European Union/European Economic Area Research Articles

Characteristic SNPs defining the major multidrug-resistant Mycobacterium tuberculosis clusters identified by EuSeqMyTB to support routine surveillance, EU/EEA, 2017 to 2019.

BackgroundThe EUSeqMyTB project, conducted in 2020, used whole genome sequencing (WGS) for surveillance of drug-resistant Mycobacterium tuberculosis in the European Union/European Economic Area (EU/EEA) and identified 56 internationally clustered multidrug-resistant (MDR) tuberculosis (TB) clones.AimWe aimed to define and establish a rapid and computationally simple screening method to identify probable members of the main cross-border MDR-TB clusters in WGS data to facilitate their identification and track their future spread.MethodsWe screened 34 of the larger cross-border clusters identified in the EuSeqMyTB pilot study (2017-19) for characteristic single nucleotide polymorphism (SNP) signatures that could identify and define members of each cluster. We also linked this analysis with published clusters identified in previous studies and identified more distant genetic relationships between some of the current clusters.ResultsA panel of 30 characteristic SNPs is presented that can be used as an initial (routine) screen for members of each cluster. For four of the clusters, no unique defining SNP could be identified; three of these are closely related (within approximately 20 SNPs) to one or more other clusters and likely represent a single established MDR-TB clade composed of multiple recent subclusters derived from the previously described ECDC0002 cluster.ConclusionThe identified SNP signatures can be integrated into routine pipelines and contribute to the more effective monitoring, rapid and widespread screening for TB. This SNP panel will also support accurate communication between laboratories about previously identified internationally transmitted MDR-TB genotypes.

Epidemiology of reported cases of leptospirosis in the EU/EEA, 2010 to 2021.

BackgroundLeptospirosis is a zoonotic disease caused by bacteria of the genus Leptospira. Humans are infected by exposure to animal urine or urine-contaminated environments. Although disease incidence is lower in Europe compared with tropical regions, there have been reports of an increase in leptospirosis cases since the 2000s in some European countries.AimWe aimed to describe the epidemiology of reported cases of leptospirosis in the European Union/European Economic Area (EU/EEA) during 2010-2021 and to identify potential changes in epidemiological patterns.MethodsWe ran a descriptive analysis of leptospirosis cases reported by EU/EEA countries to the European Centre for Disease Prevention and Control with disease during 2010-2021. We also analysed trends at EU/EEA and national level.ResultsDuring 2010-2021, 23 countries reported 12,180 confirmed leptospirosis cases corresponding to a mean annual notification rate of 0.24 cases per 100,000 population. Five countries (France, Germany, the Netherlands, Portugal and Romania) accounted for 79% of all reported cases. The highest notification rate was observed in Slovenia with 0.82 cases per 100,000 population. Overall, the notification rate increased by 5.0% per year from 2010 to 2021 (95% CI: 1.2-8.8%), although trends differed across countries.ConclusionThe notification rate of leptospirosis at EU/EEA level increased during 2010-2021 despite including the first 2 years of the COVID-19 pandemic and associated changes in population behaviours. Studies at (sub)national level would help broaden the understanding of differences at country-level and specificities in terms of exposure to Leptospira, as well as biases in diagnosis and reporting.

Multinational collaboration in solving a European Salmonella Braenderup outbreak linked to imported melons, 2021.

A genomic cluster of Salmonella Braenderup ST22, a serovar of Salmonella enterica subsp. enterica which causes symptoms of gastrointestinal illness, was notified by Danish authorities to the European Centre for Disease Prevention and Control (ECDC) on 3 May 2021. By 6 July 2021, S. Braenderup outbreak cases (n=348) had been reported from 12 countries in the European Union/European Economic Area (EU/EEA) and the United Kingdom (UK), including 68 hospitalised cases. With support from affected EU/EEA countries, and in partnership with the European Food Safety Authority (EFSA), ECDC established an international outbreak investigation team to rapidly identify the source and prevent outbreak spread. Consumption information was shared with affected countries through a standard line list, revealing that 124 of 197 cases (63%) reported having eaten (any) melons within 7 days prior to disease onset. The speed and completeness of the investigation, which identified the outbreak vehicle as galia melons imported from Honduras in June 2021, was a direct result of extensive collaboration and information sharing between countries' national food safety and public health authorities. This article describes the outbreak and the benefits, successes, and challenges of multi-country collaboration for consideration in future large foodborne outbreaks across Europe.

