Ebola emergency preparedness in EU Member States : conclusions from peer-review visits to Belgium, Portugal and Romania.
Date: 2015-09-01
Institutions: European Centre for Disease Prevention and Control
Subjects: Belgium, EU Member State, Portugal, Romania, disease prevention, emergency medical treatment, epidemic, epidemiology, health control, health policy, infectious disease, public health, research report

TECHNICAL REPORT

Ebola emergency preparedness 
in EU Member States

Conclusions from peer-review visits to  
Belgium, Portugal and Romania 

www.ecdc.europa.eu

 
ECDC TECHNICAL REPORT 

Ebola emergency preparedness  
in EU Member States 

Conclusions from peer-review visits to Belgium, Portugal and Romania  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
This report of the European Centre for Disease Prevention and Control (ECDC) was coordinated by Svetla Tsolova. 
It is based on information collected during three country visits of an ECDC assessment team of ECDC and 
EU Member State experts. 

Acknowledgements 

We would like to thank the ECDC National Focal Points for Preparedness and Response in the three EU Member 
States we visited. We also would like to thank the people that supported us in Romania, Belgium and Portugal. 
Their time and efforts are greatly appreciated. 

Romania: Raed Arafat, Călin Alexandru, Adriana Pistol, Amalia Şerban and Lavinia Zota 

Belgium: Daniel Reynders and Erika Vlieghe 

Portugal: Francisco George, Paula Vasconcelos and Cristina Abreu dos Santos 

The following ECDC National Focal Points for Preparedness were part of the review teams: United Kingdom (Paul 
Riley, Public Health England); Netherlands (Corien Swaan, Rijksinstituut voor Volksgezondheid en Milieu, Centrum 
Infectieziektebestrijding), Spain (Maria José Sierra Moros, Centro de Coordinación de Alertas y Emergencias 
Sanitarias), Germany (Ute Rexroth, Robert Koch Institute, Department for Infectious Disease Epidemiology, 
Surveillance Unit), Norway (Karin Nygård, Nasjonalt folkehelseinstitutt); and Bulgaria (Todor Kantardjiev, National 
Center of Infectious and Parasitic Diseases).  

ECDC: Karl Ekdahl, Svetla Tsolova, Graham Fraser, Irina Dinca, Hervé Zeller, Diamantis Plachouras, Birgitta de 
Jong, Ben Duncan 

We gratefully acknowledge valuable contributions from our colleagues at ECDC: Massimo Ciotti, Katrin Forslund, 
Enrico Possenti, and the Country Preparedness Section, Public Health Capacity and Communication Unit.  

Suggested citation: European Centre for Disease Prevention and Control. Ebola emergency preparedness in EU 
Member States – Conclusions from peer-review visits to Belgium, Portugal and Romania. Stockholm: ECDC; 2015. 

Stockholm, June 2015 

ISBN 978-92-9193-646-5 

doi 10.2900/041235 

Catalogue number TQ-02-15-487-EN-N 

© European Centre for Disease Prevention and Control, 2015 

Reproduction is authorised, provided the source is acknowledged

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Ebola emergency preparedness in EU Member States – Conclusions from peer-review visits  

Contents 

Abbreviations ............................................................................................................................................... iv 
Introduction and background .......................................................................................................................... 1 
Objectives and methodology ........................................................................................................................... 1 

Findings on preparedness capacity for Ebola health threat in three EU Member States ......................................... 3 
Preparedness planning .............................................................................................................................. 3 
Organisational structures ........................................................................................................................... 3 
Resources and capacities ........................................................................................................................... 3 
Intersectoral and cross-border collaboration ................................................................................................ 4 

Conclusions ................................................................................................................................................... 4 
Common good practices ............................................................................................................................ 4 
Common challenges .................................................................................................................................. 4 

Country-specific findings ................................................................................................................................. 6 
Belgium ................................................................................................................................................... 6 
Romania .................................................................................................................................................. 7 
Portugal ................................................................................................................................................... 8 

