Report from the Commission to the Council and the European Parliament on the operation of the Early Warning and Response Systems (EWRS) of the Community Network for the epidemiological surveillance and control of communicable diseases during years 2004 and 2005 (Decision 2000/57/EC)
Date: 2007-03-20
Institutions: European Commission
Subjects: disease prevention, epidemiology, health control, infectious disease, information network, public health, report

COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 20.3.2007 
COM(2007) 121 final 

REPORT FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN 
PARLIAMENT 

On the operation of the Early Warning and Response Systems (EWRS) of the 
Community Network for the epidemiological surveillance and control of communicable 
diseases during years 2004 and 2005 (Decision 2000/57/EC) 

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REPORT FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN 
PARLIAMENT 

On the operation of the Early Warning and Response Systems (EWRS) of the 
Community Network for the epidemiological surveillance and control of communicable 
diseases during years 2004 and 2005 (Decision 2000/57/EC) 

(Text with EEA relevance) 

1. 

2. 

2.1. 

2.2. 

2.3. 

2.4. 

3. 

4. 

5. 

6. 

7. 

INTRODUCTION........................................................................................................ 3 

EWRS OPERATIONS................................................................................................. 3 

Events notified in 2004 ................................................................................................ 3 

Response and follow up of the events notified in 2004 ............................................... 4 

Events notified in 2005 ................................................................................................ 5 

Response and follow up of the events notified in 2005 ............................................... 6 

NEW MEMBER STATES........................................................................................... 7 

IMPROVEMENT OF THE INFORMATICS TOOL.................................................. 7 

‘COMMON GROUND’ SIMULATION EXERCISE................................................. 8 

THE EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL ..... 8 

CONCLUSIONS.......................................................................................................... 9 

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1. 

INTRODUCTION 

Decision 2119/98/EC1 has established the Early Warning and Response System (EWRS) as a 
function  of  the  Community  Network  for  the  epidemiological  surveillance  and  control  of 
communicable  diseases.  Decision  2000/57/EC2  states  that  the  EWRS  is  reserved  to  events 
endowed  with  Community  relevance,  as  specified  in  its  Annex  I,  and  establish  the  EWRS 
operational  procedures.  Each  Member  States  designate  the  formal  contact  point  of  the 
structure and/or the authorities referred to the early warning and response function and they 
notify  the  Commission  and  the  other  Member  States  (Art  9,  2119/98/EC).  Following  the 
notification the contact points receive from the Commission a login and a password to access 
the system with a full authorization to write and read the messages3 in the system. 

Article  3.1  of  Decision  2000/57/EC  states  that  the  competent  Authorities  in  Member  States 
shall submit yearly, not later than 31 March, an analytical report of the events notified within 
the early warning and response system. It states also that the Commission shall, on the basis 
of  the  reports,  examine  in  an  annual  report  the  operations  of  the  EWRS  and  if  necessary 
propose changes thereto (Article 3.2). 

This report examines on the operation of EWRS during 2004 and 2005. It draws conclusions 
from the reports submitted by the Member States and from experiences with the operation of 
EWRS during the mentioned period. 

2. 

EWRS OPERATIONS 

2.1. 

Events notified in 2004 

During 2004 a total of 105 events were notified through the EWRS. Test messages circulated 
to check the functioning of the system and service communications have been excluded by the 
analysis. 

Out  of  105  messages,  30  were  information  messages,  32  activation  level  14  messages,  18 
activation  level  2  messages  and  3  activation  level  3  messages;  22  messages  were  related  to 
measures undertaken to respond to specific situations (intended measures, adopted measures 
and  coordination  of  measures).  The  geographical  origin  of  the  events  which  triggered  the 
notification mechanism was as follows: 12 in France, 11 in Viet Nam, 7 in Netherlands, 6 in 
China, 5 in Italy and Germany, 4 in United Kingdom and Spain, 3 in Austria, Belgium and 
Egypt, 2 in Finland, Norway, Thailand and United States, and 1 in Greece, Ireland, Lithuania, 
Sweden, Portugal, Poland, Latvia, Hungary, Iceland, Turkey, Brazil, Morocco, Senegal, Saudi 
Arabia,  Japan,  Israel,  Dominican  Republic,  Canada  and  Indonesia.  Two  messages  were 
related  with  events  occurring  in  more  than  one  country  in  Asia.  Four  were  in  the  ‘unlisted’ 
category of messages, 3 were in the ‘non applicable’ and 2 in the ‘unknown’ one.  

