Outbreak of carbapenemase-producing (NDM-1 and OXA-48) and colistin-resistant Klebsiella pneumoniae ST307, north-east Germany, 2019

Risk assessment

Germany has reported an outbreak of carbapenemase-producing (NDM-1 and OXA-48) and colistin-resistant Klebsiella pneumoniae sequence type (ST) 307. As of 21 October 2019, 17 patients in three hospitals and one rehabilitation clinic in Mecklenburg-West Pomerania in north-east Germany have been affected. Six of the 17 cases presented with clinical symptoms of infection, while 11 were identified as to be carriers.

Executive summary

Germany has reported an outbreak of carbapenemase-producing (NDM-1 and OXA-48) and colistin-resistant Klebsiella pneumoniae sequence type (ST) 307. As of 21 October 2019, 17 patients in three hospitals and one rehabilitation clinic in Mecklenburg-West Pomerania in north-east Germany have been affected. Six of the 17 cases presented with clinical symptoms of infection, while 11 were identified as be carriers.

This is the first reported outbreak in Germany of K. pneumoniae that produces both NDM-1 and OXA-48 while also involving the emerging clone ST307. The outbreak strain is closely related to a K. pneumoniae ST307 isolate producing the same carbapenemases detected earlier in Finland from a patient previously hospitalised in Russia, yet there is no epidemiological link between the Finnish case and the outbreak in Germany.

K. pneumoniae ST307 is a high-risk clone expanding globally, including in the EU/EEA. The specific German outbreak strain carries virulence markers associated with increased ability to cause disease. Genetic characteristics related to a potential survival advantage in the environment have also been described for K. pneumoniae ST307. The combination of extensive antimicrobial resistance, increased virulence and capacity to persist in the environment result in a high risk for dissemination and future healthcare-associated outbreaks of this K. pneumoniae ST307 outbreak strain in hospitals and other healthcare settings. By contrast, the risk of transmission for individuals outside healthcare settings is low. Enhanced control measures have been implemented in the involved German hospitals, and no further cases have been detected since the end of September 2019.

The highly virulent and resistant K. pneumoniae strain of this outbreak was introduced to the EU/EEA in at least two countries in 2019: Germany and in Finland. As not all EU/EEA countries have an effective screening system for carbapenemase-producing Enterobacteriaceae (CPE) in high-risk patients and may also lack the capacity to perform whole genome sequencing (WGS) – or do not routinely employ WGS on all carbapenem-resistant K. pneumoniae isolates collected at the national level – the number of such imported events may be considerably underestimated. In addition, several other high-risk clones of carbapenemase-producing K. pneumoniae have been spreading in hospitals and other healthcare settings in the EU/EEA in recent years. Hospital admissions of patients with previous hospitalisations, including prior hospitalisation in another country, are a daily occurrence in the EU/EEA, and the risk for further introduction of such high-risk clones of K. pneumoniae to hospitals in the EU/EEA, possibly resulting in other hospital outbreaks, is therefore high.

This outbreak also highlights the concomitant increase in virulence, transmissibility and antimicrobial resistance among certain K. pneumoniae strains, which are posing a considerably higher risk to human health than has previously been the case with the broader K. pneumoniae population. Early detection of such strains and close cooperation between clinicians and public health services are crucial to avoid spread into the EU patient population. There is a need for increased capacity in the EU/EEA to support outbreak investigations and surveillance with real-time WGS to identify high-risk clones and to implement enhanced control measures in order to avoid further spread.

Source: ECDC, November 2019.


ECDC: Insufficient vaccination coverage in EU/EEA fuels continued measles circulation

News story

A large measles epidemic has affected the EU/EEA Member States in the past three years, with 44 074 cases reported by 30 Member States between 1 January 2016 and 31 March 2019.

This is a high number of cases compared to the previous three years (2012–2015), according to a report issued by the European Centre for Disease Control and Prevention (ECDC) today.

Vytenis Andriukaitis, EU Commissioner for Health and Food Safety, said:

According to the objectives set by the World Health Organization, measles should have been eliminated in the European region already by 2000. However, Europe is still far from being a measles-free continent. These numbers are just unacceptable, especially given that an effective vaccine against the disease has existed since the 1960s”

Andrea Ammon, ECDC Director, said:

“Measles continues to be an EU-wide health threat. Due to failures in reaching the current global vaccination targets, 4.5 million children and teenagers in the EU/EEA below 20 years of age are unnecessarily at risk of measles. This number equals almost all children born in one year in the EU/EEA. Measles elimination can only be achieved through an active, relentless, and simultaneous commitment from all countries.”

