Infectious disease epidemiology – the Danish experience

During the 22nd EHFG, we Young Gasteiners, Durdica Vukic Marosevic and Bélène Podmore (DVM & BP), had the great opportunity to sit down with Tyra Grove Krause (TGK), the Head of Department of Infectious Disease Epidemiology and Prevention at Statens Serum Institute (SSI) in Denmark. The main duty of SSI is to ensure preparedness against infectious diseases and biological threats as well as control of congenital disorders. This includes research with over 400 publications a year, disease surveillance, special diagnostics, the maintenance of the Danish National Biobank, as well as the responsibility for vaccine supply in Denmark. We wanted to get some insights on how the Danish surveillance system for infectious diseases works, whether the Danish colleagues use big data and – following the theme of the 2019 EHFG conference – what Tyra perceived disruption to be.

Tyra Grove Krause, the Head of Department of Infectious Disease Epidemiology and Prevention at Statens Serum Institute (SSI), Denmark

DVM & BP: Can you tell us a little bit about your background?

TGK: After finishing my medical studies, I did a Ph.D. in Epidemiology at SSI, and I actually worked on allergic diseases in Greenland and through that, I got interested in infectious diseases. My initial plan was to become a dermatologist, but then I came to the department where I am working now and it’s the best job you can have! You have the routine work with data collection, data analysis and the communication of data but you also have the opportunity to do research and long-term projects to improve our surveillance system. I really appreciate the international collaboration and the whole idea of not only working with patients individually, but rather with health promotion and prevention with larger groups. There is also a lot of interest in what we do by the media and politics and if you learn how to communicate and work with the political level, you can really make an impact with your knowledge. That’s why I specialised in public health medicine.

DVM & BP: At the political level how receptive are policymakers of your input?

TGK: They want the input from experts, and sometimes we are not good enough at pointing out what is important and communicating that effectively. If we practiced that, I think we could have even greater success stories. For example, once the political level heard rumours and concerns about vaccine hesitancy, they wanted to make vaccination mandatory and asked how to roll that out. We said that it was not the right way forward from a scientific perspective, that there are a lot of reasons why children are not being vaccinated and we proposed alternative initiatives that may increase vaccination coverage instead of a mandatory vaccination policy. A large proportion of our initiatives received funding in the end. Such as an electronic vaccine reminder system for parents developed at the national level in order to improve vaccination coverage. Another initiative involved district nurses who visit new parents and educating and empowering them to be vaccination ambassadors. They were trained in how to talk to the parents about this topic and support them with their decision. The district nurses also received access to the vaccination registries so they can check to see whether children have received the vaccination. If not, they could talk to the parents and address their concerns directly.

DVM & BP: How far along are you with the implementation of this vaccination reminder system?

TGK: We have had a system in place since 2014 and it works like this: When a child turns 2, 6 ½ and 14 years old, the system automatically checks their vaccination status to see if they have missed any vaccinations. If so, an electronic letter is sent to both parents’ e-boxes. All communication from public authorities goes through this type of personal password-protected e-box. This is the main way for authorities to communicate with citizens on a personal level. Vaccination reminders are also sent through the GP app ‘My Doctor’. This initial reminder system lead to an increase in coverage of MMR vaccination (measles-mumps-rubella) of 5 percentage points. This year we are going to extend this system to send reminders to parents two weeks before the date of the recommended vaccination schedule is due, and then we will follow up one month after, to check whether the children received the scheduled vaccination and remind the parents if they didn’t.

DVM & BP: Can you tell us a bit about the datasets you work with?

TGK: We have had our surveillance system based on reports from primary care physicians (PCPs) and hospital doctors on mandatory notifiable diseases and datasets from laboratories for those diseases, which are under laboratory surveillance. As the reporting rate is quite low for some diseases and important information was often missing, we realised we had to change that system, and now the mantra is not to ask the physician for information that is already registered elsewhere. In order to reduce the workload on PCPs and to increase our data quality, we need to capture data from existing registries (hospital discharge registries, vaccination registries, death certificates, etc.). This is possible via the social security number (unique personal identifier) that is used for every contact you have with the health care system. So, we have created a microbiology database with all laboratory test results as the core of our surveillance system and aim to link it with other available registries.

