Surveillance of wildlife zoonotic diseases in the Balkans Region

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REVIEW

Surveillance of wildlife zoonotic diseases in the Balkans RegionMirsada Hukić1, Fatima Numanović2, Maida Šiširak1, Almedina Moro1, Edina Dervović1, Sanja Jakovac3, Irma Salimović Bešić1

1Institute of Clinical Microbiology, Clinical Center of the University of Sarajevo, 2Institute of Microbiology, Clinical Center of the Univer-

sity of Tuzla, 3Institute of Microbiology, Clinical Center of the University of Mostar; Bosnia and Herzegovina

Original submission:

14 December 2009;

Revised submission:

30 December 2009;

Accepted:

05 January 2010

Corresponding author:

Mirsada Hukić

Institute of Clinical Microbiology,

Clinical Center University of Sarajevo,

Bonička 25, 71000 Sarajevo, Bosnia and

Herzegovina

Phone/fax: +387 33 440 447;

E-mail: [email protected]

Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):96-105

ABSTRACT

The countries of the Balkan Peninsula have become the region with frequent outbreaks of the emerging and re-emerging disea-ses during the last decade of the 20th and the first decade of the 21st century. The majority of outbreaks were wildlife zoonotic, and vector-borne diseases, such as brucellosis, leptospirosis, li-steriosis, tularemia, Q-fever, Lyme disease, anthrax, rabies, viral hemorrhagic fevers, sandfly fever, tick-borne encephalitis and le-ishmainiasis. Epidemiological factors determined by ecology of causative agents are often the most useful diagnostic clues. The recognition of evolving problems of emerging and re-emerging diseases emphasizes the need for the development of better la-boratory diagnostic methods for the surveillance and tracking of the diseases, and for continued research of factors contributing to the transmission of the organisms. The continuous occurrence of previously unidentified infections requires prospective national strategies for timely recognition of the syndromes, causative agent identification, establishment of criteria and methods for the dia-gnosis, optimization of the treatment regime, and determination of successful approaches to prevention and control. Wildlife di-seases surveillance in the most of the Balkan countries has been coordinated by the WHO since 1992. Although new technology and communication have extremely improved in the last decade, there is a need for optimal communication lines among the Balkan countries, better exploitation of communication technologies like the Internet and other media in the field of emerging diseases.

Key words: surveillance, wildlife zoonotic diseases, Balkan Pe-nninsula

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Hukić et al Wildlife zoonoses in the Balkans Region

INTRODUCTION

A zoonosis is an animal disease that may be tran-smitted to humans in natural conditions. Almost a half out of 1700 known pathogens affecting humans are estimated to be zoonotic (1). It has been reported that there are up to 335 pathogens which were associated with emerging infectious diseases (EID) in the global human population between 1940 and 2004, and majority of them were caused by the wildlife zoonotic diseases, while vector-borne diseases were responsible for up to 22.8% (1).Many wildlife zoonotic disease (WZD) outbreaks were reported in the area of the Balkan Peninsula during the last twenty years (2). The wartime pe-riod (1992-1995) was associated with socio-eco-nomic, human demographics, behavioral, ecolo-gical and environmental (climate, ecosystems, microbial adaptation) changes that had signifi-cant impact on public health and global economy, as well as to wildlife zoonotic diseases (3). The additional variables which mostly influence zo-onoses and vector borne diseases are human po-pulation density, human population growth, and wildlife and non-wildlife host species richness (1, 3-5). Breaking of communications channels between the former Yugoslav countries during the wartime and some years in post-war periods, and lack of political will to control the diseases have also greatly contributed to the appearance of WZD outbreaks in the Balkans area. There is a need for different actions to be under-taken in order to recognize and control EIDs and WZDs. First of all, it is important to improve the reporting system of infectious diseases at the state, regional and World Health Organization le-vel. It is also important to improve several tools for controlling EIDs and WZDs such as epide-miologic field investigation, control, eliminati-on and eradication, training, diagnostic develo-pment, and basic and applied research activities including technology transfer. Surveillance of infectious diseases and continuous systematic collection, collation, analysis and interpretation of data and the dissemination of information to the authorities have to be established in order to take any actions (4-7). The purpose of the disease surveillance is to identify the changes of infecti-on and/or health status of animal and human po-pulations, and it is essential to provide rigorous

evidence of the disease absence or to determine pathogen prevalence.To be successful in the understanding WZDs a ba-sic lack of integration between disciplines needs to be eliminated, the most noticeably between human and veterinary medicine and also among different branches within these fields. Although new technology and communications have extre-mely advanced in the last decade, there is still a need for better exploitation of communication te-chnologies such as the Internet and other media in the field of EIDs (5-7).

