Memorandum by the European Centre for
Disease Prevention and Control
INTRODUCTION
1. The European Centre for Disease Prevention
and Control (ECDC) is a European Union (EU) agency tasked with
monitoring, assessing and communicating threats to human health
from communicable diseases. The Centre is based in Stockholm and
became operational in May 2005.
While public health remains primarily a Member
State competence in the EU ECDC supports the work of Europe's
national disease control agencies and coordinates EU level activities,
but does not centralise power or resources. The Centre does not
have policy or regulatory powers, and key assets such as laboratories
continue to be located in national institutes. The core functions
of the Centre can be summarized as follows: reinforce and develop
Europe's system of an EU-wide disease surveillance, reinforce
Europe's rapid alert systems against disease outbreaks, support
the EU and its Member States in strengthening preparedness and
response against epidemics, provide authoritative scientific advice
on infectious diseases and the risks they pose, work closely with
Member States and other partners to prevent and control such diseases,
and not least to communicate all its findings to the European
public health community and to a larger European public.
2. In the context of the EU, with economic
integration and open frontiers, cooperation on public health issues
is becoming more important. While the idea of creating a European
CDC had been around for quite some time amongst public health
experts in the EU, the outbreak of SARS in 2003 and its rapid
spread across countries confirmed the urgency of the creation
of an institution dedicated to EU-level cooperation on public
health issues. ECDC was set up in record time for an EU agency:
the European Commission presented draft legislation in July 2003,[1]
by the spring of 2004 ECDC's Founding Regulation had been passed[2]
and by the spring of 2005 the Centre started operating. As it
started its activities, another threat—H5N1 avian influenza
arriving in the EU's neighbourhood and the fear that it could
adapt or mutate into a pandemic strain of human influenza- confirmed
the relevance of its mission. Though ECDC's primary focus is on
health in the EU rather than global health, it is indisputable
that disease control policy in the EU has an impact on the international
picture—and vice-versa. Several organisations that have
already given evidence have mentioned ECDC in their submissions.
Because of this, the ECDC is keen to outline its role in the EU
system.
3. ECDC's written evidence is divided into
two sections:
(a) Description of ECDC and its role in strengthening
Europe's defences against communicable diseases
(b) Answers to the questions posed by the
Committee
In describing ECDC's role in communicable disease
surveillance, early warning and response (ie part (a) of our written
evidence) we address the key comments about ECDC made in written
evidence from other organisations.
STRENGTHENING EUROPE'S
DEFENCES AGAINST
COMMUNICABLE DISEASES
4. ECDC's core tasks are:
(a) Provision of scientific advice to EU
Institutions and Member States
(b) EU-level surveillance of communicable
diseases
(c) Enhancing EU-wide preparedness and response
(d) Communicating the results of its work
5. ECDC's capacity to produce risk assessments
and scientific advice to inform EU level decision making is a
relatively new development in Europe's health security. In 2003,
when SARS became an issue of concern globally and to all EU countries,
there was no mechanism in place to produce a common assessment
of the risk posed to Europe or to advise on the level of response
needed. Countries took differing views on issues such as whether
people entering the EU from affected countries should be screened
for SARS, and whether EU citizens should be advised against travelling
to the Far East. The relevance of reaching a common EU view on
such measures is this: given the open borders between EU countries,
screening of people entering the EU can only be effective if it
is done by all Member States. Though an ad hoc EU scientific group
was created to build a scientific consensus on control measures
needed against SARS, it took several weeks to reach a conclusion.
In contrast to this, in October 2005 when the arrival of H5N1
on the borders of the EU caused concern in all Member States,
ECDC was able to produce an assessment of the risk to human health
within a matter of days. Expert scientific advise an EU-wide consensus
was reached on a number of issues including the risk groups (people
working or living with poultry) was rapidly reached, along with
EU-wide guidance on the measures needed to protect these groups
(for more information on this topic see: the ECDC Avian Influenza
Portfolio http://www.ecdc.europa.eu/Health—topics/Avian—Influenza/Guidance.html
6. To fulfil its mandate to monitor, detect
and assess emerging threats related to communicable diseases or
of unknown origin, ECDC developed a database for tracking events
requiring a thorough assessment. Since May 2005, this Threat Tracking
Tool (TTT) is monitoring EU domestic threats as well as threat
from international origin and is used by ECDC to produce the Communicable
Disease Threat Bulletin shared with a restricted list of experts
from the Member States.
7. The existence, since the creation of
ECDC, of dedicated EU-level resources available to assist in the
response to communicable disease incidents of international concern
is also a new development. In the few years since ECDC became
operational, this capacity has also proved its worth. For example,
in January 2006 a cluster of human cases of H5N1 avian influenza
in Eastern Turkey caused concern that the H5N1 virus might be
becoming more transmissible to humans. An ECDC epidemiologist,
along with an expert from WHO Europe and a veterinarian from the
European Commission, were the first representatives of the international
response team to reach the villages in Eastern Turkey where the
cases occurred. ECDC experts played a key role in coordinating
for WHO the international team assisting the Turkish authorities
in investigating the incident, and were able to ensure all EU
Member States were briefed of developments. In the summer of 2007
an outbreak of the tropical disease chikungunya fever occurred
in Ravenna district in Italy, spread by local Aedes albopictus
mosquitoes. Though the Italian authorities ably contained
this outbreak, the Aedes albopictus mosquito is present
in several other European countries so this event was of international
interest. An ECDC led team (including members from WHO and national
public health institutes) visited Ravenna district and produced
an assessment of the risk to Europe from chikungunya fever, which
concluded that there is indeed potential for outbreaks in other
parts of Europe. ECDC's work on chikungunya fever—which
already began in 2006—was intensified as a result of this
(for more information on this topic see:
http://ecdc.europa.eu/Health_topics/Chikungunya_Fever/Chikungunya_Fever.html).
8. In the area of disease surveillance,
however, ECDC did not start with a "blank sheet of paper".