Antimicrobial susceptibility testing and reporting practices of public hospital microbiology laboratories in Greece, 2022: A national observational survey and call for action.

Antimicrobial resistance (AMR) in Greece is among the highest across the European Union/European Economic Area (EU/EEA), with high AMR rates even to last-line antibiotics. To better understand the clinical microbiology laboratory practices and capacities in species identification and antimicrobial susceptibility testing (AST) across public healthcare establishments in Greece, we sent a questionnaire to 98 of 128 public hospital microbiology laboratories between 1 February and 1 April 2022. Of the 73.5% (72/98) that responded, 51.4% (37/72) reported using EUCAST guidelines. Two of three laboratories used an automated instrument for species identification and AST for all laboratory samples. Broth microdilution for colistin susceptibility testing was used by 46 of the laboratories, more frequently in larger (> 400 beds) versus smaller (< 400 beds) hospitals (90.5% (19/21) vs 52.9% (27/51) respectively, p = 0.011). MALDI-TOF mass spectrometry was available in one of 10 laboratories, and more often in larger compared to smaller hospitals (p = 0.035). Although the majority of laboratories had a laboratory information system (LIS) in place, only half had the capacity to extract data directly from the LIS for the purpose of AMR surveillance; 73.6% (53/72) used restrictive antibiograms. Public microbiology laboratory AMR capacities in Greece require improvement, prioritising interventions for EUCAST guidelines implementation.

Appeal from the European tuberculosis reference laboratory network (ERLTB-Net) for improving the diagnosis of infections due to nontuberculous mycobacteria

The European Reference Laboratory Network for tuberculosis (TB) (ERLTB-Net), comprising TB reference laboratories from 30 European Union/European Economic Area (EU/EEA) countries, was created in 2010 to support ECDC and countries in TB diagnostic services, alerts, and response to outbreaks. One of the core activities is to build capacity on standardised methods for mycobacterial diagnosis and antimicrobial susceptibility testing (AST) (https://www.ecdc.europa.eu/en/about-us/partnerships-and-networks/disease-and-laboratory-networks/erltb-net). ERLTB-Net recently identified weaknesses in capacity building of diagnosis and AST for non-tuberculous mycobacteria (NTM) [ [1] Nikolayevskyy V. Maurer F.P. Holicka Y. Taylor L. Liddy H. Kranzer K. Novel external quality assurance scheme for drug susceptibility testing of non-tuberculous mycobacteria: a multicentre pilot study. J Antimicrob Chemother. 2019; 74: 1288-1294 Crossref PubMed Scopus (6) Google Scholar ] and decided to draft guidance on best practices as well as to seek for research areas.

Multi‐country outbreak of Salmonella Virchow ST16 infections linked to the consumption of meat products containing chicken meat