Annex ......................................................................................................................................................... 10 

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Abbreviations 

ECDC 

European Centre for Disease Prevention and Control  

GP 

IHR  

MoH 

PPE 

General practitioner  

International Health Regulations  

Ministry of Health 

Personal protective equipment 

SMURD  Romanian emergency rescue service: ‘serviciul mobil de urgenţǎ, reanimare şi descarcerare’ 

SOP 

Standard operating procedure 

WHO  

World Health Organization  

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Ebola emergency preparedness in EU Member States – Conclusions from peer-review visits 

Introduction and background 

This technical report is a broad-brush picture of what we consider to be the main strengths and vulnerabilities of 
Ebola emergency preparedness in three EU Member States. It contains a brief background, a description of 
objectives and an explanation of the methodological approach. Findings are organised in the following sub-sections: 
preparedness planning, organisational structures, resources and capacities, intersectoral and cross-border 
collaboration, and country-specific findings.  

European Union Member States have been faced with challenges to prepare and respond to serious cross-border 
health threats caused by an epidemic (Ebola, a highly contagious viral haemorrhagic fever) that started in West 
Africa in 2014. This has been the largest ever documented epidemic caused by Ebola virus, both in terms of 
numbers of affected people and geographical spread. On the whole, the risk of importing unrecognised cases of 
Ebola virus disease into EU countries remained low, however a single case would make substantial demands on the 
receiving tertiary hospital. Moreover, the magnitude of the risk for a community relates to the ability of public 
health and healthcare systems to recognise the case early and effectively manage all patient contacts. 

EU Member States have strengthened their healthcare systems to deal with public health crisis situations. Key 
stakeholders from other sectors (e.g. transport, international affairs, civil protection, internal affairs, and the 
military) have also been engaged in the discussions, and intersectoral collaboration has been enforced. Moreover, 
a number of EU Member States have participated extensively in the international effort to contain the epidemic in 
Africa by providing expertise, logistical and financial support. This process has been ongoing in the context of a 
new EU legal framework, set by Decision No 1082/2013/EU of the European Parliament and of the Council of 
22 October 2013 on serious cross-border threats to health.  

ECDC teams visited three Member States upon invitation. The visits were performed in the format of peer-review 
discussions with national authorities and focussed on preparedness activities, capacity strengthening, and lessons 
learned in response to the Ebola health threat. Senior preparedness experts from other EU Member States 
participated as teams members. The peer-review visits took place in Belgium, Romania and Portugal in March 2015.  

This summary report gives an overview of the applied methodology and a series of cross-cutting findings that may 
also be of relevance to other EU Member States. Different approaches implemented by individual countries are also 
briefly described. In addition, several country-specific conclusions are presented briefly. Finally, some steps 
forward are suggested that could assist in strengthening both Ebola preparedness and generic preparedness 
against health threats in the EU.  

Objectives and methodology 

The principal objectives of the visits were to support national public health leaders in reviewing their health 
emergency systems in order to identify strengths and vulnerabilities in the context of preparedness for cases of 
imported Ebola infection and (if applicable) the management of such cases.  

The following outcomes were discussed and analysed during and after the visits: 

• 

• 

• 
• 
• 
• 

Identification of practices and lessons learned with regard to imported infections of highly contagious 
infectious diseases, such as viral haemorrhagic fever, e.g. Ebola. 
Identification of activities to strengthen the preparedness for health threats due to viral haemorrhagic 
fevers, e.g. Ebola.  
Assessment of system strengths, system vulnerabilities and risks 
Sharing of experiences between EU Member States 
identification of areas for potential further support from ECDC 
input to EU debate on lessons learned from Ebola outbreak in West Africa and actions to strengthen 
preparedness in the EU Member States. 

