Director’s introduction - December 2002 

Marijan Erceg, MD, MSc

         I took over as director of Croatian National Institute of Public Health (CNIPH) on 6 December 2002. I am confident of fulfilment of continued cooperation with the people and institutions with whom CNIPH has collaborated until present. 

Health maintenance and health promotion is the basic mission of this Institute. In order to achieve this goal, we should make effective the existing knowledge and technologies in the maintenance and promotion of individual and community health. In this sense, I welcome the decision of CNIPH’s Management Board establishing a Drug Addiction Prevention Service with the charge of cooperating with other institutions on the creation, implementation, coordination and evaluation of smoking, alcoholism and drug abuse prevention programmes. 

I should like to take this opportunity to wish everyone a Merry Christmas and a Happy New Year. 
 

EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

         A 21-23 November WHO Workshop on Tracking of Infectious Diseases organized for signatory countries of the Dubrovnik Charter was attended by the Department staff and a health ministry representative. During the workshop, attendees could practice priority setting in infectious diseases using the popular Delphi method, which has potential applications for priority setting in other areas. 

A part of the workshop was devoted to analyzing national legislations related to infectious disease tracking and to the participant countries’ respective capacities to intervene adequately against infectious diseases, including with their laboratory capacities. Reaffirmed at this Meeting was the previously declared WHO attitude that monitoring, prevention and combating of infectious diseases were its priority and hence should become one to its member countries. 

Croatian Medical Association’s Croatian Epidemiological Society had its regular annual meeting on 6 December. This was an occasion for over 70 participants to hear 18 qualitative, mainly technical, lectures on the epidemiology of infectious and non-infectious diseases. 

Immunization Schedule 2003, whose circulation is 3,500 copies, has been mailed to everyone carrying out the Mandatory Vaccination Programme. It can be found on CNIPH’s web page.
 

Chronic Mass Disease Epidemiology Department

         On a WHO, ILO, and Council of Europe proposal, the Initiative for Social Cohesion of the Pact on Stability and Cooperation held its 12^th Meeting on 13-14 December in Salonika, Greece. Health, social welfare with special reference to pension reform, and housing and employment policies both as key factors of social security and preconditions to overall progress were the subjects. Attending this meeting as Croatian representative was the head of our Department. 

A contract signed between the Ministry of Croatian War of Independence Veterans and CNIPH for the project “Investigation of Suicides in Croatia” has set the objective of establishing the number of suicides committed by veterans of the recent war. The first stage of the investigation is in progress. It includes a comparative analysis of data from the Suicides Registry, Ministry of Croatian War of Independence Veterans and that on disabled ex-service men dying in 1997﷓2000, respectively on individuals with terminated disability allowance payments. Subsequent stages of the investigation will be contracted for through annexes.

International Federation of Gynecology and Obstetrics (FIGO) have been issuing annual reports on treatment results for gynaecological cancer from around the world since 1937. There have been 24 publications so far, with the latest presenting the results of world’s 74 oncological centres. Appearing for the first time, Croatia’s data (resulting from collaboration between Institute for Pathology and Gynaecological Oncology of the Zagreb Clinical Hospital Centre and Croatian Cancer Registry) will also come out in its next publication. 
 

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

On December 5-6 in Strasbourg, the Third Conference of Council of Europe’s Pompidou Group was held as part of the Tracking Long-Term Trends with Treatment Demand Data project. Common to experts in this area is the goal of creating a new strategy for drug epidemiology. Dr Dragica Katalinic, who heads the Drug Addiction Monitoring Unit with National Treated Psychoactive Drug Addicts Registry, attended the conference conducted by project coordinator Dr Michael Stauffacher. 

Before the Conference and as a first step in drug addiction analysis in individual countries, members of the Pompidou Group had sent out the data prepared in accordance with data analysis guidelines. The materials consisted of introduction, guidelines for the estimation at local level of incidence of problem drug use, and of guidelines for logistic regression in the analysis of long-term time trends. 

The conferees presented the data on their respective countries, debating data collection methods and different interpretations of certain terms (such as, “first treatment” and “all treatment demand”), and the possibility of duplicate reporting and ways of avoiding it. It was emphasized that the accuracy of this data is important not only for the study itself, but also for the decision makers who will be basing certain decisions on it. For this reason, the future publication containing this data will be of country profile type rather than detailed statistical report. 

On 7 December, there was the 10^th Consultation on Perinatal Mortality at the Croatian Medical Association. New health statistical forms on perinatal deaths introduced in 2001 have enabled Croatia to submit, for the first time to the WHO HFA database, data compliant with the established international criterion of birth weight, thus improving the international comparability of our indicators. Apart from her paper on perinatal mortality in 2001, Urelija Rodin, MSc, presented other indicators of the perinatal events affecting the outcome of child delivery and being connected with perinatal care. 


MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

At the General and Bacteriologic Serological Diagnosis Unit, Bacteriology Department, preparations are under way to introduce an ELISA assay for the detection of antinuclear antibodies (ANA, i.e., ANF). It is capable of distinguishing eight types of antigen antibodies (dsDNA, SS-A, SS-B, Sm, Sm/RNP, Scl 70, J01, CENP); to increase the precision of diagnosis it would be used on immunofluorescent assay-positive patients. The finding of these autoimmune antibodies is important primarily in differential diagnosis to discriminate between bacterial arthritis and the arthritis from autoimmune causes. These antibodies may also be a side effect in some infections. Laboratory head Dr Diana Karlovic Martinkovic has completed a training course in the new assay at manufacturer (MAST DIAGNOSTICA) laboratories in Hamburg.


HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

Director’s introduction - November 2002 

Pr Vlasta Hrabak-Zerjavic, MD, MSc

         A court order has returned Assistant Professor Marija Strnad-Pesikan, MD, PhD, to the position of CNIPH’s director pending the nomination of Marijan Erceg, MD, MSc, to it by the ministry of health. I take this opportunity to thank, as the past acting director, everyone for co-operation and support during the past year, also wishing you all much success in work. 
 

EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

         At the beginning of the month, the minister of health Andro Vlahusic, MD, MSc, enacted the Mandatory Immunisation Schedule for the Year 2003 at the proposal of CNIPH’s Epidemiology Service. Besides proposing the Schedule to the Minister, another responsibility of the Service is to monitor the implementation of the Schedule. This includes monitoring immunisation coverage, trends of diseases subject to vaccination, vaccine side-effects, and interventions in case of need. The described monitoring is carried out through notifications as part of a well run-in system with clear division of distributional responsibility, and through direct contacts, mainly by phone, with vaccinators and epidemiologists at hygiene-epidemiology outposts. 

Based on this monitoring, it was established that there was no need to change the Schedule; in consequence, it will stay the same as this year. It will impose slightly greater obligations on vaccinators of small children and adults, considering that the immunisation schedule that was introduced this year (H. influenzae type B infection at infant age, and tetanus toxoid for the 60-year-olds) now comes to full completion in combination with a simultaneous start this year of the immunisation of a new generation. 

The Schedule, whose implementation in Croatia involved using the vaccines prescribed by it, has resulted in considerable reduction in the morbidity of immunisable diseases, and in the eradication of smallpox and child paralysis. This necessitates a conservative approach to changing either the Schedule or the vaccines it makes use of, to avoid compromising the currently good epidemiological situation in Croatia just by joining the trends in some Western countries. 

December 1 marks the World AIDS Day. It is marked this year by the WHO with the slogan “Live and let live” - “Live and let others live” with a focus on fighting stigmatisation and discrimination of the HIV-infected and of AIDS cases. The guiding principle of this slogan is that the only way to defeating HIV is recognition by everyone that virus, not the infected people, is the common enemy. Infectious Disease Epidemiology Department, which runs the National HIV/AIDS Case Registry, and evaluates the National Programme for Control and Prevention of HIV/AIDS, has distributed educational materials to each Epidemiological Service unit in Croatia accordingly. These focus on suppressing the fear from HIV-positive patients.

Information on the epidemiological situation related to HIV/AIDS in Croatia can be found on CNHIP’s web pages. 

