EU HEALTH PROGRAMME. Generic Public Health Preparedness in Europe

Transcription

1 EU HEALTH PROGRAMME Generic Public Health Preparedness in Europe

2 ND EN-C Further information on the projects can be found on the Health Programme Projects database at: EAHC website on the DG SANCO Health-EU Portal and on SANCO Web Site The Executive Agency for Health and Consumers (EAHC) implements the EU Health Programme, the Consumer Programme and the Better Training for Safer Food initiative. Photos: www. fotolia.com, ISBN doi: /59355 European Union, 2011 Reproduction is authorised provided the source is acknowledged.

3 FOREWORD Be prepared!, the famous motto of boy scouts worldwide is also the underlying principle of the European Commission s work on health threats. When anticipating a health threat, we need to hope for the best, but be prepared for the worst. We call this planning process generic preparedness, and the idea is to develop capacities at all levels (governmental, professional organisations, communities and individuals) ahead of any type of health threat or hazard, so that we can react instantly. Preparedness planning is essential for developing and strengthening our capacity to detect and rapidly respond to any kind of emergency that affects, or is likely to affect people s health. One way we can support strategies and mechanisms to respond to health threats and hazards is through projects and actions co-funded by the EU Health Programme which runs from 2008 to The Health Programme is the Commission s instrument for implementing the EU Health Strategy Together for Health. The Programme supports activities that detect, prevent and respond to all types of health threats, as well as exchange information and best practices It also reinforces networking between laboratories in the Member States to ensure EU-wide cooperation on high-quality diagnosis. This brochure showcases a selection of successful projects funded by the European Commission under the EU Health Programme. Some of the projects address the most infectious and deadly microbes known to man or deal with the threat of chemical or radio-nuclear exposure. Others aim to refine surveillance systems and streamline information technologies to support risk assessment. We hope that these success stories will help the relevant organizations in all Member States work together to strengthen generic public health preparedness so that we can hit the ground running to protect our citizens when a health threat arises. Paola Testori Coggi Director-General Directorate-General for Health and Consumers European Commission Luc Briol Director European Agency for Health and Consumers 3

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5 Table of contents Introduction 5 Generic preparedness planning projects 1. The prevention and the control of existing or emerging communicable diseases 6 ENP4LAB 6 EQADeBa 8 2. The preparedness for health emergencies 10 SIDARTHa 10 REACT 12 SHIPSAN The response capacity against CBRN attacks 16 EPISOUTH PLUS 16 ASHT II 18 ORCHIDS 20 MASH 22 List of Generic Preparedness Planning Actions 24

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7 INTRODUCTION In the close economic and political alliance formed by the European Union, pandemic influenza, other contagious diseases and health emergencies caused by biological, chemical, physical or radio-nuclear agents threaten citizens health security and safety, not only in a given country, but also across borders. Accidental or intentional release of industrial chemical, radionuclear or highly pathogenic agents can cause serious public health emergencies. It should not be forgotten that the threat of terrorism has not disappeared and knows no borders. Europe must be prepared to detect and respond to any kind of threat. Preparedness planning is therefore an important tool in developing and strengthening capacities to respond rapidly to any kind of emergency affecting, or likely to affect, public health. The European Union supports Member States in their efforts to enhance generic public health preparedness planning and ensures that cross border aspects of public health emergencies are taken into consideration. EU priorities in this area are: The prevention and control of existing or emerging contagious diseases; Preparedness for health emergencies; Response capacity against chemical, biological, radio-nuclear (CBRN) threats/attacks. Recognising these challenges, a Communication 1 from the Commission on strengthening coordination on generic preparedness planning for public health emergencies at EU level was adopted in Linked to this communication is a technical guidance document entitled Strategy towards Generic Preparedness Planning. This document 2, revised in 2009, now covers all kinds of emerging health threats; it includes contagious diseases, CBRN events, environmental threats and other events that could threaten the health of European citizens. Preparedness and response planning, with respect to emerging health threats aimed at improving the health security and safety of European citizens, is also an important part of the European Health Strategy 4. One of the Health Programme s three objectives 5 the funding instrument for implementing the Health Strategy is devoted to improving citizens health security and protecting citizens against health threats. Under this framework, the Health Programme supports activities to develop strategies and mechanisms for prevention, information exchange and a comprehensive response to all types of health threats. It sustains action to ensure high-quality diagnostic cooperation between Member States laboratories, whilst providing support to reference laboratories to network at a European level. Several preparedness planning projects in the area of health threats have been financed through the first Public Health Programme ( ) and the second Health Programme ( ). This brochure presents some very good examples of successful preparedness projects that have been funded by the European Commission under the Health Programme. Some of them address the most fatal and infectious microbes known to man and deal with threats related to chemical or radio-nuclear exposures. Others refine surveillance systems, streamline communication and information technologies to support risk assessment, additionally dealing with health crisis management and EU Member States risk communication. All these projects are designed to identify best practice and disseminate their results, so that evidence-based and scientifically informed procedures can be implemented throughout the Union. They facilitate inter-operability among EU Member States public health systems, ensure business continuity, support coordinated responses and raise quality standards, so that effective emergency measures can be applied swiftly, efficiently and effectively saving time, money and ultimately, lives. Moreover, in 2009 the European Commission adopted a policy package on chemical, biological, radiological and nuclear (CBRN) security, which includes the CBRN action plan 3 and proposes a broad approach to CBRN security, ranging from prevention and detection to enhancing preparedness and response capacities

