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					ECDC – a new agency for
 Public Health in Europe

           Karl Ekdahl
 Strategic Advisor to the Director
        How the European Union functions
        on health protection
• Health care is the business of Member States
• The European Union and Parliament has no
  remit to interfere in human health care issues
• Contrasts the position for animal health
• But infection is an anomaly (the six Freedoms)
         Internal Market – 4 Freedoms

•   Free Movement of People
•   Free Movement of Services
•   Free Movement of Goods
•   Free Movement of Capital
         Internal Market – 5th & 6th Freedom

•   Free Movement of People
•   Free Movement of Services
•   Free Movement of Goods
•   Free Movement of Capital
•   Free Movement of Micro-organisms
•   Free Movement of Birds
           Decision 2119/98/EC
           ”Network decision”
• Decision of the Parliament and the Council
• Community Network for epidemiological surveillance and
  control of communicable diseases :
    Epidemiological surveillance of diseases
    Early warning and response system (EWRS)
• Under coordination by the Commission decide on:
      List of diseases under surveillance = 49
      Criteria for selection of these diseases
      Case definitions – under revision
      Nature and type of data to be collected
      Epidemiological and microbiological surveillance methods
      Guidelines on protective measures (external borders)
      Guidelines on information and guidance to the public
       ”Daughter decisions” to 2119/98/EC

• Decision 2000/57/EC ”EWRS decision”
• Decision 2000/96 ”List of diseases under
• Decision 2002/253/EC (2002/534/EC) ”Case
• Decision 2003/542/EC ”DSN decision”
          Decision 2000/57/EC
          ”EWRS decision”
• Decision of Commission
• Events to be reported
      Outbreaks involving more than 1 MS
      National outbreaks with a risk of spread to other MS
      Outbreaks outside the Community with risk of spread to MS
      Appearance/resurgence of communicable diseases or
       infectious agents wich may require timely, coordinated
       Community action to contain it
• Procedures for informtion, consultation and
• Actors = The Commission and competent authorities
  in the MS, lately also ECDC
          Dedicated surveillance networks

•   One hub with coordinator and small secretariat
•   1 epidemiologist + 1 microbiologist per MS
•   Reporting of detailed diseases data
•   Detect outbreaks and follow trends
•   Scientific studies
•   Typically funded by Commission (60%) and
    MS (40%)
           Dedicated surveillance networks

•   EnterNet – Salmonella + EHEC (HPA, UK)
•   EU-IBIS – invasive HI and menigococci (HPA, UK)
•   EWGLI – Legionella (HPA, UK)
•   Euro-HIV – HIV/AIDS (InVS, France)
•   Euro-TB – TB (InVS, France)
•   IPSE – nosocomial infections (Université Claude Bernard, France)
•   EARSS – AMR (RIVM, Netherlands)
•   EISS – influenza (NIVEL, Netherlands)
•   EUVAC.NET – VPD (SSI, Denmark)
•   ENIVD – hemorrhagic fevers (RKI, Germany)
•   ESAC – antibiotic consumption (Univ. Antwerp, Belgium)
        General infrastructural networks

• EPIET – training field epidemiology (SMI, Sweden)
• BSN – minimal datasets of all diseases (SMI, Sverige)
• IRIDE – inventory of communicable disease control
  resources in Europe (ISS, Italy)
• Eurosurveillance – bulletin (HPA, UK + INVS, France)
• EpiNorth – Network for CD control in Northern Europe
  with bulletin, website, training courses (NPHI, Norway)
• EpiSouth – mirror of EpiNorth
         Health threats in Europe –
         21st century challenges

• New threats emerge
    SARS, pandemic flu, WNV, antimicrobial resistance
• Old diseases reemerge
    HIV/AIDS, STI, TB, food borne diseases
• Threat of bioterrorism
• EU without borders: free movements of goods
  and people
• Diseases spread within hours in a globalized and
  interconnected world
        Limitations with old setup

• Surveillance networks uncoordinated and without
  sustained funding
• No central expert authority
• Limited resources for rapid response
• Unflexible system (bound by contracts)
• 10 new Member States

• Above evident during SARS crisis  ECDC
Tomteboda – Home of ECDC
          ECDC milestones