Based on ECDC’s epidemiological assessment, there is a high risk of continued widespread circulation of measles in EU/EEA in the near future, as long as significant immunity gaps and suboptimal vaccination coverage remains. In the report, ECDC has focused on three of the main factors driving this risk:

  • A large pool of people susceptible to measles in the EU/EEA, due to low historical and current vaccination coverage. Among this group are children and teenagers born in the EU/EEA after 1999 who have not been vaccinated. According to ECDC estimates, this group accounts for almost one full annual EU/EEA birth cohort of more of than four-and-a-half-million children.  The total number of people susceptible to measles in the EU/EEA will greatly exceed this figure after accounting for infants too old to be protected by maternal antibodies but too young to be vaccinated, and the adults born pre-1999 that have never been immunized. The number of countries achieving the WHO target of 95% vaccination coverage for two doses of measles-containing vaccine has dropped significantly. In 2017, only four countries achieved the target compared to 14 countries in 2007. Vaccination coverage of 95% is necessary in order to eliminate the disease.
  • A high burden of measles among infants and adults. The EU/EEA median age of cases has progressively increased over the past ten years, from a median age of 10 years in 2009 to 17 years in 2019. Adults aged 20 years and above represented 35% of reported cases between 2016–19. In the same period, the average annual notification rates were highest in infants, up to 44 times higher than the other age groups. Almost half (45%) of all measles deaths were reported in infants.
  • The continued potential of importations, which can worsen existing outbreaks or start new ones in communities where measles is not currently circulating and where immunity gaps persist. Between 2016–2019 almost half (43%) of the cases imported into EU/EEA countries acquired their infection in another EU/EEA country, mainly those countries where measles are endemic and/or are experiencing large outbreaks. As measles continues to circulate widely within the region, it remains an EU-wide threat capable of affecting any country with immunity gaps.

The report lists a number of options for tackling the problem. The most important intervention is to ensure a high-quality routine immunization program, reaching 95% vaccination coverage at the subnational level. It is also important to increase the opportunities for checking vaccination status and offer vaccination as appropriate and to offer supplementary immunization activities to close immunity gaps in older populations. Measles vaccination should be offered and promoted to those professions that involve frequent direct contact with other individuals. Furthermore, checking and updating vaccination status should be a routine practice during travel medicine consultations and general health checks.

Vytenis Andriukaitis, EU Commissioner for Health and Food Safety, concluded:

“We have to face the ‘reality check’: only four EU countries achieve the necessary target of at least 95% coverage for two doses that leads to herd immunity. Why this is important? It matters because we protect each other: in order to eliminate the disease and protect those of us who cannot be vaccinated for different reasons, we all need to vaccinate. It is not just about personal choice, it is also a form of solidarity. Both as a medical doctor and Commissioner for Health, I have been keeping vaccination very high on my priority list and I am particularly looking forward to the Global Vaccination summit that will take place September 12. This Summit will give us an opportunity to hold a fulsome debate and give a strong message: vaccines save lives and we have to be serious about it.”

Source: ECDC, June 2019.

33000 people die every year due to infections with antibiotic-resistant bacteria


An ECDC study estimates the burden of five types of infections caused by antibiotic-resistant bacteria of public health concern in the European Union and in the European Economic Area (EU/EEA).

The burden of disease is measured in number of cases, attributable deaths and disability-adjusted life years (DALYs). These estimates are based on data from the European Antimicrobial Resistance Surveillance Network (EARS-Net) from 2015.

The authors said “the estimated burden of infections with antibiotic-resistant bacteria in the EU/EEA is substantial compared to that of other infectious diseases, and increased since 2007. Strategies to prevent and control antibiotic-resistant bacteria require coordination at EU/EEA and global level. However, our study showed that the contribution of various antibiotic-resistant bacteria to the overall burden varies greatly between countries, thus highlighting the need for prevention and control strategies tailored to the need of each EU/EEA country”.

The study estimates that about 33000 people die each year as a direct consequence of an infection due to bacteria resistant to antibiotics and that the burden of these infections is comparable to that of influenza, tuberculosis and HIV/AIDS combined. It also explains that 75% of the burden of disease is due to healthcare-associated infections (HAIs) and that reducing this through adequate infection prevention and control measures, as well as antibiotic stewardship, could be an achievable goal in healthcare settings.

Finally, the study shows that 39% of the burden is caused by infections with bacteria resistant to last-line antibiotics such as carbapenems and colistin. This is an increase from 2007 and is worrying because these antibiotics are the last treatment options available. When these are no longer effective, it is extremely difficult or, in many cases, impossible to treat infections.