Since June 2017, a persistent cross-border outbreak of Salmonella Virchow ST16 has been ongoing in five European Union/European Economic Area (EU/EEA) countries, the United Kingdom (UK), and the United States (US). A total of 210 cases have been reported from the following countries: Denmark (2), France (111), Germany (26), Ireland (4), the Netherlands (34), the UK (32), and the US (1). Among the interviewed cases (55), hospitalisation rates ranged from 16.7% (2/12) in the UK, to 29.4% (5/17) and 38.5% (10/26) in France and Germany, respectively. No deaths have been reported. A majority of cases have been linked to local restaurants serving kebab meat. The number of confirmed cases represents only a small proportion of all infections in the EU/EEA, partly due to the varying sequencing capacities of countries. The comparison of the representative outbreak strains with the available genome profiles of S. Virchow ST16 from non-human isolates, revealed that most of the matching isolates belonged to broiler meat and broiler-related environments, thereby supporting the hypothesis of chicken meat as a vehicle of infections. The available information from case interviews, traceback investigations, and whole genome sequencing (WGS) cluster analysis, showed that kebab meat products containing contaminated chicken meat are the likely vehicles of infections, and that the clone has been circulating in the EU poultry meat production chain at least in France, Germany, and the Netherlands. In the absence of batch numbers of the contaminated kebab products and related Salmonella testing information, the source(s) of the infections could not be established. New infections are likely to occur in the EU/EEA affecting any age group, until further investigations are performed to identify the source(s) and point(s) of contamination along the chicken meat production chain, including the primary production upstream lines. This will allow appropriate control measures to be implemented.

Monitoring the progress achieved towards ending tuberculosis in the European Union/European Economic Area, 2018 to 2021.

We report progress in the European Union/European Economic Area (EU/EEA) towards the Sustainable Development Goal target for tuberculosis (TB) and for the associated global/regional targets. The TB notification rate and the number of TB deaths declined since 2015 but, if current trends continue, the EU/EEA will not reach the 2030 targets. Performance on treatment initiation targets declined sharply during 2020-2021, while the percentage of TB cases with successful treatment outcomes remains low, at 47.9% of the multidrug-resistant TB cases.

Legionnaires' disease in the EU/EEA*: increasing trend from 2017 to 2019.

BackgroundThe burden of Legionnaires' disease (LD) in the European Union/European Economic Area (EU/EEA) has increased during the last decade, with notification rates increasing from 1.2 to 1.4/100,000 population in 2012-16, to 1.8-2.2 within 2017-19.AimTo measure weekly excess cases during 2017-19 based on previous trends and determine whether a significant change in trend occurred, and to examine any differences in age, sex or level of imported infections.MethodsWe collated 2012-19 annual surveillance data from The European Surveillance System (TESSy) reported by EU/EEA countries. A retrospective prediction by a dynamic regression model was created from 2012-16 data to assess excess cases in 2017-19. Interrupted time series (ITS) analysis was performed to determine if a significant change in trend occurred in 2017-19 compared with the previous 5 years.ResultsWe found a 33.9% increase in cases in 2017-19 compared with the number predicted. The ITS also found a significant trend increase in 2017-19 compared with 2012-16. A significant trend increase was observed from 2017 most strongly among older age groups (> 60 years) and non-imported cases.ConclusionOur study showed a significant increasing trend in LD cases in the EU/EEA during 2017-19 compared with the previous 5 years. The distribution of cases per week suggests an overall amplification of the seasonal trends. These findings underscore that LD continues to be an infectious disease of public health concern in the EU/EEA, warranting further research into determinants of the increase.

Detection of SARS-CoV-2 infections in passengers arriving from China and their implications on air travel and public health in Italy

