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1.  Application of Chemometric Methods for Assessment and Modelling of Microbiological Quality Data Concerning Coastal Bathing Water in Greece 
Worldwide, the aim of managing water is to safeguard human health whilst maintaining sustainable aquatic and associated terrestrial, ecosystems. Because human enteric viruses are the most likely pathogens responsible for waterborne diseases from recreational water use, but detection methods are complex and costly for routine monitoring, it is of great interest to determine the quality of coastal bathing water with a minimum cost and maximum safety.
Design and methods
This study handles the assessment and modelling of the microbiological quality data of 2149 seawater bathing areas in Greece over 10-year period (1997-2006) by chemometric methods.
Cluster analysis results indicated that the studied bathing beaches are classified in accordance with the seasonality in three groups. Factor analysis was applied to investigate possible determining factors in the groups resulted from the cluster analysis, and also two new parameters were created in each group; VF1 includes E. coli, faecal coliforms and total coliforms and VF2 includes faecal streptococci/enterococci. By applying the cluster analysis in each seasonal group, three new groups of coasts were generated, group A (ultraclean), group B (clean) and group C (contaminated).
The above analysis is confirmed by the application of discriminant analysis, and proves that chemometric methods are useful tools for assessment and modeling microbiological quality data of coastal bathing water on a large scale, and thus could attribute to effective and economical monitoring of the quality of coastal bathing water in a country with a big number of bathing coasts, like Greece.
Significance for public healthThe microbiological protection of coastal bathing water quality is of great interest for the public health authorities as well as for the economy. The present study proves that this protection can be achieved by monitoring only two microbiological parameters, E. coli and faecal streptococci/enterococci instead four microbiological parameters (the two mentioned above plus Total coliforms and Faecal coliforms) that are usually monitored today. As a consequence, countries, especially those with large quantities of coastal bathing sites, can perform microbiological monitoring of their bathing waters by checking only the mentioned two parameters, thus ensuring economies of scale. Thus, funds can be used in other actions to preserve the quality of coastal water and human health. This in turn, would aid in the assessment of the quality of coastal bathing waters and provide a more timely indication of bathing water quality, hence contributing to the immediate health protection of bathers.
PMCID: PMC4274499  PMID: 25553315
public health; chemometric methods; coastal bathing quality; bacterial indicators; Mediterranean
2.  Pertussis Epidemiology in Greece and Emerging Risk Groups during the Vaccination Era (1980–2008) 
To study the epidemiology of pertussis in Greece and epidemiologic changes throughout a period of twenty-nine years, we conducted a retrospective analysis of available data of pertussis cases for the past twenty-nine years (1980–2008) and a prospective analysis of hospitalized pertussis cases from a children's hospital in Athens for eight years (2001–2008). From 1980 through 2008, the incidence of pertussis in Greece declined from 11.2 to 0.05 cases per 100,000. Epidemic cycles occurring every 3 to 5 years were observed. Since pertussis circulation cannot be fully controlled by present immunization programs, efforts should be made to vaccinate infants at the recommended age, early diagnose, treatment as well as contact tracing of pertussis cases. Control of pertussis in social susceptible populations is necessary. A national program with adolescent and adult booster could decrease the circulation of B. pertussis. Despite an overall decrease for pertussis cases, pertussis is still a present and future challenge of public health service in Greece.
PMCID: PMC3457588  PMID: 23019527
3.  Elevated Bathing-Associated Disease Risks Despite Certified Water Quality: A Cohort Study 
Bacteriological water quality criteria have been recommended to ensure bathers’ health. However, this risk-assessment approach is based mainly on routine measurements of fecal pollution indicator bacteria in seawater, and may not be adequate to protect bathers effectively. The aim of this study was to assess the risks of symptoms related to infectious diseases among bathers after exposure to seawater which was of excellent quality according to EU guidelines. This study is a cohort study recruiting bathers and non-bathers. Water samples were collected for estimating bacterial indicators. Univariable and multivariable analysis was performed to compare the risks of developing symptoms/diseases between bathers and non-bathers. A total of 3805 bathers and 572 non-bathers were included in the study. Water analysis results demonstrated excellent quality of bathing water. Significantly increased risks of symptoms related to gastrointestinal infections (OR = 3.60, 95% CI 1.28–10.13), respiratory infections (OR = 1.92, 95% CI 1.00–3.67), eye infections (OR = 2.43, 95% CI 1.27–4.63) and ear infections (OR = 17.21, 95% CI 2.42–122.34) were observed among bathers compared with non-bathers. Increased rates of medical consultation and medication use were also observed among bathers. There was evidence that bathers experienced increased morbidity compared with non-bathers though the bathing waters met bacteriological water quality criteria. These results suggest that risk assessments of recreational seawaters should not only focus on bacteriological water quality criteria.
