PROGRESS REPORT ON THE NETWORK FOR THE EPIDEMIOLOGICAL SURVEILLANCE AND CONTROL OF COMMUNICABLE DISEASES IN THE COMMUNITY
Date: 2000-09-07
Institutions: European Commission
Subjects: epidemiology, health control, infectious disease, information network, public health

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 07.09.2000
COM(2000) 471 final

PROGRESS REPORT
ON THE
NETWORK FOR THE EPIDEMIOLOGICAL SURVEILLANCE AND CONTROL OF
COMMUNICABLE DISEASES IN THE COMMUNITY

(Presented by the Commission)

EXECUTIVE SUMMARY

The Community Network for the epidemiological surveillance and control of communicable
diseases, established by the European Parliament and Council Decision 2119/98/EC, has
completed its first year of operation. It has been shown to be an effective network for health
protection in the Community. Its future development and sustainability, however, requires a
substantial resource commitment from the Commission and Member States in order that the
momentum is not lost.

legionellosis, salmonellosis,
Several systems on communicable disease surveillance (e.g.
tuberculosis) are already functioning in the Community. The progressive expansion of
comparable systems to other priority communicable diseases is now underway.

The Early Warning and Response System has been established and is now capable of
addressing disease outbreaks from whatever source, although its relative immaturity means
that its development requires nurturing.

The Commission has also identified the need for a rapid response capacity at Community
level to assist in outbreaks of disease within and without the frontiers of the European
Community.

The next period will see the Community Network’s extension on the international stage
through European Union co-operation with applicant countries, the Mediterranean partner
countries, under the Northern Dimension, and through the European Union – third country co-
operation arrangements (e.g. Canada, US).

This communication outlines how the Commission has implemented this Decision in its first
year, and puts forward its proposals for future action in this area.

II

TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................................................................................... II

1. Introduction ........................................................................................................... 5

2. Legal framework.................................................................................................... 6

2.1.

2.2.

European Parliament and Council Decision setting up the Network .............. 6

Commission Decisions ................................................................................. 6

3. The Community Network ...................................................................................... 7

3.1.

The Early Warning and Response System (EWRS) ...................................... 7

3.1.1.

3.1.2.

Response to early warnings .................................................................... 10

Lessons learned ...................................................................................... 10

3.2.

Epidemiological surveillance...................................................................... 11

3.2.1.

3.2.2.

3.2.3.

3.2.4.

3.2.5.

3.3.

3.4.

3.5.

Disease specific networks....................................................................... 13

Routine surveillance network ................................................................. 16

Inventories ............................................................................................. 16

Zoonoses................................................................................................ 17

Information sharing ................................................................................ 17

Making information available to the public................................................. 17

Incident Investigation Team........................................................................ 18

Training in communicable disease epidemiology........................................ 18

4. Third countries and International Organisations ................................................... 19

4.1.

Applicant countries..................................................................................... 19

4.2.

European Economic Area / European Free Trade Association (EEA-EFTA)
countries .............................................................................................................. 20

4.3.

4.4.

4.4.1.

4.4.2.

4.5.

4.6.

Euro-Mediterranean and Northern Dimension countries ............................. 20

European Union – North America............................................................... 23

EU – United States Task Force (EU-US Task Force).............................. 23

EU – Canada .......................................................................................... 23

Communicable diseases in developing countries......................................... 23

World Health Organization......................................................................... 23

5. Resources for the Network ................................................................................... 24

5.1.

Financing the Network ............................................................................... 24

3

5.2.

Making the Network work.......................................................................... 24

6. Conclusions ......................................................................................................... 25

Annex 1 ........................................................................................................................... xxvii

Annex 2 .......................................................................................................................... xxviii

Annex 3 ............................................................................................................................ xxix

Annex 4 ............................................................................................................................. xxx

4

PROGRESS REPORT
ON THE
NETWORK FOR THE EPIDEMIOLOGICAL SURVEILLANCE AND CONTROL OF
COMMUNICABLE DISEASES IN THE COMMUNITY

1.

INTRODUCTION

if not all people in the European Community have suffered from a
Most,
communicable disease at some point in their lives. Communicable diseases still
represent a serious risk to human health although the advent of interventions such as
antibiotics and vaccines has reduced the threat.

Communicable diseases do not respect national frontiers and can spread rapidly if
actions are not taken to combat them. They impact on individuals regardless of age,
lifestyle, or socioeconomic status. Not only do they cause illness and impose a heavy
financial burden on society, they also contribute to about one third of all deaths
occurring globally. While mortality is highest in developing countries, ill health is a
considerable cost to the industrialised world, where health care and socio-economic
costs are high.

Population mobility and migration, increased trade in food as a result of the internal
market and globalisation, and environmental changes favour the rapid spread of
disease hitherto not prevalent in the European Community. New diseases such as
AIDS are continuing to emerge and others are developing drug-resistant forms such
as multi-drug
resistant
staphylococcus aureus (MRSA). In addition, new scientific developments on the role
of infectious agents in chronic conditions such as cancer, heart diseases or allergies
are under investigation.

and methicillin

tuberculosis

(MDRTB),

resistant

The identification, monitoring and control of communicable disease outbreaks are
greatly facilitated through well-functioning surveillance systems. Not only do such
systems provide information for early detection and rapid response to outbreaks or
potential outbreaks, they also help in identifying disease trends, risk factors, and the
need for interventions. They also provide information for priority setting, planning,
implementation and resource allocation for preventive programmes and for
evaluating preventive programmes and control measures.

In responding to these various issues, the Council by its Resolution in 19921 and its
Conclusions in 19932 emphasized the need for the setting up of an epidemiological
surveillance and control network in the Community.

The Commission then put forward its proposal, which was adopted in 1998 as a
Decision of the European Parliament and Council (2119/98/EC)3 setting up a
Community Network for
and control of
epidemiological
communicable diseases in the Community. The Decision confers on the Commission
the responsibility for developing this Network and facilitating and co-ordinating its
various activities. The systems existing at national level are now part of this

surveillance

the

1 OJ C326, 1.12.1992, p. 1.
2 OJ C15, 18.01.1994, p. 6.
3 OJ L268, 3.10.1998, p. 1.

5

Network. The overall aim of the Community Network is the prevention and control
of communicable diseases in the Community, having regard to the need to integrate
this objective into international endeavours to reduce these diseases.