8 The prevention and the control of existing or emerging communicable diseases The most dangerous infectious diseases known such as the Ebola virus, smallpox and other hemorrhagic viruses are those for which we have no treatment and no vaccine and which can be transmitted through the air without physical contact. For obvious reasons, these are the agents that pose the highest risk if ever deployed in a bioterrorist attack and those that are best known to the public as extremely dangerous. These lethal illnesses therefore can only be contained and studied in a handful of laboratories around the world: known as Biosafety Level-4 (P4) facilities, these are kept to the highest standards with state-of-the art equipment and rigorously maintained at the highest level of security. These labs are very expensive to maintain: they require a lot of expertise, very skilled staff, and very secure people it is therefore very difficult to increase the number of labs like this in Europe, says Dr Giuseppe Ippolito, Scientific Director of the National Institute for Highly Infectious Diseases in Rome and project leader of the European Network of P4 laboratories (ENP4-Lab). A more cost effective and lower risk alternative to building new labs, therefore, is to foster long-term sustainable collaborative networks between those that already exist. Unique in the EU, ENP4-Lab facilitates cooperation between all the highest biosecurity laboratories in Europe. For All Nations Not only does this network provide for the harmonisation and standardisation of practices and procedures, but also, in the context of the European Union it allows for the provision of support to countries which do not have the capacity to host their own P4 laboratories. It is extremely important to remember that only a few countries in the Europe actually possess P4 laboratories, he says: the United Kingdom, Sweden, France, Germany, Italy and Switzerland. Not all European States possess the resources necessary for their construction and maintenance. A bioterrorist attack could happen anywhere in Europe; all nations can therefore benefit from ENP4-Lab. 6

9 Strengthening networks between existing laboratories, rather than building new ones, also minimises the risk of outbreaks from existing laboratories. It is prudent to keep the number of P4 laboratories low to avoid the misuse of the facilities or the unintentional use of the micro-organisms, says Dr Ippolito. For any new P4 laboratories that will be built, either under national funding or with the support of the World Health Organisation, a checklist being developed by ENP4-Lab will aid in the evaluation of all facilities to ensure standardisation and harmonisation. Quality Control Founded in 2005, the European Network of P4 laboratories (since 2007 funded under the ENP4-Lab project) was initiated in order to ensure a rapid, effective and coordinated response to an outbreak, should the worst ever occur. Working together for the past six years, all the labs across the union have shared knowledge, expertise and reagents, leading to the identification of best practice, harmonisation and standardisation across the Union. Before this project, each lab worked independently now we have a model for coordination which has been very fruitful in terms of expanding diagnostic capabilities, extending those to all Member States and developing good diagnostics for the world s most dangerous pathogens, says Dr Ippolito. For example, in the past two years the labs in the network have held a number of external quality assurance exercises, where every lab received viral samples of an unknown identity prepared by all the other labs, to be tested and identified. Every lab could therefore see if their procedures were up to the level of diagnostic quality that is required, says Dr Ippolito. Quality control exercises like this can be done for infectious agents of lower Biosafety Level rating, such as dengue fever or HIV, where the viruses can be obtained from commercial facilities, but for viral agents as dangerous and restricted as these, this kind of quality assurance exercise could only be carried out through a network like ENP4-Lab. Ebola Virus throughout Europe, says Dr Ippolito. They are extremely useful in providing the highest level of protection to all European citizens. The Next Step Moving forward, ENP4-Lab will now work with EQADeBa on a new joint effort: QUANDHIP, which will link the virologists, bacteriologists and laboratories of ENP4-Lab and EQADeBa together for a common effort. Until now ENP4-Lab has brought together the virologists in Europe into one network and EQADeBa all the bacterial specialists into another. Now for the first time, these two existing networks will come together for the speediest and most effective diagnosis of any new pathogenic outbreak. EURONET P4 Moreover vaccines for these lethal strains can only be created at P4 laboratories, as they are the only facilities with the ability to work with them. These labs will ultimately serve as sentinels for rapid diagnosis, with the early identification of new risks and also aiding the possibility of immediate treatment of infected patients 7

10 The prevention and the control of existing or emerging communicable diseases In order to prepare for the potential outbreak of an infectious disease whether through natural spreads or from a bioterrorist attack it is crucial that all European countries be equipped with high quality, reliable laboratories with the capacity to quickly and correctly identify the agent involved. Before you can treat a patient you must know what they have been infected with and the sooner you can start treatment the more effective it will be which is why a speedy diagnosis is so important, explains Dr Roland Grunow of the Robert Koch-Institut in Berlin, coordinator for the Establishment of Quality Assurances for Detection of Highly Pathogenic Bacteria of Potential Bioterrorism Risk project (EQADeBa), which aims to directly support the early warning and rapid response capacity of all European nations to ensure an effective reaction to a bioterrorist attack. Involving 23 laboratories from 20 European countries, EQADeBa is improving the diagnostic reliability of tests for bacterial strains of potential bioterrorism risk, including anthrax, plague, tularaemia, glanders, brucellosis, melioidosis and Q-fever. The clinical manifestation and the clinical picture for patients suffering from these diseases can be uncertain it can be difficult to tell from symptoms alone what the cause is, he explains. Because the symptom profiles for many diseases overlap, it can be very difficult to tell from visible symptoms what a patient may be infected with the only way to know for sure which biological agent one is dealing with is through a reliable laboratory test. You need a laboratory diagnosis to be as fast as possible to provide the right treatment for the patient and to initiate the right regimens to protect other people from also becoming infected, he says. 8