As far back as the 1990s, public health authorities across the
EU realised that the opening of Europe's internal borders would
make the control of communicable diseases on a purely national
basis increasingly difficult. Because of this, a system of EU-wide
disease surveillance evolved, along with an EU Early Warning and
Response System (EWRS) on public health threats. EWRS is a secure
messaging network linking public health authorities in the EU
Member States, ECDC and the European Commission. If a disease
outbreak occurs that has potential to spread across borders then
a Member States is obliged to post an alert on the system. EWRS
pre-dates the WHO's revised International Health Regulations (IHR)
by many years, but mirrors in many ways the IHR requirements in
the area of communicable diseases.
9. It is worth making a distinction between
"surveillance systems" and "early warning systems".
Surveillance has traditionally meant the routine collection of
data from health care providers about the occurrence of predefined
diseases or conditions—for example, HIV or tuberculosis.
This can be contrasted with "early warning" systems
that seek to identify public health events—acute outbreaks
of diseases (including new or emerging diseases) that may require
urgent action to contain them.
10. By the time ECDC became operational
in 2005 the EU had one main network focused on public health events
(the EWRS network) and a total of 17 Designated Surveillance Networks
(DSNs) collecting surveillance data on different diseases and
groups of diseases.
11. The DSNs were financed as projects under
the EU's Public Health Programme, while EWRS was managed directly
by the European Commission. The system of DSNs relied on consortiums
of national public health institutions proposing the creation
of networks and submitting proposals for EU funding. The bulk
of the EU funding to support the DSNs was routed through the various
national public health institutions which acted as project leaders
for the different DSN consortiums. In 2005, when ECDC became operational,
a total of six DSN consortiums were led by British institutions.
One of these (the EuroCJD network) was led by the National CJD
Surveillance Unit in Edinburgh, while the other five were led
by the Health Protection Agency.
12. Each of the 17 DSNs had made substantial
contributions in their respective areas, but there were also some
important drawbacks with this decentralised system of DSNs. The
DSNs evolved and developed in an uncoordinated way. They each
had different Standard Operating Procedures (SOPs), different
organisational structures, different methods for collecting data
and different reporting formats. Some DSNs collected data on only
one disease, while other collected data on several. Some covered
all EU Member States, some only a limited number, while two (EuroHIV
and EuroTB) covered the whole of Europe including the states of
the former Soviet Union. Very good European level data was available
for some diseases (eg tuberculosis and HIV/AIDS), but for other
important diseases (eg viral hepatitis) the data available was
patchy. In addition, each DSN had its own website, its own database
and its own scientific publications. All of this made life very
difficult for any user of the DSN data who wanted to get an overall
picture of the state of communicable diseases in the EU.
As well as being sub-optimal for users of surveillance
data, the previous system placed an unnecessarily heavy burden
on data providers in Member States, who had to report to numerous
different systems in different formats. The system was financially
precarious in that each DSN was financed from year to year as
an EU funded project, with the project leaders having to periodically
submit bids to the EU Public Health Programme for further funding.
The DSNs were funded as time limited projects so they were always
in danger of having their funding not renewed, as happened in
the case of one of the most successful and largest DSNs, the EuroHIV
surveillance network. At one point it was decided that this network
was not a priority for funding and it was not re-funded in time
to maintain continuity. The whole network was in danger of collapsing
until the host hub, the French Institut de veille sanitaire (INvS),
came up with emergency funds to keep the activities alive for
about a year. These problems with ensuring continuity and sustainability
of funding were eliminated once the coordination activities were
transferred to ECDC. In the second public health programme of
the EU surveillance is no longer a priority and therefore funding
is not available. As ECDC uses the EU taxpayers' money, it has
to keep its financial and human resources constantly under scrutiny
and ensure the most cost-effective investment of resources. Therefore
the integrated surveillance in Europe with one database to provide
for a "One Stop Shop" approach for policymakers and
public health institutions and continuous improvement of the quality
and comparability of data and link to the decision making process
is the most justified way forward. The evaluation and assessment
of the DSN's, inspite of all the achievements—have clearly
demonstrated the weaknesses of that system including the excess
use of resources.
13. One of ECDC's first tasks on becoming
operational was to conduct an evaluation of the DSNs and make
recommendations to its Management Board for a short/medium and
long term strategy for a coordinated EU surveillance setup. Evaluations
and reviews took place for individual DSNs while an extensive
consultation took place with public health institutions in the
Member States as to the overall strategy for surveillance. The
conclusion reached was that collection of data should be standardised
and simplified, with all surveillance data being fed into a single
database hosted by ECDC. ECDC would progressively integrate into
its own activities the surveillance previously conducted by the
DSNs. However, a guiding principle of this process is that ECDC
will only "take over" a specific DSN's surveillance
activities if and when it has capacity to provide at least the
same level of service as the DSN.
14. As of February 2008, one DSN has been
discontinued, while the surveillance activities of a further five
DSNs have been transferred to ECDC. Of the five DSNs whose surveillance
activities have been transferred to ECDC, two were DSNs formerly
led by the Health Protection Agency: the EU Invasive Bacterial
Infections Surveillance Network (EU-IBIS) and the International
surveillance network for the enteric infections Salmonella, Campylobacter
and VTEC O157 (ENTER-NET).
15. When ECDC became operational in May
2005 the start up team was about a dozen people. By the end of
2007 ECDC had recruited nearly 200 staff, and this figure will
rise to nearly 300 by the end of 2008. Overall, the creation of
ECDC represents a significant increase in the EU-level capacity
to monitor, evaluate and respond to communicable disease threats.
16. Though the development of an integrated
system of EU-wide disease surveillance is still a work in progress,
ECDC is convinced that this is the right goal to aim for. We also
believe we are on course to achieve this goal. A database capable
of capturing all the key variables for some 50 communicable diseases
has been created by ECDC and is now being used as the repository
for all EU surveillance data from 2006 onwards. New, more standardised,
case definitions for diseases under surveillance have been developed
and agreed and will shortly be published in the EU's Official
Journal. Work begun by DSNs on quality standards for laboratory
testing for various communicable diseases is being continued.
