At the national level in France, the management of a public health crisis caused by a communicable disease is primarily the responsibility of the Ministry of Health, which is aided in its task by public establishments under its supervision such as the Institut de Veille Sanitaire, France’s national health monitoring institute. At the local level, the prefects, who are the state representatives, have also been given specific powers in times of epidemic crisis. A reserve health corps was created in 2007.
France drew up its first comprehensive national plan for the prevention and control of an influenza pandemic in 2004, and last updated it in 2011. The plan is aimed at protecting the French population, as well as French citizens living abroad, against a pandemic threat and limiting the social and economic consequences of a pandemic.
Recently, the government has taken steps to prevent or limit the spread of the Ebola virus in France. These steps include screenings at airports in at-risk countries, the preparation of specialized wards in hospitals, and the dissemination of information to both health care professionals and the general public.
Public health crises can take many forms, such as disease epidemics; large-scale incidents of food or water contamination; and harmful exposure to chemical, radiological, or biological agents. Their causes may be natural, accidental, or deliberate. How France deals with a crisis and which public authorities are involved depends on the nature of the crisis. This report first focuses on the operational management of a public health crisis caused by a communicable disease. It then addresses, as examples, the 2009 national plan for the prevention and control of an influenza pandemic, and measures recently taken in the context of the current Ebola crisis.
The administrative division of France plays a role in how the government prepares for and manages a health crisis. France is divided into twenty-two regions, and there are ninety-six départements within metropolitan France. Each département has a préfet (prefect), who is the representative of the central government. For purposes of emergency planning, France is also divided into seven zones of defense, each under the responsibility of a zone prefect who will manage emergency crises exceeding the boundaries of the département. The region prefects are also given specific powers in times of epidemic crisis. Finally, France has incorporated into its national law the 2005 International Health Regulation adopted by the World Health Organization’s (WHO’s) Fifty-eighth World Health Assembly on May 23, 2005, which also has an impact on the management of public health crises.
II. Structure of Public Health Crisis Management System
The operational management of a public health crisis caused by a communicable disease principally involves the Ministry of Health; the Ministry of Interior; the Institut de Veille Sanitaire (InVS), which is France’s national health monitoring institute; the préfets (prefects), who are the state representatives in the départements;and the mayors. A reserve health corps was also created in 2007.
A. Directorate General of Health
The Ministry of Health is divided into several directorates. Among them, the Direction Générale de la Santé (DGS, the General Directorate of Health) sets forth health policies and, as a guarantor of health security, may take any measures to prevent or respond to public health crises—in particular, a crisis related to communicable diseases. Following audits and reports prepared after the SARS (severe acute respiratory syndrome) and other health crises, the DGS was reorganized in 2007 to reinforce its action on prevention, to better manage emergencies and health threats, and to improve its governance and performance.
The Health Code provides that when an epidemic threatens the country or part of the country and local means are insufficient to stop it, the Minister of Health may, by means of a ministerial regulation, set forth all appropriate measures and allocate duties to prevent the spread of such disease. The decree may give authority to the prefects to implement one or more of the needed measures. The measures taken are regularly reviewed by the High Council for Public Health (Haut Conseil de la Santé Publique), which checks whether they are appropriate.6] Created in 2004, this Council comprises six specialized commissions: transmissible diseases; chronic diseases; risks linked to the environment; patient safety; education and promotion of health; and lastly, evaluation and strategy. One of its missions is to provide the necessary expertise for the management of health risks and to evaluate the policies and strategies regarding health prevention and safety.
B. Institut de Veille Sanitaire (InVS)
The InVS’s general mission is to constantly monitor the state of the public health. The InVS is under the supervision of the Minister of Health. It was created by Law 98-535 of July 1, 1998, Relating to the Reinforcement of Health Monitoring. Its mission was extended by Law 2004-806 of August 9, 2004, on Public Health Policy to meet new challenges that were highlighted by health crises and emerging risks.
The InVS is, in particular, charged with the following:
- Detecting any threat to public health and alerting the competent public authorities;
- Gathering, analyzing, and developing information on health risks, their causes, and their evolution;
- Taking part in collecting and processing data on the state of public health;
- Carrying out or supporting any action (investigation, study, assessment, etc.) likely to contribute to the monitoring of public health; and
- Helping to manage health crises by proposing to the health authorities the necessary measures and actions to take.
The InVS monitors all fields of public health, including infectious diseases, environmental health, occupational health, chronic diseases, and international and tropical diseases. It participates in international and European cooperation programs, such as the monitoring of AIDS or tuberculosis, or setting forth monitoring systems. It is headed by a General Director. Its 2013 operational expenses were approximately €60 million and it has about 425 employees, mainly scientists.
