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Leishmania spp. are sand fly-borne protozoan parasites causing leishmaniasis in humans and animals. The aim of the study was to analyse the epidemiology of leishmaniasis in Turkey, Azerbaijan and Georgia from 2005 to 2020 and evaluate the associated risk for disease emergence in European countries. It is based on an analysis of WHO and OIE reported cases between 2005 and 2020, a review of scientific articles published in SCOPUS between 2009 and 2020 and a questionnaire survey to public health and veterinary authorities in these countries. Endemic Leishmania spp. include L. infantum in the three countries, L. major in Azerbaijan and Turkey and L. tropica and L. donovani in Turkey. Leishmaniasis is reported in humans, animals and sand flies and incidence is spatially and temporarily variable. In the southern Caucasus and particularly in Georgia, reported incidence of human visceral leishmaniasis by L. infantum remains high. However, whilst Georgia experienced a gradual decrease from4.0 cases per 100,000 population in 2005-09 to 1.13 cases per 100,000 population in 2020, the period with highest incidence in Azerbaijan, which ranged between 0.40 and 0.61 cases per 100,000 population, was 2016-2019, and no cases have so far been reported for 2020. Visceral leishmaniasis in the Southern Caucasus affects mostly young children from deprived urban areas and its closely associated to canine leishmaniasis. Turkey reported cases of visceral leishmaniasis between 2005 and 2012 and in 2016 only, and incidence ranged between 0.02 and 0.05 per 100,000 population. In contrast, the reported annual incidence of cutaneous leishmaniasis in Turkey was much greater and peaked at 7.02 cases per 100,000 population in 2013, associated to imported cases from cutaneous leishmaniasis endemic Syria. Leishmaniasis by L. infantum in Azerbaijan and Georgia represents a regional public and animal health challenge that requires support to improve diagnosis, treatment and control. The unprecedented rise of cutaneous leishmaniasis and the spread of L. tropica and L. donovani in Turkey is an important risk factor for their emergence in Europe, especially in Mediterranean countries where competent vectors are widespread.

Background Tick-borne encephalitis (TBE) is a vaccine-preventable disease involving the central nervous system. TBE became a notifiable disease on the EU/EEA level in 2012. Aim We aimed to provide an updated epidemiological assessment of TBE in the EU/EEA, focusing on spatiotemporal changes. Methods We performed a descriptive analysis of case characteristics, time and location using data of human TBE cases reported by EU/EEA countries to the European Centre for Disease Prevention and Control with disease onset in 2012–2020. We analysed data at EU/EEA, national, and subnational levels and calculated notification rates using Eurostat population data. Regression models were used for temporal analysis. Results From 2012 to 2020, 19 countries reported 29,974 TBE cases, of which 24,629 (98.6%) were autochthonous. Czechia, Germany and Lithuania reported 52.9% of all cases. The highest notification rates were recorded in Lithuania, Latvia, and Estonia (16.2, 9.5 and 7.5 cases/100,000 population, respectively). Fifty regions from 10 countries, had a notification rate ≥ 5/100,000. There was an increasing trend in number of cases during the study period with an estimated 0.053 additional TBE cases every week. In 2020, 11.5% more TBE cases were reported than predicted based on data from 2016 to 2019. A geographical spread of cases was observed, particularly in regions situated north-west of known endemic regions. Conclusion A close monitoring of ongoing changes to the TBE epidemiological situation in Europe can support the timely adaption of vaccination recommendations. Further analyses to identify populations and geographical areas where vaccination programmes can be of benefit are needed.

