venia Public Health Achievements ents in Slo in Slovenia vem alth Achie Public He Public Health Achievements in Slovenia Ljubljana, 2021 Public Health Achievements in Slovenia Editors: Pia Vračko, Urška Kolar Translation: Amidas d.o.o., 1000 Ljubljana Design: Tadeja Horvat, Ajda Bertok Photos from: iStock, Adobe Stock, Shutterstock, Freepik Publisher: National Institute of Public Health, Trubarjeva cesta 2, 1000 Ljubljana Place and year of publishing: Ljubljana, 2021 Web edition Web address: www.nijz.si Kataložni zapis o publikaciji (CIP) pripravili v Narodni in univerzitetni knjižnici v Ljubljani COBISS.SI-ID 80994819 ISBN 978-961-6945-50-9 (PDF) 01 HEALTH IN SLOVENIA 1.1 Core health indicators in Slovenia in comparison with EU-27 12 1.2 Health in the Municipality - Health card for each Slovenian municipality 15 1.3 Upgrading of the programme Health in the Municipality at Gorenjska 16 1.4 SI-PANDA – survey on the impact of the COVID-19 pandemic on people’s lives 17 1.5 National population health surveys in Slovenia 18 1.6 Inequalities in health 19 1.7 Health-related behaviours among adolescents 20 1.8 Workers' health surveillance 21 02 HEALTH POLICIES, STRATEGIES, NATIONAL PROGRAMMES AND INTERSECTORAL COOPERATION FOR HEALTH 2.1 National Cancer Control Programme 23 2.2 Managing diabetes: from strategy 2010–2020 to strategy 2020–2030 24 2.3 National Programme on Nutrition and Physical Activity for Health 2015–2025 25 2.4 Evidence-informed policy brief for prescribing antibiotics to residents in long-term care facilities 26 2.5 Comprehensive tobacco control programme in Slovenia 27 2.6 Approaches to reduce the negative effects of alcohol consumption 28 2.7 Inclusive public health – the disabled and the elderly 32 2.8 Public health approaches in cross-sectorial policies: achievements in active and healthy ageing 33 2.9 Actions on health inequalities of the Centre for Health and development Murska Sobota 34 2.10 A community approach to strengthening mental health 35 03 HEALTH INFORMATION SYSTEM - DIGITAL INNOVATIONS IN HEALTHCARE 3.1 Slovenian Cancer Registry 38 3.2 Health databases and other health and healthcare data sources 39 3.3 SLORA: web portal providing access to cancer data 40 3.4 Health Statistical Yearbook of Slovenia 41 3.5 The role and value of eHealth solutions during the COVID-19 pandemic in Slovenia 42 3.6 Contribution of the Slovenian Medical Informatics Association to the computerisation and digitalisation of health in Slovenia 47 04 SCIENTIFIC RESEARCH AND PUBLISHING IN PUBLIC HEALTH 4.1 Scientific achievements of the Department of Public Health of the University of Ljubljana, Faculty of Medicine 49 4.2 Anthropology hand in hand with public health 50 4.3 Public health research in oncology 51 4.4 Heart failure: from epidemiological burden to effective (self-)care of patients 52 4.5 Slovenian Journal of Public Health 53 4.6 Journal Javno zdravje 54 05 EDUCATION IN PUBLIC HEALTH 5.1 Public Health School 56 5.2 Education and training at the Department of Public Health of the University of Ljubljana, Faculty of Medicine 57 06 PUBLIC HEALTH ACTIVITIES 6.1 HEALTH PROTECTION AND PROMOTION 6.1.1 Website ZDAJ.net and the guide We are expecting a baby: modern, professional and accessible 61 6.1.2 Health education for future parents and mothers: starting at the beginning, supporting healthy growth and development 62 6.1.3 Health education: for joyful and healthy children and adolescents 63 6.1.4 Health in kindergarten – a health promotion programme for the youngest 64 6.1.5 Sex education programme for children and adolescents 65 6.1.6 Challenges of eating disorders 66 6.1.7 Prevention in the area of oral health 67 6.1.8 Programme for the prevention of child injuries and the promotion of safety 68 6.1.9 Provision of psychological support during the COVID-19 epidemic 69 6.1.10 Improving accessibility of help in time of mental distress and suicide prevention 70 6.1.11 A community approach to reducing health inequalities 71 6.1.12 Health promotion in schools: The Slovenian Network of Health Promoting Schools (1993–2021) 72 6.1.13 Slovenian Healthy Cities Network 73 6.1.14 The web portal Šolski lonec 74 6.1.15 The online tool of the PKMO project 75 6.1.16 Preventive programmes in Novo mesto 76 6.1.17 Maturation of young people through the This is Me programme 77 6.1.18 Sanitary and epidemiological inspection of passenger and cargo vessels in Slovenia 78 6.1.19 From research to action in order to promote healthy eating 79 6.2 REDUCING RISKY BEHAVIOURS AND DRUG DEPENDENCY 6.2.1 Interventions to control drug dependency 83 6.2.2 Approaches to reducing opioid-related mortality 84 6.2.3 Tackling the alcohol consumption problem with the SOPA approach 85 6.2.4 Social protection programme Centre for the Prevention of Addiction 86 6.2.5 Reducing harm in the area of drugs and homelessness 87 6.3 HEALTH AND ENVIRONMENT 6.3.1 Environment and health indicators 89 6.3.2 Chemical safety 90 6.3.3 National Human Biomonitoring Programme 91 6.3.4 Preparation of hygiene recommendations to prevent the spread of SARS-CoV-2 infections 92 6.3.5 Programme of measures to improve the quality of the environment in the Upper Meža Valley 93 6.3.6 Preventive programme Safe with the sun 94 6.4 PREVENTIVE AND SCREENING PROGRAMMES FOR CHRONIC DISEASE MANAGEMENT 6.4.1 Screening programmes for early detection of cancer – Programme Svit, ZORA, DORA 96 6.4.2 Integrated prevention of chronic illnesses for adults – the Together for Health programme 97 6.4.3 Screening and prevention programme for children, adolescents and students: Prevention programme ZDAJ - Health today for tomorrow 98 6.4.4 Epidemiological monitoring of dementia in Slovenia 99 6.4.5 The development of integrated care for persons with complex chronic states 100 6.4.6 Genetic testing and high risk cancer screening 101 6.4.7 Prevention and control of non-communicable diseases at NIJZ regional offices 102 6.5 COMMUNICABLE DISEASES CONTROL 6.5.1 The COVID-19 epidemic in Slovenia 104 6.5.2 Epidemiological and hygienic measures in school education to control the spread of COVID-19 – an example of excellent intersectoral cooperation 105 6.5.3 Implementation, carrying out and monitoring of measures for the control of infectious diseases in regional offices of the National Institute of Public Health 107 6.5.4 eRCO and surveillance of vaccination coverage 108 6.5.5 New developments in Slovenia’s national vaccination programme 109 6.5.6 National survey of healthcare-associated infections 110 6.5.7 National survey of sexual lifestyles and health 111 6.5.8 Activation of the local community for vaccination against TBE in Slovenia 112 6.5.9 Epidemiological surveillance of antimicrobial resistance 113 6.5.10 Setting up the COVID-19 vaccination website www.cepimose.si 114 07 PUBLIC HEALTH LABORATORIES 7.1 Establishment and operation of the National Laboratory of Health, Environment and Food 116 7.2 The role of NLZOH in controlling the COVID-19 epidemic 117 7.3 e-Exchange of microbiological orders and test results 118 7.4 Molecular methods for the typing of micro-organisms 119 7.5 The National Influenza Centre and its role in pandemics 120 7.6 The path to eradication of measles, rubella and mumps 121 7.7 Europe is polio free, but the global risk remains 122 7.8 Surveillance of whooping cough 123 7.9 Surveillance of invasive diseases caused by S. pneumoniae, N. meningitidis and H. influenzae in Slovenia 124 7.10 Surveillance of diphtheria 125 7.11 Surveillance of bacterial pathogens causing food and waterborne infectious diseases 126 7.12 Diversity of Clostridioides difficile ribotypes 127 7.13 Monitoring and control of bacterial resistance 128 7.14 National system of antimicrobial susceptibility testing 129 7.15 Molekularno determination of carbopenemases 130 7.16 Monitoring airborne pollen 131 7.17 Food safety as a public health factor 132 7.18 Monitoring of drinking water and the MPV information system 133 7.19 Quality of ambient air with PM10 particles in Maribor 134 7.20 The role of NLZOH in environmental emergencies 135 7.21 Microbiological analyses for public health protection 136 7.22 Testing for the presence of drugs 137 7.23 Official quality control of medicines 138 08 MONITORING AND DEVELOPMENT OF HEALTH CARE 8.1 Thirty years of the health care system in Slovenia 140 8.2 Self-assessment of the Essential Public Health Operations in Slovenia 141 8.3 Development of a demand projection model for specialist doctors in Slovenia 142 8.4 Achievements in emergency medical care 143 8.5 Slovenia primary healthcare model 145 8.6 Slovenian health system performance assessment 147 8.7 National clinical cancer registries 148 8.8 Monitoring the consumption of prescription medicines in hospitals 149 8.9 Experience of patients in the Slovenian healthcare system 150 8.10 The economic burden of public health problems 151 8.11 National Mental Health Programme 2018 - 2028, MIRA Programme and mental health centers 152 8.12 Intersectoral Regional Council for Public Health of Goriška region 153 09 NGOs IN PUBLIC HEALTH 9.1 NGOs in public health 157 10 SLOVENIA'S CONTRIBUTION TO INTERNATIONAL HEALTH AGENDA 10.1 Membership of the World Health Organization Executive Board 162 10.2 Coordination of European cancer projects 164 Foreword by Janez Poklukar, Minister of Health of the Republic of Slovenia Health is a fundamental value for Slovenia. As a soci- comprehensive and integrated patient care in terms ety, we strive to create conditions in which people of both the prevention and treatment of chronic have access to the best healthcare and have suf- disease. As early as in 2002, Slovenia introduced a ficient opportunities to enjoy a healthy lifestyle at programme for the early detection of cardiovascular all stages of life and in all environments. In different risk factors in adults, which has significantly con- areas of public health, we have recorded successes tributed to reducing mortality from these diseases. that can be compared internationally and establi- The implementation of organised screening for cer- shed exemplary cooperation with other ministries vical, breast and colorectal cancer has helped us sig- and civil society, particularly where success requires nificantly improve results in recent years in both the going beyond the healthcare system to address the prevention and treatment of these types of cancer. needs of the most vulnerable groups in a way that is appropriate to them. Equality in health has traditionally been very impor- tant in Slovenia. We are aware that universal access We are aware that taking a life-course approach to to healthcare is an essential but not the only condi- strengthening and maintaining health starts even tion for effectively addressing the needs of the most before birth. Slovenia has one of the lowest infant vulnerable population groups. In order to ensure mortality rate in the world due to providing health- timely access to healthcare services and participa- care for pregnant women at the primary level and tion in preventive programmes, mental health pro- well-planned antenatal and postnatal care. The high motion programmes and early disease detection accessibility of quality healthcare and preventive programmes for these population groups, we have healthcare for all population groups is reflected in successfully linked public health and primary health- a steady increase in life expectancy. High vaccina- care with other stakeholders in the local community, tion coverage is maintained through well-designed such as non-governmental organisations, social vaccination programmes; preventive dental check- work centres, kindergartens and schools. -ups during childhood and adolescence contribute to good oral health in adults. Healthy, hot meals are In addition to health indicators, this publication sets provided for all children and adolescents in scho- out many examples of good practice of which we can ols and kindergartens to help them grow healthily; be proud. Some of them are the result of projects, a healthy lifestyle is also encouraged through the while some have already become systemic solutions. promotion of exercise and a range of programmes The COVID-19 pandemic has presented us with new offering professional support to children facing pro- and different challenges and provided us with an blems as they grow up. Slovenia is also serious about opportunity to additionally enhance the traditionally meeting its international commitments on tobacco strong public health system in Slovenia and upgrade control; in 2017, with a strict ban on smoking and it with innovative solutions. Furthermore, I see the the sale of tobacco products already in place, Slo- Slovenian Presidency of the Council of the European venia introduced plain packaging for cigarettes and Union in the second half of 2021 as an opportunity to licensing for retailers of tobacco products. strengthen cooperation within the European Union in all areas of public health, particularly in working At the local level, health promotion centres have together to find innovative solutions so that we can been introduced in community health centres, and be better prepared for and better respond to the general practitioner team capacities have been challenges we face now and those we will face in the strengthened with the part-time employment of an future. additional registered nurse who is responsible for Foreword by Milan Krek, Director of the National Institute of Public Health Public health has a very long tradition in Slovenia. In line with the European guidelines, we have It dates back into the 18th and 19th century when successfully introduced three cancer screening pro- several scientific works addressing public health grams (ZORA, DORA, Svit Program). We also upgra- challenges have been published. Through the esta- ded public health approaches at primary health care blishment of the first community primary health- with targeted measures to manage four lifestyle risk care centre in Lukovica in 1927 and the work of the factors (smoking, excessive alcohol consumption, brothers Bojan and Ivo Pirc, Slovenian public health insufficient physical activity and unhealthy diet) - reached 21st century through numerous milestones. first through the development of health education centres, and in the next decade through strengthe- The Resolution on the National Health Care Plan ning the family medicine team with a registered nurse 2016-2025 »Together for a Society of Health« states who performs screening for noncommunicable dise- that it is necessary to strengthen public health in ases and performs regular checks of well-managed Slovenia and adopt a strategy for the development chronic patients. of public health activities. To this end, between 2017 and 2019, the Republic of Slovenia conducted an I am honoured to be able to serve as director of the extensive self-assessment of the essential public National Institute of Public Health in these turbulent health operations, EPHO, which provides the basis times, in the midst of the first serious pandemic after for the strategy. The COVID-19 pandemic has shown the Spanish flu. I am especially proud of how success- that the need to strengthen public health system is fully Slovenia has prepared the COVID-19 vaccination now greater than ever. campaign and that to date over 1,000,000 people have been fully vaccinated. The COVID-19 pandemic The health care system contributed a significant in Slovenia is well managed by following and upgra- share to the fact that life expectancy in 2019 was ding the recommendations of international health extended to 81.6 years, which puts Slovenia at the organizations. level of Germany and Denmark. In general, Slovenia has a strong public health system, which is well inte- The present publication describes the building grated into the national public healthcare infrastru- blocks of successful and intensive development of cture. The most important developmental improve- public health in the years after Republic of Slovenia ments in public health were the introduction of new gained its independence, and I hope this will conti- health education, promotion, prevention and scre- nue also in the future. ening programs as well as public health measures at the population level (legislation, intersectoral coordinated programs and measures to protect and promote health by acting on health determinants, national programs to reduce the burden of certain diseases and conditions - cancer, diabetes, obe- sity, HIV / AIDS, rare diseases, mental health). With the latter, we were able to significantly reduce the burden of premature mortality, mainly in the area of cardiovascular disease and suicide. 01 HEALTH IN SLOVENIA 1.1 Core health indicators in Slovenia in comparison with EU-27 1.2 Health in the municipality - health card for each Slovenian municipality 1.3 Upgrading of the programme Health in the Municipality at Gorenjska 1.4 SI-PANDA – survey on the impact of the COVID-19 pandemic on people’s lives 1.5 National population health surveys in Slovenia 1.6 Inequalities in health 1.7 Health-related behaviours among adolescents 1.8 Workers' health surveillance Core health indicators in Slovenia in comparison with EU-27 Metka Zaletel, Tatjana Kofol Bric Comparing Slovenia with European Union Member States, Slovenia ranks around the average of EU-27 in most of the health indicators. Slovenia is one of the most successful countries for several indicators, e.g., infant mortality, and on the contrary, there are few health indicators where Slovenia still remains as one of the countries with worst outcomes (e.g., suicide mortality) in spite of significant improvements in the last decade. Life expectancy has increased faster than the EU-27 average for male and female during the last decade; share of people that assess their health as good or very good, is still lower than the EU-27 average, despite an increase in recent years. The health status of a population is the result of Eurostat predicts a decrease in life expectancy in a complex interaction of many factors. Due to the Slovenia by approximately one year as a result of changes of general well - being, better control of risk the pandemic. In the same period (until 2019), life factors, research and development in medicine, and expectancy in the European Union increased by 1.4 better access to healthcare, health of population is years, more in male (1.7 years) than female. Prelimi- improving in all EU-27 countries. The pace of impro- nary estimates for pandemic consequences are not ving health and reducing health inequalities in most available for EU. countries depends on investment in the health and social system, changes of access to health services, An indicator that is often used to generalize the and health prevention and promotion in the country. health status of the population, which is influenced Comparing to EU-27 countries, Slovenia ranks close by many different factors, is self-assessed health. to the average in most indicators, is very success- Self-assessed health is a qualitative indicator of ful in some health indicators (e.g., infant mortality), personal perception of health that is widely used in and still remains at the tail end of the EU-27 in some medical, psychological, and clinical research. Perso- indicators (e.g., suicide mortality rate). The entire nal perception of health is supposed to reflect the spectrum of health and health care is best illustrated biological, socio-economic and psychosocial dimen- by few indicators presented later. sions of an individual's health, which is determined by the response to one question. Slovenia traditionally Life expectancy is one of the core indicators that ranks just below the average of EU-27 in the share of embrace health status of the population and functi- people who assess their health as good or very good oning of the health care system. It increased by 2.1 with slight increase during the last decade. years (to 81.5 years) in the period 2010–2019, incre- asing more in male (by 2.6 years) than female (by 1.7 years). Based on preliminary estimates for 2020, 86 84 82 80 78 76 74 72 70 Figure 1: Life expectancy by gender, Slo- 68 venia and EU-27, 2002–2020. Source: Eurostat database, downloaded on 3 66 June 2021 Note: estimate for Slovenia 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 for 2020 is based on excess mortality in 2020, estimate for EU-27 in 2020 is not available. Male - EU-27 Male - SI Female - EU-27 Female - SI 12 Source: Eurostat database, downloaded on 3 June 2021 Note: estimate for Slovenia for 2020 is based on excess mortality in 2020, estimate for EU-27 in 2020 is not available. An indicator that is often used to generalize the health status of the population, which is influenced by many different factors, is self-assessed health. Self-assessed health is a qualitative indicator of personal perception of health that is widely used in medical, psychological, and clinical research. Personal perception of health is supposed to reflect the biological, socio-economic and psychosocial dimensions of an individual's health, which is determined by the response to one question. Slovenia traditionally ranks just below the average of EU-27 in the share of people who assess their health as good or very good with slight increase during the last decade. Figure 2: Proportion of persons who assess their health as good or very good, by gender, Slovenia and EU-27, 2019 Male - EU Male - Slovenia 71.1 % 69.7 % The main causes of mortality describe the health More information on health in Slovenia is available in status of the population quite well when com- online sources: paring Slovenia with other countries. Age-stan- OECD/European Union (2020), Health at a Glance: dardized mortality rates in Slovenia are near to Europe 2020: State of Health in the EU Cycle, OECD the EU-27 average, the ranks of the main causes Publishing, Paris, https://doi.org/10.1787/82129230-en. of mortality (circulatory, cancer and respira- tory diseases) do not differ from countries with OECD/European Observatory on Health Systems and similar features. Slovenia has one of the highest Policies (2019), Slovenija: Zdravstveni profil države mortality rates due to external causes of death, 2019, State of Health in the EU, OECD Publishing, Paris/ which includes accidents (transport and other), European Observatory on Health Systems and Policies, suicides and other similar causes. Large proportion Brussels. of external causes of death are attributed to suici- des, where Slovenia remains one of the countries Eurostat Database: https://ec.europa.eu/eurostat/ with the highest burden. data/database Zdravstveni statistični letopis Slovenije 2019: https:// www.nijz.si/sl/publikacije/zdravstveni-statisticni-leto- pis-2019. Male - EU Male - Slovenia Mal Malee -- EU EU Mal Male Male e - -S-Sllo ovve EU en ni iaa Male - Slovenia 71. 71. 1 % 1 % 69. 69. 71. 7 % 7 % 1 %69.7 % 69.7 % FFem emaalle e - - EU EU FFem emaalle e - -SSllo ovveen ni iaa Female - EU Fem F ale em - al EU e - Slovenia Female - Slovenia 66. 66. 2 % 2 % 63. 63. 7 % 7 % 66.2 % 66.2 % 63.7 % Figure 2: Proportion of persons who 63.7 % assess their health as good or very good, by gender, Slovenia and EU-27, 2019. Source: Eurostat database, downloaded on 3 June 2021 13 S Soouurrccee:: E Euurroossttaatt d da attaabbaassee, , ddoow wnnllooaaddeedd o onn 3 3 Ju Jun nee 2 2002211 Source: Eurostat database, downloaded on 3 June 2021 Source: Eurostat database, downloaded on 3 June 2021 T Thhee m m ain ain c c au aus sees s oof f m moort rt ali alit tyy d de essccrib ribe e t thhee h he ealt alth h s sttat atuuss o o f t f thhee p pooppuulat lati ioonn q quuititee w we ell w ll whheenn c coom mpparin aring g SSlo lov veennia ia w witithh o ot thheer r c coouunnttrie ries s.. A Ag gee--ssttan anddard ardizizeedd m moort rt alit ality y rat rate ess in in SSlo lov veennia ar ia are e nneeaar r to to th th e E e E U U- -27 27 av ave erag rage e,, t thhee ran rank ks s oof t f thhee m m ain ain c cau aus seess o of f m moorrttalit ality T y ( h (cecirc ircu m ull ainat ato c ory ry, au , cs cean an s cocee f r an r an m d o d rt re res alitspp y irat irat d oesocry ry d dis rib ise e ea t as h seeess) h )e d doo alt n no h ot stt atus of the population quite well when comparing The main causes of mortality describe the health status of the population quite well when comparing ddiffe iffe r fro r fro m m c coouunnttrie ries s w witithh s s im im ilar fe ilar fe at atuure res s.. S Sl loov S veen lovnia h ia h en as as ia o o w nitnehe o ootf t f thhehee r h hco ig igh u he n eststt rie m mso . o Art rtg alit alit e y-s yt rat rat anedess d du ard ue iz e e tdtoo mortality rates in Slovenia are near to the EU-27 Slovenia with other countries. Age-standardized mortality rates in Slovenia are near to the EU-27 e exxtteern rn al al c c au aus seess ooff d de eat athh, , w whhic ichh in inc clu luddeess ac acc cid ide en avntetss ( (tt rag ran ran e, s t sphpoeort rt an an ran d ksd ootth f thee h r) r), e , s su m uic ic ain id ide c ess au an an s d es d o o otf thhe m eor s r srit im m alitilar ilar y ( circulatory, cancer and respiratory diseases) do not average, the ranks of the main causes of mortality (circulatory, cancer and respiratory diseases) do not c caauuse se s. s. L Larg arge e p pr rooppoort rt io ionn o of f eexxtteern rn al al c cau aus sees s oof d f de e d at athh iffe ar are e at at r frot t m rib ribu c ut o te u ednd t too s rie su s uic icw id ide it es h s, s, w wh imheere re S Sl lo ilar feovve at en u nia r ia r re e s. em m Sl ain ain ovs es nia has one of the highest mortality rates due to differ from countries with similar features. Slovenia has one of the highest mortality rates due to oonne e ooff th th e c e coouunntr tri ies es wi wi th th th the e hhiigh ghe esstt b buurrddeenn.. external causes of death, which includes accidents (transport and other), suicides and other similar external causes of death, which includes acccau id se en s.ts L (arg t e ran psrpooprtortio and n o ot f heextr)e,rn sualic cau idesses anodf d o etat he h ar r si em att ilarrib uted to suicides, where Slovenia remains ca M Muoor se ree s. in inL fo for argrm mea at p trio ion o n p oonn rt h he io e n al alt othfh in in ext S Selo lov ve rn en alnia is ia is cau a asvevsailab ailab of d le lee in in at ohonn arlin line e e s so attouurc rc ribeuests: e: one of the countries wi d ttho th su eic hidigh es, es w t b he ur re d Selno.v e nia remains one -o f- th O OE EC e c CDoD/u/EnEuur tri roop espeean an wi Un Un th th io ion e nh ( (2 i 2002 gh 20e0)s,t), H H b eueralt alt d hehn at at . a G a Gl laannccee:: E Euurrooppe 2 e 2002200:: S S ta ta te o te of f H H ea eal lth th i inn th th e E e E U U CCyyccle le, , O OE ECCDD PPuubblis lishhin ing g,, P P ar arisis, , hhttttppss:/ :// /ddooi. Mi.ooorrrgg/ e /110 in 0.. fo 178 178 rm 7/ 7/ at 82 82 ion12 12 o 92 92 n 30 30 h -e -en en al .t h. in Slovenia is available in online sources: More information on health in Slovenia is available in online sources: - - O OE ECCDD//EEuurrooppeean an O Obbsseerv rva attoory ry o onn H He ealt althh S Sy ysstteem ms s an andd P Pooliliccie ies s ((22001199),), S Sl loovveennijijaa:: Zd Zd rav ravs sttvveenni i pprroofil fil ddrž rž av ave e 22001199, , SSttat ate e oof f HHeealt althh in in t thhee EEU, U, - O OE ECCD O D E PPuCubDb/lis lisEhuhrin ing o g, p,e PParis aris an / /EEu Un uioro rop n pe (e2an an 02 O Ob 0)bs,see H rv rve at ato altorhryy oon at n a Glance: Europe 2020: State of Health in the EU - OECD/European Union (2020), Health at a Glance: Europe 2020: State of Health in the EU HHeealt althh S Sy ysstteem ms s an andd PPooliliccie ies s,, Bru Brus sseelsls. . Cycle, OECD Publishing, Paris, https://doi.org/10.1787/82129230-en. Cycle, OECD Publishing, Paris, https://do-i .or O g/E1C0D./Eu 178 ro 7/ pe 82 an 12 O 92 bs 30e-rva en. t ory on Health Systems and Policies (2019), Slovenija: Zdravstveni - OECD/European Observatory on Health Sy p st ro e fil ms drž an av d e P 2 o 0li1 c 9 ie ,s S (tat 20e1 o 9)f, H Selalt ov h e ninij at:he E Zd U, rav O stEvCeDn iP ublishing, Paris/European Observatory on profil države 2019, State of Health in the EU, H e O alt EC h D SPyusbtem lish s an ing, dP Poli aris c / ie Eus, Bru rope ss an e ls O .b servatory on Health Systems and Policies, Brussels. Health in the Municipality - health card for each Slovenian municipality Ada Hočevar Grom, Victoria Zakrajšek Every year the National Institute of Public Health (NIJZ) presents a set of indicators and key information on the health of the inhabitants of each Slovenian municipality. The purpose of the project is to strengthen health and prevent disease in the local environments where people live and work, and to make health information more accessible. All data and graphic displays are available at http://obcine.nijz.si. The health of the population in the local All the data are available at http://obcine. community is the foundation of a healthy nijz.si, where they are updated once a and prosperous society. There are 12 year and supplemented with new con- statistical regions in Slovenia, which tent. We can thus present the most include 212 municipalities that differ sig- important public health challenges for nificantly in terms of health indicators. different population groups. The main The project “Health in the Municipality” aim is to encourage action at local level. was created in 2015 in order to reduce The regional units of the NIJZ provide inequalities in the health of the Slove- professional support to local decision- nian population. -makers, play an important role in data interpreting and are involved in formu- “Health in the Municipality” is an online lating effective strategies at the local tool containing a set of 36 health indi- level. cators for each municipality, which are comparable among the different muni- The usefulness and convenience of this cipalities, as well as with the regions online tool has already been recogni- and the Slovenian average statistics zed in many municipalities, which is and which also shows the time trends. confirmed by regular evaluations. The A so-called “health card” is available annual data releases receive great with a summary of the current situation, attention from the media, mayors and along with a short four-page booklet other important actors at the local and with related content, interactive maps national levels. and a table with all the data are cre- ated for each municipality. Data from In 2020, the NIJZ together with the lea- NIJZ databases and external instituti- ding Slovenian project for the monito- ons are used (such as from the Faculty ring of the local level of development, of Sports at the University of Ljubljana, “Zlati kamen”, for the second time awar- Cancer Registry at the Oncology Insti- ded the honorary title of “Municipality of tute, Public Road Safety Agency, Social Health” to a municipality that recognized Protection Institute, Ministry of Finance health as an important value and stood and Statistical Office of Slovenia). out in terms of activities to improve the health of its inhabitants. The contents of the website are inten- ded primarily for local decision-makers, mayors, employees of health centres and educational institutions, repre- sentatives of various associations and non-governmental organizations, who can influence community decisions and participate in creating a healthy envi- ronment. 15 Upgrading of the programme Health in the Municipality at Gorenjska Alenka Hafner The Health in the Municipality programme, which is taking place at the national level, was upgraded by the Kranj Regional Office of the National Institute of Public Health in 2018 with the publication Health in the Municipality of Jesenice, which contains a detailed analysis of health status, lifestyle factors and healthcare, as well as proposals for measures to improve, protect and strengthen health. Based on the proposals, decision-makers committed to take health into account as a key criterion when making decisions in local policies. In 2020, the monograph Health in the Municipality with Trends and Challenges was prepared for each municipality in the region of Gorenjska. In 2016, the National Institute of Public Health (NIPH) decisions in local policies. Various institutions will issued the publication Health in the Municipality be involved in the implementation, from healthcare, for the first time for all 212 Slovenian municipalities. education, social services and economic instituti- From the very beginning, the Kranj Regional Office ons to local communities, civil society organizations of the NIPH has been actively involved in improving and associations, while empowered members of the national publications, and in 2018 it prepared Health community will also take part in the decision-ma- in the Municipality of Jesenice, which represents an king processes. It is no less important for them to be upgrade of the Health in the Municipality programme aware that the better health of the population will for the local environment. Numerous health indica- contribute to the economic and social development tors suggested that the health of the citizens of this of the municipality, and especially to a better quality municipality, which has a population of just under of life for residents. The document now represents 21,000 (or 10% of the population of Gorenjska region), the basis for the preparation of similar publications and a lower level of average educational attainment, for other Slovenian municipalities. is on average worse than in its region overall, and it also has the highest socio-economic deficit. In view In 2020, a monograph Health in the Municipality with of this finding, the Kranj Regional Office decided to Trends and Challenges was prepared for each of the cooperate with the municipal leaders in making an 18 municipalities in the region of Gorenjska. All publi- in-depth multi-year analysis of health status, life- cations are published on the regional website, and style factors and healthcare, preparing proposals thus accessible to the professional and lay audien- for measures to protect and strengthen health and ces in the region and the wider environment. presenting them to decision-makers at the muni- cipal level. In particular, they highlighted the impor- tance of reducing health inequalities and adopting a community-based approach to health. Based on this document, the decision-makers committed to taking health into account as a key criterion when making 16 SI-PANDA – survey on the impact of the COVID-19 pandemic on people’s lives Ada Hočevar Grom, Andreja Belščak Čolaković, Maruša Rehberger, Darja Lavtar Since December 2020, the National Institute of Public Health (NIJZ) has been conducting a behavioural insight survey on the impact of the COVID-19 pandemic on people’s lives (SI-PANDA). The aim of the research is to understand human behaviour in relation to COVID-19 and to assess “pandemic fatigue” during COVID-19 pandemic in Slovenia. The results of the study showed that the population of Slovenia exhibited signs of such fatigue, and that the pandemic had a most negative impact on younger groups of the population due to its syndemic potential. The results of the study are available at: https://www.nijz.si/sl/izsledki-panelne-spletne-raziskave-si-panda. The aim of the research is to understand the beha- In Slovenia, we will continue to face the long-term viour of people in relation to the COVID-19 pandemic consequences of the COVID-19 pandemic. This is not and to assess pandemic fatigue1. Understanding only because of the large number of people who have people's behaviour enables the identification of been ill or died from the disease, but also because of target groups who are at risk and helps to find solu- its syndemic impact. It is therefore crucial that steps tions that encourage better compliance with the are taken in time in the areas of healthcare and social recommendations for protective behaviour. protection, as well as in other areas, to prevent an increase in health inequalities among future genera- The SI-PANDA study has been conducted since 4 tions (Bambra et al., 2020). December 2020 in the form of a panel online survey with repetitions once every two weeks, and once a month since June 2021. Each wave of the online survey involves a sample of about 1,000 adults aged Bambra C, Riordan R, Ford J, et al. The COVID-19 pandemic and health inequa-18 to 74 years (inclusive). In the survey, we use the lities, J Epidemiol Community Health. 2020; 74: 964–86. World Health Organization (WHO) questionnaire, which was adjusted to the situation in our country, and the WHO methodology2. 1_Fatigue is a natural and expected response to a long-lasting public health crisis that has a significant impact on the individual’s everyday life. It arises gradually and is influenced by an individual’s feelings, experiences and The survey results show that signs of pandemic fati-views. Over time, the compensatory mechanisms people use to combat a gue are already appearing in general population of crisis situation begin to exhaust themselves. The resulting demotivation is also reflected in reduced awareness of the risks associated with COVID-19, Slovenia. The COVID-19 pandemic has worsened the unwillingness to receive information and failure to engage in self-protective population lifestyle, as well as contact with personal behaviours. Pandemic fatigue is a serious threat to the success of measures physicians and people's mental health. The nega-to prevent the transmission of SARS-CoV-2 infection among the population. tive impact of the pandemic is especially noticeable 2_Survey tool and guidance: behavioural insights on COVID-19. Available among the younger population, which indicates that at the website: https:/ apps.who.int/iris/bitstream/handle/10665/333549/ WHO-EURO-2020-696-40431-54222-eng.pdf?sequence=1&isAllowed=y. while the disease itself had more of an impact on the elderly, the consequences of pandemic control mea- sures affected mainly younger groups, whose finan- cial situation was also deteriorated. 17 National population health surveys in Slovenia Tina Zupanič, Darja Lavtar National surveys in the field of health and healthcare are an important source of data on the health status of the population, the use of various healthcare services and health-related behaviours. In the last 10 years, the National Institute of Public Health (NIJZ) has gained valuable experience by using mixed survey modes and introducing web surveying. The NIJZ conducts national surveys in the field of of the Population of Slovenia (2019), the National health and healthcare among the adult population of Health Literacy Survey (2020) and other smaller stu- Slovenia and school-aged children and adolescents, dies. which are an important source of data on the health status of the population, the use of various health- In 2020 and 2021, the NIJZ conducted several surveys care services and health-related behaviours. Nati- on the impact of the COVID-19 pandemic (SI-PANDA, onal cross-sectional surveys on a sample of target the first longitudinal HBSC survey). population, unlike administrative databases, give us In the last 10 years, the NIJZ has gained valuable expe- a more general and broader insight into the health of rience by using mixed survey modes among the adult the population. population (such as combining web and face-to-face Representative data for Slovenia and internatio- surveys in EHIS and ATADD surveys or combining web nal comparability were provided by the following and mail surveys in CINDI and SI-PANDA surveys) and surveys: European Health Interview Survey (EHIS; introducing web surveying among school children implemented in 2007, 2014 and 2019), Health Beha- and adolescents (such as HBSC, School Scheme). viour in School-Aged Children (HBSC; implemented The use of web surveys, whether alone or in a com- in 2002, 2006, 2010, 2014, 2018, 2020) and National bination, reduces the cost of conducting the survey, Survey on the Use of Tobacco, Alcohol and Other and these methods also allow for reaching a more Drugs (ATADD; implemented in 2012 and 2018). mobile and younger population, which is not possible with traditional modes of surveying (face-to-face, by The research CINDI Health Monitor (CINDI; imple- mail, by telephone). This ensures adequate repre- mented in 2001, 2004, 2008, 2012, 2016, 2020) is not sentation of individual subpopulations in the col- internationally comparable, but it represents a survey lected data, achieves the desired response rate and with the longest tradition in the field of public health increases the reliability of population estimates. survey research in Slovenia, and therefore provides important temporal insight into changes in health in In the last 5 years, the NIJZ has given a lot of atten- the last 20 years. tion to the qualitative aspect of preparing survey questions and answers, as questionnaires are tested Research was also carried out in narrower content before data-collection is conducted, which includes areas, such as the Slovenian National Food Consu- cognitive testing of new questionnaires (or parts mption Survey on Children (infants and toddlers), thereof) and pilot field testing. adolescents, adults and elderly (2007, 2017), the National Survey of Sexual Attitudes and Lifestyles By tracking progress in conducting survey research, (2001, 2016), School Scheme (yearly implementation the NIJZ provides quality data for indicators used for from 2009 onwards), the research Determining the national and international comparisons. Urine Levels of Sodium and Potassium in the Adult Population of Slovenia (2012), the Survey on the Use of Illicit Drugs, Tobacco and Alcohol among Prison Population (2015), the National Oral Health Survey 18 Inequalities in health Mojca Gabrijelčič Blenkuš Inequalities in health are a similarly challenging public health problem in Slovenia as elsewhere in the world, despite one of the smallest Gini indexes in the world. Regular monitoring is key to addressing and reducing health inequalities. In the last ten years, Slovenia has switched from reporting on inequalities based on the results of selected indicators to reporting on the impact of social determinants and sectoral measures on the occurrence of inequality, in accordance with the 2011 Rio Political Declaration on Social Determinants of Health1. The WHO European HESRi2 tool was tested and a lot of experience from the EU space, from JAHEE3 and the EuroHealthNet partnership was used in performing those tasks. In 2011, NIJZ published the first modern review publi- cation on health inequalities (Buzeti et al., 2011) and Ministry of Health defined “socio-economic inequalities in health” as “those differences in health conditions between social groups with different socio-economic status NIJZ that can be prevented and are unfair. In 2018, a inistry of the Environment M and Spa�al Planning ARSO OI second publication was dedicated to health inequali- ily, ties, showing inequalities during the economic crisis shared, joint data, , s s r e� (Bajt et al., 2019). It showed that in Slovenia, compa- knowledge and abour, Fam ortuni�es L ffairs and p IRSSV methodologies A p IER f l red to other EU countries, we managed to maintain o O y a l r i t c a s i o S u q relatively good health of all population groups even n i E M A ily, Social Affai D inistry of Labour DED M during the economic crisis, without increasing the VALUE Famand Equal Opportuni gap, despite relatively low health expenditures. On UMAR MULTID the other hand, population as a whole made less pro- ISCIPLINARY LEVEL gress in health than other comparable countries of Governmental level EU. MULTISECTORAL LEVEL In the third publication Inequalities in Health - Future Challenges in Intersectoral Cooperation (Gabrijelčič Figure 1: Collaboration of national institutions Blenkuš et al., 2021), published in 2021, we showed that cross-sectoral cooperation can run better if Buzeti T, Djomba JK, Gabrijelčič Blenkuš M, et al. Health Inequalities in Slove-competent central national sectoral institutions work nia. National Institute of Public Health; 2011. Available from: https://www.nijz. together to prepare arguments for individual policies si/sites/www.nijz.si/files/publikacije-datoteke/health_inequalities_in_slo-venia.pdf. or measures to support multisectoral work. Report in 2021 was prepared in close cooperation of experts Bajt M, Lesnik T, Farkaš-Lainščak J, et al. Examining Health Inequalities in Slovenia during the Financial Crisis, Key Takeaway Messages. National Institute of from the NIJZ, the Institute for Economic Research Public Health; 2019. Available from: https://www.nijz.si/sites/www.nijz.si/files/ (IER) and the Institute of the Republic of Slovenia for publikacije-datoteke/povzetki_examining_health_krajsa_angleska_2019_ elektronska_izdaja_2.pdf. Social Welfare (IRSSV) with the cooperation of the Office of the Republic of Slovenia for Macroecono- Gabrijelčič Blenkuš, M., Kofol-Bric, T., Zaletel, M., Hočevar-Grom, A., & Lesnik, T. (Eds.). Inequalities in Health - Future Challenges in Intersectoral Cooperation. mic Analysis and Development (IMAD). In the process Nacionalni inštitut za javno zdravje, 2021. Available from:: https://www.nijz.si/ of preparing the publication, a Steering Committee sites/www.nijz.si/files/publikacije-datoteke/neen_strokovna_monografija_ eng_e-verzija_5_7_21_obl_1.pdf from representatives of relevant sectors was establi- shed, which monitored the preparation and provided guidelines. With the preparation of the third publica- 1_https://www.who.int/sdhconference/declaration/Rio_political_declara-tion, we tested the operation of the Platform of nati- tion.pdf onal institutions (Figure), which we want to pilot in 2_https://www.euro.who.int/en/health-topics/health-determinants/social-the next five-year period and check the possibilities -determinants/health-equity-status-report-initiative of institutionalization in the future. 3_Joint Action on Health Equity in Europe https://jahee.iss.it/ 19 Health-related behaviours among adolescents Helena Jeriček Klanšček, Vesna Pucelj, Tina Zupanič Since 2002, the National Institute of Public Health (NIJZ) has been systematically measuring and analysing the situation, trends and comparisons in the context of the International HBSC Survey of 11-, 13- and 15-year- -olds. Based on these findings, we are planning programmes and measures for protecting and strengthening the health of children and adolescents. In 2018, we also included 17-year-olds for the first time, which allowed us to gain a more comprehensive insight into behaviour during adolescence. In 2019, we also conducted a survey among adolescents who do not attend school and are not employed. Recent decades have seen many significant deve- to alcohol, tobacco, nutrition, mental health, inju- lopments in the field of research into the health of ries and other areas. 