Download Eurosurveillance Weekly, funded by DGV of the European

Eurosurveillance Weekly, funded by DGV of the European Commission, is also available on
the world wide web at <http://www.eurosurv.org>. If you have any questions, please contact
Chris Walker <[email protected] >, +44 (0)181 200 6868 extension 3422. Neither the
European Commission nor any person acting on its behalf is liable for any use made of the
information published here.
Eurosurveillance Weekly: Thursday 4 March 1999. Volume 3, Issue 10
Contents
1. From the editors: the bigger, better, brighter bulletin
2. Influenza activity in Europe
3. Influenza vaccine components for the northern hemisphere 1999-2000
4. Public health early warning system: Andalusia, Spain
5. Hepatitis A outbreak in a German town
6. Water related surveillance in Europe
7. New variant Creutzfeldt-Jakob disease in the United Kingdom
8. March edition of Eurosurveillance, which focuses of occupationally acquired HIV infection,
is now available on the Internet
From the editors: The bigger, better, brighter bulletin
This issue of Eurosurveillance Weekly defies me to find a unifying theme in terms of clinical
topics, but it includes current data on the surveillance of infectious diseases and articles that
describe international, European, and national initiatives to improve the public health. This is
what Eurosurveillance Weekly is supposed to do, and week by week the bulletin achieves its
aims to a varying extent. We have been encouraged this week by statistics that show a
considerable increase in the numbers of people accessing the website. Welcome to those of
you who have just joined us. Enjoy, let us know what you think, tell us the communicable
disease news from your country, and come again soon.
Stuart Handysides, editor ([email protected]), PHLS Communicable Disease
Surveillance Centre, London, England
Influenza activity in Europe
Increased levels of influenza activity are still being reported in most European countries. In
Germany, the Netherlands, Norway, and Switzerland influenza activity increased at the end of
February while in Belgium, Finland, and France it remained stable.
Influenza activity in Germany has increased steadily since the end of January. Influenza types
A and B have been isolated, but in parts of the country activity has now peaked. In Ireland
influenza A (H3N2) was isolated in January during a period of moderate influenza-like activity,
which declined in February. Italy has no national surveillance for influenza so most of the
information available is qualitative and is intended to identify the circulating viruses to provide
evidence with which to guide vaccine composition. Isolations of influenza viruses have
increased since February, suggesting that there has been a corresponding increase in
circulating virus. Influenza activity began to rise in Portugal in week 51 of 1998, peaked at
122.6 cases per 100 000 population in week 4 of 1999, and then declined. Although activity
has been moderate, except during week 4, it has been higher than in previous seasons. The
incidence was 29.1/100 000 in week 8 (ending 21.2.99), which is still above the baseline
level. Consultation rates in the United Kingdom have fallen to baseline levels, after peaking
over the Christmas and New Year period (1).
Reference:
1. CDSC. Influenza and other acute respiratory infections: update and vaccine selection for
the 1999/2000 season. Commun Dis Rep CDR Wkly 1999; 9: 81.
(http://www.phls.co.uk/publications/cdr.htm)
Reported by Penny Whiting ([email protected]), PHLS Communicable Disease
Surveillance Centre, London, England; Wolfgang Kiehl ([email protected]), Robert Koch
Institute, Berlin, Germany; Lelia Thornton (thornton@[email protected]), Eastern Health Board,
Ireland; Stefania Salmaso ([email protected]), Instituto Superiore di Santà, Rome, Italy; Isabel
Marinho Falcão ([email protected]), Instituto Nacional de Saùde, Lisbon,
Portugal.
Influenza vaccine components for the northern hemisphere 1999-2000
The World Health Organization (WHO) (1) recently published its recommendations for the
components of next season’s (1999-2000) influenza vaccine for use in the northern
hemisphere:
 A/Sydney/5/97 (H3N2) - like virus
 A/Beijing/262/95 (H1N1) - like virus
 B/Beijing/184/93-like virus or B/Shangdong/7/97 - like virus
Both of the recommended strains of influenza A virus are the same as those in this season’s
(1998-1999) vaccine, and one of the two possible B strains (B/Beijing) was also included in
1998-1999 vaccine. National control authorities have been left to decide which B components
to use, on the basis of local epidemiological data.
Influenza experts recently met at WHO’s headquarters in Geneva to discuss the prevention
and control of influenza. WHO is to distribute a pandemic plan that will emphasise the
respective processes and issues for WHO and its member states to consider in their
preparations for the eventuality of an influenza pandemic (2).
