'^1 COMMISSION OF THE EUROPEAN COMMUNITIES 
Brussels, 07.03.1996 
COM(96) 78 final 
96/0052 (COD) 
}V*f 
"It; \ COMMISSION COMMUNICATION 
concerning communicable disease surveillance networks in the 
European Community 
*-#$* Proposal for a 
EUROPEAN PARLIAMENT AND COUNCIL DECISION 
creating a network for the epidemiological surveillance and 
control of communicable diseases in the 
European Community 
(presented by the Commission) 

COMMISSION COMMUNICATION 
CONCERNING COMMUNICABLE DISEASE 
SURVEILLANCE NETWORKS 
IN THE EUROPEAN COMMUNITY 
Contents 
I. INTRODUCTION: 2 
H. THE SPECIFIC NATURE OF THE EPIDEMIOLOGICAL 
SURVEILLANCE OF COMMUNICABLE DISEASES 3 
1 DEFINITION OF SURVEILLANCE 3 
2 OBJECTIVES OF SURVEILLANCE 4 
3 PRINCIPLES AND METHODS OF SURVEILLANCE 4 
4 THE DDJFERENT SURVEBLLANCE SYSTEMS 5 
5 QUALITY OF SURVEILLANCE SYSTEMS 6 
HI. INTERNATIONAL COLLABORATION PROJECTS IN THE FIELD 
OF DISEASE SURVEILLANCE 7 
1 SYSTEMS SET UP BY WHO 8 
2 SYSTEMS SUPPORTED BY THE EUROPEAN COMMUNITY 9 
3 OTHER NETWORKS 12 
IV. REVIEW OF THE EXISTING SITUATION AND PROPOSALS FOR 
FUTURE COMMUNITY ACTION 13 
1 ASSESSMENT OF THE EXISTING SITUATION 13 
2 CONCLUSIONS 15 
3 FUTURE ACTIONS 16 
ANNEX 19 
1 
L INTRODUCTION: 
The outbreak of disease due to the Ebola virus in Zaire in 1995, and before that, the 
epidemic of plague in India in 1994 have focused public attention on the need to take 
action against infectious diseases. It is a long-established fact that infectious diseases 
caused by various microbial agents tend to spread through populations irrespective of 
borders, essentially as a result of the movements of people and, to a lesser extent, the 
movement of goods and the consumption of water and foodstuffs. Additional factors 
include climatic change (global warming), increased resistance to antibiotics, the 
immunological status of individuals, and living conditions (socio-economic problems). 
The more that people travel about, and the further they travel, the greater the risks of 
these diseases spreading in the form of epidemics in unprotected populations and, as a 
corollary, the greater the health risks to populations. From Asian flu and cholera, to the 
HIV virus responsible for AIDS, examples abound both in history and in the present day. 
The agents responsible for communicable infectious diseases do not respect geographical 
frontiers. And despite substantial progress in the field of public health protection, the 
exposure of populations to the risk of contracting these diseases is increasing all the time. 
In order to take the appropriate measures necessary to block the progress of these 
infectious diseases or prevent their appearance, national health authorities clearly need to 
have as precise a picture as possible of the epidemiological situation. This can only be 
achieved through the systematic collection, analysis and interpretation of data on these 
diseases, followed by their dissemination to those responsible for public health. Taken 
together these activities amount to epidemiological surveillance, an essentially practical 
process the aim of which is to produce information so that swift action can be taken. In 
the case of communicable diseases all the specialists agree that the cornerstone is 
surveillance, with the results being used in order to control and prevent these diseases. 
Epidemiological surveillance has proved its worth over and over again, the outlay 
required being amply repaid by the savings made in terms of disease avoidance. 
In this general context, and since infectious diseases can spread easily in the European 
Union unless suitable measures are taken, it is obviously necessary to agree on the 
measures required for communicable disease surveillance. In this respect the Council and 
the Ministers for Health of the Member States meeting within the Council adopted on 
13 November 1992 a Resolution, No. 92/C 326/1l, inviting the Commission to report 
briefly on the existing arrangements established between the Member States or by the 
World Health Organisation (WHO) for the surveillance of communicable diseases, 
including food-borne diseases; to identify needs and shortcomings; and to put forward 
proposals for improvements. And the European Parliament, in its Resolution on public 
health policy after Maastricht2, invited the Commission to set up a trans-frontier network 
to devise working definitions of notifiable diseases, to collect, update, analyze and 
disseminate Member State data on notifiable diseases and to work with national and 
1 OJ of 11.12.1992. 
2 OJ No C 329, 6.12.1993, p. 375 
international agencies on such matters. Additionally, in its Conclusions 94/C 15/043 of 
13 December 1993 the Council requested the Commission to put forward proposals for 
the setting up of an epidemiological network in the Community. In its Communication 
COM(93) 559 of 24 November 1993 on the framework for action in the field of public 
health and its Communication COM(94) 413 of 9 November 1994 on AIDS and certain 
other communicable diseases, the Commission proposed specific Community measures 
in this respect, notably the creation and development of surveillance networks. 
Without claiming to be exhaustive, this present Communication reviews the existing inter-
institutional collaborative arrangements for the surveillance of communicable diseases 
in the European Union. After an explanation of the specific nature of the epidemiological 
surveillance of communicable diseases, there then follows an attempt to analyse the 
strengths and weaknesses of the present situation on the basis of certain objective criteria 
the aim of which is to meet the requirement for a high level of health protection within 
the European Community. Finally, proposals are put forward for short-and medium-term 
surveillance actions for the prevention and control of communicable diseases in- Europe, 
with due regard to the fundamental principles which underpin the construction of Europe, 
namely subsidiarity and Community added value. 
D. THE SPECIFIC NATURE OF THE EPIDEMIOLOGICAL 
SURVEILLANCE OF COMMUNICABLE DISEASES 
Before setting out into this vast area it is essential, in order to avoid potential ambiguities 
and misunderstandings, to define the context and the concepts used and to outline the 
scope of the activities concerned. Such clarification is necessary because we need to have 
a clear and simple idea of what can be achieved by the Community in this area, and 
because both nationally and at international level there is a profusion of ongoing, but little 
known, initiatives and a confusing interlacing of different systems. And on top of all this, 
there is a specific quality to the surveillance of communicable diseases which needs to 
be appreciated from the European dimension. 
1 DEFINITION OF SURVEILLANCE 
For the surposes of the present communication and decision, epidemiological surveillance 
is defined as the ongoing systematic collection, analysis and interpretation of health data 
essential to the planning, implementation and evaluation of public health practice, closely 
integrated with the dissemination of these data to those who need to know for their work 
or for decision-making. Surveillance is therefore the observation of certain health 
phenomena affecting populations or groups of populations, through the collection of 
different types of data, so that swift action can be taken if necessary to correct these 
phenomena. In principle, such observation is an ongoing process, continuing for as long 
as the phenomena are liable to occur. It is therefore an active and dynamic process which, 
from the public health point of view, can only concern situations which are liable to 
evolve rapidly if no steps are taken to correct them. 
OJ of 18.1.1994. 
In the language of the epidemiologist, the term "surveillance" is in practice used to cover 
three types of case: communicable diseases; pollution-related health risks; and the safety 
of biological products intended for incorporation to humans. In this latter case the term 
"vigilance" is used, for example haemovigilance in the case of blood or blood products. 
Naturally, surveillance can also be carried out for non-communicable diseases such as 
cancers, cardiovascular diseases or mental diseases. But because these diseases develop 
slowly, and because of the nature of the information which needs to be collected on them, 
and because there is no call for the type of urgent action called for to block a rapidly 
spreading epidemic, the term "epidemiological observation" is used instead in these cases. 
2 OBJECTIVES OF SURVEILLANCE 
In the field of communicable diseases the objectives of epidemiological surveillance are, 
firstly, to ascertain the incidence (number of new cases occurring over say a-month or a 
year) and the characteristics of a particular infectious disease, and to study its pattern of 
spread through time, space and social categories, so as to be able to take appropriate 
counter-measures. The second objective is to detect disease clusters or epidemics, or even 
abnormal health incidents, through a system of warning indicators, so that measures can 
be taken to break the specific transmission chain. And the third objective is to describe 
and measure the risk factors for contracting a communicable infection, so as to be able 
to select and implement the most appropriate preventive measures and recommendations. 
These three interdependent objectives, taken together, constitute the basis for the activity 
referred to as the control of communicable diseases. It is not some form of checking up 
on individuals by State officials, as is sometimes erroneously feared, but merely a 
question of doing everything possible to stop the spread of a disease and re-establish 
normal conditions, i.e. a high level of health protection. 
In addition to dealing with de facto situations, surveillance also serves as an instrument 
for evaluating preventive policies, particularly vaccination policy. Finally, surveillance can 
form the basis for hypotheses which can then be verified by means of epidemiological 
surveys. 
3 PRINCIPLES AND METHODS OF SURVEILLANCE 
Communicable diseases have certain basic characteristics which were described in an 
earlier Commission communication (COM(94) 413 of 9 November 1994, paragraphs 6 
to 15), to which the reader is referred. To some extent these characteristics dictate the 
surveillance methods which need to be employed, since these diseases are not all alike, 
far from it. 
In practice, and according to epidemiology specialists, surveillance can be carried out on 
the basis of clinical and/or biological criteria (the data being furnished for example by 
general practitioners and test laboratories) or on the basis of surveys (either exhaustive 
or sample, depending on the type of disease under investigation: rare and serious 
infectious diseases require exhaustive surveys, e.g. compulsory notifications or mortality 
registers, whereas common and less serious infectious diseases require sample surveys, 
based on networks of sentinel doctors and sentinel laboratories). The validity of the 
surveillance depends on the frequency of data collection, which may be continuous or 
periodic (but repeated at sufficiently close intervals). Data may be collected passively (i.e. 
by awaiting the arrival of the information) or actively (i.e. through regular or permanent 
contact with the information source). 
Surveillance also depends on the geographical level (i.e. local, national or international), 
and the data transmission medium must be the most appropriate for the requirements, 
particularly as regards speed (e.g. written questionnaire, telephone, fax or electronic data 
transmission). Additionally, a truly rigorous surveillance operation should make use of 
at least two independent and complementary surveillance systems for the same disease: 
the exhaustiveness and representativeness of the data collected can then be verified by 
comparing the data from the different systems. 
Obviously, to enable an overall picture of the situation to be obtained all the surveillance 
data must be collated at a certain central level, which means the national level in most 
countries (leaving aside those with a federal structure). The same applies at European 
level: the data need to be centralised so that they can be processed and sent out to the 
health players. 
4 THE DIFFERENT SURVEILLANCE SYSTEMS 
A number of different surveillance systems on communicable diseases are in use 
nationally or regionally. 
a) The classic system is the compulsory notification system: general practitioners are 
obliged to notify the health authorities whenever they diagnose a particular disease, at the 
same time furnishing a certain number of additional details. The centralisation of the data 
allows a close watch to be kept on the general situation. This system works reasonably 
well in some countries, less so in others (under-reporting) and in most cases is based on 
clinical diagnosis with no specific case definition. Since there is no weeding out of 
duplicate notifications or of unconfirmed cases it cannot be relied on to give an accurate 
picture of the situation. The system is most effective when the incidence of a disease is 
not too high: like any passive surveillance system it is not able to record all cases of a 
disease. 
b) For the above reasons, the compulsory notification system is very often replaced 
or augmented by networks of sentinel general practitioners. These are volunteers, forming 
a representative sample of 1 to 4% of the total number of general practitioners in their 
country in terms of age, sex, type of practice and place of practice. These doctors 
increasingly tend to be linked up electronically and their surveillance results are updated 
weekly so that a close watch can be kept on the pattern of occurrence of the diseases 
under surveillance. This system is used in particular for common diseases with a high 
incidence, since trends can quickly be spotted and information can be exchanged and 
warnings issued rapidly, almost in real time. 
c) Networks of medical biology sentinel laboratories, recruited on the same principles 
as those used for the sentinel doctors, furnish information on microorganisms (viruses, 
bacteria, germs, etc.) which they have identified in their day-to-day work, usually in tests 
to confirm clinical diagnoses. Several such networks have been set up for particular 
diseases, and they play an important role in sounding the epidemiological alarm. Not all 
Member States have set up such networks, which require considerable organisation and 
constant motivation, i.e. a significant outlay in terms of resources. 
d) Specialist reference centres for communicable diseases provide additional support 
through their expertise (identification of strains, epidemiological analysis); through the 
warnings they are able to provide when poorly identified clusters or isolated cases of rare, 
serious diseases occur; and through the technical advice they are able to give the health 
authorities. 
e) The range of surveillance systems is completed by periodic or one-off surveys, 
e.g. for studying prevalence (nosocomial infections), evaluating preventive measures 
(vaccination cover) or determining the incidence of certain unmonitored diseases. Other 
information sources (death certificates, sales of medicaments and vaccines, health 
certificates, hospital morbidity records, etc.) are also used in order to validate the 
surveillance systems indirectly. 
