Introduction
An area of great historical successes
Historically, the fi rst successes of health policy were in the area of infectious disease. The year 1848 is remembered in Europe for two things, revolutions and epidemics. When Marx wrote of a spectre stalking Europe at the time, he could as easily have substituted cholera for communism. No-one was safe, with notable victims including Tchaikovsky and the Prussian military theorist Carl von Clausewitz. The demonstration by John Snow that cholera was transmitted by contaminated water has gone down in history as one of the greatest public health successes. Other successes, such as Pasteur’s confi rmation of the germ theory, showing that it was microorganisms that caused many then common diseases, and Koch’s development of his postulates, which made it possible to link specifi c microorganisms to particular diseases, laid the foundation for a wide range of measures, from clean water to safe food production, that have allowed Europe’s citizens to be safeguarded from many of the dangers that once surrounded them. Cholera has been eliminated from Europe and the few cases of typhoid are largely contracted elsewhere. Perhaps less obviously, the practice of paediatrics has been transformed, as the hospital wards that were, as recently as the 1970s, fi lled with children with gastroenteritis, jaundice and chest infections are now long closed.
As recently as the 1950s, an estimated 50 million cases of smallpox occurred each year worldwide. Although immunization had eliminated the disease from most industrialized countries by then, Europe remained at risk and as recently as 1972, a pilgrim from Kosovo brought the disease back from the Middle East, infecting 175 people and causing 35 deaths. Yet, by 1975, the disease had been confi ned to a small war-torn area in the horn of Africa where, on 26 October 1979, Ali Maow Maalin, a Somali cook, was the last person in the world to be diagnosed with naturally occurring smallpox. Exactly two
years later, a commission of leading scientists declared that smallpox had been eradicated, a decision upheld by the World Health Assembly on 8 May 1980 (Pennington 2003).
So far, smallpox is the only infectious disease that had been affecting humans for long periods of time to have been eradicated. However, a number of other diseases are targeted for global or regional eradication, with varying degrees of success. One of those is polio. It was the development of vaccines against polio in the 1950s that provided an opportunity to target it for eradication.
In 1960, one European country, Czechoslovakia, became the fi rst to eliminate it, and other industrialized countries soon followed. In 1988, WHO, Rotary International, UNICEF and the United States Centers for Disease Control launched the Global Polio Eradication Initiative. In 1994, the Americas became the fi rst of the WHO’s regions to be declared polio free, followed in 2002 by the WHO European Region. However, the experience with polio serves as a warning. In 2010, polio returned to the central Asian part of the WHO European Region, with a major outbreak in Tajikistan. Genetic sequencing indicated that the virus had originated in northern India. As this example and several of the others in this chapter show, the price of success against infectious disease is constant vigilance.
This chapter will examine some of the major successes, and failures, in the struggle against infectious disease in Europe in recent decades. First, however, it is useful to review briefl y the burden of disease attributable to infectious disease in Europe in comparison with the rest of the world.
The burden of disease attributable to infections in Europe
In the past century, Europe has undergone a profound epidemiological transition (Omran 1971). Access to clean water, safe food production and distribution, immunization and antibiotics, among other things, have brought about a steady decline in what were once very common, and often fatal, infectious diseases. In Stockholm, for example, when piped water was introduced in 1861, 25% of babies still died within their fi rst year and only 50% survived until the age of 15, with the vast majority of deaths caused by infection (Burstrom and Bernhardt 2001). By 2010, the infant mortality rate in Sweden had fallen to 2.5 per 1000 live births, partly as a result of improved sanitation and other public health interventions. Consequently, the contribution that infectious diseases make to the total burden of disease in Europe is now very low, compared with that in the world as a whole (Fig. 7.1), although it is greater in the low- and middle-income countries of the region.
Table 7.1 shows a more detailed breakdown. Of the specifi c diseases identifi ed, sexuall y transmitted diseases contribute most in the high-income countries, followed by human immunodefi ciency virus (HIV) infection and the acquired immunodefi ciency syndrome (AIDS). In the low- and middle-income countries, respiratory infections and tuberculosis are the largest single contributors, at levels much higher than in the high-income countries of Europe.
