Version 2 (29th January 1999)Alerting System for Chemical Health
Threats Phase II (ASHTII)
WP5 Mechanism for Alerting and Engaging Public Health Authorities
and Ministers, and capacity to post potential threats on RAS-CHEM
(D3)
WP Lead Partner Organisation
Wyke S, Coleman G, Orford R, Duarte-Davidson R HPA Associate
Partners
Mathieu-Nolf M, Linke JC, Nisse P CHRU-Lille
Dragelyte G, Badaras R HESC
Pelclova D GFH
Funding and disclaimer
This report arises from the project Alerting System for Chemical
Health Threats Phase II (ASHTII; project number 2007210) which has
received funding from the European Union, in the framework of the
Health Programme. Sole responsibility for this publication lies
with the authors and the Executive Agency for Health and Consumers
is not responsible for any use that may be made of the information
contained therein.
ii
iii
ACKNOWLEDGEMENTS
Department of Health, Social Services and Public Safety Northern
Ireland.
Public Health Wales
Health Protection Scotland
iv
ABBREVIATIONS
CMO Chief Medical Officer
DHSSPS Department of Health, Social Services and Public Safety
(NI)
FOI Freedom of Information
HPA Health Protection Agency
HPS Health Protection Scotland
HSSB Health and Social Services Boards (NI)
NIH National Institute of Health (Italy)
NHS National Health Service
NFP National Focal Point
PHA Public Health Agency (NI)
PHEICs Public Health Emergencies of International Concern
WAG Welsh Assembly Government
WHO World Health Organization
1 International Reporting of Health Threats 1
2 European Alerting of Health Threats 4 2.1 Programme of
cooperation on preparedness and response to biological and chemical
agent attacks 4 2.2 The Health Security Committee (HSC) 5 2.3
Available Rapid Alert Systems 6
2.3.1 Rapid Alert System for Food and Feed (RASFF) 6 2.3.2 Rapid
Alert System for non-food consumer products (RAPEX) 6 2.3.3 The
Early Warning and Response System 6 2.3.4 Rapid Alert System for
Biological and Chemical Alert (RAS
BICHAT) 7
3 Developing a Rapid Alert System for Chemical Health Threats (RAS-
CHEM) 9
3.1.1 Why does the EU need RAS-CHEM? 10 3.1.2 RAS-CHEM users
12
3.2 Existing alerting systems at International, European and Member
states levels 13
3.2.1 The European Association of Poisons Centres and Clinical
Toxicologists (EAPCCT) 14
3.2.2 Two sub-regional European Networks 15 3.2.3 The Nordic
Association 15 3.2.4 The Society of Clinical Toxicology of German,
Austrian and
Swiss Poisons Centres (Gesellschaft für Klinische Toxikologie,
GfKT) 15
4 United kingdom 18 4.1 Specialist Public Health Protection
Resources 18
4.1.1 The Health Protection Agency (England and Wales) 18 4.1.2
Public Health Wales 19 4.1.3 Health Protection Scotland (Scotland)
21 4.1.4 Department of Health, Social Services and Public
Safety
(DHSSPS) 22 4.2 The current alerting process in the UK 24 4.3
National Services in the UK where an alert could be escalated from
the EUPC Forum 27
4.3.1 National Health Service 27 4.3.2 Primary responders 27 4.3.3
National Poisons Information Service (NPIS) 28 4.3.4 Local
Government 28 4.3.5 Intelligence Agencies 28 4.3.6 Department for
Environment, Food and Rural Affairs (DEFRA) 28
5 Czech Republic 30 The Fire Brigade Rescue Corps of the Czech
Republic 31
6 France 32 6.1 The French toxicovigilance system : its role in the
management of toxicological alerts 32 6.2 National organisation of
toxicovigilance 32
vi
6.2.1 Current situation 32 6.3 Evolution of the French legislation
34
6.3.1 National poison centres information system, the French-TESS
34 6.3.2 ToxAlert System 35 6.3.3 National organisation of health
alert 36
7 Lithuania 38 7.1 The Health Emergency Situation Centre (HESC)
38
7.1.1 Specific functions of the HESC 39
8 Germany 40 8.1 Legal obligation and legislation 40
8.1.1 Institutions, Authorities, Ministries and Government
Departments responsible for managing chemical incidents 40
8.1.2 The role German Poisons Centres in issuing a Public Health
Alert 41
9 Italy 43
APPENDIX A 44 A1 Control Authorities involved in the RASFF 44
APPENDIX B 47 B1 Reporting of IHR notifiable diseases from UK to
WHO 47 B2 Assessment of potential PHEICs not included in the
defined list of diseases 48 B3 Provision of information to WHO
about potential PHEICs not included in defined lists of diseases
49
APPENDIX A 44 A1 Control Authorities involved in the RASFF 44
APPENDIX B 47 B1 Reporting of IHR notifiable diseases from UK to
WHO 47 B2 Assessment of potential PHEICs not included in the
defined
list of diseases 48 B3 Provision of information to WHO about
potential PHEICs not
included in defined lists of diseases 49
Figure 1: The IHR alerting structure 2 Figure 2. Bindeez™ toy beads
which contained 1,4-butanediol, metabolised to GHB in humans. 11
Figure 3. Example of melamine contamination 11 Figure 4. Visual
representation of RAS-CHEM and the EUPC Forum 13 Figure 5. Reebok’s
heart-shaped charm bracelet distributed as a gift to its clients in
2006. 14 Figure 6: Summary of European Alerting Networks 17 Figure
7: Structure of the current alerting process in the United Kingdom
26 Figure 8: Structure of the current alerting process in the Czech
Republic 31 Figure 9: Organisation of the French Toxicovigilance
system 33 Figure 10: Procedure for managing toxicological alerts
and requests intended to the NCCT 34
vii
Figure 11: Health Emergency Situations Centre 39 Figure 12:
Overview of poisons centres in the Federal Republic of Germany.
41
INTERNATIONAL REPORTING OF HEALTH THREATS
1
1 INTERNATIONAL REPORTING OF HEALTH THREATS
In today’s globalised economy, disease can spread far and wide via
international travel and trade. A health crisis in one country can
impact livelihoods and economies in many parts of the world. Such
crises can result from emerging infections like Severe Acute
Respiratory Syndrome (SARS), or a new human influenza such as the
recent H1N1 international pandemic.
The International Health Regulations 2005 (IHR) came into effect on
15 June 2007, and impact governmental functions and
responsibilities across many ministries, sectors and levels. The
IHR 2005 are an international legally binding instrument in 194
States worldwide, designed to help protect all States from the
international spread of disease, including public health risks that
have the potential to cross borders and threaten people
worldwide.
IHR (2005) require countries to report defined disease outbreaks
and public health events to WHO. Building on the unique experience
of WHO in global disease surveillance, alert and response, the IHR
define the rights and obligations of countries to report public
health events, and establish a number of procedures that WHO must
follow in its work to uphold global public health security.
The IHR also require countries to strengthen their existing
capacities for public health surveillance and response. WHO is
working closely with countries and partners to provide technical
guidance and support to mobilize the resources needed to implement
the new rules in an effective and timely way.
The purpose and scope of the IHR (2005) are very broad and focus on
almost all serious public health risks that might spread across
international borders. Specific aim of the IHR (2005) are "to
prevent, protect against, control and provide a public health
response to the international spread of disease in ways that are
commensurate with and restricted to public health risks, and which
avoid unnecessary interference with international traffic and
trade." Because the IHR are not limited to specific diseases, but
are applicable to health risks, irrespective of their origin or
source, they will follow the evolution of diseases and the factors
affecting their emergence and transmission. The IHR also require
States to strengthen core surveillance and response capacities at
the primary, intermediate and national level, as well as at
designated international ports, airports and ground
crossings.
The scope includes “illness or medical condition, irrespective of
origin or source that presents or could present significant harm to
humans”. If a State Party has evidence of an unexpected or unusual
public health event, irrespective of origin or source, which may
constitute a public health emergency of international concern, they
are required to provide WHO with all relevant public health
information. In cases where there is insufficient information
available to complete the decision instrument, a state may still
keep the WHO advised through the National IHR Focal Point and
consult with WHO on appropriate health measures (if required).
National Health Bodies are involved in the communication of alerts
and there is a WHO and European Union National Focal Point in each
Member State.
2
To fulfil its mandate under the IHR (2005), WHO must rapidly and
consistently identify and assess events of potential international
public health concern. Depending on its assessment, WHO must then
inform its Member States about such threats and assist affected
states in their investigation and control. Finally, in extreme and
rare circumstances, the Director General may declare events to be
Public Health Emergencies of International Concern (PHEIC). An
effective event management process will protect international
public health security by ensuring that:
• Events are detected early
• Reactions are appropriate and based on well-founded risk
assessments and international best practice where the latter is
established
• The international community is provided with timely and accurate
information about the event
• Effective international assistance, when requested, is rapidly
provided to control threats at their source, and to reduce human
suffering, economic and social losses
Figure 1: The IHR alerting structure
The effective implementation of these obligations requires than an
adequate legal framework is in place and according to the IHR
(2005) State Parties are required to designate a National Focal
Point (NFP) (a national centre, established or designated by each
State Party) to be accessible at all times (7 days a week, 24 hours
a day and 365 days a year) for IHR (2005) related communications
with WHO IHR Contact Points. Another role of the NFP is to
disseminate information to, and consolidate input from
International Community
WHO GENEVA
IHR Secretariat
WHO Euro
3
relevant sectors of the administration within the country,
including those responsible for surveillance and reporting, points
of entry, public health services, clinics and hospitals.
