In the coming decade, Europe will dedicate billions of euros to the necessary research and innovation (R&I) to support a transition to safe and sustainable food systems. EU Agencies, individually and even more so collectively, can make a difference in supporting the European research agenda. EU Agencies are knowledge centres, bringing together know-how to inform policy makers. EU Agencies that have traditionally dealt with aspects of human health, animal health, plant health and ecosystem health in silos, now need to take a broader perspective and move towards a One Health (OH) approach. In this paper, the authors highlight the need for more transdisciplinary cooperation in support of the One Health approach, identify challenges in strengthening interagency cooperation and provide recommendations to address them. EU Agencies are natural bridges between the scientific community and policy-makers and need to dedicate time and effort in fostering this dialogue, e.g. by engaging with relevant initiatives, research projects and European Partnerships. Research generates evidence that can be used also for regulatory science, in support of policy-making. It is urgent to define transdisciplinary research needs and formulate a One Health research agenda. This would be facilitated by establishing transdisciplinary One Health Research & Innovation governance, both at national and EU levels. Ongoing large initiatives, such as the One Health European Joint Programme, have demonstrated that active dialogue with national ministries and EU agencies is beneficial for all parties. Involvement of EU Agencies in the programming of the EU Research Framework programmes is beneficial, because of their regulatory science perspective, their expertise and current or future tasks on research topics. It is timely for EU Agencies to demonstrate leadership in moving the One Health agenda forward and it is encouraging that EU Agencies have committed to establish a cross-agency task force on One Health.

Abstract This paper focusses on biological hazards at the global level and considers the challenges to risk assessment (RA) from a One Health perspective. Two topics – vector‐borne diseases (VBD) and antimicrobial resistance (AMR) – are used to illustrate the challenges ahead and to explore the opportunities that new methodologies such as next‐generation sequencing can offer. Globalisation brings complexity and introduces drivers for infectious diseases. Cooperation and the application of an integrated RA approach – one that takes into consideration food farming and production systems including social and environmental factors – are recommended. Also needed are methodologies to identify emerging risks at a global level and propose prevention strategies. AMR is one of the biggest threats to human health in the infectious disease environment. Whereas new genomic typing techniques such as whole genome sequencing (WGS) provide further insights into the mechanisms of spread of resistance, the role of the environment is not fully elucidated, nor is the role of plants as potential vehicles for spread of resistance. Historical trends and recent experience indicate that (re)‐emergence and/or further spread of VBD within the EU is a matter of when rather than if. Standardised and validated vector monitoring programs are required to be implemented at an international level for continuous surveillance and assessment of potential threats. There are benefits to using WGS – such as a quicker and better response to outbreaks and additional evidence for source attribution. However, significant challenges need to be addressed, including method standardisation and validation to fully realise these benefits; barriers to data sharing; and establishing epidemiological capacity for cluster triage and response.

Abstract Syndromic surveillance is a form of surveillance that generates information for public health action by collecting, analysing and interpreting routine health-related data on symptoms and clinical signs reported by patients and clinicians rather than being based on microbiologically or clinically confirmed cases. In England, a suite of national real-time syndromic surveillance systems (SSS) have been developed over the last 20 years, utilising data from a variety of health care settings (a telehealth triage system, general practice and emergency departments). The real-time systems in England have been used for early detection (e.g. seasonal influenza), for situational awareness (e.g. describing the size and demographics of the impact of a heatwave) and for reassurance of lack of impact on population health of mass gatherings (e.g. the London 2012 Olympic and Paralympic Games).We highlight the lessons learnt from running SSS, for nearly two decades, and propose questions and issues still to be addressed. We feel that syndromic surveillance is an example of the use of ‘big data’, but contend that the focus for sustainable and useful systems should be on the added value of such systems and the importance of people working together to maximise the value for the public health of syndromic surveillance services.

