European Union/European Economic Area Research Articles

Measuring hospital antibiotic consumption in EU/EEA countries: comparison of different metrics, 2017 to 2021.

BackgroundAntibiotic resistance poses a considerable public health threat, with data-driven stewardship a main prevention measure. While quantifying antibiotic consumption is a key component of antibiotic stewardship programmes, the choice of denominator for calculating this metric can impact comparative analyses and trend evaluations substantially, influencing targeted stewardship interventions.AimWe aim to evaluate how using hospital sector-specific antibiotic consumption rate denominators at country level impacts country rankings and trends, addressing the limitations of the commonly used 'defined daily doses (DDD) per 1,000 inhabitants per day' metric.MethodsHospital antibiotic consumption data from ESAC-Net and denominator data from Eurostat ('inhabitants,' 'bed-days' and 'discharges') for 2017-2021 were used to calculate hospital antibiotic consumption rates for 24 reporting European Union/ European Economic Area (EU/EEA) countries. Countries were ranked by their consumption rates and trends were analysed to assess the effects of using different denominators.ResultsCountry rankings and 5-year trend analyses varied depending on the denominator used. Antibiotic consumption rates were more similar when using hospital activity-based denominators 'bed-days' and 'discharges' compared with the population-based 'inhabitants' denominator. Differences in country rankings and trends were also seen among rates derived using 'bed-days' and 'discharges'.ConclusionThe study underscores the importance of using hospital activity-based denominators such as 'bed-days' and 'discharges' when evaluating hospital antibiotic consumption. ESAC-Net's historical reliance on only 'DDD per 1,000 inhabitants per day' is challenged, advocating for the use of multiple hospital activity-based denominators. Corresponding hospital activity denominators for ESAC-Net data will more effectively inform national hospital antibiotic stewardship interventions.

Developing a structured framework to address vaccination barriers for Newly Arrived Migrants in EU/EEA

Abstract Background Access to vaccination is a critical aspect of public health, particularly for newly arrived migrants (NAMs) in European Union/European Economic Area (EU/EEA) countries. Despite this, significant barriers exist, necessitating urgent attention. This study addresses the pressing need to improve vaccination coverage for NAMs by developing a General Conceptual Framework (GCF) to understand and overcome system barriers and analyzing possible strategies. Methods starting from a theoretical conceptualization, the study employed a mixed-method approach, incorporating literature review and qualitative research. The GCF was formulated based on key components of the vaccination process. Barriers and solutions were identified through a non-systematic literature review and qualitative investigation. The GCF served as a guide for study activities, facilitating data integration. Results The study outlines a structured GCF comprising five interconnected steps in the vaccination process: entitlement, reachability, adherence, achievement, and evaluation of vaccination. Barriers and solutions identified through literature review and qualitative research are presented. Strategies to enhance professional knowledge, accessibility, adherence, coverage, and intervention evaluation are proposed. Recommendations include proximity strategies, provider training, migrant-sensitive approaches, and robust data collection. Conclusions Equitable access to vaccination is paramount for public health, particularly for vulnerable populations like NAMs in EU/EEA countries. The development of the GCF represents a crucial step towards understanding and addressing barriers to vaccination access. Implementation of recommended strategies can significantly improve vaccination outcomes for NAMs, ultimately contributing to the overall health and well-being of these communities.

Developing a European framework for the prevention of communicable diseases: three points for attention.

The capacity to deliver programmes that prevent and control infectious diseases is a key public health function. The European Centre for Disease Prevention and Control (ECDC) aims to support and strengthen this capacity in European Union/ European Economic Area (EU/EEA) countries as part of its 2021-27 strategy which includes explicit attention to social and behavioural aspects of disease prevention. To achieve its strategic goals, it is important that ECDC improves its knowledge of prevention strategies, actors and activities in EU/EEA countries. In this Perspective, we summarise three challenges to implementing the prevention framework proposed by ECDC: (i) defining, recognising and identifying with 'prevention', (ii) integrating new understandings into established ways of thinking, and (iii) the need for more attention to prevention in governance. These challenges are derived from the findings of a project which conducted a preliminary mapping of prevention actors, networks and activities in four EU countries to support the development of a community of practice within the new ECDC prevention framework. This Perspective serves to draw attention to this prevention framework and the three identified challenges for those working on its implementation.

Avian influenza overview June-September 2024.

Between 15 June and 20 September 2024, 75 highly pathogenic avian influenza (HPAI) A(H5) and A(H7) virus detections were reported in domestic (16) and wild (59) birds across 11 countries in Europe. Although the overall number of detections in Europe continued to be low compared to previous epidemiological years, an increase in cases along the Atlantic, North Sea and Baltic coasts was notable, particularly an increase in the detection of HPAI viruses in colony-breeding seabirds. Besides EA-2022-BB and other circulating genotypes, these detections also included EA-2023-DT, a new genotype that may transmit more efficiently among gulls. In Germany, HPAI A(H7N5) virus emerged in a poultry establishment near the border with the Netherlands. No new HPAI virus detections in mammals were reported in Europe during this period, but the number of reportedly affected dairy cattle establishments in the United States of America (USA) rose to >230 in 14 states, and HPAI virus was identified in three new mammal species. Between 21 June and 20 September 2024, 19 new human cases with avian influenza virus infection were reported from the USA (six A(H5N1) cases and five A(H5) cases), Cambodia (five A(H5N1) cases, including one fatal), China (one fatal A(H5N6) case and one A(H9N2) case), and Ghana (one A(H9N2) case). Most of the human cases (90%, n = 17/19) had reported exposure to poultry, live poultry markets, or dairy cattle prior to avian influenza virus detection or onset of illness. Human infections with avian influenza viruses remain rare and no evidence of human-to-human transmission has been documented in the reporting period. The risk of infection with currently circulating avian A(H5) influenza viruses of clade 2.3.4.4b in Europe remains low for the general public in the European Union/European Economic Area (EU/EEA). The risk of infection remains low-to-moderate for those occupationally or otherwise exposed to infected animals or contaminated environments.

Focus, vigilance, resilience: towards stronger infectious disease surveillance, threat detection and response in the EU/EEA.

This perspective summarises and explains the long-term surveillance framework 2021-2027 for infectious diseases in the European Union/European Economic Area (EU/EEA) published in April 2023. It shows how shortcomings in the areas of public health focus, vigilance and resilience will be addressed through specific strategies in the coming years and how these strategies will lead to stronger surveillance systems for early detection and monitoring of public health threats as well as informing their effective prevention and control. A sharper public health focus is expected from a more targeted list of notifiable diseases, strictly public-health-objective-driven surveillance standards, and consequently, leaner surveillance systems. Vigilance should improve through mandatory event reporting, more automated epidemic intelligence processing and increased use of genomic surveillance. Finally, EU/EEA surveillance systems should become more resilient by modernising the underlying information technology infrastructure, expanding the influenza sentinel surveillance system to other respiratory viruses for better pandemic preparedness, and increasingly exploiting potentially more robust alternative data sources, such as electronic health records and wastewater surveillance. Continued close collaboration across EU/EEA countries will be key to ensuring the full implementation of this surveillance framework and more effective disease prevention and control.

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

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

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.