings in which procedures accompanied by skin injury are performed and to periodically verify the knowledge and compliance with the existing procedures by the personnel. In several cases, transmission was related to use of rather

36 470 Małgorzata Stępień, Magdalena Rosińska No 3 complex equipment, usually by the mid-level personnel. Basic training on the risk of blood-borne infections usually focuses on the safety of injections. Thus, it may not be adequate with regard to more complex medical devices. Lack of awareness and/or competence of the personnel indicates the need for a more precise risk assessment by nosocomial infection control teams and carrying out specific trainings tailored to the procedures performed in a defined unit. A certain limitation of the present review of outbreaks results from the difficulties to determine a clear definition of acute hepatitis C. Due to the asymptomatic course, most of acute cases remain undetected, however, the presence of symptoms and/or a significant increase of transaminase activity at the time of the first positive anti-hcv test result still do not provide a sufficient basis for diagnosis of acute hepatitis C (21). The only accepted criteria for the diagnosis of acute hepatitis C are: documented HCV seroconversion (in case of prior negative test result within the last 6-12 months) or detection HCV RNA or HCV core antigen with simultaneous lack of anti-hcv antibodies (detection of infection in the window period) (8). To meet the first of these criteria, regular anti-hcv testing should be performed. In Poland, however, it is carried out in an organized manner only in case of chronic dialysis patients. To detect infections in the window period, it is necessary to perform HCV RNA testing regardless of the anti-hcv test result (blood donors testing or, less frequently, in cases suspected of HCV infection with a known exposure). Other registered cases of acute hepatitis C, diagnosed based on clinical symptoms of acute hepatitis and/or significant ALT elevation should be considered as probable acute hepatitis C cases. Review of hepatitis C outbreaks in Poland revealed limitations with regard to the possibility of full confirmation of link between detected cases, especially concerning molecular confirmation of genetic relatedness between isolates. Lack of molecular analysis may explain the absence of outbreaks associated with exposures different from healthcare-related ones. In case of infections associated with individual exposure e.g. injection drug use, it is very difficult to determine a common exposure or transmission between individuals. Moreover, despite the high number of acute cases registered in surveillance system, in which healthcarerelated procedures were reported to be the only exposure during the incubation period of disease (62% of acute hepatitis C cases in , in which probable route of transmission was specified, Fig. 2), the majority of cases were classified as sporadic, not linked with other cases. Active searching for cases was carried out only if two or more acute cases with common exposure during incubation period were detected, most frequently occasionally. Therefore, it should be assumed that the actual number of outbreaks associated with medical procedures was higher, however, their detection was impossible due to failure to detect and register persons with asymptomatic HCV infection. Lack of the use of molecular methods in the surveillance applies also to the registered outbreaks. Out of six described outbreaks, virus genotype was determined only in three outbreaks (subtype was established only in one of them). Sequencing was not performed in any of them % Invasive medical procedures, dialysis Minor medical procedures PWID Tattooing/piercing or beauty treatments Occupational exposure HCV-infected sexual partner or householder Vertical transmission Other Unknown Fig 2. Acute hepatitis C in Poland in Percentage of probable routes of transmission of HCV in acute hepatitis C cases. Fig 2. Acute Source: hepatitis Case-based C in reports Poland collected in in routine mandatory Percentage surveillance of probable system routes of transmission of HCV in acute hepatitis C cases. Source: Case-based reports collected in routine mandatory surveillance system

37 No 3 Hepatitis C outbreaks in Poland 471 Situation described above may result from the fact that genotyping and, possibly, viral sequencing are ordered in Poland by clinicians in patients under specialist care, and the knowledge of genotype and viral sequence does not influence the therapeutic decisions in acute hepatitis C. Knowledge of HCV sequences is an added value in the epidemiological surveillance as it allows for indicating the geographical origin of the virus, examining the virus circulation depending on the route of transmission, changes in its virulence and the time of infection (22-24). Phylogenetic analysis may assist in determining the route of transmission if it is unknown or confirming the common source of infection (25). Analysis of surveillance data also revealed the lack of a common protocol of outbreak investigation. A common element of investigations consist in controlling the compliance with the existing procedures in healthcare settings. However, there is a lack of description of activities carried out to identify the source of infection or specify a group of people exposed. Having indicated the limitations of the surveillance system, however, it should be noted that current hepatitis C surveillance methods allow for detecting new outbreaks, which indicates the improvement of surveillance sensitivity. Outbreaks identified on a basis of publications occurred in 2003, i.e. prior to the implementation of the case definition used in the routine surveillance in the EU countries and before introduction of a uniform epidemiological questionnaire. CONCLUSIONS Detected outbreaks of acute HCV infections confirm that healthcare-related procedures accompanied by skin injury are an important source of new HCV infections in Poland. In the majority of cases, a detailed mechanism of transmission remains undetermined, however, in a half of detected outbreaks unsafe injections practices were indicated. Numerous breaches of existing procedures indicate a need to strengthen the monitoring of compliance with procedures and continuous education of personnel with regard to the current recommendations. Epidemiological investigations conducted in HCV outbreaks should be extended by molecular analysis of isolated viruses. There is also a need for training concerning outbreak investigation, firstly, in point source outbreak in healthcare settings. Acknowledgements The authors would like to acknowledge the colleagues from the PSES in Poznań, PSES in Wroclaw, MPMC in Gdynia and DSES in Gdańsk for providing the results or reports of epidemiological investigations conducted in HCV outbreaks. REFERENCES 1. WHO, Hepatitis C Fact sheet N 164, updated April Esteban JI, Sauleda S, Quer J. The changing epidemiology of hepatitis C virus infection in Europe. J Hepatol. 2008;48: Strader DB, Wright T, Thomas DL, et al. American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004;39: Santantonio T, Medda E, Ferrari C, et al. Risk factors and outcome among a large patient cohort with community-acquired acute hepatitis C in Italy. Clin Infect Dis 2006;43: Delarocque-Astagneau E, Pillonel J, De Valk H, et al. An incident case-control study of modes of hepatitis C virus transmission in France. Ann Epidemiol. 2007;17: Ackerman Z, Ackerman E, Paltiel O. Intrafamilial transmission of hepatitis C virus: a systematic review. J Viral Hepat. 2000;7: Pérez-Álvarez R, García-Samaniego J, Solá R, et al. Acute hepatitis C in Spain: a retrospective study of 131 cases. Rev Esp Enferm Dig. 2012;104: European Centre for Disease Prevention and Control. Hepatitis B and C surveillance in Europe Stockholm: ECDC; Commission of the European Communities. Commission Decision of 28/IV/2008 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. Available at: com/docs/1589_2008_en.pdf 10. Cianciara J, Jabłońska J, Horban A, et al. Epidemic outbreak of acute hepatitis C--clinical course, histology and effectiveness of therapy. Przegl Epidemiol. 2005;59: Polish. 11. Rorat M, Jurek T, Szleszkowski L, et al. Outbreak of hepatitis C among patients admitted to the Department of Gynecology, Obstetrics, and Oncology. Am J Infect Control. 2014;42:e7-e Savey A, Simon F, Izopet J, et al. A large nosocomial outbreak of hepatitis C virus infections at a hemodialysis center. Infect Control Hosp Epidemiol. 2005;26: Rao AK, Luckman E, Wise ME, et al. Outbreak of hepatitis C virus infections at an outpatient hemodialysis facility: The importance of infection control competencies. Nephrol Nurs J. 2013;40:101-10, Quer J, Esteban JI, Sánchez JM, et al. Nosocomial transmission of hepatitis C virus during contrast-enhanced computed tomography scanning. Eur J Gastroenterol Hepatol. 2008;20: Pañella H, Rius C, Caylà JA; Barcelona Hepatitis C Nosocomial Research Working Group. Transmission of

38 472 Małgorzata Stępień, Magdalena Rosińska No 3 hepatitis C virus during computed tomography scanning with contrast. Emerg Infect Dis. 2008;14: Silini E, Locasciulli A, Santoleri L, et al. Hepatitis C virus infection in a hematology ward: evidence for nosocomial transmission and impact on hematologic disease outcome. Haematologica. 2002;87: Massari M, Petrosillo N, Ippolito G, et al. Transmission of hepatitis C virus in a gynecological surgery setting. J Clin Microbiol, ;39: Martinez-Bauer E, Forns X, Armelles M, et al. Hospital admission is a relevant source of hepatitis C virus acquisition in Spain. J Hepatol, 2008;48: Gerlach JT, Diepolder HM, Zachoval R, et al. Acute hepatitis C: high rate of both spontaneous and treatmentinduced viral clearance. Gastroenterology. 2003;125: Wiegand J, Buggisch P, Boecher W, et al; German HEP- NET Acute HCV Study Group. Early monotherapy with pegylated interferon alpha-2b for acute hepatitis C infection: the HEP-NET acute-hcv-ii study. Hepatology. 2006;43: Hajarizadeh B, Grebely J, Dore GJ. Case definitions for acute hepatitis C virus infection: a systematic review. J Hepatol. 2012;57: Simmonds P. Genetic diversity and evolution of hepatitis C virus--15 years on. J Gen Virol. 2004;85: Jackowiak P, Kuls K, Budzko L, et al. Phylogeny and molecular evolution of the hepatitis C virus. Infect Genet Evol. 2014;21: Magiorkinis G, Magiorkinis E, Paraskevis D, et al. The Global Spread of Hepatitis C Virus 1a and 1b: A Phylodynamic and Phylogeographic Analysis. PLoS Med. 2009; 6(12):e Spada E, Abbate I, Sicurezza E, et al. Molecular epidemiology of a hepatitis C virus outbreak in a hemodialysis unit in Italy. J Med Virol. 2008;80: Received: Accepted for publication: Address for correspondence: Małgorzata Stępień Department of Epidemiology National Institute of Public Health- National Institute of Hygiene Chocimska 24, Warsaw mstepien@pzh.gov.pl tel.:

39 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Piotr Grabarczyk, Aneta Kopacz, Ewa Sulkowska, Dorota Kubicka-Russel, Maria Mikulska, Ewa Brojer, Magdalena Łętowska BLOOD DONOR SCREENING FOR BLOOD BORN VIRUSES IN POLAND Institute of Haematology and Transfusion Medicine, Warsaw, Poland ABSTRACT Blood donor screening of viral markers in Poland is based on serologic testing for anti-hcv, HBsAg, anti- HIV1/2 (chemiluminescence tests) and on nucleic acid testing (NAT) for RNA HCV, RNA HIV-1 and DNA HBV performed in minipools of 6 with real-time PCR (MPX 2.0 test on cobas s201) or with TMA in individual donations (Ultrio Plus or Ultrio Elite). Donors of plasma for anti-d and anti-hbs production are tested for parvovirus B19 DNA. Before implementation tests and equipment are evaluated at the Institute of Hematology and Transfusion Medicine (IHTM). The last 20 years witnessed a decreasing trend for HBsAg in both first time and repeat donors (1% - 0.3% and 0.1% % respectively). Prevalence of anti-hcv repeat reactive results was stable and oscillated around 0.8% for first time donors and 0.2% for repeat donors. Elevated prevalence of seropositive HIV infected donors was recently observed (7.5-9 cases/100,000 donors). Since respective molecular markers implementation HCV RNA was detected on average in 1/119,235 seronegative donations, HIV RNA in 1/783,821 and HBV DNA in 1/61,047. HBV NAT yields were mostly occult hepatitis B (1/80,248); window period cases were less frequent (1/255,146). The efficiency of HBV DNA detection depends on the sensitivity of the HBV DNA screening system. Key words: hepatitis B virus, hepatitis C virus, human immunodeficiency virus, parvovirus B19, blood donor screening, NAT ABBREVIATIONS: B19V parvovirus B19, BTC Blood Transfusion Center, IDT individual donation testing, IHTM Institute of Haematology and Transfusion Medicine, LOD limit of detection, MP minipool; MP6, MP24, MP48 minipool from 6, 24 or 48 donations; NAT nucleic acid testing, OBI occult hepatitis B, RR repeat reactive, ssdna single stranded DNA, TMA transcription mediated amplification, WP window period. In the recent years transfusion safety has undergone significant improvement. The progress is mainly related to implementation of nucleic acid testing (NAT). The first section of the article briefly describes the Polish experience in donor screening for blood born viruses with special focus on advancement in NAT technology, which is considered the key factor in blood transfusion safety. The second section of the article presents results of blood born virus testing in Poland. METHODOLOGY OF BLOOD DONOR SCREENING FOR BLOOD BORN VIRAL INFECTIONS IN POLAND Prevention of blood born virus transmission is based on specific serological and molecular viral marker testing. Up to 2012 all blood donors were tested for alanine transaminaze (ALT) while now such tests are no longer performed as molecular markers for HBV, HCV and HIV are screened. Serological testing for anti-hcv, anti-hiv -1/2 and HBsAg is now performed with fully automated systems based on chemiluminescence - Abbott Architect (Abbott, USA) and Vidas (Ortho, USA). Poland was one of the first countries to introduce NAT for blood donor screening. In 1999 molecular biology was implemented for HCV RNA screening in plasma for fractionation and for all blood donors in 2002 (1). HIV RNA testing was initiated in 2003 in blood transfusion centers which had implemented HCV screening with HCV/HIV1 Procleix assay (Chiron, United States). National Institute of Public Health National Institute of Hygiene

40 474 Piotr Grabarczyk, Aneta Kopacz et al. No 3 This first transcription mediated assay (TMA) based test was a duplex assay capable of detecting not only HCV RNA but also HIV RNA (2). In 2005, both HIV RNA and HBV DNA were listed as obligatory tests for viral markers in Poland (3). Right from the start NAT screening with PCR was performed in mini-pools (MP) and TMA was applied for individual donations (3). The mini-pools initially consisted of 48 donations and the number was reduced to 24 in PCR testing was initially performed with Cobas Amplicor and later with Cobas Ampliscreen (Roche, Germany). The nucleic acid isolation step was common for the tested markers in both tests and it was performed manually while amplification and amplicon detection steps with hybridization labeled probes were performed separately for different viruses using Cobas Amplicor Analyser (Roche, Germany). MP6 testing of minipools created by combining plasma from 6 donations (MP6) was implemented in 2007 together with real-time technique (Cobas Taqscreen MPX v.1 assay on MPX). Cobas Taqsceen MPX was a significant improvement which enabled isolation on a fully automated pippeting station (Microlab STAR, Hamilton, Switzerland). It was a truly multiplex assay, where amplification and amplicon detection were performed for several viruses simultaneously in a single tube with taq-man probes on Cobas s201 system. The evaluation performed at IHTM in 2012 demonstrated high sensitivity, good performance and increased operational efficiency of the subsequent version of the assay (MPX v2 test) as compared to the previous one. There was no longer the need for viral discriminatory testing which was the most significant difference between the two versions of the assay. Characteristic for the new version was higher analytical sensitivity. The 95% limits of detection (95% confidential limits) were evaluated for 2.87 IU/mL ( ), IU/mL ( ) and IU/mL ( ) for HBV, HCV and HIV-1 respectively. In this evaluation the Polish NAT yield cases were tested as well. The panel of such samples included most prevalent HBV (A, D and H) and HCV genotypes (1b, 3a and 4) and HIV-1 subtype B. The viral loads in individual donations ranged from 6.92 to 3.26x10 3 IU/mL for HBV, from 3.2x10 4 to 1.61x10 6 IU/ ml for HCV and from 1.17x10 2 to 5.61x10 5 IU/mL for HIV. Results were positive for all tested samples both neat and in 6-fold dilution. Invalid and false reactive pool rates were 0.05% and 0.127% respectively (4). In Poland the first triplex assay applying TMA technology was Procleix Ultrio assay (Chiron, United States), which was launched in 2005 for simultaneous screening for HCV, HBV and HIV-1 (2). In 2013 Procleix Ultrio Elite assay (Grifols, Spain) was implemented, which is equivalent to the previous assay version (Ultrio Plus assay) with the difference in primers and probes for HIV-2 detection. Unlike the Ultrio assay - both Ultrio Plus and Ultrio Elite assays use an additional reagent with concentrated lithium hydroxide which enhances disruption of HBV particles and release of ssdna for the target capture probe. All Ultrio versions target two regions of HIV-1 genome. The Ultrio Elite assay runs on Procleix Panther system, while the Ultrio and Ultrio Plus assays run on the Tigris instrument. In recent study the 50 and 95% limits of detection (LODs) for HBV using Ultrio Plus were 0.8 ( ) and 4.6 ( ) IU/mL, respectively, 2.4 ( )-fold more sensitive than Ultrio. The improvement factors on analytical sensitivity panels of HBV genotypes A to G ranged from 1.3 to 7.3 and 50% LODs (95% confidence interval) were increased from 12.5 (10-15) to 3.8 ( ) copies/ml. The improvement in analytical sensitivity translated into higher clinical sensitivity (5). In 10 thousand first time donors screened in 3 Regional Blood Transfusion Centers one Ultrio Plus HBV genotype D yield sample was found which had been missed by the Ultrio assay. According to estimates it was detected in Ultrio Plus with nine-fold higher sensitivity. The specificity of individual donation nucleic acid test (ID-NAT) reached 99.41%. 100% specificity was calculated using a repeat test algorithm (comparable to the algorithm used in serology screening) (5). In a separate analysis the results for two consecutive 18-month ID-NAT screening periods using the Ultrio and Ultrio Plus assay were compared. The significantly higher analytical sensitivity of the Ultrio Plus assay was translated into a 1.9 fold higher HBV-NAT yield in the Polish donor population, despite the fact that the HBsAg prevalence had decreased 1.5 fold (6). Further studies on TMA based assays demonstrated that LODs for HIV-1 and HCV were comparable for all TMA assay versions and addition of HIV-2 oligonuceotides to the Ultrio Elite assay does not affect the analytical sensitivity for other viruses, regardless of the genotype (7). SCREENING TESTING AND QUALITY CONTROL ORGANIZATION Nowadays donations from all over the country are screened in 21 Blood Transfusion Centers (BTCs) with serologic assays and NAT is performed on side or are commissioned to lab in another BTC. At the end of 2014 five labs tested individual donations with TMA and 12 performed NAT with real-time PCR in minipools of 6. All repeat reactive (RR) samples are sent to reference lab for confirmatory testing. Subsequent procedure for both serology and NAT screening repeat reactive samples includes testing of individual donations with methods alternative to screening TMA or PCR and confirmatory (HIV Western blot) or suplemental (HCV

41 No 3 Blood donors screening for blood born viruses in Poland 475 Western blot, anti-hbc, anti-hbs) serological marker analysis. HBsAg RR donations are tested for HBV DNA and/or with neutralization test. Since implementation of NAT in Poland the quality control system has been largely extended to include: validation of every new assay prior to implementation (performed at IHTM); evaluation and revalidation of all procedures used at BTC; laboratory audits (at least every two years); attendance in external quality programs (VQC Amsterdam, QCMD Glasgow, Labquality Helsinki); daily external quality control (EDC-NET); analysis of results for internal control (IC), analysis of false positive and false negative results; automatic equipment and system validations, control of storage and transportation conditions for samples and reagents (e.g. temperature monitoring); qualification of reagents and disposables and batch release. Every day the same control samples are tested in all donation-testing laboratories with the specific screening method. Results are then introduced by on-line software and can be compared using standard deviation, mean value and other more sophisticated statistical methods. In Poland, Parvovirus B19 (B19V) DNA testing is obligatory for donors who donate plasma for anti- D and anti-hbs production as well as cells used for immunization. B19V polymorphism is significant for the clinical sensitivity of screening assays (8, 9). It is worth to stress that genotype 2 has been identified in Poland (10) and in the neighboring countries (11, 12). It is often undetected or undetected by home made and commercial assays. Special attention has therefore been paid to evaluation of clinical sensitivity for all known virus genotypes. According to our findings the DPX test (Roche, Germany) widely used in Poland allows to accurately identify donations infected with B19V genotypes 1-3 and in consequence to prevent effectively contamination of plasma production pools with B19V DNA titers exceeding the level (>10 4 IU/mL) as recommended by the European Pharmacopeia (13). As false negative or invalid results of Parvovirus B19 DNA tests performed with real-time PCR in high viraemic samples were reported, fluorescence diagram analysis and algorithm of positive result confirmation with the purpose of excluding such phenomenon was proposed (14). Handling of such cases is monitored through regular quality control examinations performed on sample panels designed and prepared by IHTM. RESULTS OF VIRAL SCREENING For two decades, a decreasing tendency for HBsAg has been observed both for - first time and repeat Polish blood donors. In the former group the prevalence Table I. NAT yields frequency in Poland: a/hbv ( ); b/hcv ( ) and c/hiv ( ). A. Method IDT MP6 MP8 MP24 TMA R-t PCR TMA PCR In total Sensitivity U: 12 MPXv1: 22 (95% LOD, IU/mL) UP, UE: 4 MPXv2: 14 UP: 24 Ampliscreen: 360 No of donations tested 3,426,077 4,548, ,447 1,554,270 9,950,705 WP :148,960 1:324,922 1:777,135 1:255,146 OBI :58,069 1:77,100 1:210,724 1:388,568 1:80,248 HBV DNA :41,781 1 :62,314 1 :210,724 1:259,045 1:61,047 IDT MP6 MP8 MP24 MP48 B. Method Total TMA R-t PCR TMA PCR PCR Sensitivity Prociex : 6.2 MPXv1: 22 UP: 24.8 Ampliescreen:504 Amplicor: 2400 (95% LOD, IU/mL) U, UP, UE: 3.0 MPXv2: 14 No of donations tested 3,665,048 4,548, ,447 1,554,270 3,403,142 13,592, HCV RNA frequency 1:166,593 1:168,478 1:140,482 1:141,297 1:66,728 1:119,235 IDT MP6 MP8 MP24 C. Method Total TMA R-t PCR TMA PCR Procleix: 44.5 Sensitivity MPX1: 294 U: 27.6 UP: 289 Ampliscreen: 2400 (95% LOD, IU/mL) MPX2: 277 UP,UE: 28.6 No of donations tested 3,665,048 4,548, ,447 1,554,270 10,189,676 HIV RNA Frequency 1:523,578 1:1,137,228 1:210,723 1:783,821 Abbreviations of the tests names: U Ultrio, UP Ultrio Plus, UE Ultrio Elite

42 476 Piotr Grabarczyk, Aneta Kopacz et al. No 3 approximated 1% in 1994, and was decreasing in latter years reaching about 0.3% in The improvement was mainly due to the vaccination program launched in the 80-ties (15). In 2013 a drop from 0.6% to 0.3% was reported which is most likely related to the fact that the fully vaccinated young people started to join the population of blood donors. It is noteworthy that blood donation in Poland is mostly dependant on young people. In the 90-ties HBsAg incidence slightly exceeded 0.1% of repeat blood donors, whereas now in this group of donors we register no more than several infection cases per year. HBV DNA is relatively frequent in blood donors (Table I). Most cases are occult hepatitis B (OBI) 1/80,248 donations. This is the echo of one of the highest HBV incidence rates in Europe (45 per 100,000) observed in Poland in the mid-80thies (15). Window period (WP) cases are less frequent - 1/255,146. As stated previously the effectiveness of screening HBV DNA NAT depends on the sensitivity of the system used (16). Present analysis on a larger number of donations confirmed the frequency to be significantly (p<0.05, several fold) higher for both WP and OBI as compared to MP of 24 donations with IDT and MP of 6. This can be explained by a relatively slow doubling time for HBV resulting relatively long window period. Infection detection in this phase greatly depends on the sensitivity of the screening system (17). It is worth noting that HBV genotype A2 (80%) is predominant in HBsAg positive donors in Poland whereas genotype D is in minority (20%) (18). However a different distribution of genotypes in OBI donors (60% genotype D, 35% genotype A, and occasional genotype H infection cases) was observed (19). Genotype D strains were significantly more substituted than genotype A2 strains potentially affecting the course of infection (18). HCV epidemiology changes based on donors screening in Poland seems to be less optimistic as compared to HBV. Prevalence of repeat reactives for the period oscillated around 0.8 and 0.2% for first time and repeat blood donors respectively and did not reflect significant improvement. HCV RNA is detected in one per 119,235 donations on average and there is no significant overall difference related to the higher or lower analytical sensitivity of the system used. The explanation lies in the shorter doubling time as compared to HBV and thus lower significance of the screening systems for NAT yields detection efficiency. During the first several years following implementation of HCV RNA screening there appeared records of an unexpectedly high frequency of genotype 4 and subtype 3a and low frequency of subtype 1b in window period (WP) donors as compared to anti- HCV-positive persons (1). Thirty six percent (36%) of HCV infected seronegative donors exhibited subtype 1b, whereas subtypes 3a and 4c/d were identified in 40% and 14 % respectively. The distribution of genotypes was different than in anti-hcv-positive donors and CHC patients with chronic hepatitis where the frequency of subtype 1b was significantly higher (75.7 and 85.3%, respectively). The differences in distribution of genotypes in early-phase and chronically-infected donors are most likely due to different natural history of HCV polymorphic forms and recent changes in HCV infection routes related to genotypes. Previously transfusion of infected donations and other hospital procedures were believed to be main infection routs of transmission. But our last statistical analysis of epidemiologic factors independently associated (p<0.05) with recent HCV infection revealed: accidental exposure to blood, tattooing, injection and/ or non-injection drugs, two and more sexual partners within 6 months before donation and sharing shaving razor/ toothbrush (20). Since NAT implementation for HCV RNA up to the end of 2014 one transfusion transmitted hepatitis C case was described in Poland. It was reported in 2007 for a recipient of red blood cell concentrate from a regular blood donor who was HCV RNA negative in routine mini-pool (48 donations) screening (21). Although Poland is a low endemic area for HIV, a slight elevation of HIV infection frequency has been observed since 2009 and the recent level is 7-9 per 100,000 donors. A similar rule of distribution in first time and repeat blood donors was observed for seropositive HIV cases as for anti-hcv and HBsAg. Prevalence of the markers was significantly higher in the former category of blood donors as compared to the latter. Nowadays however a similar frequency for anti-hiv confirmed donors is observed in both donor groups. This may be explained by the phenomenon of test seekers in the population of blood donors. In spite of comparing to other European countries good epidemiological situation relatively high number of HIV NAT yields have been registrated. Up to the end of 2014 thirteen (13) such cases have been identified in 10 million donations. In four cases genetical polymorphism was analyzed and subtype B was identified (22). Acknowledgments We thank our colleagues from the Institute of Hematology and Transfusion Medicine and from the Regional Blood Transfusion Centers for excellent cooperation in routine collection of the data. We appreciate Ms Krystyna Dudziak for support in manuscript preparation and Ms Natalia Parda for translation. REFERENCES 1. Brojer E, Gronowska A, Medynska J, et al. The hepatitis C virus genotype and subtype frequency in hepatitis C

43 No 3 Blood donors screening for blood born viruses in Poland 477 virus RNA-positive, hepatitis C virus antibody-negative blood donors identified in the nucleic acid test screening program in Poland. Transfusion 2004; 44(12): Grabarczyk P MJ, Liszewski G, Kubicka-Russel D SE, et al. HCV RNA and HIV RNA detection by Procleix HIV 1/HCV Assay in blood donors with various results of anti-hcv and anti-hiv EIA. J.Transf. Med. 2009; 1(1): Roth WK, Busch MP, Schuller A, et al. International survey on NAT testing of blood donations: expanding implementation and yield from 1999 to Vox Sang. 2012; 102(1): Grabarczyk P, Kopacz A, Liszewski G, et al. Evaluation of the Roche Cobas (R) TaqScreen MPX Test, Version 2.0, for HCV RNA, HIV RNA and HBV DNA screening of blood donors. Transfusion 2012; 52: 219A-A. 5. Grabarczyk P, van Drimmelen H, Kopacz A, et al. Head-to-head comparison of two transcription-mediated amplification assay versions for detection of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus Type 1 in blood donors. Transfusion 2013; 53(10): Kopacz A, Gdowska J, Górska J, et al. Sensitivity of the Ultrio and Ultrio Plus assay versions in detecting window period and occult hepatitis B infection in Polish blood donors. Vox Sang. 2013; 105: Grabarczyk p,koppelman M, Boland F, et al. Inclusion of human immunodeficiency virus type 2 (HIV-2) in a multiplex transcription mediated amplification assay does not affect detection of HIV-1 and hepatitis B and C virus genotypes: A multi-center performance evaluation study. Transfusion 2015 [in press] 8. Baylis SA, Buchheit KH. A proficiency testing study to evaluate laboratory performance for the detection of different genotypes of parvovirus B19. Vox Sang. 2009; 97(1): Baylis SA, Fryer JF, Grabarczyk P. Effects of probe binding mutations in an assay designed to detect parvovirus B19: Implications for the quantitation of different virus genotypes. J. Virol. Methods 2007; 139(1): Grabarczyk P, Kalińska A, Kara M, et al. Identification and characterization of acute infection with parvovirus B19 genotype 2 in immunocompromised patients in Poland. J. Med. Virol. 2011; 83(1): Liefeldt L, Plentz A, Klempa B, et al. Recurrent high level parvovirus B19/genotype 2 viremia in a renal transplant recipient analyzed by real-time PCR for simultaneous detection of genotypes 1 to 3. J. Med. Virol. 2005; 75(1): Eis-Huebinger AM, Reber U, Edelmann A, et al. Parvovirus B19 Genotype 2 in blood donations. Transfusion 2014; 54(6): Grabarczyk P, Kopacz A, Liszewski G, et al. Evaluation of the Roche Cobas Taqscreen DPX test for parvovirus B19 DNA genotypes detection in blood donors. Vox Sang. 2013; 105: Grabarczyk P, Kalinska A, Sulkowska E, et al. False negative results in high viremia parvovirus B19-samples tested with real-time PCR. Pol. J. Microbiol. 2010; 59(2): Magdzik W CM. [Coverage of vaccination against hepatitis B in Poland in 2004]. Przegl. Epidemiol. 2006; 66 (20): G.Liszewski, A.Kopacz, P.Grabarczyk, et al. [Frequency of HBV DNA, HCV RNA and HIV RNA in blood donors - effectiveness of different screening systems.]. In: XXIII PTHiT Congress. Acta Haematol. Pol. 2009; P Kleinman SH, Lelie N, Busch MP. Infectivity of human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus and risk of transmission by transfusion. Transfusion 2009; 49(11): Grabarczyk P, Garmiri P, Liszewski G, et al. Molecular and serological characterization of hepatitis B virus genotype A and D infected blood donors in Poland. J. Viral. Hepat. 2010; 17(6): Grabarczyk P. Study on polymorphism of the transfusion transmitted viruses in Poland hepatitis B virus (HBV) and parvovirus B19 (B19V). J.Transf.Med. 2011; 4, 2: Grabarczyk P, Czerwinski M, Rosinska M, et al. Risk factors for infection among recently HCV infected blood donors in Poland. Vox Sang. 2013; 105: Grabarczyk P, Gronowska A, Brojer E, et al. Sequence analysis confirmation of transfusion-transmitted hepatitis C by red blood cells that tested negative by minipool hepatitis C virus nucleic acid testing. Transfusion 2007; 47(6): Manak M, Sina S, Anekella B, et al. Pilot studies for development of an HIV subtype panel for surveillance of global diversity. AIDS Res. Hum. Retrovir. 2012; 28(6): Received: Accepted for publication: Address for correspondence: Piotr Grabarczyk, PhD Institute of Hematology and Transfusion Medicine, Department of Virology, 14 Indiry Gandhi Str Warsaw, Poland; pgrabarczyk@ihit.waw.pl

