EUROPEAN NETWORK OF INFECTIOUS DISEASE PHYSICIANS. EU contract No: FINAL REPORT. Period from 6/15/2004 to 6/14/2007

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1 National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani EUROPEAN NETWORK OF INFECTIOUS DISEASE PHYSICIANS EU contract No: FINAL REPORT Period from 6/15/2004 to 6/14/2007 Date Signature Dr. Giuseppe Ippolito Scientific Director and Project Leader 1

2 GLOSSARY EUNID HIDs HIUs EU PPE HCWs IT INMI E-CDC European Network of Infectious Diseases physicians Highly Infectious Diseases High Isolation Units European Union Personal Protective Equipment Health-Care Workers Information Technology Istituto Nazionale per le Malattie Infettive (National Institute for Infectious Diseases) European Centres for Disease Prevention and Control 2

3 EUNID MEMBERS AND PARTICIPANTS The EUNID Coordination Team, Istituto Nazionale per le Malattie Infettive (INMI), Lazzaro Spallanzani, Rome, Italy Giuseppe Ippolito, Scientific Director Project leader Vincenzo Puro Scientific adviser Emanuele Nicastri National official Francesco Maria Fusco Project coordinator (from 1/10, 2006 to 15/6, 2007 ) Fabio Soldani Project coordinator (from 1/4, 2006 to 30/9, 2006) Andra Stoler Project coordinator (from 15/7, 2004 to 31/12, 2005) Ramona Iacovino Project secretary Lorena Fiorentini Financial administrator Raffaele Colantoni Web designer Fabrizio Latrofa IT support Co-opted experts Julia Heptonstall Agoritsa Baka Philippe Brouqui (Simon Mardel UK Greece France UK) EUNID National officials * and representatives Austria Norbert Vetter *, Otto Wagner Spital, Interne Lungenabteilung, Vienna Reinhild Strauss, Generaldirektion Öffentliche Gesundheit, BM für Gesundheit und Frauen, Vienna Belgium Renaat Peleman *, University Hospital Ghent, Dept Internal Medicine, Division Infectious Diseases, Ghent Koenraad Vandewoude, University Hospital, Ghent Denmark 3

4 Peter Skinhoj *, Epidemiklinikken Rigshospitalet, Copenhagen Ida Gjorup, Merlev Hospital - Med. Dept. Q, Merlev Estonia Kristi Ott*, West Tallinn Central Hospital, Centre for Infectious Diseases, Tallinn Kuulo Kutsar, West Tallinn Central Hospital, Centre for Infectious Diseases, Tallinn Finland Heli Siikamaki *, Central Hospital, Helsinki University, Division Infectious Diseases, Aurora Hospital, Helsinki Outi Lyytikainen, National Public Health Institute, Infectious Disease Epidemiology, Helsinki France Philippe Bossi *, Hospital Pitié-Salpetrière, Service de Maladies Infectieuses et Tropicales, Paris Christian Perronne, Hospital Pitié-Salpetrière, Service de Maladies Infectieuses et Tropicales, Paris Germany Hans-Reinhard Brodt *, Klinikum der Johann Wolfgang Goethe Universitaet, Med Klinik III/ Infektiologie, Frankfurt René Gottschalk, Office of Public Health, Frankfurt Greece Marios Lazanas *, Erythros Stavros-Red Cross Hospital, Athens Dimitrios Iliopoulos, Hellenic Centre for Infectious Disease Control, Athens Helena Maltezou, Hellenic Centre for Infectious Disease Control, Athens Ireland William Powderly *, University College of Dublin, Mater Misericordiae Hospital, Dept of Med, Therapeutics & Infectious Diseases, Dublin Gerard Sheehan, University College of Dublin, Mater Misericordiae Hospital, Dublin Italy Emanuele Nicastri *, National Institute for Infectious Diseases, Rome 4

5 Luxembourg Robert Hemmer *, National Service of Infectious Diseases, Centre Hospitalier de Luxembourg, Luxembourg Netherlands Andy IM Hoepelman *, Netherlands University Medical Center, Acute Medicine & Infectious Diseases, Utrecht Portugal Kamal Mansinho *, Hospital de Egas Moniz, Infectious Disease and Tropical Medicine Service, Lisbon Spain Antoni Trilla *, Hospital Clinic Universitat de Barcelona, Unitat de Suport i Prevencio', Barcelona Magda Campins Marti, Hospital Clinic Universitat de Barcelona, Barcelona Sarah Lafuente, Hospital Clinic Universitat de Barcelona, Barcelona Sweden Per Follin *, Swedish Institute for Infectious Disease Control, Solna Boo Jarhall, Swedish Institute for Infectious Disease Control, Solna Anders Tegnell, National Board of Health and Welfare, Stockholm United Kingdom Barbara Bannister *, Royal Free Hospital, Infection & Immunity Division, London Robert Heyderman, University of Bristol, Dept. of Pathology and Microbiology, Bristol 5

