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The network approach
to the prevention of communicable diseases (1) within the European Union
(EU) is recognised to have been a remarkable accomplishment and a demonstrable
success for surveillance and control of some priority diseases (2,3).
The Network has a number of parts (table 1) that are supported or subsidised
by Directorate General SANCO (DG SANCO) following Decision 2119/98 and
subsequent decisions (1). There is a growing appreciation, however,
of the need for greater technical support to the Commission if the strengths
of the network approach are to be built upon and current limitations
overcome (4). A consensus has been reached by European State Epidemiologists
(the heads of national communicable disease surveillance and control
centres) that a technical coordination structure (TCS) or centre should
be established to facilitate the various EU activities in this field.
For such a structure to function effectively, careful thought must be
given to the needs that the TCS should address, to its relationship
with designated national centres, and to the means for ensuring recruitment
and retention of staff with the required expertise.
Table 1: Parts
of the DG Sanco Network approach to combating communicable diseases
at European Union level
-
A Network
Committee of representatives of EU national authorities and
heads of surveillance and control centres responsible for
health protection,
-
Disease
specific networks for high priority diseases (e.g.: HIV and
AIDS, legionellosis, Salmonellosis, Verocytotoxin producing
E. coli, etc.),
-
A secure
electronic early warning system,
-
Subsidised
infrastructure projects:
-
Pan European
training (EPIET),
-
Information
for professionals and the public (Eurosurveillance Weekly
and Monthly),
-
European
communicable disease resource inventory (IRIDE).
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During 2001, a EC
funded feasibility study on developing an EU capacity to respond rapidly
to international public health threats was completed (5). It concluded
that the best preparation for threats from communicable diseases or
chemical incidents, at both the EU and national levels, was to reinforce
existing national public health surveillance and response capacity as
well as co-ordinating joint international activities. The principal
mechanism proposed to achieve co-ordination at the EU level was the
urgent creation of a small and effective TCS (15 to 20 people) to deliver
health protection, particularly with regards to communicable disease.
Since events in
the United States in 2001 (those of September 11 and subsequent anthrax
releases) and ‘copy cat’ anthrax hoaxes across Europe, the grave threat
of bioterrorism has accelerated the need to improve arrangements for
a coordinated health protection response to emergencies (6). The United
States experience has shown that deliberate releases may be dispersed
geographically, that health services will be key to early detection
of releases, and that national and international technical collaborations
are an essential part of any effective public health response. Structural
arrangements must be so arranged that, as emergencies evolve, a timely
flow of accurate and authoritative information between involved national
institutes is guaranteed. These emergencies also require frequent, probably
daily, technical summary reports for dissemination both within the Commission
and to member states that are not directly involved.
A European Union
Council Decision has established a Community mechanism to facilitate
reinforced cooperation in civil protection (7). In October 2001, the
European Council at Ghent asked the Commission to prepare a limited
term programme for the detection and identification of infectious and
toxic agents as well as the prevention and treatment of chemical and
biological attacks (8).
To avoid duplication,
and to enhance public protection these two initiatives, the network
approach to combating communicable disease and arrangements for civil
protection, must soon converge. The foundations for a communicable disease
structure should be laid as an integral part of the programme of cooperation
on preparedness and response to biological and chemical agent attacks.
To an extent this was anticipated by the Commissioner for Health and
Consumer Protection when he announced in April 2002 mechanisms both
for reinforcing emergency planning and preparedness and the creation
of a European Centre on Communicable Diseases (to be operational in
2005) (9).
This paper aims
to identify the roles and functions of a TCS and to consider their implications
for both civil protection and a future European Centre on communicable
diseases.
The need for
a EU rapid outbreak response capacity
The EU Public Health
Programme for 2001 to 2006 (Strand 2) proposes three key measures in
relation to infectious diseases (10). Firstly, it is intended that information
on infectious disease problems including prevention and control measures
should be exchanged regularly. Secondly, there is a commitment to support
and develop surveillance methods. Thirdly, arrangements are to be devised
that support a rapid and coordinated response to health threats. Considerable
technical input will be needed to address each of these measures as
effectively as is possible.