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OJ L268, 03.10.1998, p.1 
OJ L21, 26.01.2000, p.32 
Bulgaria and Romania and European Economic Area countries (Iceland, Lichtenstein and Norway) are 
part of the EWRS network. 
Activation levels are defined in Annex II of Decision 2000/57/EC 

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Concerning the repartition of the events per disease or syndrome 21 were related to influenza, 
8 to legionellosis, 6 to vCJD and salmonellosis, 5 to acute diarrhoea, 4 (4%) to tuberculosis 
and  meningitis,  3  to  cholera,  and  hepatitis,  2  to  anthrax,  encephalitis,  malaria,  rabies, 
haemorrhagic fever, dengue fever, measles and fever, 1 to diphtheria, shigellosis and mumps. 
Twenty  four  were  the  messages  in  the  ‘unlisted’  category  of  diseases  and  2  in  the  ‘not 
applicable’  one.  The  repartition  of  the  messages  per  pathogen  reflects  the  distribution  per 
disease  or  syndrome.  A  total  number  of  157  comments  have  been  posted  to  follow  up  the 
events notified. 

2.2. 

Response and follow up of the events notified in 2004 

Only  few  events  notified  in  2004  prompted  specific  measures  at  Community  level.  Most  of 
them  were  controlled  by  applying  public  health  measures  at  national  level.  Nine  events 
required a more complex response, involving coordination of measures and contacts between 
health authorities in Member States. These events have been followed up adequately and the 
large majority of the comments received through the EWRS were related to them (126 out of 
157 comments, 82,2%). The notified events have been rarely ‘closed’ by an official message.  

The following paragraphs report a brief summary of these 9 events. 

2.2.1.  Two  outbreaks  of  legionellosis  were  communicated  by  Italy  and  Germany.  Both 
outbreaks  were  associated  to  cruise  ships  requiring  urgent  contacts  among  health 
authorities  to  trace  back  all  the  persons  who  have  been  exposed  to  the  source  of 
infection  and  to  alert  the  health  authority  in  the  Member  States  in  order  to  plan 
timely measures in the ports of destination.  

2.2.2.  Six  messages  and  55  comments  (35%  of  the  total  number  of  comments)  were 
circulated following the notification of the first human cases of the highly pathogenic 
avian  influenza  virus  type  A/H5N1  in  Vietnam.  This  event  announced  the  rapidly 
expanding epidemic of avian flu in Asia. The regular circulation of messages through 
the  EWRS  and  the  organisation  of  frequent  teleconferences  in  close  collaboration 
with  WHO  allowed  Member  States  and  the  Commission  to  be  regularly  updated 
about the evolution of the situation and on the measures undertaken at National level 
and strengthened a coordinated response at Community level.  

2.2.3.  Two  events  associated  with  West  Nile  virus  infection  were  notified  by  Ireland  and 
France respectively. The first one was related to an Irish citizen who was infected in 
the Algarve region (Portugal) and it was followed up closely by Ireland and Portugal 
with the coordination of the Commission. The second one reported a number of West 
Nile cases in sentinel animals in Sainte Marie de la Mer (South of France). Both the 
events were promptly communicated through the system and the concerned Member 
States  undertook  measures  to  strengthen  surveillance  and  to  activate  contingency 
plans at national level to minimize the risk of West Nile virus infections in humans 
including its transmission by blood transfusions.  

2.2.4. 

In August France notified an event associated with a rabid dog illegally introduced in 
the EU. The dog bit or had close contacts with several persons, including children, in 
different tourist areas of France. In that occasion the information received by France 
through  the  EWRS  was  of  pivotal  importance  to  inform  in  detail  the  health 
authorities  in  Member  States  in  order  to  undertake  all  the  measures  to  trace  the 
persons who had contacts with the dog and vaccinate them.  

