Report from the Commission to the Council and the European Parliament - Report on the operation of the early warning and response system of the Community Network for the epidemiological surveillance and control of communicable diseases (Decision 2000/57/EC) during 2002 and 2003 {SEC(2005)394}
Date: 2005-03-29
Institutions: European Commission
Subjects: disease prevention, epidemiology, health control, infectious disease, information network, public health

COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 29.3.2005 
COM(2005) 104 final 

REPORT FROM THE COMMISSION TO THE COUNCIL 
AND THE EUROPEAN PARLIAMENT 

REPORT ON THE OPERATION OF THE EARLY WARNING AND RESPONSE 
SYSTEM OF THE COMMUNITY NETWORK FOR THE EPIDEMIOLOGICAL 
SURVEILLANCE AND CONTROL OF COMMUNICABLE DISEASES (DECISION 
2000/57/EC) DURING 2002 AND 2003 

{SEC(2005)394} 

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TABLE OF CONTENTS 

1. 

2. 

3. 

3.1. 

3.2. 

3.3. 

4. 

4.1. 

4.2. 

4.3. 

5. 

6. 

6.1. 

6.2. 

Terms of reference ....................................................................................................... 3 

Legal basis of the EWRS ............................................................................................. 3 

Report on the operation of EWRS in 2002 .................................................................. 3 

Events notified ............................................................................................................. 3 

Response to early warnings.......................................................................................... 4 

Updates and deactivation of the system ....................................................................... 4 

Report on the operation of EWRS in 2003 .................................................................. 4 

Events notified ............................................................................................................. 4 

Response to early warnings.......................................................................................... 5 

Updates and deactivation of the system ....................................................................... 5 

Protection of personal data........................................................................................... 5 

Conclusions .................................................................................................................. 7 

General comments........................................................................................................ 7 

Lessons learned in the SARS event ............................................................................. 9 

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1. 

TERMS OF REFERENCE 

Decision 2000/57/EC1, on the Early Warning and Response System (EWRS) for the 
prevention  and  control  of  communicable  diseases,  states  that  the  Competent 
Authorities  in  Member  States  shall  submit  yearly,  not  later  than  31  March,  an 
analytical report of the events and procedures applied within the early warning and 
response system (Article 3.1). It states also that the Commission shall, on the basis of 
the  reports,  examine  in  an  annual  report  the  operation  of  the  Early  Warning  and 
Response System and if necessary propose changes thereto (Article 3.2).  

The  Annual  Reports  from  the  member  states  and  the  preparation  of  the  related 
Commission report 2002 were delayed due to the work overload caused by the SARS 
event which developed abruptly starting on mid March 2003. Priority activities in the 
responsible  Commission  service,  related  to  the  event  and  to  the  preparation  to  a 
possible  new  outbreak,  lasted  until  late  summer  2003.  This  document  of  the 
Commission  reports  on  the  operation  of  EWRS  during  2002  and  2003.  It  draws 
conclusions from the reports submitted by the Member States and experiences with 
the operation of EWRS during the period in question. 

This  report  is  supported  by  a  Commission  Staff  Working  Paper  (CSWP)  providing 
more detailed technical information on the events communicated to EWRS. 

2. 

LEGAL BASIS OF THE EWRS 

The European Parliament and Council Decision 2119/98/EC2 has established EWRS 
as  a  function  of  the  Community  Network  for  the  epidemiological  surveillance  and 
control  of  communicable  diseases.  Decision  2000/57/EC  states  that  the  EWRS  is 
reserved to events endowed with Community relevance, as specified in its Annex I, 
and establishes the EWRS operational procedures. 

3. 

REPORT ON THE OPERATION OF EWRS IN 2002 

The information on the operation of EWRS during the year 2002, as provided by the 
Member States, can be summarised as follows. 

3.1. 

Events notified 

The  events  notified  to  EWRS  during  2002  number  fifty-two.  They  include  all  the 
messages delivered by means of the information exchange application present in the 
web  site  of  the  Health  Surveillance  System  on  Communicable  Diseases  (HSSCD) 
excluding test and service messages. 