WILDLIFE ZOONOSIS IN THE BALKANS REGION

The epidemiological situation related to zoono-ses in the Balkan countries is not well characteri-zed due to the difficult circumstances prevailing during the previous decade. There is a lack of reporting and publishing system of the infection and/or health status of animal and human popula-tions. Although there were no readily accessible data concerning epidemiology and epizootolo-gy of WZDs, limited official and published data were analyzed.

Anthrax

Anthrax is endemic in some regions of the Bal-kan Peninsula, but it is not a significant public health problem (2). However, in the past century cutaneous anthrax cases with several clinical si-gns of septicemia were recorded in Bulgaria, Bo-snia and Herzegovina (B&H) and Croatia, with a low mortality rate (1.64%) (7-9).

Brucellosis

Brucellosis is a significant health problem among animals and humans in the Balkan Peninsula. Bru-cellosis is spread in Greece, the former Yugoslav Republic of Macedonia, Kosovo, Serbia and Croa-tia (10, 11). It is an endemic disease among animals and humans in the southern part of the Balkan Pe-ninsula, Greece, the Former Yugoslav Republic of Macedonia and Kosovo at the end of 20th century, which was a consequence of the changes in politi-cal situation in this area followed by the wartime. Appearance of brucellosis represents a classical example of spreading zoonosis as a result of the population and animal migration (9, 12, 13).Brucellosis is an EID in B&H and it is still an increasing public health problem. Only one case

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of human brucellosis was reported in 1999, while in 2008 there were 988 cases reported (14). The current animal health situation in B&H shows an increase in the number of reported outbreaks in ruminants. The number of seropositive cases as compared with the number of processed se-rums in last four years has ranged from 0.047% to 1.09% (11). In Greece, cattle are also affected either by B. melitensis or B. abortus. Wild boars (Sus scro-fa) were found to be carriers and reservoirs of Brucella suis biovar 2 in Croatia (15), whereas Brucella suis biovar 3 was isolated from horses in Croatia (16). Due to the dimension of the disease-related pro-blems, there is a need to establish cooperation in the elimination and prevention of brucellosis among all countries in the region, supported by World Health Organization.

Leptospirosis

Leptospirosis is an endemic zoonosis existing Croatia and B&H (17-20). This is a widely spre-ad disease with frequent epidemic occurrence, especially among miners in B&H and foresters in Croatia (18, 21, 22). Serological testing conduc-ted in 1983 revealed antibodies to Leptospira se-rovares pomona, grippotyphosa, sejroe, australis and bataviae (21) in 10.08% of the B&H miners population. Leptospiroisis outbreak among mi-ners in B&H occurred 25 years later (2005) but caused by new serovars: L. ballum, L. ictroha-emorrhagiae, L. sejroe and L. tarassovi (22). Serological tests in patients from Croatia have shown 18 different serovars of Leptospira, with the highest prevalence of L. sejroe, L.pomona, L. australis and L. icterohaemorrhagiae (23). Leptospira seroprevalence among small rodents captured in shafts of the lignite mines in B&H of 37.5% was noted in 1983 (21). An analysis of Leptospira sp. among small ro-dents in Croatia revealed three different spe-cies: L. borgpetersenii, L. kirschneri and L. in-terrogans. Mus musculus exhibited the highest infection level which was confirmed as a major reservoir of the serogroup Sejroë (23). Leptos-pira infection was also found among European brown bears (Ursus arctos) in Croatia (24), and based on the antibody titers, several serovars fo-und were implicated: australis, sejroe, canicola

and icterohaemorrhagiae. A strong correlation between serovars in bears and serovars previou-sly isolated from small mammals in Croatia was noted (25).

Listeriosis

Listeriosis is present in the area of the Balkan Pe-ninsula, but it is not a considerable public health problem. However, occasional cases of different clinical forms of leptospirosis have been recor-ded recently (26, 27). The analysis of the conta-mination level of different kinds of raw meat (raw beef, pork and chicken) in B&H showed overall presence of Listeria spp. in 49.4% samples; L. monocytogenes detected in 23.3%, L. innocua in 22.2% and L. welshimeri in 3.9% analyzed row meat samples (28). Both beef and pork were mostly contaminated by L. monocytogenes, in 34.3% and 25.7%, respectively. Chicken had the lowest level of contamination amounting to 10.0% (28). In a study conducted in Serbia, 45% of all pigs examined harboured L. monocytogenes in their tonsils, and 3% were intestinal carriers. L. monocytogenes was detected in 29% of swabs from retropharyngeal nodes and in 19% of fecal samples of cattle. L. monocytogenes was found in 69% of minced meat (mixed pork and beef) sam-ples, in 19% of raw dry sausages, and in 21% of vacuum-packaged hot smoked sausages. Howe-ver, L. monocytogenes was not detected in the hot smoked sausages heated to internal temperature of 70-75 °C after the fumigation process (29).

