Heat waves and climate change

Climate change is deemed “the biggest global health threat of the 21st century”. (1) Global warming is now unequivocal; global average temperatures have risen by 0.85°C between 1880 and 2012. (2) Global mean temperature is projected to increase by about 1.6 to 2.6°C above the preindustrial period by the 2050s, depending on the scenario used.2 Using median values, projected temperature increases for Europe and America are between 2 and 4°C for the 2050s (relative to present-day climate). (2) Higher increases are projected over much of Asia and Australia. (3) Heat waves, defined as extended periods of extreme high temperature, are regarded as one of the primary weather-associated threats to human life. (4) As increased frequency, intensity, and duration of heat wave events occurred associated with global warming, impact of heat wave on health has drawn more and more attention worldwide. (5-7) It is well-established the relationship between extreme high temperatures and human morbidity and mortality. (8)

There is also now strong evidence that such heat-related mortality is rising as a result of climate change impacts across a range of localities. (9) For instance, the excess mortality during the extremely hot summer of 2003 in Europe and the 2010 Russia heat wave, resulted in more than 70,000 and 11,000 deaths, respectively. (10,11) Much of the excess mortality from heat waves is related to cardiovascular, cerebrovascular, and respiratory disease and is concentrated in some populations groups. These groups include women, young children and older people, people with existing health problems or disabilities, and poor and marginalised communities. They are particularly vulnerable to the health effects of climate change, whether because of existing socioeconomic inequalities, cultural norms or intrinsic physiological factors.

Other risks were associated with rising temperatures and changes in precipitation pattern. For example, the modification of viable distribution of disease vectors such as mosquitoes carrying dengue or malaria. Temperature affect the range and reproductive rates of malarial mosquitoes and also affect the lifecycle of the parasitic protozoa responsible for malaria, possibly increasing the incidence of a disease that causes 660 000 deaths per year. (12) There are equally complex relationships and important climate-related risks associated with dengue fever, cholera and food safety. (13-15)

Moreover, a heat wave can be a big threat in urban area because of the “urban heat island (UHI) effect”. The UHI effect results in the temperatures being somewhat higher in cities than in suburban and rural areas, primarily because of the abundance of heat-retaining surfaces such as concrete and black asphalt, that exacerbate the negative heat effect on residents compared with reflective, transpiring, shading, and air-flow-promoting vegetation-covered surfaces. (16,17)

The events occurred in Europe and Russia and those which occurred in Australia, 2012/2013 and 2016/2017; North America, 2012; India and Pakistan, 2015 and Europe 2015 have led to the implementation of specific policies to reduce heat-related mortality such as the National Heat Wave Plan in France, (18) and the Heatwave Plan for England. (19) Evidence suggests that effective adaptation measures would reduce the death rates associated with these heat waves. Adaptation measures also include increasing green infrastructures and urban green spaces, improving the design of social care facilities, schools, other public spaces, and public transport to be more climate-responsive. Adaptation options within health care include training of health-care workers and integrated heatwave early warning systems (HEWS). (20)

A communication and public education strategy is an essential part of the warning system, public health messages should be disseminated to all age and vulnerable groups to increase awareness of symptoms of heat-related illness.