An analysis of the 52 event notifications indicated that 41, i.e. 79% of the events, 
were notified with messages sent as plain information, while 10 (19%) of the events 
were  reported  in  the  “information  exchange”  level  actually  activating  an  Early 
Warning  (activation  level  1).  One  event  (2%)  was  notified  as  an  Early  Warning  at 

1 
2 

OJ L21, 26.10.2000, p.32 
OJ L268, 03.10.1998, p.1 

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activation level 2 and none as a level 3. The timeliness of the notification to EWRS 
and the size of the outbreak at the time of notification were noted, if available. About 
60%  (18  outbreaks)  of  the  32  outbreaks  occurring  in  the  EU  Member  States  were 
notified  within  35  days  from  the  outbreak  onset  and  with  an  outbreak  size  of  less 
than 93 cases.  

3.2. 

Response to early warnings 

Information  on  the  actions  undertaken  by  Member  States  after  reception  of  an 
outbreak  notification  was  not  regularly  communicated  to  EWRS.  A  few  Member 
States  authorities  forwarded  the  information  to  the  appropriate  departments  and 
structures  in  their  country,  after  evaluation  of  the  information  received  through 
EWRS. Only in a few cases specific measures were taken, because most outbreaks, 
although with potential Community relevance, were controlled with standard local or 
national  measures.  Three  outbreaks  required  a  more  complex  response,  involving 
contacts  between  health  authorities  of  different  Member  States:  an  outbreak  of 
pericarditis-myocarditis  in  Greece,  outbreaks  of  viral  gastroenteritis  linked  to 
permanence  in  Andorra  and,  finally,  an  outbreak  of  salmonellosis  (S.  cerro)  in 
Belgium (with cases also in France).  

3.3. 

Updates and deactivation of the system 

Updates  on  on-going  outbreaks  were  communicated  rarely.  Only  in  one  event 
(pericarditis-myocarditis in Greece) updates to EWRS were frequent and the last one 
indicated the likely end of the outbreak. This event had drawn much attention from 
the health authorities of other EU Member States. 

4. 

REPORT ON THE OPERATION OF EWRS IN 2003 

The information on the operation of EWRS during the year 2003, as provided by the 
Member States, can be summarised as follows. 

4.1. 

Events notified 

The  events  notified  to  EWRS  during  2003  number  forty-one  (excluding  test  and 
service  messages).  They  include  all  the  messages  delivered  by  means  of  the 
information exchange application present in the web site of the Health Surveillance 
System on Communicable Diseases (HSSCD). 

An analysis of the 41 event notifications indicated that 23, i.e. 56% of the events, 
were notified with messages sent as plain information, while 15 (37%) of the events 
were  reported  in  the  “information  exchange”  level  actually  activating  an  Early 
Warning (activation level 1). Two events (5%) were notified as an Early Warning at 
activation level 2 and one (2%) at activation level 3. Records of the timeliness of the 
notification by Member States to EWRS and the size of the outbreak at the time of 
notification  indicated  that  about  60%  (14  events)  of  the  25  events  occurring  in  the 
EU  were  notified  to  the  EWRS  within  14  days  from  the  onset  of  symptoms  in  the 
index case and in association of outbreak sizes of less than 15 confirmed cases. 

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4.2. 

Response to early warnings 

Information on the actions undertaken by Member States in response to an outbreak 
notification  issued  by  another  Member  State  was  not  always  communicated  to 
EWRS.  According  to  the  information  available,  however,  in  most  notified  events, 
specific control measures were not undertaken by the Member States in response to a 
notification. The Netherlands communicated that all early warnings, except the heat-
related  deaths  in  France,  were  mentioned  in  the  minutes  of  the  weekly  reporting 
meeting  at  the  National  Institute  of  Public  Health  and  the  Environment.  These 
minutes  are  sent  to  most  public  health  services  and  medical  microbiologists  in  the 
Netherlands.  Austria  communicated  that  EWRS-messages  were  delivered  via  the 
“Early Warning Austria” – E-Mail system to the regional public health boards who 
then transmit the messages to the district Public Health officers. EWRS messages are 
simultaneously reported to the reference centres and Ministry of Health departments 
concerned. 