Background Travellers are generally considered good sentinels for infectious disease surveillance. Aim To investigate whether health data from travellers arriving from Africa to Europe could provide evidence to support surveillance systems in Africa. Methods We examined disease occurrence and estimated risk of infection among travellers arriving from Africa to Europe from 2015 to 2019 using surveillance data of arthropod-borne disease cases collected through The European Surveillance System (TESSy) and flight passenger volumes from the International Air Transport Association. Results Malaria was the most common arthropod-borne disease reported among travellers from Africa, with 34,235 cases. The malaria travellers’ infection rate (TIR) was 28.8 cases per 100,000 travellers, which is 36 and 144 times higher than the TIR for dengue and chikungunya, respectively. The malaria TIR was highest among travellers arriving from Central and Western Africa. There were 956 and 161 diagnosed imported cases of dengue and chikungunya, respectively. The highest TIR was among travellers arriving from Central, Eastern and Western Africa for dengue and from Central Africa for chikungunya in this period. Limited numbers of cases of Zika virus disease, West Nile virus infection, Rift Valley fever and yellow fever were reported. Conclusions Despite some limitations, travellers’ health data can efficiently complement local surveillance data in Africa, particularly when the country or region has a sub-optimal surveillance system. The sharing of anonymised traveller health data between regions/continents should be encouraged.

Background Dengue is a disease with major impacts on public health in tropical and subtropical countries. In Europe, in the past decade, few autochthonous outbreaks were described. Aim We aimed to identify factors associated with frequency of dengue virus infection among European travellers and at assessing how surveillance data could support preparedness against autochthonous outbreaks within Europe. Methods We performed a descriptive analysis of travel-related dengue cases reported by European countries from 2015 through 2019. Using flight passenger data, we calculated travellers’ infection rates (TIR). We investigated the following associations: (i) between TIR and incidence rate in selected countries of infection and (ii) between number of travel-related cases and occurrence of autochthonous outbreaks within Europe. Results There were 11,478 travel-related dengue cases and the TIR was 2.8 cases per 100,000 travellers. Most cases were infected in Asia (71%), predominantly in south-eastern Asia. The TIR was highest among travellers returning from Asia (6.1/100,000). There was an association between the incidence rate in the country of infection and the TIR but no association between the number of travel-related cases and occurrence of autochthonous outbreaks in Europe. Conclusions The likelihood of infection in travellers is a function of the ongoing epidemiological situation in the country of exposure. The number of travel-related cases alone is not sufficient to estimate the likelihood of autochthonous outbreaks where vectors are present in Europe. Additional contributing factors such as adequate vectorial capacity and suitable environmental conditions are required.

Tick-borne encephalitis (TBE) is an infection caused by the Tick-borne encephalitis virus (TBEv) and it is common in Europe. The virus is predominantly transmitted by ticks, but other non-vectorial modes of transmission are possible. This systematic review synthesises the epidemiological impact of non-vectorial modes of TBEv transmission in Europe. 41 studies were included comprising of 1308 TBE cases. Alimentary (36 studies), handling infected material (3 studies), blood-borne (1 study), solid organ transplant (1 study) were identified as potential routes of TBEv transmission; however, no evidence of vertical transmission from mother to offspring was reported (2 studies). Consumption of unpasteurised milk/milk products was the most common vehicle of transmission and significantly increased the risk of TBE by three-fold (pooled RR 3.05, 95% CI 1.53 to 6.11; 4 studies). This review also confirms handling infected material, blood-borne and solid organ transplant as potential routes of TBEv transmission. It is important to tracing back to find the vehicle of the viral infection and to promote vaccination as it remains a mainstay for the prevention of TBE.

A questionnaire survey of animal and human health authorities in Europe revealed that leishmaniases are not notifiable in all countries with autochthonous cases. Few countries implement surveillance and control targeting both animal and human infections. Leishmaniases are considered emergent diseases in most countries, and lack of resources is a challenge for control. publishersversion published

Aedes albopictus is a known vector of dengue and chikungunya. Understanding the population dynamics characteristics of vector species is of pivotal importance to optimise surveillance and control activities, to estimate risk for pathogen-transmission, and thus to enhance support of public health decisions. In this paper we used a seasonal activity model to simulate the start (spring hatching) and end (autumn diapause) of the vector season. In parallel, the peak abundance of the species was assessed using both VectorNet field survey data complemented with field studies obtained from literature across the Mediterranean Basin. Our results suggest that spring hatching of eggs in the current distribution area can start at the beginning of March in southern Europe and in April in western Europe. In northern Europe, where the species is not (yet) present, spring hatching would occur from late April to late May. Aedes albopictus can remain active up to 41 weeks in southern Europe whilst the climatic conditions in northern Europe are limiting its potential activity to a maximum of 23 weeks. The peak of egg density is found during summer months from end of July until end of September. During these two months the climatic conditions for species development are optimal, which implies a higher risk for arbovirus transmission by Ae. albopictus and occurrence of epidemics.