ECDC has recruited top quality experts, and is capable of both
gathering and analysing data on key diseases.
17. One clear added value from ECDC's integrated
approach to communicable diseases is that in 2007 we were able
to publish an Annual Epidemiological Report analysing 10 year's
worth of data from 27 European countries covering over 50 different
diseases and disease groups. In this report we were able to give
a comparative analysis of the magnitude of the threat posed by
these different diseases. This report can be viewed online at:
http://ecdc.europa.eu/pdf/ECDC_epi_report_2007.pdf.
Hard copies of the report have also been sent to the Committee
secretariat. Our next Annual Epidemiological Report will be published
later this year. In future, as national disease surveillance institutes
get used to reporting into ECDC's surveillance database in "real
time" rather than as part of an annual data collection cycle,
it should be possible to produce reports quarterly or even monthly.
An on-going challenge is to link the European surveillance system
to the public health decision making process. This consultation
is ongoing with the European Commission.
ECDC ACTIVITIES ON
AVIAN INFLUENZA,
HIV/AIDS, MALARIA AND
TUBERCULOSIS
18. As mentioned in paragraph 15 above,
ECDC started in 2005 with just a handful of staff. ECDC has grown
steadily since then, but we are still a young organisation and
still small relative to partners such as WHO or the US Centres
for Disease Prevention and Control. ECDC has a staff of almost
200 people from 25 different nationalities. We have therefore
had to prioritise in the start up of our disease specific activities.
The ECDC is at the heart of a network of 80 competent bodies employing
over 8000 people from all EU Member States, Norway, Iceland and
Liechtenstein, including all national organisations involved in
the fight against communicable diseases such as the Health Protection
Agency.
19. Influenza became an early priority of
ECDC, given the concern about H5N1 avian influenza in the summer
and autumn of 2005. As mentioned already at paragraph 5, ECDC
produced a risk assessment on the human health implications of
the arrival of H5N1 avian influenza in the European region and
produced a significant body of technical guidance on protection
measures. Having started on pandemic preparedness in 2005 the
completion of the bulk of work on avian influenza meant that,
during 2006 and 2007 ECDC could shift its focus to enhancing preparedness
against a possible future influenza pandemic be it based on avian
influenza or another strain. ECDC has also been reinforcing the
public health response to seasonal influenza. Surveillance of
seasonal influenza in Europe will be integrated into ECDC as from
September 2008. For more information on ECDC's activities concerning
influenza see http://ecdc.europa.eu/Health_topics/influenza/Index.html
20. ECDC's activities in relation to HIV/AIDS
and tuberculosis began in 2006. An agenda for ECDC's activities
on HIV/AIDS was agreed at a meeting of national HIV/AIDS coordinators
in October 2006. An Action Plan to address tuberculosis in the
EU is currently being finalised by ECDC and will be published
in the coming months. From the beginning of 2008 the surveillance
of both HIV/AIDS and tuberculosis in the EU has been integrated
into ECDC, with surveillance of these diseases in the wider Europe
(including the countries of the former Soviet Union) is being
undertaken in collaboration with WHO Europe. For further information
on ECDC's activities in relation to HIV/AIDS see: http://ecdc.europa.eu/Health—topics/AIDS/Index.html.
For further information on ECDC's activities in relation to tuberculosis
see:
http://ecdc.europa.eu/Health_topics/Tuberculosis/Tuberculosis.html
21. ECDC has a programme that covers vector
born diseases such as malaria (see:
http://ecdc.europa.eu/About_us/projects/env—zoon.html).
Only a few thousand cases of malaria are reported each year in
the EU, and these are generally imported from outside the EU.
In contrast, a major outbreak of the mosquito born disease chikungunya
fever occurred in the French Indian Ocean department of La Reunion
in 2006 affecting 266,000 people. A risk assessment conducted
by ECDC concluded in March 2006 that there was a potential risk
of chikunguya being introduced to continental Europe in countries
where the Aedes albopictus mosquito is present (this includes
several Mediterranean and Adriatic countries). As a result, ECDC
embarked in actions to strengthen preparedness of EU MS to tackle
this potential threat: diagnostic capacity for chikungunya in
the MS was reviewed and developed through the European Network
for Imported Viral Diseases (ENIVD) and 2 one week training on
management of the emergence of chikungunya fever were conducted.
In the summer of 2007 an outbreak of chikungunya fever did in
fact occur in Ravenna district in Italy, and ECDC conducted an
assessment of the risk of further outbreaks in Europe. Given the
emerging threat to Europe of chikungunya over the past 2 years,
this has been a higher priority for ECDC's vector born diseases
team than malaria. Currently ECDC is finalising the review of
the factors that would allow the establishment of Aedes albopictus
in other part of the EU in order to allow a better targeting of
preparedness activities regarding chikungunya fever.
EXPLANATORY STATEMENT
ABOUT ECDC'S
ANSWERS TO
THE QUESTIONS
POSED BY
THE COMMITTEE
22. Response by ECDC to the questions posed
by the Committee have been drafted with regard to the fact that:
(a) The focus of ECDC's activities is the
European Union and its immediate neighbourhood
(b) ECDC's scientific activities started
up in 2005, so we have not yet addressed in depth all the issues
raised by the Committee in its questions.
ANSWERS TO
QUESTIONS POSED
BY THE
COMMITTEE
1. A recent report on Communicable Diseases
by the UK Department of Health stated that "post-war optimism
that their conquest was near has proved dramatically unfounded".
What is your assessment of the overall position? More specifically,
is it simply that not enough progress is being made in reducing
the spread of such diseases? Or is the global situation actually
deteriorating? Would it be an exaggeration to talk of a crisis?