Experience since
the formation of the Network Committee indicates that although emergencies
have rarely involved all Member States, communicable disease emergencies
and incidents involving more than one member state and requiring rapid
responses occur regularly. There have also been significant infectious
disease threats to member states from outside the EU. The specific surveillance
networks have been a major source for timely realisation that a problem
in one member state is also affecting others simultaneously (11). ‰
‰ At the beginning of each incident all countries must be kept informed,
as it is impossible in an evolving situation to know which countries
will remain uninvolved.
Critical appraisal
of past responses to international emergencies within Europe leaves
no doubt that arrangements for international co-ordination must be improved
(5). Careful planning is essential. The best preparation for a major
crisis such as the next influenza pandemic, bioterrorism or a chemical
disaster (table 2) will be through regularly exercising coordination
arrangements in lesser emergencies and reviewing performance subsequently.
Therefore, a European rapid outbreak or emergency response capacity
must be a service that is activated regularly for the sorts of emergencies
that we can expect to continue, regardless of the nature or magnitude
of the threat.
Table 2: Potential
major European health protection emergencies
- A major
community-wide outbreak of gastrointestinal disease,
- An outbreak
of an unknown illness – either biological or due to chemical
or radiological exposure,
- The appearance
of a previously unrecognised pathogen in the blood supply,
- Chemical,
biological, or radiological contamination of a water supply,
- A lost
source or an accidental release of radiation affecting a number
of countries,
- An emergent
or re-emergent infection abroad that could be imported to European
countries,
- International
concern over the safety of a vaccine,
- A serious
imported infection affecting a number of countries;
- The emergence
of a new sexually transmitted infection (STI) or the re-emergence
of a previously recognised STI;
- The next
influenza pandemic,
- Suspected
deliberate or accidental release of a serious biological agent,
- A major
international epizootic with implications for human health.
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It is especially
important these rapid European arrangements be engaged, in collaboration
with WHO, in responding to infectious disease threats outside the EU
(12). In this way, the abilities of European reference laboratories
and field epidemiology services will be challenged continuously, as
will their capacity to work together. This will further underline the
need for EU shared reference laboratories for rare infectious agents,
because it will become increasingly more difficult to maintain such
centres in each member state. Providing a coordinated EU service to
other parts of the world will also improve preparedness for whenever
new problems threaten EU citizens.
The report on EU
responses to international epidemiological emergencies acknowledged
that the networking approach to surveillance within the EU has increased
the recognition of international outbreaks and improved the management
of their investigation (3). At the same time, the report noted that
poor case ascertainment and notification in some countries limits the
outbreak detection power of international surveillance networks. By
improving the response to particular international outbreaks, a functioning
EU rapid response capacity is likely to enhance the performance of the
EU network.
Providing a rapid
outbreak and emergency response
The outbreak response
service of a TCS must have certain essential attributes (table 3). Once
a TCS ascertains possible incidents from surveillance activities, reports,
and ‘early warning’ messages, this initial information must be evaluated
against pre-established criteria, and a formal assessment conducted
through the national surveillance centres. The initial technical appraisal
and risk assessment may determine the nature of the threat, its rate
of change, its seriousness, and its potential to spread to other states.
If the threat is sufficiently serious, arrangements should be made with
national surveillance and control centres for the immediate deployment
of appropriate personnel with the necessary field epidemiology and microbiology
skills. The data gathered, together with information on the quality
of this data, will inform the outbreak coordinator(s) who can then judge
the special expertise, range of laboratory tests, and other investigations
that may be needed. While the coordinator is arranging the expert back-up,
investigators in the field can obtain further data and begin the collection
and transportation of appropriate specimens. All must be done in harmony
with national and sub-national investigating teams.
Table 3: Essential
attributes of an effective rapid European outbreak and emergency response
service
- Immediate
deployment of assistance with core skills,
- Access
to relevant expertise,
- Expeditious
specimen collection and transportation,
- Appropriate
laboratory back-up,
- Clear mandate
and leadership,
- Rapid response
– simple activation – phased escalation,
- Diplomatic
support,
- Subsequent
review
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In major incidents
involving citizens in a number of countries, the international investigation
co-ordinator must work together with the lead investigators of each
national investigating team. In many instances, it may be possible for
the lead investigator in the country most affected to combine the role
with that of co-ordinator of the associated international investigation.