44 ERRATA In the article entitled Measles in Poland in 2013 authored by J. Rogalska, which was published in the Epidemiological Review 2015; 69(2), pp , tables and figure were not inserted. Omitted tables and figure are presented below (page 452 and page 478). Fig 1. Measles surveillance performance in Poland Number of cases Year Confirmed cases Suspected cases % Indicator of surveillance sensitivity Fig 1. Measles surveillance performance in Poland

45 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Agata Zajkowska 1, Adam Garkowski 1, Piotr Czupryna 1, Anna Moniuszko 1, Monika Emilia Król 1, Jacek Szamatowicz 2, Sławomir Pancewicz 1 SEROPREVALENCE OF PARVOVIRUS B19 ANTIBODIES AMONG YOUNG PREGNANT WOMEN OR PLANNING PREGNANCY, TESTED FOR TOXOPLASMOSIS 1 Department of Infectious Diseases and Neuroinfection, Medical University of Bialystok 2 Department of Gynecology, Medical University of Bialystok ABSTRACT INTRODUCTION AND OBJECTIVE. Acute parvovirus B19 (B19V) infection is a proven risk for pregnant women and fetus. The aim of this study was to determine the prevalence of B19V antibodies among pregnant women or planning pregnancy, who were referred for preventive toxoplasmosis screening. MATERIAL AND METHODS. Between , 55 women in the age between 21 and 40 years were tested for both B19V IgG and IgM antibodies and sociodemographic information was collected. RESULTS. Among the study group, the mean age was 30 years, 43.6% of women were positive only for B19V IgG antibodies, 9% were positive for both B19V IgG and IgM antibodies and 11% were positive only for B19V IgM antibodies. Women negative for B19 IgG antibodies (47.3% ) were considered as a high-risk group of B19V viremia. The serological profile indicating infection with Toxoplasma gondii was considered as a risk factor for fetal distress. The T. gondii IgG antibodies were detected in 51% cases, in 32.7% antibodies were positive for both IgG and IgM, while in 16.3% cases both IgG and IgM were negative. CONCLUSIONS. B19V infection and overlapping of other independent risk factors during pregnancy pose a significant hazard to fetus during development. Therefore, we recommend further broadening the epidemiological database of B19V infection prevalence among women. B19V infection should be taken into account during differential diagnosis as a cause of miscarriage. Key words: Parvovirus B19, seroprevalence, pregnancy, toxoplasmosis, Toxoplasma gondii INTRODUCTION Parvovirus B19 (B19V) belongs to the genus Erythrovirus and the family Parvoviridae. It contains a single-stranded DNA and consists of about five thousand nucleotides. The small capsid is composed of two structural proteins, viral protein 1 (VP-1) viral protein 2 (VP-2) and one non-structural protein (NS-1), which may be responsible for transactivation of proinflammatory cytokines (1, 2). The infection is transmitted predominantly via the droplet route, however transmission via contaminated blood products also has been reported (3). The clinical manifestations of B19V infection vary greatly and depend on the age, hematologic and immunologic status. Most cases of B19V infection are asymptomatic. In healthy immunocompetent children the most common clinical presentation of infection is erythema infectiosum, (also called fifth disease), a mild febrile illness with rash (4). In adults it may cause clinically significant arthropathy (2, 5) Due to the tropism of B19V to erythroid progenitor cells, infection can cause transient aplastic crisis in individuals with a history of hematologic abnormalities, including increased destruction of red cells and decreased red cells production (2, 4). B19V infection in a pregnant woman, followed by transplacental transmission to the fetus, may lead to fetal anaemia, miscarriage, nonimmune hydrops fetalis or even fetal death in utero (2). The risk of infection of pregnant women is about 3-3.8%, but varies across the community groups (primary school teachers - risk of 16%) (5, 6). The vertical transmission of B19V occurs in about one third of women infected during pregnancy. Consequently, in the first trimester the risk of fetal loss is 5-10%, while in the second trimester is about National Institute of Public Health National Institute of Hygiene

46 480 Agata Zajkowska, Adam Garkowski et al. No %. It is considered that up to 20% nonimmune hydrops fetalis may be caused by B19V (7). Moreover, it has been estimated that upwards of 3,000 pregnancies annually may be lost in the European Union and the United States due to B19V infection, based on an infection rate of 0.1% and a susceptible cohort of over 3 million pregnancies involving seronegative females (8). In Poland, the risk of some infections during pregnancy, such as B19V infection, and the accurate epidemiological situation seems not to be fairly well estimated. The aim of the study was to evaluate the seroprevalence of B19V infection among young pregnant or planning pregnancy women, who were referred for preventive toxoplasmosis screening. MATERIAL AND METHODS The study was conducted among women referred to the Department of Infectious Diseases and Neuroinfections of the Medical University of Białystok and the outpatient Epizootic Diseases Clinic of the University Clinical Hospital in Białystok in order to perform screening testing for toxoplasmosis in years The study was performed among pregnant women or planning pregnancy. The study group consisted 55 women. The age was the inclusion criteria of the studied group. The following data were analyzed: the current state (pregnant/not-pregnant), number of pregnancies, number of births, pregnancy failure and the need for prevention of congenital toxoplasmosis. In the case of suspected acute toxoplasmosis of pregnant women or fetal infection, patients were directed immediately to the Department of Fetal-Maternal Medicine and Gynecology in Łódź. In the study group, none of the women did not present any clinical signs of B19V infection, and did not have a history of contact with a sick person. Testing for toxoplasmosis was the reason for the admission to the Department or outpatient clinic. Suspected of being infected with T. gondii was treated as an independent risk factor and B19 infection as a separate risk factor studied in the same pregnant. Blood samples were taken from the basilic vein. After centrifugation, serum specimens were screened for Toxoplasma gondii IgG and IgM antibodies by the commercial AxSYM TOXO IgM and TOXO IgG (Abbott Laboratories Abbott Park, IL USA). The same serum specimens were investigated for the presence of B19V IgG and IgM antibodies. Because most cases of B19V infection are usually asymptomatic we screened serum specimens for both IgG and IgM antibodies. Blood samples with hemolyzed blood, yellowish or lipemic were disqualified from the trial. The assays used to determine the presence of B19V antibodies were B19V IgM ELISA (Recombinant) and B19V IgG ELISA (Recombinant), DRG (Germany). RESULTS The study included 55 women aged between 21 and 40 years, the mean age was 30 years. Among the study group 40 women (72.7%) were pregnant during the diagnostic process (the median gestational age was 14 weeks), 11 (20%) were planning to become pregnant and 5 (9.1%) were after spontaneous abortions in the past (one woman from the last group was pregnant at the time). The serological profile indicating infection with T. gondii was considered as a risk factor for fetal distress. The IgG antibodies against T. gondii were detected in 28 cases (51%), in 18 cases (32.7%) antibodies were positive for both IgG and IgM, while in 9 cases (16.3%) both IgG and IgM were negative. In 15 cases (27.2%) the decision to start prophylaxis with spiramycin was made. The same sera specimens were examined for the presence of B19V IgG and IgM antibodies. The obtained data shows that 24 of surveyed women (43.6%) were positive only for B19V IgG antibodies, indicating permanent maternal immunity from a prior infection and no risk to fetus. 5 women (9.1%) were positive for both B19V IgG and IgM antibodies and thereby were at risk group of possible or ongoing infection. 6 women (11%) were positive only for B19V IgM antibodies, indicating ongoing active infection. Whereas 20 women (36.4%) were negative for both B19V IgG and IgM antibodies. These results may be sign that they had no previous contact with B19V. In total, B19 IgG antibodies were detected only in 29 sera (52.6%). Women (47.3%) who had no IgG antibodies were considered as high-risk group of B19V viremia. DISCUSSION B19V is a common infectious pathogen in humans worldwide. In temperate climates, the infection may occur throughout the year, however the peak incidence occurs in the period from late winter to early summer. Every 4-5 years there are cyclic small epidemics reported, most frequently related with school communities and the people in close contact with children (2, 9). The percentage of people with positive B19V IgG antibodies increases with age, however most individuals become infected during their school years (4). Patients with positive B19V IgG antibodies are generally immune to reinfection. However, in a study by Anderson et al., healthy seropositive volunteers were inoculated with B19V and one became viremic, indicating that reinfection is possible (10). Of particular interest is the infection of pregnant women who B19V can cause nonimmune hydrops

47 No 3 Seroprevalence of parvovirus B19 antibodies 481 fetalis or even fetal death. Such effect arises from the B19V tropism to P antigen cellular receptor on erythroid progenitor cells. Our study is the first published report of B19V infection prevalence among our local population. The results of the study point out the fact that over 36% of pregnant women, or planning to become pregnant, never had contact with B19V, which makes them a high-risk group of infection during pregnancy and occurrence of fetal complications. Siennicka et al. assessed the seroprevalence of B19V antibodies in the Polish general population. Their results shows that the seroprevalence of B19V infection in the general population of women in the age corresponding to our study group is similar and is over 60% (11). Our results do not differ significantly from the data reported in other European countries. In women, seroprevalence of B19V antibodies range from 58.6% (Finland) to 73.3% (Germany) (12, 13). These results are also similar to those obtained in the Sudan, where 61.4% of the participating women were positive for B19V IgG antibodies (14). In a German study, it was reported that among women of childbearing age increased seroprevalence was in those from households with two or more children (81.6%) and in women having contact with children aged <6 years at work (88.9%) (18). In the Polish study of 1,800 pregnant women, the prevalence of IgG anti-b19v was 35%, and serological features of acute parvovirosis was found in 13.5% of women (15). In another Polish study, IgM antibodies were detected in over 10% of serum samples (true positive) (16) Our study draw attention to another important issue which is the overlap of multiple independent risk factors for fetal infection. In our study, among women seronegative for B19V infection, four of them simultaneous required prophylaxis against toxoplasmosis It is difficult to prevent the transmission of B19V because the infection is usually asymptomatic and during the epidemics period exposure is common. Simple hygienic measures, such as handwashing and avoiding shared food, drinks or utensils are likely to prevent, at least partially, spread of B19V infection (9). CONCLUSIONS A significant percentage of positive tests (43% IgG) among the examined pregnant or planning on being pregnant women points to the circulation of B19V in the population, which - conjoined with other factors - poses threat to the life of fetus. The presence of IgM (11%) in the examined group accounts for the need of study on that together with refining the diagnostics of B19V infection as recommended. The given percentage of women who lack antibodies (16.3%) attests to the fact that this group is prone to infection - a factor which in correlation with other independent pregnancy risk factors poses a considerable threat to the life of fetus. The database extension on the occurrence of B19V infections among the pregnant or planning on being pregnant women is advised. REFERENCES 1. Moffatt S, Tanaka N, Tada K, et al. A cytotoxic nonstructural protein, NS1, of human parvovirus B19 induces activation of interleukin-6 gene expression. J Virol 1996; 70: Young NS, Brown KE. Parvovirus B19. N Engl J Med 2004; 350: Norja P, Lassila R, Makris M. Parvovirus transmission by blood products - a cause for concern? Br J Haematol 2012;159: Heegaard ED, Brown KE. Human parvovirus B19. Clin Microbiol Rev 2002;15: Rodis JF, Quinn DL, Gary GW Jr, et al. Management and outcomes of pregnancies complicated by human B19 parvovirus infection: a prospective study. Am J Obstet Gynecol 1990;163: Gratacós E, Torres PJ, Vidal J, et al. The incidence of human parvovirus B19 infection during pregnancy and its impact on perinatal outcome. J Infect Dis 1995; 171: Brown T, Anand A, Ritchie LD, et al. Intrauterine parvovirus infection associated with hydrops fetalis. Lancet 1984; 2: Daly P, Corcoran A, Mahon BP, et al. High sensitivity PCR detection of parvovirus B19 in plasma. J Clin Microbiol 2002; 40: Centers for Disease Control (CDC). Current Trends Risks Associated with Human Parvovirus B19 Infection. MMWR 1989; 38: Anderson MJ, Higgins PG, Davis LR, et al. Experimental parvoviral infection in humans. J Infect Dis 1985; 152: Siennicka J, Stefanoff P, Trzcińska A, et al. Seroprevalence study of parvovirus B19 in Poland. Przegl Epidemiol 2006; 60: Alanen A, Kahala K, Vahlberg T, et al. Seroprevalence, incidence of prenatal infections and reliability of maternal history of varicella zoster virus,cytomegalovirus, herpes simplex virus and parvovirus B19 infection in South-Western Finland. BJOG 2005; 112: Röhrer C, Gärtner B, Sauerbrei A, et al. Seroprevalence of parvovirus B19 in the German population. Epidemiol Infect 2008; 136: Adam O, Makkawi T, Reber U, et al. The seroprevalence of parvovirus B19 infection in pregnant women in Sudan. Epidemiol Infect 2015; 143: Marcinek P, Nowakowska D, Szaflik K, et al. Analysis of complications during pregnancy in women with serological features of acute toxoplasmosis or acute parvovirosis. Ginekol Pol 2008;7 9:

48 482 Agata Zajkowska, Adam Garkowski et al. No Siennicka J, Trzcińska A. Comparison of three enzyme immunoassays used to detect human parvovirus B19-specific IgM antibodies in sera of people suspected of measles. Med Sci Monit 2010; 16: BR Received: Accepted for publication: Address for correspondence: Adam Garkowski, Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Żurawia 14, Białystok , Poland adam.garkowski@gmail.com

49 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Katarzyna Kubiak 1, Marta Wrońska 2, Ewa Dzika 1, Małgorzata Dziedziech 2, Hanna Poźniak 2, Maria Leokajtis 2, Janusz Dzisko 3 THE PREVALENCE OF INTESTINAL PARASITES IN CHILDREN IN PRESCHOOLS AND ORPHANAGES IN THE WARMIA-MASURIA PROVINCE (NORTH-EASTERN POLAND) 1 Department of Medical Biology, University of Warmia and Mazury in Olsztyn 2 Laboratory of Epidemiological-Clinical Studies, Voivodeship Sanitary-Epidemiological Station in Olsztyn 3 State Sanitary Inspector in the Warmia and Masuria, Voivodeship Sanitary-Epidemiological Station in Olsztyn ABSTRACT OBJECTIVE. A comparison of the prevalence of intestinal parasites (IP) in preschoolers and orphans in the Warmia-Masuria province (Poland). MATERIAL AND METHODS. Between fecal samples and perianal swabs from 1052 preschoolers and 859 orphans were tested on the basis of direct saline and iodine mount, decantation test and the adhesive cellophane tape method. RESULTS. 10.8% of preschoolers and 46,3% of orphans were infected with IP. Among the six detected IP species the E. vermicularis was the most common. Infections of E. vermicularis were diagnosed in 9.5% of preschoolers and 36,7% of orphans. There were statistically significant differences in the distribution of IP between males and females in preschools. IP infections were the most frequent among 7-year-old children, 19.1% in preschools and 65.7% in orphanages, respectively. In preschools, the prevalence of IP was higher among preschoolers from the rural area (17.3%) than from the urban area (10.3%). CONCLUSION. Orphans and children from rural areas, especially at the age of 7, should be covered by systematic screening with parasitic tests throughout all of Poland. In this group of children, enterobiasis is the main health problem. The promotion of the awareness of IP infections and their prevention among parents and educational staff is required. KEY WORDS: intestinal parasites, children infection, preschoolers, orphans INTRODUCTION Worldwide, intestinal parasites (IP) are one of the major etiological factors of infectious human disease. It is estimated that 25% of these diseases are caused by parasitic protozoa and helminths (tapeworms, nematodes and trematodes) (1). The type and frequency of the incidence of intestinal parasitosis in humans depends on the climate, socio-economic conditions, education, personal and public hygiene practices and nutritional habits (1-2). A particularly high risk of parasitic infection occurs in children. In contrast to adults, children tend to be more physically active and rarely employ good hygiene habits. The tendency for geophagia in children is also a specific risk factor for infection with orally acquired soil-transmitted nematode parasites (3-4). In addition, a periodic presence in large groups in nurseries, preschools, schools or orphanages promotes direct contact and behaviors which increase the likelihood of transmission or environmental contamination with the parasites (5). The higher susceptibility for intestinal parasitic diseases in children is also caused by their poorly developed mechanisms of immunological defense. On the other hand, the ability of parasites to defend against the reactions of the host immune system may hinder the diagnosis of infection or to mask it for a long time (5). National Institute of Public Health National Institute of Hygiene

50 484 Katarzyna Kubiak, Marta Wrońska et al. No 3 The monitoring and assessment of the current epidemiological situation concerning infections and infectious diseases in Poland, including parasitic diseases, belongs to the National Institute of Public Health - National Institute of Hygiene (NIPH-NIH). In the years between , the NIPH-NIH in collaboration with the voivodeship sanitary-epidemiological stations, conducted a nationwide screening for IP. This action was repeated at five-year intervals, and covered more than 12 thousand 7-year-old children, who have the most extensive rate of IP infection, as indicated in earlier research (6). Recently, this action has been discontinued for financial, logistical and technical reasons (7). The Voivodeship Sanitary-Epidemiological Station in Olsztyn was one of the institutions actively involved in research, which also included preschoolers and orphans in Warmia and Mazury. The program was coordinated by the Division of Health Promotion and Education. And it covered laboratory diagnostics of intestinal parasitic diseases and educational campaign among parents and staff at institutions with regard to the health consequences of parasitic infections, their prevention in children and the principles of specimen collection. This paper presents the results of parasitological tests in children from selected preschools and orphanages in the Warmia-Masuria province conducted between by the Voivodeship Sanitary- Epidemiological Station in Olsztyn. MATERIALS AND METHODS Study participants. The study was conducted in 2003/2004 among children from 28 preschools and in 2005/2006 in 20 orphanages located in 18 districts of the Warmia-Masuria province (an area of 24,192 km2 with a population of 1,427,091 (as of 2006)). The study population consisted of 1052 preschoolers (47,7% boys and 52,3% girls) aged 2-7 years (mean 5.5) and 859 orphans (56.5% boys and 43.5% girls) aged 2-22 (mean 12.3). Data collection. The prevalence of IP in both examined groups was assessed on the basis of standard fecal examination methods (direct saline and iodine mount, decantation test) and the adhesive cellophane tape method according to Graham (8). Fecal smears and perianal swabs were examined under the microscope at 100 and 400 magnification. Samples containing at least one dispersive form of parasite were regarded as positive. A total of 4363 fecal samples and 4897 perianal swabs were tested. Statistical analysis. The data was analyzed using the χ 2 independence tests and Mann-Whitney test. The differences were considered to be statistically significant when the p-value obtained was less than The tests were performed using IBM SPSS Statistics (IBM SPSS, Chicago, Illinois). RESULTS In the examined populations, 114 (10.8%) of the total 1052 preschoolers and 398 (46,3%) of the total 859 orphans were infected with IP species (OR=7.1; 95%CI: ; p<0.05) (tab. I). The following parasite species were diagnosed: Enterobius vermicularis (E. vermicularis), Giardia intestinalis (G. intestinalis), Strongyloides stercoralis (S. stercoralis), Trichuris % Enterobius vermicularis 9,5 a 36,7 b Giardia intestinalis Strongyloide s stercoralis 0,2 a 0,1 0,1 4,0 b Trichuris trichiura Ascaris lumbricoides Entamoeba coli 0,1 0,1 1,3 a 12,5 b preschools (total number of examined; n=1052) orphanages (total number of examined; n=859) a,b diferent letters mean significant differences (χ 2 test, Z test, p<0,05) Fig.1 Comparison of the intestinal parasites prevalence among preschoolers and orphans in the Warmia-Masuria province a,b diferent letters mean significant differences (χ 2 test, Z test, p<0,05) Fig.1 Comparison of the intestinal parasites prevalence among preschoolers and orphans in the Warmia-Masuria province

51 No 3 Intestinal parasites in children % Males Females 49,1 a n=238 42,8 a n= ,0 a n= 65 8,9 b n=49 0 preschoolers orphans a,b diferent letters mean significant differences (χ 2 test, Z test, p<0,05) Fig.2 Intestinal parasites infections among preschoolers and orphans in the Warmia-Masuria province according to the gender a,b diferent letters mean significant differences (χ 2 test, Z test, p<0,05) trichiura (T. trichiura), Ascaris lumbricoides (A. lumbricoides); along province with according one conditionally to the gender pathogenic in terms of incidence. E. coli was diagnosed in 1.0% of protozoa E. coli and G. intestinalis were the next highest Fig.2 Intestinal parasites infections among preschoolers and orphans in the Warmia-Masuria species Entamoeba coli (E. coli) (Fig. 1). preschoolers and 6.1% of orphans, and G. intestinalis Among the positive cases 3 (2.6%) of the preschoolers and 60 (15.1%) of the orphans were infected Single cases of T. trichiura and A. lumbricoides infec- occured in 0.2% of preschoolers and 3.1% of orphans. with more than one parasite species. In both examined tions were identified only in orphanages. Two cases of S. groups, the most frequently occurring IP was E. vermicularis (p<0.05). Single infections of this species were and orphanages (Tab. I, Fig. 1). stercoralis infection were diagnosed in both preschools diagnosed in 97 (9.2%) preschoolers and 257 (29.9%) The statistically significant differences in the distribution of IP between males and females were only orphans. E. vermicularis occurred in co-infections with E. coli (0.3% in preschoolers and 6.2% orphans) and in preschools. The parasitic infections were slightly G. intestinalis (0.5% orphans). In one orphan both of more frequent among males than females (OR=0.66; these species were present. Single infections with the 95%CI: ; p<0.05) (fig.2). However, significant differences were observed in terms of the average age Table I. Number and percentage of intestinal parasites infected preschoolers and orphans in the Warmia-Ma- populations. Infected preschoolers were slightly older of infected and uninfected groups in both examined suria province than the uninfected. In the group of orphans opposite Preschoolers total examined (n=1052) Orphans total examined (n=859) Species n (%) n (%) Single Enterobius vermicularis 97 (9,2) 257 (29,9) Giardia intestinalis 2 (0,2) 27 (3,1) Strongyloides stercoralis 1 (0,1) 0 Trichuris trichiura 0 1 (0,1) Ascaris lumbricoides 0 1 (0,1) Entamoeba coli 11 (1,0) 52 (6,1) Multiple E. vermicularis + G. intestinalis 0 4 (0,5) E. vermicularis + E. coli 3 (0,3) 53 (6,2) G. intestinalis + E. coli 0 1 (0,1) G. intestinalis + S. stercoralis 0 1 (0,1) E. vermicularis + G. intestinalis + E. coli 0 1 (0,1) Total 114 (10,8) a 398 (46,3) b a,b different letters mean significant differences (χ 2 test, Z test, p<0,05) Table II. Intestinal parasites infection among preschoolers and orphans in the Warmia-Masuria province according to the age Preschoolers n(%) Orphans n(%) infected non-infected infected non-infected <3 3 (4,0) 72 (96,0) 20 (48,8) 21 (51,2) 4 16 (9,5) 153 (90,5) 3 (37,5) 5 (62,5) 5 18 (6,8) 247 (93,2) 19 (61,3) 12 (38,7) 6 21 (8,4) 228 (91,6) 10 (52,6) 9 (47,4) 7 56 (19,0) 238 (81,0) 23 (65,7) 12 (34,3) 8-12 (46,2) 14 (53,8) 9-28 (57,1) 21 (42,9) (48,9) 227 (51,1) (32,5) 137 (67,5) > (100) Mean age 5,97 11,60 12,86 5,43 (±1,25) (±SD) (±1,21) (±4,11) (±4,30) Mann-Whitney U test Z=-4,524, p<0,001, r=0,139 Z=-4,969, p<0,001, r=0,153

52 486 Katarzyna Kubiak, Marta Wrońska et al. No 3 % urban 10,3 a n=101 rural 17,3 a n= 13 a,b diferent letters mean significant differences (χ 2 test, Z test, p<0,05) a,b diferent letters mean significant differences (χ 2 test, Z test, p<0,05) Fig.3 Intestinal parasites infections among preschoolers in the Warmia-Masuria province according to the residence Fig.3 Intestinal parasites infections among preschoolers in the Warmia-Masuria province trend was observed (Tab. II). The parasite infections according to the residence were the most frequent among 7-year-old children, 19.1% in preschools and 65.7% in orphanages, respectively (Tab. II). In this age group, the dominant species was E. vermicularis (88.1% of samples were positive among 7-year-old preschoolers and 55.2% of samples were positive among orphans). In preschools, the prevalence of IP was higher among preschoolers from rural areas (17.3% of subjects infected) than from urban areas (10.3% of subjects infected) (Fig. 3). DISCUSSION In Poland, a nationwide parasitological study (periodically repeated since 1988) showed a decreasing trend in the prevalence of IP among 7-year-old children (6-11). The results of recent studies conducted during the school year 2002/2003 revealed that 14.6% of the examined children were infected with IP (6). The highest number of infected children were found in the Warmia-Masuria province, where parasitic infestations were determined to be in 29.6% of the examined population, with 19.7% from urban and 41.1% from rural areas. Our parasitological study in the Warmia-Masuria province between on a group of children from preschools and orphanages confirmed the high level of parasitic infections among children in this area. In the group of children under 7 years of age, IP infections were identified in 10.8% of the study population, and similar to results among 7-year-old children, mainly concerned on preschoolers in rural areas (17.3%). Significantly more cases of IP were diagnosed among children in orphanages, where as many as 46.3% of examined subjects were infected. In our study, a significant association was identified between age and parasitic intestinal infections. In both examined populations, the children with the most cases of parasitosis were diagnosed within the age group of 7 years. The high overall prevalence of intestinal parasitosis in children from the Warmia and Masuria region is mainly caused by infection with E. vermicularis. Eggs of E. vermicularis in this area were detected in 9.5% preschoolers, 36.7% of children from orphanages and in 30.6% of 7-year-old children (6). The problem of enterobiasis in children appears to be widespread throughout the country. In Podlasie (Masovian province) between , enterobiasis occurred on average in 31.9% of children under 7 years of age, in 35.5% of children aged 7-15 years, in 64.3% of children from orphanages, and was 20.4% higher in the examined population in rural rather than urban areas (12). In West-Pomeranian province, enterobiasis was diagnosed by Stelmaszyk and Owsikowski (13) in more than 70% of children aged 4-16 years. In Silesia, according to the Voivodeship Sanitary-Epidemiological Station, in the years pinworm infections among 7-year-old children ranged from 4.08 to 15.34%(14). Meanwhile in Krakow (Lesser Poland province), the extensiveness of E. vermicularis infection was 2.35% and ranged from 0.46% to 12.31%, (depending on the year) (15). The situation in Poland does not differ from other European countries. In Greece, Italy, Norway, and Estonia the prevalence of E. vermicularis invasions were 5.2%, 13,4%, 18% and 24.4% of the child population, respectively (16-19). The incidence of other identified species of IP (G. intestinalis, S. stercoralis, T. trichiura, A. lumbricoides and the conditionally pathogenic species of E. coli) in children in the Warmia and Masuria province is comparable to the incidence in child populations from other areas of Poland. Screening tests conducted in the last decade in different child populations revealed the occurrence of the protozoa G. intestinalis from 0,18-3,5% (6,13,14,20) and E. coli from 0.12 to 9.8% of examined

