2004 Dr Alain Moren: Challenges for field epidemiology training in a widening Europe

The Pumphandle Lecture series always features a great lecturer and the speaker for the sesquicentenary, Dr Moren, was very appropriate, demonstrating that epidemiology is now a pan-European expertise. Training is essential to maintain and improve the skills of future epidemiologists and EPIET provides courses and training attachments across the “island and the continent” of Europe.

Dr Moren praised the critical thinking of Snow whose exceptional approach was demonstrated by features that were highly controversial in his time, although now forming the foundation of what is now considered the ideals for public health epidemiology:

  • Challenging accepted knowledge.
  • Field investigation – Snow demonstrated the need for what is known at CDC Atlanta as ‘shoe leather epidemiology’.
  • Statistics and comparison of groups with and without a disease
  • Cartography – which has led to the geographic information systems to plot disease distributions
  • The importance of ‘outlying cases’ (such as the Widow of Hampstead) and anomalies such as the low number of cases at the Broad Street brewery (they had a private well with uncontaminated water)
  • Communication – including writing up his theory and investigations
  • Research
  • Intervention – the removal of the pumphandle now symbolises the ideal public health preventive act.

The challenges are different, not less, in our era. Challenging accepted knowledge has become, possibly, more honoured in theory than in action and bureaucracy, ever a limiting factor on independent thought, can often take up so much time that field investigation and research may suffer. Establishing an epidemiological network across Europe has been a remarkable achievement, although much needs to be done and adequate funding is hard to maintain against other priorities. The concept of a ‘Europe of Health’ is not just a desirable ideal, but a practical necessity for a world with increasingly blurred boundaries, frequent travel and transport of foods from one side to the other. A coordinated epidemiological network is particularly important for communicable disease, which ignores political borders and can cause a rapidly escalating crisis. It took a long time to establish the need for EPIET: the Treaty of Rome for the European Union was in 1957, while the decision to finance European epidemiological surveillance was made by an EC decision numbered 2119 only six years ago, in 1998. The network is poised for another major development in 2005, when the European Centre for Disease Prevention and Control will open in Stockholm. Decision 2119 featured some important key words:

  • Surveillance of communicable disease
  • Early warning and response
  • A permanent link between the Commission [EC] and responsible structures/authorities in Member States

There are now many networks for particular diseases, such as AIDS/HIV (the oldest, started by France), measles, hospital infection (HELICS), Legionella infection – and with a network for listeria due to start next year. Up to 51 nations participate in each network, with funding for independent networks provided by Member States and the coordination funded by the EC. ENTERNET, the surveillance system for gastrointestinal infection, has played an essential role in the control of salmonella outbreaks: to give just once example, an epidemic of over 4000 cases of Salmonella agona was achieved through networking between England and Wales, Canada, Israel and the USA.

Despite the success of the networks, they remain fragile, a patchwork still struggling to be firmly ‘joined up’: the threats including competition for funds (the surveillance of HIV and TB, for example, temporarily depended on independent funding by Member States); bureaucracy that swamps coordinators with paperwork; and, not least, yearly contracts that prevent long-term planning. Add to this the different approaches to epidemiological method, varying scientific terms and languages – and it seems remarkable that the networks have done so well. Field-orientated training, providing practical experience, has been based on several European strengths: the excellent universities, national schools of public health, the strong public health tradition of the UK and links between several countries, notably France, with CDC Atlanta. The existence of field epidemiology training programmes in several European countries (e.g. UK, Hungary, Italy, Spain, Germany) fuelled the idea for exchanges between countries – and so EPIET was born.

ET has several training objectives:

  1. To plan, implement and evaluate a European surveillance system;
  2. To perform outbreak investigations;
  3. To develop research projects and to examine public health issues;
  4. To enhance oral and written scientific communication skills;
  5. To acquire teaching skills.

There is a 2 year practical training which starts with a 3 week introductory course and includes six one week training modules that rotate between European states. The emphasis is on ‘learning by doing’, with on-site supervision by a senior epidemiologist: an important corollary is that the ‘fellows’ will go on to train others. One problem is that EPIET fellows often enjoy their attachments in another country so much that they are reluctant to return, or are recruited to the World Health Organisation (WHO): this has created some funding dilemmas for the states that funded their training. On the other hand, the existence of EPIET has had a ‘snow ball’ effect by inspiring the establishment of field epidemiology training programmes (FETPs) in Nordic countries, the Middle East and Romania. Courses are open to external participants: some 400 from all over Europe have benefited, while 119 EPIET fellows have now graduated and many hold senior positions. There are now 19 training sites, with 27 nations and the WHO participating.

Recent successes for the network include coordination of the SARS outbreak in 2003 (the subject covered in last year’s Pumphandle lecture), a large outbreak of Salmonella typhimurium 204b in 2000 and, in 2004, control of an outbreak of Hepatitis A in tourists returning from Egypt. The Hepatitis A outbreak involved over 200 cases in 14 countries. Another outbreak of Hepatitis A in 2001, affecting mainly German tourists, was traced to Ibiza and required investigation of restaurants, shops, secondary cases and other factors involved in the chain of transmission. In the UK, the network also helped to investigate Clostridium infection in IV drug users in England, Scotland and Ireland in 2000. Such investigations have raised the issue of the need for coordination of communications: we are still a long way from the CDC Atlanta example of ‘everything in one phone call’: ensuring that all relevant staff have been informed is an extremely time consuming exercise for all Member States, not least in the UK.

The European network has also supported international missions to countries outside Europe: SARS in Asia in 2003; investigating infant deaths following immunisation in Egypt; Ebola in Uganda, the Congo, Gabon and Sudan; tularaemia in Kosovo. Strong administrative back up is needed for such missions, as well as ways of working with bureaucracy to ensure appropriate dissemination of results. In addition, there are issues such as security and independence of the doctors and scientists on the missions – and the socioeconomic implications such as the impact on tourism. Investigation may continue long after the outbreak has subsided: for example, further investigation of the SARS cases in Hong Kong. Speed is of the essence for an efficient epidemiological network, something that Snow demonstrated so well in his rapid assessment of the cholera outbreak in 1854. Bias and misinterpretation by others of his results was a problem for Snow – and it still occurs, when evidence of a possible cause is pounced on and prevents further analysis of other factors.

The network has undoubtedly proved valuable to the participating Member States and partners, for example in:

  • Complementing university teaching
  • Promotion of field epidemiology in Europe
  • Training the trainers
  • Promotion of national training programmes
  • Increased mobility of epidemiologists with the EU
  • Cross border – and international – investigations
  • Coping with emergencies and bioterrorism.

Nevertheless, there is room for improvement. In 2002 the Byrne Commission Report concluded that Europe is not fully prepared for epidemics, hence the impetus for the coordinating centre in Stockholm. This ‘Eur-CDC’ will have links with laboratories, investigation, research, training, decision making and communications. It is the first important step to the ‘one stop shopping’ concept that CDC has been able to achieve in the USA. The Director of this new centre has yet to be appointed, but there may be news by the time this article appears. To conclude his lecture, Dr Moren eloquently described the benefits of a Europe that has now been a ‘space for peace’ for 50 years, with increasing harmony of human rights and economic exchange: time surely to advance Europe as a space for human networking. Dr John Snow would surely have taken up the challenge of epidemiology in Europe: meanwhile, you can find out more about EPIET on the website.