Johan Giesecke

Intervening to Reduce Inequalities in Infections in Europe

The European Centre for Disease Prevention and Control was founded in response to newly emerging infections such as severe acute respiratory syndrome and avian influenza. However, Europe faces other communicable disease challenges that have proven to be remarkably resilient to public health interventions. We present examples of communicable diseases with inequitable distribution among those with poor educational attainment, low income, or other socioeconomic factors in every European country. Because these findings are incompatible with social justice and fairness, we examine strategic interventions targeting upstream causes of communicable disease transmission keeping in mind 10 indispensable public health functions essential to reach marginalized groups. These interventions have to be tailored to the socio-political context and rely on community-based decision-making and intersectorial collaboration.

Linking Environmental Drivers to Infectious Diseases: The European Environment and Epidemiology Network

Europe is increasingly at risk of the emergence of tropical diseases that are more commonly associated with warmer climates [1]. In 2010, Southeastern Europe witnessed an upsurge in West Nile fever cases that was strongly associated with excessive heat waves that had occurred in the preceding weeks [2]. France sustained its first autochthonous dengue transmission in the summer of 2010, and Madeira is currently experiencing the first persistent dengue transmission in Europe since 1920 [3]. In addition, the first outbreak of chikungunya outside the tropics occurred in 2007 in Italy, with subsequent autochthonous cases in France and Croatia in 2010 [4], and since 2009, Greece has experienced a resurgence of indigenous cases of Plasmodium vivax transmission in environmentally and climatically suitable areas [5]. Globalization and environmental change, social and demographic factors, and health system capacities are all significant drivers of infectious diseases [6]. International travel and trade can facilitate the dispersal of vectors and pathogens to new areas that are increasingly climatically and environmentally suitable. Environmental factors, such as agriculture, irrigation, and deforestation, are other important determinants of emerging infectious diseases. Urbanization and urban sprawl have encroached upon agricultural and seminatural areas in Europe, and the trend is expected to continue in many places. One consequence of habitat destruction is the displacement of wildlife, sometimes into urban or abandoned environments, which can in turn affect human exposures to infectious pathogens. In addition to the above, climate significantly influences the transmission of infectious diseases. Many zoonotic enteric pathogens, including salmonella, cryptosporidium, VTEC, and campylobacter, are known to exhibit seasonal patterns, while climatic conditions including temperature and rainfall influence the transmission of vector-borne diseases ranging from tick-borne encephalitis to dengue [7], [8]. Thus anthropogenic climate change, which has accelerated over the past decade, may lead to shifts in the distribution of infectious diseases [9]. Environmental drivers are often epidemic precursors of disease, meaning that monitoring changes in environmental conditions can guide the anticipation and forecasting of upsurges in infectious disease [10]. At an ecological level, the utility of predictive models has been documented for a number of case studies. For example: deer mice density has been used to predict hantavirus infections [11]; rainfall and temperature have been used as predictors of high-risk areas of plague and hantavirus pulmonary syndrome [12]; sea surface temperature, elevated rainfall, and vegetation index have been used to predict outbreaks of Rift Valley fever [13]; expansion of schistosomiasis in China has been linked to climate change scenarios [14]; climate change models have been used to predict Lyme disease risk and to forecast the emergence of tick-borne infectious disease [15]; and shifts in patterns of transmission of plague and tularemia have been assessed in relation to climate change [16]. A common message from these diverse studies is that merging environmental, remotely sensed, demographic, epidemiological, and other relevant data sets on the basis of common spatiotemporal features allows for the integrated analysis of complex interactions. In turn, identifying long-term trends will build the evidence base for strategic public health action, while identifying short-term events linked to environmental conditions can help improve and accelerate early warning and response capabilities. The European Centre for Disease Prevention and Control (ECDC) has recognised the strategic importance of such capabilities and has developed an information infrastructure coined the European Environment and Epidemiology (E3) Network, aimed at monitoring environmental conditions related to infectious disease threats [17]. The E3 Geoportal (http://E3geoportal.ecdc.europa.eu/), to be launched in 2013, will support data exchanges and sustained collaborations between EU Member States, researchers, and other interested collaborators (Figure 1). The E3 Network has been specifically designed with the intent of promoting European-wide research into environmental infectious disease epidemiology, leveraging existing European Community investments in this field, and facilitating the exchange of relevant data sets. In addition, the E3 Network also aims to provide technical support for the reporting, monitoring, analysis, and mapping of data and to enhance the analytical capacity of existing resources in Europe. Results could then be disseminated to policy makers, public health practitioners, European Union and international agencies, other governmental sectors, and nongovernmental organisations. Figure 1 Strategic focus of the E3 Network. For example, data from the E3 Network have recently been used to delineate areas suitable for malaria transmission in Greece during the resurgence of locally acquired Plamosdium vivax [5]. The objective was to define the environmental profile of areas with active transmission cycles between 2009 and 2012 and, based on this, to demarcate other regions at risk for malaria reemergence in Greece. A prediction model was developed with a number of environmental variables, including temperature (day- and nighttime Land Surface Temperature (LST)), vegetation seasonal variations (Normalized Difference Vegetation Index (NDVI)), altitude, land cover categories, and demographic indicators. These variables predicted suitability of areas for persistent malaria transmission characterized by low elevation, elevated temperatures, and intensive, year round irrigated agriculture with complex cultivation patterns (Figure 2). Such spatial analyses can help guide public health preparedness and response to infectious disease threats by directing surveillance and vector control activities. Figure 2 Areas predicted to be environmentally suitable for persistent malaria transmission in Greece, 2013.

