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SURVEILLANCE REPORTAnnual Threat Report2009www.ecdc.europa.eu

Annual Threat Report2009

Annual Threat Report 2009The authors would like to thank the Competent Bodies for ThreatDetection in the Member States of the European Union for the reviewof selected threats related to their countries, namely Mike Catchpole,Robert Muchl, Márta Melles, Krisztalovics Katalin, Filomina Raidou,Assimoula Economopoulou, Rezza Giovanni, Florin Popovici, AndreasGilsdorf, Radosveta Filipova, Paul McKeown, Derval Igoe, SuzanneCotter, Marianne AB van der Sande, and José Sierra Moros.Suggested citation for full report:European Centre for Disease Prevention and Control.Annual Threat Report 2009. Stockholm: ECDC; 2010.Cover picture GettyISBN 978-92-9193-217-7ISSN 1831-9289DOI 10.2900/33498 European Centre for Disease Prevention and Control, 2010.Reproduction is authorised, provided the source is acknowledged.iiSURVEILLANCE REPORT

SURVEILLANCE REPORTAnnual Threat Report 2009ContentsGlossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vPreface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Descriptive analysis of emerging threats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.1 Temporal analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.2 Analysis by disease group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.3 Analysis by source of initial notification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.4 Analysis by region of origin and affected countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Response to threats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.1 Published threat assessments (TA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.2 Targeted expert consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.3 Mobilisation of expertise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Threats of particular interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.1 Urgent inquiries concerning food- and waterborne diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.2 Salmonella Goldcoast in Hungary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.3 VTEC in UK related to petting farms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.4 Suspicion of intentional release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.5 Biosafety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.6 Vaccine safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.7 Mumps outbreaks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.8 Measles outbreaks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.9 Contaminated drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.10 Threats related to legionellosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.11 West Nile virus in Europe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.12 Q fever in the Netherlands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.13 Autochthonous malaria in Greece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.14 Selected influenza threats in 2009 in EU/EFTA countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21iii

SURVEILLANCE REPORTAnnual Threat Report 2009GlossaryARIAcute respiratory infectionE.EscherichiaECDCEuropean Centre for Disease Prevention and ControlEEAEuropean Economic AreaEFTAEuropean Free Trade AssociationEMAEuropean Medicines AgencyEMCDDAEuropean Monitoring Centre for Drugs and Drug AddictionEPIETEuropean Programme on Intervention Epidemiology TrainingEUEuropean UnionEUROPOL European Police OfficeEWGLIEuropean Working Group on Legionella InfectionsEWGLINET European surveillance scheme for travel-associated legionnaires' diseaseEWRSEarly Warning and Response SystemFWDFood- and waterborne diseasesGPHINGlobal Public Health Intelligence NetworkHPAIHighly pathogenic avian influenzaIDUInjecting drug usersILIInfluenza-like illnessMedISysMedical information systemMMRMeasles-mumps-rubella vaccinePEPPost-exposure prophylaxisPHEPublic health emergencyProMEDProgram for Monitoring Emerging DiseasesPTPhage typeS.SalmonellaSANCO C3 Directorate General for Health and Consumers, public health and risk assessment, health threatsSANCO C7 Directorate General for Health and Consumers, public health and risk assessment, risk ucing Escherichia coliTESSyThe European Surveillance SystemTTTThreat Tracking ToolUINUrgent Inquiry NetworkVTECVerocytotoxin-producing Escherichia coliWHOWorld Health OrganizationWNNDWest Nile neuroinvasive diseaseWNVWest Nile virusv

