Przegląd Epidemiologiczny (Epidemiological Review)

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 6,19 MNiSW 7pkt VOLUME 68 2014 No 2 CONTENTS Full text: www.pzh.gov.pl/przeglad_epimed EPIDEMIOLOGICAL CHRONICLE* A Zieliński, M P Czarkowski, M Sadkowska-Todys: Infectious diseases in Poland in 2012... 177 J Rogalska, E Karasek, I Paradowska-Stankiewicz: Measles in Poland in 2012... 187 J Rogalska, I Paradowska-Stankiewicz: Mumps in Poland in 2012... 191 J Rogalska: Rubella in Poland in 2012... 195 J Rogalska, I Paradowska-Stankiewicz : Chickenpox in Poland in 2012... 201 I Paradowska-Stankiewicz, J Rudowska: Pertussis in Poland in 2012... 205 E Staszewska, B Kondej, M P Czarkowski: Scarlet fever in Poland in 2012... 209 I Paradowska-Stankiewicz, A Piotrowska: Meningitis and encephalitis in Poland in 2012... 213 H Stypułkowska-Misiurewicz, M Czerwiński: Legionellosis in Poland in 2012... 219 Stypułkowska-Misiurewicz, A Baumann-Popczyk: Shigellosis in Poland in 20112... 223 J Ostrek, A Baumann-Popczyk, M Sadkowska-Todys: Foodborne infections and intoxications in Poland in 2012... 227 S Kamińska, M Sadkowska-Todys: Yersiniosis in Poland in 2012... 235 M Sadkowska-Todys, B Kucharczyk: Campylobacteriosis in Poland in 2012... 239 M Sadkowska-Todys, M P Czarkowski: Salmonellosis in Poland in 2012... 243 M Czerwiński, M P Czarkowski, B Kondej: Foodborne botulism in Poland in 2012... 249 A Baumann-Popczyk: Hepatitis A in Poland in 2012... 253 M Stępień, K Piwowarow: Hepatitis B in Poland in 2012... 257 N Parda, Ł Henszel, M Stępień: Hepatitis C in Poland in 2012.... 265 A Zieliński:Tetanus in Poland in 2012... 271 I Paradowska-Stankiewicz, I Chrześcijańska: Lyme disease in Poland in 2012... 275 E Gołąb, M P Czarkowski: Echinococcosis and cysticercosis in Poland in 2012... 279 M Niedźwiedzka-Stadnik, M Pielacha, M Rosińska: HIV and AIDS in Poland in 2012... 283

M Stępień: Malaria in Poland in 2012... 291 M Korzeniewska-Koseła: Tuberculosis in Poland in 2012... 295 Annual reports for the year 2012 in Epidemiological chronicle: Influenza, Rabies and Sexually transmitted diseases will be published in 3.number of Przegląd Epidemiologiczny. The report on Trichinellosis as of 2012 would not be published INSTRUCTION FOR AUTHORS 301

ARTICLES IN POLISH Przegląd Epidemiologiczny 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 6,19 Punktacja MNiSW 7 TOM 68 2014 NR 2 TREŚĆ Pełne teksty: www.pzh.gov.pl/przeglad_epimed KRONIKA EPIDEMIOLOGICZNA* A Zieliński, M P Czarkowski, M Sadkowska-Todys: Choroby zakaźne w Polsce w 2012 roku... 307 J Rogalska,E Karasek, I Paradowska-Stankiewicz Odra w Polsce w 2012 roku... 313 J Rogalska, I Paradowska-Stankiewicz: Świnka w Polsce w 2012 roku... 317 J Rogalska: Różyczka w Polsce w 2012 roku... 319 J Rogalska, I Paradowska-Stankiewicz: Ospa wietrzna w Polsce w 2012 roku... 323 I Paradowska-Stankiewicz, J Rudowska: Krztusiec w Polsce w 2012 roku... 325 E Staszewska, B Kondej M P Czarkowski: Płonica w Polsce w 2012 roku... 329 I Paradowska-Stankiewicz, A Piotrowska: Zapalenia opon mózgowo-rdzeniowych i zapalenia mózgu w Polsce w 2012 roku... 333 H Stypułkowska-Misiurewicz, M Czerwiński: Legioneloza w Polsce w 2012 roku...337 H Stypułkowska-Misiurewicz, A Baumann-Popczyk: Czerwonka bakteryjna w Polsce w 2012 roku... 339 J Ostrek, A Baumann-Popczyk, M Sadkowska-Todys: Zatrucia i zakażenia pokarmowe w Polsce w 2012 roku... 341 S Kamińska, M Sadkowska-Todys: Jersinioza w Polsce w 2012 roku... 345 M Sadkowska-Todys, B Kucharczyk: Kampylobakterioza w Polsce w 2012 roku... 349 M Sadkowska-Todys, M P Czarkowski: Salmonelozy w Polsce w 2012 roku... 353 M Czerwiński, M P Czarkowski, B Kondej: Zatrucia jadem kiełbasianym w Polsce w 2012 roku... 357 A Baumann-Popczyk: Wirusowe zapalenie wątroby typu A w Polsce w 2012 roku... 361 M Stępień, K Piwowarow: Wirusowe zapalenie wątroby typu B w Polsce w 2012 roku... 363 N Parda, Ł Henszel, M Stępień: Wirusowe zapalenie wątroby typu C w Polsce w 2012 roku... 369 A Zieliński: Tężec w Polsce w 2012 roku... 373 I Paradowska-Stankiewicz, I Chrześcijańska: Borelioza z Lyme w Polsce w 2012 roku... 375 E Gołąb: Tasiemczyce tkankowe w Polsce w 2012 roku... 379 M Niedżwiedzka-Stadnik, M Pielacha, M Rosińska: Zakażenia HIV i zachorowania na AIDS w Polsce w 2012 roku... 383

M Stępień: Malaria w Polsce w 2012 roku... 387 M Korzeniewska-Koseła: Gruźlica w Polsce w 2012 roku...389 ERRATA... 322 Raporty roczne za rok 2012 do Kroniki epidemiologicznej:wścieklizna, Grypa, Choroby przenoszone drogą płciową będą opublikowane w 3.numerze Przeglądu Epidemiologicznego. W 2014 roku nie będzie raportu o włośnicy za 2012 rok INSTRUKCJA DLA AUTORÓW 395

