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Public health research literature on infectious diseases: Coverage and gaps in

Europe

Article  in  The European Journal of Public Health · February 2007

DOI: 10.1093/eurpub/ckm066 · Source: PubMed

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 European Journal of Public Health, Vol. 17, Supplement 1, 2007
ß The Author 2007. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckm066
................................................................................................
Public health research literature on infectious
diseases: coverage and gaps in Europe
P. Durando1, Laura Sticchi2, Loredana Sasso1, R. Gasparini2

Background: In this study, bibliometric methods were used to investigate prevention and control
of infectious diseases (IDs). The aim was to gain an overall view of published research on IDs in
Europe as part of the collaborative study SPHERE (Strengthening Public Health Research in Europe).
Methods: A framework for research on IDs and public health was developed with definitions,
keywords, inclusion and exclusion criteria. A detailed web search strategy based on the framework was
designed, piloted and refined. The PubMed electronic database was searched for ‘infectious diseases’ as
a whole, and for several subtopic areas, across July 1995 and June 2005. Numbers of publications
by year, country, population and Gross Domestic Product were calculated. Results: Nearly 21 000
publications on the main topic and sub-topics were found, with a progressive increase particularly since

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2000. There was a marked heterogeneity between countries. France, Italy, The Netherlands, Spain,
Germany, Switzerland, Sweden, UK and Belgium were the most prolific, and Eastern European countries
less so. ‘Vaccine-preventable diseases’, ‘Sexually transmitted diseases’, ‘Drug-resistant infections’,
‘Insect–arthropod-related diseases’ and ‘Childhood diseases’ were the main fields of scientific
production. Research on ‘Epidemiology and Surveillance’ appeared, in general, to be better
represented than research on ‘Prevention and Control’. Discussion: This is the first time such a broad
approach has been used to describe public health research on IDs across Europe. A priority should be
cooperation between European states where there is little or no, scientific production. Bibliometrics has
limitations, but is of value to indicate a general pattern.

Keywords: Europe, infectious diseases, public health, scientific research

................................................................................................

ome of the best results in medicine, during the last few
S decades, concern prevention and control of infectious
diseases (IDs), to which both vaccines and antibiotics have
contributed.1,2 Globally, some important IDs, have been
eradicated, e.g. smallpox, and for others, e.g. polio, diphtheria,
measles and tetanus,3–5 there is a clear possibility of eradication
or optimal control. Children’s health has improved, mainly
due to well-planned vaccination strategies, and targeted
national immunization schedules.6
However, many problems remain. HIV infection, micro-
organism multi-resistance to antibiotics and anti-virals and
the possibility of the next pandemic of influenza currently
face public health policy makers.7–9 Dramatic changes in the
demographic composition of populations, due to mass
migration, changing work relationships, tourism and ‘global-
ization’, have impacted on social and cultural values and also
ID epidemiology.10 Inequalities within and between countries
have been growing, as also have the use and cost of health
care.11,12 Significant economic benefits can be achieved by
improving population health,13 and a more dynamic approach
to the prevention and control of IDs will contribute to
improving general health status.
Recent developments have resulted in effective new instru-
ments for prevention, e.g. new vaccines against meningitis,
chicken pox, HPV and rotavirus infections, and diagnosis and
treatment, e.g. new drugs such as HAART for HIV infection,
antibiotics for non-susceptible strains.14–16 This study was
undertaken to gain an overview of research on ID control and
prevention as part of the collaborative study SPHERE
1 Department of Health Sciences, Section of Hygiene and Preventive
Medicine, ‘San Martino’ Hospital, University of Genoa, Genoa, Italy
2 Department of Health Sciences, Section of Hygiene and Preventive
Medicine, University of Genoa, Genoa, Italy
Correspondence: Paolo Durando, MD, Department of Health
Sciences, Section of Hygiene and Preventive Medicine, University of
Genoa, Via A. Pastore, 1, 16132, Genoa, Italy, tel: þ39 010 353 8133;
fax: þ39 010 505618; e-mail: durando@unige.it
(Strengthening Public Health Research in Europe). We
reviewed published public health research literature
covering the European Economic Area (EEA). Our objectives
were to describe production of scientific articles, and the
temporal trend over the past 10 years; define the main
research areas; compare scientific production between
European countries.
Methods
We searched PubMed from 1 July 1995 to 6 March 200517 for
papers by authors in the EEA, considered both together and
by each single country. Author’s address or affiliation was
used as a proxy for country of production. We identified
search term ‘infectious diseases’ as our general topic, and also
selected subtopics and two main research areas (see diagram,
Appendix 1).
The general topic keyword was ‘Infectious diseases’.
Subtopics were chosen from the Centres for Diseases Control
and Prevention classification18 and listed in nine groups:
‘Sexually transmitted diseases’, ‘Animal-related diseases’,
‘Bioterrorism agents and Diseases’, ‘Childhood diseases’,
‘Drug-resistant infections’, ‘Emerging infectious
diseases’, ‘Food-related diseases’, ‘Occupational risk in
healthcare’ and ‘Insects or arthropod-related diseases’.
A further subtopic was also included ‘Vaccine-preventable
diseases’ (with ‘Vaccine’ used as keyword). In addition, a
PubMed search was undertaken for one ‘specific disease’
within a main subtopic (i.e. HIV for the subtopic STDs).
All results for topics and sub topics were allocated to
research area ‘Epidemiology and Surveillance’ or ‘Prevention
and Control’, and were described for the sexually transmitted
diseases subtopic as number of published articles both for
Europe as a whole and by single state. Crude rates were also
calculated in relation to the size of the population of each
Member State and GDP.
20 European Journal of Public Health