6 EUROPEAN NETWORK OF INFECTIOUS DISEASE PHYSICIANS (EUNID) FINAL REPORT, SEPTEMBER SUMMARY The European Network of Infectious Diseases Physicians (EUNID) was a pan- European network of infectious disease clinicians with experience in the management of highly infectious diseases (HIDs) and/or high isolation units (HIUs). Sixteen Member States were involved in the project (the original 15 Member States of European Community, plus Estonia). EUNID was managed by the coordination team, based at the National Institute for Infectious Diseases (Istituto Nazionale per le Malattie Infettive, INMI), Lazzaro Spallanzani, Rome, Italy. The main aims of EUNID were to promote and substain co-operation, communication, and sharing of data and expertise on HIDs among infectious disease clinicians, with the final aim to enhance preparedness within European countries to health threats from HIDs, both those naturally occurring, newly emergent, and deliberately released. The project started in June 2004 and finished in June According to the aims and objectives of the project, the following results have been reached and adequately disseminated: a definition of HID and a list of disease that fulfil the definition; a complete archive of existing national and international guidelines on the management of HIDs; an inventory of isolation facilities existing in participating countries, including technical and logistic characteristics; a list of physicians experts in infection control, isolation and management of patients with HIDs in participating countries, including personal contacts; an agreement on best practices in infection control issues, with special focus on PPE selection, donning and removal for each HID, both for standard and high-risk situations; indications on specific medical procedures (intensive care procedures, bronchoscopy, gastroscopy, imaging exams - CT scan and RMI, Chest X rays and Ultrasound -, renal dialysis and post-mortem examination) that could be performed in patients affected by HIDs, and on criteria for patient s admission in HIU; an agreement document on specification for HIUs/referral centres for the management of HIDs, including logistic issues, technical features and staff management items; 6

7 an agreement on a core-curriculum for physician involved in the management of patients with HIDs, and a training module based on it; the construction and maintaining of a part-public and part-private web-site for the dissemination of project results to general public and for the sharing of drafts and documents among project members in the private part. 2. BACKGROUND In recent years, attention has been increasingly focused on threats to health security, including those that might be caused by emerging infections or by deliberate release of biological agents. Many events, such as the emergence of SARS in 2003, bioterrorism-related and pandemic threats, suggest that a global preparedness is needed to face these new challenges. The European Commission (EC), in the programme for Community action on public health, specifically recognises the need to improve capacity to respond rapidly and in a coordinated fashion to public health threats. Key priorities of the 2007 Work Plan included the promoting of cooperation among Member States through platforms and networking. In particular, EC included in the 2003 Work Programme a specific section requiring the development of the collaboration between isolation units and of treatment facilities for biological attacks (section ). The European Network of Infectious Disease physicians (EUNID) was a pan- European network of infectious disease clinicians with experience in the management of highly infectious diseases (HIDs) and/or high isolation units (HIUs). The network was formed in response to the specific section The main aims of EUNID were to enhance and maintain co-operation, communication, and exchange of information on HIDs among infectious disease clinicians, with the final aim to enhance preparedness and response within Europe to health threats from HIDs, whether naturally occurring, newly emergent, or deliberately released. The project started in mid 2004 and finished in mid EUNID members were experts in their fields, and came from different background. All had extensive experience in the different aspects of HIDs. Moreover, some co-opted experts collaborated with the Coordination Team in specific scientific aspects. This is the final EUNID project report, covering the whole period from 15 June 2004 to 14 June 2007, with special focus on the 3 rd year of activity (June 2006 June 2007). 7

8 3. ACTIVITIES 3.1 Network organisation and administration The network was led by the project leader (Dr G Ippolito) and managed by the EUNID coordination team, which consisted of the project leader, scientific coordinator, project coordinator, project secretary, a web-designer, and IT and financial administration support staff, and was based at the National Institute for Infectious Diseases (Istituto Nazionale per le Malattie Infettive - INMI), Lazzaro Spallanzani, Rome. The EUNID coordinator, secretary, and web designer were recruited specifically for the project. Some co-opted experts advised and assisted the coordination team on medical and scientific aspects of the project. Their major activities were: (1) to review and help guide the goals of EUNID (2) to review and edit the EUNID management reports (3) to review and edit the EUNID questionnaires, and (4) to assist with the scientific contents of the EUNID meetings, including selection of speakers. EUNID involved 30 national officials and national representatives from 16 Member States: (Austria [AU]; Belgium [B]; Denmark [DK]; Estonia [EL]; Finland [FIN]; France [F]; Germany [D]; Greece [GR], Ireland [IRL]; Italy [I]; Luxembourg [L]; Netherlands [NL]; Portugal [P]; Spain [E]; Sweden [S]; United Kingdom [UK]). Most members are infectious disease clinicians, but the group also covers expertise from public health and epidemiology to emergency preparedness, pulmonary medicine, microbiology, infection control, and critical care medicine. All of the infectious disease clinicians are associated with a national (or regional) infectious disease unit designated for the care of patients with HIDs, including four (from units in Frankfurt, Rome, Solna, and London) who are closely involved in the management of an HIU. The coordination team explored in the first year the possibility of expanding the network to include representatives from designated national (or regional) infectious disease units in all member states, candidate countries, and EEA/EFTA countries, and, with the help of the European Commission had identified possible national officials in Bulgaria, the Czech Republic, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia, and Turkey. National officials from Bulgaria, Malta, Poland and Slovenia, thanks to the contacts established during the drafting of EUNID enlargement proposal, are now members of a new project, EuroNHID (European Network for Highly Infectious Diseases), accepted for co-funding from EC (Grant Agreement n ), which will continue and reinforce the work of EUNID in the years