ECDC, EFSA and EMA have jointly established a list of harmonised outcome indicators to assist EU Member States in assessing their progress in reducing the use of antimicrobials and antimicrobial resistance (AMR) in both humans and food-producing animals. The proposed indicators have been selected on the basis of data collected by Member States at the time of publication. For humans, the proposed indicators for antimicrobial consumption are: total consumption of antimicrobials (limited to antibacterials for systemic use), ratio of community consumption of certain classes of broad-spectrum to narrow-spectrum antimicrobials and consumption of selected broad-spectrum antimicrobials used in healthcare settings. The proposed indicators for AMR in humans are: meticillin-resistant Staphylococcus aureus and 3rd-generation cephalosporin-resistant Escherichiacoli, Klebsiella pneumoniae resistant to aminoglycosides, fluoroquinolones and 3rd-generation cephalosporins, Streptococcuspneumoniae resistant to penicillin and S.pneumoniae resistant to macrolides, and K.pneumoniae resistant to carbapenems. For food-producing animals, indicators for antimicrobial consumption include: overall sales of veterinary antimicrobials, sales of 3rd- and 4th-generation cephalosporins, sales of quinolones and sales of polymyxins. Finally, proposed indicators for AMR in food-producing animals are: fullsusceptibility to a predefined panel of antimicrobials in E.coli, proportion of samples containing ESBL-/AmpC-producing E.coli, resistance to three or more antimicrobial classes in E.coli and resistance to ciprofloxacin in E.coli. For all sectors, the chosen indicators, which should be reconsidered at least every 5years, are expected to be valid tools in monitoring antimicrobial consumption and AMR. With the exception of the proposed human AMR indicators, the indicators are in general not suitable to monitor the effects of targeted interventions in a specific sector, such as in a single animal species or animal production sector. Management decisions should never be based on these indicators alone but should take into account the underlying data and their analysis. (C) 2017 European Centre for Disease Prevention and Control, (C) European Food Safety Authority and (C) European Medicines Agency. EFSA Journal published by John Wiley and Sons Ltd on behalf of European Food Safety Authority.

Since May 2016, the World Health Organization (WHO) has recommended shorter regimens to treat rifampicin-resistant/multidrug-resistant tuberculosis (RR/MDR-TB), substantially reducing the treatment duration to 9–12 months [1]. van der Werf et al. [2] estimated that only 11% of RR/MDR-TB patients in the European Union (EU)/European Economic Area (EEA) fulfilled the WHO inclusion criteria, which is similar to estimates by Lange et al. [3] and Sotgiu et al. [4]. This estimate raises concerns, as that the conventional long-duration regimen has very poor results in the EU/EEA. Health sector crisis, increasing inequality and xenophobia add to the urgency to prevent and manage MDR-TB. The main exclusion criteria are as follows. Shorter MDR-TB regimens should not be excluded because of resistance to first-line drugs or extrapulmonary sites http://ow.ly/E4oo30bsIea