Aedes albopictus is a known vector of dengue and chikungunya. Understanding the population dynamics characteristics of vector species is of pivotal importance to optimise surveillance and control activities, to estimate risk for pathogen-transmission, and thus to enhance support of public health decisions. In this paper we used a seasonal activity model to simulate the start (spring hatching) and end (autumn diapause) of the vector season. In parallel, the peak abundance of the species was assessed using both VectorNet field survey data complemented with field studies obtained from literature across the Mediterranean Basin. Our results suggest that spring hatching of eggs in the current distribution area can start at the beginning of March in southern Europe and in April in western Europe. In northern Europe, where the species is not (yet) present, spring hatching would occur from late April to late May. Aedes albopictus can remain active up to 41 weeks in southern Europe whilst the climatic conditions in northern Europe are limiting its potential activity to a maximum of 23 weeks. The peak of egg density is found during summer months from end of July until end of September. During these two months the climatic conditions for species development are optimal, which implies a higher risk for arbovirus transmission by Ae. albopictus and occurrence of epidemics.

Rabies is enzootic in over one hundred countries worldwide. In the European Union/European Economic Area (EU/EEA), the vast majority of human rabies cases are travellers bitten by dogs in rabies-enzootic countries, mostly in Asia and Africa. Thus, EU/EEA travellers visiting rabies enzootic countries should be aware of the risk of being infected with the rabies virus when having physical contact with mammals. They should consider pre-exposure vaccination following criteria recommended by the World Health Organization and if unvaccinated, immediately seek medical attention in case of bites or scratches from mammals. As the majority of the EU/EEA countries are free from rabies in mammals, elimination of the disease (no enzootic circulation of the virus and low number of imported cases) has been achieved by 2020. However, illegal import of potentially infected animals, mainly dogs, poses a risk to public health and might threaten the elimination goal. Additionally, newly recognised bat lyssaviruses represent a potential emerging threat as the rabies vaccine may not confer protective immunity. To support preparedness activities in EU/EEA countries, guidance for the assessment and the management of the public health risk related to rabies but also other lyssaviruses, should be developed.

Two months after the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the possibility of established and widespread community transmission in the European Union and European Economic Area (EU/EEA) is becoming more likely. We provide scenarios for use in preparedness for a possible widespread epidemic. The EU/EEA is moving towards the ‘limited sustained transmission’ phase. We propose actions to prepare for potential mitigation phases and coordinate efforts to protect the health of citizens.

Autochthonous outbreaks of chikungunya have occurred in the European Union (EU) after virus introduction by infected travelers. We reviewed the surveillance data of travel-related cases reported in the EU during 2012-2018 to document factors associated with increased infection rates among travelers and to assess how surveillance data could support preparedness against secondary transmission and timely control of outbreaks. Thirteen EU countries reported 2,616 travel-related chikungunya cases. We observed 3 successive epidemiologic periods; the highest number of cases (75%) occurred during 2014-2015, when most cases were associated with the Caribbean and South America. The highest infection rates among travelers were observed during the same phase. Although surveillance of travel-related cases is relevant for estimating the infection risk for travelers, we could not identify a relationship between the number of infected travelers and a higher likelihood of secondary transmission in the EU. Sí

Most Salmonella serotypes are named after geographic locations; a few others have surprisingly humorous origins., It’s easy to remember Salmonella serotypes names, isn’t it? Surely, this is because the naming system of Salmonella serotypes is by far the most scientist friendly. Traditionally, most Salmonella serotypes have been named after geographic locations. We decided to explore the geographic locations to which Salmonella serotypes refer and describe some unexpected twists in the naming scheme. We found that 93% (n = 1,475) of the 1,585 serotypes could be categorized as geo-serotypes; that is, the name refers to a geographic location. The 3 countries with the most geo-serotypes are Germany, the United Kingdom, and the United States. Other serotype names refer to the name of a person, animal, tribe, or food item or are a composite of symptoms and host. The Salmonella serotypes naming scheme has had a valuable effect on public health microbiology, and in the current era of fast development of whole-genome sequencing, it should remain a reference.

