WHO European Region (EUR) 2011-2012

The World Health Organization (WHO) Regional Office for Europe (EURO) supports public health programs in 53 Member States in the WHO European Region. Currently, there are four bilateral influenza cooperative agreements that support influenza activity in the EURO Region. These cooperative agreements are with ministries of health or other institutions that work with the U.S. Centers for Disease Control and Prevention (CDC) to build capacity in order to routinely identify, diagnose and respond to seasonal and pandemic influenza.

CDC direct country support through cooperative agreements is established in the following countries:

In addition, CDC supports WHO EURO via a cooperative agreement to provide technical and coordination support to Member States. This cooperative agreement also supports influenza activities in Romania and Kyrgyzstan.

The core activities of these bilateral agreements are:

To build sustainable national capacity for the detection, identification and response to seasonal, avian and novel influenza.
To develop interagency pandemic preparedness plans.
To strengthen capacity for integrated laboratory and epidemiologic surveillance for influenza-like illness (ILI) and severe acute respiratory infections (SARI), which includes making routine contributions to WHO’s Global Influenza Surveillance and Response System (GISRS) and implementing International Health Regulations 2005 (IHR).
To develop and train local rapid response and containment teams.

Charlene Sanders, MPH, RD (until March 2012)
Project Officer
Extramural Program
Influenza Division, NCIRD
U.S. Centers for Disease Control and Prevention
Email: csanders2@cdc.gov

Stacey Spivey-Blackford, MS (from May 2012)
Project Officer
Extramural Program
Influenza Division, NCIRD
U.S. Centers for Disease Control and Prevention
Email: ifm8@cdc.gov

Diane Gross, DVM, PhD (until June 2012)
Medical Epidemiologist
International Epidemiology and Research Team
Influenza Division, NCIRD
U.S. Centers for Disease Control and Prevention
Email: bwc3@cdc.gov

Joshua Mott, PhD (until June 2011)
Technical Officer
Influenza and Other Respiratory Pathogens
Division of Health Security, Infectious Diseases and the Environment
WHO Regional Office for Europe
Copenhagen, Denmark
Email: jmo@euro.who.int

EUR European Region map

A map of the WHO European Region (EUR) shows all 53 EUR member states/countries. The member countries, outlined with gray borders, include Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Monaco, Montenegro, Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, The Former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom of Great Britain and Northern Ireland, and Uzbekistan.

Countries with yellow shading indicate that the Influenza Division provides project funding and technical assistance through Capacity Building Cooperative Agreements. Armenia, Georgia, Moldova, and Ukraine are shaded yellow on the map. The Russian Federation is shaded green to indicate that they have a Sustainability Cooperative Agreement. Romania is shaded dark green to indicate that they receive indirect funding from the Influenza Division.

CDC Influenza Division Field Staff, indicated by a yellow dot outlined in red, are located at the WHO European Regional Office in Copenhagen, Denmark, WHO Headquarters in Geneva, Switzerland and The European Centers for Disease Control and Prevention (ECDC) in Stockholm, Sweden.

The Global Disease Detection [GDD] Site, indicated by the red “X”, is located in Kazakhstan.

WHO National Influenza Centers (NICs), indicated by a purple dot, are located in Albania (Tirana), Austria (Vienna), Belarus (Minsk), Belgium (Brussels), Bulgaria (Sofia), Croatia (Zagreb), Czech Republic (Prague), Denmark (Copenhagen), Estonia (Tallinn), Finland (Helsinki), France (Lyon and Paris), Georgia (Tbilisi), Germany (Berlin), Greece (Athens and Thessaloniki), Hungary (Budapest), Iceland (Reykjavik), Ireland (Dublin), Israel (Tel Hashomer), Italy (Rome), Kazakhstan (Almaty), Kyrgyzstan (Kyrgyzstan), Latvia (Riga), Lithuania (Vilnius), Luxembourg (Luxembourg), Malta (Msida), Netherlands (Rotterdam), Norway (Oslo), Poland (Warsaw), Portugal (Lisboa), Romania (Bucharest [2] and Lasi), Russia (Moscow and St. Petersburg), Serbia (Belgrade and Novi Sad), Slovakia (Bratislava), Slovenia (Ljubljana), Spain (Barcelona, Madrid and Valladolid), Sweden (Solna), Switzerland (Geneva), Turkey (Ankara), Ukraine (Kiev), and United Kingdom (Aberdeen, London and Glasgow).