The NFP has a duty to both assess events that may be Public Health
Emergencies of International Concern (PHEICs) and to notify them to
WHO. The majority of NFP communications are expected to relate to
disease outbreaks, however, the broad scope of IHR (2005) may
require the NFP to carry out activities with respect to events
arising from non-communicable or unknown aetiologies, including
chemical or radionuclear events. Accordingly, the required
information and communication functions and capacities must be
established for these areas as well as those concerning
communicable disease.
4
2 EUROPEAN ALERTING OF HEALTH THREATS
Each member state is responsible for the safety of its citizens and
the management of emergency situations, however communicable
diseases and chemical, biological radiation and nuclear (CBRN)
events do not respect national borders. Threats to public health
are an ongoing cause of concern for health authorities across the
world and it is important to ensure a coordinated approach between
EU countries for the public health management in emergency
situations. To ensure that the EU is ready to face such threats,
the European Commission has been working in collaboration with EU
Member States to develop appropriate response strategies.
In order to improve the EU state of preparedness and better
protection of EU citizens against health threats, the Commission
actively cooperates with international public health partners, such
as the World Health Organization (WHO), the Global Health Security
Initiative, the countries of the European Economic Area and those
particularly included in the European Neighbourhood Policy.
EU Member States are implementing International Health Regulations
(IHR), which are legally binding regulations (see chapter 1) that
have been adopted by most countries and have the aim to contain the
public health threats that may rapidly spread from one country to
another. In this context, the rapid alert system for chemical
health threats is a supporting tool for EU Member States.
Article 152 of the EC Treaty says that a "high level of human
health protection shall be ensured in the definition and
implementation of all Community policies and activities". There is
various legislation1 2 3
The Commission is working to ensure that, in the event of an
emergency Member States are able to react in a coordinated and more
effective way. The Commission have put in place a programme and
structure to identify key national personnel to enable them to
achieve the best response for each Member State.
(Decision No’s 1786/2002/EC, 1350/2007/EC and regulation (EC) No
851/2004) that underpins the Commission’s mission to support and
improve preparedness and response to potential public health
threats.
2.1 Programme of cooperation on preparedness and response to
biological and chemical agent attacks
The programme of cooperation on preparedness and response to
biological and chemical agent attacks was established with the aim
to coordinate and support the
1 Decision No 1786/2002/EC of the European Parliament and of the
Council of 23 September 2002 adopting a programme of Community
action in the field of public health (2003-2008). OJ L 271,
9.10.2002, p. 1–12. 2 Decision No 1350/2007/EC of the European
Parliament and of the Council of 23 October 2007 establishing a
second programme of Community action in the field of health
(2008-13), OJ L 301, 20.11.2007, p. 3–13 3 Regulation (EC) No
851/2004 of the European Parliament and of the Council of 21 April
2004 establishing a European centre for disease prevention and
control. OJ L 142, 30.04.2004, p. 1-11.
EUROPEAN ALERTING OF HEALTH THREATS
5
public health/ health security preparedness and response capacity
and planning of Member States against biological and chemical agent
attacks.
Specific objectives of the programme are to;
• Set up a mechanisms for information exchange, consultation and
coordination for the handling of health-related issues with regard
to attacks in which biological and chemical agents might be or have
been used;
• Create an EU-wide capability for the timely detection and
identification of biological and chemical agents that might be used
in attacks and for the rapid and reliable determination and
diagnosis of relevant cases, in particular by building on systems
already available with the aim of long-term sustainability;
• Create a medicines stock and health services database and a
standby facility for making medicines and health care specialists
available in cases of suspected or unfolding attacks;
• Draw-up rules and disseminate guidance on facing-up to attacks
from the health point of view and coordinating the EU response and
links with third countries and international organisations.
2.2 The Health Security Committee (HSC)
The Health Security Committee (HSC) is comprised of high-level
representatives and officials of the EU Member States who are
authorised to take decisions and commitments with respect to
preparedness planning and response in case of emergency. The HSC is
chaired by the European Commission and other members include
officials of the Directorate General for Health and Consumers (DG
SANCO) and other relevant Commission services and agencies (e.g.
ECDC, EMEA). The HSC holds face-to-face meetings twice a year.
Specific functions of the HSC are to;
• To exchange information on health-related threats from acts of
terrorism or any deliberate release of biological or chemical
agents with intent to harm health;
• To share information and experience on preparedness and response
plans and crisis management strategies;
• To be able to communicate rapidly in case of health-related
crises; • To advice Health Ministers and the European Commission on
preparedness and
response as well as on coordination of emergency planning at EU
level; • To share and coordinate health-related crisis responses by
Member States and the
Commission; • To facilitate and support coordination and
cooperation efforts and initiatives
undertaken at EU level and help contribute to their implementation
at national level. In order to ensure a rapid and effective
response by the EU to a wide range of emergencies, the Commission
has put in place several early warning and rapid alert systems.
These systems allow public health authorities in Member States and
the Commission to receive and trigger an alert, as well as
exchanging other relevant information regarding events likely to
affect public health at EU Level and coordination of
measures.
6
2.3 Available Rapid Alert Systems
A Public Health incident may occur at any time, and early warning
and rapid alert systems are in place to exchange information on
incidents within the EU and neighbouring or third countries. These
systems are based on an information exchange network for receiving
and triggering an alert as well as exchanging other relevant
information. Each of these systems covers a specific health threat
field.
2.3.1 Rapid Alert System for Food and Feed (RASFF)
The Rapid Alert System for Food and Feed (RASFF) was established in
1979. The purpose of the RASFF is to provide control authorities
(listed in Appendix A1) with an effective tool for exchange of
information on measures taken to ensure food safety. In 2008, RASFF
was recognised as a great success in preventing numerous cases of
food poisoning. Most important risks of food poisoning (regarding
the number of alerts) are products containing potentially
pathogenic micro-organisms, foreign bodies (such as glass fragments
in yoghurt), heavy metals (such as mercury in fish) and mycotoxins
(EU, 2008). The Commission publishes a weekly overview of alert
notifications, information notifications and border
rejections1
2.3.2 Rapid Alert System for non-food consumer products
(RAPEX)
.
The Rapid Alert System for non-food consumer products (RAPEX) is
the EU rapid alert system for all dangerous consumer products, with
the exception of food, pharmaceutical and medical devices. It
allows for the rapid exchange of information between Member States
via central contact points. The RAPEX system was established in
2002 and aims to prevent, restrict, or impose specific conditions
on the marketing or use of consumer products which can cause a
serious risk to the health and safety of consumers. The number of
RAPEX notifications is constantly rising, making it a crucial tool
in the area of risk prevention 2. The Commission publishes a weekly
overview of the dangerous products reported by the national
authorities (the RAPEX notifications) and provides information on
the product, the possible danger and the measures that were taken
by the reporting country3
2.3.3 The Early Warning and Response System
.
The Early Warning and Response System (EWRS) is a web-based system
linking the Commission, the public health authorities in Member
States responsible for measures to control communicable diseases
and the European Centre for Disease Prevention and Control (ECDC),
and has been in operation since 2004. EEA Countries (Iceland,
1 RASFF updates available at:
http://ec.europa.eu/food/food/rapidalert/index_en.htm 2 DG SANCO
(2006) Annual Report on the Operation of the Rapid Alert System for
non-food consumer products (RAPEX) 2005, European Communities,
Brussels. 3 RAPEX weekly overview is available at:
http://ec.europa.eu/consumers/dyna/rapex/rapex_archives_en.cfm
7
Lichtenstein and Norway) are also linked to the system. The EWRS
authorities in each Member State form a network committee chaired
by the European Commission to make legal decisions on communicable
diseases.
Under Decision 2119/98/EC of the European Parliament and of the
Council, and Decision 2000/57/EC (amended by Commission Decision of
28/IV/2008), Member States should inform one another and the
Commission about events likely to affect public health at the
EU-level. Therefore, the EWRS is frequently used for notification
of outbreaks, exchange of information and discussion about the
coordination of measures among players. Since its launch in 2004,
the EWRS has been successfully used in a number of events such as
SARS, avian influenza in humans and other major communicable
diseases 1
.
The Rapid Alert System for Biological and Chemical Threats
(RAS-BICHAT) is the EU Rapid Alert System used for exchanging
information on health threats due to deliberate release of
chemical, biological and radio-nuclear agents.
It is a web-based tool that fulfils the same purpose as EWRS
(notification of confirmed or suspected events, exchange of
information and coordination of measures among partners.) The
system links the Commission with the designated competent authority
and 24 hour operational contact points of each Member States.