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2.2.5.  An  outbreak  of  hepatitis  A  that  clustered  in  an  Egyptian  resort  was  notified  by 
Germany  in  August.  The  outbreak  involved  274  confirmed  cases  from  7  Member 
States  plus  Switzerland.  This  event  raised  the  issues  of  the  potential  risks  for  EU 
citizen  when  travelling  abroad,  especially  in  tropical  and  subtropical  areas  and  the 
use of potential information which could be disseminated through the travel agencies 
in the EU.  

2.2.6. 

In  October  2004  two  birds  of  pray  coming  from  Thailand  and  infected  with  the 
highly  pathogenic  avian  influenza  virus  type  A/H5N1  were  intercepted  at  the 
Zaventem airport in Bruxelles, hidden in the hand luggage of a passenger. Following 
the  confirmation  of  the  infection  the  Belgian  health  authorities  posted  an  alert 
message through the EWRS to allow Member States implementing activities to trace 
the passenger who were on the same flight and who had been potentially exposed to 
the  virus.  Twenty  two  comments  from  11  Member  States  have  been  received  to 
follow up the event. Several passengers were traced back but no influenza A/H5N1 
cases have been identified. 

2.2.7.  On 5 July 2003 the World Health Organisation reported that the last human chain of 
Severe  Acute  Respiratory  Syndrome  (SARS)  transmission  had  been  broken. 
However since July 2003 SARS reappeared in four occasions. Three incidents have 
been attributed to breaches in laboratory bio safety (Singapore, Taipei and Beijing) 
and  one  (Guangzhou,  China)  was  associated 
to  animal  and 
environmental  sources.  Commission  services  notified  the  SARS  related  events  in 
2004 through the EWRS and measures to prepare and respond to a potential return of 
SARS  have  been  strengthened  at  Community  level,  including  issues  related  to 
laboratory bio safety.  

to  exposure 

2.3. 

Events notified in 2005 

A total of 103 events were notified through the EWRS during 2005. Out of the 103 messages, 
36  were  information  messages,  49  activation  level  1  messages  and  7  activation  level  2 
messages. No activation level 3 messages have been notified in 2005. Eleven messages were 
concerned  with  measures  undertaken  to  respond  to  specific  situations  (intended  or  adopted 
measures  and  coordination  of  measures).  The  geographical  origin  of  the  events  which 
triggered  the  notifications  was  as  follows:  12  in  France,  5  in  Spain,  United  Kingdom  and 
Sweden, 4 in Germany and Denmark, 3 in Lithuania, Netherlands and Portugal, 2 in Estonia, 
Greece, Poland, Finland, Norway, Turkey, Angola and Russian Federation, 1 in Ireland, Italy, 
Latvia,  Czech  Republic,  Romania,  Croatia,  Nigeria,  Comoros  Islands,  India,  Botswana, 
Canada, the Democratic Republic of the Congo, Viet Nam, United States, Ukraine, Egypt and 
Cuba. Six messages were related with more then one country in Europe (including Member 
States) and 20 were in the ‘non applicable’ category. 

Concerning  the  repartition  of  the  events  per  disease  or  syndrome  15  were  related  to 
salmonellosis,  13  to  influenza,  10  to  acute  diarrhoea,  5  to  legionellosis  and  measles,  4  to 
vCJD,  3  to  cholera,  meningitis  and  fever,  2  to  haemorrhagic  fever,  haemolytic  uremic 
syndrome,  malaria,  shigellosis  and  rabies  and  1  to  anthrax,  hepatitis,  food  intoxication, 
melioidisis,  sexually  transmitted  infection,  rubella,  plague,  encephalitis,  diphtheria,  and 
botulism. Seventeen were the messages in the ‘not applicable category and 5 in the ‘unlisted’ 
one.  As  in  2004  the  repartition  of  the  messages  per  pathogen  substantially  reflects  the 
distribution per disease or syndrome. A total number of 131 comments have been posted to 

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follow  up  the  events  notified.  As  in  2004  the  events  have  been  rarely  ‘closed’  by  formal 
messages. 

2.4. 