53 No 3 Intestinal parasites in children 487 subjects (6,13,14,20). Geohelmints infections among children in other regions of Poland are also reported sporadically with results similar to what is found in Warmia and Masuria (6, 13,14,20). The prevalence of IP in humans is significantly correlated with social-environmental factors (5,22). Overcrowding, poor sanitary conditions and hygiene habits, low levels of parental education (or their social or educational incapacity), are the same causal factors found in other studies (23-25), and may be the main factors influencing the high prevalence of infection in children from rural areas and orphanages in the Warmia- Masuria province. Many studies have shown that IP infections in children have a significant impact on their health and usually result in malnutrition and growth stunting(1,26). Nematian et al. (27) revealed that among children in Teheran the prevalence of stunting and wasting were significantly higher in children infected by IP, especially if they were infected with G. intestinalis and E. vermicularis as compared with the uninfected. A higher prevalence of IP infections was also found by Quihui-Cota et al. (28) in Mexican schoolchildren with lower body weight and height than in normally nourished children. The poor nutritional status of infected children is caused by a decline in food intake and an increase in nutrient wastage. IP can disrupt in their hosts the absorption of nutrients, vitamins, and minerals (vit. A, B6, B12, iron, calcium, magnesium) which affects the immunity level and predisposes the host to more serious diseases (1,29). Malnutrition in children also has an impact on their social, cognitive and intellectual development(1,22,30,31). CONCLUSION In Warmia-Masuria province, children living in orphanages and in rural areas, especially at the age of 7 years, are risk group of IP infections. In this group of children, enterobiasis is the main health problem. Consequently, there is still a need for the promotion of health education to parents and educational staff at institutions to create awareness about IP infections and their prevention in children. REFERENCES 1. Alum A, Rubino JR, Khalid Ijaz M. The global war against intestinal parasites should we use a holistic approach? Inter J Inf Dis 2010;14: Östan I, Kilimcioğlu AA, Girginkardeşler N, et al. Health inequities: lower socioeconomic conditions and higher incidences of intestinal parasites. BMC Public Health 2007;7: Glickman LT, Camara AO, Glickman NW, et al. Nematode intestinal parasites of children in rural Guinea, Africa: prevalence and relationship to geophagia. Int J Epidemiol 1999; 28: Bisi-Johnson MA, Obi CL, Ekosse GE. Microbiological and health related perspectives of geophagia: An overview. Afr J Biotech 2010;9(19): Harhay MO, Horton J, Olliaro PL. Epidemiology and control of human gastrointestinal parasites in children. Expert Rev Anti Infect Ther 2010;8(2): Bitkowska E, Wnukowska N, Wojtyniak B, et al. The occurrence of intestinal parasites among children attending first classes of the elementary schools in Poland in the school year 2002/2003. Przeg Epidemiol 2004;58: Pawłowski Z. Parasitic diseases in national epidemiological chronicles. Hygeia Public Health 2011;46(1): Garcia L. S. Diagnostic Medical Parasitology, 4th ed. ASM Press, Washington, D.C; 2001: Płonka W, Dzbeński TH (1995). The occurrence of intestinal parasites among children of the first classes of the elementary school in Poland in the school year 1992/1993. Przegl Epidemiol 1995;49: Płonka W, Dzbeński TH. The occurrence o f intestinal parasites among children attending first classes o f the elementary schools in Poland in the schoolyear 1997/1998. Przegl Epidemiol 1999;53: Nasiłowska M, Dzbeński TH. Analysis of the occurrence of intestinal parasites among children of the first classes in the year Przegl Epidemiol 1991;45: Hęciak S.: Enterobiosis analysis of infections in human populations of villages and towns and infections in familie. Wiad Parazytol 2006;52(4): Stelmaszyk ZJ, Owsikowski J. Parasitosis in children from selected schools from West Pomeranian Voivodeship. Wiad Parazytol 2001;47(supl.2): Spausta G, Gorczyńska D, Ciarkowska J, et al. Frequency of human parasites in selected populations in Silesian region. Wiad Parazytol 2001;51: Nowak P, Jochymek M, Pietrzyk A. Occurrence of human intestinal parasites in selected population in Cracow region in the years on the basis of parasitological stool examinations performed in the Laboratoty of Parasitology of the District Sanitary-Epidemiological Center. Wiad Parazytol 2007;53(4): Platsouka E, Stephanou T, Marselou-Kinti O. Frequency of Enterobius vermicularis in children from the area of central Greece. Deltion. Hellinikis Microbiol Eterias 1985;30: Crotti D, D Annibale ML. Enterobiosis during in Perugia Province: Beyond diagnostics. Infez Med 2006;14(2): Bøås H, Tapia G, Sodahl JA, et al. Enterobius vermicularis and risk factors in healthy Norwegian children. Pediatr Infect Dis J 2012;13: Remm M. Distribution of enterobiasis among nursery school children in SE Estonia and of other helminthiases in Estonia. Parasitol Res 2006;99: Raś-Noryńska M, Białkowska J, Sokół R, et al. Parasitological stool examination from children without the

54 488 Katarzyna Kubiak, Marta Wrońska et al. No 3 typical symptoms of parasitic disease. Przegl Epidemiol 2011;65(4): Solarczyk P, Werner A, Majewska A. Genotype analysis of Giardia duodenalis isolates obtained from humans in West-central Poland. Wiad Parazytol 2010;56(2): Stepek G, Buttle DJ, Duce IR, et al. Human gastrointestinal nematode infections: are new control methods required? Int J Exp Path 2006;87: Okyay P, Ertug S, Gultekin B, et al. Intestinal parasites prevalence and related factors in school children, a western city sample-turkey. BMC Public Health 2004;4: Quihui L, Valencia ME, Crompton DWT, et al. Role of employment status and education of mothers in the prevalence of intestinal parasitic infections in Mexico rural schoolchildren. BMC Public Health 2006;6: Gamboa MI, Navone GT, Orden AB, et al. Socio-environmental conditions, intestinal parasitic infections and nutritional status in children from a suburban neighborhood of La Plata, Argentina. Acta Trop 2011;118(3): Stephenson LS, Latham MC, Ottesen EA. Malnutrition and parasitic helminth infections. Parasitology 2000;121: Nematian J, Gholamrezanezhad A, Nematian E. Giardiasis and other intestinal parasitic infections in relation to anthropometric indicators of malnutrition: a large, population-based survey of schoolchildren in Tehran. Ann Trop Med Parasit 2008;102(3): Quihui-Cota L, Valencia ME, Crompton DWT, et al. Prevalence and intensity of intestinal parasitic infections in relation to nutritional status in Mexican schoolchildren. Trans Roy Soc Med Hyg 2004;98: Crompton DWT, Nesheim MC. Nutritional impact of intestinal helminthasis during the human life cycle. Annu Rev Nutr 2002;22: El-Nofely A, Shaalan A. Effect of Ascaris infection on the nutritional status and IQ of children. Int J Anthropol 1999;14: Tarleton JL, Haque R, Mondal D, et al. Cognitive effects of diarrhea, malnutrition, and Entamoeba histolytica infection on school age children in Dhaka, Bangladesh. Am J Trop Med Hyg 2006;74: Received: Accepted for publication: Address for correspondence: Katarzyna Kubiak, PhD Department of Medical Biology University of Warmia and Mazury in Olsztyn Żołnierska 14c Street, Olsztyn, Poland. katarzyna.kubiak@uwm.edu.pl

55 PRZEGL EPIDEMIOL 2015; 69: Problems of infections Wioletta Rożej-Bielicka 1, Hanna Stypułkowska-Misiurewicz 2, Elżbieta Gołąb 1 HUMAN BABESIOSIS 1 Department of Medical Parasitology National Institute of Public Health National Institute of Hygiene in Warsaw 2 Department of Virology National Institute of Public Health National Institute of Hygiene in Warsaw ABSTRACT Babesiosis is an emerging parasitic, anthropo-zoonotic tick-borne disease, seldom diagnosed in humans. Caused by Protozoa, Babesia (also called Piroplasma) intraerytrocytic piriform microorganism. Infection of vertebrates is transmitted by ticks. Out of more than 100 Babesia species/genotypes described so far, only some were diagnosed in infected humans, mostly B. microti, B. divergens and B. venatorum (Babesia sp. EU1). Infection in humans is often asymptomatic or mild but is of a particular risk for asplenic individuals, those with congenital or acquired immunodeficiencies, and elderly. Infections transmitted with blood and blood products raise concerns in hemotherapy. Epidemiological situation of babesiosis varies around the world. In Europe, no increase in the number of cases was reported, but in the USA its prevalence is increasing and extension of endemic areas is observed. The aim of this publication is to describe the problems connected with the current epidemiological situation, diagnosis and treatment of human babesiosis with regard to clinical status of patients. Key words: babesiosis, Babesia sp., human babesiosis, diagnosis, treatment Babesiosis is a new emerging, anthropo-zoonosis, a parasitic disease caused by protozoa of the genus Babesia, also called Piroplasma due to the pear-shaped appearance of trophozoites at one of the life cycle stages. They are small organisms (ø = 1 5 µm) that invade erythrocytes. There are two hosts in the life cycle of these parasites: ticks, mainly Ixodidae, are the definitive host and various vertebrates, including humans, which are intermediate host. Until now, more than 100 Babesia species and genotypes were documented (1, 2, 3), but only few were reported as pathogenic for humans. In humans, the most prevalent are infections caused by Babesia microti and less frequently B. divergens, B. duncani or B. venatorum (formerly known as Babesia sp. EU1) (4). Infections in humans are associated with an increased activity of ticks, but sometimes, rather rarely, through transfusion of infected blood, blood products or transplantation of infected organ (2). Cases of congenital babesiosis were also documented (5). PREVALENCE OF BABESIOSIS Babesiosis is noted worldwide. In the North America, infections with B. microti predominate, where the tick Ixodes scapularis is the vector of the pathogen. In other continents, B. microti is also common as a parasite of rodents, however, infections in humans caused by this species are rare. Infections introduced by persons returning from endemic areas elsewhere, were noted so far mainly the USA (6). CDC (Centers for Disease Control and Prevention) epidemiological data suggest a geographical expansion and stable increase in the number of Babesia infections. In , a total of 3797 new cases were reported in the USA (7). In the tropical and subtropical countries, where malaria is common, babesiosis rarely is diagnosed. Probably, it occurs much more frequently as it was demonstrated by the results of the studies conducted in in China in patients presenting with fever and living in the Yunan County. From a detailed analysis of 449 cases, 8 infections with B. microti and 2 coinfections were identified, i.e. B. microti/plasmodium National Institute of Public Health National Institute of Hygiene

56 490 Wioletta Rożej-Bielicka, Hanna Stypułkowska-Misiurewicz, Elżbieta Gołąb No 3 falciparum and B. microti/plasmodium vivax. Infection only by Plasmodium spp. (mainly P. vivax and P. falciparum) alone was detected in 63 persons (8). B. divergens is the most common etiological agent of babesiosis in Europe (1) and Ixodes ricinus is the vector. This tick is prevalent in the whole northern hemisphere. It may also transmit B. microti as well as B. venatorum which are pathogenic for humans (9). Literature data provide descriptions of about 50 cases of confirmed babesiosis which were reported in the European countries, mainly in patients with a history of splenectomy or with impaired immunity (1, 2, 10, 11). Infections with B. venatorum (formerly known as Babesia sp. EU1) were more commonly reported (12). So far, one case of symptomatic infection with B. microti imported from Brasil (13) and some asymptomatic cases were noted in Poland (14). LIFE CYCLE OF BABESIA Following the invasion of the intermediate host bloodstream, Babesia sporozoites enter the red blood cells. They achieve trophozoite stage there, proliferate in schizogonic divisions and mature to the stage of merozoites (12). Red blood cells collapse and released merozoites enter new red blood cells. This cycle is repeated. Having entered the red blood cells, a part of merozoites differentiate into gametocytes which are infective for the tick. In the tick gut, gametocytes released from the digested red blood cells develop into gamonts (gametes) which then form zygotes in a reproductive cycle. Zygotes mature to the stage of ookinete which is able to move, and consequently, allows the pathogen to enter the hemolymph from the tick gut. The hemolymph transports the ookinetes to different parts of tick organism, including salivary glands, where the next stage of life cycle may be observed, i.e. sporogony, in which sporozoites infective for intermediary hosts are formed (15). It was demonstrated that transmission of B. microti from the tick occurs 24 hours following its feeding. This process has not been studied with other Babesia species (16). TRANSFUSSION-TRANSMITTED BABESIOSIS Babesiosis, transmitted through infected blood and blood products, constitutes a serious problem. The blood cell, being an environment for the development of Babesia, is a niche which increases the probability of pathogen transmission during transfusion. It was demonstrated experimentally that the piroplasmas survive in the erythrocytes outside the host organism. Studies were conducted under conditions providing additional stress for the red blood cells, i.e. in tubes containing anticoagulant (EDTA), not in the specific bags that increase the red blood cells survival by optimizing gas exchange. Under experimental conditions, B. microti remained alive for at least 21 days in tubes stored at 4 C (17). It was also determined that Babesia survive process of cryo-conservation of blood preparations (18). An infective dose, which may cause the disease, is relatively low. Administration of 30 infected red blood cells caused babesiosis in 40% of healthy hamsters while 10-fold higher dose resulted in infection of 100% of studied animals (4).For individuals with an impaired immunity system, even single erythrocyte containing pathogens, may be a potential source of babesiosis (19). In such persons, an exceptionally severe manifestation of infection was observed, i.e. resistant to a standard chemotherapy, usually resulting in death (20). In , 12 fatal cases of transfusion-transmitted babesiosis were registered in the USA (4, 19). It is suggested to include tests for babesiosis in the differential diagnosis of transfusion-associated anemia or fever of unknown origin (5). CLINICAL MANIFESTATIONS OF BABESIOSIS Usually, clinical symptoms appear between weeks 1 and 4 following the bite of tick infected with Babesia (2). For transfusion-transmitted babesiosis, this period may be extended up to 9 weeks and even up to 6 months in extreme cases (5). Initially, disease is manifested by general malaise and fatigue. Then, influenza-like symptoms appear, including: fever, chills, sweating, joint and muscle pain (4, 21). These symptoms are similar to malaria. and many other infectious diseases. Along with the exacerbation of symptoms, hemolytic anemia, intravascular coagulopathy, hepatomegaly and splenomegaly may occur. Babesiosis complications may include respiratory distress syndrome, heart failure, inflammation of the central nervous system and even death in extreme cases (2, 16). Complete blood count reveals the disorders of parameters resulting from excessive erythrocyte lysis. Low hematocrit, low hemoglobin concentration, thrombocytopenia and reticulocytosis are observed. Biochemical examination reveals an increased activities of transaminases, alkaline phosphatase, indirect bilirubin and lactate dehydrogenase (2, 10, 22). In immuno-competent individuals, symptoms usually resolve within a few weeks without any treatment, however, malaise and fatigue may persist for even several months. Severe manifestations of disease, which

57 No 3 Human babesiosis 491 require hospitalization, and babesiosis fatal cases are reported in patients with considerably impaired immunity. Immunosuppressed patients, individuals with a history of splenectomy, those with hemoglobinopathy, suffering from malignant tumors, infected with HIV and persons at advanced age are at the risk of severe babesiosis (23). Babesiosis course and its prognosis are dependent on the immunological status of the patient as well as Babesia species which caused the disease. Infection with B. venatorum is usually of mild to moderately severe course, with a good prognosis also for asplenic patients and those with autoaggressive diseases (12, 24), while infection with B. divergens is frequently of fulminant. Life-threatening symptoms appear immediately (2, 10, 11). The majority of fatal infections with B. divergens resulted in death within 4 7 days following the onset of symptoms of hemoglobinuria or multiple organ dysfunction syndrome (2, 21, 25, 26). Undiagnosed Babesia infections may co-exist with other tick-transmitted diseases, resulting in exacerbation and disturbances in the course of disease. Co-infection with Babesia was identified in 10% of patients with Lyme disease from the New England (USA) (27). Thus, in the USA, on babesiosis endemic territories, patients with borreliosis accompanied by complications are recommended to undergo laboratory testing for Babesia infection and antiprotozoa therapy is also indicated (22). LABORATORY DIAGNOSIS OF BABESIOSIS Babesiosis case is considered to be confirmed if pathogen or its genetic material is detected in peripheral blood. Microscopic examinations of peripheral blood smears are most frequently performed in the laboratory diagnosis. Percentage of infected red blood cells in patients is usually low. It rarely exceeds 5% in immunocompetent persons, but, in case of asplenic patients it may amount to 85% (28). In the diagnosis of babesiosis in the USA, commercial serological tests are used, e.g. immunofluorescence assay (IFA) for the presence of IgM and/or IgG antibodies against B. microti. Due to a high species specificity of Babesia antigens, these tests are hardly applicable in Europe, where infections in humans are mostly caused by the B. divergens and B. venatorum. Serological tests are not recommended to be used in the case of persons with impaired immunity system as false negative test results may appear. In case of patients with bacterial, viral infections, autoimmune disorders of connective tissue, infected with Plasmodium or Toxoplasma gondii, false positive test results may occur (2, 29). To confirm babesiosis, a biotest was also performed, consisting in the inoculation of patient s blood to the peritoneum of laboratory rodent. Nowadays, such method is hardly employed due to its low efficiency and long period of waiting for the test result, amounting to about 2 4 weeks (2, 30). Currently, polymerase chain reaction (PCR) is a reference method for diagnosis of babesiosis (31). PCR is recommended if the species of pathogen cannot be identified based on the blood smear or if the diagnosis is uncertain and medical interview and clinical symptoms are indicative of babesiosis (2). In Europe, certified commercial PCR tests intended for the laboratory diagnosis of human babesiosis are not accessible. Having considered the tests elaborated by reference laboratories for their own purposes, a gene sequence encoding for small ribosomal subunit (18S rrna) of Babesia is the most frequently employed genetic marker of babesiosis. PCR sensitivity for the 18S rrna gene was assessed at 5 10 pathogens/1µl of blood which corresponds to % parasitemia (32). Based on the initiative of the National Chamber of Laboratory Diagnosticians (NCLD), the Recommendations of the Working Group concerning laboratory diagnosis of tick-borne diseases, including babesiosis were issued in Document, which is accessible on the NCLD website in the section Recommendations, contains information on the infections with Babesia and methods of babesiosis diagnosis together with a list of reference laboratories performing laboratory testing for babesiosis in our country ( The recommendations regarding the diagnostic algorithm for cases suspected of babesiosis are on Figure 1. TREATMENT The majority of recommendations and indications for the treatment of human babesiosis are with regard to the infections caused by B. microti or B. divergens. Antimalaria drugs and some antibiotics are used in chemotherapy. A list of drugs of choice includes: atovaquone, azithromycin, clindamycin and quinine. Due to a possibility of antimicrobial resistance of Babesia, it is recommended to initiate combination therapy with the use of quinine preparations with clindamycin or atovaquone with azithromycin (9, 33). Drugs are usually administered for 7 to 10 days. However, in about 1/3 of patients, side effects of chemotherapy may be so strong that it is necessary to modify the therapy regimen or considerably reduce the dosage. Drugs which are associated with fewer side effects may not always be used in the treatment of babesiosis with an example being chloroquine. It causes fewer side effects compared to quinine, however, it is ineffective in the treatment of babesiosis caused by B. microti (34).

58 492 Wioletta Rożej-Bielicka, Hanna Stypułkowska-Misiurewicz, Elżbieta Gołąb No 3 Microscopic examination of Giemsa-stained blood smears Negative Positive Persistence of clinical symptoms Chemotherapy Microscopic examination of blood smears PCR-based blood test Negative Positive Negative Positive Repeated tests in severe cases Chemotherapy Repeated tests in severe cases Chemotherapy Figure 1. Diagnostic algorithm for suspicion of babesiosis in patients from risk groups, i.e.: (I) individuals living in endemic areas or returning from such areas, (II) patients who had blood transfusion within 6 months since the onset of symptoms, (III) patients with Lyme disease or anaplasmosis, poorly responding to standard treatment or presenting more intense symptoms than usually observed in such cases, based on Vannier and Krause (2012) (2). Antiprotozoal and antibacterial drugs, including: primaquine, quinacrine, pyrimethamine, sulfadoxinepyrimethamine, artesunate, sulfadiazine, tetracycline, minocycline, pentamidine or trimethoprim-sulfamethoxazole were ineffective in the treatment of babesiosis caused by B. microti and B. divergens (25, 33). Indications for combination therapy are the moderate and severe cases as well as the asymptomatic carriage with parasitemia lasting for more than 3 months (18, 25). In severe cases additionally, exchange transfusions may be indicated (26). Still little is know about the susceptibility of B. duncani, B. venatorum and B. divergens-like in the USA and Europe whose pathogenic potential for humans was confirmed relatively recently (1, 25). However, there is no convincing evidence that considerable differences exist in the susceptibility of these pathogens to the drugs used in the therapy of B. microti infection (1, 12, 15, 25). So far, the duration of treatment is not determined. Furthermore, the processes of drug resistance of B. duncani, B. venatorum, and B. divergens-like were not studied (12). Babesia may be present in the peripheral blood of patients for some time after the termination of chemotherapy. In case of patients with symptomatic babesiosis, who are treated with clindamycin and quinine, pathogens were still detectable up to 16 days. Untreated asymptomatic, silent babesiosis may last for a number of months (29). SUMMARY Epidemiological situation of babesiosis varies worldwide and is a subject to continuous changes. In the UE countries, no increased incidence of human babesiosis is reported, however, there is a high prevalence of borreliosis which is transmitted by ticks. Recently, a nationwide obligation was introduced in the USA to register babesiosis due to a constant increase in the number of cases and extension of territories in which infections are frequently reported. So far, no effective vaccine against babesiosis was developed. As with other tick-borne disease, prevention

59 No 3 Human babesiosis 493 of infections with Babesia consists in the usage of personal protective equipment during activities undertaken on forest or grassy areas. Interventions in the natural environment through intensification of farming, land amelioration or river management favour the increase in the number of Babesia vectors and may lead to a more frequent occurrence of human babesiosis, also in Europe. In Poland, the testing for babesiosis is recommended for a person with clinical symptoms of the disease returning from babesiosis endemic areas. Testing for babesiosis should be also considered in case of patients with Lyme disease of acute, atypical course, poorly responding to standard treatment. REFERENCES 1. Gray J, Zintl A, Hildebrandt A, Hunfeld KP, Weiss L. Zoonotic babesiosis: overview of the disease and novel aspects of pathogen identity. Ticks Tick Borne Dis 2010;1: Vannier E, Krause PJ. Human babesiosis. N Engl J Med 2012;366: Yabsley MJ, Shock BC. Natural history of Zoonotic Babesia: Role of wildlife reservoirs. Int Parasit Parasit Wildlife. 2013;2: Leiby DA. Transfusion-transmitted Babesia spp. bull seye on Babesia microti. Clinical microbiology reviews 2011;24(1): Herwaldt BL, Linden JV, Bosserman E, et al. Transfusion-associated babesiosis in the United States: a description of cases. Ann Intern Med 2011;155: Poisnel E, Ebbo M, Berda-Haddad Y, Faucher B, Bernit E, Carcy B, Piarroux R, Harle JR, Schleinitz N. Babesia microti: an unusual travel-related disease. BMC Infect Dis 2013;13: html 8. Zhou X, Li S-G, Chen S-B, Wang J-Z, Xu B, Zhou H-J, Ge H-XZ, Chen J-H, Hu W. Co-infections with Babesia microti and Plasmodium parasites along the China- Myanmar border. Inf Dis Pover 2013;2(1): Hildebrandt A, Tenter AM, Straube E, Hunfeld KP. Human babesiosis in Germany: Just overlooked or truly new? Int J Med Microbiol 2008;298: Haapasalo K, Suomalainen P, Sukura A, Siikamaki H, Jokiranta TS. Fatal babesiosis in man, Finland, Emerg Infect Dis 2010;16: Martinot M, Zadeh MM, Hansmann Y, Grawey I, Christmann D, Aguillon S, Jouglin M, Chauvin A, De Briel D. Babesiosis in immunocompetent patients. Europe Emerg Infect Dis 2011;17: Herwaldt BL, Cacciò S, Gherlinzoni F, Aspöck H, Slemenda SB, Piccaluga PP, Martinelli G, Edelhofer R, Hollenstein U, Poletti G, Pampiglione S, Löschenberger K, Tura S, Pieniazek NJ. Molecular Characterization of a Non Babesia divergens Organism Causing Zoonotic Babesiosis in Europe. Emerg Infect 2003;9(8): Humiczewska M, Kuźna-Grygiel W. A case of imported human babesiosis in Poland. Wiad Parazytol 1997;43(2): Welc-Falęciak R, Hildebrandt A, Siński E. Co-infection with Borrelia species and other tick-borne pathogens in humans: two cases from Poland. Ann Agric Environ Med 2010;17(2): Homer MJ, Aguilar-Delfin I, Telford SR, Krause PJ, Pershing DH Babesiosis. Clin Microbiol Rev 2000;13(3): Telford SR, Spielman A. Reservoir competence of white-footed mice for Babesia microti. J Med Entomol 1993;30: Eberhard ML, Walker EM, Steurer FJ. Survival and infectivity of Babesia in blood maintained at 25 C and 2-4 C. J. Parasitol. 1995;81: Wormser GP, Prasad A, Neuhaus E, Joshi S, Nowakowski J, Nelson J, Mittleman A, Aguero-Rosenfeld M, Topal J, Krause PJ. Emergence of resistance to azithromycinatovaquone in immunocompromised patients with Babesia microti infection. Clin Infect Dis 2010;50: Gubernot DM, Nakhasi HL, Mied PA, Asher DM, Epstein JS, et al. Transfusion-transmitted babesiosis in the United States: summary of a workshop. Transfusion 2009;49: Zintl A, Mulcahy G, Skerrett HE, Taylor SM, Gray JS. Babesia divergens, a boine blood parasite of veterinary and zoonotic importance. Clin Rev Microbiol 2003;16; Hunfeld KP, Hildebrandt A, Gray JS. Babesiosis: recent insights into an ancient disease. Int J Parasitol 2008;38: Mylonakis E. When to suspect and how to monitor babesiosis. Am Fam Physician 2001;63(10): Krause PJ, Daily J, Telford SR, Vannier E, Lantos P, Spielman A. Shared features in the pathobiology of babesiosis and malaria. Trends Parasitol. 2007;23(12): Häselbarth K, Tenter AM, Brade V, Krieger G, Hunfeld KP. First case of human babesiosis in Germany Clinical presentation and molecular characterisation of the pathogen. Int J Med Microbiol 2007;297: Hildebrandt A, Gray JS, Hunfeld KP. Human babesiosis in Europe: what clinicians need to know. Infection. 2013;41(6): Zintl A, Mulcahy G, Skerrett HE, Taylor SM, Gray JS. Babesia divergens, a boine blood parasite of veterinary and zoonotic importance. Clin Rev Microbiol 2003;16; Sweeney CJ, Ghassemi M, Agger WA, Persing DH. Coinfection with Babesia microti and Borrelia burgdorferi in a western Wisconsin resident. Mayo Clin Proc 1998;73: Vannier E, Krause PJ. Update on babesiosis. Interdiscip Perspect Infect Dis 2009; org/ /2009/ Brasseur P, Gorenflot A. Human babesiosis in Europe. Mem Inst Oswaldo Cruz. 1992;87:

60 494 Wioletta Rożej-Bielicka, Hanna Stypułkowska-Misiurewicz, Elżbieta Gołąb No Herwaldt BL, McGovern PC, Gerwel MP, Easton RM, MacGregor RR. Endemic babesiosis in another eastern state: New Jersey. Emerg Infect Dis 2003;9: Persing DH, Mathiesen D, Marshall WF, Telford SR, Spielman A, Thomford JW, Conrad PA. Detection of Babesia microti by polymerase chain reaction. J Clin Microbiol 1992;30: Teal AE, Habura A, Ennis J, Keithly JS, Madison- Antenucci S. A new real-time PCR assay for improved detection of the parasite Babesia microti. J Clin Microbiol. 2012;50: Krause PJ, Daily J, Telford SR, Vannier E, Lantos P, Spielman A. Shared features in the pathobiology of babesiosis and malaria. Trends Parasitol. 2007;23(12): Zygner W, Wiśniewski M. Tick-transmitted diseases which may threaten health of dogs in Poland. Wiad Parazytol. 2006;52(2): Received: Accepted for publication: Address for correspondence: Dr Elżbieta Gołąb, Professor of the NIPH-NIH Department of Medical Parasitology National Institute of Public Health National Institute of Hygiene Chocimska Warsaw egolab@pzh.gov.pl

