The State of the Art of Epidemiology in Europe

After the special issue published on the occasion of the International EUROEPI2010 meeting held in Florence last November, in this first issue of 2011 E&P takes another look at epidemiology in Europe. On page 12, a paper by Segnan & Gallo compares Italian epidemiologic research with that of other countries. Below is an interview with representatives of various European epidemiologic societies. We asked them to draw a picture of the state of the discipline in the continent, its relationship with the public health sector, the level of collaboration of research centres in the 26 European countries, as well as to outline strategies for future development. Here is what they answered.

What is the level of development of epidemiology in your country?
Do you feel the network is adequate? Is it growing?

Tapio Luostarinen (Finland) -The level of many sectors of epidemiological research in Finland is high in international comparison, but the level of clinical epidemiology could be improved considerably.

Thierry Lang (France) -There are research centres in most major universities. The network is developing, although epidemiology does not appear as a priority compared to other research domains.The development of an epidemiologic body (Institut de Veille Sanitaire) in the Ecole des Hautes Etudes en Santé Publique has created a number of jobs for epidemiologists.

Heinz Hense (Germany) - After several years of slow development, epidemiology has been thriving in recent years. Several universities provide Bachelor’s andMaster’s degrees, and the number of applicants is rapidly growing. The German Society of Epidemiology has grown at a fast pace and has presently some 500 members – almost half of these applied over the last 4 years.

Alberto Ruano (Spain) - Over the past decades, epidemiology has reached a high level of development in Spain. There are centres dedicated mainly to epidemiologic research and Spanish epidemiologists aremembers of editorial boards of high-profile journals. In 2006, the main Spanish funding agency for health research projects (the Instituto de Salud Carlos III) established new research bodies named CIBER (Centres for Biomedical Research as a Network).One of them(out of a total of seven) is dedicated to epidemiology and public health (CIBERESP). The funding was approximately 6 million Euros the first year and each CIBER can autonomously contract personnel, purchase research equipment, and so forth. The CIBERESP is comprised of highly competitive epidemiology research groups across the country, including university departments and national as well as regional public health authorities.To be a member, each group has to pass stringent admission criteria (i.e., only publications in first quartile journals are taken into account). Similar rules apply to competitive projects and technology transfer.Therefore, the main research groups on epidemiology currently belong to the CIBERESP. In my opinion, the CIBERESP initiative and structure is appropriate, although further efforts should be made to increase collaborative research among groups.This is difficult to achieve, since funding has been reduced significantly (4 million Euros for 2010). Moreover, the CIBERESP should create ways to involve clinicians in the research groups and establish collaboration with other CIBERs (i.e., respiratory diseases, obesity, etc.).

Adele Seniori Costantini (Italy) - A number of universities, research institutes, and regional agencies of the National Health System are active in the field of epidemiology. Currently, Italian epidemiologists constitute a body of professionals that, while engaging with its peers Europe-wide, have to confront a steady reduction of funding in economically challenging years.

What are relationships with public health like? Is the epidemiological method used in planning and evaluating public health activities?

Tapio Luostarinen (Finland) - Relationships are close. Epidemiologicalmethods have been applied in the planning and evaluation of cancer screening, for example, and populationbased interventions, such as the North Karelia Project.

Thierry Lang (France) - The Institut de Veille Sanitaire has strong relationships with theMinistry of Health, whose authority it is under. Links between research and public health are otherwise very person-dependent.

Heinz Hense (Germany) - Epidemiological methods and epidemiological reasoning have been increasingly adopted in public health planning. However, much of both public health measures and the health system still lacks a sound evidence base.

Alberto Ruano (Spain) - Relationship with the public health system is very close. The Spanish Society of Epidemiology (SEE) is a member of the Spanish Society for Public Health and Health Policy (SESPAS), which includes a bunch of related societies. SEE is the main member of SESPAS. Although the epidemiological method is sometimes used in planning and evaluating public health activities, it is not mandatory, and mostly depends on the personal skill of staff in each autonomous region. The planning and evaluation of public health initiatives is responsibility of each region, since public health has been delegated by the central government. The new General Law of PublicHealth (to be enforced in the comingmonths) will make evaluation of all public health initiatives mandatory.

Adele Seniori Costantini (Italy) - Epidemiology is used too little in health planning, save for certain fields where interaction with epidemiologists has been established within specific programmes, such as cancer screening. Recently, Italian epidemiologists and the Italian Epidemiological Association have paid considerable attention to the relationship between epidemiology and health service planning and have promoted several conferences and training initiatives.

What sectors have grown in the past few years? In which direction is epidemiology going? In particular, are referral centres specialised in epidemiology more widespread, or are the various public health sectors equipped with their own epidemiological services?What do you feel is the level of methodology?

Tapio Luostarinen (Finland) - Several sectors, from genetic to social epidemiology, have grown quickly during recent years, especially diabetes epidemiology.TheNational Institute of Health andWelfare covers several sectors of public health and epidemiology.Most cancer epidemiology work is carried out by the Finnish Cancer Registry, which is one of the world’s leading research institutes in its field. Several universities and other institutes also carry out high quality epidemiological studies. In Finland the level of methodology is relatively high.

Thierry Lang (France) - Surveillance epidemiology,mainly in infectious diseases and environmental issues, has been developed. The various public health sectors are generally unequipped and use expertise fromresearch teams. A recent policy has been developed to support large cohorts in various topics. In France, the level of methodology is generally good.