To perform its mission, the InVS has access to a network of seventeen regional centers called Cellules interrégionales d’épidémiologie (CIRE, Inter-regional Epidemiological Units). These CIRE fall under the authority of General Director of the InVS, but are integrated into local Agences régionales de santé (ARS, Regional Health Agencies). ARS were created in 2009 to centralize and better coordinate the various government health-related resources at the regional level. The CIRE investigate and assess potential health safety warning signs, and provide each ARS with methodological support and independent expertise regarding such warning signs.
In addition to the CIRE, the InVS works with a great number of other organizations that contribute to the monitoring of public health, particularly doctors and hospitals. Medical doctors and laboratories (both public and private) must report to their local ARS diseases that necessitate urgent local, national, or international intervention, and diseases that require monitoring for the evaluation of public health policies. A list of the diseases that must be reported is published in the Code of Public Health and is regularly updated. Information must be sent to the ARS and InVS in a manner that protects the patients’ privacy, and all those who have access to this information, in whatever capacity, are required to observe the confidentiality of the information. A violation of the confidentiality requirement is punishable by one year of imprisonment and a fine of €15,000 (approximately US$17,000). The Public Health Code does not provide for a penalty when a doctor fails to report a listed disease. However, failure to report may be prosecuted under the provisions governing the risks caused to another or the omission to render assistance when such failure results in the contamination of other individuals either because they have been in contact with the contaminated subject or have been exposed to the same source of contamination.
The InSV works in close cooperation with the European Center for Disease Prevention and Control. It is part of the Early Warning and Response System that was set up in 1998 under Decision 2119/98/EC of the European Parliament and of the Council. This alert system establishes permanent communication between the EU Member States’ public health authorities, enabling them to coordinate their efforts for the prevention and control of communicable diseases.
In February 2001, the WHO opened an office in France to help developing countries detect and control epidemics and emerging diseases. InSV also participates in international epidemic surveillance organizations such as the WHO’s Early Alerting and Reporting project and the EpiSouth network, which aims to improve communicable diseases surveillance, communication, and training among the countries of the Mediterranean and the Balkans.
C. Ministry of Health
In cases of severe health threats, especially epidemiological threats, necessitating emergency measures, the minister in charge of health has the authority to impose any proportional measures to prevent and mitigate the dangers to public health. The Minister of Health may also give authority to local prefects to take any measures necessary to apply the minister’s decisions.
The prefect directly represents the Prime Minister and each minister in the département. He is, therefore, responsible for most central functions, including internal order, civil safety, security, and health in his département. In a time of crisis of any type, he coordinates all civilian services involved in the management of such a crisis within his département. Prefects are authorized to requisition all property or services, in particular the services of any health professionals, if necessary to face a health crisis.
E. Reserve Health Corps
Law 2007-294 of March 5, 2007, established a reserve health corps to help deal with disasters, emergencies, and serious health threats. The Law was incorporated into the Health Code. The reserve corps comprises health professionals, former health professionals, and other individuals whose professional duties, experience, or level of training satisfy the requirements set forth by the Ministry of Health. The contract to serve in the reserve may provide for carrying out international missions.
III. National Plan for the Prevention and Control of the Influenza Pandemic
In 2004, France drew up its first comprehensive national plan for the prevention and control of an influenza pandemic. Its latest version was published in October 2011, and the French government has published an English-language version. The plan is adaptable and aimed at protecting the French population, as well as French citizens living abroad, against a pandemic threat and limiting the social and economic consequences of a pandemic.
The plan sets action guidelines for four different stages of an epidemic’s progression in a territory. Responses in the first stage focus on slowing down the introduction of the virus into the territory, thus allowing the government to prepare for the following stages by making vaccines available (if possible), distributing relevant health care products and equipment, and preparing health care facilities for a possible influx of patients. Health checks at the border may be part of the government’s response at this stage. Similarly, in the second stage, the authorities act to slow down the propagation of the virus in the territory so as to gain time for the scaling-up of the health care system and/or the preparation of a vaccine. Barrier measures, such as closing nurseries and schools; encouraging the public to use individual means of transport; or restricting collective activities such as performances, sports events, or other major gatherings, may be implemented at this stage. In the third stage, during which the number of affected patients peaks, the authorities try to limit the pandemic’s effect—not only from a health care aspect through the treatment of patients, but also from an economic aspect through measures to mitigate the effects of absenteeism and other pandemic-related disturbances. Finally, stage four marks both a transition back to a normal situation, and preparation for a potential second wave.
