european network of infectious disease physicians … filemarios lazanas *, erythros stavros-red...

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EUROPEAN NETWORK OF INFECTIOUS DISEASE PHYSICIANS

EU contract No:2003207

FINAL REPORT

Period from 6/15/2004 to 6/14/2007

____________________

Date

____________________

Signature Dr. Giuseppe Ippolito Scientific Director and Project Leader

National Institute for Infectious Diseases

IRCCS Lazzaro Spallanzani

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GLOSSARY EUNID European Network of Infectious Diseases physicians

HIDs Highly Infectious Diseases

HIUs High Isolation Units

EU European Union

PPE Personal Protective Equipment

HCWs Health-Care Workers

IT Information Technology

INMI Istituto Nazionale per le Malattie Infettive (National Institute for

Infectious Diseases)

E-CDC European Centres for Disease Prevention and Control

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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 UK

Agoritsa Baka Greece

Philippe Brouqui France

(Simon Mardel 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

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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

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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

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EUROPEAN NETWORK OF INFECTIOUS DISEASE PHYSICIANS (EUNID)

FINAL REPORT, SEPTEMBER 2007.

1. 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 2007.

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;

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• 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 2003-2008 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

2.3.3.7).

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 2.3.3.7.

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 2007.

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 3rd year of activity (June 2006 – June 2007).

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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° 2006205),

which will continue and reinforce the work of EUNID in the years 2007-2010.

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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 3rd 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 2003. 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

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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 e-mail 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, e-mail and

personal contacts, discussion at meetings

4.3 Coordination team Data from questionnaire, e-mail and personal contacts,

exchange of drafts and comments, discussion at meetings

4.4 Coordination team Discussion at the meeting, e-mail 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,

Julia Heptonstall

Data from questionnaire, discussion at meetings, review of

literature, exchange of drafts and comments

4.8 Agoritsa Baka, Julia

Heptonstall

Data from questionnaire, discussion at meetings, review of

literature, exchange of drafts and comments

4.9 Coordination team

4.10 Not performed Not performed

3.4 EUNID meetings

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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

(www.eunid.com) in the folder “Documents”, after registration.

The second EUNID meeting was held in London, on April 7-8, 2006. 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.

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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, 2007. 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 3rd 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, radio-

imaging (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

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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 2nd 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° 2006205), which will continue and reinforce

the work of EUNID in the years 2007-2010.

3.6 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: http://www.eurosurveillance.org/em/v12n06/1206-223.asp

o Puro V., Fusco F. M., Ippolito G. Biocontainment patient care units. Biosecur

Bioterror. 2007 Mar;5(1):86.

• Oral Communications:

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o ‘EUNID Consensus on Personal Protective Equipment for Highly Infectious

Diseases in High Isolation Units’. Speaker: Vincenzo Puro. IMED, Vienna, Austria,

February 23-25, 2007.

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, 2007.

o ‘EUNID project’. Speaker: Vincenzo Puro. International Workshop “Critical Aspects

of Highly Infectious Diseases”, Rome, Italy, May 22-23, 2007.

o ‘Medical procedures in High Isolation Units’. Speaker: Philippe Brouqui.

International Workshop “Critical Aspects of Highly Infectious Diseases”, Rome,

Italy, May 22-23, 2007.

• 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, 2007.

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, 2007.

o No authors listed. ‘EUNID project’. Presented at Network Corner at 25th

International Congress of Chemotherapy / 17th European Congress of Clinical

Microbiology and Infectious Diseases (ICC/ECCMID), Munich, Germany, March

31-April 3, 2007.

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

4.1.1 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:

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“ 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.”

and

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.

4.1.2 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 4.1.1. The group also agreed that the definition needed to be future-

proof, 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.

4.1.3 Critical points

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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

4.2.1 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 www.eunid.com , divided by diseases or by country. For further

details about disseminations see point 3.6.

4.3 Inventory of isolation facilities in EUNID countries

4.3.1 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.

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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 air-

exhausting, sealing of the rooms).

The whole data gives an exhaustive overview of current isolation capabilities in EUNID countries.

4.3.2 Methodology

Data were mainly collected by questionnaire. In some case, personal contacts, by e-mail 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 5.


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.

4.3.4 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

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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)

4.4.1 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 core-

curriculum 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 e-mail 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 4.4.3 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,

http://ecdc.europa.eu/). 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.

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 6.