9 3.2 Communication and links with other project with convergent interest Besides internal communication and exchange of data and experiences among project participants, the coordination team has established links with other EU networks with convergent interests: ENIVD (European Network for diagnosis of Imported Viral Disease), Euronet P4 (European Network of P4 laboratories), ETIDE (European Training for Infectious Diseases Emergencies) and ETHREAT (European training for health professionals on rapid responses to health threats). Reciprocal links between the networks websites are planned. Contact has also been established with the E-CDC. A representative from E-CDC, Dr. Denis Coloumbier, participated to EUNID second meeting, giving a presentation about E-CDC activities and possible fields of collaboration with EUNID. During the third year of activities, a link with members of the US Consensus Conference on Designing Biocontainment Units has been established, and the first member of this group, Prof. P. W. Smith (Medical Director, Bio-containment Patient Care Unit, University of Nebraska Medical Center) attended and actively participated in the 3 rd EUNID meeting. 3.3 EUNID methodology During the 3 years, many methodologies have been used in order to achieve the deliverables of the project. Two main questionnaires were used to collect information from members states. The first EUNID questionnaire was designed to gather information about: (1) the definition of HIDs (2) patient isolation requirements, infection control precautions and personal protective equipment (PPE), and national guidelines for six selected diseases (smallpox, tuberculosis, viral haemorrhagic fevers, SARS Co-V infection, pneumonic plague, and pulmonary anthrax) (3) the location, design, and maintenance of HIUs in EUNID countries including some technical features of HIUs. (4) the healthcare personnel trained to work in HIUs in EUNID countries (5) the numbers and final diagnoses of patients treated in HIUs in EUNID countries in National officials from 14 of 16 countries completed and returned the questionnaire. A second questionnaire was drafted to collect data on training programmes in the EUNID countries for HCWs involved in the care of patients with suspected/probable/possible HIDs. Moreover, the questionnaire asked for partners opinion on the main topics that should be included in a training programme for such HCWs. National officials from 9 of 16 countries answered to this questionnaire. In addition to the drafting and dissemination of these questionnaires, a networking strategy was used to reach the project deliverables. Each deliverable has been committed to a 9

10 member of the coordination team or to a co-opted expert or to a national official with specific expertise in the topic. Persons committed for each deliverable performed a review of existing literature, sent drafts and preliminary results to the project coordinator, who disseminate all the material to national officials and their representatives, stimulating suggestions and amendments. All the comments were forwarded to the committed person for the specific topic, who revised the draft considering comments from the partners. Usually a final agreement has been reached during the work groups and meetings, but in some cases the definitive approval of a document has been obtained after and phone contacts. Please find listed in the table 1 the main methodologies used for each deliverable. Table 1 Summary of committed persons and methodologies used for each deliverable Deliverable (see below) Committed Person Methodologies 4.1 All members involved Data from questionnaire, discussion at meetings 4.2 Coordination team Data from questionnaire, review of literature, and personal contacts, discussion at meetings 4.3 Coordination team Data from questionnaire, and personal contacts, exchange of drafts and comments, discussion at meetings 4.4 Coordination team Discussion at the meeting, and personal contacts 4.5 Vincenzo Puro Data from questionnaire, review of literature, discussion at meetings 4.6 Philippe Brouqui Review of literature, discussion at meetings, exchange of drafts and comments 4.7 Barbara Bannister, Data from questionnaire, discussion at meetings, review of Julia Heptonstall literature, exchange of drafts and comments 4.8 Agoritsa Baka, Julia Data from questionnaire, discussion at meetings, review of Heptonstall literature, exchange of drafts and comments 4.9 Coordination team 4.10 Not performed Not performed 3.4 EUNID meetings 10

11 The meetings represented, during the 3-year-long project, the main occasions for sharing experiences and knowledge. The participation has always been numerous and active. In each meeting some national officials or their representatives gave a little presentation showing the isolation facilities of their countries and the policies for management of patients with suspected/probable/confirmed HIDs. The first meeting was in Rome, on May 27-28, 2005, and was attended by national officials and national representatives from 13 of the 16 states involved in EUNID. As co-opted experts, Dr. Julia Heptonstall from UK and Dr. Agoritsa Baka from Greece were present. In that occasion, the participants reviewed the results of the first questionnaire and agreed that a revised questionnaire would be prepared from coordination team in consultation with national officials and representatives. The main results of the first meeting included the agreement about a working consensus definition of a highly infectious disease and a working list of relevant agents. National officials from the Netherlands, Germany, Sweden and United Kingdom presented their facilities and national strategies for isolation and management of patients with HIDs. During the meeting, participants discussed about criteria for patient s admission in the HIUs, about selection, donning and removal of PPE, and about the inventory of isolation facilities in European countries, but final agreement on these points was postponed to next year of activities. Finally, a strategy for the rapid fulfilment of EUNID guidelines archive was decided. The report of the first meeting is attached at the present document as Annex 1. The report of the first meeting has been disseminated and can be read by all users on the EUNID website ( in the folder Documents, after registration. The second EUNID meeting was held in London, on April 7-8, and was attended by national officials and national representatives from 13 of the 16 countries. As co-opted experts, Dr. Julia Heptonstall from UK and Dr. Agoritsa Baka from Greece were present. Dr. Denis Coulombier from E-CDC gave a presentation about E-CDC activities. The main accomplishments of this meeting included: a final agreement, after a long discussion on selection, donning and removal of PPE to be used giving care to patients with suspected/probable/confirmed HIDs; a final agreement, after a long discussion on the Core-Curriculum and the training modules for the HCWs involved in the care of such patients. An update of data collected for the inventory of Isolation Facilities in European countries was done, and an extensive discussion was done about technical and logistic specification for HIUs, criteria for patient s admission in HIUs and management of specific medical procedures in HIUs. 11