Two  outbreaks  required  a  more  complex  response,  or  stimulated  some  specific 
actions: the SARS event, which represented a major threat to the EU and required a 
coordinated  effort  by  all  Member  States,  and  the  outbreak  of  gastroenteritis  in  a 
cruise ship, which required urgent contacts among health authorities and raised some 
questions beyond its actual public health threat. 

4.3. 

Updates and deactivation of the system 

Messages  to  provide  updated  information  to  the  EWRS  on  on-going  outbreaks, 
including  deactivation  of  the  system,  were  rarely  sent.  The  system,  however,  was 
extensively used for updates on the epidemiological situation and for the exchange of 
information on measures during the SARS event.  

5. 

PROTECTION OF PERSONAL DATA  

Decision  2119/98/EC  establishes  that  Member  States  have  to  provide  a  series  of 
information  of  relevance  to  the  surveillance  and control of communicable diseases, 
including information on their occurrence, the progression of the epidemic situation, 
as  well  as  on  intended  or  adopted  measures  for  the  control  or  prevention  of  these 
diseases. The exchange of data which could be regarded as personal data has never 
occurred  during  the  operation  of  the  EWRS.  However  it  is  a  matter  of  fact  that 
exchange  of  personal  data  among  the  members  of  the  EWRS  may  prove  necessary 
for the implementation of emergency control actions involving coordination among 
Member States. The EWRS should be ready to process personal data in compliance 
with the Community legislation, namely Directive 95/46/EC3, which is addressed to 
the  Member  States,  and  Regulation  45/2001/EC4  which  applies  to  Community 
Institutions and bodies. Such data may include information on personal health status 
as far as these data are necessary for the implementation of effective and coordinated 
public health control actions. 

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4 

OJ L281, 23.11.1995, p. 31 
OJ L8, 12.01.2001, p. 1 

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An analysis of the EWRS structure and function with reference to the requirements 
of the Community legislation, can be summarized as follows: 

(1) 

(2) 

Decision 2119/98/EC provides a basis for allowing the handling of personal 
data  in  the  Community  Network,  which  is  made  up  by  public  health 
authorities identified in the said decision. 

The components of the Community Network for the surveillance and control 
of communicable diseases, are identified as follows: 

(a) 

(b) 

The  controller,  which  is  the  Commission  service  tasked  with  the 
implementation of Decision 2119/98/EC. 

The  owner  of  the  system,  which  is  the  Commission  service  that  is 
mandated with the implementation of Decision 2119/98/EC, and runs 
the  Health  Surveillance  System 
for  Communicable  Diseases 
(HSCCD)  application  for  the  exchange  of  information  in  the  context 
of EWRS. 

(c) 

The processors: 

• 

• 

• 

• 

The  members 
(the 
structures/authorities  designated  by  the  Member  States),  who 
make data available. 

the  Community  Network 

of 

The  Commission  service  tasked  with  the  implementation  of 
Decision 2119/98/EC. 

The  EWRS  and  the  HSSCD  webmasters,  who  implement  the 
access rules and the maintenance of the application. 

The Commission’s Data Centre, which stores the data on behalf 
of 
the 
implementation of Decision 2119/98/EC. 

the  Commission 

tasked  with 

service 

that 

is 

(d) 

The recipients: 

• 

• 

• 

The Commission, 

The  members 
the  Community  Network 
structures/authorities designated by the Member States), 

of 

(the 

Any other person or organization to which such data need to be 
disclosed for the implementation of public health protection and 
disease control measures. 

(3) 

Collection of national surveillance data in the Member States has to comply 
with  the  national  legislation  implementing  Directive  95/46/EC.  This  data 
collection  is  performed  according  to  national  provisions  and  is  not  in  the 
scope of the Decision 2119/98/EC. In the notification to their Data Protection 
Officer,  the  national  authorities  responsible  for  the  collection  of  such  data 
have to indicate that data are transferred to the Community Network pursuant 

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to  Decision  2119/98/EC  by  means  of  an  IT  tool  (HSSCD)  provided  by  the 
Commission. 

