sou · GXB355 · 2009-06-10 00:00:00 — Its BSL 4 facilities provide a good basis to respond to new emerging threats serving not only but through special arrangements other Nordic countries and EU. Also its P-3 animal facilities provide a valuable asset both nationally and internationally. 5Research organisation, prioritisation and strategy in SMI SMI is a strong research organisation with a large proportion of external research funding relative to the core budget. The director general states that externally funded research at SMI is necessary for several reasons: It provides overhead funds that support new equipment and running of the facilities. It attracts and keeps the best scientists in the institute, and these scientists can then also be used for SMIs core function of reference laboratory functions and giving expert advice to Swedish health authorities and health services. It builds the knowledge base at the institute to the benefit of its national advisory role. In short, externally financed research gives the institute a stronger technical and intellectual basis for solving infectious disease control issues in than it could have achieved with only the basic funding. The challenge is then to make sure that the externally funded research remains relevant to infectious disease control in and that it does not resources and attention away from the other core tasks of the institute. does not have a document that outlines its research strategy. There is, however, among all department heads an understanding that the institute should perform applied research relevant to infectious disease prevention and control. In principle, all research applications and projects must be approved by the de- partment heads and the director general, and their relevance for the SMI mandate hereby assessed. The criteria for this evaluation are, however, not explicit or in writing. In practice, the donation pro- fessors in particular, but also other research group leaders to a large extent have the to pursue their research interests or their research to areas where funding is available. An annual document from the Ministry defines the tasks that SMI is expected to work on in the coming year (see p 3). The government has a legal way (regeringsuppdrag) to impose certain tasks to the institute. (, SoS) may order background material relevant to its work from SMI. SMI has an advisory forum, , that may provide guidance on its work but this body is less relevant for guiding the research at SMI. Apart from this, there is no systematic involvement of stake- holders from Swedish society in the prioritisation of research. For instance, SoS, the food safety authority, the infectious disease control units and clinical microbiology units at the hospitals and smittskyddsläkarna do not have a formal way of influencing the research agenda at SMI. There is a danger that this lack of input may make these stakeholders feel that the research at SMI is irrele- vant to their daily work of controlling infectious diseases. SMI faces the same challenge as most similar institutes: How and to what extent should externally funded research, often defi- ned by the interests of the researchers and the availability of fun- ding, be matched to the core functions and priorities of the insti- tute? Clear leadership, a defined research strategy, and involvement of stakeholders are needed to solve this problem. 6Evaluation of research in the departments Each department and section is evaluated separately. The methods, material and criteria for evaluation are given on p 2. After a brief narrative summary a quantitative assessment on (1) the national and international impact, (2) focusing and relevance and (3) quality and quantity of the research work is given on a scale of 1–5. The section for Enteric Pathogenic Bacteria is headed by professor . The major research activity of this section is Heli- cobacter pylori. The research of the section comprises all aspects of Helicobacter infection, diagnostic, therapeutics, pathogenesis and molecular biology. Additionally the department focuses on the problems of developing resistance to the various antibiotics used to treat this disease, especially as regards problems of resistance in the normal flora of the intestine, feces and nose during and after anti- biotic therapy. The research activities also include other intestinal and non-intestinal bacteria. The authors have demonstrated their ability to rapid introduction of new methods in their projects. The number of publications and the quality of the publications in the H. pylori area is of high international level and quality, and inclu- des a large scientific network and external funding. National and international impact of H.pylori research: 4–5, focusing, relevance: 4–5, quality and quantity: 4–5. The section for respiratory and invasive infections is headed by professor . The research of this sec- tion is concentrated on pneumococcal infections but also on im- portant aspects of Group A streptococcal invasive infections and the epidemiology of Haemophilus influenza and Diphtheria and even Listeria infections. Concerning pneumococcal infection the research is covering all aspects of pathogenesis, molecular biology, regulations of genes and epidemiology, all on the highest interna- tional level. The section has continued to produce results of all these aspects in cooperation with colleagues in other countries and has a very well developed scientific network and external funding. The number of publications and the quality of the publications in the S. pneumoniae area is of high international level. National and international impact of S. pneumoniae research: 4– 5, focusing, relevance: 4–5, quality and quantity: 4–5. The section of tuberculosis is headed by and pro- fessor . Together these two senior scientists had a rather comprehensive research in the area of tuberculosis covering molecular biology, epidemiology, diagnostics, development of resistance