RAS-BICHAT is part of the Programme of cooperation on preparedness
and response to biological and chemical agent attacks2 and was
launched in 2002. RAS-BICHAT was established to serve all Member
States, particularly the Health Security Committee members3. The
overall aim of the system is to address and coordinate (together
with the Commission) all preparedness and response issues relating
to public health effects following the hostile use of biological
and chemical agents4
.
As RAS-BICHAT only deals with chemical threats in relation to
terrorist activities, the Health Security Committee has identified
the need of having a warning system that
1 DG SANCO (2007). Report from the Commission to the Council and
the European Parliament on the operation of the Early Warning and
Response System (EWRS) of the Community Network for the
epidemiological surveillance and control of communicable diseases
during years 2004 and 2005 (Decision 2005/57/EC) COM 2007 121,
Commission of the European Communities, Brussels. 2 Available at:
http://ec.europa.eu/health/ph_threats/Bioterrorisme/bioterrorism01_en.pdf
3 “The Health Security Committee is composed of health experts from
the European Union member states and the European Commission,
representatives of the European Centre for Disease Prevention and
Control (ECDC), the World Health Organisation (WHO), the World
Organisation for Animal Health (OIE) and the Food and Agriculture
Organisation (FAO)” (Source: European report, 2006). 4 DG SANCO
(2001) Programme of cooperation on preparedness and response to
biological and chemical agent attacks (Health Security), Commission
of the European Communities Health and Consumer protection
directorate-general, Luxemborg.
8
would cover the public health aspects in this area. The gap will be
filled by the further development of RAS-CHEM (Rapid Alert System
for Chemical Health Threats) – see chapter 3 for more
details.
DEVELOPING A RAPID ALERT SYSTEM FOR CHEMICAL HEALTH THREATS
(RAS-CHEM)
9
3 DEVELOPING A RAPID ALERT SYSTEM FOR CHEMICAL HEALTH THREATS
(RAS-CHEM)
As detailed in the chapter 2 (section 2.3.1 – 2.3.4) Rapid Alert
Systems are not a new concept and have been in operation since
1979, however, until recently there was no specific rapid alert
system for chemical health threats (including deliberate or
accidental release).
Due to growing public and government concern about the possible
deliberate use of chemicals for terrorist purposes, Member States
(MS) agreed the need for a mechanism to rapidly identify and
circulate information about, biological and chemical terrorist
events between MS health authorities and the Commission to allow
for rapid response throughout the European Union (EU). As described
previously systems are already in place for the rapid notification
of confirmed events with biological or chemical health risks of
supranational concern. However, no such system is available to
disseminate information on outbreaks of chemical related illnesses
and only limited data is currently available on suspected
cases.
The ASHT phase 1 project was a response to the European Commission
Health and Consumer Protection Directorate-General’s (Directorate C
– Public Health and Risk Assessment) call for proposals to
implement the priority actions defined in the 2004 work plan of the
public health programme (2003-2008) (Official Journal L 60/58-70,
27.2.04). One of the priority actions for this call for proposals
was to ‘explore the feasibility of setting up a surveillance system
for syndromes caused by exposure to chemicals recorded by poison
centres, and to detect chemicals that might be used in attacks’.
Originally this was a two year project (which started on the 1st of
October 2005) but was subsequently extended and ran for 32 months
from the 01/10/2005 until 30/06/2008.
The purpose of the ASHT phase 1 was to develop an EU system to
enable the early identification and circulation of information
about poisoning cases and clusters that might be associated with
the deliberate release of chemicals. The overall objective of ASHT
phase I was to develop the means of establishing an early warning
and syndromic surveillance system for the timely detection of
unusual health events due to exposure to chemicals, exploiting
poisons centres as front-line resource to detect sentinel events.
The target groups for this project were poisons centres, BICHAT
representatives, primary and secondary health facilities and public
health departments.
ASHT phase 1 project ended in 2008 and the European Commission have
funded a second phase, which will take the outputs of ASHT phase 1
forward. The ASHT phase II project has been funded for 3 years
(01/10/08 to 01/10/2010).
A key objective of the ASHT phase II project is to improve national
and international public health authorities’ response to potential
public health threats involving chemicals in the EU. These chemical
events may be of national or international concern and occur as a
result of either accidental or deliberate release. The process of
alerting will be facilitated by the development of an information
exchange platform (European Union Poison Centres forum) that will
allow EU Poison Centres and Public Health Officials to
10
exchange information on chemical events. The mechanisms and
strategies as to how these events are escalated to member states,
the WHO and the European Commission will also be established. The
Rapid Alert System for Chemical Health Threats (RAS- CHEM) is being
developed to enable information about validated chemical health
threats to be communicated by National Public Health Officials to
other Member States, the European Commission and WHO.
The ASHT phase II project expects to deliver:
• An information exchange platform to facilitate communication
between EU Poison Centres (EUPC Forum) as an integral part of
RAS-CHEM.
• Established policies, mechanisms and protocols to alert National
Public Health Authorities of events reported to the EUPC Forum that
may require further action and reporting to RAS-CHEM. The EUPC
Forum will provide National Public Health Authorities a valid
interpretation of what has been reported on the EUPC Forum in a
simple and easy to understand format.
• Standardised terminology to describe chemical agents and clinical
effects associated with exposure or poisoning.
The RAS-CHEM system is being developed and designed to link poison
centres throughout Europe and their associated Public Health
Authorities and Health Ministries and will include an EUPC Forum,
which will act as a web-based communication platform, with the
intention to eventually link all EU poison centres, to facilitate
and enable rapid information exchange (i.e. suspected poisoning
events).
RAS-CHEM will include a list of chemical agents identified as
public health threats and their associated health effects (symptoms
and features of poisoning). It is envisaged that exposure to an
‘unknown’ chemical agent could possibly be identified by comparison
of clinical effects and symptoms associated with reported to the
EUPC forum.
3.1.1 Why does the EU need RAS-CHEM?
In recent years, several incidents involving various chemical
agents have demonstrated a need for a rapid alert system for
chemicals. A few examples of where such a system would have proved
useful are outlined in this section.
In October 2007, a neurological illness of unknown aetiology
emerged in Angola. WHO Headquarters (HQ) and the Regional Office
for Africa (AFRO) investigated the outbreak and results showed
extremely high levels of bromide in blood samples. Further
investigation identified the cause as bromide contaminated table
salt 1
.
1 Gutschmidt G, Haefliger P and Zilker P. Outbreak of Neurological
Illness of Unknown Etiology in Cacuaco Municipality, Angola. WHO
rapid assessment and cause finding mission 02/11/07 –
23/11/07.
DEVELOPING A RAPID ALERT SYSTEM FOR CHEMICAL HEALTH THREATS
(RAS-CHEM)
11
same category as heroin in the US, was not directly present in toy
beads but analyses of samples from toy beads ingested by both
children found 1,4-butanediol, which is metabolised to GHB in
humans. Following confirmation, the New South Wales Poison Centre
notified regulatory authorities, which lead to an international
recall of the toys1
Figure 2. Bindeez™ toy beads which contained 1,4-butanediol,
metabolised to GHB in humans.
. This example highlights the importance of poisons centres in
raising an alert.
Example of the toys responsible for the GHB poisoning of two
children in Australia in 2008, available
at:http://www.brisbanetimes.com.au/news/queensland/bindeez-distributor-announces-
recall/2007/11/07/1194329300123.html (accessed 23/07/09)
Another large scale poisoning event reported recently was melamine
contamination of milk containing products, dairy and non dairy
products as well as animal feed manufactured in China in 2007-2008.
In 2008, six children died and more than 51,900 infants and young
children were hospitalized for urinary tract disorders after
consuming food tainted with melamine in China.
Figure 3. Example of melamine contamination
The melamine molecule and Thai officials collecting
melamine-tainted snacks and food products prior to destroying them.
Pornchai Kittiwongsakul/AFP/Getty images available at:
http://www.theepochtimes.com/n2/content/view/8334/ (accessed
24/07/09).
1 Gunja N, Doyle E, Carpenter K, Chan OT, Gilmore S, Browne G and
Graudins A. γ-Hydroxybutyrate poisoning from toy beads. MJS 2008;
188 (1): 54-55.
3.1.2 RAS-CHEM users
RASCHEM users will include National Public Health Authorities,
Health Ministries, RAS- BICHAT (Rapid Alert System for Biological
and Chemical Alert Threats) and WHO (World Health Organization),
and will be alerted to a potential public health threat or concern
by the relevant Health Agency 1
The main purpose of RASCHEM is to function as a rapid alert and
early warning system for chemical health threats, and as a result
will provide competent Public Health Authorities a valid
interpretation of what has been reported on the EUPC Forum in a
simple and easy to understand format.
. Public Health Authorities and Health Agencies will be responsible
for validating events reported to the EUPC Forum, if the reported
event warranted further escalation; an alert would be raised to
RAS-CHEM.