The teams were led by senior experts from ECDC. Each of the review teams included senior public health 
professionals who also serve as ECDC Competent Bodies in Member States other than the ones visited. The 
Member State experts were selected from ECDC’s network of National Focal Points for Preparedness and Response 
and had knowledge of their countries’ Ebola preparedness arrangements. Four of the experts were from Member 
States that have managed imported Ebola cases.  

The ECDC teams comprised experts from the United Kingdom, Netherlands, Spain, Germany, Norway and Bulgaria. 
Visits lasted three or three and a half working days and were each based on a programme agreed between the 
team and the country. Visits took place as follows: Belgium: 16–19 March 2015, Romania: 19–21 March 2015, and 
Portugal: 30 March–1 April 2015.  

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ECDC’s Country Preparedness Support Section has developed a protocol to review emergency preparedness based 
on the patient pathway. Five critical areas of the case management pathway for actual or suspected Ebola cases 
were included for review (see Annex, Figure 1):  

• 
• 
• 
• 
• 

point of entry 
community (primary respondents: emergency departments, primary care, public health) 
inland transportation (ambulance services) 
treatment in designated hospital 
medical evacuation 

Moreover, aspects of surveillance, communication and laboratory analysis were discussed and reviewed.  

A document review was conducted before the country visits, based on materials provided by ECDC’s National Focal 
Point for Preparedness in Belgium, Romania and Portugal. The documents included policies related to Ebola 
preparedness and response planning as well as standard operating procedures and guidelines.  

Discussions points from the protocol were reviewed and agreed upon with the Member States experts. Critical 
issues in emergency preparedness capacities and capabilities as well as lessons learned from Ebola as a health 
threat were explored through semi-structured interviews based on a short questionnaire and site visits to assess 
key facilities and hold discussions with main stakeholders.  

The ECDC/EU Member State teams met specialists in public health emergency planning, from health facilities and 
public health authorities, as well as experts from the non-health sector, for example: 

Health sector: national focal point for preparedness and response; coordinator for public health 
emergencies (ministry of health/interior); representatives from the ambulance services; infectious disease 
physicians and nurses working in hospitals designated for Ebola treatment; infectious disease physicians 
working in non-designated community hospitals; laboratory specialists (senior microbiologist, national 
reference laboratory for viral haemorrhagic fevers); representatives of professional associations for 
physicians and nurses. 

Non-health sector: transport (including ministry, national airlines/airports, and sea ports); civil protection 
(including organisations for national contingency planning); foreign affairs; defence; interior (including crisis 
management structures).  

• 

• 

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Ebola emergency preparedness in EU Member States – Conclusions from peer-review visits 

Findings on preparedness capacity for the 
Ebola health threat in three EU Member 
States 

This section provides a brief synthesis and summary of the main findings from the three countries. Public health 
and healthcare systems vary considerably between the countries, which led to the adoption of different approaches 
that fit the historical and situational circumstances. Nevertheless, we observed several similarities in the way the 
three countries addressed the Ebola health threat: professionals were highly motivated, efforts were made to 
ensure the transparency of actions and information, and collaboration with key stakeholders was intensified.  

The points presented here are grouped into four themes: preparedness planning, organisational structures, 
resources and capacities, and intersectoral and cross-border collaboration.  

Preparedness planning 

• 

• 

• 

Key stakeholders perceive the level of preparedness planning to be adequate to cope with a single Ebola 
case.  

Preparedness planning was built upon past incident/experience. Countries used the knowledge and 
experience on health threats accumulated over the last 10 years on respiratory diseases: SARS, the A(H1N1) 
pandemic, MERS-CoV, and avian influenza. Some countries added, or were planning to add, response 
measures to Marburg disease in their preparedness plans. 

Extensive work was done on guidance and protocols (standard operating procedures) for Ebola by 
developing specific new materials. 

Organisational structures 

• 

• 

Public health structures were supported by crisis management systems such as civil protection or rescue 
and emergency services.  

Specific structures or functions were established or designated to coordinate Ebola preparedness and 
response (e.g. Ebola coordinator). 

