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Eurosurveillance, Volume 11, Issue 12, 01 December 2006
Surveillance report
The Early Warning and Response System for communicable diseases in the EU: an overview from 1999 to 2005

Citation style for this article: The Early Warning and Response System for communicable diseases in the EU: an overview from 1999 to 2005. Euro Surveill. 2006;11(12):pii=666. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=666

P Guglielmetti1, D Coulombier2, G Thinus1 , F Van Loock1, S Schreck1

1. European Commission – SANCO C3 – Health Threat Unit, Luxembourg
2. European Centre for Disease Prevention and Control – Preparedness and Response Unit, Stockholm, Sweden

 


Under Decision 2119/98/EC of the European Parliament and of the Council, a network for epidemiological surveillance and control of communicable diseases in the Community was set up in 1998. One pillar of Decision 2119/98/EC is the early warning and response system (EWRS). The main objective of the network is to establish permanent communication between European Union (EU) Member States’ public health authorities, which are responsible for determining the measures required to control communicable disease-related events. Since 1998, a web based informatics tool has been developed in order to allow information to be shared between the relevant public health authorities. Between 1998 and December 2005, a total of 583 messages were circulated through the EWRS, notifying 396 events. The information shared through the system helped to coordinate public health measures in the EU. However, only few events prompted specific measures at Community level and most of them were controlled with public health measures applied at national level. Major events (such as the Severe Acute Respiratory Syndrome) and the results of simulation exercises prompted the Commission to upgrade the informatics system on the basis of user needs. Since 1 May 2004 the 10 newest Member States have provided information under the current legislation and since April 2005 the European Centre for Disease Prevention and Control (ECDC) is part of the system. Future developments will include a link between the existing EWRS and the communication platform currently developed by the ECDC.

 
Introduction

The emergence of SARS in 2003 clearly demonstrated how a previously unknown disease could spread rapidly, causing high mortality and morbidity. Fast travel and global trade facilitated transmission in the absence of relevant vaccines and drugs. Effective counter-measures were applied, but the event underlines the need for worldwide cooperation to control such contingencies. Early detection of cases and efficient international communication and coordination was an advantage to tackle the epidemic. Public health measures undertaken not only by the affected countries but by the entire international community, with the support and guidance of the World Health Organization (WHO), helped to prevent catastrophic developments. Coordination in the European Union based on the EWRS contributed to Member States’ knowledge of the situation and their readiness to stem any potential spread of the disease.

The threat of a pandemic influenza is currently prompting governments and international bodies with responsibilities in public health protection to address preparedness plans that could mitigate the potential effects of a pandemic, and to reinforce policies, contingency plans and resources, including the alert systems and their networks (1, 2).

The tools for European coordination to tackle communicable disease health threats must enable the key players to obtain and share key information on public health measures, both quickly and securely. The key players engaged in this process are the national health authorities, the national public health agencies, the Ministries for Health in Member States, and the European Commission and its agencies, in particular the ECDC.

The main objective of the paper is to outline the interactions of the EWRS key players and to describe the alert system for communicable diseases currently in place in the EU. It refers to the existing legal basis, the functioning of the system, the main players concerned with operations since its introduction, and the most recent upgrade undertaken on the basis of lessons learned from the past experience.

The legal basis

Decision 2119/98/EC established the early warning and response system as one of the two pillars of the Community network for the epidemiological surveillance and control of communicable diseases. The other pillar of the Community network is the base for the epidemiological surveillance in the EU and is made up by establishing permanent communication between the Commission and those structures which, at Member State level and under the responsibility of each Member State, are competent at national level and are charged with collecting information relating to the epidemiological surveillance of communicable diseases. The early warning and response function allows information exchange, consultation and coordination at Community level, should an event due to communicable diseases endanger public health at Community level. The network brings into communication the European Commission and the competent public health authorities in Member States responsible for determining the measures which may be required to protect public health against communicable disease threats. The system links the European Commission, the 25 Member States, Bulgaria and Romania and the European Economic Area (EEA) countries (Iceland, Liechtenstein and Norway). The ECDC has had access to EWRS since its establishment in May 2005 (3).

Under Decision 2119/98/EC, authorities communicate i) information regarding the appearance or resurgence of cases of communicable diseases, together with information on control measures applied; ii) any relevant information concerning progression of epidemic situations; iii) information on unusual epidemic phenomena or new communicable diseases of unknown origin, including in non-member countries; iv) information concerning existing and proposed mechanisms and procedures for the prevention and control of communicable diseases, in particular in emergency situations; and v) any information which could help Member States to coordinate their efforts for the prevention and control of communicable diseases, including any counter measures implemented (Art. 4, Decision 2119/98/EC)(3). This kind of information is provided through an informatics tool developed expressly for this purpose.

