Europe

Public Health Threats Today

The first epidemiological report from the European Centre for Disease Prevention and Control (ECDC) identifies antimicrobial resistance as the most serious public health threat facing Europe.

The Stockholm-based agency warns that “if the present rapid negative development is not halted, mankind will soon lose one of its most important weapons against infectious diseases”. It points out that every year, some three million people in the EU catch a healthcare-associated infection (HCAI), of whom 50,000 die, and that one patient in ten treated in EU hospitals acquires such an infection.

The report is based on national data from the 25 countries that were members of the EU in 2005 and from Norway, Iceland and Liechtenstein. Zsuzsanna Jakab, ECDC’s director, said that it would “give a major input to policy makers on where they need to invest in public health” particularly on diseases that easily cross borders and cannot be treated in one country alone.

In second place, after healthcare-associated infections, comes HIV infection. In 2005, just over 28,000 new cases were reported in the EU. Throughout the Union, there are now some 700,000 HIV-infected people – almost a third of whom are unaware they have the disease.

Other major threats are pneumococcal infections, especially among the young and the elderly; influenza – of both pandemic and seasonal varieties; tuberculosis, which was responsible for nearly 60,000 new cases in the EU in 2005; and Chlamydia infection and campylobacteriosis where some 200,000 cases are reported annually.

However, given the challenges associated with antimicrobial resistance (AMR), the ECDC makes a special plea for more accurate reporting in a bid to establish a clearer picture of the phenomenon. The data that exist, it points out, suggest that the problem is less acute in northern Europe, notably Scandinavia and the Netherlands, and that only two countries – France and Slovenia – have been successful in significantly reducing the proportion of methicillin- resistant Staphylococcus aureus (MRSA).

The agency notes that the present EU surveillance networks are focused on a few key pathogens in a system that relies on voluntary reporting from a limited number of laboratories. Not only can this be incomplete, but it can fail to shed light on the big regional differences which may exist within countries.

It would like to see existing EU and national surveillance covering trends of resistance in major important pathogens extended into two other areas. The first would involve detection of outbreaks and the spread of different problem bacteria; the second would identify novel superstrains where each isolate requires immediate and forceful action.

The ECDC study also draws attention to a relatively recent development: the way in which a large number of diseases is being detected and monitored is changing. No longer do they emerge from a doctor’s diagnosis of a patient. Instead, they tend to be discovered, often by chance, as an unexpected finding in a medical investigation or as part of a screening programme.

This shift leads the agency to offer more public policy advice. It is urging health authorities to raise the capabilities of their national laboratories to the same uniform level so that it becomes possible to draw an accurate epidemiological picture for the entire European Union.

The report also draws attention to the significant costs to health services of treating communicable diseases. In England, the process from consultation with a general practitioner to hospital admission for all communicable diseases can total £6 billion a year. In the Netherlands, the direct health service and wider indirect costs due to norovirus alone was estimated at ¤25 million in 2004.

In his foreword to the report, Markos Kyprianou, the EU Health Commissioner, acknowledges that for many of the 49 

diseases examined by the ECDC, the 10-year trend in the EU is either stable or declining. But, he too defines the emergence of new microbes as “perhaps the biggest challenge” health authorities now face, especially as “our defences are weak, or even non-existent”.

He contrasts the high-profile attention which has been given to the threat of an influenza pandemic with the observation that “deadly new microbes can also emerge in less spectacular ways”. The European Commission, he pledged, will make support for measures to address healthcare-associated infections one of its priorities in the coming months.

European Healthcare Services Present at the European Parliament and Council

During an informal meeting in Aixla- Chapelle in April, the Ministers of Health of the 27 member states reached an understanding with the Commission to regulate the healthcare services market in the European Union according to different measures. These will consist of regulations and other measures, for example guidelines.

The need for clarification concerns especially the question of reimbursement, as well as the responsibility for and the right to good quality healthcare, according to ministers. Moreover, it is essential to put in place the full conditions for patient information on the service offering and the quality of care.

In May, the European Parliament announced itself in favour of better information on patients and specialists, and for more legal security, as well as clear rules on responsibility. The bureaucratic obstacles must disappear, thanks to, for example, the promotion of electronic systems of identification of the patient, on-line healthcare and telemedicine. The members of the European Parliament want to guarantee patients access to the largest possible healthcare services in Europe.

The European deputies think that the safety and rights of patients are not guaranteed for the moment for cross-border healthcare. They asked for a precise definition of healthcare services, in order to clarify future legal rulings in the sector and to define unequivocally their domain of application. Furthermore, a European charter of patient rightsmust be adopted on the basis of the existing charter.

The members of the EU Parliament concluded by saying that close cooperation on all levels in the member states and in the EU could improve healthcare systems considerably and make them more efficient.

The Commissioner for Health, Markos Kyprianou promised to put forward a proposition on regulation before the end of the year, which will take account of the national jurisdiction in matters of organisation and funding of healthcare systems, but also the rights of insurers and suppliers in relation to cross-border freedom of movement.

Reimbursement of Services of Private, Foreign, Healthcare Providers and Non-Nationals

In the ruling of 19 April 2007 (C- 444/05), the European Court of Justice in Luxembourg decided that the absolute exclusion of reimbursement for a hospital treatment received in a foreign country violated the rights of the community. A system of prior approval, with the adoption of a table of reimbursement, would allow better adherence to the fundamental rights of the community, according to the judges. The case concerned a Greek patient who went to the United Kingdom for two hospital treatments. Reimbursement for the costs of these treatments was refused on the grounds that, according to Greek law, the cost of hospital treatments in a private, foreign clinic is not reimbursable, unless it concerns a child of under 14 years old.

For the Court, it was clear that such a rule discouraged the patient from enquiring about hospital service providers in other Member States other than that of which he/she is a member and that therefore represents a restriction of free circulation of services. There was no objection to this.

ECJ Defines Employer Obligations for the Protection of Employees

In a ruling of 14 June 2007 (C-127/05), the European Court ofJustice decided that the regulations inplace in Great Britain for the protectionof workers (Health and Safety atWork Act 1974) are legal. The lawincluded a clause according to whichevery employer must care about thesafety, health and well-being of workersat work, “in as much as that ispossible in practice”.

The directive 89/391/EEC on safety and health of workers obliges the employer to ensure the safety and health of the worker in all areas of work.

According to the EuropeanCommission, the British exception rule was too lax. The British legal conditions offer the possibility to employers to liberate themselves of their responsibilities if they can prove that the measures to guarantee the safety and health protection, compared to the cost, time and other difficulties, are completely disproportionate in relation to the risk incurred.

The decision of the judges did however follow the British explanations, according to which the Commission did not indicate in a strictly judicial fashion that this clause limited the responsibility of the employer in ignoring the provisions of the directive.

The Commission explained in this regard that the directive established the responsibility of the employer independently of any fault. According to the judges, such an interpretation of the directive is not sustained either by its wording, the preparatory work, or its classification. (HH)