23. The first two parts of the question
are covered in a recent (December 2007) Eurosurveillance editorial
Why a burden of disease study? by the Director of the ECDC. The
full article is available via
http://www.eurosurveillance.org/em/v12n12/1212-221.asp)
and key aspects are reproduced below:
— although the public health community
"knows" that Communicable Diseases (CD) have in general
decreased substantially in Europe over the last century, it was
also clear that new CDs have started to emerge and old ones re-emerge.[3]
— The success in tackling CDs, and
hence their burden, has also changed the balance between Communicable
and Non-Communicable Diseases (NCDs).
— the traditional boundaries between
CDs and NCDs are also clearly changing, as present research indicates
that many traditional NCDs have infections in their aetiology
and should perhaps now be classified as CDs rather than NCDs.
— In addition, "success"
in controlling SARS has in some quarters, especially the mass
media, raised questions of "waving shrouds" and the
necessity of the considerable expense that was involved. Such
doubts may migrate to current avian influenza and pandemic preparedness.
These perceptions also need to be rectified with the help of "evidence".
24. The editorial concluded by saying that
"Forty years ago, the United States' Surgeon General, Dr
William Stewart proposed that, with the advent of antibiotics
and the broad use of vaccines, the war against infectious diseases
had been essentially won, and that we now needed to pay attention
to other important health issues, such as chronic diseases. However,
it is clear today that we have only won a "battle":
the "war" will surely continue. Turning to less aggressive
vocabulary, perhaps it is a "never-ending dance" [With
apologies to Adrian K Ong and David L Heyman. "Microbes and
humans: the long dance". WHO bulletin volumes/85/6/06-0372200/en]
in which the human race needs to constantly find new technologies
and tools to keep "in step" with changing and new microbes!"
25. The human/microbe balance and evolutionary
struggle is not new and has been recognised over the centuries
[Hans Zinsser (Rats Lice and History), W.H. McNeill (Plagues and
People)]. Although hard evidence is lacking in all cases, many
aspects of the current "re-emergence" and "emergence"
of "new" diseases are probably "man-made".
Firstly through "developments" that have consequences
on the balance such as agricultural and animal farming (majority
of pathogens come to humans from animals), globalization, and
climate change. Secondly through non-use, incorrect use and/or
abuse of the very defensives developed (eg vaccines, poor adherence
to TB treatment, indiscriminate use and abuse of antibiotics).
Continuing success on the part of the human species in this struggle
will remain dependent upon constant and continuous vigilance and
commitment to take action irrespective of the consequences on
the health or other sectors (including financial); transparency
and avoidance of denial are other lessons learnt from past "battles"
(SARS, BSE). Also since economic development will and must continue,
investment in careful health impact assessments by all sectors,
continued research; and strengthening the health sector remain
important elements of defense. Perhaps the most important being
a strong health sector that recognizes the diseases early and
is capable of treating the diseases once detected. Amongst other
things, this requires a clear recognition by all countries (even
if current communicable disease figures are low) of the continued
importance of communicable disease, its funding, on-going training
and integration into relevant parts of the health sector (especially
primary health care: the first point of detection/defense).
26. More specifically the following factors
are important:
— the unanticipated emergence of resistance
to antimicrobial or anti malarial drugs;
— the need to develop a global approach
to the prevention and control of such threat, which proved to
be:
(a) costly but effective for diseases such
as smallpox because of existence of an effective vaccine and the
absence of non-human reservoir, but
(b) ineffective for diseases of more complex
nature, such as tuberculosis with a vaccine of limited efficacy
and treatment subject to resistance, or malaria, requiring a global
sustained approach for vector control and prone to the emergence
of resistance to the first line cheap antimalarial drugs;
27. In the case of tuberculosis, the development
of streptomycin and anti tuberculosis (TB) drugs enabled treatment
of the disease and therefore a decrease in its transmission and
dramatically lower incidence. However, the apparition of resistance
to treatment, and the persistence of higher transmission rates
in resource limited or unstable areas as well as specific risk
groups (prisons, migrant worker) resulted in the persistence and
in some instance re-emergence of TB and also multi-drug resistance/extremely
drug resistance (MDR/XDR) TB (see also section 37,38 40 &
41). Little development of new drugs and tools to treat and rapidly
detect TB and poor adherence to existing treatment have also been
contributory factors. Many countries with the highest rates of
MDR/XDR TB have "historical" connections to EU countries
(and hence related "ethnic" communities in the host
countries). This provides unique and cost efficient possibilities
to help both the countries concerned whilst at same time protecting
the host populations.
In the case of malaria, similar optimism was
raised by initial good vector control attained through the wide
use of insecticides and effectiveness of cheap treatment for malaria.
The emergence of resistance, concerns about the wide usage of
DDT and the instability in some endemic malaria area preventing
control programme from being effective resulted in the persistence
of malaria in most of its originally endemic areas.
HIV and avian influenza, being emerging threats,
were not indeed concerned by the "post war optimism".
28. ECDC would not qualify the overall situation
regarding these four diseases as a crisis. While the situation
has improved for some diseases in some areas, it has deteriorated
in other, often in relation with profound societal changes, civil
unrest and civil war often resulting in interruption of prevention
and control programme, resurgence of diseases as well as migration
of precarious populations contributing to further spread of the
diseases. There is also the question of "crisis" for
whom? In the UK for the population as a whole, it is probably
not a crisis. However, for pockets (eg some urban areas and Boroughs,
Prisons, high risk populations) where for example TB rates are
higher than the highest rates in Eastern Europe, it probably is
a crisis for the people concerned. These communities are perhaps
the very ones whose socio-economic, poverty, housing profiles
put them most at risk (including probably through lower immunity
levels). Therefore the overall goal of reducing poverty will also
most certainly help the battle against many communicable diseases.
2. What reliable data exist regarding the
numbers of people infected globally with the four diseases[4]
on which the Committee is focusing particular attention? What
trends are discernible in both the numbers infected and the patterns
of infection? And what are the main underlying causes of infection
and of any changes in its incidence and pattern?