Chronic Mass Disease Epidemiology Department

         A study on suicides among Croatian War of Independence veterans is at stage one. It has been undertaken in collaboration with the Ministry of Croatian War of Independence Veterans. For this purpose, a special epidemiological analysis has been made of the suicides committed in Croatia from 1986-2000. The work now is towards a methodology linking the National Suicides Registry data with the databases available to the above Ministry. 

At the National Health Agency in Udine, Italy, a “Survival Analysis” Workshop was held 29-30 October. The Workshop assembled the representatives of the North-East Italy Cancer Surveillance Network, and Ariana Znaor, MD, MSc, as the Croatian Cancer Case Registry representative. Following a presentation of methodological procedures in SAS, a preliminary analysis of cancer patient survival in the Friuli Region and in Croatia was made.

A visit to the Institute for Tumours, Genoa, Italy, on 11-15 November was part of the work on the project “Frequency of micronucleus in peripheral lymphocytes and human cancer risk” within the EU Programme “Cytogenetic Biomarkers and Cancer Risk in Humans”. On this occasion, Dr Znaor also held a seminar on the topic “Non-Hodgkin lymphoma: new classification and a review of risk factors”.

Organised by the Croatian Association of Diabetic Societies to mark the World Diabetes Day, a Round Table Conference attended by Verica Kralj, MD, took place on 14 November. This year’s topic was “Diabetes and eye complications: let’s see the risks”. As a diabetic complication affecting eyes, retinopathy is the leading cause of blindness and disorders of vision in the developed countries’ adults. Timely prevention may prevent the development of such complications.

The head of service attended, as CNIPH’s representative, a EUROSTAT Working Group meeting in Luxembourg 25-27 November. The topics were statistics in public health and the introduction of comparable indicators on the European level. 

Croatian Medical Association’s Croatian Epidemiological Society has scheduled its 53^rd technical meeting for 6 December on the Sljeme Mountain (The Medvednica Guest House) near Zagreb with free topics on the agenda.
 

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

The Sixth Scientific and Technical Conference of Croatian Neonatologists took place on 14 November at the Zagreb Clinical Hospital Centre’s Institute of Neonatology and Intensive Care. It was attended by Urelija Rodin, MD, MSc, who presented a paper on perinatal mortality in Croatia’s maternities. The interest focused on the high mortality rate in the newborns of the lowest birth weight (500-1000 g) and on treatment possibilities. It was emphasized that medical professionals should prepare obligatory guidelines for all Croatian maternity when dealing with the delivery of children whose survival prospects are, at present medical knowledge and capabilities, minor.

Pr Ranko Stevanovic, MD, MSc, attended the technical-scientific gathering “Croatian Primary Health Care Days” at Labin with a paper “Health Centre, Family Medicine and Health Care in the Community: the Kind of Reform Needed”. CNIPH was the co-organizer of a symposium with international participation named “Implementation of a National Information System in Croatia’s Health and Telemedicine”. Participating on our part were Pr. Vlasta Hrabak-Zerjavic, MD, MSc, Pr Ranko Stevanovic, MD, MSc and Branimir Tomic, MD.


MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

In the first half of October, our National Centre for Influenza (WHO) and Respiratory Virus Diagnosis recorded the start of this year’s respiratory viral infection season. Demonstrated in the population was the circulation of respiratory syncytial virus (RSV), adenoviruses and parainfluenza virus types 1 and 3. A sharp increase in RSV morbidity, noted at the beginning of November, displays a continuing growing trend. The first influenza virus isolations, anticipated in Croatia in January 2003, could produce an outbreak peaking in February, a repeating pattern over the past 15 years now.


HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

Director’s introduction - October 2002 

Pr Vlasta Hrabak-Zerjavic, MD, MSc

          Sponsored by the minister of health, and held 16-19 October 2002 at Mlini, Župa Dubrovačka, the Sixth Scientific-Technical Conference on Water and Water Supply was jointly organized by Croatian National Institute of Public Health (CNIPH) and county institutes of public health. The central topic was water technology and analysis in function of its health safety. 

          Another event, on 1-4 October 2002, a workshop preparing the conduct of the Global Youth Tobacco Survey (GYTS) in 12 countries of the Central and Eastern Europe was hosted by CNIPH. This survey is conducted under the auspices of WHO on a CDC (Atlanta) initiative. Having covered 66 countries so far, GYTS is being run in an extra 31 countries. On this occasion, Dr Haik Nikogosian, WHO/EURO adviser to Tobacco Free Initiative, also visited Zagreb and the Ministry of Health, the study sponsor in Croatia (CNIPH is the study carrier). 

          On October 18-19, CNIPH hosted a regional meeting intended to prepare the ESPAD (European School Survey Project on Alcohol and Other Drugs) survey. It is a project undertaken for the third time under the auspices of the Council of Europe. The meeting was organized for eight countries of the Central and Eastern Europe, ranging from Austria to Bulgaria.
 

EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

         Organized by WHO/EURO, a WHO/KNCV Regional Training in Tuberculosis Control Programme Management took place 14-25 October in Warsaw. It was devised for countries of the Central and Eastern Europe and those of the ex-USSR. There were 39 representatives, with Dr Aleksandar Simunovic attending on the part of CNIPH. The Training aimed to provide the basic guidance and establish an action framework. Invited world experts transferred their knowledge to the participants via lectures and exercises. 

          It was a two-part course. Whereas the first dealt with the epidemiology of tuberculosis and the strategy and implementation of DOTS, the second analyzed the methodology for solving tuberculosis-related problems with modern management tools. The direction the Course took was towards rapid and succinct recognition of the problem, priority setting, activity planning, and result evaluation, determination of mode of financing and final unification of any steps conceived in the Programme. In view of the growing trend of tuberculosis in Eastern Europe, it was concluded that tuberculosis control programmes are facing a major challenge.

          This country has a developed National Tuberculosis Control and Prevention Programme, as well as a stable tuberculosis-related epidemiological situation. Nevertheless, in view of the European trend, it was very useful to learn what models and simulations of effective programme measures for the control of this disease have been adapted to the conditions and specifics of the neighbouring countries.

Chronic Mass Disease Epidemiology Department

         For government employees of the EU-candidate countries, a Course named “Public Health in the EU” was held 23.09.-11.10.2002 in the Netherlands. These countries are currently adapting and harmonizing their national legislations and normative deeds in the public health domain with the EU’s. Fifty participants from 12 Central and Eastern European countries attended the Course. It aimed to acquaint the participants with the EU’s public health legislation, the feasibility of its implementation, and the creation of a common policy among the different ministries responsible for the promotion and maintenance of a healthy population.

          The new EU public health programme 2003-08 was presented stressing the need for informational and data improvements, rapid reaction in the case of epidemics and bioterrorist attacks, and action on health determinants through disease prevention and health promotion. The Course has enabled an exchange of information among the participants, a visit to several Dutch public health institutions and an acquaintance with their activity. Participating for CNIPH were Urelija Rodin, MSc, Dr Zrinka Petrovic and Dr Verica Kralj. 

          At IARC in Lyon, a conference named “Prospects for Epidemiological Research of Non-Hodgkin’s Lymphoma” was held 30-09-02.10.2002. It consisted of a plenary session and of working group sessions formed for risk factors, family studies, pathology, immunology, polymorphism, viruses, professional exposures, pesticides, UV radiation and diet. Ariana Znaor, MSc, attended a workshop as an invited observer. 

          The Society of European University Women held a conference in Dubrovnik 11-13 October on the topic “Environmental Protection and Health: What Can UWE (University women of Europe) do in the 21st Century?” Ariana Znaor, MSc, led the workshop titled “Health”. At the Workshop with food as its topic, she presented the subject “Diet and Women’s Health” authored by Marija Strnad and herself. 

          The topic of the World Mental Health Day, marked on 10 October 2002, was “Consequences of Trauma and Violence to Children and Adolescents”. The purpose of marking the day is to educate families and the society to recognize and help the individuals affected with mental diseases.
 

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

         There was a regional working meeting of the WHO 28.09-04.10.2002 in Budapest, which was attended by representatives of the 16 European countries due to undertake the
”World Health Survey”. This WHO project conducted in 73 countries will be done in Croatia on a sample of 1,000 households. Between January and April 2003 CNIPH will be running this project in collaboration with the Andrija Stampar School of Public Health and county institutes of public health. 