Resources and capacities  

• 

• 

• 

• 

• 

• 

• 

• 

All three countries have a pool of highly motivated experts.  

Public health authorities invested in providing extensive instructions on how to apply procedures and 
guidelines. Some of the countries also invested in training for first-line healthcare workers. Some health 
authorities were supported by rescue and civil protection services which provided knowledge and 
experience in crisis management, and/or by non-governmental organisations with field experience.  

Simulation exercises were recognised as an important element of the planning process for preparedness 
and as a means of strengthening knowledge and building capacity. Some countries held table-top and field 
exercises. 

Ambulance services have a critical function as first responders, and efforts were made to strengthen this 
service.  

Hospital emergency departments in designated health facilities were extensively reviewed by the authorities.  

Countries have come to recognise the importance of sustainable hospital capacity which is also considered 
as a major resource issue. There have been significant efforts to support designated health facilities (e.g. 
physical infrastructure, contingency plans, involvement of other actors such as the military).  

Technical improvements that promote efficiency and save time were introduced, e.g. a central information 
entry point (designated web page) or a surveillance system linking different sectors (health, port control, 
etc.).  

Health communication messages delivered by a trusted authority were recognised as a critical component of 
the response. Efforts have been made to provide consistent and timely information to professionals and 
society as a whole.  

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• 

Evaluation of preparedness and response to public health emergencies is an essential element of 
preparedness planning. Some countries performed mid-term evaluations and introduced changes into their 
protocols and guidance documents.  

Intersectoral and cross-border collaboration 

• 

• 

• 

• 

Preparedness plans for non-health sectors such as civil protection and border control have been developed.  

Investments were made in the aviation, border control, ambulance services, and civil protection sectors in 
order to ensure rapid response and safeguard the functionality of mechanisms needed to ensure population 
protection and infectious disease control (e.g. decontamination). Protocols are constantly updated and 
revised.  

Collaboration between countries plays an important role in maintaining high levels of preparedness. In 
particular, collaboration between laboratories was intensified (exchange of information and samples).  

Countries discussed and agreed on a system for medical evacuation (either by enhancing their own capacity 
or by enrolling into EU mechanisms).  

Conclusions  

The review of findings by the visit teams identified a large degree of similarity in the challenges which the 
countries faced in preparing for possible Ebola cases.  

Common good practices 

• 

• 

• 

• 

• 

• 

Simulation exercises were recognised as a good tool for learning. 

The value of incident (case) reviews as a learning tool to strengthen preparedness was discussed. Incident 
reviews also help to revise actions taken and improve the timeliness of response (applied in all countries at 
a different scale and scope). 

While preparing for Ebola response measures, cross-sectoral coordination was improved, given the need for 
cooperation between health, transport, border services, etc. 

‘One-stop shop’ for information on Ebola was provided to citizens, for example through telephone hotlines 
or websites.  

Lessons learned from past events were used to enhance the Ebola response. Experiences from SARS, avian 
influenza, MERS CoV and A(H1N1) fed directly into the Ebola preparedness planning. 

Efficient structures to coordinate preparedness and response measures in the context of the Ebola health 
threat were established. 

Common challenges 

Resourcing: a number of caveats were noted with regard to sufficient availability of staff and resources. 
Staff issues with regard to business continuity, in particular the number of trained staff that need to be 
mobilised to care for a single Ebola patient over a sustained period of time, and the establishments of 
procedures to manage the impact of this staff mobilisation so other hospital services are not compromised. 
Need to plan the continuity of operations in situations with more than one Ebola case.  

Personal protective equipment (PPE): challenges in obtaining and deploying Ebola-appropriate PPE in 
quantities needed to manage a confirmed case for several weeks; challenges in ensuring the timely training 
of a sufficient number of healthcare workers on how to use Ebola-appropriate PPE (challenge successfully 
resolved in some, but not all countries); challenges with excessive layering of PPE, which makes it difficult 
for healthcare workers to do their job. 