29. A global system, led by WHO, exists
for the worldwide surveillance of individual cases of H5N1 avian
influenza. This system works relatively well, as this is still
a very rare disease among humans with the number of confirmed
cases totalling in the hundreds: latest figures are available
online from the WHO and ECDC websites. For other strains of avian
influenza (for example, H3N7), and for malaria, HIV and tuberculosis
systems for reporting cases and compiling data do not exist in
all parts of the world. The Health Protection Agency, UNAIDS and
WHO have already commented on this limitation of the worldwide
data.
30. What ECDC would like to point out is
that within the European Union, and some of its neighbouring countries
systematic reporting of the major infectious diseases does in
fact take place. In June 2007 ECDC published an analysis of ten
years' worth of data on infectious diseases from the 25 countries
that were Member States of the EU in 2005 plus Iceland and Norway.
This report,[5]
which covers nearly 50 diseases, is available on ECDC's website—see
paragraph 17 above for more details. In addition, a short summary
of European data on the four diseases the Committee has a particular
interest in are given as an annex to this evidence.
3. What intergovernmental surveillance systems
exist to give early warning of outbreaks of infectious diseases?
Are these systems adequate? And what improvements might be made?
31. Please see paragraphs 8 to 17 above
for an explanation of the systems of EU-wide disease surveillance
and early warning, and ECDC's views on these systems.
32. ECDC has established working relationships
with counterpart disease control organisations in the US, Canada
and China and has close collaboration with WHO. There is also
collaboration on health security issues within the G8. With these
key international partners, ECDC and the European Commission are
working to further strengthen international cooperation on epidemic
intelligence and early warning. Successful implementation of the
new International Health Regulations will be of key importance
in achieving this—see answer to question 16 below.
4. Given the continuance of current or planned
intergovernmental programmes to prevent or control the four diseases,
what predictions can be made of their likely spread and pattern
over the next 10 years?
33. It is difficult to make predictions
with any confidence and perhaps the only certainty with emerging
infections is that Europe will certainly be surprised and need
to respond to new threats such as the most recent emergence of
oseltamivir resistant influenza viruses see http://www.ecdc.europa.eu/Health_topics/influenza/antivirals.html.
HIV/AIDS and tuberculosis are preventable diseases, there is growing
political commitment in the EU to addressing the challenges they
pose, so our aspiration would be to see the number of new cases
of these diseases in the EU fall over the coming decade. We believe
this is achievable. Malaria is not currently an endemic disease
in the EU. We believe the chances of it being reintroduced in
Europe are low, but we cannot entirely exclude this possibility
(see paragraphs 7 and 21 above). As long as H5N1 avian influenza
is endemic in the continents of Africa and Asia, we will continue
to see sporadic outbreaks among birds in Europe. Veterinary measures
to contain these outbreaks in the EU have proved effective and
we have no reason to believe they will not be effective in containing
future outbreaks. The risk to human health from these outbreaks
is low, as long as current guidance on human health protection
is followed (see paragraph 5 above). There is a possibility—but
by no means a certainty—that we will experience a pandemic
of human influenza at some point in the next decade. It is impossible
to quantify this risk as it depends on the mutation patterns of
an unpredictable virus but this possibility must be prepared for.
5. What do you consider to be the principal
blockages to achieving progress in the prevention or control of
the four diseases? And how might these blockages be removed by
more, or better-targeted or better-coordinated intergovernmental
action?
34. Poverty, war and political instability
and in many instances the lack of political commitment for the
prevention and control of these diseases are clearly among the
principle blockages to progress in rolling back these and other
communicable diseases in the developing world. ECDC is not in
a position to advise on how these blockages be removed, as our
remit is to focus on the EU and its immediate neighbours. Lack
of international cooperation, communication and transparency is
another more tractable blockage and ECDC is committed to work
to counter these blocks. It is clear, though, that the persistence
of high rates of infection in some other parts of the world is
a factor that hinders efforts to eliminate these diseases in the
EU. Communicable diseases do not respect national borders and
move swiftly. A chain is as strong as it weakest link and international
efforts to control and prevent communicable disease require a
concerted international effort in this regard.
6. What role does your organisation play in
combating the four diseases? Do you believe that it is correctly
configured and adequately resourced to do the job? With which
other organisations do you collaborate? How would you assess the
degree of synergy?
35. The role of ECDC in relation to all
of these diseases is to conduct EU-level disease surveillance,
provide guidance on evidence-based public health interventions
to the EU Institutions and Member States, and assist with the
response to incidents, ECDC works closely with WHO EURO and WHO
Headquarters in Geneva. There is excellent collaboration and synergy
with the WHO and there is a Memorandum of Understanding in place
to ensure consistency and synergy. ECDC benefits from the placement
of a WHO Liaison Officer who ensures constant contact and communication
with WHO. ECDC benefits similarly from the placement of an officer
from the US CDC who is placed in the ECDC Scientific Advice Unit.
There is also an official from the European Environment Agency
working in ECDC on the preparation of common indicators and databases.
The ECDC has finalised Memorandums of Understanding with counterpart
organisations in China, Canada and the US. ECDC has agreed Memorandum
of Understanding with the European Food Safety Authority (EFSA),
with the European Drug Monitoring Centre (EMSDDA). With the Joint
Research Centre (JRC), Institute for the Protection of the Security
of the Citizen (IPSC) and with the Swedish Rescue Agency (SRA).
These reflect the main organisations with which ECDC currently
has collaboration and co-operation apart from the EUECDC works
in close collaboration with a number of similar organisations
and European Union institutions which are the natural partners
to ECDC. A day-to-day collaboration exists with the European Commission
and a close one with the European Parliament and the currently
rotating six monthly EU Presidencies. In addition ECDC has very
close working relations with the Member States through the national
Health Ministries based in the capitals, the national Health Protection
Agencies, institutes, and surveillance agencies and the competent
bodies. Many of these partners are represented on the governing
bodies of ECDC including the Management Board and Advisory Forum.
All EU Member States that we represented on work both the Management
Board and Advisory Forum.