Two categories of successes and failures
The successes and failures that we will deal with in this chapter fall into two broad categories. The fi rst involves putting in place systems that protect the public from new or persisting threats. Public health can do this in several ways. One, which also numbers among the greatest historical successes in public health, is to immunize people against disease. This will confer protection on the individual but, as importantly, if enough people are immunized it will also confer protection on the few that are not by breaking the chain of transmission – a process known as herd immunity. Another is to identify behaviours that place people at risk and take action to reduce that risk. Many of the best known examples relate to sexually transmitted diseases and, collectively, involve the dissemination of messages about ‘safe sex’.
The second category involves securing previous gains. After systems have been put in place that protect the public from a particular threat, these need to be carefully maintained and updated when needed. This is less obvious than it seems: the history of infectious disease control is full of examples where systems have failed to be maintained or updated, and we will discuss a few examples in this chapter. A particular challenge in this category is that microorganisms are able to exploit new opportunities and to avoid barriers placed in their way.
This leads to a continued struggle between those microorganisms and the public health community, which must strive to stay one step ahead. There are many examples that affect Europe, particularly as a consequence of the massive Figure 7.1 Contribution of infectious and parasitic diseases and respiratory infections to the total burden of disease
Source: Mathers et al. 2008
Note: High-income countries in Europe are Andorra, Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Liechtenstein,
Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland, the United Kingdom
Table 7.1Burden of disease from specifi c infectious causes in disability-adjusted life-years and its percentage of the total disease burden, 2004 Europe: high incomeEurope: low and middle incomeWorld Total DALYSDALYS per 1000 population Percentage of total disease burden Total DALYSDALYS per 1000 population Percentage of total disease burden Total DALYSDALYS per 1000 population
Per of total disease bur Infectious and parasitic disease8382.11.7520310.95.1302,14446.919.8 Tuberculosis400.10.116953.61.734,2175.32.2 Sexually transmitted diseases (excluding HIV)770.20.22900.60.310,4251.60.7 HIV1960.50.49832.11.058,5139.13.8 Diarrhoeal disease1140.30.212792.71.372,77711.34.8 Childhood cluster illnessa200.00.0470.10.030,2264.72.0 Meningitis500.10.12840.60.311,4261.80.8 Hepatitis B320.10.11040.20.12,0680.30.1 Hepatitis C340.10.1370.10.09550.10.1 Respiratory infections4881.21.024195.12.497,78615.26.4 Source: Mathers et al. 2008 Notes: DALY, disability-adjusted life-years; HIV, human immunodefi ciency virus aChildhood cluster includes pertussis, polio, diphtheria, measles and tetanus
increase, in volume and pace, of global movement of people and goods.
The proximity of humans and domestic poultry provided the perfect conditions for genetic mixing of generic material from humans and birds, leading to avian infl uenza. A similar situation, although this time involving industrial production of pigs in Mexico, has allowed human infl uenza to mix with the swine version. The speed with which infl uenza spreads from person to person means that the emergence of a new strain of infl uenza can rapidly develop into a pandemic. Another threat arises from the overuse of antibiotics. Frequently, within a colony of infecting microorganisms, there will be a few that have a mutation that confers resistance to a particular antibiotic. Especially where treatment is inadequate to allow the body’s natural defences to eliminate the infection, these mutated organisms may thrive, eventually replacing all the microorganisms that were sensitive to the antibiotic.
Protecting the health of the public from new or persisting threats
Measles
According to the OECD (2011), ‘childhood vaccination continues to be one of the most cost-effective health policy interventions. . . . Coverage of these programmes can be considered as a quality-of-care indicator.’ This is particularly the case for measles, a disease that, although often mild and self-limiting, can on occasions be fatal or leave severe neurological sequelae. Because of its proven effectiveness, with an effi cacy of over 99% (van Boven et al. 2010), measles vaccination has been recommended for general administration since the 1990s, but there is still considerable variation in uptake. About half of the countries in the European Economic Area fail to achieve the 95% coverage considered necessary to achieve herd immunity (Fig. 7.2) (van Boven et al.
2010). Many of those failing to do so are among the wealthiest countries in Europe, with the highest levels of health resources. Moreover, even these fi gures may be considerable overestimates as those countries without centralized systems, such as Germany, are unable to track accurately their coverage levels.
Consequently, it has been argued that ‘immunization is not rated equally high on political agendas across countries in the EU’ (Schmitt et al. 2003). The result is that major outbreaks continue to occur regularly in some European countries (Table 7.2), while others have essentially eliminated the disease except for imported cases. Yet, despite these very mixed results, the countries of the WHO have committed to eliminating measles from its European Region by 2015 (Martin et al. 2011).