PRZEGL EPIDEMIOL 2014; 68: 177-185 Epidemiological chronicle Andrzej Zieliński, Mirosław P Czarkowski, Małgorzata Sadkowska-Todys INFECTIOUS DISEASES IN POLAND IN 2012 Department of Epidemiology National Institute of Public Health National Institute of Hygiene (NIZP-PZH) in Warsaw ABSTRACT The aim of the study is to assess the epidemiological situation for infectious and parasitic diseases in Poland in 2012. MATERIALS AND METHODS. The main source of data for this study are statistical overviews contained in the annual bulletins Infectious Diseases in Poland in 2012, and Immunizations in Poland in 2012 (NIPH-NIH, Warsaw 2013) and data contained in the articles presented in this issue of Przegląd Epidemiologiczny. Information on deaths due to infectious and parasitic diseases registered in Poland in 2012 and earlier years is based on the data of the Department for Demographic Research of Central Statistical Office. RESULTS. Upper respiratory tract infection classified as influenza and influenza-like illness were reported in 2012 in a total number of 1 460 037 cases. In comparison with 2011, it was an 26.2% increase of incidence, and as compared to the median of 2006-2010 of 286.1%. In 2012, with still the clear predominance of salmonellosis among intestinal bacterial infections, downward trend in the incidence of intestinal infections of this etiology persisted. In 2012 reported number of intestinal infections caused by Salmonella was, 8 267 (21.5/100 000), which represents incidence decrease of 4.5%. Foodborne infections of viral etiology were reported in 39462 cases (102.4/100 000). Most frequent were caused by rotaviruses - 23 692 (61.5/100, 000). In 2012, there were 4 684 reported cases of pertussis (12.2/100 000), which means an increased incidence compared with the previous year by 180 %. In 2012, there was an increase in the number of cases of mumps by 7.5% (from 2 585 to 2 779 cases), and of rubella by 46.0 %, but compared to the median of the years 2006 to 2010 it was a decrease of 52.9%. In 2012, there was not any case of congenital rubella. Number of measles cases was 70 (0.18/100 000). In 2012, there was an increase in the number of cases of invasive disease caused by H. influenzae from 31 in 2011 to 36 in 2012. Number of infections caused by Streptococcus pneumoniae remained in 2012 as compared to 2011, on almost the same level: 436 in 2012 and 430 in 2011. However, there was a 36% increase in the number of sepsis cases caused by this organism. The incidence of tuberculosis in total (all forms of TB) in 2012 decreased compared to the previous year from 22.0 to 19.6 /100000, and pulmonary tuberculosis from 20.5 to 18.2. In 2012, were reported 1 093 cases of HIV infections (2.84/100 000), compared with the previous year, it was a fall in incidence of 2.4%. 21 cases of malaria occurred in people, who infection acquired abroad in malaria endemic areas. In 2012, there were no cases of diphtheria, poliomyelitis, rabies and viral haemorrhagic fevers outside of dengue, of which 5 cases of infections acquired in endemic areas were reported to National Sanitary Inspection. Total number of people who died in Poland in 2012 due to infectious and parasitic diseases,was \ 2 774. The share of deaths from these causes in the total number of deaths was 0.72%, and the mortality rate - 7.2/100 000. Out of all those deaths 41.1% were due to sepsis. Keywords: infectious diseases, epidemiology, public health, Poland, 2012 National Institute of Public Health National Institute of Hygiene

178 Andrzej Zieliński, Mirosław P Czarkowski, Małgorzata Sadkowska-Todys No 2 PURPOSE OF THE STUDY The aim of the study is to assess the epidemiological situation of infectious and parasitic diseases covered by epidemiological surveillance in Poland in 2012 as compared to 2011 and the years 2006 to 2010. MATERIAL AND METHODS The source of data for this study are statistical overwiews contained in the annual bulletin Infectious Diseases in Poland in 2012, and Immunizations in Poland in 2012 (NIPH-NIH, CSI, Warsaw 2013) and data contained in the articles of Epidemiological Chronicle presented in this issue of Przegląd Epidemiologiczny, in which the authors made a detailed discussion of issues relating to selected infectious diseases. Data on deaths due to infectious and parasitic diseases registered in 2012 and in selected previous years were obtained from the Department for Demographic Research CSO. RESULTS AND DISCUSSION Table 1, Infectious diseases in Poland in the years 2006-2012. Number of cases, incidence per 100 000 and the number of deaths contains the data for selected diseases which are notifiable under epidemiological surveillance. Infections of the upper respiratory tract. Upper respiratory tract infection classified as influenza and influenza-like illness - in 2012, were reported in the number of 1 460 037-3789.0/100 000, as compared with 2011, it was an increase of 26.2%, and to the median of 2006-2010 of 286.1%. As in previous years, the incidence of influenza and influenza like illness was highest in children in the age group 0-14, which amounted to 12 096.2/100 000. In 2012 4 persons died from influenza, while in 2011 it were reported 95 deaths from flu. The problem is the low percentage of confirmed diagnoses of influenza. In 2012, only 133 cases had laboratory-confirmed diagnosis of influenza. Foodborne infections. In 2012, among foodborne bacterial infections like in the last decades dominated infections caused by Salmonella with continued downward trend with regard to both incidence and fractional share of salmonellosis among diseases of different etiologies, especially viral infections. Most viral infections were caused by rotavirus, which occured primarily in children. In 2012, there were reported 23 692 rotavirus infections (61.5/100 000), a decrease of 23.0% compared to the previous year and an increase of 12.3% compared to the median of 2006-2010. Total number of reported viral gastrointestinal infections was 39 462 cases (102.4 /100 000). In comparison with the previous year it was the drop, but an increase of 19.9% from the median of 2006-2010. Foodborne infections are a particular threat to children at the age of up to 2 years of age. In this age group they can often lead to severe dehydration and electrolyte imbalance. In 2012, as the viral and other intestinal infections in children under 2 years were reported 18 066 cases (2 288,4/100 000), and the probably infectious diarrhea under 2 years, 14 201 (1,798.9/100 000). Noroviral infection, occurring more frequently in adults, are also an important issue. In 2012, were 5.2% more of these infections than in 2011. In relation to the median of 2006-2010 there was an increase of 36.7%. Low percentage of laboratory confirmed diagnoses of diseases in which the primary symptom is diarrhea casuses low sensitivity of the diagnosis of noroviral infections. It is highly probable that there are much more of those than it is identified under epidemiological surveillance. The same problem applies to other bacterial infections such as campylobacteriosis, which in Poland is recognized much less frequently than salmonellosis, but in Western European countries nearly equaly often. In 2012, there have been only 13 cases of bacterial dysentery reported in Poland. A limited number of laboratory tests performed to confirm the etiology of gastrointestinal infections makes the number of cases of diarrhea of different etiology such as Yersinia sp. undereported. Diseases covered by the obligatory vaccination program (PSO). Surveillance of this group of diseases is particularly important because that the data on the incidence of these diseases have a direct impact on vaccination policy. Regarding the diseases that can be prevented by vaccination of particular concern is the increase in the incidence of pertussis that occurred in 2012. There were 4 684 cases reported with incidence (12.2/100 000). This was the highest incidence of the disease since 1971. Significant differences in the incidence of whooping cough between the provinces can at least to a large extent depend on the differences in the sensitivity of the capture of cases, and fraction of laboratory confirmations. In 2012, the incidence of mumps has increased by 7.5% which is not a significant change. In relation to the median of the years 2006-2010 it is a decrease of 16.0%. An increase in the incidence of rubella in 2012 was more pronounced. Compared with the previous year it increased of 46.0%. Older birth cohorts of men who were not vaccinated against rubella form a reservoir of this disease and until the time of vaccination coverage of the total population of teenagers and young adults, such fluctuations of incidence may be repeated. The introduction in 2003 of universal vaccination with MMR

