Announcements
On 6 June 2017, the World Health Organization (WHO) published updates to its ‘Essential Medicines List’ (EML). Read more here.

Extended deadline (from 1 July to 31 July) 2017 for call to submit papers on effectiveness and cost-effectiveness of screening and prevention of infectious diseases among newly arrived migrants in Europe. Read more here.

Eurosurveillance is on the updated list of the Directory of Open Access Journals and in the SHERPA/RoMEO database. Read more here.

Follow Eurosurveillance on Twitter: @Eurosurveillanc


In this issue


Home Eurosurveillance Monthly Release  2006: Volume 11/ Issue 12 Article 10
Back to Table of Contents
en es fr
Previous

Eurosurveillance, Volume 11, Issue 12, 01 December 2006
Surveillance report
Recognition of threats caused by infectious diseases in the Netherlands: the early warning committee

Citation style for this article: Rahamat-Langendoen JC, van Vliet JA, Suijkerbuijk AW. Recognition of threats caused by infectious diseases in the Netherlands: the early warning committee. Euro Surveill. 2006;11(12):pii=672. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=672

 

JC Rahamat-Langendoen, JA van Vliet, AWM Suijkerbuijk
Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.

 


The early warning committee was established in order to recognise threats to public health caused by infectious diseases in the Netherlands in a timely and complete fashion. This article describes the outcome of a retrospective and descriptive evaluation into the completeness of the recognitions made by the early warning committee.
Information about outbreaks of infectious disease in the Netherlands in 2002 and 2003, as reported in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine), and about infectious disease events in other countries, was compared with reports of the regular weekly meetings of the Dutch early warning committee. If an outbreak or a foreign event was not mentioned in the meetings of the early warning committee, the cause for this was established. For events in other countries, it was established on the basis of whether or not the event could have been a threat to public health in the Netherlands.
All outbreaks of infectious disease in the Netherlands, published or mentioned in the Nederlands Tijdschrift voor Geneeskunde were discussed by the early warning committee. Three of the events occurring in other countries in 2002 had not been discussed by the committee although, based on the criteria for a potential threat to the Netherlands, they should have been: the outbreak of avian influenza A/H5N1 in domestic fowl in Hong Kong, the increase among hospitalised patients of carriers of extended-spectrum ß-lactamase producing micro-organisms in Scotland, and outbreaks of measles in several countries. In 2003, all events in other countries that could have posed a threat to the Netherlands were discussed by the early warning committee.
In 2002 and 2003, the early warning committee recognised nearly all threats due to infectious diseases and outbreaks of infectious diseases which were of national importance and published in various sources of literature.


 

Introduction
Threats to public health caused by infectious diseases usually appear without warning, but can have major consequences within a very short period of time. Recognition of these threats is essential [1]. The early warning committee was established in the Netherlands in 1999 under the authority of the Inspectie voor de Gezondheidszorg (Health Care Inspectorate). Its main task is to assess information from various sources, both foreign and national, in order to recognise threats to public health caused by infectious diseases in a timely fasion. If necessary, further outbreak investigation can be done, or measurements to control the outbreak can be taken [2, 3].
The weekly meeting of the early warning committee takes place at the Rijksinstituut voor Volksgezondheid en Milieu (RIVM, National Institute for Public Health and the Environment). The participants are microbiologists and epidemiologists from various departments of the RIVM, including the Landelijke Coördinatiestructuur Infectieziektebestrijding (LCI, National Coordination Centre for Outbreak Management), as well as representatives from the Voedsel en Waren Autoriteit (VWA, Food Safety Authority). Prior to the meeting, each participant selects, from various sources of information, items (known an ‘signals’) which in his or her opinion are important to discuss at the meeting [TABLE 1] [4]. There can be several reasons for selecting a signal. These are outlined in a protocol and are based on previous experience gathered by the RIVM. A sudden change in the incidence or prevalence of an infectious disease (e.g. the upsurge of West Nile virus infections), the appearance of an infectious disease among certain groups of people or in certain places (e.g. the lymphogranuloma venereum outbreak among men who have sex with men), or the emergence of a completely new or unknown disease (e.g. SARS) are some of the reasons mentioned [3]. During the meeting, the various signals are discussed and interpreted by the participants in order to estimate the threat for public health in the Netherlands.