Decision 2000/57/EC states that the EWRS is reserved for events that have ‘Community relevance’. These events are: i) outbreaks of communicable diseases extending to more than one Member State of the Community; ii) spatial or temporal clustering of cases of disease of a similar type, if pathogenic agents are a possible cause and there is a risk of propagation between Member States within the Community; iii) spatial or temporal clustering of cases of disease of a similar type outside the Community, if pathogenic agents are a possible cause and there is a risk of propagation to the Community; and iv) the appearance or resurgence of a communicable disease or an infectious agent which may require timely, coordinated Community action to contain it (Art 1 and annex I, Decision 2000/57/EC) (4). The procedures for information, consultation and cooperation under the EWRS are described in article 2 of Decision 2000/57/EC. Three levels of consultation are defined: level 1 for information exchange, level 2 for notification of a potential threat and level 3 for definite threat (Annex II, Section 1,2,3, Decision 2000/57/EC)(2). A specific procedure for information to the general public and concerned professional is reported in section 4 of annex II of Decision 2000/57/EC and states that Member States shall provide suitable information to concerned professional and the general public and shall inform them of the measures adopted and that the Commission and Member States shall inform of any guidance agreed at Community level and when the public health is over (4).

Should one or more of the previously mentioned circumstances occur, Member States shall, on the basis of the information available, consult each other in liaison with the Commission with a view to coordinate their actions. In particular, where a Member State intends to adopt, as a matter of urgency, control measures in response to the appearance of a communicable disease, it shall, as soon as possible, inform the Commission and the other Member States. On the basis of this consultation and of the information provided Member States shall coordinate in liaison with the Commission the measures which they have adopted or intend to adopt at national level (Art 6 Decision 2119/98/EC)(3).

Each Member State designates the structure and/or the authorities referred to the early warning and response function and notifies the Commission and the other Member States (Art 9, 2119/98/EC). The public health authorities which have been formally designated represent the network of the contact points of the EWRS (3).

Description of the informatics tool currently available to implement the early warning and response under Decisions 2119/98/EC and 2000/57/EC

Since Decision 2119/98/EC entered into force, an informatics tool has provided the platform for communicating information. The tool currently linking the EWRS contact points is a web-based system. The access to the system is secured and is limited to the formally appointed contact points. As previously mentioned, following notification from Member States, the contact point receives a login and a password from the Commission to access the system, and full authorisation to write and read messages. When a message is posted on the system, it is automatically circulated to all EWRS contact points, and the network (Commission, Member States, acceding and the EEA countries, and ECDC) is informed at the same time of how the situation is progressing and of the measures planned or undertaken at national level to respond to the specific event.

On the basis of lessons learnt from past events, mainly from the SARS epidemic, and on the basis of the recommendations made in the report of the EWRS activities for the years 2002 and 2003 (3), there has been a complete technological overhaul of the system. The new EWRS application was launched in May 2004 and it is currently in use. Additional modifications of specific functions were introduced after the 2005 simulation exercises (6).

In the current application, a single message can contain a text of up to 3999 characters, and additional comments up to 1999 characters may be added. There is no limit to the number of comments that can be made following a single message. Additional documents, for a maximum of 9 Megabytes, can be attached to messages and comments. Readability and classification of the comments has been also improved. A few ‘simple search’ features were also added to the ‘threat listing’ page to select important flags (message content, syndrome/disease, pathogen, reporting reason, and country of occurrence). After rebuilding the core of the application, a calendar function was added to create a meeting agenda and to facilitate the sharing of working documents among users without overloading the core messages. To prevent the risk of overload of messages, should a specific event require a large number of notifications, a ‘follow up’ section was added. A new messaging system was also introduced in May 2005 (selective messaging) that allows participants to send a message to selected recipients. The European Commission is always notified of ‘selective’ messages. The user levels were expanded to give access both to the ECDC and the WHO. The WHO has, with the agreement of Member States, a read-only access to the system. Other security enhancements were also added.

A short message service (SMS) messaging function has been activated in order to transmit to the European Commission Officer on duty real time notification that a message has been posted on the system.