12 Moreover, national officials from Denmark, Estonia, Finland, Ireland and France presented their facilities and national strategies for isolation and management of patients with HIDs. The report of the second meeting is attached at the present document as Annex 2. The report of the second meeting has been disseminated and can be read by all users on the EUNID website in the folder Document, after registration. The third EUNID meeting was held in Rome, on May 24, National officials and national representatives from 11 of the 16 countries attended the meeting. Among co-opted experts, Dr. Philippe Brouqui from France was present. Moreover, Dr. Philip W. Smith, head of Biocontainment Patient Care Unit of the University of Nebraska Medical Centre, USA, and Dr. Michael Borg, head of Infectious Diseases Department at St. Luke s Hospital in Malta (partner in the next project, EuroNHID) were present. The EUNID meeting was included in a whole week of events focused on bio-safety, bio-security and management of HIDs: the final meeting of EuroNET-P4 project (an EC co-funded network of P4 laboratories in Europe, coordinated by INMI), and a meeting of the GHSAG-Lab (Global Health Security Action Group Laboratories) were scheduled in the same week. In the middle of the week an International Workshop on Critical Aspects of Highly Infectious Diseases was organized. Find attached the programme of the workshop as Annex 3. The presentations of the workshop for which authorizations have been obtained by the authors, are available on the EUNID web-site for all users, after registration, in the folder Documents. This workshop represented, according to all EUNID members, an useful event in order to share project s results and to consult other experts on project s still open tasks. The main results of 3 rd EUNID meeting included: a final agreement, after a discussion moderated by Dr. Bannister and Dr. Smith, on technical and logistic specifications of HIUs; a final agreement, after a discussion moderated by Dr. Brouqui, on criteria for patient s admission in HIUs; a final agreement, after a discussion moderated by Dr. Brouqui and Dr. Smith, on recommendations for some specific medical procedures to be performed in HIUs. The analyzed procedures have been: endotracheal intubation, broncoscopy, endoscopy, radioimaging (CT Scanning and MRI), renal dialysis and post-mortem evaluation. A strategy for the accomplishment of a List of experts in Europe on isolation and infection control procedures was developed with all the attendants. Moreover, national officials or their representatives from Belgium, Italy and Spain presented their facilities and national strategies for 12

13 isolation and management of patients with HIDs. Finally, a brief presentation of the next project EuroNHID was presented. The report of the third meeting is attached at the present document as Annex 4. The report of the third meeting has been disseminated and can be read by all users on the EUNID website in the folder Documents, after registration. 3.5 Clinical audits One of the planned project activity was the visits and the audits, from each national officials or their representatives, of the other HIUs/referral centres for the management of patients with HIDs in the country, if any other than their own. But, during the 2 nd EUNID meeting in London, all the project members decided not to perform these planned clinical audits because of organizational difficulties and lack of adequate funding for travel. Indeed, they judged that reaching and visiting the HIUs/referral centres personally would be difficult, and above all there was absolutely no agreement on the method to employ in performing the audits, owing to the lack of international guidelines for audits in the specific ambit of infectious diseases. Otherwise these guidelines should have been developed by the partners, requiring a great effort in a too narrow period of time. The developing of specific checklists for the auditing of HIUs is the first results planned in the next project, EuroNHID (European Network for Highly Infectious Diseases), accepted for co-funding from EC (Grant Agreement n ), which will continue and reinforce the work of EUNID in the years Dissemination All the results of the project are currently available for all visitors on the EUNID web-site, after registration. Moreover, some general aspects and some specific results were disseminated through posters or oral communications at national and international meetings, or through scientific papers on journals or scientific bulletins. In particular: Articles: o Baka A., Fusco F.M., Puro V. et al. A curriculum for training healthcare workers in the management of highly infectious diseases. Euro Surveill 2007;12(6)[Epub June 2007]. Available online: o Puro V., Fusco F. M., Ippolito G. Biocontainment patient care units. Biosecur Bioterror Mar;5(1):86. Oral Communications: 13