On the same day, the RIVM sends a report of the meeting to about 500 people engaged in the control of infectious diseases in the Netherlands. They include physicians and nurses of the municipal health services, microbiologists, specialists in infectious disease, infection control practitioners, the Ministry of Health and the Inspectorate of Health. The report is formulated in such a way that signals are not reducible to persons, institutions or locations.
To fulfill its task properly, the early warning committee must recognise all important threats caused by infectious diseases. This article describes the outcome of a study into the completeness of the recognitions made by the early warning committee.

Methods
Information from other sources than those used by the early warning committee, were compared with the reports of the meetings of the early warning committee in order to assess how completely the committee had performed its task. The sources used for this study were different from the sources of information used regularly by the early warning committee. We focused on the years 2002 and 2003, because they saw a greater mix of minor, major, foreign and national threats caused by infectious diseases than the years immediately preceding or following [5-7].

Infectious disease events in the Netherlands

Using articles and news items published in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine, NTvG) between January 2002 and June 2005, we gathered information about outbreaks of infectious diseases in the Netherlands that constituted a potential threat to public health. This is the only peer-reviewed general medical journal published in the Netherlands that has a wide distribution nationally. All outbreaks of national importance are published in this journal, either as an article or as a news item. We compared the information with the reports of the meeting of the early warning committee. If an outbreak had not been mentioned during the meeting, we tried to determine the reason for this.

Infectious disease events in other countries
Information about infectious disease events in other countries was gathered from the following sources:
- weekly bulletins from Belgium, England and Wales, Scotland, Norway and Germany, in which reports about infectious diseases were given. These bulletins are similar to the report of the early warning committee and are available on the internet (http://www.eurosurveillance.org/links).
- The ’Infectious diseases surveillance update’ section in The Lancet Infectious Diseases. This is the only international journal with such a section, and is not one of the sources used by the early warning committee. The International Journal of Infectious Diseases has a similar section, but uses information based on ProMED-mail. ProMED-mail is one of the regular sources for the early warning committee, and therefore we did not use this journal for our investigation.
Information about events in other countries gathered from these sources was compared with the reports of the early warning committee. Subsequently, we determined whether those events that were not discussed during the meeting of the early warning committee could have been a threat for public health in the Netherlands, by answering two questions:
1) was there a possibility of importation and further dissemination in the Netherlands of the micro-organism mentioned?
and/or
2) was there a possibility that the (potential) source of the infection mentioned was present in the Netherlands?

Results
Iinfectious disease events in the Netherlands
An overview of the outbreaks of infectious diseases which occurred in the Netherlands in the years 2002 and 2003, based on the information in the NTvG, and which constituted a potential threat to public health, is given in table 2. All outbreaks were also discussed in the meetings of the early warning committee.



Infectious disease events in other countries

Based on information from various sources as described above, for the year 2002 we found 122 infectious disease events in other countries. We compared these 122 events with the information from the reports of the early warning committee. Forty eight of these events were discussed during the meetings of the early warning committee. For the remaining 74, we tried to determine whether or not they represented a threat to pubic health in the Netherlands, defined by the two questions mentioned above. For three events, the answer to one or both questions was ‘yes’. These events thus represented a threat to public health in the Netherlands and ought to have been discussed by the early warning committee. The events were:
a) the outbreak of avian influenza A/H5N1 among poultry in Hong Kong;
b) the outbreak of extended-spectrum-ß-lactamase (ESBL)-producers among hospitalised patients in Scotland;
c) outbreaks of measles in various countries (Republic of Ireland, Denmark, United Kingdom, Lithuania).
Seventy one of the 74 events not mentioned during the meetings of the early warning committee did not meet the criteria for a threat to public health in the Netherlands.
For the year 2003, 106 infectious disease events were identified in the various sources of information. Forty six of these 106 were discussed by the early warning committee. None of the remaining 60 events met the criteria for a threat to public health in the Netherlands as defined by the two questions mentioned above.
As an illustration, a few events in the area of infectious diseases in foreign countries in the years 2002 and 2003 are listed in table 3. The events listed were discussed by the early warning committee, and were also found in various sources of information different from the sources used by the early warning committee.