and especially rapid detection of multiresistant strains and, new tuberculosis vaccine etc. Since tuberculosis is not so common in they have important international cooperation especially with colleagues and centres in and Latin . The international status of the section for tuberculosis is underli- ned by its position as a reference centre for WHO and participa- tion in standardisation work in international fora. National and international impact of tuberculosis research: 4–5, focusing, relevance: 4–5, quality and quantity: 4–5. The section for antibiotic resistance and hospital hygiene is represented by , and . The research of this section is of reasonable quality and relevance, although it is not as comprehen- sive as the other sections of the department of bacteriology. The research covers epidemiology of hospital infections and the bacte- ria relevant for this area, and especially of molecular biological methods for epidemiological typing and antibiotics resistance eg. MRSA and S. epidermidis and especially Clostridium difficile. National and international impact of the research: 2–3, focusing, relevance: 2–3, quality and quantity: 2–3. The section of is headed by . The research of this section is characterized by basic research including molecular biology of various bacteria and regulation of bacteria genes and pathogenic factors. In addition application of forced atomic microscopy and animal experiments on bacterial fitness. The publications of the core facility are on a high scientific level and relevant for the SMIs research using important new technical methods. Since the core facility assists other departments/ sections it is a consequence, that its own research area (regulation of genes, pathogenesis) is not so comprehensive, but the quality is good and with some international co-workers. National and international impact of the research: 3–4, focusing, relevance: 3–4, quality and quantity: 3–4. In conclusion, the research and knowledge in the department of bacteriology to their field of expertise is on a high international level, equally to what is found in comparable institutions in other Scandinavian countries, and it very well match the demands of the Swedish society. (hereafter only the Depart- ment), led by , has some 35 employees. Its main responsibilities, apart from research, are to run the national sur- veillance system for infectious diseases (SmiNet), to assist in outbreak investigations and to give advice. The Department also hosts an institute core facility in statistics with six-seven biostatisticians providing services to research groups throughout the institute. The Department hosts two fellows of the ECDC-financed two- year European Training Programme for Intervention Epidemiology (EPIET) so that every autumn a new fellow arrives when one of the previous ones graduates. As part of their training, the fellows shall conduct a research project. Previously, the department also developed a programme in infectious disease control. we present most of the research in the Department in the period 2004–08. Each project or project group is given a name and the senior researchers are listed in parentheses with PhD-students if any. Because the research in the Department is so diverse in thematics and methods, it is presented more in depth than for the other departments. Risks for infectious diseases during (, PhD of , planned 2009) SmiNet data and data on Swedes habits were used to esti- mate the risk of acquiring several infectious diseases by destination. The method is innovative, the group has been productive, and the results are highly relevant to prevention of travel-associated infec- tious diseases. Scores: National impact 5, international impact 5, focusing 4, relevance 5, quality 4, quantity 4. The influence of and trade on salmonellosis (, PhD of de , 2006) The group has found a high degree of underreporting of sal- monellosis in most European countries. They are aware of the main weakness, namely that duration of stay was not taken into account. The results provide a strong defence of Swedish salmonella control policies. They give the basis for improved prevention and they se- riously undermine the validity of EFSAs and ECDCs tables that compare salmonellosis reporting figures from individual European countries. Scores: National impact 4, international impact 5, focu- sing 3, relevance 4, quality 4, quantity 4. Outcomes after bacterial gastrointestinal infections (, and , PhD of , 2008) This group linked surveillance data from SmiNet to the Cause of Death Registry and found that patients infected with salmonellosis or campylobacteriosis in had higher death rates than the general population. They believe this is caused by frailty bias. Sco- res: National impact 4, international impact 4, focusing 4, relevance 4, quality 3, quantity 3. Tuberculosis research () Some interesting studies have been performed, such as an estima- tion of the risk of tuberculosis in rheumatic patients treated with TNF antagonists. Still, the research has been very patchy and see- mingly with no long-term research plan. It is surprising to find that there seems to be very collaboration between this Department and the laboratory research groups in tuberculosis. Scores: Natio- nal impact 2, international impact 3, focusing 2, relevance 4, quality 3, quantity 2. Outbreak investigations (and others) Outbreaks of infectious diseases provide opportunities to learn about the spread of infectious agents. It is to the credit of the De- partment that it has kept a capacity to conduct and publish such investigations, which cannot be planned in advance and therefore demand research-minded individuals who are able to rapidly launch an investigation, as acute research. Several of the studies have collaborators in county infectious disease control units. Scores: National impact 5, international impact 3, focusing 3, relevance 5, quality 4, quantity 4. Evaluation of SmiNet (and ) The articles answer two