Within the widening European Union, large-scale movements of people, animals and food-products increasingly contribute to the potential for spread of communicable diseases. The EU was given a mandate for public health action only in 1992, under the Treaty of European Union ("Maastricht Treaty"), which was broadened in the 1997 with the Treaty of Amsterdam.

While all EU countries have statutory requirements for notifying communicable diseases, national and regional communicable disease surveillance practices vary considerably (1). The Network Committee (NC) for the Epidemiological Surveillance and Control of Communicable Diseases in the EU was established in 1998 to harmonise these activities (2).

There is wide variation in the public health epidemiology training available in service and academic institutions in EU countries, and serious differences in their capacity to respond to communicable disease threats nationally (3,4). Until recently Europe could not provide a coordinated response for the investigation and control of major communicable disease problems occurring internationally. Overall, there is a critical shortage of similarly trained professionals needed to ensure a high level of human health protection.

Anticipating these training needs, the European Programme for Intervention Epidemiology Training (EPIET) started in 1995 as a collaborative venture of the 15 European member states, plus Norway. In this article we describe the progress of the EPIET programme and its achievements to date, and its role in the newly created Network Committee.

EPIET is a two-year fellowship programme, which provides training and practical experience in intervention epidemiology at the national centres for surveillance and control of communicable diseases in the EU and Norway (hereafter referred to as EU).

The objectives of the programme are:

- to strengthen the surveillance of infectious diseases in EU Member States and at Community level;

- to develop response capacity at national and at Community level to meet communicable disease threats through rapid and effective field investigation and control;

- to develop an European network of public health epidemiologists using standard methods, and sharing common objectives;

- to contribute to the development of the network for the surveillance and control of communicable disease at Community level.

EPIET is funded on a project basis by the European Commission and the EU Member States.

EPIET is aimed at EU medical practitioners, microbiologists and veterinarians who have experience in public health and interest in infectious disease epidemiology. Ideally, candidates wish to pursue a career track which will contribute to the network of European public health epidemiologists after completion of their training.

Eight to ten fellowships are advertised each year. All applications are received at the EPIET Programme office, sorted by nationality and then forwarded to a designated institute in the applicants’ country of origin (table 1). These institutes select and rank up to four candidates among their national applicants, short-listed candidates select two host institutes which they would like to join during their fellowship from a list of EPIET training sites. The potential host sites receive the applicants' curriculum vitae and, in their turn, rank those who wish to join them. A panel, comprising the representatives of at least five participating countries, makes the final selection and determines the placements of successful candidates. Placements will usually be different from the fellow's country of origin. Institutes selected to host an EPIET fellow are those with national responsibilities for communicable disease surveillance, epidemiology, and public health advice. The training site selection criteria include an assessment of the centre's potential for the practice of intervention epidemiology and the quality of training supervision available for fellows.

Table 1. Institutes participating in EPIET (as of February 2001)

Country

Participating Institute

Austria

Bundesministerium für soziale Sicherheit und Generationen

Belgium

Institut Scientifique de Santé Publique - Louis Pasteur

Denmark

Statens Seruminstitut

Finland

National Public Health Institute

France

Institut de Veille Sanitaire

Germany

Robert Koch-Institut

Greece

National Centre for Surveillance and Intervention

Ireland

National Disease Surveillance Centre

Italy

Istituto Superiore di Sanità

Norway

Statens Institutt for Folkehelse

Portugal

Instituto Nacional de Saúde

Spain

Instituto de Salud Carlos III

Sweden

Swedish Institute for Infectious Disease Control

Netherlands

Rijksinstituut voor Volksgezondheid en Milieu

United Kingdom

Communicable Disease Surveillance Centre Northern Ireland

Scottish Centre for Infection and Environmental Health

PHLS Communicable Disease Surveillance Centre

PHLS Communicable Disease Surveillance Centre Wales

About 90% of the two-year fellowship is taken up by in-service training at the host institute. For the fellow to be fully integrated into the host institute, a good working knowledge of the local language is required and may be gained at the beginning of the fellowship by intensive language courses.

Apart from general service duties, each fellow is expected to acquire practical experience in three areas: (1) Design and/or evaluation of surveillance systems, (2) investigation of infectious disease outbreaks, and (3) execution of research projects in the area of public health. Fellows should also develop communication skills (interaction with media, scientific presentations, publications in bulletins and scientific journals) and participate in teaching and training activities.