The association between measles immunization rates and measles incidence is apparent from a study of data from the 30 countries of the European Economic Area in the years 2008 to 2011. Only nine of these countries main-tained immunization rates at 95% or above (group 1) while 16 countries had rates of less than 95% (group 2) and fi ve did not report coverage data to the European Centre for Disease Prevention and Control or WHO (group 3).
The mean measles incidence in the four year period was 0.09 per 100,000 in
Figure 7.2 Coverage by measles immunization in the European Economic Area and Switzerland, 2010 or most recent available year
Source: WHO Regional Offi ce for Europe 2012 Note: See warning about the quality of data in the text
Table 7.2 Burden of m easles in countries with the highest incidence in fi rst half of 2011
Cases Incidence densitya
Europe 21,326 N.A
France 12,699 14.45
Romania 1,619 5.00
Switzerland 589 4.25
Spain 2,261 2.78
Italy 1,500 1.65
Belgium 382 1.37
Source: European Centre for Disease Prevention and Control 2011a Note: aIncidence per 10 million per day in the surveillance period
group 1, 6.72 per 100,000 in group 2 and 3.57 per 100,000 in group 3 (Riemann-Lorenz 2012).
Why do the coverage levels achieved in these countries differ so much?
National immunization systems differ widely. In broad terms they can be classifi ed as centralized or decentralized. Typical examples of centralized systems are those in Finland and the Netherlands. In Finland, vaccines are purchased centrally by the National Public Health Institute. Parents receive invitations to bring their children to be immunized when they reach the appropriate age.
Vaccines are administered, free of charge, in child care centres by public health nurses, who register the coverage rates and report them to a central offi ce on a regular basis. A government-funded compensation scheme exists for the very rare occasion when a complication arises (Schmitt et al. 2003).
Germany and France are examples of countries with private or decentralized systems. Here the systems run with minimal input from the governments. In Germany, an advisory committee, the Ständige Impfkommission, develops national immunization plans, listing vaccines against diseases considered of public health importance and recommending the timing of immunization (Wiese-Posselt et al. 2011). The 16 federal German states (Länder) are advised to adopt and recommend this plan publicly. Such a public recommendation is the legal basis for compensation following a potential vaccine-induced event.
Immunization is generally undertaken by private paediatricians or general practitioners. Those vaccines recommended by the Ständige Impfkommission are generally paid for by health insurance companies (Schmitt et al. 2003). Yet, at least until recently, there is evidence that many health workers and members of the public are unaware of these recommendations (Lauberau et al. 2001).
Unlike the situation in Finland, parents must take the initiative to bring their children to be immunized. There is no mechanism to invite them systematically and no centralized registration that would allow monitoring of coverage, and thus institute intervention where it is low. This also means that the available data on coverage are largely taken from surveys or from data collected at school entry, although the use of social health insurance data is also being explored (Kalies et al. 2008).
There are many factors involved in the success or otherwise of an immuniza-tion programme. Consequently, there is no simple relaimmuniza-tionship between the degree of centralization and the coverage rate. For example, coverage rates in the United Kingdom, a country with a centralized system, fell markedly as a consequence of a concern about the safety of the combined MMR vaccine (dis-cussed in Chapter 6). Nonetheless, many of the countries in Europe with low coverage rates have decentralized systems and many of those with high rates have centralized systems. Schmitt and colleagues (2003) have argued that cen-tralized systems have certain obvious advantages over decencen-tralized systems.
Centralized systems can often procure vaccine at lower cost through bulk pur-chasing. They can optimize distribution systems to minimize wastage. Proactive invitations to parents, follow-up of non-attenders and the ability to undertake investigations to identify barriers facing marginalized groups (Cohuet et al.
2009) are all likely to increase coverage. In contrast, in decentralized systems plans, targets and deadlines are less well defi ned.
Infl uenza
Infl uenza affects hundreds of thousands of European citizens each year. It is often complicated by pneumonia, and it is a frequent cause of hospital admissions and sometimes death, particularly among children, the elderly and those with chronic diseases. In May 2003, the 56th World Health Assembly recommended infl uenza vaccination for all people at high risk defi ned as the elderly and persons with underlying diseases (World Health Organization 2003). All EU Member States committed to the goal of attaining vaccination coverage of the elderly population of at least 50% by 2006 and 75% by 2010.