61 PRZEGL EPIDEMIOL 2015; 69: Hospital infections Anna Różańska, Jadwiga Wójkowska-Mach, Małgorzata Bulanda, Piotr B. Heczko INFECTION CONTROL IN POLISH MEDICAL WARDS DATA FROM THE PROHIBIT PROJECT Chair of Microbiology, Jagiellonian University Medical College, Kraków ABSTRACT INTRODUCTION. Nosocomial infections and the problem of their surveillance concern all patients, including patients treated in medical wards. The objective of the study was to ewaluate selected infection control practices in Polish medical wards in comparison with wards of European hospitals. MATERIAL AND METHODS. The study was conducted by means of a standardized questionnaire fullfiled by a total of 506 wards, including 10 Polish, in 24 European countries, as a part of the PROHIBIT project. RESULTS. The median number of beds in Polish wards (PW) was 35 vs. 30 in European ones (EW), while the proportion of beds in single rooms in Poland were almost ten times lower than in Europe. The number of nurses employed in PW was similar to EW. In all PW alcohol-based handrub solutions were available in more than 76% points of care and it was better situation than in EW. Similar situation in PW and EW was observed in case of existence of written procedure of UTI and CDI prevention. Differences between PW and EW were observed in the manner of usage of close drainage system in catheterized patients and in consumption of alcohol-based handrubs. CONCLUSIONS. In Poland, selected component of infection control is a challenge for the future and its implementation and realization require increasing the awareness of both medical staff and the management of hospitals. Key-word: Clostridium difficile, hand hygiene, infection prevention, urinary tract infection INTRODUCTION Nosocomial infections are among the most common adverse events in health care (1). Nosocomial infections and the problem of their surveillance concern all patients, including patients treated in medical/ internal diseases wards. Of particular importance in these types of wards are urinary tract infections and Clostridium difficile infections (2, 3, 4). The majority, i.e. about 80%, of nosocomial urinary tract infections are associated with the use of urinary catheters and occur in patients with no symptoms from the urinary tract. The procedure of urinary bladder catheterization is applied in 12 16% of hospitalized patients (5). It is estimated that urinary catheter-associated bacteriuria constitutes 40% of nosocomial infections reported in the United States annually (5). Urinary catheter-associated bacteriuria leads to numerous cases of nosocomial bacteremia in hospitalized patients; one study even demonstrated a significant correlation with increased mortality. Furthermore, urinary catheter-associated bacteriuria leads to an increased, and often improper, use of antibiotics, consequences of which are not only higher direct medication costs but also the development of a reservoir of drug-resistant bacteria, which represent a major problem in cross infection. Implementation of effective recommendations concerning the prevention of catheter-associated UTI also allows to achieve a significant reduction in costs related to treating these infections (6). Clostridium difficile infections constitute another, frequently recorded, form of clinical infections among adult patients in developed countries. Annual costs of infections of this etiology in the United States are estimated at 496 million USD from the perspective of health care providers, 547 million USD from the perspective of payers and 796 million USD at the macroeconomic level for the society as a whole (7). It was demonstrated in European studies that the hospital stay of patients National Institute of Public Health National Institute of Hygiene

62 496 Anna Różańska, Jadwiga Wójkowska-Mach et al. No 3 with CD infections is prolonged at least another 7 days or even associated with attributable mortality ranging from 1% to as much as 23% (8). Since UTI and CDI frequently occur in medical wards, it is difficult to omit these wards in hospital infection control and their characteristics make it vital for implementation and compliance with specific rules and procedures to minimize the risk of urinary tract infections, in particular the ones associated with the use of urinary catheters and transmission of spore-forming organisms. The objective of the study was to evaluate selected infection control practices in Polish medical treatment wards in comparison with wards of European hospitals. MATERIAL AND METHODS The study was conducted in 2011 by means of a standardized questionnaire taking into account the organization of surveillance in hospitals, especially in three different types of wards: intensive care, surgical and non-surgical. The questionnaires were prepared at the Institute of Hygiene and Environmental Medicine, Charité University Medicine in Berlin, in collaboration with the Chair of Microbiology, Jagiellonian University Medical College in Kraków. It was a part of the PROHIBIT project - Prevention of Hospital Infections by Intervention and Training. The questionnaires were filled out by hospital staff: the section on the hospital by the infection control team, the remaining ones by the employees of wards or the Infection Control Team. 34 European countries were invited to participate in the study, of which 24 reported their data subsequently subjected to analysis. The section of the questionnaire devoted to medical treatment wards was filled out by a total of 506 wards in 294 hospitals. In Poland, questionnaires were sent to 30 hospitals and completed ones were returned from 10 medical treatment wards in 9 hospitals (the average for individual European countries in the study was 12,25), including three small ones (up to 199 beds), 2 medium ones ( beds) and 4 big ones (over 500 beds); they were mainly public (6 hospitals). Detailed characteristics of Polish hospitals taking part in the project was presented in previous publication (9). Questions in the section of the questionnaire regarding medical wards concerned: 1. ward structure and organization, i.e. size and profile of the ward, number of admissions, employment of nurses in the ward, and availability of alcohol-based handrub, 2. organization of infection control programs operating in the ward, including the scope and basics of developing specific procedures, the scope and recipients of trainings in this respect, 3. control and prevention of urinary tract infections and infections caused by Clostridium difficile Table I. Basic characteristic of the study wards Selected elements of ward organization European wards median Polish wards median The ward size Beds in the medical ward (MW) Single bed rooms in the MW Percent single room beds on MW The number of admissions and patient-days in 2010 Number of admissions in Patient-days in Length of stay on medical ward Bed occupation on medical ward (patient-day/bed-days,%) The number of full-time-equivalent (FTE) certified nurses and nurses in training working on the ward per working day? FTE certified nurses and nurses in training per working day FTE certified nurses and nurses in training per morning shift FTE certified nurses and nurses in training per night shift FTE certified nurses on MW per working day per bed FTE certified nurses on MW per morning shift per bed FTE certified nurses on MW per night shift per bed The number of certified nurses working part- or full-time in the ward and since when? Nurses working part- or full-time Nurses working part- or full-time for <= 3 yrs Nurses working part- or full-time for > 3 yrs 12 15,5 Nurses on MW working part- or full-time per bed Nurses on MW working part- or full-time for <= 3 yrs per bed Nurses on MW working part- or full-time for > 3 yrs per bed Ratio nurses on MW working part- or full-time for > 3 yrs / <=3 yrs

63 No 3 Infection control in Polish medical wards 497 Table II. Availability of alcohol-based hand-rub in the study wards Alcohol-based handrub (liquid, gel, or foam) dispensers (wall- or All European bedmounted) available at the point of care for an individual patient wards [%] Polish wards [%] p-value Available in 0-25% at the point of care Available in 26-50% at the point of care Available in 51-75% at the point of care Available in % at the point of care Individual pocket/belt bottles or dispensers available for healthcareworkers (HCWs) in the ward Yes, for >=50 % of staff Yes, for <50 % of staff No process and outcome indicators for the year 2010, precisely alcohol-based handrub consumption. Chi-squared test was used for analyzing statistical importance of differences between Polish vs. all European medical wards participating in the study. RESULTS The median number of beds in Polish medical wards was 35, meaning that it was a little higher than the one in the group of all European hospitals. The median number of single rooms in Polish hospitals was 0.5 compared with 2 in all hospitals (median value in Polish hospitals was lower than the value of the first quartile in all hospitals of the studied group). The proportion of beds in single rooms of the Polish wards amounted to 0.8 and was lower than the corresponding median values 7.3 and the first quartile 1.4 of all wards. General medicine wards in the Polish group made up 30%, cardiology wards 20%, others 50% were wards of various profiles and this was a different distribution than for the entire group of hospitals. Both the median annual number of admissions 1,318.5 as well as person-days of stay 8,556.5 in the Polish hospitals were lower than the respective values for the entire group, i.e. 1,246 and 9,570. The Polish wards, as compared with the whole group, also had shorter average length of stay 6.3 days, in comparison with 8.9, and bed occupancy 65.6% vs. 84.3%. Detailed data regarding characteristics of the wards are presented in Table I. The number of nurses employed in the Polish wards, as compared with European wards, was similar the median value in both cases amounted to 17. Variation in nurse employment was recorded considering the period the nurses had worked in the ward in the Polish hospitals, more nurses had worked for more than three years compared with the entire group of hospitals Table I. In all Polish wards, alcohol-based handrub preparations were available in more than 76% of points of care and this constituted a better situation than in the entire group, where their availability was less than 25% of points of care in 17.1% of wards, and availability in over 76% of points of care was declared by 66.3% of wards (Table II). However, availability of pocket dispensers of handrub was declared by only one of ten Polish wards, while in the whole studied group, such preparations were available in almost 30% of wards (Table II). Table III. Ward personnel training in infection control Regular infection control (IC) training sessions for healthcare workers (HCWs) All European Polish wards established in the ward wards [%] [%] p-value No Regular IC training sessions: new HCWs Regular IC training sessions: existing HCWs What are the topics for IC training of newhcws, if the traings are performed? bloodstream infections hospital-acquired pneumonia urinary tract infections others hospital-acquired infections multi-drug resistant organisms Hand hygiene Mandatory training of IC for existing HCWs and / or for new HCWs IC training of new HCWs is mandatory Continuous training for existing HCWs is mandatory Continuous training for existing HCWs is mandatory upon infection control incidents No mandatory training Existance any campaigns for HAI prevention in the ward during the last 12 months Campaigns for HAI prevention implemented in this MW during the last 12 month

64 498 Anna Różańska, Jadwiga Wójkowska-Mach et al. No 3 Table IV. Prevention measures for urinary tract infection Urinary tract infections All European wards [%] Polish wards [%] p-value Existance of internal written policies on preventing urinary tract infections Internal written policies on preventing urinary tract infections The use of closed drainage systems in catheterized patients in the ward (except for single or perioperative catheterization) Always Sometimes Rarely Never Existance of a system for daily assessment of catheter necessity? System for daily assessment of catheter necessity The use of impregnated (antiseptic or antibiotic) urinary catheters in the ward Yes, in >= 50% of the patients Yes, in < 50% of the patients No The scope and recipients of trainings on infection control are shown in Table III. The majority, i.e. 90% of the Polish wards, kept written procedures on the prevention of urinary tract infections, although only half of them operated a system of daily assessment of whether there was still need to further maintain urinary catheters in patients, and this was a situation similar to the one in the entire group, in which the respective proportions are 80.8% and 55.6%. In the Polish wards, less frequently than in Europe, closed drainage system in catheterized patients was used (except for single or perioperative catheterization): always only in 30% vs. 82.%. Urinary catheters impregnated with antiseptics or antibiotics were not used in any of the Polish wards, while in Europe such catheters were used in less than 10% of wards (Table IV). The majority, being 80% of the Polish wards, compared with 65.6% of the European ones, had written procedures for the prevention of CD infections. In the case of care for patients with symptomatic infections, 100% of staff used protective gloves, and in the European group it was 97%. Patients with symptomatic CD infection (Clostridium difficile-associated infection, CDI) were always placed in single rooms in 20% of the Polish wards and in 50% of the wards depending on the availability of such rooms. It was a smaller percentage compared with the total for the studied wards in Europe, amounting to 43% and 30%, respectively. 20% of the Polish and 18.7% of the European wards implemented contact isolation in shared rooms, and 10% of the Polish and approximately 9% of European wards did not use isolation. For patients with CDI, the routinely used Table V. Prevention measures for Clostridium difficile associated infections Clostridium difficile associated infections All European Polish wards wards [%] p-value Existance of internal written policies on preventing C. difficile infections? Written policies on preventing C. difficile infections Do healthcare workers wear gloves to protect their hands from contaminationwhen caring for symptomatic C. difficile patients? Gloves for symptomatic C. difficile patients Are symptomatic C. difficile patients isolated in this ward? Yes, always in a single room Yes, always in single rooms if available Yes, contact isolation in shared rooms No isolation measures Do you change the surface disinfectant to a sporocidal agent (e.g. chlorinecontainingagent) for cleaning the environment of symptomatic C. difficile patients? Yes, for every symptomatic patient Yes, in case a cluster of symptomatic patients is detected No, since sporocidal agents are used in our ward on a routine basis No change Are there fixed order criteria for routine laboratory testing of C. difficile on your ward? Patient with loose stool Loose stool and concurrent antibiotic treatment Loose stools within 72 hours upon admission Other selection criteria No laboratory testing

65 No 3 Infection control in Polish medical wards 499 surface disinfectant was switched to a sporicidal agent in 70% of the Polish and in 61.8% of the European wards. In the majority of Polish 70% and European 53.4% wards, there were no established criteria for routine laboratory testing confirming CDI (Table V). Written recommendations for UTI prevention functioning in Polish wards were mainly (90%) based on current literature reports, while in Europe they mostly relied on national recommendations (84.0%). The declared reason for the introduction of these recommendations in Polish wards was primarily a desire to improve patient safety 70% (in the European group 64.%), statutory obligation in this context was indicated by 30% of Polish (17.0% of European) wards. Analogous proportions in the case of the introduction of procedures for the prevention of CD infections was identified by, respectively, 60% and 20% of Polish wards (for the entire group, the percentages were 55.5% and 31.8%). Data on the consumption of alcohol-based handrub preparations were reported by 80% of Polish wards and the median of this value was 20% lower than in the whole group of European wards, and these values amounted to, respectively, 9.7 and 12.2 ml/ person-day. DISCUSSION The studied Polish medical treatment wards are wards of similar structure of size to the other ones studied in Europe, though at the average number of beds (median: 35), their relatively weak occupancy was found: below I quartile. A significant problem of the Polish ward can be the dramatically small number of single rooms (the median below I quartile), which is also confirmed by their percentage share, which is 0.8% in Poland, with the European quartile at 1.6%. These differences mainly stem from the level of (under) financing of the Polish health care. According to OECD figures from 2009, the Polish expenditure per capita amounted to about 1,394 USD, while the average is 3,233, and was the lowest (except for Estonia) in the whole European Union (10). Still, this is a very worrying situation, because it was declared in the studied wards that the patients with CDI were placed in separate rooms if available, which, in view of the absence of single rooms, was almost infeasible in practice. This fact also explains why in the case of CDI, in the few investigated Polish wards, a single room was always used, while in Europe it was a procedure applied more than 2 times more often (20% vs. 43.1%). It was also disturbing that in the vast majority of the studied wards (70%), diagnostic tests for Clostridium difficile were not routinely performed in the indicated situations. However, in this case, the situation was not so much better in other European wards, in which more than 50% of wards also lack such solutions. Each of the raised issues (single rooms, diagnostic and disinfection with sporicidal agent) is recognized as an important component in the prevention and surveillance of CDI (11, 12). Nurse staffing in the studied wards (median) corresponds to the situation in other wards, however, our attention is drawn to a much lower proportion of nurses with little work experience (less than 3 years). This is definitely a troublesome situation as it may be associated with projected lack of nursing staff in the future. This problem affects not only the investigated medical treatment wards: in Poland, nurses with little work experience, i.e. aged under 35, accounted for only 15.5% of all employees in this position in 2009 (13), while in Greece they constituted 24.7% (14), and in Finland over 25% (15). Curiously, the average age of professionally active Polish nurses (44.2 years) (12), is identical to the one in, for instance, the USA where it amounts to 44.8 years (16). Selected studied elements for the prevention of nosocomial infections, i.e. education of personnel on the indicated subjects was not deviate substantially from that applied in other European countries. The exception was hand hygiene, which was the subject of trainings two times less frequently (50% vs. 95.9%) in Polish hospitals, and additionally Polish staff less often made use of individual pocket/belt bottles or dispensers. The median of the consumption of alcohol-based handrub for hand hygiene in the wards which reported such data (50%) was also lower by one-fifth than that for the European wards (9.7 vs ml/ person-day). On the other hand, almost in each point of care there were dispensers with alcohol-based handrub, which, possibly, made individual dispensers unnecessary. This does not change the fact that proper hand hygiene, which is, among others, the effect of intensive training courses, remains one of the key elements of prophylaxis, therefore, education in this respect is absolutely imperative. The rank of this component of surveillance of infections is confirmed by numerous studies, the results of which are published in specialist literature, and a global education campaign coordinated by WHO and entitled Save lives. Clean your hands (17, 18, 19, 20). Intensive educational activities in the framework of this campaign have been conducted worldwide for over a decade, whereas in Poland for over a year. Individual Polish (compared with numerous global) studies on hand hygiene practices among medical staff of Polish hospitals indicate an extremely low percentage of compliance of practice with theoretical recommendations in this field. Garus-Pakowska conducted research on a group of 188 medical workers in six Polish hospitals which demonstrated compliance of hand hygiene practices with theoretical requirements in a fraction oscillating

66 500 Anna Różańska, Jadwiga Wójkowska-Mach et al. No 3 only around 5% (21, 22). The proportion of compliance of hand hygiene practices with recommendations in the study by Garus-Pakowska is considerably lower even than the corresponding values reported by other authors for periods prior to the implementation of education campaigns and programs aimed at improving compliance with basic principles by medical personnel. Seto et al. observed the output proportion of HH practices compliance with the procedures at 41% and its growth in the five-year period of intensive educational activities to a level of 83% (23). Tromp et al. reported an increase in the average percentage of HH practices compliance with theoretical recommendations from 27% to 75% (24). The implementation and employees compliance with the concept of my five moments of hand-hygiene described by Sax et al. showed that hand hygiene and educational programs were related to a significant reduction in infection rates (25). Surveillance of UTI in the analyzed study was described only in terms of selected, yet key, elements. And unfortunately, even though Polish wards generally keep written procedures on the prevention of UTI, in practice what draws our attention to them is the absence of preference for closed systems, which makes them differ significantly from other European wards (30% vs. 82.5%). It is an enormous problem since, although there are no scientific reports from Polish wards that would confirm the high risk of UTI in Polish medical patients, for a long time it has been believed that the closed system is one of the most important factors in UTI prophylaxis (26). Another crucial element in preventing UTI is to recommend the use of urinary catheters only in situations in which they are strictly indispensable and their removal as early as possible (27). For this purpose, it is essential to have a system for daily assessment of catheter necessity, the possession of which was declared only by half of the surveyed Polish wards. American experiences show that it is possible to achieve a reduction of up to 50% in the use of urinary catheters (3.3% reduction in a month) and in UTI associated with their use. The critical component of such initiative must be the nurse-directed catheter removal protocol (27, 28). All Polish wards have recommendations regarding UTI, but it is worth noting that these documents had been developed in most of them on the basis of literature reports (90%), while in European wards they were primarily based on national instructions (84%). The primary reason for the introduction of recommendations in Polish wards was the desire to improve patient safety, which would indicate appreciation of the value of infection surveillance, but on the other hand, comprehensive infection control also refers to systematic recording of infections and analysis of epidemiological data, including credible benchmarking with other units of similar characteristics. Currently, in Poland, this component of infection control is a challenge for the future and its implementation and realization require increasing the awareness of both medical staff and the management of hospitals. CONCLUSIONS Presented analysis showed that the organization of health care in Polish hospitals in some respects is different from that in European hospitals. Despite of many years of activity in the area of infection control in Poland, the scope of which is regulated by law, there is still a need for intensive staff education and management staff commitment in this area. It seems that the thorough studies on the actual organization of infection control in health care Polish carried out on a larger sample of would be reasonable. REFERENCES 1. Mittmann N, Koo M, McDonald A, Baker M, Maslow A, Krahn M, Shojania KG, Etchells E. The economic burden of patient safety targets in acute care: a systematic review. Drug, Healthcare and Patient Safety 2012; 4: Lewis SS, Knelson LP, Moehring RW, et al. Comparison of non-intensive care unit (ICU) versus ICU rates of catheter-associated urinary tract infection in community hospitals. Infect Control Hosp Epidemiol 2013;34(7): Lanzas C, Dubberke ER, Lu Z, et al. Epidemiological model for Clostridium difficile transmission in healthcare settings. Infect Control Hosp Epidemiol 2011;32(6): Monistrol O, Calbo E, Riera M, et al. Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards. Clin Microbiol Infect. 2012;18(12): Nicolle L. The Prevention of Hospital-Acquired Urinary Tract Infection. Clin Infect Dis 2008; 46: Kennedy EH, Greene MT, Saint S. Estimating Hospital Costs of Catheter-Associated Urinary Tract Infection. J Hosp Med 2013; 8(9): McGlone SM, Bailey RR, Zimmer SM, et al. The economic burden of Clostridium difficile. Clin Microbiol Infect 2012; 18(3): Wiegand PN, Nathwani D, Wilcox MH, et al. Clinical and economic burden of Clostridium difficile infection in Europe: a systemic review of healthcare-facility-acquired infection. J Hosp Infect 2012; 81: Różańska A, Wójkowska-Mach J, Bulanda M, Heczko P. Organization and scope of surveillance of infections in Polish hospitals. Results of the project PROHIBIT. Przegl Epidemiol 2014; 68:

67 No 3 Infection control in Polish medical wards OECD Health Data 2011: Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31: Crobach MJT, Dekkers OM, Wilcox MH, et al. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect 2009; 15: Naczelna Rada Pielęgniarek i Położnych: Wstępna ocena zasobów kadrowych pielęgniarek i położnych w Polsce do roku article/1782/wstepna.ocena.zasobow.kadrowych.pdf. (data pobrania: ) 14. Gaki E, Kontodimopoulos N, Niakas D: Investigating demographic, work-related and job satisfaction variables as predictors of motivation in Greek nurses. J Nurs Manag. 2013;21(3): Numminen O, Meretoja R, Isoaho H, et al. Professional competence of practising nurses. J Clin Nurs. 2013;22(9-10): Rogers AE, Hwang WT, Scott LD et al.: The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4): Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009; 73: Pittet D, Allegranzi B, Sax H et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infec Dis 2006; 6: Mathai E, Allegranzi B, Seto WH et al. Educating healthcare workers to optimal hand hygiene practices: addressing the need. Infection 2010; 38: Allegranzi B, Gayet-Ageron A, Damani N et al. Global implementation of WHO s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis 2013; 13: Garus-Pakowska A, Sobala W, Szatko F. Observance of hand washing procedures performed by the medical personnel before patient contact. Part I. Interantional Journal of Occupational Medicine and Environmental Health 2013; 26(1): Garus-Pakowska A, Sobala W, Szatko F. Obervance of hand washing procedures performer by the medical personnel after the patient contact. Part II. Int J Occup Med Environ Health 2013; 26(2): Seto WH, Yuen S, Cheung C, et al. Hand hygiene promotion and the participation of infection control link nurses: An effective innovation to overcome campaign fatigue. Am J Infect Control 2013; 41: Tromp M, Huis A, de Guchteneire I, et al. The short term and long-term effectiveness of a multidisciplinary hand hygiene improvement program. Am J Infect Control 2012; 40: Sax H, Allegranzi B, Uçkay I, et al. My five moments for hand hygiene: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infection 2007; 67: Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: Parry MF, Grant B, Sestovic M. Successfur reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. Am J Infect Control 2013; 41: Saint S, Gaies E, Fowler KE, et al. Introducing a catheterassociated urinary tract infection (CAUTI) prevention guide to patient safety (GPS). Am J Infect Cotnrol 2014; 42: Received: Accepted for publication: Address for correspondence: dr Anna Różańska Zakład Epidemiologii Zakażeń, Katedra Mikrobiologii CM UJ Ul. Czysta 18, Kraków Tel , rozanska@ifb.pl

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69 PRZEGL EPIDEMIOL 2015; 69: Hospital infections Małgorzata Kołpa 1. Aneta Grochowska 1, Agnieszka Gniadek 2, Beata Jurkiewicz 1 LEVEL OF KNOWLEDGE AMONG MEDICAL PERSONNEL ABOUT INFECTIONS TRANSFERRED THROUGH DIRECT CONTACT RESULTS OF QUESTIONNAIRE SURVEY 1 Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnów; 2 Institute of Nursing and Obstetrics, Faculty of Health Sciences, Jagiellonian University Collegium Medicum; ABSTRACT INTRODUCTION. Nosocomial infections are an important issue all over the world. The most important vector for transmitting infections in a hospital are the hands of the medical personnel, which is why their adequate hygiene is an essential prevention method. THE AIM OF THE STUDY was to evaluate the medical personnel s level of knowledge on the prevention of nosocomial infections transferred through direct contact. MATERIAL AND METHODS. The diagnostic survey method with a proprietary questionnaire was used for the research. The research was conducted between May and June 2013 on a group of 100 randomly chosen medical workers of one of Cracow hospitals (nurses, doctors and paramedics). The age of the interviewees ranged from 23 to 60 years old. RESULTS. Despite the fact that most of the respondents took part in courses related to nosocomial infections and declared the will to take part in more courses related to this issue, the level of knowledge of the medical personnel on the prevention of nosocomial infections transferred through direct contact and the post-exposure procedures is insufficient. Only 28.0% of the respondents knew that the dominant hand decontamination method according to WHO is disinfection, 22.0% of the surveyed medical personnel admitted that they put covers on needles after they performed the injection and 11.0% of the interviewees mentioned that they change the gloves before contact with the patient only sometimes. CONCLUSIONS. The surveyed group has not demonstrated a sufficient knowledge of the rules of preventing infections transferred through direct contact and the post-exposure procedures. The level of knowledge of the surveyed medical personnel was dependent on, e.g., years of experience and taking part in courses on nosocomial infections. Key words: nosocomial infections, prevention of infections, hand hygiene INTRODUCTION Nowadays, nosocomial infections are one of the worldwide epidemiological, as well as sanitary and hygienic problems, both with regard to health and economy. They increase severity of the illness, contribute to an increase in mortality, as well as prolong the period of hospitalization. Nosocomial infections also include infections which are acquired by a hospital employee while performing his or her professional duties - not only during medical procedures but also while cleaning, removing contaminated waste, transporting patients and contagious material in the laundry. The risk of infection is influenced both by the employee s knowledge, exercised profession, possessed skills, using sterile equipment and protective clothes, observing procedures, as well as the principles of safe removal of medical waste, particularly sharp tools (1). The source of exogenous nosocomial infections may be microbes coming from another patient (direct way) or existing in the environment surrounding the patient (indirect way). The most frequent source and way of nosocomial infections are hands of the personnel who may transmit microbes from one patient to another National Institute of Public Health National Institute of Hygiene

70 504 Małgorzata Kołpa, Aneta Grochowska et al. No 3 (cross infection) (2). In order to limit the transmission of infections, an important role is performed by correct decontamination of the hand skin and using protective gloves (3). As early as in 1990s, the Centre for Disease Control and Prevention (CDC) acknowledged that the proper hygiene of medical personnel s hands is the most effective and cheapest method of combating the epidemics of infections (4). In accordance with the recommendations of the World Health Organization (WHO), disinfection should be the prevailing method of decontamination of personnel s hands (5). Preventive vaccinations are one of the basic methods of specific active prevention of infectious diseases. Only in the case of infection with hepatitis B virus, HBV, specific prevention in the form of vaccination is possible (6). An important element of non-specific prevention is safe work, which means, among others, putting waterproof plasters on abrasions and injuries, introducing closed systems for biological sampling, or withdrawing from repeated insertion of covers on needles (7-10). Medical personnel should be protected against infectious factors by proper personal protective equipment, including protective clothes. The clothes are supposed to constitute a barrier for blood and other body fluids, and protect from the penetration of contagia to the body (11). In case of the exposure to a potentially contagious material, an important role is performed by knowledge and the skill of applying adequate post-exposure procedures, the aim of which is the minimization of the germs transmission risk and the prevention against the establishment of the infection. (12). Shaping the attitude of responsibility for the medical staff s own health, the health of colleagues, as well as of the patients whose care is entrusted to medical personnel, including nursing personnel, takes place on each stage of medical staff training. Medical personnel should have proper theoretical and practical preparation to perform professional tasks safely. The aim of this paper is the assess the level of medical personnel s knowledge on the prevention of nosocomial infections transferred through direct contact and the principles of post-exposure prevention. MATERIAL AND METHODS The survey was conducted from May to June The respondents were 100 randomly chosen employees of one of Cracow hospitals aged 23-60: 73 nurses (73.0%), 15 doctors (15.0%) and 12 paramedics (12.0%). Great majority of the surveyed group were women (n=91, 91.0%). The respondents were the workers of Intensive Care Unit (n=29, 29.0%), Cardiology with Intensive Therapy (n=26, 26.0%), Traumatic-Orthopedic Surgery Ward (n=24, 24.0%) and Operating Theatre (n=21, 21.0%). The respondents were asked to complete an anonymous survey questionnaire of the author s own structure, including 42 open-ended and closed-ended questions. Some of the questions included socio-demographic data, whereas others concerned content-related issues. The following tests were used for calculations: Kruskal - Wallis, U Mann-Whitney, Chi-square, Spearman s rank correlation coefficient. The results for which the level of significance was less than or equal to 0.05 were assumed statistically significant. Findings Among the respondents, persons with secondary (n=45, 45.0%) and higher education (n=43, 43.0%) prevailed, the remaining respondents had vocational education (n=12, 12.0%). 50 interviewees (50.0%) had the title of certified nurse, 20 (20.0%) had Licenciate in Nursing, 13 (13.0%) had professional title of Master Nurse, and 17 survey participants (17.0%) had the title of medical doctor. An analysis of the obtained results proved that the level of the respondents knowledge on infections transferred through direct contact and post-exposure prevention was insufficient (Table 1). The majority of the medical personnel, as many as 89 interviewees (89.0%), participated before in at least one training course on nosocomial infections. The biggest number of the respondents, 46 (46.0%) took part in such a course more than 2 years ago, 19 respondents (19.0%) a year ago, 19 (19.0%) did not remember the date, whereas 16 interviewees (16.0%) were the participants of a training course last year. Also a considerable number of the survey participants, 76 respondents (76.0%), declared previous participation in some training on post-exposure procedures on body sampling. The majority of the respondents took part in this type of training over two years ago (n=37, 37.0%), 35 (35.0%) did not remember the date, 17 respondents (17.0%) participated in a training course last year, and 11 (11.0%) did over a year ago. The surveyed group declared a wish to participate in training on nosocomial infections at the frequency of two (n=93, 93.0%) or three courses a year (n=7, 7.0%). The need for a larger number of courses on nosocomial infections did not depend on the education of the respondents (p= ). Regardless of the time which passed from the last training course on nosocomial infections, the respondents knowledge was on a similar level (p=0.7899). It was also proven that the respondents who participated in training on nosocomial infections showed a higher level of knowledge than the interviewees who did not take part in such training before (p= ). The knowledge of post-exposure procedures with blood and potentially contagious material was declared