4.4.2 Methodology

See table 1


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.

4.4.4 Dissemination

The EUNID list of expert is available for all users, after registration, on EUNID web-site

(www.eunid.com), 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

4.5.1 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.

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

(www.eunid.com), in the folder “documents”, for all users after registration, and are attached at the

present document as annex 7.

4.5.2 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).


No critical points emerged.

4.5.4 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.

21

4.6 Consensus management guidelines including medical procedures and criteria for patient’s

admission

4.6.1 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 8.

4.6.2 Methodology

See table 1


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.

4.6.4 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

4.7.1 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;

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 9.

4.7.2 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 351-364) 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.


Different legislations in participating countries, and lack of clear scientific evidence.

4.7.4 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

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

4.8.1 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.

Documents regarding this deliverable are attached at the present report as annexes 10, 11,

12.

4.8.2 Methodology

25

In 2004-2005, 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.


No critical points emerged

4.8.4 Dissemination

The final document of core curriculum and the training modules are available on the web-

site 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. 2007

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

4.9.1 Main result

EUNID web-site is active from the mid of 2005. 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

26

year of the project (Contract from 1/5, 2005 to 30/4, 2006). The web-site is currently maintained by

the coordination team, with support from IT personnel from INMI.

The web-site has public and private areas. The public area is divided in two parts, a general

part without registration, and a specific part available for all users after registration: the general part

includes pages with free access to information regarding the Coordination Team, including contacts,

a description of the project, links to other networks and organisations with convergent interests, and

a section “News”, continually updated by coordination team, that report articles and guidelines of

interest for the project. Other public pages require a registration procedure. Visitors can register by

clicking the “Sign Up” link on the home page and filling in the registration form. This procedure

allows visitors to access to: the “Report Page” containing a report concerning the activities carried

out at the last EUNID meeting, the “List of members” page, with name and personal contacts of all

EUNID members, the “Guidelines” page, which contains the archive of national and international

guidelines (listed both by disease and by country), and the “Documents” page, which provides

access to the final version of meeting presentations (available in PPS and PDF format), interim and

meeting reports, and all other documents regarding EUNID activities and results. Members, through

a password different for each participating country, can have access, in addition to the public areas,

to private files which contain notices and information on project administration, as well as draft

versions of documents and articles.

By 12th September 2007, the number of web-site visitor 1996 (one thousand ninety-six)

while registered users 6705 (six thousand five).

4.9.2 Dissemination

The Web site 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.

4.10 Outbreak response management guidelines

4.10.1 Main result

The original deliverable of the project was the “Preparation of a report on a study of the

feasibility of developing additional international outbreak response resources within Europe”. This

deliverable has not been achieved, because the coordination team, in agreement with all project

participants, decided that this study is not more a task of EUNID in the current epidemiological

situation within Europe, in order to not duplicate the work of E-CDC.

EUNID project was written and submitted for co-funding in 2003, when the need of a plan

to establish an outbreak response team within European countries was very strong. E-CDC was

27

established in mid 2004, and became operative in the mid 2005. Among the main E-CDC activities

are included:

• Risk identification and risk assessment;

• Preparedness planning;

• Response to health threats and events.

These activities are carried out by the Preparedness and Response Unit, that is devoted to threat

assessment, capacity building and crisis operations. The main actions performed by Preparedness

and Response Units include the providing of technical assistance in outbreak investigation and

response through:

• Identify outbreak assistance teams (epidemiologists, microbiologists and infection control

specialists),

• Establish links with and seek for support to international partners (WHO);

• Inventory and development of response guidelines.

The similarity between the E-CDC already established activity and EUNID planned deliverable

is evident. Consequently, considered the changed scenario of needs, all EUNID members decided to

not undertake activities on this specific point. For the same reason, points 4.10.2 “Methodology”,

4.10.3 “Critical points” and 4.10.4 “Dissemination”, are not included in this report.