5 QUALITY OF SURVEILLANCE SYSTEMS 
The usefulness of a country's surveillance system to public health officials will depend 
on the quality of the- system, i.e. its capacity to provide an accurate picture of the 
epidemiological situation, as assessed by reference to a number of criteria. This is even 
more true at international level: a surveillance system at Community level would serve 
little purpose if data were not comparable. 
a) The sensitivity of a surveillance system, i.e. the proportion of cases picked up by 
the system compared with the total number of cases actually occurring in a given 
population, is a key assessment criterion. By this yardstick, the sensitivity of the 
compulsory notification systems ranges from 5% (of cases reported by comparison to the 
true total) to almost 100%. In these circumstances, where the notification rate achieved 
is below a threshold of somewhere between 50 and 80% there must be serious doubts 
about the usefulness of the system, and the system will need to be improved or 
augmented with other information sources. 
b) The representativeness of a surveillance system is, by definition, a key criterion 
in sample-based systems such as the sentinel networks. This is particularly true when the 
sensitivity of the accompanying compulsory notification system is low, since this could 
drastically alter the true picture and lead to a false assessment of the situation. 
c) The notification period, if too long, can cause problems, especially in situations 
where effective action is needed in order to control an epidemic as quickly as possible. 
Thus, while annual or quarterly notification of new cases may be appropriate for diseases 
which do not require immediate control measures, it is frankly inappropriate for diseases 
where rapid intervention is required. This factor is particularly important when we are 
dealing with a vast geographical area such as the European Community. 
d) The reliability of the results collected depends directly on whether cases are 
defined, or whether a person can be examined by several different doctors in succession, 
or is seen several times by the doctor because of relapses. 
e) The confidentiality of the data collected raises ethical and legal problems in 
particular when the notification questionnaire enables the individual to be identified and 
includes questions on the sexual behaviour of the individual or questions which can 
identify the individual as being HIV positive. There are strong reasons, therefore, for 
making the questionnaires anonymous. 
f) Other factors also play a part in the assessment of surveillance systems: two key 
factors which can compromise the usefulness and smooth functioning of a surveillance 
system are, firstly, the absence of additional data frequently essential for the 
epidemiological surveillance of a given disease, and, secondly, the lack of sufficient 
manpower to enable surveillance activities to be maintained at an appropriate level and 
the data to be analysed exhaustively. 
m. INTERNATIONAL COLLABORATION PROJECTS IN THE FIELD OF 
DISEASE SURVEILLANCE 
Historically, and quite naturally, many of the existing international communicable disease 
surveillance projects involving different countries or their specialist institutions have been 
set up on the initiative of, and under the aegis of, the World Health Organisation. The 
WHO'S span in Europe extends far beyond the discontinuous territory of the countries 
which make up the European Community. Leaving aside the diseases covered by the 
International Health Regulations (MR), these cooperation projects are voluntary, and their 
effectiveness depends on the commitment shown by the partners in collecting relevant 
data and transmitting the data for analysis and dissemination. 
These useful - in some cases vital - transnational activities necessarily have a cost, both 
in terms of investment and operation. The European Community, and more specifically 
the European Commission, has provided substantial financial support, usually in 
cooperation with WHO. 
In order to obtain as complete a picture as possible of the networks of public health 
players specialising in the surveillance of communicable diseases, the Commission 
requested a small group of experts, at the end of 1993, to produce an inventory of such 
networks, using a questionnaire for completion by health experts in the Member States. 
For the purposes of the survey, international collaboration was taken to be any activity 
geared towards improving the fight against one or more communicable diseases, and for 
which personnel had been enlisted, whether for a limited duration or otherwise, in at least 
three European countries. The list of collaboration projects identified, together with a 
description of each of them, is described in the Annex. 
1 SYSTEMS SET UP BY WHO 
This is not meant to be an exhaustive analysis of all of WHO's activities in this field. It 
is simply a brief outline of the systems operated by WHO which concern the European 
Community. 
a) The International Health Regulations (IHR), adopted by the 22nd World Health 
Assembly in 1969 and subsequently amended for cholera by the 26th Assembly in 1973, 
and for smallpox by the 34th Assembly in 1981, are designed to help prevent the 
international spread of diseases. The Regulations oblige all countries which are party to 
this international Convention (this includes all the Member States of the European 
Community but not the European Community itself) to take measures to stop the spread 
of epidemic outbreaks due to three communicable diseases: plague, cholera and yellow 
fever. Breaking with traditional control measures such as quarantine, which are usually 
inappropriate, these measures consist of the continuous epidemiological surveillance of 
imported cases, the early detection of infections and their notification to WHO within 24 
hours, and the rapid and widest possible dissemination of all relevant information. These 
three diseases are not rife in Europe, being imported diseases which have their sources 
in other parts of the world. WHO is the pivot for the Member States for the notification 
of cases. 
The system remains something of a formality, however, and does not produce extensive 
cooperation between the participating countries when incidents of these diseases occur on 
their territories. No international convention can be expected to foresee all disease 
eventualities. In some cases diseases and disorders other than those covered by the IHR, 
for example certain African haemorrhagic fevers, can be tackled by the national 
authorities in the same spirit. But in the light of experience the system's practical 
feasibility is such that it is difficult to see how Community cooperation could be of value 
in this area. 
b) The other international exchange systems under the WHO's aegis are concerned 
more with passive surveillance. Some of them merit closer attention. 
* The Expanded Programme on Immunisation (EPI), established by WHO in 1974, aims 
to control six diseases of children throughout the world (diphtheria, neonatal tetanus, 
whooping cough, poliomyelitis, measles and tuberculosis) through appropriate 
immunisation cover. For the WHO's European zone, which covers 50 countries (including 
Russia and the 15 Community Member States), WHO objective No. 5 is slightly different, 
namely to control six diseases (the same six as above, but with mumps and congenital 
rubella replacing tuberculosis and whooping cough) in the general population by the year 
2000. The Member States are in addition committed to the following four objectives: 
eradication of poliomyelitis by the year 2000; elimination of neonatal tetanus by 1995; 
95% reduction in measles mortality and 90% reduction in measles morbidity by 1995; 
routine vaccination against hepatitis B by 1995 if the prevalence of HBs antigen carriage 
is more than 8%, and vaccination of exposed groups against hepatitis B by 1997 if the 
prevalence of HBs antigen carriage is less than 8%. 
These objectives are merely recommendations, i.e. they have no binding force, and their 
attainment therefore depends on the goodwill of the national public health authorities, 
whose representatives sit in a management group and an advisory committee. These 
authorities send in their surveillance results, in principle on an annual basis: the results 
are of course a vital tool for verifying the implementation of any immunisation 
programme. But the fact is that the Member States are far from being united in their 
surveillance methods (case definitions) and their methods of determining vaccination 
coverage, thus hampering proper comparison of national situations. 
* Two other systems, the Collaborating Centre for Health and Disease Surveillance 
(Rome) and the Surveillance Centre for the Control of Food-borne Infections and 
Intoxications in Europe (Berlin) no longer appear to fulfil present day requirements. 
2 SYSTEMS SUPPORTED BY THE EUROPEAN COMMUNITY 
At the level of the European Community, Council Directive 92/117/EEC4 of 17 December 
1992 concerning measures for protection against specified zoonoses and specified 
zoonotic agents in animals and products of animal origin in order to prevent outbreaks 
of food-borne infections and intoxications provides for a system for collecting information 
on specified zoonoses and zoonotic agents. Under Article 5, Member States are obliged 
to produce a report by 31 March each year on the trends and sources of the zoonotic 
infections recorded during the previous year, and the Commission is obliged to evaluate 
the information thus obtained and report to the Standing Veterinary Committee before 1 
October each year. Leaving aside these developments, which are not directly within the 
remit of this Communication, initiatives in the field of communicable disease surveillance 
have been developed over the last decade in four areas. The first were in the Research 
sector, followed by technology development initiatives in the Telecommunications and 
Internal Market sectors, where substantial resources have been allocated. Since the entry 
into force of the Treaty establishing the European Community, the Commission has been 
endeavouring to support innovatory initiatives or to accompany the Community's overall 
activities in the context of the Framework for action in the field of public health. The 
need to coordinate these crucial public health activities so as to ensure clarity and 
coherence is now greater than ever. 
a) The Eurosentinel system is the product of a concerted initiative launched in 1988, 
funded for three years by the Biomed programme (medical and public health research). 
Its mandate was to promote the establishment of networks of sentinel general practitioners 
and to coordinate their activities in certain Member States, with the ultimate target of 
establishing a European sentinel surveillance network using electronic data 
communication resources. At national level these sentinel GPs form networks for the 
rapid dissemination, in standardised form, of information they gather during the course 
of their work, and they report their observations to a central national structure. In the case 
cf Eurosentinel the central structures are linked up to a central unit within the Institut 
d'Hygiène et d'Epidémiologie in Brussels, the role of which is to receive and store all 
OJNoL62, 15.03.1993, p. 38. 
information relating to activities in the field of sentinel surveillance, to assist and 
technically advise the networks, to organise scientific meetings and to publish a regular 
newsletter. 
Placed under the aegis of the Project Management Group, Eurosentinel has the task of 
observing the international incidence of four health matters, based exclusively on clinical 
diagnosis: measles, mumps, prescription of HIV screening tests and influenza syndromes. 
Initially comprising the existing networks of five countries (Belgium, France, Netherlands, 
United Kingdom and Switzerland), Eurosentinel has since been joined by new networks 
set up in four other countries (Ireland, Portugal, Spain and Italy). These networks, of 
variable coverage and quality, are far from uniform in their organisation. Their results, 
based exclusively on clinical diagnosis (with no biological confirmation), are tinged with 
uncertainty, the more so as there is no common definition of cases. Despite the 
discontinuation of Community support the system continues to function thanks to the 
support of health authorities of these Member States. 
b) Telematic Networks between Administrations 
i) CARE - Early warning system 
Public health authorities, whether at local, regional or national level, have the 
responsibility to ensure that the necessary information concerning cases of communicable 
diseases liable to lead to epidemics or epidemic outbreaks is available and is 
communicated in good time to all decision-making bodies and/or bodies responsible for 
implementing appropriate measures. 
The effectiveness and efficiency of national administrations in carrying out these tasks 
will be greatly enhanced by the setting up of an EU-wide modern, cost-effective and user-
friendly telematics system, linking health administrations in the Member States, so that 
they can exchange reliable information, results and experience in real time, consult each 
other prior to introducing counter-measures as in the case of epidemics, coordinate their 
responses, particularly where these might have economic and social consequences, and 
improve the formulation of policies and the planning, financing and administration of 
health services. 
The Council decision of 6 November 1995 on support for IDA (telematic interchange of 
data between administrations in the Community)5 foresees two projects in the field of 
health, namely CARE (two sub-projects : early warning system and pharmacovigilance) 
and REITOX (European network of information on drug addiction). 
The two CARE sub-projects under IDA are spin-offs of earlier efforts on the European 
Nervous System (ENS-CARE) supported by the Commission under the 3rd Framework 
Research and Technological Development Programme over the period 1991 to 1993; its 
current situation permits the gradual passage from ihe pilot to the exploitation phase, with 
OJNoL269, 11.11.1995, p.23. 