Transparency of processes: ensuring sufficient consultations with key stakeholders in a time of crisis in 
order to develop or adapt the necessary guidelines and standard operating procedures.  

Case definition: Some countries relied on relatively specific case definitions for identifying persons who 
require investigation for possible infection with Ebola virus, without specific algorithms for the investigation 
of persons considered to be at a lower probability of infection. 

• 

• 

• 

• 

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Ebola emergency preparedness in EU Member States – Conclusions from peer-review visits 

• 

Capacities:  

− 
− 

Recognised need for more exercises and training 
Emergency departments in non-designated hospitals may need further assistance in preparedness 
planning. 

Evaluation, legacy and application of lessons learned: a comprehensive evaluation plan should be 
considered so that lessons learned can be used to improve protocols and guidance. Need to ensure that 
practices and experiences from Ebola are captured and sustained to improve preparedness for future 
threats. 

Interoperability of plans between sectors: More attention could be paid to ensure the interoperability of the 
various sectoral plans with the preparedness plans from the health sector. 

• 

• 

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Country-specific findings  

Belgium  

Main findings 

• 

• 

• 

• 

• 

• 

• 

Organisational structure and collaboration: robust and concise arrangements for Ebola response governance 
and organisation, with well-recognised leadership. Intensive and effective collaboration between key 
stakeholders, including clear coordination and collaboration with key organisations outside the health sector.  
Guidelines and procedures: guidelines and standard operating procedures (SOPs) adapted or developed 
after extensive collaborative efforts, including participation of professional experts, scientific and non-
governmental organisations.  
Communication and capacity building: transparent communication with professionals and the public on the 
Ebola health threat, including one common multilingual website. Simulation exercises and numerous 
trainings for staff were organised, for the health sector and in collaboration with key stakeholders from non-
health sectors. 
Points of entry: entry checks for all passengers arriving on direct flights between Belgium and affected 
countries. Good organisation of the passengers flow at the international airport. Intensive collaboration 
between airport administration, airlines and federal health authorities. This allowed authorities to build 
confidence in the public about the implementation of safety measures, while at the same time maintaining 
regular flight schedules. The country contributed to efforts of the international community to control and 
maintain the outbreak by continuing direct flights to affected African countries so that health professionals 
could be deployed there. 
Community/primary respondents: general practitioners (GPs) were consulted at the end of the development 
process for guidelines and SOPs. Health inspectors had an important role as intermediate level between 
primary care and hospital care, particularly with regard to the decision-making process on case recognition 
and referrals.  
Inland transport: criteria distinguishing ‘dry’ from ‘wet’ cases were applied to determine the transportation 
mode (dry case: mild disease, manifestation without dispersion of liquids; wet case: severe manifestation of 
disease, including bleeding and/or vomiting). Protocols were developed for transportation modes and the 
use of different types of personal protective equipment (PPE).  
Hospitals designated as Ebola treatment centres: three hospitals in three different areas of the country were 
designated for Ebola care. Structures were modified to meet requirements for isolation and protection of 
staff when receiving and treating highly infectious patients.  