In addition to these function the system is linked to the Medical Intelligence System (MedISys) (7). MedISys is a piece of software that browses the web every 20 minutes in order to find articles, documents and latest news about health matters. About 350 keywords are currently used and 1200 websites are visited. Access to the system has been granted to Ministries of Health, national surveillance institutes, specific EU supported projects, ECDC and WHO. Graphs, statistics and world maps allow a quick identification of threats and localisation of the events. The system is based on the European Media Monitor, which is freely accessible to all (8).

The ECDC was officially established in May 2005, but started activities in March 2005. As the assistance of Commission by the ECDC in operating the EWRS is stated in the ECDC founding regulation, the agency was rapidly integrated into all EWRS related activities (9). The ECDC has been connected to the EWRS since April 2005. ECDC has implemented its threat monitoring mandate using the EWRS messages as a source of information on threats in Europe, complemented by an active search of additional formal and informal sources.


The EWRS operations

Since Decision 2119/98 entered into force at the end of December 2005, a total of 583 messages have been circulated through the EWRS. These messages notified a total of 396 events. The first message (about legionellosis) was posted on 30 November 1998 and no further messages were posted in 1998. Figure 1 reports the number of the events notified through the EWRS from January 1999 to December 2005, including the level of activation as defined by procedures reported in annex II of Decision 2000/57/EC (4).

 

The nature of the events (diseases and/or syndromes) notified during the same period 1999-2005 is reported in Table 1. The trend of the diseases and syndromes which have been reported at least five times in one year (haemorrhagic fever, salmonellosis, meningitis, influenza, SARS and measles) is reported in Figure 2. Only a few events have prompted specific measures at Community level; most were controlled by applying public health measures at national level. Events which required a more complex response, involving coordination of measures and contacts between health authorities in Member States, are summarised in Table 2. Comments were added to the majority (around two thirds) of these events. Details concerning the specific events reported in the Table are available in the annual reports of the EWRS (5, 10).

 
 




The SARS epidemic dominated the EWRS activity from March to June 2003. Figures on EWRS activities during this period are reported in Table 3 and Figure 3. The system provided a unique tool to circulate reliable information quickly to the Commission and to the Member States. During the first phase of the event in particular, the EWRS was able to pick up a notification posted by France on 11 March 2003 about a real and serious threat in Vietnam. The content of messages circulated during the SARS outbreak can mostly be put under two categories. The first category is reports of measures undertaken by Member States to control the spread of SARS, and it provided very useful information which helped to coordinate the response to SARS at national and at EU level (Table 3). The second category is case and update reports, which provided useful and additional information to Member States when weighing the impact of imported cases in the EU. This second set of information was consistent with the WHO notifications. The nature and magnitude of the event caused a huge and rapid flow of messages. Starting from the second week of the outbreak, this situation caused an overload of the EWRS mailbox and had a negative impact on processing and interpreting data and on control activities (5). The problem was solved by creating a specifically dedicated mailbox for selected messages (case and update reports, official communications, call for meetings and consultation teleconferences, etc.). These elements provided the basis for the upgrading of the system (5, 10).



Discussion

The European collaboration on communicable diseases only started recently, within the context of the public health framework set out in the Commission Communication of 24 November 1993 on the framework for action in the field of public health. The network for the epidemiological surveillance and control of communicable diseases in the Community with its early warning and response function operating under Decisions 2119/98/EC and 2000/57/EC has been one of the most successful public health instruments.

The EWRS is being used more and more frequently to share relevant information between the Member States, the Commission and the ECDC. The system currently available is a unique tool that helps to coordinate public health measures intended to control communicable diseases threats in the EU. The increased number of messages circulated through the EWRS mirrors the efforts done in implementing the current EU legislation on communicable diseases, and also shows the value of such an instrument for appropriate communication between partners.

Although the EWRS is not intended to be a tool to monitor communicable diseases in the EU, analysis of events notified since 1999 tells us about the nature and frequency of the threats which required a response at Community level. The knowledge of these figures can help Member States, the Commission and the ECDC to strengthen mechanisms and actions and thereby to be better prepared to respond to specific events and to predict, at least in part, what we can expect at short and medium term.

A/H5N1 related events were the most frequent cause of notification in 2004 (21 events) and the second most frequent in 2005 (13 events). Sharing information encouraged a tangible effort to coordinate measures for strengthening preparedness to respond to the potential progression of the pandemic alert phases. The Member States were regularly informed through the EWRS about the measures undertaken at national level and a consistent response was reached at Community level (for the most part, monitoring the situation, implementing active surveillance, advising EU citizens travelling to and from affected areas, strengthening synergies with veterinary services, and finalising pandemic plans).