Many national guidelines also recommend yearly vaccination against infl uenza for all elderly people.
These recommendations are based on studies of vaccine effectiveness, which have been summarized in regularly updated Cochrane Systematic Reviews. A review published in 2006 concluded that vaccination prevented pneumonia, hospital admissions and deaths among elderly people residing in long-term care facilities, and also had modest effectiveness against complications of infl uenza among elderly living in the community (Rivetti et al. 2006). A recent update of this review was more sceptical of the evidence. It found only one randomized controlled trial (showing effectiveness of vaccination against infl uenza symptoms) against 74 observational studies, which were judged to be of insuffi cient quality to be used in assessing the effectiveness of infl uenza vaccination (Jefferson et al. 2010).
European countries have been very diverse in their uptake of these vaccination policies, and among countries that have national infl uenza vaccination policies there is large variation in the universality of the programmes (Mereckiene et al. 2008a, 2010). Some countries have been very successful in increasing vaccination uptake, others much less so. As a result, vaccination uptake among the elderly also differs strongly between countries. Not all countries have a system in place to monitor uptake, but among those who do, vaccination coverage in 2008 among those aged 65 and older ranged from 2% in Lithuania to 82% in the Netherlands (Mereckiene et al. 2008b). While vaccination uptake has gone up over time, achieving the target of 75% coverage remains a challenge (Mereckiene et al. 2010). Countries that require a co-payment from elderly people appear to have lower coverage rates than countries that do not (Kroneman et al. 2003). Figure 7.3 illustrates these variations.
While variations in uptake rates between countries should provide good opportunities to study the population health impact of infl uenza vaccination, the data needs to be analysed carefully because infl uenza is a relatively unreliable cause of death, and many infl uenza deaths may be hidden in other cause-of-death categories such as pneumonia and ischaemic heart disease. Some studies have indeed found that increased vaccination coverage is associated with lower mortality at the population level (Kwong et al. 2008; Fireman et al. 2009), but others have not (Rizzo et al. 2006; Simonsen et al. 2007). In any case, the effect is likely to be small and diffi cult to detect. As excess mortality attributable to infl uenza has been between 5% and 10%, on average, during the infl uenza seasons in the past several decades (Simonsen et al. 2007), and the protection of vaccination against excess death is likely to be lower than 50%, one would
expect a coverage rate of say 60% to be associated with a few percentage points reduction of total mortality at most (Fireman et al. 2009).
We conclude that some countries have been highly successful in achieving a high uptake of infl uenza vaccination among the elderly, and while this has probably reduced complications, the population health impact remains somewhat elusive.
HIV infection and AIDS
The fi rst cases of AIDS in Europe, the disease caused by HIV infection, were reported in 1982 (Francioli et al. 1982; Rozenbaum et al. 1982; Vilaseca et al.
1982). By the end of 2010, an estimated 2.3 million people in the European region were living with an HIV infection and many millions had died of AIDS and its complications in the preceding three decades.
The story of AIDS in Europe is one of some successes, many failures, and many missed opportunities (Atun et al. 2008). The epidemic took very different forms in different countries. To some extent, these refl ected intrinsic differences in the countries involved, such as the very limited scale of movement of people into the USSR in the 1980s; consequently, the epidemic in countries such as the Russian Federation and Ukraine came much later than in western countries.
However, to a considerable extent the differing forms of the epidemic also refl ected differences in the policies that were adopted by the authorities in each country.
Figure 7.3 Uptake of infl uenza immunization by individuals older than 65 years of age vaccinated in 2008 or nearest year
Source: Mereckiene et al. 2008b
Prevention of the transmission of HIV requires a multifaceted strategy combining measures of proven effectiveness in reducing the transmission of HIV in general and those specifi c to different modes of transmission. The former include voluntary counselling and testing to enable those infected to become aware of their status (Voluntary HIV-1 Counseling and Testing Effi cacy Study Group 2000) and treatment with antiretroviral drugs, as those with a very low viral load are unlikely to transmit the infection (Donnell et al. 2010).
Mass media campaigns increase uptake of testing for HIV in the short term but
Mass media campaigns increase uptake of testing for HIV in the short term but