In Europe, surveillance indicates that the 2018 West Nile fever transmission season started earlier than in previous years and with a steeper increase of locally-acquired human infections. Between 2014 and 2017, European Union/European Economic Area (EU/EEA) and EU enlargement countries notified five to 25 cases in weeks 25 to 31 compared with 168 cases in 2018. Clinicians and public health authorities should be alerted to ensure timely implementation of prevention measures including blood safety measures.

Autochthonous outbreaks of chikungunya and dengue during the past decade showed that continental Europe is vulnerable to Aedes albopictus–borne infections. Ae. albopictus has spread geographically, resulting in more people exposed to risk. Timely application of adequate mosquito suppression measures may delay, or even prevent, the vector population from crossing the potential epidemic abundance threshold should a pathogen be introduced. Health authorities should be on alert to detect early cases to prevent autochthonous outbreaks.

Since December 2016, Brazil has faced a large outbreak of yellow fever with ca 1,500 confirmed human cases. In the first 2 months of 2018, Brazil reported almost as many cases as in 2017 as a whole. In these 2 months, five imported cases were reported among unvaccinated European travellers. Three had travelled to Ilha Grande, a popular destination among European tourists. Physicians and European travellers visiting Brazil should follow yellow fever vaccination recommendations.

This article uses the experience of five European countries to review the integrated approaches (human, animal and vector) for surveillance and monitoring of West Nile virus (WNV) at national and European levels. The epidemiological situation of West Nile fever in Europe is heterogeneous. No model of surveillance and monitoring fits all, hence this article merely encourages countries to implement the integrated approach that meets their needs. Integration of surveillance and monitoring activities conducted by the public health authorities, the animal health authorities and the authorities in charge of vector surveillance and control should improve efficiency and save resources by implementing targeted measures. The creation of a formal interagency working group is identified as a crucial step towards integration. Blood safety is a key incentive for public health authorities to allocate sufficient resources for WNV surveillance, while the facts that an effective vaccine is available for horses and that most infected animals remain asymptomatic make the disease a lesser priority for animal health authorities. The examples described here can support other European countries wishing to strengthen their WNV surveillance or preparedness, and also serve as a model for surveillance and monitoring of other (vector-borne) zoonotic infections.

Between 2014 and 2015, the European Centre for Disease Prevention and Control was informed of an increase in numbers of Salmonella enterica serotype Chester cases with travel to Morocco occurring in six European countries. Epidemiological and microbiological investigations were conducted. In addition to gathering information on the characteristics of cases from the different countries in 2014, the epidemiological investigation comprised a matched case–case study involving French patients with salmonellosis who travelled to Morocco that year. A univariate conditional logistic regression was performed to quantify associations. The microbiological study included a whole genome sequencing (WGS) analysis of clinical and non-human isolates of S. Chester of varied place and year of isolation. A total of 162 cases, mostly from France, followed by Belgium, the Netherlands, Spain, Denmark and Sweden were reported, including 86 (53%) women. The median age per country ranged from 3 to 38 years. Cases of S. Chester were more likely to have eaten in a restaurant and visited the coast of Morocco. The results of WGS showed five multilocus sequence types (ST), with 96 of 153 isolates analysed clustering into a tight group that corresponded to a novel ST, ST1954. Of these 96 isolates, 46 (48%) were derived from food or patients returning from Morocco and carried two types of plasmids containing either qnrS1 or qnrB19 genes. This European-wide outbreak associated with travel to Morocco was likely a multi-source outbreak with several food vehicles contaminated by multidrug-resistant S. Chester strains.

