Marc Struelens completed his medical degree from the Université Libre de Bruxelles (ULB) in 1980. After obtaining a Diploma of Tropical Medicine at the Prince Léopold Institute of Tropical Medicine in Antwerp, he worked for 3 years as a research associate doing clinical and laboratory research at the International Centre for Diarrhoeal Diseases Research in Bangladesh. He then returned to Brussels where he specialised at ULB Erasme Hospital and was later appointed assistant then associate professor in clinical pathology. He also obtained a masters in hospital infection control at the ULB, and was appointed in 1990 as hospital infection control physician at Erasme hospital.
He obtained a PhD in microbiology in 1993 at the same university with a thesis on the molecular epidemiology of nosocomial infections. He is currently professor of medical microbiology at the Faculty of Medicine of the ULB, director of the Department of Microbiology, Erasme Hospital, and head of the Infectious Diseases Epidemiology Unit, School of Public Health at the ULB.
He has published over 140 peer-reviewed articles and 15 book chapters and served as editor for international journals including Microbial Drug Resistance, Clinical Microbiology and Infection, Journal of Medical Microbiology, Reviews in Medical Microbiology, Infection, Genetics and Evolutiona, and Journal of Microbiological Methods. He is a member of several national and international advisory boards and European Union (EU) supported research networks in the fields of microbiology, hospital infection, and antimicrobial resistance. He has chaired the European Study Group on Epidemiological Markers, the Belgian Study Group on Study and Prevention of Hospital Infection, and the Belgian Infectious Disease Advisory Board. He is currently President of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID), for which he has served as scientific officer since 1997.
TLID: What drew you into infectious diseases?
MS: My interest in biology began when I was a kid. I had a microscope and was fascinated with the wonderful diversity of life forms in environmental samples I used to visualise. I then read a book called the War on Microbes, which described the medical victories of pioneering microbiologists, and this really filled me with enthusiasm. When I went to work as a fresh medical graduate in Bangladesh I realised the huge challenge that infection represented, especially in these poverty-stricken populations, as well as the potential of research to advance prevention. In the past 20 years from when I had my first-hand encounter with infectious and tropical diseases, I believe that the numbers of emerging infections and antimicrobial resistance has proved a point that these challenges are greater than ever in all parts of the world.
TLID: You became the new President of ESCMID in 2003. What does your role involve, and are there any new initiatives you have planned for the society during your term as President?
MS: The mission of the society is to promote excellence in the scientific study and diagnosis, treatment, and prevention of infectious disease. The role of its President is to provide vision and leadership of a team of dedicated colleagues who are responsible for fulfilling this mission as elected members of the executive committee. Among the new initiatives that I am keen to progress during my term of presidency are several issues. They include: the efforts to increase cohesion across countries and disciplines, to expand the society membership base, and support the participation of colleagues in eastern and central Europe especially. We also wish to further develop partnerships with organisations in the field of infection, microbiology, and public health such as the WHO, the European Commission, national specialist societies, and continental societies such as the Federation of European Microbiological Societies for example. Also in that same area of unifying a fragmented field, are efforts to organise a single annual congress within ESCMID to cover infection, microbiology, and anti-infective therapy in Europe. Finally one of the major initiatives that we are strengthening is professional guidance and development of best practise models in the infectious disease and microbiological service line. This of course is at the core of our activities such as post-graduate training programmes, and continuing medical education in which we already provide training to approximately 300 health professionals a year. We would like to expand that again by fostering partnerships with other organisations. Harmonisation of microbiological standards is essential for exchanging information between laboratories, and conducting international infectious disease and antimicrobial resistance surveillance programmes. ESCMID is actively contributing to this goal through its EU-supported European Committee on Antimicrobial Susceptibility Testing.
TLID: There has been a lot of concern about the pharmaceutical industry scaling down the development of new anti-infectives. How are ESCMID involved in fostering new partnerships with industry to encourage research and development?
MS: ESCMID definitely shares this concern, and we are actively seeking solutions to what we consider as a serious impending shortage crisis of effective drugs that may unfold in 10 years from now. We recently reviewed the issue during a European conference titled The role of research in combating antimicrobial resistance, which was organised jointly with the European Commission in Rome, and we are organising another focused international symposium called Antimicrobial therapy in the 21st century, in Stockholm in June. The objectives of that symposium are to bring together all stakeholders and review the need for new antimicrobial agents the regulatory situation, and how industry and academia can develop a more productive research partnership. This entails exploring ways to combine private and public funding for drug discovery and development. We need to also look at the role of regulatory bodies like the European Agency for Evaluation of Medicinal Products as research facilitators, and improve the design and efficiency of clinical trials in this field. Finally we need to look to the future with regards to new molecular approaches to drug and target discovery.