17-year-olds were included in children and adolescents. Slovenia participated in this survey for the first time in 2018, which gave us the regular monitoring of international indicators an insight into health-related behaviours in this age of health, social context, current challenges and group, about which we normally have less data, as health-related behaviours by taking part in the inter- this group is mostly not included in research on ado- national survey Health Behaviour in School-Aged lescents or adults. This allowed us to fill an existing Children (HBSC1). HBSC is a survey conducted every gap in data. In 2019, for the first time, we conducted four years under the auspices of the World Health a customized survey among dropouts and young Organization among 11-, 13- and 15-year-olds atten- adults attending the programmes Project Learning ding school in more than 40 countries, which provi- for Young Adults (PUM-O). The term dropouts deno- des an assessment of the situation in the country, tes adolescents who do not attend school and are comparisons and monitoring of trends over the years not employed. This is a particularly vulnerable group and international comparisons. Slovenia joined the among adolescents and young adults, about whom survey in 2002 and conducted surveys in the years we have very little data on health and health-related 2002, 2006, 2010, 2014, 2018. Our special achieve- behaviours. The data are also difficult to obtain, so ments include2 the annual reports and the first policy they are even more valuable to provide insight into brief for political decision-makers in 2012, which the situation and plan further activities to help this provided a brief but comprehensive overview of the population. health status of children and adolescents, as well as proposals for measures. The findings and proposals In 2020, just before the second wave of the COVID- for measures were presented to representatives of 19 epidemic in Slovenia, we also conducted the first three ministries – the Ministry of Health, the Mini- longitudinal HBSC survey to determine what impact stry of Education, Science and Sport and the Mini- the first wave of the epidemic had on Slovenian ado- stry of Labour, Family and Social Affairs. This publi- lescents. cation, along with other publications presenting the situation, trends and inequalities, was an important starting point for the preparation of various national 1_For more information about the HBSC survey, please visit the website: http://www.hbsc.org/. documents and also for planning and evaluating vari- 2_The above-mentioned publications are available on: https://www.nijz.si/ ous measures and programmes in Slovenia related sl/z-zdravjem-povezana-vedenja-v-solskem-obdobju. 20 Workers' health surveillance Ticijana Prijon The health of workers is a major and growing public health problem, especially in terms of the negative effects of work on the health of employees and the ageing of the working population. For years the health of workers has been excluded from shaping the vision and strategy of public health. Therefore, the NIJZ has been forced to establish a new field of expertise aimed at studying the health of workers as well as workplaces. The size of the problem is reflected by the fact that Within the framework of set tasks, the professional in 2020 more than 12,300,000 working days were contents of the »National Platform for the Promo- lost due to sick leave, and expenditures for health tion of Occupational Health« (PZD) have also been insurance benefits amounted to more than €440 mil- prepared. The basic aim of PZD (https://pzd.razvoj. lion, which represents about 13% of all expenditures dev/) is to raise awareness and inform employers, of the Health Insurance Institute of Slovenia (ZZZS). employees, experts and other stakeholders about In addition, we note that in Slovenia there are cur- the benefits and methods in the promotion of health rently no developed systems or established mecha- in the workplace. With PZD we also want to improve a nisms to assist in the reintegration of workers after healthy working environment as well as the physical long-term sick leave, nor any effective early vocatio- and mental health of employees, reduce health-re- nal rehabilitation programmes. lated absenteeism and work disability and thus the cost of benefits, reduce the number of occupatio- The basic field of work within the framework of wor- nal injuries as well as occupational and work-related kers' health consists of an analysis of causes, disse- diseases, reduce presenteeism in Slovenian compa- mination of data and preparation of publications on nies and consequently increase employee satisfa- health-related absenteeism, promotion of health in ction and productivity. the workplace and participation in interdisciplinary interdepartmental working groups to ensure the safety and health of employees in the Republic of Slovenia. Through an analysis of long-standing trends in Prijon T. Zdravstveni absentizem zaradi z delom povezanih kostno-mišičnih health-related absenteeism (as part of the PKMO obolenj in duševnih stresnih motenj v Sloveniji. Primerjalna analiza začasne nezmožnosti za delo v letih 2015 in 2019. National institute of Public Health, project), the incidence of work-related musculoske-2020. Available from: https://www.nijz.si/sites/www.nijz.si/files/uploaded/ letal disorders (MSDs) and psychosocial risks (PSRs) pkmo_analiza_bs_zaradi_z_delom_povezanih_kmo_in_dusevnih-stres-nih_motenj.pdf. was identified in relation to the burden and chara- cteristics of individuals and workplaces in various Prijon T. Najpogostejša z delom povezana kostno-mišična obolenja po anatomskih regijah. National Institute of Public Health, 2020. Available from: economic activities and health regions. The analysis https://www.nijz.si/sites/www.nijz.si/files/uploaded/pkmo_najpogostejsa-k-represents a direct connection between the actual mo-po-anatomskih-regijah.pdf. prevalence of the most common forms of MSDs and Prijon T. Duševne in vedenjske motnje v luči začasne nezmožnosti za delo. PSRs among employees in Slovenia that are related Primerjalna analiza zdravstvenega absentizma v letih 2015 in 2019. National to work, on whose basis employers, in cooperation Institute of public Health, 2020. Available from: https://www.nijz.si/sl/publikacije/dusevne-in-vedenjske-motnje-v-luci-zacasne-nezmoznosti-za-delo-with occupational safety and health experts, can -primerjalna-analiza. plan preventive measures and other activities for averting and managing issues and risks in this area in a direct and targeted way (Prijon, 2020). 21 02 HEALTH POLICIES, STRATEGIES, NATIONAL PROGRAMMES AND INTERSECTORAL COOPERATION FOR HEALTH 2.1 National Cancer Control Programme 2.2 Managing diabetes: from strategy 2010–2020 to strategy 2020–2030 2.3 National Programme on Nutrition and Physical Activity for Health 2015–2025 2.4 Evidence-informed policy brief for prescribing antibiotics to residents in long-term care facilities 2.5 Comprehensive tobacco control programme in Slovenia 2.6 Approaches to reduce the negative effects of alcohol consumption 2.7 Inclusive public health – the disabled and the elderly 2.8 Public health approaches in cross-sectorial policies: achievements in the field of active and healthy ageing 2.9 Actions on health inequalities of the Centre for Health and Development Murska Sobota 2.10 Community approach to strengthening mental health National Cancer Control Programme Sonja Tomšič, Branko Zakotnik In 2010 and 2017 Slovenia adopted the National Cancer Control Programme (NCCP), which brings together comprehensive measures for controlling cancer in Slovenia. In that period the growth trend of age-standardised incidence of cancer eased off, even declining among men, the survival rates for cancer patients have been improving, and significant shifts have been made in the area of improving quality for cancer patients through integrated rehabilitation and palliative care. During its first Presidency of the Council of the Euro- effectiveness of the healthcare system. In a 10-year pean Union in 2008, Slovenia set cancer as a priority. period the overall survival rate of cancer patients In this way it supported international and national improved by 3 percentage points (5-year net survival efforts to comprehensively address this important for the period 2011–2016 was 58%), principally owing public health issue of modern times. In 2010 the first to the detection of cancer in earlier stages, which National Cancer Control Programme 2010–2015 was was helped significantly by all three cancer scree- adopted, setting out three strategic goals1: ning programmes, which in addition to the two men- tioned earlier include breast cancer screening in the • Slowing down the increase in incidence; DORA Programme. Appropriate and timely diagnosis • Increase survival rates; and treatment also contribute significantly to the survival rate. In Slovenia in general, access to modern • Improve the quality of life for cancer patients. therapeutic options is good. For the most common cancers, we will soon be able to continuously monitor NCCP 2017−2021 sets out strategic and specific the quality of care on the national level. As in 2017 we goals to upgrade the original NCCP 2010−2015, which started introducing so called national clinical regi- was prepared on the recommendations of the Euro- stries, which will contain more detailed data on dia- pean Commission written in the EPAAC2 project. gnosis and treatment. In the ten years of common efforts, we can highlight In order to improve the quality of life of cancer pati- the following achievements and a few challenges. ents we started to upgrade the organisation of inte- The number of new cases of cancer (incidence) is grated rehabilitation, which links together all levels of still growing, but if we exclude the effect of popula- healthcare and thereby enables high-quality services tion ageing, we can see that the growth is less steep, as close as possible to home. In the area of palliative with the trend among men after 2010 even reversing care, we are enhancing the knowledge of all health and decreasing annually by 0.3%. A major contri- workers, with specialised palliative departments butor to this is undoubtedly the introduction and being set up at hospitals along with mobile teams. exemplary functioning of the national screening pro- The third National Cancer Control Programme 2022– grammes (the ZORA Programme for cervical cancer 2026 is currently in the process of being adopted, and the Svit Programme for colorectal cancer), while and it contains ambitious objectives for the future. primary preventive measures have also contributed significantly. There is, however, a worrying trend of growth in lung cancer among women. 1_National Cancer Control Programme 2017−2021. Available at: www.dpor.si The survival of cancer patients is a composite indicator that reflects both the characteristics of pati- 2_European Partnership for Action against Cancer. Available at: http://www. epaac.eu/ ents and the organisation, accessibility, quality and 23 Managing diabetes: from strategy 2010–2020 to strategy 2020–2030 Jelka Zaletel, Jožica Poličnik, Kerstin Vesna Petrič In order to manage diabetes until 2030 it will be necessary to strengthen health literacy; increase empowerment for successful self-management of diabetes and good quality of life; ensure effective clinical guidelines, clinical pathways, protocols of cooperation, supply plans, discharge plans, supply coordinators and case coordinators; offer a community-based approach for health on a municipal level, a new structure or process for harmonisation and connection on a territorial or regional level, and harmonised and connected intersectoral measures on a state level, territorial/regional levels and in local communities. The National Diabetes Management Programme of specialist diabetological activities. In 2020 COVID- 2010–20201 was the first strategic document dealing 19 undermined the health care of people with chro- with the management of diabetes - everything from nic and acute conditions, and interrupted the imple- reducing the incidence of type 2 diabetes and its mentation of programmes to improve health and early detection, to reducing the number of complica- preventive check-ups for early detection of chronic tions and mortality due to diabetes. The related acti- illnesses, and in a social sense it worsened the deter- vities have connected partners of different subject minants of health for certain sections of the popula- fields and occupational groups, the NIJZ, Ministry of tion. As people with diabetes are among those most Health and ZZZS, and representatives of those suffe- at danger, a fundamental development document is ring from diabetes. In this period access to education urgently needed which in the case of diabetes as a has increased, together with the implementation model illness would support and establish strategic of uniform and regularly renewed clinical guidelines action. with the introduction of registered nurses as coor- dinators of care in general practices. In this period, The coordinative group, which harmonised and moni- access to modern medications and medical devices tored the activities of the National Diabetes Manage- has increased. We have seen improved availability of ment Programme from 2010 to 2020, has on the basis the key data and information necessary for monito- of diabetes management trends, a broad discussion ring the management of diabetes. Despite changes and external evaluation, prepared starting points for in lifestyle, we can observe positive shifts concerning strategic guidelines until 2030, on the basis of which a healthy diet and physical activities. the Ministry of Health formed a National Programme for Managing Diabetes 2020–2030, which the Gover- Regardless of these successes, there are still gaps nment of the Republic of Slovenia adopted on 24 which are systematic in nature. There are considera- June 2021. ble differences in health between different parts of Slovenia, a high prevalence of diabetes and a distinct Approaches and tools for realising the common idea increase in its incidence in certain areas and clear of the partners include strengthening health literacy differences between areas. This draws attention to and support for the process of empowerment for the greater health needs of certain populations, the successful self-management of diabetes and good need for public health measures to improve lifestyle quality of life; offering clinical guidelines, clinical factors and factors connected with the health care pathways, protocols of cooperation, supply plans, system in these environments, and the need for discharge plans, supply coordinators and case coor- measures outside health care. Health care, which dinators; using a community-based approach for often demands the inclusion of many experts from health on a municipal level, a new structure or pro- different fields and specialities, and can therefore be cess for harmonisation and connection on a territo- fragmented, is of a high quality only if it is harmonised rial or regional level and harmonised and connected and connected, bearing in mind that the circumstan- intersectoral measures on a state level, territorial/ ces in different parts of Slovenia differ widely. Except regional levels and in local communities. for differences in access to suitable care for people with diabetes on a primary level, there are also huge differences in the diabetological teams, which causes significant differences in access to care on the level 1_https://www.obvladajmosladkorno.si/. 24 National Programme on Nutrition and Physical Activity for Health 2015–2025 Katja Povhe Jemec In 2015 the Slovenian National Assembly adopted the Resolution on the National Programme on Nutrition and Physical Activity for Health 2015–2025 (National Programme 2015–2025) (Ministry of Health, 2015). The purpose of the National Programme 2015–2025 is to improve the dietary and physical movement habits of the population from the early period of life up until late old age. Through it we are seeking to offer equal opportunities for maintaining health for all, including socially and economically more vulnerable groups of the population, to stop and reverse the trend of increasing body mass among people and to aid in reducing the occurrence of chronic diseases. In this way we will also make an important contribution to the quality of life and prosperity of society. Through the National Programme 2015–2025 we are 8. the role of the healthcare system, fulfilling the following strategic goals: 9. education and training and research, • reducing the proportion of the population with excessive body mass and obesity, 10. information and awareness-raising. • reducing the proportion of the population that is Due to the complexity and numerous challenges in physically inactive and has an inappropriate diet, the area of healthy nutrition and regular physical activity, we are pursuing cross-sectoral links, and • increasing the number of children who are breast- seeking synergies with agricultural policy guideli- -fed and reducing the proportion of malnourished nes, with the guidelines of the National Sports Pro- and functionally less capable elderly people and gramme, Strategy of Slovenian Tourism for a Green, patients, Active and Healthy Slovenia, with integrated tran- • increase the availability and demand for foods sport strategies (promoting and facilitating the con- with more favourable nutritional composition. ditions for healthy, active mobility with a reduction in the carbon footprint) and with the social policy Action plans are focused on certain priority areas guidelines for social activation and reducing the risk that require the close and effective cooperation of of poverty. Through cooperation in the area of infra- several departments: structural and environmental policy we are creating an environment that is more favourable for physical 1. ensuring healthy diets in line with guidelines and activity. We are encouraging local communities to recommendations, plan green areas for the promotion of physical acti- 2. improving the range of choices on offer that are vity and to ensure the conditions for healthy, active beneficial for health in cooperation with stakehol- mobility. We wish to reduce the time spent sitting in ders in the food production business and trade the workplace, in kindergarten, at school and home. and in hospitality and tourism, Changing dietary and physical movement habits 3. ensuring the accessibility of healthy dietary cho- is a lengthy process, where only through interde- ices for socially and economically at-risk groups, partmental cooperation can we create the conditi- ons where individuals will want and be able to exert 4. ensuring safe food that is beneficial to health, an influence on over-eating, the incidence of cardi- with emphasis on sustainable local supply and ovascular diseases, cancer and other diseases rela- self-sufficiency, ted to diet and lack of physical exercise, which have a 5. labelling, presentation and marketing of food, major impact on the quality of life for all of us. 6. physical activity for health, 7. an environment that encourages regular physical 1_Ministry of Health of the Republic of Slovenia National Programme on Nutri-activity, tion and Physical Activity for Health 2015–2025. Ljubljana, Ministry of Health of the Republic of Slovenia, 2015. https://www.dobertekslovenija.si/nacionalni-program-2015-2025/. 25 Evidence-informed policy brief for prescribing antibiotics to residents in long-term care facilities Polonca Truden Dobrin, Maja Šubelj, Bojana Beović Physicians in long-term care facilities (LTCFs) often prescribe broad-spectrum antibiotics without adequate prior microbiological diagnostics to treat health complications due to infections. Inadequate antibiotic prescribing poses an additional health risk for vulnerable elderly people, and further contributes to the increased incidence of antimicrobial resistance (AMR). With the help of technical and professional support from the Evidence-Informed Policy Network (EVI- PNet) of the World Health Organisation (WHO) Regi- onal Office for Europe, the WHO Office in Slovenia, the Ministry of Health and the National Institute for Public Health (NIJZ), in cooperation with key field experts, we prepared an Evidence-Informed Policy Brief (EBP) (EVIPNet Europe, 2018). After reviewing the literature, we selected evidence-based options to optimize antibiotic prescribing in Slovenian LTCFs. Residents of LTCFs are often colonized by multidrug- -resistant bacteria against which broad-spectrum antibiotics are not effective. LTCFs are places where the spread of resistant microbes is easy, as residents are unaware of AMR, greater awareness with regard live in a relatively closed environment with limited to such issues is also needed among patients and mobility, have repeated contact with other residents, their relatives/carers. staff and visitors, and are often in contact with the The proposals from the EBP were taken into acco- hospital environment. unt in the preparation of the National Strategy »One Regular monitoring and control of antibiotic prescri- Health« for the control of AMR and the Action Plan for bing and AMR with feedback to prescribers are key the period 2019-2021 (Ministry of Health, 2019). They to improving antibiotic prescribing. In addition, the were also taken into account when planning the acti- development and implementation of appropriate vities of clinical pharmacists at the primary health- guidelines and clinical pathways for diagnosis and care level. treatment, including the consideration of diagnostic criteria for common infections, is important to imp- rove antibiotic prescribing. There is also a need to establish continuing education programs for medical EVIPNet Europe, Evidence brief for policy. Antibiotic prescribing in long-term staff and to provide health information to residents/ care facilities for the elderly. Copenhagen: WHO Regional Office for Europe; patients and their relatives/carers/visitors. Regular 2018. Available from: https://www.euro.who.int/en/health-topics/Life-stages/ healthy-ageing/publications/2018/antibiotic-prescribing-in-long-term-care-training of physicians on the appropriate prescribing -facilities-for-the-elderly of antibiotics and on diagnosing specific conditions Ministry of Health. Državna strategija »Eno zdravje« za obvladovanje odpor-and distinguishing viral from bacterial infections is nosti mikrobov. [National Strategy »One Health« for Microbial Resistance Management 2019–2024.] Ljubljana: Ministry of Health; 2019, Available from: known to improve the use of antibiotics. Because https://www.gov.si/novice/nov-vlada-sprejela-drzavno-strategijo-eno-physicians are often confronted with patients who -zdravje-za-obvladovanje-odpornosti-mikrobov-2019-2024-z-akcijskim-nacrtom-za-obdobje-2019-2021/. 26 Comprehensive tobacco control programme in Slovenia Helena Koprivnikar A comprehensive programme of tobacco control is conducted in Slovenia Following the adoption of a new law in 2017, the percentage of smokers fell in the adult population, and the decline among adolescents continued. There are still a lot of challenges, and these are defined and addressed in the Strategy to Reduce the Consequences of Tobacco Use 2021–2030 (in the confirmation process), which has the long-term goal of a tobacco-free Slovenia in 2040. Slovenia has a 25-year legislative tradition in the area available in pharmacies, and prescription medicines of controlling tobacco. The Restriction on the Use prescribed by a doctor, are covered by the individual. of Tobacco and Related Products Act1, adopted in Programmes and activities to prevent smoking and to March 2017, includes the latest effective measures help people quit smoking are also provided by non- of controlling tobacco, including uniform packa- -governmental organisations. ging. Following adoption of the act, among European countries Slovenia advanced from 28th place to 8th Continued work in the area of controlling tobacco and place on the scale of measures to control tobacco dealing with existing challenges are addressed in the (Joossens et al., 2020), after nearly two decades the Strategy to Reduce the Consequences of Tobacco percentage of smokers fell among the adult popula- Use 2021–2030 (in the confirmation process), which tion in total and among both genders (in 2021 every has the long-term goal of a tobacco-free Slovenia in fifth inhabitant aged 18 to 74 smokes tobacco), while 2040. the spread of smoking continued to decline amongst adolescents (Koprivnikar et al., 2021). The reduction in the spread of smoking was brought Joossens L, et al. The Tobacco Control Scale 2019 in Europe. Brussels: Association of European Cancer Leagues, Catalan Institute of Oncology; 2020. about not just by legislation but also by programmes Koprivnikar H, Korošec A, Rehberger M, Lavtar D, Zupanič T, Rudolf A. Pregled and activities to prevent smoking, the reduction in najnovejših podatkov o uporabi tobačnih in povezanih izdelkov v Sloveniji. Lju-exposure to tobacco smoke and encouraging people bljana: National Institute of Public Health, 2021. to quit smoking, which are conducted as part of preventive healthcare in the context of preventive 1_Restriction on the Use of Tobacco and Related Products Act (ZOUTPI). check-ups, preventive activities and programmes Official Gazette of the Republic of Slovenia, Nos. 9/17 and 29/17. to promote health in health promotion and health education centres, visits by staff from these centres to kindergartens, primary and secondary schools, and programmes such as the Slovenian Network of Healthy Schools and Health in Kindergarten. There are various forms of assistance available in Slovenia to help people give up smoking. In the aforementio- ned centres experts offer free support for giving up smoking in the form of group workshops or individual counselling. Every day from 7 to 10 am and 5 to 8 pm there is a free telephone counselling service at 080 2777, which offers information on giving up smoking and the possibility of guidance over the phone in the process of giving up. Nicotine replacement therapy, 27 Approaches to reduce the negative effects of alcohol consumption Maja Roškar, Sandra Radoš Krnel, Vesna Kerstin Petrič, Nataša Blažko, Marjetka Hovnik Keršmanc Alcohol is one of the key public health problems in Slovenia, so major attention is focused on the development of preventive programmes and measures to prevent and reduce the harm of alcohol, and also to monitor the consequences of alcohol use, as key elements of a successful alcohol policy. Figure 1. Comparison between Slovenia and the average for 30 European countries (28 EU members plus Switzerland and Norway) using a scale of 0 to 100, which tells us the extent to which countries have adopted certain alcohol policy measures, merged into ten action areas for a comprehensive alcohol policy (WHO, 2018). In terms of international comparisons, in the last alcohol, (5) Reducing the negative consequences few years, Slovenia has had greatest success in the of drinking and alcohol intoxication, (6) Health ser- following areas: drink-driving countermeasures, lea- vices response; dealing with hazardous and harmful dership and awareness, the monitoring of alcohol- alcohol consumption and addiction in healthcare -related issues, restricting the availability of alcohol, settings, (7) Community and workplace action, (8) reducing the negative consequences of drinking and Restricting the advertising and marketing commu- alcohol intoxication, and treating hazardous and nication of alcoholic beverages, (9) Reducing the harmful alcohol drinking and addiction in healthcare health impact of the illicit provision and sale of alco- settings. The country has had less success in the hol and informally produced alcohol, (10) Affordability areas of restricting the marketing communication of alcohol, pricing policies. of alcoholic beverages, reducing the impact of the informal production of alcohol and of the illicit provi- Driving under the influence of alcohol sion and sale of alcohol, and reducing the affordabi- lity of alcohol, although other countries are also per- Traffic legislation in Slovenia includes not only restri- forming poorly in these areas (Figure 1, Table 1). ctive measures to combat drink-driving but includes also specific preventive measures. Non-obligatory Figure 1. Comparison between Slovenia and the ave- medical examination with counselling (brief inter- rage for 30 European countries (28 EU members plus vention) was introduced. It is aimed at drivers of Switzerland and Norway) using a scale of 0 to 100, motor vehicles, who drove under the influence of which tells us the extent to which countries have alcohol (0.50 to 0.80 grams of alcohol per kilogram of adopted certain alcohol policy measures, merged blood) and special groups of drivers (e.g. novice dri- into ten action areas for a comprehensive alcohol vers, professional drivers; up to 0.50 grams of alco- policy (WHO, 2018). hol per kilogram of blood). Medical examination with counselling is done by selected general practitioner, Ten action areas: (1) Drink-driving policies and cou- who screens for hazardous and harmful alcohol drin- ntermeasures, (2) Leadership, awareness and com- king and motivates for behavioural change. Based on mitment, (3) Monitoring and surveillance of alco- the examination 4 penalty points can be deleted, but hol-related issues, (4) Limiting the availability of only once every two years. 28 alcoholic beverages, (9) Reducing the health impact of the illicit provision and sale of alcohol and informally produced alcohol, (10) Affordability of alcohol, pricing policies. Table 1: Selected effective measures of alcohol policy (left column) which have been adopted partly or entirely in Slovenia (right column). Preventing driving under the influence of alcohol The gradual reduction of the PARTLY – The highest permitted blood alcohol level is 0.50 grams of alcohol per permitted quantity of alcohol in the kilogramme of blood (ZPrCP). blood of drivers to 0.0 g/l National Programme on Road Traffic Safety 2013-2022 includes not only random breath testing but also educational and awareness raising activities and campaigns to prevent drink-driving. Introduction of 0.0 g/l permitted YES blood alcohol for young drivers, (ZPrCP) public-transport drivers and drivers of heavy goods vehicles Random testing of alcohol content in YES – Drivers can have a maximum of 0.24 milligrams inclusive of alcohol in a litre exhaled breath of exhaled breath, on the condition that even with lower concentrations of alcohol they show no signs of behavioural disturbance that could result in irresponsible behaviour on the road. Professional drivers, public transport drivers, driving instructors, learner drivers, drivers with children and certain other drivers are not permitted to have any alcohol in their organism (ZPrCP). Gradual qualification for a driving YES – Upon having a driving licence revoked for driving under the influence of licence alcohol, drivers are required to attend rehabilitation programmes before taking the driving test again (ZVoz). Limiting the availability of alcohol State control over the retail sale of PARTLY – In order to sell or offer alcoholic beverages at public events, the alcohol (state monopoly on the sale organiser must obtain a permit issued by the administrative unit (ZOPA). Despite of alcohol, introducing licences to the opposition of public health experts and alcohol policy makers, an amendment sell alcohol) to the ZOPA law was adopted in 2017, according to which the sale of alcoholic beverages containing less than 15 volumes of alcohol (permitted beverages are beer, wine, etc.) is again al owed at public sports events. Specific minimum age for the sale YES – The sale and offer of alcoholic beverages to persons under 18 years is and purchase of alcoholic beverages prohibited (ZOPA). Restriction of sales by hour and day YES – The sale of alcoholic beverages between 9 pm and 7 am on the fol owing day is prohibited in shops; the sale of spirits in restaurants and hospitality establishments from the start of the daily opening hours up to 10 am is prohibited (ZOPA). The television sale of alcoholic beverages is prohibited (ZAvMS). Ban on working under the influence YES of alcohol (ZVZD) Reducing the affordability of alcohol Taxation – raising the minimum tax PARTLY – Excise duty has been introduced for beer, intermediate alcoholic rates, in line with inflation, for all beverages and ethyl alcohol. Excise duty has not been introduced for wine and alcoholic beverages, with rates at fermented drinks, i.e. it is set at EUR 0 (ZTro-1). Excise duty is not tied to inflation. least proportionate to the alcohol content. Setting the minimum price of alcohol. Prohibiting special offer and promotional prices. Managing persons with hazardous and harmful drinking and treatment of mental and behavioural disorders due to alcohol consumption Table 1: Selected effective measures of alcohol policy (left column) which have been adopted partly or entirely in Slovenia (right column). Brief interventions for persons with PARTLY – A measure is being implemented under the Drivers Act and as part of the hazardous and harmful drinking, in National Programme of Primary Prevention for Cardiovascular Diseases. Not all Key: ZOPA – Restrictions on the Use of Alcohol primary healthcare and other general/family medicine physicians detect hazardous and harmful alcohol Act, ZVoz – Drivers Act, ZTro-1 – Excise Duty environments consumption, but clinical guidelines exist for early detection and brief measures. Act, ZPrCP – Road Traffic Rules Act, ZZUZIS-A Activities are enhanced through the project SOPA – Together for a Responsible – the Act Amending the Health Compliance Attitude Towards Alcohol Consumption. of Foodstuffs and of Products and Materi- als Coming into Contact with Foodstuffs Act, ZAvMS – Act on Audiovisual Media Services, Treating mental and behavioural YES – Treatment costs of treatment are covered by health insurance. ZVZD – Health and Safety at work Act. Table disorders and other diseases due to taken from the publication Alkoholna politika v Sloveniji (Alcohol Policy in Slovenia, Roškar et al., alcohol consumption 2019). 29 Reducing harm in a drinking environment Increasing the responsibility of those PARTLY – A fine is imposed on a legal entity, the responsible person of the legal serving alcohol entity, sole trader, responsible person of a sole trader performing independent activity and the responsible person of an individual that performs an independent activity, if they serve a person showing signs of intoxication, and on anyone that enables a person under the age of 18 years to drink alcoholic beverages in a public place (ZOPA). Training of serving personnel and PARTLY – Specific programmes have been developed, but legal provisions are not management for responsible serving fully in place. and ensuring safe environments Restricting the marketing communication of alcoholic beverages Complete ban on advertising PARTLY – The advertising of alcoholic beverages containing more than 15% alcohol alcoholic beverages by volume is prohibited. Alcoholic beverages with less than 15% alcohol by volume may not be advertised on the radio or television between 7 am and 9.30 pm, and in cinemas before 10 pm (ZZUZIS-A). Advertising may not appear on panels, boards, posters or illuminated signs that are less than 300 metres from nursery schools and schools (ZZUZIS-A). The advertising message must contain a message about the harmfulness of drinking alcohol. Key: ZOPA – Restrictions on the Use of Alcohol Act, ZVoz – Drivers Act, ZTro-1 – Excise Duty Act, ZPrCP – Road Traffic Rules Act, ZZUZIS-A – the Act Amending the Health Compliance of Foodstuffs and of Products and Materials Coming into Contact with Foodstuffs Act, ZAvMS – Act on Audiovisual Media Services, ZVZD The legislation also in – Health and Safety at wor cludes thr k Act. Table takenee t from ypes of r the publication ehabili Alkoholna - politika van Slo d publish pr veniji (Alcohol ofessional articles. Our wish is for us tation pr Policogr y in Slamm ovenia, es, man Roškar et al., dat 2019).or y to persons who have as a society to be aware that the attitude of future been issued Drivi a ng under r t e he v i oc nflue ation nce of al of cohol a driving license and who parents to alcohol and pregnancy is a reflection of have bee T n se raffic legis nt latio e n n in c S ed f lovenia or driving un includes not only res der the influe trictive measures to conmc b e at drink-drthe br iving but i oader soc ncludes ial attitude to drinking alcohol, and also specific preventive measures. Non-obligatory medical examination with counselling (brief of alcohol. In c intervention) wase of po as introduced. I stpon t is aimed e atm d e riv nt of a r ers of motor ve e v hicoc les, ation who drove und that pr er the influe e ncv e e ofnting pr egnancies exposed to alcohol is a of the driving lic alcohol (0.50 to e 0.8nse the per 0 grams of alcohol son must atte per kilogram of blood) n and on d spec e of ial groups of d comm rivers (e.g.on r novic esponsibilit e y of society. drivers, professional drivers; up to 0.50 grams of alcohol per kilogram of blood). Medical examination with the rehabilitation counsel ing is done bpr y s ogr electeamm d gene es, ral pracbut titionerfir , w stly ho scre he ens fomust r hazardous and harmful alcohol undergo m drinking a edic nd motial e vates f x or amination. The c behavioural change. Based on t ourt dir he examinatio ects n 4 penalty poi MOSA – Mobilising the Communit nts can be deleted, y for Responsibi- but only once every two years. The legislation also includes three types of rehabilitation programmes, the per ma son t ndatory o on to persoe of the thr ns who have been iee r ssued ehabilitation pr a revocation of a driving o lic- ense an lit d w y T ho ho avw e ar bee ds Alc n ohol grammsees: short ntenced for driv er educ ing under the ational w influence of alcoh ork ol. In cshop ase of p s, longer ostponement of a revocation of the driving license the person must attend one of the rehabilitation programmes, but firstly he must undergo medical psychosoc examina ial w tion. Th ork e co shop urt direc s, an ts the p d tr erson e to atm one e of nt of alc the three reh ohol MOSA (Mobilising the Community for Responsibility abilitation programmes: shorter addiction. The above legislation was effective in imp- Towards Alcohol (www.infomosa.si)) , an entity fou- rovement of road traffic safety. nded in 2008, has made an important contribution to identifying alcohol-related issues and reviewing Alcohol and pregnancy approaches to the reduction of the alcohol-rela- ted burden in Slovenia. With the aim of transferring More intensive NIJZ work in the area of alcohol and knowledge, increasing effectiveness and bringing pregnancy began with the project Alcohol and Preg- different alcohol policy actors together, MOSA provi- nancy, which ran in 2013–2014 mainly in the Gorenj- des information on alcohol-related issues in Slovenia ska region and was headed by the then Health Pro- in a transparent way that is accessible to all. MOSA tection Institute (today a unit of the NIJZ) of the Kranj provides the general public and the profession with NIJZ. In the project we linked up a gynaecologist and access to a variety of databases (databases on pre- obstetrician, paediatrician, professional worker at a ventive programmes, research studies, entities and school for future parents from the local health centre organisations, sources of help, publications) and and public health experts from the NIJZ, with the aim to information on current events relating to issues of protecting unborn children from the effects of surrounding alcohol and on approaches to the issue alcohol. On 9 September 2014 for the first time Slo- in Slovenia and around the world (Kamin in Roškar, venia marked the international FASD Day, which bore 2021). the key message: “In pregnancy there is no safe alco- holic drink no safe quantity of alcohol and no safe Development and evaluation of preventive pro- time to drink alcohol. Abstinence is the best decision grammes and interventions to prevent and reduce for a woman who is pregnant, could become preg- the harm of alcohol. nant or is nursing a child.” Since that time, we have marked this day each year, and we have prepared and In Slovenia a range of different preventive and pro- disseminated health education materials to inform motional programmes, as well as interventions, are and raise awareness of future parents and the gene- carried out to address the alcohol problem (MOSA ral public. With the aim of sensitising various expert database includes 70 preventive programmes), but circles (healthcare, social services, hospitality) to for the most part they are aimed at children and ado- this issue, we organise lectures and workshops lescents and their parents, while there is less focus 30 here on young adults and older people – for the most Restricting the digital marketing of alcohol part there is just information and awareness-raising about the alcohol issue, and there is less focus on The growing use of digital media has created new pursuing the goal of changing behaviours, and few opportunities for market communication about vari- such programmes for which there is evidence of their ous products, including alcohol. The marketing com- effectiveness. munication of alcohol encourages adolescents to try out alcoholic beverages in earlier years and in larger For this reason, based on various existing European quantities (Anderson et al., 2009; Kenny in Hastings, documents and portals of good practice, we drew up 2011). For this reason, the NIJZ is actively involved the Criteria for Evaluating Public Health Interventions in European development projects that pursue the with the aim of identifying and selecting examples development of effective legislation in this area, of good practice (Radoš Krnel et al., 2020). Their since modern forms of digital marketing of alcohol purpose is to draw up clear guidelines for identifying are almost entirely exempted from existing legisla- and selecting good practice in the field of public tion, which in Slovenia, as in the majority of other health, which will serve as guidelines for the crea- countries, was developed before the appearance of tion, planning, design, and implementation of various new channels of marketing. interventions. Cooperation with non-governmental organizations (NGOs) Ministry of health is co-financing different pro- Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. The Lancet grammes and activities of NGOs in the field of har-2009; 373:2234–46. mful and hazardous alcohol use. Programmes are Kamin T, Roškar M. MOSA - Addressing alcohol issues in Slovenia through aimed at different vulnerable population groups, an upstream multiple stakeholder approach. V: Knox K, Kubacki K, Thiele S.R. (eds.). Stakeholder involvement in social marketing: challenges and approa-especially youth – with the involvement of organized ches to engagement. Abingdon; New York: Routledge, 2021, str. 55-71. youth. Programmes include awareness raising activi- Kenny P, Hastings, G. “Understanding social norms: upstream and down-ties, promotion of healthy choices, drink-driving pre- stream applications for social marketers”. V G Hastings, K Angus in C Bryant, Handbook of Social Marketing. Los Angeles, London: Sage, 2011, str. 61-80. vention, interventions aimed at harmful drinkers and their families, advocacy, implementation surveillance Radoš Krnel S, et al. Merila za izbiro in ocenjevanje primerov dobrih praks. Ljubljana: Nacionalni inštitut za javno zdravje, 2020. of different measures (e.g., mystery shopping). From World Health Organization. Alcohol consumption, harm and policy response 2017 on, the Ministry of Health has substantially fact sheets for 30 European countries. Copenhagen: WHO Regional Office for increased financial resources in this field. Europe, 2018. 