10 
the general architecture and infrastructure for communicable diseases, health data and 
indicators and pharmacovigilance. 
Under current IDA plans, CARE-Early warning system (CARE-EWS) work will 
concentrate over the next two years on development of the pilot system between national 
administrations, while strictly adhering to the general system architecture foreseen for 
IDA. Apart from the infrastructure and architecture aspects of a system such as CARE-
EWS linking national administrations, the content of information to be exchanged will 
have to be determined. This will have to be specified by the Commission in collaboration 
with the administrations. To this end, the Commission is presenting a proposal for a 
decision by the European Parliament and the Council concerning the setting up of a 
European Community system for the epidemiological surveillance and control of 
communicable diseases. 
The Commission has already presented a communication and a proposal for a decision 
on a programme concerning health data and indicators.6 The latter programme, as distinct 
from the effort directed towards communicable disease surveillance, aims at providing the 
necessary information on health status and health determinants and would, as appropriate, 
draw from information generated by communicable disease surveillance. It does not, 
however, have the objective of securing the rapid sharing of detailed, validated and in 
most cases confidential information, and the coordination of responses, when cases of 
communicable diseases liable to lead to epidemic outbreaks occur. 
ii) The G7 Global Healthcare Applications Project 
The G7 Global Healthcare Applications Project contains a sub-project, "Towards a Global 
Public Health Network", a key element of which is the design of an international data 
exchange in the areas of communicable disease surveillance through new 
telecommunication technologies. These activities take into account the experience 
acquired from the "Wonder project" run by the USA's "Centers for Disease Control", as 
well as the recommendations made to the President of the United States by the National 
Science and Technology Council in the report "Infectious disease - a Global Health 
Threat". This detailed report presents an overview of the problems and of the obstacles 
to combating infectious diseases and proposes a step-by-step model for the adoption of 
appropriate measures, including a Worldwide Communication Network. 
c) European Centre for the Epidemiological Monitoring of AIDS 
This Centre, financed by the European Community in the context of the BIOMED 
research programmes and the Europe against AIDS programme, was set up in 1987 in 
Paris. It is responsible for the surveillance of AIDS and HIV infection in the European 
Community and the other territories covered by WHO Europe, with whom it collaborates. 
The Centre receives non-aggregated data on diskette every three months from all the 
countries in the WHO's European zone, which extract the data from their national data 
bases. They include various indicators concerning the disease and its diagnosis, together 
COM 95 (449) of 16.10.1995. 
11 
with comments on the trends over the past three months. The data are depersonalised so 
that it is not possible to identify the individuals concerned, whatever their geographical 
location. The Centre also produces tables of figures and collects data concerning 
anonymous screening programmes. 
d) Ongoing surveillance activities 
Currently, because Member States' surveillance systems differ so widely, the data issued 
by Member States on communicable diseases are not intercomparable. In addition, not 
enough epidemic outbreaks are detected and correctly investigated. In such circumstances 
it is only rarely that appropriate recommendations can be formulated, because there is a 
lack of epidemiologists trained in this type of intervention. Field epidemiology, which 
involves the application of epidemiological methods to surveillance, to data production, 
to public health action and to the monitoring of infectious diseases, is the approach which 
is needed in order to contain and, if possible, clear up epidemics. In this context, there 
is clearly a need for collaboration as regards training students in the epidemiology of 
communicable diseases. 
The development of a cadre of public health personnel with a common knowledge base, 
common skills and a common approach to epidemiology could greatly stimulate 
harmonised activities in the field of public health, and especially in the field of 
communicable disease prevention. For this reason the Commission has since 1994 been 
providing financial support, under the programme on AIDS and other communicable 
diseases, for a field epidemiology training programme coordinated by the IHE in Brussels. 
The project involves sending ten or so epidemiologists from the Community to locations 
in other Member States for a two-year period in order to acquire experience and skills 
in the field of epidemiological intervention (control of communicable diseases) -
something which is lacking in the Community at present. Thanks to this innovative 
project a new network of specialists in the surveillance of communicable diseases is 
gradually emerging, and this network should be up and running properly within the next 
two or three years. 
In a similar context, the AIDS Centre in Paris is currently coordinating a feasibility study 
for the creation of a European bulletin of communicable diseases, which would publish 
surveillance data on a monthly basis. The producers of the national bulletins have already 
set up a coordination structure, in liaison with the national institutions responsible for 
surveillance in the Member States, with a view to setting up such a bulletin permanently 
at European level. This bulletin would regularly publish data from existing and future 
surveillance networks and from epidemiological surveys; would compare the different 
national approaches to public health; and would collect information of international 
interest from the Member States' national bulletins. 
3 OTHER NETWORKS 
As shown in the Annex, other international networks of a similar nature have been set 
up by surveillance professionals in the public sector, sometimes in collaboration with the 
private pharmaceutical industry, as is the case for influenza. Other networks concern 
meningitis, listeriosis and paediatric diseases. 
12 
IV. REVIEW OF THE EXISTING SITUATION AND PROPOSALS FOR 
FUTURE COMMUNITY ACTION 
1 ASSESSMENT OF THE EXISTING SITUATION 
Since detailed information on all the factors necessary for a rigorous assessment is not 
available, it is not easy to provide an in-depth analysis of the existing situation 
concerning disease surveillance at Community level, still less so to deliver a judgment 
on it. However, it is useful to review the situation on the basis of a checklist, whether this 
be of diseases grouped together thematically, or of modes of transmission, or of the 
criteria which determine the quality of a surveillance system, as mentioned at point II.5. 
The criteria for assessing the pertinence of a surveillance operation and the suitability of 
the existing system or systems can be organised as follows: 
a) By type of disease: 
b) diseases preventable by vaccination 
sexually transmitted diseases, hepatitis B, AJDS/HTV 
hepatitis (C and unclassified) 
food-borne diseases 
zoonoses (for the record) 
imported diseases 
respiratory diseases (tuberculosis) 
nosocomial infections 
By modes of transmission: 
1. water-borne: - cholera, hepatitis A, legionellosis (water quality) 
2. zoonotic: 
3. food-borne: - brucellosis, trichinosis, Campylobacter, echinococcosis, 
rabies, Yersinia, etc. 
- salmonellosis (S. enteridisi, typhimurium, virchow, napoli) 
- listeriosis 
- E. coli % 
- shigella 
- etc. 
4. inter-human: -AIDS 
- STDs (syphilis, chlamydiases, genital herpes) 
- tuberculosis 
- hepatitis B and C 
- influenza and influenza syndromes 
- meningitis: Haemophilus influenzae B; meningococci, 
A,B,C; pneumococcus 
- etc. 
13 
5. blood: - HIV/AIDS 
- hepatitis B and C 
- etc. 
6. environmental: - legionellosis 
- aspergillosis (nosocomial infections) 
- etc. 
7. particular: - Creutzfelt-Jakob disease 
- etc. 
c) By the criteria determining the quality of a surveillance system: 
. sensitivity 
. representativeness 
. notification frequency 
. reliability 
. confidentiality 
. follow-up (resources allocated) 
In the light of this general review it could be possible to compare the existing situation 
with what could theoretically be done in the way of disease surveillance. The 
Commission, working in close cooperation with the Member States' authorities 
responsible for communicable disease surveillance, intends to put forward appropriate 
proposals for the adoption of measures necessary to improve this type of epidemiological 
surveillance in the Community. It is already clear that tuberculosis and hepatitis C, which 
the Commission mentioned in its Communication (COM(94) 413), should be considered 
under this approach as meriting particular attention. 
As a general rule, it appears that collaborations are becoming more sophisticated, with 
increasingly standardised methodology and better technical support. Projects which were 
developed within single institutions, without an effective partnership between partners, 
have tended to be less successful. Of course, the opposite is true (when the various 
opposing elements are^all brought together). Historically, projects had not always had 
clear objectives underpinned by an effective setting of criteria and scientific standards. 
Ongoing, independent scientific input is essential for a project to be successful, and has 
not always been present. 
The strength of any collaboration depends on the quality of the data at the point where 
it originates and therefore relies on the quality of national systems, which are 
heterogenous. Procedures such as coordinating and improving existing systems (rather 
than developing new systems) and developing uniform agreed case definitions, are 
important to the development of effective collaborations. Clearly, within any one 
collaboration one partner might take the lead, or have a greater role than others. 
14 
2 CONCLUSIONS 
After examination of the various international cooperation schemes for communicable 
disease surveillance, and after consultation by the Commission of national experts and of 
those responsible for disease surveillance in the Member States, a certain number of 
conclusions, on which there is agreement, can be drawn. 
a - There is a growing need for European collaboration on the prevention of 
communicable diseases and such collaboration should be accorded the highest priority. 
Reasons for this include: the increasing mobility of populations due to tourism, business 
and migrations in general; the increasing freedom of movement for goods; the re-
emergence in Europe of once familiar infectious diseases such as tuberculosis and 
poliomyelitis; the emergence of new infections, such as those due to various strains of 
E. coli 0157 secreting cytotoxins; the breakdown of communicable disease prevention 
measures in various parts of eastern Europe, etc. 
b - In order to promote effective preventive action against communicable diseases, 
European Community collaboration in the fields of public health surveillance and 
microbiology is essential. At present, there is not even a list of structures and laboratories 
to enable analyses and identifications to be carried out at Community level. 
c - The fact that various joint surveillance projects are being considered, or are starting 
to see the light of day, shows that the need for European collaboration is widely 
recognised. However, since there are clearly gaps, overlaps and wide variations (in terms 
of quality, quantity, uniformity over time, and reliability) in the data yielded by the 
present systems, these activities need to be coordinated within the Community. 
d - There are currently wide differences in the Member States' vaccination programmes 
and schedules. The improvement of surveillance and of research to facilitate the 
harmonisation of vaccines would bring much-needed rationalisation to this area of public 
health. 
e - In order to improve surveillance at European level there is a need to identify more 
precisely those areas in which there is duplication of activity and to establish priorities 
for the implementation of collective projects. Accordingly, there is a need to promote 
collaboration between experts from the national institutions responsible for communicable 
disease surveillance. Activities in this domain ought to be coordinated with the activities 
already being carried out by the World Health Organisation, particularly WHO/Euro. 
f - The establishment of contact networks, which are necessary for the development of 
these activities, would be facilitated by the organisation of regular meetings between the 
experts responsible for the national surveillance programmes. These meetings should be 
devoted to the public health problems inherent in communicable disease surveillance, 
microbiology and identification of the problems and priorities at European level. 
g - All the Member States without exception should participate in such a network, with 
full account being taken of the fact that the degree of surveillance and prevention of 
communicable diseases varies substantially from country to country. Since infectious 
15 
diseases know no frontiers, consideration should be given to extending the network to 
include neighbouring non-Member States or countries with special relations with the 
Community (such as the USA), on a basis yet to be defined. 
h - Several of the existing European surveillance networks for certain specific infections 
could serve as models for other infections, since they employ standard case definitions 
and methodologies agreed on jointly by the participants and transmit their regularly 
updated data to a coordinating centre at regular intervals. The following are examples of 
high interest: 
• The system for notifying AIDS and HIV cases to the European AIDS 
Epidemiological Surveillance Centre in Paris, resulting in trend data which constitute a 
useful basis for preventive action. This example, could be followed in order to develop 
similar information systems for hepatitis, tuberculosis and sexually transmitted diseases. 
• The EWGLI information system for laboratory-diagnosed legionellosis cases, 
coordinated by the Public Health Laboratory Service's (PHLS) Communicable Disease 
Surveillance Centre in London, which permits the swift detection of epidemics with a 
common source. It provides trend data, enabling preventive measures to be taken as 
quickly as possible. A similar system, SALMNET, is proposed for salmonellosis and 
could also be applied to listeriosis and infections due to strains of E. coli 0157 secreting 
verotoxin. 
i - To achieve greater harmonisation in areas such as quality control and the most 
sophisticated techniques (e.g. phage typing and genotype establishment, identification of 
viruses responsible for African haemorrhagic fevers) used for identifying micro-organisms 
with ever greater precision. 