No 2 Infectious diseases in Poland in 2012 179 Table I. Infectious diseases in Poland 2006-2012. Number of cases, incidence per 100 000 population and number of deaths by disease and year Disease Categories of International Classification of Diseases (ICD-10) Median in years 2006-2010 2011 2012 number of cases incidence* number of deaths** number of cases incidence* number of deaths** number of cases incidence* 1 2 3 4 5 6 6 8 9 10 11 Cholera EU A00 0 0 0 0 0 0 0 0 0 Typhoid fever EU A01.0 3 0.008 0 2 0.005 0 2 0.005 0 Paratyphoid fevers A, B, C EU A01.1-A01.3 2 0.005 0 2 0.005 0 5 0.013 0 total A02 9 732 25.5 4 8 813 22.9 3 8 444 21.9 7 Salmonella infections EU A02.0 9 549 25.0 2 8 652 22.5 1 8 267 21.5 1 Salmonella Enteritis parenteral infections A02.1-A02.9 136 0.36 2 161 0.42 2 177 0.46 6 Shigellosis EU A03 33 0.09 0 18 0.05 0 13 0.03 0 total A04 6 595 17.3 14 6 539 17.0 75 7 046 18.3 167 enteropathogenic, enterotoxigenic, enteroinvasive E. coli A04.0-A04.2 1 191 3.12 0 650 1.69 0 532 1.38 0 Other bacterial intestinal enterohaemorrhagic E. coli EU A04.3 4 0.010 0 5 0.013 0 5 0.013 0 infections other intestinal E. coli A04.4 908 2.38 0 860 2.23 0 845 2.19 0 campylobacteriosis EU A04.5 270 0.71 0 354 0.92 0 431 1.12 0 yersiniosis EU A04.6 206 0.54 0 238 0.62 0 201 0.52 0 other specified and unspecified A04.7-A04.9 4 078 10.7 13 4 432 11.5 75 5 032 13.1 167 Other bacterial intestinal infections in children under 2 years A04 2 846 369.9 0 2 160 263.0 1 2 119 268.4 0 total A05 2 740 7.2 4 2 195 5.7 0 1 787 4.6 12 staphylococcal A05.0 217 0.57 0 283 0.73 0 147 0.38 0 Other bacterial botulism foodborne intoxications A05.1 46 0.12 0 35 0.09 0 22 0.06 2 Clostridium perfringens A05.2 4 0.010 1 24 0.062 0 5 0.013 0 other specified A05.3-A05.8 125 0.33 0 53 0.14 0 52 0.13 2 unspecified A05.9 2 347 6.2 3 1 800 4.7 0 1 561 4.1 8 Other bacterial foodborne intoxications in children under 2 years A05 109 13.2 1 112 13.6 0 72 9.1 0 Giardiasis /lambliasis/ EU A07.1 2 945 7.7 0 1 736 4.5 0 1 655 4.3 0 Cryptosporidiosis EU A07.2 0 0 0 1 0.003 0 2 0.005 0 total A08 32 559 85.4 2 44 906 116.6 4 39 462 102.4 5 Viral and other rotaviruses A08.0 20 902 54.7 0 30 769 79.9 2 23 692 61.5 1 specific intestinal noroviruses A08.1 1 068 2.8 0 1 402 3.6 0 1 475 3.8 0 infections other specified and unspecified A08.2-A08.5 7 711 20.2 2 12 735 33.1 2 14 295 37.1 4 Viral and other specific intestinal infections in children under 2 years A08 15 260 1901.7 0 21 250 2587.8 1 18 066 2288.4 0 Diarrhoea in children under 2 years, NOS, presumed of infectious origin A09 11 096 1389.2 1 13 068 1591.4 1 14 201 1798.9 0 number of deaths** Tuberculosis EU, 1) total A15-A19 8 236 21.6 743 8 478 22.0 640 7 542 19.6 630 respiratory A15-A16; A19 7 654 20.1 727 7 879 20.5 617 7 018 18.2 620 Plague EU A20 0 0 0 0 0 0 0 0 0

180 Andrzej Zieliński, Mirosław P Czarkowski, Małgorzata Sadkowska-Todys No 2 1 2 3 4 5 6 6 8 9 10 11 Tularaemia EU A21 3 0.008 0 6 0.016 0 6 0.016 0 Anthrax EU A22 0 0 0 0 0 0 0 0 0 Brucellosis (new cases) EU A23 2 0.005 0 0 0 0 0 0 0 Leptospirosis EU A27 6 0.016 1 4 0.010 1 2 0.005 0 Listeriosis EU A32; P37.2 33 0.09 2 64 0.17 4 54 0.14 8 Tetanus EU A33-A35 19 0.05 5 14 0.04 5 19 0.05 4 Diphtheria EU A36 0 0 0 0 0 0 0 0 0 Whooping cough EU A37 1 987 5.2 0 1 669 4.3 0 4 684 12.2 0 Scarlet fever A38 11 179 29.3 0 18 267 47.4 0 25 421 66.0 0 total A39 296 0.78 18 296 0.77 16 241 0.63 11 Meningococcal meningitis and / or encephalitis A39.0; A39.8/G05.0 190 0.50 2 193 0.50 0 165 0.43 1 disease EU sepsis A39.1-A39.4 190 0.50 14 192 0.50 15 146 0.38 9 Erysipelas A46; O86.8 4 805 12.6 13 3 425 8.9 11 4 241 11.0 9 Legionellosis EU A48.1-A48.2 28 0.07 0 18 0.05 0 10 0.03 0 Syphilis (total) EU, 2) A50-A53 932 2.44 2 955 2.48 3 993 2.58 4 Gonorrhoea EU, 2) A54 330 0.87 0 298 0.77 0 733 1.90 0 Other sexual transmitted diseases caused by Chlamydia EU, 2) A56 627 1.64 0 319 0.83 0 314 0.81 0 Lyme disease A69.2 8 255 21.7 3 9 157 23.8 1 8 784 22.8 4 Ornithosis A70 1 0.003 0 0 0 0 0 0 0 Q fever EU A78 0 0.003 0 0 0 0 0 0 0 Typhus fever, spotted fever and other rickettsioses A75; A77; A79 0 0 0 2 0.005 0 3 0.008 0 Acute poliomyelitis EU Spongiform encephalopathy acute paralytic poliomyelitis, wild virus acute paralytic poliomyelitis, vaccine-associated (VAPP, cvdpv) A80.1; A80.2; A80.4; 0 0 0 0 0 0 0 0 0 A80.0; A80.3-9 0 0 0 0 0 0 0 0 0 Creutzfeldt-Jakob disease (CJD) A81.0 13 0.03 19 21 0.05 21 17 0.04 23 variant Creutzfeldt-Jakob disease (vcjd) EU A81.0 0 0 0 0 0 0 0 0 0 Rabies EU A82 0 0 0 0 0 0 0 0 0 Viral encephalitis total A83-A86; G05.1 514 1.35 19 399 1.04 11 376 0.98 4 tick-borne viral encephalitis A84 294 0.77 2 221 0.57 1 189 0.49 1 other specified A83; A85; B00.4; B02.0 41 0.11 4 37 0.10 1 47 0.12 4 unspecified A86 167 0.44 13 141 0.37 10 111 0.29 2 total A87; G02.0 1 167 3.06 4 1 039 2.70 5 1 285 3.33 3 enteroviral A87.0 37 0.10 0 23 0.06 2 102 0.26 0 Viral meningitis other specified and unspecified A87.1-A87.9; B00.3; 1 130 2.96 4 1 016 2.64 3 1 166 3.03 3 B02.1 Dengue fever EU A90-A91 4 0.010 0 5 0.013 0 5 0.013 0 Yellow fever EU A95 0 0 0 0 0 0 0 0 0 Lassa fever EU A96.2 0 0 0 0 0 0 0 0 0