The development of the Community Network, its budgeting and priorities are an
integral component of the action programme proposed in the "Communication from
the Commission to the Council, the European Parliament, the Economic and Social
Committee and the Committee of the Regions on the health strategy of the European
Community" and the associated "Proposal for a Decision of the European Parliament
and of the Council adopting a programme of Community action in the field of public
health (2001-2006) [COM (2000) 285 final]

This report outlines how the Commission has implemented the Decision in its first
year, and outlines its strategy for consolidating and strengthening Community action
in this field.

2.

LEGAL FRAMEWORK

2.1.

European Parliament and Council Decision setting up the Network

The European Parliament and Council Decision 2119/98/EC, which entered into
force on 3 January 1999, requires that the Community Network on communicable
diseases should promote co-operation and co-ordination between Member States,
assisted by the Commission, in relation to early warning and control, as well as
epidemiological surveillance.

In addition it

• delegates responsibility for

Commission,
representatives;

assisted

its progressive technical
comprised

committee

implementation to the
of Member States'

by a

• places obligations on the Member States to communicate to the Network relevant

information that would assist in the Community's policy on prevention;

• provides for the Commission to make information available to Member States;

• presents opportunity for co-ordinated action between Member States, and with
in liaison with the

non-Member States and international organisations,
Commission.

2.2.

Commission Decisions

In order to implement the Early Warning and Response System covering the widest
range of infectious diseases, and to set priorities for epidemiological surveillance, the
Commission adopted two Decisions during its first year of managing the Network:

• Decision 2000/57/EC4 on the early warning and response system for

the
prevention and control of communicable diseases which specifies the types of

4 OJ L21, 26.01.2000, p.32.

6

events to be reported, and the procedures for information exchange and reporting
by Member States.

• Decision 2000/96/EC5 which specifies the list of communicable diseases to be
placed progressively under Community surveillance and the criteria for their
selection.

3.

THE COMMUNITY NETWORK

The setting up of the Network yields added value in a number of ways:

– it puts in place a system of continuous, well-structured, reliable and effective
communication at Community level between national communicable disease
surveillance authorities and the European Commission;

– it facilitates the rapid, reliable and commonly agreed identification of cases of
communicable diseases occurring inside the Community, or outside and imported
or likely to be imported;

– it gives the competent authorities the opportunity and the means to consult
together on the preventive measures to be taken and helps them in the co-
ordinated introduction of such measures and the evaluation of their effectiveness;

– it gives the authorities support for analysing and interpreting data and for
from

to stop communicable diseases

developing the necessary measures
spreading.

These objectives are being achieved in the first place by putting into practice the two
main components of the Network – the Early Warning and Response System and a
system of epidemiological surveillance.
the Network provides a
framework for a spectrum of other activities (see also 3.3 - 3.5) that contribute to the
timely exchange of information and response for health protection.

In addition,

Routine exchanges use a variety of communication tools. However, the principle
information exchange within the Network is taking place via the Internet (see Annex
4). The communication link used within the network is the “Health Surveillance
System for Communicable Diseases” (HSSCD) within the “European Public Health
Information Network” (EUPHIN), which is part of the electronic “interchange of
data between administrations” (IDA – Decision N° 1719/1999/EC of the EP and of
the Council of 12 July 1999 on a series of guidelines, including the identification of
projects of common interest, for trans-European networks).

According to Decision 2119/98/EC, Member States should consult each other, in
liaison with the Commission, with a view to co-ordinating their efforts for the
prevention and control of communicable diseases, in particular when they intend to
adopt specific measures for their control. Member States may, if they wish, act
together. These efforts will become more important as the Network develops and as
its activities take on wider international implications.

5 OJ L28, 03.02.2000, p.50.

7

3.1.

The Early Warning and Response System (EWRS)

The EWRS provides the competent public health authorities of the Member States
and the Commission with an efficient and rapid exchange of information on
outbreaks or potential outbreaks of communicable diseases and on preventive
measures (see Annex 2 for the designated contact points).

This system is not intended to, nor does it react to isolated incidents in a Member
State that do not have wider implications.

Decision 2000/57/EC makes it clear that all events which could lead to outbreaks of
Community significance should be reported under the EWRS irrespective of whether
or not a disease-specific network at Community level has been set up. Such events
are defined according to their level of increasing concern, namely:

• Level 1 - Information Exchange

Information collected by recognised sources suggests that an event is likely.

• Level 2 - Potential threat

Information on an event or indicators for such an event point to a potential
health threat.

• Level 3 - Definite threat

An event results in a public health threat.

Depending on the degree of concern, the Commission and Member States agree on
appropriate action that might be taken individually or together.

An average of about three events has been reported per month on outbreaks of
Community significance (TABLE 1).

8

TABLE 1 - Events reported in the Network Early Warning and Response System
July 1999 – May 2000

Disease acquired within the Community
Legionnaire's diseases; follow up of a report by the European Working group for legionnaire’s
disease (EWGLI) (France)
Outbreak of Legionnaire's diseases associated with whirlpools (Belgium)
Case of variant Creutzfeldt-Jakob Disease (France)
Outbreak of listeriosis; follow up of an alert by the EU Rapid Alert System for Food (RASFF)
(France)
Outbreak of Legionnaire's diseases (Spain)
Cluster of fatal meningococcal infection (Italy)
Tick-borne rickettsioses; follow up of press rumours (Italy)
Outbreak of listeriosis (France)
Cases of meningococcal infection (UK)
Cluster of Salmonella typhi murium DT 104 (Spain)
Cluster of Legionnaire's diseases (UK)
Cluster of Legionnaire's diseases (Spain)
Unidentified severe illness occurring in heroin users (UK, Ireland)

Disease acquired outside the Community
Case of suspected viral haemorrhagic fever, confirmed as Yellow fever (Côte D'Ivoire)
Outbreak of Salmonella paratyphi B involving several Member States; (Turkey)
Meningitis due to enterovirus; follow up of RASFF alert (Romania)
Food poisoning (Venezuela)
Cholera (India)
Diphtheria (Eastern Europe)
Malaria; resurgence of malaria in Dominican Republic
Case of Lassa fever; (Ghana)
Case of severe invasive diphtheria (Hungary)
Case of Lassa fever; (Sierra Leone)
Case of Lassa fever; (Nigeria)
Case of tuberculosis (The Gambia)
Cases of meningococcal infection associated with pilgrimage (Saudi Arabia)