          The Ministry of Health of the Republic of Croatia has nominated CNIPH to carry out the Global Youth Tobacco Survey (GYTS). It was started by the WHO jointly with the CDC (Center for Disease Control in Atlanta) and UNICEF. Under the auspices of the Ministry of Health, WHO/EURO and CDC a training course was organized for GYTS investigators from 12 countries of Central and Eastern Europe. The Course was attended by Dr Tanja Coric, GYTS investigator for Croatia.

MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

         As an acute infection acquired in pregnancy, toxoplasmosis, and a common and, as a rule, innocuous zoonosis may cause severe foetal damage. Since 1948 when Sabin and Feldman introduced the first serologic test (so-called “dye test”, a highly sensitive and specific one) diagnosing of toxoplasmosis has been based on the demonstration of serum antibodies. Its serologic diagnosis has posed a permanent challenge ever since, due to the need to develop tests that would reliably discriminate between fresh and older infections, something of crucial importance in the diagnosis of toxoplasmosis in pregnancy. Despite dye test still being a golden standard in demonstrating the infection, it cannot reliably distinguish between fresh and old infections. The serologic diagnosis of toxoplasmosis with dye tests started at CNIPH’s Parasitology Laboratory more than 40 years ago is continually complemented with new tests in line with the developments of medical science and technology in other countries. Whereas infection is demonstrated using indirect fluorescence for IgG antibodies (ITFA), differentiating between fresh and older infections requires a set of serologic tests such as indirect immunofluorescence for IgM antibodies (ITFA IgM), enzyme immunotest to IgM antibodies (ELISA IgM), immunosorbent agglutination test to IgM antibodies (ISAGA IgM) and IgG antibody avidity test (IgG avidity). These are done at CNIPH. 

HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

Director’s introduction - September 2002 

Pr Vlasta Hrabak-Zerjavic, MD, MSc

          Prompted by an HIV-positive girl starting to attend school, the Croatian Health Ministry has engaged this Institute's professionals in the articulation both of intervention measures and of measures designed to create acceptance of HIV-positive individuals and ensure their living full lives, including receiving an education, employment, social integration etc.

          Attended by several members of our staff, the Ninth Meeting on Mediterranean Diet and Health took place on the Brijuni Islands 12-15 September. It was followed from 18-22 September by the Third Croatian Congress on Occupational Health to which they contributed with their papers.

          At Helsingor, Denmark, a European WHO consultative meeting on Framework Convention on Tobacco Control took place on 23-24 September with me representing Croatia. It discussed the latest text of the Convention prepared by the chairperson of the Intergovernmental Negotiating Body, as well as remarks from the preparatory meetings at Brussels, Moscow, Sofia and Tallinn. Joint proposals were made to improve the text and present it at the Fifth Meeting of the International Negotiating Body scheduled for Geneva in October. Likewise, handed in to participants was the European Strategy for Tobacco Control (Croatia is a Drafting Group member), which was adopted by a Resolution passed at the Fifty Second Meeting of the Regional Office for Europe. 

          This year too this Institute contributed to the marking of the World Heart Day on the “Heart for Life” topic. This involved distribution of educational materials in collaboration with the Croatian Cardiological Society, our director’s participation in the press conference on the day and short contributions in radio broadcasts. 

EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

         An anti-influenza vaccine for the season 2002/03 will be distributed to county public health institutes. Manufactured by Chiron, S.pA., Italy, a drug trademarked Agrippal meets WHO recommendations by its composition: A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like and B/Hong/Kong/330/2001-like. Administration of the vaccine is intramuscular by single-dose single-use injections. It was designed primarily for these categories of the insured: individuals aged above 65 years, patients affected by chronic cardiac, pulmonary or renal disease, diabetics, post-transplantation patients, other severely ill and health workers. 

         For the above population categories, the influenza immunisation is free. Because of the ever-increasing interest in vaccination, Croatian Institute for Health Insurance has ensured slightly more than 500,000 vaccine doses, more than the previous years. 

         As in previous years, primary health service physicians, chiefly family physicians who order the vaccine from a competent county through regional epidemiologists, should be immunisation campaign carriers. To avoid queuing, our recommendation to vaccinators and county public health institutes is to inform their local populations of the start of the immunisation campaign, vaccination sites and immunisation timetable. To those interested in receiving the vaccine we recommend to check first with their chosen physician whether he/she may vaccinate them. If not, they should seek vaccination at a county public health institute’s regional hygiene-epidemiology outpost. 

Chronic Mass Disease Epidemiology Department

         Between 30 August and 3 September, the 13th Congress of European Anthropological Society took place in Zagreb. The Department's female physicians V. Hrabak-Zerjavic, V. Kralj, M. Silobrcic and I. Brkic presented their poster “Epidemiology of Cerebrovascular Diseases in Croatia”. On World Alzheimer's Day (21 September), Dr M. Silobrcic gave a lecture titled “Alzheimer's Disease in the Elderly” at the City of Zagreb Institute of Public Health's Gerontological Forum. She described the neurological, psychiatric and psychological aspects of the Alzheimer disease, emphasizing the necessity for the disease to be recognised at the earliest stages and adequately treated with the drugs currently available. Also stressed was the need for improved statistical monitoring of the disease.

A_z
World Alzheimer's Day
21 September

         During September, the base of our Cancer Case Registry was converted from ICD-9 to ICD-10, another conversion involving a change from International Classification of Diseases for Oncology’s first to second revision. Currently in print is Bulletin no. 25 with the topic “cancer incidence in Croatia 2000”. Starting with no. 26 the published data will be conformant with ICD-10. 

         Ariana Znaor, MD, MSc attended 26-28 September in Zagreb the Fifth International Conference on Health Insurance in Transition as a co-author of the paper “Croatia's Participation in International Projects on Validation of Cytogenetic Endpoints as Cancer Risk Biomarkers” by A. Fucic, A. Znaor, M. Strnad, which was presented within module 2 of the Conference “Frontiers in Biotechnology”. 


SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

         The Third Croatian Congress on Occupational Medicine with International Participation called “Working Ability and Age” was held 18-22 September on the Brijuni Islands. It was organised by the Croatian Medical Society’s Croatian Occupational Health Society under the auspices of the deputy prime minister Mrs Zeljka Antunovic, Ministry of Health, Ministry of Labour and Social Welfare, Croatian Parliament's Committee on Work, Social Policy and Health, Istrian County, Town of Pula. Co-organisers of the Congress were Croatian Institute of Occupational Health, Croatian National Institute of Public Health, Andrija Stampar School of Public Health, and Institute of Medical Research and Occupational Health. 

         The Congress was attended by 280 occupational health, industrial safety, and public health professionals from seven European countries. Pr Vlasta Deckovic-Vukres, MD, MSc, who was also the Congress vice-chair, and Dr Dragica Katalinic participated with their papers. A part of the Congress was the promotion of the first Croatian textbook on occupational health and environment by Professor Marko Saric and by Professor Eugenija Zuskin. Writing this book involved 50 collaborators, among whom Pr Vlasta Hrabak﷓Zerjavic, MD, MSc and Pr Vlasta Deckovic-Vukres, MD, MSc from CNIPH. Ending with a round table conference, the Congress passed some decisions on the future of medical activities in Croatia which will be submitted to the Ministry of Health, Croatia.

MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

         At Scorze near Venice a one-day training and education seminar on the use of the BioVideobact device for automatic reading of bacterial sensitivity was held. Besides other Croatia microbiologists, our Bacteriology Department microbiologists also attended there. The BioVideobact device reads the values directly from an antiobiogram plate made using the Kirby-Bauer method, calculating the minimum inhibitory concentration (MIC) automatically for the antibiotics tested. Using a programme compliant with the NCCLS parameters, the programme enables rapid and accurate interpretation of the sensitivity finding in regard of the isolated micro-organism's biological characteristics. A built-in epidemiological programme permits the result read to be classified in 9 different files, which allows of systematic monitoring of the sensitivity of problematic bacterial isolates with regard to patient, sample type, antibiotics and the setting from which the patient may originate (hospital ward, outpatient setting etc.). All entered information being archived, it can be checked at any time either in the form of a table or histogram. The device is already widely used in other European countries. In addition to making routine uses of it, they also apply it within their national bacterial resistance monitoring programmes for major bacterial isolates (enterobacteria, enterococci, staphylococci). 

HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

Director’s introduction - August 2002 

Pr Vlasta Hrabak-Zerjavic, MD, MSc

            An extraordinary meeting of CNIPH’s Preventative Health HQ was convened in connection with vast floods in some European countries and the potential threat of floods developing in Eastern Europe. It considered the current situation in areas potentially under threat.  The conclusion reached was that all CNIPH’s services were in full readiness to discharge their duties regarding the ensuring of safe drinking water supply, and undertake, if necessary, sanitary and preventative measures against communicable and other diseases likely to be caused by floods.  Also presented were activity reports by other services, such as civil defence, toxicological services, veterinary service etc. It was concluded that the epidemiological situation was under control and that daily contacts with the Osjecko-Baranjska and Vukovarsko-Srijemska counties needed pursuing until the danger was over. 

            On 29-31 August, I attended a consultative meeting in Sofia of the South-East European countries on a WHO Framework Convention for Tobacco Control.  It discussed the latest draft proposed by the chair of the Intergovernmental negotiating body for the Convention and the amendments proposed for the forthcoming meeting of Smoking-free Europe Programme’s national co-ordinators.

EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

         A regular annual analysis of communicable diseases based on obligatory case notifications has been made for the year 2001.  As in previous years, over 60,000 individual notifications were received and processed.  Patient analysis was by diagnosis, age, sex, place of residence and month of affection with disease.  Processed tabularly, such data comprise 13 books kept at the Department for archival, operative and analytical purposes.  The processing resulted in an annual report on the trends of communicable disease in Croatia in 2001.  A portion of this report appears in CNIPH’s Croatian Health Service Statistical Annual.


Chronic Mass Disease Epidemiology Department

“Your health is impaired by just three cigarettes a day”

             The prevailing view among smokers is that several cigarettes a day will do no harm to their health.  However, a large prospective cohort study (The Copenhagen City Heart Study) covering 12,000 people over the period 1976-98 found the risk for myocardial infarction in the females smoking only 3-5 cigarettes daily to be double the normal (RR=2.14). In addition, they also ran a higher risk for all causes of death (RR=1.86).  Such risk levels in males will develop if smoking 6-9 cigarettes/1-2 cigars a day.  The higher female risk is interpreted as being due to the sensitivity of their respiratory system, and the fact that tobacco smoke exerts an action on the level of oestrogen that protects from cardiac diseases.
Source of information: Journal of Epidemiology and Community Health 2002; 56:706-706.

            The Ministry of Science and Technology has accepted a project proposal titled “Cancer patient survival in Croatia, 1987-96”.  Besides envisaging Assistant Professor Marija Strnad as the principal investigator, the project will involve Pr. Vlasta Hrabak-Zerjavic, MSc, Urelija Rodin, MSc and Ariana Znaor, MSc as associates from CNIPH.  Survival analysis will be done in collaboration with the North-East Italy Cancer Surveillance Network by using the International Association of Cancer Registries-recommended methodology.

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

Dr Dragica Katalinic, head, National Treated Psychoactive Drug Addicts Registry, represented Croatia on 29-30 July at the Vienna meeting of the UN Office for Addiction Control and Crime Prevention.  The topic of the focal group of addiction prevention experts was planning and running a study to collect as rapidly as possible some information on i.v. drug users.  The study would be carried out in 28 countries of the Central and Eastern Europe and Central Asia.  This is expected to improve assessments of the number of i.v. drug users and acquire extra knowledge about their demographic characteristics, method of treatment, HIV and hepatitis surveillance, mortality, as well as other data necessary for improved surveillance and care of this group of drug addicts.  

            Pr. Ranko Stevanovic, MD, MSc attended on our part the 10th Cochrane Colloquium at Stavanger, Norway, 31 July-4 August. He sought to gather a maximum of information about the Cochrane Colloquium Initiative (an expanding leading evidence-based medicine agency, which is establishing worldwide collaboration) so that Croatia might join it officially and enable an early foundation of a Cochrane Centre in this country.

MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

            The final recommendations by the Predeal Meeting stressed the common wish for the activities aimed at combating tuberculosis within national programmes to be continued and intensified. These activities result from the joint tuberculosis control strategy, and especially the one related to the subsequent implementation of DOTS.

HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

Director’s introduction - July 2002 

Pr Vlasta Hrabak-Zerjavic, MD, MSc

              Further to the conclusions of the Conference “Place and Role of Institutes of Public Health in Croatia’s Health System” of 10 June 2002, public health institutes’ directors held a meeting on 2 July 2002 at Croatian National Institute of Public Health (CNIPH). It defined the contents of the materials in preparation, finalized the composition of working groups for epidemiology with microbiology, for school health and for medical ecology. Public health institute representatives to participate in the drafting of materials for these activities were proposed for the Working Group on Public Health, which is responsible for social medicine, epidemiology of chronic noncommunicable diseases and health promotion. At a meeting on 25-26 July attended by public health institute directors, Working Group on Public Health in enlarged form, and members of individual working groups a vision of institute development was presented, charges defined according to their respective activities and a network of institutes and individual technical units set. This included a human resources standard to be submitted to the Ministry of Health of the Republic of Croatia, Croatian Institute for Health Insurance, and Croatian Medical Chamber for further consideration. 


Deputy Director, Assist. Prof. Marija Strnad, MD, PhD.

              The minister of health nominated by decree of 8 January 2002 a Working Group on Public Health, setting before it the task of carrying out, in the area of public health, the goals and tasks of the World Bank-financed loan for the Health System Project. A 17-member-strong Group includes five from CNIPH (V. Hrabak-Zerjavic, U. Rodin, R. Stevanovic, A. Znaor, and M. Strnad, the leader). At its first meeting, the Group elected S. Lang for vice-chairman and A. Znaor for its Secretary. So far, the Group has held six meetings. Within CNIPH’s web page, the Group has opened its web page (www.hzjz.hr./radnagrupaJZ), as well as the web page of the First Congress on Preventive Medicine and Health Promotion due to take place in October 2003 in Zagreb. (It will be organized by CNIPH and our other public health institutes.). The minister has agreed to take the sponsorship and be on the Organizing Committee of our First Congress. To the minister of health the Working Group has submitted its first technical report titled “Draft Disease Prevention and Health Promotion Act”. As part of the Ninth Motovun Summer School on Health Promotion, a “Course on Health and Health Policy” was held 11-13 July at Motovun. It was attended by V. Hrabak-Zerjavic, M. Strnad, U. Rodin and R. Stevanovic. Working Group on Public Health’s rapporteur was M. Strnad, with M. Erceg presenting the afore-mentioned draft law. By creating a network of social medicine, health promotion and chronic disease epidemiology units this group has actively joined the formation of a public health network in Croatia. 

              As part of the Ninth Motovun Summer School on Health Promotion, a “Women’s Health” Workshop had its session 4-5 July 2002 in Poreč. On the part of the CNIPH it was attended by M. Strnad (workshop leader), D. Katalinic, U. Rodin, M. Silborcic Radic and A. Znaor. For WHO, Isabel Yordi presented the guidelines on the European strategy for women’s health. The workshop materials appeared in Motovunski glasnik No. 23, which is published by the Croatian Network of Healthy Cities.



EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

            Our professional Dr Borislav Aleraj participated in the WHO-organized Meeting on Malaria in Sofia, Bulgaria, on 24-26 June 2002 together with a Ministry of Health, Croatia, representative. To the meeting, actually organized by WHO’s department running the “Roll back malaria” (RBM) project, Dr. Aleraj gave an account of the state and control of malaria in Croatia. 