14 o EUNID Consensus on Personal Protective Equipment for Highly Infectious Diseases in High Isolation Units. Speaker: Vincenzo Puro. IMED, Vienna, Austria, February 23-25, o Highly Infectious Diseases: evidence for isolation and minimal requirements for Health Care Settings. Speaker: Francesco M. Fusco. National Seminar Infektionsverhutung bei Kontaktinfektionen sowie aerogen ubertragbaren Erkankungen, Vienna, Austria, March 9-10, o EUNID project. Speaker: Vincenzo Puro. International Workshop Critical Aspects of Highly Infectious Diseases, Rome, Italy, May 22-23, o Medical procedures in High Isolation Units. Speaker: Philippe Brouqui. International Workshop Critical Aspects of Highly Infectious Diseases, Rome, Italy, May 22-23, Posters: o Baka A. et al. A Core Curriculum for Health Care Workers on Training in Management of Highly Infectious Diseases. Presented at International Meeting on Emerging Diseases (IMED), Vienna, Austria, February 23-25, o Fusco F.M. et al. High Isolation Hospital Beds for Patients with Highly Infectious Diseases: an Inventory of Resources in Europe. Presented at IMED, Vienna, Austria, February 23-25, o No authors listed. EUNID project. Presented at Network Corner at 25 th International Congress of Chemotherapy / 17 th European Congress of Clinical Microbiology and Infectious Diseases (ICC/ECCMID), Munich, Germany, March 31-April 3, The coordination team, in collaboration with co-opted experts and national officials and/or their representatives, wish to continue to disseminate the project s results by publication of articles and reports on international scientific journals and epidemiological bulletins. Consequently, other articles are currently in advanced phase of writing. 4. RESULTS and DELIVERABLES 4.1 Definition and specification of HIDs Main result The working definition of Highly Infectious Disease and the list of agents that cause infections that satisfy the definition were agreed at the first EUNID meeting, as: 14

15 and A highly infectious disease is transmissible from person-to-person, causes life-threatening illness, and presents a serious hazard in health care settings and in the community, requiring specific control measures. Viral haemorrhagic fevers (VHF) (marburgvirus, ebolavirus, Crimean Congo haemorrhagic fever virus, Lassa virus, and South American haemorrhagic fever - Junin, Machupo, Sabia, and Guanarito) viruses; SARS Co-V Multi Drug- and Extensively Drug- resistant (added in 2007) M tuberculosis (MDR- and XDR-TB, known or suspected infection) Emerging highly pathogenic strains of influenza virus Smallpox and other orthopox infections (eg monkeypox, camel pox, but excluding vaccinia virus) Other emerging highly pathogenic agents, including agents of deliberate release (eg pneumonic plague) It was also agreed that the following agents would not be included in the list of HIDs: Group A streptococci, Neisseria meningitidis, Clostridium difficile, methicillin resistant Staphylococcus aureus, pulmonary anthrax, other multidrug resistant (eg GISA) strains of S aureus, other multidrug resistant organisms (eg vancomycin resistant enterococci), dengue and yellow fever viruses, measles virus, hepatitis A virus, varicella zoster virus, vaccinia virus, and rabies virus Methodology In the first EUNID questionnaire the following proposed definition was given: Highly infectious diseases pose a very high concern because of their potential ease of dissemination or transmission and high morbidity and mortality, and a list of diseases (smallpox, tuberculosis, VHFs, SARS, pulmonary plague, pulmonary anthrax) has been proposed. Coordination team collected the answers and all the proposed changes were discussed during the first EUNID meeting. After a long discussion, the group agreed to modify the proposed definition and adopted the definition reported in the point The group also agreed that the definition needed to be futureproof, such that it would encompass newly emergent diseases which might, at least initially, be of unknown lethality and transmissibility, and flexible enough to be adaptable to advances in treatment, prevention, and understanding of natural history and epidemiology Critical points 15

16 The most important critical point of this deliverable was the difficulty emerged during the discussion. Indeed, it was very difficult to harmonize EUNID definition with different national guidelines and with different background of the participating countries. Above all, an extensive discussion was needed to define the diseases that should be included, especially about tuberculosis and influenza virus. About tuberculosis some partners do not consider it as highly infectious, but finally MDR-TB (and, later, XDR-TB) was included because it is of concern in many EUNID countries, particularly Estonia and Austria, and because of wider concern about transmission risks associated with imported cases from the Ukraine and other countries in the former Soviet Union, where MDR-TB has become a problem. About influenza, the group recognised that, although person-to-person transmission of avian influenza H5N1 had not yet been conclusively proven, there was great concern that the virus might become transmissible, and concurred with WHO that suspect cases should be managed as though the virus was highly infectious. Finally a agreement on a general definition of influenza strains that should be included in the definition has been reached. 4.2 Archive of existing national guidelines on isolation and management of patients with HIDs Main result EUNID project accomplished an archive of existing national guidelines on HIDs in participating countries. The archive focuses on national guidelines in the field of management of HIDs, in particular for smallpox, plague, SARS Co-V infection, tuberculosis, emergent influenza viruses, and viral haemorrhagic fevers, but it will also include details of guidelines relevant to good infection control practice. Moreover, relevant international guidelines on infection control have been included. So far, 102 links to national documents/guidelines regarding all the participating countries and 30 links to European and international documents and guidelines are available. Furthermore, 29 hard documents, obtainable from the coordination team, were collected. These documents are available on divided by diseases or by country. For further details about disseminations see point Inventory of isolation facilities in EUNID countries Main result Complete data are available from Austria, Denmark, Estonia, Finland, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Sweden, and the United Kingdom, and partial data are available from Belgium, France, Portugal and Spain. 16