The WHO European Regional Office (EURO), indicated by a blue star, is located in Copenhagen, Denmark. WHO Headquarters is located in Geneva, Switzerland.

Thirty-two weekly EuroFlu influenza surveillance bulletins were published. On average, 47 out of 53 Member States reported data and sentinel severe acute respiratory infection (SARI) data from 12 countries was included for the first time.
Updated guidance for sentinel surveillance incorporating lessons learned from the 2009 H1N1 influenza pandemic was published.
For the first time, pandemic and seasonal influenza vaccine policies were surveyed and used in all 53 Member States.
The National Influenza Center (NIC) in Malta recognized by the World Health Organization (WHO).
Published recommendations for best practices in pandemic preparedness, which were identified through evaluation of the 2009 H1N1 influenza pandemic.
Three peer-reviewed articles were accepted for publication.

U.S. CDC Direct WHO Regional Office Support

The five-year cooperative agreement Surveillance and Response to Pandemic and Avian Influenza by Regional Offices of the World Health Organization began in September 2006 and is in its final year. The WHO Regional Office for Europe (EURO) is located in Copenhagen, Denmark. The Office serves 53 Member States that together have a population exceeding 900 million people. Five of the 53 countries receive funding via bilateral cooperative agreements with the U.S. Centers for Disease Control and Prevention (CDC): Armenia, Georgia, Moldova, Russian Federation and Ukraine. In 2011, WHO EURO staff ran the regional surveillance platform EuroFlu (www.euroflu.org), which is organized in collaboration with the European Centre for Disease Prevention and Control (ECDC). At the annual WHO European Regional Influenza Surveillance Network Meeting, WHO EURO staff provided training and technical assistance to Member States to establish and strengthen sentinel surveillance for influenza (including SARI), supported the sharing of influenza viruses for influenza vaccine development, implemented a first survey on vaccine policies and uptake in the whole region, supported pandemic plan revisions, and developed and disseminated technical guidance.

In 2011–2012, WHO EURO will continue the aforementioned activities and will focus on assisting countries in establishing burden estimates for influenza disease and determining risk factors for severe disease associated with influenza infection. These efforts will support the work of National Immunization Technical Advisory Groups with a view of increasing influenza vaccine uptake in priority groups. At least one NIC will be assessed for recognition by WHO and a training for laboratories from Eastern Europe will be provided to that center. To further enhance the harmonization of surveillance data in the WHO European Region, expert meetings will be held on SARI data and qualitative indicators and missions will be conducted in selected countries with established sentinel SARI surveillance. WHO EURO/ECDC/ European Commission pandemic indicators will be revised.

During the first post-pandemic season, the influenza A(H1N1)pdm09 (2009 H1N1) virus was dominant in the Region. Vigilance for disease outbreaks and potential changes to the 2009 H1N1 virus was high. Some countries experienced strains on their critical care services similar to those experienced during the pandemic and persons who developed severe disease had similar risk factors. Surveillance activities in the European Region showed the 2009 H1N1 virus to be virtually unchanged genetically or antigenically compared with strains that were circulating in 2009.

WHO EURO increased its activities related to seasonal influenza vaccine recommendations, policies and use in the Region.

Surveillance Activities

The EuroFlu bulletin was published weekly including sentinel SARI data from 12 new countries.
The WHO Regional Office for Europe guidance for sentinel influenza surveillance in humans was updated, incorporating lessons learned from the 2009 pandemic.
The first regional influenza surveillance network meeting for the 53 Member States was organized jointly with ECDC.
A report describing the key features of the 2010–2011 influenza season was published.
For the first time, WHO EURO published recommendations for seasonal influenza vaccine, combining WHO recommendations on influenza virus strains for inclusion in the 2010–2011 vaccine and the current WHO recommendations regarding risk groups to target for vaccination.
WHO EURO collaborated with the Vaccine European New Integrated Collaboration Effort (VENICE) and ECDC to perform an annual survey on influenza vaccination in EU/EEA Member States and facilitate the start of a regular, standardized collection of information on seasonal influenza vaccination strategies from all WHO EURO Member States. The data collected will allow vaccine uptake to be monitored over time and to assess gaps in provisions.
Surveys on vaccination policies and uptake of 2009 H1N1 monovalent influenza vaccines were administered among the 53 Member States. The results of both surveys have been presented at international meetings.