Unpredictable incidents represent a significant proportion of notified events. The system proved to be a unique tool to circulate reliable information, not only during the unforeseen SARS epidemic, which dominated the EWRS activities from March to May 2003, but also during one-off incidents which required the rapid implementation of public health measures, such as, the event related to the rabid dog illegally imported into the EU that bit or had close contact with several EU citizens, and the incident linked to erroneously distributed samples of live influenza virus A/H2N2 to carry out proficiency testing (Table 2).

Further analysis by the Commission, Member States and the ECDC of the reported events through the EWRS and of the public health responses in term of measures planned and undertaken in response to the notified threats will be essential to better understand and to strengthen the capacity to efficiently tackle communicable diseases in the EU.

All events that required urgent notifications and a more complex response and coordination of measures (Table 2) were notified without delay, demonstrating a clear improvement after 2003 (5). These events were a significant test of the usefulness of the EWRS. The system fulfilled its institutional role by circulating messages in a timely fashion among the EWRS contact points in Member States, by providing shared positions among the national public health authorities, and by facilitating the exchange of information on specific issues. The consultation platform provided by EWRS was very much appreciated by the authorities of the Member States and resulted in consistent national decision making for the control of these events.

The analysis of the content of activation level 1 messages (which include information messages) demonstrates that a number of them still remain focused on risk assessment issues and that a large part deals with requests for information about similar events identified in other Member States. The integration of specific functions of the current EWRS informatics tool in the communication platform that ECDC is developing will be instrumental to focus the use of the system to cover those circumstances as laid down in Decisions 2119/98/EC and 2000/57/EC.

The integration of the 10 new Member States in the EWRS was a special challenge. New Member States made efficient use of the EWRS, demonstrating a level of activity comparable to that of the old Member States. Since accession in May 2004 the 10 new Member States have had full access to the EWRS and have made active use of the system both to notify new events and to follow up with comments events been notified by other Member States or by the Commission. A recent analysis prepared by the ECDC, covering the period from June until December 2005, demonstrates that the amount of threats notified through EWRS is comparable for old and new MS (after adjustment for population), showing good integration of new MS in the EU alert system for communicable diseases (11).

EWRS was the communication tool used during the simulation exercise 'Common Ground' that was conducted by the UK’s Health Protection Agency (HPA) as a command post exercise on 23 to 24 November 2005. This exercise was the second of two EU exercises commissioned by the European Commission to evaluate the ability and capabilities of Member States to respond to a health-related crisis, in this case an influenza pandemic. EWRS was made available for the exercise to all 25 Member States plus Norway, Iceland and Switzerland. Despite heavy use during the exercise (437 messages circulated, an average of nearly 10 messages per hour, and 3672 responses), the system performed efficiently and no breakdown was registered. Nevertheless, given the nature of the simulation, there was considerable overload and heavy traffic, and users rapidly became overwhelmed by the huge number of messages. As the EWRS was the only system for simultaneous European communication available, participants used it for all sorts of information exchange, although the system was only developed, as laid down in Community legislation, for official notification of measures and their coordination. As previously mentioned, the future communication platform developed by the ECDC will be also important for strengthening information sharing during emergency situations like those simulated during EU-wide exercises.

The EWRS should also be considered in the perspective of the future implementation of the revised International Health Regulations (IHR) (12, 13). IHR will enter into force on 15 June 2007, and require gradual implementation, to be completed by 2016 at the latest. Close coordination between the Commission and Member States will help to optimise their implementation, and better protect EU citizens from public health emergencies due to communicable diseases. In particular the ECDC and the EWRS will be instrumental to help the implementation process of IHR in a stronger and more coherent way (12, 13).

EWRS contact points (As of 14 September 2006).