  1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change. The Lancet. 2009; 373(9676): 1693–1733.
  2. IPCC, 2013a: Summary for Policymakers In: Climate Change 2013: The Physical Science Basis. Contribution of Working Group I to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change Change [Stocker TF, Qin D, Plattner GK, Tignor M, Allen SK, Boschung J, Nauels A, Xia Y, Bex V, Midgley PM (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 1–30.
  3. Bassil K, Cole D. Effectiveness of public health interventions in reducing morbidity and mortality during heat episodes: A structured review. Int J Environ Res Pub Health. 2010; 7: 991–1001.
  4. Luber G, McGeehin M. Climate change and extreme heat events. Am. J. Prev. Med. 2008; 35: 429–435.
  5. Wang C, Chen R, Kuang X, Duan X, Kan H. Temperature and daily mortality in Suzhou, China: a time series analysis. Sci Total Environ. 2014; 466–467.
  6. Gronlund C, Zanobetti A, Schwartz J, Wellenius G, O’Neill MS. Heat, heat waves, and hospital admissions among the elderly in the United States, 1992–2006. Environ Health Perspect. 2014; 122: 1187–1192.
  7. Gao J, Sun Y, Liu Q, Zhou M, Lu Y, Li L. Impact of extreme high temperature on mortality and regional level definition of heat wave: a multi-city study in China. Sci Total Environ. 2015; 505: 535–544.
  8. Forsberg, B. Heat-related respiratory hospital admissions in Europe in a changing climate: a health impact assessment. BMJ Open. 2013; 3: e001842.
  9. Smith K, Woodward A, Campell-Lendrum D. Human health—impacts adaptation and co-benefits. Climate change 2014: impacts, adaptation, and vulnerability Working Group II contribution to the IPCC 5th Assessment Report. Cambridge University Press, Cambridge, UK and New York, NY, USA; 2014.
  10. Robine J, Cheung S, Roy S, Oyen H, Herrmann F. Report on excess mortality in Europe during summer 2003. EU Community Action Programme for Public Health. Grant Agreement 2005114. 2007.
  11. Agence France-Press. Russian heat wave caused 11,000 deaths in Moscow: Official. 2010. Press release. 2010.
  12. WHO. World malaria report. World Health Organization, Geneva; 2012.
  13. Bhatt S, Gething P, Brady O. The global distribution and burden of dengue. Nature. 2013; 496: 504-507.
  14. Sutherst R. Global change and human vulnerability to vector-borne diseases. Clin Microbiol Rev. 2004; 17: 136-173.
  15. WHO. World Meteorological Organisation. Atlas of health and climate. World Health Organization, Geneva; 2012.
  16. Roth M. Review of urban climate research in (sub) tropical regions. Int J Climatol. 2007;27:1859–1873.
  17. Gabriel K, Endlicher W. Urban and rural mortality rates during heat waves in berlin and Brandenburg. Germany Environ Pollut. 2011;159(8–9):2044–2050.
  18. Pascal M, Le Tertre A, Saoudi A. Quantification of the heat wave effect on mortality in nine French cities during summer 2006. PLoS Curr. 2012: 4:RRN1307.
  19. Public Health England. 2015. Heatwave Plan for England. Protecting health and reducing harm from severe heat and heatwaves. Public Health England, London, UK.
  20. Ghasem S, FitzGerald G, Aitken P, Verrall K, Tong S. Are heat warning systems effective? Environmental Health. 2013: 12-27.


Ana Pinto de Oliveira
Public Health Resident
Arnaldo Sampaio Public Health Unit, Lavradio, Portugal

Catarina Oliveira
Public Health Specialist
Arnaldo Sampaio Public Health Unit, Lavradio, Portugal

Interview with Robert Otok, Director of ASPHER

We have been reading ASPHER’s strategic Objectives 2016-2020. We are right now just in the middle of this period of time. Could you tell us some of the achievements ASPHER (Association of Schools of Public Health in the European Region) has accomplished so far regarding those strategic goals?

ASPHER 2020, which was inaugurated during the 50th anniversary year of the Association, presents a comprehensive and balanced agenda guiding the strategic development of ASPHER during an important period, critical in many ways for the future of Public Health in Europe and globally.

As we reach the midterm mark of this time period, several key achievements have been reached by ASPHER. These include the continued development of ASPHER’s core competences programme with the publication of the 5th edition of competences list. The list remains a core reference for the development of public health education in Europe, while also supporting public health careers and systems development.

A central project underway is the collaborative development of a series of tools for public health workforce development and professionalization in Europe. This is being undertaken as part of a groundbreaking agenda set by the WHO Regional Office for Europe within a framework of the European Action Plan (EAP) for Public Health Capacities and Services Strengthening. The tools will be presented at the European Public Health Conference in Ljubljana this November and will be made available for use by countries and other relevant stakeholders soon thereafter.

ASPHER has also made strides to bolster collaboration between keystone public health organizations. Cooperation across organizations that pool ideas, resources, and capacity can only strengthen Public Health today and brighten the outlook for the field in the future. ASPHER is maintaining historically close ties with the European Public Health Association (EUPHA), and forging new key partnerships – including those with the International Association of National Public Health Institutes (IANPHI) and the Association of Schools and Programs of Public Health (ASPPH), which is ASPHER’s counterpart organization across the Atlantic.

There are other exciting developments still to come under the ASPHER 2020 agenda. These include the launch of the Public Health Training Academy, which is meant to constitute a training platform for individuals seeking continuing professional development opportunities in public health. ASPHER is also improving the formula for its annual Deans’ and Directors’ Retreats – a major membership event of the Association.

We know one of the foremost pillars of ASPHER working is on Professionalization of the Public Health Workforce. Could you explain the ASPHER’s work in this area?

