Europe must learn from the E. coli outbreak
Addressing possible scenarios could strengthen systems, equipping them for future public health emergencies – write Rachmat Irwansjah, Anjeli Narandran, Naoko Noda and Sunkyoung Lee
The recent outbreak of a fatal strain of E. coli has had a significant impact on both health and non-health sectors in Europe. It started with a report to the European Early Warning and Response System that severe illness was causing concern in Germany. The illness caused people to suffer from haemolytic uremic syndrome and bloody diarrhoea - which were later identified as complications of an infection by a particular group of Escherichia coli bacteria, known as Enterohaemorrhagic E. coli.
Many people have since been sent to hospital, with several requiring intensive care. Other European Union countries - including Austria, Czech Republic, Denmark, France, Greece, Luxembourg, the Netherlands, Poland, Spain, Sweden, and the United Kingdom have since reported cases. The majority of the people affected had recently visited northern Germany. The condition of those afflicted continued to worsen with some eventually dying of complications. Since the source of infection was ostensibly identified, the situation in Germany has been mitigated and the number of new infections has declined rapidly. But, new cases emerged in the French Bordeaux region and Southern Sweden - with no travel history related to the Germany.
The European Commission responded to the outbreak in Germany through its EWRS. Rapid assessments, outbreak investigations and daily situation updates were conducted to identify the source of infections and contain the outbreak. Some possible sources of infection were investigated - including meat, dairy products and vegetables - and some precautionary measures were announced to the public. Citizens were urged to avoid certain types of vegetables and maintain sound hygiene practices like regular hand washing and sanitary food preparation. Although the investigation in Germany revealed the source of the disease to be contaminated bean and seed sprouts, the initial announcement advising the public to avoid cucumbers from Spain nevertheless had an impact on intra-regional trade and agriculture. It resulted in significant economic losses to cucumber farmers in Almeria and Malaga, as their exports were banned by many countries.
The recent cases in France and Sweden have led Europe to reinforce their epidemiological investigation in four key areas: food source identification, collaborative trace-back investigations, awareness-raising among clinical practitioners and public health advice. A joint task force was established by the European Food Safety Authority comprised of its own experts as well as those from the commission, member states, the European Centre for Disease Prevention and Control and the World health Organisation - with the aim of conducting trace-back investigations. The investigations determined that the source of the outbreak was imported seeds from Egypt.
An outbreak is by definition, sudden and often unpredictable. But some lessons could be drawn from this experience to improve current preparation and response strategies, so as to ensure even greater efficacy in the event of future outbreaks. Public communication strategies should be strengthened for early warning and response. They should be made in a cautious and effective manner in combination with stringent containment measures in order to avoid widespread panic. The importance of a sound public communication strategy became apparent during the outbreak of Severe Acute Respiratory Syndrome in Asia and was emphasised during the recent H1N1 pandemic.
The former showed that there was correlation between communication strategies adopted by different countries and the success of a country in dealing with SARS. Countries that communicated the risk by delivering factual and timely information to the public, as was the case in Singapore and Vietnam, were able to successfully reverse the situation. By contrast, the pandemic alert issued in response to the H1N1 outbreak created public panic and triggered stringent public health measures in different countries. Although the pandemic proved to be milder than had been expected, the reactive measures affected non-health sectors - such as transportation, due to travel restrictions and mandatory quarantine procedures, and education - due to the closure of public schools.
The recent outbreak of E. coli in Europe also indicated the importance of involving multiple stakeholders from health and non-health sectors - including businesses and civil-society, in preparatory and response measures. Plans need to reach beyond authorities, in what the United Nations has begun to encourage as a "whole of society" approach. This idea is to encourage better involvement of other sectors for a swift and successful response as well as to minimise impacts of any public measures on non-health sectors. The application of a multi-sector approach in the plan could be in the form of joint outbreak investigation or assessment, incorporating it into a communication strategy comprehensible to people who don't have access to a lot of knowledge on public health.
The E. coli outbreak and experience with SARS and H1N1 all indicate the need for preparatory and response systems to accommodate a range of infectious agents, including biological and non-biological agents - when anticipating any public health emergency of the future. And the E. coli outbreak has provided the impetus for reform of the way Europe deals with public health crises. What should follow is a period of evaluation of current practices, revisiting of old assumptions and reflection on the implications of the uncertainties surrounding the next possible outbreak or pandemic. Even in times of relative calm - a consistent, inclusive and future-oriented approach to planning, could prove to be a worthwhile investment for governments, health and non-health sectors. Addressing future uncertainties now could strengthen existing systems, equipping them for any public health emergency that may occur in the future.
Rachmat Irwansjah, Anjeli Narandran, Naoko Noda and Sunkyoung Lee work for the Asia-Europe Foundation – but write here in a personal capacity