Chemical incidents will be reported to RAS-CHEM whilst chemical
terrorist threats will be reported to RAS-BICHAT.
1 In England, Wales and Northern Ireland the relevant Health Agency
is the Health Protection Agency (HPA) and Scotland the relevant
Health Agency is Health Protection Scotland (HPS).
DEVELOPING A RAPID ALERT SYSTEM FOR CHEMICAL HEALTH THREATS
(RAS-CHEM)
13
Figure 4. Visual representation of RAS-CHEM and the EUPC
Forum
Essentially the RAS-CHEM system will comprise two parallel but
compatible IT systems. RASCHEM will be used by Public Health
Officials in the detection of cross border chemical health threats;
this will include a number of toxic chemical agents and will be
fully tested. The EUPC forum will be used by European poisons
centres to communicate emerging chemical hazards and to inform the
treatment of exposed individuals. The EUPC forum will feed into
RASCHEM, both systems will be analogous in content and
operability.
A fundamental requirement for both applications to operate
successfully is to develop and introduce a standardised approach
for notifying Public Health Authorities, Health Ministries and
Officials.
3.2 Existing alerting systems at International, European and Member
states levels
Poison centres are already linked to networks (e.g. toxicovigilance
and pharmacovigilence) that are also used for alerting purposes.
However, the majority of these networks are informal, such as
toxicovigilance, which are informal and consist of professional
associations who aim to share information and issue alerts on a
voluntary basis. Some of these networks may have a national or
regional focus but for most of them membership is
international.
A recent example of existing poisons centres informal alerting
systems was the lead contamination children’s charm bracelets sold
with Reebok trainers in 2006. The UK
Rapid Alert System –Biological and Chemical Alert Threats (RAS
BICHAT)
Public Health Authorities (Member States)
Validated Not
RAS-CHEM
14
National Poisons Information Service (NPIS) issued an alert on the
online poisons information database TOXBASE about lead
contamination of 300,000 charm bracelets provided as free gifts to
Reebok customers. A product recall was issued on the 23rd March
2006 following the death of a 4 year child who had swallowed the
heart-shaped charm of the bracelet 1
.
Photo of the type of Reebok bracelet which caused the death of a
four years old child, and was the subject of a voluntary recall by
Reebok International Ltd. and the Consumer Product Safety
Commission on 23rd March 2006, available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d323a1.htm (accessed
23/07/09)
Another example of lead contamination of was the large product
recall of Mattel® toys in August and September 2007. Almost 20
million toys were recalled due to the discovery that the paint used
in the toy’s contained large concentrations of lead.
In some European countries poison centres national networks have
been established on a more formal basis and poisons centres are
recognised in national legislation and have a legal obligation to
report poisoning incidences to a central national body, for example
in Germany, poisons centres report cases to the Federal Institute
for Risk Assessment (BfR). As a result these networks are usually
linked to higher institutions such as Ministry of Health or another
government body.
More information about these different structures is provided below
and summarised in Figure 6.
3.2.1 The European Association of Poisons Centres and Clinical
Toxicologists (EAPCCT)
The EAPCCT is an international network of poisons centres and
clinical toxicologists, members include poisons information
specialists, clinical toxicologists and other professionals working
in the field of clinical toxicology. The EAPCCT board have
1 Berg KK, Hull HF, Zabel EW, Stanley PK, Brown MJ and Homa DM.
Death of a child after ingestion of a metallic charm – Minnesota,
2006. Morbidity and Mortality Weekly Report; 2006; 55 (12): 340-
341.
15
recently begun to issue alert messages to members via its mailing
list, and alerts are filtered by the EAPCCT General Secretary who
decides if an alert should be escalated to members. The EAPCCT
website also provides members with a private discussion forum and
is another means of issuing alert messages to Poisons centres. The
EAPPCT is involved in the ASHTII project.
3.2.2 Two sub-regional European Networks
In Europe, there are two recognized sub-regional networks of
poisons centres: the Nordic Association of Poisons Information
Centres and the Society of Clinical Toxicology of German, Austrian
and Swiss Poisons Centres.
3.2.3 The Nordic Association
Poisons centres in Denmark, Finland, Iceland, Norway and Sweden
form the Nordic Association. The Nordic Association aims to share
experience and co-operation between Nordic countries. Communication
between members is regular and mainly consists of exchanging
information on products and discussions around problematic cases.
Alerts can be circulated by telephone or e-mails. The Nordic
association of poisons centres are a collaborating partner on the
ASHTII project.
3.2.4 The Society of Clinical Toxicology of German, Austrian and
Swiss Poisons Centres (Gesellschaft für Klinische Toxikologie,
GfKT)
This Society includes staff from German-speaking poisons centres
and professionals working in the fields of clinical, analytical or
forensic toxicology. Its principal activities include data
harmonization and data pooling between poisons centres, developing
common protocols and standards. Members can use this society to
transmit an alert by telephone or e-mail. The society of clinical
toxicology of German, Austrian and Swiss Poisons Centres are also
involved in the ASHTII project.
DEVELOPING A RAPID ALERT SYSTEM FOR CHEMICAL HEALTH THREATS
(RAS-CHEM)
17
SICAP and TOXALERT
Structure Association of professionals working in the field of
clinical toxicology
Poisons centres in Austria, Germany and Switzerland.
4 poisons centres in the UK (Birmingham, Cardiff, Edinburgh and
Newcastle)
10 poisons centres and 3 toxicovigilance centres, and the database
TOXALERT.
9 poisons centres and the Federal Institute of Risk Assessment
(BfR)
9 poisons centres accredited by the National Institute of
Health.
Poisons centres in Denmark, Finland, Iceland, Norway and
Sweden.
How alerts are communicated
Email Email or telephone
Publishing an alert on TOXBASE Email or telephone
TOXALERT is planned to have an ‘alert’ function. Email or
telephone
Poisons centres report incidents to BfR who are responsible for
issuing an alert.
Informal email or telephone communication
Email or telephone.
4 UNITED KINGDOM
Under the International Health Regulations (2005), Member States
are required to designate a National IHR Focal Point (NFP) to be
accessible at all times for communications with the World Health
Organization (WHO) IHR Contact Point. The NFP has a duty to both
assess events that may be Public Health Emergencies of
International Concern (PHEICs) and to notify them to WHO.
In the wake of emergencies both natural (e.g., floods and foot and
mouth disease in cattle) and manmade (e.g., 9/11 and general
terrorism), the Parliament of the United Kingdom passed The Civil
Contingencies Act 2004. The Act imposes legal obligations on
emergency services, public health related bodies and local
authorities (Category 1 responders) to assess the risk of, plan,
and exercise for emergencies, as well as undertake Business
Continuity Management. Category 1 responders include; Local Council
Authority councils, Environment Agency, Police, Fire and Rescue
Service, Ambulance Service, Health Protection Agency, Health
Protection Scotland, National Public Health Service Wales, Primary
Care Trusts*
The Act also places legal obligations for increased co-operation
and information sharing between emergency services (e.g. Ambulance
service and Police Force) and also to non-emergency services (e.g.
Utility services). Non-emergency services are defined as Category 2
responders and include; Utilities (Electricity, Gas, Water and
Sewerage, Public Communications Providers [both landline and
mobile]), Transport Operators (Train and Bus Operating Companies),
Health and Safety Executive and Strategic Health Authorities.
(England), Hospital Trusts and Port Health Authorities.
The Civil Contingencies Act seeks to manage the risk before an
event and ensure the resiliency of government after an event has
occurred.
4.1 Specialist Public Health Protection Resources
4.1.1 The Health Protection Agency (England and Wales)
The Health Protection Agency (HPA) is an independent organisation
dedicated to protecting people’s health throughout England, Wales
and to some extent Northern Ireland. The HPA is a tertiary service
in Scotland. The HPA provide impartial scientific and medical
advice and authoritative information on health protection issues to
a broad range of stakeholders including the public, professionals
and to UK government. The organisation comprises a Centre for
Emergency Preparedness and Response, a Centre for Infections, a
Centre for Radiation, Chemicals and Environmental Hazards, a
Regional Microbiology Network as well as Local and Regional
Services. The Centre for Radiation, Chemicals and Environmental
Hazards has a Radiation Protection Division and a Chemical Hazards
and Poisons Division (including a commissioned National
* NHS Boards in Scotland, Health and Social Care Trusts in Northern
Ireland and Local Health Boards in Wales.
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Poisons Information Service), responsible for providing advice
about the known health effects of chemicals, radiation, poisons and
other environmental hazards. The HPA operates a 24-hour dedicated
chemical response hotline.
The remit of the HPA is: protecting people, preventing harm and
preparing for threats. Specific roles of the HPA include;
• Providing impartial expert advice on health protection and
providing specialist health protection services
• Identifying and responding to health hazards and emergencies
cause by infectious disease, hazardous chemicals, poisons or
radiation;
• Anticipating and preparing for emerging or future threats
• Supporting and advising other organisations with a health
protection role
• Improving knowledge about health protection through research and
development, education and training.