The Communicable Diseases Network is set up to detect and control communicable
disease in people regardless of the cause and manner of transmission. Its principal
the disease to other persons; by
aim is to prevent
epidemiological surveillance and investigation of the outbreak to try to identify its
cause; and through investigation of cases of human disease to identify control
measures. It provides the necessary information to take preventive action and is
particularly concerned with a situation which may develop at Community level.

transmission of

further

Therefore, although the main target of the Network and particularly the EWRS
component is not to detect an unsafe product or contaminated food, on occasions a
part of the information could contribute to the identification of food or products as
the source of infection, e.g. a recent outbreak of listeriosis in France or the outbreak
of
legionnaires disease associated with “spa pools”. On these occasions the
information will continue to be transmitted to the EU Rapid Alert System for Food
(RASFF) or the EU Rapid Alert System for Product Safety (RAPEX). Conversely
information from the RASFF or the RAPEX on contaminated food or a defective
product provide the information necessary for the epidemiologist to ascertain the
cause of illness in a Member State which in its absence would have appeared
sporadic or disconnected.

9

For these reasons the various authorities involved in the EWRS, RASFF and the
RAPEX share relevant information. This co-operation at Community level provides a
synergy of action that is necessary to ensure that the health of people in Europe can
be adequately protected.

3.1.1.

Response to early warnings

The EWRS has already proved its worth in both detecting sources of infection giving
rise to outbreaks of disease and in providing for co-operation between Member
States. For example:

• The outbreak of paratyphoid fever affecting tourists returning from a Turkish
holiday resort in 1999 affected more than 300 travellers. An international team
was set up to perform an outbreak investigation. With the assistance of the
Turkish authorities, an epidemiological study with an environmental investigation
identified certain food items as the probable source of the outbreak. The EWRS
ensured the rapid availability of information. The results of the investigation have
been shared with the Turkish authorities to prevent future outbreaks.

• Following a message through the EWRS on an outbreak of Legionnaire's disease
at a trade show in Belgium and an earlier outbreak at a flower show in
Netherlands, an early warning and response meeting was held to review these
outbreaks and the need for future preventive activities. Work in this area is
currently ongoing in order to assess the need for any further Community activity.

• Several messages through the EWRS on viral haemorrhagic fevers in travellers
returning from endemic countries have been transmitted in 1999 and in 2000 from
different Member States. This has allowed rapid exchange of information on the
cases and action to be taken regarding their contacts in the Community.

• Information was transmitted by several Member States through the EWRS on the
recent outbreak of meningococcal meningitis in people returning to Member
States from the annual pilgrimage (Haj) to Saudi Arabia. This raised awareness of
the potential occurrence of cases in pilgrims and their contacts. Information on the
preventive and control measures taken in Member States was also shared through
the EWRS.

3.1.2.

Lessons learned

The responsibility of the designated authorities is to communicate to the Network
information on an event that could be of Community significance. There is therefore
a certain amount of discretion on the part of the authority on the point at which its
responsibilities have to be put into effect. Similarly, the responsible authority may
not have immediately at hand all the information it requires to make an informed
report and could create unnecessary alarm in other Member States if it prematurely
declares an alert.

One of the most difficult problems still to be overcome is determining at which point
the potential outbreak should be notified. When does speculation become a likely
risk? These questions are discussed routinely within the Network Committee and the
annual reports drawn up by the Commission, as required by Decision 2000/57/EC,
will greatly facilitate drawing conclusions based on the lessons learned from

10

particular incidents. This will be the case from 31 March 2001 when Member States’
time provide the Commission with the
competent authorities will for the first
information relevant to establish such reports. A more in-depth analysis will then be
undertaken.

The experience gained so far has also highlighted the fact that, in order to ensure a
well-functioning EWRS, close links must be maintained between the national
authorities competent for the EWRS and the routine surveillance structures in their
Member State.

3.2.

Epidemiological surveillance

The Communicable Disease Network is being developed as a “network of networks”
on specific diseases or groups of diseases.

Since 1992, the Commission has provided support to several communicable disease
the AIDS and
specific surveillance projects (networks)
Communicable Diseases programme, HIV/AIDS,
salmonellosis,
tuberculosis, training programmes for field epidemiology, together with publications
on the subject of surveillance. The programme has also funded specific inventories of
resources for communicable disease surveillance, prevention and control.

in particular, under

legionellosis,

A number of these networks have been and are still supported in their pilot phase
through the Fifth Framework R&D Programme; helping to establish and validate i.a.
diagnostic systems and epidemiological methods. This is reflected by the inclusion of
surveillance in the work programme of the activities linked to infectious diseases in
the Quality of Life programme and the INCO programme.

The existing networks have already proven to be efficient in both detecting sources
of infection giving rise to outbreaks of disease and in providing information for
prevention.

• The concerted action of the surveillance centres involved in the European
Working group for Legionnaire's disease (EWGLI) has demonstrated the
effectiveness of 'pooling' information from several Member States to confirm an
outbreak and source of infection attributable to one place, such as a hotel in one
country. This information is then transmitted to that country allowing for the
introduction of specific control measures to end the 'outbreak' and prevent future
cases.

• 'Enter-net' (previously Salm-net) was able, through surveillance of a few human
cases in each country, to trace the cause of cases of salmonella to food items
originating from a single producer and distributed throughout Europe, again
allowing control measures to be taken by the competent authorities.

• The projects dealing with HIV/AIDS and tuberculosis have contributed
significantly to understanding the epidemiology of
these diseases in the
Community and the sharing of information on the risk factors for contracting them
in different Member States. This has helped the development of Community-wide
prevention strategies.

11

The model for each of the existing disease specific networks is of one co-ordinating
Institute supported by the national institutes in other Member States. New disease
specific networks will be based on the same principle of a central co-ordinating
institute or 'hub'.

Information provided to the Commission from these networks is also used to provide
the necessary synergy of action at EU level by making the information available to
other EU systems related to public health surveillance.