As for drug regulation, there are certainly options to review the current regulatory hurdles, and perhaps be creative towards replacing some of the requirements by a more up-to-date legislation. On the other hand there is also an increasing concern about safety as well as the ecological impact of anti-infectives, which unfortunately translates into more complex and larger size drug trials in this area. So, I don't think that we can simplify a lot of these regulatory requirements, but perhaps some of the traditional rules need to be critically examined in a constructive manner to see whether the maximum added value demonstrating efficacy and safety in the broader sense can be guaranteed. Finally, the possibility of pursuing the orphan drug option should be carefully considered as one way to provide incentives to develop anti-infectives for narrow indications.
TLID: The European Centre for Disease Prevention and Control (ECDC) is now becoming a reality. But there has been much debate over the years on what kind of role the centre will have. Can you comment on this, and whether the present plans for the new organisation will fulfil its goal? How do you envisage ESCMID will work with the new organisation?
MS: The present plans are a timely step in the right direction. We all know that the orchestra of EU communicable disease surveillance networks has been in great need of a conductor for many years. The centre will have a major coordinating role, not only in disease surveillance, but also in providing scientific advice to national and EU policy, as well as technical assistance to control international epidemics. But we believe the level of funding and the scope of expertise that will be brought aboard in the beginning at least, will not provide very credible means of fulfilling its mission. So it may start a somewhat underfunded and understaffed agency unfortunately. In general terms, now speaking as a citizen rather than a microbiologist, I think that it comes down to, do we really care and want to build health security for European people? If you look at the stark contrast in the level of funding of EU health programmes of €0·40 per caput compared with an agricultural subsidy of €25 per head of cattle, it is quite a telling comparison.
Technically, ESCMID has provided not only support to the proposal to establish the centre, but has also contributed a position paper that has informed legislative discussions in the European Parliament on this proposal. We have emphasised two areas that we felt could be considered for further investment in the future. The first one would be to consider expanding the centre's activities in the field of research and reference laboratory services. This could fill some gaps that are presently encountered in the national infectious disease research and public health capacity. The relation between microbial evolution including drug resistance and virulence, and rapid changes in the epidemiology of infections, as dramatically shown with viruses such as the severe acute respiratory syndrome coronavirus crossing the species barrier, should be better addressed by research funding agencies in Europe. This is one of the areas that we have emphasised as presenting an opportunity to integrate laboratory research with epidemiological monitoring, and is currently not covered in the centre design. The second one is the role of training an expanded workforce of field epidemiologists but also of “front-line” microbiologists and clinicians. All these practitioners are part of the emerging infection surveillance, alert, and health-care service line that needs to be implemented across Europe for the centre to be able to get the right information, and also coordinate appropriate response in case of a major epidemic. Learned societies like ESCMID should contribute to bridging this gap in public health training of infection specialists. In other words, we feel that there are other aspects than the pure coordination of surveillance and international response at the top level that need to be supported, in parallel with the launching and development of the ECDC's activities. ESCMID has offered to contribute its multidisciplinary membership's expertise to the advisory forum of the ECDC. The Commission has supported the value of such a future contribution.
ESCMID school in Utrecht, Netherlands
© 2004 ESCMID
TLID: You are involved in a diversity of research areas in the fields of microbiology, hospital infection, and antimicrobial resistance. What are the issues that you are most interested in, or concern you the most?
MS: In a way we are moving from the naive “war on microbe” paradigm to a post-modern ecological survival vision, where we should be more adaptive towards the irresistible evolution of microbial parasites. In this area my personal interest focuses on the molecular epidemiology of the emergence and dissemination of antibiotic-resistant bacteria. A fascinating model is Staphylococcus aureus, a well-known pathogen, but with tremendous genomic flexibility. Its adaptive capacity through the acquisition of foreign genetic material is really unfolding under our very eyes. One problem is the emergence of a new form of disease, and an increasing resistance to the whole armamentarium of drugs that we currently have against this pathogen. On a more technical side in our iniversity hospital, my laboratory is involved in developing molecular tools for rapid diagnosis and also epidemiological tracing of microbial pathogens in the nosocomial setting. And I believe that what has been lagging behind the technological advances are the clinical and economical evaluations, in terms of public health gains, of these technologies. There is a great need of well-controlled intervention studies to assess their impact on prevention of infection, control of antimicrobial resistance, and improved quality of care. I think that this is another challenging research field for the future.
TLID: The problem of meticillinresistant S aureus (MRSA) is growing worldwide. As well as MRSA in the hospital setting we are now seeing community-acquired infection on the increase. What do you see as the major hurdles in infection control we need to overcome if we are going to rid ourselves of MRSA?