IV. Responding to the Ebola Crisis
The first case of Ebola infection in Guinea was identified by a French laboratory on March 23, 2014. This prompted French authorities to inform the European Commission and the European Health Security Committee, and to monitor the epidemiological situation in African countries where the virus is present in collaboration with the WHO and the European Center for Disease Control. An interministry task force, including a prefect and representatives from the Ministry of Health and the Ministry of Foreign Affairs, was set up to coordinate the French response to the Ebola threat. The InVS is continuously monitoring the epidemiological situation, both in France and internationally, and special measures were put into place for the early detection and isolation of any person who might be contagious on French territory. Screening processes have been set up at the airports of at-risk countries to assess travelers going to France, and informational brochures have been given to airlines to be distributed to passengers traveling between France and at-risk countries. French citizens are encouraged to postpone any travel to at-risk countries. If a person infected with the Ebola virus is detected in France, that person is to be transported to a specialized health care facility, where that person will be treated in isolation. The government has published a list of hospitals that have been set up and certified by an ARS to treat Ebola patients. The government has also provided information to medical professionals on the symptoms of the Ebola virus, on the procedures to protect themselves from infection, and on the procedures to alert the health authorities if they come across a potential Ebola patient.
Prepared by Nicolas Boring
Foreign Law Specialist*
* This is a revised and updated version of a report authored in 2009 by Nicole Atwill, Senior Legal Specialist at the Law Library of Congress (retired).
 Code de la Defense art. R.1211-4, http://www.legifrance.gouv.fr/affichCode.do?cidTexte=LEGITEXT 000006071307&dateTexte=20141028.
 Code de la Sante Publique art. L.3131-8, http://www.legifrance.gouv.fr/affichCode.do?cidTexte=LEGITEXT 000006072665&dateTexte=20141028.
 Décret No 2007-1073 du 4 juillet 2007 portant publication du règlement sanitaire international (2005) adopté par la cinquante-huitième Assemblée mondiale de la santé le 23 mai [Decree No. 2007-1073 of July 4, 2007, on the publication of the International Health Regulations (2005)Adopted by the Fifty-eighth Health Assembly on May 23, 2005], Journal Officiel de la République Française [J.O.] [Official Gazette of France], July 7, 2007, p. 11570, http://www.legifrance.gouv.fr/affichTexte.do;jsessionid=AA3B324B58F8360A41FC03636B303E8A. tpdjo06v_3?cidTexte=JORFTEXT000000467563&categorieLien=id.
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 Code de la Sante Publique art. L.3131-1.
 Id. art. L.3131-2.
 Code de la Sante Publique art. L.1411-4.
 Loi 98-535 du 1er juillet 1998 relative au renforcement de la veille sanitaire et du controle de la sécurité sanitaire des produits destinés à l’homme [Law 98-535 Relating to the Reinforcement of Health Monitoring and of the Control of the Health Safety of Products Destined for Man], J.O., July 2, 1998, p. 10056, http://legifrance.gouv. fr/affichTexte.do;jsessionid=20D3E80627BA733894E9F14916C2B1F6.tpdjo16v_2?cidTexte=JORFTEXT000000573437&categorieLien=id.
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 Id. art. 15; Code de la Sante Publique art. L1413-2.
 As of October 29, 2014, the exchange rate for dollars to Euros was US$1.27:€1.00.
 Institut de Veille Sanitaire, Rapport Annuel [Annual Report] 2013 at 68–69, http://www.invs.sante.fr/ publications/rapport_annuel/2013/sources/index.htm.
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 Id. arts. D.3113-6 & D.3113-7.
 Id. arts. L.3113-1 & R.3113-2.
 Id. art. R.3113-5.
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 Id. art. 223-1. This article provides that “directly exposing another to a risk of immediate death or of wounds likely to result in mutilation or permanent infirmity by the manifestly deliberate violation of a special obligation of safety or prudence imposed by law or regulation,” is punishable by one year of imprisonment and a fine of €15,000. Id. (translation by the author).
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 Id. at 4.
 Id. at 11.
 Id. at 39.
 Id. at 47.
 Id. at 50.
 Id. at 55–61.
 Id. at 65.
 Nous agissons contre Ebola [We Are Acting Against Ebola], Ministère des affaires sociales, de la santé et des droits des femmes [Ministry of Social Affairs, Health, and Women’s Rights], http://ebola.sante.gouv. fr/nous-agissons-contre-ebola/ (last visited Oct. 30, 2014).
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 Id.; Liste des établissements de santé de référence habilités pour la prise en charge des patients cas possibles ou confirmés de maladie à virus Ebola [List of Reference Health Care Establishments Certified to Take Charge of Possible or Confirmed Ebola Virus Patients], Ministère des affaires sociales, de la santé et des droits des femmes [Ministry of Social Affairs, Health, and Women’s Rights] (Sept. 25, 2014), http://ebola.sante. gouv.fr/IMG/pdf/2014_09_25_-_listingesr_maj_modifidferta-2-2.pdf.
Last Updated: 06/09/2015