In May 2016, the World Health Organization (WHO) updated its treatment guidelines for drug-resistant tuberculosis (TB) and included a recommendation for the use of the shorter multidrug-resistant (MDR) TB regimen [1]. The WHO update is based on information provided by observational studies coordinated by the International Union Against Tuberculosis and Lung Disease, Médecins sans Frontières and the Damien Foundation which showed that the shorter treatment regimen resulted in a higher likelihood of treatment success compared to the longer conventional treatment in the study settings [2–5]. The shorter MDR-TB regimen consists of a standardised treatment course lasting 9–12 months and includes kanamycin, moxifloxacin, prothionamide, clofazimine, pyrazinamide, isoniazid and ethambutol. It is recommended for patients with rifampicin-resistant (RR) or MDR-TB (cases with TB bacilli resistant to at least isoniazid and rifampicin) who have not been treated previously with second-line drugs and in whom resistance to fluoroquinolones and second-line injectable agents has been excluded or is considered highly unlikely. It is not recommended for pregnant women and patients with extrapulmonary TB. In the European Union, 11% of all MDR-TB cases are eligible for the shorter MDR-TB regimen The authors acknowledge the contribution of the nominated tuberculosis surveillance experts of the EU/EEA member states for providing the data to TESSy: Alexander Indra (Austrian Agency for Health and Food Safety, Vienna, Austria), Maryse Wanlin (Respiratory Diseases Fund, Brussels, Belgium), Tonka Varleva (Ministry of Health, Sofia, Bulgaria), Aleksandar Simunovic (Croatian Institute of Public Health, Zagreb, Croatia), Maria Koliou (Directorate of Medical and Public Health Services, Nicosia, Cyprus), Jiri Wallenfels (University Hospital Bulovka, Prague, Czech Republic), Peter Henrik Andersen (Statens Serum Institut, Copenhagen, Denmark), Piret Viiklepp (National Institute for Health Development, Tallinn, Estonia), Hanna Soini (National Institute for Health and Welfare, Turku, Finland), Walter Haas (Robert Koch Institute, Berlin, Germany), Ourania Kalkouni (Hellenic Centre for Disease Control and Prevention, Athens, Greece), Gábor Kovács (Koranyi National Institute of Tuberculosis and Pulmonology, Budapest, Hungary), Thorsteinn Blondal (Primary Health Care Centre Capital Area, Reykjavik, Iceland), Joan O’Donnell (Health Protection Surveillance Centre, Dublin, Ireland), Dace Mihalovska (Centre for Disease Prevention and Control, Riga, Latvia), Edita Davidavičienė (National Tuberculosis and Infectious Diseases University Hospital, Vilnius, Lithuania), Irene Demuth (Health Directorate, Luxembourg, Luxembourg), Analita Pace Asciak (Superintendence of Public Health, Valletta, Malta), Erika Slump (National Institute for Public Health and the Environment, Bilthoven, the Netherlands), Trude Margrete Arnesen (National Institute of Public Health, Oslo, Norway), Maria Korzeniewska-Koseła (National Tuberculosis and Lung Disease Institute, Warsaw, Poland), Antonio Diniz (Directorate General of Health, Lisbon, Portugal), Domnica Ioana Chiotan (Institute of Pneumology "Marius Nasta", Bucharest, Romania), Jerker Jonsson (Public Health Agency of Sweden, Stockholm, Sweden), Petra Svetina (University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia), Ivan Solovic (National Institute for Tuberculosis, Lung Diseases and Thoracic Surgery, Vyšné Hágy, Slovakia) and Maeve Lalor (Public Health England, London, UK).

A multi-country cluster of multidrug-resistant tuberculosis (MDR TB) involving 25 migrants has been delineated by whole genome sequencing (WGS). All cases have a recent history of migration from Somalia (22 cases), Eritrea (2 cases) and Ethiopia (1 case). Cases have been reported by Germany (13 cases), Switzerland (8 cases), Austria (2 cases), Finland and Sweden (1 case each). A WGS analysis of the 25 cluster isolates supports the hypothesis that the cases are part of a chain of recent transmission likely to have taken place either in the country of origin or in a place along the migration route to the country of destination. Based on the currently available information, it is not possible as of yet to rule out that transmission occurred in an EU/EFTA country.

Abstract Introduction In preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS). Hypothesis/Problem The further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events. Methods The EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student’s t test was used to test any identified changes in pattern of attendance. Results Very few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for “chemicals, poisons, and overdoses, including alcohol” and “acute alcohol intoxication” were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012). Conclusions Syndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions. TodkillD, HughesHE, ElliotAJ, MorbeyRA, EdeghereO, HarcourtS, HughesT, EndericksT, McCloskeyB, CatchpoleM, IbbotsonS, SmithG. An observational study using English syndromic surveillance data collected during the 2012 London Olympics – what did syndromic surveillance show and what can we learn for future mass-gathering events? Prehosp Disaster Med. 2016;31(6):628–634.

The history of agriculture includes many animal and plant disease events that have had major consequences for the sector, as well as for humans. At the same time, human activities beyond agriculture have often driven the emergence of diseases. The more that humans expand the footprint of the global population, encroach into natural habitats, alter these habitats to extract resources and intensify food production, as well as move animals, people and commodities along with the pathogens they carry, the greater the potential for pathogens and pests to spread and for infection to emerge or re-emerge. While essential to human well-being, producing food also plays a major role in disease dynamics. The risk of emergence of pests and pathogens has increased as a consequence of global changes in the way food is produced, moved and consumed. Climate change is likely to increase pressure on the availability of food and provide newly suitable conditions for invasive pests and pathogens. Human population displacements due to economic, political and humanitarian crises represent another set of potential drivers for emerging issues. The overlapping drivers of plant, animal and human disease emergence and environmental changes point towards the concept of 'One Health'. This paradigm underlines the urgent need to understand the influence of human behaviour and incorporate this understanding into our approach to emerging risks. For this, we face two major challenges. One is cultural; the second is methodological. We have to look at systems not under the narrow view of specific hazards but with a wider approach to system dynamics, and consider a broad spectrum of potential outcomes in terms of risk. In addition, we have to make sense of the vast amounts of data that are available in the modern age. This paper aims to help in preparing for the cultural and methodological shifts needed in our approach to emerging risks.