This project is primarily realized through ASPHER’s active engagement in WHO Europe’s Coalition of Partners (CoP) work on implementation of the EAP for Public Health Capacities and Services Strengthening. The relevant CoP projects include:

  1. Development of the Road Map towards professionalization of the public health workforce in the European Region. This is a tool meant to support countries in developing policies related to public health workforce professionalization. The Road Map recognizes the diversity of public health systems in place across Europe and should act as a guide to countries to choose the path that suits their culture and needs to strengthen and professionalize their workforce. The Road Map seeks to reinforce the professional identity of the current public health workforce and help to align public health services and operations with the public health workforce development.
  2. Development of a Handbook for managing public health professional credentialing and accreditation systems in the European Region to serve as a reference tool for the national education and health systems to ensure the competencies both required and presently possessed by the public health workforce.
  3. Development of a core competencies Framework for the public health workforce in the European Region. This should be of use for human resources practices to enable an ongoing standardized and consistent assessment and development of public health knowledge and skills at individual, service, organizational, and country levels, thus, supporting public health professionalization and credentialing.

Does ASPHER have any plan to facilitate the application of its proposals about professionalisation to medical residency programmes in Europe? What EuroNet and public health residents in general can do to support and participate in ASPHER?

The EuroNet Medical Residents in Public Health (MRPH) plays an important role in the development and the implementation of the public health professionalization agenda. The Network already actively contributes to the work of the CoP providing a specialist workforce and fresh perspectives from a younger generation. Input from EuroNet and its individual members is critical for the success of this effort.

The specialist training EuroNet MRPH members obtain makes them also particularly relevant to ASPHER. It is no surprise then that both associations actively collaborate, share mutual understanding and friendship. Italy is an interesting example of a country where all schools providing residency and specialist training in public health became ASPHER members – such a membership context provides powerful potential for working closely together.

To learn from your experience, which are the aspects of ASPHER that led you to get involved with the association? How did you benefit from being involved in ASPHER?

ASPHER is a family, with all the baggage that it brings – both pluses and minuses. Still, what I think keeps me (and I believe not only me) with ASPHER is its unique atmosphere and the people who are part of the organization.

Over the past years, I have sought to secure its professional shape and high performance standards. Being the Association of Schools of Public Health, (i.e. concrete institutions, with staff, students and graduates), extends the impact of ASPHER through the schools’ infrastructure, the services they provide in training, research and societal contributions. It is an extremely powerful organisation – essential for the growth of the Public Health in Europe and globally. Working at ASPHER is therefore an extraordinary journey, an eye-opening experience, reflecting the complexity of the truly unique field the Public Health is.

Which do you think are the future challenges for the future public health workforce and how young public health professionals could prepare to face those challenges?

My personal take is that we are currently challenged to identify clear career options/paths and to make quality training available to enable smooth navigation through the complexity of the public health field and the choices it offers. ASPHER makes continuous efforts to address this. Young public health professionals should remain courageous and pertinacious. I would recommend that they find someone they can trust to lead them in facing their career challenges and in their turn, mentor newcomers as they move forward and gain experience.



This is a Story about Networks

This is a story about networks. A story about the balance between their simplicity and the impact they can bring about. My name is Miguel Cabral and I’m a Medical Resident of Public Health (MRPH), in Amadora, Lisbon, Portugal. One of the great things the Portuguese Public Health (PH) residency has is the chance for MRPH to do some of their training abroad, while still receiving their salary. Another great thing is that we have 3 months for an optional internship, which means we can pretty much choose anything we want to do in the world, as long as we work on a PH area under the supervision of a PH specialist.

In my case this was very handy. My wife was doing an internship in Rome for her residency. I wanted to find an internship that would allow us to be together and make the most out of the experience on a professional level but also on a personal level. So, I “just” had to find an internship somewhere in Rome that would not require an Italian speaking person (I can understand basic Italian but you don’t want to hear me speak).

So… networks of people. Here is where a Maltese MRPH gets into the picture. A friend of mine, that is also part of the European Network of MRPH (EuroNet MRPH), passed by Lisbon and we had a coffee and a pastel de Belém by the Tejo River. I hadn’t searched too much for internship opportunities yet, but he told me he knew the perfect guy for me to do my internship with. The next day, I had an email message from Dr. Carlo Favaretti with a general proposal of what an internship with him would be like. And boy, I was thrilled! As my wife puts it: there were many words I liked, all together.

Fast-forwarding the bureaucracy needed, some months later, I was entering the Public Health Institute of Università Cattolica del Sacro Cuore, in Rome. The institute hosts several interesting institutions. One of them is a World Health Organization (WHO) Collaborating Centre focused on Leadership in Medicine. The other one is a spin-off from the University called V.I.H.T.A.L.I. (Value In Health Technology and Academy for Leadership & Innovation). I like to think institutions reflect the people that are part of them, and the institute had several remarkable people indeed, both on professional and personal levels. But we’ll get back to that shortly.