7. What are the main non-health causes (eg
global warming, poverty, changes in land use, international travel,
lifestyle, population) of the spread of the four diseases? To
what extent can intergovernmental action in non-health fields
contribute to alleviation of their spread? What action is taking
place or planned in these areas? And what more needs to be done?
Do you consider that there is sufficient `joined-up' thinking
in approaching the problem?
36. Poverty, war and political instability
and lack of political commitment are clearly among the principle
blockages to progress in rolling back these and other communicable
diseases in the developing world. ECDC is not in a position to
advise on how these blockages be removed in the developing world,
as our remit is to focus on the EU and its immediate neighbours.
37. Looking at the situation within the
EU, there is good evidence that individuals with lower socio-economic
positions suffer disproportionately from communicable diseases
(this is also true for chronic diseases such as cancer and health
disease. Communicable diseases are distributed unevenly throughout
society, with marginalized and vulnerable groups bearing a disproportionate
burden. These groups are not only negatively impacted by a few
"signature infections" such as TB or HIV but rather
by a wide array of other communicable diseases. Thus, there seems
to be a need to devise targeted interventions for a wide range
of communicable diseases in marginalized and vulnerable groups.
In its work on helping EU/EEA member states improve pandemic preparedness
ECDC emphasises the need for "joined-up" whole society
approaches see http://www.ecdc.europa.eu/Health_topics/Pandemic_Influenza/updates1.html
and we are finding this message is being received and followed.
38. The four communicable diseases being
examined by the Committee might not be directly linked to climate
change in the EU; however, impending potential climate change-related
threats should be monitored. `Joined-up' thinking can proactively
address the problem both for the short- and the long-term, and
should address surveillance; policy; assurance; and research.
8. Cases of Tuberculosis fell progressively
in the UK until the mid-1980s but started to rise again in the
early 1990s. Around 6,500 cases are now reported each year, an
increase of about a quarter since the early 1990s. What are the
main factors of the revival of Tuberculosis infections in Britain?
And how could intergovernmental action help to reverse the trend?
39. In most countries in the European Union
incidence of tuberculosis has experienced a decline in the last
5 years (2.5% per year) after a period of increase or stagnation
observed in several countries in the early 1990s. The increasing
trend observed during the 1990s was due to a decrease in awareness
and reduction of resources and services for TB prevention and
control. In addition, the breaking down of Soviet Union and the
whole Socialist system (including Health Care) in Europe occurred
at that time.
40. In recent years some countries like
the United Kingdom are experiencing again an increasing trend
in tuberculosis. This is largely due to increase in TB cases of
foreign origin especially in younger age groups (Source: Surveillance
of Tuberculosis in Europe, EuroTB Annual Report, Paris 2007, available
in: http://www.eurotb.org/).
Tuberculosis in many EU countries and other developed countries
is aggregating in vulnerable populations, such as migrants, prisoners,
homeless and in poor areas in large cities among others. Resources
and actions should be addressed to these groups of the population
in order to ensure appropriate access to health care and quality
tuberculosis treatment.
41. As a request of the European Commission,
ECDC has drafted a TB Action Plan to fight tuberculosis in the
EU which describes a framework of actions to be implemented at
national and at the EU level. Collaboration with countries in
the wider European Region and in the world should be considered
when developing strategies to fight TB since TB rates are much
higher in those countries and the disease doesn't respect borders.
9. Tuberculosis is potentially curable by
long-term antimicrobial therapies. Yet the numbers of reported
cases worldwide seem to be rising. Are the necessary medicines
not getting through to patients? What are the barriers to effective
long-term therapy? Are we now seeing infections which stem from
other conditions—eg HIV/AIDS? Or are there other reasons
why a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
42. Other contributors have commented on
the worldwide situation. ECDC would like to make some comments
on the specific situation in the EU. In most EU countries the
number of cases of tuberculosis being reported is low and has
decreased in the last five years—see paragraphs above.
43. In countries such as the Baltic States,
there is an important overlap between the TB and the HIV epidemics.
Current antiretroviral regimen are extremely potent at reconstituting
the immunity of HIV infected persons, and in the case of persons
infected with TB causing bacteria, in preventing them from developing
the disease TB. That a substantial proportion of HIV infected
persons are not diagnosed, and hence cannot benefit from early
antiretroviral therapy is a barrier to controlling both HIV and
TB. MDR-TB and XDR-TB is a serious challenge in this context.
44. ECDC has developed an Action Plan for
Tuberculosis in the EU—see paragraphs above.
10. To what extent do you believe that the
2004 Stockholm Convention limiting the use of DDT against Malaria-carrying
mosquitoes has been a factor of increases in the spread of the
disease? Has any risk analysis been carried out comparing the
relative dangers to human health posed by DDT and Malaria?
45. A risk/benefit analysis of the use of
DDT against malaria-carrying mosquitoes would need to look at
issues of chemical safety, impact on the food chain, environmental
impact and occupational health and safety impact, in addition
to its effectiveness as a vector control intervention. ECDC is
not in a position, at present, to conduct such an analysis as
our mandate does not extend to all these areas. Our focus is exclusively
on infectious diseases.
11. What intergovernmental action is planned
or in hand for early detection of the transmission of Avian Flu
from birds to humans and of human-to-human transmission in potential
source countries? Is this proving sufficiently effective to prevent
an Influenza pandemic? What more could be done?
46. The global lead on human aspects of
pandemic preparedness/Avian Influenza is with WHO with OIE and
FAO being responsible for the animal and food aspects respectively.
UNSIC's role is to coordinate the various UN agencies. A series
of Global International meetings (Washington, Geneva, Beijing,
Vienna, Bamako and New Delhi as well as a technical meeting in
Rome) have taken place since 2005. These were variously Ministerial,
Pledging and Senior Officials Meetings that began immediately
following the concern over Avian Influenza. Within the EU there
have been specific meetings of health ministers in this topic
in 2004, 2005, 2006. In addition, there have been joint meetings
of Chief Medical Officers and Chief Veterinary Officers and also
cross-sectoral meetings of veterinary, Consular, Foreign Ministry
Cabinet Office and health officials at which ECDC has actively
participated. ECDC also participates in the European Commission
Health Security Committee on this work.