Discussion
This study shows that, in 2002 and 2003, the early warning committee was capable of recognising outbreaks of infectious diseases in the Netherlands, published or mentioned in the NTvG, which constituted a potential threat to public health. In addition to the regular sources used by the committee, each committee member represents a scientific network. These networks, and other people engaged in the control of infectious diseases in the Netherlands who regularly receive reports from the early warning committee, all contributed to the completeness of the information discussed during the meetings.
Our study into infectious disease events in other countries found that during the year 2002, three events that met the criteria for threat to public health in the Netherlands were not discussed by the early warning committee. Together with the committee members who participated during 2002, we tried to reconstruct the reasons why these events were not discussed. The outbreak of avian influenza A/H5N1 among poultry in Hong Kong was probably not discussed because at the time there were no human cases. Today, with advanced understanding of the impact of avian influenza, such an event would most probably be discussed.
Another event that was not discussed during by the early warning committee were the problems with ESBL-producing organisms in Scotland. ESBL is an enzyme capable of inactivating a broad spectrum of antibiotics. It is mainly produced by Gram negative bacteria, especially nosocomial Klebsiella spp [17,18]. This specific event was important, because ESBL production had spread among species, including E. coli and Enterobacter spp, as well as klebsiellas. Because of the restrictive usage of antibiotics, ESBL is not yet of major concern in the Netherlands, where incidence is low. However, it is an emerging problem, and in that sense, it should have been discussed during by the early warning committee. The results of this study were discussed with the participants of the early warning committee. During this discussion it was mentioned that, besides a lack of attention for emerging resistance to antibiotics, the early warning committee also does not give enough attention to hospital acquired infections.
A third event that met the criteria of a threat to public health in the Netherlands, but was not discussed by the committee, were various outbreaks of measles in different countries. These events were not discussed because they were limited in size, with only regional spread. Information about the outbreaks appeared most of the time at a fairly late stage of the outbreak, so that it was not useful any more to take any measures related to these outbreaks in the Netherlands.
Our study has some limitations. A threat to public health is not a well defined concept. We compared the signals mentioned in the reports of the early warning committee with published data in order to make completeness plausible. However, only major or unusual outbreaks or events are likely to be published. Events that were not published in the sources of information used in this study were not taken into account, nor was information about events that were not published at all. We cannot know whether or not such events could have been of national importance. However, health threats other than those mentioned in this study may have existed.
In order to make an early warning system more sensitive, additional sources of information, formal (e.g information from surveillancesystems) as well as informal (e.g. information based on media reports), may be necessary [19, 20]. We included scientific literature as a source of information, partly because of the lack of attention paid to antibiotic resistance and hospital acquired infections by the early warning committee. However, more signals do not automatically make a better early warning system. More study into the methodology of early warning and into defining threats to public health, both in the Netherlands and abroad, is needed.
This study was undertaken during a period in which there were many developments, both nationally and internationally. At a national level, the Centre for Infectious Disease Control was recently established to prevent and control infectious diseases through effective prevention, greater vigilance, and rapid response to potential outbreaks (http://www.rivm.nl/en/aboutrivm/organization/cib/index.jsp). One of the main tasks is clear and reliable communication with professionals engaged in the control of infectious diseases. The reports of the early warning committee play an important role in this.
At the international level, several developments should be mentioned. The European Centre for Disease Prevention and Control (ECDC) in Stockholm, Sweden, has been established to help strengthen Europe’s defences against infectious diseases. Surveillance of communicable disease and keeping track of emerging health threats inside and outside Europe are a few of its main tasks [21]. The ECDC could itself become a major source of information for countries in Europe. As for the early warning committee in the Netherlands, it will be necessary to identify criteria to be used for selecting source information [22].
The implementation of the revised International Health Regulations (IHR) is another relevant international development [23]. In 1995, the World Health Assembly decided that the IHR should be thoroughly revised. One major change is that a member state must report all events that possibly could endanger public health in other countries, regardless of the cause of the event. For this, timely and complete recognition of health threats at a national level is of importance.
The conclusion of this study is that, in 2002 and 2003, the early warning committee in the Netherlands recognised nearly all threats due to infectious diseases and outbreaks of infectious diseases which were of national importance and published in various sources of literature. The early warning committee can serve as an example to other countries or organisations in recognising threats to public health caused by infectious diseases.