For instance, we use it for influenza surveillance now, to see whether patients diagnosed microbiologically with influenza have been hospitalised, received Intensive Care Unit (ICU) treatment and whether they have any underlying illnesses based on previous diagnoses, vaccination status, etc. For some diseases, you still need data that is not available in the registries (for example sexual behaviour or detailed travel information). For these, you will still need active reporting and information directly from the physicians. If we detect a laboratory-confirmed case of a mandatory notifiable disease, we send a notification to the physician to fill out an electronic form but only for the information we are missing. We already have information on whether the patient is hospitalised, has an underlying illness, their vaccination status and previous test results that we can get from the registries. Currently, the form is sent in paper format and is not automated but early next year it will become electronic and we hope to link it to the existing microbiological database and automate it.  

We haven’t received funding to develop the whole system at once so it has been built up piece by piece. For now, the influenza surveillance works fine with linkage to all registries, but we haven’t done that yet for other pathogens. That is still in the pipeline.

DVM & BP: Do you use any information from social media?

TGK: Not yet. We do not have a social media monitoring system, but I know that the National Health Authority is considering using social media because they are responsible for communicating the information to citizens. And they did a similar campaign focused on information on HPV vaccination as was done for the HPV crisis in Ireland.  

DVM & BP: Do you see any benefit of using social media for infectious disease surveillance?

TGK: Yes! As an example, during the HPV crisis in Denmark there were suddenly reports of potentially severe side effects on social media and television programmes, which led to a huge decline in vaccine coverage. In this situation, you need big data and social media information to detect that there is concern. After that, you need to follow up with large-scale epidemiological studies to examine the hypothesis. One study that was done, and which is about to be published, is where we used machine learning to identify health service contact patterns of the girls who were vaccinated and reported side effects. This contact pattern could be used as an outcome to compare differences between vaccinated and unvaccinated girls. This type of analysis is too complex for classical epidemiology and this is where big data and machine learning can be beneficial for infectious disease research. At our institute, we also did a case-control study comparing those who had side effects and controls who were vaccinated but didn’t report side effects, and you could see that they had different contact patterns before their first vaccination. The girls with side effects had more contact with their GPs and psychological support even before HPV vaccination, compared to those who didn´t report side effects.

What is clear is that you need to do the studies, but you also need to respond to the crisis by informing the public. A good example are social media campaigns. Throughout the whole process, you need to use big data to detect there is a problem, to confirm or to analyse the problem and to communicate you need social media. We have a lot of information on our website, but interviews with focus groups revealed that the regular parent does not go to our website to get the information, so we need to be there where the people are, and communicate on social media.

DVM & BP: Relating to communication, how in your experience do you think it best to communicate your findings?

TGK: I think it is very difficult to communicate emotions to the public. I am a medical epidemiologist – I like to communicate the data because that is what I am an expert in, but you have to balance the emotions with the brain. You have to use both tools when you communicate.

DVM & BP: From your experience, how do you think it is best to present data effectively to policymakers?

TGK: The politicians are interested in economics. We need to explain, how many cases we can prevent and what are the cost-savings if they are prevented. To the citizens, we need to communicate numbers, which are understandable. They don’t understand the concept of 1% risk or 50% effectiveness. You have to mention how many people die from this disease every year and how many deaths you could prevent if you vaccinate or something like that to make it tangible. We do not communicate much with the public – that is the role of the national health authority.  We communicate more with healthcare providers.

DVM & BP: What is the challenge of communicating with healthcare providers?

TGK: In the case of healthcare-associated infections (HAI) we have underestimated the challenge of communicating data to the hospital departments and make them use the data. It was easier to see an impact and change on the local level with point prevalence studies because the teams would go out to the departments, and they would allocate staff to do a survey, look at the medical records, have a dialogue with the staff and discuss the results with them.