Tularemia

Francisella tularensis has been recognized as a human pathogen for almost 100 years and it is the etiological agent of the zoonotic disease, tulare-mia. The organism has been isolated from over 250 different species, including fish, birds, amp-hibians, rabbits, squirrels, hares, voles, ticks and flies. An important aspect of F. tularensis patho-genesis is the transmission via arthropod vectors into mammalian host. Chrysops spp. and Taba-nus spp. also designated as deer fly and horsefly, respectively, are common arthropod vectors of Francisella transmission to humans, resulting in initial clinical presentation with ulceroglandular form of the disease (30, 31)Due to its easy dissemination, multiple routes and low dose infection, morbidity and mortali-

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ty rates, F. tularensis subsp. tularensis has been classified as a category A bioterrorism agent by the CDC (32).Tularemia is an emergent infectious disease in several countries at the Balkan Peninsula. The first outbreak of tularemia occurred in B&H in 1995, during the wartime (33). A large tulare-mia outbreak occurred in Kosovo in the early postwar period, 1999-2000 (34). Only sporadic cases of tularemia have been recognized and re-ported since the first epidemic in Kosovo (32, 34). There are no data about tularemia seropre-valence in general population or in the high risk groups, e.g. foresters, hunters, veterinarians, or soldiers.Epidemiological and environmental investigati-ons were conducted to identify sources of infec-tion, modes of transmission, and household risk factors in Kosovo. The results suggested that the infection was transmitted through contaminated food or water and that the source of the infection were rodents (34). Environmental circumstances in the war-torn Kosovo led to epizootic rodent tularemia and its spread to displaced rural popu-lations living under circumstances of substandard housing, hygiene, and sanitation (34).Tularemia outbreak areas in 1962 and 1997-2006 periods in Bulgaria were different. The first case of tularemia was reported in 1997. Starting from 1998 to 2008, 296 cases were registered. Ampli-fied fragment length polymorphism (AFLP) and multiple-locus variable number of tandem-repe-ats analysis (MLVA) typing, confirmed epidemic spread and evolution, and comparison of strains isolated from different regions in Bulgaria and Turkey resulted in the finding of the common “Balkan” genovar of Francisella. In addition, several novel genotypes of endosymbionts of Francisella-like organisms have been found in Hyalomma and Dermacentor ticks (9).

Lyme disease

Lyme boreliosis is an emergent disease in many Balkan countries: Bosnia and Herzegovina, Cro-atia, Slovenia, Serbia and Bulgaria (35-39). It is a zoonosis transmitted from animals to humans by ticks of Ixodes ricinus complex. Lyme borreli-osis is caused by Borelia burgdorferi sensu lato, which has four different species (36). In order to evaluate prevalence rate of tick-borne bacterial

pathogens, unfed adult Ixodes ricinus ticks were collected from vegetation at 18 localities throu-ghout Serbia in 2001, 2003, and 2004, a total of 287 ticks were examined by PCR technique for the presence of Borrelia burgdorferi sensu lato; prevalence rate for B. burgdorferi sensu lato was 42.5% (36, 39). The presence of five B. burgdor-feri sensu lato genospecies, namely B. burgdorfe-ri sensu stricto, B. afzelii, B. garinii, B. lusitani-ae, and B. valaisiana was identified by restriction fragment length polymorphism (RFLP) analysis (39). The most frequent B. burgdorferi sensu lato genospecies was B. lusitaniae, followed by B. burgdorferi sensu stricto. These findings indicate a public health threat in Serbia related to tick-borne diseases caused by B. burgdorferi sensu lato (39).