About 10% of the fellowship is taken up by formal training courses.

The EPIET fellowship starts with a three-week introductory course in infectious disease epidemiology, held every autumn in Veyrier-du-Lac, France. This course offers systematic lectures in applied epidemiology, interactive case studies, practical exercises in small groups, and the development of a study protocol based on a current public health problem in a EU country.

During the remaining 23 months, four to five one-week courses (modules) are held in any of the participating institutes in the areas of communication, immunisation, surveillance, advanced statistics, and rapid assessment methods in emergencies. Fellows are also encouraged to attend appropriate courses organised in their host country.

Twice during the two-year training period fellows join alumni and colleagues from host institutes in an annual EPIET scientific seminar, where they present papers describing the results of their various services and research activities.

Local supervision in the host institute is a major determinant of the quality of the training and is provided by a designated trainer who may spend 10% or more of his/her work time on supervising a fellow. Fellow and trainer are responsible for ensuring that the EPIET training objectives and any personal learning objectives related to the fellow’s career are achieved. Additional support is provided by two to three training programme coordinators, who are accessible for advice to all fellows.

During the fellowship an EPIET programme coordinator together with a trainer and an EPIET fellow from different collaborating institutes will carry out a training site appraisal. For one day they systematically review the training environment and the training activities of the EPIET fellow, then make recommendations on how to further enhance training. The results of the visit are summarised in a formal appraisal report which is made available to all collaborating institutes and reviewed in the course of follow-up visits.

To date (February 2001), 62 fellows have entered the EPIET programme (n=51) or the closely affiliated German FETP (n=11) (4). Currently, 43 fellows have completed their training; another 19 are still in training. Figure 1 shows the number of fellows by their country of origin and their country of training.

The average age for the 51 EPIET fellows on entry into the programme was 35 years (range 26-46). Forty-one (80%) were medically qualified, 6 were veterinarians (12%) and one each a biologist, a pharmacist, a social scientist and a research scientist. Thirty-three (65%) fellows held a Masters' or higher degree in a public health-related field (MPH, MSc, PhD); 27 (53%) had worked outside of their own country for variable lengths of time before joining the programme.

Among the 36 EPIET fellows of the first four cohorts, 33 were subsequently employed in an environment where they could apply and further develop their knowledge and skills acquired. Twenty found employment in national or regional institutes in their country of origin, four in a centre with responsibility in European or supranational surveillance, and five in their host site. Another four fellows extended their training to obtain specialist accreditation.

The presence of an EPIET fellow has stimulated all institutes to further develop links with other collaborating institutes within the EU and to improve their capacity to respond to outbreaks within their national boundaries (4). Trainers involved with EPIET have gained useful experience of a wide range of training material and techniques, and the activity fostered binds between senior infectious disease epidemiologists from different EU countries. This has led increasingly to a unified approach to communicable disease surveillance, intervention epidemiology, and public health research.

Since the first introductory course in November 1995, fellows have been actively involved in evaluating or developing national surveillance systems, e.g. for Legionnaires’ disease, tuberculosis, poliomyelitis, trichinellosis, HIV infection among intravenous drug users, hepatitis B, sexually transmitted diseases, verotoxin-producing Escherichia coli (VTEC), waterborne outbreaks, and adverse events following immunisation.

Fellows were also involved in comparing surveillance data from different European countries, e.g. on VTEC infection and Haemolytic Uraemic Syndrome, Q fever, salmonellosis, campylobacteriosis, sporadic listeriosis, and legionellosis.

At EU level, EPIET fellows and their colleagues contributed to European networks, such as the European Working Group on Legionnaires’ Disease (EWGLI) and the International Surveillance Network for Enteric Pathogens (ENTER-NET).

Fellows investigated many outbreaks of infectious disease at local and national level, but were also involved in most major cross-border investigations within the EU. Between 1999 and 2000, a total of 61 outbreaks of infectious disease were investigated at national level with EPIET fellows in the role of lead or co-investigators (table 2).