• July 2003: Commission’s proposal to establish ECDC
• December 2003: Council decision that Sweden will host
  the Centre
• April 2004: Regulation 851 establishing the Centre
• December 2004: Director Zsuzsanna Jakab nominated
• March 2005: Director takes office (start-up phase)
• May 2005: Centre operational
• October 2005: Move to own facilities at Tomteboda
• 2007: Evaluation of the possible need to extend the scope
  of the Centre’s mission
         Very broad mandate
         Founding Regulation 851/2004/EC

•   Close cooperation with MS and EU bodies
•   Surveillance
•   Risk identification and risk assessment
•   Preparedness planning
•   Response to health threats and events
•   Training
•   Communication
•   Scientific opinions and guidelines
       Staffing and budget (2004 cost)

• 2005:         29+20 staff     5M€
• 2006:         50+40 staff    18 M €
• 2007:         90+60 staff    27 M €
• 2008:        120+80 staff    36 M €
• 2009:        150+100 staff   45 M €
• 2010-2013:   180+120 staff   50 M €
               ECDC Organigramme


                     Director’s Cabinet
                      External Relations
                     Country Strategies
                     Media & Information
                     Secretarial support

Scientific Advice                                Preparedness and
                       Surveillance and                                  Services
 Scientific Panels                                   Response
                       Communication                                   Finance & Budget
                                                  Threat Assessment
                        Data Management                                Human Resources
Advanced Analysis                                  Capacity Building
 Knowledge Base           Surveillance                                  ICT & Logistics
                                                   Crisis Operations
                                                                       Publications & Info
Matrix organisation

               Director and Director’s Cabinet

  Scientific      Surveillance &   Preparedness &   Administrative
   Advice         Communication       Response        Services


                   Antimicrobial Resistance

   HIV/AIDS and other STI and bloodborne viral infections

      Other horizontal Working Groups and Task Forces
        ECDC horizontal actions

• Forming partnerships
• Risk assessment
• Enhance surveillance activities
• Developing guidance and scientific opinions
• Disseminate information
• Assess country preparedness and capacity
  (country visits)
• Advocacy
        Director’s Cabinet

• Overall co-ordinating responsibility of all ECDC
• Governance (AF and MB)
• Integrated information system
• Communication strategies, media relations,
  Eurosurveillance, website
• External relations
“I would like to consult Europe –
but I don’t know the number there”

                    Henry Kissinger
           Commission        EP
                                  EU agencies

              community      countries
         Framework for Country Strategy

• Directory of contact points
    MB appoint and publish competent bodies
• Overview of health systems
    Detailed inventory of resources and expertise
     (build on IRIDE)
• Identification of need for support
    Action plan for 5 countries in 2006
• Working with regional networks
    EpiNorth, EpiSouth
         Scientific Advice Unit (I)

• Provide sound and independent technical and
  scientific advice
    Questions, guidelines, toolkits
    No own research capacity
• Well acquainted with the front-line of research in
  all areas of CD control
    Actively participate in key scientific conferences and
         Scientific Advice Unit (II)

• Network of experts and scientists in Europe
    Roster of experts
    Network of European reference laboratories
• Strong on new and emerging health threats
• Cooperation with laboratories
• Support member states in national endeavours
    Turn policies/guidelines into action if needed
    Advocacy
         Process for scientific questions

• Competence in house?
• Competence in one of the DSNs?
• Competence in one of the Scientific Panels?

• In real life, probably combination of these.
        Surveillance and Communication
• Gradually coordinate/integrate surveillance
  networks into ECDC
• Consolidate surveillance with DSN’s and national
  surveillance institutes
• Prepare case definitions
• Set up data-bases at ECDC
• Receive data from DSNs
• Technical assistance to MS on surveillance
• Surveillance  public health action
         Output of surveillance data

• “Surveillance is data for action”
• Data dissemination through various means
    Eurosurveillance scientific voice of ECDC
    Public and privileged web pages
    Surveillance reports
    Articles in scientific journals
    All necessary data should be easily available through
     the ECDC web portal
    Strategic partnership with the EpiNorth network and
         Preparedness and Response Unit (I)