In order to take the epidemiological surveillance system further, activities are
planned comprising five separate components (TABLE 2). These are described
below:

TABLE 2

Components of Epidemiological Surveillance Activity

• Disease specific networks – dedicated to one or several diseases or special

health issues of importance to the Community;

• Routine surveillance network – collating national routinely collected and

available communicable disease surveillance data from Member States;

• Inventories – describing current systems of surveillance, prevention and control;

• Zoonoses – reporting information on human zoonoses data;

• Information sharing - an exchange area via Internet where relevant information

can be shared between national authorities.

12

3.2.1. Disease specific networks

in a comparable way,

Disease specific networks will, through their 'hubs' and national structures, process
incoming data from national surveillance
and analyse,
organisations. Commission Decision 2000/96/EC identifies which
specific
communicable disease networks or ones covering special health issues of
Community importance and common to several agents such as antimicrobial
resistance (i.e. the ability of micro-organisms to become resistant to antibiotics) and
nosocomial infections (i.e. infections acquired in hospitals) should be developed as a
priority.

It is envisaged that the co-ordinating centre (hub) for each disease network will be
responsible for the ongoing systematic collection,
interpretation, analysis, and
dissemination of data and information on the diseases under surveillance. These
'hubs' will be identified mainly from national surveillance centres responsible for the
collection and analysis of
level and nominated for
this data at national
epidemiological surveillance by the Member States (Annex 3 lists national
surveillance structures nominated and notified by Member States). In most cases, the
national surveillance structures also have responsibility for investigating outbreaks
and for providing national expertise on control and prevention of communicable
diseases.

So as to ensure reliable and comparable data, the networks, and in particular the co-
ordinating hubs, must meet certain minimum standards,
specific
epidemiological competence and experience, timeliness in reporting and accuracy in
analysing of data etc.. The Commission, in co-operation with the Member States
representatives in the Network Committee, is currently developing a series of such
standards.

such as

To ensure comparability of data,
it would be desirable if standard operating
procedures could be developed in the area of surveillance. Decision 2119/98/EC
requires for each disease-specific network:

• case definitions,

• determination of the nature and type of data and information to be collected and

transmitted

• epidemiological and microbiological surveillance methods.

These case definitions and surveillance methods have to be developed having regard
to those used for the purpose of collecting data at national level to ensure that
surveillance is performed in the most cost-effective way and with specific emphasis
on the Community added value of the information.

In addition, areas where further research or validation of methods is needed, will be
identified.

Surveillance network projects currently funded by the Commission in the
Community Network are listed in TABLE 3.

13

Disease specific networks

TABLE 3

Area covered

Acronym

Operating hub

Operational:

Legionellosis

Salmonellosis,
infection with E. coli
O157

EWGLI

Enter-net

PHLS, Communicable Disease Surveillance Centre
(CDSC), London

PHLS, Communicable Disease Surveillance Centre
(CDSC), London

Tuberculosis

EuroTB

Institut de la Veille Sanitaire (InVS), Paris

HIV/AIDS

Influenza

Euro HIV

Institut de la Veille Sanitaire (InVS), Paris

EISS

Nederlands instituut onderzoek van de gezondheidszorg
(NIVEL)

haemorrhagic

ENIVD

Robert Koch Institut (RKI), Berlin

Viral
fevers

Antimicrobial
resistance

Nosocomial
infections

Pilot phase:

Hepatitis C

EARSS

Rijksinstituut voor Volksgezondheid en Milieu (RIVM)

Helics

Université Claude Bernard – Lyon I

Smittskyddsinstitutet (SMI), Stockholm

Campylobacteriosis

Robert Koch Institut (RKI), Berlin

Meningococcal
disease

Measles, pertussis,

Infection with H.
influenzae

Brucellosis, rabies

Basic
network

surveillance

PHLS, Communicable Disease Surveillance Centre
(CDSC), London

Statens Seruminstitut
Superiore di Sanità, Rome

(SSI), Copenhagen /

Istituto

National Centre for Surveillance and Intervention, Athens

Smittskyddsinstitutet (SMI), Stockholm

Disease specific networks will identify events that require a response either through
the EWRS, if it meets the required criteria, or less rapidly through other means of
epidemiological surveillance in the Network. The challenge for the Network,
therefore, is to react quickly and effectively for rapid events and to improve public
health over a longer term by using information from epidemiological surveillance at
a European level complemented by news and reports from many sources outside the
Community, for example through information exchange with third countries or the
World Health Organization.

14

Seventeen of the 41 diseases and special health areas defined in Annex 1 of
Commission Decision 2000/96/EC now have specific surveillance networks in place
or starting in 2000 as either performing networks or feasibility studies (see Table 3).

The existing surveillance networks remain a priority for funding in 2001 and future
years within the Community Network. Those which are feasibility studies are also a
priority but the definition of a future surveillance network structure and operation
will depend on the results of these studies which are awaited through 2000 and early
2001.

The setting up of new disease specific networks, pilot networks or feasibility projects
for future networks is one of the major priorities for the Community Network for
2001 and beyond (see Table 4). These include diseases which are priorities for
disease specific networks and other diseases for which both routinely collected
information and information on significant outbreaks is required at a Community
level but which may be considered not cost-effective or a priority for individual
separate disease specific network. Information on these diseases can be collected in
the future through the routine surveillance network or as an addition to other disease
specific networks.

Table 4 – Priorities for 2001 and beyond

Priority disease/ special area for disease specific networks
Listeriosis
TSEs variant CJD
Cryptosporidiosis
Malaria
Pneumococcal Dis
Hepatitis B
Polio
Rubella
Diphtheria
Mumps
Gonococcal Disease
Syphillis
Chlamydial disease

Required information on these diseases may be part of a routine surveillance network or
other networks:
Botulism
Hepatitis A
Shigellosis
Leptospirosis
Cholera
Plague
Giardiasis

Required under the Zoonoses Directive and may be part of a routine surveillance
network or other networks:
Echinococcosis
Yersiniosis
Trichinosis
Toxoplasmosis

15

The speed with which these priorities can be achieved is dependent on both the
available resources at a Community level to support technically these networks and
the ability of Member States to build the capacity to undertake progressive
Community surveillance that requires additional national resources.

3.2.2.