No 2 Infectious diseases in Poland in 2012 181 1 2 3 4 5 6 6 8 9 10 11 Crimean-Congo haemorrhagic fever EU A98.0 0 0 0 0 0 0 0 0 0 Disease caused by Marburg or Ebola virus EU A98.3; A98.4 0 0 0 0 0 0 0 0 0 Varicella B01 141 349 370.7 1 172 855 448.7 0 208 276 540.5 1 Measles EU B05 100 0.26 0 38 0.10 0 70 0.18 0 Rubella EU total B06; P35.0 13 146 34.5 0 4 290 11.1 0 6 263 16.3 0 congenital rubella P35.0 1 0.24 0 0 0 0 0 0 0 Viral hepatitis total B15-B19 4 104 10.8 229 3 995 10.4 259 3 933 10.2 288 type A EU B15 155 0.41 0 65 0.17 0 71 0.18 1 type B EU, 3) B16; B18.0-B18.1 1 475 3.9 68 1 583 4.1 49 1 583 4.1 52 type C /case definition from 2005/ EU, 3) B17.1; B18.2 2 353 6.2 137 2 338 6.1 194 2 292 5.9 217 other specified and unspecified B17.0; B17.2-B17.8; B18.8-B18.9; B19 60 0.16 23 39 0.10 16 20 0.05 18 AIDS EU, 4) B20-B24 167 0.44 123 184 0.48 130 156 0.40 118 Newly diagnosed HIV infections EU, 4) Z21 838 2.20 x 1 120 2.91 x 1 093 2.84 x Mumps EU B26 3 271 8.6 0 2 585 6.7 0 2 779 7.2 0 Malaria EU B50-B54; P37.3-P37.4 22 0.06 1 14 0.04 0 21 0.05 0 Echinococcosis EU B67 36 0.09 2 19 0.05 1 28 0.07 1 Trichinellosis EU B75 51 0.13 0 23 0.06 0 1 0.003 0 Pneumococcal invasive disease EU Haemophilus influenzae, invasive disease EU total B95.3/ inne 273 0.72. 430 1.12. 436 1.13. meningitis and / or encephalitis B95.3/ G04.2; G00.1 161 0.42 8 192 0.50 15 145 0.38 8 sepsis A40.3 116 0.30 5 188 0.49 6 256 0.66 6 other specified and unspecified B95.3/ inne; J13 64 0.17 9 123 0.32 20 128 0.33 22 total B96.3/ inne; A41.3 31 0.08. 31 0.08. 36 0.09. meningitis and / or encephalitis B96.3/ G04.2; G00.0 23 0.06 4 11 0.03 2 11 0.03 0 sepsis A41.3 15 0.04 1 14 0.036 2 15 0.039 0 Bacterial meningitis and / or other specified G00.2-G00.8; G04.2 149 0.39 9 139 0.36 19 128 0.33 24 encephalitis unspecified G00.9; G04.2 424 1.11 74 353 0.92 77 310 0.80 60 Meningitis other and unspecified G03 395 1.04 38 493 1.28 41 597 1.55 31 Encephalitis other and unspecified G04.8-G04.9 92 0.24 70 96 0.25 48 117 0.30 48 Influenza and influenza-like illness EU J10; J11 374 042 981.3 18 1 156 357 3 001.5 95 1 460 037 3 789.0 4 Congenital toxoplasmosis EU P37.1 7 1.87 2 4 1.03 1 10 2.59 0 Persons bitten by animals suspected of having rabies or contamination of saliva of these animals after which it was taken vaccination against rabies 7 102 18.6. 7 842 20.4. 7 999 20.8. * incidence, respectively per 100 000 population total, children under 2 years and live births (congenital disease); ** number of deaths according to data from the Demographic Surveys and Labour Market Department-CSO; EU - disease under European Union surveillance ; 1) data from Institute of Tuberculosis and Lung Diseases; 2) data from Centre for Health Information Systems (CSIOZ); 3) number of cases and incidence total (including mixed infections with HBV + HCV); 4) data from Department of Epidemiology, NIPH -NIH by date of diagnosis of infection / disease