3 FUTURE ACTIONS 
a) On the basis of these conclusions, there will be two major strands to the 
Community's future actions concerning communicable disease surveillance and control: 
- Firstly, the establishment of a system for the surveillance and control of 
communicable diseases at Community level, requiring the exchange, at appropriate 
moments, of accurate and reliable information concerning diseases for which specific case 
definitions, identifications and verifications are required. It is proposed to set up this 
system on the basis of a European Parliament and Council decision, and to exploit the 
infrastructure set up by the IDA programme. 
- Secondly, various measures such as the development and coordination of intra-
Community collaborations; assistance for pilot projects to facilitate the setting up and 
smooth running of the key elements of surveillance systems at national level; exchanges 
of experience, notably through meetings of experts; cooperation with non-member 
countries and international organisations competent in this field; the training of field 
epidemiologists; the production and dissemination of information tools, such as 
epidemiological surveillance bulletins; support for European microbiologists for the 
16 
creation of an inventory of collaborative ventures in Europe and of national resources 
currently available in the relevant fields of microbiology. These measures will be 
undertaken in the context of the future programme concerning AIDS and certain other 
communicable diseases, for which the Council adopted a common position on 2 June 
1995 (OJ 95/C 216/02)7 and which was the subject of a conciliation procedure, pursuant 
to Article 189b of the Treaty, on 19 December 1995. 
b) As regards the setting up of a system for the surveillance and control of 
communicable diseases at Community level, the Commission, in its communication of 
24 November 1993 on the framework for action in the field of public health, outlined the 
principles and strategies to be followed in implementing Community activities directed 
towards the attainment of the health protection objectives laid down by Articles 3(o) and 
129 of the Treaty establishing the European Community. The role of the Community is 
to underpin the efforts of the Member States in the public health field, to assist in the 
formulation and implementation of objectives and strategies, and to contribute to the 
continuity of health protection provision across the Community, setting as a target the 
best results already obtained in a given area anywhere in the Community. 
The Commission's proposal for the creation of such a network advocates that the Member 
States should participate fully in its organisation and implementation. The network's task 
will be to ensure coordination in the collection, processing and exchange of information 
necessary for the prevention and control of communicable diseases. Focusing on disease 
prevention, and. following the principles of subsidiarity and proportionality, this 
Community action is designed to help the authorities responsible for public health to take, 
at State level, measures to block the progression of these infectious diseases or to prevent 
their appearance. 
c) Consequently, this proposal seeks to establish a system of close cooperation and 
effective coordination between Member States in the field of surveillance, both routine 
and emergency, with a view to improving the prevention and control in Europe of a 
certain number of serious communicable diseases which necessitate the introduction of 
measures for the protection of populations. The proposal is modelled on Community 
instruments already adopted in similar areas for the accomplishment of similar objectives. 
The data in question will be collected in aggregated form and will in no case enable 
individuals to be identified. Thus, they will not conflict with Community instruments 
concerning the protection of personal data, such as Council Directive C 95/46/EC of 24 
October 1995 on the protection of individuals with regard to the processing of personal 
data and the free movement of such data8. They will however comply with the 
Community provisions concerning systems of information exchange between 
administrations. 
d) The setting up of this network for the surveillance of communicable diseases takes 
account of, and is based on, the situation already existing in this field at European level. 
It also aims to avoid unnecessary duplication of work by ensuring that all Member States 
7 OJNoC216, 21.8.1995, p. 2. 
8 OJNo L 281, 23.11.1995, p.31 
17 
have the same conception of surveillance, as a result of defining with them the type of 
information required and the arrangements appropriate for each group of communicable 
diseases. Finally, other parties will be associated with the network: these will include the 
competent international organisations (notably WHO), the surveillance networks to which 
Member States already belong, and non-member countries. Cooperation with the USA 
towards the setting up of a global early warning and response system has already begun 
within the framework of the EU-USA action plan, and also within the framework of the 
Gl Global Healthcare Applications Project, in which Canada and Japan are also involved. 
An important aspect of this latter project is the application of new technologies to the 
international exchange of data in the field of communicable disease surveillance. 
e) The recently created Task Force on Vaccines and Viral Diseases should also help 
to coordinate efforts to establish a European Communicable Disease Surveillance System 
building on existing pilot activities and legislative initiatives. Its main thrust should be 
to ensure adequate information flows between the vaccine research community and the 
surveillance networks and to focus on endemic identifiable infections as well as voluntary 
data constituencies on specific outbreaks. Furthermore, the Task Force would catalyze the 
integration of common European expertise into the surveillance system at a level of 
specific laboratory facilities. 
f) The implementation of the decision will yield added value in a number of ways: 
It will ensure the setting up of a system of continuous, well-structured, reliable 
and effective communication at Community level between national communicable disease 
surveillance authorities, something which is lacking at present; 
It will facilitate the rapid, reliable and commonly agreed identification of cases 
of communicable diseases occurring inside the Community, or occurring outside and 
therefore being imported or likely to be imported; 
It will give the competent authorities the opportunity and the means to consult 
together on the preventive measures to be taken, and it will help them in the coordinated 
introduction of such "measures and the evaluation of their effectiveness; 
It will give the authorities the support they need for analysing and interpreting 
data and for deploying the necessary measures to stop communicable diseases from 
spreading. 
18 
ANNEX 
I - EXISTING COLLABORATIONS 
A - Surveillance 
/ - WHO Collaborating Centre for Health and Disease Surveillance 
Diseases surveyed 
Notifiable diseases or diseases otherwise subject to systematic/obligatory reporting at a 
national level. 
Data sources 
Periodical bulletins of communicable disease surveillance prepared by participating 
countries, according to the variable criteria which may apply, and supplemented by 
retrospective cumulative data from WHO Regional Office and the statistical office of 
WHO Headquarters. 
International reporting 
Twenty five countries submitted data by post to the centre at the Instituto Superiore di 
Sanita in Rome. Data is available for Albania, Austria, Belgium, Bulgaria, 
Czechoslovakia, Denmark, Germany, Finland, France, Greece, Hungary, Iceland, Ireland, 
Israel, Italy, Luxembourg, Malta, Monaco, Morocco, Netherlands, Norway, Poland, 
Portugal, Romania, San Marino, Spain, Sweden, Switzerland, Turkey, United Kingdom, 
Russia and Yugoslavia. 
International feedback 
Eight bulletins summarising disease occurrence by YEAR by COUNTRY have been 
produced since the scheme's inception. 
Inputs 
100% provided by participants. Start up moneys of $3,000 US were provided by WHO 
Regional Office. 
Dates of i) commencement and ii) completion 
i) 1983 ii) ongoing. 
19 
Value 
Four enquiries have been received in the last 3 years. The quality of the data reported 
nationally does not merit the effort of international collation in the views of the 
Collaborating Centre. 
20 
2 - Expanded Programme on Immunisation 
Diseases surveyed 
Incidence of Diphtheria, Tetanus, Pertussis, Poliomyelitis, Measles, Mumps, Rubella. 
Immunisation coverage. 
Data sources 
Generally based on passive reporting via notification schemes in countries11. Assessment 
of vaccine coverage uses different approaches in different countries (see below, "Research 
in Methodologies of Immunisation Programmes Management in Europe"). 
International reporting 
Tabulated data is sent periodically to WHO European Regional Office in Copenhagen. 
International feedback 
A publication summarising immunisation coverage and incidence of six target diseases 
(Diphtheria, Measles, Pertussis, Poliomyelitis, Tetanus and Tuberculosis) is produced 6 
monthly. 
Inputs 
Submission of tabulated data to WHO by participating countries. 
Dates of 0 commencement and ii) completion 
i) Longstanding ii) Ongoing 
Value 
International comparisons have given an impetus to beneficial modifications of national 
schedules. Identification of risk areas (eg Diphtheria in the countries of the former 
USSR). 
21 
3 - Eurosentinel 
Diseases surveyed 
Range of communicable diseases. 
Data sources 
Clinical diagnoses from various networks of sentinel General Medical Practitioners (GPs). 
Case definitions used vary between networks but are invariably physician based. 
International reporting 
Weekly totals of disease occurrence are sent by fax to the Institute of Hygiene and 
Epidemiology, Brussels. Data is available from Belgium, France, The Netherlands, 
Portugal, Spain, Switzerland and United Kingdom. 
International feedback 
A Bulletin of the Institute of Hygiene and Epidemiology is prepared periodically, as 
resources permit, on behalf of the collaborating networks. This tabulates disease 
occurrences by country by week and is posted to collaborators. 
Inputs 
Submission of tabulated data to Institute of Hygiene and Epidemiology by participating 
networks. The Institute of Hygiene and Epidemiology estimate their input to co-ordinate 
the scheme to be 1 hour of medical staff time, 1 hour of scientific staff time and 4 hours 
of clerical staff time per week with all inputs since 1991 provided nationally. 
Dates of i) commencement and ii) completion 
i) 1988 as EC concerted action programme, ii) 1991 but the Institute of Hygiene and 
Epidemiology has continued the scheme on an informal and unfunded basis since then 
as a service to the collaborating networks. 
Value 
Acts as a clearing house for information about activities in the field of sentinel practice 
schemes and a source of scientific support for them. During the 1989 influenza epidemic 
the data was used to review spread through Europe and to encourage vaccination and to 
brief the media in certain countries. 
Potentially the scheme could support the development of sentinel networks in those 
countries which do not possess them and also organise international studies based in 
those participating networks which are already established. 
22 
4 - WHO Surveillance Programme for Control of Foodborne Infections and Intoxications 
in Europe. 
Diseases surveyed 
Foodborne disease, defined as "a disease of an infectious or toxic nature caused by or 
thought to be caused by the consumption of food or water". 
Data sources 
Reporting from the responsible surveillance institution. Criteria for including data differ. 
Some countries consider a disease as foodborne only when the causative agent was 
identified in the patient as well as the food; other countries find it satisfactory when 
there is epidemiological evidence and yet others include all diarrhoeal diseases. 
International reporting 
Reporting procedures vary between countries. Data is sent to the Institute of Veterinary 
Medicine - Robert von Ostertag Institute (FAO/WHO Collaborating Centre for Research 
and Training in Food Hygiene and Zoonoses, Berlin. Data is, or until recently was, 
available from Albania, Austria, Belgium, Bulgaria, Cyprus, Czechoslovakia, Denmark, 
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Luxembourg, 
Malta, Monaco, Netherlands, Norway, Poland, Portugal, Romania, Spain, Sweden, 
Switzerland, Turkey, United Kingdom, USSR, Yugoslavia. 
International feedback 
Five reports have been published since the schemes inception. The most recent covered 
the period 1985-1989 and was published in 1992. Data is presented in a series of country 
reports with little attempt at inter-country comparisons. More immediate feedback is 
provided by newsletters which are published approximately 4 times per year. 
Inputs 
Submission of tabulated data to Robert von Ostertag Institute by participating networks. 
Dates of i) commencement and ii> completion 
i) 1980 ii) Ongoing. The programmed is intended to become of the 4 components of the 
Food Safety Pilot (ie application), one of the 4 subsidiary projects of the European 
Nervous System (ENS) /CARE Telematics programme, funded by European Commission 
to develop European electronic communications networks. 
Value 
Stimulus to national authorities in their efforts to strengthen the prevention and control 
of foodborne diseases. 
23 
5 - British Paediatric Surveillance Unit (BPSU) and Union of European Paediatric 
Societies and Associations 
Diseases surveyed 
Rare infectious diseases and infection related conditions in patients under 16 years of age. 
(Up to 12 disorders at any one time). Rare non infectious conditions are also surveyed. 
Infectious diseases which are, or have been, surveyed are HIV/AIDS, Neonatal Herpes, 
Sub-acute Sclerosing Pan Encephalitis, Haemolytic Uraemic Syndrome, Congenital 
Toxoplasmosis, Rheumatic Fever, Congenital Rubella, MMR associated Meningo­
encephalitis, Acute Flaccid Paralysis, Haemophilus influenzae type B (HiB) vaccine 
failures. 
