The belief that one day there might be a shield against communicable diseases and other serious cross-border threats to health gives a false sense of protection. Shields and armour belong to the histories of weaponry, as well as animal evolution. In both cases, where carapace, scales or plate were not as efficient as awareness of danger and prompt action to face a threat.
Studies show that screening potentially infectious people coming from an affected area is useless. Most communicable diseases don’t stop at borders. They travel in infected humans or animals or they expand their geographic spread by the settlement of their biological vectors in newly conquered areas of the world. During the last 10 years, we witnessed the SARS Coronavirus and the pandemic influenza A (H1N1) 2009 virus as they spread worldwide with no real hindrance. With the E. coli STEC O104 outbreak in 2011, we also realised that an emerging health crisis can come from within the European Union.
Despite all our efforts, we only become aware of a new disease or outbreak after the epidemic has been ongoing for quite a while, making containment at its original source too late to be efficient. We have to live with the ability of some diseases to spread ineluctably.
Not all health threats have this ability; communicable diseases can spread around the world, while ash clouds or radioactive dust can spread at a continental level. Other threats such as most viral hemorrhagic fevers or chemical disasters, are confined to their original or to neighbouring territories.
Communicable diseases are the focus of cross-border health threats because, being caused by biological entities, they can perpetuate themselves. Pathogens can sneak into a niche and settle there for a long time or even forever.
At the beginning of this century, the Global Outbreak Alert and Response Network (GOARN) was set up for swift responses to epidemics. The GOARN is piloted by the World Health
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Jean Claude Manuguerra heads the Laboratory for Emergency Response to Biological Threats at the Institut Pasteur, is the Chairman of the Committee for the Prevention and Control of Influenza, and is also Chairman of the steering committee of the Global Alert and Response Network. As a member of the French National Network of Laboratories he represents France at the group ‘Laboratory Network’ of the Global Health Security Initiative. He is the leader of the Work Package 3 in charge of outbreak assistance within the European Centre for Disease Control-European Network of Imported Viral Diseases-Community Laboratory.
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Organisation (WHO) and is a technical collaboration between a number of institutions and networks which pool resources for the fast identification, confirmation and response to outbreaks of international importance. The GOARN provides an operational framework to link this expertise and skill so as to keep the international community constantly alert and ready to respond to the threat of outbreaks. The implementation of the International Health Regulations (IHR 2005) has led GOARN to reflect on the possible extension of its mission into non-communicable diseases along the same lines the proposal for a decision of the European Parliament and of the Council on serious cross-border threats to health.
Prompt response is paramount in a health crisis, and the earlier the alert the better. Alert, from its Italian origin all'erta, literally “on the height or on the watch”, means being watchful (concept of preparedness) and prompt to meet danger or emergency (concept of responsive action). There are many ways to be alerted to disease; one such way is surveillance. In the past 20 years a number of surveillance networks dedicated to important infectious diseases have been successfully implemented within the EU. These have been mainly in a “bottom up” manner, such as the European Influenza Surveillance Scheme (EISS – now EuroFlu), the Surveillance of Tuberculosis in Europe (EuroTB) network, the Network for Human Salmonella Surveillance in Europe (Salm-Net) and the European Network for Imported Viral Diseases (ENIVD). The high technical performance of these EU networks was remarkable. Fourteen of these networks have now been partially or totally gathered under the umbrella of the European Centre for Disease Control (ECDC), becoming Community Networks of Reference Laboratories (CNRL), with a recurrent funding directly from the ECDC. These “disease specific” networks put the EU in a very effective position with regard to surveillance of the most important infectious diseases. The IHR, which is implemented worldwide, concerns more than just infectious diseases, so there is a need for the EU to match this new approach.
The IHR is an important instrument against health threats of international importance, which makes disease control and prevention worldwide more efficient. It was first put into
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real practice with the 2009 H1N1 influenza pandemic and proved to be a workable tool.
There are lots of positives to be found in the current information sharing both within the EU and between the EU and the rest of the world; however, this could be made more effective. One difficulty is the need to control the flow of information. How can we make sure that preliminary data are not taken as confirmed by local, national or even European health authorities? Jumping to conclusions too quickly before data could be verified and confirmed, and before further analysis could be carried out, caused chaos during the E. coli STEC O104 outbreak in 2011. The epicentre was in northern Germany but it affected the rest of Europe and beyond, with a tremendous negative impact on Spanish farmers.
The EU has important assets for fighting major health crises caused by infectious diseases, and is mainly well prepared. There is always room for improvement, and the Proposal for a decision of the European Parliament and of the Council on serious cross-border threats to health is very welcome. If the Health Security Committee is to become a formal committee, it will clarify its position, give it more visibility and make it more efficient. Other proposals in Chapters III and IV (articles 6 to 9), dealing with permanent surveillance and ad hoc monitoring and early warning and response systems, are in line with the global move to a more comprehensive preparedness worldwide and to a strengthened organisation within our Union.
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Surveillance and early warning
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