EFNS TASK FORCE

Teaching of neuroepidemiology in Europe: time for action

V. Feigina, M. Braininb, M. M. B. Bretelerc, C. Martynd, C. Wolfee, N. Bornsteinf, C. Fieschig,

P. Sevcikh, M. L. Limai, G. Boysenj, E. Beghik, C. Tzouriol, V. Demarinm, E. Gusevn,

S. Lopez-Pousao and L. ForsgrenpaClinical Trials Research Unit, School of Population Health, Faculty of Health and Medical Sciences, University of Auckland, Auckland, New

Zealand; bNeurologische Abteilung, Landesnervenklinik Gugging, Maria Gugging, Austria; cDepartment of Epidemiology and Biostatistics,

Erasmus University, Rotterdam, The Netherlands; dMRC Environmental Epidemiology Unit, Southampton General Hospital, Southampton,

UK; eGKT School of Medicine, King’s College, London, UK; fStroke Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel

Aviv, Israel; gDepartment of Neurological Sciences, University of Rome Medical School, Rome, Italy; hDepartment of Neurology, University

Hospital Pilsen, Czech Republic; iServicio de Neurologia, Hospital de Santo Antonio, Porto, Portugal; jDepartment of Neurology, Hvidovre

Hospital, Hvidovre, Denmark; kInstitute Richerche Farmacologiche, Milan, Italy; lHopital de la Salpetriere, Paris, France; mKlinika za

neurologiju, KB ‘‘Sestre Milosrdnice’’, Zagreb, Croatia; nDepartment of Neurology, Russian State Medical University, Moscow, Russia;oMemory and Dementia Unit, Hospital Santa Caterina, Girona, Spain; and pDepartment of Neurology, Umea University Hospital, Umea,

Sweden

Keywords:

EFNS Task Force,

Europe, neuroepidemiol-

ogy, research, teaching

Received 19 November 2003

Accepted 23 February 2004

Many epidemiological and clinical studies in Europe, especially in Eastern Europe and

countries in transition, are of poor methodological quality because of lack of back-

ground knowledge in clinical epidemiology methods and study designs. The only way

to improve the quality of epidemiological studies is to provide adequate under-

graduate and/or postgraduate education for the health professionals and allied health

professions. To facilitate this process, the European Federation of Neurological So-

cieties (EFNS) Task Force on teaching of clinical epidemiology in Europe was set up

in October 2000. Based on analyses of the current teaching and research activities in

neuroepidemiology in Europe, this paper describes the Task Force recommendations

aimed to improve these activities.

An evidence-based approach to the prevention and

management of neurological disorders is impossible

without robust knowledge on their risk factors, natural

history, frequency, outcomes and effective treatment

strategies. Many epidemiological and clinical studies in

Europe, especially in Eastern Europe and countries in

transition, are of poor methodological quality because

of the lack of background knowledge in clinical epi-

demiology methods and study designs. This implies that

considerable resources (both human and monetary) are

being employed inefficiently. In addition, there is a great

need for up-to-date knowledge of the epidemiology of

neurological disorders in Europe, including the methods

of assessment used in clinical epidemiology. The only

way to improve the quality of epidemiological studies is

to provide adequate undergraduate and/or postgradu-

ate education for the health professionals and allied

health professions. However, before any guidelines can

be proposed to improve the training in the neuro-

epidemiology throughout the Europe, background data

on current teaching activities in the field in Europe are

needed. To meet these objectives, the European Feder-

ation of Neurological Societies (EFNS) Task Force on

teaching of clinical epidemiology in Europe was set up in

October 2000. The ultimate goal of the Task Force was

to develop consensus recommendations aimed to im-

prove training in the field of clinical epidemiology in

Europe, with the emphasis on neuroepidemiology and

evidence-based practice in neurology. In the context of

this report, we consider clinical epidemiology as a part

of neuroepidemiology, when the specific neurological

disorder is the target.

Methods

A self-administered questionnaire was developed by the

members of the Task Force and sent with a cover letter

to all members of the Task Force and EFNS Scientist

Panel on Neuroepidemiology. The questionnaire inclu-

ded 16 questions addressing the following issues: avail-

ability and structure of educational programmes in

clinical epidemiology for undergraduate and post-

graduate students, major topics and structure of the

programmes, availability and the need for neurologists

with experience in epidemiology, availability and

the need for local teaching courses in various fields of

Correspondence: Prof. Valery Feigin, Clinical Trials Research Unit,

Faculty of Medical and Health Sciences, University of Auckland, 3

Ferncroft Street, Grafton, Auckland, New Zealand (tel: +649

3737599 ext. 84728; fax: +649 3731710; e-mail: v.feigin@ctru.

auckland.ac.nz).