71 No 3 Infections transferred through contact - knowledge among personnel 505 by 93 interviewees (93.0%). The majority of the medical personnel assessed their knowledge of post-exposure procedures as good (n=66, 66.0%), 31 survey participants (31.0%) as poor, 2 (2.0%) as very good, and 1 person did not have any knowledge of it, in his/her opinion. No statistically significant relationship between the subjective assessment of one s own knowledge and the real level of knowledge of post-exposure prevention and the prevention against infections transferred through direct contact (p=0.1692) was found. As many as 63 respondents (63.0%) could not correctly indicate the dates of the next blood tests of a person exposed to potentially contagious biological sampling. The awareness of the existence of active prevention against HBV virus group was revealed by as many as 61 respondents (61.0%). Only 23 interviewees knew the minimum level of anti-hbs antibodies protecting against hepatitis B virus. Few respondents could mention the least amount of blood which may be the source of infection with HBV and HCV (7.0% and 13%, respectively). A little more, 34 interviewees (34.0%) knew what amount of blood can cause human immunodeficiency virus (HIV) infection. The knowledge of blood drawing procedures was declared by 74 survey participants (74.0%). Only 40 respondents (40.0%) knew that vein palpation is correctly performed before disinfection in protective gloves. A considerable part of the respondents, 22 interviewees (22.0%) admitted that they put covers on needles after making an injection. As many as 13 respondents (13.0%) indicated that only sometimes or rarely they change gloves before contact with the next patient. The use of personal protective equipment was declared by 97 respondents (97.0%). In the opinion of as many as 31 interviewees (31.0%), there was a frequent shortage of protective gloves at their work stand, 28 (28.0%) said that they are sometimes missing, and for 41 respondents (41.0%) they are accessible without any limitations all the time. Only 32 respondents (32.0%) knew how long they should wait after skin disinfection with disinfecting agent before making an injection. Few respondents were aware (n=28, 28.0%) that disinfection is the method of hand contamination recommended by WHO. The necessity to apply contact isolation in the case of discovering infection with Clostridium difficile, Enterococcus faecium, Staphylococcus aureus was known respectively to: 18 (18.0%), 35 (35.0%) and 25 respondents (25.0%). The biggest number of interviewees in the surveyed group, 36 (36.0%), was in the profession for years, for 29 (29.0%) the job seniority was 5-15 years, for 20 (20.0%) up to 5 years, and for the remaining 15 respondents (15.0%) it was years. It was proven that the longer seniority of medical staff, the higher level of knowledge on post-exposure procedures and the prevention of infections transferred through direct contact (p= ). The highest level of knowledge was revealed by employees with higher or secondary education, the lowest one by the respondents with vocational education (p<0.0001). Moreover, it was discovered that the lowest level of knowledge was possessed by the respondents with the professional title of medical doctor, whereas the level of knowledge of the survey participants with the professional title of Master Nurse, Licenciate in Nursing or certified nurse was similar (p<0.0001) (Fig. 1). DISCUSSION The level of knowledge on the prevention of infections and the application of adequate methods in medical procedures is an important element influencing both the health and life of patients and the working medical personnel (13). Despite the growth of the education level and gaining higher qualifications by medical staff, the knowledge on nosocomial infections is still too low. This paper proves that despite the participation of majority of the respondents (89.0%) in training on nosocomial infections, the level of medical personnel s knowledge on that was insufficient. The survey conducted by Garus-Pakowska and Szatko proved that bigger knowledge was possessed by nurses who took part in training on the prevention of infections and demonstrations of proper hygiene of hands over the last year (13). On the other hand, the analysis of the author s own survey did not show a relationship between the level of knowledge and the time which passed from the last course. The respondents who participated in this type of training revealed a higher level of knowledge than the interviewees who did not take part in this type of training so far. Owłasiuk and Litwiejko claim that the most frequent cause of not using gloves by medical personnel is their wrong size (37.2%). Among other mentioned factors there was, among others, the shortage or an insufficient number of protective gloves (14.4%) (1). An analysis of the author s own survey revealed an alarming fact - only 41.0% of the respondents mentioned the lack of limitations in the access to protective gloves in the workplace. What results from the research conducted by Garus- Pakowska is that the level of using gloves in accordance with the procedures was estimated at 50.0%. An observable small percent of washing hands before the contact with a patient, as well as the repeated usage of protective gloves for contacts with other patients suggests that hand hygiene in the eyes of medical personnel is more important from the point of view of the employee himself/herself than patients (4). In the author s own survey it was proven that as many as 13.0% of the respondents

72 506 Małgorzata Kołpa, Aneta Grochowska et al. No 3 only sometimes or rarely changed gloves before contact with another patient. The repeated insertion of covers on the used needle after making an injection increases the risk of prick. As many as 22.0% of the respondents admitted using such practices. Owłasiuk and Litwiejko give similar example: 59.3% of the survey participants put the cover on the needle after making an injection, 18.6% did it frequently and 15.8% did it always or usually. The majority of the respondents did not give any reason for their behaviour (1). Kosonóg and Gotlib in their research into the observance of asepsis and antisepsis in selected procedures proved that over a half, namely 60.0% of the respondents knew how long they should wait after skin disinfection with disinfecting agent before making an injection (3). A little different results were obtained in this survey: only 32.0% of the respondents gave the correct answer to this question. Nurses, as interviewees taking direct care of the patients are responsible for their health, and are the professional group which is particularly exposed to infections. The majority of medical personnel understand the necessity to observe the principles of hygiene and antisepsis but they often do not apply them. A positive aspect in the hospital personnel s attitude is the fact that the great majority of them feel the need for further education and development of their knowledge by participating in training courses. Therefore, it seems advisable to implement a larger number of courses on nosocomial infections. CONCLUSIONS 1. The level of knowledge on the prevention of infections transferred through direct contact and postexposure procedures depended on job seniority, education and the academic degree of the respondents. No relationship between the level of knowledge and the time which passed from the last course was found. 2. The respondents who participated in some training on nosocomial proved a higher level of knowledge than interviewees who were never trained on that. 3. The respondents declared a wish to participate in future courses on nosocomial infections. 4. The surveyed group did not prove sufficient knowledge on the principles of the prevention against infections transferred through direct contact. REFERENCES 1. Owłasiuk A, Litwiejko A, Zawodowe zagrożenie biologiczne wśród pielęgniarek rodzinnych. Probl Med Rodz 2009; 11(2): Roszak A, Bezpieczeństwo epidemiologiczne w pracy pielęgniarki / pielęgniarza opieki paliatywnej. Piel Pol 2009; 2(32): Kosonóg K, Gotlib J, Ocena wiedzy pielęgniarek na temat aseptyki i antyseptyki w wybranych procedurach medycznych. Probl Piel 2010; 18(1): Garus-Pakowska A Wpływ obciążenia pracą na przestrzeganie procedur higienicznych przez personel medyczny. Med Pr 2011; 62(4): Pittet D, Allegranzi B, Boyce J, World Health Organization, World Alliance for Patient Safety, First Global Patient Safety Challenge Core Group of Experts. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations, Infect Control Hosp Epidemiol 2009, 30: Gładysz A, Rymer W, Szetela B. Narażenie zawodowe pracowników medycznych na krwiopochodne zakażenia HIV, HBV i HCV- Profilaktyka przed i poekspozycyjna. Pol Przegl Chir 2008; 80(3): Roszak A, Zawodowe zagrożenia biologiczne pracowników medycznych. Piel Pol 2009; 4(34): Szczeniowski A, Gańczak M, Implementacja przepisów regulujących zapobieganie ekspozycji zawodowej na patogeny krwiopochodne z perspektywy Polski jako kraju Unii Europejskiej. Med Pr 2011; 62(1): Zielińska-Jankiewicz K, Kozajda A, Szadkowska - Stańczyk I, Ochrona pracowników szpitali przed ryzykiem związanym z ekspozycją na czynniki biologiczne. Med Pr 2005; 56(5): Rybacki M, Walusiak J, Wągrowska-Kosik E. Opieka profilaktyczna nad pracownikami zagrożonymi zakażeniem krwiopochodnym w świetle obowiązujących przepisów prawnych. Med Pr 2008; 59(4): Bartkowiak G, Kurczewska A, Odzież ochronna. Ogólnopol Przegl Med 2005; (6): Mazur-Milewska K, Figlerowicz M, Służewski W, Zawodowe narażenie na materiał potencjalnie zakażony wirusami przenoszonymi drogą krwi zasady postępowania. Dent Forum 2010; 38(1): Garus-Pakowska A, Szatko F, Wiedza pielęgniarek na temat zakażeń związanych z opieką zdrowotną. Probl Hig Epidemiol 2009; 90: Received: r. Accepted for publication: r. Adress for correspondence: Małgorzata Kołpa Państwowa Wyższa Szkoła Zawodowa w Tarnowie ul. Mickiewicza 8, Tarnów Tel , Małgorzata Kolpa@interia.pl

73 PRZEGL EPIDEMIOL 2015; 69: Hospital infections Marta Wałaszek THE ANALYSIS OF THE OCCURENCE OF NOSOCOMIAL INFECTIONS IN THE NEUROSURGICAL WARD IN THE DISTRICT HOSPITAL FROM 2003 TO 2012* The St. Lukas District Hospital in Tarnów SUMMARY INTRODUCTION. The patients in the neurosurgical ward are exposed to many risk factors causing nosocomial infections. These factors are related to operations, invasive diagnosing and monitoring of the nervous system and mechanical support of vital functions. Therefore, the objective of the undertaken studies was to assess the prevalence and structure of the healthcare-associated infections (HAI) in patients hospitalized in the neurosurgical ward in the St. Lukas District Hospital in Tarnów. MATERIAL AND METHODS. The analyzed data concerned 13,351 patients hospitalized from 2003 to To analyze the data, the standard epidemiological methods and standardized definitions of nosocomial infections proposed by European Center for Disease Prevention and Control (ECDC) were used (1, 2). RESULTS. 516 cases of nosocomial infections were detected. The most common infections among these cases were surgical site infections (SSI). The number of SSIs cases was 140 and cumulative incidence rate (CI) per 100 operations was 1.72%, including: 52 cases of craniotomy (CRAN) (CI per 100 operations was 2.44%); 50 cases of spinal fusion (FUSN) (CI was 3.32% ); 24 cases of laminectomy (LAM) (CI was 0.93%); 10 cases of ventricular shunt operations (VSHN) (CI was 3.75%); 4 cases of other operations (OTH) (CI was 0.23%). The second most common infections were bloodstream infections (BSI) with 128 cases (CI was 0.96%), including: 91 cases of primary BSI and 37 cases of secondary BSI and the incidence density rate (ID) was 4.75 per 1000 central catheter days. The third most common infection was pneumonia (PN) with 127 cases (CI was 1.02%), with incidence density rate of per 1000 intubation-days. The next most common detected infections were urinary tract infections (UTI) with 74 cases (CI was 0.58%). This type of infections included: 65 cases of infections associated with a urinary catheter and 9 cases not associated with a urinary catheter. The incidence density for UTI with a urinary catheter was 1.93 per 1000 urinary catheter days. The list of detected infections is closed by gastrointestinal system infections (GI) with 35 cases (CI was 0.23%) and the skin and soft tissue infections (SST) with 12 cases (CI was 0.07%). The etiological agent that was most frequently isolated from materials gathered from patients diagnosed with SSI, BSI and SST was Staphylococcus aureus. Acinetobacter baumannii was the most frequently detected in the cases of PN, Escherichia coli in the cases of UTI, and Clostridium difficile in the cases of GI. CONCLUSIONS. Ten-year observation of infections detected in the neurosurgery ward gave the possibility to conduct a thorough epidemiological analysis of prevalence of nosocomial infections with recommendation aiming at reasons for prevention. Key words: nosocomial infections (HAI), neurosurgery, surgical site infections, bloodstream infections, urinary tract infections, pneumonia INTRODUCTION In the neurosurgical wards, the surgical interventions performed on the sensitive nerve tissue generate many risk factors for developing postoperative complications. One of these complications can be nosocomial infections, which in the neurosurgical wards most often occur in the form of surgical site infections. Equally often during patent s hospitalization other forms of serious nosocomial infections are detected, such as: bloodstream infections, pneumonia, urinary tract infections, they are directly related to the provided invasive National Institute of Public Health National Institute of Hygiene

74 508 Marta Wałaszek No 3 treatment. These infections pose a significant medical, ethical and economic problem, they can cause a serious damage to health and even permanent disability of a patient. In Poland there are few publications discussing the issues of prevalence of nosocomial infections in patients treated neurosurgically. The conducted study of the structure and prevalence of nosocomial infections in the neurosurgical ward aimed at setting the priority directions of preventive measures. The specific objectives included the specification of: morbidity rate of nosocomial infections, clinical forms of infections, morbidity rate of nosocomial infections for the selected medical procedures and the etiological agents of infections. MATERIAL AND METHODS The study included 13,351 patients hospitalized in the neurosurgical ward in the St. Lukas District Hospital in Tarnów from 2003 to In the diagnosing and classifying the infections in the initial period of surveillance, the definitions formulated by Centers for Disease Control and Prevention (CDC) were used. The definitions were issued in the Polish language version by Polish Society of Hospital Infections (Polskie Towarzystwo Zakażeń Szpitalnych) (1). For the purpose of this paper, in order to determine the clinical forms of detected infections, the revision of back-data about infections in the neurosurgical ward including ECDC definitions was conducted (2, 3). The registry of detected infections used the classification of infections into the following clinical forms of infections: surgical site infection (SSI), pneumonia (PN), urinary tract infection (UTI), bloodstream infection (BSI), gastrointestinal system infection (GI), other infections (OTH). In this study, the neurosurgical operations are classified according to International Classification of Diseases (ICD 9-CM -). The ICD 9-CM operational procedures were mapped for the purpose of surveillance over infections in accordance with CDC and ECDC guidelines. Six groups of neurosurgical operations were distinguished as a result of the used division: LAM laminectomy, FUSN spinal fusion, RFUSN refusion of spine, CRAN craniotomy, VSHN - ventricular shunt operations, including revision and removal of shunt, OTH other operations (2, 4). Information about patients with nosocomial infections was collected with the use of an active surveillance method through daily analysis of microbiological and analytical test results, review of patient s documentation, consultation with doctors and liaison nurses. Data about the treatment of patients were obtained by using an electronic database in the hospital system InfoMedica. The cumulative incidence rate was used in order to assess the epidemiological situation of nosocomial infections. The cumulative incidence rate was calculated by giving a number of new cases of HAI in the studied population in the time unit according to the formula: the number of HAI cases divided by the number of operations multiplied by 100 for SSI and the number of hospitalizations multiplied by 100 for the other forms of nosocomial infections. Density incidence/1000 (DI) was also calculated. It describes the number of BSI divided by the number of person-days when the invasive devices were used. These factors provide information about the intensity of infection prevalence. Microbiological tests were conducted on patients with suspected nosocomial infection. The following clinical material was collected for the microbiological tests: blood, urine, swab from the wound, faces, bronchial aspirate, bronchial alveolar lavage BAL, the tips of vascular catheters and others. The identification of staphylococci, bacilli from the Enterobacteriaceae family, non-fermenting bacillus and yeast-like fungi was made with the use of Vitek 2 Compact the automatic identification system (the biomérieux company). RESULTS 13,351 patients were hospitalized during the study period from 2003 to 2012 in the neurosurgery ward in the St. Lukas District Hospital in Tarnów. The total number of patients included 7076 men (53%) and 6253 (47%) women. The average age of hospitalized patients was 52 Table I. Healthcare-associated infections (HAI) diagnosed in patients who were treated surgically and conservatively on the neurosurgical ward from 2003 to 2012 (number of patients and HAI cases). Patients All hospitalized patients Patients treated surgically Patients treated conservatively n % n % n % Patients without HAI Patients with 1 HAI Patients with 2 HAIs Patients with 3 HAIs Patients with 4 HAIs Patients with HAI (total) Patients without HAI Total

75 No 3 Hospital infections in neurosurgery ward 509 Table II. Healthcare-associated infections (HAI). The number of patients and cumulative incidence rate (CI) on the neurosurgical ward from 2003 to Year Number Patients Patients Patients Patients Patients Patients Number CI Number of of HAI with SSI with BSI with PN with UTI with GI with SST of patients % operations cases n CI % n CI % n CI % n CI % n CI % n CI % Total CI cumulative incidence, SSI surgical site infections, BSI bloodstream infections, PN pneumonia, UTI urinary tract infections, GI gastrointestinal system infection, SST skin and soft tissue infections. years, and the average age of patients with healthcareassociated infections (HAI) was 55 years. On average, the patients stayed on the ward for 8.1 days. HAI was detected more frequently in patients treated surgically, in this group the infections were diagnosed in 335 patients. Whereas in the group of patients treated conservatively the infections were diagnosed in 60 patients. Among the patients diagnosed with nosocomial infections, 334 (2.5%) patients had diagnosed one form of the infection, 61 (0.5%) patients had diagnosed two forms of the infection, 14 (0.1%) patients had diagnosed three forms of the infection and 6 patients (0.04%) had diagnosed four forms of HAI. The total number of detected nosocomial infections was 516 in 415 patients, which means that some patients had more than one nosocomial infection (Table I). Operations were performed to 8,153 (61%) patients and 5,198 (39%) patients underwent conservative treatment. HAI incidence rate was higher in men than in women. In the study period, the average cumulative incidence (CI per 100 hospitalizations) was 3.86%, and was the highest in 2004 (6.03%) and the lowest in 2008 (2.92%). Among all patients treated on the neurosurgical ward the number of detected SSI cases was 140, cumulative incidence (CI per 100 hospitalizations) for SSI was 1.72%. The number of detected BSI cases was 128, the cumulative incidence (CI per 100 hospitalizations) for BSI was 0.96%. The number of detected pneumonia cases was 127 with the cumulative incidence of 1.02%. The number of detected cases of UTI was 74 with the incidence rate of 0.58%. The cases of GI and SST were the least frequent with the low cumulative incidence (Table II). All clinical forms of HAI were diagnosed in patients who underwent operations and cumulative incidence was 5.4%. In most cases the infections were diagnosed in patients who had ventricular shunt operations (VSHN) 47 cases (17.7%). In this group the most frequent infections were pneumonia 15 cases and urinary tract infections 11 cases. The second group of patients who underwent operations and were diagnosed with infection were patients who had craniotomy 245 cases (11.5%). In this group the most frequently detected infections were pneumonia 80 cases and bloodstream infections 65 cases. Surgical site infections were most often diagnosed among patients who underwent spinal operations such as laminectomy (LAM) and spinal fusion (FUSN) (Table III). Table III. Healthcare-associated infections (HAI) in patients who underwent operations on the neurosurgical ward from 2003 to The types and number of operations and the type of HAI. Type of operation LAM FUSN CRAN VSHN OTH Total Number of operations SSI (n) BSI (n) PN (n) UTI (n) GI (n) SST (n) Total Cumulative incidence n = the number of nosocomial infections, CI cumulative incidence, SSI surgical site infection, BSI bloodstream infection, PN - pneumonia, UTI urinary tract infection, GI gastrointestinal system infection, SST skin and soft tissue infections, LAM laminectomy, FUSN spinal fusion, CRAN craniotomy, VSHN ventricular shunt operations, OTH other operations.

76 510 Marta Wałaszek No 3 Table IV. Incidence density of primary bloodstream infections (BSI-incidence density) associated with central venous catheters and peripheral venous catheters on the neurosurgical ward from 2003 to Year Primary BSI Number of BSI-CVC Number of CVC-days BSI incidence density * associated with CVC BSI (primary) (UR) CVC ratio Number of BSI-PCV Number of PVC-days BSI incidence density * associated with PVC Number of BSI-UO Number of BSI-UNK Total Incidence density *- incidence density per 1000 CVC-days, CVC central venous catheter, PVC peripheral venous catheter, UO - unknown origin, UNK missing, unavailable data, UR - central venous catheter utilization ratio Surgical site infections operations were performed, 140 cases of SSI were diagnosed including: 52 cases of SSI per 2129 craniotomies (CI per 100 operations was 2.44 %); 50 cases of SSI per 1502 spinal fusions (CI was 3.32%); 24 cases of SSI per 2575 laminectomies (CI was 0.93%); 10 cases of SSI per 266 ventricular shunt operations (CI was 3.75%); 4 cases of SSI per 1671 other operations (CI was 0.23%). Bloodstream infections. The number of diagnosed cases of primary bloodstream infections was 91 including 36 cases associated with a central venous catheter (BSI- CVC) and 50 cases associated with a peripheral venous catheter (BSI-PVC) and 5 cases with the unknown source of infection. Incidence density (ID) for BSI-CVC was 4.75 per 1000 central catheter days and incidence density for BSI-PVC was 0.67 per 1000 PVC-days (Table IV). According to the infections surveillance report in the NNIS program , the detected incidence density of BSI-CVC was 4.6/1000 central catheter days and the risk was 0.46 (11). While in the NHSN report from and 2011 incidence density of BSI-CVC reached lower level: from 0.8 to 0.9/1000 central catheter days and the risk was 0.17 (12, 13). According to the latest HAI surveillance report published by ECDC (14) the detected incidence of BSI was 3%, and incidence density was 3.5/1000 central catheter days. In the above mentioned study by Maki at al. (15) the incidence of BSI-CVC was 2.7 per 1000 CVC-days. Observational studies conducted by Pronovost at al. (16) in 2010 give hope for reducing bloodstream infections associated with a central venous catheter to zero along with the possibility of maintaining this result for a longer period of time. Table V. Cases of respirator-associated pneumonia and density incidence (DI per 1000 intubation days) on the neurosurgical ward from 2003 to Year Number of PN Number of PN-IAP Number of intubationdays Ventilator-associated PN PN-IAP incidence density* ( ) (IUR) PN-IAP ratio Number of PN-HAP Number of person-days without intubation PN-HAP incidence density* ( ) Total Incidence density *- incidence density per 1000 intubation-days, IAP intubation associated pneumonia, HAP pneumonia diagnosed in non-intubated patients, IUR intubation utilization ratio

77 No 3 Hospital infections in neurosurgery ward 511 Pneumonia. Among 127 patients with diagnosed with nosocomial pneumonia, 69 cases were associated with intubation (PN-IAP according to the definition used by ECDC) or ventilation (PN-VAP according to the definition used by CDC) and 58 cases of non-ventilator associated pneumonia (PN-HAP). Incidence density of intubation-associated pneumonia (PN-IAP) was 51.7 per 1000 intubation-days (Table V). Using the classification of nosocomial pneumonia proposed by CDC, in the studied population 69 cases of VAP (IAP according to the definition used by ECDC) associated with artificial ventilation (intubation) were diagnosed, and 58 cases of hospital acquired pneumonia (HAP) not associated with artificial ventilation. Incidence density for VAP/ IAP was per 1000 intubation-days and the risk was In the infections surveillance report in the NNIS program (ICU) the detected incidence rate of VAP was 11.2/1000 ventilation-days and the risk was 0.29 (11). In the NHSN program the detected incidence density was 5.3/1000 person-days and the risk was 0.36 (12). In the European infections surveillance program by ECDC, IAP infections amounted to 6.5 per 1000 intubation-days (14). Urinary tract infections. In the group of 74 patients with nosocomial urinary tract infections, 65 of diagnosed cases were associated with a urinary catheter and 9 cases were not associated with a urinary catheter. Incidence density for UTI associated with a urinary catheter was 1.93 per 1000 urinary catheter days (Table VI). Incidence density for UTI with a urinary catheter was 1.9 per 1000 urinary catheter days and the risk was In the infections surveillance report in the NNIS program the detected incidence density was 6.7 per 1000 catheter days and the risk was 0.85 (11). In the NHSN report the incidence density of UTI was 8.8 per 1000 catheter days and the risk was 0.27 and in 2011 the risk was 0.23 (12). The obtained infection rate for UTI on the neurosurgical ward is comparable with the NNIS report and too low in comparison with the NHSN report. In the ECDC report the incidence rate for UTI was 4.1 per 1000 urinary catheter days (14). Etiological agents of infections. On the basis of additional cultures obtained from patients with infections who were hospitalized on the neurosurgical ward in the studied period, 440 microorganisms were isolated. The isolated microorganisms were qualified as etiological agents causing nosocomial infections. The number of strains of gram-negative coccidia equaled 215 (48.75%), gram-negative baccili equaled 210 (47.85%), fungi equaled 13 (2.95%), viruses equaled 2 (0.45%). Among the etiological agents that were isolated from materials obtained from patients with primary BSI the following agents prevailed: S. aureus 31 (34%), S. epidermidis 20 (22%), S. hominis 11 (12%) and others. In the cases of nosocomial pneumonia the following agents prevailed: A. baumannii 29 (32%), S. aureus 12 (13%), E. coli 11 (12%), and others. The following etiological agents were prevailing in the cases of urinary tract infections: E. coli 25 (40%), P. aeruginosa 9 (15%), C. albicans fungus 8 (13%) and others. DISCUSSION The incidence of HAI on the neurosurgical ward in the St. Lukas District Hospital was 3.86%. In the conducted studies, Göcmez et al. (5) observed that incidence of HAI associated with neurosurgery was 3.65%. According to the studies conducted as a part the Active Surveillance of Nosocomial Infections program, which is developed and coordinated by Polish Society of Hospital Infections, incidence of HAI on the surgical Table VI. Urinary tract infections with incidence density (incidence density per 1000 catheter days) for urinary catheter associated infections on the neurosurgical ward from 2003 to Year Number of UTI Number of UTI with urinary catheter Incidence density - UTI with urinary catheter Incidence density -* UR UTI with ratio urinary catheter ( ) Number of urinary catheter days Number of UTI without urinary catheter Number of person-days without urinary catheter Incidence density -* UTI without urinary catheter ( ) Total Incidence density*- incidence density rate per 1000 urinary catheter days, UR urinary catheter utilization ratio

78 512 Marta Wałaszek No 3 wards affected over 2% of patients and on the non-surgical wards even 4.56% of patients (6). In the study that involved 6,444 patients and that was conducted on the neurosurgical ward in Szczecin, Wieder-Huszla et al. (7) describes the occurrence of HAI in 128 (2%) patients. In our study HAI was diagnosed more often in the group of men 3.87% than in the group of women 2.22% and the obtained results were statistically significant. Experiences of other authors confirm the described dependencies (5, 7). Among etiological agents that we identified and that caused the diagnosed HAI cases, gram-positive microorganisms were detected most often comprising 48.75% of cases, among which the strains of Staphylococcus aureus constituted 69%. Gram-negative bacteria occurred relatively frequently constituting 48.75% of cases and among them the most frequent was Acinetobacter Baumannie 30%. The occurrence of particular species of microorganisms depended on the site of infection (6). The analysis of collected data indicated that the most often recorded forms of HAI were SSI which was diagnosed in 140 patients and constituted 27.1% of all nosocomial infections on the studied neurosurgical ward. Cumulative incidence of SSI was 1.7%. Hover et al. (8) showed the incidence of SSI in neurosurgical operations at the level of 2.15%. Kim et al. (9) studied 2,803 surgical patients on the neurosurgical ward and they identified the incidence of SSI at the level of 2.62%. Among the etiological agents that were isolated on the studied neurosurgical ward from materials obtained from patients diagnosed with SSI the most common were Staphylococcus aureus (56%), Acinetobacter baumannii (14%), Enterobacter cloacae (7%) and others. Other etiological agents causing SSI were showed by Wieder-Huszla el al. (7). The second group of HAI diagnosed on the neurosurgical ward are bloodstream infections. BSIs were diagnosed in 128 patients out of 13,352 patients hospitalized in the studied neurosurgical ward. Wójkowska-Mach el al. (10) presented the analysis of incidence of bloodstream infections. The analysis was conducted in 120 Polish hospitals where in the group of 513,807 patients the number of diagnosed BSI cases was 332. In the studied neurosurgical ward pneumonia was the third most essential type of infections among patients with HAI. In Poland, it is assumed that 0.5 5% of all hospitalized patients get nosocomial pneumonia (17). Other authors also agree that nosocomial pneumonia is the third most common infection diagnosed in patients who underwent operations and the most common nosocomial infection in the intensive care units (18, 19). In the analyzed neurosurgical ward, in most cases nosocomial pneumonia was caused by the following microorganisms: Acinetobacter baumannii (32%), Staphylococcus aureus (13%) and others. The obtained results are consistent with reports presented by other authors (20, 21). The fourth essential group of infected patients were patients diagnosed with urinary tract infections (UTI). UTIs were diagnosed in 74 (14.3%) patients and cumulative incidence rate was 0.58%. The obtained results were comparable with those presented in literature (22, 23). Among etiological agents that we identified and that caused UTIs the most common was Escherichia coli (40%). Many authors in their studies show identical microbial flora isolated in urinary tract infections in the area of neurosurgery (7, 24). Apart from four basic forms of HAI, also gastrointestinal system infections (GI) were monitored. GIs were detected in 6.8% of hospitalized patients, cumulative incidence rate was 0.23%. In more than half of GI cases (51%) no etiological agent was isolated, in the remaining cases Clostridium difficile (23%) was the most common. According to the Bandoła et al. team, we can observe increased frequency of occurrence of these infections in the hospital environment (25). The last form of the discussed HAIs that were detected in the studied ward were skin and soft tissue infections (SST). The etiological agents of SST were most often Staphylococcus aureus (42%), and Escherichia coli (25%). In the conducted studies about the incidence and structure of HAI during ten-year observation period, there was no significant trend of increase or decrease in the number of nosocomial infections. Incidence of HAI in specific forms such as: SSI, BSI, PN, UTI, GI and SST also remained at similar level over the years. Implemented prevention procedures, constant improvement of monitoring system and extending knowledge of medical staff allowed for the better detection of infections. The rules of surveillance and prevention of nosocomial infections in the studied ward were developed in 2001 and they concerned among others: hand hygiene, perioperative prevention, venous cannulation, urinary catheterization, dealing with the equipment for oxygen therapy. The used prevention procedures allowed for maintaining the nosocomial infections al the similar level for many years, with higher detection rate of infections. SUMMARY AND CONCLUSIONS 1. Ten-year observation of infections detected in the neurosurgical ward shows that: a) HAIs were diagnosed in 3.86% of patients; b) The most common forms of HAIs were surgical site infections, bloodstream infections and pneumonia, some patients had more than one form of nosocomial infection; c) The most common etiological agent of HAI was Staphylococcus aureus.