Austria: H. Hrabcik and R. Strauss (Bundesministerium für Gesundheit und Frauen); Belgium: D. Reynders (Federal Public Health Service); Cyprus: O.Kalakuta (Ministry of Health Medical and Public Health Services); Czech Republic: M.Vit (Public Health Officer); Denmark: K.Molbak (Statens Serum Institut) and S.Poulsen (National Board of Health); Estonia: M.Muzotsin (Health Protection Inspectorate); Finland: P.Ruutu (Kansanterveyslaitos); France: S.Veyrat (Ministère de la Santé et des Solidarités) and J.C.Desenclos (Institut de Veille Sanitaire); Germany: G.Krause (Robert Koch Institute) and M.Kramer (Federal Ministry for Health); Greece: A.Hatzakis and O.Adrami (Centre for Infectious Diseases Control); Hungary: A.John (Fooszaltályvezeto Népegészségügyi Minisztérium Népegészségügyi Fooszaltályvezeto); Ireland: K.Kelleher (Health Service Executive) and D.O’Flanagan (Health Protection Surveillance Centre); Italy: M.G.Pompa (Ministero della Salute); Latvia: O. Kravcenko and Jurijs Perevoscikovs (Public Health Agency); Lithuania: V. Gailius (Ministry of Health) and R.Liausediene (Centre for Communicable Diseases Prevention and Control); Luxembourg: P.Huberty-Krau (Direction de la Santé); Malta: M.Micallef and C.Gauci (Dipartiment Tas-Sahha Publika); Netherlands: RIVM-Centre for Infectious Disease Control; Poland: A.Trybusz (Sanitary Inspectorate); Portugal: M.Da Graça Freitas (Direccão-Geral da Saúde) and M.T.Paixão (Instituto Nacional de Saúde); Slovakia: Ministry of Health - Public Health Authority of the Slovak Republic; Slovenia: A.Kraigher (Inštitut za varovanje zdravja); Spain: Dirección General de Salud Pública Ministerio de Sanidad y Consumo; Sweden: A.Tegnell (The National Board of Health and Welfare); United Kingdom: A.Wight (Department of Health); Bulgaria: R.Filipova (Ministry of Health); Romania: R.P.Costinea (Ministry of Health); Iceland: H.Briem (Directorate of Health); Liechtenstein: E.M.Hiebl (Amt für Gesundheitsdienste); Norway: P.Avitsland (Norwegian Institute of Public Health). ECDC: D. Coulombier (Preparedness and Response Unit, ECDC); European Commission: S.Schreck and P.Guglielmetti (SANCO Health Threats Unit – C3).


Acknowledgements
We would like to thank Celine Verkaeren for the assistance and the preparation of the tables and figures.


References

1. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions on pandemic influenza preparedness and response planning in the European Community. Bruxelles, 28.11.2005, COM (2005) 607 Final.
http://eur-lex.europa.eu/LexUriServ/site/en/com/2005/com2005_0607en01.pdf

2. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions on strengthening coordination on generic preparedness planning for public health emergencies at EU level. Bruxelles, 28.11.2005, COM (2005) 605 Final.
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3. Decision no 2119/98/EC of the European Parliament and of the Council of 24 September 1998 setting up a network for the epidemiological surveillance and control of communicable diseases in the Community. Official Journal of the European Communities 3. 10. 98 L 268.
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4. Commission Decision of 22 December 1999 on the early warning and response system for the prevention and control of communicable diseases under Decision No 2119/98/EC of the European Parliament and of the Council. (Notified under document number C(1999) 4016)(2000/57/EC). Official Journal of the European Communities 26.01.2000 L 21.
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5. Report from the Commission to the Council and the European Parliament. Report on the operation of the Early Warning and Response System of the Community Network for the Epidemiological Surveillance and Control of Communicable Diseases (Decision 2000/57/EC) during 2002 and 2003. Bruxelles, 29.03.2005 SEC (2005) 394.
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6. A pandemic influenza exercise for the European Union. Exercise ‘Common Ground’.
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7. Medical Information System. https://medisys.jrc.it/ and http://medusa.jrc.it

8. Europe Media Monitor. http://press.jrc.it/NewsBrief/worldedition/en/en.html

9. Regulation (EC) no 851/2004 of the European Parliament and of the Council of 21 April 2004 establishing a European centre for disease prevention and control. Official Journal of the European Union 30.04.2004 L 142.
http://eur-lex.europa.eu/pri/en/oj/dat/2004/l_142/l_14220040430en00010011.pdf

10. Report from the Commission to the Council and the European Parliament. Report on the operation of the Early Warning and Response System of the Community Network for the Epidemiological Surveillance and Control of Communicable Diseases (Decision 2000/57/EC) during 2004 and 2005. In press.

11. Different approaches to gathering epidemic intelligence in Europe. Eurosurveillance Weekly. Vol 11, 4, 27 April 2006
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12. Communication from the Commission to the European Parliament and the Council on the International Health Regulations com (2006) 552.
http://ec.europa.eu/health/ph_international/documents/comm_ihr_552_2006_en.pdf

13. Fifty-Eighth World Health Assembly - WHA 58.3 agenda item 13.1 - 23 may 2005 revision of the International Health Regulations.
http://www.who.int/csr/ihr/IHRWHA58_3-en.pdf

 

 



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