On occasions, it can be anticipated that the pressure may be too great
for both roles to be combined. The TCS personnel can link with national
authorities and draw on the Committee of European State Epidemiologists
(CESE). Explicit ‘rules of engagement’ should be available so that both
roles can function effectively. It is essential to maintain the flow
of authoritative information to member states and to the European Commission
on the evolving investigation and the control measures being employed.
These liaison and co-ordination challenges, however, are no different
from those that are regularly overcome by national centres when responding
to their own major national incidents.
This approach will
require the TCS to develop a model contract between designated national
institutes (those that are likely to arrange for staff to be seconded
at short notice to an outbreak investigation), the European Commission,
and the member states or the international body that request assistance,
that sets out the duties and obligations on all parties once a formal
‘outbreak response’ has begun. A simple objective procedure can be established
for activating the response.
After completion
of the response to the incident, it will be important to conduct an
appropriate review that makes recommendations on how the response could
have been improved.
EU-readiness
to respond rapidly to outbreaks
The European Commission
must establish a process, managed by the TCS and assisted by the Network
Committee on Communicable Diseases and the Civil Protection structures,
that unlocks the considerable and diverse expertise in designated national
centres and deploys it wherever and whenever needed (1). Field epidemiology,
risk assessment and good communications are essential to almost all
emergencies. Beyond these core skills, however, the exact expertise
required differs according to the emergency or outbreak, for example
whether microbiological or toxicological skills are preferable. It is
unlikely that an international European centre, however large, could
ever possess the staff, let alone the necessary language skills required
for even the majority of circumstances. Nevertheless, almost all the
appropriate staff will be available within the 15 national centres and
national laboratories. The TCS could arrange for technical experts and
representative officials to develop a consensus over each of the issues
to be addressed and types of expertise required in the outbreak response
contract. Close involvement of the Network Committee should ensure linkage
with the national political points of contact for the Network Decision
and related communicable disease issues. Particular work needs to be
undertaken to strengthen and co-ordinate European laboratory services
to ensure that appropriate levels of technical expertise are available
rapidly during emergencies (13).
EU Technical
co-ordination against biological and chemical attacks
The objectives of
the EU programme of cooperation on preparedness and response to biological
and chemical agent attacks have been specified as: a) to set up a mechanism
for information exchange and consultation, b) to create an EU-wide capability
for the timely detection and identification of biological and chemical
agents, c) to create a medicines stock and health services database,
and d) to prepare and disseminate guidance on responding to attacks.
Over the following eighteen months the programme will be directed by
an Inter-Service Task Force under DG SANCO, a Health Security Committee,
and about 15 persons in a Technical Coordination Team.
In coordination
with the Commission, the Health Security Committee will address immediately
all public health responses to attacks in which biological and chemical
agents might be involved, will provide advice for emergencies related
to such attacks, and will help to implement relevant strategies that
may be agreed at EU level.
The rapid detection
and identification of cases and aetiological agents will be aided by
surveillance and notification guidelines, the preparation of common
investigation protocols, and an international inventory of laboratory
capabilities. Strategies will be developed to secure production of appropriate
medicines and stockpiles will be created in each member state. Rules
and guidelines on the management of people, products (food, materials,
precursors), produce and animals, and decontamination procedures will
be compiled.
While the mandate
of this initiative is confined to bioterrorist attacks, civil protection
and deliberately released agents, the Commission’s team will have to
recognise the vital role of surveillance and international outbreak
management to an effective public health response. In the United States,
following September 11 and the anthrax attacks, local public health
infrastructure is being strengthened with an investment of over a billion
dollars in 2002-3 (14). Similarly, these European aims cannot be achieved
without strengthening surveillance and enhancing the capacity to respond
to non-deliberate
communicable disease outbreaks.
The Technical Coordination
Team on the health aspects of bioterrorism will not cover the range
of provisions for non-deliberate outbreak response. Nevertheless, an
effective rapid response service is indispensable for full preparedness
for deliberate releases. The creation of a TCS, by strengthening the
EU framework for surveillance and prevention of communicable diseases,
would provide a means to establish and sustain the rapid outbreak response
service. It could also be ready to host the preparations laid down by
the bioterrorism team when plans for an EU Communicable Disease Centre
come to fruition in 2005, not long after the bioterrorism team completes
its work.