79 No 3 Hospital infections in neurosurgery ward The epidemiological situation in the studied neurosurgical ward did not significantly differ from the conditions in units with a similar profile. 3. HAI surveillance with epidemiological agents being taken into consideration is essential for the proper assessment of the incidence rate of nosocomial infections, their structure and identification of their source and determination of direction for taking or intensifying effective preventive actions. REFERENCES 1. Reiss J, Grzybowski J. Definicje zakażeń szpitalnych. Polskie Towarzystwo Zakażeń Szpitalnych, Kraków European Center for Disease Prevention and Control. Point prevalence survey of healthcare associated infections and antimicrobial use in European acuta care hospitals protocol version 4.3. Stockholm: ECDC; eu/en/publications/ publications/0512-ted-pps-hai-antimicrobial-use-protocol.pdf. Date of entry: Grzesiowski P, Gudzińska - Adamczyk M, Lejbrant E, Tymoczko A. Definicje zakażeń szpitalnych na podstawie decyzji wykonawczej Komisji Europejskiej nr2012/506/ UE z dnia r. Z komentarzem ekspertów SHL. Stowarzyszenie Higieny Lecznictwa. Warszawa 2013; CDC s/nhsn operative procedure category mapping to ICD-9-CM codes, October Available from: pdfs/ pscmanual/9 pscssicurrent.pdf. Date of entry: Göçmez C, Celik F, Tekin R, Kamaşak K, Turan Y, Palancı Y, Bozkurt F, Bozkurt M. Evaluation of risk factors affecting hospital-acquired infections in the neurosurgery intensive care unit. Int J Neurosci Data wejścia Bulanda M, Heczko PB. Zakażenia szpitalne w oddziałach zabiegowych. Przew Menadż Zdrowia 2001; 3(10): Wieder-Huszla S, Jurczak A, Sołowiej S. Analiza częstości występowania zakażeń szpitalnych w oddziale neurochirurgii. Probl Hig Epidemiol 2013; 94(3): Hover AR, Sistrunk WW, Cavagnol RM, Scarrow A, Finley PJ, Kroencke Ad, Walker JL. Effectiveness and Cost of Failure Modeand Effects Analysis Methodology to Reduce Neurosurgical Site Infections. 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80 514 Marta Wałaszek No 3 Received: 6 November 2014 Accepted for publication: 26 February 2015 Address for correspondence: dr Marta Wałaszek Szpital Wojewódzki im. Św. Łukasza w Tarnowie ul. Lwowska 178a Tarnów zak@lukasz.med.pl tel. 14/

81 PRZEGL EPIDEMIOL 2015; 69: Recommendations Polish Group of HCV Experts: Waldemar Halota, Robert Flisiak, Anna Boroń-Kaczmarska, Jacek Juszczyk, Małgorzata Pawłowska, Krzysztof Simon, Krzysztof Tomasiewicz, Piotr Małkowski RECOMMENDATIONS FOR THE TREATMENT OF HEPATITIS C POLISH GROUP OF HCV EXPERTS 2015 Diseases with HCV aetiology are rarely diagnosed on the basis of the clinical picture because they are usually asymptomatic or only mildly symptomatic for many years. Consequently, diagnosis is often preceded by an incidental detection of laboratory markers indicative of HCV infection. Studies conducted in Poland in recent years have demonstrated that anti-hcv antibodies are found in % of Poland s inhabitants, depending on the study population and methodology. The studies have indisputably confirmed the presence of HCV RNA in the blood, indicating active infection, at 0.6%. The figure is equivalent to approx. 200,000 adult members of the Polish population who require urgent diagnosis and treatment. The estimated number of patients diagnosed during the period of availability of HCV therapy is approx. 30,000, which corresponds to the detection rate of 15% (1, 2, 3). Around 20-40% of acute infections are believed to resolve spontaneously. HCV infection only becomes apparent after many years. One in five of chronic infection cases are diagnosed at the stage of advanced pathological changes in the liver, i.e. cirrhosis or, less commonly, hepatocellular carcinoma. HCV infection also triggers a range of extrahepatic syndromes usually cryoglobulinaemia which produces clinical manifestations in 5-25% of cases (4). Treatment should be provided to all HCV-infected patients diagnosed with acute and chronic hepatitis and the fibrosis stage F 1. The primary aim of therapy is to halt or reverse histological lesions, particularly liver fibrosis (5-7). Treatment should preferably be initiated at early stages of the disease due to higher efficacy, however in the event of problems with the availability of drugs, priority should be given to the following sub-groups of patients: with liver fibrosis (F 3), waiting for liver transplantation or who have had liver transplantation, undergoing haemodialysis, especially patients waiting for kidney transplantation, with extrahepatic manifestations of HCV infection (membranous glomerulonephritis, cryoglobulinaemia, lichen planus, cutaneous porphyria, B-NHL lymphomas and others), with hepatocellular carcinoma with HCV aetiology, co-infected with HBV. ACUTE HCV INFECTION The sole objective criterion in the diagnosis of acute hepatitis C (AHC) is the presence of laboratory markers indicative of AHC (elevated alanine aminotransferase activity, anti-hcv and/or HCV RNA) in patients whose prior HCV tests were negative or with patients after a documented exposure to HCV infection. In other cases, the diagnosis of acute hepatitis C may be inconclusive. It is important to note that while HCV RNA is detectable as early as 1-3 weeks post infection, anti-hcv antibodies cannot be detected until 4-10 weeks after HCV infection. After the onset of the first clinical symptoms, if they occur, anti-hcv antibodies are present only in 50-70% of infected individuals, and it takes three months for the figure to reach 90%. What is more, some patients do not develop anti-hcv antibodies at all. In such cases, HCV infection is diagnosed by determining the presence of HCV RNA. Therapy can be considered if HCV RNA is still detectable at week 12 after the onset of the first clinical symptoms or determination of laboratory markers. Treatment should be based on pegylated interferon alpha (PegIFNα) 2a or 2b administered in monotherapy for 24 weeks. In cases of HIV-HCV co-infection, combined therapy with ribavirin (RBV) should be considered (6). CHRONIC HCV INFECTIONS The diagnostic criterion for chronic diseases with HCV aetiology is the presence of HCV RNA (in blood serum, liver tissue or peripheral blood mononuclears) sustained for at least six months in a patient with markers of liver disease or an extrahepatic manifestation of infection. Chronic HCV infections may take the form of chronic hepatitis C and cirrhosis or hepatocellular carcinoma. The selection of treatment regimen should involve determination of the virus genotype and assessment of the stage of liver fibrosis. Therapy should National Institute of Public Health National Institute of Hygiene

82 516 Polish Group of Experts No 3 be monitored by assaying the concentration of HCV RNA by techniques ensuring that the limit of detection is below 15 IU/ml for qualitative assessment, and does not exceed 25 IU/ml for quantitative assessment. DRUGS RECOMMENDED IN THE TREATMENT OF CHRONIC HCV INFECTION The Recommendations include exclusively drugs which have been registered in any country worldwide, and especially drugs approved by the EMA (European Medicines Agency) or FDA (Food and Drug Administrations), as these medications are likely to be available on the Polish market (Table I). Other DAA drugs are also acceptable, provided that they are approved by the EMA or FDA, according to their SPC. The following therapeutic regimens are applied in clinical practice: 1. PegIFNα + RBV 2. PegIFNα + RBV + DAA 3. DAA + RBV 4. DAA + DAA +/- DAA +/- RBV GENERAL RECOMMENDATIONS The selection of a therapeutic regimen must take into consideration the current availability, efficacy and safety profile, and must be preceded by providing the patient with easily understood information about the duration of therapy, potential adverse reactions associated with each drug, importance of complying with the prescribed treatment regimen and rules governing therapy continuation and interruption. If adverse reactions occurring during triple drug therapy with interferon make it necessary to modify the treatment, the first step is to reduce the doses of RBV and/or PegIFNα. If the measure proves ineffective, DAA should be discontinued. DAA monotherapy is unacceptable due to the risk of selection of resistant strains. IL28B genotyping is not required during the selection of patients for treatment options because it restricts the accessibility of therapy without providing any pharmacoeconomic benefits (6). Testing for HCV mutations prior to the initiation of treatment is justified only in patients who are infected with genotype 1a which is rarely detected in Poland. If the Q80K mutation is identified on the viral genome in these patients, therapeutic regimens containing SMV should not be used. Liver fibrosis is assessed in a 5-point scale from 0 to 4 based on liver elastography performed using a technique allowing quantitative measurement of liver tissue stiffness expressed in kpa (SWE or TE), or liver biopsy. If coexisting liver diseases with a different aetiology are suspected, and the result of a non-invasive examination is not in accord with the patient s clinical condition or discrepancies between results of various non-invasive tests are identified, liver biopsy is recommended (unless there are contraindications to the procedure) in order to provide a conclusive result. In rare cases of contraindications to performing liver biopsy and elastography patients should receive treatment recommended for fibrosis stage F4 without undergoing fibrosis assessment (6). Treatment with a regimen containing PegIFNα may be considered effective if no HCV RNA is detected in blood at week 24 after the completion of therapy, signifying sustained virological response (SVR24). In interferon-free therapies sustained virological response is assessed 12 weeks after the completion of treatment (SVR12). However, until indisputable Table I. Dosage regimens of drugs included in the Recommendations (drugs in different groups are listed alphabetically). Drug category Class Drugs Daily dosage Asunaprevir (ASV) Boceprevir (BOC) NS3 inhibitors (proteases) Paritaprevir (PTV) Simeprevir (SMV) Telaprevir (TVR) Direct Acting Antivirals (DAA) Interferons Others NS5B inhibitors (polymerases) NS5A inhibitors Pegylated interferons alpha (PegIFNα) Dasabuvir (DSV) Sofosbuvir (SOF) Daklatasvir (DCV) Ledipasvir (LDV) Ombitasvir (OBV) PegIFNα2a PegIFNα2b Ribavirin (RBV) * PTV and OBV are combined in one tablet with ritonavir (PTV/OBV/r) ** SOF can be combined in one tablet with LDV (SOF/LDV) 200 mg/day in 2 doses 2,400 mg/day in 3 doses 150 mg/day in 1 dose* 150 mg/day in 1 dose 2,250 mg/day in 2 doses 500 mg/day in 2 doses 400 mg/day in 1 dose** 60 mg/day in 1 dose 90 mg/day in 1 dose** 25 mg/day in 1 dose* 180 mg/week 1.5 mg/kg/week 1,000 or 1,200 mg at body weight <75 kg or >75 kg

83 No 3 Recommendations for the treatment of hepatitis C results of studies investigating long-term efficacy of DAA treatment (especially without interferon) are obtained, ALT and HCV RNA monitoring at weeks 48 and 96 after the end of therapy is advisable. The efficacy of treatment should be assessed by methods whose lower limit of detection is <15 IU/ml. HCV-infected people, especially with coexisting cirrhosis, should be systemically monitored for the development of hepatocellular carcinoma (HCC). Ultrasound examination of the liver and, if needed, additional determination of alpha-fetoprotein (AFP) should be performed at 24-week intervals also after the completion of effective therapy. Assessment of alpha-fetoprotein (AFP) concentration should not be used alone for early diagnosis of HCC. However, it may be useful in determining the prognosis of diagnosed cancer and in therapy monitoring. If a cancer lesion is suspected, four-phase CT examination with contrast or MRI with contrast is recommended. Contrast-enhanced ultrasound, however, is not recommended for the routine diagnosis of HCC (8-13). The therapy of HBV-HCV or HIV-HCV co-infection is the same as the treatment recommended for infection with the HCV virus alone. As with other comorbidities, patients should be assessed for possible drug interactions. Infections with all HCV genotypes in children (past 3 years of age) should be routinely treated with dual drug therapy (PegIFNα and RBV). Patients who have failed prior treatment based on PegIFNα, regardless of the stage of liver fibrosis, should be retreated with an alternative regimen which is expected to show a significantly higher efficacy. Patients approved for liver transplantation including those who have had the procedure should first receive a treatment regimen without interferon, in accordance with recommendations listed in Table IV. The precondition for protecting transplanted liver from HCV infection is the suppression of viraemia to undetectable levels at least a month prior to the transplantation procedure, which justifies the initiation of therapy as early as possible after approval for liver transplantation. However, if the expected period until the procedure is so short that it does not guarantee effective suppression of the virus, anti-hcv treatment should not be initiated, and the patient should be closely monitored for the relapse of viraemia in order to introduce interferon-free therapy as promptly as possible. Patients with contraindications to interferon alpha treatment (Table II) or interferon alpha intolerance (Table III) should be routinely prescribed interferonfree treatment. Table II. Contraindications to interferon alpha therapy. Interferons alpha should not be used in the following cases: history of hypersensitivity to interferons or any of the excipients, decompensated cirrhosis, hepatitis or another disease with autoimmune aetiology, status post transplantation of liver or any other organ, patients approved for liver transplantation, severe, especially unstable heart disease whose difficult-tocontrol status was verified by a cardiologist, metabolic syndrome and difficult-to-treat diabetes, following consultation with an endocrinologist, depression, suicidal ideation or attempts documented by psychiatric evaluation, thyroid diseases accompanied by abnormal TSH levels, anaemia, thrombocytopenia < 90,000/μL, absolute neutrophil count < 1,500/μL. Table III. Interferon intolerance criteria. hypersensitivity to interferon or any of the excipients, autoimmune disease, exacerbation of a previously existing comorbidity, decrease in initial body weight by more than 20%, depression, suicidal ideation or attempts, thyroid function disorders, haemoglobin concentration < 8.5 mg%, thrombocytopenia < 50,000/μL, absolute neutrophil count < 500/μL. SPECIFIC RECOMMENDATIONS The basic criteria for differentiating the therapeutic approach include HCV genotype and stage of liver fibrosis. Infections with HCV genotype 1 Treatment of patients with mild liver fibrosis (F1-F2) Triple drug treatment based on PegIFNα+RBV and DAA can be considered in patients who have not been previously treated or have had a relapse after a conventional dual drug regimen. Non-responders or partial responders to prior therapy based on PegIFNα should be retreated with an interferon-free regimen regardless of the stage of liver fibrosis. Therapy with boceprevir Triple drug treatment with BOC can be considered in patients who have not been previously treated or have had a relapse of infection after an ineffective PegIFNα+RBV therapy. BOC treatment is preceded by four weeks of dual drug therapy which is referred to as the lead-in phase. The therapy is based on one of PegIFNα in combination with RBV. Boceprevir should be added starting at week 5 of therapy (14). Duration of treatment in previously untreated patients: 28 weeks (4 weeks of lead-in therapy + 24 weeks of

84 518 Polish Group of Experts No 3 triple drug therapy) if HCV RNA is not detectable in blood serum at weeks 8 and 24; 48 weeks (4 weeks of lead-in therapy + 32 weeks of triple drug therapy + 12 weeks of PegIFNα and RBV) if viraemia detected at week 8 of therapy becomes undetectable at week 24. Duration of treatment in patients with a relapse of infection: 48 weeks (4 weeks of lead-in therapy + 32 weeks of triple drug therapy + 12 weeks of PegIFNα and RBV). Triple drug therapy with BOC should be discontinued in the following cases: HCV RNA is 1000 IU/mL at week 8 of therapy; HCV RNA is 100 IU/mL at week 12 of therapy; HCV RNA is detectable (recommended limit of detection 25 IU/mL) at week 24 of therapy. Therapy with daclatasvir The drug should be used in interferon-free therapy, in combination with sofosbuvir (DCV + SOF) for 12 weeks. In patients previously treated with a protease inhibitor the therapy should be extended to 24 weeks and the addition of RBV should be considered (15). DCV can also be used in conjunction with asunaprevir (DCV+ASV) after the latter is approved for marketing in Poland (16, 17). Therapy with paritaprevir/ r/ombitasvir and dasabuvir Patients infected with HCV subgenotype 1b should take PTV/r/OBV + DSV for 12 weeks. The regimen is complemented by RBV in patients infected with subgenotype 1a. The regimen recommended for patients infected with a virus of an unknown genotype 1 subtype or with mixed HCV G1 subtype is the same as for patients infected with HCV genotype 1a (18, 19). Therapy with telaprevir Triple drug treatment with TVR can be considered in patients who have not been previously treated or have had a relapse of infection after an ineffective PegIFNα+RBV therapy. Initially, patients should receive treatment in combination with PegIFNα and RBV for 12 weeks. Then, patients with undetectable viraemia at weeks 4 and 12 of therapy should receive PegIFNα and RBV alone for another 12 weeks. Triple drug therapy with TVR should be discontinued if the concentration of HCV RNA exceeds 1,000 IU/mL at week 4 or 12 of treatment. In other patients, dual drug therapy should be continued until week 48. If viraemia is detectable at week 24 or 36, treatment must be discontinued (20). Therapy with sofosbuvir Triple drug therapy with SOF is used in combination with PegIFNα and RBV for 12 weeks (21). The recommended duration of therapy with sofosbuvir combined with ledipasvir is 12 weeks in patients who have not been treated before, and 24 weeks in other patients (22). Therapy with simeprevir Initially, patients should receive triple drug therapy with SMV in combination with PegIFNα and RBV for 12 weeks. Then, SMV is discontinued and patients are treated with PegIFNα and RBV alone for another 12 weeks. Triple drug therapy with SMV should be discontinued if HCV RNA is detectable at week 4 or 12 (23). Treatment of patients with advanced liver fibrosis (F3-F4) and contraindications to or intolerance of interferon The following therapeutic regimens are recommended: PTV/r/OBV+DSV 12 weeks in patients infected with G1b, with fibrosis stage F3, PTV/r/OBV+DSV+RBV 12 weeks in patients infected with G1b, with fibrosis stage F4 and compensated liver function, PTV/r/OBV+DSV+RBV 12 weeks in patients infected with G1a (also in unspecified subgenotype 1 or mixed genotype 1 infections), with fibrosis stage F3, PTV/r/OBV+DSV+RBV 24 weeks in patients infected with G1a (also in unspecified subgenotype 1 or mixed genotype 1 infections), with fibrosis stage F4 and compensated liver function, SOF+DCV 12 weeks in patients with fibrosis stage F3, SOF+DCV+RBV 24 weeks in patients with fibrosis stage F4, SOF/LDV 12 weeks in patients with fibrosis stage F3, SOF/LDV 24 weeks, with fibrosis stage F4 and compensated liver function, SOF/LDV+RBV 24 weeks in patients with fibrosis stage F4 and decompensated liver function, SOF+SMV+/-RBV 12 weeks, SOF+RBV 24 weeks if the combination of SOF with DCV or SMV is not possible. DCV can also be used in combination with asunaprevir (DCV+ASV) after the drug is approved for marketing in Poland (16, 17). Infection with HCV genotype 2 Dual drug therapy with interferon PegIFNα combined with RBV should be used in previously untreated patients. The duration of treatment is 24 weeks, however it may be reduced to 16 weeks in patients with low baseline viraemia (< 400,000 IU/mL) which is undetectable after 4 weeks of therapy. The

85 No 3 Recommendations for the treatment of hepatitis C treatment should be discontinued as ineffective if viraemia in the blood serum does not decrease by at least two logarithmic values (i.e. 100-fold) after 12 weeks of therapy. Therapy without interferon SOF in combination with RBV should be used for 12 weeks only in cases listed below: contraindications to or intolerance of interferon (see the Tables), inefficacy of prior PegIFNα+RBV therapy (relapse, partial or complete lack of response) in patients with advanced liver fibrosis (stages F3-F4), decompensated liver function. The duration of treatment can be extended to 24 weeks in patients with cirrhosis (F4). Infection with HCV genotype 3 Dual drug therapy with interferon PegIFNa combined with RBV should be used in previously untreated patients. The duration of treatment is 24 weeks, however it may be reduced to 16 weeks in patients with low baseline viraemia (< 400,000 IU/mL) which is undetectable after 4 weeks of therapy. The treatment should be discontinued as ineffective if viraemia in the blood serum does not decrease by at least two logarithmic values (i.e. 100-fold) after 12 weeks of therapy. Triple drug therapy with interferon The combination of PegIFNα, RBV and SOF should be used for 12 weeks in patients who have failed the dual drug regimen PegIFNα+RBV (relapse, partial or complete lack of response) and have low-stage liver fibrosis (F1-F2). Therapy without interferon SOF+RBV therapy should be used for 24 weeks in patients with contraindications to or intolerance of interferon and in patients with decompensated liver function. 24-week therapy based on the combination of SOF+RBV with LDV or DCV should be used in patients who have failed triple drug therapy or SOF+RBV or patients with advanced fibrosis (stages F3-F4). Infection with HCV genotype 4 Treatment of patients with mild liver fibrosis (F1-F2) Therapy with daclatasvir Triple drug therapy with DVC in combination with PegIFNα and RBV should be used for 24 weeks, if HCV RNA is undetectable at week 4 or 12 of therapy (recommended limit of detection <15 IU/mL). If HCV RNA is detectable in any of these tests, treatment with PegIFNα and RBV alone should be continued for another 24 weeks. The DCV+SOF combination can be used in interferon-free therapy for 12 weeks, but the treatment should be extended to 24 weeks in patients who have been previously treated with a protease inhibitor. Therapy with paritaprevir/r/ombitasvir Treatment with PTV/r/OBV in combination with RBV should be continued for 12 weeks. Therapy with sofosbuvir Triple drug therapy with SOF is used in combination with PegIFNα and RBV for 12 weeks. Interferon-free therapy based on the SOF/LDV combination should be continued for 12 weeks in previously untreated patients, and 24 weeks in patients who have failed prior therapy. Therapy with simeprevir Initially, patients should receive triple drug therapy with SMV in combination with PegIFNα and RBV for 12 weeks. Then, SMV is discontinued and patients are treated with PegIFNα and RBV alone for another 12 weeks. Triple drug therapy with SMV should be discontinued if HCV RNA is detectable at week 4 or 12 of treatment. Treatment of patients with advanced liver fibrosis (F3-F4) and contraindications to or intolerance of interferon The following therapeutic regimens are recommended: PTV/r/OBV+RBV 12 weeks, in patients with fibrosis stage F3, PTV/r/OBV+RBV 24 weeks, in patients with fibrosis stage F4 and compensated liver function, SOF+DCV 12 weeks in patients with fibrosis stage F3, SOF+DCV+RBV 24 weeks in patients with fibrosis stage F4, SOF/LDV 12 weeks in patients with fibrosis stage F3, SOF/LDV 24 weeks in patients with fibrosis stage F4 and compensated liver function, SOF/LDV+RBV 24 weeks in patients with fibrosis stage F4 and decompensated liver function, SOF+SMV+/-RBV 12 weeks. Infection with HCV genotypes 5 and 6 Triple drug therapy with interferon The combination of PegIFNα, RBV and SOF should be used as primary therapy for 12 weeks in all patients, both those who have not been previously treated and who have failed prior therapy.

86 520 Polish Group of Experts No 3 Table IV. Therapeutic options in the treatment of infections with different HCV genotypes. Genotype Population Drugs Duration of therapy BOC+PegIFNα+RBV weeks (incl weeks of BOC) DCV+ASV 24 weeks PTV/r/OBV+DSV 12 weeks in patients infected with G1b PTV/r/OBV+DSV+RBV 12 weeks in patients infected with G1a * Fibrosis at F1-F2 SOF+DCV 12 weeks SOF/LDV 12 weeks TVR+PegIFNα+RBV weeks (incl. 12 weeks of TVR) SMV+PegIFNα+RBV 24 weeks (incl. 12 weeks of SMV) SOF+PegIFNα+RBV 12 weeks and 6 Advanced fibrosis (F3-F4), Contraindications to or intolerance of IFN (Tables 2 and 3) DCV+ASV PTV/r/OBV+DSV PTV/r/OBV+DSV PTV/r/OBV+DSV+RBV PTV/r/OBV+DSV+RBV SOF+DCV SOF+DCV+RBV SOF/LDV SOF+RBV SOF+SMV+/-RBV Decompensated liver function SOF/LDV+RBV 24 weeks Untreated patients PegIFNα+RBV weeks Contraindications to or intolerance of IFN, Inefficacy of PegIFNα+RBV in patients with advanced fibrosis (F3-F4), Decompensated liver function 24 weeks 12 weeks if F3, in patients infected with G1b 12 weeks if F4, in patients infected with G1b 12 weeks if F3, in patients infected with G1a 24 weeks if F4, in patients infected with G1a * 12 weeks if F3 24 weeks if F4 12 weeks if F3; 24 weeks in F4 24 weeks 12 weeks SOF+RBV 12 weeks (24 weeks if F4) Untreated patients PegIFNα+RBV weeks Contraindications to or intolerance of IFN, Decompensated liver function SOF+RBV 24 weeks Inefficacy of PegIFNα+RBV in patients with fibrosis (F1-F2) SOF+PegIFNα+RBV 12 weeks Inefficacy of triple drug therapy or SOF+RBV or fibrosis (F3-F4) SOF+DCV+RBV SOF/LDV+RBV 24 weeks 24 weeks DCV+PegIFNα+RBV 24 weeks PTV/r/OBV+RBV 12 weeks Fibrosis at F1-F2 SMV+PegIFNα+RBV 24 weeks (incl. 12 weeks of SMV) SOF+DCV 12 weeks SOF/LDV 12 weeks SOF+PegIFNα+RBV 12 weeks Advanced fibrosis (F3-F4), Contraindications to or intolerance of IFN PTV/r/OBV+RBV SOF+DCV SOF+DCV+RBV SOF/LDV SOF+SMV+/-RBV Decompensated liver function SOF/LDV+RBV 24 weeks Untreated patients and inefficacy of previous therapy SOF+PegIFNα+RBV 12 weeks Contraindications to or intolerance of IFN, Advanced fibrosis (F4) or history of SOF+RBV 24 weeks decompensated liver function 12 weeks if F3; 24 weeks if F4 12 weeks if F3 24 weeks if F4 12 weeks if F3; 24 weeks if F4 12 weeks * In patients infected with virus of an unknown genotype 1 subtype or with mixed genotype 1 infection the recommended treatment is the same as in patients infected with virus of genotype 1a. Table V. Therapeutic options for patients prior to and after liver transplantation Genotype Population Drugs Duration of therapy 1,2,3,4,5,6 SOF+RBV Until transplantation, not longer than 24 weeks 1,4 Approved for liver transplantation PTV/OBV/r+DSV+RBV (G1) PTV/OBV/r+RBV (G4) SOF/LDV+RBV 12 weeks in G1b infection (if Child-Pugh A; 24 weeks in G1a or G4 infection) 24 weeks 1,3,4,5,6 SOF+DCV+/-RBV weeks 2 SOF+RBV weeks 1,4 Post liver transplantation PTV/OBV/r+DSV+RBV (G1) PTV/OBV/r+RBV (G4) SOF/LDV+RBV SOF+SMV+/-RBV 24 weeks 24 weeks 24 weeks weeks

87 No 3 Recommendations for the treatment of hepatitis C Dual drug therapy without interferon The combination of SOF and RBV should be used for 24 weeks in patients with contraindications to or intolerance of interferon and liver fibrosis stages F3-F4, but also decompensated liver function. Treatment of patients approved for liver transplantation or patients with recurrence of infection after liver transplantation Patients who have been approved for liver transplantation or who have had a recurrence of infection post liver transplantation should only use interferon-free regimens listed in Table V. REFERENCES: 1. Cornberg M, Razavi HA, Alberti A, et al. A systematic review of hepatitis C virus epidemiology in Europe, Canada and Israel. Liver Int 2011; 31 Suppl 2: Flisiak R, Halota W, Horban A, et al. Analysis of risk factors related to HCV infection in Poland. Eur J Gastroenterol Hepatol 2011; 23: Panasiuk A, Flisiak R, Mozer-Lisewska I, et al. Distribution of HCV genotypes in Poland. Przegl Epidemiol 2013; 67: Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol 2014; 61: S Halota W, Flisiak R, Boroń-Kaczmarska A, et al. Rekomendacje leczenia wirusowych zapaleń wątroby typu C Polskiej Grupy Ekspertów HCV Przegl Epidemiol 2014; 68: Pawlotsky JM, Aghemo A, Dusheiko G, et al. EASL recommendations on treatment of hepatitis C Michaluk-Zarębska D, Flisiak R, Janczewska E, et al. Effect of pegylated interferon or ribavirin dose reduction during telaprevir based therapy on SVR12 in null-responders and relapsers with advanced liver fibrosis (AdvEx study). J Hepatol 2014; 60 Suppl 1: Backus L, Boothroyd DB, Phillips BR, Mole LA. Impact of sustained virologic response to pegylated interferon/ ribavirin on all-cause mortality by HCV genotype in a large real-world cohort: the US Department of Veteran Affairs Experience. Proceedings of the American Association for the Study of Liver Disease 2010; Boston MA. Hepatology 2010; 52 (Suppl 4): S428A. 9. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53: Clavien PA, Lesurtel M, Bossuyt PM, et al. OLT for HCC Consensus Group. Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report. Lancet Oncol 2012; 13: e Singal AG, Volk ML, Jensen D, et al. A sustained viral response is associated with reduced liver-related morbidity and mortality in patients with hepatitis C virus. Clin Gastroenterol Hepatol 2010; 8: e van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA 2012; 308: Wasiak D, Małkowski P. Wytyczne leczenia raka wątrobowokomórkowego (HCC). Med Sci Mon Rev Hepatology 2013; 13: Victrelis, Charakterystyka Produktu Leczniczego. 15. Daklinza, Charakterystyka Produktu Leczniczego. 16. Kumada H, Suzuki Y, Ikeda K, et al. Daclatasvir plus asunaprevir for chronic HCV genotype 1b infection. Hepatology 2014; 59: Manns M, Pol S, Jacobson IM, et al. All-oral daclatasvir plus asunaprevir for hepatitis C virus genotype 1b: a multinational, phase 3, multicohort study. Lancet 2014; 384: Viekirax, Charakterystyka Produktu Leczniczego. 19. Exviera, Charakterystyka Produktu Leczniczego. 20. Incivo, Charakterystyka Produktu Leczniczego. 21. Sovaldi, Charakterystyka Produktu Leczniczego. 22. Harvoni, Charakterystyka Produktu Leczniczego. 23. Olysio, Charakterystyka Produktu Leczniczego. Received: Accepted for publication: Address for correspondence: Prof. Krzysztof Tomasiewicz Department of Infectious Diseases Medical University in Lublin Staszica 16, Lublin Tel krzysztof.tomasiewicz@umlub.pl

