FOR A TWINNING PROJECT
REPUBLIC OF BULGARIA AND REPUBLIC OF
Twinning Project reference number
“Strengthening of the National Surveillance System for
PHARE INSTITUTION BUILDING
TWINNING PROPOSAL FOR PARTNERSHIP
Strengthening of Communicable Disease Surveillance.
Member State: REPUBLIC of ITALY
MS body responsible for implementation:
MINISTRY OF HEALTH - GENERAL DIRECTORATE FOR EUROPEAN UNION AND INTERNATIONAL RELATIONS
Acting with the following partners:
I.N.M.I. (NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES) ISS (NATIONAL INSTITUTE OF HEALTH)
-DR.SSA MARIA PAOLA DI MARTINO. DIRECTOR GENERAL FOR EU AND
INTERNATIONAL RELATIONS MOH. PIAZZALE INDUSTRIA 20 –
00144 ROME. TEL.+0659942716 FAX FAX +0659942541
E- MAIL email@example.com
-DR. NICOLA SCHINAIA. RESEARCHER, MEDICAL EPIDEMIOLOGIST
DEPARTMENT OF INFECTIOUS, PARASITIC AND IMMUNO-MEDIATED
ISTITUTO SUPERIORE DI SANITÀ, 299 VIALE REGINA ELENA, 00161 ROME
Tel +0649902032, Fax +0649902558 E-mail: firstname.lastname@example.org;
Beneficiary Country: REPUBLIC of BULGARIA
Twinning Reference Number: BG/2005/IB/SO/01
A. Services proposed by Member State as required by the Bulgarian Fiche
Additional Service: e-learning
B. Methods and organisation
C. The Partner Organisation
D. Comparative advantage
A. Services proposed by Member State:
The aim of the project is to improve the health status of the people of Bulgaria through
targeted interventions to prevent the causes as well as to reduce the morbidity and
mortality from communicable diseases (CD).
The overall objective is to contribute to a sustainable improvement of policies for CD
control, through a comprehensive action for each activity area. Special emphasis will be
placed in the relevant European Union (UE) policies concerning this important area.
The specific purposes envisaged to reach the goal are:
- the review of the current system for CD surveillance,
- the suggestion of improvement measures,
- the test the new system
- the enhancement countrywide of the capacity of the relevant staff, that will manage the
The project will focus as an overall result to the re-organization and the strengthening of
the services involved in the CD surveillance and control.
The Italian Partner will give to its Bulgarian counterpart the support of its long and in
many instances successful experience not in the form of advises or, here and there,
technical assistance, but in the form of co-operation and support to achieve through joint
effort and commitment the results entailed in the Fiche, which will be better defined in the
Twinning Working Plan.
The components of the proposed cooperation plan are:
1) Cooperation in reviewing the current system of CD surveillance;
2) Assistance and cooperation to improve redesign local and territorial health
services in the surveillance system network;
3) Definition and design of the relevant IT tools involved in the network for the
4) Assistance and cooperation to design and initiate the creation of a network of
5) Preparation of a comprehensive of training plan, according to the analysis of
the needs of the new system and services;
6) Production of the appropriate set of guidelines and manuals for the
management of the surveillance system countrywide;
7) Plan the necessary workshops and meeting as well as the dissemination
material and events;
8) Planning and development of the methodology to establish an on-going
programme on social communication and health promotion, targeted to
lifestyles involved in the occurrence of CD;
9) Development of initiatives to prepare the appropriate legislative interventions
to implement the present laws and to introduce new legislation.
Such components will be characterized by the following actions described in the
present document in a very concise form, according to their development in time.
First phase of activity, identified with the designing of the Twinning Work Plan (TWP).