The study was developed by experts at ECDC and the Burden of AMR Collaborative Group, and published in The Lancet Infectious Diseases. The results of this study are also used by the Organisation for Economic Co-operation and Development (OECD) to estimate the economic burden of antibiotic resistance.


Weekly updates: 2018 West Nile fever transmission season

Situation update

Between 5 and 11 October 2018, EU Member States reported 85 human West Nile virus infections in Italy (41), Romania (12), Greece (11), France (6), Hungary (6), Bulgaria (5), Austria (3) and the Czech Republic (1). EU neighbouring countries reported 48 cases in Israel (29) and Serbia (19).
In two areas (NUTS 3 level), human cases were reported for the first time, one new area in France and one in Bulgaria. All other human cases were reported from areas that have been affected during previous transmission seasons.
This week, 12 deaths were reported by Italy (7), Romania (2), Serbia (2) and Greece (1).

In the same week, 13 outbreaks among equids were reported by Hungary (5), France (3), Italy (2), Germany (1), Greece (1) and Spain (1).

In September, a 31-year-old veterinarian was diagnosed with suspected West Nile Virus (WNV) infection after having performed necropsy of a just-deceased owl (great grey owl, Strix nebulosa) found in a wildlife park near Poing, Ebersberg, Bavaria. WNV was detected in the owl by PCR in tissue samples recovered during the necropsy. In the veterinarian, positive serological tests, with IgM antibodies (IF titre 1:80), strongly indicated WNV infection. Further tests of follow-up samples from the patient to confirm the diagnosis are pending.

Assessment: WNV infections acquired after occupational exposure by necropsy on birds (blue jay, the USA, 2002), mice (in the USA, 2002) and horses (South Africa, 2008) have been reported in literature, and are not unexpected. It is important to note that in this case, transmission by mosquitoes can be excluded.

In 2018 and as of 11 October 2018, EU Member States have reported 1 402 human cases in Italy (536), Greece (294), Romania (268), Hungary (203), Croatia (45), France (22), Austria (18), Bulgaria (11), Slovenia (3) and the Czech Republic (2). EU neighbouring countries reported 482 human cases in Serbia (369), Israel (110) and Kosovo* (3). To date, 154 deaths due to West Nile virus infection have been reported by Italy (43), Romania (38), Greece (35), Serbia (34), Bulgaria (1), the Czech Republic (1), Hungary (1) and Kosovo* (1).

During the current transmission season, 235 outbreaks among equids have been reported by Italy (122), Hungary (84), Greece (14), France (8), Romania (2), Germany (2), Austria (1), Spain (1) and Slovenia (1).

In accordance with European Commission Directive 2014/110/EU, prospective blood donors should defer for 28 days after leaving an area with evidence of West Nile virus circulation among humans unless the results of an individual nucleic acid test are negative.

*This designation is without prejudice to positions on status, and is in line with UNSCR 1244 and the International Court of Justice Opinion on the Kosovo Declaration of Independence.

Source: ECDC, 15 Oct 2018


Weekly updates: 2018 West Nile fever transmission season

Situation update

Between 17 and 23 August 2018, EU Member States reported 136 human cases of West Nile fever: Italy (59), Greece (31), Romania (25), Hungary (19) and France (2). EU neighboring countries reported 82 cases: Israel (49) and Serbia (33).

Human cases were reported for the first time in two areas in Romania and one area in Greece. All other human cases were reported from areas that have been affected during previous transmission seasons.

This week, 19 deaths were reported by Greece (7), Romania (5), Serbia (4) and Italy (3).

In the same week, ten outbreaks among equids were reported by Hungary (6), Greece (2) and Italy (2).

In 2018, as of 23 August 2018, EU Member States reported 410 human cases: Italy (183), Greece (106), Hungary (58), Romania (56), France (5) and Croatia (2). EU neighboring countries reported 210 human cases: Serbia (159), Israel (49) and Kosovo* (2). To date, a total of 39 deaths due to West Nile fever have been reported by Serbia (15), Greece (11), Italy (6), Romania (6) and Kosovo*(1).

During the current transmission season, 64 outbreaks among equids have been reported by Italy (41), Hungary (18) and Greece (5).

*This designation is without prejudice to positions on status and is in line with UNSCR 1244 and the International Court of Justice Opinion on the Kosovo Declaration of Independence.