Highlights Two recent flights from Beijing and Shanghai (China) to Milan (Italy) brought near about 100 severe acute respiratory syndrome coronavirus 2-infected passengers to Italy on 26 December 2022. 38% (35/92) of the travellers on the first flight landed at Milan’s airport, and 52% (62/120) of those on the second flight were positive. All the travellers had to stay in quarantine in places marked by local health authorities. Dear Editor, Two recent flights from Beijing and Shanghai to Milan brought near about 100 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected passengers to Italy on 26 December 2022. All the arrivals were tested and sequenced to ensure the detection of possible variants of the virus amid China’s surge in coronavirus disease 2019 (COVID-19) cases after it nullified the stringent zero-COVID-19 policy following mass public protests. About 38% (35/92) of the travellers on the first flight landed at Milan’s airport, and 52% (62/120) of those on the second flight were positive. Although COVID-19-positive travellers had already known Omicron variants, Italy plans to mandatorily test all arrivals from China henceforth1. Considering the uncertainty of the scale of spread, many countries like United States of America, United Kingdom, Japan, India, South Korea, Malaysia, and Taiwan have imposed similar restrictions on air travel from China1. US Centres for Disease Control and Prevention (CDC) is encouraging the Traveller-based Genomic Surveillance programme (TGS) to characterize and sequence emerging variants at a faster rate. TGS collects random nasal swabs from arriving international travellers; the programme is expanding to include 290 weekly flights from China2. European CDC, and the European Union/European Economic Area (EU/EEA) Member States are working closely with the WHO to enhance surveillance on emerging variant threats via the Strategic Analysis of Variants in Europe (SAVE) Working Group. The number of COVID-19 cases surged in China and peaked on 31 December 2022 (Fig. 1). There is a lack of authentic data from China on COVID-19 cases. China has started depositing SARS-CoV-2 sequences in Global Initiative on Sharing Avian Influenza Data (GISAID) EpiCoV in higher numbers. Out of the total 592 sequences submitted from China, 437 (collected in December 2022) mainly belonged to the lineages BA.5.2, BF.7, BQ.1, BA.2.75, XBB, BA.2, and the variants BA.5.6, BA.4.6, BM.4.1.1 and BA.2.3.20. Considering EU/EEA citizens have relatively high vaccine coverage rates and population immunity, as well as the prior emergence and subsequent replacement of variants circulating in China by other Omicron sublineages, this surge in cases in China is not expected to impact Europe3,4.Figure 1: The highest peak after the year 2020 corresponds to 7204 cases on 31 December 2022. Taken from https://www.worldometers.info/coronavirus/country/china.The world is all set to welcome the New Year 2023, but things may not stay normal as it has become after a long period of obligatory antipandemic measures5. The WHO has requested Beijing to provide real-time data on the number of positive cases, genetic sequencing, hospitalisations, mortality and vaccinations. WHO has backed steps taken by other countries imposing travel restrictions to protect their populations. When the most populated country in the world, China, with 1.4 billion people, suddenly scrapped the zero-COVID policy, an explosion in the number of cases was expected6. Air travel is contemplated to facilitate the spread of COVID-19 cases worldwide via travellers. Safe and efficient ‘travel bubbles’ across the borders, strict temperature screening at entries, rapid testing, quarantine, GPS (Global Positioning System) tracking, dissemination of public health information, and mandatory certification of COVID-19-free status in the form of test reports can lead to some extent curb transmission of COVID-197. The pandemic has affected the travel and aviation industry. While new vaccines and antiviral agents have greatly reduced the risk of severe hospitalisation and mortality, the threat of new emerging variants that evade vaccine immunity can complicate efforts to return to a normal travel routine8. In such a scenario, there should be a thorough evaluation of vaccine effectiveness postintroduction. As vaccine efficacy may vary considerably among different vaccine products, vaccines with lower effectiveness may impact public health negatively. A national cohort study from Chile by Wilder-Smith A. and Mulhollan M. can serve as a useful model to monitor vaccine effectiveness over time against different variants and in different ethnic groups and settings9. As per a Cochrane systematic review, the favourable evidence for most travel-related control precautions is very low. Most studies predicted a positive effect in the form of a delayed peak of case surges; however, results varied from no delay at all to a delay of l day to 85 days. International travel restrictions may help limit the spread of COVID‐19; however, screening travellers only for symptoms at borders or at arrival is likely to miss many cases. Quarantine that lasts for a minimum of 10 days, along with testing and people following rules, can prevent the spread of COVID‐198,10. The measures taken by different countries regarding international travel should be watched in recent times, and the outcomes can be analysed to comment on the effectiveness of the same. Ethical approval Not applicable. Sources of funding No funding was provided for this research project. Author contribution R.S., A.M. and R.R. developed the original draft. R.K. and B.K.P. reviewed the literature and critically edited the manuscript. All authors read and approved the final manuscript. Conflicts of interest disclosure All authors declare no conflicts of interest. Research registration unique identifying number (UIN) Name of the registry: NA. Unique identifying number or registration ID: NA. Hyperlink to your specific registration (must be publicly accessible and will be checked): NA. Guarantor Ranjit Sah. Data availability All data are included in the manuscript.