Response and follow up of the events notified in 2005 

Measures undertaken by Member States at national level were sufficient to control the spread 
of the large majority of events. However six events required a coordinated response involving 
contacts  between  health  authorities  in  Member  States.  Four  of  them  were  related  to  the 
propagation of the avian influenza threat to the European region (Romania, Russia, Ukraine 
and Turkey).  

2.4.1.  The highly pathogenic avian influenza virus type A/H5N1 entered Russia during the 
month of August 2005. The events, as well as the three additional outbreaks of avian 
influenza  in  Romania,  Turkey  and  Ukraine,  were  promptly  notified  by  the 
Commission  to  the  Member  States.  Sharing  of  information  through  messages  and 
phone  conferences  encouraged  a  tangible  effort  to  coordinate  and  undertake 
measures to strengthening preparedness to respond to the potential progression of the 
pandemic  alert  phases.  The  Member  States  were  regularly  informed  through  the 
EWRS  about  the  measures  undertaken  at  National  level  and  a  consistent  response 
was  reached  at  Community  level  (Mainly  monitoring  the  situation,  implementing 
active  surveillance,  advising  EU  citizens  travelling  to  and  from  affected  areas, 
strengthening synergies with veterinary services, finalising pandemic plans).  

2.4.2. 

In March 2005 a large outbreak of Marburg hemorrhagic fever required the technical 
assistance of the staff of a number of European Non Governmental Organisations in 
Angola. As a result of the outbreak a EU citizen died in Luanda; other NGOs staff 
members  who  had  contacts  with  sick  or  infected  patients  were  quarantined  or 
evacuated  to  the  respective  countries  of  origin  (mainly  Italy  and  Portugal). 
Information  provided  through  the  EWRS  allowed  the  coordination  of  a  rapid 
response to undertake measures at national level to prepare the special isolation units 
in hospitals (Bio security level 4), to quarantine the contacts and to ship or transport 
across the EU the samples for laboratory diagnosis.  

2.4.3.  On 13 April 2005 the Commission circulated an EWRS message concerning an event 
related to a mistakenly distributed samples of live influenza virus A/H2N2 to carry 
out  quality  control  tests  (proficiency  testing).  The  concerned  A/H2N2  virus  was 
similar to the A/H2N2 strain that circulated in humans in 1957-58 at the beginning of 
the so-called Asian influenza pandemic. Vials containing the live virus had been sent 
by  the  College  of  American  Pathologists  to  more  than  3.700  laboratories  in  18 
countries  from  October  2004  until  early  April  2005.  In  the  EU  the  strain  has  been 
distributed  to  Belgium,  France,  Germany,  Italy  and  United  Kingdom.  The  EWRS 
contact  points  in  the  concerned  Member  States  have  been  informed  by  the 
Commission about the incident and operational procedures for the destruction of the 
virus have been rapidly undertaken at national level. All the samples received have 
been destroyed and no cases of influenza - like syndrome was identified among the 
persons involved in handling and processing of the samples.  

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3. 

NEW MEMBER STATES 

Since  the  date  of  accession  in  May  2004  the  10  new  Member  States  had  full  access  to  the 
EWRS  and  they  used  actively  the  system  both  to  notify  new  events  and  to  follow  up  with 
comments to events which have been reported by other Member States or by the Commission. 
Six new Member States in 2004 (Estonia, Hungary, Latvia, Lithuania, Poland and Slovenia) 
and  6  in  2005  (Czech  Republic,  Estonia,  Latvia,  Lithuania,  Poland  and  Slovenia)  posted  a 
total  of  7  and  10  messages  in  2004  and  2005  respectively. Out of the 7 messages posted in 
2004, 3 were activation level 1 messages, 2 activation level 2 messages and 2 were messages 
related  to  measures  undertaken  to  respond  to  specific  epidemiological  situations  (intended 
measures).  Concerning  the  nature  of  the  events  which,  in  2004,  triggered  the  notification  3 
events  were  associated  with  outbreaks  of  acute  diarrhoea,  and  single  messages  were 
notifications related to dengue virus, legionellosis, shigellosis and West Nile virus. Out of the 
10 messages circulated during 2005, 8 were activation level 1 messages and 2 were messages 
notifying measures planned to respond to specific events. Events related to outbreaks of avian 
flu, acute diarrhoea and salmonellosis were  notified two times and single  notifications  were 
associated with tick borne encephalitis, malaria, food intoxication and cholera.  