Listeria monocytogenes outbreak: 47 cases including 9 deaths

Frozen corn and possibly other frozen vegetables produced in a company in Hungary are the likely source of an outbreak of Listeria monocytogenes that has been affecting Austria, Denmark, Finland, Sweden and the United Kingdom. Despite the product recall ordered by the Hungarian Food Chain Safety Office, new cases may still emerge, says the updated risk assessment published by ECDC and the European Food Safety Authority (EFSA).

As of 8 June 2018 and since 2015, 47 listeriosis cases have been confirmed as part of this outbreak, nine of them resulting in death, which represents a case fatality rate of 19%.

On 29 June 2018, the Hungarian Food Chain Safety Office banned the marketing of all frozen vegetables and frozen mixed vegetables produced by the company between August 2016 and June 2018, and ordered their immediate withdrawal and recall. All freezing activity at the plant was stopped in June 2018.

The recall is likely to reduce the risk of human infections significantly, but new cases may still emerge as long as contaminated products are still on the market and in consumer’s freezers. Additionally, the long incubation period of listeriosis (up to 70 days), the long shelf life of frozen corn products and the consumption of frozen corn bought before the recall and eaten without being properly cooked can also originate new cases. Any contaminated vegetables from the 2017 and 2016 production seasons are a risk for consumers until their withdrawal and recall is completed.

To reduce the risk of Lmonocytogenes infection due to frozen vegetables, ECDC and EFSA’s risk assessment suggests that consumers should thoroughly cook frozen vegetables that are not labelled as ready-to-eat, even those that are sometimes consumed without cooking, for example in salads and smoothies. This applies especially to consumers most at highest risk of contracting listeriosis – such as the elderly, pregnant women, and persons with weakened immune systems.

The food source of this outbreak was initially thought to be limited to frozen corn, but the use of whole genome sequencing found matching strains of L monocytogenes in other frozen vegetables produced by the Hungarian company in 2016, 2017 and 2018. The finding suggests that the strains have persisted in the processing plant despite the cleaning and disinfection procedures that were carried out. The ECDC-EFSA report calls for further investigations, including thorough sampling and testing, to identify the exact points of contamination.

Source: ECDC, 4 Jul 2018


Europe is free of polio, but the risk of importation remains.

The WHO European Region is polio-free, says European Regional Certification Commission (RCC). Three
countries (Bosnia and Herzegovina, Romania and Ukraine) remain of special concern to the RCC expert
panel due to suboptimal immunization coverage, weakness in surveillance, vaccine shortages and other
The circulation of wild poliovirus in countries outside Europe shows that there is a continued risk for the
disease being imported into the Region. Outbreaks of vaccine-derived poliovirus types 2 and 3 in several
African countries and in Syria show the potential risk for further international spread. Such outbreaks can
only occur when the population is insufficiently immunized.
Efforts are underway throughout the Region to comply with WHO recommendations on containment of
all polioviruses currently held in laboratories or vaccine manufacturing facilities. Countries are expected
to either destroy potentially infectious poliovirus materials or ensure they are securely stored in a WHOcertified
poliovirus essential facility.
For options for intervention available to EU/EEA Member States, see the ECDC risk assessment. An
update of the current global polio situation can be found below.

ECDC: Check your vaccination status before the holiday season


12 Jun 2018

Measles cases continue to increase in EU/EEA countries with more countries experiencing outbreaks of the disease.

ECDC Director Andrea Ammon says,

Measles outbreaks are still occurring in a number of EU countries. This fact makes it more important than ever for people to get vaccinated with two doses of a measles-containing vaccine to protect themselves and their families before the holiday season.

The highest number of cases to date in 2018 is in Romania (3 284), France (2 306), Greece (2 097) and Italy (1 258) respectively. Twenty-five deaths have also been reported by these countries in 2018. Additionally, there is an ongoing outbreak in England and Wales with 1 346 confirmed measles cases reported this year. This is according to the most recent measles data collected by ECDC through epidemic intelligence and published in the Communicable Diseases Threats Report (CDTR).

ECDC also publishes its ECDC’s monthly measles and rubella monitoring report which gives more information on age and distribution of cases as well as vaccination coverage rates.

In order to reach elimination and protect those most vulnerable to severe complications and death from measles such as infants, 95% of the population needs to be vaccinated with two doses of measles-containing vaccine. Only five EU/EEA countries reported at least 95% vaccination coverage for both doses of measles-containing vaccine according to the most recent data collected (WHO 2016 ), showing that further sustained action is needed.



Unveiling vaccine hesitancy in the Federation of Bosnia and Herzegovina

April 2018

A young girl is smiling as a doctor injects vaccine, in Bosnia and Herzegovina

Rates of immunization in the Federation of Bosnia and Herzegovina are declining.