A step forward in antibiotic use and resistance monitoring: a quarterly surveillance system pilot in 11 European Union/European Economic Area countries, September 2017 to May 2020.

BackgroundSurveillance of antimicrobial resistance (AMR) and antimicrobial use (AMU) in Europe is currently annual.AimTo study the feasibility and scalability of a quarterly AMR/AMU surveillance system in the European Union/European Economic Area (EU/EEA).MethodsWe conducted a longitudinal study within the scope of the EU-JAMRAI project. Seventeen partners from 11 EU/EEA countries prospectively collected 41 AMU and AMR indicators quarterly from September 2017 to May 2020 for the hospital sector (HS) and primary care (PC). Descriptive statistics and coefficients of variation (CV) analysis were performed.ResultsData from 8 million hospital stays and 45 million inhabitants per quarter were collected at national (n = 4), regional (n = 6) and local (n = 7) levels. Of all partners, five were able to provide data within 3 months after each preceding quarter, and eight within 3-6 months. A high variability in AMU was found between partners. Colistin was the antibiotic that showed the highest CV in HS (1.40; p < 0.0001). Extended-spectrum beta-lactamase-producing Escherichia coli presented the highest incidence in HS (0.568 ± 0.045 cases/1,000 bed-days per quarter), whereas ciprofloxacin-resistant E. coli showed the highest incidence in PC (0.448 ± 0.027 cases/1,000 inhabitants per quarter). Barriers and needs for implementation were identified.ConclusionThis pilot study could be a first step towards the development of a quarterly surveillance system for AMU and AMR in both HS and PC in the EU/EEA. However, committed institutional support, dedicated human resources, coordination of data sources, homogeneous indicators and modern integrated IT systems are needed first to implement a sustainable quarterly surveillance system.

Non-pharmaceutical interventions in response to the COVID-19 pandemic in 30 European countries: the ECDC-JRC Response Measures Database.

In response to the COVID-19 pandemic, the European Union/European Economic Area (EU/EEA) countries implemented a wide set of non-pharmaceutical interventions (NPIs), sometimes with limited knowledge on their effect and impact on population. The European Centre for Disease Prevention and Control (ECDC) and the European Commission’s Joint Research Centre (JRC) developed a Response Measures Database (ECDC–JRC RMD) to archive NPIs in 30 EU/EEA countries from 1 January 2020 to 30 September 2022. We aimed to introduce a tool for the wider scientific community to assess COVID-19 NPIs effect and impact in the EU/EEA. We give an overview of the ECDC–JRC RMD rationale and structure, including a brief analysis of the main NPIs applied in 2020, before the roll-out of the COVID-19 vaccination campaigns. The ECDC–JRC RMD organises NPIs through a three-level hierarchical structure and uses four additional parameters (‘status’, ‘implementation’, ‘target group’ and ‘geographical representation’) to provide further information on the implementation of each measure. Features including the ready-for-analysis, downloadable format and its agile taxonomy and structure highlight the potential of the ECDC–JRC RMD to facilitate further NPI analysis and optimise decision making on public health response policies.

The Outbreak of Human Monkeypox in 2022: A Changing Epidemiology or an Impending Aftereffect of Smallpox Eradication?