Data sources 
Defined diagnoses of conditions under surveillance reported monthly by a postal report 
card ("orange card") by 1,160 participating hospital paediatricians. 
International reporting 
This is made to BPSU at the British Paediatric Association Offices in London. An 
important feature is the requirement to make a nil return if no cases of the diseases under 
surveillance have been seen by the paediatrician. Data is available form the United 
Kingdom and Ireland. Similar but separate schemes have now commenced in Germany 
and the Netherlands. 
International feedback 
Six annual reports have been published since the schemes inception. The most recent 
was published in 1993. Regular scientific publications are made. 
Inputs 
Submission of report cards to BPSU by participating clinicians. 
Dates of i) commencement and ii) completion 
i) 1986 ii) Ongoing. The Union of European Paediatric Societies and associations formed 
a working group in 1991 to develop a network of European paediatric surveillance units. 
The group includes 9 countries and has applied for EC funding as a concerted action 
programme for 1993. 
Value 
The scheme has enhanced ascertainment and the provision of data of good quality for a 
variety of rare conditions. It has been imitated in other countries and is being considered 
by other specialties. 
24 
6 - EURO. NES Scheme for Surveillance of Nosocomial Infection 
Diseases surveyed 
Nosocomial infections and Pneumonia in Intensive Therapy Units (ITUs) to identify risk 
factors, evaluate control measures and assess the feasibility of a surveillance system. 
Data sources 
For a one month period participating physicians in ITUs form a convenience sample of 
volunteering hospitals reported to national centres the isolation from their patients of 
microorganisms which were hospital acquired. Data was available on the age and sex of 
the patient and the severity of clinical illness, the procedure undergone, intercurrent 
illness/therapy, smoking habits and the existence of infection at admission. 
International reporting 
Data was posted to the University of Lyon, France. Data was obtained from Belgium, 
Denmark, France, Germany, Greece, Ireland, Italy, Netherlands, Portugal, Spain, Sweden, 
Switzerland, United Kingdom. 
International feedback 
Analysis of risk factors has been received back from coordinators. Scientific publication 
is awaited. 
Inputs 
Study costs within countries met by participants. EC provided software, organised 
meetings and funded collaborative aspects. 
Dates of H commencement and ii) completion 
i) 1990 ii) 1992: data analysis continuing. Fieldwork was of 1 month's duration. 
Value 
Potential for setting standards for in-patient care. 
25 
7 - WHO Influenza Surveillance 
Diseases surveyed 
Laboratory isolation of influenza virus or serological evidence of influenza infection. 
Data sources 
Specimens submitted by clinicians to diagnostic laboratories within countries. 
International reporting 
Data is sent by post or fax to the WHO Influenza Collaborating Centres on Influenza 
Reference and Research in London and Atlanta, USA. Data is obtained from 46 
laboratories in 25 developed countries and 64 laboratories in 52 other countries, covering 
nearly all parts of the world. 
International feedback 
A weekly influenza report is received by fax from Atlanta giving disease occurrence by 
time and place. Data also features in the notices of influenza activity in the WHO 
Weekly Epidemiological Record. 
Inputs 
Submission of data by responsible institutes in participating countries. 
Dates of H commencement and ii) completion 
i) 1990 ir) Ongoing. 
Value 
The scheme is critical for knowing the correct strains to incorporate in vaccines. When 
allied to other systems it could allows the epidemiological characteristics of different 
strains to be evaluated. 
Potentially a model for international collaboration in communicable disease surveillance 
as well as permitting the computation of the velocity of spread of influenza 
internationally. 
26 
8 - Influenza (EUROGROG) 
Diseases surveyed 
Laboratory isolation of influenza virus or serological evidence of influenza infection 
combined with clinical diagnoses via sentinel schemes and other non-specific indicators 
of activity (eg. hospital activity, sickness absence, consumption of specific 
pharmaceuticals. 
Data sources 
Specimens submitted by clinicians to diagnostic laboratories and various other indicator 
activities within countries. 
International reporting 
Data is sent by post or fax to the Institut Pasteur in Paris. 
International feedback 
A weekly influenza bulletin is sent by post from Paris giving activity (disease occurrence 
by week by country or French Department) in 23 countries. 
Inputs 
Submission of data by responsible institutes in participating countries. 
Dates of H commencement and ii) completion 
i) 1984 ii) Ongoing. 
Value 
The scheme allows the epidemiological characteristics of different strains to be evaluated. 
Potentially a model for international collaboration in communicable disease surveillance 
as well as permitting the computation of the velocity of spread of influenza 
internationally. Could lead to more accurate information on, and greater harmonisation 
of, action thresholds. 
27 
9 - European Working Group on Legionella Infection (EWGLI) 
Diseases surveyed 
Laboratory evidence of Legionellosis defined according to strict diagnostic criteria in 
patients with a clinical or radiographic diagnosis of pneumonia. 
Data sources 
Case reporting via clinicians and diagnostic laboratories to responsible national co­
ordinating centres within countries. 
International reporting 
Data is sent by post, fax or computer network to the PHLS Communicable Disease 
Surveillance Centre (CDSC), London, the centre having been moved from the National 
Bacteriological Laboratory, Stockholm with a view to incorporating the scheme into the 
Early Warning Pilot, one of the 4 subsidiary projects of the European Nervous System 
(ENS) /CARE Telematics programme, funded by DGXIII to develop European electronic 
communications networks (Appendix VII). Data is obtained from Austria, Belgium, 
Czechoslovakia, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Netherlands, 
Norway, Portugal, Spain, Sweden, Switzerland, Turkey, United Kingdom, USSR, 
Yugoslavia. 
International feedback 
A computer disk is sent by post from London, monthly, giving disaggregated data on 
diagnostic status, time (onset and report date), resort visited, period of visit, person 
(characterised by age, sex and country of residence) and institute of report. Cluster alerts 
are also issued. 
Inputs 
Submission of data by responsible institutes in participating countries. 
Dates of i) commencement and ii) completion 
i) 1987 ii) Ongoing. 
Value 
Unique data source for some participating countries where Legionellosis is not subject 
to any reporting/notification requirements. Permits control activity where clusters 
identified. Strengthens the efforts of national institutions in controlling disease. Model 
for international collaborative effort. 
28 
10 - European Monitoring Group on Meningococci (EMGM) 
Diseases surveyed 
Meningococcal meningitis and septicaemia. 
Data sources 
Case reporting via national centres with responsibility for meningococcal surveillance. 
International reporting 
Data is sent to King's College School of Medicine and Dentistry, University of London. 
Data is obtained from Albania, Austria, Belgium, Bulgaria, Croatia, Czech Republic, 
Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, 
Latvia, Malta, Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovak Republic, 
Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom, Yugoslavia. 
International feedback 
Periodic reports are provided giving incidence by country by year. Data on age, outcome 
and prophylactic and curative therapy is also provided. Data on serogroups and subtypes 
from reference laboratories and sulphonamide resistance is also given. 
Inputs 
Submission of data by responsible institutes in participating countries. The co-ordinating 
centre is funded by the UK National Meningitis Trust (a charity). 
Dates of i") commencement and ii) completion 
i) 1991? ii) Ongoing. Application to the EC is intended. 
Value 
Standardisation of surveillance and laboratory techniques and reagents. Development of 
an audit process for meningococcal disease management in Europe. 
29 
11 - WHO Collaborating Centre for Rabies Surveillance and Research 
Diseases surveyed 
Human and animal rabies. 
Data sources 
Case reporting via clinicians, veterinary surgeons and diagnostic laboratories to 
responsible national co-ordinating centres within countries. 
International reporting 
Data is sent to the WHO Collaborating Centre for Rabies Surveillance and Research at 
the Federal Research Centre for Virus Disease of Animals, Tubingen, Germany. Data is 
obtained from Austria, Belgium, Bulgaria, Croatia, Czechoslovakia, Denmark, Estonia, 
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, 
Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovenia, Spain, 
Sweden, Switzerland, Turkey, United Kingdom, Yugoslavia. 
International feedback 
A quarterly report is produced tabulating cases by species, by district, by quarter. 
Inputs 
Submission of data by responsible institutes in participating countries. 
Dates of i) commencement and ii) completion 
i) ? ii) Ongoing. 
Value 
Identifies changes in epizootic cycle. Informs animal immunisation programmes and 
decisions on offering immune prophylaxis to humans. 
30 
12 - European Centre for the Epidemiological Monitoring of AIDS 
Diseases surveyed 
AIDS and HIV infection. 
Data sources 
Every three months the national representatives in charge of AIDS surveillance 
systems provide individual anonymous data on diagnosed AIDS cases. Data from HIV 
seroepidemiological studies, including information on methods and results, are also 
provided. 
International reporting 
All the countries in the WHO European Region, including all the European Union 
Member States, participate in the surveillance system. A uniform AIDS case definition 
and standardised methods of data transmission are used. The Centre collects, analyses and 
disseminates results at European level. 
International feedback 
The data collected are recorded in quarterly reports which include updated results 
of AIDS surveillance and various articles from seroepidemiological surveys or European 
multicentre studies. There are separate quarterly reports for the WHO European region 
and for the European Union countries. Twice a year, the EU report includes detailed 
information for each country. Scientific publications are produced by the Centre and also 
by other users of the data sets which are available to surveillance and research teams of 
participating countries. 
Inputs 
Data are sent to the Centre on diskettes or by E-mail. Representatives of the 
participating countries receive copies of the compiled data sets (quarterly) and sets of 
slides presenting the data (twice a year). The quarterly reports are distributed to a network 
of 900 correspondents. Standardised tables are also available on Internet. 
Dates of i) commencement and ii) completion 
i) 1984 ii) ongoing 
Value 
The Centre regularly provides standardised information allowing the evaluation 
of the HIV/AIDS epidemic situations and trends at European level. It reinforces efforts 
of national and international institutions to control the epidemic and is a working model 
of international collaboration. 
31 
B - Training 
1 - Institut pour le Développement de l'Epidémiologie Appliquée (IDEA) 
Participants 
Public health professionals. 
Duration and Locations 
3 weeks at Veyrier du Lac, France. 
Subject matter 
Field epidemiology including a surveillance project (usually a knowledge, attitudes, 
practice survey). 
Instruction is in French. 
Assessment (including formal qualifications awarded) 
Those who complete the course receive a certificate of completion. 
Benefit to participants 
Enhancement of abilities in field investigation. 
Value 
Additional practical skills to organisation sending student. 
Dates of i) commencement and ii) completion 
i) 1984 ii) Ongoing. 
32 
2 - Seminars on Infectious Disease, Communicable Disease for Environmental Health, 
Surveillance of Infection. 
Participants 
Public Health Professionals: c40/seminar. 
Duration and Locations 
5 days: Glasgow (UK). 
Subject matter 
Epidemiology and control of infection suitable for an international audience. 
Assessment (including formal qualifications awarded) 
None. 
Benefit to participants 
Exchanges of ideas and establishment of international working relationships. 
Value 
Establishment of avenues for information exchange. 
Dates of i) commencement and ii) completion 
i) Longstanding ii) Ongoing 
33 
C - Information 
Eurosurve il lance: European Communicable Disease Bulletin 
Diseases 
Communicable diseases. 
Data sources 
Articles published in national bulletins of the European Union Member States, 
original articles regarding investigation or of recent outbreaks reports, review articles 
based on European data. 
International reporting 
The production of the bulletin is coordinated by a French-English permanent team. 
The scientific committee is composed of members of the National Public Health Centre 
and the European Centre for the Epidemiological Monitoring of Aids in France, and of 
the PHLS - Communicable Disease Surveillance Centre in England. The 15 Member 
States of the European Union are represented by editors of national surveillance bulletins 
or by surveillance representatives in the case of Member States without such bulletins. 
They compose the editorial board. 