4.1.1.1 Chemical Hazards and Poisons Division
The Chemical Hazards and Poisons Division (CHaPD) provides advice
to UK government departments and agencies (England, Wales and to
some extent Northern Ireland) on human health effects from
chemicals in water, soil and waste as well as information and
support to the NHS and health professionals on toxicology.
The strategic goal of CHaPD is to anticipate and prevent the
adverse effects of acute and chronic exposure to hazardous
chemicals and other poisons. Every day in Britain, serious chemical
incidents occur which threaten people's health. Such potential
health threats might involve chemical fires, chemical contamination
of the environment, or the deliberate release of chemicals and
poisons. Exposure to hazardous substances can also occur during
accidents at home and work, and as a result of deliberate and
malicious releases.
Guidance is available round-the-clock from medical toxicologists,
clinical pharmacologists, environmental scientists, epidemiologists
and other specialists. The division also advises doctors and nurses
on the best way to manage patients who have been poisoned through a
contract with the National Poisons Information Service
(NPIS).
There are five supra-regional CHaPD teams located in; Birmingham,
Cardiff, Chilton, London, and Nottingham.
4.1.2 Public Health Wales
Public Health Wales is a newly created organisation that has been
established as a result of the recent NHS reorganisation in Wales.
It represents the largest specialist public health resource in
Wales, with its remit being the provision of resources, information
and advice to enable the Welsh Assembly Government, local
authorities and other NHS bodies to discharge their statutory
public health functions. Public Health Wales plays a vital role in
health protection in Wales, meeting its responsibilities
through:
• Consultants in Communicable Disease Control and Health Protection
Teams (South East, Mid & West and North Wales).
Responsibilities extend beyond communicable disease control and
include chemical, radiation, environmental hazards and emergency
preparedness);
• Consultant in Environmental Public Health Protection (with
all-Wales environmental public health protection
responsibilities);
• The Communicable Disease Surveillance Centre (providing
specialist advice in relation to epidemiological studies and
investigations, incident management and epidemiological
surveillance techniques);
• A microbiology laboratory network;
• Provision of an out of hours health protection service;
• Wider public health professionals working for Public Health
Wales, but outside of the health protection discipline. This wider
public health resource contributes to the organisation’s out of
hours health protection service and is available in times when
surge capacity is required to deal with major acute events;
• Dedicated public health communications team.
Public Health Wales has a broad range of expertise, including
public health risk assessment; risk communications, public health
response co-ordination, environmental epidemiology, surveillance,
emergency planning and response, environmental inequalities,
research and development.
In preparing for, and responding to, chemical health threats,
Public Health Wales works closely with the HPA. Depending upon the
nature of the chemical incident and/or threat(s), it may be
appropriate and necessary for other agencies to also contribute to,
and inform, the specialist public health response. Information and
advice may therefore be provided by a range of partner agencies,
including the Environment Agency (Wales), emergency services, local
authorities, Food Standards Agency (Wales), Health and Safety
Executive (Wales), Welsh Assembly Government and private agencies
such as water companies.
The specialist public health resource provided by Public Health
Wales is able to provide a timely response to acute incidents on a
24/7/365 basis. Should a major incident be declared, public health
protection specialists will take directions initially from the
emergency services (particularly fire service colleagues) and then
actively contribute to the public health management of the incident
(including any appropriate follow-up). For chronic or routine
chemical-related issues or events, the collective specialist public
health resource will provide a co-ordinated routine health
protection/health gain response. In addition, public health
specialists are able to provide a strategic response to support the
development of relevant policy.
Closer and stronger working links have been forged between Public
Health Wales and the HPA in Wales through the appointment of a
Consultant in Environmental Public Health Protection. This has
resulted in more effective and efficient ways of working that
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21
allow a closely integrated service to be delivered to those that
need it wherever they are in Wales.
4.1.3 Health Protection Scotland (Scotland)
Health Protection Scotland (HPS) is a specialist Division of NHS
National Services Scotland (NSS), which is a non-departmental
public body accountable to the Scottish Government, responsible for
providing strategic support services and expert advice to NHS
Scotland.
Health Protection Scotland works in partnership with others, to
protect the Scottish public from being exposed to hazards which
could damage their health and to limit any impact on health when
such exposures cannot be avoided. HPS works closely with other
public health and related organizations in Scotland and the rest of
the UK and beyond including.
• 14 local NHS Boards and their Health Protection Teams
• 32 Local Authorities; Environmental Health and other
Departments
• Scottish Environment Protection Agency
• The Health Protection Agency (UK)
• National Poisons Information Service (NPIS)
HPS coordinates the surveillance and investigation of communicable
diseases at national (Scotland) level. HPS also maintains
surveillance of non-communicable hazard incidents associated with
exposure to chemical, physical and other environmental hazards via
the Scottish Environmental Incident Surveillance System (SEISS) a
web based reporting system. The 14 local NHS Boards are required to
report any significant public health incidents or threats to public
health occurring in their local areas to HPS, for onward alerting
as appropriate, including incidents fulfilling the criteria
specified in the IHR.
HPS provides expert advice and support on health protection matters
including risk analysis (risk assessment, management and
communication) relating to microbiological and chemical hazards,
bringing together expert knowledge from within and outside Scotland
as necessary. HPS also advises the Chief Medical Officer for
Scotland and the Scottish Government on health protection matters
and assists in the development of national policy and national
level initiatives.
HPS are responsible for coordinating the management of incidents
and outbreaks within Scotland when these involve more than one NHS
Board area, are national or supra-national (e.g. pandemic
influenza) or are very unusual (CBRN). HPS also advise the Scottish
Government on the strategic aspects of managing outbreaks and
incidents (including bio-terrorism and deliberate release (CBRN)).
HPS supports the local NHS Boards in their role as health
protection advisers to local Strategic Coordination Groups
22
(SCGs) set up to manage any local incident under the provisions of
the Civil Contingencies Act.
HPS acts to ensure a coordinated response across Scotland by
working with the Health Protection Teams in the 14 local NHS Boards
and assists with maintaining adequate capacity and resilience
across Scotland. HPS maintains mechanisms for the rapid
dissemination of information and alerting messages to the NHS in
Scotland.
HPS also provides support in the form of education and training
activities for Health Protection Staff and other related fields
within Scotland. HPS collaborates in a variety of research and
development activities as well as Quality Assurance initiatives
associated with improving health protection capability and response
and improving public health outcomes.
4.1.4 Department of Health, Social Services and Public Safety
(DHSSPS)
The Department of Health, Social Services and Public Safety
(DHSSPS) is one of 11 Northern Ireland Departments created in 1999
as part of the Northern Ireland Executive by the Northern Ireland
Act 1998 and the Departments (Northern Ireland) Order 1999.
The DHSSPS’s mission is to improve the health and social well-being
of the people of Northern Ireland. The Department endeavours to do
so by ensuring the provision of appropriate health and social care
services, both in clinical settings such as hospitals and GPs’
surgeries, and in the community through nursing, social work and
other professional services. It also leads a major programme of
cross-government action to improve the health and well-being of the
population and reduce health inequalities. This includes
interventions involving health promotion and education to encourage
people to adopt activities, behaviours and attitudes which lead to
better health and well-being. The aim is a population which is much
more engaged in ensuring its own health and well-being.
The Department has three main business responsibilities:
Health and Social Care (HSC), which includes policy and legislation
for hospitals, family practitioner services and community health
and personal social services;
Public Health, which covers policy, legislation and administrative
action to promote and protect the health and well-being of the
population; and
Public Safety, which covers policy and legislation for fire and
rescue services
4.1.4.1 Public Health Agency (Northern Ireland)
The review of public administration (April 2009) saw a range of
functions in Health and Social Care Services (HSCS) brought
together to focus on improving the health and wellbeing of everyone
in Northern Ireland, and resulted in the formation of the new
Public Health Agency (PHA).
In the interim and until the new public health structure within NI
has been clarified, the Communicable Disease Surveillance Centre
(CDSC) NI will be the contact point to refer IHR and PHEIC related
issues to the HPA. It is likely that the majority of events will
concern communicable disease there are also provisions for chemical
and radiological
UNITED KINGDOM
23
issues. As an interim solution (pending clarification of structures
as a consequence of the review of public administration) CDSC (NI)
will act as the Northern Ireland single contact point for all IHR
issues. In terms of chemical and radiological issues CDSC (NI) will
be acting outside its corporate remit as defined by the DHSSPS and
outside its corporate expertise. For these issues it will seek to
liaise with the PHA Director of Public Health who has statutory
responsibility for such events and with the Chief Medical Officer,
DHSSPS.
These arrangements will be revisited by the Director of Public
Health when post-RPA health protection infrastructure has been
determined.
Notifying the UK National Focal Point of an incident in Northern
Ireland
• Report of PHEIC by PHA or other agency to CDSC (NI)
• The notifier together with DHSSPS and CDSC (NI) agree their
assessment against the IHR criteria, and subsequent action
• CDSC (NI) notifies the HPA.
UK National Focal Point requests information on (alleged) events in
Northern Ireland (within potentially very short IHR specified
timescales).