            Croatia used to be a malaria-endemic country, but in the early 1950’s it was eradicated through a very well organized anti-malarial campaign. The last native case was recorded in 1954, with in 1962 the WHO officially declaring malaria eradicated. We have been a malaria-free country ever since. Nevertheless, each year a certain number of “imported” cases occur, mainly among our nationals after a stay in some malaria-endemic part of the world. Partly this also happens in foreigner visitors arriving from a country affected by malaria. In order to maintain such favourable conditions and prevent possible recurrence of local malaria through its uncontrolled introduction, we carried out, and do now, a range of preventive measures spanning from mosquito control to proper treatment of the cases. From the accounts presented at the meeting we learned about the anti-malarial measures used by other countries, also gaining first-hand knowledge of undesirable consequences of a weakening or abandonment of protective measures. This relates to the countries having successfully eradicated malaria before and now witnessing its recurrence and localization, as well as experiencing great difficulties in combating malaria and putting it under control. 
 

Chronic Mass Disease Epidemiology Department

            Whereas at the 4-5 July 2002 Women and Health Workshop within the Motovun Summer School on Health Promotion Dr M. Silobrcic Radic gave a lecture called “Mental Health and Women”, Dr. A. Znaor presented one called “Problems of Malignant Diseases in Croatia’s Female Population”. 

            Another segment of the same school at Motovun provided, 5-7 July 2002, a course named “Media and Health: Solutions to Critical Situations”, attended by Dr D. Katalinic, Dr M. Silobrcic Radic, and Dr I. Brkic. The purpose of the course was to raise the quality and credibility of public information, a precondition of which is good cooperation between health workers and reporters.

            Different methods of active learning through exchange of experience, problem solving, role playing, and small group discussions were used. One specific goal of the course was to enable learning and developing the algorithms to deal with normal and crisis situations. 

            In Trieste, Italy, an advanced course in statistical data analysis for cancer case registries was organized for EUROCIM (European Cancer Incidence and Mortality) users 17-19 July 2002. Organized by European Network of Cancer Registries (ENCR), it was attended by Ariana Znaor, MD, MSc.

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

            To optimize the cooperation between health workers and reporters, the Motovun Summer School on Health Promotion held 5-7 July a course “Media and Health: Solutions to Critical Situations”.  As a participant in Poreč on July 9 of its “Women and Health” Workshop, D. Katalinic presented the topic “Psychoactive Drug Dependencies in Women”. Dr U. Rodin’s topic was “Motherhood and Perinatal Child Care”.  As part of the same school, a Course on Health and Health Policy took place 11-14 July.  Pr Ranko Stevanovic, MSc, gave a lecture “Redesign of Activities in the Operationalization of Public Health Interventions”.

MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

            The Twenty-Third Annual Congress of the European Society for Mycobacteriology” took place 23-26 July 2002 in Dubrovnik. This was the first time its venue was in Croatia. CNIPH, Croatian Medical Association’s Croatian Society for Medical Microbiology and Parasitology, and European Society for Mycobacteriology were congress organizers. 

            There were 250 conferees, who were the leading professionals from European and non﷓European countries (USA, Canada, Japan, India, and Republic of South Africa). The latest breakthroughs and knowledge from the areas of fundamental research and clinical practice that accelerate the diagnosis and treatment of tuberculosis and other mycobacterioses were presented. 
The lectures and posters comprised the topics ranging from evolution, epidemiology, virulence, to pathogenesis, drug resistance, M. tuberculosis and other clinically important mycobacteria.

            Invited lectures delivered by eminent scientists R. Brosch (Institut Pasteur, Paris); J.O: Falkinham III from the Virginia Institute (USA); L.G. Wayne from the Tuberculosis Research Laboratory (USA); R. Manganelli from the Padua University, and G. Palfi from the Hungarian Anthropological Department at the Historical Museum have attracted special attention. As a particular novelty stood out Dr. Brosch’s research finally disproving the theory of evolution for M. tuberculosis according to which it was an evolutionary ancestor of M. bovis (a primarily animal pathogen). In evolutionary and genetic terms, M. tuberculosis is more closely related to their common ancestor. This – in the light of genetic diagnostics of M. tuberculosis – contributes to identifying it unambiguously and more rapidly. 

            Participating in her capacity of Organizing Committee chair, Dr. V. Katalinic-Jankovic was also active as a co-author of two posters: (i) “Genetic Typing of Drug-Resistant and Drug-Sensitive Strains of M. Tuberculosis Using the Ligase-Mediated PCR Method”, done with colleagues from the R. Boskovic Institute, (ii) “Epizooty of Tuberculosis in Cows”, written with her Croatian and Slovene veterinarian colleagues. The close of the Congress was marked by a working meeting of the European Society for Mycobacteriology, giving of awards for the best posters, and an announcement when this gathering is due to be held in Europe next.   


HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

            Three new brands of source water appeared on Croatian market in July. The first, named “Sv. Rok”, was manufactured by a firm from Sv. Rok (from Lika region’s southeast). The second, named “Aqua sana”, was manufactured at Vrlika in the Dalmatinska Zagora region. The third source water is “Jana” from Sv. Jana. Since the start of their introduction, CNIPH’s Water and Public Water Supply Health Safety Department has carried out the verification procedure of these source waters by performing the physical-chemical, chemical, microbiological and virological analyses laid down by the Regulation on Fundamental Requirements for Natural Mineral, Source and Table Waters.

Director’s introduction - June 2002 

Pr Vlasta Hrabak-Zerjavic, MD, MSc

              Sponsored by the Ministry of Health of the Republic of Croatia and organised by Croatian National Institute of Public Health, Institute of Public Health Zagreb and county institutes of public health, a consultation was held at the health ministry on 10 June 2002. It dealt with the topic “Place and Role of Public Health Institutes in Croatia’s Health System”.   Introductory presentations were followed by a round table conference on “Activity and Role of Institutes of Public Health within a Reformed Health System”.  With institute representatives, round table moderator was the minister of health, Andro Vlahusic, MD, MSc. The conclusion reached by the round table conference was that for public health the existence of these institutes at the national and county levels was unquestionable.  Further, it was concluded that the epidemiology of infectious diseases was doing an excellent job and should be supported as such.  The epidemiology of non-infectious diseases should be made just as efficient and its staff made complete.

            The necessity of establishing a network of social medicine, health statistics, health promotion and disease prevention units, as well as of ensuring their financing was also noted. As regards medical ecology, being public health institutes’ primary activity, it should establish a Working Group charged with drawing up an organisational proposal for the health ecology system. Concluding that school health should remain in public health institutes, the consultation required it to expand its preventive concerns to the broader community.  Concerning microbiology reference was made to its importance for the operation of the health care system, and the need for its professionals to design a microbiological activity network, including the developmental needs and a financing model. For occupational health, the conclusion was that the passage of a new health care act should be preceded by a pertinent consultation.

EPIDEMIOLOGY SERVICE  
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

            A meeting of the World Health Organization’s European Office held in Copenhagen 20-21 June 2002 established that conditions had been fulfilled to proclaim WHO European region poliomyelitis-free, i.e. rid of child paralysis.

            It is three years since a poliomyelitis case was reported last in the European Region, made up of 51 nations and a population of 873 million (including the European and all countries newly formed from the ex-USSR).  Over these three years all Member states have collected the evidence of eradicating the poliomyelitis virus on their territory, of their health system being capable of timely detection of a possible introduction of the virus from endemic areas, and of preventing the viral spread among their respective populations.

            This represents a big step in the direction of global eradication of child paralysis, which, after the eradication of smallpox in 1980 will be the second disease eradicated by vaccination. As the American WHO Region eradicated child paralysis in 1994, Western Pacific Region in 2000, for global eradication of poliomyelitis this remains to be achieved in WHO South East Asian, African and Eastern Mediterranean regions.

            Until then we are obliged to maintain the high immunisation coverage and carefully monitor enterovirus trends in the population.

            Croatia introduced vaccination against child paralysis in 1961. In the mass immunisation campaign of 1961/62, there was coverage of the whole population aged up to 20 years. Such method of introducing the immunisation led to a marked drop in morbidity, making poliomyelitis a rare disease.  The last case in Croatia was reported in 1989.

            One of our renowned infectologists, born before the introduction of vaccination, said once that every mother feared lest her child should become affected and was very powerless to prevent it.  Preschool- and school-age children could notice some of their company suddenly falling ill and subsequently becoming invalided for life. Older infectologists still recall with unease the “iron lungs” used to keep children and adults alive where bulbar paralysis had developed.