11 Strength in Numbers By linking 23 laboratories together through a new network, EQADeBa allows the identification of best practice: by sharing knowledge and information with each other, microbiologists and lab technicians across the continent are now able to determine which diagnostic tools are the most reliable. This network is fit to exchange reference materials, support each other s analyses, confirm the identification of samples and exchange personnel to be trained. Most of us didn t really know each other before this project, but now we have quite a well established network, says Dr Grunow. We are able to learn from each other about new techniques and new approaches to diagnose these highly pathogenic agents and in so doing are able to identify the best practices. One of the methods they employed to identify the best diagnostic tools available were three external quality assurance exercises (EQAE) involving each of the laboratories assessing a number of samples of bacteria using a set of different laboratory tests. All available microbiological, molecular and immunological approaches are being evaluated and authenticated. Through such quality assurance and authentication exercises, EQADeBa is not only able to identify the best laboratory techniques, but also identify which labs have the need to improve their standards and operations. Recommendations that can lead to a further improvement of diagnostic approaches were developed by the network partners. Through these exercises, a couple of laboratories were able to identify their own gaps and to improve their methodologies, says Dr Grunow. And ultimately, it is very important to generate reference laboratories that can confirm the results of other laboratories. In addition, EQADeBa has developed a check-list of 180 criteria for labs to use in a self-evaluation of their biosafety and biosecurity in laboratories, says Dr Grunow. During the course of our project, three partners set up or are on the way to complete a new Biosafety Level 3 (BSL3) laboratory in Spain, Poland and in Lithuania, three highly contained labs for highly pathogenic bacteria and viruses were established, he says. They used our biosafety/-security check-list and said it was extremely helpful for them to apply the recommendations given to design these laboratories to the best possible standards. Coming Together to Prepare for the Worst Moving forward, EQADeBa will now establish a new network, QUANDHIP, working with Euronet-P4 to bring together the expertise of virologists who are working on highly pathogenic viruses such as Ebola, Marburg, Dengue fever and yellow fever. We think it will be very helpful to have this exchange to cover more pathogenic viral and bacterial agents this will help us quickly diagnose new outbreaks of unknown pathogens, says Dr Grunow. These agents are quite simple to produce in many cases even simpler than a bomb and they can have a very large effect on the population if released. They could affect a large number of people and hinder many resources of health care systems due to their infectious potency and high pathogenicity. This is why the pan-european dimension to their work is so important: infectious agents like these will not recognise borders, and could spread throughout the European Union quickly if not immediately identified and correctly treated. By identifying the best practices across the Union and disseminating them to all members, QUANDHIP can substantially facilitate the preparedness of all appointed laboratories in all EU Member States to respond to any potential threat or event. By joining the virologists and bacteriologists together into one network where they can share experience and best practice, we hope to give an added value to the European dimension of this project, says Dr Grunow. Natural Threats It is very important to remember, however, that our work is relevant not just to bioterrorist threats: these pathogens can occur naturally and do so in many areas in Europe, he says. These diseases tend to be rare, but they can still occur naturally, and you often don t know how frequently they occur in different areas throughout Europe. Even if the worst never happens and none of these bacterial agents are deployed through a terrorist act, the work of EQADeBa will nonetheless still help to protect the health of all European citizens in this way. EQADeBa EQADeBa node.html 9

12 The preparedness for health emergencies As a health threat emerges, there can be significant delays between the onset of an epidemic and the launch of an appropriate response by services and authorities costly in terms of money spent, time wasted and lives lost. Being able to know early that a health emergency situation has begun is crucial to be able to respond appropriately. But how exactly can the authorities know that an epidemic has begun? Diagnostic laboratory tests that identify a viral or bacterial agent can indicate with a high degree of certainty if an outbreak is underway, such as for seasonal flu, but these can take a great deal of time and there can be unexpected events health authorities need another mechanism to spot emerging epidemics. One answer is syndromic surveillance, which seeks to use existing health data in real time to provide immediate analysis and feedback to those charged with the investigation and follow-up of potential outbreaks. Under the Public Health Programme the European Commission has co-funded the European Emergency Databased Syndromic Surveillance System SIDARTHa, which consists of an automated, computerised system to monitor symptoms and syndromes from routine emergency service data collection. SIDARTHa gathers the electronic data that emergency health services are already collecting such as the suite of symptoms that characterise influenza-like-illness and amalgamates them together for the real-time syndromic surveillance of the emergence of both communicable and non-communicable health threats at local or regional level. By gathering information from emergency departments, dispatch centres and ambulance services, we can continuously update information to create real-time surveillance, explains Dr Thomas Krafft, scientific-technical coordinator of the project. If, for example, there is a higher demand than expected for the emergency ambulance transport of patients with respiratory symptoms, public health authorities could be automatically alerted. This allows public health authorities to immediately start implementing adequate measures to react to the potential threat, he says. This really is an early warning system. Without such an automated system, it could take up to a week to get sufficient data to recognise a public health threat. This is about buying time for authorities so they can be more efficient. Saving Time and Money Though technological solutions can sometimes appear costly to change and replace, Dr Krafft explains that SIDARTHa will not render any existing data collection system redundant. Using already existing data without the additional workload for data collection or analysis, SIDARTHa is very cost-effective. This also makes it an affordable tool for accession countries to work in line with EU Member States. Our work is based on the philosophy that you should not put additional effort into monitoring and surveillance, but instead use existing data and techniques to simply give added value to the data and the systems, he explains. SIDARTHa is not intended to replace any systems in place throughout the European Union only to complement them to create more efficient and responsive reactions. By monitoring syndromes and symptoms, the system can also detect if there is an outbreak of non-communicable diseases as well, such as heat-related illnesses. Conversely, the system will also help services and authorities determine if there is no health threat posing a risk to the population in other words, if there is only a perceived threat. For example, after the explosion of the Icelandic volcano in 2010 and the ensuing ash cloud, many people across Europe worried about the risk of cardiac and respiratory aggravation. The European Centre for Disease Prevention and Control asked us to test out SIDARTHa during this time to see if there were Our work is based on the philosophy that you should not put additional effort into monitoring and surveillance, but instead use existing data and techniques to simply give added value to the data and the systems. 10

13 any health impacts from the volcanic ash plume, he says. We found no increased demand for emergency care services. It is important to be able to distinguish between real threats and perceived threats. European Dimension As an example of how an automated system like SIDARTHa could have improved the response to an emergency health threat in the past, Krafft points to the outbreak of SARS in Toronto, Canada in There was a sign that there was an increased demand for the transport of patients, but the authorities and emergency services did not understand what was emerging, he explains. As a result, many ambulance crews came into contact with patients who were either affected by SARS or suspected to be affected, and entire ambulance crews had to be put into quarantine. A service like SIDARTHa could have put up a signal quite early to the authorities and to the emergency services, which would then have been able to deal with the situation more efficiently and competently, with adequate protection in place for health workers. The use of a system such as SIDARTHa can increase also the cooperation between the emergency services and the public health authorities during such crises. Toronto now has a syndromic surveillance system in place. For the development of an automated system based on geo-processing methods, statistical modelling and analysis for European health authorities, the project team had the added difficulty of devising a system that could function in any region in any European Member State a tricky challenge. The data collection systems are very different between and even within Member States there are different coding systems, different data fields, different availabilities of data, explains Dr Krafft. After carefully going through the range of data inputs that were being used across Europe, they devised a specific coding manual that uses a limited range of data inputs, leading to a standardised system applicable in the whole union. SIDARTHa can work in different settings throughout Europe because we conceptualised a framework that is applicable to all settings and that can also be flexibly adjusted to local and regional needs, or even quickly monitor an actual health threat that needs surveillance this is a universal tool that can rapidly monitor the unpredictable, he says. There are regional or national syndromic surveillance systems already in place, but this for the first time adds the European dimension and by this, unique European added value. SIDARTHa 11