Before my internship, I thought I would mainly deal with the topics of Health Technology Assessment (HTA) and Leadership, since Dr. Favaretti is the president of the section on HTA from the European Public Health Association (EUPHA) and is part of the Leadership Centre, on top of having extensive experience in health management. However, I got a big bonus, as I’ve also ended up dealing a lot with the topic of Value Based Health Care (VBHC), which is becoming quite trendy in Portugal (and a bit everywhere).

The most astonishing thing I’d like to point out is how much I’ve learned in so little time. I’m convinced that a temporary switch of network and work environment allows one to get in touch with so many different ideas, perspectives and methodologies that it feels like some sort of intensive course on whatever the topic dealt with. In my case, I would particularly highlight the areas of HTA and VBHC. In the classes I had about HTA they usually just addressed clinical and economical evaluation, so to find out something so schematic as the EUnetHTA model was very positive. And on the topic of VBHC, the discussion in Portugal is very centred on the notion of Value by Michael Porter, the author that launched the concept, by defining value as a formula that divides the outcomes of the patient by the costs used to obtain those outcomes. To me, it seemed strange to apply this to a National Health Service (NHS) type of health system. And, of course, I was not alone. During this internship I learned about Sir Muir Gray and Dr. Jani Anant’s work on the field and their notion of triple value, which is particularly more adequate, in my PH view. I was fortunate enough to even meet them in person, as the institute has very good relations with them. This is another benefit of trying out new networks as one might even get in touch with connections from that network.

Figure 1. The entrance of the Università Cattolica del Sacro Cuore

As I see it, sometimes you get lucky and you grow a lot in professional terms with these internship opportunities, some other times you get very lucky and you end up also growing personally due to the relationships you build. I’ve learned a lot from the senior and junior specialists in the institute, but I’ve also learned with and because of the MRPHs in the Institute. In Italy, the PH residency is mainly based on Universities. I was able to connect with MRPH from different stages of residency and in the case of UCSC, the residents are very proactive and they even organize Global Health Courses for Medical Students in the University. How cool is that?! If they wanted to host a EuroNet MRPH meeting, I think they would probably do it without any trouble!

Besides all this, there was also Rome and Italy. There is culture around every corner and under every rock (I mean literally as during my stay they found new ruins when a bit of pavement on a road sunk due to the rain). I was able to travel around quite a lot and visit several landmarks in and outside of Rome. It is amazing how even in tiny cities I’ve visited there were some amazing monuments to be seen and the food was always good. The only travelling I didn’t enjoy was the traffic, which is quite hectic. Other than that, I have only good things to point out of my internship.

Therefore, I highly recommend every MRPH to do an internship outside their usual network of connections, as the benefits will likely out weight the costs. I was lucky enough to have someone in my network (thank you Stefan!) that was able to point out the perfect internship for me, but there are also other ways to go. For instance, you can make use of the internship program from EuroNet MRPH. Or if you are very keen on a specific place or topic that is not on the EuroNet list, you can also make use of the list of WHO’s collaborating Centres. You’ll likely have to put in a bit more effort to make it happen, but it will most likely pay off. In my case it definitely did. I’ve learned a lot, ate a lot of good food (and drank a lot of macchiato coffees as only Italy can provide), visited amazing places and enriched my network with a group of very knowledgeable, proactive and generous people. My experience would not be the same without them and I’m very thankful for them. I look forward to attending a EuroNet Meeting there very soon!


Miguel Cabral
Medical Resident of Public Health (MRPH)
Amadora, Lisbon, Portugal

EUPHAnxt: A New Team, A New Logo

EUPHAnxt is a unique network within the European Public Health Association (EUPHA), for students and young professionals in the field of public health.

EUPHA is an umbrella organisation for public health associations and institutions in Europe. Currently, EUPHA has 81 members from 47 countries, bringing together around 19,000 public health experts for professional exchange and collaboration throughout Europe.

EUPHAnxt was established in 2011, and has grown bigger each year. It is a free and open initiative that aims to inform and involve the future generations into the European and multidisciplinary network of public health associations.

The new team: Sara McQuinn (EUPHAnxt Coordinator), Pasquale Cacciatore (EUPHAnxt Communication Manager),  Keitly Mensah (EUPHAnxt Conference Manager) and Anton Hasselgren (EUPHAnxt Partnership Manager).

We strive to further expand the network, build partnerships and strengthen the presence of students and young professionals in the European public health community. We aim to gather all young public health professionals and students in Europe. You are welcome to join us by subscribing to our newsletter and follow our social media channels.