� 2004 EFNS 795

European Journal of Neurology 2004, 11: 795–799

clinical epidemiology including neuroepidemiology.

Particular emphasis was placed on questions related to

programmes and needs in neuroepidemiology. The re-

sponse rate was 67% and completed questionnaires were

available for analysis from 18 EFNS member countries:

Albania, Bulgaria, Croatia, Czech Republic, Norway,

Denmark, Estonia, France, Hungary, Israel, Italy,

Moldova, the Netherlands, Portugal, Russia, Spain, the

UK, and Sweden. There were no dropouts among

responders who agreed to complete the questionnaire,

and those who did not respond provided no reasons for

refusal. Regrettably, no information was received from

some European countries with known teaching pro-

grammes in clinical epidemiology (such as Finland).

To evaluate research activity in clinical epidemiology

we also performed a simplified MEDLINE search

(from 1966 to October 2003) for epidemiological pub-

lications of any type and in any language from coun-

tries included in this survey (country name had to be

listed under the �institution� heading), with particular

emphasis on selected fields of neurology included in the

questionnaire. We used a combination of keywords,

subject heading words, or words in titles, such as �epi-demiology�, �risk factor(s)�, �incidence�, �prevalence�,�mortality�, �morbidity�, �prevention� with such key

words or title words as �stroke�, cerebrovascular dis-

ease�, �transient ischaemic attack (TIA)�, �subarachnoidhaemorrhage�, �dementia�, �cognitive decline�, �Alzhei-

mer’s disease�, �Parkinson’s disease�, �multiple sclerosis�,�epilepsy�, or �seizures�. The selection of diseases was

based on areas of particular interest to the EFNS Task

Force and Scientist Panel on Neuroepidemiology

members. This report is aimed to provide an analysis of

some critical issues that remain to be addressed in

teaching of clinical neuroepidemiology in Europe.

Results

Completion of the questionnaire was based on subjective

opinion of the responders in 39% of cases, on personal

opinion and review of corresponding university educa-

tional programmes – in 28% of cases, and on personal

opinion, opinion of colleagues review of corresponding

university educational programmes – in 33% of cases.

The relatively low response rate was a limitation of the

survey, which we tried to compensate by extensive dis-

cussion of our findings with some external experts in the

fields. In the countries analysed, 193 departments of

epidemiology in 231 medical schools were identified.

Some characteristics of educational activities in clinical

epidemiology in selected European countries are pre-

sented in Table 1. Educational programmes on clinical

epidemiology for undergraduate students were present in

15 countries (83%), with the median of 23 academic

hours per programme (range: from 6 h in Croatia to

250 h in Spain). All of the epidemiology programmes

included courses on the basics of clinical epidemiology

and fundamentals of biostatistics, 83% – a course on

study design methods, 61% – a course on applied epi-

demiology, and 11% – other courses.

Courses on applied clinical epidemiology for post-

graduate students were held in 12 of 14 countries who

participated in the survey (67%), with the most com-

mon courses being clinical epidemiology (62%), epi-

demiology of cardiovascular disease and cancer (54%),

and epidemiology of cerebrovascular disease (46%). Of

six countries where neither basic nor applied clinical

epidemiology teaching courses for postgraduate stu-

dents were held, all the respondents indicated a need for

teaching courses in clinical epidemiology, including

clinical neuroepidemiology (57%). Educational courses

of MSc, MPH, DSc, or PhD in clinical epidemiology

were available in 12 of the 18 countries (67%), and

seven of them offered a PhD programme (Bulgaria,

France, Netherlands, Norway, Israel, Portugal, and

Spain). Both domestic and international courses were

held in six countries (55%), while only domestic courses

– in five (45%). The mean number of teaching courses

for postgraduate students per country (university sur-

veyed) was 5.2 (range: one in Croatia, Norway,

Hungary, and Portugal to 10 in Israel), with a range of

five to 30 students per course.

Although the scope of research interest in clinical

neuroepidemiology varied widely across the countries

(Table 2), only two of the countries included possessed

neurologists formally certified in clinical epidemiology

(the Netherlands and the UK). However, eight

respondents (44%) indicated a clear need for such a

specialist. A national society of epidemiology was pre-

sent in nine countries (50%): Bulgaria, France, the

Netherlands, Norway, Denmark, Portugal, Spain,

Sweden, and the UK, but none of the countries had a

national society of neuroepidemiology (in Spain and the

UK, national associations of neurologists have a Special

Interest Group in Neuroepidemiology). For 1966–2003,

published articles in the selected fields of neuroepide-

miology constituted 2.3% of all articles published in

clinical epidemiology, ranging from as low as 0–0.7%

in Albania, Moldova, and Russia to as high as 3.8–3.9%

in Sweden and UK. A direct correlation was observed

between the number of neuroepidemiological publica-

tions and the availability of undergraduate and post-

graduate teaching programmes in clinical epidemiology.