Immunization rates in the Federation of Bosnia and Herzegovina are as low as 40% in some areas and continuing to decline, increasing the risk of large disease outbreaks. But, no one knows precisely why.

Growing vaccine hesitancy, misinformation in social media, lack of trust in the health system, a shortage of health workers and supply issues are all suspected reasons for low coverage rates. However, these are mostly assumptions with little evidence.

“Right now our immunization programming is based on a lot of assumptions,” says Dr Sanjin Musa, epidemiologist at the Institute for Public Health in Bosnia and Herzegovina. “We need better data to understand which population groups have the lowest coverage and why it is so low.”

Using WHO’s Tailoring Immunization Programme (TIP) – a structured research approach – the country is working to identify populations susceptible to vaccine-preventable diseases, diagnose barriers and motivators to vaccination, and recommend evidence-informed responses to improve coverage.

State of immunization

TIP was developed in 2013 by the WHO Regional Office for Europe to assist health care professionals, public health authorities and decision-makers in tailoring services to close gaps in immunization coverage. The first step in the TIP process is for countries to conduct a situational analysis to take stock of data on coverage and outbreaks, gather key stakeholders, and identify knowledge gaps.

In 2016, only 78% of children in Bosnia and Herzegovina received the third does of diphtheria-tetanus-pertussis (DTP)-containing vaccine, 79% received the third dose of polio, and 83% the first dose of measles vaccine – all falling short of global targets of at least 90 to 95%. Vaccination coverage also varies greatly within cantons and cities, and in some areas rates fall between 40-50%.

These low rates put the country’s population at-risk for large disease outbreaks. In the last decade there have been large outbreaks of measles, mumps and rubella, in part due to the disruption of immunization programmes during the war in the early 1990s, but also to vaccine hesitancy.

“With current large measles outbreaks across the Region, including in nearby Italy, Romania and Serbia, the country is constantly on high alert for outbreaks.”

Dr Sanjin Musa, epidemiologist at the Institute for Public Health in Bosnia and Herzegovina

“With current large measles outbreaks across the Region, including in nearby Italy, Romania and Serbia, the country is constantly on high alert for outbreaks,” says Dr Musa. Immunization is free and mandatory in the country, but there are no mechanisms to ensure compliance.

Researching reasons for low coverage

After the TIP situation analysis was completed in 2017, the country began working to identify areas where more research was needed. They are now conducting two studies.

The first study is looking at health worker attitudes towards immunization in order to develop further trainings and tools. Some health workers currently either lack knowledge about immunization or fear allegations following adverse events.

The second study is reviewing patient records in primary care centres in order to identify characteristics of caregivers who do or do not vaccinate their children, such as age, number of children or income level. Once these characteristics are defined, immunization strategies can be develop to improve access to immunization and reduce vaccine hesitancy.

“Building trust and understanding the community is essential to responding to vaccine hesitancy,” says Katrine Bach Habersaat, Technical Officer, Vaccine-preventable Disease and Immunization in the WHO Regional Office for Europe. “Many people assume vaccine hesitancy is about people being unwilling to be vaccinated, but under the surface it is often about the convenience factor and how easy it is to get their children vaccinated.”

The country’s TIP studies are expected to be completed later this year. It is part of WHO’s work with 11 countries in south-eastern Europe to speed up progress in reaching the goals and strategic objectives of the European Vaccine Action Plan 2015–2020 (EVAP).



“Thanks, anti-vaxxers: Measles is on the rise in Europe
Our grip on infectious diseases is slipping as people turn away from vaccination”

(Sara Chodosh, February 21, 2018.)


Measles – WHO European Region

Between 1 January 2014 and 1 March 2015, WHO received notification of over 23 000 cases of measles in the WHO European Region. The most affected country is Kyrgyzstan with over 7 000 cases reported in just the first seven weeks of 2015. Significant numbers of measles cases have also been reported in Bosnia and Herzegovina, Croatia, Georgia, Germany, Italy, Kazakhstan, Russian Federation and Serbia.

Measles virus D8 has been the most commonly identified circulating genotype.

WHO advice

Based on the current situation and available information, WHO encourages Member States to scale up vaccination against measles across age groups at risk. This will help putting an end to the several outbreaks currently hitting countries of the European Region and preventing similar outbreaks in the future.

At the same time, all countries need to maintain a very high routine measles vaccination coverage so that similar outbreaks will not happen again in the Region, and measles can be eliminated once and for all.

Disease outbreak news
6 March 2015