International feedback 
A French-English pilot issue was published and distributed to professionals 
involved in public health in 1995 (12 000 recipients). An electronic version was set up 
on Internet. Monthly routine production should follow the feasibility study conducted in 
1995, which was funded by DGV of the Commission of the European Communities. 
Inputs 
Two meetings of the editorial board and six meetings of the scientific committee 
each year, to select, appraise and finalise articles. Regular contacts by fax or E-mail 
ensure close collaboration within the network. The publishing and mailing of the bulletin 
are carried out by the European Centre for the Epidemiological Monitoring of Aids. 
Dates of i) commencement and ii) completion 
i) 1995 ii) 1998 (for the project submitted to the Commission) 
Value 
The feasibility study revealed genuine interest from readers (evaluation 
questionnaire) and the European collaborators. 
34 
Eurosurveillance aims at increasing the circulation of information in the field of 
communicable diseases epidemiology between national surveillance systems and 
professionals involved in Public Health within the European Union. Moreover, the 
establishment of close, regular contacts between experts in charge of national 
communication should develop the quality and speed of information exchanges beyond 
the bulletin itself and should contribute to better control of communicable diseases in the 
European Union. 
35 
D -Other 
Research in Methodologies of Immunisation Programmes Management in Europe 
Diseases 
Diphtheria, Tetanus, Pertussis, Poliomyelitis, Measles, Mumps, Rubella. 
Activity 
National Immunisation Programme Managers have met together to expedite developments 
in three areas: 
1 Methods used to assess vaccine coverage. 
2 Assessment of surveillance methods used to detect adverse reactions. 
3 Investigation of outbreaks of vaccine preventable disease (predominantly to concentrate 
on measles). 
International co-ordination 
International Children's Centre, Paris. 
Inputs 
Funded as EC Concerted Action. 
Dates of i) commencement and ii) completion 
i) 1991 ii) Ongoing 
Value 
Pooling of structural and process data from participating countries. Allows sharing of 
experience and notice to be given of potentially helpful technologies (ie salivary testing 
for anti-measles antibodies). 
36 
II - PLANNED COLLABORATIONS 
A - Surveillance 
1 - SALMNET 
Diseases to be surveyed 
Laboratory confirmed human Salmonella infection. 
Data sources 
Reporting from the responsible national collaborating centre to the European coordinator. 
Discussions and exchange of isolates is being co-ordinated by the PHLS Central Public 
Health Laboratory, London, to harmonise phage typing on a European basis. 
International reporting 
Reporting would be by regular submission of a floppy disk to the European coordinator 
by each collaborating centre. An exploratory workshop in London was attended by 
representatives from Austria, Belgium, Denmark, France, Germany, Ireland, Italy, 
Netherlands, Portugal, Spain, Sweden, Switzerland, United Kingdom. 
International feedback 
An aggregate database would be created and returned to each country. The PHLS 
"Exception Reporting Scheme" will be used to analyse the data to identify anomalously 
high levels of isolation and facilitate outbreak recognition. 
Date of i) commencement 
i) 1993. The programme has been fundend as an EC Concerted Action under the 
BIOMED1 Scheme (Science, Research and Development). The programme is intended 
to become one of the communicable disease components of the Early Warning Pilot (ie 
application), one of the 4 subsidiary projects of the European Nervous System (ENS) 
/CARE Telematics programme, funded by the Commission to develop European 
electronic communications networks. 
Value 
Identification of European wide Salmonella problems. Enhancement of the ability to 
detect multi-state outbreaks. Harmonisation of reference techniques. 
37 
2 - CARE. ENS Influenza Surveillance 
Diseases to be surveyed 
Laboratory isolation of influenza virus or serological evidence of influenza infection 
combined with clinical diagnoses via sentinel schemes. 
Data sources 
Reporting from the responsible national collaborating centre to the European coordinator. 
International reporting 
Reporting would be by computer network to the European coordinator at Université Citi 
2, Paris, by each collaborating centre. 
International feedback 
It is intended that a disaggregated database will be created for online interrogation by 
participants in the network. 
Date of i) commencement 
i) 1990. The programme is intended to become one of the communicable disease 
components of the Early Warning Pilot, one of the 4 subsidiary projects of the European 
Nervous System (ENS) /CARE Telematics programme, funded by the Commission to 
develop European electronic communications networks. 
Value 
May expedite data feedback. 
38 
3 - WHO Global Surveillance Programme for Recognition and Response to Emerging 
Diseases. 
Diseases to be surveyed 
New, emerging or re-emerging diseases and drug resistant micro-organisms. 
Data sources 
Enhanced laboratory reporting at country level to the existing WHO collaborating centres, 
which will be strengthened. 
International reporting 
This will be to WHO Headquarters at Geneva (Division of Communicable-Diseases in 
close co-ordination with Divisions of Epidemiological Surveillance, Health Situation and 
Trend Assessment and Emergency and Humanitarian Action). 
Reporting of bacterial resistance to antibiotics would be by computer network 
(WHONET). 
International feedback 
To be developed. 
Date of i) commencement 
i) 1994. 
Vajue -
Enhancement of capabilities at country level. Development of stronger intervention 
capacity at WHO/HQ level to facilitate prompt, co-ordinated action.' Training components 
will be incorporated and research opportunities will develop. 
39 
4 - European Study Group on Haemolytic Uraemic Syndrome 
Diseases to be surveyed 
Clinical diagnoses of haemolytic uraemic syndrome and laboratory isolations of VT+ 
Ecoli 
Data sources 
Paediatric dialysis units and diagnostic microbiology laboratories. 
International reporting 
Some reporting is already carried out by post to the University of Wurzburg in Germany. 
Italy submits some data currently. Interest has been indicated from Belgium^and United 
Kingdom. 
International feedback 
None as yet. 
Date of i) commencement 
i) Italy and Germany have shared data since 19S8. The programme had been proposed 
for funding as an EC Concerted Action under the BIOMEDl Scheme of the European 
Commission (Science, Research and Development). 
Value 
The diseases are of relatively low incidence, although the sequelae are serious. European 
surveillance may expedite risk factor identification. 
40 
5 - European Network on Congenital Toxoplasmosis 
Diseases to be surveyed 
Congenital Toxoplasmosis for which a clinical and laboratory based case definitions are 
to be developed. 
Data sources 
Participating countries institutions are to be asked to identify geographically defined 
populations of pregnant women in urban, and, if possible, in rural areas. Data on 
seroprevalence will be compared. A multi centre randomised trial of therapy has also 
been proposed and a long term cohort study of the offspring of women who sero-convert 
in pregnancy. 
International reporting 
Different aspects of the work will be reported to different co-ordinating centres. 
Participating in the inaugural workshop were Austria, Belgium, Denmark, Finland, 
France, Germany, Hungary, Italy, Netherlands, Norway, Poland, Sweden, Switzerland, 
United Kingdom. Overall co-ordination is from the Statens Seruminstitut, Copenhagen. 
International feedback 
None as yet. 
Date of i) commencement 
i) 1993 The programme has been funded as an EC Concerted Action under the 
BIOMEDl Scheme of the Commission (Science, Research and Development). 
Value 
Analysis of data from a variety of localities will give indications as to routes of infection. 
Standardisation and quality assurance at a European level becomes possible of diagnosis 
and treatment. Resolving uncertainties about the outcomes of treatment may be 
expedited. 
41 
6 - Nordic countries case-control study of listeriosis 
Diseases to be surveyed 
Listeriosis. 
Data sources 
Physicians in participating countries will make a notification of listeriosis to the national 
institute for infectious disease control by fax. Data is tabulated by year by county by 
person (characterised by age, sex, occupation, clinical disease status and whether 
pregnant). 
International reporting 
Data will be reported by computer diskette by post to co-ordinating centres at Oslo and 
in Uppsala University. Participating countries will be Denmark, Finland, Norway, 
Iceland. 
International feedback 
None as yet. Format to be decided. 
Date of i) commencement 
i) 1991 (Planning) 
Value 
Increasing the understanding of the contributory factors to disease development and 
spread. 
42 
B - Training 
European Field Epidemiology Training Program 
Participants 
Medical, Veterinary and Public Health Graduates from European countries. Initially 6-12 
in number. 
Duration and Locations 
1 month theoretical training at a rotating location followed by 22 months field attachment 
in a country other than that from which the student comes. 
Subject matter 
Applied epidemiology of Communicable Diseases and Environmental Hazards. 
A working knowledge of English and the language of the country where field attachment 
is to be performed is required in practice although languages will not be used as a criteria 
for admission to the course. 
Assessment (including formal qualifications awarded) 
None although certain educational objectives will be set such as the ability to: 
1) Influence decision makers in Public Health. 
2) Assume service responsibility in epidemiology and respond to disease clusters. 
3) Develop and maintain an international perspective. 
Benefit to participants 
Comprehensive training in field epidemiology and decision making in acute Public Health 
problems. 
Value 
Development of a cadre of professionals with a commitment to addressing Public Health 
problems at the European level. 
Develop a common approach to many problems based on a common training which will 
facilitate harmonisation of approaches to problems and decision making in Europe. 
Date of i) commencement 
i) 1995 probably represents the earliest practicable year in which students can be taken. 
43 
Proposal for a 
EUROPEAN PARLIAMENT AND COUNCIL DECISION 
creating a network for the epidemiological surveillance 
and control of communicable diseases 
in the European Community 
ML/ 
EXPLANATORY MEMORANDUM 
1 In its communication COM(93) 559 of 24 November 1993 on the framework for 
action in the field of public health, the Commission outlined the principles and 
strategies to be followed in implementing Community activities directed towards 
the attainment of the health protection objectives laid down by Articles 3(o) and 
129 of the Treaty establishing the European Community. The role of the 
Community is to underpin the efforts of the Member States in the public health 
field, to assist in the formulation and implementation of objectives and strategies, 
and to contribute to the continuity of health protection provision across the 
Community, setting as a target the best results already obtained in a given area 
anywhere in the Community. 
2 In accordance with Article 129 of the Treaty establishing the- European 
Community, the Commission presents proposals for the adoption by the European 
Parliament and the Council of incentive measures intended to contribute towards 
ensuring a high level of human health protection. These measures are geared 
towards encouraging cooperation between the Member States, lending support to 
their actions and promoting coordination of their policies and programmes, and 
towards fostering cooperation with third countries and with international 
organisations competent in the sphere of public health. This present Commission 
proposal, based on Article 129 and already announced in the Commission's 
programme of work for 1995, comes under the principle of shared competence 
between the Community and the Member States and seeks to create a network for 
the epidemiological surveillance and control of communicable diseases in the 
European Community. Full participation by the Member States in the organisation 
and implementation of the network should help to ensure coordination and mutual 
cooperation in the collection, processing and exchange of information necessary 
for the prevention and control of communicable diseases. This Community action 
is therefore geared towards disease prevention and will follow the principles of 
subsidiarity and proportionality. 
i Infectious diseases caused by various microbial agents tend to spread through 
populations and through space, essentially as a result of the movements of people 
and, to a lesser extent, the movement of goods and the distribution of drinking 
water and foodstuffs. Additional factors include climatic change (global warming), 
increased resistance to antibiotics, the immunological status of individuals, and 
living conditions (socio-economic problems). The more that people travel about, 
and the further they travel, the greater the risks of these diseases spreading in the 
form of epidemics and, as a corollary, the greater the health risks to populations. 
From Asian flu and cholera, to the HIV virus responsible for AIDS, examples 
abound both in history and in the present day. The agents responsible for 
communicable infectious diseases know no geographical frontiers. And despite 
substantial progress in the field of public health protection, the exposure of 
populations to the risk of contracting these diseases is increasing all the time. 
^s 
In order to take the appropriate measures necessary to block the progression of 
these infectious diseases or prevent their appearance, national health authorities 
clearly need to have as precise a picture as possible of the epidemiological 
situation. This can only be achieved through the systematic collection, analysis 
and interpretation of data on these diseases, followed by dissemination of the data 
to those responsible for public health. Taken together these activities amount to 
epidemiological surveillance, an essentially practical process the aim of which is 
to produce information so that swift action can be taken. In the case of 
communicable diseases all the specialists agree that the cornerstone is 
surveillance, with the results being used in order to control and prevent these 
diseases. Epidemiological surveillance has proved its worth over and over again, 
the outlay required being amply repaid by the savings made in terms of disease 
avoidance. 