Conclusions

This survey demonstrates that the teaching activity in

undergraduate and postgraduate clinical epidemiology

796 V. Feigin et al.

� 2004 EFNS European Journal of Neurology 11, 795–799

varies considerably across Europe. Despite widely

expressed needs for further epidemiological studies in

various fields of neurology, the number of neuroepi-

demiological articles published to date is relatively low,

especially from countries in transition, largely because

of the lack of availability of relevant undergraduate and

postgraduate teaching programmes in clinical epidemi-

ology. Albania, Moldova and Russia have no curricu-

lum for either undergraduate or postgraduate academic

courses in clinical epidemiology, and only a few coun-

tries (Israel, the Netherlands, Norway, Sweden, the

UK) offer an internationally recognized PhD course in

clinical epidemiology. Only two countries (the UK and

the Netherlands) have neurologists with qualifications

in clinical epidemiology and none of the countries sur-

veyed has a national society of neuroepidemiology. The

following are the possible ways to improve training and

research in neuroepidemiology in Europe.

Task Force Recommendations

(1) A structured curriculum for undergraduate training

in clinical epidemiology should be introduced in all

medical schools (universities), with a special module on

neuroepidemiology. As a minimum, this training should

include basics of clinical epidemiology and principles of

evidence-based medicine, including Good Clinical

Practice guidelines and critical appraisal of the litera-

ture. The time allocated for training in clinical epi-

demiology may vary depending on particular courses

included in the training, but should generally not be

<30 academic hours.

Table 1 Characteristics of educational activities in clinical epidemiology in selected European countries*

Country

Programme(s) Course(s) for postgraduate students

Demand for annual teaching

courses in neuroepidemiology

for postgraduate students

(courses needed most)

Availability for

undergraduate

students

Hours per

programme for

postgraduate

students

Type of

degree

Type of

course

Albania ) – – – Basics of clinical

epidemiology

Bulgaria + 56 MSc, MPH,

DSc, PhD

Domestic and

international

Neuroepidemiology

Croatia + 6 MSc, MPH Domestic Epidemiology of

cerebrovascular disease

Czech Republic + 13 – – Basics of clinical epidemiology

and neuroepidemiology

Denmark + 40 MSc, MPH Domestic Epidemiology of cerebrovascular

disease and head trauma

Estonia + 102 – – Basics of clinical epidemiology

France + NR MPH, MSc, PhD Domestic and

international

Clinical epidemiology,

neuroepidemiology

Hungary + 12 MSc, MPH Domestic Basics of clinical epidemiology

Israel + 42 MSc, MPH, PhD Domestic and

international

Neuroepidemiology

Italy + 8 MPH Domestic Neuroepidemiology

Moldova ) – – – Neuroepidemiology

the Netherlands + 16 MSc, DSc, PhD Domestic and

international

Neuroepidemiology

Norway + 40 MPH, DSc, PhD Domestic and

international

Neuroepidemiology

Portugal + 5 MPH, PhD Domestic Basics of clinical epidemiology

and neuroepidemiology

Russia ) – – – Basics of clinical epidemiology

and neuroepidemiology

Spain + 250 MPH Domestic and

international

Neuroepidemiology,

genetic epidemiology

Sweden + 10 MPH, DSc, PhD Domestic and

international

Basics of clinical epidemiology

the UK + 20–30 MSc, MPH, DSc,

PhD

Domestic and

international

Neuroepidemiology, basics

of clinical epidemiology

(depends on demand)

*Countries listed in alphabetical order.

NR, not reported; MSc, Master of Science; MPH, Master of Public Health; DSc, Doctor of Science; PhD, Philosophy Doctor.

Teaching of neuroepidemiology in Europe 797

� 2004 EFNS European Journal of Neurology 11, 795–799

(2) Postgraduate training in neuroepidemiology should

be restricted to accredited training institutions with the

appropriate experience according to national medical

organisation rules and needs. Annual teaching courses,

both extramural and intramural, in clinical epidemiol-

ogy and neuroepidemiology should be available for

specialists working in the numerous neuroscience

groups in Europe. The use of internet- and computer-

based teaching materials in epidemiology (e.g. Global

Health Network http://www.pitt.edu/�super1/, Clinical

Epidemiology for Effective Clinical Practice http://

www.intensivecare.com/Tutorial.html, Evidence Based

Medicine Tool Kit http://www.med.ualberta.ca/ebm/

ebm.htm, etc.) should also be encouraged. A full-time

2-year curriculum for clinical neuroepidemiology and

evidence-based neurology adopted by the American

Academy of Neurology http://www.aan.com/students/

program/neuroepi.pdf is recommended for interested

neurologists, especially for research neurologists/neu-

roscientists and those who wish to pursue an academic

career, or work in the public health sector. To ensure

that high calibre neurologists are attracted and

retained, they should expect attractive career prospects.

