Progress and Challenges in Measles and Rubella Elimination in the WHO European Region.

The elimination of both measles and rubella remains a priority for all 53 Member States of the World Health Organization (WHO) European Region. To provide an update on the epidemiological status of measles and rubella in the Region, we reviewed surveillance data on both diseases for 2023 submitted monthly by national surveillance institutions. We analyzed the cases of measles and rubella for 2023 by age group, case classification, vaccination, hospitalization, and importation status and report on measles-related deaths. In 2023, 60,860 measles cases, including 13 fatal cases, were reported in 41 countries. Most cases (95%; n = 57,584) were reported by six countries: Azerbaijan, Kazakhstan, Kyrgyzstan, Romania, the Russian Federation, and Türkiye. Of the 60,848 cases with data on age, 19,137 (31%) were 1-4 years old and 12,838 (21%) were 5-9 years old. A total of 10,412 (17%) were 20 years and older. The genotypes identified in the Region were largely dominated by D8 variants (n = 1357) and the remainder were B3 variants (n = 221). In 2023, 345 rubella cases were reported by 17 countries, mostly from Poland, Kyrgyzstan, Tajikistan, Türkiye, and Ukraine. A total of 262 cases (76%) were classified as clinically compatible and 79 (23%) were laboratory-confirmed. To achieve the elimination of measles and rubella in the Region, political commitment needs to be revived to enable urgent efforts to increase vaccination coverage, improve surveillance and outbreak preparedness, and respond immediately to outbreaks.

Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions.

Universal immunization substantially reduces morbidity and mortality from vaccine-preventable diseases. In recent years, routine immunization coverage has varied considerably among countries across the WHO European Region, and among different populations and districts within countries. It has even declined in some countries. Sub-optimal immunization coverage contributes to accumulations of susceptible individuals and can lead to outbreaks of vaccine-preventable diseases. The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the WHO European Region by ensuring equity in immunization and supporting immunization stakeholders in devising local solutions to local challenges. The factors that influence routine immunization uptake are context specific and multifactorial; addressing immunization inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local level immunization stakeholders must first identify the underlying causes of inequities, and based on this information, tailor resources, or service provision to the local context, as per the organization and characteristics of the health care system in their countries. To do this, in addition to using the tools already available to broadly identify immunization inequities at the national and regional levels, they will need new pragmatic guidance and tools to address the identified local challenges. It is time to develop the necessary guidance and tools and support immunization stakeholders at all levels, especially those at the subnational or local health centre levels, to make the vision of EIA2030 a reality.

Diphtheria in the WHO European Region, 2010 to 2019.

BackgroundDiphtheria is uncommon in the World Health Organization (WHO) European Region. Nevertheless, sporadic cases, sometimes fatal, continue to be reported.AimTo report on diphtheria cases and coverage with first and third doses of diphtheria, tetanus and pertussis vaccines (DTP1 and DTP3, respectively) for 2010-19 in the Region with a focus on 2019.MethodsData on diphtheria cases were obtained from WHO/United Nations International Children's Emergency Fund (UNICEF) Joint Reporting Forms submitted annually by the Region's Member States. WHO/UNICEF Estimates of National Immunization Coverage for DTP1 and DTP3 were summarised for 2010-19. For 2019, we analysed data on age, and vaccination status and present data by country on DTP1 and DTP3 coverage and the percentage of districts with ≥ 90% and < 80% DTP3 coverage.ResultsFor 2010-19, 451 diphtheria cases were reported in the Region. DTP1 and DTP3 coverage was 92-96% and 95-97%, respectively. For 2019, 52 cases were reported by 11 of 48 countries that submitted reports (including zero reporting). Thirty-nine countries submitted data on percentage of their districts with ≥ 90% and < 80% DTP3 coverage; 26 had ≥ 90% districts with ≥ 90% coverage while 11 had 1-40% districts with < 80% coverage.ConclusionLong-standing high DTP3 coverage at Regional level probably explains the relatively few diphtheria cases reported in the Region. Suboptimal surveillance systems and inadequate laboratory diagnostic capacity may also be contributing factors. Still, the observed cases are of concern. Attaining high DTP3 coverage in all districts and implementing recommended booster doses are necessary to control diphtheria and prevent outbreaks.

Progress Toward Measles Elimination - European Region, 2009-2018.

