Education And Debate

Communicable disease outbreaks involving more than one country: systems approach to evaluating the response

BMJ 2001; 323 doi: (Published 13 October 2001) Cite this as: BMJ 2001;323:861
  1. Laura MacLehose, research fellowa,
  2. Helmut Brand, directorb,
  3. Ivonne Camaroni, European Programme for Intervention Epidemiology Training fellowc,
  4. Naomi Fulop, senior lecturer, health services delivery and organisational researcha,
  5. O Noel Gill, consultant epidemiologistd,
  6. Ralf Reintjes, consultant in communicable disease epidemiologyb,
  7. Oliver Schaefer, specialist registrar in public health medicinea,
  8. Martin McKee, professor of European public healtha,
  9. Julius Weinberg (, provice chancellor (research)e
  1. a London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. b Institute of Public Health for North Rhine-Westfalia, Münster, Germany
  3. c PHLS Communicable Disease Surveillance Centre, Cardiff CF4 3QX
  4. d PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
  5. e City University, London EC1 0HV
  1. Correspondence to: J Weinberg
  • Accepted 27 June 2001


The growth in international trade and travel has increased the likelihood that outbreaks of infection will involve more than one country. The response to such an international epidemiological emergency is complex, involving national and international agencies. We evaluated responses to five outbreaks, with various transmission routes, involving more than one member state of the EU. We examined the complex nature of the collaboration required for an effective response and identified critical weaknesses in coordination, funding, and reporting.

Summary points

Increasing international trade and travel have led to concern that there will be outbreaks of infection involving more than one country

The detection of and response to international outbreaks needs to be international and coordinated

An analysis of the response to several international outbreaks has shown inadequacies in detection, coordination, funding, and reporting

Support for disease surveillance and control in less developed countries should be expanded to strengthen global surveillance


We studied five past outbreaks, selected primarily to capture different routes of disease transmission (table). We compiled these case studies using various data sources.8 Over 50 semistructured interviews were undertaken to determine what happened, what should have happened, why the difference, and what improvements could be made. Interviewees were selected through the relevant European disease surveillance network(s), member states national communicable disease surveillance centres, the World Health Organization, and the Centers for Disease Control and Prevention (Atlanta, United States). The snowball method9 identified further interviewees. We reviewed published and unpublished material.

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Selected case studies

We undertook a postal survey with questions on preparedness for an influenza pandemic in Europe and the role of the European Programme for Intervention Epidemiology Training in international incidents. Our analyses included techniques of …

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