A  recent  analysis  prepared  by  the  European  Centre  for  Disease  Prevention  and  Control 
(ECDC)5, covering the period from June until December 2005 demonstrates that the amount 
of threats notified through EWRS is comparable between new and old Member States (after 
adjustment on the population), showing a good integration of new Member States in the EU 
alert system for communicable diseases.  

4. 

IMPROVEMENT OF THE INFORMATICS TOOL 

The older HSSCD application developed in 1991 no longer met the requirements both in user 
needs  and  in  security.  In  addition,  as  it  has  been  also  remarked  by  Member  States  the 
overloading  of  messages  during  particularly  important  events,  like  SARS,  created  some 
difficulties  and  obstacles  to  use  it.  For  these  reasons  it  was  decided  to  do  a  complete 
technological  and  ergonomic  overhaul  of  the  application  to  meet  the  user  needs.  The  new 
application  has  been  launched  the  17th  May  2004  and  it  was  very  much  appreciated  by 
Member  States  in  several  occasions.  However,  also  after  the  lessons  learnt  from  the  recent 
‘Common  Ground’  exercise,  some  improvements,  such  as  a  function  helping  in  extracting 
information in a timely and effective manner, are deemed necessary and they are under active 
consideration. 

In the current application the possibility to expand the size of attachments to the messages has 
been improved as well as the possibility to write and read all the comments directly under the 
message  text.  A  few  ‘simple  search’  features  were  also  added  to  the  threat  listing  page  to 
select  important  flags  (Message  content,  syndrome/disease,  pathogen,  reporting  reason,  and 
country of occurrence). After rebuilding the core of the application, it was added a calendar 
function to create a meeting agenda and to facilitate the sharing of working documents among 
the  users  without  overloading  the  core  messages.  To  prevent  this  risk,  especially  during 
relevant  events,  a  ‘follow  up’  section  was  added,  allowing  players  to  add  additional 
information on an event without sending e-mails to the users. A new messaging system was 
also  introduced  in  May  2005  (Selective  messaging)  that  would  allow  players  to  send  a 

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message  to  selected  recipients.  On  these  selective  messages,  the  European  Commission  is 
always notified.  

The search function was improved and was given the same layout as the main threat listing 
page. A few ergonomic and practical changes were implemented, allowing Member States to 
edit part of their own details. A printer-friendly detailed listing of users was added to allow 
for easier administrative maintenance. A special session for reference documents (Legal texts, 
technical guidance documents, operation procedures) has been created. 

An  SMS  messaging  function  has  been  activated  in  order  to  transmit  to  the  European 
Commission users’ real time notification by SMS that an urgent message (level 2 and 3) has 
been posted on the system. 

The  user  levels  were  expanded  to  give  access  both  to  the  ECDC  and  the  WHO,  giving  the 
later, with the agreement of Member States, a read-only access on selected threat messages. 
Lastly, other enhancements to security were added. 

5. 

‘COMMON GROUND’ SIMULATION EXERCISE  

Exercise ‘Common Ground’ was conducted by the UK’s Health Protection Agency (HPA) as 
a command post exercise over a two-day period on 23 to 24 November 2005. This exercise 
was the second of two European Union exercises commissioned by the European Commission 
to evaluate the ability and capabilities of Member States to respond to a health-related crisis, 
in  this  case  an  influenza  pandemic.  EWRS  was available  for  the  exercise  to  all  25  Member 
States plus Norway, Iceland and Switzerland. 

EWRS was extensively used during the exercise (437 messages and 3672 responses) to enable 
communication  between  all  the  players.  No  breakdown  of  the  system  has  been  registered. 
Nevertheless,  giving  the  nature  of  the  simulation,  there  was  considerable  overloading  and 
heavy  traffic.  In  the  early  stages  EWRS  performed  effectively;  however,  as  the  exercise 
progressed the users rapidly became overwhelmed with a huge number of messages. Member 
States noted that excessive time and resource was spent tracking relevant information and, for 
some, this became impossible giving the limited resources available. Participants commented 
on the difficulties of extracting information in a timely and effective manner. As the EWRS 
was  the  only  system  for  simultaneous  European  communication  available,  players  used  the 
system  for  all  sorts  of  information  exchange  when  it  was  developed  only  for  official 
notification of measures and coordination of the latter as lay down in community Legislation.  