• HPA routes information requests through to CDSC (NI)
• CDSC (NI) notifies DHSSPS
• CDSC (NI) (with DHSSPS authority) requests information/ action
through PHA
• CDSC (NI) collates the information received and produces a report
for DHSSPS
• With DHSSPS approval CDSC (NI) sends report to HPA
Dissemination of information within Northern Ireland as decided by
the UK CMO and DH
• CMO/ DH authorises dissemination of information by HPA with/
without accompanying UK Government comments
• DH and HPA to jointly consider to whom information should be
disseminated and how
• HPA notifies CDSC (NI)
• CDSC (NI) notifies DHSSPS and assists in development of
dissemination plan. In most foreseeable circumstances this will
follow the principles developed by DH/ HPA. However, local
variation in terms of Health Service structures and existing
dissemination mechanisms will need to be accounted for.
• Potential modes of dissemination include:
o Through on-call public health rota(s)
o Through existing CMO cascade
24
o Through media using DHSSPS press office
• PHA / Trusts will assist DHSSPS / CDSC (NI) in implementation of
the dissemination plan.
4.2 The current alerting process in the UK
It is not possible to devolve responsibility for notifying events
to WHO to individual devolved administrations, Crown Dependencies,
or overseas territories. Notifying events to WHO under IHR 2005 is
the responsibility of the UK Government, because an event which
needs to be considered for possible notification to WHO will not
necessarily be a single incident occurring in only one place. Nor
will an event (or an incident that is part of a wider event) in the
territory of a devolved administration, Crown Dependency, or
overseas territory necessarily engage only the responsibilities of
the Crown Dependency or overseas territory. The current alerting
process in the UK is represented in Figure 7.
The UK Government has designated the Health Protection Agency
(Centre for Infections) as the UK's National Focal Point (NFP) and
a joint protocol has been developed between the Department of
Health (DH) and the HPA for the assessment and reporting of Public
Health Emergencies of International Concern (PHEICs) by the NFP.
The NFP has a duty to both assess events that may be PHEICs and to
notify them to WHO. The majority of NFP communications are expected
to relate to disease outbreaks, however within the scope of IHR
(2005), PHEICs may also include events arising from
non-communicable or unknown aetiologies, including chemical,
biological or radionuclear events.
The UK Government welcomes any contributions the DAs wish to make
to the assessment of events that occur (at least partly) within
their territories. Such contributions should be provided to the HPA
national focal point, and where the HPA puts an assessment to the
Chief Medical Officer (CMO) for decision, the DA contribution will
then be included by the HPA with that assessment.
For the HPA to be in a position to consider whether events should
be notified to WHO as potential PHEICs it is essential the HPA
receives information from all parts of UK, devolved
administrations, Crown Dependencies and overseas territories about
events that need to be considered in this category.
The HPA’s existing surveillance responsibilities already mean that
the HPA receives information about events in England. The HPA
already has well established contacts within England, because of
its day to day involvement in health protection matters for
England. Devolved administrations, Crown Dependencies and overseas
territories are asked to ensure that they have arrangements in
place to ensure that they alert the HPA without delay to any events
in their areas that need to be assessed to decide whether they are
PHEICs, and to provide a single contact point through which the HPA
may route requests for information about urgent IHR issues.
It will not always be desirable to put a decision to notify an
event into the public domain. The HPA will include in its Freedom
of Information (FOI) publication scheme a commitment to publish
information about notifications to WHO and events considered
UNITED KINGDOM
25
for notification. It will therefore be possible for Das to respond
to questions by saying that information will be published in due
course. Sometimes it may be necessary to release information for
example, if required by Parliament or by WHO decision. Where
feasible the UK Government will consult with the DA government
concerned if it occurs in their territory. A DA will also liaise
with UK government (where feasible) about any information regarding
a notification they wish to make public.
The default HPA contact point is the Duty Doctor rota at the Centre
for Infections (CfI) at Colindale, London. Individual DAs have been
requested to provide a single contact point through which the HPA
may route requests for information about urgent IHR issues.
The HPA have produced three specific algorithms for providing
information to WHO about potential PHEICs (see Appendix
B1-B3).
The Director-General is responsible for determining if the event is
a public health emergency according to criteria within the IHR. At
the request of the state, WHO shall collaborate in the response to
public health risks and other events by providing technical
guidance and assistance by assessing the effectiveness of the
control measures in place, including mobilisation of international
teams of experts for on-site assistance when necessary.
26
Figure 7: Structure of the current alerting process in the United
Kingdom
Health Protection Agency (National Focal Point)
Category 1 responders: Ambulance service Local council authorities
Environment Agency Primary Care Trusts Hospital Trusts Port Health
Authorities National Poisons Information Service (part of Health
Protection Agency) Police Service Fire and Rescue Service Health
Protection Agency Health Protection Scotland National Public Health
Service Wales Public Health Agency
Local Public Health Director (Wales) Public Health
Agency (NI)
Welsh Assembly Government
Health Protection Scotland (HPS)
Intelligence Agencies (UK)
27
4.3 National Services in the UK where an alert could be escalated
from the EUPC Forum
4.3.1 National Health Service The National Health Service (NHS)
provides healthcare to anyone normally resident in the United
Kingdom and the majority of services are free at the point of use
for the patient (although charges are associated with eye tests,
dental care, prescriptions, and many aspects of personal care). The
NHS is largely funded from general taxation (including a proportion
from National Insurance payments). The UK government department
responsible for the NHS is the Department of Health, headed by the
Secretary of State for Health. Most of the expenditure of The
Department of Health (£98.7 billion in 2008-9) is spent on the
NHS.
There are four National Health Services in the UK, including;
• National Health Service (England)
• Health and Social Care (Northern Ireland)
4.3.1.1 Hospitals and A&E departments Hospital emergency
departments (sometimes termed accident & emergency (A&E)
department or casualty department) provide initial treatment to
patients with a broad spectrum of illnesses and injuries, some of
which may be life-threatening and require immediate attention. If a
case involving a potential chemical health threat was referred to
Hospital and warranted further investigation, the hospital would
consult the National Poisons Information Service, the Health
Protection Agencies (HPS – Scotland, HPA – England and Wales) or
the National Health Service.
4.3.1.2 NHS Direct and NHS24 NHS Direct and NHS24 (Scotland) are
national health information resources, providing expert health
advice, information and reassurance to members of the public either
over the telephone or the internet (website). If a suspected case
or potential chemical health threat was received by either service
(NHS Direct or NHS24) then the National Poisons Information Service
(NPIS) would be consulted for further advice or information.
4.3.2 Primary responders As outlined in the introduction to this
chapter there are legal obligations and responsibilities placed on
emergency services (Category 1 responders) to plan, prepare and
respond to major emergencies under the Civil Contingencies Act
2004.
Primary responders include; ambulance, fire and police services. If
a potential chemical health threat was received by either service
then they would alert either the National Poisons Information
Service, Local and Regional services or both. In some circumstances
they may report concerns directly to the Health Protection Agency
(England, Wales and Northern Ireland) or Health Protection
Scotland.
Department of Health, Social Services and Public Safety (NI)
Intelligence Agencies (UK)
The proposed structure of the EUPC-Form would enable poisons
centres to communicate concerns at this stage in the alerting
process.
4.3.4 Local Government A potential chemical health threat maybe
reported to local government (e.g. local council authorities).
Local government would then seek further information from Local and
Regional services (England) Public Health Wales, the Public Health
Policy Unit (Scotland), or the Public Health Agency (NI).
4.3.4.1 Local and Regional Services (England and Wales) and Public
Health Policy Unit (Scotland) Local and Regional Services
(England), Public Health Wales, Public Health Policy Unit
(Scotland), or the Public Health Agency (NI), could be alerted to a
potential chemical health threat by either Primary responders or
local government. They would then escalate the information to the
Chemical Hazards and Poisons Division of the Health Protection
Agency (England, Wales and Northern Ireland). If an alert was
limited to Scotland, then Health Protection Scotland would be
consulted, however if a national threat was suspected, concerns
would be raised and shared with the Health Protection Agency.
4.3.5 Intelligence Agencies Intelligence services include;
• MI5 – Security Service • MI6 – Secret Intelligence Service If
Intelligence agencies were alerted to a potential chemical health
threat it would depend on National security related issues if this
information would be cascaded over to the Health Protection Agency
(England, Wales and Northern Ireland) or Health Protection Scotland
and up-to the Department of Health (DH), DHSSPS and RAS-
BICHAT.
4.3.6 Department for Environment, Food and Rural Affairs (DEFRA)
DEFRA (the Department for Environment, Food and Rural Affairs) is a
Government Department linked to a number of other UK Government
departments including; Veterinary Medicines Directorate, Marine and
Fisheries Agency, Animal Health, Centre for Environment Fisheries
and Aquaculture Science, Food and Environment Research Agency,
Veterinary Laboratory Authority. Non departmental public bodies
associated with DEFRA include; Environment Agency and Natural
England, public corporations
UNITED KINGDOM
include British Waterways and others include Forestry Commission
(non ministerial department) and the National Parks
Authorities.