fundamental questions of SmiNet: What proportion of the true cases is captured by surveillance and how early does the system register the cases? The evaluation shows that SmiNet performs well. Such studies are far too seldom conducted and rarely reported. Scores: National impact 4, international impact 2, focusing 4, relevance 5, quality 4, quantity 3. Pertussis epidemiology () After several years with no vaccination, introduced a cel- lular vaccine in 1996. Several articles and two large reports on the follow up since then have been published. It is somewhat surprising to see that this study is financed by two vaccine manufacturers, which are involved both in the steering group and as authors. Sco- res: National impact 5, international impact 5, focusing 4, relevance 5, quality 4, quantity 4. Long terms effects of viral hepatitis (, , , ) Data from SmiNet on patients with chronic viral hepatitis B or C was linked to the Causes of Death Registry and the Cancer Regi- stry to demonstrate increased mortality and cancer incidence in these patients. These population-based studies could probably not have been done in any other country because only has these data. Scores: National impact 4, international impact 5, focu- sing 4, relevance 5, quality 5, quantity 4. Studies of HIV infection and sexually transmitted infections (, , , , Inga Velicko) There are a few articles on HIV epidemiology, on the spread of a new variant of Chlamydia trachomatis, and several more news-like articles in on epidemiological trends of sexually transmitted infections, including the challenges of syphilis and LGV among men who have sex with men. Scores: National impact 4, international impact 3, focusing 3, relevance 5, quality 3, quan- tity 3. Food- and waterborne diseases (, , and others) The Department has studied causes of yersiniosis, campylobacte- riosis, and EHEC infections using various epidemiological designs. Such studies are highly dependent on the country and their fin- dings are truly national. Scores: National impact 4, international impact 2, focusing 3, relevance 4, quality 4, quantity 3. Influenza (, , , and others) This research has aimed at increasing preparedness for the seasonal influenza epidemics and pandemic influenza, using innovative sur- veillance methods. Of outstanding potential in pandemic prepared- ness and research is the MicroSim project. It is surprising that only one person seems to be working on this project. demiology research area is very promising although the research results so far have been moderate. Scores: National impact 5, inter- national impact 3, focusing 4, relevance 5, quality 4, quantity 3. has been involved in several virological studies of herpes viruses. There are also some modelling studies by researchers in the statistics core-facility. There are also some studies of characterisation of certain bacterial isolates. These studies are so diverse that they have not been scored. General observations regarding research in the Department Several challenges for research in the Department were observed: Since 2005, the new vention (ECDC), located just 100 m from SMI has recruited seve- ral staff members from , including its two professors and leaders, and , who are now unit heads for science and communication, respecti- vely, at ECDC and younger talent such as , and . ECDC deals with surveillance, scientific advice, preparedness and epidemiological training, which are tasks familiar to this Department. As the ECDC is not involved in laboratory research, positions there are probably less attractive to staff of SMIs laboratory based departments. The Department will probably remain vulnerable to brain drain because ECDC offers higher salaries and lower taxes and, to some people, much more interesting professional environment and tasks. The Depart- ment has also been drained of other key staff members such as de , , , and and two seniors (and ) is about to retire. Many former staff members (, , and ) moved to . Such drainage of talented personnel may hamper the development of a robust research portfolio in the De- partment. No permanent donation professor Previously, held the combined positions of de- partment head and donation professor. After leaving to join ECDC as chief scientist, he is still formally only on leave. The Director General has decided to not fill the position as donation professor with a new permanent candidate, but rather fill it with a temporary staff member in only a position. This may put this Depart- ment at a disadvantage in renewing its research portfolio. Less external research funding The possibility of getting external research funding depends among other factors on the scientific track record of the applicants and the priorities of the research funding bodies. Epidemiological research is almost by default preoccupied with distribution and determi- nants of diseases in the local population. (In contrast to the study of microbes.) Thus, it may be less international in nature and therefore less likely to be published in major international journals. Furthermore, the epidemiology of infectious diseases in may not be a priority area for international funding bodies like the EU framework programmes. This may put this Department at a disadvantage in financing a research portfolio. Compared to the other department, the work in the Department seems to be driven more by external expectations and largely influ- enced by routine activities. Among these are the activities related to running the national surveillance systems for infectious diseases (SmiNet and others), including reporting of results to the health services, mass media and ECDC. This latter activity has increased tremendously over the last few years. The Department is also called upon by regional infectious disease control units to assist in out- break control, and this also leads to requests from the mass media. The Department represents SMI and in several disease group specific networks run by