Heinz Hense (Germany) - The development of epidemiology is positive inmost areas, though at different paces.Considerable development is enjoyed by epidemiology of health care and prospective cohort research, but also genetic and infections disease epidemiology are quickly increasing.While social inequality, migration, and international topics still deserve greater attention. There is no referral centre for epidemiology in Germany so far. However, centres of excellence have developed both in state institutions, such as the Robert-Koch-Institute, and in universities.

Alberto Ruano (Spain) – Over the past few years, certain areas of epidemiology have grown considerably in Spain, especially cancer, genetic, cardiovascular, and social epidemiology. The health administration usually has its own epidemiologic services.There are also internationally recognised centres of excellence such as IMIM(Barcelona), CREAL (Barcelona), and the National Centre of Epidemiology (Madrid). The methodological level is quite good, although there is heterogeneity on training capabilities among professionals in different regions. Currently there are six public health Master’s degrees [Santiago, Madrid (2), Alicante, Granada, and Barcelona] with good quality epidemiology.

Adele Seniori Costantini (Italy) - Epidemiological research is mainly carried out in specialised epidemiological bodies of the National Health Service, and in universities. Epidemiological competence is generally poor in the local health care and prevention services. Clinical epidemiology is the most developed field of research and that with the highest number of publications; other important areas are cancer, genetic, environmental, and occupational epidemiology.Molecular epidemiology has been quickly expanding and has attracted epidemiologists in clinical, as well as in aetiological research. At the same time, the role of epidemiology in studying the relationships between health and social context is gaining importance.

How much does epidemiology in your country participate in European projects? To your knowledge, what are themain sectors where European collaboration is ongoing or planned? 

Tapio Luostarinen (Finland) - Finnish epidemiologists participate actively in European projects, especially if the disease or exposure of interest is so rare that joint projects are a necessity. Naturally, EU funded networks of excellence and concerted actions bring Finnish epidemiologists together with their European colleagues. European collaboration is active in cancer and social epidemiology.

Thierry Lang (France) - Leadership of European projects is highly insufficient, due to the extreme complexity in administration created by the intertwining of French and European regulations and the lack of support from research administrations.

Heinz Hense (Germany) - I have no exact figures. I know, however, that German epidemiologists participate in a considerable number of European projects, both on epidemiologic topics and interdisciplinary research questions.

Alberto Ruano (Spain) - Although reference centres participate in European projects related to cancer, respiratory diseases, and health inequalities, this is an area requiring improvement. In general, participation is scarce, and few groups are leading European projects.

Adele Seniori Costantini (Italy) - As illustrated in the paper by Gallo and Segnan (see pages 11-16), Italy participates in about 50% of the projects funded under the scope of FP7. This mainly concerns epidemiology of cancer and cancer screening, health care and decision making, clinical continuity amongst the elderly, aging, environmental health, drug safety, and infectious diseases.

What would you consider necessary for further promotion on the European level (conferences, training, research projects) and what could be done for improvement?What role would the IEA have in all this?

Tapio Luostarinen (Finland) - A necessary precondition for improvement is that public health and epidemiological research be constantly funded by the EU. Currently, most funding goes to basic research. Similar funding of epidemiological research would create considerably higher output. In our country, it would be important to activate research projects; conferences and training alone do not make progress.

Thierry Lang (France) - I do not see any actions, since the main obstacle to the development of epidemiology is the low priority given by research institutes to this discipline. Heinz Hense (Germany) - Relevant areas for inter-European epidemiologic research are: • prevention • environmental exposure (e.g., indoor air, fine dust, noise) • health systems • health performance and consequences of social inequality.

Alberto Ruano (Spain) -Workshops at international meetings, international courses, and calls for collaboration among researchers could be used to improve collaboration.The International Epidemiological Association as well as the European Epidemiology Federation could serve as forums to exchange ideas (through their websites), enabling search engines to locate members and their interest areas.Web-based discussion groups could facilitate this communication.

Adele Seniori Costantini (Italy) - On the European level, conferences and seminars fall within the scope of, and are financed by, research projects; some training is also provided by research funds. The European Educational Programme in Epidemiology (EEPE, Fiesole) sponsored by the IEA, the WHO Centre for Environment and Health, and the Italian Association of Epidemiology, offers annually generalmodules on epidemiological study design and statistical analysis, and special modules on a wide range of topics. This project is a very good opportunity to share knowledge and experience. Opportunities such as this should be more widely supported by the governments of the European states.

In which sector should the greatest effort for growth be made on the European level, in particular as concerns Eastern European countries: training, pilot projects, evaluation of actions, and/or analytical research?

Tapio Luostarinen (Finland) - Training is important but it should be followed by analytical research projects. I suppose that a trained Eastern European epidemiologist will more likely benefit his native country if training is organized in his country or at least in Eastern Europe. Pilot projects and evaluations provide more direct help.

Thierry Lang (France) -Training through exchanges of doctoral and post-doctoral students and researchers might be an interesting method to explore.

Heinz Hense (Germany) - All of the above! Topics should include health care system evaluation and improvement, cross-country inequality, trans-border infectious disease epidemiology.

Alberto Ruano (Spain) - Efforts should be focused on evaluation of interventions, and in these countries on training and pilot projects.

Adele Seniori Costantini (Italy) - Priority should be given to evaluate the outcomes of different health care strategies. We urgently need to find strategies to improve the health of individuals and communities, to guarantee deprived people the same level of disease prevention and care. Epidemiologists can contribute to this effort by measuring the impact of changes and differences on the health of individuals and populations, as well as measuring the efficacy of different strategies adopted to face old and new public health problems.