17 For each country, we collected data concerning the following items: number of hospitals with rooms equipped with negative pressure and anteroom; number of hospital beds available in the rooms equipped with negative pressure and anteroom; number of hospital beds equipped with negative pressure and anteroom in which intensive care capabilities are available; some logistic features of these rooms (position in a separate building, in a single ward, in the same ward as other hospital facilities -, direct connection with a BSL 3/4 laboratory area); some technical features of these rooms (number of air changes per hour, way of airexhausting, sealing of the rooms). The whole data gives an exhaustive overview of current isolation capabilities in EUNID countries Methodology Data were mainly collected by questionnaire. In some case, personal contacts, by or by phone, were necessary to obtain information. After the collection of all data, the coordination team wrote a draft report on current capabilities of isolation in European Countries. In this draft, few sentences describing the isolation capabilities of each country were included. During the second meeting, each partner agreed to review, update and correct these few sentences. During the third year of the project, some information were revised and updated, while some missing data from Belgium, France and Portugal were collected. The complete report is attached at the present document as annex Critical points The complete accomplishment of this deliverable presented some critical points. Indeed, it is very hard to obtain national data without a national commitment. Sometime, only national authorities are recognized by the single hospital/institution that should provide data. Moreover, some of the information that EUNID would like to gather (eg the numbers and locations of all monitored negative pressure isolation rooms with anteroom) may not be readily available, since this information is not centrally held, unless an inventory has recently been performed at national/federal level. Finally, in each country the criteria of collection and registration of these data is different, and these differences make the collection of well-organized information very difficult Dissemination The inventory of isolation facilities in EUNID countries is available on the web-site, for all users, after registration, and has been presented through a poster at IMED, and through oral 17

18 communications at national seminar in Vienna and at international workshop in Rome. See point 3.6 for further details. 4.4 Inventory of health care professionals who work in the isolation facilities (list of experts) Main result EUNID produced a list of physicians with expertise in infection control and management of patients with HIDs in participating countries. Experts have been selected on the basis of the corecurriculum developed by EUNID (see point 4.8 for further details). For each name included in the list, affiliation, current work position, complete address, phone and contacts, and main fields of expertise are indicated. The accomplishment of a complete inventory of skilled staff (divided in physicians, nurses, therapists, technicians, laboratory workers and housekeeping staff) trained to care for patients affected by suspected/probable/confirmed HIDs resulted not possible. Indeed, the differences among participating countries in recruiting and training staff are considerable (see for further details). Consequently, EUNID consortium agreed that, without standardization on training requirements for the staff involved in the care of patients with HIDs, it is impossible to obtain harmonized and homogenous data on the number of skilled staff. All EUNID members agreed to change this deliverable into the achievement of a list of physicians experts in infection control and in the management of HIDs, and agreed to use the commonly accepted EUNID core-curriculum to select the names to be included. Moreover, EUNID members agreed to look for a link with E-CDC, in order to integrate the list of experts produced by E-CDC. Indeed, in 2006, E-CDC began to produce a list of experts (see E-CDC web-site, According to the web-site, E-CDC is looking for external experts to help the Centre to develop and maintain its scientific position. The areas of professional background that are included in the call are: clinical infectious diseases, microbiology, public health, epidemiology, statistics and/or modelling of infectious diseases, social sciences, medical informatics, scientific and/or risk communication, programme evaluation, bioterrorism, training in any of the above areas, and other expertise within the remit of E-CDC. The specific area of infection control, including isolation and management of HIDs is not included, although it can be considered as incorporated in some of the previously listed areas. E-CDC requires to physicians who sign themselves as experts to give a brief curriculum, and to give their availability as scientific advisers or scientific consultants. 18

19 In order to integrate (and not to duplicate) E-CDC work, EUNID coordination team will establish contact with E-CDC staff, in order to propose the EUNID list as an integration of E-CDC list, in the specific field of infection control including isolation and management of HIDs, and to propose all the name included in the EUNID list as scientific advisers. The list of expert is attached at the present document as annex Methodology See table Critical points The main critical point is the heterogeneity of criteria of staff recruitment and/or selection. Indeed, because of lack of standardization in Europe on core-curriculum required for HCWs selected for giving care to patients affected by suspected/probable/confirmed HIDs, each country apply its own criteria for staff selection. Consequently, the questions included in the first questionnaire (number of skilled staff trained to care for patients affected by HIDs) produced a large variety of different, not-standardized answers, or absolutely no answers. Only in few countries the staff posted to care for patients with HIDs had been previously specifically trained, and only by their own hospitals/institutions. In some other countries all the hospital/ward staff is planned to be involved in the care of such patients. In other country some staff members had been selected, on a voluntary basis, without specific training. In some other countries, finally, specific plans for staff selection simply do not exist Dissemination The EUNID list of expert is available for all users, after registration, on EUNID web-site ( and has been presented through a poster at ICC/ECCMID, and through oral communication at international workshop in Rome. See point 3.6 for further details. 4.5 Exchange of good practices on infection control precautions including PPE Main result Exchange of experiences and good practices of infection control precautions among the partners has been successfully promoted and implemented all along the 3 years of the project. During each meeting, and sometime during the routine activities, the sharing of national guidelines and internal procedures on infection control always represented a focal and interesting point. 19