Q-fever

Q-fever has been present in the region of the Balkan Peninsula since it was first recorded as ‘’the Balkans flu’’ (1941–1942), and it occurs in the form of small-scale epidemics and epizooti-es (8, 40). Across the ex-Yugoslavia territories Q fever was discovered rather early – in Za-greb (1948), Banat (1950), Bosnia (1951, 1953), Sandzak (1953), Serbia (1953, 1956 – the Pirot strain), Dalmatia (1957), Vojvodina (1957), Gac-ko (1959), Croatia (1962), B&H (1964), Pula (1972), Vojvodina (1983), Croatia (1984), Vojvo-dina (1984), Bosnia (1985), Kosovo and Metohi-ja, Cacak (1985), Vojvodina (1991, 1992, 1993, 1994, 1995), Macva (in sheep from Kosovo 1998), Montenegro (1999), Serbia (2003), B&H (1998., 2000., 2002., 2004) (41,42). Analyzing the available epizootiological and epi-demiological data on the incidence of Q fever in the region, it could be concluded that beside classical locally focused character of the disease, incidence of new epidemics was also influenced by uncontrolled dislocation of animals, mostly sheep and goats (41- 44). Although some experts deny the significance of Q fever from the view-point of veterinary medicine, the latent forms of this disease in domestic animals and abortions in sheep and goats result in huge economic lo-sses, thus confirming the importance of Q fever as a problem of the veterinary practice (39. 41). Moreover, having also in mind the fact that ve-terinarians together with other professionals are



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very exposed to this infection, it is obvious that Q fever must not remain marginalized in the ve-terinary science. The frequent incidence of this disease in humans should be followed by syste-matic investigations of the infections in animals and natural reservoirs (42, 43).

Hantavirus infections

The Balkan Peninsula has been known as a hig-hly endemic region for hantavirus infections. So far our research has shown that at least two dif-ferent Hantaviruses (HTV) (the murine Dobrava (DOBV) and the avricoline Puumala (PUUV) vi-ruses), each carried by a different rodent species, have been circulating in the area (44,45). So far two viruses, Puumala and Dobrava have been identified as causative agents of hemorrha-gic fever with renal syndrome in Albania, B&H, Greece, Croatia, Kosovo, Montenegro, Slove-nia and Serbia (45-50). Additionally, Tula virus, which is considered a non-pathogenic hantavirus was detected in small mammals (51). However, Clethrionomys glareolus, Apodemus agrarius and Apodemus flavicollis are the main reservoirs of hantaviruses in the region (46). The incidence of haemorrhagic fever with renal syndrome (HFRS) varies in a cyclic fashion, with peaks occurring every three to four years, coinciding with peaks in rodents population (45). Several HFRS outbreaks were registered in the area of the Balkan Penin-sula in: 1967, 1986, 1987, 1989, 1995 (45, 51), and 2002 with more than 1000 HFRS cases. Dual infections with hantaviruses and leptospira were also detected in humans as well as in rodents (52). In the Balkan states where PUU and DOB viruses co-circulate, seroprevalence in general population is between 1.6% (Slovenia) up to 5.18% in B&H, which has been recognized as a highly endemic region for hantavirus infections for over 56 years (45,51,53). As early as in 1952 the first ‘’proba-ble’’ HFRS case was described in the region - the victim was a soldier and infection occurred near Fojnica city, B&H. The first documented HFRS outbreak was reported in 1967, followed by five outbreaks in the region and the majority of the af-fected population was located in B&H. The total number of HFRS reported cases was 1242, but the real number of HFRS cases is probably higher because the surveillance of infectious disease had not been regular until 1992 (53).

Rabies

Rabies remains endemic within a number of co-untries in Southeast Europe including Romania, Bulgaria, B&H and Turkey (7, 44, 55, 56). With the exception of Turkey, the red fox (Vulpes vul-pes) is the principal disease reservoir in Southeast Europe. However, cases of rabies in dog (Canis familiaris) are regularly reported. In contrast to Northern Europe, the raccoon dog (Nyctereutes procyonoides) does not appear to be a vector in the south. In Bulgaria, dogs are the main vectors bringing rabies into contact with humans and li-vestock. Foxes are the principal reservoir species for rabies in Romania although cases in dogs are regularly reported. Despite a gradual decline in dog rabies, urban pockets of the disease remain in many regions of Turkey. Furthermore, there is some evidence that the foxes have been a signi-ficant vector for rabies and might be responsible for increased rabies in cattle. Rabies in Croatia has been registered in wild animals (mostly foxes) and sporadically in domestic animals (dogs, cats). The last human case was described in 1964. The fox and dogs are the principal reservoir species for rabies in B&H. Throughout the region there is evidence of cross-border movement of rabies by both wildlife and canine vectors (55,56). The lyssaviruses currently consist of 7 esta-blished genotypes or lineaages of rabies(-like) vi-ruses (56) of which classical rabies virus is found throughout the world and associated with terre-strial mammalian hosts and American bats forms genotype 1. Phylogenetic relationships among sequences of five viruses isolated in B&H have shown the presence of two phylogenetic lines, one which is present in the Northwestern part and the other, which is present in the Northeastern part of the country. Viruses are closely related to Western European isolates of rabies virus (56).