47. The key strategy for preventing H5N1
avian influenza becoming a human pandemic virus is to reduce,
and if possible eradicate, circulation of H5N1 in the bird populations.
Veterinary measures (including sometimes bird vaccination) implemented
in Vietnam, China and Thailand have greatly reduced outbreaks
in poultry population in those countries but have failed to eradicate.
This in turn has reduced the number of cases of humans infected
with H5N1 in these countries. However efforts to reduce circulation
of H5N1 among birds have been unsuccessful in some other parts
of the world notably Indonesia and Egypt and there are now indications
of the infection becoming entrenched in India and Bangladesh.
48. An essential parallel strategy is to
promote pandemic preparedness planning. Even if H5N1 does not
turn out to be the virus that causes a pandemic, at some point—another
influenza virus will. There were three influenza pandemics in
the 20th century (starting in 1918, 1957 and 1968), so its certain
that we will face a pandemic at some point in the 21st century.
49. Considerable effort has been put into
pandemic preparedness planning in EU countries. Between June 2005
and October 2007 ECDC led teams working with WHO and the European
Commission that visited and help all 27 EU Member States plus
Norway, Iceland and Liechtenstein to assess and strengthen their
plans and preparedness. A report on the state of pandemic preparedness
in the EU was published by ECDC in December 2007. This concludes
that considerable progress has been made since 2005, but a further
2 to 3 years of sustained effort is needed to complete the process
of preparedness. For more information see: http://ecdc.europa.eu/Health_topics/Pandemic_Influenza/updates1.html
ECDC plans to have similar visits to Turkey, Croatia
and the Former Yugoslav Republic of Macedonia during 2008.
12. To what extent do you consider that the
rise in infections in the four diseases is attributable to increased
microbial resistance to antibiotics? What intergovernmental action
is taking place in this area?
50. Re-emergence of TB in the European Union
has been fuelled by the HIV epidemic and the development of multidrug-resistant
(MDR) TB strains. In many European countries, where the incidence
of TB remains unacceptably high, resistance to the most effective
anti-TB agents, ie isoniazid and rifampicin (MDR TB), as well
as to second-line antibiotics (extensively drug-resistant TB,
or XDR TB) poses a serious challenge to control.
51. MDR TB represented 15-20% of TB cases
in Baltic States, whereas it only represented 0-6% of TB cases
in other countries. MDR TB is generally more common in patients
of foreign origin, especially coming from the Former Soviet Union.
By 1st May 2007, 17 out of 30 EU plus EEA/EFTA countries and 4
Former Soviet Union countries had reported TB cases fitting the
definition of XDR TB.
52. ECDC has developed an Action Plan for
Tuberculosis in the EU—see paragraph 41 above. This contains
a strand on addressing MDR-TB and XDR-TB.
53. Doxycycline—an antibiotic of the
tetracycline class—is active again Plasmodium and is among
the drugs recommended for malaria prophylaxis in areas of chloroquine
resistance, eg sub-saharan Africa. There is, to our knowledge,
no report of doxycycline-resistant Plasmodium. However, malaria
prophylaxis with doxycycline is a risk factor for infection with
resistant bacteria, eg doxycycline-resistant Staphylococcus aureus.
54. Antibiotics, ie antibacterial agents,
are not active against viruses such as avian influenza or HIV,
so antibiotic resistance is not considered to be a factor in the
rise of these infections.
13. In a number of countries, including the
UK, there is a problem with hospital-acquired infections. What
intergovernmental sharing of knowledge is taking place to help
bring this problem under control?
55. Prevention and control of hospital-acquired
infections, as well as of infections due to antibiotic-resistant
bacteria in hospitals and in the community, is a priority activity
of ECDC.
56. Surveillance of these infections is
performed via three dedicated European surveillance networks focusing
on healthcare-associated infections (IPSE/HELICS), antibiotic-resistant
bacteria (EARSS) and antimicrobial use (ESAC), respectively. These
dedicated surveillance networks will be gradually integrated to
the routine activities of the agency. ECDC is also financing a
European network for the standardisation of antimicrobial susceptibility
testing, EUCAST.
57. In addition to surveillance, an extensive
work plan has been developed by ECDC to improve prevention and
control of antimicrobial resistance and healthcare-associated
infections in the European Union. These new activities that are
gradually being implemented by ECDC and include:
— regular meetings of a network of
national antimicrobial resistance focal points (one per country)
to share experiences on how to control antimicrobial resistance,
both in hospitals and in the community;
— country visits to evaluate the implementation
of Council Recommendation 2002/77/EC on the prudent use of antimicrobial
agents in human medicine and reporting on these visits (8 country
visits performed, more planned in 2008);
— advice and guidance on key diseases
such as MRSA and Clostridium difficile-associated disease (2007-08);
and
— organisation of a European Antibiotic
Day to increase awareness of Europeans about antibiotic resistance
and the need to use antibiotics rationally. This will be an annual
event, which will first focus on the general public and use of
antibiotics by outpatients, but will gradually focus on other
topics, including multidrug-resistant bacteria, antibiotic use
and infection control in hospitals. The first European Antibiotic
Day will be 18 November 2008.
14. Are there any difficulties with regard
to patents or intellectual property which are impeding the flow
of medicines or other control methods to those infected? Is intergovernmental
action needed to improve the situation?
58. ECDC's activities focus primarily on
scientific data and analysis. Our work to date has not included
an analysis of intellectual property issues, so we do not have
any comments to make on in relation to this question.
15. What interchange exists between States
in regard to knowledge of and training in the diagnosis and treatment
of the four diseases or regarding preparations for dealing with
outbreaks? What improvements might be made through intergovernmental
action?