20 During the second meeting a specific work session was dedicated to accomplish a consensus on appropriate PPE to be used for each HIDs, and an agreement of the safe procedures of donning and removal of PPE for each diseases, considering both standard and high-risk (likely to produce aerosol) situations. The discussion finally led to a consensus on PPE for each HID, on the basis of the need dictated by the specific disease but also considering a balance between the need for protection into the framework of European legislation on work safety and the necessity to ensure adherence of the HCWs, for example by avoiding over-protection or reducing the redundancy of requirements for the different diseases. Detailed results are available on the web-site ( in the folder documents, for all users after registration, and are attached at the present document as annex Methodology Preliminary data on this point were collected with the first questionnaire, where some questions on selection, donning and removal of PPE were included. In particular, coordination team asked for which PPE are used in giving care to patients with HIDs, and requested to provide detailed information on removal procedures of PPE for each disease. Collection of data evidenced similar criteria of selection, with some differences on some diseases, especially tuberculosis, while sequences of removal changed widely. During the first meeting, EUNID members agreed to further discuss the point after an extensive review of literature and to put their conclusions within the framework of European Community legislation on safety at work. The coordination team revised the available evidence from the literature, and prepared draft schemes showing the advisable/preferred PPE for each considered infection, for further discussion by EUNID members during the second meeting in London. During the second EUNID meeting, a working group discussed this topic in detail. Each proposed scheme was discussed and modified if necessary. A final agreement has been finally reached for both routine and high-risk situations (i.e. aerosol-producing procedures) Critical points No critical points emerged Dissemination The agreement on PPE selection, donning and removal for each HIDs, both for standard and high-risk situation, is available in the EUNID web-site for all users, in the folder documents, after registration, and has been presented through an oral communication at IMED and at international workshop in Rome. See point 3.6 for further details. 20

21 4.6 Consensus management guidelines including medical procedures and criteria for patient s admission Main result The EUNID archive demonstrates that, in most cases, recommendations for the management of HID already exist, in the appropriate languages at national level, and, where they do not, detailed European or other guidance (e.g. from WHO, and from CDC, Atlanta) is readily available as a reference (see deliverable 4.2). Consequently, EUNID members considered more interesting to develop indications only on specific aspects of the management. They also decided to include in this deliverable the development of criteria for patient s admission in HIUs, that was initially joined with deliverable 4.1. Coordination team co-opted initially Dr. Simon Mardel, who gave up after some months for other emerging duties, and then Dr. Philippe Brouqui in September 2006, to accomplish this specific deliverable. Dr. Brouqui reviewed existing literature and developed specific guidelines on criteria for patient s admission and on some specific medical procedures, selected on the basis of the discussion done during first and second EUNID meeting. In particularly, the medical procedures analyzed include: intensive care procedures, bronchoscopy, gastroscopy, imaging exams (CT scan and RMI, Chest X rays and Ultrasound), renal dialysis and post-mortem examination. Indications proposed by Dr. Brouqui were discussed during third EUNID meeting in Rome. Many participants proposed comments and amendments. First of all, because of lack of evidence due to the limited number of patients with HIDs decrypted in the scientific literature, it was decided to not consider the final results as guidelines, but as indications and/or expert s opinions. After the discussion, Dr. Brouqui revised his draft, in order to include comments and different opinions by other members of the network. A revised draft has been sent to all project participants for further suggestions and comments. Currently, a preliminary draft of these recommendations, including contrasting issues emerged during the third meeting, is available on EUNID web-site. The definitive version will be disseminated as soon as possible. The draft is attached at the present document as annex Methodology See table Critical points 21

22 Many critical points emerged on this issue. First of all, it became early clear that complete management guidelines can only duplicate the already existing, and well accepted, documents. Consequently, the second critical point was the selection of specific issues to be treated. Some of the proposed issues were included in the deliverable 4.7, while some others were included in the deliverable 4.5. The main critical point was the scarcity of data existing in the literature. Indeed, HIDs are very rare, and mainly they hit developing regions, where some medical procedures are not routinely applied. Consequently, the main source of information was represented by experiences emerged during the SARS outbreak. Because of the scarcity of data, evidence-based recommendations are impossible to develop, and consequently these can be based on personal experiences and expert s opinions, that not always are convergent. When a final consensus has no been reached on some points, EUNID members decided to include in the final document the different opinions Dissemination A preliminary draft is currently available on the web-site, where final document will be published as soon as possible. This deliverable has been presented through a poster at ICC/ECCMID and through oral communication at international workshop in Rome. See point 3.6 for further details. 4.7 Definition of requirements for isolation facilities in Europe Main result A comprehensive consensus document on specifications for isolation facilities, with special focus on HIUs, has been reached. The document includes both logistic and technical aspects of HIUs. Staff requirements and policies for staff management are discussed, too. In particular, the document presents the EUNID agreement on the following topics: the appropriate number and distribution of units within each Member State; the minimum technical requirements for facilities and services provided by such units, including requirements for the whole structure and for each patient s room; the management of airflow control and potential air contamination; clinical staff numbers, training and health assessment; staff and patient circulation pathways within the unit; transport of patients and laboratory specimens outside the unit; 22