A Rapid Alert System for Food and Feed (RASFF) already operates
within DEFRA and is housed in the suite of RAS systems in the
European Commission. The purpose of the RASFF is to provide the
control authorities with an effective tool for exchange of
information on measures taken to ensure food safety. It is
envisaged that if an alert was picked up by this already
established rapid alerting system it would be fed-across to
RAS-CHEM.
30
5 CZECH REPUBLIC
The Czech Republic has one poison centre, the Toxicological
Information Centre, which serves the entire population of the Czech
Republic (10 million inhabitants). The poison centre is situated in
the Department of Occupational Medicine of the General University
Hospital and Charles University in Prague. The poison centre
provides information and advice in case of exposure to toxic agents
both to health care professionals and the general public. The
poison centre operates 24 hours a day, 7 days a week.
Simultaneously, a specialised centre for Radiation incidents is in
the same location. The current alerting process in the Czech
Republic is represented in Figure 8.
In accordance with the International Health Regulations (2005), the
National Focal Point is based at the Ministry of Health, in the
office of the Main Public Health Officer who works closely with the
Department of Crisis Management of the Ministry of Health. This
Department provides partial financial support to the Toxicological
Information Centre; especially concerning a limited antidote stock
both for the toxic and radionuclide’s exposures, however no formal
alerting system links the Toxicological Information Centre to the
Ministry of Health. However, exercises concerning emergency
preparedness both for chemical and radiological incidents occur in
different time intervals. In addition, in cases of public health
concern, the Toxicological Information Centre is consulted by the
Ministry of Health.
The Czech Fire Brigade Rescue Corps is the main controlling unit
and a coordinator of the integrated rescue system, which unites all
rescue system components for performing rescue and clearing works
in a state of an emergency or crisis. The Fire Brigade Rescue Corps
of the Czech Republic cooperates with other components of the
integrated rescue system (paramedics, police, army), as well as
with the administration, state and local authorities, legal and
physical entities, non-profit organizations and civil associations.
At present, the Fire Brigade Rescue Corps of the Czech Republic
also plays the main role in the state’s preparedness for emergency
situations. In 2001, the Czech Fire Brigade Rescue Corps was
integrated with the Head Office for Civil Protection. The Corps is
responsible for the protection of citizens in a similar way as in
some other European countries. The Fire Brigade Rescue Corps of the
Czech Republic deals with fire prevention, crisis management, civil
emergency planning, citizen protection and integrated rescue
system.
The National Focal Point and the Department of Crisis Management
would be consulted if there was an incident involving chemicals of
public health concern. When contacting or prior to contacting the
National Focal Point information would be obtained from various
sources including:
• Fire Rescue Service 24h
• Department of Crisis Management
• Toxicological Information Centre 24h
CZECH REPUBLIC
31
Figure 8: Structure of the current alerting process in the Czech
Republic
Ministry of Health
Antidotes Stock (toxic chemical agents and radionuclide
exposures
Main Public Health Officer - National Focal Point
Department for Crisis Management
Corps of the Czech
of Public Health
6 FRANCE
6.1 The French toxicovigilance system : its role in the management
of toxicological alerts
Toxicovigilance could be defined as the surveillance of the toxic
effects of a product, a substance or a mixture on human health. The
toxicovigilance system works as a surveillance system: it collects
data continuously with the aim of alerting, preventing and
providing information on the occurrence or consequences of toxic
events to public authorities and public. The toxicovigilance system
works as a vigilance system : it monitors previously unknown or
unrecorded health events possibly associated to environmental
factors.
Finally, toxicovigilance draws on toxicological and epidemiological
assessment and is deeply involved in surveillance, vigilance and
alert in environmental health, as chemical exposure.
6.2 National organisation of toxicovigilance
6.2.1 Current situation
Currently, the French toxicovigilance system is essentially based
on a network of 10 Poison control and toxicovigilance centres (PCC)
and 3 Toxicovigilance centres (TVC), located throughout France
under the responsibility of the Ministry of Health. PCC and TVC
face two missions according to the public health code : 1) they
provide by phone a free 24/7 toxicological expertise, on acute or
chronic risks to anyone who call (public, health professionals or
administrations) ;
2) they collect environmental and medical data providing from
people queries or other medical networks (for example, emergency or
intensive care units), and develop specific medical networks on
toxicovigilance topics (lead poisoning in children, carbon monoxide
poisoning, exposure to chemicals during pregnancy, etc.).
Note that the 3 TVC only respond to health professionals or
administrations in business hours. All information on products and
health events collected by the PCC is recorded in a national
specific information system, named the French-TESS (Toxic Exposure
Surveillance System)1
Since 2004, the coordination of the toxicovigilance system has been
provided by the French Institute for Public Health Surveillance
(InVS)
. Members of the PCC or TVC on call can log on instantaneously to
this database in order to record new files and query on details of
products of exposure. The French-TESS also allows for toxicological
and epidemiological studies ; this system is described in part
II.
2
1 In french : Système d’information des centres antipoison -
SICAP
as part of the National
2 In french : Institut national de veille sanitaire - InVS
FRANCE
33
Figure 9: Organisation of the French Toxicovigilance system
.
National Coordination Committee for Toxicovigilance (NCCT) French
agency for food safety (Afssa), French health products safety
agency (Afssaps), French agency for occupational and environmental
health safety (Afsset), PCC, French ministry of Health (DGS),
InVS,
Agricultural social mutual fund (MSA)
Operational Unit of the NCCT (Executive Board) French agency for
food safety (Afssa), French health products safety agency
(Afssaps), French agency for occupational and environmental health
safety
(Afsset), PCC, French ministry of Health (DGS), InVS
Working groups of the NCCT • Drugs
• Phytopharmaceutics
• Chemical products
34
Figure 10: Procedure for managing toxicological alerts and requests
intended to the NCCT
6.3 Evolution of the French legislation
A French law adopted in July 2009 strengthens the role of national
coordination of toxicovigilance by the French Institute for Public
Health Surveillance (InVS). Furthermore, health professionals are
required to declare poisoning cases which they know to PCC;
industrials are compelled to declare qualitative and quantitative
compositions of dangerous mixtures to PCC.
6.3.1 National poison centres information system, the
French-TESS
The French-TESS has been operational since 1999 and is currently
used by all PCC. This system has been confirmed by an order of the
ministry of health dated of June 2002 the 18th.
French-TESS is composed of:
1 FND-TE : Base Nationale des Cas d’Intoxication – BNCI
located in the Paris PCC. This database includes data on poisoning
and exposure cases recorded during the usual activity of the PCC ;
this database contains at the present time, more than 1.6 million
cases ;
Emission – Transmission Alerts and requests
Reception – Registration Forwarding to the operational unit
Examination, reformulation, Validation
Operational unit of the NCCT (executive board)
NCCT – scientific and administrative desk (InVS)
Notice Working groups
• The French national database of Substances and Products1
Every exposure in the French national database of Toxic Exposures
is linked to one or more products registered in the French national
database of Substances and Products. PCC staffs can upload
information from these databases to evaluate (for the emergency
response) the risk for the patient.
located in the Nancy PCC. This database includes validated
information and composition on more than 200 000 agents
(substances, mixtures, drugs) provided by public who called and by
manufacturers. Confidential information on the composition of
products is transmitted according to an article of the public
health code (when, following an intoxication, the PCC ask the
industrial) or thanks to voluntary declarations of industrials to
PCC. With the recent law, industrials would be obliged to transmit
this information to PCC for dangerous mixtures in the 30 days after
the release on the market.
French-TESS is continually enriched: for example, information are
imported from other databases like drugs database of the French
health products safety agency or industrials products via a quite
new web system of declaration. PCC also import intoxication cases
from emergency, other hospital services and all notifications to
toxicovigilance system. A new version of this information system is
in progress using secured web technology for better ergonomics and
ability to share patient files between PCC.
French-TESS is overall the essential tool for toxicovigilance. A
Decision Information System, based on the French-TESS, provide
complete and easy ways to analyse the full databases (except
personal data), with a daily update. PCC also establish activity
reports, multi-criteria queries, studies on products associated
with poisoning cases and toxicovigilance surveys. All requests of
the NCCT are associated with queries on French-TESS by the way of
the Decision Information System. Moreover, it is also projected to
elaborate an early detection alert system on French-TESS / Decision
Information System based on statistical analyses of the number of
exposure cases by class of agents or by agent (quite similar to the
American NPDS database).
6.3.2 ToxAlert System
ToxAlert is a secured website developed by French Poison Control
Centres at the request of the French Ministry of Health in order to
manage toxic alerts and for toxicovigilance surveys. It could be
considered as a collaborative website for toxicovigilance
management.
To achieve these objectives, ToxAlert has two main features: a
content management system and an e-form defining and generating
system. Each toxic alert or toxicovigilance survey has a dedicated
space in the website. User rights are managed for each space:
administrator, expert, contributor, reader. The content management
system allows users (except for readers) to create or upload files
in a space: news, texts, FAQs, pictures, galleries and links. Each
file is submitted to referral experts and
1 FND-SP : Base Nationale des Produits et Compositions – BNPC
36
published only if validated. All appointed users of a space can
then access the pool of validated files.