(4) 

The  Commission  service  tasked  with  the  implementation  of  Decision 
2119/98/EC has to adopt measures to ensure a level of security appropriate to 
the  processing  of  health  data  (art.  10  of  Regulation  45/2001)  in  the 
Community Network, in compliance with art. 22 Regulation 45/2001. To this 
end,  the  features  of  the  system  have  been  analyzed  with  reference  to  the 
security  requirements  of  Regulation  45/2001/EC,  with  the  findings  that 
organizational and technical security measures can be implemented to: 

• 

• 

• 

improve the control of the access to information; 

enhance the security of some communication procedures of the 
information exchange tool (HSSCD); 

improve  the  handling  of  information  received  through  the 
EWRS. 

To allow the exchange of personal data, when necessary, within the activities of the 
EWRS, the measures that are related to the areas for improvement indicated in item 4 
above have been implemented and a notification to the Data Protection Officer of the 
Commission  made  in  compliance  with  art.  25  of  Regulation  45/2001/EC.  Internal 
rules for the handling of messages in compliance with Regulation 45/2001/EC have 
been prepared and implemented in the Commission Unit charged with the operation 
of EWRS. Moreover, in their quality of recipients of the information provided by the 
Community  system,  the  public  health  authorities  of  the  Member  States  have  to 
document the implementation of guidelines for the handling of information received 
through the EWRS. 

6. 

CONCLUSIONS 

6.1. 

General comments 

Analysis  of  the  content  of  messages  transmitted  through  EWRS  indicates  that 
notifications  are  sometimes  delayed  with  respect  to  the  date  of  onset  of  the  event. 
This  is  because  Member  States  have  to  be  certain  about  the  facts  and  about 
Community relevance before making formal notifications via the EWRS. Analysis of 
the content of messages transmitted through EWRS in 2002 and 2003 indicates that a 
gradual  but  clear  improvement  in  the  notification  process  is  taking  place.  In  2002 
many  notifications  referred  to  events  that  had  already  been  characterised  or  even 
filed.  For  a  number  of  events  notified  in  2003,  the  delay  of  notification  may  be 
related  to  the  time  necessary  for  the  collection  of  sufficient  evidence  to  allow 
meaningful  conclusions  from  the  analysis  of  the  data.  To  improve  timeliness  of 
notifications,  a  check-list  of  criteria  for  the  assessment  of  Community-relevant 
events, in compliance with Annex I of Decision 2000/57/EC, has been introduced in 
2003.  Application  of  the  list  facilitates  a  more  uniform  and  timely  notification  of 
events  to  EWRS.  The  notification  to  EWRS  of  cases  of  SARS,  an  event  which 
dominated EWRS activity during 2003, with clear Community relevance, was very 
rapid. 

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The SARS event represented a significant test for  the usefulness of  EWRS. EWRS 
fulfilled effectively its institutional function, not only with the timely circulation of 
the  alert  among  the  national  authorities,  but  also  by  facilitating  the  exchange  of 
information,  the  provision  of  technical-scientific  advice  and  the  formulation  of 
common  positions  among  the  national  public  health  authorities.  The  consultation 
platform  provided  by  EWRS  was  very  much  appreciated  by  the  authorities  of  the 
Member States and resulted in consistent national decision making for the control of 
the  disease.  A  more  detailed  analysis  of  the  performance  of  the  system  during  this 
event is given below. 