The Bulgarian and Italian Partner will jointly proceed in the examination and validation of
preceding studies and analysis, on the basis of which the proposed Twinning Project has
been drafted and produce the operational programme. Specifically the joint activities will
a) Analysis and assessment of the protocols, methods and outcomes of the currently existing surveillance system.
b) Preparation of a comprehensive evaluation of the need for methods and tools in the area of collection and management of epidemiological data, and of the methods of
communication between and among public services involved in the functioning of the
health sector, especially the emergency sector.
d) Review of the Bulgarian legislation and Regulations especially in what concerns the Laboratories
e) Design of a project in which will be clearly identified the four “W”: who does - what -
when - where, in order to allocate appropriately from the beginning the tasks and
responsibilities, and have a clear and shared time table.
f) Work out of the appropriate methods and tools for an initial ex ante evaluation of the Twinning Work Plan, for the evaluation in itinere and for its feed back into the
g) Selection of the appropriate indicators:
- of achievement, to control the performance in reaching the programmed steps towards the attainment of the expected results;
- of result, to measure the direct and immediate effects;
- of impact, to evaluate the long term effects (structural changes);
h) Assessment of the needs for conventional and innovative training and plan the related
activities to fulfil them.
i) Identification of the priority target groups, toward which to address activities of awareness and coordination, to achieve the result of strengthening the surveillance of
Communicable Diseases as indicated in the Twinning Fiche.
Specifically the involved Italian expertise will convey a comprehensive approach in the
CD surveillance and control, that has been developed over the last 15 years, in close
cooperation with the 15 EU Member States (MS): the response to CD occurrence has
increasingly been a concerted European pursuit over the last 15-20 years, when it
appeared clear that emerging and re-emerging CD were becoming an ever increasing
global threat to the world‟s population.
On the basis of epidemiological and social data coming from the Bulgarian situation and
the most appropriate similar Italian situations, a correlation matrix will be prepared to
facilitate the identification of crucial target groups more vulnerable to specific
communicable diseases, for which to address ad hoc actions.
In this regard the appointment of a Resident Twinning Adviser (RTA) with a mixed
background, both legislative, health sector oriented, with programme management
experience seems of the greatest value to harmonize the multidisciplinary activities
entailed by this project;
Second Phase, the start up phase of implementation of the Twinning Project.
The Italian Partner cooperation will be immediately addressed to the support of activities
i) Organization of targeted training, in this regard our experience, built up through
activities in Italy and in similar cooperation projects within neighbouring countries, has
taught that there are various patterns of training programmes and a combination of topics
in the area of CD surveillance and control. As a consequence the Italian Partner, also in
consideration of the problems exposed in the Bulgarian Fiche, envisages as first step the
focus on the specific professional profiles operating at central level (MoH, NIHI, NICIPD,
reference hospital for CD) in the CD surveillance and control sector.
Afterwards, the different levels of training will be developed towards the countrywide
health professional profiles, bearing in mind from the beginning the need of homogeneous
criteria and goals and involvement of all the personnel (doctors, nurses, technical
personnel, epidemiologists, laboratory personnel) ;
ii) actions aimed to the implementation of the CD surveillance system in Bulgaria, in all
its aspects: notification level, reporting, analysis, feedback and ultimate use for action. In conjunction with the Bulgarian counterpart, a set of diseases will be selected and a mixed
set of surveillance methods implemented.
The following diseases are likely to be dealt with priority:
- viral hepatitis,
- tuberculosis and other potentially epidemic-prone emerging airborne diseases (eg avian
- HIV/AIDS/STIs (Sexually Transmitted Infections),
- illicit drug use related infections, and zoonoses.