Forty of 53 the Member States conducting influenza surveillance currently have NICs recognized by WHO. Through the cooperative agreement, NICs receive training, support to improve laboratory quality, reagents and funds to ship viruses to WHO Collaborating Centers for Reference and Research on Influenza (WHO CC). Best practices in pandemic preparedness have been developed.

Laboratory Activities

Guidance on how to become a WHO recognized NIC was published.
The NIC in Malta was formally recognized by WHO, bringing the number of countries in the Region with a WHO-recognized NIC to 40.
Twenty-two countries sent 40 shipments of viruses to the WHO CC using the global WHO Shipment Fund.
International Air Transport Association (IATA)-certified training was provided to 36 staff from NICs and WHO Country Offices on the shipment of infectious substances.
In FY 2011, 59 influenza laboratories in 44 Member States participated in WHO’s External Quality Assessment Project (EQAP) for PCR (80% correct).
Of 22 southeastern and eastern European Member States, 19 laboratories from 16 countries participated in a Regional External Quality Assessment (EQA) for virus isolation compared with 11 laboratories from nine countries in 2008. Also, seven laboratories from five countries participated in a Regional EQA for antiviral susceptibility testing.
As a follow up to the Regional EQA, NICs from Kazakhstan, Kyrgyzstan, Moldova and Uzbekistan were provided with a practical course on influenza virology isolation in collaboration with the NIC in St. Petersburg, Russia.

During the first post-2009 H1N1 pandemic influenza season, a number of countries experienced severe cases in the same risk groups as during the pandemic; information sharing on clinical management was arranged at the Regional level.

In addition, WHO EURO’s efforts focused on the evaluation report of the pandemic response in the Region and on three multi-country workshops which provided an update on countries’ pandemic preparedness plans and changes made based on evaluations of the pandemic response.

WHO Europe conducted a separate evaluation of NIC pandemic preparedness.

Preparedness Activities

In October 2010, WHO EURO convened a workshop to develop recommendations for best practices in pandemic preparedness based on the evaluation conducted in the WHO European Region on the usefulness of pandemic preparedness activities in response to the 2009 pandemic.
A report describing best practices in pandemic preparedness for NICs was published.
WHO EURO, in collaboration with ECDC and the Health Protection Agency, United Kingdom, established a platform for critical care clinicians to share, in real-time with other clinicians across the Region, their experiences regarding the clinical management of severe cases associated with influenza A(H1N1)pdm09 infection. This allowed countries that were affected later in the influenza season to prepare their critical care services.
Between September and November 2011, WHO EURO and ECDC conducted four workshops on pandemic preparedness that included 45 Member States. Twenty-eight Member States have evaluated their pandemic response (12 have been published) and 32 Member States are in the process of revising their national pandemic plans (three have been published). Key changes being made to pandemic plans by Member States and requirements for future pandemic preparedness planning were documented.
WHO EURO staff participated in the external review of the pandemic response conducted by the IHR (2005) review committee.

WHO EURO, in conjunction with selected Member States, hosted the following regional and inter-country trainings in 2010–2011:

In collaboration with the NIC in St. Petersburg, Russia, a practical course on influenza virology isolation was conducted.
IATA-certified training was provided to 36 staff from NICs and WHO Country Offices on the shipment of infectious substances.
The first regional influenza surveillance network meeting for the 53 Member States was organized jointly with ECDC in June 2011.
Training for 200 sentinel network clinicians and laboratory specialists was provided in Romania.
A workshop on best practices in pandemic preparedness was held.

Caroline Brown, PhD
Programme Manager, Influenza and Other Respiratory Pathogens Programme
WHO Regional Office for Europe
World Health Organization
Copenhagen, Denmark
Email: cbr@euro.who.int

Pernille Jorgensen, MPH
Epidemiologist, Influenza and Other Respiratory Pathogens Programme
WHO Regional Office for Europe
World Health Organization
Copenhagen, Denmark
Email: pej@euro.who.int