In this general context, if we look at the European area as a single entity it is 
obviously essential to standardise communicable disease surveillance. In this 
respect the Council and the Ministers for Health of the Member States meeting 
within the Council adopted on 13 November 1992 a Resolution, No 92/C 326/1 \ 
inviting the Commission to report briefly on the existing arrangements established 
between the Member States or by the World Health Organisation (WHO) for the 
surveillance of communicable diseases, including food-borne diseases; to identify 
needs and shortcomings; and to put forward proposals for improvements. And the 
European Parliament, in its Resolution on public health policy after Maastricht2, 
invited the Commission to set up a trans-frontier network to devise working 
definitions of notifiable diseases, to collect, update, analyze and disseminate 
Member State data on notifiable diseases and to work with national and 
international agencies on these matters. Additionally, in its Conclusions No 94/C 
15/04 of 13 December 19933, the Council requested the Commission to put 
forward proposals for the setting up of an epidemiological network in the 
Community. In its Communication COM(93) 559 of 24 November 1993 on the 
framework for action in the field of public health and its Communication 
COM(94) 413 of 9 November 1994 on AIDS and certain other communicable 
diseases, the Commission proposed specific Community measures in this respect, 
notably the creation and development of surveillance networks. To this end, the 
Commission proceeded to consult outside experts, including both national experts 
competent in the surveillance and control of communicable diseases and senior 
officials of the national Health Ministries sitting on the High Level Committee on 
Health, and has taken their comments fully into account. 
Consequently, this proposal seeks to establish a system of close cooperation and 
effective coordination between Member States in the field of surveillance, both 
routine and emergency, with a view to improving the prevention and control of 
a certain number of serious communicable diseases which necessitate the 
OJ of 11.12.1992 
OJ No C 329, 6.12.1993, p. 375 
OJof 18.1.1994 
He 
introduction of measures for the protection of populations. The proposal is 
modelled on Community instruments already adopted in similar areas for the 
accomplishment of similar objectives. The data in question will be collected in 
aggregated form and will and will in no case enable individuals to be identified. 
Thus, they will not conflict with existing or forthcoming Community instruments 
concerning the protection of personal data, such as Council Directive C 95/46/EC 
of 24 October 1995 on the protection of individuals with regard to the processing 
of personal data and the free movement of such data4. They will however comply 
with the Community provisions concerning systems of information exchange 
between administrations. In addition, the Decision contains specific provisions 
aimed at ensuring cohesion with other relevant Community policies, namely the 
Common Agricultural Policy, freedom of movement of goods and persons, and 
exchanges of data between administrations. 
The setting up of this network for the surveillance of communicable diseases takes 
account of, and is based on, the situation already existing in this field at European 
level. It also aims to avoid unnecessary duplication of work by ensuring that all 
Member States have the same conception of surveillance, as a result of defining 
with them the type of information required and the arrangements appropriate for 
each group of communicable diseases. Finally, other parties will be associated 
with the network, under arrangements yet to be worked out. These will include 
the competent international organisations, non-member countries (such as the 
United States of America, with whom cooperation is already planned), and the 
surveillance networks to which Mernber States already belong. 
The implementation of the decision will yield added value in a number of ways: 
a) It will ensure the setting up of a system of continuous, well-structured, 
reliable and effective communication at Community level between national 
communicable disease surveillance authorities, something which is lacking at 
present; 
b) It will facilitate the rapid, reliable and commonly ajgreed identification of 
cases of communicable diseases occurring inside the Community, or occurring 
outside and therefore being imported or likely to be imported; 
c) It will give the competent authorities the opportunity and the means to 
consult together on the preventive measures to be taken, and it will help them in 
the coordinated introduction of such measures and the evaluation of their 
effectiveness; 
d) It will give the authorities the support they need for analysing and 
interpreting data and for deploying the necessary measures to stop communicable 
diseases from spreading. 
OJ No L 281, 23.11.1995, p.31 
Mi 
The action envisaged can only be undertaken on the basis of a European 
Parliament and Council decision adopting the measures proposed for the setting 
up of a Community system needed to ensure cooperation between Member States 
and coordination of their respective systems in this area. It does not require the 
harmonisation of national laws and regulations. 
^ 
Proposal for a 
EUROPEAN PARLIAMENT AND COUNCIL DECISION 
creating a network for the epidemiological surveillance 
and control of communicable diseases 
in the European Community 
THE EUROPEAN PARLIAMENT AND THE COUNCIL OF THE EUROPEAN 
UNION, 
Having regard to the Treaty establishing the European Community, and in 
particular Article 129 thereof, 
Having regard to the proposal from the Commission1, 
Having regard to the opinion of the Economic and Social Committee2, 
Having regard to the opinion of the Committee of the Regions3, 
Whereas the prevention of diseases, and in particular of the major health scourges, 
is a priority for Community action, requiring a global and coordinated approach 
between Member States, 
Whereas the European Parliament, in its Resolution on public health policy after 
Maastricht4, invited the Commission to set up a trans-frontier network to devise 
working definitions of notifiable diseases, to collect, update, analyze and 
disseminate Member State data on notifiable diseases and to work with national 
and international agencies on these matters, 
Whereas in its resolution of 2 June 1994 on the framework for Community action 
in the field of public health5 the Council agreed that priority should be given at 
present to communicable diseases in particular; 
Whereas in its conclusions of 13 December 19936, the Council considers that there 
is a need to develop at Community level a network for the surveillance and 
control of communicable diseases, the main purpose of which would be to collect 
and coordinate information from monitoring networks in the Member States; 
OJ No ... 
OJ No ... 
OJ No ... 
OJ No C 329, 6.12.1993, p. 375 
OJNoC 165, 17.6.1994, p.l. 
OJNoC 15, 18.1.1994, p. 6. 
M 9 
5 Whereas in these same conclusions the Council requests the Commission to 
devote special attention, in its proposals relating to the framework for action in 
the field of public health7, to setting up an epidemiological network in the 
Community, taking account of current proceedings and mechanisms existing at 
Community level and that of Member States, and ensuring the comparability and 
compatibility of data; 
6 Whereas in their resolution of 13 November 19928, the Council and the Ministers 
for Health meeting within the Council underline the desirability of improving, 
within the Community, the coverage and effectiveness of existing networks 
between Member States (including data-processing networks), and of maintaining, 
establishing or strengthening coordination between them for monitoring outbreaks 
of communicable diseases, where such action could add to the value of existing 
measures; 
7 Whereas in this same resolution, the Council and the Ministers for Health meeting 
within the Council underline the value of collecting data from the Member States 
on a limited number of rare and serious diseases which require large samples for 
epidemiological study; 
8 Whereas in this same resolution, the Council and the Ministers for Health meeting 
within the Council invite the Commission to examine the desirability of giving 
priority to certain suitable proposals relating to the control and surveillance of 
communicable diseases, in the light, inter alia, of their estimated cost-
effectiveness; 
9 Whereas, in accordance with the principle of subsidiarity, any new measure taken 
in an area which does not fall within the exclusive competence of the Community, 
such as the epidemiological surveillance and control of communicable diseases, 
may be taken by the Community only if, by reason of the scale or effects of the 
proposed action, the objectives of the proposed action can be better achieved by 
the Community than by one or more Member States; 
10 Whereas measures in the health field must take into account other actions 
undertaken by the Community in the field of public health or which have an 
impact on public health; 
11 Whereas European Parliament and Council Decision .../.../EC adopting a 
programme of Community action on the prevention of AIDS and certain other 
communicable diseases within the framework for action in the field of public 
health9 envisages a number of Community actions for the creation and 
development of networks for the control and surveillance of certain communicable 
COM(93) 559 final, 24.11.1993. 
OJNo C326, 11.12.1992, p. 1. 
OJ No ... 
.To 
diseases, the early detection of such diseases, and promotion of the training of 
field epidemiologists; 
12 Whereas cooperation with the competent international organisations, notably with 
regard to disease classification, must be fostered; 
13 Whereas cooperation with third countries, notably in the case of the emergence 
or resurgence of serious communicable diseases, must be supported; 
14 Whereas the emergence or recent resurgence of serious communicable disea:es 
has demonstrated that when an emergency situation occurs all relevant information 
must be communicated swiftly to the Commission in an agreed form of 
presentation; 
15 Whereas the introduction of specific Community arrangements will help to ensure 
that all Member States are swiftly informed in the event of such an emergency 
situation, so that the protection of the population can be ensured; 
16 Whereas the provisions of Council Directive 92/117/EEC10 concerning measures 
for protection against specified zoonoses and specified zoonotic agents in animals 
and products of animal origin in order to prevent outbreaks of food-borne 
infections and intoxications apply equally to information concerning zoonoses 
which affect human beings, and whereas the same directive provides for a system 
for collecting and transmitting information on specified zoonoses and zoonotic 
agents, 
17 Whereas the setting up of a network for the epidemiological surveillance and 
control of communicable diseases at Community level necessarily presupposes 
observance of the legal provisions concerning the protection of individuals with 
regard to the processing of personal data and the introduction of arrangements to 
guarantee the confidentiality and security of such data and information; whereas 
in this connection the European Parliament and the Council adopted Directive 
95/46/EC on 24 October 1995, 
18 Whereas the Community projects in the field of the telematic interchange of data 
between administrations (IDA)11 and the G7 projects should be closely coordinated 
with the implementation of the Community actions relating to the epidemiological 
surveillance and control of communicable diseases; 
19 Whereas it is important, in an emergency situation, that the competent national 
structures should strengthen their cooperation, notably with regard to the 
identification of biological samples; 
OJ No L 62, 15.03.93, p. 38. 
OJNoL269, 11.11.1995, p.23. 
^1 
20 Whereas these Community arrangements for the rapid exchange of information do 
not affect the Member States' rights and obligations under Treaties or bilateral and 
multilateral conventions; 
21 Whereas it is important that the Commission should implement the Community 
network in close cooperation with the Member States; whereas a procedure 
therefore needs to be established to ensure the Member States* full participation 
in this implementation; 
22 Whereas an agreement on a modus vivendi between the European Parliament, the 
Council and the Commission concerning measures for the implementation of acts 
adopted under the procedure laid down in Article 189b of the Treaty was reached 
on 20 December 1994; 
^ 
HAVE DECIDED AS FOLLOWS: 
Article 1 
A general network for the epidemiological surveillance and control of 
communicable diseases shall be set up in the European Community. 
This Community network shall be formed by putting into permanent 
communication with one another, through all appropriate technical means, 
structures which, at the level of each member State and under the responsibility 
of the Member State, are charged with collecting information relating to 
epidemiological surveillance and coordinating control measures. 
Article 2 
For the purposes of this decision the following terms shall have the following 
meanings: 
1 - epidemiological surveillance: the ongoing systematic collection, analysis, 
interpretation and dissemination of health data concerning communicable diseases, 
for the purpose of enabling appropriate counter-measures to be taken; 
2 - control of communicable diseases: the range of measures taken by the 
competent public health authorities to stop the spread of communicable diseases, 
as well as epidemiological studies, in particular of the pattern of spread of such 
diseases over time and space and analysis of the risk factors for contracting such 
diseases, the results of which enable appropriate preventive measures to be 
devised. 
Article 3 
For every Member State, the epidemiological surveillance and control of 
communicable diseases at Community level shall apply to: 
a) the appearance or resurgence on its territory of cases of serious and/or rare 
communicable diseases as listed in the Annex; 
b) the importation onto its territory, from another Member State or a non-
Community country, of cases of serious and/or rare communicable diseases 
as listed in the Annex. 
i"3 
Article 4 
For the purposes of implementing this decision the Commission shall be assisted 
by a committee consisting of representatives from the Member States and chaired 
by a representative of the Commission. 