The improvement of the CD information system, and a model for the development of the
CD-oriented social communication to the public will be the system improvements entailed
by our project;
iii) actions aimed to the support of the design and initiate the creation of a network of
isolation facilities. They will include the following tasks:
? to develop, share and document good practices ( through real and virtual meetings, by
development of consensus guidelines)
? to develop accessible, complete and accurate inventories of the infectious diseases and
? to facilitate the access to the Italian maximum containment laboratory for the
diagnostic of level 4 agents
? to standardize the procedure for transport of biological samples from patients with
? to develop training (by development of an agreed core curriculum) on management of
isolation facilities and highly infectious diseases, by defining isolation facilities by
level of security, defining criteria for „highly infectious‟ diseases
iv) innovative training and community actions aimed at the creation of a programme of
continuous medical education (CME), as well as the involvement of community-based
organizations (CBOs) as an added value for the empowerment of the population or the
prevention of CD.
Third Phase, the Implementation Phase of the Project In this phase, on the bases of the results reached in the two preceding one the cooperation
of the Italian Partner will be focused in assisting the Bulgarian partner in:
? final elaboration of regulation for participation of Labs in data collection for CD
? development of standard Operating Procedures on CD labs surveillance according
to EU norms and accepted international standards;
? regulation for involvement of private labs in the CD surveillance;
? regulation for quality control of private labs in the CD surveillance with regard to
TB - HIV/AIDS;
? development of national standard protocol on CD laboratory surveillance
? updating guidelines for specimen collection, packaging and transportation and
? updating of existing legislation.
The Italian partner, due to its own experience will be in condition to give a specific
contribution in organizing the network of computerized laboratories to interact with each
other and rapidly transmission of results and information.
At this regard the design of an unified network will based on the “hub and spoke” model.
According to such a model all the centres act following pre-defined hierarchy procedures
respecting the goals and the strategies mutually agreed among all the labs of the system. In
other terms this is a hierarchical system in which specific pre-defined rules govern in any
moment the relations among all the centres and the role of each one of them. This will
guarantee, as already tested, the best performance also in case of emergency.
The National Reference Laboratory for Tuberculosis will be de facto the hub of the
network that will be created for this specific disease.
E-learning - Constructing a system of continuous education based on open distance
training and e-learning methods and tools and preparation of the website.
During this phase the Italian partner offers as an additional service the designing and
implementation of an e-learning system. The activities of the project should also be
addressed to capitalize on the possibilities offered in the field of teaching by Information
and Communication Technology (ICT) to make an even larger impact through the
progressive development of a web community addressed to the so called “continuous
The Italian proposal therefore includes making a web site, producing a so called web
community of scholar and the setting up, using ICT, an authentic forum for debate,
discussion, learning and dissemination to support:
i) the development of competences on Communicable Diseases and risk
ii) a Geographic Information System (GIS) finalized to the mapping of the general
situation and especially the monitoring of the most affected areas.
In fact some of the modules of the above described training programmes mentioned
before can be diffused to a larger number of persons. This activity will be established
during the time life of the project also developing a permanent link between the Italian
and Bulgarian institutions involved in the project.
This continuous education centre will be open primarily addressed to:
? representatives of the national, regional and local health administrations
? representative of health supervising institutions;
? research institutes;
? representative of the public and private service sectors;
? schools and education institutions.
Fourth Phase, concerning evaluation and diffusion of the results. With the collaboration of the Evaluation Group Of the Ministry of Health internal
evaluation procedures will be carried on with regard to:
- the process of implementation and
- the out put of the project.
The results will be examined with special regard to quality.
The set of indicators used will be the one established and shared between the partners
already in phase one.
As to the diffusion of the results, the requirement of the European Union will be respected.
Particular attention will be given to the diffusion of the guide lines and other operational
materials. Workshops and conferences will be organized for the dissemination of the
Methods and organisation
A) Methods: a multi-method approach will be requested, both in the activities of
cooperation which are offered in each phase, and in the activities of certain phases.
The following strategies will be employed:
? Organization of training workshops and seminars in Bulgaria, involving relevant
professional profiles, as above outlined
? Involvment of relevant Bulgarian staff, both as trainers of trainers, and as trainees,
as well as contributing to the development of the activities entailed in the workplan
for the CD surveillance system
? Regular visits of selected experienced Italian staff, to run the training seminars,
and to oversee the unfolding of the planned activities, acting as one-to-one (or one-
to-few) tutor of the Bulgarian professional counterparts.