This localised outbreak of neurological symptoms associated with enterovirus A71 (EV-A71) is notable in terms of its magnitude and the severity of symptoms of the reported cases. As part of this assessment it was determined that no similar outbreaks have been detected in the rest of Spain. Other EU Member States have not reported concomitant enterovirus outbreaks and ECDC is not aware of signals of other unusual enterovirus outbreaks in the EU. Reporting of such clusters and outbreaks through the Early Warning and Response System (EWRS) is encouraged.

Background Syndromic surveillance aims to provide early warning and real time estimates of the extent of incidents; and reassurance about lack of impact of mass gatherings. We describe a novel public health risk assessment process to ensure those leading the response to the 2012 Olympic Games were alerted to unusual activity that was of potential public health importance, and not inundated with multiple statistical 'alarms'.Methods Statistical alarms were assessed to identify those which needed to result in 'alerts' as reliably as possible. There was no previously developed method for this. We identified factors that increased our concern about an alarm suggesting that an 'alert' should be made.Results Between 2 July and 12 September 2012, 350 674 signals were analysed resulting in 4118 statistical alarms. Using the risk assessment process, 122 'alerts' were communicated to Olympic incident directors.Conclusions Use of a novel risk assessment process enabled the interpretation of large number of statistical alarms in a manageable way for the period of a sustained mass gathering. This risk assessment process guided the prioritization and could be readily adapted to other surveillance systems. The process, which is novel to our knowledge, continues as a legacy of the Games.

Background: Early warning and robust estimation of influenza burden are critical to inform hospital preparedness and operational, treatment, and vaccination policies. Methods to enhance influenza-like illness (ILI) surveillance are regularly reviewed. We investigated the use of hospital staff 'influenza-like absences' (hospital staff-ILA), i.e. absence attributed to colds and influenza, to improve capture of influenza dynamics and provide resilience for hospitals.Methods: Numbers and rates of hospital staff-ILA were compared to regional surveillance data on ILI primary-care presentations (15-64 years) and to counts of laboratory confirmed cases among hospitalised patients from April 2008 to April 2013 inclusive. Analyses were used to determine comparability of the ILI and hospital-ILA and how systems compared in early warning and estimating the burden of disease.Results: Among 20,021 reported hospital-ILA and 4661 community ILI cases, correlations in counts were high and consistency in illness measurements was observed. In time series analyses, both hospital-ILA and ILI showed similar timing of the seasonal component. Hospital-ILA data often commenced and peaked earlier than ILI according to a Bayesian prospective alarm algorithm. Hospital-ILA rates were more comparable to model-based estimates of 'true' influenza burden than ILI.Conclusions: Hospital-ILA appears to have the potential to be a robust, yet simple syndromic surveillance method that could be used to enhance estimates of disease burden and early warning, and assist with local hospital preparedness.

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This chapter will examine the impact of terrorism on the physical and mental health of victims, and the insights this provides for the public health needs of urban populations facing ongoing terrorist threat. The main focus will be health outcome studies following the terrorist attacks on London on 7 July 2005 (known as the 7/7 Bombings). Qualitative accounts of individuals who survived the 7/7 Bombings, epidemiological data on physical and psychological injuries and satisfaction with and outcome of psychological screening and treatment offered to victims with Post-traumatic Stress Disorder (PTSD) will be shared. These encapsulate the direct experiences of victims and health professionals after this particular terrorist attack and comparison with similar attacks in other cities are made. Firstly, our aim is to present evidence that demonstrates the need to have emergency public health protocols that facilitate the proactive and coordinated tracing of all victims, minutes to months, after a terrorist attack, to offer health assessment, monitoring and treatment and, thereby, facilitate robust data for much-needed epidemiological research. Secondly, we aim to show that outreach to victims must involve government and non-government agencies, the media and, arguably, the Internet, as normal referral routes to healthcare cannot be assumed to be reliable.