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89 PRZEGL EPIDEMIOL 2015; 69: Public health Arkadiusz Kuziemski, Krystyna Frankowska, Ewa Gonia, Beata Czerniak, Olena Bakhurynska, Zbigniew Sobociński EVALUATION OF THE EFFICIENCY OF HOSPITAL ANTIBIOTIC POLICY APPLIED IN DR JAN BIZIEL UNIVERSITY HOSPITAL NO 2 IN BYDGOSZCZ IN Jan Biziel University Hospital No 2 in Bydgoszcz ABSTRACT The Hospital Infection Control Team (HICT) of Dr Jan Biziel University Hospital No 2 in Bydgoszcz developed and implemented the principles of a rational antibiotic therapy in A behavior algorithm has worked since Implementation of the principles of a rational antibiotic therapy was part of the hospital antibiotic policy. THE AIM OF THE STUDY is to evaluate either introductory principles of the rational antibiotic therapy, after five-year experience lived up to expectations in the range specified by the authors. MATERIAL AND METHODS. Hospital microbiological maps, comparisons of antibiotic cost, specification of microbiological tests made before and after introduction of the principles of a rational antibiotic therapy have been analyzed. Annual antibiotic consumption has been counted according to the defined daily dose (DDD) index created by the WHO. RESULTS. After 6 years of implementation of the rational antibiotic therapy principles, the decrease in number of isolated strains which are resistant to Klebsiella pneumoniae ESBL and Acinetobacter baumanii (resistant to carbapenems) has been indicated. The number of the Pseudomonas aeruginosa isolates has increased approximately three times, and the number of resistant isolates to carbapenem has grown six times. The cost of antibiotics has been gradually decreased in 2012 in order to represent 9,66 % of all drug budget (without drug programs). Detailed analysis of antibiotic consumption has showed that after the implementation of rational antibiotic therapy principles the consumption of meropenem has increased twice in comparison to the all drugs. The number of microbiological tests grew from 0,20 to 0,29 per one patient, which means material to microbiological tests has been taken from every third patient. Annual DDD index calculated on 100 person-days has been reduced from 59,552 in 2007 to 39,90 in 2009, and it is 47,88 in The principles of rational antibiotic therapy in comparison with the other elements of antibiotic policy in hospital have caused positive changes in antibiotic ordinance. CONCLUSIONS. 1. It is required to adhere to the principles of a rational antibiotic therapy by medical staff mainly on the administrative restriction of access to antibiotics. 2. Monitoring changes in drug resistance of hospital flora is an essential element of the principles of a rational antibiotic therapy modification. Key words: antibiotic usage, hospital antibiotic policy INTRODUCTION The consequence of implementing a quality management system ISO 9001:2008 (QMS) by the Hospital Infection Control Team (HICT) was to develop principles of a rational antibiotic therapy. HICT has collected data of commonly used antibiotics from a particular hospital department and a hospital pharmacy prior to their introduction. Analysis has showed that some of them were abused. Approximately 80% of the antibiotic budget was assigned for the purchase of only three drugs: amoxicillin with inhibitor, cefuroxime and ciprofloxacin all of which are intravenous. It has been found out by the analysis of a hospital microbiological National Institute of Public Health National Institute of Hygiene

90 524 Arkadiusz Kuziemski, Krystyna Frankowska et al. No 3 map that hospital flora has not changed for some years and consisted of similar phenotypic pathogens with similar antibiotic resistance. Strains of Klebsiella pneumoniae, Acinetobacter baumannii and Staphylococcus aureus dominated. This stagnation could have been a consequence of antibiotics overuse and threatened the selection of drug-resistant bacteria which had been not observed. It has been found out that the number of microbiological diagnostic tests did not equal to the real needs. In this context it was evident that antibiotics were often used empirically. The pharmacy data has showed that the lack of a coherent antibiotic policy in hospital complicated the conduct of tender procedures. Analysis of antibiotic costs in drug annual budget has showed that the budget was too high and ranged from 15 to 27%. Based on these findings, HICT has identified the following priorities for the rational antibiotic therapy: 1. Administrative access restriction to antibiotics as a preventive action against appearance of pathogens resistant to antibiotics in the hospital microbial flora. 2. Adaptation of microbiological diagnostics to the actual needs in the context of targeted antibiotic therapy. 3. Limitation of indications for empiric antibiotic therapy. 4. Simplification of antibiotic purchase procedures during tenders. 5. Cost reduction of the in antibiotic treatment. The aim of the study is to evaluate either introductory principles of the rational antibiotic therapy, after five-year experience lived up to expectations in the range specified by the authors. The principles of the rational antibiotic therapy have been worked out according to the following assumptions. The antibiotics have been divided into four groups according to their therapeutic effect and their accessibility: Group I - prophylactic antibiotic therapy is used if there are no markers of infection, risk factors are present or surgery is planned. Unrestricted access. Group II - empirical antibiotic therapy is used as monotherapy or combination therapy if it is clinically indicated: serious condition a patient, manifestation of an infection, a toxic septic state. Unrestricted access. Group III - the first-line antibiotic therapy is used if a patient s clinical condition requires the inclusion of an antibiotic due to the current markers of infection (clinical, local, etc). Unrestricted access. Group IV - restricted antibiotic therapy can be used after obtaining a Director s written consent. Antibiotic order execution will take place after applying justification in cause: it is required by patient s clinical condition, replacement of the empirical antibiotic therapy according to antibiogram results, inclusion of targeted antibiotic therapy based on antibiogram and other clinical situations which justify the usage of antibiotics. Due to differences in accessibility in the Group IV it has been divided into a Group IV a and a Group IV b. The Group IV a contains of antibiotics which are in stock of the hospital pharmacy. The Group IV b contains of antibiotics which will be delivered from outside to the hospital pharmacy and therefore the access to them may be extended in time. MATERIAL AND METHODS The study included the hospital records from the years which contains: 1. Hospital microbiological maps ( ). Particular attention was given to the phenotype of isolated bacterial strains, especially in the context of their drug resistance. The number of carried out tests and antibiograms clinically indicated. The result interpretation of drug resistance was in accordance to recommendations of the European Committee on Antimicrobial Susceptibility Testing. 2. Comparison of pharmacy cost of antibiotics ( ). We have analyzed annual cost of antibiotics compared with the budget of all the medicines, and the cost of individual antibiotics. 3. It has been recorded that usage of antibiotics in the Units divided into groups of antibiotics after implementation of the principles of the rational antibiotic therapy ( ). Their cost share and basis of usage. ADDITIONAL RECOMMENDATIONS 1. In each case of suspected infection a material should be taken for microbiological tests in accordance with the instructions before administering antibiotics. 2. It is recommended to use primarily antibiotics of the Group III based on antibiogram. 3. As far as possible the principles of sequential therapy should be applied (transition from parenteral to peroral) observing the principle of antibiotic therapy in the same group and generation. 4. Cases which will raise diagnostic or therapeutic doubts, and has not met the requirements of antibiotic usage especially in the Group IV should be consulted by Hospital Epidemiologist. 5. It is recommended that antibiotic prophylaxis has not exceeded 48 hours and antibiotic therapy of the Group II, III and IV has been carried out for at least 10 days. The Hospital Infection Control Team has developed an algorithm of procedure for the process of the quality

91 Fig. 1. Algorithm of antibiotic therapy rules No 3 Efficiency of hospital antibiotic policy 525 Fig. 1. Algorithm of antibiotic therapy rules management system ISO 9001:2008, which is shown in Figure 1. The principles of rational antibiotic therapy were introduced by decree of the hospital Director on 1 October Hospital microbiological maps, comparisons of antibiotic cost, specification of microbiological tests made before and after introduction of the principles of a rational antibiotic therapy have been analyzed. The number of microbiological tests was converted into one bed and one patient, based on data from 2007 to In order to compare the costs, the percentage of antibiotics has been calculated in relation to drug general budget and 16 percentage of various antibiotics in relation to antibiotic budget. The costs of antifungals and antivirals drugs have not been calculated in the antibiotic therapy cost. Annual antibiotic consumption has been counted

92 526 Arkadiusz Kuziemski, Krystyna Frankowska et al. No 3 according to the defined daily dose (DDD) index created by the WHO. The Microsoft statistical program has been used for calculation. RESULTS In 2007 the hospital microbiological maps showed that among all bacterial isolates derived from clinically relevant material, the strains of staphylococcus, enteobacteriacae, acinetobacter and pseudomonas dominated. According to drug resistance determination of bacterial strains, the following mechanisms of resistance have been detected: methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamases (ESBL) among Enterobacteriaceae especially Klebsiella pneumoniae and carbapenemases produced by the strains of Acinetobacter and Pseudomonas. After 6 years of implementation of the rational antibiotic therapy principles, the decrease in number of isolated strains which are resistant to Klebsiella pneumoniae ESBL and Acinetobacter baumanii (resistant to carbapenems) has been indicated. The number of the Pseudomonas aeruginosa isolates has increased approximately three times, and the number of resistant isolates to carbapenem has grown six times. The number of methicyllin-resistant staphylococcus strains (MRSA) has not changed significantly (Table III). The cost of antibiotics has been gradually decreased in 2012 in order to represent 9,66% of all drug budget (without drug programs) (tab. IV). Detailed analysis of antibiotic consumption has showed that after the implementation of rational antibiotic therapy principles the consumption of meropenem has increased twice in comparison to the all drugs. The cost of meropenem comparing to the antibiotic budget has increased from 10% to 27.95% (tab. V) within 5 years. About 90% of meropenem consumption has been generated by four units: neonatal and adult intensive care, general surgery and hematology. The number of microbiological tests was made from clinically relevant materials and have increased from 10.8 to per one bed in The number grew from 0,20 to 0,25 per one patient (tab. II), which Percentage of antimicrobial resistance testing increased from 22,78% in 2007 to 28,23% in 2013 (tab. I). Annual DDD index calculated on 100 person-days has been reduced from 59,552 in 2007 to 39,90 in 2009, and it is 47,88(tab. VI) in Currently, the hospital uses 35 kinds of antibiotics. DISCUSSION Table I. The number of drug resistance tests made in (clinically relevant material) Years Cultures Positive % Table II. The number of microbiological tests made in per one bed and one patient (clinically relevant material). Year Number of tests Number of beds Number of patients Number per bed Number per patient Table III. The most commonly isolated bacteria with drug resistance in (clinically relevant material) Years Staphylococcus MRSA Eneterobact. Kl pneumoesbl. Ac./ resistant to carbapenems Pseud/ resistant to carbapenems Table IV. The costs of antibiotics and their percentage in drug budget in years Years Drug budget Cost of antibiotics Percentage The modern medicine problems in the treatment of infections are caused by increasing resistance among pathogens and poor pharmaceutical sector performance

93 No 3 Efficiency of hospital antibiotic policy 527 Table V. Percentage of meropenem in the drug and antibiotic budgets in % 19.92% 18.89% 16.61% 22.94% 27.95% 22.54% Table VI. Antibiotic consumption according to DDD100 person days in Lata DDD in synthesizing new antibiotics. The stand of the WHO was determined in 2001 and European Union legislation followed it (6,7). The aim of administrative action was suppression of antibiotic use, incremental drug resistance, increase in the number of hospital infections and better surveillance of this phenomenon in outpatient centers (8,9,10). An example of antibiotic overage was the index of antibiotic use per 59,52 DDD/100 persondays in Dr Jan Biziel University Hospital No 2 in In Poland, the Hospital Infection Control Teams are responsible for these tasks (10). The Hospital Infection Control Team (HICT) of Dr Jan Biziel University Hospital No 2 in Bydgoszcz was established in HICT developed and implemented the principles of a rational antibiotic therapy in A behavior algorithm has worked since Implementation of the principles of a rational antibiotic therapy was part of the hospital antibiotic policy (1,2,3,4,5). The hospital administration, the hospital pharmacy and the microbiological diagnostic unit were engaged in realization of assumptions about the hospital antibiotic policy. In contrary to other similar projects, the implemented algorithm of antibiotic therapy points the code of conduct for physicians, and allows them not to limit the level of their decisiveness and their responsibility for infection treatment. A consultation with a clinical microbiologist and / or a hospital epidemiologist is the last element of the algorithm. It is reserved for the most difficult cases. Division of antibiotics into four groups has differentiated accessibility to them. The goals were achieved after five years from implementation of principles of a rational antibiotic therapy. The number of microbiological tests has increased twice per 1 bad, and the number of drug resistance testing is 50% higher per year. This is a proof that physicians keep the algorithm of antibiotic therapy and limit the usage of empirical antibiotic treatment. The PPS studies which were carried out in May and June 2014 showed that the algorithm principles were ignored only in two cases, and antibiotic consumption was applied among 29% patients (438 patients). The percentage index of hospital infections is 5,25 %. These are results below average for this type of domestic and foreign epidemiological study (9). Antibiotic therapy cost calculated as a percentage share in hospital drug budget has decreased to 10 %, which is at similar level for the last two years. In 2011antibiotic consumption per year, according to DDD/100 person-days, was 35,68. It was counted without peri-procedural antibiotic prophylaxis. This value is close to the consumption of antibiotics which has been shown at score-based study in Negative effect of principles of a rational antibiotic therapy has been Meropenem consumption growth. The costs went up from 10% to 27%. Wards with the highest incidence of hospital infection have had about 80% of Meropenem consumption. However, in 90% cases this antibiotic has been implemented on the basis of drug resistance results. In order to change this tendency, the Infection Control Committee held talks with heads of the wards. In 2013 Meropenem consumption was decreased. Analysis of microbiological maps have not showed growth in the number of drug resistant isolates except for Pseudomonas aeruginosa producing carbapenemases. Probably it is the effect of Meropenem consumption growth. Antibiotic division into four groups has caused simplification in tender procedures. The hospital is using 35 types of antibiotics now. An intravenous form of amoxicillin was retreated from hospital formulary in 2012 because of low efficiency that was proven by science. The principles of rational antibiotic therapy in comparison with the other elements of antibiotic policy in hospital have caused positive changes in antibiotic ordinance. The base of these changes is the drug resistance result. It has significantly increased the antibiotic costs. Index DDD/100 person-days has fallen by 11,64. Negative phenomenon was carbapenem consumption growth in twice. It may have influenced on the 6 times growth in number of the Pseudomonas aeruginosa isolates which produce carbapenemases. CONCLUSIONS 1. It is required to adhere to the principles of a rational antibiotic therapy by medical staff mainly on the administrative restriction of access to antibiotics. 2. Monitoring changes in drug resistance of hospital flora is an essential element of the principles of a rational antibiotic therapy modification.. REFERENCES 1. Hanberger H, Skoog G, Ternhag A, et al.antibiotic consumption and antibiotic stewardship in Swedish hospitals. Ups J Med Sci Apr 11. [Epub ahead of print] 2. Cooke J1, Stephens P2, Ashiru-Oredope D, et al. Antibacterial usage in English NHS hospitals as part

94 528 Arkadiusz Kuziemski, Krystyna Frankowska et al. No 3 of a national Antimicrobial Stewardship Programme. Public Health Aug;128(8): doi: /j. puhe Epub 2014 Aug Del Arco A, Tortajada B, de la Torre J, et al. The impact of an antimicrobial stewardship programme on the use of antimicrobials and the evolution of drug resistance. Eur J Clin Microbiol Infect Dis Aug 16. [Epub ahead of print] 4. Cairns KA, Jenney AW, Abbott IJ, et al. Prescribing trends before and after implementation of an antimicrobial stewardship program. Med J Aust Mar 18;198(5): Goff DA.: Antimicrobial stewardship: bridging the gap between quality care and cost. Curr Opin Infect Dis Feb;24 Suppl 1:S doi: /01. qco Trivedi K, Dumartin C, Gilchrist M, et al. Identifying Best Practices Across Three Countries: Hospital Antimicrobial Stewardship in the United Kingdom, France, and the United States. Clin Infect Dis (2014) 59 (suppl 3): S170-S178 doi: /cid/ciu Pollack LA, Srinivasan A. Core Elements of Hospital Antibiotic Stewardship Programs From the Centers for Disease Control and Prevention Clin Infect Dis (2014) 59 (suppl 3): S97-S100 doi: /cid/ciu File T.M., Jr, Srinivasan A, Bartlett J.G. Antimicrobial Stewardship: Importance for Patient and Public Health Clin Infect Dis (2014) 59 (suppl 3): S93-S96 doi: / cid/ciu Hryniewicz W, Kravanja M, Ozorowski T. Sprawozdanie z realizacji Narodowego Programu Ochrony Antybiotyków. Narodowy Instytut Leków, Ustawa o zapobieganiu oraz zwalczaniu zakażeń i chorób zakaźnych u ludzi Dz.U Received: Accepted for publication: Address for correspondence: Arkadiusz Kuziemaski Jan Biziel University Hospital No 2 Ujejskiego 75, Bydgoszcz

95 PRZEGL EPIDEMIOL 2015; 69: Public health Agata Schubert 1, Marcin Czech 1,2, Anita Gębska-Kuczerowska 3 EVALUATION OF ECONOMIC EFFECTS OF POPULATION AGEING METHODOLOGY OF ESTIMATING INDIRECT COSTS 1 Warsaw University of Technology Business School 2 Department of Pharmacoeconomics, Medical University of Warsaw 3 Public Health Unit, National Institute of Public Health-National Institute of Hygiene ABSTRACT Process of demographic ageing, especially in recent decades, is steadily growing in dynamics and importance due to increasing health-related needs and expectations with regard to a guarantee of social services. Elaboration of the most effective model of care, tailored to Polish conditions, requires an estimation of actual costs of this care, including indirect costs which are greatly related to informal care. The fact that the costs of informal care are omitted, results from a determined approach to analyses. It is discussed only from a perspective of budget for health and does not cover societal aspects. In such situation, however, the costs borne by a receiver of services are neglected. As a consequence, the costs of informal care are underestimated or often excluded from calculations, even if they include indirect costs. Comprehensive methodological approach for estimating the costs of informal care seems to be important for a properly conducted economic evaluation in health care sector. Keywords: indirect costs, population ageing, evaluation methods, informal care INTRODUCTION According to the data of the Central Statistical Office (CSO), derived from the Polish Census as of 31 st March 2011, a total of 6,730,000 persons at postproductive age (60/65 years and over) lived in Poland, i.e. 17% of Polish population (1,2). Process of demographic ageing, especially in recent decades, is steadily growing in dynamics and importance due to increasing health-related needs and expectations with regard to a guarantee of social services (3,4). Increasing demand is accompanied by a raised awareness of investment in health at each stage (5). Based on demographic projections, it is assumed that population ageing scale would be increasing. Up to 2050, there would be an increase in the number of elder persons with a decrease of the number of Polish population. Percentage of persons at post-productive age would range from 14.7% in 2013 to 32.7% in Such increase would result from a reduced fertility rate and prolonged life expectancy (6). Increasing demand for long-term care calls for reforms in health care system (7). Elaboration of the most effective model of care, tailored to Polish conditions, requires an estimation of actual costs of this care, including indirect costs. COST OF LONG-TERM CARE Geriatric conditions incur direct costs which are associated with long-term care, drugs administered in chronic diseases and expensive long-term services with an example being hospitalization. In Poland, the highest unit costs of both hospital and outpatient care were triggered by persons over the age of 70 years (8). Having considered the fact that economic effects of long-term care are evaluated with reference to patients at post-productive age, the aspects of lost productivity are often excluded while estimating the total costs of care. Problem of care over the elderly has an impact on productivity. It generates indirect costs due to a commitment of persons in informal caregiving. In the majority of cases, these persons are relatives: children, spouses, grandchildren, who entirely or partially dedicate their time to the elder person (9,10). Such aspect of longterm caregiving is not recognized sufficiently enough. It should be taken into account in health care planning, National Institute of Public Health National Institute of Hygiene

96 530 Agata Schubert, Marcin Czech et al. No 3 especially due to ethical and moral issues and legal obligations of all parties. Informal caregiving is not costfree as it generates societal costs. Carers of the elderly often have to resign from the work or their free time as to take care of their elder relatives. Constant caregiving is associated with physical and psychological burden, especially if a carer is not prepared enough and supported. Consequently, it may pose a risk of burnout and pathological interpersonal relationship (11). Excessive burden for carers may have an effect on their effectiveness in fulfilling the obligations at work. Therefore, not only the impact of caregiving on productivity loss due to resignation from a job should be considered but also its reduction resulting from exhaustion (free time is not devoted to the rest). According to the WHO definition, long-term care is defined as activities undertaken by informal (family, friends and neighbours) and formal carers, including professionals and auxiliaries (health, social, and other workers) with the goal to ensure that an individual who needs assistance with the activities of daily living can maintain the best possible quality of life, adequate to personal preferences and needs, with the greatest possible degree of independence, personal fulfilment and human dignity (12). Approximately 80% of environmental care recipients and 90% of inhabitants of social care centres are persons over the age of 65 years. Thus, long-term care is often considered to be a synonym of care over the elderly (13). Demand for the services for the elderly is increasing from year to year. Simultaneously, experience of other European countries suggests that an increase in the number of nursing homes is not the only solution to this problem. One of the arguments which questions the relevance of such solution are high costs of running of nursing homes and its relatively small effectiveness (4,14). Informal care may yet become an alternative solution. It should not be considered, however, as a cost-free service, resulting from ethical, moral and legal obligations of relatives. Thus, there is a necessity of proper estimation of actual informal care costs, including indirect costs as to ensure that decisions made are rational and socially approved. LONG-TERM CARE IN POLAND AND WORLDWIDE A risk of disability and potential necessity of counting on long-term refers to all age groups, however, such a risk increases with age. Increasing number and percentage of elder persons in population leads to a rise of demand for long-term and constitutes a challenge in planning of care over the elderly, especially due to a dynamics of ageing in this population (15,16). It is estimated that the percentage of elder persons over the age of 80 years in the population would increase from 4.7% to 11.3% in in the European countries (17). Similar demographic changes are observed in all European countries. Thus, it is comprehensible that organization of long-term and national management would have to become a political priority as to meet civilization standards and societal expectations (18,19). Methods of long-term financing differ in particular countries as with regard to the sources of care financing (private or public), liability (local or central), or adopted criteria of defining the differences in the scope of services (health care and long-term care). From the analysis of the OECD transpires that private and public expenditures on long-term care on average accounted for 0.1 up to 3.6% of GDP (Portugal and Sweden, respectively). Results of aforesaid study suggest that financing of long-term care in the OECD countries would double from 2005 to 2050 (17). In a number of countries, long-term policy is of diverse nature as it is in case of health care and social welfare system organization and its financing. In a part of countries, it is claimed that poor and lonely persons should benefit from public long-term services and that family is first to bear the responsibility for care over such persons (Canada, USA). In several European countries (Germany, Sweden, Netherlands, France), long-term care is guaranteed for everyone who needs it regardless of the financial status. As it can be seen, favoured models of care do not always involve the phenomenon of singlehood and social and cultural changes being introduced into family, but more a social pressure on political decisions (societal services) (20). Beside the differences in the approach to long-term financing, the quantity of resources for this care should depend on demographic ageing index or, being more precise, the value of synthetic indicators (e.g. DALY) (21,22). As it was stated earlier, the differences in expenditures on long-term care in particular countries do not result exclusively from demographic disparities. To a large extent, they are associated with balancing the share of informal care, i.e. formal (economic, organizational and legal) and traditional issues (social and cultural norms). From such perspective, the costs of informal care are frequently omitted or considered to be cost-free services. Thus, if their share is not included, it leads to public savings. Simultaneously, if they are not involved in indirect costs, it may lead to a shift of burden and generating the costs of human capital. The OECD analyses of long-term expenditures suggest that Poland belongs to the countries with the lowest level of expenses on such care, i.e. 0.4% of GDP. It is only an approximate value which includes exclusively public expenditures on long-term care. It does not involve private expenses of households, and even more indirect costs associated with long-term care.

97 No 3 Estimating indirect costs of ageing population 531 Such approach in the methodology of cost evaluation ranks Poland very low on the list of expenditures for this care (17). In Poland, there is no separate and uniform longcare system and its services are distributed by different sectors of social welfare system (23). Within the terms of health care system, services are rendered while social welfare system includes both services and monetary benefits. Despite the costs of system (e.g. sensu stricto related to health care), monetary benefits are rendered with the examples being attendance allowance and benefit, to which persons receiving retirement pension and pension, incapable of working or having a certificate of incapability of self-support are entitled. Persons over the age of 75 years receive allowance or benefit regardless of the degree of incapability (24). Preferences for a family-based model of long-term care in Poland result from a number of reasons, including i.a. cultural factors, but also barriers relating to the access to institutional care and private long-term care. Simultaneously, Poland is experiencing similar changes that are reported in many highly industrialized countries, which affect the potential of informal care due to reduced fertility, longer life expectancy, resignation from multigenerational model of family, employment outside the place of residence, modifications in stereotypes of societal roles and singlehood (16,25). DIRECTIONS OF LONG-TERM CARE ORGANIZATION AND METHODS OF ASSESSMENT A challenge for the future years would be the organization of long-term care which would ensure services of high quality with concomitant optimization of the costs. There are diverse organizational forms of care in countries (a number of variables) which to a large extent hinders the comparative analysis of care system effectiveness with regard to the costs borne. For other purposes, a division of long-term care was introduced by the place in which the care over the disabled person is guaranteed: Home-based care medical and social care is rendered by formal and/or informal carers, mainly in the place of residence of the care receiver; Institutional social care services aimed at supporting a person in daily activities, rendered 24 hours a day outside the place of residence; Institutional medical and nursing care services referring to medical aspects of care, rendered in health care units (26). costs Fig.1. Dependence degree Dependence degree vs. costs of home-based long- -term care a, sector of social care b and health care sector (doctor and nursing care) c (by Jackson). For such division, Jackson conducted an analysis aimed at determining the criteria of optimal care. Having compared the costs in particular sectors, the total cost of care, including indirect costs, was estimated. It was assumed that the quality of care in all sectors is stable and the cost of care increases with a rise of receiver s dependence. Estimation of home-based care costs raises the greatest difficulties as despite the costs of formal home-based care, expenditures on running the household, the costs of informal care should be calculated, without the possibility to calculate its market value (market price). Indirect cost associated with long-term care is mainly related to the loss of human capital of carers (due to professional deactivation, burnout, reduced professional effectiveness). For both institutional social care and medical care, the main component of costs are costs related to running a unit, operational costs (nutrition, cleaning) and nursing costs. Due to its specialist nature, health care sector generates relatively high costs, regardless of the degree of dependence (disability of a patient). Economic analyses suggest that in case of low degree of dependence, the most cost-effective is home-based care while with a high degree of dependence specialized, institutional medical care (13). For proper establishing of such relations, it is necessary to correctly estimate the costs, borne in particular age groups and different models of care. As it was stated earlier, a special role in home-based care is played by indirect costs. In countries, where home-based care mainly depends on informal care, underestimation of indirect costs may lead to erroneous conclusions, i.e. home-based care is the most cost-effective model. Thus, funds and resources in system are transferred as to delay the development of needless, capital-intensive institutional care. Estimation of indirect costs of home-based longterm care would ensure the evaluation of societal costs of care. Such an approach to this problem would allow