In 2010, all 53 countries* in the World Health Organization (WHO) European Region (EUR) reconfirmed their commitment to eliminating measles and rubella and congenital rubella syndrome (1); this goal was included as a priority in the European Vaccine Action Plan 2015-2020 (2). The WHO-recommended elimination strategies in EUR include 1) achieving and maintaining ≥95% coverage with 2 doses of measles-containing vaccine (MCV) through routine immunization services; 2) providing measles and rubella vaccination opportunities, including supplementary immunization activities (SIAs), to populations susceptible to measles or rubella; 3) strengthening surveillance by conducting case investigations and confirming suspected cases and outbreaks with laboratory results; and 4) improving the availability and use of evidence for the benefits and risks associated with vaccination (3). This report updates a previous report (4) and describes progress toward measles elimination in EUR during 2009-2018. During 2009-2017, estimated regional coverage with the first MCV dose (MCV1) was 93%-95%, and coverage with the second dose (MCV2) increased from 73% to 90%. In 2017, 30 (57%) countries achieved ≥95% MCV1 coverage, and 15 (28%) achieved ≥95% coverage with both doses. During 2009-2018, >16 million persons were vaccinated during SIAs in 13 (24%) countries. Measles incidence declined to 5.8 per 1 million population in 2016, but increased to 89.5 in 2018, because of large outbreaks in several EUR countries. To achieve measles elimination in EUR, measures are needed to strengthen immunization programs by ensuring ≥95% 2-dose MCV coverage in every district of each country, offering supplemental measles vaccination to susceptible adults, maintaining high-quality surveillance for rapid case detection and confirmation, and ensuring effective outbreak preparedness and response.

[Elimination of measles in the WHO European Region-challenges persist]. / Eliminierung der Masern aus der Europäischen Region der WHO ­ Herausforderungen bleiben.

BACKGROUND: Measles incidence in the 53 Member States of the World Health Organization (WHO) European Region has fallen dramatically in recent decades. The European Regional Verification Commission for Measles and Rubella Elimination (RVC) verified that 43 member states had interrupted endemic measles transmission for ≥12 months by the end of 2017. However, measles incidence in the region increased sharply in 2018 compared to 2017. The purpose of this article is to assess the current status of measles in the Region in relation to its elimination goal. It also discusses challenges and actions needed to reach this goal. METHODS: Measles surveillance data presented for 2017 and 2018 (as of 1 February 2019) were submitted by all 53 member states. The measles elimination status of countries was obtained from the 2018 report of the seventh meeting of the RVC. RESULTS: In 2017, 25,863 measles cases were reported in 44 countries of the WHO European Region. In 2018, 82,596 measles cases were reported in 47 countries. Most cases were reported by Ukraine (64%) and Serbia (6%). Age was known in 82,588 cases: 8% were <1 year old, 17% were 1-4 years old, 38% were 5-19 years old and 37% were ≥20 years old. Data on vaccination status were provided for 76% of the cases, of which 62% were unvaccinated. Seventy-two measles-related deaths were reported from 10 countries. CONCLUSIONS: For the elimination of measles in the European Region, a high population immunity rate and accurate epidemiological surveillance remain essential. Long-term political commitment by all Member States in these areas is crucial to attain the elimination goal.

Towards equity in immunisation.

In the World Health Organization (WHO) European Region, differences in uptake rates of routine childhood immunisation persist within and among countries, with rates even falling in some areas. There has been a tendency among national programmes, policymakers and the media in recent years to attribute missed vaccinations to faltering demand or refusal among parents. However, evidence shows that the reasons for suboptimal coverage are multifactorial and include the social determinants of health. At the midpoint in the implementation of the European Vaccine Action Plan 2015-2020 (EVAP), national immunisation programmes should be aware that inequity may be a factor affecting their progress towards the EVAP immunisation targets. Social determinants of health, such as individual and household income and education, impact immunisation uptake as well as general health outcomes - even in high-income countries. One way to ensure optimal coverage is to make inequities in immunisation uptake visible by disaggregating immunisation coverage data and linking them with already available data sources of social determinants. This can serve as a starting point to identify and eliminate underlying structural causes of suboptimal uptake. The WHO Regional Office for Europe encourages countries to make the equitable delivery of vaccination a priority.

Progress and challenges in measles and rubella elimination in the WHO European Region.