23 requirements for patient management laboratory services; requirements for clinical waste handling; methods of decontamination of staff; methods of decontamination of the units and associated equipment; security measures to protect the unit from damage and intrusion. A complete agreement among project members on each point has been reached. The final version of the report is available on the web-site and is attached at the present document as annex Methodology During the second EUNID meeting in London, a discussion group on the minimal requirements for HIU in European countries was created, taking into account different national legislations. After the meeting Dr. Bannister, national official from UK, wrote a draft document that was available for partners revision. In an additional experts meeting in Vienna on February 22, 2007, a step-by-step document written on the basis of the review of the literature and, above all, on the analysis of an article recently published on an international journal by an U.S. panel of experts on the same issue (Smith P.W. et al. Designing a Bio-containment Unit to Care for Patients with Serious Communicable Diseases: A Consensus Statement. Biosecurity and Bioterrorism: biodefense strategy, practice, and science. Volume 4, Number 4, 2006, pages ) was revised. The step-by-step document, with proposal of agreement as reached in Vienna, was proposed to all EUNID members during the third EUNID meeting in Rome. A specific session of the meeting, conducted by Dr. Bannister and by Prof. Smith (the first author of the article on Biosecurity and Bioterrorism), was devoted to this point. After an extensive discussion, some suggestions were included in the draft, and a complete consensus was obtained. Dr. Bannister revised the draft taking into account all the suggestions emerged during the third meeting Critical points Different legislations in participating countries, and lack of clear scientific evidence Dissemination The final document on this deliverable is available on the web-site for all users, after registration. Moreover, a scientific article on this point will be submitted for publication on a relevant international scientific journal as soon as possible. This article is in advanced status of writing, and is currently under last revision by Dr. Heptonstall, before submission. This deliverable 23

24 has been presented through an oral communication at national seminar in Vienna and at international workshop in Rome. See point 3.6 for further details. 4.8 Core curriculum and training modules for HCWs who are involved in the care of patients affected by HIDs Main result A core-curriculum for physicians involved in the management of patients with HIDs and a module for a 3-days course have been developed and are available on the web-site for all users, after registration. The core curriculum includes both theoretical knowledge and practical skill. The topic that should be well known by HCWs involved in the management of HIDs are: general disease-specific knowledge (aetiology, epidemiology, modes of transmission, clinical presentation, diagnosis and treatment), public health-related issues of each HID, specific knowledge of hospital infection control, including appropriate management of hospital and family contacts, occupational exposure, PPE, disinfection, decontamination and waste management, and biosafety issues. Moreover, these HCWs should have technical knowledge about procedures inside an HIU. About practical skill, according to core curriculum, HCWs should be able to: use safely and correctly the respiratory protection and other PPE, perform infection control procedures, use and check correctly an HIU. Moreover, these HCWs should have specific training in team working and specific practical skill on some country - specific items (such as stretcher transport isolator, or special ambulances). In order to achieve this level of knowledge and practical expertise, a course has been developed. The course is targeted primarily at infectious disease clinicians and other hospital-based health care professionals (including hospital infection control practitioners, intensivists, emergency medicine practitioners, nurse-consultants, and clinician-managers), and puts a strong emphasis on the public health response to infectious disease emergencies. The course is intended to be taught over three days on site in a healthcare facility with an attached high level isolation unit, so that trainees can gain exposure to the specialised equipment and techniques used in such units, developing theoretical and practical knowledge at the same time. 12. Documents regarding this deliverable are attached at the present report as annexes 10, 11, Methodology 24

25 In , national officials have provided information about national accreditation requirements for infectious disease clinicians: in most countries, experience within a HIU is not a requirement for accreditation, and in some others, there is no formalised accreditation process. However, institutes with designated national HIUs regularly run specific training courses for their own and external staff, and hold regular drills and exercises that involve nurses, paramedics, and health care workers from other specialties as well as infectious disease clinicians. Dr. Agoritsa Baka, the expert with specific expertise in training co-opted for this deliverable, spent in more occasions some time in Rome, working in close relation with the coordination team. In April 2005, a questionnaire was sent to all EUNID members about current training requirements in their country for healthcare professionals working in HIUs and/or caring for patients with HIDs. The questionnaire also sought the partners views on whether formal, standardised training of such professionals in the management of HIDs was desirable, and asked them to list the key elements of an optimum training programme. Dr. Baka used these data to develop a draft core curriculum and outline training course. This draft was presented to all participants and discussed in detail at the second annual EUNID meeting in April 2006, amended by the coordination team, and subsequently further refined jointly by co-opted experts Dr. Baka and Dr. Heptonstall Critical points No critical points emerged Dissemination The final document of core curriculum and the training modules are available on the website for all users, after registration. Moreover, the final document has been revised and organized by Dr. Baka, Dr. Heptonstall and the coordination team as an article, already published on Euro Surveillance, with Dr. Baka as first author (Baka A. et al. A curriculum for training healthcare workers in the management of highly infectious diseases. Euro Surveillance monthly releases Volume 12 / Issue 6). This deliverable has been presented through a poster at IMED and through oral communications at international workshop in Rome. See point 3.6 for further details. 4.9 EUNID website development with public access site for information and members only area Main result EUNID web-site is active from the mid of It was developed by a web-designer funded by the EUNID project grant, who ended his collaboration with INMI at the middle of the second 25