PMCID: PMC3386571  PMID: 22754456
bacterial indicators; bathers; health effects; recreational water; swimming; sea-water quality
4.  Determinants of Exposure to Environmental Tobacco Smoke (ETS) among Non Smoking Adolescents (Aged 11–17 Years Old) in Greece: Results from the 2004–2005 GYTS Study 
The aim of the study is to investigate the determinants of exposure to ETS among Greek adolescents aged 11–17 years old. The GYTS questionnaire was completed by 5,179 adolescents. About 3 in 4 responders (76.8%) were exposed to ETS at home, and 38.5% were exposed to ETS outside of the home. Gender, age group, parental and close friends smoking status were significant determinants of adolescent’s exposure to ETS. The results of the study could be valuable for the implementation of public health initiatives in Greece aiming to reduce the burden of adolescent’s exposure to passive smoking.
PMCID: PMC2819788  PMID: 20195445
Environmental Tobacco Smoke; adolescents; Greece
5.  Diagnostic Clinical and Laboratory Findings in Response to Predetermining Bacterial Pathogen: Data from the Meningitis Registry 
PLoS ONE  2009;4(7):e6426.
Childhood Meningitis continues to be an important cause of mortality in many countries. The search for rapid diagnosis of acute bacterial meningitis has lead to the further exploration of prognostic factors. This study was scheduled in an attempt to analyze various clinical symptoms as well as rapid laboratory results and provide an algorithm for the prediction of specific bacterial aetiology of childhood bacterial meningitis.
Methodology and Principal Findings
During the 32 year period, 2477 cases of probable bacterial meningitis (BM) were collected from the Meningitis Registry (MR). Analysis was performed on a total of 1331 confirmed bacterial meningitis cases of patients aged 1 month to 14 years. Data was analysed using EPI INFO (version 3.4.3-CDC-Atlanta) and SPSS (version 15.0 - Chicago) software. Statistically significant (p<0.05) variables were included in a conditional backward logistic regression model. A total of 838 (63.0%) attributed to Neisseria meningitidis, 252 (18.9%) to Haemophilus influenzae, 186 (14.0%) to Streptococcus pneumoniae and 55 (4.1%) due to other bacteria. For the diagnosis of Meningococcal Meningitis, the most significant group of diagnostic criteria identified included haemorrhagic rash (OR 22.36), absence of seizures (OR 2.51), headache (OR 1.83) and negative gram stain result (OR 1.55) with a Positive Predictive Value (PPV) of 96.4% (95%CI 87.7–99.6). For the diagnosis of Streptococcus pneumoniae, the most significant group of diagnostic criteria identified included absence of haemorrhagic rash (OR 13.62), positive gram stain (OR 2.10), coma (OR 3.11), seizures (OR 3.81) and peripheral WBC≥15000/µL (OR 2.19) with a PPV of 77.8% (95%CI 40.0–97.2). For the diagnosis of Haemophilus influenzae, the most significant group of diagnostic criteria included, absence of haemorrhagic rash (OR 13.61), age≥1year (OR 2.04), absence of headache (OR 3.01), CSF Glu<40 mg/dL (OR 3.62) and peripheral WBC<15000/µL (OR 1.74) with a PPV of 58.5% (95%CI 42.1–73.7).
The use of clinical and laboratory predictors for the assessment of the causative bacterial pathogen rather than just for predicting outcome of mortality seems to be a useful tool in the clinical management and specific treatment of BM. These findings should be further explored and studied.
PMCID: PMC2714179  PMID: 19641629
6.  Development and assessment of a questionnaire for a descriptive cross – sectional study concerning parents' knowledge, attitudes and practises in antibiotic use in Greece 
Upper Respiratory Infections (URIs) are common in children. The cause is usually viral, but parents' attitude often contributes to inappropriate antibiotic prescribing, promoting antibiotic resistance. The objective is to describe the process of developing a questionnaire to assess parents' Knowledge, Attitude and Practices (KAP) concerning the role of antibiotics when children suffer from URIs, as well as to evaluate the response rates, the completeness and the reliability (Cronbach) of the questionnaires. Finally, to note any limitations of the study.
Literature review, along with pre – testing yielded a questionnaire designed to assess the parents' KAP – level. A postal survey was set, in a national sample of 200 schools stratified by geographical region. The participants consist of a multistage geographical cluster sample of 8000 parents. The influence of demographic characteristics (i.e. sex, age, education) was analyzed. Cronbach index test and factor analysis were used to assess the reliability of the questionnaire.
The response rate of the parents was 69%. Islands presented the lowest response rate while in Northern Greece the response rate was the highest. Sixty – eight point nine percent of the sample returned questionnaires fully completed, while 91.5% completed 95% of the questions. Three questions out of 70 were answered in a very low rate which was associated mostly with immigrant respondents. The section describing parents' attitude toward antibiotic use was not completed as much as the sections of knowledge or practices. The questions were factor analyzed and 10 out of the 21 extracted factors were finally evaluated, reducing the number of independent variables to 46. The reliability of the questionnaire was 0.55. However, only items that increased the Cronbach when added were eventually included in the final scales raising the internal consistency to 0.68. Limitations of the study, such as the vocabulary and form of the questionnaire and the idiocycrancy of the respondents, emerged during the analysis.