Main strengths in preparedness planning, organisation and function 

• 

• 

• 

• 

• 

• 

• 

• 

Clear criteria for deciding on a case (symptoms compatible with disease, e.g. fever; evidence of exposure; 
assessment of risk behaviour).  
Guidelines and flowcharts on algorithms were developed, regularly updated, and disseminated to different 
levels of the healthcare system.  
Medical staff was informed, trained and provided with advice on how to detect, protect and control the 
spread of highly contagious viral haemorrhagic fevers such as Ebola. Public and professional communication 
measures were substantial, with a strong commitment to establish a multilingual ‘one-stop shop’ website for 
reference.  
Organisational structures were enforced and specific structures were established to improve the 
coordination with counterparts. The appointment of an Ebola coordinator and deputy coordinator was a 
great step forward and improved coordination at clinical and political levels.  
Collaboration between authorities was enhanced in the context of Ebola. Regular reports produced by the 
Ebola coordinator were discussed and disseminated to relevant stakeholders. The risk management and risk 
assessment groups collaborate efficiently. 
Direct flights to affected countries were not interrupted, which helped the international community of health 
professionals to continue their efforts to contain the outbreak in West Africa.  
Designated healthcare facilities were in frequent contact with public health authorities, which improved 
certain organisational aspects and capacities. There was an exchange between healthcare facilities and 
public health authorities on adopted practices. 
Laboratory capacity was sufficient; diagnoses were timely. 

Challenges and lessons learned 

Availability of staff was discussed both for the public health area as well as for primary, secondary and 
tertiary care. Also debated was the sustainability of functions at different levels of the healthcare system if 
more than one case of Ebola would have to be treated. Shortage of staff and work overload can cause 
significant pressure when trying to sustain other (routine) activities.  

• 

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Ebola emergency preparedness in EU Member States – Conclusions from peer-review visits 

• 
• 

• 

• 

Lack of resources was responsible for not organising more simulation exercises.  
There is no standardisation of PPE because hospitals initiated procurement of PPE at different times. This 
may be an issue if the country wants to build a common stockpile. 
Some guidelines/protocols were still in development or in the finalisation stage. Professionals dealing with 
risk groups need to be more involved in technical discussions and testing guidelines (e.g. carers for asylum 
seekers). Risk assessments for targeted populations should be supported by more analyses of specific data.  
A detailed analysis of suspected cases should be performed to reveal weak points so that the system can be 
improved further. It is particularly important to assess the level of burden placed on the system and how 
this was addressed.  

Main measures proposed by ECDC 

• 
• 
• 

• 

• 

Preparation of clear plans for system sustainability and resource supply.  
Comprehensive analysis of algorithms of case management based on the experience with suspected cases.  
Initiatives for more simulation exercises with counterparts from all levels of the health system (including 
GPs) and non-health sector stakeholders. GPs preparedness and their involvement in simulation exercises 
may need to be further discussed and assessed.  
Review and evaluation of entry screening: lessons learned could be performed in collaboration with 
countries who applied similar policies. Sharing best practices between airport and airline authorities, and 
marine and railway authorities, may support the learning process.  
Evaluation of system performance and incorporation of legacy and lessons learned into generic 
preparedness planning. 

Romania  

Main findings  

• 

• 

• 

Romania initiated and established a wide range of measures in a short time. The peer-review team 
concluded that the country is well on its way to being fully prepared to detect, transport and care for an 
imported Ebola case, while at the same time ensuring adequate staff protection. However, more work 
needs to be done in order to be fully prepared.  
Areas identified for further improvement mainly concern procurement of PPE, transportation equipment, 
training in proper use of PPE, developing and disseminating more detailed national guidelines, and 
simulation exercises. 
In order to fully capitalise on the investment made, it is important to ensure that the advances made in 
preparedness will also be applied to future health threats, e.g. MERS-CoV, SARS, highly pathogenic 
influenza strains, polio, and MDR/XDR tuberculosis.  