Monitoring and assessing vaccine safety: a European perspective

The success of vaccination programs is an uncontroversial reality – in Europe as well as worldwide. On the other hand, the perceived risk of adverse events in the general public is the most important threat for implementing successful vaccination programs in Europe. For this reason, monitoring and assessing vaccine safety is a priority for public health. Vaccine safety is assessed both before and after vaccine authorization. In postmarketing settings, different activities related to vaccine safety usually involve several different stakeholders. In 2005, a new EU agency, the European Centre for Disease Prevention and Control, was established with the aim to strengthen Europe’s defences against infectious diseases. Implementing stable links between different stakeholders and defining clear roles in the EU is paramount in order to provide optimal and transparent information on adverse reactions following immunization, with the final goal of increasing compliance to safe and effective vaccination programs.

Polio and the risk for the European Union

Martin Eichner and Stefan Brockmann warn that “Vaccinating only Syrian refugees—as has been recommended by the ECDC—must be judged as insufficient; more comprehensive measures should be taken into consideration.” In response to the recent developments regarding wild-type polio virus (WPV) circulation in Israel and a cluster of poliomyelitis cases in Syria, the European Centre for Disease Prevention and Control (ECDC) has published two risk assessments for the European Union (EU). In those assessments, we stated that European countries are currently at high risk of WPV introduction and that there are areas of low vaccination coverage at increased risk for an establishment of local transmission of WPV. Importantly, in addition to vaccinating Syrian refugees, ECDC has invited European Member States to assess their national vaccination coverage against polio (we estimate that 12 million residents in the European Union younger than 30 years are unvaccinated), detect areas at risk, and to engage in complementary action, especially among vulnerable groups living in poor sanitary conditions, recommend to travellers to areas with WPV circulation to ensure they have an updated polio vaccination status, enhance their surveillance system based on the requirements established by the Regional Certification Commission for Polio Eradication, strengthen their existing environmental and enterovirus surveillance to complement acute flaccid paralysis surveillance (with the present suboptimum quality of EU polio surveillance systems it is probable that WPV circulation is not promptly detected), assess their laboratory capacity, and to update their preparedness plans for polio outbreaks. We declare that we have no confl icts of interest.

Assessing vaccination coverage in the European Union: is it still a challenge?

Assessing vaccination coverage is of paramount importance for improving quality and effectiveness of vaccination programs. In this article, some of the different systems that are used for assessing vaccination coverage within and outside the EU are reviewed in order to explore the need for improving vaccination coverage data quality. All countries in the EU have implemented vaccination programs for children, which include vaccinations to protect against between nine and 14 infectious diseases. Collecting and assessing vaccination coverage regularly is part of such programs, but the methods used vary widely. Some quality issues are evident when data reported through administrative methods are compared with seroprevalence studies or other surveys. More thorough assessment of vaccination coverage and more effective information sharing are needed in the EU. A homogeneous system for assessing vaccination coverage would facilitate comparability across countries and might increase the level of the quality of both the national and local systems. Cooperative and coordinated responses to vaccine-preventable disease threats might be improved by better information sharing.

A network strategy to advance public health in Europe.

