3 May 2002

by Julie Clayton, BioMedNet News

Does Europe need centralized infectious-disease monitoring, as the US has in its Centers for Disease Control? Many observers feel it is woefully unprepared for bioterrorist attack, but they disagree about whether to centralize or simply network.

Spurred by the recent anthrax attacks in the United States, the European Commission's Commissioner for Public Health and Hygiene, David Byrne, has visited the Centers for Disease Control and Prevention, in Atlanta to view its operations first-hand. The trip clearly left a lasting impression: Byrne announced plans for the new center on 15 April to delegates attending the European Regional Red Cross and Red Crescent Conference in Berlin.

The center aims to improve and coordinate surveillance for infectious disease in Europe, according to spokesman Thorsten Muench. In an editorial in Eurosurveillance in December, Byrne stated that at present Europe's resources and procedures were "woefully inadequate" to cope with an act of bioterrorism.

"I am working to establish a European Centre on Communicable Diseases (ECCD) which should become operational in 2005. Over the next year we will start to bring the necessary external expertise on board to prepare the ground for this new development," he said.

To some observers, the move is a welcome step in an ongoing debate on how Europe should deal with infectious diseases.

"I very much welcome David Byrne's initiative - it is absolutely necessary, and probably the only possibility, at this time, of improving surveillance in Europe," said antibiotic resistance expert Herman Goossens, professor of microbiology at the University of Antwerp, Belgium, in an interview with BioMedNet News.

But it may not go far enough, he says, in preparing Europe for a major event such as a bioterrorism attack.

"Europe is not ready to respond to bioterrorism attacks - at least if it comes to higher levels of infections," agreed Matthias Niedrig, of the Robert Koch Institute in Berlin, who spoke at a press conference of the 12th European Congress of Clinical Microbiology and Infectious Diseases in Milan. "National institutes have the necessary experience, but we need more resources, especially in the area of diagnostics," he said.

Niedrig is the director of the European Network for Viral Infectious Diseases, or ENIVD, one of several surveillance networks that ECCD is intended to support. ENIVD monitors the outbreak and spread of infections including tick-borne encepalitis, West Nile virus, and African Yellow Fever. His remit would also include the smallpox virus.

"We only have a few locations in which to perform pox diagnostics. But if you have a real outbreak situation of 50 to 100 samples, we do not have the capacity to do quick diagnosis," he warned.

Niedrig fears that the new ECCD may not provide adequate funding for ENIVD, and will in any case be too slow in its creation to be of immediate help. In the meantime, "we have no budget for outbreak investigation either in European or developing countries," he said.

The situation is urgent, agreed Maria Guismodo, head of the Clinical Microbiology Laboratory at the Luigi Sacco Teaching Hospital in Milan.

"In Italy we have just two labs for facing bioterrorism, my own one here in Milan, and in Rome. But we don't have any organized network or education program," she said.

Since 1998, a group of scientists including Michel Tybayrenc, at the French national research laboratories in Montpellier and Marc Struelens at the Erasmus Hospital in Brussels has called for a different kind of European Centre for Infectious Disease (ECID).. But the idea was rejected, as the council and parliament of the European Union decided to launch a decentralized set of disease-specific networks (The Community Network for the Epidemiological Surveillance and Control of Communicable Diseases (Decision 2119/98/EC)). Besides ENIVD, these cover HIV/AIDS, influenza, and viral hemorrhagic fevers, Legionella, tuberculosis, meningococcus, Salmonella, Campylobacter and E.coli 0157.

Byrne's new ECCD would strengthen and extend these networks, and create new ones, according to his spokesman Muench. It would also develop informatics and database management, and links with outside organizations such as WHO, OECD and Council of Europe.

"It is not intended to develop a European CDC like the one in Atlanta/USA, but rather to develop a small but efficient center for co-ordinating Community efforts," he said. This could develop within an existing European institution, with the emphasis on public health, Muench revealed to BioMedNet News.

But Tybayrenc and his colleagues, who are fighting to keep their own proposal alive, argue that the network system has inherent weaknesses, including the lack of a director and duplication of resources. In contrast, they argue in an article published this month (The European Centre for Infectious Diseases: An adequate response to the challenges of bioterrorism and major natural infectious threats, Infection, Genetics and Evolution, 1:3:179-181) that their own ECID would be a "centralized structure with walls," with "advanced research" and sharing of resources as high priority.

Others, however, support Byrne's network-based ECCD. "It's very sensible," commented public health physician Julius Weinberg, at City University in London, who prefers the network approach, particularly one that would involve existing national facilities.

"There's good evidence that the network approach has been quite successful," he said. "Many of the European networks have shown that by combining data from various different countries they can detect events that would not have been detected any other way, such as for the Legionellaand Salmonella networks." (Weinburg admits, however, that the system failed to achieve a consistent response across different countries to the H5N1 influenza strain.)

The alternative proposal, for a full-blown CDC-style center, would itself waste resources and duplicate what already exists at national levels, he believes. He advocates "good effective generic public health systems" that deal routinely with a range of infectious diseases - not specific bioterrorism-response systems - because "you actually don't know what the next bioterrorism event is going to be." He also favors limiting the amount of surge capacity.

"You can build endless P4 facilities against the day that someone releases a very virulent pathogen," he said, "but laboratories have to be doing something in the meantime."

Italy's Guismodo disagrees. The network-based ECCD, she declares, "will not be enough at all." Instead, she recommends replacing national and local initiatives with coordination by a central European institute.

Struelens and others fear that the new ECCD will also fail to pay sufficient attention to the technology needed for dealing with antibiotic resistance.

"All countries use their own [monitoring] system and there's variation regarding drugs and methodology," he warned.

Antibiotic resistance is occurring at an alarming rate, both in hospitals and in the community, with the highest numbers of cases in Southern Europe - particularly in Spain, Greece and Portugal, according to Goossens. In November 1991, the European Union began to address the problem by campaigning for the 'prudent use' of antibiotics in human medicine, animal health, and agriculture. It also set up systems to monitor antibiotic resistance and consumption. But according to Struelens, the methodology involved needs an upgrade to achieve higher resolution and portability.

To achieve the necessary critical mass of expertise and technology for future needs, a geographically centralized European Centre for Infectious Diseases is inevitable, Goossens said. "But it's probably not going to happen in my lifetime," he predicted.

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