            WHO holds a special web site (http://www.polioeradication.org/) devoted to the eradication of this disease with some further information available about the disease and its eradication.  At the Epidemiology Department, a short promotional/educational film can be obtained, featuring exceptionally impressively how poliomyelitis used to upset life.  It has impressive pictures of halls with several dozen “iron lungs”, also showing a man with a childhood infection still living in an “iron lung” today.

            It is important to note that all speakers at the ceremony announcing poliomyelitis eradication were most grateful to vaccinators, to those who administer the vaccine within the routine schedule of child immunisation, and especially to those who had made an extra effort to immunise the children with limited access to the health system. Understood by this is vaccinating in remote areas and exposing own health, with, in some cases, risking own lives. Undoubtedly, these praises also went to Croatian vaccinators who had achieved high immunisation coverage in routine vaccinations by making maximum efforts to reach those children who, for various reasons, could not have been taken to local clinics.  

Chronic Mass Disease Epidemiology Department

            On 12 June 2002, Module IV of the “Healthy Counties” Project was attended by Ariana Znaor, MD, MSc in addition to Assistant Professor Marija Strnad, MD, PhD and Dr Tomislav Bednjak. It took place at Krapinske Toplice where teams from Dubrovačko‑Neretvanska, Istrian and Varaždinska counties presented action plans for the health of their counties.

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc  

            Using the data from all maternity wards in Croatia, a Bulletin of births and perinatal deaths was drawn up and published in 2001 on this Institute’s web page.  Child deliveries totalled 40,879 with 41,178 liveborn, a 6% decline on 2000.

              Council of Europe’s Pompidou Group held its 32^nd Meeting of Psychoactive Drug Epidemiology Experts 27-29 May 2002.  Croatia’s representative was Dr Dragica Katalinic, head, National Treated Psychoactive Drug Addicts Registry. The subjects discussed were the past progress and preparations for the Strategic Conference on Drug Epidemiology 2003, which is expected to formulate a new strategy for the future development of drug epidemiology.  Namely, interventions in this field presuppose in addition to the monitoring of trends and key indicators of drug use the creation of models and development of theories to explain the reasons and differences arising between individual countries with the passage of time. In the process, analysis would focus on sociocultural and socioeconomic causes of existing trends in and methods of drug taking. In other words, besides promoting psychomedical epidemiology efforts would be made for a maximum promotion of social epidemiology as well.

MICROBIOLOGY SERVICE
Head, Dr Vera Katalinic-Jankovic

            This year a larger outbreak of haemorrhagic fever with renal syndrome was also reported. At this Institute’s Virology Department, in all patients the diagnosis was set by serological testing using the indirect immunofluorescence method (IFA).  For 94 (67.1%) of the 140 clinically reported patients the diagnosis was confirmed.

            Haemorrhagic fever with renal syndrome is a systemic infectious disease caused by Hantavirus genus viruses.  Its first case in Croatia was diagnosed in 1952. Its occurrence has been regular ever since, mostly being sporadic (two smaller outbreaks involving 14 people each were registered) until 1995, when an outbreak affecting 125 people occurred.  This was accompanied by the disease happening in several localities simultaneously.

            Confirmation of the disease is most often through serologic reactions. IgM and IgG antibody determinations are made using the indirect immunofluorescence test (IFA). There is a high sensitivity and specificity to the IgM capture ELISA method. It can detect disease‑specific IgM antibodies four to five days after the onset of disease. They reach their maximum titre after 2-3 weeks, falling during 3-6 months.  Although haemagglutination inhibition test (HI) shows 97% sensitivity, cross-reactions occur.  


HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc

            WHO experts held a meeting 26-28 May 2002 in Geneva on the subject of food safety assessment in regard of the presence of acrylamide. Its being a toxic product, classified into the 2A carcinogen group, raises the question of its role in human cancer aetiology. Acrylamide arises by frying, baking and thermally processing foods with high carbohydrate content.  Pending the conclusions of WHO experts, no change in the diet method is recommended.

            Because the Regulation was not harmonised with the fundamental requirements of modern technological trends, there could be, and already has been, an increase in the number of unfit meat products. This year, a greater number of meat products were found to deviate from their labelled composition (as detected in relation to meat type by the protein origin assay). The causes were increased levels of added nitrites as well as proved presence of fermented rice colour (Monascus red). This data will help guide meat product surveillance and analysis.  

            Food and Dietary Food Safety Unit daily encounters the problem of classifying the products that are neither dietary products nor medicines. Thus, it took an initiative for the passing of some amendments either to the existing Dietary Food Health Safety Regulation or else for the passing of a final draft of the amended regulation. It is also suggested to solve the issue of undefined products through amendments to the Drugs Act or through a special regulation.

Pr. Vlasta Hrabak-Zerjavic, MSc, MD

            As a member of the Working Group for the drafting of a European strategy for  control of smoking, I attended the Hague 24-25 May 2002 meeting of national coordinators of the WHO’s Tobacco-free Europe programme. Following a debate, national coordinators adopted the document with minor amendments, forwarding it to the WHO/EURO for the next step in the adoption procedure.

            At Hillerod near Copenhagen, on 26-28 May 2002 I attended a meeting of national coordinators for the “Meeting Health Needs of Vulnerable Populations” programme.  It was decided to take “Health Development in Southeast Europe” as the main topic for the period 2002-03.  Presented to the meeting were three starter projects of the programme. They are strengthening of infectious disease surveillance, development of mental health care in the community, health safety of foods and nutrition. The funding of programme execution has been secured through donations.

            In connection with the occurrence of haemorrhagic fever with renal syndrome or “mouse fever”, the institute staff prepared a press release. Additionally, reacting to the manner of media presentation of salmonellosis outbreaks in Čakovec and Gospić, and  writings about anthrax, they contacted media representatives on several occasions.

Deputy director, Assistant Prof. M. Strnad, MD, MPH, PhD  

            On 16 May 2002 in collaboration with Croatian Medical Association’s Croatian Society for Caenology, the Municipal Office for Work, Health and Social Welfare organized a forum “Prevention and Early Detection of Breast Cancer”, with a focus on presenting the preventive mammography-screening programme in the Zagreb City area. There I presented a paper on breast cancer epidemiology. At a technical meeting of the Croatian Medical Association’s Croatian Society for Caenology called “Breast Ultrasound Diagnostics” held at Baška on the island of Krk 19 May 2002 I delivered a paper on the same topic.

            A round table conference “Usefulness of Healthy Diet for Active and Healthy Aging” organized by the Centre for Gerontology, Zagreb City Institute of Public Health, and Croatian Farmers League was part of the International Medicine and Technology Fair.  There I presented a paper on diet and carcinoma.  On Hvar, the second international symposium on complementary supportive therapies named “Art and Science in the Development of Life Potentials” was held 27‑31 May 2002. Its organizers were the Faculty of Education and Rehabilitation, and Croatian Society for Psychosocial Oncology from Zagreb. My participation involved a plenary presentation “Epidemiology and Chronic Health Disorders”. 

EPIDEMIOLOGY SERVICE
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

            The eradication of measles (regional target of the WHO/EURO to be achieved in Europe by 2007) and then of rubella being in sight, we would give two relevant suggestions.

1. Local epidemiological service, which shall do the survey of a case and his/her contacts, must be notified of any measles and rubella case suspects, so that relevant information (vaccination status, similar diseases in the environs) could be gathered. This obligation has prescribed by the Infectious Disease Population Protection Act.  Hence, it is particularly important to have a confirmation or exclusion of any measles and rubella suspects by laboratory testing (serologically and/or by virus isolation) at the Virology Division, CNIPH.  In fact, notifications of as few as eight cases came in last year. They all were based on clinical picture unaccompanied by laboratory confirmation. Therefore, as regards measles, the situation in Croatia is exceptionally good, and we may already have attained eradication.  However, to be certain in our knowledge, we need laboratory diagnosis for each case. The situation with rubella is roughly as favourable, because there were three case notifications.  Furthermore, we can no longer send the WHO aggregate reports on measles and rubella, case reporting being individual with pertinent vaccination status and laboratory finding data.  