INTRODUCTION: Despite availability of safe and cost-effective vaccines to prevent it, measles remains one of the significant causes of death among children under five years of age globally. The World Health Organization (WHO) European Region has seen a drastic decline in measles and rubella cases in recent years, and a few of the once common measles genotypes are no longer detected. Buoyed by this success, all Member States of the Region reconfirmed their commitment in 2010 to eliminating measles and rubella, and made this a central objective of the European Vaccine Action Plan 2015-2020 (EVAP). Nevertheless, sporadic outbreaks continue, recently affecting primarily adolescents and young adults with no vaccination or an incomplete vaccination history. The European Regional Verification Commission for Measles and Rubella Elimination was established in 2011 to evaluate the status of measles and rubella elimination based on documentation submitted annually by each country's national verification committee. DISCUSSION: Each country's commitment to eliminate measles and rubella is influenced by competing health priorities, and in some cases lack of capacity and resources. All countries need to improve case-base surveillance for both measles and rubella, ensure documentation of each outbreak and strengthen the link between epidemiology and laboratory data. Achieving high coverage with measles- and rubella-containing vaccines will require a multisectoral approach to address the root causes of lower uptake in identified communities including service delivery challenges or vaccine safety concerns caused by circulating myths about vaccination. CONCLUSIONS: The WHO European Region has made steady progress towards eliminating measles and rubella and over half of the countries interrupted endemic transmission of both diseases by 2015. The programmatic challenges in disease surveillance, vaccination service delivery and communication in the remaining endemic countries should be addressed through periodic evaluation of the strategies by all stakeholders and exploring additional opportunities to accelerate the ongoing elimination activities.

The measles outbreak in Bulgaria, 2009-2011: An epidemiological assessment and lessons learnt.

Measles re-emerged in a nationwide outbreak in Bulgaria from 2009 to 2011 despite reported high vaccination coverage at national level. This followed an eight-year period since the last indigenous cases of measles were detected. The Bulgarian National Centre of Infectious and Parasitic Diseases collated measles surveillance data for 2009-2011. We analysed data for age group, sex, ethnicity, diagnosis confirmation, vaccination, hospitalisation, disease complications, and death and describe the outbreak control measures taken. The outbreak started in April 2009 following an importation of measles virus and affected 24,364 persons, predominantly Roma. Most cases (73%) were among children < 15 years old. Vaccination status was available for 52% (n = 12,630) of cases. Of children 1-14 years old, 22% (n = 1,769) were unvaccinated and 70% (n = 5,518) had received one dose of a measles-containing vaccine. Twenty-four measles-related deaths were reported. The Roma ethnic group was particularly susceptible to measles. The magnitude of the outbreak resulted primarily from the accumulation of susceptible children over time. This outbreak serves as a reminder that both high vaccination coverage and closing of immunity gaps across all sections of the population are crucial to reach the goal of measles elimination.

[The State of Measles and Rubella in the WHO European region].

The long-standing and widespread use of vaccines against measles has resulted in a dramatic decline in cases and measles mortality worldwide compared with the pre-vaccination era.All regions of the World Health Organization (WHO) have measles elimination goals and the WHO regions of the Americas, Europe and Western Pacific also have rubella elimination goals. This article aims to report on progress toward elimination of measles and rubella in the WHO European Region based on the latest available data. We also discuss current challenges and actions needed to reach this goal in the Region. Despite substantial progress made towards controlling measles and rubella, the countries of the WHO European Region continue to face challenges in interrupting endemic transmission of these diseases. Widespread outbreaks and endemic transmission of measles and rubella persisted in some countries of the Region in 2014 and have continued in 2015. Interrupting endemic transmission in each and every country is necessary to declare elimination for the entire Region. High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. In the absence of sustained political commitment and implementation of the required strategies by all countries, the goal of eliminating these diseases in the WHO European Region is at stake.

Situación del sarampión y la rubéola en la región europea de la OMS / The state of measles and rubella in the WHO European region