Summary Middle East respiratory syndrome coronavirus (MERS‐CoV) cases without documented contact with another human MERS‐CoV case make up 61% (517/853) of all reported cases. These primary cases are of particular interest for understanding the source(s) and route(s) of transmission and for designing long‐term disease control measures. Dromedary camels are the only animal species for which there is convincing evidence that it is a host species for MERS‐CoV and hence a potential source of human infections. However, only a small proportion of the primary cases have reported contact with camels. Other possible sources and vehicles of infection include food‐borne transmission through consumption of unpasteurized camel milk and raw meat, medicinal use of camel urine and zoonotic transmission from other species. There are critical knowledge gaps around this new disease which can only be closed through traditional field epidemiological investigations and studies designed to test hypothesis regarding sources of infection and risk factors for disease. Since the 1960s, there has been a radical change in dromedary camel farming practices in the Arabian Peninsula with an intensification of the production and a concentration of the production around cities. It is possible that the recent intensification of camel herding in the Arabian Peninsula has increased the virus' reproductive number and attack rate in camel herds while the ‘urbanization’ of camel herding increased the frequency of zoonotic ‘spillover’ infections from camels to humans. It is reasonable to assume, although difficult to measure, that the sensitivity of public health surveillance to detect previously unknown diseases is lower in East Africa than in Saudi Arabia and that sporadic human cases may have gone undetected there.

SUMMARYRapid and wide dispersal of passengers after flights makes investigation of flight-related outbreaks challenging. An outbreak ofSalmonellaHeidelberg was identified in a group of Irish travellers returning from Tanzania. Additional international cases sharing the same flight were identified. Our aim was to determine the source and potential vehicles of infection. Case-finding utilized information exchange using experts' communication networks and national surveillance systems. Demographic, clinical and food history information was collected. Twenty-five additional cases were identified from Ireland, The Netherlands, Norway, USA and Canada. We conducted a case-control study which indicated a significant association between illness and consumption of milk tart (OR 10·2) and an egg dish (OR 6) served on-board the flight. No food consumed before the flight was associated with illness. Cases from countries other than Ireland provided supplementary information that facilitated the identification of likely vehicles of infection. Timely, committed international collaboration is vital in such investigations.

SUMMARYIn September 2011, a patient cluster with a rareSalmonellaserotype – Strathcona – was identified in Denmark. An outbreak investigation was initiated to reveal the source in order to stop the outbreak. In addition to hypothesis-generating interviews, comparable analyses of patients’ household shopping receipts were conducted. A matched case-control study with 25 cases and 56 population register controls was conducted to test the findings of the hypothesis-generating investigation. In total, 43 cases ofSalmonellaStrathcona were reported in Denmark. Additionally, 28 cases were reported from Germany, Italy, Austria and Belgium. The results of the investigation in Denmark showed that 8/10 cases had bought datterino tomatoes prior to disease onset. Illness was associated with a specific supermarket chain [matched odds ratio (mOR) 16·9, 95% confidence interval (CI) 2·2–130], and having consumed elongated small tomatoes (OR 28·1, 95% CI 2·6–302). Traceback investigation showed that the tomatoes came from an Italian producer. This outbreak, linked to tomatoes, underpins the growing recognition of the broad source range ofSalmonellaand the ability of fresh produce to cause multi-country outbreaks. It is important to strengthen the international cooperation between public-health and food-safety authorities in the European Union to investigate future multi-country outbreaks in order to prevent illness from ready-to-eat produce.

Background A major food safety incident in China was made public in September 2008. Kidney and urinary tract effects, including kidney stones, affected about 300,000 Chinese infants and young children, with six reported deaths. Melamine had been deliberately added at milk-collecting stations to diluted raw milk ostensibly to boost its protein content. Subsequently, melamine has been detected in many milk and milk-containing products, as well as other food and feed products, which were also exported to many countries worldwide. Objectives The melamine event represents one of the largest deliberate food contamination incidents. We provide a description and analysis of this event to determine the global implications on food and feed safety. Discussions A series of factors, including the intentional character of the milk contamination, the young age of the population affected, the large number of potentially contaminated products, the global distribution of these products, and the delay in reporting led this event to take on unexpected proportions. This incident illustrated the complexity of international trade of food products and food ingredients that required immediate actions at international level. Conclusion Managing food-safety events should be done internationally and early on as soon as multinational consequences are expected. Collaboration between food-safety authorities worldwide is needed to efficiently exchange information and to enable tracking and recalling of affected products to ensure food safety and to protect public health.

A multinational outbreak of salmonellosis linked to the Riga Cup 2015 junior ice-hockey competition was detected by the Finnish health authorities in mid-April and immediately notified at the European Union level. This prompted an international outbreak investigation supported by the European Centre for Disease Prevention and Control. As of 8 May 2015, seven countries have reported 214 confirmed and suspected cases, among which 122 from Finland. The search for the source of the outbreak is ongoing.