Routine surveillance network

As has been shown by the "Inventory of the Means of Controlling Communicable
Diseases in the European Union, Norway and Switzerland" by the ISS (Istituto
Superiore di Sanità, Italy), several important communicable diseases are already
under some form of national surveillance in some or all Member States. However,
the surveillance methods may vary with respect
to case definitions and other
epidemiological and microbiological methods used. As some Member States do not
collect information on the same list of communicable diseases nor use the same
surveillance methods, in the presentation of the data this needs to be carefully
interpreted and explicitly stated. Nevertheless, a comparison of data compiled from
these existing sources would be of value at the Community level for prevention and
control of communicable diseases where a dedicated disease specific network does
not yet exist or may not be justified on the grounds of cost-effectiveness.

The Commission has already funded a pilot project for the development of a network
which could collate available and routinely collected surveillance data. The results of
this project should be available at the end of 2001.

3.2.3.

Inventories

Reliable information is also needed on current systems of communicable disease
surveillance and control in the Member States. The Commission is supporting a number
of projects of this kind (TABLE 5).

TABLE 5
Inventories for the Community Network

•

•

•

•

•

Inventory on resources for communicable diseases in Europe including applicant
countries.

EUVAX, Scientific and technical evaluation of vaccination programmes in the
European Union.

Resources for communicable diseases related to tourism and travel.

Arrangements for dealing with zoonoses.

Scientific evaluation of
emergency involving more than one Member State.

the arrangements for managing an epidemiological

For such inventories, regular updating is important if they are to be used as sources
of information for the Network and other organisations. This is a priority for 2001
and arrangements will be made by the Commission to ensure updating of these
inventories and their link to the EUPHIN-HSSCD Internet
interface for both
professional and public access to this information. Resources will be provided
through the new Public Health Programme.

16

3.2.4.

Zoonoses

At present the Commission, in accordance with Directive 92/117/EEC6 compiles a
report on trends and sources of eleven zoonotic agents in animals, animal feedstuffs,
food and humans based on annual data obtained from Member States. The data
supplied on human zoonoses from Member States are those collected by national
surveillance. Within the Community Network under Decision 2119/98/EC,
surveillance of human cases of zoonoses is a large and important area and already
there are networks in place that collect national information on salmonellosis and
verocytotoxic E.coli
supported for 2000 on
campylobacter, brucellosis and rabies. Bovine tuberculosis could be incorporated
into the existing network on human Tuberculosis. For the remaining human diseases
caused by listeria, echinococcus, trichinella, yersinia and toxoplasma, it is envisaged
that either a disease specific network will progressively be put in place for this
purpose for some, or in others the information will be collected within the routine
surveillance network. This will provide the substantial part of the information on
human cases in the annual zoonosis report. The ongoing redrafting of Directive
92/117/EC is in line with this approach to avoid unnecessary duplication of work in
Member States and the Commission.

and feasibility projects

are

3.2.5.

Information sharing

is also important

The Commission believes it
to encourage contacts between
authorities in a timely way. Therefore, a special information exchange service via the
Internet is to be installed for the sharing between authorities/structures and the
Commission of relevant
information. This applies especially to epidemiological
information concerning diseases on the priority list where specific networks have not
yet been put in place but also to any relevant information, for the Community,
concerning other communicable diseases including information on unusual epidemic
phenomena and new (communicable) diseases of unknown origin.

3.3.

Making information available to the public

Transparency leads to public acceptance, and this is essential to the endorsement of
the Network by the public. Data on routine surveillance and information on
outbreaks and responses needs to be disseminated in different ways depending on the
underlying cases and the audience, be it policy makers, professionals or the public.
Some data will be restricted to European experts and public health authorities. Other
data will be accessible to the public. However, at all times personal medical data
must be protected.

The e-Europe Action Plan, endorsed at the EU-Summit in June, foresees as a priority
action for public health that, via digital technology across Europe, the public has
access to key health data. A precise measure to complement this action will be the
setting up of a specific information network for citizens on communicable diseases
into which the publicly accessible data from the Network for the epidemiological
surveillance and control of communicable diseases will be fed. Some parts of the

6 OJ L62, 15.03.1993, p.38.

17

Health Surveillance System for Communicable Diseases (HSSCD) are already
publicly accessible7

In addition, the Commission is expecting, with the help of Member States, to build
on its existing initiatives in this area such as 'Eurosurveillance' and 'Eurosurveillance
the
Weekly', which are co-ordinated by national
monthly publication that has been running for several years, and 'Eurosurveillance
weekly', the electronic version8, currently provide fairly rapid information on current
communicable disease issues in the Community to those in the field and in policy
areas. Their continued funding for potential integration into the Network is being
addressed, and their
relation to the various network components and to the
Commission will be strengthened.

'Eurosurveillance',

institutes.

3.4.

Incident Investigation Team

Although the Community, Member States and European Institutions already play a
significant role in global outbreak investigations by sending expert teams, their role
could be enhanced through the Community Network. A pilot project on promoting
the co-operation of epidemiological experts in Member States within a world wide
effort to assess and manage major infectious diseases threats on the spot is being
funded by the Commission. The pilot project will take into account the experience
gained through previous investigations in putting European investigating teams
together for missions outside the Community and will examine the feasibility of
setting up an investigation force in certain outbreaks especially when the affected
States request specialist, technical and medical assistance. Such a force could also
provide assistance to outbreaks of serious disease in countries within the
Community.

The goal of this project is to improve co-ordination between Member States in
responding effectively to calls for assistance. This is particularly relevant at this time
as WHO is proposing the creation of a global strategy for response to outbreaks.

Thus the question of financing of such teams needs to be addressed. A common
format for financing needs to be established. Member States could bear the expenses
for their experts whilst the Commission covers the costs for co-ordinated action. This
joint action will demonstrate European added value in a cost-effective way.

3.5.

Training in communicable disease epidemiology

Epidemiology training has been provided by various academic institutions
throughout Europe but the standard varies considerably and few training programmes
have focused mainly on infectious diseases and interventions. There is a particular
need in the European Union for a continuous vocational programme
in
communicable disease epidemiology including field investigations.

7 HSSCD : http://hsscd.euphin.org/.
8

'Eurosurveillance'
http://www.eurosurv.org .