The data collected in real-time from the surveillance system for HAI is not used as effectively as the point prevalence studies and the question is: How do we go from the collection of data to the implementation of the knowledge at the local level? We need to move into social sciences and maybe other disciplines to determine how we can get the information out and used more effectively.

DVM & BP: Regarding the theme of the EHFG 2019 conference of a “healthy dose of disruption” – do you think there is anything that has been disrupted in infectious disease epidemiology or is there something you want to be disrupted?

TGK: I think that the biggest disruption for us was the development of a central, national microbiology database. That was a challenge. Before that, every laboratory considered their data as being their own. Eventually, we argued that in order to improve patient care it is beneficial to see and obtain the test results generated in another region, and not to duplicate test results. Also, the value for public health surveillance of having one centralised database as we’ve already discussed with the example of influenza. And to resolve the concerns about publishing research, it was decided to have a steering group with representatives from all laboratories that decides on each research project and ensures there is an author from each laboratory on each research publication. That was a big step!

Somehow, there is still this idea of ownership of data, which is pervasive. We have a public health system and I think the data that we generate in this public health system should be open for all who can use it to improve public health. That is important and is in everybody’s interest. Of course, the data has to be safeguarded, and assurances need to be made that the data is not misused. But, I think this is still something that needs to be disrupted – the access to data, and the whole concept that when you collect data in the health system it is not something you own.

This interview was conducted by Young Gasteiners Durdica Vukic Marosevic (DVM) and Bélène Podmore (BP).

Let’s fight vaccine hesitancy: an urgent public health emergency

Even though the World Health Organization (WHO) has declared that “immunization is one of modern medicine’s greatest success stories” with around 2 to 3 million deaths prevented every year, in 2019 WHO rated vaccine hesitancy as one of the 10 biggest threats to global health worldwide. The session on Vaccine Ecosystems Health Check was a stimulating thought-provoking discussion in which experts from different backgrounds discussed the complexity of the vaccine ecosystem, the challenges and the need for collaboration. The moderator of the session, Natasha Azzopardi Muscat, president of the European Public Health Association (EUPHA), consultant in public health and senior lecturer at the University of Malta shared with us her experience and insights after the session.

GM & RMC: Do you think that public health professionals are doing enough to fight vaccine hesitancy?

NAM: In general, I think that the Public Health Community did not wake up early enough to the whole issue of vaccine hesitancy and how vaccination patterns were changing. The increase in vaccine hesitancy was already well established when experts felt the need to put this on the agenda and take action. It was only when the recent measles outbreaks began that we started to say that “business as usual” is not going to work. Though, in fact, this had been building up slowly for years. So first and foremost, we, the public health professionals, have probably reacted too late.

Secondly, as part of their routine work, public health professionals are often involved in many different aspects of vaccination including running immunisation programmes, designing them and doing cost-benefit analyses. However, one of the things that we probably do not do enough is to engage with some of our clinical colleagues who are very trusted by their patients such as general practitioners, nurses, pediatricians, geriatricians or pharmacists. Public health professionals are not working enough with these constituencies that can play such an important role to help to overcome vaccine hesitancy on a one-to-one basis.

That is what I call working downstream. Working upstream, I think in several countries many public health professionals have done wonderful work, even at great personal risk, engaging with the newspapers and social media to overcome vaccine hesitancy and working with faith leaders and other groups that are particularly resistant to vaccination.

GM & RMC: What else can Public Health Professionals do to fight vaccine hesitancy?

NAM: We can always do more. We can change the way in which we deliver the message. We can make the narrative more empathic, and we need to understand that those who do not vaccinate their children are not bad parents, but they are mostly misguided. Maybe, the question should not be what can we do more, but, instead, what can we do differently?

GM & RMC: Could you highlight some examples of good practice carried out in Europe to fight vaccine hesitancy?