Annual Threat Report 2009SURVEILLANCE REPORTPrefaceECDC exists to help the EU and its Member States protectEuropeans from infectious diseases. In order to do this,ECDC and its partners need to be constantly vigilant againstthe emergence of new epidemics and other such healththreats. Epidemic intelligence officers in ECDC, togetherwith our national and international counterparts, are therefore exchanging information and monitoring for unusualpatterns of illness, seven days a week, 52 weeks a year.Most years, this work is largely invisible. Small-scale multicountry disease outbreaks happen pretty much every weekin Europe: Legionella bacteria are found in the water pipesin a large holiday hotel, and tourists from two or threedifferent countries are identified as having being exposedto them. A food processing plant in one country seems tobe the source of salmonella infections in a neighbouringcountry. EU-level information sharing enables us to quicklyidentify and assess these sorts of threats. National healthauthorities then work together with ECDC, the EuropeanCommission and each other to resolve the situation andprotect the people at risk. These sorts of outbreaks rarelymake headlines or command the attention of policy makers.However, they can have a profound impact on the peopleaffected. Both the pathogens I mentioned earlier, andmany others that we deal with, can cause severe illnessand even death. The value of ECDC’s work on rapid detection and assessment of health threats, then, is that it canhelp national authorities to save lives. This is happeningday after day, week after week in Europe.The 2009 influenza A(H1N1) pandemic, thankfully, provedto be less deadly than had first been feared. Nonetheless,as of 3 May 2010 nearly three thousand people in the EUwere confirmed as having died from this virus, with the totaldeath toll (i.e. including people who died from the virus,but were never tested for it) likely to be much higher. Evena relatively benign multi-country outbreak has some fatalconsequences. This is something the health professionalsin ECDC, the European Commission and their nationalcounterparts are well aware of. It is why we strive eachyear to be vigilant against health threats and work togethereffectively to protect EU citizens from them.I hope you will find this report interesting and useful.Marc SprengerDirector2009 was unusual in that a multi-country disease outbreakoccurred that did, in fact, grab the attention of policy makersand the media in Europe, and indeed around the world. I amtalking, of course, of the 2009 influenza A(H1N1) pandemic.The pandemic virus emerged in Mexico and the US in lateApril 2009, and within a matter of days, cases were beingseen in EU countries. One of the key findings of this reportis that the infrastructure and systems in place in the EU fordealing with health threats were heavily used by MemberStates during the 2009 pandemic, and proved to be veryuseful. National authorities shared a lot of informationwith each other on the situation in their countries andbenefited from authoritative epidemiological analyses,risk assessments and scientific guidance from ECDC.1