31 Inclusive public health – the disabled and the elderly Marko Štanta, Marko Vudrag Integration of vulnerable people into society must be one of the most important goals of health policies and programmes if we want to improve and maintain public health. In doing so, it is essential to adapt society to the limitations of the individual. We have relatively small but numerous and heterogeneous vulnerable groups among the population, so that together their total share of the population is significant, and every third individual is on the margins of society for various reasons and risks social exclusion. Experience to date shows that the benefits of inclu- health' and ‘health in all policies' more effectively and sion are many, not only for people with disabilities bring the topic of health closer to all citizens. but for all citizens. Active inclusion programmes help reduce social exclusion and promote a healthier life- In the municipalities that have expressed interest, style for all citizens. A more accessible and thus frien- coordination of social and health services is carried dlier social environment reduces health inequalities out through the Council for the Disabled. In order and improves the public health of society as a whole. to respond more quickly to the needs in this con- text, information was collected in 2018 on social and In the Nova Gorica Regional Office of the NIJZ, we health services and their providers in the local envi- participate in the project A municipality tailored to ronment. It was received by all service providers, the needs of the disabled, which was started by the municipal administrations and citizens. As part of Association of Working Disabled People of Slovenia. the coordination and with the cooperation of muni- The project uses the disability policies in local com- cipalities, public institutions and NGOs, workshops munities under Agenda 221, which allows for regu- on health, informal long-term care, exercise and free lating the situation of all members of vulnerable emergency transport for the disabled and elderly are groups (the disabled, the elderly, the unemployed, being carried out in a coordinated manner. Special the homeless, those living below the poverty line, the attention is given to people on the social margins, so chronically ill, etc.). This is intended for the develo- periodic visits are carried out to examine their situa- pment of disability policy plans and is based on the tion and provide them with appropriate support and Standard Rules for the Equalization of Opportunities assistance. for Persons with Disabilities (UN General Assembly, 1993), adopted by the United Nations in 1993. Muni- cipalities that have received the title A municipality UN General Assembly. Standard Rules on the Equalization of Opportunities for tailored to the needs of the disabled have a Council Persons with Disabilities. Resolution adopted by the General Assembly, 1993, A/RES/48/96. Available from: https://www.refworld.org/docid/3b00f2e80. for the Disabled, which acts as an advisory body to html (Accessed 7 June 2021). the mayor. In the Goriška region, representatives of the Nova Gorica Regional Office of the NIJZ also par- ticipate in councils for the disabled. The participation 1_Zveza delovnih invalidov Slovenije. Invalidska politika v lokalnih skupnostih – Agenda 22. https://www.zdis.si/node/441. of an NIJZ representative in such social bodies brings the possibility of direct participation of the NIJZ in the development of municipal policies through advi- sing mayors and municipal councils. In this way, it is possible to implement the ‘community approach to 32 Public health approaches in cross-sectorial policies: achievements in active and healthy ageing Andreja Mezinec, Monika Robnik Levart in Mojca Gabrijelčič Blenkuš Ageing is a process that begins at birth and affects all aspects of our lives. Active and healthy Ageing (AHA) is very important for the entire cycle of life. In Slovenia the dynamics of population ageing are moving very quickly, and should be taken into account in the preparation of the country’s strategic plans. There is a need for joint integration, cooperation and involvement of different stakeholders, both cross-sectorial and multidisciplinary. The main purpose of the AHA is to develop multidisci- with stakeholders working on ageing at regional and plinary competencies and inter-sectoral approaches also local levels. In 2021, the fifth joint report on the to integrating health into different sectoral actions »Compendium of NIJZ activities for 2020 in the field and policies and to monitoring development policies of aging« (Robnik Levart et al., 2021) was prepared, relevant to public health at both the European level which this time has a national dimension and a view and within the World Health Organization (WHO). of the COVID-19 situation, in addition to a regional Through its activities, the National Institute of Public perspective. Currently, by linking and maintaining the Health (NIJZ) aims to strengthen research, networ- network, the NIJZ strives to support the preparation king and awareness of the importance of such issues and implementation of the action plan to improve inside the NIJZ (integration with already well-esta- public health content and thus enable Slovenia's lon- blished areas of work) and beyond, with a focus on g-term strategy for healthy ageing. understanding the areas of ageing, demographic and environmental changes, the lifelong approach, inter- In 2020, the NIJZ was recognized by the WHO as an generational integration and other topics related to important stakeholder in the field of healthy ageing AHA. Therefore, ageing is a cross-sectional or inte- and in the Advisory Committee of Older Persons grating theme across many of the work areas of the (lead by SURS)1. NIJZ. Activities in the field of AHA are also suppor- ted by the United Nations and the WHO, notably in the context of the Decade on Ageing 2021-2030, as well as the European Commission through its Green Paper on Ageing – Promoting solidarity and responsi- bility between generations. The mission of the NIJZ is to contribute to the better health and greater well-being of the population of Slo- venia. Despite great efforts, NIJZ cannot perform its task solely with the support of the health care sector, there is a need for broader integration and coopera- tion between different sectors and stakeholders. With the AHA.SI project in 2014-2016 (preparation of Figure: Work of the regions, OE Nova Gorica, Challenges of ageing in the Nova Gorica region, participation in the SILVER SMEs project, presentation of the the basis for inclusion in the Strategy for Long-Lived ASTAHG project at the conference in Tolmin. Society), where the NIJZ was the leading partner, it took an important step in bringing together experts working on the challenges related to an ageing soci- http://www.staranje.si ety. With the successor project ASTAHG, the NIJZ http://www.staranje.si/aktualno/aktivno-zdravo-staranje-v-odmaknjenih-further expanded the activities and strengthened -podrocjih-projekt-astahg#read-more the cooperation of the different political decision- Robnik Levart M, Mezinec A, Gabrijelčič Blenkuš [uredniki]. Zbornik NIJZ aktiv- -makers at the regional level of operation. nosti za leto 2020 na področju staranja. Ljubljana: Nacionalni inštitut za javno zdravje, 2021 (v pripravi). All nine Regional Offices of the NIJZ were involved in the implementation of the AHA methodology at 1_https://www.stat.si/statweb/NationalStatistics/AdvCommittees-their level of operation. They established networks Description/99. 33 Actions on health inequalities of the Centre for Health and Development Murska Sobota Peter Beznec The Centre for Health and Development Murska Sobota implements programmes on reducing health inequalities by including health in regional development plans at different tiers of government and in cooperation with different sectors. In partnership with University of Maribor and the World Health Organisation, we conduct research on economic effects of the health care system on the economy and employment at national and regional levels. Additionally, we research impacts of social entrepreneurship on health of vulnerable population groups, and on the economic and social development at the regional level. The Centre for Health and Development Murska develop tools and methods to improve our understan- Sobota (CHD) was established by the National Insti- ding of the social and economic benefits of a health tute of Public Health (NIJZ) to implement the acti- care system for the wider environment in which the vities of the Programme Mura (Buzeti and Maučec system is functioning, and how to maximise its posi- Zakotnik, 2008), focused on reducing health inequa- tive impacts on sustainable development on a regio- lities in Pomurje region by including health in regional nal as well as on a national scale. A study on economic development plans and intersectoral collaboration. footprint of the health care system in Slovenia (Bekő, The World Health Organisation (WHO) recognised 2019) by University of Maribor Faculty of Economics the innovative programme as an example of a good and Business, CHD and WHO Venice office was one of practice. In 2008 the CHD became a WHO Collabo- the results of the programme. rating Centre with an agenda to implement capacity building in the field of intersectoral investment in Throughout our activities we strive to act locally, to health and is currently the only WHO Collaborating implement developmental projects, with positive Centre in Slovenia. As the programme Mura ended, impact on health and quality of life of residents of we continued our efforts in the field of health inequa- Pomurje region, and health promotion projects, such lities and in 2011 published the first publication focu- as Programme on empowerment and raising awa- sing on health inequalities and causes of inequalities reness of heart failure1 (in partnership with Murska in Slovenia (Buzeti, 2011). Sobota General Hospital) and Empowerment and rai- sing awareness for the health of Roma population (in CHD is the coordinator of the WHO Regions for Health partnership with the Association for development of Network for Pomurje region. In cooperation with NIJZ Roma tourism, sport and culture in Republic of Slove- and Ministry of Health we organise international nia “Nova pot- Nevo drom”). public health summer schools which are attended by members from the Regions for Health Network, Healthy Cities Network, and other professionals from Buzeti T, in Maučec Zakotnik J. Vlaganje v zdravje in razvoj v Sloveniji: program Mura. Murska Sobota: Centre for Health and Development Murska Sobota, different sectors. 2008. In the programme “Building capacities for intersecto- Buzeti T, Djomba JK, Gabrijelčič Blenkuš M, et al. Health Inequalities in Slovenia. National Institute of Public Health; 2011. Available from: https://www.nijz. ral cooperation in the field of health determinants si/sites/www.nijz.si/files/publikacije-datoteke/health_inequalities_in_slo-and investments in health for reduction of health venia.pdf inequalities” co-financed by the Ministry of Health Bekő, J, Jagrič T, Fister D, Brown C, Beznec P, Kluge H, in BoyceT. The economic effects of health care systems on national economies: an input-output and in partnership with the WHO European Office analysis of Slovenia. Applied Economics, 2019; 51: 37, 4116-4126. for Investment for Health and Development (Venice office) we established an international initiative of 1_https://www.czr.si/index.php/projekti_reader-en/programme-for-aware-professionals and scientists. Together we worked to ness-and-empowerment-on-heart-failure.html 34 A community approach to strengthening mental health Nuša Konec Juričič, Domen Kralj, Marjeta Peperko The key orientations of the Celje regional office of the National Institute of Public Health (NIJZ) are knowing the health status and needs of the population and responding to them. In response to the high rate of suicide in the Celje region, the Suicide Prevention Group has been implementing the Mental Health Strengthening and Suicide Prevention programme over the last two decades (Konec Juričič, 2013). In 2017, we restarted the operation of the Celje Local Action Group for the Prevention of Addiction due to the problem of abuse of psychoactive substances and new technologies. The key orientations of the Celje regional office of We have also successfully transferred the experi- the National Institute of Public Health (NIJZ) are ence gained from this coordination to the field of knowing the health status and needs of the popula- preventing suicide and strengthening mental health. tion and responding to them. In response to the high As part of the interdisciplinary Regional Group for rate of suicide in the Celje region, the Suicide Preven- the Prevention of Suicide, we have been carrying tion Group has been implementing the Mental Health out targeted training programmes since 2001, which Strengthening and Suicide Prevention programme have been attended by more than 12,000 experts and over the last two decades (Konec Juričič, 2013). In laypeople. Through regular and proactive communi- 2017, we restarted the operation of the Celje Local cation with the media, we take care of raising awa- Action Group for the Prevention of Addiction due to reness and improving understanding of the topics the problem of abuse of psychoactive substances of mental health and suicidality, and consequently and new technologies. contribute to dispelling myths and reducing stigma in these areas. Between 2007 and 2016, we ensured The high rate of suicide and abuse of psychoactive the operation of a self-help group at our office in substances and new technologies are public health Celje to support people with depression and their problems that need to be managed through integra- relatives. As there was a large gap in our region in ted and coordinated approaches by stakeholders terms of easily and quickly accessible psychologi- from different sectors and professions, as well as cal assistance for people in distress, we opened the users themselves. At the Celje regional office of the centre for psychological first aid “Tu smo zate” (We National Institute of Public Health (NIJZ), we started Are There for You) in 2010 at the Celje regional office coordinating stakeholders within the framework of of the NIJZ with the consent of key regional stakehol- the Local Interdisciplinary Action Group (LAS) Celje ders. The counselling centre, which we connected for the Prevention of Addiction in the 1990s. After to the Posvet counselling network in 2015 as part of the successful implementation of many training pro- the MOČ project, has been continuously operating in grammes and the then innovative needle exchange Celje for eleven years. It is visited annually by between for illicit drug users, and upon transferring this task 250 and 300 clients, who, with the support of coun- to another provider, we suspended the group's work sellors, overcome difficulties that could otherwise in 2013. Since 2017, when we revitalized the group's turn into more serious social or health problems. In work due to the growing abuse of new psychoactive addition, the Celje regional office has been organi- substances and non-chemical addictions, we have zing weekly meetings of Alcoholics Anonymous for been holding regular annual meetings for experts in sufferers and their relatives for 20 years, as well as the health, education, social and non-governmen- weekly meetings of a support group for women with tal sectors, designed to strengthen their knowledge relationship dependency. The groups provide mem- and competencies. bers with support and motivation to change their behaviour and consequently improve all aspects of their health. 35 We estimate that in the Celje region we have forged an effective network of stakeholders in the field of mental healthcare in the broadest sense. The network is gradually including three centres for the mental health of adults and two centres for the mental health of children and adolescents operating in the Celje region. The connected network of stakeholders enables us to ensure the flow of key information, to respond effectively to the problems of individuals and groups, to organize professional discussions, and to supplement our content and programmes. It also provides support and motivation to all those who participate in it, with a common goal of the greater well-being of our residents. Konec Juričič N, Lekić K. Tu Smo Zate : Krepitev Duševnega Zdravja in Preprečevanje Samomorilnosti Na Celjskem - Skupnostni Model Zavoda Za Zdravstveno Varstvo Celje. Zavod za zdravstveno varstvo; 2013. Available from: https://www.nijz.si/sites/www.nijz.si/files/uploded/tu_smo_zate_publika-cija_25_10_2013_4.pdf 36 03 HEALTH INFORMATION SYSTEM - DIGITAL INNOVATIONS IN HEALTHCARE 3.1 Slovenian Cancer Registry 3.2 Health databases and other health and healthcare data sources 3.3 SLORA: web portal providing access to cancer data 3.4 Health Statistical Yearbook of Slovenia 3.5 The role and value of eHealth solutions during the COVID-19 pandemic in Slovenia 3.6 Contribution of the Slovenian Medical Informatics Association to the computerisation and digitalisation of health in Slovenia Slovenian Cancer Registry Vesna Zadnik, Sonja Tomšič The Slovenian Cancer Registry, having operated continually for over 70 years, is recognised as one of the oldest and best population-based cancer registries in the world. With high-quality data on the burden of cancer in the country, it is a point of reference for experts in drafting national cancer control plans. These contribute to the prevention and early detection of cancer as well as improving treatment, survival and quality of life for all cancer patients. The Slovenian Cancer Registry (www.onko-i.si/eng/ articles, publications, through cooperation with the crs) is one of the oldest and highest quality popula- media and on our own web portal Slora. tion-based health registries in Europe and the world. Established in 1950 at the Institute of Oncology Lju- Experts employed at the Cancer Registry conduct bljana, over seven decades of continuous operations in-depth epidemiological research on cancer inci- it has maintained its core mission of a national popu- dence, time trends, spatial distribution, cancer pati- lation-based registry for the collection, processing ent survival and the effectiveness of cancer scre- and presentation of high-quality data on the burden ening programmes. At the same time, by providing of cancer in the country. Cancer reporting is manda- data and statistical services the Cancer Registry is a tory and legally required in Slovenia. reference point for many national and foreign rese- archers performing clinical and epidemiological rese- The Cancer Registry is part of a national public health arch. Cancer Registry experts are also frequently activity that monitors the health of the population contacted by individuals or groups, usually associa- and guides strategic developments in oncology. It tions and civil initiatives, seeking answers to specific provides and regularly publishes indicators on the questions on cancer in their local area. The Cancer number of new cases (incidence), the number of all Registry recognises that civil society is a key par- patients (prevalence) and the survival of cancer pati- tner for successful action against cancer and takes ents. The data support the National Cancer Control all such requests very seriously, carefully analysing Plan in planning and evaluating primary and secon- the issues presented and interpreting the results dary prevention, diagnosis, treatment, and rehabili- responsibly. tation of cancer patients, as well as in planning the capacity and resources needed for cancer control in Slovenia. In addition to this, the quality of patient care can also be monitored through the detailed data on diagnosis and treatment recorded in the Registry's clinical registries. Indicators and results of analyses are published in regular annual reports, Figure: In 2020, the Slovenian Cancer Registry celebrated its 70th anniversary of continuous operation. Historical facts and anecdotes are presented at www.onko-i.si/eng/crs/70-years- -of-the-cancer-registry and in a brochure published especi- ally for the occasion. 38 Health databases and other health and healthcare data sources Metka Zaletel, Tina Zupanič The National Institute of Public Health (NIJZ) monitors the majority of the public health and healthcare data and, together with other stakeholders, forms a health information system to support decision-making in Slovenia. Health and healthcare data are based on four closely related pillars. Health and healthcare data to support decision-ma- for a long time to fully digitize all areas of health care king in Slovenia are based on four pillars that are clo- monitoring, for example the latest successful and sely interconnected: ongoing renovations of databases such as electro- nic certificate of justified absence from work (eBol), I. Regular annual databases managed on the basis of electronic registration of death (eDeath) and moni- the Health Care Databases Act toring the outpatient services (eSZBO), which will II. Data from national surveys that provide insight into enable faster monitoring of data, reduce administra- risky behaviors, self-assessment of health and well- tive burden and provide even better support to the -being, etc. processes of formulating health policies and con- crete measures within the Slovenian health system. III. Data from other administrative and statistical sou- rces that »enrich« basic data sources with additional National research data are becoming increasingly information on socio-demographic structure or use important in the health information system. The NIJZ of services conducts general research on large representative samples of the population of Slovenia, such as the IV. Statistics of the eHealth system, which provides National Survey on Health and Health Care, and field a lot of interesting data on the use of the healthcare research, such as research on illicit drug use, mental system health, etc. In the last five years, the NIJZ has upgra- The health information system to support deci- ded the survey methodology with an emphasis on sion making in Slovenia is managed by the NIJZ and combined survey methods, which enables quality other stakeholders. The NIJZ monitors the majority research and at least partial relief of the population. of public health and healthcare data and manages Data from other administrative and statistical sou- relevant databases on patients and services, such as rces and eHealth bring added value to the first two data on causes of death, deliveries and child births, pillars, as they enrich the data and enable analyzes hospitalizations, waiting times, infectious diseases, that are more thematically- and problem-oriented. injuries and poisonings, absences from work, vacci- Combining the listed data with an appropriate legal nations, and health care professionals. In December basis enables a broad view of the health of the popu- 2019, a broader review of the Slovenian health infor- lation and the use of the health system. mation system was performed by the World Health Organization, which confirmed the high quality of the system and data and the achievement of the desired standards. The NIJZ also has the role of an authori- zed provider of national statistics and represents a national contact point for reporting to international organizations in the field of health statistics. In addi- tion to the NIJZ in Slovenia, the data are managed by several other key stakeholders, including the Onco- logy Institute, the Golnik University Clinic, the Val- doltra Orthopedic Hospital and the Pediatric Clinic of the University Medical Center Ljubljana. The NIJZ, together with other stakeholders, has been working 39 SLORA: web portal providing access to cancer data Vesna Zadnik, Nika Bric In 2010, the interactive web portal Slora (from the Slovenian words for Slovenia and cancer) was set up at www.slora.si, enabling easy and quick access to up-to-date data on the cancer burden in Slovenia. Links to foreign databases also enable simple international comparisons of the cancer burden. The onKOvid subpage provides up-to-date information on the impact of the Covid-19 epidemic on the cancer burden and the management of cancer patients in Slovenia. Thanks to the Slovenian Cancer Registry, which has The verified content of the Slora website, strict qua- been operating within the Institute of Oncology Lju- lity criteria and extensive media promotion of the bljana for over 70 years, Slovenia has a very long tra- site put a spotlight on the disease we call cancer and dition when it comes to monitoring the population make it more understandable to the general public. burden of cancer. In 2010, an innovation was introdu- The Slora web portal serves to simplify the evalua- ced in the Slovenian healthcare system for providing tion of the impact and performance of the National information to experts and the lay public: an intera- Cancer Control Plan and has significantly reduced ctive web portal that provides easy and quick access the amount of misinformation in the public domain to data on cancer in Slovenia at both the national and regarding the cancer burden in Slovenia (outdated, administrative unit levels, and it also enables compa- incorrect data or misinterpretations). Secondary, risons of cancer burden indicators with other coun- though not insignificant outcomes of the web portal tries. The web portal is called SLORA, after the initial are tied to the technological and organisational fun- letters of two words in Slovenian denoting its subject ctioning of the Cancer Registry: data processing and – Slovenia and cancer. It can be accessed at www. routine analysis are simplified and faster, and the slora.si. The content is also fully available in English, likelihood of errors is reduced. and a built-in communication bridge enables direct contact between users and experts. Additional con- tent provides the user with information on proven risk factors for cancer and possible ways to prevent and detect malignant disease early on. The Glossary is a collection of concepts and methods to help the user properly understand the indicators presented and the epidemiology of cancer more broadly. During the Covid-19 epidemic, the Slora web portal has provided up-to-date information on the impact of the epide- mic on the cancer burden and the management of cancer patients in Slovenia on its onKOvid subpage. A key feature of the Slora web portal is an innovative application for direct access to data from the Cancer Figure: The interactive web portal Slora is available to users at www.slora.si. Registry database, which allows users to retrieve aggregated data according to parameters of their choice. The data is compiled via search windows – for each epidemiological indicator (incidence, mortality, prevalence, survival) an independent search window is available. The query results are shown in graphical and tabular form and can be further processed and stored by the user. 40 Health Statistical Yearbook of Slovenia Mojca Simončič, Damjana Vardič, Marjana Hladnik The Health Statistical Yearbook of Slovenia offers an organized and understandable overview of contents related to various aspects of population health. All this health-related information is very helpful in highlighting important public health issues, daily work on the assessment of the health status of the population, and in deciding on and adopting appropriate policies. The publication focuses on clear graphic displays, data visualizations and infographics in combination with short summaries of major contents regarding important public healthcare topics. The first publication Statistical Report on the Work Good quality healthcare data and information are very of the Healthcare Service in the SR of Slovenia was important for future planning and decision-making launched in 1966 with presentations of 1965 data, regarding the main healthcare issues of the popula- and presents the basis of today's Health Statisti- tion. The publication Health Statistical Yearbook of cal Yearbook of Slovenia (Zavod SRS za zdravstveno Slovenia was created, and is annually updated, with varstvo v Ljubljani Republiški zdravstveni center, the help of the inter-organizational1 cooperation of 1966). The volume of the publication was shorter, experts who use their experience and knowledge to as many publications at that time were still manu- prepare quality content as a basis for future decisio- ally typed on one side of paper, and all the data were n-making measures. presented in tabular form, mostly only with absolute numbers. Due to fast changes of the environment and the growing need for quality data and informa- tion, the publication was gradually changed, supple- mented and revised. The last major transformation was carried out in 2013. The publication has been given a new structure for all chapters. The introduction at the beginning of each chapter serves primarily to present the main highli- ghts of the content. The main part of the publication highlights the national situation over a longer period of time, with highlights on the last year. The regio- nal part of the publication compares regions with the national average. The last part of each chapter shows the situation internationally, with Slovenia and Figure: The poster Health in Slovenia, 2019 EU comparisons. The main guideline of the publication is a clear and Emerson J. Visualizing Information for Advocacy: An Introduction to Informa-simple visualization of the main contents of public tion Design. New York: OSI, 2008. health topics. Contents are divided into nine chap- Veszelszki Á. Information visualization: Infographics from a linguistic point of view. In: Benedek, András − Nyíri, Kristóf (eds.): The Power of the Image Series ters, presented with distinctive and recognizable Visual Learning, 2014; 4. pictograms, which give a quick and clear insight of the Zavod SRS za zdravstveno varstvo v Ljubljani Republiški zdravstveni center - content. The introductory part is followed by graphic zdravstvena statistika: Statistično poročilo o delu zdravstvene službe v SR and tabular presentations, supplemented with short Sloveniji za leto 1965. Ljubljana, december 1966. summaries of important public healthcare topics and several simple and clear infographics (with the visu- 1_Ljubljana Institute of Oncology, Environmental Agency of the Republic of alization or visual presentation of data) (Veszelszki, Slovenia, Statistical Office of the Republic of Slovenia, Radiation Protection Administration of the Republic of Slovenia, Ministry of the Interior, Police, 2014; Emerson, 2008). Ministry of Health, Health Insurance Institute of Slovenia, University Clinic of Respiratory and Allergic Diseases Golnik (Klinika Golnik), National Laboratory of Health, Environment and Food, Blood Transfusion Centre of Slovenia and others. 41 The role and value of eHealth solutions during the COVID-19 pandemic in Slovenia Dalibor Stanimirović, Vedrana Matetić The public healthcare system in Slovenia has been struggling with numerous challenges in recent years, due to various systemic and socio-economic circumstances and unfavourable public health trends (WHO, 2016). The system has been facing management issues and a shortage of resources on one hand, and often outdated and inappropriate legislation on the other. To confront these challenges and ensure the sustainability of the public healthcare system, profound and wide-ranging changes to the current healthcare arrangements are needed. In view of that, the digitalisation has been deemed eHealth in its current form covers digital solutions essential for innovation and setting up a more effi- such as electronic prescription (ePrescription), cient and successful healthcare system. The term electronic appointment (eAppointment), Central “digitalisation” is in this text defined as a compre- Registry of Patient Data (CRPD, containing specia- hensive introduction of information and communica- list reports, microbiology reports, discharge letters, tions technology (ICT) solutions into the healthcare ambulatory exam reports, vaccinations, and other system operational and business processes. In inter- patient records), and Patient Portal, to name just a national strategic documents, ICT represents one few of the most important. Then, of course, there is a of the essential instruments for achieving the imp- whole range of back-end infrastructure and network roved medical treatment of patients and ensuring platforms that actually enable the use of eHealth timely monitoring of all operating parameters in the solutions, but they are not generally user-oriented healthcare system (European Commission, 2018). and therefore they are not specifically outlined in The most recent Slovenian strategy document, i.e. this text. Considering the events since the publica- “Resolution of the national healthcare plan 2016– tion of the first strategic document involving health- 2025”, lists several specific goals in the area of ICT care digitalisation in 2005, the implementation of in healthcare. In compliance with the EU documents eHealth solutions from 2016 onwards represents an emphasising the efficiency, accessibility, and flexibi- important milestone in the history of the Slovenian lity of healthcare systems, it primarily highlights the healthcare system. This is supported by statistical implementation of unified and efficient ICT soluti- data and different evaluations carried out by natio- ons as an overarching strategic objective. Such ICT nal and international institutions. The percentage solutions would provide relevant data for the medical of ePrescriptions among all drug prescriptions in the treatment of patients and support evidence-based year 2019 was above 92% (calculated as a monthly decision-making (Official Gazette of the Republic of average). In absolute figures, this represents more Slovenia, 2016). than 1,150,000 ePrescriptions per month. Similarly, the share of eAppointment referrals averaged more Dependable medical, financial, and administrative than 95% per month in the last year (more than data would enhance the planning and management 300,000 referrals per month). The number of health- of both individual healthcare providers and the -related documents sent by healthcare providers healthcare system in general (Stanimirovic, 2015). into the CRPD is rising steadily. The Patient Portal The research reveals that successful healthcare digi- had more than 768,000 visits in 2019, compared to talisation projects have enormous strategic impor- 548,000 visits in 2018. Table 1 shows the cumulative tance for further advancing the healthcare system growth in the use of eHealth solutions in Slovenia and the far-reaching impact on economic growth and on an annual basis since their introduction into the social development (Wolff, 2020). healthcare system in 2016 until the end of 2019. The cumulative figures for this year are understandably Digitalisation in process and the COVID-19 outbreak not yet available. Over the years, it is possible to see The Slovenian healthcare digitalisation project (eHe- a constant growth in the use of eHealth solutions, alth), following the national, European, and World and according to interim data in 2020, these figures Health Organization guidelines on ICT in healthcare, are likely to increase in absolute or relative terms is one of the key long-term goals of the public sector this year, despite the distressing and unpredictable in Slovenia (Ministry of Health, 2005). The Slovenian public health situation due to the COVID-19 epidemic. 42 CRPD is rising steadily. The Patient Portal had more than 768,000 visits in 2019, compared to 548,000 visits in 2018. Table 1 shows the cumulative growth in the use of eHealth solutions in Slovenia on an annual basis since their introduction into the healthcare system in 2016 until the end of 2019. The cumulative figures for this year are understandably not yet available. Over the years, it is possible to see a constant growth in the use of eHealth solutions, and according to interim data in 2020, these figures are likely to increase in absolute or relative terms this year, despite the distressing and unpredictable public health situation due to the COVID-19 epidemic. Table 1: Annual growth in the use of eHealth solutions in Slovenia, 2016–2019 CRPD is rising steadily. The Pat ient Portal had more than 768,000 visits in 2019, compared to 548,000 v isits in 2018. Table 1 shows the cumulative growth in the use of eHealth solutions in Slovenia on an annual basis since their introduction into the healthcare system i 2016 n 201 6 until the en 2017 d of 2 019. The 2018 2019 cu mulative figures for this year are understandably not yet available. Over the years, it is possible to se eA e p a c po onsint tanm t en gro tw th in the uNsu e m o b f e eHre o altf e h s Roe lu fteiorr nsa,ls an d accord 241, ing to 379 inte rim dat 2,509, a in 202 518 0, th ese 3,564,993 3,946,878 fig ures are likely to increase in absolute or relative terms this year, despite the distressing and unpredictable public health sit % ua o tio f a n dlu R e teofe thrr e a C ls O VID-19 epidemic. 42.96 84.71 95.11 93.92 T e ab Plere 1: sc A rnip nutio al gn rowth in the N us um e o be f eH r e o alt fh solutions in Slovenia, 2016–2019 ePrescriptions 12,326,845 13,095,808 13,867,192 13,895,517 % of al Prescr 2016 iptions 2017 87. 2018 23 2019 88.73 92.33 93.47 eAppointment Number of eReferrals 241,379 2,509,518 3,564,993 3,946,878 CRPD Number of % of al Refer do rals cuments 42.96 84.71 3,180,704 95.11 6,436, 93.92 900 9,411,132 15,201,309 e PPraetie scripntit P on Number of ortal ePrescriptionN s umber of v 12, is 326, its 845 13,095,808 13, 669 867,192 13,895, 262, 517 012 548,512 768,255 % of al Prescriptions 87.23 88.73 92.33 93.47 Table 1: Annual gr CRPD Number of owth in the use of eHealth solutions in Slovenia, 2016–2019 documents 3,180,704 6,436,900 9,411,132 15,201,309 APn a tieenv t P alu ortal ationN b umy be trh of e vis M its inistry of P 669u blic A 262, dm 012 inistra 548, tio 512 n for 768, th 255 e 2016–2018 period shows that the usage An e valuation by the Ministry of Public Admini- benefits of ePrescription and eAppointment, such as str o ation f f eHe or the 2016–2018 period sho alth solutions (ePrescript w io s that the n and eAppointm stre ent) amlin resu ed an lted d m in or sig e eff nific ectiv an e tr t e sav atm i engs in nt pr t oc he he esses, althcare An evaluation by the Ministry of Public Administration for the 2016–2018 period shows that the usage usage soy f esHtee alt of mh; s o eHe th lut e io nalth M s (ein Pre solutions isstcry ript o ionf P and ( ueePr bApp escription lico A int d m m entin ) is resu an tltedd ratio in s n ig ’ns e ific s an t t i sm avi at n simplific gse in o t f t he hh e e alt ation of pr ac hc oc c are u edurmu es f lated s or patie aving nts, gr s e is at appro er stan- ximately eAppointm system; the e M nt) r inistry esult of Pub ed in signific lic Administration’ant sa s estim vings in EUR 40 million (Ministry of Public Adatm e oin f t is he trat accu io mu n, lat 2 e dard 0s diz 1 av 9 in )g.s I isn ad approdx ation, qualit i itmio ate y an nly t o d saf fin et an y of ccial s ollectaving ed he s, the ev alth data, aluation the EUR he 40 althc million ar ( e M s in yst istry e ofm; Pu the blic A Ministr dminist y of ration,Public 2019). I Admi n addit-ion to fin cancial savings, th onsultations e evalu betw atio ee n n general practitioners and spe- nistr h hi i ghli ation ghl ghits ot' ghs estimat thse o r s t ysh teer mice of the ac s byesntee fit m s o ifc eP cumulat bre es n crie ptfiiotn ed sa s o andf eAvings eP pproe instc mreip nt, t sio uc n h a as n st d re e amA li p ne p d o anin d t m m or e e nt, such as streamlined and more cialists, lower administrative costs, availability of data is e e appr ffe ffecti cveotiximat v t e rea t tm ely re enta EUR tpm roc ees40 nstes, million psiro mp ce lific (Ministr ss ati e ons ,o f y of spim roce Public pdlific ures at fo io r p nat iefontf s, p grreoatceer dstuan or analysis an re d d r s ard izfo at ese r ion, ar p at ch, etie c nts, greater standard . The annual dynamics of ization, quality and safety of collected health data, consultations between general practitioners and specialists, Administration, 2019). In addition to financial q lo u w alit er ad y m an inist d r s ativafe e co t sty s, of c av o ailab lle ility c t o e f d d at h a fe o alt r an h a d lys at is a, and c re o se ns arc u h, lt e sa tat c. i T o hens an vings fr b nu etw al dynee am om the evn ics g o e f neral practition aluation of the Ministrers and sp y of Public ecialists, savings, the evaluation highlights other systemic lo sav w ingesr ad from tm he in ev ist alu ratat ioniv o e f t c he os M t in sis,t av ry of ailab Public ilit Ad y m ino istf d rati at on a f is o illus r an trated aly in F Administr sigisu an re 1. d res ation is illustr eatarch, etc ed in Figur . T e 1 h. e annu al dynamics of sFiav gur in e 1 g:s Es fr timoatm ed t sahvien e gs fvralu om e at Preio scrnip o tio f t n a h n e d M eAppin oi is nt tmry ent ,o 2f 0P 16 u – b 20 lic 18 Ad ministrat ion is illustr ated in Figure 1. The Digital Economy and Society Index (DESI) €20.000.000,00 Figu€re 18. 1 000.: E 000, st 00 imated savings from ePrescription and eAppointme of the Eur nt, ope 2016–2018 an Commission is a compound €16.000.000,00 €17.526.931,59 index, which encapsulates pertinent indi- € €14.000.000,00 cators on digital performance and monitors s in €12.€20. 000. 000. 000,00 000,00 ving the developments in digital competitive- f sa €10.€18. 000. 000. 000,00 000,00 €12.337.794,30 o ness of EU Member States. DESI Report 2019 €8.000.000,00 ount indicates a big breakthrough in the develo- €6.€16. 000. 000. 000,00 000,00 €17.526.931,59 Am € €4.€14. 000. 000. 000,00 000,00 pment and usage of eHealth services in Slo- s in €2.000.000,00 venia, ranking Slovenia in 6th place in the EU €12.000. €0,00 000,00 €2.187.328,11 €3.122.040,63 €3.203.915,51 ving €1.186.715,72 (European Commission, 2019) (Figure 2). 2016 2017 2018 €12.337.794,30 f sa €10.000.000,00 Slovenia's position (marked in black) is well o €8.000.000,00 Time scale (in years) above the EU28 average (marked in white), ount and it also ranks better than many countries €6.000.000,00 ePrescription eAppointment Am with comparable GDP (or even higher) and a Figur €4. e 1: Estimat 000. ed sa 000, vings fr 00 om ePrescription and eAppointment, 2016–2018 comparable population. €2.000.000,00 €2.187.328,11 €3.122.040,63 €3.203.915,51 Digital solutions for m €0, onit 00 oring €1. qualit 186.715, y an 72 d safety in the quality or safety of their own medical treatment. hospitals are also relatively well developed. 