Reference:
1. WHO. Recommended composition of influenza virus vaccines for use in the 1999-2000
season. Wkly Epidemiol Rec 1999; 74: 57-61. (http://www.who.int/wer/74_1_26.html)
2. WHO. 50 years of influenza surveillance: much still to do to stop a common killer. WHO
press release WHO/11. 17 February 1999. (http://www.who.int/inf-pr-1999/en/pr9911.html)
Reported by Carol Joseph ([email protected]), PHLS Communicable Disease
Surveillance Centre, London, England
Public health early warning system: Andalusia, Spain
A public health early warning system was set up in Andalusia during the 1992 Seville World
Fair (EXPO 92). Its aim was the swift identification of food poisoning and environmental
diseases, such as legionnaires' disease, if they occurred in the fair’s showgrounds, in order to
prompt immediate responses by public health care services (24 hours a day). Similar public
health measures have been implemented in other areas of mass gatherings, such as sites of
pilgrimages and holiday resorts.
After EXPO 92, the health authority decided to expand the experiment throughout Andalusia
and extend it to include other infectious and non-infectious hazards. The early warning
system was provided with a legal and organisational framework. Every incident identified is
defined as an ‘alert’. Alerts may refer to:





outbreaks;
clusters;
statutorily defined urgent notifiable diseases;
sudden and unexpected health risk for the population; or
social alarm calling for response by public health care services.
A total of 404 alerts were registered during 1998 (5.5 per 100 000 population). Seventy per
cent of the alerts referred to food poisoning, 11% to waterborne diseases, 14% to other
infectious and parasitic diseases, and 3% to environmental problems. Primary health care
services identified and reported 62% of the alerts, hospital services 24%, consumers 6%,
emergency health services 4%, and others 4%. Eighteen alerts came from the National
Centre for Epidemiology (Centro Nacional de Epidemiología) and European networks.
The system has three intervention levels: district, provincial, and regional. The system’s
sensitivity for identifying problems, both in number and range, has risen during the
intervening years. The system is equipped with quality indicators for monitoring its progress.
Reported by J García ([email protected]) and J Guillén ([email protected]), Consejería de
Salud, Sevilla, Spain (http://www.csalud.junta-andalucia.es/saand/svea)
Hepatitis A outbreak in a German town
Twenty-seven cases of acute hepatitis A were detected in a small German town between
January and July 1998, where no more than three cases are usually identified in a year.
Twenty-three of the cases were children (aged 1 to 16 years) and three nursery schools and
seven schools were affected. The child believed to be the index case probably acquired the
infection on holiday in Cuba.
The initial management in the nursery schools included improving hygiene, observation of the
children’s health, and vaccination against hepatitis A. The initial vaccination coverage was
low because funding arrangements for the family physicians who were responsible for
administering the vaccine were unclear. Increasing numbers of cases caused anxiety in the
population. It was decided that a community health doctor should administer the vaccine,
funded by ‘sick funds’.
The resulting mass vaccination campaign (>1000 vaccinations) brought the outbreak under
control within five weeks, and follow up vaccination was arranged in a similar way. Although
vaccination for people at risk can be funded by the sick funds, a wider public health approach
that includes epidemiological and health policy aspects may suffer when funding
arrangements are uncertain. This incident illustrates the importance of ensuring that funding
arrangements for public health interventions are in place to enable effective outbreak control.
Initial control measures need to be rapid and thorough to prevent further spread of the
infection. In this outbreak the initial measures were insufficient and too late which resulted in
a need for mass immunisation to bring it under control.
Reported by Oliver Schaefer ([email protected]), London
School of Hygiene and Tropical Medicine,London, England from: Oppermann H, Ribbentrop
A, Kiehl W. Hepatitis-A-Ausbruch in einer Kreisstadt Sachsen-Anhalts. Epidemiologisches
Bulletin 1999; (5): 30-1.
Water related surveillance in Europe
‘Water is excellent’, wrote the Greek poet Pindar many centuries ago. In the context of water
supplies, excellence means water that is wholesome and clean, although not necessarily free
from all contaminants. The history of water related disease in Europe suggests that we have
often fallen short from the ideal of safe - and sustainable - water supplies for our populations.
Outbreaks, and emergencies such as floods, remind us periodically of the importance of
maintaining safe supplies for human consumption. There are three important elements to the
infrastructure needed for the surveillance of water supplies. Firstly, high standards of water
quality depend on vigilant surveillance of water contaminants and pollutants. Secondly, good
national databases and exchange of information between countries are needed, since neither
microbiological nor toxicological contamination of supplies respect boundaries. Thirdly,
coordination is needed to enlist the many disciplines that play a part in addressing the water
problems of particular countries and those that affect multiple countries. Water problems
include inequalities in access to reliable supplies, difficulties in providing resources for
appropriate public health surveillance, and the challenge of balancing the human need for
water against the need to maintain high ecological standards.