El largo y generalizado uso de las vacunas contra el sarampión se ha traducido en un drástico descenso en los casos y la mortalidad por sarampión en todo el mundo en comparación con la época anterior a la vacunación. Todas las regiones de la Organización Mundial de la Salud (OMS) tienen el objetivo de conseguir su eliminación. Las regiones de la OMS de las Américas, Europa y el Pacífico Occidental tienen, así mismo, la meta de eliminar la rubéola. Este artículo tiene como objetivo informar sobre el progreso hacia la eliminación del sarampión y la rubéola en la Región Europea de la OMS sobre la base de los últimos datos disponibles. También se discuten los retos actuales y las acciones necesarias para alcanzarlo. A pesar de los importantes avances alcanzados hacia el control de sarampión y la rubéola, los países de la Región Europea de la OMS siguen enfrentando desafíos en la interrupción de la transmisión endémica de estas enfermedades. Algunos brotes epidémicos y la transmisión endémica del sarampión y la rubéola persistían en algunos países de la Región en 2014 y han continuado en 2015. La interrupción de la transmisión endémica en todos y cada uno de ellos es necesaria para declarar la eliminación en toda la Región. La alta inmunidad de la población y la vigilancia de alta calidad son los pilares para eliminar el sarampión y la rubéola. Sin la existencia de un compromiso político sostenido y de la aplicación de las estrategias requeridas por parte de todos los países, el objetivo de la eliminación de estas dos enfermedades en la Región Europea de la OMS está en juego (AU)

The long-standing and widespread use of vaccines against measles has resulted in a dramatic decline in cases and measles mortality worldwide compared with the pre-vaccination era. All regions of the World Health Organization (WHO) have measles elimination goals and the WHO regions of the Americas, Europe and Western Pacific also have rubella elimination goals. This article aims to report on progress toward elimination of measles and rubella in the WHO European Region based on the latest available data. We also discuss current challenges and actions needed to reach this goal in the Region. Despite substantial progress made towards controlling measles and rubella, the countries of the WHO European Region continue to face challenges in interrupting endemic transmission of these diseases. Widespread outbreaks and endemic transmission of measles and rubella persisted in some countries of the Region in 2014 and have continued in 2015. Interrupting endemic transmission in each and every country is necessary to declare elimination for the entire Region. High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. In the absence of sustained political commitment and implementation of the required strategies by all countries, the goal of eliminating these diseases in the WHO European Region is at stake (AU)

Toward rubella elimination in Europe: an epidemiological assessment.

BACKGROUND: The elimination of rubella and prevention of congenital rubella syndrome (CRS) by 2015 are established goals for Europe. Our aim was to review the epidemiology of rubella in relation to this goal. MATERIAL AND METHODS: National surveillance institutions from 32 European countries provided information on rubella and CRS surveillance systems and data for 2000-08. We reported the number of notified rubella cases by year for countries with a national mandatory notification system for rubella covering total country population consistently throughout 2000-08 and analysed rubella surveillance data for 2008. RESULTS: Throughout 2000-08, 24 countries conducted passive routine surveillance based on mandatory reporting rubella covering total country population. Altogether these countries reported 526,751 rubella cases. The median incidence per million inhabitants declined from 7.2 in 2000 to 0.3 in 2008. By 2008, the number of countries with mandatory notification systems for rubella increased to 28. These countries reported 21,475 rubella cases of which 1.5% (n=317) were laboratory-confirmed. Most cases (n=21,075; 98%) were reported from Poland, Italy and Romania. Ten countries reported zero rubella cases and five others reported an incidence of <1 per million inhabitants. In 2008, 20 CRS cases were reported from five countries. CONCLUSION: The overall decline in rubella incidence and increase in the number of countries conducting rubella surveillance through a mandatory notification system are notable achievements toward the goal of rubella elimination in Europe. However, in a few countries with high rubella incidence the risk for CRS still exists. Achievement and maintenance of the required high vaccination coverage and high-quality surveillance of rubella and CRS including laboratory testing of all suspected cases are fundamental to eliminate rubella and prevent CRS in Europe.

Who gets measles in Europe?

BACKGROUND: Measles outbreaks continue to occur in Europe as a result of suboptimum vaccination coverage. This article aims to describe individuals susceptible to measles, and provide an overview of affected groups and the public settings in which measles transmission occurred in Europe in 2005-2009. METHODS: Individuals susceptible to measles were described and categorized on the basis of factors leading to nonvaccination and vaccine failure. A literature search was conducted to identify affected groups and public settings in which measles transmission occurred. RESULTS: Most individuals susceptible to measles are previously uninfected and unvaccinated. The reasons for nonvaccination in individuals eligible for vaccination ranged from lack of information to poor access to health care. Several outbreaks have emerged in Roma and Sinti, Traveller, anthroposophic, and ultra-orthodox Jewish communities, and immigrants identifying them as being particularly at risk. Public settings for transmission included mostly educational and health care facilities. CONCLUSIONS: Improved efforts are needed to strengthen immunization programs, identify barriers for measles-containing vaccine uptake, and explore methods to target vulnerable populations that are not being reached with routine immunization delivery services. Specific measures are needed to prevent and control measles in educational and health care facilities. Failure to identify who gets measles and implement the elimination strategies raises concerns for the successful and sustainable elimination of measles in Europe.