? Targeted short-term visits of selected Bulgarian health professionals in selected
institutions in Italy, to gain first-hand insight in specific techniques relevant to CD
surveillance and control
Some information will be provided in the ensuing paragraphs about such strategies.
a.1. Specifically, the first phase requires methods generally called of multicriteria analysis
and involves conceptual tools such as S.W.O.T. (Strengths; Weaknesses; Opportunities;
Threats) analysis to explore more in details the critical aspects stressed in the Twinning
Fiche and examine them in reference with the attainment of the goals of the project.
Matrix enlightening the conditions of congruence with European standards will be proposed as important starting from the initial phase of making the Twinning Work Plan (TWP).
At the end of the first draft of the TWP a Method for ex ante evaluation, defined by the Evaluation Group of the Ministry of Health, will be used to validate the plan and to advise, if necessary changes and additions.
At this regard the collaboration with the institutional Bulgarian partners from the health governmental and non governmental institutions operating both at the national, regional and local in the field, will be essential.
Existing data and information will be collated, exchanged , and discussed. definitions, guidelines, inventories, training modules as scheduled will be developed, which be reviewed by participants with relevant organisations at national level
a.2. In what concerns the monitoring activities, the important aspect is to define the set of
indicators of achievement according to which the implementation of activities and /or the performance as to be evaluated.
In collaboration with the Bulgarian partners, there will be a selection of the relevant indicators more adequate to the characteristics of the Bulgarian society, which will also be confronted with Italian and generally European one.
A specific attention will be given to the sector of serum - epidemiology, for a most accurate monitoring of the diffusion of contagious diseases.
Avviare un'attività di studi di siero-epidemiologia, per un più accurato monitoraggio della
a.3. Drawing from the intensive experience of the Italian Partner the training courses will
be innovative in character, because based on active participation of the trained. Different methods will be used: the traditional classroom lessons will be included in a minimum number and include tools such as self evaluation. In addition specific subjects will be discussed using non traditional learning such as discussion group and goal oriented debates.
a.4. The methods proposed for evaluating the completed project, will derive from European as well as Italian experience of ex post evaluation. In this regard the indicators selected and shared during the TWP will be crucial and they will, themselves be evaluated. The result of such evaluation, especially in regard of taking into account factors and characteristics of the Bulgarian context, will constitute an important input for planning the successive experiences.
The methods and actions of diffusion of the results will be advised according to other experiences of European projects. Specifically, the Italian partner will cooperate in the preparation of materials and actions addressed to the target groups defined at the TWP phase. Among the tools for diffusion should be stressed the creation of a website in English and Bulgarian.
a.5. Expected Results
The medium-term outcome of this twinning programme are envisaged to be the following systems accomplished and put in place:
? Improvement of the CD surveillance systems and of the protocols for the operative
action of the ISPs‟ epidemiologic regional offices
? Improvement of the Bulgarian experts‟ professionalism
? Continue assistance of ISS in order to join to the European standards
B) The Partner Organisation:
Partner Contact Point:
The Ministry of Health, General Directorate for EU and International Relations (DG
RUERI) - Ms. Di Martino is the General Director for EU and international relations at the Italian
Ministry of Health within the Department of the Prevention and Communication. Her
Sector is responsible, among other, for bilateral agreements and in implementation of
international policies and partnerships actions. She holds a senior position in the Ministry
of Health, and has a coordination role within the Evaluation Group of Investments at the
Ministry of Health.
Dr. Nicola Schinaia (CV attached) is proposed as Project Leader.
Dr. Schinaia is a senior professional at the Italian Health Institute (ISS). He has a long
standing experience of collaborative projects in the field of CD surveillance, and has
served several times as WHO Consultant in the same field.
