National Institute of Public Health and the Environment
Bilthoven, The Netherlands

Contact person

Mirna Robert - Du Ry van Beest Holle
RIVM, National Institute for Public Health and the Environment
Epidemiology & Surveillance
Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven
PO Box 1, 3720 BA Bilthoven
The Netherlands
Tel: +31 30 274 2905
Fax: +31 30 274 4409

Description of institute

National Institute of Public Health and the Environment (RIVM)
 The main role of the RIVM is to provide information for the policy making and control functions of the central government. This means that the institute's products (information, advice, data, reports, publications) provide support for the government's policy on public health and the environment

Epidemiology and Surveillance (EPI)
EPI is one of five units of the Centre of Infectious Disease Control at RIVM. The epidemiological research of the EPI has three main key areas. The first is the surveillance of infectious diseases, for early warning, to monitor trends in the occurrence of infectious diseases and to assess the public health impact of the diseases. Secondly, following signals from our own early warning system or on the request of the Inspectorate of Health and of the local Public Health Services we support local authorities in outbreak investigations. For example in 2003 we investigated the outbreak of avian influenza H7N7 among poultry and humans, and in 2006 a large cooling tower associated outbreak of Legionnaires disease. Thirdly, we conduct epidemiological research to investigate determinants of the spread of infectious disease among the human population and to evaluate interventions.

EPI is set up in several multidisciplinary projects. The EPI staff has professional expertise on epidemiology of infectious diseases, statistics and modeling as well as basic knowledge on immunology, microbiology and pathology of infectious diseases. In addition, information technology plays an important role within the department. There is close cooperation with microbiological laboratories, municipal health authorities and other stakeholder. Approximately 90 persons work at EPI, half of whom are permanent staff. EPI is well equipped with modern computer systems.

Training opportunities

During the two-year training, all EPIET training objectives can be met. The trainee can be amply involved in all major activities of the department and there are regular opportunities for international missions.

Training supervision

Dr. Mirna Robert – Du Ry van Beest Holle (EPIET cohort 8, ) is the supervisor of the fellows, who further will be supervised by other staff members / senior epidemiologists, depending on the involvement in specific projects.

Language requirements

Within the department communication in English is possible with all colleagues. However, in order to be actively involved in field investigations and to communicate with the public health services, it is highly recommended to learn to read and speak the Dutch language. Nearly all fellows manage to do so in a couple of months.

Training history

The previous EPIET fellows trained at RIVM and will be happy to answer your questions: Alumni at RIVM:
Number of EPIET fellows trained at institute: Ten (1996, 1997, 1998, 1999, 2000, 2003, 2004, 2005, 2006, 2007) Available as a training site for cohort 14: Yes

Other information

The RIVM is based in Bilthoven, which is located in the centre of The Netherlands. The institute is easy to reach by train, e.g. from Utrecht and Amsterdam (where several fellows live), and RIVM buses provide regular transportation from the station to the institute. Sports facilities include a fitness centre on the compound and runs are frequently organized in the nearby nature reserve.

Annex: description of research programme and outbreak control

National Immunisation Programme
Notwithstanding the successes of the National Immunisation Programme on the incidence of the target diseases, continuous surveillance using various methods is needed. This includes surveillance of disease, vaccination coverage, immune status, pathogen (antigenic variation) and adverse events. In addition we address the need and possibility for extension of the national immunisation programme with new target diseases, based on the current available knowledge with regard to vaccine, disease, pathogen and cost-effectiveness. Epidemiological studies currently carried out include: study on pertussis among unvaccinated infants to obtain insight into their sources of infection and thereby in the optimal vaccination strategy; study on the effect of Hepatitis B vaccination of children, born to carrier mothers, with different vaccination schemes; cost-effectiveness analyses of rotavirus and human papillomavirus vaccination. In the event of increased incidence investigations are carried out, such as follow-up of congenital rubella infected individuals who were affected during the rubella outbreak among orthodox reformed people refusing vaccination in 2005. Enhanced surveillance is set up: such as pneumococcal surveillance after introduction of pneumococcal vaccination with conjugate vaccine of children.

Epidemiology and surveillance of Sexually Transmitted Diseases (STD)
STDs, including HIV, are a major public health problem because of the persistent high incidence, in particular in specific risk groups, the lack of efficient therapy for many viral STD, the often asymptomatic initial course of some bacterial infections, the potentially severe sequelae due to untreated or asymptomatic infections, especially among women (like infertility and ectopic pregnancy) and the emergence of antibiotic resistant pathogens. Our project deals with the surveillance and analysis of STD in the Netherlands and the molecular epidemiology of hepatitis B virus infections. The surveillance of STD is facilitated by a web based reporting system. The epidemiology of hepatitis B is studied in connection to a modeling and cost-effectiveness study to advise the Ministry of Health on the efficacy of current vaccination strategies. Furthermore, in 2005 a project is started to implement the surveillance of resistance in gonococci, and we are preparing an evaluation plan for an upcoming community wide Chlamydia screening pilot study among adolescents and young adults