Annual Threat Report 2009SURVEILLANCE REPORTIntroductionWhen ECDC became operational in 2005, it started to ‘gatherand analyse data and information on emerging publichealth threats’ (Article 9 of the Founding Regulations of theCentre1). According to Article 2(e), health threat ‘shall meana condition, agent or incident which may cause, directly orindirectly, ill health’. Article 3(1) of the Founding Regulationsfurther states that ECDC’s mission is to ‘identify, assess andcommunicate current and emerging threats to human healthfrom communicable diseases’, while Article 8 adds thatECDC shall ‘assist the Commission by operating the earlywarning and response system’ and ‘analyse the content ofmessages received by it’. ECDC has been hosting the EarlyWarning and Response System (EWRS) application sinceNovember 2007 and assists the European Commission byoperating the system2-9.This is the first Annual Threat Report published as a separate document. Previously, it was included in the ECDCAnnual Epidemiological Report, where event- and indicatorbased surveillance results were presented together.This document describes emerging threats that were eitherdirectly reported to ECDC through Member State notifications on EWRS according to defined criteria2, 3, or foundthrough active screening of various sources, includingnational epidemiological bulletins, international networks(Program for Monitoring Emerging Diseases (ProMED),Global Public Health Intelligence Network (GPHIN)), media,and various additional sources, both formal and informal.The EWRS was implemented in 1998, based on Decision2119/98/EC of the European Parliament and of the Councilto set up a network for epidemiological surveillance andcontrol of communicable diseases in the Community.The first message distributed in the EWRS was relatedto legionellosis and posted on 30 October 199810. A newEWRS application was introduced on 17 May 2004 andhas been hosted by ECDC since 17 November 2007. EWRSmessages are labelled according to their activation level,where level 1 refers to ‘information exchange’, level 2indicates a ‘potential health threat’ and level 3 a ‘definitepublic health threat’2. In the EWRS application, events canbe posted as original messages (message threads) or ascomments to original messages. In addition, messages canbe posted as a selective exchange of information betweenMember States, e.g. if not all Member States are concernedor if confidential information is exchanged (e.g. contacttracing). It should be noted that the number of messagethreads, comments and selective exchange messagesreported through the EWRS does not correspond to thethreats monitored by ECDC in the course of its routineepidemic intelligence activities.All health threats identified through epidemic intelligenceactivities are documented and monitored by using a dedicated database, called the Threat Tracking Tool (TTT). Alldata analysed in this report are extracted from this tool.The analysis covers the period from June 2005, when theTTT was activated, until the end of 2009, with specialemphasis on threats emerging in 2009.The expression ‘opening a threat’ refers to the way ECDCassesses threats during its daily threat review meetings,internally known as ‘roundtable meetings’. The roundtableconsists of ECDC experts that evaluate potential threatsand validate events which require further attention oraction from ECDC due to their relevance for public healthor the safety of EU citizens. The following criteria to opena threat and further monitor an event are used: More than one Member State is affected. A disease is new or unknown, even if there are no casesin the EU. There is a request from a Member State or from a thirdparty for ECDC to deploy a response team. There is a request for ECDC to prepare a threat assessment of the situation. There is a documented failure in an effective controlmeasure (vaccination, treatment or diagnosis). There is a documented change in the clinical/epidemiological pattern of the disease, including changesin disease severity, the way of transmission, etc. The event matches any of the criteria under the IHR orEWRS.Following Decision No. 2000/57/EC of the EuropeanParliament and of the Council, events are consideredrelevant to be reported to the EWRS if one or more ofthe criteria mentioned below are met2. After the revisedInternational Health Regulations (IHR) entered into force on15 June 2007, the decision was amended, and criteria nowinclude both IHR notifications and the possible exchangeof details following contact tracing 3.EWRS criteria1. Outbreaks of communicable diseases extending to morethan one Member State of the Community.2. Spatial or temporal clustering of cases of a disease of asimilar type if pathogenic agents are a possible causeand there is a risk of propagation between MemberStates within the Community.3. Spatial or temporal clustering of cases of disease of asimilar type outside the Community if pathogenic agentsare a possible cause and there is a risk of propagationto the Community.4. The appearance or resurgence of a communicabledisease or an infectious agent which may require timelycoordinated Community action to contain it.3

Annual Threat Report 20095. Any IHR notification has to be reported also throughEWRS.6. Any event related to communicable diseases with apotential EU dimension necessitating contact tracingto identify infected persons or persons potentially indanger may involve the exchange of sensitive personaldata of confirmed or suspected cases between concernedMember States.Analysis is performed both quantitatively (e.g. comparingthe number of threats) and qualitatively (describing thecontent of threats).4SURVEILLANCE REPORT

Annual Threat Report 2009SURVEILLANCE REPORT1 Descriptive analysis of emerging threats1.1 Temporal analysisThe 192 emerging threats monitored in 2009 representa 24% decrease compared with 2008. This decrease islargely related to the emergence of the 2009 pandemicinfluenza A(H1N1) at the end of April 2009, which promptedan unprecedented worldwide response and resulted infewer threats being reported (and therefore monitored) inepidemic intelligence sources, including EWRS11.Threats monitored in TTTSince June 2005, 806 threats have been monitored, witha median of 13 threats per month and a range of 5 to 39.The seasonal distribution of threats shows a tendency topeak around summer and autumn. These peaks are mainlyrelated to food- and waterborne diseases and legionellosisrelated threats (Figures 1 and 2).Messages circulated in EWRSFrom January 2005 until the end of 2009, 934 new messagethreads were posted in the EWRS. In 2009, the number ofmessage threads (509) increased fivefold compared withthe previous two years (Table 1). In addition, the proportion of level 3 messages (definite public health threat)increased from less than 2% for the period 2006 to 2008to 44% (226) in 2009 (Figure 3). The influenza pandemic ismainly responsible for this increase in the number of TTTthreats: 88% (449) of all message threads and 99% (223) oflevel 3 message threads in 2009 were related to influenza.In 2009, ECDC monitored 192 threats, of which 174 (91%)were new threats opened in 2009, 10 (5%) were carriedover from 2009, and 8 (4%) represented recurrent threats,opened prior to 2009 and monitored continuously. Recurrentthreats were related to human cases of avian influenza(worldwide since 2005, in the European region in 2005),chikungunya fever (2005), poliomyelitis (2005), denguefever (2006), cholera (2006), as well as two threats relatedto the new variant of Creutzfeldt-Jakob disease (2006, 2007).Figure 1: Distribution of threats monitored through TTT by month, June 2005 to December 2009,EU and EFTA Member StatesNumber of newly opened JanJunJanJunJanJun02009Figure 2: Distribution of threats by month, 2006 to 2009, EU and EFTA Member StatesFood- and waterborne diseases80Legionelliosis60Other mber of newly opened threats1005