14 The preparedness for health emergencies The more that people and goods move into and around the European Union, the greater the potential for the spread of infectious diseases such as tuberculosis, meningococcus and influenza and thus the greater need for coordinated responses to prevent the spread and to minimise the harm from infectious diseases within the EU. A crucial component for managing any outbreak is surveillance: understanding how large the epidemic is, how quickly it could spread and where it could spread to (as well as where treatment regimens are working and how fast). Mass gathering events can be particularly potent, such as sporting events, which feature fast and large movements of people into and out from areas with a high potential for the transmission of infectious agents from person to person. There are many different ways of surveying a mass gathering, but as yet there are no evidence-based clear, harmonised procedures available to assist any country in the Union in deciding which core capacities are needed for surveillance. There are a range of surveillance tools that can be implemented, but many of them are quite costly, says Dr Gérard Krause, Director of the Department for Infectious Disease Epidemiology at the Robert Koch-Institute in Germany, and the scientific coordinator for REACT, the Response to Emerging Infectious Disease project, based at the Robert Koch Institute in Berlin. The ultimate aim of the project is to help achieve a common European standard for the response to emerging public health threats that are likely to be applicable and acceptable throughout the EU. Figuring out how best to prepare for every new major event can tie up a lot of resources in the public health area authorities seem to try and figure out every time how to prepare, but we do not do so in a standardised or evidencebased way, he says. When we hosted the world football championship in Germany, we analysed the situation and realised we only needed to temporarily adapt the existing system instead of implementing new structures. Organisers across Europe and indeed the world have faced similar problems and have had to come up with new systems in short periods of time, at great expense. However if we can develop tools that are applicable throughout the union it will not be necessary to re-invent the wheel on every occasion, which may end up saving us from a spiral of increased spending on resources. Tracing the Contacts One of the most inconsistent approaches to public health outbreaks both in Europe and worldwide in the past has been the tracing of the movements of individuals who have come into contact with infected people (or who are suspected of being infected but are not hospitalised), known as contact tracing. Such contacts can easily spread infectious agents across regions and nations, especially if they have quickly travelled to one area for a mass gathering event, such as a sporting or religious event, but monitoring their movements has often proven difficult to implement in the past and difficult to explain to the public. The first step towards creating an evidence-based approach to contact tracing was to conduct a lengthy review of the literature and we discovered that very little had actually been published on the subject and few publications had approached the topic in a scientific way, says Dr Krause. Clinicians, laboratories and other sources Local/regional public health authorities National IHR Focal Point World Health Organization Target for the WP 6 toolkit 12

15 Moreover, almost all previous work on contact tracing focused on air travel alone land-based travel and public transport in particular, can easily facilitate the transmission of infectious agents. Because we focus our work on optimising contact tracing procedures using all the evidence available, this will actually increase security throughout the union, he explains. By focusing resources and avoiding unnecessary contact tracing, this alleviates disturbances for travellers, while at the same time saving public funds and resources. One particularly important tool that they have developed is the contact tracing risk assessment profile (RT-RAP) that will allow public health officials to make important, key decisions when faced with an emergency situation say, for example, if a passenger on a coach is diagnosed with tuberculosis or measles. The system would guide the decision maker through the decision making process, helping him analyse the evidence and make the optimum choice at each step. So far we have only focused on ground travel, but this would also work for airplanes and ships, says Dr Krause. We could expand to other situations, such as schools, workplaces and others. Helping the Helpers Another key group that should be monitored after coming into contact with infected individuals is health care workers, who suffer from a high risk themselves of becoming ill or for passing on infections to others. REACT is developing generic approaches towards illnesses, rather than a disease-specific approach. We need to be open to monitoring diseases which may not yet be known to us, says Dr Krause. Taking a generic approach will also be fruitful for all areas of health preparedness and public health protection to prevent the spread of infectious diseases through international cooperation. Our aim is to provide evidence-based approaches for how things could be done, says Dr Krause. These activities will lead to harmonisation but not harmonisation for harmonisation s sake. We only aim to provide material and good, scientifically based-evidence for the different activities. REACT Prevention/React/react node.html? nnn=true Mass gathering on ground transportation 13

16 The preparedness for health emergencies Passenger ships including ferries and cruise ships can be considered as leisure or accommodation places or means of transport. Travellers can get sick during their holidays and, as in land based holiday places, outbreaks have been linked with ferries and cruise ships. If control measures are not in place on a ship, for a number of reasons, passenger ships can carry a high risk of the outbreak of a health emergency on board: the age of the population of travellers (sometimes as many as 5,000 people) is considerably high and therefore quite vulnerable. Nearly all food and drinking water sources are shared, leading to the risk of a rapid spread of any contagion or infectious microbe. Water for bathing and swimming is also shared hottub and pool pipelines full of warm water and human waste create ideal habitats for infectious microbes, which can circulate through the ship. Cruise ships are particularly important to regulate precisely because they are essentially enclosed spaces, explains Professor Christos Hadjichristodoulou, an epidemiologist at the University of Thessaly and Project Leader of the EU SHIPSAN TRAINET Project, which has produced review documents, training manuals and conducted training exercises for port authorities in Europe. If hygiene measures are not implemented, a huge transmission from person to person may occur. Outbreaks of gastroenteritis and even Legionnaires disease on board cruise ships are not unknown, and when they do occur, can make vivid and memorable news in the media. SHIPSAN TRAINET aims to both facilitate the implementation of International Health Regulations to enhance the common EU policy, but also to create a common European framework for ship sanitation inspection, surveillance and the control of outbreaks. Their work is expansive, covering guidelines for inspections, food safety and hygiene, surveillance of communicable diseases, medical facilities, outbreak plans, pest and waste management, water purification and waterborne diseases. Until now there has been no common policy on ship sanitation for countries in the European Union, he says. The US has operated harmonised standards for almost 30 years and SHIPSAN has started to do the same for the EU in the last few years. Ship to Port Means of international transport can pose a risk not only to the travellers, but also to the citizens of Europe living in the cities they visit. The Mediterranean is one of the world s highest traffic zones for cruise shipping. In Piraeus alone (site of the SHIPSAN SHIPSAN TRAINET project, January 2011, Greece 14