182 Andrzej Zieliński, Mirosław P Czarkowski, Małgorzata Sadkowska-Todys No 2 over time is expected to further improve epidemiological situation of rubella. For several years, are observed small outbreaks measles in different age groups, usually associated with importation of this disease to our country. It also involves the migration to Poland people who do not vaccinate their children. In 2012 there were reported 70 cases of measles, but in 2011 only 38. The increase in incidence as compared with the previous year was 84.2 %, but compared with the median of 2006-2010 it was a decrease of 30.8 %. At low incidence, even small outbreaks of measles cause significant changes in the percentages of incidence, which, even if of no great epidemiological importance, indicate problems with vaccination against measles of people from certain ethnic or social groups. In 2012, invasive disease caused by H. influenzae occurred in the number of 36, with five cases more than in the previous year. The improvement of the epidemiological situation regarding infections caused by Haemophilus influenzae type b ( Hib) may indicate the effectiveness of vaccination against Hib. Tuberculosis. The incidence of all forms of tuberculosis in 2012 decreased compared to the previous year from 22.0/100 000 to 19.6/100 000 and regarding pulmonary tuberculosis from 20.5/100 000 to 18.2/100 000. As in previous years there has been large, in extreme cases, tripling the differences in incidence between different provinces. The most serious epidemiological situation of tuberculosis is in Lubelskie, Świętokrzyskie and Śląskie. Differences in the incidence of tuberculosis between the provinces are the hallmark of not only the epidemiological situation in these regions, but also the demographic problems and living conditions of the population. During the last decade it was seen a downward trend in the incidence of tuberculosis in Poland. Other infectious and parasitic diseases. At the present time a serious problem represent invasive infections caused by Streptococcus pneumoniae. Number of reported cases of S. pneumoniae infections in total amounted to 436 (1.13/100 000). In 2012, at least 36 of these cases were fatal; 8 in the course of meningitis, 6 due to sepsis, and 22 deaths occurred in the course of other diseases caused by this microorganism. There are strong indications that the number of S. pneumoniae infections that occurin Poland is much higher than the number of notifications for epidemiological surveillance. The year 2012 was another year in which was seen the increase in the incidence of scarlet fever. There were 25 421 cases reported, incidence (66.0/100 000) which as compared to the previous year, was an increase of 39.1%, and compared with a median of 2006 2010 was an increase of 124.9%. There were no deaths due to scarlet fever. In 2012, there were reported 241 cases of invasive meningococcal disease (0.63/100 000). In relation to the median of the years 2006-2010 it was a decrease of 19.4%. Since 2002, it is observed growing trend of newly diagnosed HIV infections. In 2012, the reported number was 1 093 (2.84/100 000). It is an increase of 29% to the median of the years 2006-2010. These data indicate low efficiency of preventive measures. Despite the scarcity of information about risk factors of new infections, there are some indications that the cause of the observed increase in incidence are unprotected sexual contacts, mainly between men. Important public health problem are viral hepatitis C and B. Of these, the most serious epidemiological problem is hepatitis C against which there is no effective vaccine. In 2012, the number of reported new cases was 2 292, and the incidence was 5.9/100 000. Compared with the previous year, this is a decrease of 2%, and compared to the median of 2006-2010 by 3.6%. The reversal of the increasing trend in the incidence of hepatitis C gives hope for further improvement related to hygiene and sterilization quality in medical institutions. However, due to the fact that it is a chronic disease having sometimes serious consequences such as cirrhosis and primary liver cancer after many years, the annual increase of newly detected infections accumulate to the level of very serious public health problem. The epidemiological situation of hepatitis B differs because of the possibility of active immunization. In 2012, the number of reported cases of hepatitis B was 1 583 (4.1/100 000). The incidence since the previous year has not changed. But among obligatorily vaccinated children in age group 0-14 there were not any cases of infection. For many years Poland is a country with very low endemicity of hepatitis A. Few dozens occurs annually, rarely more than one hundred cases (in 2012 there were 71). Cases are usually associated with the arrival of people infected with HAV from abroad and with the occurrence of small outbreaks. The incidence of Lyme borreliosis had a clear upward trend from 1998 to 2009, but in the years 2010-2012 incidence of this disease has not changed significantly. In the year 2012, there were 8 784 cases (22.8/100 000), which in relation to the median of the years 2006 to 2010 was the increase in the incidence barely of 5.3%. In 2012, number of reported cases of echinococcosis was 28, by 47.3% more than in the previous year, but in relation to the median of the years 2006 to 2010 it was a decrease of 22.9%. Outbreaks of trichinosis, which were quoted several times in previous years, especially after the consumption of wild boar meat in 2012, did not occur. Only one

No 2 Infectious diseases in Poland in 2012 183 affected person was reported. This is probably related to better veterinary supervision over the meat of hunted animals, especially wild boar. Endemic malaria does not occur in Poland, but some cases are imported from endemic regions. In 2012 there were 21 cases of malaria diagnosed in people who have acquired an infection abroad. In 2012, there were reported 189 cases (0.49/100 000) of tick-borne encephalitis. This was a decrease of 14.5% compared with the previous year. Due to the fact that 111 cases of encephalitis were diagnosed without determining the etiological factor, number of encephalitis cases transmitted by ticks could be higher. 1 285 cases (3.33/100000) of viral meningitis were reported. This increased incidence of 23.7% from the previous year. In 2012, there were reported 34 cases of flaccid paralysis in children aged 0-14 years, which gives the incidence of 0.59/100 000 Distribution of notifications from individual provinces is uneven. Of the three provinces: Opolskie, Podkarpackie and Podlaskie there were no reports. In contrast, the value of the expected incidence 1/100 000 was obtained in only four provinces: Kujawsko-Pomorskie, Małopolskie, Warmińsko- Mazurskie and Świętokrzyskie. Reporting of flaccid paralysis is an important and objective test of the sensitivity of the epidemiological surveillance and unfortunately for a number of years the results of these reports give us a bad certificate In 2012, there were no cases of especially dangerous infectious diseases: plague, anthrax, diphtheria, poliomyelitis, rabies and viral haemorrhagic fevers except for dengue, of which 5 cases acquired in endemic areas reported to the epidemiological surveillance system. Deaths and mortality from infectious diseases. Data provided by the Department of Demographic Studies of the Central Statistical Office indicate that in 2012, due to infectious and parasitic diseases died in Poland 2 774 people. It takes into account the deaths caused by some forms of meningitis and encephalitis, and flu (symbols: G00 - G05 and J10 - J11 of International Classification of Diseases, ICD- 10). The share of deaths from infectious diseases in the total number of deaths in Poland in 2012 (384 788 deaths) was 0.72%, and the mortality rate 7.2 /100 000. In comparison with the analogous indicators recorded in the previous year (respectively 0.91% and 8.8 ) values for 2012 were significantly lower - respectively 20.6% and 18.6 %. Thus, the upward trend in mortality from infectious diseases observed in Poland after 1998 was halted, especially in the last 5 years (Figure 1 Mortality from infectious diseases per 100 000 population and the percentage of deaths due to infectious diseases in general number of deaths in Poland in the years 1983-2012 ). A clear reduction in mortality from infectious diseases recorded by the CSO, was the effect of a sharp reduction in the number of deaths in which the cause was streptococcal or another septicemia, most often not specified (meningococcal and neonatal sepsis excluded - codes A40 and A41 by ICD-10). In 2012, we recorded 1 141 such cases (the year before 1 773), which meant a decrease of 35.6% compared with the previous year. So sharp decline from year to year in the number of deaths from sepsis could not be due to the improvement of the epidemiological situation or result from a reduction in sepsis mortality. It occurred in consequence of the verification of the death certificates done at the request of the Department of Epidemiology, NIPH-NIH to the Department for Demographic Research CSO. In requesting a verification Department of Epidemiology pointed out that the observed in Poland in recent years increase in the number of deaths due to sepsis may indicate a departure from recommended by ICD-10 coding first of all the conditions preceding sepsis, leading to it. As a result of such verification the number of deaths, for which sepsis was identified as a cause decreased by 14,0 12,0 Mortality per 100 000 Percentage 1,4 1,2 10,0 1,0 Mortality per 100 000 8,0 6,0 4,0 0,8 0,6 0,4 Percentage 2,0 0,2 0,0 0,0 Fig. 1. Infectious diseases mortality per 100 000 population and deaths from infectious diseases as percentage of all Fig. 1. Infectious diseases mortality per 100 000 population and deaths from infectious diseases as percentage deaths by year - Poland 1983-2012 of all deaths by year - Poland 1983-2012 Year