2. Keeping a favourable health status and achieving the final eradication of measles requires the maintenance of high immunization coverage not only nationally, but also in each county and hygienic-epidemiological area. The legal measles immunization coverage is 95% (all other vaccinations 90%).  It requires the physicians who provide medical services to preschool children and schoolchildren to attain and maintain this high immunization coverage level by making calls for and encouraging child immunization.

The information about “mouse fever” and protective measures has appeared on our web pages.

  Chronic Mass Disease Epidemiology Department

      Marking May 31, the World No-Tobacco Day, WHO has this year placed special emphasis on smoking-free sporting events, declaring for the purpose “Tobacco-free sports – play it clean” as its slogan.  Croatia decided to take “Tobacco-free recreation and sport” as its slogan.

      The World No-Tobacco Day was marked in Zagreb by a promoting event in the Ribnjak Park. There winners of the “Cease Smoking and Win” CNIHP‑organized competition were drawn. Other events include a ministry of health-organized “Tobacco‑free Recreation and Sport” conference, scheduled for June 5 at the Old Town Hall.  

      Organized by the Rab Psychiatric Hospital and Croatian Alzheimer Disease Society and taking place on 3-5 May 2002, the 1^st Symposium on Psycho Geriatrics was attended on our part by Dr Maja Silobrcic. The main topics of the gathering were dementias with focus on Alzheimer disease, monitoring of the patients’ psycho geriatric needs, treatment conditions and outpatient care.  

      At the Ninth Congress on Family Medicine in Dubrovnik 9-11 May 2002, Ariana Znaor, MSc, presented a paper “Do our cancer prevention efforts suffice?” authored by Assistant Prof. M. Strnad, MD, MPH, PhD, and A. Znaor, MSc.

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc 

      At Balatonaliga, Hungary, a conference “For better health services through international cooperation” was held 19-21 April 2002.  It was organized by the Hungarian Institute for Primary Health Care and by the Hungarian Scientific Society for Family Medicine. The conference, exchanging views on the progress of national projects, particularly those dealing with the prevention of cardiovascular disease and the implementation of public health programmes overall, was attended on our part by Pr. Ranko Stevanovic, MD, MSc.  A term for the next meeting later this year at which results and solutions would be presented was agreed.  For the next year, another meeting was agreed which would be dealing with collaboration development. 

      At the Ninth Congress on Family Medicine in Dubrovnik Pr Ranko Stevanovic, MSc presented two papers: “Disappearance of Adult Preventive Medical Care and Active Adult Care – Replaceability of Preventive Care with Specialist Care” and “Preventive Medical Care of Infants and Young Children in Croatia’s Paediatric Service and Family Medicine Service”.  The second paper was co-authored by Urelija Rodin, MD, MSc.  

      International project “Rapid Assessment and Response on HIV/AIDS Related Risk Behaviour among Especially Vulnerable Young People” (RAR) has been completed; the Croatian and English versions of the final report are being drafted. Using the Rapid Assessment Method, the study was carried out among drug users, out-of-school young, as well as young victims of prostitution in Zagreb, Rijeka, Split and Osijek. The project has received financial support from UNICEF and the Canadian Development International Agency.

MICROBIOLOGY SERVICE  
Head, Dr Vera Katalinic-Jankovic

            Croatian Society for Medical Microbiology and Parasitology has organized the Sixth Croatian Congress on Clinical Microbiology, held 15-17 May 2002 at the Opera Hotel in Zagreb.

            Main topics of the Congress were devoted to nosocomial infections, infections in immunocompromised, as well as to the bacterial resistance problem both in Croatia and in the context of its participation in European projects on antimicrobial resistance surveillance (EARSS, European Antimicrobial Resistance Surveillance System).  

            Three lectures were given by our Service staff:  Prof. Dr G. Mlinaric-Galinovic: “Smallpox Virus and Bioterrorism”, Dr. V. Katalinic-Jankovic: “Opportunistic Infections due to Atypical Mycobacteria”, E. Missoni-Mlinaric, MSc: “Advances in Serodiagnosis of Candidiasis”.  B. Hunjak, MSc, and Dr V. Kruzicevic presented a poster “Gardnerella vaginalis in Cervical Infections”.  Updated information in this last illustrated the incidence of this bacterium in bacterial vaginosis, which is the most common urogenital infection among the women of generative age. In his poster “Immune Response to 2000/2001 Influenza Vaccine in Elderly” Dr V. Drazenovic showed the value of a protective antibody titre in persons aged above 65 years. Such titre levels ranged from 67 to 99% depending on the type of virus.

            A poster “Incidence of Herpes Simplex Virus in Cases of Gingivostomatitis”  by Dr V. Drazenovic et al. reported an 85%-incidence of this virus in the children aged 0-4 years and an incidence of 42% among immunocompromised.  It stressed the importance of rapid and accurate diagnosis. “Quantitative Gas Chromatography Assay of Volatile Fatty Acids” was the topic of a poster by M. Franotovic, ChE, MSc, and M. Obrovac describing the standardization of a specific method for the identification of anaerobe bacteria.

            In her poster “Determination of Antibodies to Y. enterocolitica from 1997 to 2002” D. Perkovic, MSc, described finding this antibody in 47% of the sera from patients with rheumatic symptomatology.

HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc  

              The service began receiving for analysis samples of certain medicinal products (stomatological materials and disinfectants) for product certificate and marketing authorisation required for their registration in Croatia.  In addition, at our suggestion (Vjera Haberle, MSc) a new group of medicinal products (“medical cosmetics”) was accepted and established, which will be included in the Drug and Medical Product Act (pending the amendments thereto). This Institute is authorised for health safety testing of the products belonging to this group as well; the first is already being tested.  This process will enable the registration of a larger number of agents, primarily those designed for application to the skin.  For the present, the marketing of these products - formerly classified as “auxiliary medicinal agents – preparations” - is not covered by any law.   

            Recently the Swedish scientists reported finding acrylamide in such foodstuffs as potato and bread that had been subjected to the thermal processing at high temperatures. Their finding has prompted the WHO to organize a gathering in Geneva on 25-27 June 2002.  Basing themselves on the available acrylamide information, the experts should make its risk assessment for human health.  Potential cancerogenicity and neurotoxicity are associated with the acrylamide that develops during roasting, longer cooking and frying.  The key question is how to avoid this hazard, i.e. by what method one should prepare food without acrylamide developing.

Director’s introduction - April 2002

Pr. Vlasta Hrabak-Zerjavic, MSc, MD

            At the invitation of the Croatian Ministry of Health’s Health System Project a meeting took place in Koprivnica on 10 April. It was attended by representatives of BIS Healthcare Group (a counselling firm), institutes of public health, Andrija Stampar School of Public Health, Faculty of Medicine and the health ministry’s working group. The debate concerned the BIS Healthcare Group health reform proposals, which deal with public health as well.  After a lengthy consideration, it was decided to accept the five main responsibilities suggested as a purview of public health institutes, with a proviso that a proposal for future development of public health should be drawn up immediately. The proposal that the institutes should have no direct access to patients was rejected (except for epidemiology and ecology for which an agreement was reached about this issue).  As regards school health and microbiology, Working Subgroups were charged with refining of proposals and suggesting of solutions.  

            On an eight-member WHO/EURO team, I participated in Athens on 20-22 April in the final drafting of the European Anti-Smoking Strategy (formerly European Action Plan for Smoking Control).  The document will be submitted to member countries for comment and discussion at the 24-25 May 2002 Hague Meeting of national coordinators.

Deputy director, Assistant Prof. M. Strnad, MD, MPH, PhD  

            On 13 April 2002, I took part in the VIth Symposium on Palliative Treatment of Pain in Malignancies with the invited lecture titled “Statistical evaluation of carcinoma incidence in Croatia”. The gathering was organized by Croatian Medical Association’s Croatian Society for the Treatment of Pain.

            Organized by WHO, Italian Ministry of Health, and the Friuli-Giulia Region, an international conference named “Disability and Health” was organized in Trieste, Italy, on 17‑20 April.  Its aims were to prompt a debate on the vision and measurement of health and disability, and discuss prospects for the application of the International Classification of Functioning, Disability and Health (ICF).