Europe has a long tradition of preventing disease and prolonging life expectancy through organized public health interventions. Nevertheless, considerable challenges remain in a European Union that permits free movement of goods, services, money and people. While pathogens travel freely across borders, national control measures do so to a lesser extent. Thus, public health is hampered by societal, economic, financial and cultural differences and suboptimal collaboration between responsible agencies. These challenges became initially apparent during the SARS emergency and subsequently during the avian influenza threat that drew a lot of media attention. With the foresight to enhance preparedness and response to communicable disease threats the European Union created a specialized agency in Stockholm, Sweden. This new EU agency, the European Centre for Disease Prevention and Control (ECDC), has the mandate to control communicable diseases in Europe. Since the existing measures were inadequate to deal with multi-country outbreaks, ECDC strives to assess the risk to Member States. This effort can be enhanced through collaboration and networking between European public health practitioners. ECDC has been operational since May 2005 and although still relatively small (151 staff members as of February 2008), the organization is rapidly growing. ECDC, according to its mission1 and under the guidance of its Management Board and Advisory Forum, has focused on developing an integrated surveillance system for the EU, setting up a system for rapid response to outbreaks and epidemics, establishing a unit for health communications and scientific advice (figure 1). The latter provides independent scientific opinions, expert advice, data and information on pertinent public health issues in Europe and leads an initiative on climate change and migrant health. The Health Communication Unit is responsible for communicating the scientific and technical outputs of the Centre to European health professionals and to the general European public, as well as …

Lessons learnt in Europe on tuberculosis surveillance, outbreaks and BCG vaccination in 2011

Only a few European scientific journals publish articles on respiratory infectious diseases and tuberculosis (TB). The European Respiratory Journal ( ERJ ) and Eurosurveillance are two examples with a different focus. Eurosurveillance , which is published by, but editorially independent from, the European Centre for Disease Prevention and Control (ECDC) is a European peer-reviewed scientific journal devoted to the epidemiology, surveillance, prevention and control of communicable diseases, with a focus on topics that are of relevance to Europe. To inform the readers of the ERJ about what was published on TB epidemiology, surveillance, prevention and control this editorial will provide a summary of articles published in Eurosurveillance and in other journals in 2011 on TB in Europe. We used Eurosurveillance as a model to get an overview of the TB areas covered by a European journal directed at public health. All articles published on TB in Eurosurveillance in 2011 were identified, and grouped into three categories: outbreak reports; surveillance reports; and BCG (bacille Calmette–Guerin) vaccination. We searched the bibliographic database MEDLINE for other studies from Europe on similar topics. The information provided in the articles was summarised in tables. The interpretation of the results and their relevance for TB control and elimination in Europe is discussed in the sections below. The articles published on TB outbreaks in Europe are summarised in table 1 [1–7]. View this table: Table 1– Tuberculosis (TB) outbreak reports in Europe published in 2011 Three papers published in Eurosurveillance described an outbreak of TB in a European country. A study from Rome, Italy showed that 118 (9%) neonates tested QuantiFERON-TB Gold In-Tube (QFT-GIT; Cellestis, Carnegie, Australia) positive after exposure to a sputum-culture positive nurse at a maternity ward [1]. Since there are no estimates of QFT-GIT sensitivity and specificity in newborns it is unknown what the risk of progression to active TB is for children with …

HIV surveillance and injecting drug users in Greece

Evangelos Alexopoulos (Sept 28, p 1095) questioned the validity of HIV surveillance data in an outbreak of HIV in injecting drug users (IDUs) in Athens, Greece. This outbreak, fi rst reported in 2011, has continued in 2013 with nearly 1000 new HIV cases reported during this period in IDUs. In an in-depth assessment of the situation of HIV in Greece, the European Centre for Disease Prevention and Control found the HIV surveillance system of the Hellenic Center for Disease Control and Prevention to be functioning well, with adequate mechanisms in place to identify unique new cases and to exclude duplicates from surveillance reports. Molecular phylogenetic analysis of the new HIV cases further supports that the cases reported are unique and likely to have been infected from mid-2010. Once the outbreak was identified, efforts were intensified to test and scale up prevention in IDUs in Athens. Since 2012, the ARISTOTLE programme has contributed to surveillance and case finding. This shift to more active surveillance has increased the sensitivity of the system, with data providing a more accurate representation of the situation. This outbreak is occurring at a time when Greece is experiencing severe financial constraints, making the allocation of limited public health resources a challenge. It is essential that Greece sustains and scales up funding for outreach, needle and syringe exchange programmes, and opiate substitution therapy to try to reduce HIV transmission in IDUs.