ECDC. All this important activity must be prioritised above research, which may hamper research in the Department. Relationships between this department and other departments The Department is located in a separate half way between the main SMI complex and the ECDC. This separation seems to mark more than a geographical separation. Historically, there has to some extent been a mutual lack of understanding bet- ween one hand and the other departments on the other hand. This is not unique to SMI. All over Europe, similar national institutes struggle to overcome the schism between microbiologists and epidemiologists, each of them sometimes claiming to represent the superior approach to controlling infec- tious diseases. This situation may explain that given the large research portfolio of the institute, there are remarkably few pro- jects that involve formal research collaboration between the Department and the laboratory-based departments. The choice of a virologist as the new head of department was partly an attempt to bring the departments closer together. It was believed that a virologist, being an insider, could facilitate colla- boration by speaking the microbiologists own language. One of her initiatives has been to form thirteen horizontal disease groups at the institute, trying to bring together everyone who works on the same disease(s), no matter their departmental affiliation. There is a hope that these groups, that meet twice a year, may lead to new research projects with horizontal collaboration. From the out-side, however, the choice of virologist and not an epidemiologist at the helm of the Department may have been regarded as giving less priority to epidemiological research. Also, the statistics core facility in the Department has contri- buted to bringing departments closer together. The statisticians have not only assisted microbiologists with their analyses, but also with design of studies. has, during the last five years, produced a wealth of high quality research with a very high rele- vance for Swedish infectious disease prevention and control. The Department has not attempted to choose one or two key topics and headed for the global research peak in those areas, but rather attempted to perform applied research of decent quality in a wide range of subjects that are relevant to daily infectious disease pre- vention and control. Apart from in the influenza area, there seems to be a clear re- duction over the last few years following the departure of the most productive senior researchers, and . Both and have professor positions at and the PhD students they had when leaving SMI have continued under their supervision at SMI. However, their scientific input to the department has been greatly reduced and seems not to have been replaced by others. There are also several other challenges. Thus, the future of research in the department is vulnerable, and action is needed. So far, it seems that the new department director has not been given the resources and circumstances that will allow the department to regain strength also in the research area. senior epidemiologists with a research background are needed. There are several promising areas, such as the influenza research and infectious disease modelling (MicroSim). In the latter area, the department should probably seek international collaborators. Also, there are potential in developing other areas as well: There seems to be research on the epidemiology of vaccine-preventable diseases apart from pertussis. SmiNet data can be linked to data from a vaccination registry to produce interesting research opportunities. See more on research linked to the vaccina- tion programme below. Also, studies using linkage of SmiNet data linked to other health registries can be explored. It would probably be fruitful to set up an automatic linkage of SmiNet data with microbial characterisation data produced in the laboratories at so as to realise the full poten- tial of the activities at the institute. From a Norwegian and Finnish perspective, it also seems odd that there is almost no research (nor surveillance) on health care associated infections in the Department. One may wish to consider moving this area from to . National activities to support the vaccination programme The evaluation committee understands that there will be a complete evaluation of the Swedish national vaccination pro- We have anyway wanted to comment on the research activities at SMI relevant to the vaccination programme. Surveillance of vaccination coverage A high coverage is the most important prerequisite for the success of a vaccination programme. This is especially true for those diseases where the vaccine induces herd immunity, which is the protection of the non-vaccinated minority by eliminating the disease-causing agent from the community. For instance, measles vaccination coverage among Swedish children is now so high that importation of cases from abroad will not set off an epidemic in because the few non-immune individuals are so widely dis- persed that the spread will soon die out. The health authorities need to have an updated overview of the vaccination coverage, both for reporting to WHO and as a basis for adjustments in the promotion of vaccination. For instance, a decli- ning coverage of measles vaccination is a serious warning that needs to be countered. The optimal way of monitoring coverage is through a national vaccination register with person identifiers where all vaccines given to children in are duly registered. We understand that a national vaccination register is being considered. We believe that, if such a register is developed, its potential in research must be exploited. Linkage of the vaccination register and disease registers may provide a wealth of information on positive effects of vaccination and probably alleviate the fear of long term side effects, as seen in where such linkage disproved the hypothesis that MMR vaccine caused autism.