EUPHAnxt current projects and initiatives include:

  • To co-organise skill-building sessions at the annual European Public Health (EPH) conference to promote training and education. This year the conference will be in Ljubljana, Slovenia Nov 28th-Dec 1st. We hope to see you there!
  • A fun and informative newsletter where we share our latest activities and news addressed to students and young professionals interested in public health.
  • The abstract mentoring programme, which provides an opportunity for young and/or less experienced abstract submitters to receive feedback from expert reviewers on abstracts that are to be submitted to the EPH Conference.
  • An Informal Internship Programme, where our goal is to put students and young professionals interested in doing an internship at the EUPHA office or within one of the EUPHA sections, in contact with the relevant public health professional.

If you have any queries, or would like more information regarding EUPHAnxt, please email: info.euphanxt@eupha.org. We also have Facebook, Twitter, Instagram and LinkedIn accounts where we share our latest activities, and interesting public health news! Come join us ® https://eupha.org/euphanxt


Sara McQuinn
EUPHAnxt Coordinator

The health we breath: Porto air quality

Worldwide, outdoor (ambient) air quality is a serious threat to health, estimated to cause millions of premature deaths due to cardiorespiratory diseases and lung cancer. Affected regions include both urban and rural areas. In 2016, the majority of the world population was living in areas in which maximum concentration of air pollutants were not met (1). In what concerns to sources, anthropogenic factors are the most relevant to negative effects of ambient polluted air (2).

Since 2013, the International Agency for Research on Cancer has defined polluted ambient air and particulate matter (PM) (separately) as carcinogenic to humans (group 1). In addition to strong evidence that polluted air cause lung cancer, there is also an increased risk of bladder cancer. Despite local variations, these conclusions are valid globally (3).

It is expected that in 2050, two-thirds of world population will be living in cities. By converging all opportunities and services in one area, overpopulated cities are also a challenge in terms of health risks and hazards. Creating and transforming sustainable cities implies intersectoral work, particularly governors and policymakers. In order to monitor and recognise success, World Health Organization (WHO) developed core health indicators for different sectors, including one in urban air quality. The indicator evaluates annual average of 2.5 and 10 concentrations in relation with WHO air-quality guidelines (4).

In 2016, Portugal had 91,3% of days classified as very good/good in terms of air quality index (IQAr) by the Portuguese Environment Agency. In the same year, Porto Litoral (coast) had 95,3% days with the same classification (Figure 1) (5). This index includes measures on five air polluted substances such as PM, ozone (O3), nitrogen dioxide (NO2), sulfur dioxide (SO2) and carbon monoxide (CO) (6).

Data on polluted air concentrations of 2.5 is provided by the WHO Global Observatory, including data on 190 countries. The Portuguese 2016 annual mean concentration of 2.5 was 8,1 µg/3, meeting WHO guidelines of lower than 10 µg/3 (7) (8). In the same year, the annual mean concentration of 2.5 (204 days of validated data) was 2.9 µg/3 in Porto (Sobreiras – Lordelo do Ouro station) (9). Data on both country and city levels of 10 was not available in the same sources. While Porto results are suitable so far, the predictions of research data using modelling methods are not optimistic. Even if precursor emissions and population remain constant, Porto will be the district most affected concerning 10 high concentration days and related health impact in 2100 (10).

Though in 2016, Portugal and Porto results on 2.5 met WHO guidelines, climate change and inaction specially on anthropogenic factors will be responsible for worse scenarios with serious consequences to human health.

Figure 1. Porto Coast Air Quality Index 2016 (adapted from Portuguese Environment Agency)



  1. World Health Organization. Ambient (outdoor) air quality and health [Internet]. Fact sheets. 2018. Available from: http://www.who.int/news-room/factsheets/detail/ambient-(outdoor)-air-quality-and-health
  1. World Health Organization. Ambient air pollution: Pollutants. Air Pollution; Available from: http://www.who.int/airpollution/ambient/pollutants/en/)
  1. World Health Organization. IARC: Outdoor air pollution a leading environmental cause of cancer deaths; Available from: http://www.iarc.fr/en/mediacentre/iarcnews/pdf/pr221_E.pdf
  1. World Health Organization. Health Indicators of sustainable cities in the Context of the Rio+20 UN Conference on Sustainable Develpment. 2012; Available from: http://www.who.int/hia/green_economy/indicators_cities.pdf?ua=1
  1. Fernandes AC, Guerra MD, Ribeiro R, Rodrigues S. Relatório do Estado do Ambiente 2018. Agência Port do Ambient. 2018; Available from: https://sniambgeoviewer.apambiente.pt/GeoDocs/geoportaldocs/rea/REA2018/REA2018.pdf
  1. Portuguese Environment Agency. Air quality; Available from: (https://qualar.apambiente.pt/qualar/index.php?page=5&subpage=6).
  1. World Health Organization. Concentrations of fine particulate matter (PM2.5); Available from: http://apps.who.int/gho/data/node.sdg.11-6-viz?lang=en
  1. Lodgejr J. Air quality guidelines. Global update 2005. Particulate matter, ozone, nitrogen dioxide and sulfur dioxide. Environ Sci Pollut Res. 1996; Available from: http://apps.who.int/iris/bitstream/handle/10665/69477/WHO_SDE_PHE_OEH_06.02_eng.pdf?sequence=1
  1. Portuguese Environment Agency. Station statistics; Available from: https://qualar.apambiente.pt/qualar/index.php?page=4&subpage=4).
  1. Dias D, Tchepel O, Carvalho A, Miranda AI, Borrego C. Particulate matter and health risk under a changing climate: Assessment for Portugal. Sci World J. 2012; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361258/)