Annual Threat Report 2009SURVEILLANCE REPORTThe majority of all threats (81%) were related to clustersof legionellosis (Figure 5).The number of message comments (820) posted in responseto new notifications increased almost fourfold comparedwith 2008, as did the number of selective exchanges(721) (Table 1).The proportion of threats related to food- and waterborneoutbreaks decreased from 42% (42) in the second halfof 2005 to 15% in 2009 (29), while the number of monitored threats on a yearly basis was similar for the entiremonitoring period, ranging between 29 and 68 threats(Table 2). The proportion of threats related to vaccinepreventable diseases varied between 6% and 13% (11–28threats) over the monitoring period; in 2009, 18 threats(9%) were monitored. Eight threats monitored in 2009were related to tuberculosis (4%) and four to hepatitis,HIV and blood-borne infections. No threats regardinghospital-acquired infections and antimicrobial resistancewere monitored in 2009.EWRS system usage (user access) increased significantlyin April 2009, after the start of the 2009 influenza A(H1N1)pandemic (Figure 4).1.2 Analysis by disease groupThe distribution of threats monitored per disease groupin 2009 is comparable to those monitored in previousyears (Table 2), except for threats related to diseases ofenvironmental or zoonotic origin, which increased from20 (20%) monitored threats in 2005 to 114 (59%) in 2009.Figure 3: Distribution of EWRS message threads by year of posting and level, 2005 to 2009,EU and EFTA Member States600Level 1Number of messages500Level 2400Level 3300Other messages200100020052006200720082009Table 1: Distribution of EWRS message threads, comments and selective exchange by year of posting,EU and EFTA Member StatesYear of posting20052006200720082009Overall totalMessage threads1031388599509934Message comments1312233002108201,684Figure 4: Frequency of EWRS usage by day, 2009, EU and EFTA Member StatesNumber of newly opened 1/090Selective messages2502081697211,150