The  SARS  outbreak  also  demonstrated  the  utility  and  flexibility  of  the  new 
mechanism  of  the  Scientific  Support  to  Policies  present  in  the  6th  Framework 
Programme for RTD5. The Extraordinary Council of Health Ministers meeting held 
on  6  May  2003  called  on  the  Commission  to  financially  support  research  and 
development  of  validated  diagnostic  test,  therapeutic  interventions  and  vaccines.  A 
special  call  was  published  on  3rd  July  2003  just  two  months  after  the  Council  of 
Ministers meeting with the aim  of developing an EU capability for strategic use of 
R&D resources against SARS and in the event of similar outbreaks. This call was the 
result of intense discussions among Commission services and relevant experts in this 
field including the SARS Expert Group. Seven research projects were funded with an 
ad  hoc  EU  research  budget,  amounting  to  about  13.6  M€.  Details  of  EU  funded 
projects can be found at: http://www.cordis.lu/lifescihealth/ssp.htm. 

The  messages  on  the  events  notified  in  2002  and  2003  do  not  indicate  which 
criterion,  among  those  indicated  in  Annex  I  of  Decision  2000/57/EC,  had  been 
considered  relevant  by  Member  States  when  reporting.  Indicating  the  relevant 
criterion  for  notification  by  the  notifying  authority  is  important  for  evaluating  the 
relevance  and  functionality  of  the  criteria  as  well  as  their  consistent  application. 
Efforts are being made to ensure that such indications are provided. 

In 2003 the EWRS has been used occasionally by the national health authorities as a 
working  tool  for  the  exchange  of  different  types  of  information,  as  exemplified  by 
messages related to events 12 (poultry influenza in the Netherlands), 28 (West Nile 
virus in France), and 33 (influenza in EU). However, the use of EWRS as a practical 
tool  to  provide  and  receive  information,  with  the  aim  of  improving  awareness  and 
knowledge  about  events  in  a  framework  of  co-operation  among  national  public 
health  authorities,  was  still  not  fully  exploited.  The  reasons  for  this  are  being 
considered with the authorities of the Member States and conclusions will be drawn 
on improvements needed. 

Analytical  annual  reports  of  the  events  and  on  the  EWRS  procedures  applied  and 
additional reports on specific events of particular significance have been provided by 
some  Member  States  in  compliance  with  art.  3  of  Decision  2000/57/EC  but  not  by 
all.  It  is  felt  by  some  that  such  reports  duplicate  initial  notifications  and  reports. 
There is clear preference for additional reporting on specific events only where there 
is added value besides that provided by the initial notification and report. 

This, together with a number of operational improvements that are deemed necessary 
are under active consideration. 

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OJ L294, 29.10.2002, p.1 

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6.2. 

Lessons learned in the SARS event 

During the SARS outbreak the EWRS has proved useful in various ways. 

The  system  provided  a  unique  tool  to  circulate  reliable  information  quickly  to  the 
Commission and to the members of the EWRS. 

Especially during the first phase of the event, the EWRS was able to pick up a very 
early and specific notification on a real and very serious threat. 

The  content  of  messages  circulated  during  the  SARS  outbreak  comes  under  two 
categories: 

•  First,  those  reporting  the  measures  undertaken  by  the  Member  States  to  control 
the  spread  of  SARS  provided  the  most  useful  information  to  co-ordinate  the 
response to SARS at national and at EU level. 

•  Second,  case  and  update  reports  provided  useful  and  additional  information  and 

they were consistent with those published afterwards by the WHO. 

Member  States  found  these  messages  very  helpful  and  requested  that  situation 
reports providing an assessment for decision makers should be made available in the 
future. 

The nature and magnitude of the event caused a very big and rapid flow of messages. 
Starting from the second week of the outbreak, this situation caused an overload of 
the EWRS mailbox and had a negative impact on processing and interpreting data on 
control  activities.  The  problem  was  solved  by  creating  a  specifically  dedicated 
functional  mailbox  for  selected  messages  (e.g.  Case  and  update  report,  official 
communications, call for meetings and consultation teleconferences etc.). Afterwards 
a special operational mode was set up to confine communications and coordination 
activities  during  special  events  which  require  intensive  and  prolonged  information 
exchange. 

Following  these  improvements,  it  is  expected  that  the  EWRS  should  guarantee 
exchange  of  information  among  EWRS  members  in  an  efficient  way  during  future 
global alerts or during an emergency situation. 

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