The Commission representative shall submit to the committee a draft of the 
measures to be taken. The committee shall deliver its opinion on this draft within 
a time limit which the chairman shall lay down according to the urgency of the 
matter. The opinion shall be delivered by the majority laid down in Article 148(2) 
of the Treaty in the case of decisions which the Council is required to adopt on 
a proposal from the Commission. The votes of the representatives of the Member 
States within the committee shall be weighted in the manner set out in that 
Article. The chairman shall not vote. 
The Commission shall adopt the measures envisaged if they are in accordance 
with the opinion of the committee. If the measures envisaged are not in 
accordance with the opinion of the committee, or if no opinion has been delivered, 
the Commission shall forthwith submit to the Council a proposal concerning the 
measures to be taken. The Council shall act by a qualified majority. 
If, within three months of the matter being referred to it, the Council has not 
adopted measures, the Commission shall adopt the measures proposed and 
implement them immediately. 
Article 5 
The measures referred to in Article 4 concern in particular: 
- . case definitions, in particular the clinical definition and, where appropriate, 
the microbiological characterisation of the agent responsible; 
- the nature and type of data and information to be collected by the 
structures referred to in Article 1 in the field of epidemiological 
surveillance; 
- the epidemiological and microbiological surveillance methods; 
- the protective measures to be taken, in particular at ports and airports, 
notably in emergency situations; 
- information, recommendations and guides to good practice for the public; 
r 7 
Article 6 
Each structure referred to in Article 1 shall communicate to the Community 
network and the Commission: 
- information on the communicable diseases referred to in Article 2, together 
with information on control measures applied; 
- any useful information concerning the progression of epidemic situations 
in the Member State to which the institution belongs; 
- any evaluation element which will aid cooperation between Member States 
for the purpose of the control of communicable diseases, in particular the 
conservation of biological samples taken from patients for transmission to 
specialist laboratories linked to the Community network. 
Article 7 
Each Member State shall appoint, within six months following the entry into force 
of this decision, the structure or structures referred to in Article 1, and shall notify 
the Commission thereof. 
Article 8 
The Commission may amend or supplement the Annex in accordance with the 
procedure provided for in Article 4. 
Article 9 
This decision shall apply without prejudice to Council Directive 92/117/EC 
concerning measures for protection against specified zoonoses and specified 
zoonotic agents in animals and products of animal origin in order to prevent 
outbreaks of food-borne infections and intoxications, and shall take account of the 
information collection and transmission procedure provided for in that directive. 
Article 10 
This decision shall apply without prejudice to European Parliament and Council 
Directive 95/46/EC on the protection of individuals with regard to the processing 
of personal data and on the free movement of such data, and to Council 
Decision 95/468/EC on a Community contribution for telematic interchange of 
data between administrations in the Community (IDA). 
rj-
Article 11 
This decision shall not affect Member States' reciprocal rights and obligations 
deriving from existing or future bilateral or multilateral agreements or 
conventions in the domain covered by the decision, and which are in line with the 
decision's subject, methods of implementation and objectives. 
Article 12 
This decision is addressed to the Member States and shall enter into force three 
months after the date of its publication in the Official Journal of the European 
Communities. 
Done at Brussels 
For the European Parliament For the Council 
The President The President 
sc 
ANNEX 
The communicable diseases referred to in Article 3 are divided into groups of 
serious and/or rare disorders, namely: 
- concerning paragraph a): 
diseases requiring measures to be taken at local level and reported on 
periodically to the Member States' public health authorities in accordance with 
arrangements specific to each of these diseases and defined in accordance with 
Article 5, notably: 
- diseases preventable by vaccination (tuberculosis, tetanus, poliomyelitis, 
diphtheria, meningitis, measles, mumps, rubella, influenza and influenza 
syndromes, etc.), 
- sexually-transmitted diseases (hepatitis B, AIDS/HIV, chlamydiasis, etc.), 
- viral hepatitis (including hepatitis C and other as yet unclassified categories of 
hepatitis), 
- food-borne diseases (listeriosis, salmonellosis, etc.), 
- water-borne diseases and diseases of environmental origin (legionellosis, etc.), 
- nosocomial infections, 
- other diseases transmissible by non-conventional agents (including Creutzfeldt-
Jakob disease, etc.). 
- concerning paragraph b): 
the same diseases as under paragraph a), plus diseases requiring 
exceptional measures to be taken at national and international levels, such as: 
- diseases covered by the International Health Regulations (yellow fever, cholera, 
plague) 
- other diseases (rabies, typhus fever, African haemorrhagic fevers, malaria and 
any other as yet unclassified serious epidemic disease, etc.). 
s^ 
FINANCIAL STATEMENT 
TITLE OF OPERATION 
Proposal for a European Parliament and Council decision creating a network for 
the epidemiological surveillance and control of communicable diseases in the 
European Community. 
BUDGET HEADING INVOLVED 
Part A of the budget. 
LEGAL BASIS 
a) Actual legal basis: 
Article 3(o) and Article 129 of the Treaty on European Union. 
b) References: 
Conclusions of the Council and the Ministers for Health of the Member States 
meeting within the Council of 16 May 1989 on the improvement of the general 
system for collecting epidemiological data, including the application of the new 
definition of AIDS cases (OJ No C 185, 22.7.1989, p. 7). 
Resolution of the Council and the Ministers for Health of the Member States 
meeting within the Council of 13 November 1992 on the monitoring and 
surveillance of communicable diseases (OJNo C 326, 11.12.1992, p. 1). 
Commission communication on the framework for action in the field of public 
health (COM (93) 559 final, 24 November 1993). 
Council conclusions of 13 December 1993 on the setting up of an epidemiological 
network in the European Community (OJ No C 15, 18.1.1994, p. 6). 
*8 
DESCRIPTION OF OPERATION 
4.1 General objective 
Implementation at Community level of a system of epidemiological 
surveillance in the field of communicable diseases, to meet the following 
objectives: 
- firstly, to ascertain the incidence and the characteristics of a 
particular infectious disease or group of diseases, and to study the pattern 
of spread of the disease through time, space and social categories, so as 
to be able to take appropriate counter-measures; 
- secondly, to detect disease clusters or epidemics, or even abnormal 
health incidents, so that measures can be taken to break the specific 
transmission chain; 
- thirdly, to describe and measure the risk factors for contracting a 
communicable infection, so as to be able to select and implement the most 
appropriate preventive measures and recommendations. 
4.2 Method employed for attaining these objectives 
The setting up and running of a system for the surveillance and control of 
communicable diseases at Community level, requiring the exchange, at 
appropriate moments, of accurate and reliable information concerning 
diseases for which specific case definitions, identifications and 
verifications are required. It is proposed to set up this system on the basis 
of a European Parliament and Council decision, and to exploit the 
infrastructure set up by the IDA programme. 
4.3 Period covered 
- Open-ended. 
- Implementation report to be transmitted to the Council and the 
European Parliament following the creation of the network, and 
further reports to be transmitted following any adaptations to the 
system. 
CLASSIFICATION OF EXPENDITURE OR REVENUE 
Non-differentiated appropriations. 
S3 
6 TYPE OF EXPENDITURE OR REVENUE 
Nil 
7 FINANCIAL IMPACT 
No financial impact in Part B of the budget. 
8 ANTI-FRAUD MEASURES PLANNED 
Measures in the rules on the reimbursement of travelling and subsistence costs of 
experts convened. 
9 ELEMENTS OF COST-EFFECTIVENESS ANALYSIS 
9.1 Specific and quantifiable objectives: 
The aim is to establish a Community network for the epidemiological 
surveillance and control of communicable diseases, by achieving the 
following objectives: 
- setting up of a system of close cooperation and effective 
coordination between Member States in the field of surveillance, both 
routine and emergency, with a view to improving the prevention and 
control in Europe of a certain number of serious communicable diseases 
which necessitate the introduction of measures for the protection of 
populations; 
- list of diseases and/or groups of diseases kept under surveillance 
at Community level; 
- case definitions, in particular the clinical definition and, where 
appropriate, the microbiological characterisation of the agent responsible; 
- the nature and type of data and information to be collected in the 
context of epidemiological surveillance; 
- epidemiological and microbiological surveillance methods; 
- protective measures to be taken, in particular at ports and airports, 
notably in emergency situations; 
- information, recommendations and guides to good practice for the 
public; 
- designation of the structure responsible for coordination for 
particular diseases and/or groups of diseases. 
S O 
9.2 Players concerned 
1. The Member States' competent health authorities at national, 
regional and local levels, and competent international organisations. 
2. Health professionals, institutions, laboratories and epidemiological 
health services. 
9.3 Grounds for the operation 
As regards the setting up of a system for the surveillance and control of 
communicable diseases at Community level, the Commission, in its 
communication of 24 November 1993 on the framework for action in the 
field of public health, outlined the principles and strategies to be followed 
in implementing Community activities directed towards the attainment of 
the health protection objectives laid down by Articles 3(o) and 129 of the 
Treaty establishing the European Community. The role of the Community 
is to underpin the efforts of the Member States in the public health field, 
to assist in the formulation and implementation of objectives' and 
strategies, and to contribute to the continuity of health protection provision 
across the Community, setting as a target the best results already obtained 
in a given area anywhere in the Community. 
The Commission's, proposal for the creation of such a network advocates 
that the Member States should participate fully in its organisation and 
implementation. The network's task will be to ensure coordination in the 
collection, processing and exchange of information necessary for the 
prevention and control of communicable diseases. Focusing on disease 
prevention, and following the principles of subsidiarity and proportionality, 
this Community operation is designed to enable the authorities responsible 
for public health to take, at national level, measures to block the 
progression of these infectious diseases or to prevent their appearance. 
An operation as extensive as the creation and development of a network 
which will link the competent authorities of all Member States can only 
be undertaken on a Community scale. 
9.4 Monitoring and evaluation of the operation 
9.4.1 Monitoring of the operation 
The setting up and functioning of the network will be monitored 
by the Commission, which will submit reports to the Council, the 
European Parliament, the Economic and Social Committee and the 
Committee of the Regions. The Commission will base its reports 
on the national reports and on any evaluations carried out. 
61 
9.4.2 Evaluation 
* Evaluation will take the form of: 
- an evaluation of the effective establishment of the network, 
with the participation of independent experts; 
- reports on the quality and effectiveness of the network's 
functioning, to be submitted by the Commission to the other 
Community institutions. 
* Evaluation methods and intervals: 
- establishment of regular reports on any adaptations which 
may be introduced. 
10 ADMINISTRATIVE EXPENDITURE (PART A OF THE BUDGET) 
The effective mobilisation of the administrative resources required will result from 
the Commission's annual decision on the allocation of resources, taking account 
of any additional staff and funds allocated by the budgetary authority. 
10.1 Effect on the number of workers 
Types of workers 
Officials, or A 
temporary B 
staff C 
Other resources 
Total Staff running the operation 
Permanent 
workers 
1 
1 
1 
3 Temporary 
workers 
0 
0 Source of the workers 
DGor 
service 
1 
1 
1 
3 Additional 
personnel 
0 
0 
0 
0 Duration 
10.2 Financial impact of employing additional staff 
Nil 
6d 
10.3 Increase in other administrative expenditure resulting from the 
operation 
Budget heading Amount Method of work 
Meetings A2510 92 650 * 4 meetings of the committee, 2 
representatives/Member State, 
4 x 30 x 770 Ecus 
The resources needed to cover the expenditure described below will be 
obtained by redeploying existing financial resources; no additional 
resources will be required. 
Staff expenditure (Titles Al, A2 and A5) 
3 x 100 000 Ecus = 300 000 Ecus 
Administrative expenditure: 
Cost of meetings (A-250) 
3 meetings x 15 experts x 879 Ecus = 39.555 Ecus 
- Mission costs (A-130) 
24 Brussels-Luxembourg missions x 200 Ecus = 4 800 Ecus 
30 Member States missions x 750 Ecus = 22 500 Ecus 
Total: 366 855 Ecus 
&3 


ISSN 0254-1475 
COM(96) 78 final 
DOCUMENTS 
EN 05 
Catalogue number : CB-CO-96-087-EN-C 
ISBN 92-78-00943-1 
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