Tick-borne encephalitis

Tick-borne encephalitis virus is the causative agent of the most prevalent arboviral human infections in Europe. Three subtypes have been identified: European (TBEV-Eu), Far Eastern (TBV-FE) and Siberian (TBEV-Sib). The vector of TBEV-Eu transmission is the tick Ixodes rici-nus, whereas I. persulcatus is the vector of other two subtypes. The virus is maintained in nature through cycles involving tick and wild vertebra-

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te hosts and also by transovarial and transstadial transmission in its vector. Many different verte-brates have been implicated in the maintenances and circulation of the TBE virus. The major ca-usative role in Central Europe seems to belong to Apodemus flavicollis and Myodes glareolus, not only because they are abundant in the regions where TBE incidence is high and they are exce-llent hosts for both nymphal and larval stages of the tick, but also because they promote transmi-ssion by co-feeding (44,57,58).The distribution of TBEV is well coordinated with its vector distribution. There is a lack of data related to TBEV seroprevalence among the wild animals in the Balkan region. Data from Slovenia have shown that the infection prevalence in ro-dents sampled in Slovenia in the period between 1990 and 2008 entirely varied based on the ro-dent species, from 14% in Myodes glareolus to 2-4% in Apodemus species (57-59).Tick-borne encephalitis (TBE) in Slovenia repre-sents a serious public health problem with hun-dred official reported cases (58). In Croatia TBE was first discovered in 1953. The only really do-cumented natural focus of tick-borne encephalitis was the northern part of the country, between the Sava and Drava rivers. Alleged cases from other parts of Croatia still have to be confirmed and analyzed, and additional research and collabora-tion between different professionals is required (44, 57, 59). Official data show no occurrence of TBE in Albania, Bosnia and Herzegovina, Bulga-ria, the Former Yugoslav Republic of Macedonia and Turkey (57).

Sandfly fever

Sandfly fever viruses (SFV) are moderately ende-mic along the Adriatic coast of Albania, Croatia, B&H, Slovenia and landlocked Serbia, and fo-cally distributed throughout Greece and the for-mer Yugoslav Republic Macedonia (44, 60-65). Historical data of the sandfly fever (Pappataci fever) indicate its origin in B&H at the end of the 19th century (62, 63). Before the World War II, the pappataci fever in the former Yugoslavia was mainly detected in Herzegovina, Dalmatia, Mon-tenegro and especially in Macedonia, where its prevalence coincided with that of Phlebotomus papatasi (64, 66). Most of the clinical and epi-demiologic studies had been conducted in B&H

between 1886 and 1962 (66-68), but there was no published data about the SFV infection between 1971 and 2006. The recent infection was found in 9.38% to 12.50% of patients during the period of three years (2006-2008) (68). The first extensive serological investigations of the prevalence of the arbovirus infection were reported in 1975-1982 (64, 68-70). The results indicated a high prevalence of the antibodies to Naples and Sicilian sandfly fever viruses in Dal-matian population, North Croatia and Kosovo. On the island of Brač, 57.6% of the population had antibodies for the Naples virus and 15.6% for the Sicilian virus, in Kosovo- 27.9% and 9.6%, respectively. The prevalence of the Naples virus infection reached 62.1% in the inhabitants of B&H in 1962 (69). These results indicated the continuous circulation of Naples virus in nature. Finding the TOSV positive results in clinical samples after more than forty years (66), means that the virus has been circulating in this region, but has not been the point of interest of local rese-archers. It is very important to direct the attention of clinicians to sandfly fever (papatasi fever) be-cause the disease was unrecognized in the region until recently.