5. TOOLS and INDICATORS

Some tools and indicators were originally chosen to monitor and survey project’s results and

outcomes. This tools and indicators have been lightly modified in order to face critical points,

changed needs and evolving issues emerged during the project (see chapter 4. Results and

Deliverables for further details).

a. Project Meetings: number held according to time table; percentage of network participants

attending; percentage of meetings where all minutes/discussion papers/ reports were

disseminated. Four meetings have been organized and successfully accomplished: 3 general

meetings (first EUNID meeting, Rome, May 27-28, 2005; second EUNID meeting, London,

April 7-8, 2006; third EUNID meeting, Rome, May 24, 2007) and one additional meeting

with coordination team, co-opted experts and one national official (Vienna, February 22,

2007). The percentage of network participants who attended the three general meetings were

81.25%, 81.25% and 68,75% respectively. The percentage of participants who attended the

additional meeting in Vienna was the 100% of invited person. All (100%) the reports and

documents came out from the 4 meetings have been adequately disseminated mainly

28

through the web-site, but also through other channels (see point 3.6 “Dissemination” for

further details)

b. Inventories of isolation facilities in Europe and of the health professionals who work in

them: reported accuracy, completeness, and accessibility. The inventory of isolation

facilities in Europe has been successfully completed. Its accuracy is the best as possible

considering the difficulties (see point 4.3.3 for further details). Completeness is good:

complete data has been obtained from 75% of participating countries, while not complete

but satisfactory data has been obtained from remaining 25% of participating countries. The

inventory is accessible on the web-site, and has been adequately disseminated (see point 3.6

“Dissemination” for further details). The inventory of health professionals who work in the

isolation facilities has not been accomplished, because of lack of standardization in

European countries in the selection criteria of the staff involved in the management of

patients with HIDs. This deliverable has been modified, and a list of European physicians

experts in infection control, isolation and management of HIDs has been completed and

adequately disseminated. See point 4.4 for further details.

c. Guidelines: number published and adopted or referenced by authorities, professional,

organisations or individuals at local, national or international level. EUNID developed,

according to expected results, two different guidelines/recommendations. The first one is

focused on specifications for technical, logistic and staff management issues for HIUs

and/or referral centres for the management of patients with suspected/probable/confirmed

HIDs (see point 4.7 for further details). The second one should be considered a

recommendation/expert’s opinion instead of a guideline, and is focused on specific medical

procedures to be performed in to patients affected by HIDs, and on criteria for patient’s

admission in the HIUs (see point 4.6 for further details). Both the document are available on

the EUNID web-site, and scientific papers based on them are currently in advanced status of

writing or editing. Consequently, the number of EUNID guidelines adopted or referenced by

local, national and international authorities and organisations can not still be evaluated.

d. Core curriculum on isolation and management of highly infectious diseases: agreement to,

and adoption of, curriculum by authorities and professional organisations at national level.

The EUNID core-curriculum and related training modules have been developed and

disseminated adequately (see point 4.8 for further details). Recently this result has been

disseminated through an article, categorized as “guidelines”, on Euro Surveillance Monthly

Release. In the article, adequate links with web-site are present. Until now, another

European co-funded project, ETIDE (European Training for Infectious Diseases

Emergengies), decided to adopt for one of its aim the core-curriculum developed by

29

EUNID, and to use related EUNID training module as an useful guide to develop its own

training programme.

e. Website: hit –counting and feedback from network members, health professional and

general public. EUNID web-site (www.eunid.com) is functioning by 2 years (see point 4.9

for further details). It represents an useful tool for sharing documents among project

members and an useful source of data and information for all users interested in infection

control and management of HIDs. Indeed all the project activities (except administrative

topics and preliminary drafts) are available for all visitors after registration, while project

members can access to public and private parts through a password specific for each

country. The web-site will also represent an helpful instrument for the next project,

EuroNHID, that will continue and implement the EUNID work. Consequently, the use of

web-site will be disseminated and promoted further in the future. Until now, the total

number of visitors is 1996, while the total number of registered users 76.

f. Study of the feasibility of developing additional European outbreak response resources:

completion , publication and dissemination. This deliverable has not been performed, in

order to avoid duplication with E-CDC activities (see point 4.10 for further details).

The EUNID website (www.eunid.com, see deliverable 2.4.9) is currently in use and

provides an important tool to manage the project and to share and disseminate information among

infectious disease clinicians and other professionals with an interest in highly infectious diseases

and infection control. The coordination team is responsible for ensuring that the content of the

website is accurate and up to date. The Coordination Team, with the support of an IT expert,

regularly maintains and updates the site.

____________________

Date

____________________

Signature Dr. Giuseppe Ippolito Scientific Director and Project Leader

This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of thecontractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarilyrepresent the view of the Commission or the Directorate General for Health and Consumer Protection. The EuropeanCommission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use madethereof.