Deputy Project Leader
Dr. Massimo Ciccozzi (CV attached) is proposed as Deputy Project Leader.
Dr. Ciccozzi is a senior professional at the ISS. Within the Epidemiology Unit of
Department of Infectious, Parasitic and Immune-Mediated Diseases is the focal point for
the improvement of diagnostic tools for the CD surveillance at global level
Resident Twinning Adviser.
Dr. Manuel Bressan (CV attached) is proposed as RTA of the Project.
Dr. Bressan has a legal and diplomatic background, as well as first-hand experience in
international projects management in the health sector.
Italian Human Resources Involved
The Italian Ministry of Health will ensure the overall coordination of the various
professionals involved, as well as will retain the political profile entailed by the bilateral
diplomatic agreement, that has been signed in 2005. The following key professionals will
be involved as medium term experts:
? prof. arch. Simona Ganassi Agger (CV attached), member of the Evaluation Group
for public Investments of the Ministry, involved in coordinating the experts activities.
The Italian Health Institute (ISS, Istituto Superiore di Sanità) will contribute
professional expert in the field of CD surveillance, both notification-based, as well as
laboratory-aided, either directly or through networked institutions:
? CD Surveillance Principles, with the supervision of the Director of the Epidemiology
Unit dr. Giovanni Rezza (CV attached);
? Disease-oriented CD Surveillance, with the involvement of the Head of the
HIV/AIDS/STI surveillance dr. Barbara Suligoi (CV attached); ? Data collection and management expertise, will be coordinated by dr. Mario
Figliomeni (CV attached);
? Logistics of project activities implementation expertise, will be coordinated by dr.
Cristiano Bumbaca and Luca Avellis (CV attached); ? Social communication expertise will be coordinated by prof. Tommaso Pilato, also
representative of a non governmental organization active both in Italy and Bulgaria
and neighbouring countries (BALNE);
? Training delivery and scientific communication strategies will be coordinated by
dr. Sergio Bianchi, also representative of a non-profit organization active in Italy and
abroad (AGENFOR) for methodological issues of training courses
The National Institute of Infectious Diseases “Lazzaro Spallanzani”, in particular, will
coordinate, implement and oversee the hospital and laboratory-based activities of CD
surveillance, with special emphasis for containment of spread of serious threats. A team of
its experts will be involved, comprising:
? Doctor Giuseppe Ippolito, Scientific Director of the NIID
? Doctor Vincenzo Puro, (CV included),
? Doctor Enrico Girardi, (CV included).
As it was indicated before, Italy has been improving its national CD surveillance system
several times over the last decade, adapting to the rapidly changing needs of the
occurrence of emerging and re-emerging CD. Moreover, this has been a Europe-wide
process (culminating with the very recently established European Centre for CD
Surveillance in Stockholm); Italy has been and still is a very active member of such
process, which has increased our country‟s attitude towards international cooperation.
Furthermore Italy presents similarities to Bulgaria both in terms of geographically
disadvantaged areas with clearly different patterns of CD incidence, and in terms of social
and economic composition.
The Italian Partner will give priority attention to ensure that the programme receive
support and visibility to the health and social issues which are its focus. The high profile
of Project Leader will be instrumental to assure full attention in the Italian as well as
To further emphasize the appropriateness of the collaboration between Italy and Bulgaria,
it should be reminded that the Bulgarian and Italian Governments have signed in October
2000 a Memorandum of Understanding in the field of Health and Medical Sciences which
has been followed on March 2005 by a Program of Cooperation in the Health sector. This
Twinning experience would be one of the many contributions to such high profile political
Such diplomatic agreement may also ensure the sustainability of the activities
implemented in this project even beyond the time span of this Twinning Programme, as
well as to include additional areas within the CD surveillance and control (eg animal
health and food borne infections). Finally, our twinning institutions are established
partners of collaborations with bilateral, and multilateral projects with other countries or
WHO in the area of CD surveillance and control.