The recently revised EU Drinking Water Directive (1) recognises the need to achieve
compliance with essential quality and health parameters throughout the European Union (EU).
Experience gained from implementing the previous directive in 1980 (2) has convinced the EU
that member states need a flexible and transparent legal framework to address failures and to
meet standards, while allowing individual countries to achieve higher standards, or add other
parameters if they wish. The directive applies to water for direct human consumption as well as
water used in the food industry. Other directives cover natural mineral waters and waters used
in medicinal products. To be ‘wholesome and clean’ waters must be free of microorganisms,
parasites, and substances which, in numbers or concentrations, constitute a potential danger
to human health; it must also meet certain minimum requirements in all member states. The
directive aims to protect human health from the adverse effects of contamination, but mainly
covers quality standards, points of compliance, water quality monitoring, and remedial actions.
Member states have two years in which to comply with the directive, during which time any
amendments to national laws should be made.
The holistic approach needed to maintain and monitor water ecosystems is covered by two
other recent European initiatives. The first is the draft water framework for EU member states
(3). This draws on the precautionary principle, developed in Germany in the 1980s
(‘Vorsorgeprinzip’), which applies when there are threats of serious or irreversible damage.
The principle holds that a lack of full scientific certainty does not justify postponing measures to
prevent environmental degradation. Another important principle is that the polluter should pay
for the cost of preventing pollution, as first developed at the Stockholm Conference in 1972.
The draft water framework goes much further than previous water initiatives in requiring plans
for the management of river basins. Public consultation is an important part of these cyclic
plans. The water framework directive aims to protect aquatic and wetland ecosystems, to
promote sustainable water use, and to contribute to mitigating the effects of floods and
droughts. The emphasis on ecological systems acknowledges the effect of water
contamination on microscopic and macroscopic flora and fauna in lakes, rivers, and estuaries.
This initiative suggests a need to re-examine the traditional divide between the monitoring of
microorganisms and of chemicals and other non-biological pollutants. Just as waterborne
outbreaks are occasionally caused by chemicals, modern specialists in water surveillance
must consider all the possible threats to human health from water contamination and pollution.
The second recent European water initiative, the draft Protocol on Water and Health (4), aims
to combine the monitoring of renewable resources and public health surveillance. In particular,
it proposes a new legal instrument covering water and health. The European Environment and
Health Committee (EEHC) identified the need for a protocol in 1996 and invited the World
Health Organization (WHO) and the United Nations Economic Commission for Europe
(UN/ECE) to develop the document for signature at the Third European Ministerial Conference
on Health in June 1999. As in the water framework, the emphasis is on a holistic, ecological
approach. Important elements of the draft protocol include the surveillance of waterborne
diseases (including those related to microorganisms) and the establishment of early warning
and response systems. Its scope includes provisions for surface freshwater, groundwater,
estuaries, coastal waters used for recreation or the harvesting of shellfish, water in the course
of abstraction, transport, treatment or supply, and waste water. The response systems
proposed will depend upon prompt identification of outbreaks or incidents posing significant
threats to health and on their prompt notification to public authorities. A commitment is made to
ensure public involvement, both by providing education about water and health and in the
dissemination of information when water problems occur. The legal instruments regarding
water quality and associated target dates will give a renewed priority to WHO guidelines for
drinking water quality (5-7).
These initiatives have several implications for water surveillance in the EU and in Europe as a
whole. The legally binding nature of the proposals is likely to increase the demand for high
quality surveillance of infections related to water and the short and long term effects of
pollutants. More research will be needed on the health effects of water contaminants and
pollutants and of the influence of floods, other water disasters, and the impact of climate
change on water sources. The concept of sustainable development of water resources
requires both knowledge and acknowledgement of the need to achieve the best balance
between human health and that of the ecosystems. Waterborne disease databases will need
further and more coordinated development to provide sources of information about outbreaks
that can be shared and used to prevent future threats to public health. A recent review of
waterborne disease suggested that many countries have no national monitoring and recording
system for waterborne outbreaks (8). In the United Kingdom (UK), the Communicable Disease
Surveillance Centre of the Public Health Laboratory Service has published waterborne disease
reports only since 1995, although the Drinking Water Inspectorate has published eight annual
reports on water incidents and on water quality (9). The recent report from the UK Group of
Experts on Cryptosporidium in Water Supplies included a welcome emphasis on the
importance of epidemiological investigation and surveillance, including guidelines on methods,
questionnaires, and informing the public during outbreaks (10). The emphasis on
cryptosporidium reflected its predominance in reports of water related outbreaks in the UK, but
the epidemiological recommendations apply to other waterborne infections.