Table 2. Examples of outbreak investigations at national and EU level in 1999 and 2000, with EPIET fellows as lead or co-investigators

At national level  

Legionellosis outbreak at a commercial fair in Kapellen, Belgium, 1999 

Stenotrophomonas maltophilia possibly related to the potable water distribution system in an ICU of a Belgian hospital, 1999

Viral gastroenteritis in a health-resort, Finland, December 1999

Tularemia in Finland, 1999

Community outbreak of Hepatitis A in Roubaix, France, May 2000

Salmonella panama in France, August – September 2000

MRSA in a university hospital in Germany, March 2000

Gastroenteritis in a nursing home due to Norwalk-like virus, Brandenburg, Germany, March 1999

Suspected waterborne outbreak of Norwalk virus gastroenteritis in a hotel resort in Italy, July 2000

Salmonella typhimurium: in coastal Norway, February 1999

A whirlpool associated outbreak of Pontiac fever at a hotel in Northern Sweden, April 1999

A foodborne gastro-enteritis outbreak caused by Norwalk-like virus in 30 day-care centres,Sweden, March 1999

Outbreak of Salmonella typhimurium PT 20 scattered throughout The Netherlands, October-November 1999

Measles outbreak in a community with a very low vaccine coverage in The Netherlands, July-December 1999

Salmonella outbreak in a bakery in Northern Ireland, June 1999

Staphylococcus food poisoning outbreak in two wedding receptions in Rhondda cynon Taff (South Wales), July 1999

Meningococcal disease in schools in South Wales, January -February 1999

Legionellosis associated with a hotel in Cardiff, Wales, 2000

Acute endophthalmitis following cataract surgery in a district hospital in Lanarkshire Health Board, Scotland

At EU level 
(cross-border investigations)

Salmonella paratyphi B among EU tourists returning from Turkey,1999

Clostridium infection and deaths among intravenous drug users, England, Scotland, Ireland, 2000

EU-wide outbreak of Salmonella typhimurium 204b, 2000

Meningitis W135 in pilgrims returning from the Haj, 2000

While EPIET’s main focus is the Community, the programme has responded with increasing frequency to requests for participation by non-EU countries and organisations of the United Nations system, particularly WHO. Examples are outbreak investigation of major international importance, the development, implementation or evaluation of surveillance systems, and other public health related activities (table 3).

Table 3. International missions (outside EU) in 1999 and 2000 with involvement of EPIET fellows

Outbreak investigations 

Influenza, Afghanistan, 1999

Bacterial Meningitis, Sudan, 1999

Viral meningitis, Romania and Moldova 1999

S. paratyphi among tourists, Turkey, 1999

Marburg virus, Democratic Republic of Congo, 1999

Infants deaths following immunisation, Egypt, 2000

Tularemia, Kosovo, 2000

Suspected anthrax, Ethiopia, 2000

Design, implementation, evaluation of surveillance systems

 Hurricane in Orissa State, India,1999

Health event surveillance among Kosovar refugees, Albania & Macedonia,1999

Cholera surveillance, Mozambique, 2000

Other activities

Polio eradication programme, various countries, 1999

Measles elimination programme, Sudan,1999

Unsafe Injection Practices survey, Burkina Faso, 2000

Assessment of neonatal tetanus status, Zimbabwe, 2000

In 1999, five years after its start, an external evaluation of EPIET was carried out to assess to what extent the programme achieves its stated objectives. While the overall assessment of the programme has been very favourable (5), the evaluation team identified some key areas which require attention: sustained long-term funding, establishment of clear and externally validated standards across all training sites, accreditation, and the integration of EPIET in the European Network for the Epidemiological Surveillance and Control of Communicable Diseases.

Member states have struggled to fund an increasing proportion of the training posts. Inevitably, this has lead to more conditional funding (funding tied to a particular country, either in a sending or hosting capacity) and sometimes to the exclusion of countries with limited financial resources. Recently, excellent applicants have been refused whilst first-rate training posts remain unfilled. Establishing a European network requires that all countries have equal access to the programme irrespective of their ability to make additional financial contributions.

Human health protection requires long-term investment. If EPIET is to maintain momentum in developing an effective European cadre of intervention epidemiologists it must be upgraded from a project to a sustainable programme.

The quality of training that can be provided by host institutes is variable and EPIET must help build capacity at weaker training institutions. This is essential for building an efficient EU Network on communicable diseases. Possible strategies to strengthen such sites include the placement of alumni, exchange of senior epidemiologists from various EPIET host institutes, and more frequent and targeted training-the-trainer sessions. Deployment of additional personnel for institute strengthening would require new administrative and financial mechanisms.

