Interview: Professor Tzeni Kremastinou

Professor Tzeni Kremastinou, President of the BoD, Hellenic Center for Disease Control and Prevention (HCDCP)

Τζένη Κρεμαστινού

Molecular epidemiology is a relatively new field in public health. To what extent has it been developed in our country?

Molecular epidemiology has been developed in Greece at both an operational and a research level. Many reference laboratories are using molecular methods for typing microorganisms and for the surveillance of epidemic incidents, such as of meningococcal meningitis, salmonellosis, multiresistant nosocomial microbes, hepatitis viruses and human immunodeficiency virus (HIV) and malaria. Moreover, there is wide co-operation with European and other international surveillance networks, through which the molecular data derived from the Greek laboratories are being accepted.


Some believe that the genome and other molecular parameters regarding the analysis of microbes or/and the microbe vectors is an entirely research domain, that has nothing to do with the prevention and control of disease. Do you share this point of view?

As I mentioned before, the molecular techniques provide some very important tools, internationally and in Greece, assisting in the everyday function of the public health services. These tools help us answer, in a timely and valid way, questions regarding the tracking of a microorganism’s origin, the geographical distribution of the subtypes, the potential spread of an epidemic and finally regarding the pattern of dispersion of an infection between populations or within a population. So, to understand the pattern of the spread of a nosocomial pathogen within a health-care facility, for instance (which, by the way, is critical information necessary for building a strategy to combat and constrict nosocomial infections), we absolutely have to use molecular methods. Molecular methods are also widely used in the diagnosis of viral diseases and therefore in the monitoring of their epidemiology.


What is or should be the role of the HCDCP in molecular and environmental epidemiology?

All the HCDCP scientific departments make use of molecular epidemiological data, and many molecular techniques are routinely used at the central and peripheral public health laboratories and reference laboratories, every day. A recent example is the detection of malaria subtypes, which was based on molecular techniques.


Professor Kremastinou, you have been the President of the HCDCP’s BoD for 3 years, which has coincided with one of the most difficult periods (economically) in the modern history of our country. Please, share with us your important experience of this.

It is true that I took over the presidency of the agency during the difficult circumstances of the last few years. On the one hand it coincided with the economic crisis and a significant cut in the budget and funds for public health and the HCDCP. On the other hand, a number of serious infectious diseases (re)emerged and there has been a pressing need for emergency public health measures. Such diseases (or health conditions) include the influenza pandemic, malaria, West Nile Virus (WNV) infection, increasing microbial resistance to antibiotics and resistant pathogens in our hospitals, multidrug-resistant tuberculosis, the HIV epidemic among intravenous drug users and, most recently, the re-emergence of rabies in wild animals. In addition, a continued migratory flow has caused some serious public health issues. All the above have produced a continuing need for finding funds and for careful prioritization of expenditure, and have led to an increased work load for the already overburdened and understaffed specialized scientific personnel of the organization. Moreover, our participation in international bodies such as the ECDC, Centers for Disease Control and Prevention (CDC), European Union (EU) and World Health Organization (WHO),requires constant communication and preparedness at the highest scientific level.

Nevertheless, during this difficult period there have been some successful interventions in the operation of the organization, such as the publishing of the HCDCP’s monthly e-bulletin, the reformatting of the web site, the implementation of social media, and a strengthening and improvement of epidemiological surveillance and intervention. At this point, I feel I should make a special mention of the program for combating malaria, which has been innovative and extremely successful.  Our participation in the European programs EPIET and EUPHEM has also been decisive because the HCDCP has been selected as a training site for the ECDC and three fellows are being trained here at the moment.

Additionally, I believe that the strong support of the public health laboratories by the HCDCP, and of the national reference centers, is essential because these laboratories are the cornerstone of public health actions and processes. Other very important functions are the implementation of the health map and the national cancer and rare diseases registries, the successful claim for European territorial co-operation programs, participation in joint actions by the EU, and the health interventions carried out almost daily in the community.


How important or decisive is the role of the HCDCP in the effective protection of public health today? And in the future?

There is no ‘public health’ in our country, nor in any other country of the world, without the equivalent of the HCDCP. The need for such agencies led to the establishment of a central European organization for public health (ECDC). Organizations like HCDCP serve, among many other things, the need for detection and surveillance of infectious diseases, detection of and intervention in epidemics, health education and published guidelines, and the ‘know-how’ and technical support for health-related issues. I have to point out that the HCDCP has been expanding its activities into the area of chronic disease during the past few years, despite the unfavorable economic conditions. The successful implementation of the cancer and rare diseases registries already mentioned is moving in this direction. My ambition, in the near future, is to build on this by implementing actions such as the study and prevention of health inequalities and focusing on a healthy life style and eating and other habits for the Greek population (nutrition, smoking, regular physical activity), which affect both chronic and infectious diseases (as documented by numerous studies).


You are undoubtedly an influential woman with great experience in the field of public health. Where are the developments and progress in this field leading us, in Greece and abroad?

Public health is not an unambiguous concept and depends on a variety of socio-economic factors. Public health is strongly related to and affects the development and productivity of a country. It is well known that 80% of deaths world-wide are attributable to chronic diseases. Modern public health is based internationally upon the foci of health promotion, prevention and management of non-communicable diseases, control of environmental hazards and tackling the social determinants of health. However, we should not neglect infectious diseases, which can lead very rapidly to unpredictable and emergency situations and require continuous preparedness in order to diagnose and combat them. The effective control and management of both chronic and infectious diseases increases the healthy life expectancy of a population and should be our first priority. This is the major ‘pursuit’ of public health globally.


What would you advise public health professionals, especially now, during this uncomfortable climate we are experiencing?

In order to justify their position, public health professionals have to understand in depth the role of the public health officer; they should be scientifically up to date and they need to prioritize the problems and provide the right solutions based on solid scientific data, especially now when resources are limited. It is also very important that they foster good communication skills with the public and communities and have solid arguments when introducing issues to them.


Finally, what attracted you to the public health domain, when you started your career? Would you recommend the young scientists to deal with relevant to your domain professions and why?

Love for public health was a major motive. Clinical medicine provides the satisfaction of diagnosis and cure, but public health, in which I believed from a very young age, sees things from a much broader perspective.

My occupation within public health started, at the beginning of my career, at the Laboratory of Hygiene and Epidemiology of the Medical School of the University of Athens, and then at the National School of Public Health. There I was given the chance to practice and participate in the design and implementation of general strategies and policies for population health. I consider myself blessed and am happy that my tutors in the field of public health were Professor Dimitris Trichopoulos and late Professor George Papaevaggelou. Following their example throughout my chosen path, I always aim to realize the potential of my colleagues and their further development. I would strongly suggest that young scientists pursue a role in public health because of its broad horizons (at national and international levels) and because of the aforementioned approach, from a broad perspective, with the aims of the promotion of good health and prevention of bad health. However, they should be prepared to gain the most satisfaction from their role through constant education and vigilance, in a period when the financial and emotional rewards are restricted.

We thank you warmly.

Edited by Philip Koukouritakis