2016 In 2002, 2017 Due to the CO 2018 VID-19 pandemic, the project was unfor- the Ministry of Health set up a system for monito- Time scale (in years) tunately suspended in April 2020. ring warning events and reporting by healthcare providers. In accordance with the requirements, Specialized online expert systems, which enable ePrescription eAp adv po anc intment hospitals have introduced internal digital solutions ed decision-making support and predictive analytics with the help of artificial int in the form of online self-assessment questionna- elligence, are ires, which enable monitoring of quality and safety used in individual areas. However, this approach is not indicators, as well as appropriate actions in the widespread in Slovenia and is not routinely used by event of identified deviations. The development of healthcare providers. Expert systems, which are usu- a national web portal is also underway, which will ally used in combination with decision-support algori- enable patients to report perceived deviations in thms and smart devices, are mostly used in monitoring 43 The Digital Economy and Society Index (DESI) of the European Commission is a compound index, which encapsulates pertinent indicators on digital performance and monitors the developments in digital competitiveness of EU Member States. DESI Report 2019 indicates a big breakthrough in the development and usage of eHealth services in Slovenia, ranking Slovenia in 6th place in the EU (European Commission, 2019) (Figure 2). Slovenia's position (marked in black) is well above the EU28 average (marked in white), and it also ranks better than many countries with comparable GDP (or even higher) and a comparable population. Figure 2: Use of eHealth services in EU Member States (DESI Report 2019). and interpretation of simultaneous 50% analyses of a large amount of data in specific areas, where this is 40% substantively and technologically feasible (COVID-19 patients, chro- 30% nic patients, monitoring of cancer use patients, clinical chemistry, etc.). tage of 20% Nevertheless, it should be emphasi- zed that this branch of digital solu- Percen 10% tions is only in its infancy in Slovenia and that the main initiatives for the 0% development of such approaches EE FI DK SE ES SI 8 UK IT NL HR BE LU LT AT SK CZ PL PT LV FR RO IE BG EL CY DE HU MT EU2 have come from national and inter- EU28 Member States national research projects in recent years. Figur Dig e 2: Use of eHe ital solutions alth servic for mones in EU Me itoring q mber Stat uality an es (DE d safeSI Re ty port 2019). in hospitals are also relatively well developed. In 2002, the Ministry of Health set up a system for monitoring warning events and reporting by healthcare providers. In accordance with the requirements, hospitals have introduced internal digital solutions in As we can see, a multilateral analysis of the maturity, virus is still present, and the epidemiologists are the form of online self-assessment questionnaires, which enable monitoring of quality and safety indicato usage rs, as , an well d eff as ic ap ien pcropriate ac y of eHe tions in the ev alth puts Sloevnte of identified d nia high on eviations. The dev discussing elopm the en po t of a ssibility of a second (or third) national web portal the list of the m is o also un st suc d c erway, w essful c hich will enable patie ountries in the ar nets to re a of port p waerc v eived d e of COeviations in VID-19 b the y the end of the year. Protective qualit eHe y or safety of t alth. But aft heir own er the fir medic st CO al treatm VID-19 c ent. D ase wue to th as disce C ov O e V-ID-19 p m aendem asur ic, the project was es such as social distancing and mask urnfortunate ed in Slo lvy s e uspended in April 2020. nia at the beginning of March 2020 and the wearing are still required. The epidemic and the epidemic was declared several days later, the questions accompanying measures had severe consequen- Specialized online expert systems, which enable advanced decision-making support and predictive of the benefits of eHealth during this situation began ces on the Slovenian economy and healthcare and analytics with the help of artificial intelligence, are used in individual areas. However, this approach is to appear. Although several analyses and assessments other social subsystems. To lessen the impact, the not widespread in Slovenia and is not routinely used by healthcare providers. Expert systems, which of eHealth were performed in the past, there has been government adopted several regulatory measures, are usually used in combination with decision-support algorithms and smart devices, are mostly used no observation or evaluation of the potential benefits the total value of which exceeds EUR 6 billion (Offi- in monitoring and interpretation of simultaneous analyses of a large amount of data in specific areas, whe of re t eHe his is alth substantive solutions ly an in d t the e c chn ont oelogic xt ally of feas the ib e le ( pide COV mic ID . -19 p c atients ial Gaz, chronic patien ette of the Re ts, public of Slovenia, 2020). Still, mo Renitoring of markablycancer , man patients, clinical chemi y aspects of the de svtry, etc. elopm). N e ever nt antheless d use , it should be it is alr eemphasize ady ob d that this vious that the epidemic will have pro- branch of digital solutions is of digital solutions in he only in althcar its in e ha fan v cy in e bee Slovenia and t n studied so hat tfhe m oun ain in d an itiatives fo d lasting c r the onsequences. dfev ar elo , inpment of suc cluding thoh approaches have se of a peripher come fro al natur m e national an , which oft d e in n ternational research projects in Generally speaking, we could say that the soci- recent y manif ears. est barely sufficient importance for a legitimate research interest. Nevertheless, it is possible to detect oeconomic situation in the EU is even worse. The As we can see, a multilateral analysis of the maturity, usage, and efficiency o Eur f eH ope ealth puts Slovenia an Commission the lack of research interest in such a vital area as the is proposing to harness the high on the list of the most successful countries in the area of eHealth. But afte full potr t e he first COVID-19 potential benefits of digital solutions in situations like ntial of the EU budget for the mobilisa- case was discovered in Slovenia at the beginning of March 2020 and the epidemic was tion of inv declare estmed several the COVID-19 pandemic. In accordance with these star- nts and financing of key areas for days later, the questions of the benefits of eHealth during this situation bega the r n t ec o a v pp er ear. Although ting points, we provide below an outline of the course y of the EU Member States. The Com- several analyses and assessments of eHealth were performed in the past, there has been no of the COVID-19 epidemic in Slovenia and an overview mission is planning on activating an emergency of socio-economic consequences and response mea- European Recovery Instrument amounting to EUR sures at the national and EU level. And, most importan- 750 billion, together with the three important tly from the point of view of our manuscript, we present safety nets for workers, businesses, and sovere- an analysis regarding the role and value of eHealth igns amounting to a package worth EUR 540 billion, solutions for healthcare professionals and patients thus reaching EUR 1,290 billion of targeted support during the COVID-19 pandemic in Slovenia. measures for the recovery of EU Member States (European Commission, 2020). These funds will The first COVID-19 infection case in Slovenia was be channelled through the EU budget to Member discovered on 4 March 2020. The epidemic was offi- States for key areas such as reinforcing healthcare cially declared on 12 March. The government quickly and social systems, and supporting the green and introduced a series of restrictive measures to fight digital economy, with the final goal of ensuring the the COVID-19 outbreak. Due to the relatively positive sustainable development and stabler socioecono- developments, the measures were gradually phased mic foundations of EU Member States. If the crisis out at the beginning of April. The government decla- continues for longer or if there is a second wave red the COVID-19 epidemic officially over on 31 May. of the pandemic, there will be additional funds The total number of cases was 3,312 on 9 September. for appropriate measures, as emphasised by the The number of deaths due to COVID-19 was estimated representatives of the European Commission. at 135. Although the epidemic was declared over, the 44 Considering the digitalisation aspect, one should solutions soared overnight and the reported learning ask what the role and value of eHealth solutions for curve flattened surprisingly. Healthcare professionals healthcare professionals and patients were during started using eHealth solutions more intensively, due the COVID-19 pandemic. The daily operation of the to the extraordinary circumstances and other inherent healthcare system came to a halt during the epi- factors, but also due to pressure from patients. On the demic, the exception being emergency procedu- other hand, patients have shown the greatest inte- res and the treatment of oncological patients. The rest in monitoring their health and well-being through work of healthcare professionals was extremely health-related documents accessible via the Patient difficult due to the new treatment protocols and Portal and CRPD. flatten the risk ed su of inf rprising ection. ly. Healthcare On the other pro han fessionals d, patie s nts tarted using eHealth solutions more intensively, due ke Statistical data supports the qualitative findings men- to the ex pt in-per traordinary son visits t circ o he umst althc an ar ces and other e institutions t inh o a erent fac tion tors, b ed abo u v t e also due to pre . The CRPD an ssure fro d the P m atie pat nt P ients. ortal in par- On the other h minimum, due t and o a f ,e patients ar of inf have shown the gr ection, but also becea a- test interest i ticular e n mon xperie it n o c ring ed their hea a significlth an ant d in wel cre l-be ase ing use of the changed treatment practice and various in usage through health-related documents accessible via the Patient Portal an during the lockdod CRPD. limitations imposed by healthcare institutions. wn period and immediately thereafter (Figure 3). However, other eHealth solutions, despite St eHe atistical alth an data s d its v upports the qualit arious solutions (ativ ePr e findings m escription, entione the vd ab er ove. y limit The CRP ed oper D and the Patien ation of the he t Port althc al ar in e s ystem particular e eAppointme xpe nt, Prien atieced a s nt P ignificant in ortal, CRPD crease in ) sudde u nly sage du in m rin o g t st ar h e e lo as ck an do d r wn pe estrictriod and ed patie immediately nt admission, have th bec ere am after (Figu e the only w re a 3 y t ). H o pr o o wever, other vide quick, eff iceH ie ealth nt, an s d olutions, de maintain spite ed a rthe ver elativ y limited o ely stable le p v eration o el of use f the safe healthcare services and to ensure approp- , which also healthcare system in most areas and restricted patien c t admission, have m onfirms their critic aintained a al importan re c lat e f ively st or the m able edic riate communication, both internally between al tre- helevel o althc f ar use e pr , w of hich also co essionals an nfirm d ext s their critical i ernally betwee m n portanc atm e e for the m nt of patieedical nts antreatme d the o n v t o er f pat all funients and ctioning of the hethe o althcve ar rall fu e pr n of ctioning o essionals f t anhe d entire patie he nts. alt A h ft car er e sy the stem e . ntire healthcare system. initial shock of the epidemic, the interest of health- Figure 3: Growth in the use of individual eHealth solutions in Slovenia during the COVID-19 epidemic care professionals and patients in using eHealth and immediately thereafter. Al documents in the Central Microbiology laboratory reports Visits of the Patient Portal Registry of Patient Data in the Central Registry of Patient (specialist reports, discharge Data 160.000 letters, patient summary records, etc.) 60.000 140.000 1.600.000 50.000 120.000 1.400.000 1.200.000 40.000 100.000 isits ts ts f v en 1.000.000 r o m enm 80.000 be ocu 30.000 d ocu 800.000 d Num 60.000 ber of ber of 600.000 Num 20.000 Num 40.000 400.000 10.000 200.000 20.000 0 0 0 01 02 03 04 05 06 07 01 02 03 04 05 06 07 01 02 03 04 05 06 07 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- 2020- Time scale (1-7 month, 2020) Time scale (1-7 month, 2020) Time scale (1-7 month, 2020) Figure 3: Growth in the use of individual eHealth solutions in Slovenia during the COVID-19 epidemic and immediately thereafter. Experience from the first wave of the COVID-19 epidemic has shown that eHealth solutions have a very important role in such situations. Usage statistics have clearly shown that both healthcare professionals and patients recognise the many benefits of eHealth in unexpected 45 and crisis circumstances that affect the healthcare system. Furthermore, the advantages of eHealth solutions for healthcare professionals and patients have proved to have an even greater impact in such conditions than in “normal” circumstances. Experience from the first wave of the COVID-19 epinational and international public health crises, demic has shown that eHealth solutions have a very such as the present and probably all subsequent important role in such situations. Usage statistics pandemics. have clearly shown that both healthcare professionals and patients recognise the many benefits of eHealth in unexpected and crisis circumstances that affect the healthcare system. Furthermore, the advantages of eHealth solutions for healthcare professionals and patients have proved to have an even greater impact in such conditions than in “normal” circumstances. Act Determining the Intervention Measures to Contain the COVID-19 Epi-Conclusions demic and Mitigate its Consequences for Citizens and the Economy. Official Gazette of the Republic of Slovenia, 2020; 49/20, 61/20. It seems that the COVID-19 epidemic has done more European Commission. Communication from the Commission to the European Parliament, the European Council, the Council, the European Econo-to raise awareness and usage of eHealth solutions in a mic and Social Committee and the Committee of the Regions on enabling very short period of time than any other initiative before, the digital transformation of health and care in the Digital Single Market; empowering citizens and building a healthier society. SWD (2018) 126. Bru-be it of a political, legislative, administrative, or financial ssels, 2018. character. Given this alarming fact, it should be thoro- European Commission. Digital Public Services. Digital Economy and Soci-ughly examined and discussed what we did wrong, or ety Index Report 2019. https:/ ec.europa.eu/digital-single-market/en/desi what we did not do right, in having failed to intensify European Commission. Communication from the Commission to the the use of eHealth solutions and convince users of the European Parliament, the European Council, the Council, the European Economic and Social Committee and the Committee of the Regions. The manifold benefits offered by digital solutions in the pre-EU budget powering the recovery plan for Europe. COM (2020). Brussels, 2020. -pandemic era. The reasons for this undoubtedly go back to the lack of political will, insufficient stakeholder Ministry of Health. eHealth 2010. Strategy for informatization of the Slovenian health care system 2005-2010. Ministry of Health of the Republic of commitment, the absence of clearly defined sectoral Slovenia, Ljubljana, 2005. policies and compelling goals for users with different Ministry of Public Administration. Evaluation of the effects of the imple-motivating rationales, and a lack of training and educa- mentation of eHealth project: ePrescription and eAppointment. Ministry of Public Administration of the Republic of Slovenia, Ljubljana, 2019. tion of users (healthcare professionals and patients). In addition to the outlined factors, the wide-ranging Resolution on the National Health Care Plan 2016-2025. Official Gazette of the Republic of Slovenia, 2016; 25/16. advocacy of eHealth and digitalisation, which is one of Stanimirovic, D. A framework for information and communication techno-the fundamental principles in promoting national public logy induced transformation of the healthcare business model in Slovenia. health initiatives, has certainly failed. Journal of global information technology management, 2015; 18 (1), pp. 29-47. If so, perhaps this epidemic (pandemic) may well mark Wolff, J., Pauling, J., Keck, A., & Baumbach, J. The Economic Impact of Artificial Intelligence in Health Care: Systematic Review. Journal of Medical a turning point in the perception of digitalisation as not Internet Research, 2020, 22(2), e16866. only one of the crucial drivers for the development and World Health Organization. Regional Office for Europe, European Obser-promotion of public health, but also as an indispensable vatory on Health Systems and Policies. Albreht, T, Pribakovic Brinovec enabler in efforts to exploit existing healthcare system R, Josar, D. et al. Slovenia: health system review. World Health Organization. Regional Office for Europe, 2016. https:/ apps.who.int/iris/ capacities and potentials, and empower patients in handle/10665/330245. 46 Contribution of the Slovenian Medical Informatics Association to the computerisation and digitalisation of health in Slovenia Ivan Eržen, Mojca Paulin, Živa Rant The Slovenian Medical Informatics Association (SDMI) is a professional association working in the field of healthcare information technology. It is a distinctly interdisciplinary and intersectoral association that links together health workers, IT experts and other stakeholders who depend on good information within the healthcare system. In more than 30 years of operation the members of the association have left a significant mark on the development of healthcare informatics in Slovenia. The association was founded back in October 1988. It The association played an exceptionally important connects internationally with related organisations. part in establishing the foundations of computeri- Since 1992 the association has been a full member sing healthcare in Slovenia, by drafting the strategic of the EFMI (European Federation for Medical Infor- development document in this field in the first few matics), and since 1993 a member of the IMIA (Inter- years of the new millennium. Moreover, its members national Medical Informatics Association). It is also have successfully cooperated in various working a member of HL7 (Health level 7 International) and bodies of the Ministry of Health, such as the Coun- ISTEH (International Society for Telemedicine and cil for Informatics in Health (SIZ) and the Committee Health). for Health Informatics Standards (OZIS), in drawing up the expert basis for telehealth and in individual The association organises professional events in the expert groups in establishing e-Zdravje (e-Health) in field of medical informatics, collaborates with orga- Slovenia. nisations and institutions involved in the science and research of medical informatics, promotes the Several sections operate within the association: research activities of its members, cooperates with the journal Informatica Medica Slovenica, which has competent organisations in the field of medical infor- been issued since 1994 in print and electronic form, matics, informs members and professional circles of the Healthcare Section (SIZN), Telehealth, SDMI issues and advances in the association's operations academy and HL7. The association also has its own and publishes the professional journal Informatica website (http://www.sdmi.si/), which posts current Medica Slovenica (IMS). Every two years since 1990 events, reports, news, materials, articles, pictures, it has alternately organised a conference and profe- invitations to various events and information on ssional meeting. A major emphasis at the meetings these events in the field of medical informatics at is the exchange of professional knowledge, opinions, home and abroad, while at the same time it serves as views and linking of all partners in the healthcare a space for disseminating expert materials and infor- system in the effort to integrate information techno- mation to expert circles and the general public. logy into the system. The activities of the association's members are also evident in their active participation at European and Adamič Š, Eržen, I. (Eds.) 30 let Slovenskega društva za medicinsko informa-tiko : [Publication on the 30th anniversary of the Slovenian Medical Informa-world conferences and collaboration in international tics Association]. Slovenian Medical Informatics Association, 2018. projects and international working groups co-finan- ced by the European Commission. 47 04 SCIENTIFIC RESEARCH AND PUBLISHING ACTIVITIES IN PUBLIC HEALT 4.1 Scientific achievements of the Department of Public Health of the Faculty of Medicine of the University of Ljubljana 4.2 Anthropology hand in hand with public health 4.3 Public health research in oncology 4.4 Heart failure: from epidemiological burden to effective (self-)care of patients 4.5 Slovenian Journal of Public Health 4.6 Journal Javno zdravje Scientific achievements of the Department of Public Health of the Faculty of Medicine of the University of Ljubljana Lijana Zaletel Kragelj The research group of the Department of Public Health of the Faculty of Medicine of the University of Ljubljana is a group with great methodological potential. It carries out research in numerous fields of public health, both on the effects of physical factors (e.g. pollution of ambient air) and also the social environment (e.g. sense of coherence) on the health of the population. Research in the field of oral public health is also increasing. The Department of Public Health at the Faculty of a study is being prepared on the effect the sense of Medicine of the University of Ljubljana (DPH – UL FM) coherence has on the effectiveness of treatment is a very small department, but nevertheless pos- outcomes in selected groups of cancer patients. sesses large research potential in the fields of public Also important is research into the effects of previ- health (PH) and occupational, transport and sports ous bad experiences on different aspects of health. health (OTSH) in Slovenia. Its ranks include metho- Special mention should be made of the methodologi- dologically powerful researchers who are capable of cal approach for identifying the profiles of population doing research in different fields. The main aspects groups for the effective functioning of PH measures of health that are often the emphasis of such efforts (Brajović, 2018). Another focus is the effect of social are quality of life and self-assessed health. Important networks on the health of the population, especially areas of research in the last five years have included the elderly. The research group also tries to intro- the following: duce into its research new methodological approa- ches in the field of PH in Slovenia – besides geograp- 1. Research in the field of environmental health to hical analyses it is, for example, increasing the use of examine the effects of various factors on the health analysis of social networks. of the population. Within this field, the DPH – UL FM researchers direct their attention towards studying 3. The integral effect of the environment on health is the influence of different environmental factors on also included in research in the field of OTSH. the health of the population. Key among these are ambient air pollution, indoor air pollution and food 4. In the past five years, significant advances have contaminants. Special mention must be made of been made in research in the field of oral PH. Special research into sick building syndrome (Dovjak, 2019). mention should be made here of research into the The observed aspects of health that are the focus effects of fluorides on oral health and the influence of special attentions also include respiratory disea- of oral health on the perception of general health. ses and reproductive organ diseases/problems with the functioning of the reproductive system. In terms of methodology, special mention should be made Brajović M, Bellis M, Kukec A, Terzić N, Baban A, Sethi D, Zaletel-Kragelj L. of knowledge in the field of geographic analysis Identification of adverse childhood experiences strongly predicting suicidal methods. behaviour among emerging adults in Montenegro and Romania: a new way to targeted cost-effective prevention. Ann Ist Super Sanita. 2018; 54: 348–57. Available from: https://www.iss.it/documents/20126/45616/ANN_18_04_12. 2. As part of their research into the effects of social pdf. factors on the health of the population, DPH – UL FM Dovjak M, Kukec A. Creating healthy and sustainable buildings: an assessment researchers work above all in examining the effects of health risk factors. Cham: Springer Open, cop., 2019. Available from: https:/ link.springer.com/content/pdf/10.1007%2F978-3-030-19412-3.pdf. of the sense of coherence on the quality of life and the self-assessment of health (Štern et al., 2021). In Štern B, Zaletel-Kragelj L, Hojs-Fabjan T. Impact of sense of coherence on quality of life in patients with multiple sclerosis. Wien Klin Wochenschr. 2021; recent years, research has been directed at patients 133: 173–81. Available from: https:/ pubmed.ncbi.nlm.nih.gov/32617708/. suffering from multiple sclerosis and migraine, while 49 Anthropology hand in hand with public health Maruška Vidovič The researching of “natural experiments” in the world has already led to significant anthropological and biomedical discoveries. Research of isolated populations in the world has shone light on numerous unknown health conditions which are often also associated with particular ecological and cultural features. The first anthropological and public health project, in reproductively closed populations that have been a very ambitious, multi-year project that has been to affected by genetic drift occur in just a few genera- date the most wide-reaching, was Population Stru- tions. This leads to the fixation of individual alleles, ctures of Slovenia, and this was the foundation for and the microevolutionary changes enable the popu- our research. Based on the results obtained, from lation to modify certain characteristics. The research year to year we supplemented and built on continued was dominated by two aspects of population struc- holistic anthropological and biomedical research. ture and their mutual relationship: an assessment of We initiated the project together with the Institute the isolation of individual villages (subpopulations) of Anthropology in Zagreb. In Slovenia, too, we the- and the level of kinship between them and within refore researched “isolated populations”, which offer them (inbreeding), which is relatively high, especially certain advantages for anthropological and medical in the sub-Alpine area. Our research has frequently research. pointed out guidelines for public health action. The valley of Selška dolina, a closed mountain valley, For a number of years, we have been very active and the population living in it, were selected for our and successfully involved in international research anthropological population research due to its spe- collaboration. In Selška dolina we were joined by cific geographical position, historical events (coloni- anthropologists from renowned foreign universities. sation), local socio-cultural reasons and special eco- Together we conducted research associated with logical conditions. The research on a research model way of life and health. We collaborated with Oxford that represents a “natural research laboratory” University and the president of ICAF at IUAES in con- enabled us to arrive at some important conclusions nection with dietary analysis. We carried out rese- regarding the population living in the valley among arch on menopause and menopausal symptoms with the Škofja Loka hills. medical anthropologists from Amherst University, Massachusetts, USA. We conducted research with Research of population structures presents a comp- anthropologists from the University of Western lete spectrum of biological, sociological and demo- Australia in Perth on hormonal stress (the levels of graphic factors that influence the genetic structure cortisol and testosterone) in relation to way of life. of a population. Population structure is a reflection On the subject of ageing and fragility of the inhabi- of various processes that arise through the common tants of Selška dolina we carried out a bilateral Slo- dynamic formation of different population characte- venian Research Agency (ARRS) project with Ohio ristics over time (through generations) and in space State University, Columbus, USA, and an analysis of (in an ecological niche). the genetic diversity of the Selška dolina population We carried out research of population structures on in a bilateral ARRS project with the Institute of Gene- several levels. We used group parameters: the biolo- tic Engineering and Biotechnology of the University gical properties of the human organism: morphologi- of Sarajevo. The NIJZ with the assistance of the ARRS cal, physiological, dermatoglyphic (palm and finger- published an editorial original book by Maruška Vido- prints) and dental characteristics, as well as certain vič, Anthropology and Public Health. socio-cultural characteristics: migrational, isonymic, linguistic and demographic. Through these parame- ters we traced microevolutionary processes which 50 Public health research in oncology Vesna Zadnik, Tina Žagar Researchers in the field of oncological epidemiology and public health working within the Epidemiology and Cancer Registry unit of the Institute of Oncology Ljubljana address challenges in the field of cancer control in a number of national and international research projects, the results of which enable the adoption and implementation of evidence-based programmes at the levels of primary, secondary and tertiary cancer prevention. Researchers in the field of oncological epidemio- • Identify and analyse factors that are important for logy and public health working within the Epidemi- improving the quality of life of cancer patients, for ology and Cancer Registry unit of the Institute of reducing the burden of late effects of the dise- Oncology Ljubljana address challenges in the field of ase and treatment, and for improving survival of cancer control in a number of national and interna- cancer patients. tional research projects, the results of which enable experts and decision-makers to adopt and imple- • Examine the socio-economic inequalities in ment evidence-based programmes at the levels of cancer risk factors, cancer burden and cancer primary, secondary and tertiary cancer prevention. treatment in Slovenia, and propose possible mea- The core task of oncological epidemiology is cancer sures to reduce these inequalities. burden estimation, which is determined using data • Develop and introduce new methods and tech- from the internationally renowned Slovenian Cancer nologies for collecting, processing, analysing and Registry. In recent years, a special focus has been interpreting health data with relevance for the placed on research on socio-economic inequalities, Slovenian public health landscape. which can be observed both in Slovenia and globally. The main purpose of public health research in onco- The specific objectives of public health research in logy is to provide integrated research and evidence- oncology are: -based cancer control in Slovenia, and to place the • Analyse the burden of cancer in Slovenia based on progress Slovenia is making in an international con- data from the national Cancer Registry and place text. Research results and findings are published in the indicators in an international context. monographs and articles in top-ranked scientific jou- rnals. • Identify the most important risk factors for cancer and propose evidence-based primary prevention measures. • Monitor the impact of existing national cancer screening programmes and provide for the intro- duction of new ones. • Develop quality of care indicators (for diagnosis, treatment, rehabilitation, and palliative care) for each type of cancer, using clinical registries, and ensure their monitoring, analysis, and appropriate interpretation. Figure: Embedding of oncological epidemiology and public health oncology research into evidence-based integrated cancer control in Slovenia. 51 Heart failure: from epidemiological burden to effective (self-)care of patients Jerneja Farkaš Lainščak The results of systematic research work represent an important scientific advancement in the international arena, as they provide the first comprehensive data on heart failure from this part of Europe. They are also important in the socio-economic sense as they enable the planning of public health measures to manage the burden of heart failure, which will increase further based on the demographic projections of the ageing Slovenian population. Heart failure is the only cardiological condition examination. Heart failure was found in 221 subjects; whose frequency is increasing. Few national studies the prevalence of this condition in the research have been conducted on the rates of hospitalizati- sample was 11.9%. Conservative extrapolation to the ons due to heart failure, and there is no data at all for general population showed a heart failure prevalence Central and Eastern Europe. We analysed the Slove- of 4.7%. nian national hospitalization database for the period 2004–2012 and found that during this time there As the healthcare system fails to keep up with the were approximately 6,000 hospitalizations per year burden of the disease, care in heart failure is incre- (median age 78 years, 55% women). We observed asingly being transferred to the home environment, an increase in the crude rate of hospitalizations due to the patients themselves and their informal caregi- to heart failure (from 249 to 298/100,000 residents) vers. Bearing in mind the importance of the active role and a decrease in age-standardized rates (from 249 of patients in the treatment process, we systemati- to 232/100,000 residents). Up to 20% of patients cally conduct research on the knowledge and skills of died during the first year after hospitalization, and up patients with heart failure related to the disease, its to 40% of patients were re-hospitalized during the (self-)care and its impact on various aspects of life. first year after their discharge from hospital. Quantitative and qualitative research approaches allowed us to gain insight into the health-related We conducted a cross-sectional epidemiological quality of life of patients and the main barriers and study titled Screening Of adult urBan pOpulation incentives for implementing self-care behaviours. To diAgnose Heart Failure (SOBOTA–HF) among the We used the findings as a basis for the development residents of Murska Sobota. The research was con- of health education programmes and materials on ducted in two phases: in the first phase we perfor- heart failure, which are better tailored to the needs of med screening examinations, to which we invited patients and support them to a greater extent in eve- all individuals from a representative sample of the ryday living with the disease (nepopustljivo-srce.si). population of Murska Sobota, aged 55 and over (N = 2861), and in the second phase we performed dia- gnostic examinations in individuals who have a risk of developing heart failure based on natriuretic peptide (NT-proBNP) levels equal to or greater than 125 pg/ Omersa D, Farkaš-Lainščak J, Eržen I, Lainščak M. National trends in heart ml, and determined the prevalence of heart failure. failure hospitalization rates in Slovenia 2004−2012. Eur J Heart Fail 2016; 18: 1321-8. The screening examination was performed in N = Lainščak M, Omersa D, Sedlar N, Anker S, Farkaš-Lainščak J. Heart failure pre-1851 subjects (response rate 64.7%). The subjects valence in the general population: SOBOTA-HF study rationale and design. whose NT-proBNP level was equal to or greater than ESC Heart Fail 2019; 6: 1077-84. 125 pg/ml (N = 1002) were invited to the General Sedlar N, Lainščak M, Farkaš-Lainščak J. Living with chronic heart failure: Exploring patient, informal caregiver and healthcare professional percepti-Hospital Murska Sobota for a detailed diagnostic ons. Int J Environ Res Public Health 2020; 17: 1-16. 52 Slovenian Journal of Public Health Saša Zupanič The Slovenian Journal of Public Health has been published quarterly by the National Institute of Public Health (NIJZ) since 1962. It has been published as a scientific journal with English abstracts since 2003, and since 2014 in the English language only. The journal's mission is to promote new achieve- Our policy is aimed at achieving the highest possi- ments in the broad field of public health in Slovenia ble IF. We try to select 30 to 35 internationally ori- and Central and Southeast Europe. The Slovenian ented citable articles out of 200 manuscripts every Journal of Public Health publishes internationally ori- year. Selecting 18% means three articles out of 16 ented articles and encourages an interdisciplinary manuscripts per month. As we receive a lot of good approach to public health. The journal is intended quality manuscripts it is a very demanding task for as a source for the exchange of new public health our reviewers and editors. concepts and solutions among researches in Central and Southeast Europe. For 2020 we expect an IF higher than 1.1. The scope of the Slovenian Journal of Public Health The Slovenian Journal of Public Health is indexed in covers all specific issues in public health, and thus many databases: SSCI, JCR, Web of Science (WoS), includes primary care, the prevention of communi- PubMed, PubMed Central, Scopus, DOAJ, PsycINFO, cable and noncommunicable diseases, health pro- CAB Abstracts, Global Health, ProQuest, The motion, environmental and occupational health, Summon, Cabell's Directory, Celdes, CNKI Scholar, organization and management in public health, and CNPIEC, EBSCO Discovery Service, Google Scholar, the social and economic aspects of public health in J-Gate, Naviga, Primo Central (ExLibris), SCImago Central and Southeast Europe. (SJR), TDOne (TDNet), WorldCat. The journal publishes mainly original research and scientific papers, and sometimes also study proto- cols, systematic reviews and invited editorials. The articles are submitted to a peer review process carried out by at least three international reviewers from different areas of public health. The process is double-blinded, fast, fair and constructive. Slovenian Journal of Public Health has had an IF since 2011: IF (2011) = 0.452, IF (2012) = 0.163, IF (2013) = 0.732, IF (2014) = 0.417, IF (2015) = 0.203, IF (2016) = 0.429, IF (2017) = 0.620, IF (2018) = 1.074, IF (2019) = 1.097. In 2019, we achieved the highest total cites, IF, 5-year IF and IF without journal self-cites in our history. Our rank in the SSCI Public, Environmental & Occupati- onal Health category is among the highest to date, which also applies to our ranking among Slovenian scientific journals. https://www.nijz.si/sl/nijz/revija-zdravstveno-varstvo 53 Journal Javno zdravje REVIJA JAVNO ZDRAVJE Matej Vinko, Tadeja Horvat, Erna Pečan Javno zdravje is a new Slovenian peer-reviewed journal covering a wide area of public health. It strives for enhancing and networking of science and expertise in the field of public health. In the last 4 years the journal has published over 40 scientific and professional articles that have helped to broaden the public health discussion in Slovenia. Public Health, the science and the art of preventing and accessibility of mental health services in Slove- disease, prolonging life, and promoting health thro- nia. The journal publishes another special section ugh organized community efforts, is intrinsically titled Methodological conversations where two rese- intertwined with the physical and social environment archers take the roles of early career researcher and a (Winslow, 1920). In step with constant changes in methodologist and discuss various challenges rese- the world around us, public health evolves with new archers face at the start of their career. Topics cove- approaches, theories, and subsequently with new red in Methodological conversations range from bias terminology. For the development of the Slovenian in epidemiology to validity and reliability of measures public health workforce, it is of great importance to used in survey questionnaires. Along the presented facilitate the exchange of ideas, experiences and special sections journal also published professional contemplations in Slovenian language, thus maxi- and scientific articles, which present the majority of mising the accessibility of such discussions to the published articles, as well as book reviews, confe- widest circle of professionals. We have a long history rence proceedings and other types of articles, all of of scientific publishing in the field of public health in them dedicated to the field of public health. Slovenia, but since recently there has been no peer- -reviewed journal covering the broad discipline of public health that would publish its articles in Slove- Eržen I. Uvodnik. Javno zdravje. 2017;1(1):1 nian language. To fill that gap the National Institute of Public Health introduced a new journal titled Javno Winslow C-EA. The untilled fields of public health. Science. 1920 Jan 9; 51(1306):23–33 zdravje (Slovenian for public health) (Eržen, 2017). The first issue of the journal that was published in October 2017 contained, among professional and scientific articles, a special section titled Perspecti- ves. In the special section prepared by a guest editor, short commentary pieces of professionals are pre- sented to highlight a selected public health issue from relevant viewpoints of public health and related professions. Among topics addressed in Perspecti- ves in past issues of the journal were frailty, alcohol use disorder, public health workforce development, 54 05 EDUCATION IN PUBLIC HEALTH 5.1 Public Health School 5.2 Education and training at the Department of Public Health of the University of Ljubljana, Faculty Of Medicine Public Health School Ivan Eržen The rapid development of public health, which has been especially fast in the last two decades - both in terms of content and scope of work - has led to a steady increase in the need to provide successful approaches to ensuring better health of the population. In order to respond to these needs, both in research and education, the Public Health School was established in Slovenia in 2020 and operates within the framework of the National Institute of Public Health (NIJZ). The need for a public health school has been present Another important area of work of the Public Health in Slovenia practically since independence. As early School is research, which is rather dispersed, as as 2004, a group of public health teachers led by experience shows the great advantage of networ- Marjan Premik prepared a comprehensive document king with other research organizations. The NIJZ is that provided the professional basis for the establi- already linking up with research organizations and shment of a Public Health School in Slovenia (Premik, project teams in its partners, which are also able to 2004). Unfortunately, the project was not realized at tackle very challenging research questions in public the time. In the years since, the situation and related health. The Public Health School will continue to needs have changed. In Slovenia, public health edu- support and develop such models. cation is provided at all five Slovenian universities. Public health content is thus included in the accre- The Public Health School therefore provides a roof dited curricula of at least 15 faculties and colleges of and support for various research projects and edu- higher education. cation and training programmes in the field of public health. Accredited programmes leading to a specific Most of the programmes are taught by professors level of education will continue to be delivered by who are also employed at the NIJZ, and the possibi- universities and other higher education organisa- lity of further development of the education within tions, with cooperation of the Public Health School the School of Public Health, which operates under in terms of content and modern teaching methods. the auspices of the NIJZ, became apparent. The NIJZ Within the Public Health School, particular emphasis is strongly involved in staff and skills development. will be placed on coordinating and supporting the NIJZ experts are involved in the teaching of accredi- implementation of the many educational activities ted and non-accredited forms of public health edu- already carried out by the NIJZ in the field of public cation. Training is provided at different levels and in health. different areas of public health expertise, carried out either by the experts themselves or in collaboration with experts who are otherwise employed elsewhere. There is a dense network of colleagues, who conti- Premik M (edit), Bilban M, Zaletel-Kragelj L, Artnik B. Slovenska šola za javno nuously raise their knowledge and abilities while wor-zdravje: strokovne podlage za ustanovitev. Ljubljana: Univerza v Ljubljani, Medicinska fakulteta, Katedra za javno zdravje, 2004. king together on individual projects, both foreign and domestic. The international dimension also makes it possible to involve international experts. In addition, the NIJZ has a good insight into the training needs of the public health workforce. 56 Education and training at the Department of Public Health of the University of Ljubljana, Faculty Of Medicine Lijana Zaletel Kragelj The Department of Public Health at the Faculty of Medicine of the University of Ljubljana is the leading educational institution for public health in the country. Together with external teaching staff it provides both undergraduate (Medicine and Dental Medicine integrated master’s programmes) and post-graduate courses (Doctoral and specialist study programmes). It covers areas of public health and occupational, transport and sports health. The Department of Public Health at the Faculty of dentists in Slovenia, within which it is the only accre- Medicine of the University of Ljubljana (DPH – UL dited institution to carry out one quarter of the pro- FM) is a very small department, but is nevertheless gramme. This is part of the Two-semester Post-gra- the leading educational force in the field of public duate Study of PH (TPSPH), which is a fundamental health (PH) and occupational, transport and sports organised part of the programme of this specialised health (OTSH) in Slovenia, and its influence also rea- study course. The competence-oriented TPSPH is ches beyond Slovenia's borders. Together with exter- constantly being upgraded, and its latest version in nal teaching staff the DPH – UL FM provides both 2021 has adapted it for distance learning with the undergraduate and post-graduate courses. The DPH use of the UL FM e-classroom, which operates on – UL FM can take pride that its teaching staff inclu- the Moodle platform. The first two full professors in des the first full professor in the field of OTSH and the field of PH in Slovenia have also prepared a draft the first full professor for PH in Slovenia. The DPH – UL renewal of the PH specialisation programme in Slo- FM team currently includes four full professors. The venia which complies with European guidelines and most important areas of the courses are: would be entirely competence-oriented. 1. Basic education is part of the integrated master's 4. The international influence of the DPHZ – UL FM is programmes Medicine (IMPM) and Dental Medi- the fruit of a 10-year project of cooperation in the field cine (IMPDM). We find that awareness of the impor- of public health in South-Eastern Europe. DPH – UL tance of public health for the effective operation of FM participated in this project as one of the leading the health care system, within which future doctors partners in the preparation of extensive teaching and dentists will operate, is falling at the UL FM. As materials, the first and second editions of which have a result, the amount of PH content in the IMPM and already been published (Burazeri and Zaletel-Kragelj, IMPDM is also decreasing, regardless of the all the 2013a; Burazeri and Zaletel-Kragelj, 2013b). efforts invested by the DPH – UL FM and the broader professional public. 2. On the other hand the DPH – UL FM is very success- Burazeri G (urednik), Zaletel-Kragelj L (urednik). A handbook for teachers, researchers and health professionals. Vol. I, Health: systems - lifestyle - poli-ful in the UL doctoral study programmes Biomedi- cies. 2nd ed. Lage: Jacobs, 2013a. Available from: http://www.seejph.com/ wp-content/uploads/2013/12/Volume-I-Health.pdf cine (with the independent scientific course Public Health) and Environmental Protection. Competence- Burazeri G (urednik), Zaletel-Kragelj L (urednik). A handbook for teachers, researchers and health professionals. Vol. II, Health investigation: analysis - -oriented education and training is very well received planning - evaluation. 2nd ed. Lage: Jacobs, 2013b. Available from: http://www. by students, as shown in the large amount of interest seejph.com/wp-content/uploads/2013/12/Volume-II-Health-Investigation. pdf. in enrolment. 3. The DPH – UL FM is also very successful in the field 1_Univerza v Ljubljani, Medicinska fakulteta. Spletna učilnica. Dvosemestrski of specialist studies in public health for doctors and podiplomski študij Javno zdravje [website on the Internet]. Available from: https:/ pouk.mf.uni-lj.si/course/index.php?categoryid=164. 57 06 PUBLIC HEALTH ACTIVITIES 6.1 HEALTH PROTECTION AND PROMOTION 6.1.1 Website ZDAJ.net and the guide We are expecting a baby: modern, professional and accessible 6.1.2 Health education for future parents and mothers: starting at the beginning, supporting healthy growth and development 6.1.3 Health education: for joyful and healthy children and adolescents 6.1.4 Health in kindergarten – a health promotion programme for the youngest 6.1.5 Sex education programme for children and adolescents 6.1.6 Challenges of eating disorders 6.1.7 Prevention in the area of oral health 6.1.8 Programme for the prevention of child injuries and the promotion of safety 6.1.9 Provision of psychological support during the COVID-19 epidemic 6.1.10 Improving accessibility of help in time of mental distress and suicide prevention 6.1.11 A community approach to reducing health inequalities 6.1.12 Health promotion in schools: The Slovenian Network of Health Promoting Schools (1993–2021) 6.1.13 Slovenian Healthy Cities Network 6.1.14 The web portal Šolski lonec 6.1.15 The online tool of the PKMO project 6.1.16 Preventive programmes in Novo Mesto 6.1.17 Maturation of young people through the This is Me programme 6.1.18 Sanitary and epidemiological inspection of passenger and cargo vessels in Slovenia 6.1.19 From research to action in order to promote healthy eating Website ZDAJ.net and the guide We are expecting a baby: modern, professional and accessible Barbara Mihevc Ponikvar, Zalka Drglin The new National Institute of Public Health website ZDAJ.net (www.zdaj.net) and the printed Guide to Pregnancy, Childbirth and Early Parenthood We are expecting a baby are important tools for health promotion and informing future parents. The guide on pregnancy, childbirth and early a wealth of information on healthy living, health and parenthood We are expecting a baby is intended for healthcare during pregnancy, childhood and ado- pregnant women and future fathers. Many renowned lescence. Access to the web and a wealth of informa- medical and other experts contributed to its creation. tion puts users in a more active role in acquiring health It collects key professionally verified information and knowledge, while at the same time challenging them guidance for pregnancy and early parenthood. They to choose quality information in the massive websi- inform future parents about the care for their own tes that are available. Healthcare professionals who and the child's health, about the course of pregnancy, meet the target population thus play an important childbirth and the postpartum period, as well as role in directing and raising the awareness of users about the care of the baby, cooperation with him and to websites where professionally supported and about family relations. The guide offers answers to verified content and popular topics are available. The many questions and directions, where to get additi- ZDAJ.net website and the Expecting a Baby guide are onal information, support or help. It is available to any very warmly received by users and experts, according expectant mother who receives it during a preventive to their first experiences; they are an excellent com- check-up in early pregnancy. It encourages self-care, plement to the preventive medical check-ups during cooperation between partners and parents, and the pregnancy and health education programs. They also creation of a loving and safe family environment. It played an exceptional role during the COVID-19 pan- raises awareness of the importance of early child- demic, when health education programs for future hood, which is crucial for a child's development and parents took place in a truncated form, or for some forms the foundation of a healthy adult. The guide time were not even accessible. accompanies future parents into a new period of life with an attractive design, with understandable and transparent content enriched with gentle verses. For more detailed and additional content, direct parents Bujnowska-Fedak MM, Waligóra J, Mastalerz-Migas A. The internet as a source of health information and services. Adv Exp Med Biol. 2019;1211:1–16. to the website ZDAJ.net. Plantin L, Daneback K. Parenthood, information and support on the internet. The World Wide Web has become an easy, accessi- A literature review of research on parents and professionals online. BMC Fam Pract. 