6. 

THE EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL  

The European Centre for Disease Prevention and Control (ECDC) was officially established 
in May 2005 but started activities from March 2005. As the transfer of EWRS operation to the 
ECDC  is  stated  in  the  ECDC  founding  regulation,  ECDC  was  rapidly  integrated  in  all 
activities related to EWRS 

The ECDC has been connected to the EWRS since April 2005. ECDC participated in EWRS 
meeting  held  after  its  establishment  and  contributed  in  close  collaboration  with  the 
Commission to the discussions.  

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ECDC has implemented its threat monitoring mandate using the EWRS messages as a source 
of information on threats in Europe, complemented by an active search of additional formal 
and informal sources. Information on threats are compiled into a weekly report communicated 
to the Commission and the Member States. 

7. 

CONCLUSIONS 

Analysis  of  the  EWRS  operations  demonstrates  that  the  system  is  used  more  and  more 
frequently  by  Member  States  and  it  is  currently  considered  an  appropriate  tool  to 
communicate rapidly information to coordinate measures and risk management at Community 
level. The total number of notifications circulated through the EWRS has doubled in 2004 and 
2005  compared  with  the  previous  report.  New  Member  States  used  the  EWRS  efficiently 
demonstrating an activity comparable to the old Member States.  

All the events which required a more complex response and coordination of measures which 
have been reported in detail under paragraph 2.2 for 2004 (two legionellosis events in cruise 
ships;  A/H5N1  in  Vietnam;  two  West  Nile  virus  events;  incident  of  the  rabid  dog  illegally 
introduced in France; outbreak of hepatitis A in an Egyptian resort; A/H5N1 incident in birds 
of pray; and the four SARS related events) and under paragraph 2.4 for 2005 (A/H5N1 events 
in the European region; outbreak of Marburg hemorrhagic fever in Angola; and the A/H2N2 
incident) were notified without delay, demonstrating a clear improvement after 2003. These 
relevant  events  (as  it  was  for  SARS  during  2003)  represented  a  significant  test  for  the 
usefulness  of  the  EWRS.  The  system  fulfilled  its  institutional  role  by  timely  circulating 
messages among the EWRS contact points in Member States, by providing shared positions 
among the national public health authorities, and by facilitating the exchange of information, 
as well as scientific advice, on specific issues.  

However, in particular the analysis of the ‘information’ and ‘level 1’ messages showed that a 
number  of  them  were  focused  on  risk  assessment  issues  and  that  a  large  part  of  them  were 
requests to know if events similar to those which have been notified were identified in other 
Member  States.  Concerning  this  point  the  future  involvement  of  the  ECDC  in  assisting  the 
Commission in operating the EWRS (Art.8 of the Regulation 851/2004)6 should improve the 
situation,  focusing  on  use  of  the  EWRS  as  laid  down  in  Decisions  2119/98/EC  and 
2000/57/EC. 

Application of the new functions in the threat listing page made possible a better specification 
of criteria considered relevant by Member States when reporting as well as a better definition 
of syndrome and diseases, pathogens and the geographical origin of the events. However the 
still  high  number  of  messages  in  the  ‘non-applicable’,  ‘unknown’  and  ‘unlisted’  categories 
suggests updating and better defining those lists.  

The new application developed for the EWRS has been appreciated by Member States and it 
resulted in a real improvement of the performance of the utilisation of the system. In addition 
the  timely  notification  of  the  relevant  events  improved  in  comparison  with  the  previous 
report. 

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A number of Member States did not provide the annual analytical reports on the operation of 
the  EWRS  (Art.3  of  Decision  2000/57/EC).  Member  States  suggest  to  focus  the  yearly 
analysis of the EWRS operation on the events (such as those reported under paragraphs 2.2 
and  2.4  for  2004  and  2005)  which  triggered  a  significant  response  in  term  of  public  health 
measures  undertaken  or  planned  and  which  have  prompted  coordination  of  measures  at  EU 
level. 

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