17 TRAINET Course For Port Health Officers in January 2011), 25 million passengers come to the city s 25 kilometres of docks every year. Therefore, health programs implemented on ships, as well as the application of hygiene measures at port terminal stations, are important in order to prevent the spread of infectious diseases, through sickened passengers, contaminated sewage, hazardous chemicals and other hazardous materials. However, exercising extreme caution is not always the most prudent course of response, says Prof Hadjichristodoulou. If you shut down a ship even for just one hour, that is extremely costly to the economy of both the visiting port and the ship s company and for large ships, the costs are even higher, he explains. The reaction needs to be proportionate to the risk. The risk assessment needs to be well conducted. A contributing factor to overreactions by port authorities, he says, is inconsistencies in port safety and hygiene standards a ship that passes inspection in one country or city could be penalised at the next, leading to confusion. Moreover, ships that are penalised or shut down even for a short time are not always reported to the next port officers at the next port of call need to know what problems existed and what actions were taken in order to minimise the risks both to the passengers on board and to the citizens of the port city (and surrounding regions). We need to have common standards for how we define an outbreak and guidelines on how we respond to an outbreak, says Prof Hadjichristodoulou. Now, with a harmonised set of standards and a streamlined communication system, dialogue and cooperation between ports has been facilitated. Stringent but prudent and harmonised regulations will not only make life easier for ships and ports. Our ultimate objective is to protect the health of consumers, he says. We need to have common standards for how we define an outbreak and guidelines on how we respond to an outbreak. Common Effort Unique among the projects funded under the European Health Programme, SHIPSAN brought industrial and commercial representatives to join academics, health officers and other experts to produce evaluations, guidelines and other materials for the protection of the health of European citizens. Commercial operators of cruise lines joined medical doctors, environmental health officers, epidemiologists, academics, health authority officials, engineers and chemists to produce the SHIPSAN guidelines and training manual. All in all 85 experts from Europe as well as North America and Australia came together to inform the SHIPSAN research, develop training manuals, and execute training exercises. It was quite challenging to bring all these individuals together from different backgrounds and to find a common language to use for communications, says Prof Hadjichristodoulou. But it was quite important that we establish a network with all the different stakeholders and get all these experts to work together in harmony in order to reach an agreement on the requirements and the manual. In the area of shipping regulations as a whole, many authorities and players who are implicated in surveillance and regulations are also required to partake in feeding into the SHIPSAN project, including the European Commission services and agencies (ECDC, EΜSA) as well as the World Health Organisation and International Maritime Organization. This is for the very simple reason that ships move around, ensuring their cleanliness and safety is complex. Not every project would have to involve so many authorities and stakeholders this was a complicated project, he says. However if the industry is held to high safety standards and the industry is maintained as a healthy contributor to the European economy, the benefits to all European citizens could be enormous. That is why this was a common effort, he says. SHIPSAN TRAINNET 15

18 The response capacity against CBRN attacks EPISOUTH PLUS The Episouth Network and the EpiSouth-Plus Project Effective vaccines exist for only a few public health threats. In the absence of the capacity for mass vaccinations, surveillance is the best (and frequently the only) tool that public health officials may use to contain the spread of infectious diseases. In order to respond quickly and effectively, we need to be able to anticipate what threats we will need to deal with and define the tools, instruments and approaches that can help to face these expected, but also unexpected, public health threats which may also come from outside the EU says Maria Grazia Dente of the Italian National Institute of Health in Rome, coordinator of the EpiSouth-Plus Project, a new challenge for the EpiSouth Network, founded in Infectious agents do not recognise geographical or political boundaries. Whether carried by migratory populations, cargo trade or wildlife, health threats will always be capable of crossing into and out of the EU. If we only monitor within the EU, we will only know about these threats once they occur within EU borders says Dente. We need a global, interoperable early detection system for the benefit of European and Neighbouring countries so we can respond more effectively to public health threats. A Common Ecosystem Joining together countries from across the entire Mediterranean region, the EpiSouth Network is forging links and allowing the exchange of information between countries both within and outside the EU, including Albania, Algeria, Bosnia & Herzegovina, Bulgaria, Croatia, Cyprus, Egypt, Former Yugoslav Republic of Macedonia (FYROM), France, Greece, Israel, Italy, Jordan, Kosovo, Lebanon, Libya, Malta, Montenegro, Morocco, Palestine, Romania, Serbia, Slovenia, Spain, Syria, Tunisia and Turkey. As of June 2010, the EpiSouth network includes 27 countries. The majority of these nations are in fact not EU Member States; their collaboration and support is crucial, says Dente, to ensure and enhance, for example, the surveillance of diseases that could spread to the EU. Between 2006 and 2010 more than 100 epidemiologists and public health officials joined EpiSouth, creating a Network of public health institutions throughout the Mediterranean, implementing training in field and applied epidemiology and establishing a new cross-border web-based epidemic intelligence platform to share relevant public health information. In so doing, EpiSouth has established an unprecedented framework for collaboration on epidemiological issues to improve surveillance, communication and training throughout the Mediterranean and South East Europe. As part of the work done from , EpiSouth developed a strategic plan for the epidemiological monitoring of a select list of zoonoses (infections that can be transmitted to humans via animals and insects): Brucellosis, Leishmaniasis, Campylobacteriosis, Rabies and West Nile Virus. These are problematic throughout the Mediterranean and therefore all countries in the Region must cooperate in order to monitor, predict and respond to these health threats. West Nile virus, for example, is largely spread by migratory birds that travel between continents, oceans and the different areas of the Mediterranean Basin (including the EU). Through the EpiSouth secured platform, it was and is possible for the EpiSouth partners to share information on these health threats. Last year, with the AH1N1 flu pandemic, EpiSouth contributed says Dente to share information with countries outside the EU and this helped to better describe the epidemic situation. Mobile populations, including business travelers, tourists and immigrants, can also facilitate the spread of common public health problems. EpiSouth developed a strategic plan on vaccine preventable diseases and migrant populations, in which they assessed the status of these diseases in the Mediterranean and outlined specific policy recommendations to enhance the access of migrants to vaccination. Filling Gaps and Building Bridges The EpiSouth-Plus Project represents a new phase of the Network s activities. It started in October 2010 and will run for 30 months. DG SANCO/EAHC, EuropeAid and the national participating Institutions are the funders of this initiative, together with the contribution of the Italian Ministry of Health and ECDC. Based on the work done since the beginning of the Network s activities in 2006, EpiSouth-Plus will fill the gaps and needs that were identified in the previous years. In particular, the laboratories in the Mediterranean region will be better connected and coordinated to ensure the development of cross-border laboratory services, enhance complementarity among vertical and fragmented laboratory networks and help to overcome of national logistic and legislation constraints. 16