Status of rubella and congenital rubella syndrome surveillance, 2005-2009, the World Health Organization European Region.

BACKGROUND: The World Health Organization European Region has a goal for rubella elimination and congenital rubella syndrome (CRS) prevention. Although all Member States recommend a rubella-containing vaccine in their national immunization programs, rubella and CRS continue to occur, and surveillance quality varies throughout the region. METHODS: To describe the status of regional rubella and CRS surveillance and assess progress toward elimination, we reviewed surveillance practices by surveying all 53 Member States and analyzed rubella and CRS surveillance data during 2005-2009. RESULTS: Overall, 41 (91%) of 45 responding Member States have nationwide rubella surveillance, and 39 (87%) have nationwide CRS surveillance. During 2005-2009, rubella cases reported in the region decreased by 94% from 206,359 cases to 11,623 cases. The greatest decrease (99%) was observed in newly independent states of the former Soviet Union. In the rest of the region, high rubella incidence was observed in Poland, Romania, Italy, and San Marino during 2005-2008 and in Poland, Bosnia and Herzegovina, and Austria in 2009. A total of 68 CRS cases were reported during 2005-2009. CONCLUSIONS: As the foundation to achieving and verifying rubella elimination, high-quality rubella and CRS surveillance needs to be implemented and sustained in all Member States.

Invasive meningococcal disease in Malta: an epidemiological overview, 1994-2007.

Since 1996, Malta has experienced an upsurge of invasive meningococcal disease (IMD) following an almost 30 year period with a negligible number of annually reported cases. We reviewed the 233 IMD cases notified during a 14 year period (1994-2007), and analysed epidemiological and laboratory surveillance data. The crude incidence per 100,000 inhabitants peaked in 2000 at 8.1 [95 % confidence interval (CI) 5.7-11.6] and again in 2006 at 8.9 (95 % CI 6.4-12.4), thereby placing Malta amongst the countries with the highest incidence of the disease in Europe. Of the total cases, 137 (59 %) were confirmed and 30 (13 %) were classified as probable. However, 66 cases (28 %) had no laboratory evidence of the disease and were classified as possible. Information on the serogroup was available for 114 cases. Serogroup B formed the largest proportion (76 %, n=87) followed by serogroup C (16 %, n=18). B : 4 : P1.19,15 strains (n=46) predominated throughout the study period since their first identification in 1998. With 28 deaths attributed to IMD, the overall case fatality rate was 12 %. Apart from stressing the importance of maintaining high vigilance for IMD, our findings underscore the importance of enhancing laboratory surveillance of the disease, including characterization of the meningococci. Until vaccines against a broad range of serogroup B meningococci become available for universal use, the main methods of control remain the early treatment of cases and the prevention of secondary cases.

Measles in Europe: an epidemiological assessment.

BACKGROUND: Measles persists in Europe despite the incorporation of the measles vaccine into routine childhood vaccination programmes more than 20 years ago. Our aim was therefore to review the epidemiology of measles in relation to the goal of elimination by 2010. METHODS: National surveillance institutions from 32 European countries submitted data for 2006-07. Data for age-group, diagnosis confirmation, vaccination, hospital treatment, the presence of acute encephalitis as a complication of disease, and death were obtained. 30 countries also supplied data about importation of disease. Clinical, laboratory-confirmed, and epidemiologically linked cases that met the requirements for national surveillance were analysed. Cases were separated by age: younger than 1 year, 1-4 years, 5-9 years, 10-14 years, 15-19 years, and older than 20 years. Countries with indigenous measles incidence per 100 000 inhabitants per year of 0, less than 0.1, 0.1-1, and more than 1 were grouped into categories of zero, low, moderate, and high incidence, respectively. FINDINGS: For the 2 years of the study, 12 132 cases of measles were recorded with most cases (n=10 329; 85%) from five countries: Romania, Germany, UK, Switzerland, and Italy. Most cases were unvaccinated or incompletely vaccinated children; however, almost a fifth were aged 20 years or older. For the same 2 years, seven measles-related deaths were recorded. High measles incidence in some European countries revealed suboptimum vaccination coverage. Of the 210 cases that were reported as being imported, 117 (56%) came from another country within Europe and 43 (20%) from Asia. INTERPRETATION: The suboptimum vaccination coverage raises serious doubts that the goal of elimination by 2010 can be attained. Achievement and maintenance of optimum vaccination coverage and improved surveillance are the cornerstones of the measles elimination plan for Europe.