Main strengths in preparedness planning, organisation and functions 

• 

• 

• 

• 

• 

• 

• 

• 

Clear organisational structure: robust and concise arrangements for Ebola response governance and 
organisation, with well recognised leadership. There has been a strong national Ebola committee in place 
since October 2014, with a cross-sectoral approach which involves all relevant actors. Governmental 
decisions covering the main aspects of Ebola preparedness are efficiently distributed and well known. 
Technical and scientific competency in the National Institute for Public Health and in the Matei Bals 
Infectious Disease Hospital is high. Both institutions serve as national resource centres for advice and adapt 
international scientific guidelines to the Romanian context. Matei Bals infectious disease hospital has 
developed SOPs and trained staff in the use of advanced isolation equipment, e.g. negative pressure 
chambers. 
A designated treatment facility in a field military hospital was identified as a single treatment unit for an 
Ebola case. The hospital can host assigned staff in a secluded compound. 
There is a parallel reporting system in place to detect a potential Ebola case, both through regular 
surveillance reporting within the public healthcare system and through the 112 emergency number. 
There is a highly proficient rescue service in place with five dedicated SMURD ambulances, complete with 
isolation units. Helicopters and airplanes for domestic and international patient transport are also available. 
The Romanian emergency medicine system is highly efficient and seamlessly integrated into the rescue 
services, thus ensuring high-quality patient management, infection control and staff protection. Staff in the 
emergency rooms was well aware of Ebola and has efficient routines in place for triage and isolation. 
It seems that GPs are aware of Ebola symptoms, reporting routines, and personal protection with ‘light PPE’ 
and distancing (assessment based on limited access to information).  
The border control is well integrated into the district public healthcare system; cooperation with the police, 
customs, and rescue services is good. 
Because of the lack of PPE, some avian influenza PPEs are getting reused. 

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Challenges and lessons learned 

• 

• 

• 

• 

• 

The identification of a number of ‘suspected cases’ (none infected with Ebola virus disease) has 
demonstrated the sensitivity of Romania’s alert system and also enabled Romania to exercise parts of its 
Ebola preparedness plan. 
Procuring large quantities of the splash-proof PPE for the treatment and care of symptomatic Ebola case 
has proved to be challenging. The low quantity of Ebola-specific PPE available severely limits the number of 
healthcare staff who can be trained in the safe ‘donning’ and ‘doffing’ of PPE. 
The number of healthcare staff trained in how to safely ‘don’ and ‘doff’ Ebola-specific PPE is relatively low; 
guidance available in health facilities is not always consistent or detailed enough. 
Romania has experienced a ‘brain drain’ of healthcare workers in recent years, which means that the 
number of trained staff available across the healthcare system is not always optimal. Given the large 
number of skilled staff needed to care for a symptomatic Ebola case, having to manage such a case for 
several weeks would put significant pressure on the Romanian healthcare system. 
Romania’s preparedness efforts against earlier health threats – notably avian influenza in 2005–2006 and 
the 2009 influenza pandemic – have provided a useful foundation for preparing against Ebola.  

Main measures proposed by ECDC 

• 

• 

• 

• 

A national Ebola exercise, testing the full sequence of events and all interactions between the various 
institutions and authorities, should be undertaken to further improve preparedness. 
Preparedness could be further strengthened by the development of national guidance on certain key areas 
(e.g. ‘donning’ and ‘doffing’ of PPE), by further investment in training, and by holding a national Ebola 
preparedness exercise. ECDC could support these efforts by training material on the proper use of PPE, 
including an instructional video in Romanian. 
Romania could benefit from the experiences from avian influenza, the A(H1N1) pandemic and Ebola 
through a comprehensive ‘lessons-learned’ exercise, which should include critical incident reviews of the 
handling of suspected cases. 
The experience gained from Ebola preparedness should be used to develop a generic, integrated, cross-
sectoral infectious disease preparedness plan. 

Portugal 

Main findings  

• 

• 

• 

The review team concluded that Portugal has effectively implemented comprehensive and integrated Ebola 
emergency preparedness measures, tested and improved through the structured management of several 
probable cases (none of them positive).  
It is apparent that key responder organisations within and outside the health service have gained much 
from their activities on Ebola preparedness.  
Portugal should shift into its planned evaluation phase in order to consolidate the gains made in 
preparedness for highly infectious communicable diseases (staff skills, organisational preparedness, physical 
infrastructure). 