184 Andrzej Zieliński, Mirosław P Czarkowski, Małgorzata Sadkowska-Todys No 2 nearly half (from 2 034 before verification to 1 141). Sepsis still, as in previous years, remains the most common cause and account for 41.1% of all deaths due to infectious diseases (previous year 52.0%). Among the infectious diseases that have caused the greatest number of deaths in 2012, except for sepsis were: tuberculosis and its late sequelae (640 deaths, 23.1% of all deaths due to infectious and parasitic diseases), viral hepatitis and their long-term effects (all types together - 296 deaths, 10.7%), intestinal infection caused by Clostridium difficile (127 deaths, 4.6%), bacterial meningitis and / or encephalitis (122; 4.4%), and AIDS (118; 4.3). The above-mentioned diseases together (including sepsis) were the cause of almost 90% of all deaths from infectious diseases in 2012 Draws attention growth in the number of deaths from intestinal infections caused by Clostridium difficile, which prior to 2008 were recorded in Poland only occasionally (from 0 to 3 deaths per year). Increased number of laboratories performing its detection, only partially explains the increase, and therefore it should be noted that Cl. difficile was in 2012, the pathogen that caused the most outbreaks of nosocomial infections reported to surveillance (82 outbreaks, 27% of all reported outbreaks). Differences in mortality recorded between provinces in 2012, as compared to the differences observed in the previous year increased significantly. The ratio of the highest to the lowest was 4.7:1. The share of deaths from infectious diseases in the total number of deaths ranged from 0.24% in Podlaskie and 0.34% Kujawsko-Pomorskie to 1.07% in the Zachodniopomorskie and 1.12% in Pomorskie; and mortality from infectious diseases from 2.3/100 000 in Podlaskie and 3.3 in Kujawsko-Pomorskie to 10.3 in the Zachodniopomorskie and 10.9 in Mazowieckie. The share of infectious and parasitic diseases in the causes of death for men in 2012 (0.77%; mortality Mortality per 100 000 70,0 60,0 50,0 40,0 30,0 20,0 10,0 0,0 Fig. 2. Total Male Female Age groups Infectious diseases mortality per 100 000 population by gender and age group - Poland 2012 Fig. 2. Infectious diseases mortality per 100 000 population by gender and age group - Poland 2012 rate 8.3/100 000), as in previous years, surpassed that in women (respectively 0.67% and 6.2). Male mortality rate from infectious diseases was 35.0% higher than the mortality rate of women and it was higher for all age groups except 10-14 years old. In the age group 5-9 years difference to the disadvantage of men was almost 5-fold (but related to six deaths in total), in the group of 30-34 years - 4-fold, and in the 15-19 age group - almost four times. (Fig.2. Mortality from infectious diseases (per 100 000 population) in Poland in 2012, by gender and age) According to the long-term trend, the proportion of infectious and parasitic diseases in the causes of death of urban residents was significantly higher than that of rural residents. In the cities, infectious and parasitic diseases were the cause of 0.84% of the total deaths, while in rural areas 0.54%. Overall mortality from infectious diseases in urban areas (8.4/100 000) was higher than the mortality rate in rural areas (5.4) by 57.0% and in only one age group (15-19 years), this difference was reversed. The biggest difference to the detriment of the city, almost 4-fold - occurred in the age group 30-34 years. (Figure 3 Mortality from infectious diseases (per 100 000 population) in Poland in 2012, according to the environment and age) Mortality per 100 000 70,0 60,0 50,0 40,0 30,0 20,0 10,0 0,0 Fig. 3. Total Urban Rural Age groups Infectious diseases mortality per 100 000 population by location (urban/rural) and age group - Poland 2012 Fig. 3. Infectious diseases mortality per 100 000 population by location (urban/rural) and age group - Poland 2012 Most deaths due to infectious and parasitic diseases was noted among the elderly 80-84 years old and the highest mortality from these diseases among the oldest people over the age of 84 years (56.4 per 100 000). However the largest percentage of infectious diseases as a causes of death, occurred in children under the age of 9 and adults aged 30-44. In the group of children 0-4, this share was 1.9 %, including infants 1.1% (5.2 deaths per 100 000), in children 2 years old - 3.8%, in 3 years old - 10.3%, 4 years old - 5.8% and 5 years old - 7.5%); while in the group of children aged 5-9

No 2 Infectious diseases in Poland in 2012 185 years - 2.9%. Among the causes of adult deaths in the age group of 30-34 years old the proportion of deaths due to infectious diseases was 1.6%, in the group of 35-39 years old - 2.0% in the group 40-44 years old - 1.7%. Thus, verification of death certificates reported to the CSO as initially deaths from sepsis, resulted not only in a reduction in the total number of deaths due to infectious diseases recorded in 2012, but has also lead to reduction of the differences in the share of infectious diseases in total mortality int different age groups. SUMMARY Epidemiological situation of infectious diseases in Poland in 2012, except for a large, 180% increase of the incidence of pertussis, did not show a dramatic change compared with the previous year. Increases occurred in some diseases that can be prevented by vaccination: measles, rubella, and invasive Haemophilus influenzae type b, but in the case of measles increased incidence of 84.2% concerned the small number of cases from 38 in 2011 to 70 in 2012. In 2012, it was continued the tendency of decline in the incidence of food poisoning and infections of bacterial etiology with an increase in the incidence of the disease of viral etiology. In 2012, there was no significant improvement in terms of the largest problem of epidemiological surveillance in Poland, which is a low percentage of laboratory confirmation of diagnoses of illnesses and infections. With the continuing high level of mandatory vaccinations coverage, percentage of people undergoing the recommended vaccination is not improved. There is also increasing the number of conscious refusals of obligatory vaccination (1-2%). Received: 30.04.2014 r. Accepted for publication: 05.05.2014 Address for correspondence: Prof. dr hab. med. Andrzej Zieliński Zakład Epidemiologii Narodowy Instytut Zdrowia Publicznego PZH ul. Chocimska 24, 00-791 Warszawa e-mail: azieliński@pzh.gov.pl