NAM: For example, in Malta, the Association of Public Health Medicine (MAPHM) has just issued a statement on vaccination a couple of weeks ago. Also, the Italian Public Health Association (SItI) has done extensive work to raise awareness about the effect of changing the health law on vaccine coverage rates in many areas.

GM & RMC: In the next five to ten years, what do you think are going to be the main challenges that the vaccine ecosystem is going to be facing?

NAM: We need to recall that vaccine hesitancy is one manifestation of a broader social movement: anti-society, conspiracy theories, mistrust, misinformation, general sceptical questioning, etc. Thus, if this is going to continue to grow, then we will probably have a much bigger problem. It could take, for example, one scandal or one issue of corruption to bring the whole “house of cards” down.

On the other hand, the perception around vaccination may change if there are some really good breakthroughs with new vaccines, for example, against certain forms of cancer as we have recently seen with the HPV Cancer vaccine. Cancer is a disease that captures people’s emotions and imagination, and reframing vaccination as a preventive measure for these kinds of illnesses could perhaps bring a new life to the vaccination issue.

In terms of challenges within the vaccine ecosystem, if there are going to be more vaccines and if weare then able to change people’s perceptions and increase the demand, a series of processes need to be improved. We will need to make sure to have a good supply chain, that the vaccines are licensed and that they are truly accessible across all parts of the world. One group of countries that have difficulties accessing vaccines are the group of countries that get “stuck in-between”. Those countries that are not “poor enough” and thus do not get support to buy their vaccines, however, they can neither afford to buy these new vaccines. We have to avoid that kind of situation because if people know that there are these new vaccines being supplied in other countries but their health system does not afford them, they may start becoming sceptical.

GM & RMC: During the workshop today, we took part in a really interesting and engaging activity in which we played different roles within the vaccine environment in Europe. Do you think this type of interactive games can help to educate the public health community?

NAM: I’m always surprised by the extent to which a lot of people in the public health community still fail to grasp the essence – namely that public health is politics. Public health is not just science, it is the political layer on top of science and humanity. Thus, I find a lot of people who work in the area of vaccine-preventable diseases very concerned with getting the science right, however, they do not feel that it is also their role to be aware and involved in other aspects such as risk communication, procurement systems, the logistics, etc..  You cannot work as a public health professional in the area of immunisation without getting involved in these other areas too. I think it was a good idea to just take some time out and play a game and learn lessons about the perspectives of the other players in this system and understand who you need to be talking to. It is not only about not understanding the other perspective; the problem is that we are often not even talking to the other players in the system because we all work on our “little island”.

Natasha Azzopardi (in the centre) with the two Young Gasteiners Raquel Medialdea-Carrera (left) and Guido Maringhini (right) during the European Health Gastein Forum 2019 #EHFG2019

This interview was written by the Young Gasteiners Guido Maringhini and Raquel Medialdea-Carrera.

Involvement of Young Gasteiners in the COVID-19 response

The rapid spread of the COVID-19 coronavirus has posed unprecedented challenges for health systems and governments across the globe. For the majority, the virus will produce only mild symptoms, but for the most vulnerable members of our society consequences can be detrimental. Whilst containment remains a top priority for all countries, it has become increasingly apparent there is no one-size-fits-all approach in tackling the spread of the disease.

The EHFG has called on its YFG network of health professionals to showcase the ongoing efforts they are making in response to the pandemic.

Olivia Biermann, PhD student, Centre for Global Health, Department of Global Public Health, Karolinska Institutet, is supporting the British charity Evidence Aid as an advisor in fighting the COVID-19 infodemic and assisting in the compilation of an Evidence Collection. The collection, which will be available in different languages, consists of summaries of relevant systematic literature reviews. Olivia notes, “Since there are not yet many high-quality systematic literature reviews on COVID-19, we also use information from SARS and MERS, as well as acute respiratory infections”. Funds for the project have been received from H2H/DFID.