High genetic diversity of measles virus, World Health Organization European Region, 2005-2006.

During 2005-2006, nine measles virus (MV) genotypes were identified throughout the World Health Organization European Region. All major epidemics were associated with genotypes D4, D6, and B3. Other genotypes (B2, D5, D8, D9, G2, and H1) were only found in limited numbers of cases after importation from other continents. The genetic diversity of endemic D6 strains was low; genotypes C2 and D7, circulating in Europe until recent years, were no longer identified. The transmission chains of several indigenous MV strains may thus have been interrupted by enhanced vaccination. However, multiple importations from Africa and Asia and virus introduction into highly mobile and unvaccinated communities caused a massive spread of D4 and B3 strains throughout much of the region. Thus, despite the reduction of endemic MV circulation, importation of MV from other continents caused prolonged circulation and large outbreaks after their introduction into unvaccinated and highly mobile communities.

The benefit of molecular characterization during a measles upsurge in Denmark.

Molecular characterization of measles virus was part of the epidemiological investigation of 27 measles cases reported in Denmark in 2006. RT-PCR detected measles virus RNA from various types of clinical specimens in 24 cases. Virus genotypes were determined by sequencing the nucleocapsid (N) gene. Four different genotypes, B3, D4, D5 and D9 were identified including two variants of the D4 genotype. In combination with the epidemiological data four clusters of measles cases and three sporadic cases were revealed. Our study showed that measles in Denmark resulted from imported measles virus strains. The limited duration and short chain of transmission of the identified clusters ascertain that the interruption of measles virus circulation is being sustained. However, measles transmission still has a potential to occur. To minimise the development of pools of susceptible individuals high (>/=95%) routine vaccination coverage with two doses of measles-containing vaccine needs to be attained. Molecular epidemiological studies have proved to be both a useful and a necessary component of an enhanced surveillance system required in the measles elimination phase.

Patterns of antibiotic use in the community in Denmark.

A cross-sectional descriptive population survey was conducted in 2003 to examine epidemiological characteristics of antibiotic use in the community in Denmark and particularly in the area of self-medication with antibiotics. Self-medication with antibiotics was rare in Denmark. 97% of antibiotics used were obtained after a medical consultation. While the existing legal framework preventing over-the-counter dispensation of antibiotics must be maintained, our results show that, in Denmark, interventions to optimize antibiotic use should primarily focus on the prescribers.

Increase and change in pattern of hospital antimicrobial use, Denmark, 1997-2001.

OBJECTIVES: To analyse the changes and compare antimicrobial consumption in public hospitals in Denmark over the period 1997-2001. METHODS: Data on the number of WHO defined daily doses (DDD) were obtained from the Danish Medicines Agency. Data on the number of bed-days were obtained from the National Board of Health. We calculated antimicrobial consumption in hospitals as the number of DDD per 100 bed-days for all antibacterials for systemic use i.e. group J01 of the Anatomical Therapeutic Chemical (ATC) classification and for classes of this group. RESULTS: During 1997-2001, antimicrobial use in hospitals in Denmark significantly increased by 18%, from 38.0 to 44.8 DDD per 100 bed-days (P < 0.005). Most of this increase (55%) was attributed to an increase in consumption of commonly used classes of antimicrobials, mainly penicillins with extended spectrum (ATC group J01CA), beta-lactamase-sensitive penicillins (J01CE) and beta-lactamase-resistant penicillins (J01CF). The 'broad-spectrum' and newer antimicrobials, i.e. combinations of penicillins with beta-lactamase inhibitor (J01CR), cephalosporins (J01DA), carbapenems (J01DH) and fluoroquinolones (J01MA) contributed to 36% of the increase. Together, these amounted to 16% of total consumption in hospitals in Denmark in 1997, rising to 19% in 2001. CONCLUSIONS: Although antimicrobial consumption in public hospitals in Denmark is low compared with other countries, the steady increase and change in pattern of their use are causes of concern, deserving close monitoring and further investigations.