(monthly publ.): http://www.ceses.org/eurosurv – 'Eurosurveillance'

(weekly publ.):

18

The Commission has subsidised, since 1994, a programme for epidemiological
training with the aims of strengthening the surveillance and control of communicable
diseases [European Programme for Intervention Epidemiology Training (EPIET)].

This programme has been acclaimed by the Member States, and it now needs to be
put on a sustainable basis.

4.

THIRD COUNTRIES AND INTERNATIONAL ORGANISATIONS

Communicable diseases do not respect frontiers, and cases of serious disease have been
imported from other parts of the world, as stated earlier. Furthermore, tuberculosis,
syphilis, viral hepatitis and diphtheria have re-appeared in regions bordering the Union.
The emergence of drug resistant forms of communicable diseases also poses a
significant threat to public health.

In this context, Article 152 (3) of the EC Treaty requires that the Community and the
Member States foster co-operation with third countries and the competent
international organisations in the sphere of public health. This has already been taken
up by the European Parliament and Council Decision (2119/98/EC) which requires the
Commission to foster co-operation in this sense with international organisations (e.g.
WHO) and third countries. In this way the Community will be prepared for disease
outbreaks occurring beyond its frontiers and will be able to assist other countries in their
endeavours to control an outbreak of disease with implications for the Community.

The Commission priority, with its existing resources, is to assist applicant countries in
their efforts to implement the Network as part of the process to approximate to the
Community “acquis”.

The Commission also recognises that it must contribute as well to wider efforts towards
the global control ofcommunicable diseases within the limit of its available resources
and expertise on communicable diseases, and any relevant data protection legislation.

A significant contribution to facilitate co-operation in surveillance and enable third
countries to co-operate with EU networks is coming from projects funded by INCO (5th
R&D Framework Programme) such as those on malaria and tuberculosis drug
resistance, Lassa and other haemorrhage fevers and diphteria in Eastern Europe. Further
activities are now to be funded in the Mediterranean area,
in line with the
recommendations of the Montpellier Conference.

4.1.

Applicant countries

With regard to the applicant countries, the Commission is monitoring their progress
in developing the institutional basis for the implementation of the Community
Network Decisions as part of the “acquis”. The following steps a²re being taken:
• Extending invitations to representatives of the applicant countries to preparatory

meetings of the Network Committee and its working groups;

• Requesting

applicant

participating
structures / authorities who would in due course participate in the Network
according to Article 9 of Decision 2119/98/EC;

nominate

countries

the

to

• Proposing that applicant countries join the Early Warning and Response System,
as soon as the necessary legal requirements for their participation have been
fulfilled; and

19

• Encouraging applicant countries to use the funding opportunities resulting from
joining disease specific
their participation in Community programmes for
surveillance networks. To date, an increase in applications for participation in
individual disease-specific networks has been made by applicant countries.

4.2.

European Economic Area / European Free Trade Association (EEA-EFTA)
countries

The EEA-EFTA countries (Iceland, Liechtenstein, Norway) already take part in the
activities of some of the existing projects and activities of the Community Network.
The formal extension of the Network Decision to these countries is a priority for the
development of the Network and will lead to their more active participation.

4.3.

Euro-Mediterranean and Northern Dimension countries

International co-operation is being fostered through the Community's commitment to
work with the Euro- Mediterranean (EUROMED) initiative9 and to this end a
Declaration was adopted at
the Euro-Mediterranean Ministerial Conference on
Health in Montpellier, 3 December 1999 (see Table 6).

TABLE 6
Extract from the Declaration of the
Euro-Mediterranean Ministerial Conference on Health
MONTPELLIER, 3 December 1999 :

“The setting up of a European Community Network for the surveillance and control of
communicable diseases represents an opportunity for further developing co-operation among
Partners, where possible. The Conference suggests that, in the course of establishing this
European Community Network, the possibilities of co-operation with Mediterranean Partners
will be examined, particularly with regard to data collection methods, the use of common or
compatible case definitions and exchange of information. The Partners will take the necessary
steps to promote this co-operation.”

Co-operation with countries on the Community's northern borders is also being
encouraged with the 'Northern Dimension' countries (Estonia, Iceland, Latvia,
Lithuania, Norway, Poland, and the Russian Federation) (Figure 1). The Commission
Action Plan for the Northern Dimension in the external and cross-border policies of
the European Union 2000-2003 foresees close co-operation with the Network in view
of the combat of communicable diseases (see Table 7).

9 Partners participating in the Euro-Mediterranean initiative : the Council of the European Union, the European
Commission, EU-Member States, Algeria, Cyprus, Egypt, Israel, Jordan, Lebanon, Malta, Morocco, Syria,
Tunisia, Turkey, Palestinian Authority.

20

TABLE 7

Extract from the Action Plan for the Northern Dimension in the external and
cross-border policies of the European Union 2000-2003, adopted by the
Commission :

“Activities relating to surveillance and the control of communicable diseases should be
implemented in close co-operation with the Community Network for Epidemiological
surveillance, Control of communicable diseases, with the EU-US Task Force on
Communicable Diseases, as well as the task force set up by the Baltic Sea States Summit
in Kolding to elaborate a joint plan to enhance disease control in the region.”

21

Fig. 1:

The Community Network on Communicable Diseases:

Co-operation with third countries

European Union
EFTA-EEA Countries
EFTA Country
Accession Countries
USA (EU-US Task Force on Communicable Diseases)
Mediterranean Partner Countries
Northern Dimension Partner Countries

22

4.4.

European Union – North America

4.4.1.

EU – United States Task Force (EU-US Task Force)

Co-operation with the United States towards the setting up of a global early warning
surveillance and response system has already begun. This is taking place within the
framework of the EU-US task force on communicable diseases. It is taking place in the
light of the conclusions of the Health Council of 12 November 1998. These state that
the activities of the Task Force should be focused on the scope of activities
conducted in the framework of the Community Network for the epidemiological
surveillance and control of communicable diseases. The Commission is therefore
reflecting on how to integrate the EU side of the Task Force into the Community
Network.

The EU side has recently informed the US about the need for a revision of the
mandate and structure of the Task Force and is awaiting reaction from US side.

4.4.2.

EU – Canada

In the framework of the EU-Canada Action Plan and on the basis of the scientific and
technical co-operation agreement between the EU and Canada, the Commission has
launched a multi annual project to encourage EU-Canada collaboration in the field of
research and development in health telematics, and is working in other areas of
mutual interest.