19 Coverage of Episouth plus project in the Mediterranean Region and Western Balkans Common procedures in interoperable Generic Preparedness and Risk Management Plans will be promoted to reduce intercountry variability, enhance capacity building and cross-border concerted actions and facilitate the elaboration of national plans and communication strategies. The sharing of alerts and epidemic intelligence information among EpiSouth countries will be enhanced through the development of interoperability with other Early Warning Platforms and especially the European Early Warning and Response System (EWRS), as forecasted by current EU legislation. The requirements of the WHO International Health Regulations (IHR)-2005 will be considered in EpiSouth-Plus and their implementation at country level will be facilitated through a strategic document based on assessments and surveys on how national plans and legislations can interact and interfere with these requirements. Strengthening Solidarity and Security EpiSouth-Plus is unique among projects funded by the EU and other international initiatives in the field of health preparedness in its focus on the Mediterranean region as a whole, including non-ue countries as well as all three WHO Regional Offices that cover the Mediterranean. In addition to facilitating epidemiological communication and practical training, this regional approach strengthens solidarity and cohesion within the European Community and between EU and non-eu countries, especially for information sharing regarding cross-border public health threats and for the implementation of the IHR, which have among their challenges that of interacting with national procedures and legislations and that of facilitating a common international action in case of need. Moreover, it reduces the disparities in the different approaches to early warning and preparedness by bringing together EU and non-eu countries in all the planned activities. Ultimately, EpiSouth-Plus contributes to the stability of the region as well as to improving public health protection. EpiSouth Plus 17

20 The response capacity against CBRN attacks Diseases know no borders, and chemical threats can be just as capable, if not more, of spreading over long distances and affecting large numbers of people. A chemical factory fire, for example, in a border region on a windy day could, within hours, spread tens to hundreds of kilometres. A rupture at a pesticide manufacturing plant in Seveso, Italy, in 1976 released a cloud of dioxins and contaminated an area ten kilometres in diameter. Even more dangerous can be incidents in or near water a warehouse fire near Basel in 1986 led to mercury, pesticides and other chemicals running into the Rhine and affecting over 1,000 kilometres of waterway, crossing six countries, before emptying into the North Sea. Large contamination events of hazardous chemicals require a rapid alert system in order to trigger a rapid and appropriate response, to protect the health of potential victims of the deliberate as well as accidental release of poisons, which unlike viral or bacterial agents, can harm and kill very quickly. However not all chemical threats are as visible and dramatic as a factory explosion many are more subtle, such as the contamination of consumer products. The contamination of milk with melamine from China in 2008 for example took many months to pan out and an estimated 300,000 people fell sick. The detective work can be intricate. We were forced to ask: How can we acquire information on chemical poisonings quickly and clearly? How can we develop an early warning system? says Dr Rob Orford, Project Manager for the Alerting System for Chemical Threats, Phase II (ASHT II). The answer was identified by the first phase of that project: poison control centres. Because most people in Europe (except the UK) can call their local poison centre to get advice, these centres are therefore good sentinels to detect events of mass poisoning, he says. Now, with the development of a chemical alert system, those poison centres will be able to take that information and put it into a larger network for the monitoring of incidents and events on a larger scale. Syndromic Surveillance Other poison control centres can access the information to see if anything anywhere in Europe corresponds to their own reports. Funny smells, strange feelings, suites of symptoms like dizziness and vomiting can all be tracked on regional, national and international levels to monitor health effects from chemical contamination. Like SIDARTHa, ASHT II can provide syndromic surveillance to help monitor health emergencies where the cause is unknown. This is extremely important, says the ASHTII group, because tracing the source of a chemical poison can be extremely tricky. Famous instances, such as the contamination of toy beads manufactured in China and sold in Australia that resulted in several children being exposed to the toxic drug GHB (gamma hydroxybutyric acid) relied on poison centres for toxic vigilance. A quicker system could have prevented more children from suffering seizures and comatosis. This isn t just about the big bang events like big explosions or terrorist attacks, says Dr Orford. Smaller incidents like chemical spills or the contamination of consumer products need a system in place to help monitor their effects. A one stop shop was needed that everyone could access so we could pick up on incidents appropriately and perform a risk analysis before moving onto risk management. A one stop shop was needed that everyone could access so we could pick up on incidents appropriately and perform a risk analysis before moving onto risk management. 18

21 Harmonising Language The result: ASHT II have now developed the concept of the Rapid Alert System for Chemical Health Threats (RAS-CHEM), which now includes a risk assessment tier for poison control centres to share information, and a risk management tier for national authorities and health ministries to escalate information to the EU. RAS-CHEM is an early warning system for DG SANCO. Member States now have a common platform to share information and act together regarding chemical incidents that could cross borders and affect citizens throughout the European Union. However, creating a network of centres and databases covering all 27 European Member States was not as simple as linking all the poison centres together. A system that all centres and individuals could use was needed; prior to ASHTII, a large diversity of terms was employed by different agencies and centres. Without a standardised set of terminologies, there was the potential for similar syndromes to be put into the system without being grouped together. A big portion of our work was standardising the terminology we needed to make sure that symptoms such as vomiting and nausea would be collected together appropriately, says Dr Orford. In all they reviewed all symptoms following exposure to over 100 toxic agents, compiling a list of over 1000 terms in full. This ultimately was about designing an IT system for reporters. The ASHTII working group is composed of scientists and clinical toxicologists from the UK, Germany, France, Lithuania, Czech Republic and Switzerland. ASHTII 19