Siobhan O’Connor, Lecturer, School of Health in Social Science, The University of Edinburgh, has been supporting student nurses as they prepare to join the health workforce in the United Kingdom (UK). With the rising numbers of COVID-19 infections, hospitals are finding it increasingly difficult to cope with the number of patients presenting with respiratory problems. To alleviate some of the additional pressure being placed on the National Health Service (NHS) UK parliament is passing emergency legislation which will enable final year nursing students to enter the workforce several months early.

As a registered nurse, Siobhan too will return to work clinically in hospital wards over the coming weeks and, in the meantime, is contributing in other ways such as providing telephone triage for COVID-19 assessment hubs, helping to identify individuals who are symptomatic and referring them to the most appropriate health services. She acknowledges “The next few weeks will be extremely busy but as a Young Gasteiner, I am proud to be one of thousands of nursing and other young professionals across Europe responding to this global crisis”.

Raquel Medialdea Carrera, Epidemiologist, EPIET Fellow, European Centre for Disease Prevention and Control (ECDC) and Health Promotion and Disease Prevention Directorate, Ministry of Health, Malta, began working with the World Health Organization in February, deploying with the Global Outbreak Alert and Response Network (GOARN). Joining the Go.Data team, who are responsible for supporting the implementation and use of the epidemiology software tool Go.Data, she was mandated to Latin American in order to support preparedness and training in the context of the COVID-19 response, which included missions to Mexico, Colombia, Brazil, and Argentina.

Additionally, Raquel has been aiding the COVID response in Malta by conducting the implementation of Go.Data for the management of data from suspected and confirmed cases, assisting with surveillance activities, and carrying out investigations on the chains of transmission of cases.

Anca M. Sarbu, Head of Quality Management and Organisational Development, Klinik Meissenberg AG, Switzerland, is currently leading the hospital’s crisis and risk management team in the fight against COVID-19. On the side, Anca initiated and is now leading The Digital Aid Project (DAP), an ad-hoc, non-profit, public health and social action addressing the challenges faced by the vulnerable inpatient groups and staff in retirement and nursing homes, rehabilitation, and mental health facilities. The goal of DAP is to provide timely and effective support to vulnerable inpatients and organisations in need through the Aid Toolkit and the Digital Health Chart. Anca says, “We, at The Digital Aid Project aim to provide aid and #LeaveNoOneBehind before it’s too late!”. Both the Aid Toolkit and the Digital Health Chart will be available in multiple languages and free of charge by mid-April.

The responsibilities of Stefan Buttigieg, Higher Specialist Trainee, Public Health Medicine, Ministry for Health, Malta, have evolved over the course of the pandemic, initially deployed to the COVID-19 Response Team as part of the Swabbing and Helpline Team he now describes his role as “a hybrid of communications, IT, and data management”.

As well as assisting with the implementation of Go.Data across the Maltese Islands, Stefan has had the opportunity to develop Malta’s COVID-19 Data Dashboard and a Public Health Chatbot nicknamed Covee. He says, “The main observation is that for every crisis, there is a silver lining. In this case, the digital transformation of healthcare is happening right in front of our own eyes and there is an exponential use of technology in all sectors”.

Karolina Mackiewicz, MyData Global Events Lead and International Projects Manager ECHAlliance (European Connected Health Alliance) says, “While the whole world is looking for ways to curb and combat COVID-19, the data-based applications to track and isolate the suspected cases are getting more and more attention from health authorities and governments”. Discussions around what kind and how much of data the governments should have are surfacing and after many years spent battling for privacy and control over the use of personal data, the threat of sacrificing it for the fight against COVID-19 is real.

To support the initiatives based on ethical data sharing, which try to empower users, MyData Global, an international non-profit, which advocates for fair, just, and sustainable digital society, have started the weekly MyData vs COVID-19 community calls. Coordinating this project, Karolina is responsible for reaching out to the initiatives, hosting the calls, and providing comprehensive updates to the community. The calls gather more than 60 participants each and, as Karolina notes, “serve as a platform to inform, exchange, and connect across sectors and borders”.