Results Norway, Finland, Belgium, France and Ireland showed the

Approximately 21 000 published articles were found in our
study. Figure 1 shows their distribution by country: France,
Italy, The Netherlands, Spain, Germany, Switzerland, Sweden,
UK and Belgium were the most prolific, with an overall
production ranging from 3898 to 899 articles.
Our general keyword ‘Infectious diseases’ identified
relatively few articles. In 1995, 64 articles were identified
rising to 228 in 2005. The yearly production of these
‘Infectious diseases’ articles was always more for
‘Epidemiology and Surveillance’ than ‘Prevention and
Control’ over the entire period monitored: 46 vs 18, 72 vs
32 and 161 vs 67 published articles per year in 1995, 2000
and 2005, respectively.
Total number of articles for all subtopics are shown in
table 1. ‘Vaccine-preventable diseases’ showed the largest
number, followed by ‘Sexually transmitted diseases’. For all
largest research production when considered by population,
with a production of 50 or more articles per million inhabitants.
Also, the general category of ‘Infectious Diseases’, showed a
similar country distribution (data not shown).
For the variable GDP, Estonia, Switzerland, The
Netherlands, Iceland, Sweden, Finland and Denmark had the
highest production, publishing 4000 or more articles per
trillion US dollars of GDP.
Our specific disease-based search on HIV yielded 4881
articles, with those related to ‘Epidemiology and Surveillance’
and ‘Prevention and Control’ totalling 3327 and 1554,
respectively. Switzerland, Luxemburg, Denmark, The
Netherlands, Norway, Spain, France, Sweden, Italy and
Belgium produced 10 or more articles per million
inhabitants on ‘Epidemiology and Surveillance’ and ‘HIV’,
and Estonia, Switzerland, Spain, The Netherlands, Denmark,
Lithuania, Italy, France and Luxemburg produced more than

subtopics, with the exception of ‘Vaccine-preventable diseases’,
the crude number of articles on ‘Epidemiology and
Surveillance’ area was higher than that on ‘Prevention and
Control’.
Among the subtopics, ‘Sexually transmitted diseases’,
‘Drug-resistant infections’, ‘Insects or arthropod-related dis-
eases’ and ‘Childhood diseases’ emerged as the main fields of
scientific production over the 10-year period.
We assessed the results as totals for each country, and by
population and GDP. Data related to the search ‘Epidemiology
and Surveillance’ are reported in figures 2 and 3. Switzerland,
Iceland, Luxemburg, Denmark, The Netherlands, Sweden,
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500 articles per trillion US dollars of GDP as for ‘STDs’.
Discussion
Before analysing our data, it is worthwhile underlining some
limits of our methodological approach to the present research:
the use of a single means of web search (PubMed), the
difference in sensitivity of the selected keywords used, together
with the fact that selection of articles was made only for
‘all type’ publications, without stratifying results according to
impact factor. Despite these shortcomings, some results of our
study appear to be of interest and worthy of further discussion.