22 The response capacity against CBRN attacks In the event of a release of a hazardous substance, large numbers of people will need to be decontaminated quickly and effectively so as to halt the spread of contamination and prevent further harm, as well as to prevent the contamination of emergency responders and hospital facilities. Infrastructures, protocols and guidelines exist worldwide for the response to such incidents such as the deliberate release of chemical agents on public transport systems, or the emergency response to an industrial accident but very little empirical evaluation of these has been completed to date. Now for the first time, an EC-funded scheme, the Optimisation through Research of Chemical Incident Decontamination Systems (ORCHIDS) project based in Salisbury, UK, is exploring ways to optimise mass casualty decontamination response mechanisms from first principles. In recent years, European Countries have established welldeveloped provisions to decontaminate large numbers of casualties in a mass casualty incident explains Dr Richard Amlôt, ORCHIDS Technical Leader at the Centre for Emergency Preparedness and Response at the UK Health Protection Agency. The ORCHIDS project is evaluating mass casualty decontamination in this civilian context, ensuring that what we have in place is optimised for a range of emergency scenarios. Drawing from the expertise of public health agencies specialising in decontamination and mass casualty incidents across Europe, ORCHIDS is reviewing protocols, activities and research with partners in the Czech Republic, France and Sweden in order to optimise response capabilities throughout the Union. Exploring the tools available to respond to a range of potential contaminants, they are delivering quantitative evidence from applied laboratory toxicological testing as well as field-based operational research trials involving human participants. This project is ultimately about ensuring that the systems we have in place for decontaminating large numbers of people will work in a range of situations, says Dr Amlôt. And of course, we are also making sure that health agencies across Europe are properly informed about the ORCHIDS project outcomes so that these measures will be applied effectively. Informing the Science By conducting a thorough review of the literature, developing an online portal to key resources creating a database of core 20

23 stakeholders and linking them together through a novel network, ORCHIDS is connecting health responders across the European Union to share knowledge and best practice. ORCHIDS is more than the networks we will build; we are also conducting original research that we plan to publish in open literature, says Amlôt. For example, ORCHIDS has carried out field tests of decontamination procedures involving mobile showering units involving real human participants, including children, in order to evaluate the capacity of emergency services to effectively respond to incidents involving vulnerable groups. Many children, like individuals with language barriers and the elderly, will need further support to undergo these decontamination processes. With field trials, ORCHIDS was able to vary and measure the parameters that determine the effectiveness of the showering process. By measuring how long each person took to disrobe, shower and re-robe in accordance with varied instructions, this field test was able to optimise the procedure to ensure that vulnerable civilians could shower while still allowing others to move through at high speed. The results of this study were published in the journal Prehospital and Disaster Medicine in October Agency and The UK Health Protection Agency Emergency Response Department and Chemical Hazards and Poisons Division. The list of stakeholders and collaborators within the EU Member States and internationally continues to grow, which will facilitate the development and refinement of mass casualty decontamination protocols to be adopted within the EU. The pan-european component of their work is crucial, says Dr Amlôt. They have identified some significant variations in the manner in which jurisdictions and regions across the continent prepare for mass casualty incidents, he says. Identifying and evaluating these differences in approach will help inform our understanding of best practice in this area. Through research and field-based trials and exercises, the ORCHIDS project is able to identify the evidence-based best practices that exist in Europe and disseminate the appropriate guidelines across the Union. Every European citizen should be able to receive the best possible evidence-based intervention as quickly as possible, should the worst occur, he says. ORCHIDS We aim to inform the scientific evidence-base as well as emergency response says Dr Amlôt. Moreover, what we develop and disseminate will be as applicable to smaller scale incidents as well as those involving mass casualties these can include chemical factory accidents, collapsed buildings and so on, he says. Each year, across Europe, there many incidents where emergency decontamination is performed. There are many incidents where responders and the public can benefit from research like ours that was developed with the worst case scenario in mind. Equality Across Europe The ORCHIDS project involves the work and collaboration of four project partner agencies: the Army Biomedical Research Institute in France; the Faculty of Military Health Sciences at the University of Defence in the Czech Republic; the CBRN Defence and Security Division at the Swedish Defence Research 21

24 The response capacity against CBRN attacks Mass emergencies involving the release deliberate or accidental of radioactive or hazardous chemicals are rare. However, incidents, such as the sarin attack in the Tokyo subway, the radioactive leaks at Chernobyl and Three Mile Island, the use of nerve gases by Saddam Hussein and of course, the detonation of nuclear bombs in the second World War remain in the public consciousness because they are so difficult to control and so deadly. It is essential that we are prepared to respond to such incidents, rare as they are. The desire to prepare for counter terrorism and make society more resilient to such activities is extremely high on the political agenda in all nations, says Dr Åke Sellström, coordinator and Dr Ann Göransson Nyberg, project manager for the MASH project (which deals with mass casualties following the release of toxic chemicals or radioactive compounds), based at the European CBRNE Center, affiliated to the University of Umeå in Sweden. However, the belief that we are already prepared is often understood at a political level When we were tasked with examining the preparedness of the European Union for such events and to see how prepared we are, we found that we are actually not very well prepared, he says. There is a significant gap between political desires and actual preparedness. Crucially, the first responders the emergency medical teams that would cope with the first victims of an event, such as the detonation of a dirty radioactive bomb in a busy city centre are not equipped with the plans, the strategies, the procedures and do not dispose of medical departments or laboratories to cope with such an incident, should the worst occur. Moreover, any single incident would stretch the resources of a single country, especially those that are already the least prepared. Therefore an EU-wide response plan is crucial in order to prepare for an event in any one nation or region. Some of the countries in the Union are very poorly prepared, but the best prepared ones can help the least to raise their standards and work together to protect the health of all European citizens, says Dr Sellström. Roadmap to Protection The crucial step before increasing the capacity and preparedness in any country and thus spending on resources of equipment, training and infrastructure is the layout out of clear roadmaps and timelines that everyone could follow. MASH s action drawn up after thorough reviews of the literature and the state of preparedness throughout Europe, has made such roadmaps available. They are available through the project information portal and include general and more detailed guides on how to plan for a mass contamination event with chemical or radioactive materials. They lay out strategies for increasing the response capacity with feasible targets within fixed timelines (three years and ten years) and longer term targets beyond ten years. The rational was to prioritise issues correctly and to put preparation for big chemical and hazardous incidents at the top of the agenda, says Dr Sellström. Some things are relatively easier to do, so we suggest those be done in the first three years, such as making sure that emergency rooms and laboratories are properly equipped and all first responders adequately trained. Then later you can modernise them and upgrade standards. 22