Epidemiology of gastroenteritis and (other) zoonotic diseases

 Gastroenteritis has a high incidence and has major socio-economic costs to society. Studies to determine the incidence, etiology and risk factors of gastroenteritis were carried out in general practices (1996-1999, weekly returns of consultations still ongoing) and in the community (1999). Currently, a study on hospitalizations for gastroenteritis is in preparation, to determine the incidence, etiology and clinical course of hospitalized patients. The project team also runs enhanced surveillance systems for STEC O157 and Listeria monocytogenes and is responsible for the routine surveillance of Salmonella, Campylobacter, and mandatory reporting of a.o. hepatitis A, Shigella and foodborne infections. Furthermore, in 2007 new diagnostic tools for detection of all STEC serogroups are evaluated, in close collaboration with eight public health laboratories. Also, studies on prevention of norovirus outbreaks in nursing homes are currently being executed. Within the project team increasingly other zoonotic diseases are studied (lyme disease, dengue, hepatitis E). We contribute to the EU zoonosis report and actively participate in the EU network of excellence MedVetNet, the Foodborne Viruses in Europe network and Enter-net. Finally, based on laboratory data, an outbreak warning application was developed and now in use, in which clearly elevated levels of a specific microorganism (or of specific serotypes or phagetypes for Salmonella) are recognized. Surveillance and investigation of outbreaks and, where appropriate, support of outbreak management is carried out in collaboration with Food Inspection Services and Municipal Health Services.

Epidemiology of respiratory infections

 The focus of the respiratory infections group currently lies on the surveillance and analysis of trends in influenza-like illness in the population linked to the virological determination of influenza strains in the population, and vaccination data. Such surveillance has existed for many years among General Practitioners, and we are now extending this to nursing home populations. Based on this, integrated surveillance during pandemic phases is being developed, building on experience gained during a 2003 outbreak of avian influenza in the Netherlands. To assess the impact of and risk factors for lower respiratory tract infections, epidemiological and microbiological surveillance and analysis of CAP is being developed, linked to the exploration of possibilities of syndromic surveillance of severe respiratory conditions. Surveillance and analysis of trends in the incidence of other respiratory infections also includes the study of Legionella, psittacosis and Q-fever infections. For Legionella, international collaboration exists to explore risk factors of travel-associated Legionellosis. The molecular epidemiology of TB, and the impact of current interventions, is being analyzed in collaboration with the National Reference Laboratory within the Centre for Infectious Disease Control, the National TB Control Organization KNCV, and the EPI mathematical modeling group.

Nosocomial) infections

Nosocomial or hospital infections develop unintentionally during hospital treatment. In the Netherlands, 5 to 10% of hospital patients contract a nosocomial infection. This causes extra suffering for the patient and brings additional costs to the health service. The important questions are thus: is the number of hospital infections increasing or diminishing? Can we prevent them? How can these infections best be counteracted? PREZIES, which stands for the Prevention of Hospital Infections through Surveillance, is a collaborative association of participating hospitals, the Quality Institute for Health Care (CBO) and the RIVM-EPI. Within this surveillance system, professionals in the hospital are responsible for tracing, registering and reporting data concerning hospital infections. The participating hospitals can compare their results with those from other hospitals.

Antibiotic Resistance Surveillance
The EPI department invests and participates in national and international surveillance systems on antimicrobial resistance. It took the lead in the establishment of an European Antimicrobial Resistance Surveillance System (EARSS).

EARSS, funded by the European Center for Disease Control, is an international network of national surveillance systems, collecting comparable and validated antimicrobial susceptibility data for public health action. EARSS performs on-going surveillance of susceptibility to invasive infections of Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, E. faecium, E. faecalis, Pseudomonas aeruginosa and Klebsiella pneumoniae and monitors variations in antimicrobial resistance over time and place. By January 2007, about 900 microbiological laboratories serving 1400 hospitals and over 100,000 million European citizens in 32 countries have provided susceptibility data on more than 200,000 invasive isolates. An interactive web-site is available (www.rivm.nl/earss), illustrating large differences in levels of resistance for important groups of antibiotics between countries. In 2005, EARSS also started with the collection of S. pneumoniae serotype data and in a satellite study in cooperation with the international SeqNet group, EARSS now collects spa-typing data of S. aureus strains from 28 national reference centers. The possibility of community acquired MRSA is investigated in a survey among livestock / pigs, and through sentinel surveillance of skin lesions and MRSA in the community.

At national level, the EPI department collects epidemiological background information of all MRSA strains send to the national reference center. In addition, the prevalence and potential risk factors for carriage of MRSA in animal husbandry, farmers and their families is currently under investigation. In two regions in the Netherlands (North and South), we study the prevalence of MRSA infected skin lesions among general practitioner’s patients.

In addition, EPI participates in national antibiotic resistance surveillance systems collecting routine data from medical microbiological laboratories, hospital infection control programs and from first line urinary tract infection projects.

Mathematical Modelling of Infectious Diseases Over the last decades, mathematical modelling has become an indispensable tool in planning for infectious disease control. The mathematical modelling project at EPI addresses public health questions such as:
  • What are the costs and benefits of various alternative hepatitis B vaccination programs?
  • What will be the effect of a new drug therapy on HIV prevalence among homosexuals in Amsterdam?
  • What is the impact of an influenza pandemic on health care demand?
Finding answers using classical epidemiological methods is hard, if not impossible. Mathematical modelling is a tool that can handle such questions. The mathematical modelling project at the EPI aims to develop dynamic mathematical models for various infectious diseases, and use these models for answering specific questions from the public health authorities. The work is often done in collaboration with other groups.

Outbreak investigations
The department regularly supports local health officials in the investigation and control of outbreaks. In national infectious diseases emergencies our department has often coordinated the investigation. We also increasingly collaborate with European / global counterparts in international outbreaks.		    
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