Figure 1 Overall scientific production (crude number of published papers) on selected topic and subtopics, by EU Countries,
during the study period

Table 1 Published papers on ‘‘Epidemiology and Surveillance’’ and ‘‘Prevention and Control’’ AND subtopics investigated, during
the study period, in ‘overall Europe’

Subtopics

Sexually Drug- Bioterrorism Occupational Animal Food- Childhood Emerging Insects– Vaccine-
transmitted resistant risk in borne- related diseases Infectious arthropods - preventable
diseases infections healthcare diseases diseases diseases related diseases
diseases

Epidemiology and 3114 1184 36 102 181 222 555 113 561 1810
Surveillance
Prevention and 1499 349 61 77 55 135 139 47 383 4433
Control
Total published 4613 1533 97 179 236 357 694 160 944 6243
papers

Figure 2 Overall scientific production, by EU Countries, on the basis of size population (number of published papers/1,000,000
inhabitants)
Figure 3 Overall scientific production, by EU Countries, on the basis of the Gross Domestic Product (GDP) (number of published
papers/trillion US dollars of GDP)
The EEA has been demonstrated to be an important
producer of public health research on IDs. Starting from
1995, production of literature has shown a progressive
increase, particularly since 2000, reaching a peak in the last
year of the study period. This trend can be considered real, in
our opinion: since the aforementioned methodological limits
were present throughout the study period. Developments in
basic and applied research, particularly in biotechnology,
molecular epidemiology and genetics, may explain this trend.
We are aware that numerous new vaccines and pharmacolo-
gical molecules and diagnostic tests applied to IDs have been
studied in the recent past: their availability and routine use in
health-care practices have significantly changed the natural
history and general epidemiology of several diseases. Conjugate
pneumococcal and meningococcal vaccines and those against
chicken pox, in the field of prevention, anti-virals and
antibiotics for multi-resistant micro-organisms, new molecular
techniques, such as polymerase chain reaction and genetic
sequencing are important examples of improvements in this
research field.16,19–22
We observed a wide heterogeneity in scientific production
on IDs in Europe. This became immediately apparent from
our first web searches: both analysing data generally and by
specific subtopic, large differences between country article
production emerged. This is consistent with results from other
SPHERE research groups: public health research is propor-
tionate to health needs at a geographic level.
Bibliometrics on infectious diseases in EU 21
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However, the situation is more complex than appears from
analysing only crude numbers of published articles. Analysing
our results on the basis of both State population and GDP, a
different scenario seems to emerge, particularly for the variable
GDP: Eastern European countries seem to acquire more
importance.
With regard to our subtopics, we found 4613 published
articles for ‘Sexually transmitted diseases’, 4881 for ‘HIV’ and
6243 for ‘Vaccine’ subtopics, respectively: far more than that
obtained through the first web search using ‘Infectious
diseases’ when 1201 articles were collected. As previously
stressed, this confirms methodological limits in our research,
depending upon the sensitivity of each keyword used. Yet, the
balance of scientific production by country, for this subtopic,
these are similar to those found for ‘Infectious diseases’:
France, Italy, Spain, The Netherlands, Switzerland, Germany,
Sweden, Belgium and UK are still the largest European
producers. Comments on data from the country population
size and GDP analysis do not differ from those previously
outlined.
With regard to heterogeneity of production observed across
Europe, with different results emerging from the analysis
for each specific item, no definite conclusions can be drawn.
A first priority should be cooperation to help those Member
States with no scientific production as well as a need to
harmonize research in Europe.
Another general trend emerges: the research area
‘Epidemiology and Surveillance’ seems to be more frequent
22 European Journal of Public Health
than that ‘Prevention and Control’. This could reflect a need,
during the last few years, of Governments of developed
countries to establish the frequency of the main important