Mariana Perez Duque
Public Health Resident
Public Health Unit ACeS Porto Ocidental, ARS Norte, Portugal

What can we do to reduce vaccine hesitancy?

The SAGE Working Group on Vaccine Hesitancy defined vaccine hesitancy as ‘the delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence’ (1).  Indeed, it is complex and the reasons cited in the literature are varied, from fears about vaccine safety, worries about ‘overloading’ the child’s immune system, distrust of the pharmaceutical industry and collective amnesia regarding the dangers of vaccine preventable diseases (2). Many parents, unfamiliar with diseases like tetanus and meningitis, make incorrect conclusions when it comes to calculating the risk-benefit of vaccinating their children.

The current measles outbreak in Europe is the direct result of vaccine hesitancy. 13,234 cases have been reported across Europe since July 2017 (3). Sadly, there were also 18 deaths due to measles in this period (3). In Ireland, we have had 76 cases of measles in 2018 so far, with an ongoing outbreak in Dublin as I write this. What can we do to end this outbreak and prevent the resurgence of other vaccine preventable diseases?

Reviewing the current evidence on what can be done to address vaccine hesitancy is not particularly inspiring. Reminders, whether they are telephone, text or postal, and family incentive rewards have been proven to increase vaccine uptake, but there is limited evidence that they work for vaccine-hesitant individuals (4). A trusted health care professional can also have an impact on changing parental attitudes, but the evidence for the various communication tools that have been designed as aids for these professionals to use is mixed (4). More research and better measurement of outcomes is needed in this area (4). It is not enough just to measure change in attitude to vaccines, we must see if this change in attitude actually leads to increased vaccine uptake.

Example of the spread of an outbreak in the game Vax!

There are advocates for more innovative approaches. Some argue that social marketing frameworks could provide solutions (5). Others propose that children should be taught positive messages about vaccinations in school, as part of their health education, science or even citizenship classes, in order to ‘inoculate’ them against vaccine hesitancy in the future (6). A friend of mine, who teaches teenagers, created a lesson to teach her students critical analysis skills, using information on the benefit and safety of HPV vaccination. These kind of skills are vital for navigating the ‘fake news’ widespread on social media. For younger children, there are online games demonstrating how vaccines work (7). One review found 16 different games in 2016 (7). I lost 20 minutes trying to stop an outbreak with rapid vaccination at this particular link: https://vax.herokuapp.com/game  

It’s a little bit addictive! Could positive attitudes to vaccines be engrained at a young age using these methods?

A mixture of targeted interventions to deal with parents in the midst of today’s crisis, as well as methods targeting future generations, will be necessary to tackle this complex issue. It is time to try new approaches. Please contact me at laura.heavey@hse.ie, if you know of any innovative methods to improve vaccination rates that are ongoing in your country



  1. MacDonald NE, the SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015; 33:4161–4164
  2. Marti M, de Cola M, MacDonald NE, Dumolard L, Duclos P. Assessments of global drivers of vaccine hesitancy in 2014 Looking beyond safety concerns. PLoS ONE. 2017; 12(3):e0172310.
  3. European Centre for Disease Prevention and Control. Monthly measles and rubella monitoring report. Stockholm: ECDC; 2018
  4. Dube E, Gagnon D, MacDonald N. Strategies intended to address vaccine hesitancy: Review of published reviews. Vaccine. 2015; 33: 4191-4203.
  5. Nowaka GJ, Gellinb BG, MacDonald NE, Butler R, the SAGE Working Group on Vaccine Hesitancy. Addressing vaccine hesitancy: The potential value of commercial and social marketing principles and practices. Vaccine. 2015; 33:4204–4211
  6. Wilson K, Atkinson K, Crowcroft N. Teaching children about immunization in a digital age. Human Vaccines & Immunotherapeutics. 2017; 13 (5):1155–1157.
  7. Ohannessian R, Yaghobian S, Verger P, Vanhems P. A systematic review of serious video games used for vaccination. Vaccine. 34 2016; 34: 4478–4483.