98 532 Agata Schubert, Marcin Czech et al. No 3 for rational (cost-effective) organization of care in ageing population, assuring the balance between formal and informal home-based care and institutional care. It seems to be a false assumption that institutional care is the most expensive model of care while home-based care is of the highest effectiveness. The actual cost is affected by the degree of dependence of a disabled person. Effective management of services and rational allocation of receivers to appropriate sectors of care have an impact on limiting the societal costs. Having considered different methodologies adopted in worldwide studies analyzing the costs of long-term care and geriatric conditions, there are high disparities in the results achieved. To the largest extent, inclusion of indirect costs and selection of methods used to analyze these costs lead to differences in results obtained. Results of systematic review of studies discussing the costs of care over patients with dementia suggest that the calculation of costs of informal care differed even more than twofold between studies. In the analysis, a total of 28 studies, investigating the costs of disease from various perspectives, using different methods of cost assessment were discussed. In more than 70% of studies analyzed, the cost of informal care was calculated, however, the estimated value of working hour of a carer differed to a large extent. It resulted from serious differences in methodologies adopted, which hindered the comparison of particular results (27). Costs of informal care have a great impact on the final results of study as they frequently account for a high percentage of total costs. In the study conducted by Schwarzkopf et al., the cost of care over the patients with dementia in Germany was estimated, including the costs of informal care. Share of informal care cost accounted for more than 80% of total costs, assessed from a societal perspective. The cost of informal care increased with the rising degree of dependence (28). METHODOLOGY OF ASSESSMENT OF INDIRECT COSTS OF CARE A number of care systems shift a great part of longterm care to the area of informal care, which in many situations is an effective form of care continuation. Studies suggest that home-based informal care reduces the costs of specialist care and delays the qualification to long-term care unit (29). Having substituted and supplemented the formal medical care, a person benefiting from informal care may stay longer in home settings, thus, generating savings for long-term care system. On the other hand, provision of such care may be a challenge (burden) for the carers. Studies suggest that persons who care for family member for a long time present depression symptoms. They are likely to consider their health status as poor. In many cases, they have to resign from their careers (30,31,32). All these factors are associated with lost productivity and generate societal costs. Having selected an optimal model of care, it is necessary to indicate the actual costs of particular options for the society with determining the indirect costs which are of importance in informal care. If the value of informal care is considered as a costfree care in economic analyses, it may lead to negative consequences from a societal perspective. Societal perspective, involving the indirect costs, is taken into consideration in the reimbursement process as it is included in the recommendations of the Agency for Health Technology Assessment and Tariff System. Implementation of societal perspective is restricted in analyses due to i.a. methodological and interpretative ambiguities concerning the estimation of indirect costs (33). Having analyzed the cost of informal care, it is essential to calculate the time dedicated to caregiving, value of this time and its utility. For each of these issues, there is a range of possible methodological approaches. To assess the time spent on informal caregiving, two methods are commonly adopted, i.e. the diary and the recall method (34). First of the aforesaid methods is more precise, but concomitantly more difficult and time-consuming to perform. The diary method requires a study participant to note all activities related to caregiving performed in a day. Such method is also challenging for a researcher due to time-consuming analysis of results. Alternative recall method is less time-consuming, however, it raises doubts with regard to the credibility of results (35). Another obstacle is associated with the qualification of activeness and clarification whether the activities are directly related to caregiving or those defined as typical housework. To eliminate such problem, it is necessary to adequately prepare the questionnaire and categories of activities. Selection of a proper evaluation method of indirect costs of informal care is of importance while analyzing the costs of long-term care. Despite the time spent on caregiving, another element constitutes a determination of the value of this time. Proxy good method is the most indirect method of estimating the value of time spent on caregiving. It corrects the time devoted to informal care by market value of services rendered within such care (36,37,38). The value of time is dependent on the type of activities. Namely, housework is evaluated differently from attendance support which is treated as nursing care. A basic disadvantage of this method consists in the fact that informal care is equal to formal care with regard to quality, and that they are ideal substitutes. This method does not take into account the preferences for the type of care from the perspective of both the carer and receiver. Furthermore, it requires a precise determination

99 No 3 Estimating indirect costs of ageing population 533 of time spent on particular activities. Another variant of cost assessment is the method of alternative costs, where the value of lost benefits for a person providing informal care is determined (36,39). Usually, the value of lost benefits is similar to the value of remuneration of a person, corrected by time spent on caregiving. If a carer does not perform paid work, a substitute value of remuneration is used. Its dimension is dependent on a carer s willingness to provide care for an hour. Another method of establishing the equivalent of work consists in calculating the average remuneration for person of similar demographic profile. A basic feature of this method is attributing different monetary values of the same activities to a carer and his market remuneration, and not to the type of activities. To prepare a reliable assessment of informal care value, using these me thods, it is required to have a complete list of tasks, time spent on their execution and calculation of particular tasks. Such method of indirect cost assessment may be employed in the majority of economic analyses due to purely financial nature. Both methods do not consider the differences between the hours of care provided with regard to the moment of caregiving (the first and last hour of care), and disparities in particular tasks. Furthermore, they do not consider the impact of caregiving on a carer, including negative aspects associated with devotion of time and those of positive nature, i.e. satisfaction derived from the care over a relative. Long-term provision of informal care may have negative effects, not only on health but also, in a broader sense, on well-being. Another element of the assessment of informal care is establishing its impact on the quality of life of a carer. Provision of informal care may lead to physical and psychiatric problems in carers, or even to an increased risk of diseases and premature death (40,41). Assessment of life quality may be used to analyze the impact of caregiving on a carer. The greatest challenge of such analyses results from a difficulty in assessing the relation between caregiving and its impact on the quality of life. It may be hard to decide whether the efforts associated with caregiving affect the quality of life or a carer, presenting some health conditions, is more likely to negatively perceive attendance activities belonging to his obligations. For example, depression symptoms, listed in particular questionnaires, may result from the health status of a relative, being care receiver, and not from caregiving itself. If there is such an impact of disability of a family member on a carer, it should be taken into account in economic analyses, including societal perspective, however, it may not be defined as a negative influence of caregiving on a carer. Literature data suggest a number of generic methods to measure health effects, e.g. EQ5D, SF 36, CDQLP (42,43). Generic health-related instruments allow for a comprehensive assessment of impact of caregiving on carers. There are also specific instruments to measure carer s quality of life such as CareQol. They describe seven dimensions of burden resulting from caregiving.: fulfilment, relational dimension, mental health dimension, social dimension, financial dimension, perceived support and physical dimension. It creates a complete picture of effects of these factors on carer s well-being (44). There are also instruments used for carers of persons with specific conditions such as caregiver Quality of Life Index-Cancer Scale, assessing the quality of life of carers taking care over patients suffering from cancers (44) or caregiver-targeted quality-of-life measure (CGQOL) used to measure the quality of life of carers of patients with dementia (45). SUMMARY There are considerable disparities with regard to approach and methodology, which finally affect the results, in the worldwide analyses of costs generated by long-term care and treatment of geriatric conditions. Probably, the issues regarding the inclusion of i.a. indirect costs and selection of methods used to evaluate these costs may have the greatest impact on the differences in results obtained and difficulties in conducting comparative analyses. Simultaneously, demographic situation calls for a reliable evaluation of these costs for cost-effective management of medical and long-term care for the elderly. There is a necessity of elaborating the standards for the assessment of indirect costs in informal care, including its limitations, utility of use under Polish conditions, possibilities of adjusting to currently used instruments and methodological recommendations for measuring the costs and its usefulness in care planning in Poland. REFERENCES 1. Wyniki Narodowego Spisu Powszechnego Ludności i Mieszkań lu_nps2011_wyniki_nsp2011_ pdf (accessed on ). 2. Główny Urząd Statystyczny. Ludność - bilans opracowany w oparciu o wyniki NSP ( htm (accessed on ). 3. Błędowski P. Wilmowska - Pietruszyńska A.: Organizacja opieki długoterminowej w Polsce problemy i propozycje rozwiązań. Polityka Społeczna. 7.(2009), Help Wanted? Providing and Paying for Long-Term Care. helpwantedprovidingandpayingforlong-termcare.htm (accessed on ).

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Acta Psychiatr Scand 2010:121: Schwarzkopf L, et al. Costs of Care for Dementia Patients in Community Setting: An Analysis for Mild and Moderate Disease Stage. Value in Health 2011;14: Van Houtven C H, Norton E C. Informal care and Medicare expenditures: testing for heterogeneous treatment effects. J Health Econom 2008; 27: Beach S R, Schulz R, Yee J L. Jackson S. Negative and positive health effects of caring for a disabled spouse: longitudinal findings from the caregiver health effects study. Psychology and Aging 2000; 15(2): Schulz R, Beach S R. Caregiving as a risk factor of mortality. JAMA 1999;282(23): LoGiudice, D, Kerse N, Brown K, et al. The psychosocial health status of carers of persons with dementia: a comparison with the chronically ill. Quality of Life Research (4): Wrona W, Hermanowski T, Jakubczyk M, et al. Koszty utraconej produktywności w analizach farmakoekonomicznych II. Badanie opinii w grupie ekspertów. Przegl Epidemiol 2011; 65: Van den Berg B. 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101 No 3 Estimating indirect costs of ageing population Drummond M.F., Sculpher M.J., Torrance G.W. et al. Methods for the economic evaluation of health care programmes. 3rd ed.oxford: Oxford University Press, Netten A. An approach to costing informal care. Canterbury:University of Kent, McDaid D. Estimating the costs of informal care for people with Alzheimer s disease: methodological and practical challenges.tangling caregiver and family effects. Int J Geriatr Psychiatr 2001;16: Robine J.M., Michel J.P., Herrmann F.R. Who will care for the oldest people in our ageing society? BMJ 2007;334: Schulz R., Beach S.R.Caregiving as a risk factor for mortality: the Caregiver Health Effects Study.JAMA. 282(23) (1999), Haley W E, Roth D L, Howard, G, et al. Caregiving strain estimated risk for stroke and coronary heart disease among spouse caregivers: Differential effects by race and sex. Stroke 2010; 41: Ware J E, Gandek B. Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project. J Clin Epidemiol 1998;51: Brazier J,Roberts J,Tsuchiya A, et al. A comparison of the EQ-5D and SF-6D across seven patient groups. Health Econ 13(9) (200): Brouwer W B F,van Exel N JA, van Gorp B, et al. The CarerQol instrument: A new instrument to measure carerelated quality of life of informal caregivers for use in economic evaluations. Qual Life Res 2006;5(6) : Edwards B., Ung L. Quality of life instruments for caregivers of patients with cancer: a review of their psychometric properties. Cancer Nurs 2002;25(5): Received: Accepted for publication: Address for correspondence: Professor Marcin Czech, PhD,MD Department of Pharmacoeconomics Warsaw Medical University Żwirki i Wigury Street 81, Warsaw, Poland marcin.czech@wum.edu.pl

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103 PRZEGL EPIDEMIOL 2015; 69: Public health Tomasz Konopka 1, Elżbieta Dembowska 2, Małgorzata Pietruska 3, Paweł Dymalski 4, Renata Górska 5 PERIODONTAL STATUS AND SELECTED PARAMETERS OF ORAL CONDITION OF POLES AGED FROM 65 TO 74 YEARS 1 Department of Periodontology, Wroclaw Medical University, Poland 2 Department of Periodontology, Pomeranian Medical University in Szczecin, Poland 3 Department of Periodontal and Oral Mucosa Diseases, Medical University of Białystok, Poland 4 Private Practice in Toruń, Poland 5 Department of Periodontology and Oral Diseases, Medical University of Warsaw, Poland ABSTRACT INTRODUCTION. The goal of this study was the evaluation of the periodontal health by means of CPI score in inhabitants of big and small cities in the age range from 65 to 74 and making comparison with previous Polish and European studies from XXI century. Also an average number of natural teeth, the edentulous persons percentage, the percentage of people with oral function maintenance and prevalence of oral mucosal diseases were evaluated. There were also attempts to evaluate essential behaviours related to the oral health and the percentage of people that are treated with use of non-reimbursed or reimbursed services. MATERIAL AND METHODS. Studies were conducted in 5 big cities: Warszawa, Szczecin, Wrocław, Białystok and Toruń, as well as in 4 towns, such as Oława, Police, Łobez and Ełk. From sampling 7400 people aged from 65 to 74 years for the study reported only 807 people. In the mouth evaluated CPI score, number of natural teeth and prevalence of pathological lesions on cavity mucosa. Answers for questions on selected attitudes and health-seeking behaviours related to the oral health and the range of dental treatment were also analysed. RESULTS. Distribution of values of CPI codes in the whole group was as follows: CPI0-1.2%, CPI1-9.4%, CPI2-16.6%, CPI3-21.8%, CPI4-19.7% and the number of people excluded from examinations (1 tooth in the sextant or edentulous 31.3%). The state of the periodontium was worse in big cities and in men. An average number of teeth was 13.7 and was higher in big cities and in men. The percentage of edentulous persons was 28.9% and was higher in towns and in woman. The percentage of people with oral function maintenance was 25.15% and was higher in big cities and in men. The most three common pathologies of the oral cavity were leukoplakia and leukokeratosis that were found in 10.5% of examined people, candidiasis 5.82% and lichen planus 2.2%. CONCLUSION. The state of the periodontium of Poles at the age from 65 to 74 has not been improved in XXI century, but also does not significantly differ from an average European level. An average number of remaining teeth of Poles at this age has increased, but remains under a European average; also the prevalence of edentulism has decreased, but still remains one of the highest in Europe. The percentage of people with oral function maintenance is very low, thus needs for prosthetic treatment and rehabilitation of masticatory ability remain high. Precancerous lesions in the oral cavity are quite common in this age group. Health-seeking behaviours related to the oral health of older Poles are inadequate and result from a low level of knowledge on dental prophylaxis. Key words: epidemiological oral health examination, periodontal diseases, tooth loss, oral mucosa diseases, oral health behaviours INTRODUCTION The World Health Organisation significantly changed accents in periodontal goals of oral hygiene in the age range from 65 to 74 for 2020 in comparison to In 2010, it was assumed that no more than 5% of people at this age was toothless, 75% had at least 20 functional dentitions and there should have been no more than 0.5 of dentition sextant with the highest CPI (Community Periodontal Index) score that is 4 (1). For National Institute of Public Health National Institute of Hygiene

104 538 Tomasz Konopka, Elżbieta Dembowska et al. No 3 year 2020 assumptions are more general: reduction of a number of teeth extracted because of dental caries and periodontal diseases, reduction of a number of edentulous persons, increase of a number of remained natural teeth, increase of the percentage of people with at least 21 remained teeth, reduced prevalence of active periodontal infections oral mucosal diseases (2). This difference relates to deviation in epidemiological studies from the CPI score as a simple evaluation method for the periodontal health due to many limitations (3). However, the evaluation of this score allows relating actual studies to previous Polish and European studies and outlining the trend in the periodontal health improvement. For this group, the evaluation of number of teeth in the oral cavity, giving the edentulous persons by percentage and percentage of people with retained chewing function, that is of people having 21 or more natural teeth, is very important. In general, cohort studies acknowledged the importance of periodontitis as an independent risk factor of atherosclerosis, coronary disease, heart attack, and even cardiovascular mortality. The meta-analysis of 7 cohort studies from years 1993 to 2003 regarding patients confirmed a significant relationship between periodontitis and occurrence of the coronary heart disease (summary estimate of risk ratio was 1.24, 95% confidence interval , p=0.048) adjusted by confounding variables for age, gender, smoking, BMI, study quality and method of periodontal disease assessment (4). Already this example demonstrates an importance of periodontitis for cardiovascular diseases, which are known to be the first cause of death among adult Poles. Thus, from one side the knowledge on periodontitis and number of teeth in the age range from 65 to 74 demonstrates previous attempts in the preventive healthcare and dental treatment, and on the other side may explain the clinical course of many modern-age diseases, such as diabetes, atherosclerosis and osteoporosis. In XXI century, dental transregional epidemiological studies for this age group were conducted in Poland in years 2002 and 2009 (5). The goal of actual studies was the evaluation of the periodontal health by means of CPI score in inhabitants of big and small cities in the age range from 65 to 74 and making comparison with previous Polish and European studies from XXI century. Also an average number of teeth at this age, the edentulous persons percentage, the percentage of people with oral function maintenance and prevalence of oral mucosal diseases were evaluated. There were also attempts to evaluate essential health-seeking behaviours related to the oral health and the percentage of people that are treated with use of non-reimbursed or reimbursed services. MATERIAL AND METHODS Studies were conducted in 5 big cities: Warszawa, Szczecin, Wrocław, Białystok and Toruń, as well as in 4 towns, such as Oława, Police, Łobez and Ełk. In the Ministry of Internal Affairs and Administration, a group of one thousand people in the age range from 65 to 74 was chosen by two-level sampling for every big city and 600 people for towns. In total, 7400 people were chosen for the study. These data were passed to studies supervisors in respective voivodeships to invite (by mails or telephone) these people to participate in the examination conducted in stationary dental offices. The following number of people attended examinations in the period from October to January : Warszawa - 199, Szczecin - 198, Wrocław - 147, Białystok - 72, Toruń - 39, Oława - 46, Police - 41, Łobez - 30 and Ełk 35. In total, 807 people (455 women and 352 men) were examined, i.e. referral for examinations was 10.9%. All patients gave consent to the examination and data processing by signing appropriate statements approved by ethical committees in medical universities of Warszawa, Szczecin, Wrocław and Białystok. Exclusion criteria were general (f.e. bacterial endocarditis in medical history) and local (f.e. acute odontogenic state) contraindications for a periodontal examination. Examinations were conducted in an artificial light by means of a dental mirror and a periodontal probe 621 WHO. The probe is graduated every 1 mm at one end and on the other one by sections up to 3.5 mm, from 3.5 to 5.5 mm, 8.5 and 11.5 mm, and is ended with a ball in a diameter of 0.5 mm. For aims of this work, the evaluation of CPI score, number of teeth and occurrence of pathological clinical lesions in the oral cavity mucosa were chosen by means of detailed anamnestic and clinical periodontal examinations. In individual dentition sextants (anterior and posterior teeth in jaws) the highest value of CPI code was evaluated. Calculation of a number of teeth did not include third morals. Figure 1 The average number of teeth in towns and small cities depending on the type of dental care Fig. 1 18,1 Big Duże cities miasta 9,1 15,7 Małe Towns miasta Reimbursed NFZ service Non-reimbursed Prywatnie service The average number of teeth in towns and big cities depending on the type of dental care 8,9

105 No 3 Periodontal status and selected parameters of oral carity 539 Answers for questions on selected essential attitudes and health-seeking behaviours related to the oral health (reason and frequency of dental visits, number of teeth brushing during the day, toothbrush change frequency during the year, flossing of approximal surfaces). The range of dental treatment (only reimbursed services, only in offices that provide non-reimbursed services or mixed services) were also answered (Fig 1- dental examination chart). All examinators (periodontists) were calibrated (the intra and inter-examiner calibration) in the Department of Periodontology and Oral Diseases, Medical University of Warsaw at the beginning of the study. The examinations were carried within a program financed by The Health Ministry Ocena stanu zdrowia jamy ustnej i jego uwarunkowania w populacji polskiej w wieku i lat ( Oral cavity health condition and determinants in Polish population in the age range from 35 to 44 and 65 to 74 ). RESULTS Distribution of values of CPI codes in the whole group was as follows: CPI0-1.2%, CPI1-9.4%, CPI2-16.6%, CPI3-21.8%, CPI4-19.7% and the number of people excluded from examinations (1 tooth in the sextant or edentulous 31.3%). The state of the periodontium was worse in inhabitants of big cities (CPI0-0.75% and CPI4 21.9%) in comparison to towns (CPI0-3.64% and CPI4 18.8%). The mean number of sextants with CPI codes was as follows: CPI0 0.5, CPI , CPI , CPI , CPI4 0.5; 2.3 excluded. The state of the periodontium was worse in men (CPI vs. 3.3, CPI4 0.6 vs 0.4) with a higher number of excluded sextants in women (2.5 vs. 2.2). An average number of remaining teeth in the whole group was 13.7 and was higher in big cities (14.3 vs. 12.8) and in men (14.4 vs. 12.6). The percentage of edentulism was 28.9% and was higher in towns (29.8% vs. 27.9%) and in woman (30.5% vs. 27.5%). The percentage of people with oral function maintenance in shortened dental arches (at least 20 remaining natural teeth) was 25.15% and was higher in big cities (27.8% vs. 23%) and in men (27.6% vs. 23.3%). The most three common clinical pathologies of the oral cavity were leukoplakia and leukokeratosis that were found in 10.5% of examined people (significantly higher occurrence in men % vs 7.9%), candidiasis 5.82% and lichen planus 2.2%. In the examined group 21.7% of people did not visit a dental office throughout the year, 32.8% visited a dental office once, 20.8% twice and 24.6% more than twice. The main reason for a visit was pain (48.8%). In the examined group 5.7% of people did not use a toothbrush during the day, 18% did it once a day, 50.2% twice a day and 26% more than twice a day. Only 17.22% of examined people was regularly flossing the approximal surfaces. As much as 19.2% of examined people did not use a toothbrush or did not change it throughout the year, 36.1% changed a toothbrush once a year, 22.5% twice a year and 22.2% more than twice a year. 21.7% of examined people, who do not use dental treatment were excluded, 25.8% of people were only treated privately with use of non-reimbursed services, 23.1% were treated only with use of reimbursed services and 29.6% were using reimbursed services and sometimes were paying for dental treatment. Depending on the type of dental care (only non-reimbursed or reimbursed services) in residents of big cities a number of remaining teeth in people using non-reimbursed services was average twice higher (18.9 vs. 9.1), and in town this difference was also significant, although not as spectacular (15.7 vs. 8.9). DISCUSSION Table I presents a comparison of the periodontium state indicated by CPI score in Polish national studies covering people in the age range from 65 to 74. In actual studies the state of the periodontium is much worse (the lowest percentage of people with CPI 0 and definitely the highest, over 41% percentage of people with gingival pockets over 3.5 mm). This result is influenced by higher and higher number of retained teeth among Poles at this age and clinical symptoms of periodontitis associated with these teeth. In own studies, only inhabitants of cities were evaluated, whereas previous studies were conducted also in villages where a number of teeth is lower and the state of the periodontitis better. It is worth to underline that in the own study only calibrated periodontists were conducting studies, what in comparison to previous studies could have an impact on the evaluation of the CPI score. The actual studies confirmed previous observations (5) of worse state of the periodontium in men and inhabitants of towns, what should be related to a higher number of teeth in these groups. In 2004, periodontal goals of WHO for 2010 for the age range from 65 to 74, that is 0.5 of sextant from CPI4 were realised. The number of Polish inhabitants at this age with an active periodontitis has been increasing. In comparison to national and superregional European studies conducted after 2000, better state of the periodontium in the population of people at the age from 65 to 74 was just in Hungary (2004) CPI % (26.2 and 11%) (6) and in Spain (2005) CPI3+4-38% (27.2 and 10.8%) (6). Worse state of the periodontium was found in Greeks (2005) CPI % (44.5 and 15.4%) (7), Bulgarians (2002) CPI % (44.1 and 19.4%) (7), the Dutch (2001) CPI3+4-66% (46 and

106 540 Tomasz Konopka, Elżbieta Dembowska et al. No 3 20%) (8) and the Germans (2005) CPI % (48 and 39.8%) (9). Relatively good results of Poland in the scale of Europe may result from a very high percentage of excluded sextants (in own studies 31.3%). It is confirmed by observations from 2000 of Slovak patients at the age from 65 to 74 and demonstration of only 15% of people with gingival pockets (CPI3+4) with an average number of excluded sextants in the WHO database, the highest on the world, that amounts to 4.3 (10). Analysis of the actual WHO database in the Niigata University regarding periodontal diseases suggests departing from using the CPI score in epidemiological studies. There are only four quite actual European data (Denmark 2001, Hungary 2003, Germany 2005 and Spain 2005) for the age range from 65 to 74 (10). In comparison to studies from 2002 and 2009 a significant, almost twofold increase of number of remaining teeth in Poles at the age from 65 to 74 (Table II) is visible. It is a very positive trend in improvement of the state of the oral cavity of older Poles. All recent Polish studies demonstrate better prevalence of remaining teeth in men of this age. The actual average difference amounts to around 2 teeth in favour of males and is similar to a difference from a study conducted in Also the trend of better retention of teeth by inhabitants of big cities is stable. In previous studies it was observed for inhabitants of villages. In this regard due to a significant increase of a number of retained teeth in Poles at the age of 65 to 74 within the last 12 years, our country gained an average European level. The lowest number of retained teeth had Hungarians (2004) (11), Greeks (2005) (12) and Danes (2001) (8); a similar number was found in the Germans (2005) (9), whereas the highest in Spanish (2005) 14.2 (6) and Swiss people (2002) (13). The comparable data are not complete, because epidemiological studies of the oral cavity of people over 60 were conducted often in other age groups. Main medical reasons for teeth loss in adults is dental caries and periodontitis, much more rarely orthodontic or prosthetic indications and trauma. Dental carries is definitely more common reason for teeth extraction than periodontitis. For example, the distribution of reasons of teeth extraction in the Scottish population was as follows: caries 54%, periodontitis 15%, orthodontic indications 9%, prosthetic indications 6%, other reasons were heterogenic and difficult to unambiguously determine (14). In own studies the relationship between a number of teeth and type of dental care (non-reimbursed and reimbursed services) was shown. It has a direct correlation with economic situation, and is particularly visible in big cities. Another profitable observation in this age group of Poles is a significant reduction of percentage of edentulism in the last 5 years by as much as 15% (Table III). Also this time observations of bigger edentulous in women and inhabitants of towns are confirmed. These differences have been reduced, especially in comparison to 2002, with almost 8% higher percentage of edentulous in women and over 12% higher percentage of edentulous in inhabitants of villages. In spite of such a huge improvement almost 29% of edentulous in Poles at the age from 65 to 74 remains one of the highest percentage in Europe. In last 14 years in available publications, higher percentage was found only in Greece (2005) % (12). In other countries edentulous persons at this age was much more rare: Germany (2006) % (14), Hungary (2004) % (11), Denmark (2001) % (8), Spain (2005) % (6) and Switzerland (2002) Table I Comparison of the periodontal state expressed by the CPI index in transregional studies ranging in age from 64 to 75 years in Poland in the XXI century Year N Environment CPI0 CPI1 CPI2 CPI3 CPI4 Exluded sextants Urban, rural 4.8% 13.6% 19.9% 11.7% 2.3% 47.6% Urban, rural 7.8% 15.1% 15.4% 7.6% 1.6% 52.4% Big cities, towns 1.2% 9.4% 16.6% 21.8% 19.7% 31.3% Table II Comparison of the average number of teeth in transregional studies of people aged from 64 to 75 years in Poland in the XXI century Year Mean of teeth (±SD) Women/men Environment ± vs. 7.7 Urban/rural 9.1 vs ± vs. 7.2 Urban/rural 6.7 vs ± vs Big cities/towns 14.3 vs 12.8 Table III Comparison of the edentulous persons percent in transregional studies of people aged from 64 to 75 years in Poland in the XXI century Year Percent Women/men Environment % 44.4% vs. 36.8% Urban/rural 35.6% vs 47.9% % 45.7% vs. 41.2% Urban/rural 43.5% vs. 44.7% % 30.5% vs. 27.5% Big cities/towns 27.9% vs 29.8%

107 No 3 Periodontal status and selected parameters of oral carity % (13). In all of these countries the percentage of edentulous persons has been reduced for the last two decades, and in most of them edentulous is also higher in women, but this difference is being effaced (15). In spite of it significant differences in edentulous exist between European countries, as well as between geographic regions within a country, between groups of different level of education, place of living, income and lifestyle. In own studies, occurrence of at least 20 natural remaining teeth indicating an oral function maintenance applied to around 25% of all examined people, and was 4% higher in men and almost 5% in big cities. This result is three times worse from WHO global goals from oral health It is difficult to relate actual result to studies of this age group of Poles in 2002 and 2009 (5), because in previous studies an oral function maintenance was defined as at least 20 natural or dental restorations in a functional contact. In available publications only one quite actual relation (2004) to Hungarians at this age was found 21 or more teeth in 22.6% of examined people (11). Maintenance of oral function in older people with shortened dental arches in the highest extent is influenced by sociodemographic and economic factors (16). Relatively often occurrence of oral precancerous lesion, that is leukoplakia, in older Poles draws attention. That is why the necessity to promote oncological prophylaxis, and especially minimal anti-smoking intervention in this age group, is confirmed. Health-seeking behaviours regarding oral hygiene of older Poles are bad. 78.3% of examined people visit an office regularly (at least once a year). The main reason of a visit was pain (48.8%). Just 25% of examined people were used to attend periodic control visit without a clear reason. In Germany, 88.8% of people at the age from 65 to 74 visit an office at least once a year (9), in Denmark 88.2% (8) and the main reason for a visit is control of the oral cavity. From own studies, 5.7% of older Poles do not use a toothbrush to clean their teeth or prosthetic restoration, 19.2% do not use a toothbrush or does not change it throughout the year and only 17.2% of them floss approximal surfaces. In this range, worse results demonstrate Greeks at the age from 65 to 74: 60% of examined people visited an office mainly due to the pain, 14.5% did not use a toothbrush at all during the day, and only 7.5% (7) regularly flossed approximal surfaces (7). CONCLUSION To sum up, the state of the periodontium of Poles at the age from 65 to 74 has not been improved in XXI century, but also does not significantly differ from an average European level. An average number of remaining teeth of Poles at this age has increased, but remains under a European average. A crucial factor which determines teeth retention at this age is socio-economic and life-style factors. Also the percentage of edentulous persons has decreased, but still remains one of the highest in Europe. The percentage of people with oral function maintenance is very low, thus needs for prosthetic treatment and rehabilitation of stomatognathic system remain high. Precancerous lesions in the oral cavity are quite common in this age group, that is why screening studies within oncologic prophylaxis in this age group should also relate to the oral cavity. 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108 542 Tomasz Konopka, Elżbieta Dembowska et al. 14. McCaul LK, Jenkins WMM, Kay EJ. The reasons for the extraction of various tooth types in Scotland: a 15-year follow up. J Dent 2001; 29: Müller F, Naharro M, Carlsson GE. What are the prevalence and incidence of tooth loose in the adult and elderly population in Europe? Clin Oral Impl Res 2007; 18: Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Heath Programme. Community Dent Oral Epidemiol 2005; 33: No 3 Received: r. Accepted for publication r. Adress for correspondence: Tomasz Konopka Department of Periodontology Wrocław Medical University 26 Krakowska Street, Wrocław, Poland Tel tomasz.konopka@umed.wroc.pl