Vladana Stefanovic, Specialist of Social Medicine (Public Health and Community Medicine), Institute for Student Healthcare of Novi Sad, Serbia, has been contributing to the fight against COVID-19 in a variety of ways. Within her Institute she is acting as the liaison with senior policy and decision makers, informing them of available resources and the measures that have been taken during the pandemic. Due to staff shortages she is also undertaking shifts in the hospital’s respiratory unit, acting as the first point of contact for patients presenting with respiratory symptoms, treating and referring them to the appropriate facilities for testing.

With Serbia enforcing a curfew forbidding all those over the age 65 years of age from leaving their house, apart from once a week between 4:00 and 7:00 am, Vladana has also been assisting the elderly in her family and community, ensuring they have food and necessary supplies. Finally, in her hometown of Novi Sad a fair hall has been converted into a COVID field hospital, Vladana says, ‘I’m next in line to go and perform physician duties there, we will see in the next few days if I will be needed’.

In the context of the current COVID-19 pandemic, the EHFG is planning for the 2020 Forum to take place in Bad Hofgastein, Austria, from 30 September – 2 October as originally announced, with the YFG programme to begin on 29 September. The EHFG will, of course, continue to closely monitor developments, prioritising the safety of all participants and staff by following advice from relevant authorities.

“Our main task is to ensure that we do not pose questions to patients that are actually unethical to ask”

Anja Schiel is a Senior Adviser & Statistician at the Unit for Health Technology Assessment (HTA) and Reimbursement, Norwegian Medicines Agency (NoMA). At the EHFG, she gave her perspective on “Making real world data real” during a workshop under the same title about improving regulatory approval of new therapies.

According to the World Health Organization, HTA is the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organisational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform policy decision making.

ER: What was the key message of the workshop “Making real word data real”?

AS: My message would be that drug development is complicated but there are new ways forward that are promising. In my opinion, we need to find good ways forward that ensure that we do the right thing and not fall for a hype. Sometimes we tend to think in isolated silos, but we have to listen to everybody who is involved if we want to succeed. For example, a solution that works for one stakeholder, like the regulator or the HTA agency, may not be a solution for patients or clinicians. This is the main reason why in the last ten years there has been an increased willingness in improving cross-stakeholder communication. We heard about the IMI project in this session [The Innovative Medicines Innovative (IMI) EHDEN project which aims to build a data network that allows access to data of 100 million EU citizens, standardised to a common data model].

I strongly believe in this project, because we have never witnessed such strong communication between different stakeholders. Even industry representatives have experienced it as a forum in which they can talk with each other at a very different level than ever before. And even the HTA agencies and the regulators have a much-improved understanding of each other’s work and perspectives. It is key that one doesn’t have to align everybody but one can at least understand each other’s needs better. And because of that, one might actually change one’s own behaviour and have other decision-makers in mind when giving advice or deciding on something.

AJ: Do you think that patients should have a bigger role, for example, by having an actual seat in the decision-making process at the European Medicines Agency (EMA)?

AS: Actually, the EMA currently runs a huge project on patient involvement. In the past, there was none and the EMA was criticised for that; now they are trying really hard to improve this. In particular, in the scientific advice process with companies in an early stage of product development, it is nowadays quite common that patient representatives are present at the meetings. It is very similar to NICE appraisals meetings, where there are always patients present. This also depends on the countries: for small countries, like Norway, it may be hard to find a patient organisation. In that case, you need to find someone who is willing to look beyond their own perspective and represent the patients as a group and not only their own disease-specific perspective. However, when you are patient it is extremely difficult to take on a group perspective.

The healthcare system has acknowledged that once you are diagnosed with something serious, you cannot be objective. No one would expect you to be objective in that situation. Our main task is to ensure that we do not pose questions to patients that are actually unethical to ask, like making a decision between A and B if both are unacceptable because they may be unsafe. We have a huge responsibility in protecting patients from these situations, which were common fifty years ago when patients were left alone in desperate situations. We really must prevent patients from having to make desperate decisions, because in these circumstances decisions can never be educated or objective.

AJ: Do you think there should be more room for the emotional perspective of patients? After all, it is their unique perspective on things.