Laura Heavey
Specialist Registrar in Public Health Medicine
Department of Public Health, HSE, Sligo, Ireland

A crossroads for Public Health in Ireland: Slaintecare and proportionate universalism

This July the UK celebrated 70 years of the National Health Service which famously entitled healthcare to all “from cradle to grave”. Unfortunately progress on universal healthcare in the post-colonial Irish state has been much slower. In May 2017, a cross-party parliamentary committee produced a 10-year plan for the future of healthcare. Their report was called the “Sláintecare Report” (Sláinte translated from Irish means health) (1). It was ambitious with many recommendations including:

  1. The phasing out of private care in public hospitals
  2. Eliminate charges for access to public hospital care
  3. Reduce drug prescription charges
  4. Universal access to GP care without charge
  5. Expand public hospital capacity
  6. Reduce waiting lists for first outpatient department appointments and hospital treatment

However, progress on implementation has been slow and the signs are that the required funding will not be made available in the next budget. This is not the only barrier to implementation, doctors’ unions including the Irish Medical Organisation have come out against the plan to remove private medical practice from public hospitals (2).

This points to an important aspect within an Irish healthcare system which is the role of private healthcare. Figure 1 shows that amongst Euronet countries for which data is available from the OECD, Ireland has the highest per capita spend on healthcare and the highest spend on voluntary private health care and out of pocket payments (3).

Figure 1. OECD data on per capita spending on health (all functions) of Euronet countries in 2016, based on current prices and current purchasing power parity in US dollars

The Whitehall Studies, led by Sir Michael Marmot, was a prospective cohort study of civil servants in the UK between 1967 and 1988 which examined the relationship between mortality and employment status. They demonstrated that even when controlled for lifestyle factors such as, smoking status, blood pressure, obesity and cholesterol, mortality rates followed a gradient from those of lowest status to those of highest status. For instance, those men in the lowest grade had a mortality rate three times that of the highest grade (4).

This result showing a social gradient in health outcomes has been replicated many times and the idea of “Proportionate Universalism” was coined by Sir Michael Marmot and proposed as a means of addressing this gradient of health inequalities in the “Marmot Review” (5). It describes public health interventions which are aimed at the entire population, universal, but which are proportionally weighted in favour of those in most need.

Proportionate Universalism has shown success in reducing health inequalities in the UK by addressing inequalities in healthcare provision and in the social determinants of health (6). However, it is not clear this means of addressing health inequalities would be sufficient to make a meaningful difference in an Irish context.

The continuum of health need in Ireland is not linear, with a major influence on this based on the marketization of healthcare within the system. Those who can afford Private Health Insurance have better access to hospital consultants and diagnostics, even within the public system (7). On top of this there are further financial barriers in out-of-pocket payments for primary care and prescriptions. Like Julian Tudor Hart described in his paper on the “Inverse Care Law”, those with most need have the least access to services (8).

The two tiered nature of the Irish healthcare system was encapsulated in the name of a book written 10 years ago on the subject called “Irish Apartheid”. If a Proportionate Universalism public health strategy is to be effective in Ireland we must follow the example of our European neighbours and move towards universal healthcare, oppose doctors who wish to protect their private practice and give our support to the spirit of Sláintecare.



  1. Shorthall R. Houses of the Oireachtas Committee on the Future of Healthcare Slaintecare Report. Houses of the Oireachtas: Oireachtas; 2017.
  2. Irish Medical Organisation. Irish Medical Organisation Submission to the Independent Review Group on Private Practice in Public Hospitals. Dublin: Irish Medical Organisation; 2018.
  3. Health expenditure and financing: Health expenditure indicators [Internet]. OECD Health Statistics  (database). 2018 [cited 29 July 2018]. Available from: https://www.oecd-ilibrary.org/content/data/data-00349-en.
  4. Marmot MG, Stansfeld S, Patel C, North F, Head J, White I, et al. Health inequalities among British civil servants: the Whitehall II study. The Lancet. 1991;337(8754):1387-93.
  5. Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M. Fair society, healthy lives. The Marmot Review. 2010;14.
  6. Egan M, Kearns A, Katikireddi SV, Curl A, Lawson K, Tannahill C. Proportionate universalism in practice? A quasi-experimental study (GoWell) of a UK neighbourhood renewal programme’s impact on health inequalities. Social Science & Medicine. 2016;152:41-9.
  7. Burke SA, Normand C, Barry S, Thomas S. From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health policy. 2016;120(3):235-40.
  8. Hart JT. The inverse care law. The Lancet. 1971;297(7696):405-12.


Christopher Carroll
Specialist Registrar in Public Health Medicine, Ireland

Service sanitaire: a first step towards the decompartmentalisation of the French health system?