Between March and May 2013, three multi-country outbreaks of hepatitis A virus (HAV) infection were reported through the Epidemic Intelligence Information System for Food- and Water-borne diseases (EPIS-FWD) of the European Centre for Disease Prevention and Control (ECDC). The aim of this work is to put these outbreaks into a European Union (EU) and European Economic Area (EEA) perspective and highlight opportunities for improving detection and investigation of such outbreaks. Although HAV outbreaks are not unusual in the EU/EEA, having three large food-borne multi-country outbreaks declared within three months is an unexpected event, particularly when at least two of these outbreaks are associated with frozen berries. Factors influencing the occurrence of these events include the increased number of susceptible Europeans, the limited coverage of HAV vaccination, the global trade of potentially contaminated products introduced in the EU/EEA, and the 'awareness chain effect' leading to a wave of notifications. Further studies should be conducted to understand the risk posed by frozen berries. Laboratory capacity and surveillance of viral infections in the EU/EEA, as well as HAV vaccination recommendations to travellers to endemic countries should be strengthened. Finally, timely reporting food-borne events through EPIS-FWD, to ensure timely response. .

Between August 2011 and January 2013, an outbreak of Salmonella enterica serovar Stanley (S. Stanley) infections affected 10 European Union (EU) countries, with a total of 710 cases recorded. Following an urgent inquiry in the Epidemic Intelligence Information System for food-and waterborne diseases (EPIS-FWD) on 29 June 2012, an international investigation was initiated including EU and national agencies for public health, veterinary health and food safety. Two of three local outbreak investigations undertaken by affected countries in 2012 identified turkey meat as a vehicle of infection. Furthermore, routine EU monitoring of animal sources showed that over 95% (n= 298) of the 311 S. Stanley isolates reported from animal sampling in 2011 originated from the turkey food production chain. In 2004-10, none had this origin. Pulsed-field gel electrophoresis (PFGE) profile analysis of outbreak isolates and historical S. Stanley human isolates revealed that the outbreak isolates had a novel PFGE profile that emerged in Europe in 2011. An indistinguishable PFGE profile was identified in 346 of 464 human, food, feed, environmental and animal isolates from 16 EU countries: 102 of 112 non-human isolates tested were from the turkey production chain. On the basis of epidemiological and microbiological evidence, turkey meat was considered the primary source of human infection, following contamination early in the animal production chain.

International audience; From January to September 2013, a marked increase in notifications of Salmonella Paratyphi A infections among travellers returning from Cambodia occurred in France. An investigation revealed 35 cases without a common source: 21 in France, five in Germany, three in the Netherlands, one in Norway, one in the United Kingdom, four in New-Zealand. Data suggest an ongoing event that should trigger further investigation. Travellers to Cambodia should observe preventive measures including good personal hygiene and food handling practices.

International audience; An outbreak of the monophasic variant of Salmonella enterica serotype 4,[5],12:i:- occurred in November and December 2011 in France. Epidemiological investigation and food investigation with the help of supermarket loyalty cards suggested dried pork sausage from one producer as the most likely source of the outbreak. Despite the absence of positive food samples, control measures including withdrawal and recall were implemented.

The 25 European overseas countries and territories (OCTs) are closely associated with the European Union (EU) through the four related UE Member States: Denmark, France, the Netherlands and the United Kingdom. In 2008 and 2009, these four EU Member States, in association with the European Centre for Disease Prevention and Control (ECDC), reviewed the OCTs' needs, with the objectives of documenting their capacity to prevent and respond to infectious diseases outbreaks, and identifying deficiencies. This Euroroundup is based on the review's main findings, and presents an overview of the OCTs' geography and epidemiology, briefly introduces the legal basis on which they are linked to the EU and describes the surveillance and infectious disease response systems. As a result of their diversity the OCTs have heterogeneous epidemiological profiles. A common factor, however, is that the main burden of disease is non-communicable. Nevertheless, OCTs remain vulnerable to infectious diseases outbreaks. Their capacity for surveillance, early detection and response to such outbreaks is generally limited, with laboratory capacity issues and lack of human resources. Avenues for capacity strengthening should be explored by the OCTs and the related EU Member States, in collaboration with ECDC and regional public health networks where these exist. .