Acknowlegdements
We thank Dr. M.A.E. Conyn-van Spaendonck, MD PhD, head of the Center for Infectious Diseases Epidemiology of the RIVM, J.K. van Wijngaarden, MD, Chief Inspector of Public Health at the Health Care Inspectorate, and A. Timen, MD, consultant in communicable disease control at the National Coordinator Center for Outbreak Management of the RIVM, for their useful remarks on former versions of this article. We thank S. Hahné, MD, for carefully reading the final version.

This article is based on a study first reported in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicin) [Recognition of the threats caused by infectious diseases in the Netherlands in 2002 and 2003 by the weekly meetings of the early warning committee] Ned Tijdschr Geneeskd. 2005;149:2238-42. Dutch


References

1. Wijngaarden van JK. [Pro-active government]. In: Dissel JT van, red. Refresher course Infectious diseases 2004. Leiden: Leiden Universiy Medical Centre (Boerhaave Commissie); 2004, p. 131-145. In Dutch.
2. Suijkerbuijk AWM, Vliet JA van. [The early warning committee]. Infectieziekten Bulletin. 2001;10;368-70. In Dutch
3. Bosman A, Vliet JA van. [Surveillance of and recognizing threats caused by infecious diseases]. In: Helsloot I, Steenbergen J.E van. Control of Infectious Diseases. Studies into organisation and practices. Den Haag: Boom; 2005. In Dutch.
4. Melker HE de, Conyn-van Spaendonck MAE, Sprenger MJW (red). [Infectious Diseases in the Netherlands. Epidemiology, diagnostics and control]. RIVM 1997. Den Haag: Sdu;1997. In Dutch.
5. Bosman A, Mulder YM, Leeuw JRJ de, Meijer A, Ry van Beest Holle M du, Kamst RA, et al.[Avian flu epidemic 2003: public health consequences]. RIVM report 630940001. 2004. In Dutch.
6. Furth AM van, Zaaijer HL. [Meningococcal disease in the Netherlands: media hype, but not an epidemic]. Ned Tijdschr Geneeskd. 2001;145(36):1716-8. In Dutch.
7. Christian MD, Poutanen SM, Loutfy MR, Muller MP, Low DE. Severe acute respiratory syndrome. Clin Infect Dis. 2004;38(10):1420-7.
8. Melles DC, Hendriks WD, Ott A, Verbrugh HA. [Outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in the Rijnmond region: the largest outbreak in the Netherlands]. Ned Tijdschr Geneeskd. 2004; 22;148(21):1038-43. In Dutch.
9. [Universal vaccination against meningococcal serogroup C and pneumococcal disease]. Den Haag: Health Council of the Netherlands, 2001; publication number 2001/27. In Dutch.
10. Lopman B ea. Increase in viral gastroenteritis outbreaks in Europe and epidemic spread of new norovirus variant. Lancet. 2004;363:682-88.
11. Haks K, Schout C, Cremer WS, Sigurdsson V, Ameijden EJC van. [Increased consultations and numbers of sexually transmitted diseases at the STD clinic of Utrecht, 1994-2002]. Ned Tijdschr Geneesk. 2004;148(33):1632-5. In Dutch.
12. Kievits F, Adriaanse MT. [Large increase in sexually transmitted diseases [news round up]]. Ned Tijdschr Geneesk. 2003;147:1380. In Dutch.