PRZEGL EPIDEMIOL 2014; 68: 187-190 Epidemiological chronicle Justyna Rogalska, Ewa Karasek, Iwona Paradowska-Stankiewicz MEASLES IN POLAND IN 2012 Department of Epidemiology, National Institute of Public Health National Institute of Hygiene in Warsaw ABSTRACT BACKGROUND. In 1998 Poland, along with all other Member States in the WHO European Region, implemented Measles Elimination Program coordinated by WHO. It requires achieving and maintaining very high vaccine coverage (>95%), recording all cases and suspected cases of measles, and laboratory testing of all suspected measles cases in the WHO Reference Laboratory. In Poland it is a Laboratory of Department of Virology, NIPH-NIH. AIM. To assess epidemiological situation of measles in Poland in 2012, including vaccination coverage in Polish population, and Measles Elimination Program implementation status. METHODS. The descriptive analysis was based on data retrieved from routine mandatory surveillance system and published in the annual bulletins Infectious diseases and poisonings in Poland in 2012 and Vaccinations in Poland in 2012, and measles case-based reports from 2012 sent to the Department of Epidemiology NIPH- NIH by Sanitary-Epidemiological Stations. RESULTS. In total, there were 70 measles cases registered in Poland in 2012 (incidence 0.18 per 100,000). The highest incidence rate was observed among infants (2.08 per 100,000) and children aged 1 year (2.47 per 100,000). In 2012, 37 cases (52,9%) were hospitalized due to measles. No deaths from measles were reported. Vaccination coverage of children and youth aged 2-11 years ranged from 83.6% do 99.6% (primary vaccination in children born in 2011-2006) and from 76.6% do 96.7% (booster dose in children born in 2003-2001). Performance of the surveillance system was insufficient with only 127 measles-compatible cases reported in 2012 (33% of expected reports). Fifty cases (71%) were confirmed by IgM ELISA test. SUMMARY AND CONCLUSIONS. The epidemiological situation of measles deteriorated in 2012 in comparison to proceding year. The results indicate a need to further promote Measles Elimination Program in Poland, maintain the high immunisation coverage and improve measles surveillance system. Keywords: measles, infectious diseases, epidemiology, Poland, 2012 INTRODUCTION Since 1998, Poland has been actively participating in the Measles Elimination Program, coordinated by the World Health Organization (WHO). In May 2012, the World Health Assembly adopted a declaration on elimination of the disease by end of 2020 in at least five out of six WHO regions. The program requires recording and investigating all cases and suspected cases of measles, and laboratory testing (either serology or virus isolation) of all suspected measles cases in the WHO Reference Laboratory (Laboratory of Department of Virology, NIPH-NIH). Laboratory testing of all suspected cases of measles demonstrates high sensitivity of surveillance, and genetic characterization of wild type strains of measles virus allows identification of the source of infection and differentiation between native and imported cases. The aim of the study was to assess epidemiological situation of measles in Poland in 2012, including vaccination coverage in Polish population, and Measles Elimination Program implementation status based on WHO surveillance sensitivity indicators. MATERIAL AND METHODS The descriptive analysis of epidemiological situation of measles was based on data retrieved from routine mandatory surveillance system and published in the annual bulletin Infectious diseases and poisonings in Poland in 2012, and measles case-based reports from 2012 National Institute of Public Health National Institute of Hygiene

188 Justyna Rogalska, Ewa Karasek, Iwona Paradowska-Stankiewicz No 2 sent to the Department of Epidemiology NIPH-NIH by Sanitary-Epidemiological Stations. Vaccination coverage was assessed based on data published in the annual bulletin Vaccinations in Poland in 2012. Measles cases were classified according to the criteria of surveillance case definition implemented in the European Union (Commission Decision of 28 April 2008 amending Decision 2002/253/EC). Measles cases were categorized into confirmed, probable and possible cases. RESULTS Epidemiological situation of measles in 2012. In 2012, a total of 70 measles cases (incidence 0.18 per 100,000) were registered in Poland, i.e. almost two times more than in 2011. Fifty cases (71.4%) were laboratory confirmed, whereas in 10 cases (14.3%) the diagnosis was based only on clinical symptoms. Ten cases that met the clinical criteria for measles and were epidemiologically linked to cases with laboratory-confirmed measles have been classified as probable cases. Measles cases were registered in 10 out of 16 voivodeships (Tab. I). The highest number of cases occured in slaskie voivodeship (22 cases, incidence 0.48 per 100,00) and mazowieckie voivodeship (21 cases, incidence 0.40 per 100,000). In the voivodeships, where measles cases were registered, the incidence did not exceed the threshold of measles elimination specified by the WHO as one case per 1,000,000 inhabitants. In 2012, six measles outbreaks were reported in three voivodeships (1 in dolnoslaskie voivodeship, 2 in mazowieckie and 3 in slaskie), involving in total 42 individuals. One outbreak registered in dolnoslaskie voivodeship occurred among people of Romanian origin. Three imported measles cases were recorded in 2012 (from France, Ukraine and United Kingdom). They were not linked to any of the observed in 2012 outbreaks. The highest incidence rate was observed among children under 5 years of age (1.02 per 100,000), especially infants (2.08 per 100,000) and children aged 1 year (2.47 per 100,000). Based on data from individual reports of cases, of 70 measles cases registered in 2012, 39 patients (56%) were unvaccinated (including 6 children in first year of life, not subjected to mandatory vaccination), 4 patients (6%) vaccinated with 1 dose of measles vaccine and 8 patients (11%) vaccinated with 2 doses of the vaccine. For 19 cases (27%) vaccination status was unknown. In 2012, 37 of all registered measles cases (53%) were hospitalized. Complications occurred in 16 patients (23%), including 12 measles cases diagnosed with pneumonia. No deaths from measles were reported in 2012. Vaccinations against measles in 2012. The existing scheme of vaccination against measles remained unchanged since 2005 and consists of primary dose for children at 13-14 months and booster dose at 10 years of age. Live attenuated combined vaccine against measles, mumps and rubella (MMR) is used. In 2012, Poland mantained a high vaccination coverage in children. As of 31 st December 2012, vaccination coverage Table I. Measles in Poland during 2006-2012. Number of suspected and confirmed cases and incidence per 100 000 population by voivodeship Median 2006-2010 2011 2012 suspected cases confirmed cases suspected cases confirmed cases suspected cases confirmed cases Voivodeship number incidence per 100 000 number incidence per 100 000 number incidence per 100 000 number incidence per 100 000 number incidence per 100 000 number incidence per 100 000 POLAND 152 0.4 100 0.26 63 0.16 38 0.1 127 0.33 70 0.18 1. Dolnośląskie 11 0.38 7 0.225 - - - - 24 0.82 18 0.62 2. Kujawsko-pomorskie 6 0.265 1 0.05 6 0.29 3 0.14 6 0.29 1 0.05 3. Lubelskie 8 0.37 7 0.32 2 0.09 - - 3 0.14 - - 4. Lubuskie 2 0.2 1 0.1 1 0.1 - - 1 0.1 - - 5. Łódzkie 7 0.27 4 0.155 5 0.2 4 0.16 1 0.04 1 0.04 6. Małopolskie 17 0.52 3 0.075 12 0.36 12 0.36 7 0.21 3 0.09 7. Mazowieckie 28 0.54 23 0.44 18 0.34 10 0.19 30 0.57 21 0.4 8. Opolskie 8 0.77 3 0.29 2 0.2 1 0.1 1 0.1 - - 9. Podkarpackie 15 0.715 18 0.86 5 0.23 3 0.14 3 0.14 1 0.05 10. Podlaskie 2 0.165 0 0 - - - - 1 0.08 - - 11. Pomorskie 5 0.23 1 0.05 1 0.04 - - 7 0.31 1 0.04 12. Śląskie 12 0.26 8 0.17 5 0.11 2 0.04 30 0.65 22 0.48 13. Świętokrzyskie 1 0.08 0 0 1 0.08 1 0.08 0 0 - - 14. Warmińsko-mazurskie 1 0.07 0 0 1 0.07 1 0.07 0 0 - - 15. Wielkopolskie 17 0.5 11 0.32 3 0.09 - - 11 0.32 1 0.03 16. Zachodniopomorskie 4 0.21 3 0.18 1 0.06 1 0.06 2 0.12 1 0.06

