Public health services are key components, deeply involved at each stage, from preparation and prevention to early warning and crisis management. The cabinet of the Ministry of Health assesses propositions from public health agencies and issues decisions. The Senior Defence and Security Officer (HFDS) coordinates actions related to CBRN. In the case of a crisis, the Ministry can activate the public health crisis centre, which is in liaison with the Ministry of Interior’s CIC and with health structures at territorial, national, European and international level.
The Ministry of Health includes a service dedicated to crisis situations, the Department of Public Health Emergencies (DUS). It relies on a number of public health agencies and on a laboratory network. The most relevant agencies in the context of an infectious disease crisis are the French National Institute for Public Health Surveillance (InVS), the French Health Products Safety Agency (AFSSAPS), and the Health Emergency Preparedness and Response Agency (EPRUS). Food safety and environmental issues are addressed by the French Agency for Food, Environmental and Occupational Health and Safety (ANSES).
9.5.1 Department of Public Health Emergencies (Département des Urgences Sanitaires – DUS)
This structure within the General Health Directorate, Ministry of Health, takes part in the preparation of the response to health risks and threats linked to natural events, outbreaks, technological accidents or terrorism acts, including bioterrorist events. It relies on a global integrated approach.
A key component, the DUS, develops policy and doctrine for the health reserve corps and prepares the response to serious health threats, including terrorist actions. It is responsible for the operational coordination of the response, including the operational management of emergency or health crisis situations. A unique point of entry for information relative to alerts, it gathers, analyses and registers information when national or international events occur. There is an operational centre for the reception and regulation of health and social emergencies (CORRUSS).
The DUS receives information from departmental and interregional institutions and from InVS. The DUS is also linked with other services dealing with crises, for example the Interdepartmental Operations Centre for Crisis Management (COGIC) of the Ministry of Interior or the French Joint Operations Planning and Command and Control Centre (CPCO) of the Ministry of Defence.
9.5.2 French National Institute for Public Health Surveillance (Institut de Veille Sanitaire – INVS)
InVS, the motto of which is “watch, monitor, alert”, is responsible for continuous monitoring of the population’s health status, health surveillance, health alerts, and assistance in health crisis management.
Surveillance of infectious diseases is one of the missions given to the Institute, tasked with identifying public health threats at an early stage, giving early warning, and providing information to decision-makers. It also monitors on-going events and does post-crisis evaluation in order to integrate lessons learned. In fiscal year 2010, the budget for the infectious disease surveillance programme amounted to EUR 21.2 million, representing 33% of the overall operating budget. The A(H1N1) influenza programme received an additional 2% .
The Institute uses specific as well as non-specific (syndromic) surveillance systems. Syndromic surveillance can be defined as the collection of non-statistical data on health trends, followed by their analysis and interpretation. Its objective is the early detection of health threats and real-time (or near real-time) health impact assessment of events. It has for example proven effective in the monitoring of infectious disease outbreaks such as gastrointestinal diseases, influenza, and viral meningitides, as well as cold spells or heat waves. This tool must be effectively integrated into the public health system . It is intended to enhance and not replace other traditional approaches for epidemic detection.
Adapted to take into account bioterrorism (or even chemical or radiological terrorism), it could contribute to the early detection of a bioterrorist event, focusing on symptoms instead of confirmed diagnoses (detection through syndromic surveillance instead of through clinician reporting), thus reducing the delay between exposure and administration of a prophylactic or curative treatment (when available). It could also give information about the size, spread, and other characteristics of an outbreak after detection.
In France, the Syndromic Surveillance Programme was launched in 2004 by the InVS, following the consequences of the 2003 heat waves. Prior to that, the health surveillance and early warning systems were nearly entirely based on sentinel networks and mandatory declarations for a list of diseases. The methodology is based on use of retrospective and prospective studies. It implies defining specific criteria, like alert indicators and thresholds. Bioterrorism is one of the potential situations taken into account.
The French syndromic surveillance system, SurSaUD®, relies on three kinds of sources to collect data: emergency departments (OSCOUR® network), emergency general practitioners service (SOS Médecins) and, for mortality data, city registry offices. These three systems are entirely computerized and automated. The data are automatically collected daily, and then transmitted after encryption. This transfer respects the national patient confidentiality rules. For the sake of analysis, the following data are collected from the emergency departments: age, gender, zip-code, reason for emergency admission, and main medical diagnosis (based on the CIM10). The collected data must then be analyzed which relies on algorithms.
Evaluations are crucial to be able to demonstrate the utility of syndromic surveillance. However, they are difficult to carry out and specific criteria of evaluation must be defined . The French system has, for example, been assessed in the context of the 2006 heat wave . Almost all the data required for daily analysis were acquired. But one important observation was that it was not possible to use other data transmission methods other than internet, highlighting the necessity to develop solutions to be able to proceed even in case of a network failure. The authors also noted the study presented some limitations, as several parameters were not taken into account and the time period was limited as was the representativeness (with less than 40% of all emergency departments regional activity analyzed). They underlined the need to research and determine criteria which should be evaluated in other situations, as well as the possible necessity to confirm the results through other studies under the same weather conditions.