13. Bovée LPMJ, Peerbooms PGH, Hoek JAR van den. [Shigellosis, a sexually transmitted disease in homosexual men]. Ned Tijdschr Geneesk. 2003;147:2438-9. In Dutch.
14. Greeff SC de, Schellekens JFP, Mooi FR, Melker HE de. Pertussis in the Netherlands, 2001-2002. RIVM report 128507010/2003.
15. Boon S den, Schellekens JFP, Schouls LM, Suijkerbuijk AWM, Docters van Leeuwen B, Pelt W van. [Doubling of the number of cases of tick bites and Lyme borreliosis seen by general practitioners in the Netherlands]. Ned Tijdschr Geneesk. 2004; 148(14):665-9. In Dutch.
16. Gotz HM, Ossewaarde JM, Nieuwenhuis RF, Meijden WI van der, Dees J, Thio B, Zwart O de, Laar MJ van der. [A cluster of lymphogranuloma venereum among homosexual men in Rotterdam with implications for other countries in Western Europe]. Ned Tijdschr Geneeskd. 2004;148(9):441-2. In Dutch.
17. Neeling AJ de.[ESBL: superbug or troublemaker].Infectieziekten bulletin. 2002;7: 273-4. In Dutch.
18. Stürenburg E, Mack D. Extended-spectrum ß-lactamases: implications for the clinical microbiology laboratory, therapy, and infection control. J Infect. 2003;47(4):273-95.
19. Heymann DL, Rodier GR. Hot spots in a wired world: WHO surveillance of emerging and re-emerging infectious diseases. Lancet Infect Dis. 2001;1(5):345-53.
20. Grein TW, Kamara KO, Rodier G, Plant AJ, Bovier P, Ryan MJ, Ohyama T, Heymann DL. Rumors of Disease in the Global Village: outbreak verification. Emerg Infect Dis. 2000;6(2):97-102.
21.Commission publishes proposal for establishing a European Centre for Disease Prevention and Control (ECDC). Can Commun Dis Rep. 2004;30(5):50-2.
22. Kaiser R, Coulombier D, Baldari M, Morgan D, Paquet C. What is epidemic intelligence, and how is it being improved in Europe? Euro Surveill. 2006;11(2):E060202.4. Available from: http://www.eurosurveillance.org/ew/2006/060202.asp#4
23. Nicoll A, Jones J, Aavitsland P, Giesecke J. Proposed new International Health Regulations. BMJ. 2005;330(7487):321-2.

 



Back to Table of Contents
en es fr
Previous

The publisher’s policy on data collection and use of cookies.

Disclaimer: The opinions expressed by authors contributing to Eurosurveillance do not necessarily reflect the opinions of the European Centre for Disease Prevention and Control (ECDC) or the editorial team or the institutions with which the authors are affiliated. Neither ECDC nor any person acting on behalf of ECDC is responsible for the use that might be made of the information in this journal. The information provided on the Eurosurveillance site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her physician. Our website does not host any form of commercial advertisement. Except where otherwise stated, all manuscripts published after 1 January 2016 will be published under the Creative Commons Attribution (CC BY) licence. You are free to share and adapt the material, but you must give appropriate credit, provide a link to the licence, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Eurosurveillance [ISSN] - ©2007-2016. All rights reserved
 

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.