The concept of intervention epidemiology has been mainly developed through the Epidemic Intelligence Service (EIS) Programme in the United States of America (6). The USA implemented training in intervention epidemiology in 1951 (7). Since then, over 2000 persons have been trained in this programme and subsequently contributed to the public health in the USA and beyond.

Despite Europe’s heterogeneity in culture, language and organisation of health care, EPIET has successfully adopted a training approach similar to EIS. But accreditation is needed to ensure that high calibre candidates continue to be attracted. They in turn should expect career prospects at least as attractive as in academic training programmes (8). While a two-year training programme is too short to lead independently to national or European accreditation, the fellowship period should be recognised towards national accreditation in one of the related disciplines. Currently, only Ireland and UK have relevant accreditation schemes, and here the EPIET fellowship has been counted towards accreditation in public health medicine. Similar arrangements are needed in the other member countries or at EU level.

The aims of the EU Network Committee and of EPIET are highly complementary. Developing a European-wide surveillance, early warning and rapid reaction capability requires competent communicable disease epidemiologists with a common approach to intervention epidemiology and a shared European perspective. A shared long-term vision between EPIET and the Network Committee needs to be developed now to ensure that these needs can be fully met.

Nous souhaitons remercier tous les responsables de formation EPIET ainsi que les départements concernés des instituts participants pour leur travail et leur soutien à EPIET / We would like to thank all EPIET training supervisors and focal points in the participating institutes for their work and continuous support to EPIET: Dr Helga Halbich-Zankl, Dr Reinhild Strauss (Autriche / Austria); Dr Godfried Thiers, Mrs Solvejg Wallyn, Dr Carl Suetens, (Belgique / Belgium); Dr Else Smith, Dr Tove Ronne (Danemark / Denmark); Dr Hanna Nohynek, Dr Pekka Nuorti (Finlande / Finland); Prof Jacques Drucker, Dr Jean-Claude Desenclos, Dr Henriette de Valk (France); Dr Andrea Ammon, Dr Thomas Breuer (Allemagne / Germany); Dr Bernhard Schwartländer; Dr Iannis Tselentis (Grèce / Greece); Dr Darina O'Flanagan (Irlande / Ireland); Dr Donato Greco, Dr Stefania Salmaso, Dr Giuseppe Salamina, Dr Ciofi Degliatto (Italie / Italy); Dr Preben Aavitsland (Norvège / Norway); Dr Guilherme Gonçalves (Portugal), Dr. Maria-Theresa Paixão; Dr Juan Fernando Martinez Navarro, Dr Dionisio Herrera (Espagne / Spain); Prof Johan Giesecke, Dr Karl Ekdahl (Suède / Sweden); Dr Jacob Kool, Dr Mark Sprenger, Dr Marina Conyn Van Spaendonck (Pays-Bas / The Netherlands); Dr Elizabeth Mitchell, Dr Brian Smyth (Royaume-Uni, Irlande / UK, Northern Ireland); Dr Peter Christie, Dr John Cowden (Royaume-Uni, Ecosse / UK, Scotland); Dr Sarah O'Brien, Dr Mike Catchpole, Dr Christopher Bartlett (Royaume-Uni, Angleterre / UK, England); Dr Roland Salmon, Dr Meirion Evans (Royaume-Uni, Pays de Galles / UK, Wales); Dr Guenael Rodier, Dr David Heymann (OMS Genève / WHO Geneva); La Commission Européenne / The European Commission

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2 Decision No 2119/98/EC of the European Parliament and the Council of 24 September 1998 setting up a network for the epidemiological surveillance and control of communicable diseases in the Community. Official Journal of the European Communities. 3.10.98: L268/1-5

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4 Petersen L, Ammon A, Hamouda O, Breuer T, Kießling S, Bellach B, et al. Developing national epidemiological capacity to meet the challenges of emerging infections in Germany. Emerg Infect Dis 1997;3:425-34.

5 The report of the Evaluation of the European Programme for Intervention Epidemiology Training, 1999. Available at URL: http://www.epiet.org, or from author.

6 Goodman RA, Bauman CF, Gregg MB, Videtto JF, Stroup DF, Chalmers NP. Epidemiologic Field Investigations by the Centers for Disease Control. Public Health Rep 1990; 105: 604-610.

7 Thacker SB, Goodman, RA, Dicker RC. Training and Service in Public Health Practice, 1951-90--CDC's Epidemic Intelligence Service. Public Health Rep 1990; 105: 599-604.

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