IDs, in order to better plan and organize health care policies.
The lack, both of a deeper analysis on the contents of our
articles and, especially, of the separation of observational from
experimental studies in our search do not permit to draw
definitive conclusions on this item yet.
On the other hand, it may be that public health research
focuses too much attention on descriptive research and
not enough on the active-interventional approach. In this
respect, it seems that European public health policy makers
need to focus attention and efforts in the future on
optimization of research production in the ‘Prevention and
Control’ setting. The only exception was the subtopic
‘Vaccine-preventable diseases’, where ‘Prevention and
Control’ was more frequent than ‘Epidemiology and
Surveillance’. This is not unexpected: vaccines are primary
instruments in the prevention of many infectious diseases.
Finally, some comments on results regarding the subtopics
investigated.
‘Vaccine-preventable diseases’, ‘Sexually transmitted dis-
eases’, ‘Drug-resistant infections’, ‘Insects or arthropod-related
diseases’ and ‘Childhood diseases’ emerged as the main fields
of scientific production. These groups of diseases focus on the
main public health problems in EU Countries, with good
results being demonstrated, in recent years, in terms of
prevention, diagnosis and treatment.
Some subtopics, such as ‘Bioterrorism’, ‘Emerging infectious
diseases’ and ‘Occupational risk in healthcare’ appeared from
our search to be areas in which public health research output
should be significantly increased. We need to respond to the
impacts of globalization, and the changing world political
scenario and also to offer greater safety from infections to
healthcare workers. The experience of SARS, the potential next
influenza pandemic, and old diseases that are re-emerging
(e.g. tuberculosis), justify more attention focused on the
subtopic ‘Emerging infectious diseases’. ‘Animal-borne infec-
tions’ was not a very sensitive keyword for our purpose, but as
this is an area of scientific concern, further investigations
should be made.
In balancing these demands, it is also important for public
health research to ensure that existing problems are tackled
without being ‘distracted’ by potential threats.
Conclusions
Today, it is recognized that both evidence-based medicine and
prevention require a well-structured scientific approach to
design effective public health interventions.23 The present
study is the first, to our knowledge, to describe, with a broad
approach, the state of public health research on IDs in Europe.
Even if the bibliometric methodology used may present some
limitations and results could, in some way, be biased, we
believe that SPHERE represents a useful tool, both for scientists
and public health policy makers, to plan and organize research
on IDs, with clear implications for future EU (and other)
funded programmes in Europe.
Acknowledgements
SPHERE Project was funded by the European Commission
Sixth Framework Research programme, Co-ordinator
Professor Mark McCarthy, during the period 2005–07.
Data from the present research were presented, in part,
at the 14th European Conference on Public Health (EUPHA)
Montreux, Switzerland, 16–18 November 2006.
Special thanks to Federica Compagnino, MD and Silvia
Pernigotti, MD, Postgraduate students, who collaborated for
the analysis of the data.
Conflict of interest: None declared.
Key points

Starting from 1995, there has been a progressive
increase in the production of literature, particularly
starting from 2000, to reach a peak in the last year of
the study period.

A marked heterogeneity exists in Europe concerning
scientific production on IDs: this phenomenon
concerns both the number of papers published by
each Country and the specific fields of the research.
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‘‘Vaccine-preventable diseases’’, ‘‘Sexually-transmitted
diseases’’, ‘‘Drug-resistant infections’’, ‘‘Insect-arthropod-
related diseases’’ and ‘‘Childhood diseases’’were the
main fields of scientific production.

Is clearly evident that a first priority is to cooperate to
help States with no, or a very low, scientific
production and that there is a real need to harmonize
research throughout Europe.

It is essential for further studies to better focus on the
real state of the art of research on IDs in the EU,
possibly with a more analytic approach than
biobliometrics.
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