This article presents a concise mini review about human monkeypox (MPX), in response to the current outbreak in non-endemic countries. MPX is one of the viral zoonotic diseases which is attributed to monkeypox virus (MPXV) and causes a smallpox-like disease. Despite its ability to infect various mammals, the animal reservoir for MPXV is still unconfirmed. The disease usually lasts for an average of 2-4 weeks before complete recovery. The incubation period for MPXV ranges from 5-21 days and the illness starts with prodromal phase, which is characterized by fever, chills, muscle pain, back pain, general malaise, lymph node enlargement, and headache, followed by rash. MPX is a self-limited illness with spontaneous recovery in most cases. In the middle of May 2022, an outbreak of human MPX has been declared by the World Health Organization (WHO) across various WHO regions, and in countries that are not endemic for the disease. As of June 08, 2022, the number of confirmed MPX cases that were reported across 18 countries of European Union/European Economic Area (EU/EEA) has reached 704 cases. Worldwide, and as of June 08, 2022, a total of 1285 confirmed MPX cases were reported in non-endemic countries across four WHO regions. Exportation of MPXV from Africa to other continents has been increasingly reported. Lacking travel connections to Africa among most current reported cases in 2022 raises an alarm about the changing epidemiology of the disease which warrants a stringent epidemiological surveillance to prevent further escalation of the current outbreak in non-endemic countries.

Systematic review of spontaneous reports of myocarditis and pericarditis in transplant recipients and immunocompromised patients following COVID-19 mRNA vaccination

ObjectivesTo determine whether spontaneous reporting rates of myocarditis and pericarditis differed in immunocompromised patients compared with the whole population overall, and in terms of demographics, vaccine dose and time-to-onset.DesignSystematic review...

Significant increase in azithromycin “resistance” and susceptibility to ceftriaxone and cefixime in Neisseria gonorrhoeae isolates in 26 European countries, 2019

BackgroundThe European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) performs annual sentinel surveillance of Neisseria gonorrhoeae susceptibility to therapeutically relevant antimicrobials across the European Union/European Economic Area (EU/EEA). We present the Euro-GASP results from 2019 (26 countries), linked to patient epidemiological data, and compared with data from previous years.MethodsAgar dilution and minimum inhibitory concentration (MIC) gradient strip methodologies were used to determine the antimicrobial susceptibility (using EUCAST clinical breakpoints, where available) of 3239 N. gonorrhoeae isolates from 26 countries across the EU/EEA. Significance of differences compared with Euro-GASP results in previous years was analysed using Z-test and the Pearson's χ2 test was used to assess significance of odds ratios for associations between patient epidemiological data and antimicrobial resistance.ResultsEuropean N. gonorrhoeae isolates collected between 2016 and 2019 displayed shifting MIC distributions for; ceftriaxone, with highly susceptible isolates increasing over time and occasional resistant isolates each year; cefixime, with highly-susceptible isolates becoming increasingly common; azithromycin, with a shift away from lower MICs towards higher MICs above the EUCAST epidemiological cut-off (ECOFF); and ciprofloxacin which is displaying a similar shift in MICs as observed for azithromycin. In 2019, two isolates displayed ceftriaxone resistance, but both isolates had MICs below the azithromycin ECOFF. Cefixime resistance (0.8%) was associated with patient sex, with resistance higher in females compared with male heterosexuals and men-who-have-sex-with-men (MSM). The number of countries reporting isolates with azithromycin MICs above the ECOFF increased from 76.9% (20/26) in 2016 to 92.3% (24/26) in 2019. Isolates with azithromycin MICs above the ECOFF (9.0%) were associated with pharyngeal infection sites. Following multivariable analysis, ciprofloxacin resistance remained associated with isolates from MSM and heterosexual males compared with females, the absence of a concurrent chlamydial infection, pharyngeal infection sites and patients ≥ 25 years of age.ConclusionsResistance to ceftriaxone and cefixime remained uncommon in EU/EEA countries in 2019 with a significant decrease in cefixime resistance observed between 2016 and 2019. The significant increase in azithromycin “resistance” (azithromycin MICs above the ECOFF) threatens the effectiveness of the dual therapy (ceftriaxone + azithromycin), i.e., for ceftriaxone-resistant cases, currently recommended in many countries internationally and requires close monitoring.