Chemical incidents provide a larger challenge, partly because of the greater uncertainty about
health effects, and also because cross-boundary surveillance systems have lagged behind
those established for gastrointestinal and other infections. The extent of the ‘Red Rhine’
incident in 1986 - in which the River Rhine in Switzerland, Germany, and the Netherlands
suffered chemical contamination following a fire in a factory - was detected only because a
relatively small quantity of a red dye (Basazole Red 71L) in the mixture facilitated follow up with
fluorescence measurements (11). Such incidents have shown the need for further
development of risk assessment regarding pollution (12) and this is reflected in the emphasis
on monitoring and assessing risk in the new European initiatives.
References:
1. Council of the European Union. Directive 98/83/EC on the quality of water intended for
human consumption. Official Journal of the European Communities 1998; 330: 32-54 (5
December)
2. Council of the European Union. Directive 80/778/EEC on the quality of water intended for
human consumption. Official Journal of the European Communities 1980; 229: 11 (15 July)
3. Council of the European Union. Amended proposal for a Council Directive establishing a
framework for concerted action in the field of water policy. Com (97)49 final 97/0067; Com
(97)614 final 97/0067; Com(98)76 final/0067
4. United Nations Economic Commission for Europe/ World Health Organization Regional
Office for Europe. Draft Protocol on Water and Health to the 1992 Convention on the
Protection and Use of Transboundary Watercourses and International Lakes. (Draft
prepared for Pre-conference meeting for the Third Ministerial Conference on Environment
and Health, June 1999) Copenhagen: WHO EUR/ICP/EHCO, 1998.
(http://www.who.dk/london99)
5. World Health Organization. Guidelines for drinking water quality. 2nd edition, volume 1:
recommendations. Geneva: WHO, 1993
6. World Health Organization. Guidelines for drinking water quality. 2nd edition, volume 2:
Health criteria and other supporting information. Geneva: WHO, 1996
7. World Health Organization. Guidelines for drinking water quality. 2nd edition, volume 3:
surveillance and control of community supplies. Geneva: WHO, 1997
8. Hunter P R. Waterborne disease: epidemiology and ecology. Chichester: Wiley, 1997: 34
9. UK Drinking Water Inspectorate. Drinking water 1997. London: The Stationery Office, 1998
10. UK Department of the Environment, Transport and the Regions (DETR). Cryptosporidium
in water supplies. Third Report of the Group of Experts (Chairman: Professor Ian Bouchier).
London: The Stationery Office, 1998
11. Dieter H H. The Red Rhine incident: a toxicological view. In: Golding A M B, Noah N,
Stanwell-Smith R (editors). Water and public health, London: Smith-Gordon & Nishimura,
1994: 59-76
12. Douben P E T (editor). Pollution risk assessment and management. Chichester: Wiley,
1998
13. World Health Organization. Guidelines on studies in environmental epidemiology.
Environmental health criteria 27. Geneva: WHO, 1983
Reported by Ros Stanwell-Smith ([email protected]), PHLS Communicable Disease
Surveillance Centre, London, England
New variant Creutzfeldt-Jakob disease in the United Kingdom
A total of 39 deaths of definite and probable cases of new variant Creutzfeldt-Jakob disease
(nvCJD) in the United Kingdom had been notified by 31 January 1999 (1). Three deaths
occurred in 1995, 10 in each of 1996 and 1997, 15 in 1998, and 1 in 1999.
Reference:
1. Monthly Creutzfeldt-Jakob disease figures. Department of Health, press release 1 March
1999.
(http://193.32.28.101/coi/coipress.nsf/Contents+by+Date+No+Frame?SearchView&Quer
y=FIELD+DepartmentCode+CONTAINS+GDH+AND+FIELD+Date+>=+01/01/1999+AND
+FIELD+Date+<+01/04/1999&SearchOrder=3)
Reported by Caroline Akehurst ([email protected]), PHLS Communicable Disease
Surveillance Centre, London, England
March edition of Eurosurveillance, which focuses of occupationally acquired
HIV infection, is now available on the Internet
The March 1999 issue of the monthly Eurosurveillance bulletin, also funded by the European
Commission, is now available both on paper (in English and French) and on the Internet (in
English, French, Portuguese, and Spanish) at http://www.ceses.org/eurosurv/
Contents:



A summary of occupationally acquired HIV infections described in published
reports to December 1997
Surveillance of occupational exposure to bloodborne pathogens in health care
workers: the Italian national programme
Accident compensation and occupationally acquired HIV infections in German
health care workers