Leishmainiasis

Leishmainiasis is widespread on the Balkan Pe-ninsula. It is a protozoan parasitic infection cau-sed by Leishmania infantum that is transmitted to human beings through the bite of an infected female sadfly (71). The disease occurs in urban centers and rural highland villages in Albania, B&H, Croatia, Greece, Montenegro, Serbia, Ro-mania and Slovenia (71-76). Zoonotic visceral leishmaniasis (VL) is a re-emerging disease in the Balkan area (1, 3-5, 73, 74). The re-emerging is probably due to a combination of factors inclu-ding increased monitoring, intensified research, demographic change, land-use/land cover chan-ges that create new habitants and/or changes in microclimate, and changes in seasonal climate (2). Some human cases are usually detected in the area every year (74-76). Visceral leishmani-asis in 50 children was reported from Albania in 2009 (72). Leishmaniasis is mostly a problem in veterinary medicine. The investigation of 272 dogs sera originating from different regions in Albania



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and Kosovo have shown specific antibodies for Leishmania in 3.3% of animals. All leishmania-positive animals were stray dogs (74, 75). Those animals contribute to the maintenance of Leish-mania transmission in endemic areas, and a con-trol of the canine stray population should be con-sidered (74-78). A historical review on human and canine leishmaniasis in Croatia documents the presence of stable disease foci in coastal and in-sular territories of central and southern Dalmatia since the beginning of the 20th century (71,74). Among the species which may act as Leishmania infantum vectors in Croatia, Phlebotomus tobbi and P. neglectus were the most abundant (74).

Echinococcosis

Echinococcosis remains a very serious public health problem in Southeast Europe, although a decrease in incidence has been observed in some endemic areas during the last decades (77-80). However, in some non-endemic areas an increase in infected cases and new foci of animal echino-coccosis were registered during the same time (77). The disease is very common in the Balkan Peninsula, with the former republics of Yugosla-via having one of the highest prevalence rates (77-80). Echinococcosis is zoonosis transmitted by dogs in livestock-raising areas and acciden-tally affects men. The most frequent site of hyda-tid cysts is in the liver (78%), followed by lungs (17%), and less frequently, spleen, kidneys, he-art, bones, central nervous system, and elsewhere (80).

Trichinelosis

In the majority of Southeast European countries cases of trichinellosis among the human and ani-mal populations were described in the late 19th or early 20th century (80-81). Trichinella infec-tions among wildlife were also described in the aforementioned countries (5, 80). Today, the pre-valence of trichinellosis between the Balkans and bordering countries is different (81-83). A high prevalence of trichinellosis in domestic animals and humans has been reported in Bulgaria, Serbia and Montenegro, Romania and Croatia (80-84), and a moderate prevalence was found in B&H. Trichinellosis has not been found among dome-stic animals and humans in Greece and Macedo-nia in recent years, while in Turkey and Slovenia

human trichinellosis is sporadic (83). A re-emer-gence of trichinellosis is connected with the chan-ges in the social and political systems in Bulgaria and Romania (81, 84). In B&H, Kosovo, Serbia as well in Croatia, however, the re-emergence of trichinellosis did not only happen due to political and social changes, but also due to the war that took place in these countries during the last years of the 20th century (84). There are some other zoonoses and vector-bor-ne diseases with more or less documented evi-dence on epidemiological, clinical or etiological features (1, 8, 44, 85, 86). The special attention deserves tuberculosis and rickettiosis, because the outbreaks affected the history of the Balkan Peninsula.

THE SURVEILLANCE OF WILDLIFE ZOONOSIS DISEASES

The last outbreaks of avian A (H5N1) and swine influenza A (H1N1) showed the importance of greater collaboration between physicians and ve-terinarians as well as for the disease surveillance in humans, domestic animals and wild animals (5). The surveillance of diseases in wild animals is a relatively new activity compared to the sur-veillance of diseases in humans or domestic ani-mals (5, 7). At the moment, there is no Balkan-wide network of health surveillance. Since 1992, the disease surveillance in most Balkan countri-es is irregular and coordinated by the WHO. A number of new zoonotic infections emerged or re-emerged during the past 17 years, caused by social, political, climate and environmental chan-ges in the area. The communication channels among Balkan countries were broken, so preven-tive action has not been done. There is an urgent need for building of a European health survei-llance network. It should include the following elements: national surveillance programs that cover the whole country; human diseases, dome-stic animal diseases, all wildlife species, and all diseases; comparable methodology among surve-illance programs, so that it is valid to compare results; strong interaction among surveillance programs, so that new information and knowled-ge is rapidly and efficiently shared. Recent initiative called One Health, which sup-ports the unique approach to zoonoses, is a con-cept of the worldwide strategy for expanding

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interdisciplinary collaborations and communica-tions in all aspects of health care for humans and animals (86).

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ACKNOWLEDGEMENTS/DISCLOSURES

Competing interests: none declared.

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