In September 2018, more than 45 thousand French health students will be involved in the “sanitary service” (service sanitaire). This program has been launched by the French government in January 2018 and it concerns medical, dental, nursing, physiotherapy, and midwifery students; all other health students will be involved from 2019 on. The objective is to train them in prevention and health education, competencies that are now missing from most health training curricula, through the elaboration an implementation of a practical project to the benefit of the population.

The sanitary service responds to the first axe of the national health strategy 2018-2022, which is to develop a prevention and health promotion policy. Throughout three weeks, the students will be trained in public health, project management, prevention, health promotion and they will then have three weeks of hands-on experience in a interdisciplinary team. They will be supported by a pedagogic referent (référent pédagogique) from their university and a proximity referent (référent de proximité) from the structure where they will intervene. The places of intervention will mostly be middle and high schools, but also retirement houses and structures managed by social services.

The biggest challenge for universities, at one month from the beginning of the program, is to provide a quality training and support to the students, in order to respond to the expectations and needs of the structures where they will intervene, the population and the students themselves.

Sources (in French) :


Maria Francesca Manca
Public Health Resident, France

EuroNet MRPH Working Group on e-cigarettes and tobacco harm reduction: A research to assess competencies amongst Residents in Public Health

The fight against smoking is an international problem and, in many cases, it is far from being adequately implemented. An essential starting point to perform a comprehensive and accurate medical program for smoking cessation is the healthcare professionals’ awareness about smoking products and smokers’ habits. In fact, in the last years, customers have changed their behaviours and tastes, switching from consumption of normal cigarettes to electronic cigarettes (e-cigarettes) or other nicotine and tobacco products.1

Available literature shows that the actual healthcare professionals’ level of knowledge on this issue is sub-optimal, with likely negative implications on chances to help users to undertake cessation or harm-reduction pathways.2

Public Health workforce – current and future – has a major role to play here, as on the identification of better prevention policies and strategies. Hence, the idea underpinning this Working Group with EuroNet MRPH. This research comes from a proposal joint with Prof. Josep Maria Ramon Torrell of the University of Barcelona, Spain (Hospital Universitari de Bellvitge): with him, we designed the study protocol, with the aims to evaluate, through a European cross-sectional survey, the current level of knowledge about e-cigarettes and tobacco harm reduction strategy, and to highlight possible weaknesses in public health residency curricula in order to enhance Public Health Residents’ competences on these topics.



  1. Farsalinos KE, Romagna G, Tsiapras D, et al. Characteristics, Perceived Side Effects and Benefits of Electronic Cigarette Use: A Worldwide Survey of More than 19,000 Consumers. Int. J. Environ. Res. Public Health 2014;11:4356-4373. doi:10.3390/ijerph110404356
  2. Moysidou A, Farsalinos KE, Voudris V, et al. Knowledge and Perceptions about Nicotine, Nicotine Replacement Therapies and Electronic Cigarettes among Healthcare Professionals in Greece. Int J Environ Res Public Health. 2016;13:514. doi:10.3390/ijerph13050514


Pietro Ferrara
Department of Experimental Medicine University of Campania “Luigi Vanvitelli”, Naples, Italy

Multinational survey assessing learning climate and satisfaction during Public Health residency: an update from the Working Group

Learning climate has an important impact on knowledge and skills we acquire during residency. It encompasses many important aspects, such as the quality of supervision, professional relations between colleagues, quality of formal education and others. Numerous studies in the literature have sought to assess quality of training in different areas of medicine. However, in the area of public health training, there are no published studies on learning climate assessment or residents’ satisfaction during the residency.

The lack of literature in the area of assessing Public Health training inspired us to start a working group, which will perform a multinational study assessing learning climate and satisfaction during Public Health residency. The purpose of the study is to prepare the basis for evidence-based improvement of public health training in Europe.

Literature review was performed to identify tools currently used to evaluate learning climate during medical residency. Of all the questionnaires available, the working group chose D-RECT as the most applicable for our study. With author’s permission, we modified the questionnaire to suit Public Health residency. The new adapted questionnaire consists of 50 questions divided into 12 subscales. We proposed a new name for the modified questionnaire: European Residency Educational Climate Test (E-RECT).

The study will start after receiving the Ethics Committee approval. At this stage of the study, the questionnaire is being translated via a back-and-forth process into the language of each country. The piloting and validation process will follow, before we distribute the questionnaire  to all public health residents in each country.

The data obtained in the study will provide the opportunity to compare results between different countries and see what are the differences, the good practices and the opportunities to improve national residency programs. We encourage residents to respond to the invitation, when they receive it – fill in the online questionnaire to ensure that your voice is heard.


Špela Vidovič
National Institute for Public Health, Slovenia