2009;10(1):34. ble, and popular tool for finding information, inclu- Bernhardt JM, Felter EM. Online pediatric information seeking among mothers ding health-related information. Expectant parents of young children: results from a qualitative study using focus groups. J Med and parents of children are among the most active Internet Res. 2004;6(1):e7. users of the Internet, which is why we have dedica- ted a large part of the website of the prevention pro- gram ZDAJ - ZDAJ.net specifically to them. It gathers 61 Health education for future parents and mothers: starting at the beginning, supporting healthy growth and development Zalka Drglin In Slovenia, the implementation of preventive healthcare and health education for various target groups is stipulated by the law. Hereby, we present the health education for pregnant women, future parents and mothers, which is carried out in health centres. Maternity schools (or Childbirh classes) have a long is presented in the form of electronic and printed tradition in Slovenia and in the beginning were atten- materials. The programme is regularly carried out ded only by pregnant women. A modern programme in community health centres across Slovenia, with called Pregnancy, Childbirth and Parenthood pro- an emphasis on the active participation of future gramme1 is currently available, aimed at pregnant parents and their empowerment on the way towards women and expectant fathers. Experts from various a family life. Attendance is high: in 2019, 17,238 preg- fields help future parents develop new skills for caring nant women and future fathers participated in the for their own and the baby's health during pregnancy Pregnancy, Childbirth and Parenthood programme , and after birth, as well as inform them about the course who also expressed great satisfaction with the pro- of pregnancy, delivery and postpartum period, how to gramme in their responses2. care for and cooperate with the baby, and family rela- tionships. The most important topics covered are the For pregnant women who do not have any health pro- physiological processes of pregnancy, childbirth, the blems, the Pregnancy Exercise Programme, carried postpartum period, lactation and breastfeeding, as out by specially trained physiotherapists or kinesio- well as practical tips for improving health. The pro- logists, is also available in centres for health promo- gramme includes information on the importance of tion in the community primary healthcare centres. a healthy lifestyle for the pregnant woman, foetus, The programme consists of two exercise sessions mother, father and baby (nutrition, physical activi- of 60 minutes per week, provides scheduled sets of ties, rest…), which contributes to a quality life and exercises suitable for pregnant women, and lasts a the good health of everyone in the family, with a spe- total of sixteen weeks. cial emphasis placed on deviations and warning signs In addition, we are now introducing a Breastfeeding at which it is necessary to seek medical attention. Counselling Programme, which includes telephone Expectant parents also acquire new skills related to and personal counselling and is intended for mothers cooperating with the baby from birth, and informa- who are experiencing problems with lactation and tion about the baby's needs and development. They breastfeeding. Timely professional and accessible learn about the different aspects of ensuring safety counselling and support are provided by healthcare and receive information about healthcare services professionals who have passed the International in the perinatal period, their rights and options, and Board Certified Lactation Consultants (IBCLC) exam. how to find help and support for different life situa- tions. The first of seven two-hour sessions is sche- duled during early pregnancy, and the remaining six in the third trimester of pregnancy. The first session, where future parents learn about various aspects of 1_https://www.nijz.si/sl/vzgoja-za-zdravje-za-bodoce-starse. a healthy lifestyle in pregnancy, including the impor- 2_https://www.nijz.si/sites/www.nijz.si/files/uploaded/publikacije/leto-tance of physical activity and good physical fitness, pisi/2019/4.3_vzgoja_za_zdravje_2019.pdf. is accompanied by a lesson with a physiotherapist where they receive practical instructions and exer- cises. Selected information within the programme 62 Health education: for joyful and healthy children and adolescents Vesna Pucelj The public healthcare system in Slovenia offers various services for providing preventive healthcare, part of which is also health education. National Health education programmes for children and adolescents have a long tradition in Slovenia. They are implemented at the primary level of healthcare in cooperation with educational and other institutions. Within the school system, health promotion and health education for children and adolescents are updated and supplemented through the regular school curriculum and as additional programmes or activities. The Health Education for All Children and Ado- activity, prevention of addiction and other risk beha- lescents (VZOM)1 programme has been implemen- viours, education for healthy sexuality, prevention of ted for many years, approximately since 1995, as part cancer, prevention of infectious diseases, growing of regular systematic preventive health examinati- up, positive self-image, interpersonal relationships, ons of children and adolescents in the school/kinder- etc. garten setting and in the local community. Currently, health education for children and adolescents is part The providers of the VZOM programme from com- of the Preventive Healthcare Programme for Children munity health centres cooperate with most kinder- and Adolescents – the ZDAJ Programme – Health gartens, primary and secondary schools in Slove- Today for Tomorrow. In the VZOM programme, pro- nia. In the school year of 2018/19, for example, they viders cover all key target groups, that is preschool provided their activities to almost 95% of all primary children and their parents, schoolchildren and peda- school classes2. gogical and other staff in kindergartens and schools. Health education providers also work with young Meetings or counselling take place during the peri- people who do not finish their regular schooling and odical health examinations as individual health edu- are unemployed (also known as drop-outs or NEET cation and/or group works, and in educational insti- youth – neither in employment, education or tra- tutions mostly as group works within regular classes, ining) for various reasons, but are attended Project science days, activity days, etc. The key providers of Learning for Young Adults programme (PUM-O). The the VZOM programme are specially trained nurses, providers have carried out a series of workshops with as well as psychologists, kinesiologists, dieticians them and their mentors, most often in the field of and other professionals. Health education is more mental health, physical activities, nutrition, and addi- than just sharing information; it is an active learning ction. In 2019, the education providers established process that considers personal experiences and cooperation with all PUM-O organizations. socioeconomic factors. It aims to provide information and encourages individuals and groups to take care of their health. The contents are spirally upgraded according to the age of the children or adolescents. 1_https://www.nijz.si/sl/vzgoja-za-zdravje-za-otroke-in-mladostnike. Health education thus includes all important health 2_https://www.nijz.si/sites/www.nijz.si/files/uploaded/publikacije/leto-education topics, such as healthy nutrition, physical pisi/2019/4.3_vzgoja_za_zdravje_2019.pdf. 63 Health in kindergarten – a health promotion programme for the youngest Nives Letnar Žbogar The Health in Kindergarten programme promotes health for children from 1 to 5 years of age, in the kindergarten setting and beyond. An important part is training for professionals in kindergartens and providing up-to- -date information on the protection and strengthening of health. The programme develops and strengthens the capacity of kindergartens to create health-promoting environments, provide conditions and strengthen the ability of individuals to maintain and improve their health throughout life. Various activities are planned at the national level and carried out with national-regional coordination. The programme assigns health as an important content (intergenerational cooperation, I feel good, value, promotes it and directs the implementation time for a tasty treat, and so on). We also strengthen of activities to maintain and strengthen well-being understanding of the content and targeted messa- and health in kindergartens. At the beginning of the ges through regional meetings with coordinators 2019/20 school year, 87,708 children were enrolled in from kindergartens, materials and visits to kindergar- kindergartens, i.e. 82.7% of all children aged 1–5, of tens. which 94.1% were children aged 4 and 5 and 67.5% were children aged 1 and 2. Children spend 6 to 9 The activities are planned at the national level and hours a day in kindergarten, so the kindergarten as carried out with national-regional coordination a physical and social environment affects the deve- (via the nine regional offices of the NIJZ). A unified lopment, well-being and acceptance of a child, but approach allows for equal opportunities throughout also represents an environment for obtaining infor- the country. Through regional coordination, we also mation and learning skills, as well as an opportunity encourage and strengthen the community appro- to inform parents and maintain contact with them. In ach to health (cooperation of kindergartens with the addition to pedagogical knowledge, the health-re- health service, founders and other stakeholders in lated knowledge and competencies of kindergarten their community). employees (i.e. health literacy) are very important in Kindergartens join the programme on a voluntary this context. basis. All training materials are made available to all An important part of the programme is training for kindergartens on the website https://www.nijz.si/sl/ professionals in the kindergarten (2x per year) and zdravje-v-vrtcu, and reporting on the activities they the provision of up-to-date information with which have implemented also earns the kindergartens pro- we want to support employees in their efforts to motion points. In the 2019/20 school year, reports maintain and improve their own health and that of the were submitted by 37.6% of kindergartens, and the children they work with. The training is well attended activities were carried out for 24,100 children (27.5%). and highly rated. We started with 50 participants in We issued 2,113 different certificates. 2006, around 500 in recent years, and in 2020 there The support by the NIJZ significantly helped the were 1,250 participants (due to the epidemic, the tra- employees of the kindergartens to achieve the ining was conducted through videos). acceptance and support of a healthy lifestyle by the The basic messages are the ever-present themes of parents (e.g., drinking unsweetened tea, celebrati- a healthy lifestyle (physical activity, nutrition, mental ons without unhealthy food, spending time outdoors health, infectious diseases, hygiene and hygiene every day, vegetable tastings). conditions, oral health, safety, etc). Every year we focus on a certain topic – the common thread with which we bring particular attention to the featured 64 Sex education programme for children and adolescents Alenka Hafner Nearly all children and adolescents in Slovenia, from kindergarten to the end of secondary education, have in recent times received formal sex education in a uniform manner. In the field of healthcare, sex education is mainly performed by specially trained graduate nurses, health education providers, and partly also by graduate nurses from paediatric/school outpatient clinics. The development of content, preparation of materials and training of providers in the field of healthcare take place under the supervision of the Kranj Regional Office of the National Institute of Public Health. The Slovenian educational programme for the health national experts (clinical psychologists, graduate of children and adolescents has undergone signifi- nurses, specialists in gynaecology and obstetrics, cant changes in recent years. Health education has public health specialists, psychiatrists, sexologists, been stipulated in the Rules for the Implementation and pedagogues) in the field of sexual and reprodu- of Preventive Healthcare at the Primary Level since ctive health or health of children and adolescents. 1998 as a right of all children and adolescents; howe- While developing approaches, we have tested peer ver, its implementation was not unified until 2015. education in the past, but the current formal method At that time, the conditions for the implementation of education provided by full-time health education of the programme were provided by realizing the providers makes it much easier to achieve the goal objective of providing content to all children and ado- of providing uniform and professional content to all lescents, initially in the population of primary school children and adolescents, from kindergarten to the children: key contents were defined, materials for end of secondary education. Sex education is spi- providers were prepared (the manual Improving rally upgraded from the earliest years to the end of the health of children and adolescents), a national the secondary school period and is supposed to be network of providers was established, and conti- carried out in the form of three pillars, the first and nuous, stable funding was ensured. In the following second of which take place under the responsibility years, the programme expanded to the children of of the healthcare system. The first pillar takes place kindergarten and secondary school students. in combination with systemic health examinations in the 6th grade of primary school (under the title Sex education (education for healthy sexuality) is Growing Up) and in the 1st year of secondary school part of the health education programme. Since 1999, (under the title Love and sexuality) and is performed the Kranj Regional Office of the NIPH has been taking by a graduate nurse from a paediatric/school clinic care of unifying implementation, developing content in the form of a 45-minute workshop. As part of the and preparing materials, as well as educating provi- second pillar, the education provider conducts a ders in the field of healthcare. All materials are cre- 90-minute workshop on the school premises for the ated and updated in cooperation with regional and 9th graders of primary schools (Educa- tion for Healthy Sexuality), and in the secondary school period, topics from the field of sexuality are presented accor- ding to the identified needs of a parti- cular school. The third pillar should be implemented by professional staff of kin- dergartens and schools. The regular cur- riculum already includes some topics in this field and materials (Health through Art) have been prepared for the uniform implementation of additional topics. 65 Chal enges of eating disorders Alenka Hafner Due to their serious consequences, eating disorders represent an important public health problem that requires action, as well as the raising awareness of society as a whole. The school environment has an important role in preventing these disorders, and together with healthcare can make a key contribution to early detection and treatment by raising awareness and reducing the stigma of such conditions. The Kranj Regional Office of the National Institute of Public Health conducts research on the prevalence of these disorders, prepares materials and carries out education of key stakeholders and the general public. Eating disorders are an important public health pro- and pedagogical workers. In 2011, the Unit published blem, especially during adolescence. Adolescents a booklet Understanding Eating Disorders, which who experience these disorders often deny them as contains a synthesis of everything related to the well as refuse appropriate professional help. At the origin and development of these disorders, possibi- same time, both parents and teachers who notice lities of help, state-of-the-art views on family struc- the presence of these disorders are often in distress, ture and its role in today's society, as well as what it do not know how and when to act, and similar pro- means to be an adolescent today and how to develop blems are often experienced by primary healthcare from an adolescent into a mature and responsible professionals. Due to the serious consequences, adult. In 2016, they prepared guidelines in the field of this problem requires action by various sectors as eating disorders for publication in the manual Health well as raising the awareness of society as a whole. through Art, intended for pedagogical workers. In The school environment has an important role in the 2018, the third updated leaflet Understanding Eating prevention of these disorders, and healthcare and Disorders was published, which is an important aid in education together can, with increased awareness identifying these disorders and can also be a tool for and reduced stigma of mental disorders, including starting a conversation with a person who has such a eating disorders, make a key contribution to early disorder. In 2018, they also participated in the mono- detection and consequent early interventions. The graph Mental Health of Children and Adolescents in education of parents and adolescents as well as the Slovenia by contributing the chapter Eating Disor- education of health professionals who do not work in ders. We also regularly cooperate in this field on the the field of mental health are important. online counselling portal To sem jaz.net, where the questions from children and adolescents related to The Kranj Regional Office of the NIPH has been con- eating disorders are classified among the most dif- ducting research on the prevalence of these disor- ficult. In addition, we regularly conduct training for ders and their risk factors in Slovenia since 1999, in various professional audiences (pedagogues, health addition to preparing materials for the professional professionals…) and cooperate with the media. and lay public and conducting training for medical Figure 1: Materials by the regional office of the NIJZ on the issue of eating disorders. 66 Prevention in the area of oral health Martin Ranfl, Christos Oikonomidis Oral health is an inseparable part of general health. As such it demands special attention in the context of public health. To this end, the National Institute of Public Health (NIJZ) has a Working Group for prevention in the area of oral health, which addresses this area comprehensively, looking at its broader significance for society. Oral health is an inseparable component of general country in kindergartens and primary schools. It is health and has an important influence on the indi- important here for the recommendations to be clear vidual's quality of life. Diseases in the oral cavity are and standardised. To this end, in 2015 we drew up an among the most widespread chronic non-infectious expert publication entitled Vzgoja za ustno zdravje diseases, and their extreme consequence – loss of (Education for Oral Health) (Ranfl et al., 2015), which teeth – can seriously limit the individual and their was adopted by the University of Ljubljana Senate as health in general. Around the world, oral health is a university textbook, and which provides key expert closely interwoven with public health; the measure recommendations and guidelines for the care of of using fluoride to prevent caries even ranks among one's own oral health in terms of diet and oral hygi- the 10 greatest achievements of public health in the ene. past century. Oral or dental public health is a special branch of public health, which in certain countries In 2019, in cooperation with the Department of Public merits its own field of studies, and departments in Health at the Faculty of Medicine of the University of public health institutions deal specifically with it. Ljubljana and with the Stomatology Clinic of the Uni- The public health profession in Slovenia did in fact versity Medical Center Ljubljana, we joined forces in recognise the importance of oral health in the past, implementing a project of monitoring oral health in but unfortunately the field has not received much Slovenia (Artnik, 2020). The project included rese- attention. The year 2014 was a turning point in Slo- arch among adults, children and adolescents about venia for oral public health, since it marked the esta- the habits related to oral health. The analyses con- blishment of a special group for this branch of public ducted and published represent a basis for eviden- health within the NIJZ. ce-based action, decision-making and monitoring of the effectiveness of measures. Since 2014 we have regularly monitored the level of human resources coverage in the field of oral health. In the first year the report comprised just data on dentists, but later the monitoring added other pro- fessionals that make up a dental team. In 2014 we began marking World Oral Health Day, a campaign organised each year by the World Dental Federation (Fédération Dentaire Internationale, FDI). We merged together activities into one common banner, Pamet v roké – za usta in zobé (Intelligence in your hands – for mouth and teeth) (Oikonomidis and Ranfl, 2021), and each year we adapt the slogan of the campaign. Through these activities we are trying to empower people and to underline the importance of oral health for general health, along with the effect of our own Artnik B, Ranfl M, Blatnik J, Magajna A, Rostohar K. Ustno zdravje odraslih, care and responsibility for it. 2019. Ljubljana. Katedra za javno zdravje Medicinske fakultete, Nacionalni inštitut za javno zdravje: 2020. Empowering the people of Slovenia and caring for Oikonomidis C, Ranfl M. Pamet v roké- za usta in zobé. Ljubljana, Nacionalni oneself are more successful if the knowledge and inštitut za javno zdravje: 2021. skills can be acquired in childhood. Dental educa- Ranfl M, Oikonomidis C, Kosem R, Artnik B. Vzgoja za ustno zdravje: prehrana tion is provided in an organised form throughout the in higiena, strokovna izhodišča. Ljubljana. Nacionalni inštitut za javno zdravje: 2015. 67 Programme for the prevention of child injuries and the promotion of safety Mateja Rok Simon The Slovenian Programme for Child Injury Prevention and Safety Promotion includes a combination of counselling for parents, home visits and assistance in the use/installation of safety equipment. Programmes of this type are important for reducing socio-economic inequalities in ensuring the safety of children, as they are most effective in families where parents have a low level of education, among recipients of social assistance, and in single-parent families. A survey of Slovenian parents' behaviour in ensu- to families in the first year of a child's life during home ring the safety of their young children revealed that visits by a community nurse. The community nurse, an alarmingly low proportion of parents implement together with the parents, verifies the safety of the measures to prevent injuries, showing large diffe- home with the help of the Home Safety Check Lists, rences among families depending on the education advises the parents on the appropriate safety mea- and socio-economic status of parents (Rok Simon, sures specific to the child's age, and assists them in 2017). The most effective way to reduce inequalities the use/installation of safety devices. Counselling in ensuring the safety of children is the use of safety and assistance are individually tailored and inten- promotion programmes, which include a combina- ded primarily for families with parents who are less tion of counselling for parents, home visits and the aware and who, for various reasons, do not imple- provision/installation of safety equipment (Ingram et ment safety measures and do not use safety equ- al., 2012). To this end, the National Institute of Public ipment. The programme is supported by the website Health has developed a comprehensive counselling ZDAJ.net that publishes, in addition to other content, programme for parents, which is integrated into the the most important information and materials on the existing child healthcare system. The programme prevention of child injuries for parents and the profe- starts as early as in the gynaecological clinic, where ssional public. pregnant women get information about the choice of equipment for newborns in the booklet Choose Safe Equipment for Your Baby and duringthe course Pre- paration For Childbirth And Parenthood. Subsequ- ently, counselling for parents is provided in paedia- tric clinics at each preventive medical examination of the child. This has proven to be an effective way to improve parental awareness and implement mea- sures to prevent injuries in children. In addition, pae- diatric clinics ensure the credibility and relevance of individual messages, and parents also have the most trust in healthcare professionals (Zonfrillo, 2018). Figure 1: Examples of leaflets The problem with preventive paediatric counselling is time constraint due to the multitude of information on various health topics that needs to be provided to Rok Simon M. Vpliv izobrazbe staršev in izbranih socialno ekonomskih dejavni-parents. Therefore, in the field of safety promotion, kov na izvajanje ukrepov za preprečevanje poškodb majhnih otrok. Doktorska disertacija. Ljubljana: Univerza v Ljubljani, Medicinska fakulteta, 2017. a combination of personal counselling and the use of health education materials, namely ‘Taking care Ingram JC, Deave T, Towner E, Errington G, Kay B, Kendrick D. Identifying facilitators and barriers for home injury prevention interventions for pre–school of children's safety', is used, offering facts about the children: a systematic review of the quantitative literature. Health Educ Res. risks of injuries to children and simple instructions 2012; 27(2): 258–68. for implementing safety measures. As an upgrade to Zonfrillo MR, Gittelman MA, Quinlan KP, Pomerantz WJ. Outcomes after injury prevention counselling in a paediatric office setting: a 25-year review. BMJ paediatric counselling, counselling is also provided Paediatr Open. 2018; 2(1): e000300. 68 Provision of psychological support during the COVID-19 epidemic Matej Vinko, Helena Jeriček Klanšček, Nuša Konec Juričič, Saška Roškar Epidemics that last for months and permeate all aspects of our lives have a significant impact on population mental health. To prevent mental health issues and distress due to the epidemic and its consequences a Psychological Support Task Force was established in Slovenia. The task force with over 30 members, including both non-governmental and governmental organisations, provided timely psychological support and coordinated efforts on a national scale. The mental health impact of the COVID-19 epidemic NGOs working with at-risk populations using a survey was evident from its start. In response numerous instrument. A national survey on psychosocial needs institutions and individual professionals introdu- was conducted focusing on different population ced activities and services to address the needs for groups that were exposed to increased levels of risk psychological support arising due to the epidemic. factors (health care workers, parents of school-aged During the first wave of the epidemic in March 2020 children, social care workers etc.). In order to provide the National Institute of Public Health (NIJZ) acted accessible psychological support a free of charge as a coordinator and facilitator of a number of mental 24/7 helpline was established. Psychological support health related activities (Vinko et al., 2020). Following was also made available in individual and group the first wave of the COVID-19 epidemic, Slovenia format to employees in NGOs and social care institu- adopted a renewed National Protection and Rescue tions. PSTF produced a large collection of psychoe- Plan in the Event of an Epidemic (NPRP), setting the ducational materials addressing acute needs related framework for the Psychological Support Task Force to epidemic (from guidelines on psychological first (PSTF) (Ministry of Defence, 2020). The latter was aid to grief and bereavement advice during COVID- the acknowledgment and formalization of good pra- 19). Collaboration was also established with the nati- ctice of networking and collaboration of NIJZ and a onal public broadcasting organisation with whom the number of NGOs in the field of public mental health PSTF co-created mental health related content that during the first wave of the epidemic. PSTF, compri- was aired on television and radio programmes. sing over 30 members representing users, service providers, researchers and decision makers, was convened in October 2020 at the start of the second Ministry of Defence, Administration of the Republic of Slovenia for Civil Pro-wave of the epidemic in Slovenia by NIJZ and Ministry tection and Disaster Relief. National Protection and Rescue Plan in the Event of Health. Mental health needs assessment was the of an Epidemic, version 2.0. 2020 cornerstone of PSTF activities – on bi-weekly basis Vinko M, Roškar S, Novak Šubara T, Tančič Grum A. Local mental health support in Slovenia during COVID-19: setting up primary health care helplines. EuroHe-data on mental health needs was collected from althNet Magazine, 2020 (15). 69 Improving accessibility of help in time of mental distress and suicide prevention Helena Jeriček Klanšček, Saška Roškar, Nuša Konec Juričič, Matej Vinko In the field of mental health, the focus and effort in the last decades was directed towards improvement of accessibility of help, destigmatisation and raising awareness about mental health topics; also, effort was invested in prevention of suicide mortality which decreased for over 30 %. The field of public mental health has gained national Next to the presented programmes, the last decades wide recognition in the last decades. It comprises of also gave rise to comprehensive research on mental systematic measurement of mental health indica- health in Slovenia, which resulted in several publica- tors, data analysis and development and evaluation tions on mental health in adults, children and ado- of programmes in the field of mental health. In 2008 lescents. The obtained results and insights served the Mental Health Act was launched which enabled as background and corner stone for planning and legal regulation of the mental health field. In addition, preparing strategic documents and actions in the in 2018 the Resolution On The National Mental Health field of mental health. Programme 2018 - 2028 was accepted which empha- sizes priority topics in the field of mental health and Strengthened efforts to promote mental health and pinpoints principal institutions and sectors respon- at the same time prevent mental illnesses have led sible for activities as planned in the Action Plan 2018 to better accessibility of services and narrowing the – 2020 and 2021 – 2023. inequalities gap, to less stigma and greater aware- ness about mental health among general public and Among major achievements in the past period it is last but not least to a 30% decrease in suicide mor- worthwhile mentioning the prevention – promotion tality in Slovenia. programme To sem jaz (eng. This is me) and the web counselling service for youth of the same name, the establishment of free of charge psychoeducational workshops for management of depression, anxiety and stress (for patients and their relatives) within health promotion centres Promotion which are part of the primary community primary healthcare centres throughout Slovenia, the formation of the network of psychological counselling services which offer free help to individuals in times of emotional distress, the implementation of evidence based public health approaches in the field of suicide prevention (e.g. responsible reporting on suicide in the media, edu- cation of different gatekeepers), the pilot setting up of Community mental health centres for adults and Community mental health centres for children and adolescents in selected Health Care Centres in Slo- venia and last but not least, setting up free of charge psychological help during the COVID – 19 pandemic. 70 A community approach to reducing health inequalities Tatjana Krajnc Nikolić, Teodora Petraš, Martin Ranfl According to some socio- economic and health indicators, the Pomurje region is below the Slovenian average experiencing health inequalities. In the activities of promoting health and reducing health inequalities, we focus on close collaboration with the local community. We pay special attention to vulnerable groups. Pomurje borders three countries, which affects the culture and lifestyle of its inhabitants. Therefore, the Murska Sobota Regional Office worked closely with stakeholders from Hungary and Croatia, and since 2014 also with partners from Austria. The experts of the Murska Sobota Regional Office available evidence, present current health indicators focus on reducing health inequalities through health and selected examples of activities aimed at impro- promotion. In cooperation with the local environment, ving the health of the Roma, which have been imple- we carry out public health activities and connect mented since 2016. We have prepared a Programme local stakeholders, implementing of the World Health for Strengthening Public Health in the Roma Commu- Organization's approaches, the so-called »whole of nity, the first such comprehensive approach aimed at society approach« and »health in all policies« in pra- improving the health of the Roma people. ctice. We are aware of the importance of the implementing At the Murska Sobota Regional Office, we have alre- public health activities within the local community, ady developed a strategic »bottom-up« approach and we focus our activities to fulfil local population addressing health inequalities through health pro- needs with their active cooperation. In carrying out motion, which we first successfully implemented in the activities, we take into account the specific the Pomurje region, and then transferred to all Slo- needs of an individual vulnerable groups, available venian regions. Our goal was to equip people with resources and the impact of the social and cultural knowledge and skills for greater control over their environment. By being present in the local commu- health and strengthen the role of an individual in a nity, connecting and creating a network of stake- local community through a planned long-term and holders, we reach a wider part of the population and interconnected approach. The EU DG Sante also make it easier to encourage them to a healthier life- assessed the approach as successful and co-fi- style (for example, in the promotion of physical acti- nanced the ACTION-FOR-HEALTH project, aimed at vity: Zgeni.se: zimska gibanica, non-smoking: Bur- transferring this approach to other European cou- ning message). ntries (Krajnc Nikolić T, 2013). Important results of the project were, among others, the transfer of knowledge and experience of our regional office in addressing health inequalities and preparing strate- gic documents for other environments. In order to reduce health inequalities in the Roma ethnic community, we deliberately and systemati- cally connect with all relevant stakeholders in the implementation of activities to improve the health Krajnc Nikolić T, Belović B, Erzen I. The strategic approach to health inequa-of the Roma people. In the publication »Public health lities in the Pomurje region and Slovenia. Murska Sobota: Institute of Public approaches for the Roma ethnic community in Slove-Health, 2013 Available from: https://www.brighton.ac.uk/_pdf/research/ health/afh-strat-app-to-hi-in-slovenia1.pdf nia« (Krajnc Nikolić, 2018) we explain the causes of the health status of the Roma people based on the Krajnc Nikolić T et al. Public health approaches for the Roma ethnic community in Slovenia. Ljubljana: National Institute of Public health, 2018. 71 Health promotion in schools: The Slovenian Network of Health Promoting Schools (1993–2021) Mojca Bevc The Slovenian Network of Health Promoting Schools1 (SMZŠ) has been operating with the support of the Ministry of Health and the Ministry of Education, Science and Sport since 1993 and was one of the first members of the European Network of Health Promoting Schools (Schools for Health in Europe Network Foundation, SHE)2. From the first 12 pilot schools in 1993, the SMZŠ expanded to 400 institutions in 2021, including 71% of all primary schools, 34% of all secondary schools, 28% of all student dormitories and three institutions for children with special needs. The National Institute of Public Health (NIJZ) and its The SMZŠ programme has been operating for 28 regional offices lead the national and regional coordi- years, which would not have been possible without nation, prepare an annual programme with selected the support of ministries, national and regional coor- current public health topics, which is presented at dination and a huge number of aware and interes- regular regional educational meetings, and provide ted principals, team leaders, as well as pedagogical, schools with ongoing professional support. In their medical and other associates. Regular regional edu- work, they follow national and international guideli- cational meetings, in particular, are an opportunity for nes and principles in the field of health promotion for new knowledge, professional orientations, networ- children and adolescents. king and examples of good practices in the field of health promotion to spread to other environments. Each school has a team of staff (repre- sentatives of management, teachers, students, parents, local communities, health services) who systematically plan tasks, take a holistic approach to health in different ways – health content is provi- ded through the curriculum, with various projects/activities focused on a healthy lifestyle – and also involve parents, the local community, the health service and other interested health institutions. According to the SMZŠ programme and reports, various activities in schools are aimed primarily at raising the aware- ness of students, teachers and parents about healthy eating, promoting physi- cal activity at school and in leisure time, strengthening mental health and other topics that promote the healthy lifestyles of children and adults 1_Slovenska mreža zdravih šol: https://www.nijz.si/sl/slovenska-mreza-zdra- (addiction prevention, environmental content, edu- vih-sol. cation in the digital world, schooling during the pan- 2_Schools for Health Europe: https://www.schoolsforhealth.org/. demic, safety, etc.).3,4 3_Poročilo o delu SMZŠ v šolskem letu 2019/2020: https://www.nijz.si/sites/ www.nijz.si/files/uploaded/porocilo_zs_2019_2020_koncna_27_1_21.pdf. 4_Infografika 2019/2020: https://www.nijz.si/sites/www.nijz.si/files/uploaded/infografika_27_1_21_koncna.pdf. 72 Slovenian Healthy Cities Network Zlatko Zimet The core principles of healthy cities build on the Health for All principles, which are mainly concerned with values to achieve better healthcare and a better quality of life, as well as the development of the basic healthcare system. The Healthy Cities Project began in 1986 under the umbrella of the World Health Organization (WHO). Slovenia joined the project in 1989 and today 40 municipalities are involved in the project. It is one of the most successful programmes to improve health in local communities. Healthy cities was launched as a project in 1986 school, and we have redesigned/remodelled the under the auspices of the WHO Regional Office for website and published the SNHC Gazette, all with the Europe and the first Slovenian cities joined in its aim of adressing health promotion and facilitating early stage in 1989. The concept of healthy cities is knowledge transfer to the local population/at the supported by the WHO strategy and is fully aligned local level. with the European policy framework Health for All, the 2030 Agenda for Sustainable Development, the The responsibility of each member municipality is Copenhagen Consensus of Mayors and the Belfast to create a health profile of the city, which consists Charter. of an assessment of the situation and serves as a base for the Council's project with a programme of The Healthy Cities approach is based on equity, par- priorities in the fields of healthcare, environment, ticipatory governance and solidarity, cross-secto- economy, social protection, security or another field, ral cooperation and actions/efforts to improve the depending on the problems identified in the local health determinants. The national network works in environment (Benko, 2020). The member municipa- a cohesive and unifying way, providing encourage- lities evaluate the effectiveness of the programmes ment, support and advice at the local and national through annual evaluations. Due to the well-desi- levels (Krampač, 1996). gned programmes within the SHCN, our vision is to accredit the national network with the WHO while The Programme, coordinated by the National Insti- phase VII is still ongoing (Zimet, 2021). tute of Public Health (NIJZ), operates in phases, and in 2019 moved to phase VII, which will last until 2025. In empowering people to improve the health and Forty municipalities are currently included in the nati- satisfaction of citizens, local politics and civil soci- onal network, and we strive to increase their number ety are crucial. A healthy city is a long process and from year to year in order to attain the objectives pur- path, not just an outcome. The National Coordina- sued through the principle of continuous expansion. tion under the responsibility of the NIJZ through joint efforts will constantly strive to achieve the principles In the current phase, the common goal is to radically of Health for All. improve »the health and well-being of the population, reduce inequalities, and strengthen public health”. In order to achieve this, in 2019 we connected with sub-networks and established the Slovenian Healthy Cities Network (SHCN) Steering Committee to be Benko E. Program projekta Koper – Zdravo mesto za obdobje od 2020 do 2024. Koper: University of Primorska Faculty of Health Sciences, 2020. better connected with key ministries, governmental and non-governmental organizations. We organize Krampač I. Projekt Maribor zdravo mesto 1989 – 1996. Maribor: Center zdravo mesto Maribor, 1996. annual regional, national and international meetings. Zimet Z. Zdravo mesto – Glasnik slovenske mreže zdravih mest. Online edition: We actively participate in a public health summer No. 1, 2021. 