Main strengths in preparedness planning, organisation and functions 

• 

• 
• 
• 

• 

• 

Portugal has achieved full preparedness for Ebola infection through a well organised and well 
communicated infrastructure.  
There was intensive involvement of key stakeholders in the planning and response phases.  
Staff skills and knowledge have improved in the preparedness process.  
Documentation and structural arrangements (e.g. organisational policies and protocols) were made 
available for the management of highly infectious diseases such as Ebola infection.  
Information systems are used for the reporting and the analysis of data; there are data links with other 
sectors (e.g. airport and maritime port authorities). Most of the time, however, authorities used the 
telephone and contacted on-call duty personnel for initial contacts or preliminary discussions on suspected 
cases.  
A number of simulation exercises and training activities were conducted, involving all levels of the 
healthcare system (primary, secondary, tertiary), as well as national and regional authorities.  

Challenges and lessons learned 

Staff skills: health authorities need to ensure that the skills, competencies and capacities for the 
management of highly infectious diseases are maintained at all responder organisations. 
Designated hospitals: staffing capacity and capabilities for the effective and safe care of Ebola patients may 
be a challenge if the duration of treatment of a single case is too long or if there are a number of cases 
simultaneously. A need for comprehensive business continuity plans for the affected specialist hospital 
services has been acknowledged.  

• 

• 

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Ebola emergency preparedness in EU Member States – Conclusions from peer-review visits 

• 

• 

• 

Use of sophisticated multilayer personal protective equipment (PPE) has been recognised as an issue. 
Therefore, equipment and guidelines will be further reviewed; this includes a potential simplification of PPE. 
Guidance and protocols have been regularly reviewed, yet an update in the light of experience with 
probable (or confirmed) cases and international recommendations is needed.  
To facilitate efficient tracing and monitoring and avoid a definition which compromises sensitivity, patient 
contacts may need to be classified by level of risk. 

Main measures proposed by ECDC 

• 

• 

• 

• 

• 

• 

Monitoring and support of healthcare workers returning from service in affected countries in West Africa: 
guidance should be developed for the monitoring and support of healthcare workers returning from clinical, 
laboratory or epidemiological support work in the affected countries.  
Points of entry: assess awareness of procedures for managing highly infectious patients in undesignated 
ports. 
Designated hospitals need to discuss the mutual provision of medical and specialist nursing staff in the 
event that one of them admits a confirmed case.  
Protocols need to be developed for the monitoring of the clinical environment and the laboratory staff 
involved in the care of Ebola patients. Protocols should use a reasonably sensitive definition for the initiation 
of investigations in the event of illness and define the roles of occupational health for all hospital services 
(e.g. medical, psychological, and counselling) involved in Ebola patient care. 
Further expert review of the PPE to be initiated, with a view to a possible agreement somewhat simplified 
specifications; PPE requirements should be adjusted to risk and ensure reasonable clinical efficacy and a 
long duration of use.  
An evaluation of Ebola preparedness should include reviews of critical incidents from probable case 
assessments, subjective feedback from system participants, and the analysis of proxy information on 
system operation.  

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Annex 

Figure 1. Viral haemorrhagic fevers: pathways and potential responders, conceptual scheme  

Cross-cutting topics
• Surveillance
• Case finding
•

Infection prevention and 
control
• Laboratory
•
• HR, training
• coordination

Info, communications

Five modules
A. Primary responders
B. Point of entry
C. Medevac
D. In-country transport
E. Designated hospital

All organisations
• Suspect case recognition
• Patient management 
and staff protection
• Plans and preparation

Travellers

Point of entry

Border check

Symptomatic

Asymptomatic

Infection 
prevention 
and control 
at border

Transport

Community

Medevac

Contacts

Public 
Health

Aircraft 

Disembarkation

Transport

Primary 
health 
centre

Emergency 
department

Treatment in designated hospital

Critical abilities include:
• Isolation
• Personal protective equipment
• Samples
• Waste management
• Post-mortem, etc.

Possible point of recognition as suspect case

112
Ambulance

After 21 days

10 

 
 
 
 
 
 
 
 
 
 
 
 
 
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