59. Since the mid-1990s the EU has funded
the European Programme for Intervention Epidemiology Training
(EPIET). This is a two year fellowship scheme aimed at doctors
and other public health professionals from across the EU. Ten
percent of the time is taken up by formal training courses and
the remainder by placement at a training site in a European country
different from the fellow's country of origin. This scheme, which
since 2006 has been financed by ECDC, has helped expand capacity
across the EU in surveillance and control of communicable diseases,
including (but not limited to) the four diseases the Committee
is interested in. It has also fostered exchange of knowledge by
creating a cadre of like-minded practice-oriented epidemiologists
who have a European perspective on disease surveillance and outbreak
investigation.
60. Fostering the pooling of knowledge on
communicable disease prevention and control between EU Member
States, and supporting specialised training programmes are core
activities of ECDC. See paragraphs 4 to 17 for more about ECDC's
general remit in this regard and 18 to 21 for further details
of work done on the four diseases. See also paragraphs 43 and
44 regarding work done on preparedness against a possible influenza
pandemic.
16. The International Health Regulations 2005
are intended to provide a global framework for the rapid identification
and containment of public health emergencies. How effective do
you consider this response system to be? Do improvements need
to be made?
61. The revised International Health Regulations
(IHR) are a major step forward for global health security. The
new system, the revised IHR created, is still in its infancy.
It is too soon to comment on the systems effectiveness: rather,
the challenge at present is to make the new system work. Key to
this will be ensuring national authorities have the capacity to
meet the new obligations the revised IHR places on them. Though
the IHR obligations mirror, to a large extent, the reporting requirements
under the EU's Early Warning and Response System (EWRS) on public
health threats (see paragraph 8 above), there may still be work
for ECDC to do in providing technical support to some of the EU
Member States in order to help them implement the revised IHR.
17. What intergovernmental planning has been
undertaken to cope with the impact of an outbreak of infectious
disease caused by deliberate release of micro-organisms into the
environment? Is there adequate liaison between the various agencies
involved, including intelligence, law enforcement and health care
professionals? How could action by intergovernmental bodies help
further?
62. An agenda for EU cooperation against
the threat of deliberate release of micro-organisms was adopted
by EU Health Ministers in November 2001. This included the creation
of an EU Health Security Committee (HSC) to foster cooperation
and joint planning in this area. The HSC continues to meet regularly
and is hosted by the European Commission with technical input
from ECDC. An updated agenda for EU cooperation in the area of
Bio-Preparedness was outlined in a Green Paper issued by the European
Commission in November 2007. For more information on EU cooperation
in this field see: http://ec.europa.eu/health/ph—threats/Bioterrorisme/bioterrorisme_en.htm
18. Though our remit is focused specifically
on known infectious diseases, we would be interested to know how
you view the global threat from new or previously unrecognised
ones and from the transmission of infections from animals to humans.
63. The emergence of completely new microbes,
or the adaptation of existing microbes into new more dangerous
forms, is one of the major threats we face in the area of communicable
diseases. We discover new communicable diseases at the rate of
about one every two years. These present particular challenges
for prevention and control as—by definition—when a
disease is new it can take some time to discover how it is transmitted,
how it can best be prevented and what (if any) the treatment options
are. New communicable diseases that have emerged in the past few
decades include HIV/AIDS (in the 1980s), new variant Creutzfeldt-Jakob
disease (in the 1990s) and SARS (2003). Of these three diseases,
it is thought that all had their origins in animal diseases. However
there are also other ones that are not clearly of animal origin
The most recent example for Europe is the emergence of oseltamivir
resistant human influenza viruses where ECDC is working especially
with the UK based part of the VIRGIL network see http://ecdc.europa.eu/Health_topics/influenza/antivirals.html
64. There are a number of existing animal
diseases that can infect humans, including salmonella, campylobacter
and rabies. ECDC and the European Food Safety Agency (EFSA) produce
a joint annual report on the extent of these zoonoses in the EU.
For more information see: http://www.efsa.europa.eu/EFSA/efsa_locale-1178620753812_1178671312912.htm
19. What resources (subscriptions, staff,
training, medicines etc) does the UK Government commit to intergovernmental
bodies to help in the fight against the four diseases listed?
65. There is one senior expert on secondment
from the Health Protection Agency (Professor Angus Nicoll CBE)
who works full time for ECDC. However, many UK government officials
and Health Protection Agency (HPA) and other staff contribute
their time and expertise to ECDC on a part time basis by attending
meetings and sitting on expert panels. This input is highly valued
by ECDC and should be acknowledged. A senior official from the
UK Department of Health attends ECDC Management Board meetings,
which take place three times a year. Senior experts from the HPA
attend meetings of ECDC's Advisory Forum, which meets four times
a year and the Editorial Board of our scientific journal Eurosurveillance,
which meets once a year.
66. HPA experts also regularly contribute
to ad hoc scientific panels convened by ECDC to address specific
scientific questions. For example, in 2007 it was an HPA official
who chaired ECDC's scientific panel looking at the likely effectiveness
of using human H5N1 vaccines as so called "pre-pandemic"
vaccines.
20. Do you wish to provide any other relevant
information in addition to what you have said in answer to the
above?
67. Please see paragraphs 1 to 22 above
for an introduction to ECDC and its work on communicable disease.
Please see also our website www.ecdc.europa.eu
and our scientific journal Eurosurveillance www.eurosurveillance.org.
28 February 2008
1 Proposal for a regulation of the European Parliament
and of the Council establishing a European Centre for Disease
Prevention and Control COM(2003) 441. Back
2
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. OJ L 142, 30.4. 2004: 1-11. Back
3
SARS, Legionella and Marburg Fever (some two dozen new pathogens
have been discovered over last 25 years) and old ones re-emerge
such as Tuberculosis, Chikungunya and Avian Influenza as potential
threat to human health. Back
4
HIV/AIDS, Tuberculosis, Malaria and Avian Influenza. Back
5
Annual Epidemiological Report on Communicable Diseases in Europe,
ECDC, Stockholm, June 2007 Back
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