4.5.

Communicable diseases in developing countries

Within developing countries a limited number of communicable diseases contribute
disproportionately to the continued high levels of ill health of the population and
continue to hold back national development efforts. In these countries, the strategy of
confronting major communicable diseases must be clearly linked with the efforts for
reducing poverty. HIV/AIDS, Malaria and Tuberculosis together contribute a major
proportion of the disease burden of poverty across the globe. In this domain,
innovative and additional initiatives are being taken by the Commission in the
context of the Community development policy.

4.6.

World Health Organization

The WHO has identified communicable diseases as a priority issue. It has a crucial
role to play in developing the capacity of its members, in particular the 51 countries
of the European region, to deal with communicable diseases. Its contributions will be
particularly helpful in the framework of the accession process of the Central and
Eastern European Countries.

Mutual exchange of information already exists with WHO regarding outbreaks of
implications. The WHO
communicable diseases that may have international
Outbreak Verification List, compiled by its outbreak team on the basis of reports
received from a multitude of sources, is sent to the Network, and reciprocally
relevant
information from Network sources is fed to the WHO services. The
Commission endorses the efforts by WHO to create a global strategy to detect
outbreaks of disease and to set out the structure for an international response to such
outbreaks.

23

Case definitions used in the Community Network will be co-ordinated with WHO in
order to ensure that there is no duplication of effort made by the Member States
under the different reporting systems, and to ensure that through compatible data
more effective and responsible prevention strategies will result.

The Commission and Member States will need to ensure that the future International
Health Regulations being developed by WHO are compatible with the Community
Network requirements, and their application will be carefully monitored, given the
close links of this Regulation with issues covered by the World Trade Organisation
(WTO).

WHO will be invited to strengthen its participation in all the mentioned existing
activities related to the Community Network.

5.

RESOURCES FOR THE NETWORK

5.1.

Financing the Network

The Communicable Disease Network is now a permanent part of the “acquis”. Its
future viability depends on the availability of adequate funding, both from the
Member States and at Community level. The latter is being addressed, inter alia,
within the framework of the new public health programme [COM (2000) 285 final].
In addition, important research projects are underway under the 5th Framework
Programme of Research and other sources of Community funding are available for
specific projects (e.g. IDA, MEDA).

The financial commitment of the Member States will also be considerable since costs
associated with the routine national network operations will have to be sustained.

5.2.

Making the Network work

It has already been shown that the preferred structure is a “network of networks”
with central “hubs” for each disease or group of diseases. Each “hub” collects,
collates and transmits information on epidemiological surveillance for each of the
topics provided by link Institutes in other Member States. They provide the
Community with ready access to all the up to date information needed to contribute
to prevention. This structure of networks harnesses the specific knowledge and
expertise that already exist at national level and is the optimal way to operate the
Network economically and in a technically sound way. The additional resources
needed in the current structure are less then would be required otherwise, and
encourage synergy of action both within departments of an Institute, and between
Institutes. The Commission also benefits in that it can immediately locate the most
likely source of authoritative advice. This has proved invaluable in its attempt to
propose actions for example relating to Legionella in spas in fairs, and in dealing
with technical or medical questions on specific diseases which require specialist
knowledge.

The Decision requires that the Commission manages and co-ordinates the activities
of the Network (including the disease specific Networks set up in this framework).
the politically sensitive EWRS and
This obligation involves management of

24

technical co-ordination of the epidemiological surveillance components. This latter
includes:

• medical assessment of data/information transmitted to the Commission;

• monitoring the new medical information on emerging and re-emerging diseases,
within and outside the European Community,
in collaboration with Member
States surveillance institutes in order to identify new areas for routine surveillance
and to keep abreast of developments on control measures and prevention
strategies employed by Member States and third countries;

• scientific assessment of the effectiveness (quality control) of disease specific

networks and surveillance structures;

• ensuring the provision of telematics expertise in order to manage the databases

needed for the Network;

• up dating of interconnected databases.

The Commission is providing the necessary resources for these functions and is of
the opinion that these important tasks should continue, and expand in an appropriate
structure under its authority.

6.

CONCLUSIONS

The Community Network for the epidemiological surveillance and control of
communicable diseases, established by the European Parliament and Council
Decision 2119/98/EC, has completed its first year of operation. It has been shown to
contribute effectively to health protection in the Community.

systems on communicable disease

legionellosis,
Several
salmonellosis,
tuberculosis) are already functioning in the Community. The
progressive expansion of comparable systems to other priority communicable
diseases is now underway.

surveillance

(e.g.

The Early Warning and Response System (EWRS) has been established and is now
capable of addressing disease outbreaks from whatever source, although its relative
immaturity means that its development requires nurturing.

The Commission has also identified the need for a rapid response capacity at
Community level to assist in outbreaks of disease within and without the frontiers of
the European Community.

The next period will see the Community Network’s extension on the international
stage through EU co-operation with applicant countries, the Mediterranean partner
countries, under the Northern Dimension, and through the EU/US Task Force.

The future development and sustainability of the Network require a substantial
resource commitment from the Commission and Member States in order that the
momentum is not lost.

25

An indicative list of actions and their priority is given in Table 8 :

Table 8:
Indicative list of actions:
(Level of priority: S (short term), M (medium term) and L (long term) perspective)

Early warning and response
-

Evaluation of the Health Surveillance System for Communicable Diseases (EUPHIN-HSSCD)

-

-

-

-

In depth analysis of the EWRS based on the annual reports by the Member States’ competent
authorities

Exploring possibilities for expanding the Early Warning and Response System to non-
communicable disease threats

Assessment of possibilities for setting up European incident investigation teams

Continuation of epidemiological training schemes.

Epidemiological surveillance
-

Establishment of case definitions, criteria for nature and type of data and information to be
collected and transmitted, and epidemiological and microbiological surveillance methods for
further disease specific networks

-

-

-

-

Setting up a routine surveillance network with surveillance data currently available from
national surveillance

Developing further inventories describing current systems of surveillance

Implementation of zoonoses surveillance under the Network

Creation of an exchange area within EUPHIN-HSSCD where relevant information could be
shared

Information and publicity

–

–

–

Restricted surveillance data bases will be displayed within the HSSCD for the various disease
specific networks mainly for the use of staff responsible for running those networks;

Communicable disease information on surveillance and prevention will be displayed for public
information on HSSCD;

Surveillance data, outbreaks, and other epidemiological information will be presented
frequently electronically and in publications and press releases.