25 Looking Ahead MASH also has laid out in its publications and suggestions for future research priorities, such as further investigations into the biomarkers that improve the detection, identification and monitoring of chemical threats, including a greater understanding of the patho-physiology in exposed individuals who do not exhibit physical symptoms. Monitoring them will help to maintain surveillance of the outbreak, as well as predict the potential future health problems of individuals, says Dr Göransson Nyberg. Researchers will need to work together and learn from each other to develop the best tools possible, says Dr Sellström. Science and research are developing rapidly worldwide. I come from a research background, so I know that if we are to improve the preparedness situation, we need to understand the importance of research and develop new tools. Though such research is expensive to conduct, it is crucial, and can be more easily done through networks such as those that now exist in the European Union. Incident management, for example, could and should include the use of media platforms such as television and radio to communicate with the public; secure databases with realtime surveillance capacities should be established quickly and competently; treatment centres should be set up at a distance from the incident scene with secure transport links and so on. Similar generalised guidelines for triage care, decontamination and hospital management are laid out crucial because until the MASH project, no consensus triage systems existed that could include the evaluation of chemical or radioactive risks. It is important that results are transformed into operational projects and networks that contribute to strengthening preparedness to threats that might result from radioactive substances or toxic chemicals and these projects are thus helping to increase the overall level of preparedness by society for harmful events. MASH All goals and guidelines were developed based on the results from research and reports in previous work, which evaluated injury panoramas under various possible scenarios: the release of 10 kilograms of mustard agent in a city leaving 50 people severely injured; the release of 13 tons of sulphur dioxide in a football stadium by terrorists leaving 1,000 dead; an explosion of 65 tons of chlorine from a derailed train leaving 1,500 people injured and one dead; an explosion of a radioactive medical agent contaminating hundreds of people; and the planting of five grams of iridium on a train seat, contaminating more than 40 commuters. These scenarios are extremely worrying, and very unlikely, but distressing enough that we should be prepared to deal with any of them, says Dr Sellström. Thus, if you can respond to all these scenarios, then you are truly prepared. 23

26 List of Generic Preparedness Planning Actions ARPEC Antibiotic Resistance and Prescribing in European Children ASHT Alerting System and Development of a Health Surveillance System for the Deliberate Release of Chemicals by Terrorists HPAweb_C/ ASHT II The Alerting System for Chemical Health Threats phase II CIE TOOLKIT The Public Health Response to Chemical Incident Emergencies InternationalActivities/CIEToolkit Climate-TRAP Climate Change Adaptation by TRaining, Assessment and Preparedness ECIIS (conference) European Conference on Immunisation Information Systems ECORAIP European Content for public health awareness of Rural population on Avian Influenza Prevention ENP4 Lab European Network of P4 Laboratories EPISOUTH Network for communicable disease control in southern Europe and Mediterranean countries EPISOUTH PLUS A Network for the Control of Public Health Threats and other biosecurity risks in the Mediterranean Region and Balkans type=1&id=21308 EQADeBa Establishment of Quality Assurances for Detection of Highly Pathogenic Bacteria of Potential Bioterrorism Risk Prevention/EQADeBa/EQADeBa node.html? nnn=true European Workshop on Ethics (conference) Ethics in our preparedness against an influenza pandemic in Europe today ETHREAT European Training for Health Professionals on Rapid Response to Health Threats ETIDE European Training in Infectious Disease Emergencies EURO-MOMO European monitoring of excess mortality for public health action EURONHID European Network for Highly Infectious Diseases FASTVAC A generic framework for FAST production and evaluation of emergency VACcines FLUSECURE Combating FLU in a combined action between industry and the public sector in order to SECURE adequate and fast interventions in Europe HEALTHREATS Integrated Decision Support System for HEALTH THREATS and crisis management GESTURE (conference) Global exchange of viral sequences to underpin response to health threats HEIBL (conference) Harmonizing European Initiatives of high-level Biocontainment Laboratories HIALINE Health Impacts of Airborne Allergen Information network IPPHEC Improve the Preparedness to give Psychological Help in the Event of Crises MASH MASs-casualties and Health-care following the release of toxic chemicals or radioactive materials 24

27 ORCHIDS Evaluation, optimisation, trialling and modelling procedures for mass casualty decontamination PHBLM Increasing Public Health Safety Alongside the New Eastern European Union Border Line PHLawFlu Public Health Law to Support Pandemic Influenza Preparedness PROMOVAX Promote Vaccinations among Migrant Populations In Europe QUANDHIP Quality Assurance Exercises and Networking on the Detection of Highly Infectious Pathogens, under negotiation REACT Response to Emerging infectious disease: Assessment and development of Core capacities and Tools Prevention/React/react node.html? nnn=true SHIPSAN TRAINNET EU Ship Sanitation Training Network SIDARTHa European Emergency Data-based System for Information on, Detection and Analysis of Risks and Threats to Health Triple S-AGE Syndromic Surveillance Survey, Assessment towards Guidelines for Europe WHO Emergency medical Services Assessment of emergency medical services preparedness in the framework of national crisis management structures in EU member states WHO Health security Support health security, preparedness planning and crisis management in EU, EU accession and neighbouring (ENP) countries WHO influenza epidemic preparedness Strengthening national pandemic influenza and other epidemic preparedness in Europe WHO Support Health security Support health security and preparedness planning in EU neighbouring (ENP) countries 25

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30 6 Notes

31 7