The European response to control and manage multi- and extensively drug-resistant Neisseria gonorrhoeae.

Because cefixime and ceftriaxone resistance in Neisseria gonorrhoeae and gonorrhoea treatment failures were increasing, a response plan to control and manage multidrug-resistant N. gonorrhoeae (MDR-NG) in Europe was published in 2012. The three main areas of the plan were to: (i) strengthen surveillance of antimicrobial resistance (AMR), (ii) implement monitoring of treatment failures and (iii) establish a communication strategy to increase awareness and disseminate AMR results. Since 2012, several additional extensively drug-resistant N. gonorrhoeae (XDR-NG) strains have emerged, and strains with high-level ceftriaxone resistance spread internationally. This prompted an evaluation and review of the 2012 European Centre for Disease Prevention and Control (ECDC) response plan, revealing an overall improvement in many aspects of monitoring AMR in N. gonorrhoeae; however, treatment failure monitoring was a weakness. Accordingly, the plan was updated in 2019 to further support European Union/European Economic Area (EU/EEA) countries in controlling and managing the threat of MDR/XDR-NG in Europe through further strengthening of AMR surveillance and clinical management including treatment failure monitoring. The plan will be assessed biennially to ensure its effectiveness and its value. Along with prevention, diagnostic, treatment and epidemiological surveillance strategies, AMR surveillance is essential for effective control of gonorrhoea.

Reports of myocarditis and pericarditis following mRNA COVID-19 vaccination: a systematic review of spontaneously reported data from the UK, Europe and the USA and of the scientific literature

ObjectivesTo combine spontaneously reported data from multiple countries to estimate reporting rate, and better understand risk factors for myocarditis and pericarditis following COVID-19 messenger RNA (mRNA) vaccines.DesignSystematic review of spontaneously...

Tuberculosis Surveillance in Romania Among Vulnerable Risk Groups Between 2015 and 2017.

PurposeRomania has the highest tuberculosis (TB) burden in the European Union/European Economic Area (EU/EEA) comprising almost a quarter (23.4%) of the reported patients in 2017, and a TB notification rate six times higher than the EU/EEA average. Although the overall TB notification rate in Romania declined from 154/100.000 individuals to 66/100.000 individuals in the general population between 2002 and 2017, TB notification rates remain high in certain vulnerable populations groups such as prisoners, the homeless population and among drug users.Patients and MethodsWe conducted a descriptive study regarding TB monitoring data in Romania, including the aforementioned TB risk groups.ResultsAnalysis regarding notified TB cases among these risk groups indicates that TB rates are 7 to 18 times higher than in the general population. One of the most alarming aspects regards the exceedingly high proportion of HIV-seropositivity among drug users and the high mortality rates among the homeless population and among drug users with TB.ConclusionThis data underlines the importance of early identification among social risk groups using outreach active case-finding (ACF) activities, possibly combining TB screening with screening for other common, possibly life-threatening, co-morbidities for which an effective treatment is available. ACF could have a decisive role in TB control and eradication in Romania, when aimed at these high-risk groups.

Multi‐country outbreak of Salmonella Enteritidis sequence type (ST)11 infections linked to eggs and egg products – 8 February 2022