Third countries and international organisations
-

Guidance to applicant countries to their efforts to implement the Network Decision as part of
the Community acquis

Extension of the Network Decision to the European Economic Area and the European Free
Trade Association

Promotion of co-operation with partners of the Euro-Mediterranean initiative

Fostering co-operation with countries participating in the “Northern Dimension” activities

S,M,L

S,M,L

M

S

S,M,L

S,M,L

S,M

S,M,L

S,M

S

S,M,L

S,M,L

S,M,L

S

S

M,L

M,L

S,M

Further development of the co-operation with the US in the framework of the EU-US task force
on communicable diseases

S,M,L

Enhancing co-operation with international organisations, in particular WHO

26

-

-

-

-

-

Annex 1

List of Acronyms

EEA

EFTA

European Economic Area

European Free Trade Association

ENTER-NET International surveillance network for

the enteric infections –

Salmonella and VTEC 0157 (Previously Salm-net for Salmonellosis)

EPIET

European Programme for Intervention Epidemiology Training

EUPHIN-
HSSCD

European Public Health Information Network - Health surveillance
system for communicable diseases

EUROMED

Initiative for co-operation by the European Union and countries
bordering the Mediterranean Sea

EWGLI

European Working Group for Legionnaire's Disease

IDA

Interchange of data between administrations

RAPEX

Rapid Alert System for Product Safety

RASFF

Rapid Alert System for Food

VTEC

Verocytotoxic E. Coli

WHO

WTO

World Health Organization

World Trade Organisation

xxvii

Designated authorities of the EWRS of the Network for the epidemiological surveillance and control of communicable
diseases in the Community:

Annex 2

Belgie / Belgique

Ministère de la Communauté française
Direction Générale de la Santé

Vlaamse Gemeenschap
Administratie Gezondheidszorg

Commission communautaire commune
Service de la Santé et de l’Aide aux personnes

Institut Scientifique de la Santé Publique – Louis Pasteur

Danmark

Statens Serum Institut

Sundhedsstyrelsen
(National Board of Health)

Deutschland

Robert Koch-Institut

España

France

Greece

Ireland

Italia

Luxembourg

Nederland

Österreich

Portugal

Centro Nacional de Epidemiología del Instituto de Salud Carlos III

Ministère de l’Emploi et de la Solidarité
Direction Générale de la Santé
Bureau des maladies transmissibles

Institut de la Veille Sanitaire
Département des maladies infectieuses

Ministry of Health and Welfare

Department of Health and Children
National Disease Surveillance Centre

Ministero della Sanità
Dipartimento della Prevenzione

Direction de la Santé
Division de l’Inspection Sanitaire

Ministerie van Volksgezondheid
Inspectie voor de Gezondheidszorg

Rijksinstituut voor Volksgezondheid en Milieu (RIVM)
Centrum voor infectieziekten

Bundesministerium für Arbeit, Gesundheit und Soziales (BMAGS)
Direcção-Geral da Saúde

Instituto Nacional de Saúde

Suomi/Finland

Ministry of Social Affairs and Health
Department for Promotion and Prevention

Kansanterveyslaitos (KTL)
(National Public Health Institute)

Sverige

Socialstyrelsen
(National Board of Health and Welfare)

United Kingdom

The Department of Health
Communicable Disease Branch

European
Community

European Commission
Health and Consumer protection DG
Public Health Directorate
Communicable, rare and emerging diseases Unit

xxviii

Annex 3

Designated epidemiological surveillance structures within the Network for the
epidemiological surveillance and control of communicable diseases in the Community

Belgie / Belgique

Institut Scientifique de la Santé Publique – Louis Pasteur

Danmark

Statens Serum Institut

Deutschland

Robert Koch-Institut

España

France

Greece

Ireland

Italia

Centro Nacional de Epidemiología del Instituto de Salud Carlos III

Institut de la Veille Sanitaire
Unité des maladies infectieuses

National Centre for Epidemiological Surveillance and Intervention

National Disease Surveillance Unit

Istituto Superiore di Sanità (ISS)

Luxembourg

Direction de la Santé, Division de l’Inspection Sanitaire

Nederland

Inspectie voor de Gezondheidszorg

Osterreich

Portugal

Sverige

Rijksinstituut voor Volksgezondheid en Milieu (RIVM)
Centrum voor infectieziekten

Bundesministerium für Arbeit, Gesundheit und Soziales
(BMAGS)

Instituto Nacional de Saúde

Smittskyddsinstitutet
(Swedish Institute for Infectious Disease Control)

Suomi / Finland

Kansanterveyslaitos (KTL)
(National Public Health Institute)

United Kingdom

European
Community

Public Health Laboratory Service
Communicable Disease Surveillance Centre
European Commission
Health and Consumer protection DG
Public Health Directorate
Communicable, rare and emerging diseases Unit

xxix

Annex 4

Communications link for the Network

The principal communication link used within the Network is the “Health Surveillance
System for Communicable Diseases” (HSSCD) which forms part of the “European Public
Health Information Network” (EUPHIN). EUPHIN is designed to be a system for sharing,
exchanging and disseminating information on public health within the Community. The
system is an integral part of the electronic “interchange of data between administrations”
(IDA – Decision N° 1719/1999/EC of the EP and of the Council of 12 July 1999 on a series
of guidelines, including the identification of projects of common interest, for trans-European
networks which are operated via the Internet).

The HSSCD allows sharing and exchange of information on early warning and response and
the surveillance of communicable diseases. It currently provides a general purpose telematic
services including electronic mail, posting articles for access by discussion groups, search
capacity, and downloading of documents from other hosts on the network. Some HSSCD
databases are restricted to European experts and public health authorities (e.g. if they contain
personal medical data); others will continue to be accessible to the public.

EUPHIN has the capacity to cover various areas of health related data. At present, the Health
Indicators Exchange Monitoring System (HIEMS)
is already included. EUPHIN will
gradually be expanded to cover injury data, rare diseases, blood, organs and data in other
fields.

xxx