MS: Unfortunately, I am not convinced that we are still at the stage when we can reasonably set an objective to get rid of MRSA at the hospital level, because it has reached an endemic situation in many parts of Europe and other parts of the world. It is true though that some northern European countries have been exceedingly successful at keeping it out of their hospitals through a very rigorous approach, both in terms of screening for patients carrying this organism, as well as implementing resource-intensive efforts at barrier precautions, patient isolation, and decolonisation of staff, or patients carrying the organisms. These principles have proved their worth, and they should be supported and deployed for the time being in the most cost-effective manner in other countries as well. We have tried to achieve such a national strategy in Belgium, for example, with variable success. We had a decrease for about 5 years in the overall incidence and prevalence of MRSA in Belgian hospitals, but this trend has now reversed. One of the underlying problems we understand is the build up of reservoirs of chronic carriers in the elderly patients. And this is of course much more difficult to control. So the majority of MRSA that we are seeing in hospitals now are being introduced by chronically ill patients carrying these nosocomial strains on admission. Thus the number of patients we have to isolate or to screen is increasing, and putting a lot of pressure on resources.
What has become clear is that the increasing prevalence of MRSA nosocomial infection is a reflection of the damage caused to our health-care system due to budgetary constraints and re-engineering of health-care services in many countries. In fact MRSA is a symptom of ill health of the health-care system in many places. So we also have to build investment to provide the skilled workforce required to afford hospital care in good conditions. These include allowing enough time for hand hygiene, for example, and allowing the possibility to put patients in single room isolation, or to close down certain wards when the situation is out of control. And this of course costs a lot, but I find it hopeful now that the public and the media are becoming much more aware of the consequences of getting infected with such “superbugs” while going to the hospital. The health-care system administrators and policy makers have to reconsider whether it would indeed be cost-effective to reinvest more resources at a staffing level, for microbiological support, and infectious-disease-control policies to at least contain the spread of this organism, which is causing so much damage, and reduce the incidence of nosocomial infection.
Community-acquired MRSA is perhaps even more worrisome, because there we have even less access to the epidemiological reservoir, and it looks like we are witnessing a multifocal and multiclonal emergence of new strains of S aureus, which appear to be more virulent and more elusive. We have to be very active in identifying new risk groups outside the health-care system, and try to develop containment strategies. It is early days and the future will tell whether we can succeed.
TLID: With the addition of new member countries to the EU in May, what kind of challenges and implications does that have for infectious diseases in Europe?
MS: The first point is that the challenge that has been spoken about with regards to EU enlargement has already been there for many years. The European Commission forecasts about 3 million immigrant workers from the ten new members into the EU who would be settling in the existing countries during the next 15 years. This compares with a similar number of people who have already moved in that direction during the 1990s. I think we have already faced quite a lot of movement within various parts of Europe including the eastern, western, and central parts. The health implicationsare clear. We only need to look at the news, for example, the recent detection of an outbreak of multidrug resistant tuberculosis in the Netherlands. So we are already dealing with situations that have arisen from the introduction of people carrying communicable disease from one part of the continent, where there is high prevalence, to other parts where it has been better controlled in the past decades.
The approach to that is having solidarity at several levels. At the first level, we need to avoid going into tight restriction rules on mobility of workers. These would only push immigrants underground, and therefore bar them access to the health-care system. I think that is the perfect recipe for outbreaks to occur in vulnerable sections of the population of the host country. And the second point is having international cooperation to promote the best practise as far as microbiology, diagnosis, patient care, and prevention programmes are concerned. This is true for tuberculosis, HIV infection, MRSA, and other resistant bacteria in the health-care setting.
I think there is tremendous potential for cooperation, and ESCMID has identified it as one of its priorities. The goal is to provide cross-country and multidisciplinary training in all professional disciplines in the infectious disease field to at least contribute to sharing expertise. This will require a lot more research into what the different models of practise are. ESCMID study groups have undertaken, for example, a multinational study in 37 countries called the Antimicrobial Resistance Prevention and Control (ARPAC) study, the results of which will be presented at the European Congress of Clinical Microbiology and Infectious Diseases in Prague, in May. We show that in a selection of voluntary hospitals in these countries, a programme of MRSA surveillance and control is routinely performed, but that many are faced with a number of problems in implementing best practise, such as hand hygiene with alcohol-based solutions or active screening, and isolation of carriers. Certainly, there is an opportunity here to benchmark our policies and practises, define a research agenda for testing interventions, and look for the most cost-effective strategies. This will be addressed later this year at a forthcoming international consensus conference on controlling antibiotic resistance in hospitals.