No 2 Measles in Poland in 2012 189 Table II. Number and percentage of children vaccinated against measles in Poland 2009-2012 according to birth year (primary and booster vaccinations)* As of 31th December 2009 As of 31th December 2010 As of 31th December 2011 As of 31th December 2012 Year of birth number % of children vaccinated number in children and youth aged 2-11 years ranged from 83.6% do 99.6% (primary vaccination in children born in 2011-2006) and from 76.6% do 96.7% (booster dose in children born in 2003-2001) (Tab. II). As in previous years, differences between voivodeships in performance of primary vaccination in children at 13-15 months of age were observed. Percentage of children born in 2011 vaccinated with trivalent vaccine against measles, mumps and rubella (83.6% in Poland) ranged from 77.6% in mazowieckie voivodeship to 97.3% in warminskomazurskie voivodeship. Measles Elimination Program implementation status in 2012. WHO European Region measles elimination strategy requires maintaining a sensitive and timely surveillance of measles and measles-compatible cases, with serologic testing of one suspect case per 100,000 population. Considering the number of people living in Poland, there is a need to perform laboratory diagnostics for at least 385 cases per year. Over time, a decrease % of children vaccinated number % of children vaccinated number % of children vaccinated Primary dose 2006 362 139 99.0 379 510 99.4 361 648 99.5 361 874 99.6 2007 375 221 98.3 402 018 99.0 379 510 99.4 377 818 99.5 2008 342 111 84.3 400 927 98.1 402 018 99.0 403 615 99.3 2009 x x 340 509 84.4 400 927 98.1 404 820 98.9 2010 x x x x 340 509 84.4 395 336 97.9 2011 x x x x x x 318 126 83.6 Booster dose 2001 7 368 2.1 278 437 79.2 333 289 94.9 338 718 96.7 2002 4 294 1.3 6192 1.8 274 437 81.2 319 971 94.7 2003 x x 1 904 0.6 x x 255 409 76.6 2004 x x x x x x x x * vaccination against measles, rubella and mumps - MMR (based on Vaccinations in Poland in 2012, NIPH-NIH, Warsaw 2013) Fig 1. Measles surveillance performance in Poland 2003-2012 in number of confirmed measles cases should be accompanied by an increase in the number of notified and laboratory tested suspected cases of measles. In Poland in 2012, the number of reported suspected measles cases was higher than in 2011, but, as in previous years, still insufficient. In 2012, a total of 127 cases and suspected cases of measles were reported in Poland which constitutes 33% of the expected reports and shows a low sensitivity of surveillance system (Fig. 1). Along with a reliable evidence of the elimination of indigenous measles, efficient detection of the disease imported from other countries is also important in measles elimination strategy. Therefore, the key activities should be investigating all suspected cases of measles, including secondary cases in outbreaks, and performing genotyping of measles virus. In 2012, surveillance of measles suspected cases in the country was uneven. No voivodeship registered sufficient number of suspected measles cases to meet or exceed the threshold of measles 300 76 250 Number of cases 200 150 100 50 14 12 18 38 46 39 10 16 33 0 Fig 1. Measles surveillance performance in Poland 2003-2012 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Confirmed cases Suspected cases % Indicator of surveillance sensitivity

190 Justyna Rogalska, Ewa Karasek, Iwona Paradowska-Stankiewicz No 2 elimination specified by the WHO as one case per 1,000,000 inhabitants. The highest number of suspected cases was registered in Mazowieckie voivodeship (30 reports, incidence 0.57/100,000) and Śląskie voivodeship (30 reports, 0.65/100,000) (Tab. I). In two voivodeships (Świętokrzyskie and Warminsko-mazurskie) none suspected measles cases were registered in 2012 which suggests not active participation in the WHO measles elimination program. Number of serological tests performed in suspected measles cases in 2012 was insufficient. Of 127 recorded cases and suspected cases of measles, 84 (66.1%) were diagnosed with IgM ELISA test. In 72 of these cases (85.7%) the serological test was performed in the WHO Reference Laboratory in the Department of Virology NIPH NIH, in 6 cases (7.1%) in laboratory of Voivodeship Sanitary Station and in 6 cases in a private laboratory. According to the law on control of infections and infectious diseases in humans (Act of 5 December 2008 on prevention and control of infections and infectious diseases in humans, Dz.U.08.234.1570 with further amendments) measles is subjected to statutory notification by a doctor within 24 hours from the time of diagnosis or suspicion of infection. Despite the improvement in comparison to the previous year, the median number of days between the first visit to the doctor and notification of case or suspected measles case to the local sanitary-epidemiological stations was 4 days and therefore exceeded the applicable time. To maintain high sensitivity of the serological diagnosis of measles, the specimen should be collected between 7 and 45 day after rash onset date. The highest titer is observed on 8 day. The median number of days between rash onset date and specimen collection date increased from 8 days in 2011 to 10 days in 2012. In 26 cases, the material was taken earlier than seven days from the onset of the rash. In one patient, the material was collected after 45 days. SUMMARY AND CONCLUSIONS The epidemiological situation of measles in 2012 deteriorated compared to the previous year. The incidence of measles almost doubled compared to 2011. Additionally, too low sensitivity of measles surveillance allows to doubt in the completeness of the reports. Performance of serological tests in suspected measles cases is still too poor. The WHO measles elimination strategy requires confirmatory tests to be performed in laboratories with the necessary accreditations. At the moment, the only reference center in Poland is a laboratory of the Department of Virology NIPH-NIH. It has accreditations for testing under the program provided by the WHO and the Polish Centre for Accreditation. Referral of laboratory testing in accredited laboratory is free of charge. In the current situation the most important element of the strategy of measles elimination in Poland, in addition to maintaining high vaccine coverage, is intensification of activities in regions with poor surveillance of cases and suspected cases of measles. In addition, it is necessary to intensify surveillance in areas inhabited by ethnic groups with a lower vaccination coverage, which may be a reservoir of the measles virus and a cause of virus circulation after it s importation from abroad. Reaching out to minorities and carrying out vaccination campaigns among these groups is an essential part of the measles elimination program. An efficient epidemiological surveillance will allow tracking imported cases as a source of infection for under-vaccinated communities. It is necessary to further promote measles elimination program among physicians, taking into account the dissemination of detailed information about the plan and implementation of the program, the current epidemiological situation of the disease and, above all, the need to document and laboratory confirm all cases and suspected cases of measles. Important elements of the strategy are also increasing awareness of the role of a Reference Laboratory in the implementation of the program and performance of free of charge laboratory testing. Received: 5.03.2014 Accepted for publication: 12.03.2014 Address for correspondence: Justyna Rogalska Department of Epidemiology National Institute of Public Health National Institute of Hygiene 24 Chocimska Street, 00-791 Warsaw, Poland e-mail: jrogalska@pzh.gov.pl