(3) Postgraduate training abroad in applied clinical

neuroepidemiology should be in epidemiological cen-

ters of excellence recommended by the European

international neurological organisations (e.g. European

Federation of Neurological Societies, European Brain

Council, European Neurological Society, etc.). Part-

nerships in national and international applied clinical

epidemiology (neuroepidemiology) training and service

should be encouraged.

(4) Based on national needs and resources, national

neurological societies in Europe should consider form-

ing a scientific panel or group on neuroepidemiology

within the society that would facilitate training and

state-of-the-art research in neuroepidemiology. It is

recommended that a specialist in clinical epidemiology

and/or biostatistics be involved, or at least consulted, at

early planning/designing stage of any neuroepidemio-

logical research.

(5) Major European research charity institutions

(Wellcome Trust, INTAS, INCO-Copernicus etc.)

should consider a higher funding priority for interna-

tional collaborative research projects in neuroepidemi-

ology that involve a collaboration between well

established academic center(s) of excellence and less

well established centers, especially those from Eastern

European countries. This would not only advance

knowledge and provide better quality data across var-

ious European populations but also facilitate education

and training in neuroepidemiology, and implementa-

tion of the study results.

(6) Training in the basics of neuroepidemiology must

complement a neurological curriculum for postgraduate

training. European national and international neuro-

logical societies should organize regular short-term

teaching courses (workshops) in clinical neuroepide-

miology as an integral component of their ongoing

annual scientific conferences, with prizes/certificates for

best studies in neuroepidemiology. Offering scholar-

ships to support excellent research in neuroepidemiol-

ogy and for attending neuroepidemiological workshops

should also be encouraged.

Table 2 Fields of research interest in clinical neuroepidemiology in selected European countries

Country Stroke Dementia

Movement

disorders

Demyelinating

disorders Epilepsy Other

Published articles

in neuroepidemiology* (%)

Albania + + + + + ) 0

Bulgaria + ) + ) ) ) 10 (1.2)

Croatia + + + + + + 11 (2.0)

Czech Republic + + ) ) ) ) 12 (1.0)

Denmark + + ) + + + 402 (3.0)

Estonia + ) + + + + 8 (0.7)

France + + ) ) ) ) 377 (1.5)

Hungary + ) ) ) ) ) 38 (1.9)

Israel + + + + ) + 180 (3.6)

Italy + + + + + + 572 (2.7)

Moldova + + ) ) ) + 0

the Netherlands + + + + + + 553 (2.9)

Norway + + + + + + 122 (1.8)

Portugal + + + ) + + 25 (3.0)

Russia + + ) + + + 39 (0.7)

Spain + + + + ) + 318 (2.8)

Sweden + + + + + ) 482 (3.9)

the UK + + + + + + 612 (3.8)

*Number of MEDLINE cited articles in the field of epidemiology of stroke, dementia, movements disorders, multiple sclerosis, or epilepsy

(seizures) and their proportion (%) in the total number of articles published in the field of clinical epidemiology for 1966–2003 by country.

798 V. Feigin et al.

� 2004 EFNS European Journal of Neurology 11, 795–799

(7) Although a number of general clinical epidemiology

educational materials are available, there is a pressing

need for developing specialist educational materials in

neuroepidemiology. Such materials could be developed

by the EFNS in collaboration with other major inter-

national neurological societies (e.g. World Federation

of Neurology) and leading experts in neuroepidemio-

logy.

Acknowledgements

The Task Force wishes to thank all the members of the

EFNS Scientist Panel on Neuroepidemiology and the

EFNS Head Office for their assistance in gathering

information for this report. We would like to thank the

following colleagues for their valuable comments and

constructive criticism on early version of the manu-

script: Prof. Albert Hofman (The Netherlands), Prof.

Geoffrey Donnan (Australia), Prof. David O. Wiebers

(USA), Prof. Ruth Bonita and Dr Thomas Truelsen

(WHO), Prof. Julien Bogousslavsky (Switzerland),

Dr Derrick Bennett (New Zealand), and Prof. Amos

Korczyn (Israel).

Teaching of neuroepidemiology in Europe 799

� 2004 EFNS European Journal of Neurology 11, 795–799