            On 27 April 2002, a scientific gathering titled “Carbohydrates in Nutrition and Dietetics” took place in Osijek.  It was organized by the Croatian Academy of Medical Sciences and the Osijek Town League against Cancer.  The paper with which I participated was called “Complex Carbohydrates and Carcinoma”.  On the part of a group of authors (A. Kaic, K. Antonic-Degac, Z. Petrovic, E. Mesaros-Kanjski), Dr. Z. Petrovic presented the paper “Carbohydrates in the Diet of Croatia’s Schoolchildren”.

EPIDEMIOLOGY SERVICE
(Ministry of Health Reference Centre for Epidemiology), head, Prof. Mate Ljubicic, MD, ScD

Infectious Disease Epidemiology Department

            At the beginning of spring 2002, the number of reported cases of haemorrhagic fever with renal syndrome was slightly higher than in the several years past. Until present, 24 cases of the disease popularly known as “mouse fever” have been reported in comparison with the whole last year’s 10. As its name hints, the disease is linked with a direct or indirect contact with small forest rodents and their excreta. Consequently, it occurs in humans in the years marked by vast numbers of these rodents.  Their large presence being connected with climatic, dietary and other, partly unknown, ecological factors, it is not readily explainable or predictable. From the described circumstances, which are capable of leading to infection, one would chiefly expect the individuals who most often have repeated or lasting (direct or indirect) contact with rodents in the course of their work to be intensively affected, as is the case this year. Those affected can be forestry workers, farmers, hunters.  Aware of the route of infection, these groups take routine measures for the prevention of infection by guarding food and drink in the field from rodents, keeping their hands clean, avoiding drinking from unkempt forest wells and pools of water, as well as avoiding lying on the ground. One could thus recommend to all forestland visitors such simple health maintenance measures as also afford protection from some diseases transmissible from wild animals to humans (e.g. leptospirosis, intestinal parasites).

            The Epidemiology Department has compiled Minimum Requisite Preventative Measures for Reducing the Risk of Legionnaire’s Disease in Hotels.  Before the start of tourist season, their text was sent out to hotels through the Sanitary Inspectorate. They can be found on this Institute’s web pages.

  Chronic Mass Disease Epidemiology Department

            World Health Day 2002, whose slogan was “Move for Health”, was marked by  mass walking to the Sljeme Mountain, and a sporting, educational and entertainment programme at the Puntijarka hut.  The event was organized by the Ministry of Health of the Republic of Croatia, Croatian National Institute of Public Health and the City Office of Health, Work and Social Welfare.

            Mr. Stjepan Mesic (president of the republic), Dr. Andro Vlahusic (minister of health), other members of the government and of the Zagreb City Council were also among the programme’s active participants.  For participants, the Department personnel calculated their body index mass and handed out promotional materials.

            Joining WHO’s Quit & Win competition, this Institute is conducting a “Cease Smoking and Win” competition aimed to prompt smokers make a proper decision about smoking, and contribute in this way to their own health and to the creation of a smoke‑free environment.  Our competition is open to anyone aged 18 years and above, having smoked regularly for the past year until this competition and decided to refrain from smoking for four weeks.  These participants should complete an entry form. 

            On 17 April 2002 Mrs. Ariana Znaor, MD, MSc, attended the meeting in Udine, Italy, of the North-Eastern Italy’s Cancer Control Network. There future collaboration arrangements were made for Croatian Cancer Registry.  This involves patient survival analysis and testing the automatic cancer case registration programme.

            As an educational associate, Dr Znaor attended in Pula from 18-20 April 2002 module 2 (Planning for Health) within the management programme in local administration and self-government.  The module, coordinated by Dr. Selma Sogoric and supervised by the CDC, was named “Operative and Working Management for Health”. 

            On 18-21 April 2002, an international conference on “Promoting Health through Physical Activity and Nutrition” took place on 18-21 April 2002 at Radenci, Slovenia. The Institute staff attending it included Pr V. Hrabak-Zerjavic, MD, MSc, K. Antonic‑Degac, MSc, Assistant Prof. Dr. A. Kaic-Rak, Dr Z. Petrovic and Dr I Brkic. They presented two posters: (i) Health Promotion in Croatia within the First Croatian Health Project, (ii) Promoting Health and Proper Nutrition in Special Government Protection Areas in Collaboration with NGOs. 

            A Radenci Declaration was passed stressing the need for the activities involved in the promotion of proper nutrition and physical activity to be run simultaneously.

SOCIAL MEDICINE SERVICE
Head, Pr Marina Kuzman, MD, MSc 

            A meeting on Croatia’s Programme of Official Statistics was held on 17 April 2002 at the Central Bureau of Statistics. It assembled the participants from the institutions concerned with the implementation of the Republic of Croatia’s Statistical Research Programme.  Dr. Branimir Tomic, who heads our Health Statistics Department, attended on the part of this Institute. The Central Bureau of Statistics director Mr. Gredelj emphasized that the Statistical Research Programme 2003 and a master plan for the period from 2004 onwards, as well as a State Statistics Act should be developed by the end of 2002. 

            EUROSTAT advisor Mr. Heinrich Brüngger described the current position and future organization of the state, respectively official statistics. Among other, he explained that the official statistics would have as its base: (i) The basic principles of the UN’s official statistics, (ii) EU rules for European statistical system (322/97), (iii) the IMF’s special standard on data dissemination. Unlike the present procedure, the Statistical Research Programme 2004 will no longer be forwarded to the Parliament by the Statistical Council, which proposes it to the government.  Likewise, a middle term statistical research programme (adoptable by the government on the advice of the Statistical Council) is scheduled for development.

MICROBIOLOGY SERVICE  
Head, Dr Vera Katalinic-Jankovic  

            The “4^th Symposium on Sexually Transmitted Diseases” held in Dubrovnik on 15‑17 April 2002 has attracted infectologists, urologists, dermatovenerologists, epidemiologists, microbiologists and other physicians from the public health area.  The main topics were devoted to the diagnosis and prevention of sexually transmitted diseases. 

            The presentations were about new developments from the areas of diagnosis and treatment of infections caused by human papilloma virus, hepatitis B virus, hepatitis C virus, and the HIV virus.  Chronic infections of the prostate received special focus. Representing our Microbiologic Service was B. Hunjak, MD, MSc from the Urogenital Infection Diagnostic Unit.

            Also participating was some staff from our other services who gave lectures. Namely, Borislav Aleraj, MSc on “Sexually Transmitted Diseases in Croatia in 2001”; Pr Ranko Stevanovic, MD, MSc  et al. on “Cases of hepatitis B, C, E and non-A, non-B seen in General/Family Medicine Service”;  Pr Marina Kuzman, MD, MSc on “HIV/AIDS-Related Risk Behaviours in Croatia’s Particularly Vulnerable Groups of Young People”.  

            The Symposium conclusion stressed the need for public health physicians and clinicians to collaborate on the prevention of the occurrence and spread of STDs.  

HEALTH ECOLOGY SERVICE
Head, Krunoslav Capak, MD, MSc  

            On 10-13 April 2002, the Service’s staff presented their works at the annual Conference of Sanitary Inspectors at Supetar.  K. Capak; MD, MSc: “Some new trends in the approach to securing the food health safety system operation”; D. Brlek-Gorski:, MD: “Food infections and intoxications”; Z. Dadic, MSc, DSc: “Use of small household appliances for “improving the quality” of drinking water – a necessity or blunder”. M. Katalenic, MSc (with Vesna Matic, a senior boundary inspector, as co-author): “Tattooing in the gap between  regulations”.  E. Lovric, ChE, presented a poster titled “New Guidelines for Drinking Water Safety”.

            Under the guidance of J. Balenovic, MSc, a method for assaying food gluten was introduced in the Food and Dietetic Product Unit.  It is done using an antigen-antibody reaction ELISA test. Sensitivity of the test is 0.002%. Introducing this method has led to an expansion of the control of safety in foods labelled “without gluten”. To celiac disease patients, this is an extension of the list of foods allowed in their diet.  In cooperation with the Croatian Society for Celiac Disease, a national survey of the present state is being planned. Its aim is to establish what foods are gluten-free but not labelled as having this property. The survey would cover primarily the foodstuffs that are of greatest interest to these patients.

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