73 The web portal Šolski lonec Rok Poličnik The web portal Šolski lonec (‘School Pot’) is a national website intended to support the implementation of nutrition guidelines in educational institutions. The portal was created as a result of cooperation between public health and education sectors, and is intended for professionals responsible for planning and preparing school meals. It includes content, recipes, ideas and good practices that can help with providing food at school or educating young people about the importance of healthy eating. Slovenia has a long tradition of organized school access to choices that are beneficial for health, while nutrition, as the first beginnings of care and social focusing on caring for the population of children and responsibility regarding nutrition and health of chil- adolescents and preventing the occurrence of chro- dren in schools date back to the period after the nic non-communicable diseases. Second World War, and the system of organized school meals was preserved even after the country The portal includes useful professional content on gained independence. The first practical instructi- healthy diet, nutritionally balanced school menus, as ons for preparing school meals were developed in well as descriptions and links to national projects and Slovenia in the 1980s, and modern nutrition guideli- good practices in the field of children's nutrition and nes were adopted in 2005 as part of its National Food physical activity. The portal also offers an e-cook- and Nutrition Action Plan for 2005-2010. The system book that provides ideas to spice up school menus. of organized school meals is the responsibility of the In cooperation with the Jožef Stefan Institute, a school department, and the public health sector also menu planning tool has also been developed, which has an important role. In accordance with the School is connected to the national food database. Simulta- Nutrition Act, the health sector is responsible for neously with the development of updated nutrition preparing professional guidelines for healthy eating, guidelines in this period, we are also developing a while the public health professionals systematically tool for managing school meals planning, which can ensure the monitoring of school meals in practice be customized according to the needs of individual and provide nutrition organizers in educational insti- educational institutions, and supports the entire tutions with advice on nutrition guidelines. process from receiving food, managing recipes and menus and ordering food in kindergartens, primary The web portal Šolski lonec (www.solskilonec.si) and secondary schools. was established in 2014 with the finan- cial support of the Ministry of Health, and it is currently being upgraded due to the updating of dietary guidelines. The development of the portal is in line with the objectives of the National Programme on Nutrition and Physical Activity for 2015–2025, which includes among its priorities the importance of providing nutrition in accordance with guidelines and recommendations, pro- motes cross-sectoral cooperation and 74 The online tool of the PKMO project Ticijana Prijon Musculoskeletal disorders (MSDs) and psychosocial risks (PSRs) in the workplace have been for decades the main cause of health-related absenteeism, prolonged absence from work, occupational disability and early retirement. Our analysis shows that incidences of MSDs and PSRs in Slovenia have been increasing each year, as has the average duration of absences from work for health reasons (Prijon, 2020). Having a significant impact, MSDs and work-related includes links to the most relevant chapters of the PSRs are a major burden on the health system and online tool, dealing with the respondent's self-repor- also represent a financial and economic burden, thus ted problems. By referring employees to the relevant causing a major socio-economic as well as pervasive educational content with measures to prevent MSDs social problem. and PSRs at work we want to ensure that each indi- vidual receives the most necessary information. The The National Institute of Public Health (NIJZ) and online tool contains several photos and videos with the Faculty of Health Sciences of the University of step-by-step implementation of the proposed activi- Primorska (UP FVZ) have developed an online tool ties and measures in practice. to help workers and employers. The online tool is part of the project »Promotion of activities to pre- The PKMO project team designed the online tool to vent MSDs and PSRs at work« (abbreviated PKMO) help raise awareness of the issue of MSDs and PSRs and funded by the Ministry of Labour, Family, Social at work, to reduce their incidence and prevent their Affairs and Equal Opportunities of the Republic of consequences in the working population, especially Slovenia and the European Social Funds. The PKMO among employees over 45 years of age. online tool includes a set of measures to prevent new disorders and at the same time manage the existing MSDs and PSRs in the workplace. The tool is based on the incidence analyses of the most common work- Prijon T. Zdravstveni absentizem zaradi z delom povezanih kostno-mi- šičnih obolenj in duševnih stresnih motenj v Sloveniji. Primerjalna ana- -related MSDs and PSRs in Slovenia and its content liza začasne nezmožnosti za delo v letih 2015 in 2019. NIJZ gradivo (2020). includes only scientifically supported findings and Available from: https://www.nijz.si/sites/www.nijz.si/files/uploaded/pkmo_ analiza_bs_zaradi_z_delom_povezanih_kmo_in_dusevnih-stresnih_ principles. It is available publicly and free of charge motenj.pdf. at https://pkmo.si/. The tool is set up in the form of a basic e-manual and an in-depth e-textbook, conta- ining detailed descriptions of work-related MSDs and PSRs, ergonomic measures to improve workplaces, kinesiological measures at work and in leisure time, PSRs management activities at work and recommen- dations to employers. A special feature of the PKMO online tool is the introductory »Find and Eliminate« questionnaire. Based on the answers given in the questionnaire, each user receives an individualized report on their risk for MSDs and PSRs in relation to work, according to age, gender, and the type of work they perform. Moreover, basing on the identified risk and possible pre-existing problems, the report 75 Preventive programmes in Novo Mesto Doroteja Kuhar Preventive programmes are organised systemically in Slovenia and aimed at various target groups. In the Novo Mesto Health Region we have for a number of years successfully coordinated these programmes and we are cooperating well with their providers. Over these years we have met regularly with the providers for specific population groups and helped resolve various issues and obstacles. Since back in 2009, at the then Novo Mesto Health had major support from our then regional responsi- Institute we have established the regional responsi- ble physician. As a family medicine practitioner, she ble person on the side of the providers for each spe- was well able to underline the importance of imple- cific target group, as defined in the Rules on imple- menting the programme and the major role of the menting preventive healthcare on the primary level. family physician in people's trust in the programme. Together with the regional responsible persons we One of our regular tasks as part of coordinating pre- first agreed on the agenda of meetings, including ventive programmes was regular visits to health in them expert topics and helping find providers of centres in the region. Meetings were attended by expert content. We met at least once a year with the management representatives, the heads of indivi- providers for a specific population group. At each dual departments and the then regional responsible meeting we especially highlighted the current issues physician. This gave us an insight into the regionally and helped them resolve problems that arose in their specific implementation of programmes at the level work. We included them in regional activities. Thus, of the individual health centre. for instance the health centre in the region invited us to present the public health aspect and importance On a regional level we also linked up with private pro- of carrying out preventive checks for children and viders operating in the public network. The basis for adolescents to the heads of primary schools in their good cooperation was ensured by our continuous area. communication with providers and regular response to the needs of individual environments, where we Also cooperating were the municipalities of the fou- always advocated the public health importance of nder and representatives of the programme funding preventive care. We presented our good cooperation provider. One of the important aspects was the active with providers at meetings with regional responsible participation of schools in implementing these types physicians and coordinators for adult healthcare, of programmes, which contributed to the co-crea- which were organised by the NIJZ central unit. The tion of the healthiest school environment. In this we COVID-19 epidemic temporarily limited our coordi- linked up with the area unit of the Novo Mesto Edu- nation work, and this will pose an even greater chal- cation Institute. We participated in regular advisory lenge for the future. boards of family medicine practitioners in individual health areas, where the topics included implementa- tion of the Svit Programme. Throughout this time, we 76 Maturation of young people through the This is Me programme Ksenija Lekić, Nuša Konec Juričič, Petra Tratnjek, Domen Kralj, Alenka Tacol, Marjan Cugmas The This is Me programme, established in 2001 at the Celje Regional Office of the National Institute of Public Health, aims to strengthen young people’s mental health and mental resilience. The evidence-based programme has been repeatedly recognized by the international professional public as an example of good practice in the field of organized mental healthcare for adolescents, and has also been described in a publication by the World Health Organization (WHO, 2019). In addition to other national awards, the programme has received the Prizma award for communication excellence. The youth mental health programme This is Me, the addresses the development of psychological resi- development of which is supported by the Ministry of lience and social and emotional competencies that Health, is based on two main approaches to work: support young people during adolescence and act as protection in crisis situations. The approach has 1. Online consultation been tested and supported by evidence – the results The online counselling centre www.tosemjaz.net of an in-depth evaluation of the effectiveness of the provides young people with anonymous, publicly work model conducted by the Centre for Psychodia- available, free-of-charge and easily accessible pro- gnostic Resources show that the workshops have a fessional advice. The answers to questions about the positive impact on both the school class and the indi- challenges and hardships of growing up are provided vidual in terms of mental health. The goal is to have a by a multidisciplinary and inter-institutional online provider carry out all 10 preventive workshops descri- counselling network, which brings together more bed in the manual Maturing through the This is Me than 60 specialists/volunteers (doctors from various programme1 in the same school class in one or two disciplines, psychologists, social workers and other school years. The workshop providers are teachers experts). The editorial office, which is located in Celje (usually class teachers). The National Education at the National Institute of Public Health, takes care Institute of the Republic of Slovenia recommends the of the online counselling activity, coding of online use of the manual to all teachers and schools, espe- submitted questions and analytics. The extensive, cially counsellors and class teachers. On average, unique online database currently contains more than about 10,000 children and adolescents participate 45,000 conversations – questions from young people in the programme per school year. The programme and answers from experts. An analysis of more than is included in the National Mental Health Programme 18,000 online questions (2012–2020) shows that and is intended for gradual systemic introduction young people most often submit questions about into the school environment. issues related to their relationships with peers, fri- ends and family, falling in love, physical maturation The free-of-charge and publicly available programme and sexuality, and self-image. About 75 percent of literature: the questions are asked by girls, and nearly 60 per- • The manual for preventive work with adolescents cent of users are between 13 and 17 years old. About Zorenje skozi To sem jaz is available online at: a tenth of the questions in the entire database are https://www.nijz.si/sl/prirocnik/tosemjaz. represented by ‘the toughest questions', those rela- • The professional monograph on online counselling ted to crisis situations. They are associated with Srečanja na spletu is available online at: https:// suicidality, eating disorders, self-harm, anxiety and www.nijz.si/sl/publikacije/srecanja-na-spletu. depression, and various forms of violence. • WHO. This is Me: mental health programme for 2. Preventive work in the school environment based youth, Slovenia. In: Case Studies: The WHO on the model of 10 workshops European Health Equity Status Report Initiative. Copenhagen: World Health Organization, Regional The comprehensive model of 10 preventive work- Office for Europe, 2019. shops, designed for preventive work with ado- lescents from 13 to 17 years of age, systematically • https://www.euro.who.int/__data/assets/pdf_ file/0016/411343/HESRi-case-studies-en.pdf. 77 Sanitary and epidemiological inspection of passenger and cargo vessels in Slovenia Boris Kopilović, Andreja Rebec, Nevenka Ražman Since 2005 Slovenia’s sole maritime passenger terminal has been in Koper. The recommendations for preventing risks to public health related to vessel transport are set out in the International Health Regulations. In 2006 the European Union implemented the SHIPSAN project, where risks to public health are determined by means of sanitary and epidemiological inspections. The majority of vessels inspected at the Port of Koper are cargo ships, but inspections also cover three passenger ships a year. Koper is well known for having the sole maritime pas- cargo, vehicles, waste (EU Shipsan Act Joint Action senger terminal in Slovenia, which each year records Shipsan, 2016). the appearance of new ship operators. Record num- bers were reached in 2019: 115,581 passengers1, The Ship Sanitation Certificate is a document that although this was followed by a curtailment due to confirms the compliance of the vessel with the the novel coronavirus pandemic. requirements of international health legislation and serves as a confirmation for entry to the port, valid Meanwhile sanitary and epidemiological inspections for six months. of cargo vessels have continued uninterrupted and no fall in numbers has been noted. We anticipate the return of passengers to the Port of Koper. This will require the adaptation of the pas- Conditions on ships have a considerable effect on senger terminal, but prior to that the adoption on the public health, since they may be a source of infecti- EU level of guidelines as what in fact these terminals ons or a means of transferring vectors internatio- should comprise. In the future it will also be necessary nally. Controlling outbreaks on vessels is harder than to inspect more passenger ships. Health services in facilities on dry land. Studies have shown that the should be better connected and common criteria most common infections/outbreaks are: viral gastro- valid across the entire EU should be determined. enteritis, influenza, hepatitis A, cyclosporiasis, Many European countries have ‘special' inspectors diphtheria, E. coli, measles, meningococcal meningi-who are involved exclusively in inspecting vessels. tis, rubella, salmonellosis, scabies, dysentery, sexu- For the moment Slovenia has no such inspectors, but ally transmissible diseases, trichinosis, tuberculosis, it would be good to consider whether to set up such chicken pox and cholera. The factors that contribute a service. In other countries this is known as the Port to such outbreaks can be prevented or reduced thro- Health Authority. We believe that this is arranged ugh appropriate measures, training of ship crews and best in the USA, where these services fall under the advice to passengers (Mouchtouri, 2010). Department of Defense (Kopilović et al., 2018). In accordance with the EU SHIPSAN ACT or EU SHIPSAN manual, inspections are performed by qua- lified inspectors at the port, and they enter a report in the information system (EU Shipsan Act Joint Action Shipsan, 2016). Regular inspections are carried out European Manual for hygiene standards and communicable disease surveillance on passenger ships. Eu shipsan act joint actionshipsan. 2nd edition; in accordance with special criteria every six months. April 2016. Additional inspections are performed following the Kopilović B. Kleibencetl J. Colarić M., Jug P. Pregled potniških ladij. e-NBOZ, unsatisfactory outcome of a regular inspection or sept. 2018; Pridobljeno na spletni strani: https://www.nijz.si/sl/e-nboz-0#- following the elimination of deficiencies. Inspections september-2018, dne 8.6.2021. are also carried out in the event of complaints or an Mouchtouri V., Nichols G., Rachiotis G., Kremastinou J., Arvanitoyannis I., Riemer T., Jaremin B., Hadjichristodoulou C. State of the art:public health and outbreak of an infectious disease. Inspections cover passenger ships. Int Marit Health 2010; 61, 2: 49–98. all factors of risk to public health: people, air, drinking water, food, recreational water (spas, pools), ballast 1_Potniški terminal. Luka Koper. 2021; Pridobljeno 7.6.2021 s spletne strani: water, sea water, vectors, animals, plants, baggage, https://luka-kp.si/slo/terminali-191/single/potniski-terminal-255. 78 From research to action in order to promote healthy eating Matej Gregorič, Vida Fajdiga Turk, Urška Blaznik Each one of us is “exposed” to food, while our dietary patterns differ and change from day to day as well as from one period of life to another. This a special challenge for researchers. That is why NIJZ has, for already a decade, participated in a network of experts who gather and analyse data on nutrition at the European Food Safety Authority (EFSA), where we co-create the common EU Menu methodology. On a national level we researchers are active in the • dietary habits have improved, especially as programme group Nutrition and Public Health at the regards regularly having breakfast amongst chil- Slovenian Research Agency, where we have already dren and young people; prepared numerous initiatives based on scientific evidence to improve the population's diet. We have • the trend of falling regular consumption of fresh so far succeeded in carrying out the following acti- vegetables has stopped; vities: • sweet drinks are being consumed less frequently, • we have investigated dietary intake from the point and this drop is particularly marked among young of view of nutrients that may cause health pro- people; blems and identified population groups with more • the habit of adding more salt to food at the table risky diets; has been reduced; • we have harmonised efforts in the field of limiting • healthy fats are being used more and more often the intake of sugar, salt, and unhealthy fats with in cooking; European initiatives; • the trend of increasing overeating and obesity • we have provided legal bases for the legislative among children and young people has stopped. restriction of trans-fatty acids in our diets; • we have reviewed the situation regarding vitamin Dietary behavioural factors, such as inappropri- D supplies and on this basis named a group to pre- ate ingredients and amounts of certain foods, less pare guidelines for the sufficient supply of vitamin appropriate methods of preparing food and the food D; intake rhythm, are the main reasons for premature morbidity and mortality rates for cardiovascular dise- • we have made efforts and directed our work ases, diabetes, obesity, and other conditions. Two towards increasing the selection of food products thirds of Slovenia's adults already have risk factors that are beneficial for health, in cooperation with connected with their diets, such as increased blood the national food industry; sugar levels, high blood pressure, high blood cho- lesterol levels and increased body weight. As it is • we have helped increase awareness and the qua- possible to successfully change and control most lity and balance of food in public institutions and of these factors – by raising awareness among the restaurants with guidelines for healthy nutrition, population, and the creation of the skills and suppor- with cross-sectorally planned programmes, pro- tive environments needed for healthy choices to be jects, measures and the marking of important made – it makes sense to continue with the outlined events (e.g., monitoring nutrition in schools, activities. Changing dietary habits is a long process, expert support for food providers, the School so citizens have at their disposal suitable support Scheme, Traditional Slovenian Breakfast, World within the health care system to achieve a long-term Food Day). change in their habits, as well as numerous other After more than a decade of planned work in compli- supportive public health policies, which go beyond ance with the guidelines of strategic national pro- the reach of the health sector. grammes (Ministry of Health, 2015), various favou- rable trends are also evident with regard to people making more prudent choices and having healthier diets: • consumers have become more health-consci- Ministry of Health of the Republic of Slovenia. National Programme on Nutrition and Physical Activity for Health 2015–2025. Ljubljana, Ministry of Health ous in their choices and also check the origin of of the Republic of Slovenia, 2015. Available from: https://www.dobertekslovenija.si/nacionalni-program-2015-2025/. foodstuffs; 79 6.2 REDUCING RISKY BEHAVIOURS AND DRUG DEPENDENCIES 6.2.1 Interventions to control drug dependence 6.2.2 Approaches to reducing opioid-related mortality 6.2.3 Tackling the alcohol consumption problem with the SOPA approach 6.2.4 Social protection programme Centre for the Prevention of Addiction 6.2.5 Reducing harm in the area of drugs and homelessness Interventions to control drug dependence Mateja Jandl, Ada Hočevar Grom, Andreja Drev, Ines Kvaternik, Živa Žerjal, Maša Serec The National Institute of Public Health (NIJZ), with the assistance of government and non-governmental organisations, gathers and provides access to key epidemiological data in the area of use of illicit drugs. Through activities to reduce harm and by drawing attention to the appearance of new psychoactive substances, it contributes to the protection of public health. The establishment of a network of mobile units to implement harm reduction programmes and provide prevention in 2018 signalled the upgrading of existing programmes and introduction of some of the latest programmes. The NIJZ systematically gathers data covering drug proposals for action and classifying NPS on the list use among adolescents (Health Behaviour in School- of illicit drugs. All this contributes to reducing the risk -Aged Children (HBSC) and European school survey to health, while at the same time provides legisla- on alcohol and other drug use among students tive and repressive authorities scope for appropriate (ESPAD) surveys) and the adult population (Survey action. The Slovenian system is integrated into the on tobacco, alcohol and other drugs), the spread European Union Early Warning System, within which of infectious diseases, an estimate of problem drug information is rapidly exchanged among Member users, treatment of drug use problems and monito- States of the EU and European Monitoring Centre for ring drug related deaths and mortality due to drug Drugs and Drug Addiction (EMCDDA) and Europol. use. Data is also gathered in respect of reducing the supply of illicit drugs, along with data on the use of The Ministry of Health has pursued the development drugs among persons serving prison sentences. and upgrading of a network of mobile units for imple- The NIJZ also collaborates with researchers at the menting preventive action and harm reduction pro- Jožef Stefan Institute, which analyses communal grammes in the area of illicit drugs as part of the wastewater for drugs and their metabolic products. Operational Programme 2014–2020. In low-threshold programmes health personnel are embedded in social The NIJZ Koper Regional Office coordinates a network protection teams, where users of illicit drugs receive of 20 harm reduction programmes in the area of illi- comprehensive psychosocial and health treatment. cit drugs which are located throughout Slovenia, Testing of psychoactive substances is carried out in and which as part of day centres, mobile units, night the mobile laboratory in the night-time setting and shelters and safe houses for drug users offer help regularly every week in the stationary laboratory. to drug-dependent clients and homeless persons. The field programmes of substitution treatment for Programmes offering sterile needle exchanges come opioid dependence and programmes of health and into contact with a hidden population of high-risk social rehabilitation foster stable treatment and pro- drug users and thereby contribute to preventing the vide activities for re-socialisation, employment re-in- spread of infectious diseases and to reducing the tegration and prevention of recidivism. visible use of drugs. The NIJZ coordinates the national and regional networks of the Early Warning System for the appe- arance of New Psychoactive Substances (NPS). This 1_HBSC - Health Behaviour in School-Aged Children ali Z zdravjem povezano vedenje v šolskem obdobju comprehensive system links together the key insti- tutions and non-governmental organisations that 2_ESPAD – European school survey on alcohol and other drug use among students ali Evropska raziskava o alkoholu in preostalih drogah med šolsko can help in the rapid detection and monitoring of mladino NPS, and in informing various circles that can offer 3_EMCDDA - Evropski center za spremljanje drog in zasvojenosti z drogami 83 Approaches to reducing opioid-related mortality Mateja Jandl, Ada Hočevar Grom, Ines Kvaternik With the start of the implementation of the public health intervention “take-home naloxone” in the field of reducing drug-related mortality, Slovenia has joined other countries where this medicine is successfully used to prevent deaths due to opioid overdose. Naloxone is an effective life-saving medicine, and the intervention “take-home naloxone” is one of the most important in reducing the number of deaths due to opioid overdose. Reducing mortality from opioid overdose is a major authorized and available since March 2021 in all cen- public health challenge in Europe, as the number of tres for the prevention and treatment of drug addi- deaths among drug users has been increasing in the ction and pharmacies that supply the centres with last decade. In 2018, the drug-related mortality rate medicines. in Slovenia among users aged 15 to 64 was 41 deaths per million people, which exceeded the number in the Reducing vulnerability EU for that year (23.7 deaths per million). The main approaches to reducing the number of deaths due to In Slovenia, we have a well-developed network of non- opioid overdose used in Slovenia are mainly focused -governmental organizations that implement harm on the following important areas: reduction programmes for substance abuse, whose basic goal is to ensure less risky drug use, reduce the Prevention of overdose-related mortality possibility of infections and thus ensure the social inclusion of drug users. A network of mobile units Experts in the field of dependence treatment in implements harm reduction programmes, outpatient Slovenia recognized the intervention “take-home substitution treatment programmes, a substance naloxone” as effective and feasible as early as 2016, analysis laboratory and a unit for social and medical when the professional basis for its introduction was rehabilitation. prepared. Naloxone is an opioid antagonist used to counteract the effects of opioids in cases of an Reducing the risk of overdose opioid overdose. The most important part of the intervention is education on overdose and distribu- In Slovenia, the network of centres for the prevention tion of naloxone to opioid users and other people who and treatment of illicit drug addiction is very easily may be present during an overdose. The programme accessible, and no surcharge is required for substi- trains participants to recognize signs of overdose, to tution treatment, as this type of treatment is cove- know that it is necessary to call the emergency medi- red by health insurance. The network of programmes cal service immediately, to know the basic procedu- in Slovenia is well-spread geographically, and tre- res of resuscitation and application of naloxone, and atment programmes also exist in prisons. to know that they must stay with the person who has overdosed until paramedics arrive. In Slovenia, nasal naloxone (in the form of a nasal spray) has been 84 Tackling the alcohol consumption problem with the SOPA approach Tadeja Hočevar The national developmental project SOPA (Together for a Responsible Attitude Towards Alcohol Consumption) is taking place in Slovenia from 2016 to the end of January 2022. It involves activities for the development and piloting of an interdisciplinary approach to limiting excessive alcohol consumption among the adult population of Slovenia, and the preparation of a proposal for the implementation of the approach at the system level. The current results show that the project is exceeding the set goals. The SOPA project pursues the following objectives media and among the general public. in order to limit the problem of alcohol consumption to reduce health inequalities (Hočevar et al., 2022; As part of the project activities, almost 600 experts Hočevar et al., 2018): have been trained to support individuals and groups in ending excessive alcohol consumption, more than I) Building and strengthening capacity. This involves 50,000 community members have been addressed, raising awareness and training the professionals, over 4,000 have been involved in the process of political decision-makers, representatives of NGOs stopping their excessive alcohol consumption, and that deal with groups of people with various vulne- almost 1,000 of these have also successfully done rabilities, media representatives and members of the so . This represents a 175% success rate relative to community in topics relating to the harm caused by the goal set for the project. In addition, eight regional alcohol consumption, and the resources and support and 18 local interdisciplinary groups of SOPA actors methods available for encouraging adults to give up were established, 15 media representatives trained excessive alcohol consumption. in writing about alcohol in the media in a way that is appropriate for public health, and several media cam- II) Cross-sectoral interdisciplinary cooperation. paigns were conducted throughout Slovenia, while Cooperation between health workers in medical cen-the ‘Alcohol Free Day' was celebrated every year1. tres and clinics, social workers at centres for social Based on the evaluation, and if there is the appropri- work and experts at employment offices and in NGOs ate political will, the approach can be implemented at dealing with groups with special vulnerabilities con- the system level. stitutes a key bridge between the healthcare and social sectors. III) Piloting of the approach in 18 local areas around Slovenia. The approach is being tested in 18 local areas, with selected health and social workers and representatives of NGOs and employment offices working together to provide activities of the ‘shor- t-form measure' of support for people who wish to bring their hazardous and harmful alcohol consu- mption to an end. IV) Proposal for establishing the approach at a system-wide level. After the pilot project is evalu- ated, a proposal will be drawn up to implement the Figure 1: Map of local areas in which the SOPA pilot project is being implemented measures as part of the national public health pro- tection programme. V) Removing the taboo and stigma from alcohol-rela- Hočevar, T., Henigsman, K., Štruc, A., Založnik, P. Utemeljitev pristopa SOPA – ted problems in Slovenian society. This is carried out Skupaj za odgovoren odnos do pitja alkohola Izbrani ukrepi zamejevanja pitja through the objectives referred to above, and par-alkohola med odraslimi prebivalci Slovenije. Ljubljana: NIJZ, 2022 (Forthco-ming). ticularly through the building and strengthening of Hočevar T, Henigsman K, Štruc A. SOPA – Skupaj za odgovoren odnos do pitja professional capacities and raising awareness in the alkohola. Ljubljana: National Institute of Public Health, 2018. 85 Social protection programme Centre for the Prevention of Addiction Vanja Žmak The Centre for the Prevention of Addiction began operating in 1996, its work has continued through the years to the present day, and will go on with a vision, compassion and enthusiasm to achieve even better and greater results. The centre operates within the National Institute of Public Health at the Maribor Regional Office. The content offered has expanded over the years, • physical and psychological non-violence, mainly due to the growing need to address younger generations of users. For the purpose of evaluating • continuing education or employment, the programme, we have also introduced a monito- • undergoing supervised urine tests, ring group to follow the users who no longer have such frequent contact with us, and to record the • respect for supervision by all who form a safe number of successful abstainers. social network for the user and provide an incen- tive to maintain abstinence, Our work is based on the idea that users remain inte- grated in the home environment and maintain impor- • following instructions and adopting a new life- tant social contacts throughout their participation in style, the programme. In this way, they can feel included, • involvement of the user's most important loved useful and active members of their family and surro- ones in rehabilitation. undings. We work from the assumption that the level of addiction among programme users is not yet seri- Upon completion of the programme, the user is able ous enough that they should be excluded from their to adhere to a higher quality lifestyle and achieves home environment and included in a therapeutic autonomy in performing daily activities and obligati- community or low-threshold programmes. ons. Most users are secondary school or university stu- The Centre for the Prevention of Addiction is thus the dents, a certain proportion are also employed, and only high-threshold programme in this part of Slove- all have an appropriate support network. We include nia in which the users can address their drug-related the foundations of volunteer work and elements of problems in the home environment. self-help in our work. In this process, we involve the entire National Institute of Public Health (NIJZ) in Moreover, we offer the only programme in the Podra- cooperation with the Slovene Philanthropy, Asso- vska region that is designed for those experimenting ciation for Promotion of Volunteering (https://www. with illicit drugs, who are not yet considered to have filantropija.org/). developed an addiction. Participation in the programme is voluntary and requ- The vision we have for our work is that we may expand ires the active participation of users in solving pro- the programme to other regions and include the tre- blems. The conditions for participation are: atment of non-chemical addictions. • abstinence from all illicit drugs, alcohol, chemical substances, alkohola, kemičnih substanc, 86 Reducing harm in the area of drugs and homelessness Ines Kvaternik, Živa Žerjal The Koper Regional Office of the National Institute of Public Health has for a number of years coordinated programmes to reduce harm in the area of drugs and homelessness, providing sterile utensils for safe use of drugs, removing returned infective materials for destruction and gathering epidemiological data on drug use and the needs of high-risk drug users. The Koper Office coordinates a network of 20 pro- Numerous studies show that harm-reduction mea- grammes to reduce harm in the area of illicit drugs and sures actually reduce the incidence of transmission homelessness. In this way it contributes significantly of infectious diseases and at the same time do not to protecting public health, preventing infections contribute to any increase in the number of drug with blood-transmitted viruses and reducing conflict users. These programmes also inform and encou- between addicted and homeless persons and the rage illicit drug users to put their way of life in order, local community, as well as spurring the development to use drugs in less risky ways, reduce the sharing of new measures in the area of public health. of injection utensils and to save and return used infective utensils to the programmes. In this way The harm-reduction programmes are spread thro- they provide users with the necessary knowledge ughout Slovenia, and in the context of day centres, about preventing transmission of infectious disea- classic field work and field work with mobile units, ses and encourage them to handle infective waste night shelters and safe houses for drug users they responsibly and to be included in various addiction offer help to addicts and homeless persons. The assistance programmes – from treatment to social programmes include the free service of a needle rehabilitation. exchange, which represents a basis for all other approaches to reducing harm that are effective in the area of protecting the health of individuals and the community. Unimpeded access to sterile utensils constitutes a measure of preventive care, and at the same time access to the highest number of intrave- nous drug users. It facilitates contact with a hidden population of high-risk users and in this way con- tributes to reducing the health risks for addicted persons and the community, and enables the social inclusion of users. 87 6.3 HEALTH AND ENVIRONMENT 6.3.1 Environment and health indicators 6.3.2 Chemical safety 6.3.3 National Human Biomonitoring Programme 6.3.4 Preparation of hygiene recommendations to prevent the spread of SARS-CoV-2 infections 6.3.5 Programme of measures to improve the quality of the environment in the Upper Meža Valley 6.3.6 Preventive programme Safe with the sun Environment and health indicators Nataša Kovač, Peter Otorepec Environmental pollution is an important determinant of wellbeing, as it affects human health and development as well as many socio-economic factors that also determine the quality of life. The effects of the environment on human health are monitored with environmental and health indicators. These indicators are data presented in an agreed manner, which have been developed in accordance with the methodology of the World Health Organization – ENHIS (Environment and Health Information System)1. They are intended to be used by decision-makers to support decision-making and by the general public to help them understand environmental and health issues. The environment/health data set consists of 25 indicators that link the health and environmental determinants of a dise- ase with the effects of the environment on human health (see figure below). A polluted environment can be the cause of gastrointestinal diseases, cardiova- scular diseases, respiratory diseases, cancers, hormonal disorders, disorders in nervous system development and sleep disorders. By using these indicators, we want to answer the question of whether the impact of a polluted environment on human health is decreasing. As the rela- tionship between the environment and health is complex, the indicators address various aspects such as quality of water bodies, climate change, air quality, radi- ation, food safety, chemical safety and noise. Environmental and health indica- tors are developed by the Slovenian Envi- ronment Agency in cooperation with the National Institute of Public Health and the National Laboratory for Health, Envi- ronment and Food. As indicators are used to monitor the implementation of the objectives of the EU environmental health policy, they also serve to monitor the Resolution on the National Environmental Action Programme for the period 2020– 2030 (Official Gazette of the Republic of Figure 1: The set of indicators related to the environment and health Slovenia, 2020), to prepare reports on the The Environmental Agency of the Republic of Slovenia, 2021 (http://kazalci.arso.gov.si/sl/indica-state of the environment and to compre- tors-trend?term_node_tid_depth_i18n%5B%5D=7). hensively assess the impact of the envi- ronment on human health. 1_ENHIS, Environment and Health Information System, https:/ www.euro.who.int/en/data-and-evidence/environment-and- -health-information-system-enhis/enhis-database. Resolution on the National Environmental Action Programme 2020–2030. Official Gazette of the Republic of Slovenia, 2020; 31/20. Available from: http://www.pisrs.si/Pis.web/pregled-Predpisa?id=ODLO1985 89 Chemical safety Lucija Perharič Chemical safety contributes to health protection and prevention of diseases conditions and poisonings, which may arise as a consequence of exposure to natural and synthetic chemicals. NIJZ is a key stakeholder in chemical safety assurance, in particular by assessing complex risks, introducing the internationally accepted professional approaches to risk assessment and novel methodologies as well as capacity building and risk communication. Chemical safety is the use of chemicals in such a way, that contributes to assurance of health protection and prevention of diseases, conditions and poiso- nings, which may arise as a consequence of exposure to natural and synthetic chemicals from various envi- ronmental segments, from food and consumer pro- ducts, during work or in free time. Chemical safety includes all the circumstances, where the exposure may occur: production, transport, use, disposal as well as coincidental or intentional exposure to natu- ral chemicals and chemicals released during chemi- cal accidents. To assure safe use of chemicals it is essential to be fully aware of their physico-chemico- -biological properties, the risks associated with the exposure, possess technical knowledge on safe han- dling and use of chemicals and be able to communi- cate effectively with all the stakeholders Ciraj M, Vračko P (eds) Chemical safety and protection of human health: Chemical safety is a multidisciplinary, transdiscipli-the Slovenian experience. Copenhagen: WHO Regional Office for Europe, nary and multisectoral activity. In Slovenia, the health 2016. Available from: https://www.euro.who.int/__data/assets/pdf_ file/0005/324293/Chemical-safety-protection-human-health-Slovenian-sector is an important driving force in the chemical -experience.pdf safety area (Ciraj and Vračko, 2016). The National Bitenc K, Blaznik U, Bolčič Tavčar M, Fatur T, Gale I, Galičič A, Fuart Gatnik M, Institute of Public Health (NIJZ) is a key stakeholder Golja V, Ivartnik M, Kirinčič S, Kukec A, Miljavac B, Perharič L, Pollak P. V Pollak P, Perharič L (eds). Navodila za izdelavo ocene tveganja za zdravje ljudi zaradi in assessing complex risks, introducing the internati-izpostavljenosti kemijskim in mikrobiološkim dejavnikom iz okolja z izbranimi onally accepted professional guidance and novel risk poglavji in praktičnimi primeri – I.del. Ljubljana: National Institute of Public Health, 2017. Available from: https://www.nijz.si/sites/www.nijz.si/files/publi-assessment (RA) methodologies onto the national kacije-datoteke/navodila_nijz_za_oceno_tveganja_kem_in_mikrobiol_ dejavnikov.pdf. level (Bitenc et al., 2017). Besides the above, for the last two decades, the NIJZ has contributed signifi- Fatur T, Bolčič Tavčar M, Lešer V, Kirinčič S, Blaznik U, Golja V, Ivartnik M, Pavlič H, Perharič L. (2021) A risk assessment workshop inspired by a EUROTOX spe-cantly to RA capacity building (Fatur et al., 2021) and cialized course. Toxicol Lett 2021; 350(suppl. 1): s229-s230. Available from: risk communication. https:/ www.eurotox2021.com/wp-content/uploads/EuroTox-2021-Final-abstract-book-by-Elsevier.pdf. 90 National Human Biomonitoring Programme Lucija Perharič Human biomonitoring is a tool for determination and surveillance of physiological changes associated with exposure to chemicals. It serves for assessment of exposure, effects and sensitivity. Human biomonitoring assures scientific basis for public health interventions and policy making. In the national human biomonitoring programme, NIJZ was the initiator and remains a key player aiming at health protection and disease prevention secondary to chemical exposure. Human Biomonitoring (HBM) is determination and year later (Perharič and Vračko, 2012). NIJZ has rema- surveillance of changes in human tissues, fluids, ined a key player in planning executing and interpre- cells and biochemical processes resulting from ting the HBM results, HBM based risk assessment, exposure to chemicals. HBM of exposure is deter- proposing risk reduction measures and following- mination of concentrations of exogenous chemicals -up the efficacy of risk reduction measures (https:// in bodily fluids and tissues and is becoming an ever www.nijz.si/sl/humani-biomonitoring-hbm-v-slove- more important tool in exposure assessment from all niji). NIJZ is also a member of the EU HBM platform routes of exposure and a variety of sources, such as (https://www.hbm4eu.eu/). As an example of good air, water, food, consumer products, house dust. HBM practice in health protection and disease prevention, has been asserting itself in assessment of effects it is worthwhile stressing a systematic regular surve- secondary to chemical exposure (biomonitoring of illance of blood lead concentrations in children living effects) and assessment of congenital and acqui- in a polluted hot spot of Upper Meža valley, which has red capacities of an organism to respond to chemi- been running since 2004 and has contributed signi- cal exposure (biomonitoring of sensitivity). In risk ficantly to reduction of health risks from exposure to assessment process, the HBM replaces exposure lead (Ivartnik et al., 2019). estimation based on surrogate exposure markers, while in risk management HBM serves as a follow-up tool in evaluation of risk reduction measures. HBM Ivartnik M, Pavlič H, Hudopisk N. Levels of lead in children’s blood in the assures scientific basis for public health interventi-Upper Meža Valley. ARSO – Kazalniki okolja. Ljubljana: Slovenian Environment Agency, 2018. Available from: http://kazalci.arso.gov.si/sl/content/vsebnost-ons and policy making (WHO, 2015). -svinca-v-krvi-otrok-na-obmocju-zgornje-meziske-doline-2. Perharič L, Vračko P. Development of national human biomonitoring pro-In the last 15 years, we have witnessed a worldwide gramme in Slovenia. Int J Hyg Environ Hlth. 2012; 215(2): 180-4. swing of HBM. In 2006, National Institute of Public Woorld Health Organisation. Human Biomonitoring: facts and figures. Copen-Health (NIJZ) gave an initiative for establishing a hagen: WHO Regional Office for Europe, 2015. Available from: https://www. euro.who.int/en/media-centre/events/events/2015/04/ehp-mid-term-renational HBM Programme in Slovenia, which started a view/publications/human-biomonitoring-facts-and-figures. 