AS: The unique perspective is actually quite often reflected when we talk about measures of success in a trial. Patients can explain to us what a relevant endpoint would be for them, whereas clinicians tend to measure things that are easily measurable and objective. Patients can bring in the perspective on what is relevant to their everyday quality of life. This is also a huge difference between HTA agencies and regulators, because for HTA, taking into consideration the quality of life is absolutely essential, whereas, for the regulatory side, it is more about an objective assessment of whether the risks outweigh the benefits.

This interview was conducted by the Young Gasteiners Elena Roel (ER) and Arjan van der Star (AJ).

“We need a Greta!” Talking about European alcohol policies.

As the Director of the Division of Non-communicable Diseases and Promoting Health through the Life-course, Bente Mikkelsen focuses her work on achieving the SDGs through the reduction of premature deaths from NCDs by one third before 2030, promoting health, and through impacting at country level in the context of the WHO General Programme of Work. WHO co-hosted the session “European alcohol policies – rethinking and strengthening implementation” at the European Health Forum Gastein 2019, which was organised together with EHFG, EU-HEM, MCI Management Center Innsbruck, IOGT-NTO and International Youth Health Organization, and supported by the Republic of Slovenia.

JK: WHO co-hosted the session “European alcohol policies – rethinking and strengthening implementation” at the European Health Forum Gastein 2019. Why does WHO prioritise this particular topic?

BM: Worldwide 3 million people die from alcohol consumption every year, in Europe, it is 1 million people. It is one of the biggest causes of premature death, especially among men and the youth. Alcohol is a risk factor for cardiovascular diseases and cancer and causes a lot of ill-health. Reducing the harmful use of alcohol as a risk factor for NCDs (non-communicable diseases) is a very important priority in the WHO European region of 53 countries.

JK: In how far is there a need to “rethink” the implementation of policies?

BM: First of all, I think that the policies we have in the region, under the WHO European Action Plan for reducing harmful use of alcohol, are already fairly good. We have had three consultations this year – one with the Member States, one with multi-stakeholder organisations like NGOs, and just this week (1st week of October 2019) we had a consultation with 35 Member States in Prague. It was confirmed that what we call the WHO “best buys” are still the “best buys”. This is confirmed scientifically; the measures are proven to be affordable and really effective.

JK: What are the WHO “best buys”?

BM: The “best buys” is sort of a buzzword for cost-effective policy interventions. In the whole area of NCDs, we have 88 defined interventions and 16 of them are labelled as “best buys”. It is about banning or restricting marketing, pricing and taxation, and reducing access to alcohol, and it is about. This is the winning strategy if you want to protect the population against harmful use of alcohol.

But we can see that industries and retailers react to these strategies. For example, they can adjust to tax increases by reducing their price and consequently the price for the consumer is still the same regardless of the tax. Therefore, we need to refine the policies and interventions in place. Even if we have the right tools, we are not able to scale up the implementation in all countries in Europe in order to improve the health of the population.

JK: You mentioned that the ones who suffer the most are men and the youth. Do you think there is a gendered dimension to harmful use of alcohol?

BM: 1.5 years ago, the WHO European region put forward a “men’s health strategy”. This was done because we could see that we are generally doing well when it comes to the reduction of premature deaths – except for men. We see that so-called masculine lifestyles are unhealthy, as men take a lot more risks, they drink more, they smoke more, they do not go to the doctor, they are not health literate, and they underuse the health system. So, there is certainly a gender difference on the use of alcohol. And if you add drink-driving you have yet another component. We know that in the WHO European region, one in every 5th death in young people is attributable to alcohol consumption, namely due to injuries; the most important category is road traffic accidents due to drink-driving.

JK: What needs to be done?