On 2 September 2021, France reported an increase in Salmonella Enteritidis ST11 infections. By 11 January 2022, 272 confirmed cases had been reported in five European Union/European Economic Area (EU/EEA) countries and the United Kingdom (UK): Denmark (n=3), France (n=216), the Netherlands (n=12), Norway (n=7), Spain (n=22), and the UK (n=12) in 2021. Two deaths were recorded in adult men. Twenty-five cases were hospitalised. Sixty cases reported consumption of eggs/egg products. Some cases reported in France in 2021 had visited restaurants serving eggs distributed by a common supplier, Spanish Packing Centre A. The eggs originated from three Spanish farms, one testing positive for the outbreak strain. Fresh table eggs from the farms linked to the outbreak were withdrawn and redirected for use in heat-treated egg products. No other countries received eggs from the same farms via Packing Centre A during summer 2021. Therefore, the source of infection for cases in late 2021 and in countries other than Spain and France could not be established. This 2021 outbreak is linked microbiologically to a historical cross-border outbreak reported by the Netherlands in 2019. Eggs consumed by cases in the Dutch outbreak were traced back to a Spanish farm, but it was not possible to identify an epidemiological link with the 2021 outbreak. This suggests a wide distribution of the outbreak strain that could affect the food supply chain and/or earlier steps in the production chain. There may be multiple heterogeneous sources of S. Enteritidis ST11, and the outbreak strain could also be circulating at other farms, inside or outside Spain. The risk of new infections caused by the outbreak strain and contaminated eggs remains high in the EU/EEA. It is therefore important to foster cross-sectoral investigations of contaminations in the egg supply chain in countries where S. Enteritidis ST11 has been detected.

Human papillomavirus vaccination in the European Union/European Economic Area and globally: a moral dilemma.

While many European Union/European Economic Area (EU/EEA) countries recently expanded human papillomavirus (HPV) vaccination to boys, HPV vaccine supply is currently limited for girls in low- and middle-income countries (LMIC) that are severely affected by HPV.Globally, about 50% of countries have introduced HPV vaccination. Some LMIC with high burden of cervical cancer have not yet introduced HPV vaccination, or are reaching suboptimal vaccination coverage. While WHO issued a call for cervical cancer elimination in 2018, a global shortage of HPV vaccines is currently predicted to last at least until 2024.We reviewed national policies of EU/EEA countries and recommendations of the World Health Organization (WHO) Strategic Advisory Group of Experts on immunisation to discuss current challenges and dose-sparing options. Several EU/EEA countries have extended HPV vaccination to boys and the European Cancer Organisation has issued a resolution for elimination of all HPV-associated cancers in both sexes. The European Centre for Disease Prevention and Control concluded in its 2020 guidance that cost-effectiveness of extending routine vaccination to boys depends on several context-specific factors. The extension of HPV vaccination to boys in EU/EEA countries may affect global availability of vaccines. Temporary dose-sparing options could be considered during the COVID-19 post-pandemic period.

Multi‐country outbreak of multiple Salmonella enterica serotypes linked to imported sesame‐based products

Since January 2019, 121 cases of Salmonella enterica infections with six different serotypes linked to sesame-based products have been reported in five EU/EEA countries. The serotypes are S. Amsterdam, S. Havana, S. Kintambo, S. Mbandaka, S. Orion, and S. Senftenberg. Case interviews in four countries revealed consumption of sesame-based products (halva or tahini) prior to illness. Almost half of the cases are in children ≤10 years, who also represent over half of hospitalised cases. No deaths have been reported. Since November 2019, 14 batches of sesame-based products originating from Syria, tested positive for one or multiple Salmonella outbreak strains (twelve from Brand A, two from Brand C). Based on available epidemiological, microbiological, and traceability information, the probable vehicles of infection are sesame-based products imported from Syria, at least in countries involved in the traceability of the positive batches. These products are sealed and ready to be consumed, suggesting that the contamination occurred before the products reached the European Union/European Economic Area (EU/EEA) market. The intermittent occurrence of human cases and the identification of positive food samples since 2019 indicate the availability of the contaminated sesame-based products on the EU/EEA market for over two years. This has posed a risk for human infections and severe clinical illness with several Salmonella serotypes, particularly among children. Control measures implemented since August 2020 on the involved batches of sesame-based products have not prevented the occurrence of human cases to date. Moreover, the concerned products have a long shelf life and might still be stored in people’s homes. Considering the limited information on product manufacturing and distribution, there remains a risk for new Salmonella infections in the EU/EEA linked to imported sesame-based products from Syria.