A critical component
of any outbreak or emergency response service is the rapid deployment
of personnel trained in the core skills of field epidemiology and investigation.
The universal way the necessary ‘surge capacity’ is maintained is through
the development and maintenance of an appropriate training programme.
In the face of the new urgency posed by bioterrorism, member states
and the Commission should endorse their commitment to the European Programme
for Intervention Epidemiology Training (EPIET) (15).
Functions of
an EU TCS
In the light of
the above it is clear that any central technical capacity to support
communicable disease surveillance, prevention and control, along with
broader aspects of civil protection, should have a range of functions
other than simply being the means for coordinating a rapid outbreak
response service. It is necessary to consider the wider range of functions
that a TCS could perform on a day-to-day basis that would support and
strengthen the network approach, while avoiding competition with designated
national institutes (table 4).
Table 4: Functions
of an EU Technical Co-ordination Structure for Communicable Diseases
- Moderation
and development of the EU Early Warning System,
- Maintenance
and development of a Rapid European Outbreak Response Service
by co-ordinating the use and supplementation of resources in
the national centres and disease specific networks in the EU,
- Co-ordination
of the rapid preparation of technical advice in emergency situations
for the Commission,
- Provision
of technical briefings on policy issues for consideration by
the Network Committee and the Public Health Program,
- Co-ordination
of the structured evaluation of disease specific networks on
behalf of the Network Committee,
- Production
and dissemination of authoritative information for professionals
and the public (eg Eurosurveillance weekly and monthly),
- Facilitation
of a ‘Designated EU Reference Laboratory Service’ that commissions
international reference services,
- Management
of the European public health training for health protection
(e.g. the EPIET training programme) and other international
training initiatives,
- Maintenance
of the inventory of resources for communicable disease prevention
and control in the EU (IRIDE),
- Advising
the related research programme of DG-Research so that it supports
the Public Health Programme on communicable disease,
- Liaison
and co-ordination action with national European surveillance
and response centres and Ministries of Health,
- Liaison
with other international bodies, e.g. WHO-Euro, WHO-GOARN, to
ascertain health threats from communicable diseases outside
the EU and to assist the co-ordination of international responses.
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This range of functions
envisages the TCS taking responsibility for technical co-ordination
of some of the infra-structural arrangements already developed on behalf
of DG-SANCO such as the EPIET training programme, publishing the bulletins
Eurosurveillance and Eurosurveillance Weekly and extending surveillance
outputs from the existing disease specific networks to provide more
information for the public as is required under Commission directives.
It can also be anticipated that a system for designating EU reference
laboratories is likely to evolve, analogous to that co-ordinated by
WHO. Such designations already exist under particular EU legislation
(16). The Structure will need a clear line of accountability back to
the Commission and the Network Committee. However the TCS should also
work with comparable national and international technical bodies (e.g.
WHO-Euro, WHO-GOARN) especially in the context of the current WHO attempt
to revise the international health regulation and in mounting responses
to global threats and emerging diseases. It should also be the linkto
EU research funding bodies to ensure that these best serve public health
priorities.
Challenges for
the EU TCS
A range of functions
that is broader than just the co-ordination of emergency outbreak response
and complementary to any bio-terrorism preparedness planning is essential
for an EU based TCS and poses a greater challenge for the proposed centre
or unit. When putting in place the procedures, guidelines, and technical
capacity to respond to international communicable disease events, DG-SANCO
should consider the implications for its programme for deliberate release
preparedness.
It is probable that
national public health institutes or their designated structures will
broadly favour a TCS whose primary function can be seen as supporting
the communicable disease network approach, and hence support and reinforce
their own national activities. By facilitating an explicit responsibility
for national units to provide a rapid outbreak response service in support
of each other, an EU TCS should have a positive working relationship
with designated national institutes from the outset. This will be reinforced
if national centres are the prime source of the TCS core technical staff
who could be seconded into the centre for extended (2 to 3 year) periods.
This would also overcome the difficulty the European Commission has
had in recruiting public health staff with sufficient field experience.
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