Mass gatherings are regarded as potential risks for transmission of infectious diseases, and might compromise the health system of countries in which they are hosted. The evidence for increased transmission of infectious diseases at international sporting mass gatherings that attract many visitors from all over the world is not clear, and the evidence base for public health surveillance, epidemiology, and response at events such as the Olympics is small. However, infectious diseases are a recognised risk, and public health planning is, and should remain, a crucial part of the overall planning of sporting events. In this Series paper, we set out the planning and the surveillance systems that were used to monitor public health risks during the London 2012 Olympic and Paralympic Games in the summer of 2012, and draw attention to the public health issues-infectious diseases and chemical, radiation, and environmental hazards-that arose. Although the absolute risk of health-protection problems, including infectious diseases, at sporting mass gatherings is small, the need for reassurance of the absence of problems is higher than has previously been considered; this could challenge conventional public health surveillance systems. Recognition of the limitations of health-surveillance systems needs to be part of the planning for future sporting events.

Heatwaves are a seasonal threat to public health. During July 2013 England experienced a heatwave; we used a suite of syndromic surveillance systems to monitor the impact of the heatwave. Significant increases in heatstroke and sunstroke were observed during 7-10 July 2013. Syndromic surveillance provided an innovative and effective service, supporting heatwave planning and providing early warning of the impact of extreme heat thereby improving the public health response to heatwaves.

Estimates of influenza based on influenza like illness (ILI) may not capture the full spectrum of illness or result in early warning. We tested a syndromic surveillance method using hospital staff influenza like absence (ILA) to potentially enhance ILI. Rates of ILA were compared to regional surveillance data on ILI and confirmed positive influenza A test results (PITR) in hospitalised patients. ILA demonstrated accurate seasonal trends in influenza as defined by ILI, but provided more realistic estimates of the relative burden of pH1N1, and potentially earlier warning than ILI and PITR, which is likely to improve accuracy of influenza monitoring.

We assessed whether implementation of a combination of interventions in London tuberculosis clinics raised the levels of HIV test offers, acceptance and coverage. A stepped-wedge cluster randomised controlled trial was conducted across 24 clinics. Interventions were training of clinical staff and provision of tailor-made information resources with or without a change in clinic policy from selective to universal HIV testing. The primary outcome was HIV test acceptance amongst those offered a test, before and after the intervention; the secondary outcome was an offer of HIV testing. Additionally, the number and proportion of HIV tests among all clinic attendees (coverage) was assessed. 1,315 patients were seen in 24 clinics. The offer and coverage of testing rose significantly in clinics without (p = 0.002 and p = 0.004, respectively) and with an existing policy of universal testing (p = 0.02 and p = 0.04, respectively). However, the level of HIV test acceptance did not increase in 18 clinics without routine universal testing (p = 0.76) or the six clinics with existing universal testing (p = 0.40). The intervention significantly increased the number of HIV tests offered and proportion of participants tested, although acceptance did not change significantly. However, the magnitude of increase is modest due to the high baseline coverage.

In February 2013, novel coronavirus (nCoV) infection was diagnosed in an adult male in the United Kingdom with severe respiratory illness, who had travelled to Pakistan and Saudi Arabia 10 days before symptom onset. Contact tracing identified two secondary cases among family members without recent travel: one developed severe respiratory illness and died, the other an influenza-like illness. No other severe cases were identified or nCoV detected in respiratory samples among 135 contacts followed for 10 days.

www.thelancet.com/infection Vol 13 December 2013 1003 higher direct costs of products whose manufacturing methods are altered. A pricing paradox exists in farming whereby antibiotics, a scarce natural resource, cost less than implementation of more eff ective hygiene practices. Reversal of this paradox might lead to higher food prices. In the UK, a cross-government antimicrobial strategy has been launched. The key elements are: improvement of infection prevention and control practices in human and animal health; optimisation of prescribing practice; improvement of professional education, training, and public engagement; development of new drugs, treatments, and diagnostics; better access to and use of surveillance data; better identifi cation and prioritisation of research into antimicrobial resistance; and strengthened international collaboration. The UK Govern ment is working alongside other governments under the auspices of the WHO to improve global anti microbial steward ship and surveillance.