The response rate and the completeness of the questionnaires were higher than expected, probably attributed to the involvement of the teachers. The study findings were satisfactory regarding the development of a reliable instrument capable to measure parents' KAP characteristics.
PMCID: PMC2686701  PMID: 19413902
7.  Regional differences in mortality in Greece (1984–2004): The case of Thrace 
BMC Public Health  2008;8:297.
Mortality differences at national level can generate hypothesis on possible causal association that could be further investigated. The aim of the present study was to identify regions with high mortality rates in Greece.
Age adjusted specific mortality rates by gender were calculated in each of the 10 regions of Greece during the period 1984–2004. Moreover standardized mortality rates (SMR) were also calculated by using population census data of years 1981, 1991, 2001. The mortality rates were examined in relation to GDP per capita, the ratio of hospital beds, and doctors per population for each region.
During the study period, the region of Thrace recorded the highest mortality rate at almost all age groups in both sexes among the ten Greek regions. Thrace had one of the lowest GDP per capita (11 123 Euro) and recorded low ratios of Physicians (284) per 100 000 inhabitants in comparison to the national ratios. Moreover the ratio of hospital beds per population was in Thrace very low (268/100 000) in comparison to the national ratio (470/100 000). Thrace is the Greek region with the highest percentage of Muslim population (33%). Multivariate analysis revealed that GDP and doctors/100000 inhabitants were associated with increased mortality in Thrace.
Thrace is the region with the highest mortality rate in Greece. Further research is needed to assess the contribution of each possible risk factor to the increased mortality rate of Thrace which could have important public health implications.
PMCID: PMC2538537  PMID: 18721482
8.  Tobacco use among students aged 13–15 years in Greece: the GYTS project 
BMC Public Health  2007;7:3.
Data on the prevalence of tobacco use among teenagers in Greece are limited. We examined the prevalence of smoking among middle-school students in Greece using the Global Youth Tobacco Survey (GYTS).
The Global Youth Tobacco Survey was implemented in Greece during the academic year 2004 – 2005 by the University of Thessaly and the National School of Public Health. Data were collected using the GYTS self-administered anonymous questionnaire, which was distributed by specifically trained field workers to a nationally representative sample of middle-school students aged 13–15 years (through randomly selected schools and classes), randomly selected through a two-stage cluster sample design. Data processing and statistical analyses were performed at the Centers for Disease Control and Prevention (CDC).
About one third of the students 32.1% (29.4 – 35.0) reported that they had tried tobacco in the past, while 16.2% (14.3 – 18.4) reported being current users of tobacco products. In addition, 1 in 4 of ever smokers reported that they began smoking before the age of 10 years old. Almost 1 in 5 never smokers reported being susceptible to initiate smoking in the next year and about 89.8% (88.3 – 91.1) of the respondents were exposed to environmental tobacco smoke in their homes and 94.1% (93.2 – 94.9) in public places. Finally, a strikingly high number of students 95% (89.5 – 97.7) reported that they were able to buy their own cigarettes without restrictions.
The results of the GYTS show that the prevalence of smoking in middle-school children is alarmingly high in Greece. Smoking among young people constitutes a significant problem that is destined to worsen in the absence of any comprehensive efforts focused on strict anti-smoking legislation, policies and tobacco control interventions targeting children at a young age.
PMCID: PMC1784081  PMID: 17207291
9.  Management of environmental health issues for the 2004 Athens Olympic Games: is enhanced integrated environmental health surveillance needed in every day routine operation? 
BMC Public Health  2006;6:306.
Management of environmental health issues is an integral part of public health systems. An active integrated environmental health surveillance and response system was developed for the Athens Olympics to monitor and prevent exposure to environmental hazards. The potential for permanent implementation of the program was examined.
The environmental health surveillance and response system included standardization, computerization and electronic transmission of data concerning environmental inspections of 17 site categories (restaurants, swimming pools etc) of public health interest, drinking and recreational water examinations and suggested corrective actions. The Olympic Planning Unit integrated and centrally managed data from 13 public health agencies, recommended, supervised and coordinated prompt corrective actions. Methods used to test the effectiveness of the program were the assessment of water quality test and inspection results trends over time using linear regression and epidemiological surveillance findings.
Between January 2003 and September the 30th, 2004, 196 inspectors conducted 8562 inspections, collected 5024 water samples and recommended 17 027 corrective actions. In 10 cruise ships used as floating hotels inspectors conducted 10 full inspections, 2 re-inspections, and 27 follow-up inspections. Unsatisfactory inspection results (r = 0.44, p < 0.0001) and positive water quality tests (r = 0.39, p < 0.001) presented an overall decrease trend over time. In August, 2003, an outbreak of salmonellosis was linked to a hotel restaurant which accommodated athletes during a test event.
Lessons learned for future events include timely implementation and installation of communication processes, and rapid and coordinated response to unsatisfactory inspection results. Routine national programs need to adopt enhanced environmental health surveillance aimed at public health decision-making, but with a different perspective.
PMCID: PMC1764887  PMID: 17176469

Results 1-9 (9)