ToxAlert also allows e-forms to be defined, generated and published
in the website. All completed e-forms are immediately available for
authorized users; Epidemiologic and statistical analyses can be
performed on the data at any time.
The National Coordination Committee for Toxicovigilance uses
ToxAlert to share data and files concerning current national toxic
alerts and surveys, and to collect data about selected toxic
exposures. All committee documents (meeting reports, announcements,
e-mails, survey results) are also available on ToxAlert.
In a near future, the use of ToxAlert will be extended to regional
toxicovigilance networks. Another project would be to connect
ToxAlert with the current national PCC database to inform
physicians about a related survey as they record a specific
case.
ToxAlert is a useful tool for PCC and French toxicovigilance
networks.
6.3.3 National organisation of health alert
6.3.3.1 Toxicological alert
The existing alerting system is initiated by PCC and the Department
of Emergency Preparedness and Response of the Health General
Directorate (DGS) - French Ministry of health. In case of a toxic
event detected by PCC, ministries or agencies that could have
significant public health impact, this signal is sent to DGS by
phone and email. Alert information will then be transmitted by the
DGS through email and its website DGS-Urgent
(https://dgs-urgent.sante.gouv.fr/).
French Institute for Public Health Surveillance (InVS) is
specifically mandated for launching health alert to the Minister
for Health. Accordingly, InVS provides a 24/7 on call duty to
health professionals and administrations. Contact for emergency
requests is:
[email protected]. Furthermore, the French
Institute for Public Health Surveillance (InVS) has provided since
2005 an email address in case of toxicological alerts:
[email protected].
The ministry of Health has initiated since 2003 a national on-call
duty to support toxicological risk assessment (chemical accident,
chemical terrorism attack) and provide a real-time specific
expertise. Senior toxicologists are on call 24/7 to respond to
health ministry or its agencies in such cases.
6.3.3.2 General national health alert system
The Operational Public Health Centre is a functioning centre
established within the Department of alert, response and
preparedness of the Ministry of Health. It is accessible at all
times (24/7) and has the ability to collect all public health of
national and international concern. While the vast majority of
events will relate to communicable disease outbreaks, it is
important to note that this centre has a broad scope of activities
in respect of events arising from non-communicable or unknown
aetiologies, such as chemical or radiological.
This Centre has also been designated as National Focal Point for
the implementation of the International Health Regulations (IHR).
Mandatory functions of the NFPs include : (1) sending to WHO IHR
Contact Points urgent communications concerning IHR (2005)
implementation ; and (2) disseminating information to, and
consolidating input from, relevant sectors of the administration
within the country, including those responsible for surveillance
and reporting, points on entry, public health services, clinics and
hospitals. By the Early Warning and Response System (EWRS) network
and other RAS (Rapid Alert System), this centre sends information
to the European Commission and other Member States.
Other activities of the Department of alert, response and
preparedness include the establishment and maintenance of all
national public health emergency response plans, the ability to
assess all reports of urgent events with other public health
agencies and to rapidly determine the control measures required to
manage any urgent public health alert.
38
7 LITHUANIA
In Lithuania there is only one poison centre (Lithuanian Poison
control and Information Centre) which is situated within the Health
Emergency Situation Centre (HESC). The Lithuanian HECS forms part
of the Lithuanian Ministry of Health.
The Lithuanian poison centre provides information and advice to
health care professionals and the general public in event of
poisoning incidents (either accidental or intentional) 24 hours a
day, seven days a week. If information received by the poison
centre appears to be of national public health concern (e.g.
pharmacovigillance) the HESC is officially notified (according to
mandatory procedure). The alert would be escalated up from the
poisons centre, to the HECS who would also inform the Ministry of
Health. The HESC is the National Focal Point for Lithuania
according to the International Health Regulations 2005.
7.1 The Health Emergency Situation Centre (HESC)
The HESC is a state funded institution that is accountable to the
Ministry of Health and is responsible for undertaking the
administration and management of public health functions. The
structure of the HESC can is represented in Figure 11. The Director
of the HESC is a member of the Health Security Committee (Health
and Consumer Protection Directorate-General, European Commission),
and is also a member of NATO SCEPC Joint Medical Committee.
Representatives of HESC are also members of sections of Health
Security Committee and their working groups.
LITHUANIA
39
Figure 11: Health Emergency Situations Centre
The HESC is involved in the coordination of preparedness of
institutions and National Health Care Systems to work in cases of
crisis and emergency. The HESC is also the National Focal Point and
National Coordination Centre according to the International Health
Regulations 2005 (since 2008). The HESC also houses the poisonings
control and information bureau, coordinates the activities of
ambulance dispatch centres and manages the state medical
reserves.
7.1.1 Specific functions of the HESC
• Organisation and implementation of activities of Emergency
Management Centre for the Ministry of Health
• Act as the National Focal Point and health emergency contact
point (24 hours/ 7 days a week) for RAS-BICHAT, EWRS and IHR
reporting responsibilities.
• Preparation of legal acts, emergency planning, prepareness and
response and producing guidelines for the effective management of
medical and natural disasters.
• Responsible for organising training events (e.g. exercises,
conferences and seminars) and disseminate information to the
general public.
• Advice and scientific consultation is provided by the Poisonings
Information and Control Bureau (service available 24 hours a day/ 7
days a week).
Ministry of Health
Health Emergency Situations Centre (embedded within the Ministry of
Health)
Administration
Storage of medicines of the Ministry of Health
40
8.1 Legal obligation and legislation
In Germany, the Act on the Protection Against Hazardous Substances
(Gesetz zum Schutz vor gefährlichen Stoffen) or ‘Chemicals Act’ as
last amended by an Act of 2 July 2008 (Bundesgesetzblatt I, 1146)
aims to protect man and the environment from the harmful effects of
dangerous substances and preparations, in particular to identify
them, avert them and prevent their occurrence. It includes the
responsibility of German federal states to establish and maintain
poisons centres. This legislation is mainly directed to routine
handling of chemicals but not to the management of chemical
emergencies.
8.1.1 Institutions, Authorities, Ministries and Government
Departments responsible for managing chemical incidents
Germany consists of 16 federal states. According to the German
constitution federal states are responsible for most aspects of
administration, e. g. health care, police and education. Federal
states have their own legislation which means that the rules for
the management of incidences may differ.
On the other hand, the federal government is responsible for
providing guidelines and frames to harmonize administrational
actions, facilitate cooperation of federal state administrations,
and provide European and international contact points.
There are several institutions and ministries who would be involved
in and responsible for response to health threats within the
Federal Republic of Germany.
Management starts on a local level of authorities and service,
including
• Police
• Local government bodies
If the management of the event exceeds the ability of local forces,
an incident of disaster (Katastrophenfall) is declared and help is
provided from other parts of the federal state. Under these
conditions the following authorities are involved:
• Federal State Ministries of the Interior
• Federal State Ministries of Health
• and adjunctive authorities
If the problem requires resources that are in excess of those
available from the federal state authorities then the German Joint
Information and Situation Centre (Gemeinsames Melde- und
Lagezentrum von Bund und Ländern, GMLZ) at the Federal
GERMANY
41
Office of Civil Protection and Disaster Assistance (BBK) would be
responsible for coordinating help from other Federal states or EU
member states.
Other Federal Ministries and institutions that could be involved
include;
• Federal Ministry of the Interior
• Federal Ministry of Health
• Federal Ministry for Food, Agriculture and Consumer
Protection
• Federal Institute for Risk Assessment (BfR)
• Federal Office of Consumer Protection and Food Safety (BVL)
Such Federal Ministries and Institutions are involved if
specialised expert judgement is required, or if international
information exchange has to be performed. These Ministries and
Institutions provide the national focal points for European and
international alert systems.
Due to the number of Institutions and Ministries involved in
coordinating response to different public health threats in
Germany, well defined mechanisms for raising an alert about
potential public health threats do exist. Poisons centre may be
involved in the early detection of an event.
8.1.2 The role German Poisons Centres in issuing a Public Health
Alert
Traditionally, the role of poisons centres was restricted to
medical advice in individual poisoning. Since the 1990 revision of
the Chemicals Act, the role of German poisons centres has been
expanded to include toxicovigilance activities.
Poisons centres (Information and Treatment Centres for Poisonings)
are officially mentioned in section 16e of the Chemicals Act.
Today, the Federal Republic of Germany has nine poisons centres.
Different Ministries in the federal states throughout the German
Republic are responsible. Figure 12 summarizes the geography of
German poisons centres (PC), the federal state and ministry that
are responsible for them.
Figure 12: Overview of poisons centres in the Federal Republic of
Germany.
Poisons Centre Responsible for State(s) Ministry responsible
for
Poisons Centre
Ministries for Social Affairs
Ministries for Social Affairs and Health
42
Berlin Berlin, Brandenburg Senate of Health
Mainz Hesse, Rhinel