BM: I think we need to scale up the implementation of the tools which we then call the “best buys” the “good buys” and also the “buys”. And we have figures on how impactful they are on mortality and on DALYs (Disability Adjusted Life Years). We are looking more and more into the lifestyles, and we start with health literacy at an early age. We see that we have to regulate social media and advertisements much more, because the youth is being bombarded by unhealthy choices via these channels. And through the life course, we have many different options; we can work with kindergartens, schools, workplaces, and also cities quite easily. At the national level it always takes very long to pass legislations etc. while on city level you can implement measures much more quickly. And also, we have to follow very closely how the commercial sector is acting. Unfortunately, the alcohol sector is also learning from the tobacco sector and many of the already identified tactics used by the tobacco industry are now also being used by the alcohol industry, as already documented in several scientific publications.

JK: In how far does WHO collaborate with the industry to work on these issues?

BM: In the context of alcohol it is not really a partnership. We organise ourselves at WHO under what we call the “framework for non-state actors”, used to assess conflicts of interest or perceived conflicts of interest. For example, accepting funds from an alcohol producer, even if it is a very small amount of money, can be perceived as a conflict of interest. It is very important to note that our interaction with the alcohol industry should never lead to or imply “partnership”, “collaboration” or any other similar type of engagement that could give the impression of a formal joint relationship, the reason being that such engagements would put at risk the integrity, credibility and independence of WHO’s work.

JK: How is the “framework for non-state actors” organised?

BM: WHO holds dialogue meetings with the umbrella organisations for alcohol producers. The nature of this interaction is limited to dialogue and exchange of information for achieving positive outcomes for public health.

JK: This year’s theme of the EHFG was about disruption. Can you think of a disruptive way forward regarding harmful use of alcohol?

BM: I think the disruption lies in the way of implementation rather than in the actual tools we are using. Just now we published a case study from Russia. What we can do is use more nuanced instruments, as for example models for differentiated prices according to the drinking patterns. But I would call that refinement. I think the disruption is more about how to mobilise the population so they actively request from their governments to be protected from alcohol.

JK: Alcohol consumption is also very much of a cultural practice. How can social norms be changed? Does it need disruption or will change occur over a longer period of time?

BM: It is said that drinking alcohol is part of a larger European culture, and this is also why we (Europeans) are the biggest consumers of alcohol in the world. Nowhere else is alcohol used to that extent. And of course, alcohol marketing is aimed at reinforcing these so-called “cultural practices” that sustain high levels of alcohol consumption. Unfortunately, I do not think it will be possible to change this immediately but we know that social norms can be changed. I think there are countries that want to protect their youth by waiting longer until alcohol is accessible to them, like in the Scandinavian countries, where you have alcohol monopolies, for example. I think it is probably a bit of both (disruption and change over time), because we know what works but we just have to do it.

That said, one of the big misconceptions is that one glass of red wine protects your heart. But we have proof that this is not true at all. So, there is absolutely no health in any one unit of alcohol. If we are at least able to present science in a good way so that people can take healthy choices, then this is the way forward. And maybe this is a slow way, but it is still the way we need to go.

You know when we went to this consultation in Prague, we only had non-alcoholic drinks. For the first time, there was non-alcoholic champagne, wine and beer. We can see that producers are also refining the taste. You would not have guessed that there was no alcohol in it. So maybe that’s some disruption?

JK: Imagine the EHFG in 10 years from now with yet another session on alcohol policies. What would you like to see there?

BM: I think we need a Greta! (referring to environmental activist Greta Thunberg). We need somebody who really understands the harm of alcohol. And maybe then we will also see a lot of youth mobilising for healthier lives, where alcohol is not included. We already see a steady decrease in consumption. But in the end, we are not talking about a full ban on alcohol, but we clearly say that “less is better”.

The WHO “best buys” to reduce the harmful use of alcohol [1]
Increase excise taxes on alcoholic beverages
Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media)
Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)

[1] World Health Organization (2017), Tackling NCDs – “best buys” and other recommended interventions for the prevention and control of non-communicable diseases, www.who.int/ncds/management/best-buys/en/

The interview was conducted by Young Gasteiner Johanna Kostenzer, Marie Sklodowska-Curie Postdoc Researcher at Erasmus University Rotterdam.