91 Preparation of hygiene recommendations to prevent the spread of SARS-CoV-2 infections Majda Pohar, Nina Pirnat, Irena Veninšek Perpar, Pavel Pollak The SARS-CoV-2 epidemic required the development of hygiene recommendations to prevent the transmission and spread of SARS-CoV-2 virus in various activities, among various stakeholders. Hygiene recommendations make an important contribution to preventing the transmission and spread of infections in the population and safer implementation of most economic and non-economic activities. At the outbreak of the SARS-CoV-2 epidemic, hygiene and chimney sweeping services at home, providers recommendations were key to preventing the trans- of registration procedures and technical inspecti- mission and spread of SARS-CoV-2 virus in the popu- ons of vehicles, car washes, driving schools and dri- lation. The recommendations were prepared taking ving tests, language and computer courses…). We into account the risk of transmission and spread of prepared instructions for the safe performance of infection that arises during the performance of cer- various public services (implementation of admini- tain activities. All the recommendations were based strative and other public-law matters, funeral acti- on the results of internationally recognized profe- vities, all types of public transport). We prepared ssional research and good practices that have also recommendations for body care, safe performance been adopted by other countries1. of various recreational sports activities (both outdo- ors and indoors). In the field of culture, recommen- The first recommendations were for food stores, dations were made for visiting cultural institutions, cleaning and disinfection of non-medical premises, performing amateur cultural activities in groups, for proper ventilation of enclosed spaces, cleaning of cinema, theatre and music facilities, for music scho- public toilets, selection of suitable disinfectants and ols, for providing and attending religious activities, proper preparation of effective disinfectant soluti- etc. In cooperation with the Ministry of Education, ons, proper handling of food and associated packa- Science and Sport, we prepared comprehensive ging, cleaning of common areas, ventilation and sel- hygiene recommendations for kindergartens, scho- f-protective behaviour of users in multi-apartment ols and universities, as well as student dormitories, buildings. recommendations for the implementation of compe- Before the return of the first group of Slovenian citi- titive sports and sports competitions. We also parti- zens from abroad, who were ordered to be quaranti- cipated in the preparation of recommendations for ned, we prepared recommendations for behaviour in various professional sports activities, healers and the hotel where COVID-19 patients were accommo- psychologists. dated. Recommendations are constantly updated based on During the relaxation of measures after the first new professional findings. Most of the recommenda- wave of the epidemic, recommendations for cate- tions for the implementation of activities are publi- ring establishments followed: first for food delivery, shed on the NIJZ website: https://www.nijz.si/sl/ then, in cooperation with the Chamber of Commerce sproscanje-ukrepov-covid-19. and Industry of Slovenia, recommendations for per- forming catering and tourism activities. We made recommendations for various shops and service and repair activities (technical shops and shopping 1_https://www.cdc.gov, https://www.ecdc.europa.eu/en centres, stationery stores, bookstores, photocopy shops, clothing stores, footwear stores, sewing and shoemaking services, craft and service providers 92 Programme of measures to improve the quality of the environment in the Upper Meža Val ey Matej Ivartnik Due to the long tradition of the lead extraction industry, the area of the Upper Meža Valley is heavily contaminated with this toxic metal. The residents are thus exposed to lead as a result. In 2007, measures to reduce lead exposure were implemented. They are primarily aimed at limiting exposure to lead-contaminated dust, which is the most important source of lead intake in the human body. The goal of the programme is to reduce the lead content in the blood of children to below 100 µg/l. The Upper Meža Valley lies in the north of Slovenia levels of lead (≥100 µg/l), three years into the pro- and is known mainly for its lead extraction industry, gramme about 20% of the children, and afterwards which is still the leading industry in this area. Due the downward trend in lead levels stopped at about to past emissions, the environment is heavily pol- 10% of the children. In the period 2019/2020, this luted with lead, the soil being the most polluted. The proportion decreased again to 4.6% (2019) and 4% valley is home to about 7,000 people whose health is (2020), which already corresponds to the set goal potentially compromised. Lead is a toxic metal that (less than 5% of children with blood lead content has various harmful effects and no useful functions ≥100 µg/l). The basic goal of the programme is there- in the human body. Younger children are the most fore achievable through targeted implementation of vulnerable group, due to their physiological chara- measures and self-protective behaviour of the popu- cteristics and higher intake of lead in the body. From a lation. Even after the goal is achieved, there will still health point of view, any presence of lead in the body be room for improvement, but amendments to the is undesirable, but this is not achievable in populated programme content will be necessary: limiting the areas contaminated with lead. The lead exposure of lead extraction industry, the possibility of implemen- the population in the Upper Meža Valley began to be ting measures on private land, limiting the implemen- monitored as early as 70 years ago. Occasional mea- tation of activities that cause dust (construction, surements have repeatedly shown high concentrati- agriculture). However, lead will remain in the valley, ons of lead in the blood of the population. After reaf- and residents will have to adhere to self-protection firming this in 2002, it was time to shift from research measures to reduce exposure in the future. to problem solving. A Decree (Official Gazette of the Republic of Slovenia, No. 119/2007) was thus adopted in 2007, which defines the purpose, goals and activi- ties of the environmental remediation programme for the Upper Meža Valley. Various actors carry out acti- vities in accordance with the Decree to reduce chil- dren's exposure to lead. The local communities have been implementing various measures to prevent chil- dren from coming into contact with contaminated soil and dust, such as resurfacing of gravel surfaces, arranging children's playgrounds, wet cleaning of hard surfaces and planting grass on bare areas. The Slovenian Environment Agency (ARSO) is in charge of monitoring air and soil pollution, while the Nati- onal Institute of Public Health (NIJZ) is in charge of coordinating the work, information and promotional Figure: Comparison of the proportions of three-year-old children from the activities and monitoring the lead content in chil-Upper Meža Valley based on the lead content measured in children’s blood. dren's blood. The latter is also the basis for assessing the progress achieved. Before the start of the pro- gramme, about half of the children had high blood More information: http://www.sanacija-svinec.si/index.php/aktualno. 93 Preventive programme Safe with the sun Simona Uršič, Nataša Šimac The prevention programme Safe with the Sun was established in 2007 in response to the worrying trend of increasing rates of skin cancer in Slovenia. It is based on the fact that the incidence of skin cancer is associated with exposure to UV radiation and the frequency of sunburn, especially in childhood. With the programme we want to increase awareness among the population of the harmful effects of UV radiation and the importance of self-protection measures. The programme is being implemented in kindergartens and primary schools. So far, 552,466 children have participated in the programme. The programme was created in cooperation between The programme is carried out every year in establi- the National Institute of Public Health (NIJZ), the shed steps: in the early months of the year, we collect Association of Slovenian Dermatovenerologists applications, then organize training for programme and the Cancer Society of the Celje region. The providers (professionals employed in kindergartens programme is led and coordinated by the NIJZ. The and primary schools), who then teach children in a main activity of the programme is raising awareness systematic and age-appropriate way. The knowledge of the harmful consequences of the sun's rays and acquired with regard to self-protection is then put the measures that can be used to effectively reduce into practice by the children in various outdoor acti- these. The target population is kindergarten chil- vities during the summer months, which is an added dren, and since 2010 also primary school students. value of the programme. This is followed by an annual In 2007, we piloted the programme for the first time evaluation of the programme. Training for programme in a kindergarten in Celje. Since 2008, kindergartens providers includes lectures by experts in various from all regions of Slovenia have been participating fields (meteorology, dermatology, ophthalmology, in the programme. The guidelines of the programme non-ionizing radiation, epidemiology of skin cancer, are followed by kindergartens as a whole and not vitamin D) and a presentation of the implementa- only by individual registered units of kindergartens, tion of the programme. All communication with the so the number of children acquainted with the con- programme providers takes place through the online tents of the programme is in fact much higher than application of the National Institute of Public Health. recorded (385,524). The share of registered schools We have developed a distinct overall graphic image of is also growing; by 2019, 166,942 primary school stu- the programme. Professionals in kindergartens and dents had participated in the programme. schools assess that the programme and knowledge acquired by children are both of high quality. The programme was not implemented in 2020 due to the COVID-19 epidemic. Nevertheless, we called Our goal: implementation of the programme in all kin- on schools and kindergartens to raise awareness dergartens and primary schools. of the importance of protection against UV radia- tion and we published e-materials for this purpose. Our vision: that the implementation of UV protection Moreover, despite the epidemic the programme was measures is adopted by all citizens as a way of life. implemented anyway, particularly in kindergartens, which shows that in many places they have already 10 included it in their regular activities. In 2021, we adju- 17 sted the implementation of the programme to better suit the conditions brought about by the epidemic 10 (online training, etc.). This time, about 60,000 chil- 17 dren are participating in the programme. Spending time outdoors is encouraged during the COVID-19 epidemic, so the implementation of protective mea- sures against solar UV radiation is especially impor- tant. SOLARIJ 30 Figure: Icons from the graphic image of the programme, which illustrate the basic recommendations for protection against UV radiation. 94 Preventive programme Safe with the sun 6.4 PREVENTIVE AND SCREENING PROGRAMMES FOR CHRONIC DISEASE MANAGEMENT 6.4.1 Screening programmes for early detection of cancer – Programme Svit, ZORA, DORA 6.4.2 Integrated prevention of chronic illnesses for adults – the Together for Health programme 6.4.3 Screening and prevention programme for children, adolescents and students: Prevention programme ZDAJ - Health today for tomorrow 6.4.4 Epidemiological monitoring of dementia in Slovenia 6.4.5 The development of integrated care for persons with complex chronic states 6.4.6 Genetic testing and high risk cancer screening 6.4.7 Prevention and control of non-communicable diseases at NIJZ regional offices Screening programmes for early detection of cancer – Programme Svit, ZORA, DORA Dominika Novak Mlakar, Tatjana Kofol Bric, Urša Ivanuš, Katja Jarm One of the best methods for early detection of precancerous and cancerous changes is organized screening of the healthy population, which allows for targeted detection of cancer or changes that would in the absence of medical intervention eventually turn into cancer. In Slovenia, we carry out population-based organised screening programmes for breast (DORA), cervical (ZORA) and colorectal cancer (the Svit Programme). All three screening programmes are comprehensive and organised according to European guidelines for quality assurance in cancer screening. Screening programmes in Slovenia effectively reduce the incidence of cancer or detect cancer in the early stages, when treatment is less intensive, quality of life is better, and the survival rate is higher. Colorectal cancer is one of the five most common 70% participation of women aged 20-64 years in cancers in Slovenia in both genders combined, whe- the programme and high-quality service at all levels. reas before screening started 10 years ago it was the About 1,700 high-grade cervical precancerous chan- second most common. In terms of colorectal cancer ges are detected every year, which allow treatment patient survival Slovenia lags behind the EU average, to prevent cancer. The story of Slovenia's success in but the gap is narrowing. Since 2009, the Svit organi- cervical cancer control has also been recognized by zed screening programme1 has been available at the the World Health Organization and published on its national level. Residents of Slovenia aged 50 to 74 are website. HPV vaccination will make another impor- invited to participate in the programme. Over the years tant contribution to the elimination of cervical cancer the response rate of the target population to the pro- in the future. gramme has been increasing and currently reaches 65%. The programme is based on the laboratory The Slovenian breast cancer screening programme detection of blood in a stool sample. In persons with DORA3 is an organized programme in which we invite a positive test result a colonoscopy is performed, and women between the ages of 50 and 69 to have a precancerous changes are removed. Persons who mammogram every two years. The goal is to reduce have a negative stool test are re-invited to partici- breast cancer mortality among the target popula- pate in the programme two years later. Since 2011, the tion by up to 30%. The programme is recognized as Cancer Registry has recorded a decline in colorectal an European example of an effectively organized cancer incidence at the national level with a con- programme for early detection of breast cancer. sequent reduction in mortality. 60% of cancer cases Given the 74% participation of women and meeting detected in the screening programme are in stages I other performance indicators according to European and II, when patients do not need additional oncolo- guidelines, the programme predicts a long-term gical treatment. The five-year survival of patients dia- reduction in mortality due to breast cancer in Slove- gnosed with cancer in the Svit Programme is 90%. nia. The DORA programme was introduced in 2008, and since 2017 it has been available to all Slovenian Cervical cancer is today no longer one of the most women in the target population. We invite about common cancers in Slovenia. Based on the age- 140,000 women each year and perform about 100,000 -standardized incidence rate of 7/100,000 and the screening mammographies. The participation rate mortality rate of 2/100,000, Slovenia has in recent between 2008 and 2020 was 74%, and breast cancer years been ranked among the countries with the was detected in 3,640 women, of which as many as lowest burden of this cancer. This was not always the 70% of cases were diagnosed in a localized stage case – when the Cancer Registry was established when five-year survival is almost 100%. The DORA in the early 1960s, cervical cancer was the second programme is distinguished by centralized manage- most common cancer in women in Slovenia and the ment, quality control of both equipment and the sta- most common in women under the age of 50, while ff's work, screening registry, specially trained staff, the incidence rate of 27/100,000 was comparable operation according to uniform guidelines, a single with today's rate in Africa, where cervical cancer is uniform computer application and appropriate com- still among the most common cancers in women. The munication with the target population. reduction in the burden of cervical cancer in Slove- nia is the result of the efficient operation of the ZORA 1_ https://www.program-svit.si/ screening programme2, which achieves more than 2_https://zora.onko-i.si/program-zora 3_https:/ dora.onko-i.si/ 96 Integrated prevention of chronic il nesses for adults – the Together for health programme Sanja Vrbovšek In recent decades developed countries have been faced with the heavy burden of chronic illnesses, which are a consequence of demographic changes and unhealthy lifestyle habits. At the same time, we are noticing large differences in health between different population groups. The Together for Health programme, accessible to all adults in Slovenia, aims to actively monitor the health of the country’s population and its improvement by providing directions and specialist support in efforts to encourage people to lead a healthier lifestyle, and thereby enjoy a higher quality of life. The programme Together for Health provides all that ensure health improvement activities in local adults in Slovenia with a comprehensive programme communities and provide health education on a for the integrated prevention of chronic illnesses primary healthcare level. These centres currently (CI), which connects public health and family medi- employ almost 400 additional professionally trained cine, and encompasses three mutually linked fields employees (specially trained nurses, physiothera- of activities in prevention and health improvement: pists, psychologists, dieticians, kinesiologists). 1. Preventive check-ups in general practices 3. Health improvement activities that are carried out All adults in Slovenia aged 30 years and above may in local communities participate in preventive check-ups with the general Depending on the needs of local communities, practitioner of their choice. This check-up is inten- experts from the health improvement centres orga- ded for the early detection of persons with biolo- nise events and programmes to improve health and gical, behavioural and psychosocial risk factors to encourage the target populations to join preventive develop CI, the early detection of persons at high risk programmes and national screening programmes for of developing CI and the detection of persons in the early cancer detection. These activities are organi- early phases of CI. The preventive check-ups are per- sed in different environments (e.g. in work organisati- formed by registered nurses with special expertise ons, NGOs, local communities), which ensures better who work in the general practitioner's team. There access. Efforts to improve the health of the local are currently almost 500 registered nurses working population also include setting up a network of diffe- according to such a model of preventive check-ups. rent stakeholders from the local environment accor- They are employed in almost all general practices, of ding to the model of a joint approach to health which which there are over 900 in Slovenia. can support an individual in maintaining a healthy lifestyle and self-sufficiency for CI sufferers. In the 2. Health education workshops and individual coun- Together for Health programme, health improvement selling for the prevention or optimal management centres are responsible for connecting health care of chronic illnesses with the community in the local environment. The interventive part of the programme Together The Together for Health programme is financed enti- for health, which consists of health education work- rely by the Health Insurance Institute of Slovenia. shops and individual counselling (Fig. 1), is inten- ded for persons with risk factors for CI, with a high Research and development activities and manage- risk of developing CI and with already present CI. At ment of the programme are organised by an interdi- these consultations participants acquire professi- sciplinary group of experts at the National Institute onal information, skills and support for a long-term of Public Health in cooperation with experts from the change to lifestyle with the aim of improving health basic health activity and numerous other health wor- and strengthening mental health. This part of the kers and colleagues from practice. programme is based on the process of empowering persons to look after their own health. More on the Together for Health programme: https:// www.skupajzazdravje.si/. These activities are carried out in health improve- ment centres located in all health centres around Slovenia. These are key organisational structures 97 Screening and prevention program for children, adolescents and students: Prevention program ZDAJ - Health today for tomorrow Polonca Truden Dobrin, Kerstin Vesna Petrič, Tanja Mate, Sonja Paulin, Tjaša Pibernik, Jerneja Kožar, Sonja Dravec The amendment to the Rules for the implementation of preventive health care at the primary level Pravilnik za izvajanje preventivnega zdravstvenega varstva na primarni ravni (Official Gazette of the Republic of Slovenia, 2021), brings an update of the preventive program and supplementation with step-by-step treatment for children with risk factors or threats and determines the management of the program. The comprehensive prevention program is now called Program ZDAJ - Health Today for Tomorrow. The name summarizes the lifelong perspective and the importance of the health of children and adolescents for health in adulthood. With the program, we want to ensure equal opportunities and rights in the field of preventive health care and improve the inclusion of target groups in the preventive program. The implementation of modern prevention programs providing a modern approach and supportive envi- for children and adolescents affects the health of the ronment in the school and local community. population in later life, so the update of the Rules is an important contribution to public health. The pro- An important novelty is the establishment of program gram defines preventive health care for newborns in management with professional bodies at the state the maternity hospital and then for all age groups: level, comparable to other national prevention and infants, preschool children, pupils, high school stu- screening programs. Thus, cooperation between key dents and students at the primary level of health stakeholders and networking of program providers is care. Special attention is paid to children with deve- being re-established. lopmental disabilities and registered athletes. The The website www.zdaj.net was established for the provisions of the Rules bring innovations in the field purpose of promoting the Program ZDAJ and to of preventive examinations, health education and inform the target population and the professional escalated treatment. Special attention is given to public about preventive health programs for chil- reaching deprivated and vulnerable groups of chil- dren and adolescents and other health education dren and adolescents (e.g., young people who for contents. The relevance of this website has increa- various reasons left the school environment or aban- sed due to the COVID-19 epidemic, as it offered the doned schooling immigrant children…), as well as opportunity to quickly raise awareness of the target those studying abroad on the basis of compulsory population about the importance of health promo- health insurance rights and to some others. tion during this time as well. The Program ZDAJ takes a lifelong perspective appro- Given the current epidemiological circumstances, ach - current activities in children and adolescents the implementation of updated prevention programs to reduce current health risks and threats as well will be an important part of the exit strategy to reduce as those manifested by related diseases later in life the impact of the pandemic on the health of children and enable each child to maximize their potential. It and adolescents. increases the responsiveness to the current health needs of children and adolescents and enables flexi- bility in developing new approaches and treatments. 1_Pravilnik za izvajanje preventivnega zdravstvenega varstva na primarni Program providers work in a coordinated team that ravni. Official Gazette of the Republic of Slovenia, 2021; 19/98, 47/98, 26/00, 67/01, 33/02, 37/03, 117/04, 31/05, 83/07, 22/09, 17/15, 47/18, 57/18 in 57/21. approaches systematically to individuals and groups, Available from: https://www.uradni-list.si/1/objava.jsp?sop=2021-01-1157. 98 Epidemiological monitoring of dementia in Slovenia Mercedes Lovrečič, Barbara Lovrečič Projections indicate that the number of patients with dementia will rise. There is a need for active and continuous implementation of activities and programmes focused on promoting a healthy lifestyle, care for one’s health, raising public awareness and destigmatising the disease, ensuring all rights, early recognition of difficulties, the earliest possible diagnosis and treatment, comprehensive care, and access to treatment and social care services. Dementia is a disease with cognitive decline that hin- The NIJZ is establishing public health epidemiologi- ders independent life and reduces the quality of life cal monitoring of dementia: we have made several of the sufferer and those close to them. The pheno- estimates of the prevalence of dementia based on menon is underestimated, with dementia frequently Slovenian population data, including forecasts up to being recognised and diagnosed late, and consequ- 2030, we have implemented a healthcare indicator ently treated late. Current information systems do of the use of medications for treatment of dementia, not enable us to carry out epidemiological monitoring and have drawn up the first preliminary assessment of the issue at a satisfactory level. The WHO Action of the economic costs of dementia. Epidemiological Plan (2017–2025) envisages the establishing of an monitoring of dementia represents the foundation information system for epidemiological monitoring of for successful planning of measures to combat the dementia by 2025, along with regular reporting in at issue and evaluation of their effectiveness. least half the countries of the world, since it is a chal- lenge for the entire world. With the aim of reducing the stigma of dementia, raising public awareness, better early detection and According to WHO data, in 2018 there were around 50 treatment of dementia and with a view to the networ- million people with dementia in the world, and by 2050 king of various departments, stakeholders, experts this number should treble to 152 million. Given the and non-governmental organisations, the NIJZ in growing problem of dementia, the WHO declared it a cooperation with the Scientific Research Centre of public health priority of the 21st century even before the Slovenian Academy of Sciences and Arts, in mar- the appearance of the SARS-CoV-2/Covid-19 pande- king the world month and day of Alzheimer's disease, mic, which affected persons with dementia particu- organises a traditional expert meeting with the active larly badly due to their vulnerability to infection with participation of Slovenian members of the European SARS-CoV-2, greater risk of worse progress of the Parliament, who adopt written resolutions from the Covid-19 illness and complications, including death. meeting with recommendations. In June 2016 the Slovenian Government confirmed the Strategy of Controlling Dementia in Slovenia up to 2020, which represents the first and fundamental Ministry of Health of the Republic of Slovenia. Strategy for Managing Demen-document for a coordinated and integrated appro- tia in Slovenia up to 2020. 2016. Available from: https://www.gov.si/assets/ ach of all stakeholders in dealing with the issue of ministrstva/MZ/DOKUMENTI/Preventiva-in-skrb-za-zdravje/nenalezljive-bolezni/Strategija_obvladovanja_demence.pdf. dementia. The purpose was to provide preventive WHO. Dementia: number of people affected to triple in next 30 years, 2017. measures, early detection of the disease and an Available 2021 from http://www.who.int/news-room/detail/07-12-2017-de-appropriate standard of health and social protection mentia-number-of-people-affected-to-triple-in-next-30-years. as well as healthcare for persons with dementia. Cur- WHO. Global Dementia Action Plan on the Public Health Response to Demen-rently a strategic document for addressing dementia tia 2017–2025. Geneva, 2017. Available from the website https:/ apps.who. int/iris/bitstream/handle/10665/259615/9789241513487eng.pdf;jsessio-up to 2030 is being drawn up. nid=741F95B5F30AA44B98C70E02700127A8?sequence=1. 99 The development of integrated care for persons with complex chronic states Jelka Zaletel, Denis Oprešnik The model for integration of care for persons with complex chronic states includes: the reorganisation of care on a secondary health care level (the coordinator acts as a uniform entry point and together with the clinical specialist is the administrator of the patient’s procedural path; the multidisciplinary clinical expert group; the protocol of care to unify clinical paths); systematic cooperation with the social care system; connecting with the community via home care and cooperation with local health improvement groups. The fragmentation of care and difficulties in harmo- • the establishment of a multidisciplinary clinical nising among institutions, disciplines, patients and expert group and the preparation of a care proto- other stakeholders who are involved in caring for col to unify clinical pathways, which defines the people with complex chronic states, worsens health form of referral from the primary to the secondary and other treatment results. Better connected and level, and the course of treatment on the secon- harmonised care is also one of the starting points dary level with the introduction of a package of of the Resolution on the National Health Care Plan services; 2016–2025 and some other strategic documents in Slovenia. This is why Novo Mesto General Hospital • the establishment of systematic cooperation with and Health Center Novo Mesto, supported by the the social care system; NIJZ and other partners from the EU, worked together • connecting with the community via home care in the common action project CHRODIS PLUS (2017– and the health education centre, or the health 2020) to develop a model for integrating care for improvement centre by means of cooperation in complex, chronic states on the basis of a study case local health improvement groups. dealing with the treatment of a chronic wound. The group consisted of representatives of key A strategic meeting was organised on a national level disciplines, institutions and patients. Based on the for the further development and broader use of the analysis of context, aspects of key disciplines and model. The main outcome of the meeting was the institutions, the estimated needs of people with establishment of an ad hoc group for the develo- chronic wounds and an analysis of the pathways of pment of integrated care, which includes represen- patients at the highest risk (significant arterial vas- tatives from the Ministry of Health, the ZZZS, NIJZ cular disease of the leg), key elements for the model and other organisations, including representatives were identified (Oprešnik et al., 2021): of patients. They identified necessary system chan- ges in the field of financing (e.g., the package of ser- • the reorganisation of care with the introduction of vices), IT solutions and legislation. a coordinator for the secondary health level which is a uniform entry point and is, together with the clinical specialist, the administrator of the pati- ent's procedural pathway; 1_Joint Action CHRODIS PLUS. Available online at: http:/ chrodis.eu/07-fostering-the-quality-of-care-for-people-with-chronic-diseases/. Oprešnik D, Piletić M, Mršić M, Klemenčič S, Počrvina L. Development of a model of integration for complex chronic conditions across levels of healthcare and the community in Novo mesto, Slovenia. Ann Ist Super Sanita. 2021; 57(1): 97–106. doi: 10.4415/ANN_21_01_15. PMID: 33797412. 100 Genetic testing and high risk cancer screening Mateja Krajc, Srdjan Novaković The development of molecular genetics enabled detection of genes that are associated with a higher risk of cancer. With the help of genetic tests, it is possible to identify, among patients with certain types of cancer, those individuals, who most likely inherited a genetic disorder. With genetic tests we can also identify their healthy relatives at higher cancer risk and may offer them personalised cancer screening programs. An organized carrier screening, as well as cancer outpatient clinic was set up. We are one of the few screening for mutation carriers is in place at the Insti- institutions that provides patients not only genetic tute of Oncology Ljubljana (OIL), since 1999. Carriers testing, but also comprehensive assessment, which of defective genes can be up to 15 times more likely to includes genetic counselling, cancer screening and develop cancer than their peers who do not have the preventive interventions, as well as psychological defect. Therefore, the detection of at-risk individuals support. / families is of great importance for the prevention and early detection of hereditary forms of cancer. In In 2019, we became the holder of the National Regi- addition to cancer prevention planning, patients may stry of tested individuals from families with heredi- receive tailored targeted therapy. tary cancer, which enables continuous quality con- trol of the assessment. In 2008, an important agreement was reached with the Health Insurance Institute of Slovenia to include Our first and most important goal remains the provi- genetic testing and counselling for hereditary can- sion of high-quality medical care, which is in accor- cers in the national health insurance scheme. Since dance with Slovenian and international guidelines then, multidisciplinary genetic assessment has been and recommendations, for all individuals that are provided at OIL, including development of clinical entitled to cancer genetic assessment. An equ- pathways and guidelines for high risk individuals. ally important goal is to ensure greater access to our experts and thus enable appropriate genetic We introduced the latest molecular diagnostic tech- assessment of all individuals from high risk families, niques and after 2008 fully took over the implemen- regardless of which part of Slovenia they come from, tation of genetic testing for hereditary forms of within an acceptable period of time. cancer. In accordance with the development of the profession, we started conducting genetic tests for sporadic forms of cancer as well. In 2014, we acquired Important links: the first powerful next-generation sequencer. Department of Cancer genetics Clinic: The multidisciplinary genetic team collaborates https://www.onko-i.si/dejavnosti/zdravstvena_ internationally with centres of excellence in other dejavnost/skupne_zdravstvene_dejavnosti/genet- countries. In 2017, the OIL became a reference centre sko_svetovanje for rare diseases in the European Reference Network on Genetic Tumor Risk Syndromes, operating under Department of Molecular Diagnostics: the auspices of the European Commission. https://www.onko-i.si/dejavnosti/zdravstvena_ Individuals at high cancer risk are screened at the dejavnost/diagnosticna_dejavnost/oddelek_za_ OIL, and since September 2010, especially dedicated molekularno_diagnostiko 101 Prevention and control of non-communicable diseases at NIJZ regional offices Teja Tovornik, Branko Gabrovec Public health experts working at the National Institute of Public Helath (NIJZ) regional offices in the field of prevention and control of non-communicable diseases are responsible for a wide range of professional areas. Depending on local needs, their activities are focused on identifying and responding to the most pressing needs of the local and regional environment. Public health experts at NIJZ regional offices are developed the Health in the Municipality program involved in managing databases of health care pro- with key health indicators for all 212 Slovenian muni- viders at regional level, through the process of data cipalities. With this information tool, NIJZ regional collection and control, data communication and har- offices have acquired an additional means to enco- monization with the reporters and informing health- urage local decision-makers and other partners to care providers about innovations in methodological work together to strengthen the health of the popu- guidelines. lation, respond quickly to their needs and reduce social inequalities in health. All NIJZ regional offices perform regional coordina- tion of various health education and disease pre- The COVID-19 epidemic in 2020 and 2021 conside- vention programs, developed at the national level, rably impacted the content and methods of work in and take care of their implementation, expansion the field of non-communicable diseases prevention and provsion by partners in regional and local envi- and control. NIJZ regional offices employees are wor- ronments. Programs that cover various health topics king in various ways to implement and revive health and are delivered by community primary health cen- promotion and disease prevention programs, which ters, in schools and with other partners in the com- were discontinued during the epidemic and to main- munities. The programs are: Health in Kindergarten; tain the motivation of various stakeholders for pre- Slovenian Network of Healthy Schools; Health in the ventive work. Municipality; Slovenian Network of Healthy Cities programs, Health education of children and ado- Other projects run by NIJZ and its regional offices lescents, Dental education for children and ado- are Measures to control COVID-19 with an emphasis lescents, Programs for healty lifestyles for adults, on vulnerable populations, Together for a Responsi- and national cancer screening programs Svit, ZORA ble Attitude to Drinking Alcohol (SOPA), Joint Action and DORA. In all educational institutions, public Preparedness and Action at Entry Points (Healthy health experts of the NIJZ regional offices provide GateWays), Strengthened International Health support and counseling in the field of nutrition of Regulations and Preparedness in the EU Joint Action, children and adolescents. Alpine Space Transnational Governance of Active and Healthy Aging, European Joint Action on Anti- Regional public health offices transfer information microbial Resistance and Healthcare-Associated and knowledge on protective and health risk factors Infections, and Good luck, student! are. to regional environments, such as healthy eating and physical activity, responsible alcohol consumption, Poleg enovitih nalog, ki jih izvajajo vse OE in katerih reducing the prevalence of smoking and illicit drug cilj je, da so jih deležni vsi prebivalci Slovenije, OE raz- use. Since 2019, in accordance with the National vijajo pristope in izvajajo naloge, ki izhajajo iz regij- Mental Health Programmes, they have also been coor- skih potreb in značilnosti. Nekateri od teh se zaradi dinating the mental health activities in the region, and specifike izvajajo zgolj v lokalnem/regijskem okolju, since 2020 they have been paying more attention to nekateri so prerasli na nacionalni nivo. the importance of sleep hygiene for health. In addition to the common tasks, performed by all NIJZ Thru its regional offices, NIJZ ensures partnerships regional offices with the aim to provide equal access with the local communities. In cooperation with com- to health promotion programs to all residents in Slo- munity primary health centers and other stakehol- venia, NIJZ regional offices develop approaches and ders in local communities, including NGOs, a strong perform tasks arising from regional health needs and community engagement for health is showing excel- characteristics. Due to their specific nature, some lent results in improving health and reducing health of them are implemented only in the local / regional inequalities in local environments, with special emp- environment, and some have been rolled-out across hasis on vulnerable population groups. In 2016, NIJZ the whole county. 102 6.5 COMMUNICABLE DISEASES CONTROL 6.5.1 The COVID-19 epidemic in Slovenia 6.5.2 Epidemiological and hygienic measures in school education to control the spread of COVID-19 – an example of excellent intersectoral cooperation 6.5.3 Implementation, carrying out and monitoring of measures for the control of infectious diseases in Regional Offices of the National Institute of Public Health 6.5.4 eRCO and surveillance of vaccination coverage 6.5.5 New developments in Slovenia’s national vaccination programme 6.5.6 National survey of healthcare-associated infections 6.5.7 National survey of sexual lifestyles and health 6.5.8 Activation of the local community for vaccination against TBE in Slovenia 6.5.9 Epidemiological surveillance of antimicrobial resistance 6.5.10 Setting up the COVID-19 vaccination website www.cepimose.si The COVID-19 epidemic in Slovenia Eva Leban, Manja Grašek, Matija Mozetič, Veronika Učakar In Slovenia, the first case of COVID-19 was confirmed on 4 March 2020 in a person who arrived from Morocco. Due to the growing number of cases in the following days, an epidemic was declared by the Slovenian Government on 12 March 2020 and numerous measures were introduced to limit the spread of the disease. By 31 May 2020, when the status of epidemic was ted vaccination strategy against COVID-19. Vaccina- suspended, a total of 1,473 cases of SARS-CoV-2 tion of people aged 70 and over began at the end of infection had been confirmed, with the highest daily March, and vaccination of people aged 60 and over number of confirmed cases being 61 two weeks after and chronic patients began in April. Vaccination of the start of epidemic. In the period from 1 June 2020 people aged 50 and over began in the last week of to 18 October 2020, the number of confirmed cases April, and vaccination with the Janssen vaccine was was 12,213. The highest number of daily confirmed also started in the same week. From the start of cases was 898, which happened on 16 October 2020. vaccination until 31 May 2021, the proportion of resi- An epidemic was declared again three days later. In dents vaccinated with all doses was 19.4%. Regularly the period from 19 October 2020 to 31 May 2021, the updated data on the vaccination coverage are availa- number of confirmed cases was 240,359, with the ble at the following link: https://tinyurl.com/nfdutrtf. highest daily number of confirmed cases 3,428 at the beginning of January 2021. From the first confirmed Monitoring of adverse events after vaccination with case up to and including 31 May 2021, we confirmed COVID-19 vaccines in Slovenia is supported by the 254,045 cases of SARS-CoV-2 infection and recor- Register of Adverse Events after Vaccination, mana- ded 4,694 deaths within 28 days of infection con- ged by the NIJZ. Data is submitted to the Register by firmation. all public health institutions and other legal entities and individuals in the healthcare sector, regardless At the end of December 2020, Slovenia started vacci- of the concession. The NIJZ exchanges collected nating against COVID-19, which is the exit strategy data on adverse events after vaccination and other from the epidemic. Vaccination began first among important data related to the safety, efficacy and care recipients and employees in retirement homes use of vaccines with the Slovenian Public Agency as well as among exposed health workers and their for Medicines and Medical Devices. Regularly upda- co-workers, and then among people aged 75 and ted data on adverse events after vaccination with over and among particularly vulnerable chronic pati- COVID-19 vaccines are published on the NIJZ website ents. Vaccination was initially performed only with in the form of weekly reports. the Pfizer/BioNTech vaccine, and from the second week of January also with the Moderna vaccine. In The epidemiological picture is improving at the time the second week of February, vaccination with the of writing this article. Due to the previously deteriora- AstraZeneca vaccine was also started in people aged ting epidemiological situation, we reintroduced strict 18–65 (particularly vulnerable chronic patients) in control measures at the beginning of April 2021 (i.e., accordance with updated recommendations on pri- from 1 April to 11 April 2021) to gain time to achieve a ority groups for vaccination, as well as vaccination higher vaccination rate of the population and thus of immobile people regardless of age. Vaccination maintain the undisturbed functioning of the health- of the elderly (aged 75 and over) began in the last care system, which was threatened by a resurgence week of February. Vaccination of employees in edu- of infections. cation began in March in accordance with the upda- 104 Epidemiological and hygienic measures in school education to control the spread of COVID-19 – an example of excel ent intersectoral cooperation Milan Krek, Polonca Truden Dobrin, Mario Fafangel, Peter Otorepec, Eva Grilc, An Galičič, Ana Hojs, Simona Uršič In the school environment, infectious agents that cause acute respiratory infections can spread rapidly, and spread the disease among many students and staff who are in contact with each other. Providing education posed a major challenge in the wake of the COVID-19 epidemic. Since March 2020, a special working group at the National Institute of Public Health (NIJZ) has been preparing recommendations for the field of education to limit the spread of SARS-CoV-2 infection, based on ever new scientific findings and monitoring of the epidemiological situation. We coordinated the action with representatives of the Ministry of Education, Science and Sport, and other key stakeholders were also involved: representatives of school principals, trade unions representing the employees in education sector, and occasionally representatives of parents and students. After the end of the first wave of the COVID-19 epi- factors for a severe COVID-19 disease with serious demic in Spring 2020, new concepts and school complications and adverse outcomes such as long models with recommendations for the new school COVID, post-COVID syndrome or fatal outcome. year were developed in cooperation with the Ministry Safety must also be ensured for children who have of Education, Science and Sport and the Institute health risks that put them at greater risk. of the Republic of Slovenia for Education. We publi- shed recommendations Education in the Republic of The infection can be transmitted from the envi- Slovenia in conditions related to COVID-19 - Models ronment to the school as well as from the school to and recommendations (Kustec et al., 2020). Models the families of the children and employees. The risk and recommendations and thus epidemiological and of transmitting the infection into the school is high hygienic measures have been carefully considered during the period of high number of infected people. on the basis of scientific findings and approaches The risky epidemiological situation requires a great from other countries. The WHO, ECDC, CDC and deal of diligence and consistency in the implementa- other international organizations guidelines were tion of protective measures. taken into account. Classes were held virtually due to the intensity of the Models and recommendations were presented to epidemic wave, which in Slovenia was more severe and school management at meetings of principals, and lasted longer than in other European countries. Live at meetings of specialists in pediatrics and school instruction started earlier than in some other coun- medicine. Since the beginning of the school year, the tries because we designed an imaginative system of working group at the NIJZ has been meeting regu- action for safe instruction in the school environment larly with representatives of the Ministry of Science, and at the same time developed appropriate proto- Education and Sports and has been in contact with cols in the event of an infection at school. the Ministry of Health and the Advisory Group at the Models and recommendations, developed in the Ministry of Health. Summer 2020 and upgraded later, enable children Action in the field of education is demanding beca- education in the school premises at a relatively high use pupils and students, their educators and other level of the epidemic in Slovenia. Careful handling of employees spend several hours in closed school the infected cases and the implementation of qua- premises, performing various works and services to rantine measures create the conditions for a relati- ensure the school process to run smoothly. Parents vely safe environment in schools. and various external contractors also enter the Great progress in controlling infections and thus school premises. Many are older or have other risk restarting live lessons was brought about by the 105 rapid testing of school staff and the priority vaccina- With voluntary vaccination, rapid testing and self-te- tion of employees. In the future, we expect further sting will reduce the risk of infection in schools and improvement in the epidemiological situation and a colleges, thus enabling live education process with reduction in the risk of transmitting the infection in all the benefits it brings to children and adolescents schools due to an increase in the share of vaccinated and the functioning of society as a whole. employees as well as parents and grandparents of children and adolescents living in joint households. Vaccination of children and adolescents with health Kustec S, Logaj V, Krek M, Flogie A, Truden Dobrin P, Ivanuš Grmek M. Vzgoja in izobraževanje v Republiki Sloveniji v razmerah, povezanih s covid-19 – Modeli risks and vaccination of students will be an important in priporočila. Ministry of Education, Science and Sport, 2020. Available from: step forward in enabling live education process. https://www.zrss.si/digitalnaknjiznica/Covid_19/. 