At the European level, the InVS coordinates Triple S – Syndromic Surveillance Survey and assessment towards guidelines for Europe – a 3-year project launched in 2010. Co-financed by the European Commission, it involves 24 organizations from 14 countries. Its objective is to assess existing European syndromic surveillance systems and will provide scientific and technical guidelines for the development of such systems. It aims at enhancing European capabilities regarding (near) real-time surveillance and monitoring in the context of expected or unexpected health-related events.
9.5.3 French Health Products Safety Agency (Agence Française de Sécurité Sanitaire des Produits de Santé – AFSSAPS)
Created in 1998, AFSSAPS’s missions encompass scientific and medico-economic evaluation, laboratory control and advertising control, as well as inspections of industrial sites. It takes safety decisions concerning health products, from manufacturing to marketing, and coordinates monitoring activities once they are authorized. This includes the management and evaluation of biomedical research, to ensure protection for the people involved by assessing the safety and quality of products.
AFSSAPS contributes to preparedness and response against bioterrorism and emerging health threats by assessing therapies and publishing therapeutic guidelines. Factsheets for drug treatment protocols address anthrax, plague, tularaemia, brucellosis, viral hemorrhagic fevers, smallpox, botulinum toxin, Q fever, other bacterial infections, biological agents for which no specific or prophylactic treatment can be recommended, as well as the course of action in an emergency situation when the agent is not yet identified (available on the AFSSAPS website). It would be involved in crisis management regarding issues pertaining to medical countermeasures. It could for example need to issue temporary authorizations for use (ATU), which are exceptional procedures enabling the use of pharmaceutical products without a marketing authorization in France, outside the usual framework of a clinical trial (e.g. for smallpox vaccination). ATU can be granted for health products meant to treat, prevent, or diagnose serious or rare diseases, when no appropriate approved therapeutic alternative exists and when the efficiency and safety are presumed given current scientific knowledge of the product. Moreover, in this context, maintaining stockpiles means performing regular quality controls and has thus generated specific requirements in terms of laboratory activities.
At last, AFSSAPS contributes directly to biological safety and security. According to Article R.5139-1 of the Public Health Code, created by Decree n°2010-736 of 30 June 2010, it issues and manages authorizations regarding production, transport, importation, exportation, possession, supply, transfer, acquisition, and use of micro-organisms and toxins. Article L.5139-1, modified by Ordinance n°2010-18 of 7 January 2010, specifies that these measures apply to microorganisms and toxins when their use could pose a risk for public health, as well as to products containing these agents.
9.5.4 Health Emergency Preparedness and Response Agency (Etablissement de Préparation et de Réponse Aux Urgences Sanitaires – EPRUS)
This specific structure was created in 2007 to improve preparation and response to health crises and is dedicated to the management of acquisition, production, imports, stockpiling and distribution of pharmaceutical products: it manages the French national stockpile of medical countermeasures (“Loi n°2007-294 du 5 mars 2007 relative à la préparation du système de santé à des menaces sanitaires de grande ampleur”, “Décret n°2007-1273, 27 August 2007”). Its mission is to implement the crisis management strategies drafted by the General Health Directorate.
It also has to organize the health reserve corps, recruiting on a voluntary basis. It can be called when facing a situation of exception exceeding the usual capacities, in order to strengthen medical and social care structures. Reservists can be mobilized through a joint decree from the Ministries of Health and Interior. This corps is divided in two, with health professionals liable to be called up very quickly for intervention on national territory or abroad, and a pool including retired health professionals and medical and paramedical students for reinforcement in case of a long term serious health threat.
9.5.5 Biotox-Piratox Laboratories’ Network
In 2003, in the aftermath of the anthrax letters event and the following hoaxes, a three-level laboratories network was created in order to deal with the consequences of a biological attack. The network includes civilian private and public laboratories, as well as military laboratories. A scientific council consisting of civilian and military experts meets monthly.
The network provides capacities in terms of biological or chemical toxicological analysis of environmental, veterinary or human samples. Laboratories can be involved in evaluating suspicious envelopes, parcels or substances; foul play against animals, plants, and especially the food chain, the water network, and the transport of biological agents; and victims in case of biological or chemical attacks. Achieving a better coordination and standardization of laboratory procedures implies a process of accreditation. Beyond detection and identification for crisis management, the objective is also to take into account forensics requirements and guarantee traceability with a procedure acceptable from a legal point of view (the sample constitutes evidence).
The first level of this network gathers many laboratories which have a role for screening and alert. They can collect and send samples, and ultimately proceed to a first analysis. The second level, which has a key role in the global system, is composed of reference laboratories and associated laboratories, designated in each defense area, and which have the capacities to identify some or all agents linked to bioterrorism. The last level is constituted by national reference laboratories; the BSL-4 laboratory is integrated in this level, as well as military laboratories such as the Centre d’Études du Bouchet (CEB) or the Centre de Recherche du Service de Santé des Armées (CRSSA).