During 2008 to 2013, 215 outbreak alerts, also known as 'urgent inquiries' (UI), for food- and waterborne diseases were launched in Europe, the majority of them (135; 63%) being related to salmonellosis. For 110 (51%) UI, a potential food vehicle of infection was identified, with vegetables being the most reported category (34; 31%). A total of 28% (n = 60) of the outbreaks reported had an international dimension, involving at least two countries (mean: 4; standard deviation: 2; range: 2-14). Participating countries posted 2,343 messages (initial posts and replies, excluding updates), with a median of 11 messages per urgent inquiry (range: 1-28). Of 60 multicountry UI, 50 involved between two and four countries. The UI allowed early detection of multicountry outbreaks, facilitated the identification of the suspected vehicles and consequently contributed to the timely implementation of control measures. The introduction of an epidemic intelligence information system platform in 2010 has strengthened the role of the Food-and Waterborne Diseases and Zoonoses network in facilitating timely exchange of information between public health authorities of the participating countries.

A multistate outbreak of hepatitis A virus (HAV) among European travellers returning from Egypt occurred between November 2012 and April 2013. A total of 14 European Union (EU)-European Free Trade Association (EFTA) countries reported 107 cases. Twenty-one cases from six countries were affected by strains of sub-genotype IB harbouring identical RNA sequences, suggesting a common source outbreak. An international outbreak investigation team interviewed a number of cases with a trawling questionnaire to generate hypotheses on potential exposures. Some of these exposures were further tested in a case-control study based on a more specific questionnaire. Both trawling and case-control questionnaires aimed to collect cases' vaccination details as well as epidemiological information. Most cases participating in either questionnaire (35/43) had been staying in all-inclusive hotels located along the Red Sea. The case-control study found cases associated with exposure to strawberries or mango (multivariable analysis p value: 0.04). None of the 43 cases interviewed in any of the two questionnaires had been vaccinated. The most common reasons for non-vaccination was unawareness that HAV vaccination was recommended (23/43, 53%) and perceiving low infection risk in all-inclusive luxury resorts (19/43, 44%). Vaccination had not been recommended to five of the six cases who sought travel medical advice before travelling. Public health authorities should strongly reinforce measures to remind travellers, travel agencies and healthcare providers of the importance of vaccination before visiting HAV-endemic areas, including Egypt. .

Since the beginning of November 2014, nine outbreaks of highly pathogenic avian influenza virus (HPAIV) A(H5N8) in poultry have been detected in four European countries. In this report, similarities and differences between the modes of introduction of HPAIV A(H5N1) and A(H5N8) into Europe are described. Experiences from outbreaks of A(H5N1) in Europe demonstrated that early detection to control HPAIV in poultry has proven pivotal to minimise the risk of zoonotic transmission and prevention of human cases.

This perspective on hepatitis A in the European Union and European Economic Area (EU/EEA) presents epidemiological data on new cases and outbreaks and vaccination policies. Hepatitis A endemicity in the EU/EEA ranges from very low to intermediate with a decline in notification rates in recent decades. Vaccination uptake has been insufficient to compensate for the increasing number of susceptible individuals. Large outbreaks occur. Travel increases the probability of introducing the virus into susceptible populations and secondary transmission. Travel medicine services and healthcare providers should be more effective in educating travellers and travel agents regarding the risk of travel-associated hepatitis A. The European Centre for Disease Prevention and Control (ECDC) endorses the World Health Organization’s recommendations on vaccination of high-risk groups in countries with low and very low endemicity and on universal vaccination in countries with intermediate endemicity. Those recommendations do not cover the use of hepatitis A vaccine to control outbreaks. ECDC together with EU/ EEA countries should produce evidence-based recommendations on hepatitis A immunisation to control outbreaks. Data about risk behaviours, exposure and mortality are scarce at the EU/EEA level. EU/EEA countries should report to ECDC comprehensive epidemiological and microbiological data to identify opportunities for prevention.