• Epidemic intelligence
    Keep track of emerging health threats inside and
     outside the EU
    ProMed, GOARN, GPHIN, GIDEON and other
     Community alert systems
• Timely advice on such threats
• Assisting the Commission by operating the Early
  Warning and Response System (EWRS) with a
  24h/7d duty system
          Preparedness and Response Unit (II)

• Provide technical assistance in outbreak
  investigation and response
      Identify outbreak assistance teams
      Identify and mobilize lab capacity
      Training activities
      MoU with international partners (WHO)
      Inventory and development of response guidelines
           Output of epidemic intelligence data

• European Commission
    Commissioner briefing
• Member States
    Early Warning and Response System
    ECDC threat assessment weekly bulletin
• Public
    Eurosurveillance weekly
    ECDC website
          Training activities

• Activities in 2005
    Development of a training strategy document
     (with EPIET)
    Consultation of Member States
    Participation to training on ad-hoc basis
    Planning an outbreak team leader course
• Planned Activities in 2006-2007
      Transition of EPIET
      Identify training needs and topics
      Short courses on national level
      Develop training materials and manuals (web based)
         Scope of ECDC from 2010

• First rock solid in CDs = priority 1
• Review starts in May 2007
    Co-decision of Council and EP needed to extend scope
• Even if this happens not before 2010
    5 years only for CDs
• If extended - gradual process:
    Starting with health monitoring, analysis and reporting?
    Additional resources needed
        Key message

• ECDC could only be strong if built on strong
  European networks and ideas
• ECDC will provide needed services and give a
  clear added value to the European CD control
• ECDC will channel the best available resources
  (own and others) to where they will be best
How the European Union is
Preparing for Influenza - a
Perspective from the ECDC
         European Union – many strengths

•   Well resourced compared to other global regions
•   Some strong centralised health systems
•   Some strong public health systems
•   Enthusiasm to make EU and ECDC work
•   World class laboratories
•   Good vaccine manufacturing base
•   Innovative approaches x 25 +
•   European wide and international perspective
Controlling spread of influenza?
       Influenza milestones

• March 2005 - Euro Pandemic Preparedness
  Workshop 1 – Luxemburg
• May 2005 – ECDC became operational
• European Commission Generic and Pandemic
  Documents Launched
• October 2005 Euro Pandemic Preparedness
  Workshop 2 Copenhagen
• November 2005 – First Europe wide command
  post exercised (’Common Ground’)
• May 2006 Euro Pandemic Preparedness
  Workshop 3 Uppsala
        There have also been ’events’
        - mostly around bird flu
• H5N1 approaching relentlessly from the East
• Dead gull in September 2003
• Poultry outbreaks in Romania and Turkey
  Autumn 2005
• Human outbreaks on the fringes – Turkey
  January 2006
• Political events – London, Beijing etc
        Aims of the Workshops

• Coordinated approach European Commission,
  WHO/Europe and ECDC
• 52 European countries
• Share best practice
    All European countries have pandemic plans
• Inform about developments
• Latterly maintain momentum
        Intensive ECDC activities between
        workshops - examples
• Detailed influenza assessments in EU MS
    National and local
    Pandemic, seasonal and avian influenza
    Public health and microbiology
• Planning on surveillance
• Modelling
• Guidance Production
        Work on H5N1

• Essential but rather a distraction
• Huge opportunity costs for ECDC
• Kept the political momentum
        Recommendations from Uppsala
        Workshop, May 2006

• Complete toolkit and training packages for AI in
• Further country visits in EU and WHO region
• Sub-regional meetings to address interoperability
  and practical preparedness issues
• Further work on indicators
• Next EU / WHO plenary workshop will be July
         Issues for the EU – lots of these

• Interoperability issues
• Variable uptake of influenza seasonal vaccination
• Adjusting to H5N1 being either endemic or an occasional
• A common anti-viral policy?
• Agreement on public health measures to be recommended
• Local preparations only starting
• Intersectoral work (Ministries of Health, Agriculture,
  Education etc working together)
• Interpreting Ferguson et al 2006 for policy development
    What’s going to happen with H5N1 in
    the bird and the pandemic

“It is difficult to make
   ….especially about
   the future”
                    Yogi Berra
        Baseball Player & Sage