Annual Threat Report 2009SURVEILLANCE REPORTThe majority of monitored threats (n 140, 80%) in 2009originated from confidential sources (sources with restrictedaccess). EWRS accounted for 30% of monitored threatsfrom confidential sources (42 threats). The number ofthreats originating from public sources decreased by 36%compared to 2008 (Table 3). Information from confidentialsources including the EWRS is treated as confidential andonly distributed to the EWRS Focal Points in the MemberStates until it becomes publicly available, either throughmedia sources or through publication in scientific journals,e.g. Eurosurveillance.Six of the monitored threats in 2009 were not related tospecific diseases but to events, i.e. mass gatherings (the 6thFrancophone Games in Beirut, the Universiade in Belgrade,the EXIT and Guca festivals in Serbia, and the 12th IAAFWorld Championships in Athletics in Berlin), an earthquakein Italy’s Abruzzo region, a request for information fromthe European Commission on the unexplained death of alaboratory worker in Taiwan, and a request from the US CDCon animal die-offs in Spain and the risk to human health.In 2009, thirteen of the monitored threats (7%) wererelated to influenza, including the 2009 influenza A(H1N1)pandemic. Other monitored threats related to influenza werethe recurrent threat of avian influenza (worldwide and in theEuropean region), seasonal influenza, the contaminationof an experimental influenza A(H3N2) vaccine with a liveA(H5N1) strain, an outbreak of highly pathogenic influenzaA(H7) virus in poultry in Spain, a human case of influenzaA(H9N2) in Hong Kong, and influenza A(H3N2) in mink inDenmark. Nevertheless, the most common events monitoredin 2009 were clusters of travel-associated legionellosis,which accounted for 48% of the monitored threats.1.4 Analysis by region of originand affected countriesSeventy percent of the monitored threats in 2009 affectedthe EU and EEA/EFTA countries. This proportion has beensteadily increasing from 35% in the second half of 2005(Figure 6).The 2009 influenza A(H1N1) pandemic was monitoredfrom a global perspective, as were the threats related toA(H5N1) avian influenza, chikungunya fever, dengue fever,cholera and poliomyelitis. During 2009, the monitoredthreats affected 112 countries worldwide, excluding the2009 influenza A(H1N1) pandemic.1.3 Analysis by source of initialnotificationIn 2009, the European Working Group on LegionellaInfections (EWGLI) was the main source of new threats thatwere reported in relation to clusters of travel-associatedlegionellosis.Of 30 EU/EEA countries, 26 (87%) were affected by monitored threats, excluding the 2009 influenza A(H1N1)pandemic. Italy was the country most affected by monitoredTable 2: Number of threats monitored by year and group of disease, EU and EFTA Member StatesDisease groupsFood- and waterborne diseasesVaccine-preventable diseases and diseases due to invasive bacteriaInfluenzaTuberculosisHepatitis, HIV, sexually transmitted infections, blood-borne infectionsAntimicrobial resistance and healthcare- associated infectionsDiseases of environmental or zoonotic originOtherOverall total**2005*42136213201299Year and number of threats 63843111037095886* Includes only the second half of 2005.** The number of new threats monitored does not correspond to the number of threats monitored by year as several threats were carried over from previous year(s).Figure 5: Number of threats monitored by year, June 2005 to December 2009, EU and EFTA Member StatesNumber of monitored threats300Legionella clusters250Other threats200150100500200520062007200820097

Annual Threat Report 2009SURVEILLANCE REPORTAmong the three candidate countries (the former YugoslavRepublic of Macedonia, Turkey, Croatia) and the five potential candidate countries (Serbia, Bosnia and Herzegovina,Montenegro, Albania and the United Nations-administeredprovince of Kosovo), three were affected by a total of 14monitored threats: Turkey (11), Croatia (2) and Serbia (1).Again, these numbers exclude the monitoring of the 2009pandemic influenza A(H1N1).threats (41 threats), which accounted for 21% of the 192threats that affected EU/EEA countries in 2009. The majorityof the monitored threats from Italy were due to clustersof legionellosis (n 32, 78%). ECDC monitored 24 threatsfrom the UK, 18 threats each from France and Spain, and15 from Germany. All other EU/EEA countries accountedfor fewer than 10 monitored threats in 2009.No threats in relation with Iceland, Liechtenstein, Lithuaniaor Luxembourg were monitored in 2009, with the singleexception of pandemic influenza A(H1N1).Table 3: Initial sources of information for newly opened threats, by year, EU and EFTA Member StatesNumber of new threats monitoredConfidential sourcesEWGLIEWRSWHOInformation from Member StatesEuropean surveillance networksOther confidential sourcesTotalPublic sourcesPROMEDMedIsysGPHINEurosurveillancePublic reports available on the internetOther public sourcesTotalOverall 17255322857408103417485153235138224806* Includes only the second half of 2005.** The number of new threats monitored does not correspond to the number of threats monitored by year as several threats were carried over from previous year(s).Figure 6: Distribution of monitored threats in 2009 by affected region(s), EU and EFTA Member StatesRussiaAustralia and OceaniaWorldwideMiddle-EastAmericasAsiaAfricaOther European countriesEU/EEA/EFTA08306090120150

Annual Threat Report 2009SURVEILLANCE REPORT2 Response to threatsIn 2009, ECDC’s response

SURVEILLANCE REPORT Annual Threat Report 2009 v ARI Acute respiratory infection E. Escherichia ECDC European Centre for Disease Prevention and Control EEA European Economic Area EFTA European Free Trade Association EMA European Medicines Agency EMCDDA European Monitoring Centre for Drugs and Drug Addictio

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