106 Implementation, carrying out and monitoring of measures for the control of infectious diseases in Regional Offices of the National Institute of Public Health Alenka Trop Skaza Important measures in controlling infectious diseases are epidemiological surveillance, surveying (interviewing) infected individuals, managing clusters, outbreaks and epidemics, collecting human and environmental samples, proposing measures to prevent the spread of infectious diseases and monitoring the epidemiological situation. In the case of laboratory diagnostics, close collaboration with different laboratories is required. Protecting human health from infectious diseases involves a variety of activities, an important part of which is vaccination. The regional vaccination coordinators and our associates are responsible for coordinating all vaccinations and providing professional support to vaccination teams in the field. Operational epidemiological measures for the pro- threats in the field of infectious diseases are carried tection of human health are being implemented at out in all the regional offices of the National Insti- the level of NIJZ regional offices. Epidemiologists/ tute of Public Health (NIJZ) according to the princi- public health specialists, graduate sanitary engine- ple of merging regions (NM+CE; LJ+KR; RA+MB+MS; ers and nurses are involved in the operational work. KP+NG). By implementing measures and all activities before In the segment of epidemiological monitoring with and after the occurrence of infectious diseases and unified action, we provide: their monitoring, we ensure an effective and unified • timely detection and reporting of infectious dise- response aimed at the prevention of infectious dise- ases for which notification is required by law, ases and infections in Slovenia. It is important to pro- tect people in a timely manner through vaccinations • risk assessment for the spread of infectious dise- and other medicines in the event of epidemiological ases, indications and to carry out vaccinations themsel- • determining an indication, proposing and imple- ves, which includes the management of travellers. In menting targeted measures to prevent the spread addition to preventive vaccinations related to health of individual infectious diseases, outbreaks and indications, the work of epidemiological regional epidemics, teams also includes the implementation of preven- tive vaccinations and chemoprophylaxis in persons • providing sampling, transport, laboratory diagno- who have been in contact with a patient with a spe- stics of human and environmental samples. cific infectious disease and are unprotected against this disease, or when infection can be prevented by The implementation of outpatient work not only timely chemoprophylaxis. Communication and ensu- includes the implementation of various vaccinations, ring professional support to vaccination providers but also procedures for purchasing, handling and and stakeholders in healthcare institutions, as well storing vaccines and medicines, recording all work as cooperation with various institutions in epidemi- procedures, billing for services, explanatory duty, ological treatment, is the basis for successful and determining indications and excluding contraindi- professional operational work. cations, issuing certificates, preparing reports and reporting of vaccinations performed and prescripti- The algorithms of action adopted in the event of the ons issued for antimalarials and antibiotic chemop- occurrence or outbreak of certain infectious dise- rophylaxis. ases require immediate action by epidemiologists. The epidemiologist of the regional office is obliged to As this is one of the basic activities of public health, immediately and actively search for exposed persons we assume that in order to carry out this task it will be and to ensure the urgent implementation of mea- necessary to ensure appropriate working conditions sures to prevent and control the spread of the patho- in the long run and, above all, sufficient staff support. gen. Continuous monitoring and rapid response to 107 eRCO and surveil ance of vaccination coverage Veronika Učakar Universal vaccination programmes have greatly reduced the burden of diseases that can be prevented by vaccination. The collection of data on vaccinations performed is very important for assessing the protection of our population. The Electronic Register of Vaccinated Persons and Adverse Events after Vaccination (eRCO) was established in 2017. The data collected in the eRCO will enable more accurate estimates of the vaccination coverage of target population groups and real-time monitoring of vaccination performance. Vaccination is the most important among the specific being gradually integrated into the system, and their measures for the prevention and control of infectious inclusion in the system is gradually improving. In the diseases. In addition to the outstanding benefits for period 2017–2019, the quality of data from the eRCO the individual, it is important to emphasize the bene- was not yet satisfactory for providing national esti- fits of vaccination for the community. For some highly mates of the vaccination coverage of target groups, contagious diseases (e.g. measles), the vaccination so the NIJZ continued to collect aggregated data rate must be at least 95% if “herd immunity” is to be on all performed vaccinations. A national estimate achieved. This also protects against infection those of the vaccination coverage for pre-school children people who, for health reasons, cannot be vacci- was produced for the first time for 2020, based on a nated or whose immunity has not developed after random sample of approximately 1,000 children for vaccination. As the vaccination coverage decreases, whom vaccination is mandatory based on data from the likelihood of recurrence and spread of such dise- eRCO. The vaccination coverage against measles/ ases increases. mumps/rubella was 95.2% (93.8–96.3%), against diphtheria/tetanus/whooping cough/haemophilus Vaccination coverage means the proportion of per- influenzae/polio 94.3% (92.8–95.5%) and against sons vaccinated against a certain infectious disease pneumococcal infections 69.7% (67.0–72.6%), and or with a certain vaccine in the target population in was higher than in previous years. a certain area, or the proportion of timely vaccinated individuals in the target population. Based on the As part of the national vaccination campaign of Slo- vaccination coverage, we can estimate how many venia's population against COVID-19, the inclusion people in the target population are protected. The of all providers of this vaccination in the eRCO was collection of data on vaccinations, the geographical ensured, which enabled the production of more distribution of vaccination and the distribution of accurate estimates of vaccination rate and a real- vaccination by individual target population groups -time overview of the implementation of vaccination. is necessary for the planning and implementation of The data was available to various stakeholders and the Vaccination Programme (Official Gazette of the the general public through an interactive display on Republic of Slovenia, 2021) and the evaluation of its the NIJZ website. effectiveness in controlling infectious diseases. In 2017, the NIJZ established the eRCO within the portal eZdravje, which gives vaccination providers a Program cepljenja in zaščite z zdravili 2021. Official Gazette of the RS, No. uniform method of recording performed vaccinati- 113/20; p. 4736–51 Available from: https://www.nijz.si/sl/program-cepljenja-in-ons in local systems, and the data is then transfer- -zascite-z-zdravili-2021. red to the eRCO in real time. Not all vaccination pro- viders are yet submitting data to the eRCO; they are 108 New developments in Slovenia’s national vaccination programme Nadja Šinkovec Zorko, Marta Grgič Vitek, Veronika Učakar In the past three years a number of new features have been introduced into the national vaccination programme in Slovenia. A recommended vaccination against tick-borne encephalitis (TBE) for children and adults, vaccination of boys against human papillomavirus (HPV) infections and vaccination of children from six months to two years of age against influenza have been added. In addition, vaccination against COVID-19 began at the end of 2020. Slovenia ranks among those countries with the In Slovenia, as in the other EU/EEA countries, vacci- highest incidence of TBE in Europe. In 2019 there was nation against flu is especially recommended for an expansion of the national vaccination programme groups at higher risk of severe infection. In past years with the recommended vaccination against TBE for vaccination against flu covered by CHI was available adults who in the current year reach the age of 49, to persons 65 years and over, patients with chronic and for children who in the current year reach the age diseases, pregnant women and persons suffering of three. These persons are eligible for three doses from obesity. In the 2020/21 season children aged of the TBE vaccine covered by compulsory health six months to two years were added to the groups of insurance (CHI), which is also available to those who people eligible for flu vaccination covered by CHI. are late in getting vaccinated. In 2021 there was a shift in the age range for providing the recommended In 2019 there was a replacement of the 10-valent TBE vaccine for children, from three years old to one pneumococcal conjugate vaccine used in the vacci- year old children. nation programme for children against pneumococ- cal infections, with the 13-valent vaccine. On 1 Janu- The programme of vaccination against HPV infection ary 2020 there was a replacement of the 5-valent has been carried out for girls in the 6th grade of pri- vaccine (against diphtheria, tetanus, whooping mary school since the 2009/2010 school year. Girls cough, Haemophilus influenzae type b and polio- who did not get vaccinated against HPV in the 6th myelitis) with a 6-valent vaccine (against diphtheria, grade can also get vaccinated later. Vaccinations for tetanus, whooping cough, Haemophilus influenzae both groups of girls are covered by CHI. The 2021/2022 type b, poliomyelitis and hepatitis B) and a change school year will see the start of vaccinations for boys in the vaccination schedule from 3 + 1 to 2 + 1. At the against HPV, also covered by CHI, as a recommended end of last year (27 December 2020) Slovenia began vaccine in the 6th grade of primary school. The aim of its rollout of vaccinations against Covid-19, which expanding this vaccination programme is to directly has been funded from the national budget and was contribute to reducing the burden of HPV infections added to the national vaccination programme for and their consequences among males, while we also 2021 as an emergency vaccination. anticipate an indirect effect in terms of reducing the burden of HPV infections and their consequences among females. 109 National survey of healthcare-associated infections Irena Klavs In the third Slovenian national healthcare-associated infections (HAIs) prevalence survey, conducted in all Slovenian acute care hospitals in November 2017, we estimated that on the day of the survey 4.4% patients had at least one HAI and an additional 2.2% patients were still treated for HAIs. The results will inform the evidence-based prevention and control of HAIs in Slovenia, which is an important public health priority. In the third Slovenian national HAIs prevalence Factors associated with HAIs included central vascu- survey, conducted within the European point preva- lar catheter (adjusted odds ratio (aOR) 4.1; 95% con- lence survey of HAIs and antimicrobial use in acute fidence intervals (CI): 3.1–5.4), peripheral vascular care hospitals, we estimated the prevalence of all catheter (aOR 3.0; 95% CI: 2.3–3.9), urinary cathe- types of HAIs and identified factors associated with ter (aOR 1.8; 95% CI: 1.4–2.3) and operation during HAIs. The Results were published in a peer reviewed hospitalization (aOR 1.6; 95% CI: 1.2–2.0). journal the Slovenian Journal of Public Health (Klavs et al., 2019). The prevalence of HAIs in Slovenian acute care hospi- tals in 2017 was substantial, especially in intensive Patients were enrolled into a one-day cross-secti- care units. HAIs prevention and control is an impor- onal study in November 2017. Descriptive analyses tant public health priority. National surveillance of were performed to describe the characteristics of HAIs in intensive care units should be developed to patients, their exposure to invasive procedures and support evidence-based prevention and control. the prevalence of different types of HAIs. Univari- ate and multivariate analyses of the association of having at least one HAI with possible risk factors were performed to identify risk factors. Among 5,743 patients, 4.4% had at least one HAI and an additio- Klavs I, Serdt M, Korošec A, Lejko Zupanc T, Pečavar B; SNHPS III. Prevalence nal 2.2% were still treated for HAIs on the day of the of and Factors Associated with Healthcare-associated Infections in Slovenian Acute Care Hospitals: Results of the Third National Survey. Zdr Varst. survey, with a prevalence of HAIs of 6.6%. The preva- 2019;58(2):62-69. doi: 10.2478/sjph-2019-0008. lence of pneumonia was the highest (1.8%), followed by surgical site infections (1.5%) and urinary tract infections (1.2%). The prevalence of bloodstream infections was 0.3%. In intensive care units, the pre- valence of patients with at least one HAI was 30.6%. 110 National survey of sexual lifestyles and health Irena Klavs We have described the sexual behaviour of the general population aged 18-49 years old, estimated the lifetime prevalence of self-reported sexually transmitted infections (STIs), and described STI-related health care. Sexual behaviour was very diverse and STIs were relatively common. The results will inform evidence- -based national sexual and reproductive health prevention and control policies and strategies, including STI prevention and control. Data was collected over 2016-2017 from a probability Approximately every tenth sexually experienced indi- sample of the general population, aged 18-49 years vidual reported having had genitourinary symptoms old, by a combination of face-to-face interviews suggestive of STIs, but only a minority of them repor- and self-administered questionnaires. Statistical ted having had the respective STIs diagnosed. The methods for complex survey data were used to acco- proportion of sexually experienced individuals that unt for stratification, clustered sampling, and weigh- reported having been diagnosed with an STI at least ting. once (chlamydial infection, gonorrhoea, non-speci- fic urethritis, syphilis, genital warts, genital herpes or A total of 1,929 individuals participated (the survey hepatitis B) was 2.4% for men and 6.7% for women. response rate was 55.5%). Having had the first expe- Independent risk factors associated with self-repor- rience of heterosexual intercourse before the age of ted STIs in women included at least 10 lifetime sexual 15 was reported by 7.3% of men and 3.8% of women partners and having been forced into sex at least aged 18-24 years old. The majority of men (83.5%) once. The majority of the most recent STI episodes and women (71.8%) reported having more than one in women were treated by gynaecologists and in men heterosexual partner during their lifetime, and having by dermatovenerologists. Approximately half of the at least 10 was reported by 22.0% of men and 11.2% of STI patients were advised to engage in safer sex, and women. A new heterosexual partner during the last the majority reported having notified their sexual year was reported by more men (17.2%) than women contacts. (9.8%). Having had sexual intercourse with someone while in a stable heterosexual relationship with some- The survey showed that the sexual behaviour of the one else at least once in their lifetime was reported general population of Slovenia was very diverse, and by 26.0% of men and 17.8% of women. However, both that STIs were relatively common. The results will men and women reported about a similar number of inform evidence-based national sexual and reprodu- occasions of heterosexual sex within the last 30 days ctive health prevention and control policies and stra- (the median was 4). Vaginal intercourse at least once tegies, including STI prevention and control. in their lifetime was reported by 95.5% of men and 95.1% of women, oral intercourse by 90.1% of men and 91.2% women, and anal intercourse by 49.3% of men and 49.1% of women. 111 Activation of the local community for vaccination against TBE in Slovenia Irena Grmek Košnik Tick-borne encephalitis (TBE) is the most common viral disease of the central nervous system in Slovenia. The hosts of the virus are small forest animals, and the virus is transmitted by ticks. In Slovenia, an average of 250 people per year (incidence 13.5/100,000 inhabitants) developed the disease during the years 2000–2011. The morbidity of TBE in Slovenia is highest in the Gorenjska region. In Gorenjska, an average of 60 people per year deve- than in the rest of Slovenia. We designed a model for loped the disease in 2010 (incidence 30/100,000 vaccinating a large proportion of the population at inhabitants), mostly in the area of the Škofja Loka the lowest possible price to provide basic protection administrative unit (26 people per year, disease to the socially weakest part of the population. In the incidence 50/100,000 inhabitants). In addition to first campaigns, we connected with the Lions Club Lithuania and Estonia, Slovenia is one of the coun- Brnik and the Lions Club Škofja Loka to provide free- tries with the highest TBE morbidity and the lowest -of-charge vaccination to 850 children from socially immunization (12 % of the population is vaccinated). disadvantaged families. We continued in cooperation Patients with TBE are severely ill and usually need to with the municipalities so that the municipality finan- be treated in hospital. There is no specific cure for ced the costs of the vaccination team, and people the disease, and thus only the symptoms are trea- only paid the value of the purchase price of the ted. About 2% of patients die. Thirty-six percent of vaccine for the entire vaccination service. Vaccina- patients are left with permanent damage, such as tion did not require making an appointment, and was mental and psychiatric disorders, memory disorders, carried out on weekends in the local community, more thinking disorders, concentration disorders, balance precisely in primary schools and health centres in and coordination disorders, tremors, paresis and the areas where people reside. The implementation, paralysis, emotional instability, headaches, hearing however, was professional, carried out by healthcare and speech disorders. professionals. In this way, a breakthrough in vacci- nation was created. Vaccination campaigns are still The most effective way to prevent TBE is vaccination. exceptionally well-received today. The campaigns It is recommended for people from one year of age also contributed to the immunization of the popula- who live or move around in areas where TBE occurs. tion against TBE. The campaign model is followed by Vaccination is self-paid, and since 2019 has been numerous health centres, such as Zdravstveni dom covered by compulsory health insurance for children Ljubljana, Zdravstveni dom Maribor and Zdravstveni aged three years and adults aged 49 years. dom Celje, to mention only the largest. The model In 2010, employees of the then Institute of Public was also described in the renowned science maga- Health Kranj (ZZV Kranj) – one of the former regio- zine Vaccine (Košnik and Lah, 2013). nal offices of the National Institute of Public Health – developed a new model of promoting vaccination and started implementing vaccination campaigns. Košnik IG, Lah AK. A campaign to increase the vaccination rate in a highly We, the employees, recognized the great need for endemic tick-borne encephalitis region of Slovenia. Vaccine. 2013; 31(5): 732-4. doi: 10.1016/j.vaccine.2012.12.005. vaccination. Gorenjska is the most endangered area, where in 2010 the morbidity was 2.4 times higher 112 Epidemiological surveil ance of antimicrobial resistance Maja Šubelj Antimicrobial resistance (AMR) has emerged as a major public health problem. Epidemiological surveillance of AMR is important for assessing the situation, tracking trends and planning public health measures. The European Antimicrobial Resistance Surveillance placed on the website of the EU-JAMRAI project and System (EARSS) was established in 1998 in coordi- the NIJZ, and the NIJZ regularly reported on progress nation in the Netherlands. In 2010 the network was to the Ministry of Health. The purpose of the visit transferred to the European Centre for Disease Pre- to the Czech Republic was to provide a platform for vention and Control (ECDC) as the European Antimi- discussions on measures in the field of human and crobial Resistance Surveillance Network (EARS-Net). veterinary health in the EU, in particular concerning EARS-Net is intended to collect reliable and com- the formulation and implementation of the National parable data on the prevalence and spread of major Strategy and Action Plan »One Health«( Ministry of invasive bacterial infections with clinically and epide- Health, 2019). The NIJZ hosted Swedish colleagues miologically significant AMR, and to produce analysis together with the Ministry of Health and the Veteri- and reports on AMR, monitor trends, and assess the nary Faculty of the University of Ljubljana, where the problem for public health activities and action. Slo- main topic was the exchange of experiences and pra- venia joined the EU network and added its data in ctices regarding cross-sectoral action in medicine 2000, and since 2002 all Slovenian medical microbi- and veterinary medicine regarding acceptance and ological laboratories with all indicator isolates have implementation of the National Strategy and Action been cooperating voluntarily. Until 2019 EARS-Net Plan »One Health«2. was coordinated by the National Institute of Public Health (NIJZ), and in that year it was taken over by Since 2020, the NIJZ has been leading the European the National Laboratory for Health, Environment and Surveillance of Antimicrobial Consumption Network Food (NLZOH), with the NIJZ participating in data col- (ESAC-Net). The NIJZ cooperates with the National lection and analysis, data transmission to the ECDC Collaborating Mechanism at the Ministry of Health. In and preparation of reports (NIJZ, 2019), as well as the future it is necessary to continue the established participating in the European Coordination Com- connections and cooperation, and we also want to mission (Disease Network Coordinating Committee; strengthen research and education in this field. DNCC) at the ECDC. In 2017–2021, the NIJZ participated as a partner in the EU Joint Action on AMR and Healthcare-Associated 1_Epidemiološko spremljanje nalezljivih bolezni v Sloveniji. Nacionalni Inštitut Infections (HCAIs) (EU-JAMRAI). The main objective za Javno Zdravje, Center za Nalezljive Bolezni: Ljubljana; 2019. of the project was to take action and support the 2_Državna strategija »Eno zdravje« za obvladovanje odpornosti mikrobov. EU countries in implementing effective health poli- [National Strategy »One Health« for Microbial Resistance Management 2019–2024.] Ljubljana: Ministry of Health;2019 Available from: https://www. cies to combat AMR and reduce the burden of HCAIs. gov.si/novice/nov-vlada-sprejela-drzavno-strategijo-eno-zdravje-za- -obvladovanje-odpornosti-mikrobov-2019-2024-z-akcijskim-nacrtom-Dissemination and promotion of these policies were -za-obdobje-2019-2021/. 113 Setting up the COVID-19 vaccination website www.cepimose.si Mitja Vrdelja, Janina Žagar The website www.cepimose.si (let’s get vaccinated) is part of the campaign to promote vaccination against COVID-19, Nalezimo se dobrih navad – cepimo se (Let’s catch some good habits – let’s get vaccinated). It is one of the key cornerstones for successfully containing the epidemic in Slovenia, as its later planned transformation into the central national website for vaccinations is one of the more important public health activities and confidence in public health measures in Slovenia. During the COVID19 pandemic, which has caused one the Slovenian Ministry of Health and theGovernment of the biggest global health crisis of the past century, Communication Office, and is conducted as part a central digital information platform was set up in of the project Measures to manage the spread of the form of the independent website www.cepimose. COVID-19 with a focus on vunerable groups of popu- si as a part of the national COVID-19 vaccination pro- lation, funded by the Slovenian Government and the motional campaign, The website primarily provides European Union from the European Social Fund as information about vaccination against COVID-19.Its part of the Union's response to the COVID-19 pande- content will be later supplemented with information mic. It is aimed at both the general public and health about vaccination against flu, while in the long term professionals covering the latest news, presenting it will provide information about all vaccinations in the vaccination plan and providing updated infor- Slovenia. The short-term, and in the given situation mation on vaccination centres and side effects. Fre- extremely important aim of the website www.cepi- quently asked questions are addressed by experts, mose.si is to provide science-based vital information special sections provide information about the vacci- about COVID-19 vaccination for different population nes and their working, health tips and useful mate- groups , while its long-term objective is to become rials. The site publishes findings of the pandemic the central national and first such website for the fatigue research, as well as an interactive data pre- field of vaccinations in Slovenia. The purpose of the sentation of COVID-19 vaccination in Slovenia and a current site as well as its later upgraded and expan- link to vaccination registration. Based on individual ded versions is to establish and maintain confidence target groups responsiveness, public opinion moni- in the safety and effectiveness of vaccines and the toring and the attainment of targets, the website is recommendations of experts, to motivate various upgraded accordingly, while the findings of ongoing population groups to get vaccinated, increasing evaluation offer important information necessary for vaccination coverage as a result. successfully expanding content to the entire field of vaccination in Slovenia. The website www.cepimose.si represents an impor- tant part of the cam- paign Nalezimo se dobrih navad – cepimo se, which the Slove- nian National Institute of Public Health (NIJZ) created together with 114 07 PUBLIC HEALTH LABORATORIES 7.1 Establishment and operation of the National Laboratory of Health, Environment and Food 7.2 The role of NLZOH in controlling the COVID-19 epidemic 7.3 e-Exchange of microbiological orders and test results 7.4 Molecular methods for the typing of micro-organisms 7.5 The National Influenza Centre and its role in pandemics 7.6 The path to eradication of measles, rubella and mumps 7.7 Europe is polio free, but the global risk remains 7.8 Surveillance of whooping cough 7.9 Surveillance of invasive diseases caused by S. pneumoniae, N. meningitidis and H. influenzae in Slovenia 7.10 Surveillance of diphtheria 7.11 Surveillance of bacterial pathogens causing food and waterborne infectious diseases 7.12 Diversity of Clostridioides difficile ribotypes 7.13 Monitoring and control of bacterial resistance 7.14 National system of antimicrobial susceptibility testing 7.15 Molecular determination of carbapenemases 7.16 Monitoring airborne pollen 7.17 Food safety as a public health factor 7.18 Monitoring of drinking water and the MPV information system 7.19 Quality of ambient air with PM10 particles in Maribor 7.20 The role of NLZOH in environmental emergencies 7.21 Microbiological analyses for public health protection 7.22 Testing for the presence of drugs 7.23 Official quality control of medicines Establishment and operation of the National Laboratory of Health, Environment and Food Tjaša Žohar Čretnik In 2013, the Slovenian Government adopted a Decision on the establishment of the National Laboratory of Health, Environment and Food (NLZOH). The NLZOH thus became the central, largest public health laboratory in Slovenia, dealing with environmental protection, diagnostic and public health microbiological activities, chemical and microbiological analyses of various types of samples, and research and pedagogical activities. By merging the laboratory and environmental capa- communication of test results to the information cities of nine regional Institutes of Public Health and systems of clients. We unified the quality assurance the Institute of Public Health of the Republic of Slo- system, strengthened the accredited activities and venia, the NLZOH gained the opportunity to further renewed all the necessary authorizations and work develop and adapt its activities to the needs of the permits. residents of Slovenia. Almost 800 employees work at eleven locations across Slovenia. The laboratory The project of standardising work methods is extre- provides its services to over 8,000 partners annually. mely extensive and demanding, as it also includes the Its work includes performing tasks for six ministries, development and introduction of new work methods it holds 25 permits and authorizations for the imple- and adaptation to new technologies. These techno- mentation of activities and is appointed as the nati- logies, especially in the field of medical microbiology, onal reference laboratory for 10 fields. By employing encouraged us to develop a new form of work orga- more than 1,000 different methods, 770 of which are nization, specifically the establishment of remote accredited, it performs more than 1,500,000 labora- laboratory units in hospitals. Such units will allow tory analyses annually. tests that can be performed quickly to be performed by appropriately trained staff virtually at the bedside. With the merger, the NLZOH began a gradual restru- Tests requiring complex and expensive equipment, cturing of the institute's activities, the main purpose on the other hand, will be performed in central labo- of which is to provide state-of-the-art services, rati- ratories. onal use of resources and development-oriented operations. In the first years of operation, we inves- After almost eight years of operation, the establi- ted most in new laboratory and business information shment of the NLZOH is regarded as a success- systems to support joint operations. In 2021, we also ful move in the country's governance, which has established electronic management and archiving of enabled us to develop faster, attain better professi- quality assurance system documentation and busi- onal cooperation and organizational flexibility, and a ness documentation. We are proud to have develo- greater ability to respond to emergencies. ped electronic ordering of microbiological tests and 116 The role of NLZOH in control ing the COVID-19 epidemic Barbara Zdolšek One of the key tasks of the National Laboratory of Health, Environment and Food (NLZOH) in the field of prevention and control of infectious diseases is to respond to emergencies. During the COVID-19 pandemic, the NLZOH played a key role in diagnostics, network monitoring of the pathogen, reporting, introduction of new methods and communication among stakeholders. At the time of the pandemic caused by SARS-CoV-2, The NLZOH coordinated the tracking of SARS-CoV-2 the NLZOH responded firstly in the field of diagno- variants, which also involved the participation of the stics. We introduced diagnostics as early as in Janu- Clinical Institute of Special Laboratory Diagnostics ary 2020, and the first positive case was diagnosed (KISLD) of the University Children's Hospital of the on 4 March 2020. We swiftly developed and upgraded University Medical Centre Ljubljana, which perfor- molecular diagnostics in just a few weeks, so that it med sequencing, the National Institute of Biology, was available at seven locations and mostly in a thre- which tested the presence of variants in waste water, e-shift workday. Test results were available to requ- the Institute of Microbiology and Immunology of the esters within 24 hours, and usually within 8 hours, University of Ljubljana, which also performed a part which is an extremely short response time. We per- of the molecular characterization of positive samples formed over half of all diagnostic tests in the state, from their laboratory, and the Veterinary Faculty of which was over 840,000 tests, by June 2021. We per- the University of Ljubljana, which tested the infecti- form testing for hospitals, health centres, health- vity of different lines. In the period from 1 January care entry points, private healthcare institutions and 2021 to 7 June 2021, 8,752 samples were analysed at other clients (e.g. large sports competitions). The the NLZOH by sequencing whole genomes, of which COVID-19 pandemic surpassed any other event that 1,611 genomes were sequenced in collaboration with has occurred in almost a hundred years of the exis- the ECDC. Information on the distribution of variants tence of microbiological laboratories in Slovenia. The by region, and especially the tracking of more dange- daily volume of testing during the pandemic equalled rous new variants, was important in deciding on mea- the annual volume of testing beforehand. sures to contain the epidemic. Together with GISAID, we produced an animation on the variants of SARS- We also introduced testing for the presence of anti- -CoV-2 in Slovenia (https://www.nlzoh.si/phylodyna- bodies in the NLZOH laboratories. An important part mics/). of the diagnostics was the establishment of faster transport routes of samples and the establishment The NLZOH also has an Operational Contact Point and optimization of electronic connections for orde- for SARS-CoV-2 at the ECDC, which is responsible ring tests and reporting results. for timely entry of microbiological data for Slovenia in the European TESSy database. Later, the NLZOH played an important role in vali- dating the tests used at the national level for rapid population testing and self-administered tests intended for schoolchildren. 117 e-Exchange of microbiological orders and test results Daša Kavka At the Centre for Medical Microbiology of the National Laboratory of Health, Environment and Food we have developed, together with the company SRC Infonet d.o.o., an e-ordering module, which enables the electronic exchange of microbiological orders and test results. Since its design in 2017 and until today, nine hospitals across Slovenia have successfully integrated the module, and during the SARS-CoV-2 epidemic, the module has enabled us to quickly connect most entry points for COVID testing across Slovenia. The Centre for Medical Microbiology of the Nati- It offers many advantages for the client, such as easy onal Laboratory of Health, Environment and Food sample definition and easier selection of the approp- has been keeping up with the trends spurred by riate microbiological test. New tests are added as the impact of digitalization with the development soon as they are introduced. The client has an over- of new information technologies. Together with the view of the orders and always knows at what stage company SRC Infonet d.o.o., we have developed an an order is. As soon as any results are known in the e-ordering module, which enables the electronic course of a test, they are already available in the cli- exchange of microbiological orders and test results. ent's IS in the form of a partial report. It is also possi- Ordering microbiological tests is quite complica- ble to transfer critical values to the client's IS. ted. The reason is the great variety and large set of samples, which must be defined quite precisely to The e-ordering module also offers advantages for the achieve quality performance of tests. The activity microbiology laboratory. The take-over of samples is performed by each client must be taken into account, faster because samples and tests are clearly defi- and all additional data must be provided for the cor- ned. All data is automatically transferred from the rect interpretation of results. On the clients' part, the client's IS to the LIS, which reduces the possibility of need to receive reports in electronic form is increa- errors as there is no manual input into the LIS. Proto- sing due to the management, analysis and storage of cols and worksheets are created automatically. The business and professional data that we provide with order can be easily redirected to another laboratory. the report. Since its design in 2017 and up to the present day, The module is designed to be fully integrated into the nine hospitals across Slovenia have successfully laboratory information system (LIS) and the client's integrated the module, and the University Medical existing information system (IS). The exchange of Centre Maribor, which is our largest client, is gradu- data between the LIS and the client's IS takes place ally joining. During the SARS-CoV-2 epidemic, the via the medGateway platform. This is a cloud service module enabled us to quickly connect most entry provided by the REST (API) interface. The interface is points for COVID testing in Slovenia. More than 50 secured by encrypting traffic over the SSL server cer- connections have been established, which will also tificate protocol (HTTPS). enable the continuation of the project by connecting clients at the primary level. 118 Molecular methods for the typing of micro-organisms Sandra Janežič Typing of pathogens is important in understanding sources of infections, the circulation of pathogens between reservoirs, and for antimicrobial resistance monitoring. All state-of-the-art molecular methods for typing micro-organisms are available in Slovenia. In the period from 2008 to 2021, the activity of mole- In Slovenia, all modern methods for accurate chara- cular characterization of mainly bacterial pathogens cterization of various infectious pathogens are ava- developed strongly at the NLZOH and earlier at some ilable at the NLZOH. This knowledge enables better regional Institutes of Public Health (ZZV). In the ini- investigations of outbreaks, better international tial period, these were pulse electrophoresis (PFGE) comparability, and in the event of an emergency such or targeted molecular characterizations such as spa as an epidemic, it provides an important information typing for Staphylococcus aureus (Dermota et al., for decision makers. 2015) and ribotyping for Clostridioides difficile. In 2014, we also started introducing bacterial genome sequencing (whole genome sequencing, WGS). We are mainly active in the development of approaches Dermota U, Mueller-Premru M, Švent-Kučina N, Petrovič Ž, Ribič H, Rupnik M, for the analysis of whole genomic sequences in C. Janežič S, Zdovc I, Grmek-Košnik I. Survey of community-associated-methi-cillin-Resistant Staphylococcus aureus in Slovenia: identification of commu-difficile (Janezic et al. 2019; Janezic et al. 2020). We nity-associated and livestock-associated clones. Int J Med Microbiol. 2015; 305(6): 505-10. doi: 10.1016/j.ijmm.2015.05.002. are also a learning centre for this field at the Euro- pean Society for Clinical Microbiology and Infectious Janezic S, Rupnik M. Development and Implementation of Whole Genome Sequencing-Based Typing Schemes for Clostridioides difficile. Front Public Diseases (ESCMID Collaborative Centre). Health. 2019; 7: 309. doi: 10.3389/fpubh.2019.00309. Sequencing of whole genomes of various micro-or- Janezic S, Blazevic I, Eyre DW, Kotnik Kevorkijan B, Remec T, Rupnik M. Possible contribution of shoes to Clostridioides difficile transmission within hospi-ganisms is used in Slovenia to track transmissions tals. Clin Microbiol Infect. 2020 Nov 6: S1198-743X(20)30691-1. doi: 10.1016/j. cmi.2020.11.001. in the hospital environment, to track transmissi- ons between reservoirs, to monitor antimicrobial Golle A, Janezic S, Rupnik M. Low overlap between carbapenem resistant Pseudomonas aeruginosa genotypes isolated from hospitalized patients and resistance (Golle et al., 2017), to serotype problema-wastewater treatment plants. PLoS One. 2017 Oct 19; 12(10): e0186736. doi: 10.1371/journal.pone.0186736. tic Salmonella strains and to study outbreaks (e.g., outbreak of monophasic S. Typhimurium in 2019). During the SARS-CoV-2 epidemic, we have actively participated in sequencing and data analysis to track variants of the virus. 119 The National Influenza Centre and its role in pandemics Katarina Prosenc Trilar The NLZOH Laboratory for Public Health Virology is the National Influenza Centre, which monitors the circulation of influenza viruses and other respiratory pathogens in Slovenia and makes an important contribution to the country’s preparedness for pandemics. It works hand in hand with epidemiological experts and international organizations (ECDC, WHO). It played a key role in the 2009 influenza pandemic and is closely involved in managing the COVID-19 pandemic. Systematic monitoring of the circulation of influenza Due to its activities, the NLZOH Laboratory for Public and other respiratory infections in Slovenia has been Health Virology was well prepared in 2009 when the carried out since 1999. The Laboratory for Public new influenza virus A(H1N1)pdm09 appeared and Health Virology has been appointed by the Ministry caused a pandemic. The virus emerged in Mexico and of Health of the Republic of Slovenia as the Natio- the USA in April 2009, and on 10 May 2009 we had nal Influenza Centre, and it has been accredited and already established a molecular detection method re-accredited each year by the World Health Organi- (real-time PCR) in the laboratory, started regular zation (WHO) upon verification of fulfilment of the testing and on 11 June 2009 confirmed the first case requirements. We are actively involved in the network in Slovenia. During the first wave, the laboratory and of national influenza centres coordinated by the diagnostic part of our work took place only in our WHO (Global Influenza Surveillance and Response laboratory, and up until the second wave, molecular System) and in the European Influenza Surveillance detection of the new influenza virus was established Network within the European Centre for Disease Pre- with our help in other laboratories across the coun- vention and Control (ECDC). try. The Laboratory for Public Health Virology follows gui- In 2020, our laboratory immediately joined a network delines in the development of virological methods of laboratories in which detection of SARS-CoV-2 and epidemiological methods of monitoring the cir- was established and the diagnostic capacity rapidly culation of influenza and other pathogens causing increased several fold. The importance of mutual respiratory infections. Monitoring has been exten- cooperation of laboratories in Slovenia and close ded to other viruses that cause respiratory disea- cooperation of laboratories in international networks ses. We maintain methods to detect avian influenza was once again demonstrated. viruses that have the potential to infect humans. In addition to the standard antigenic typing of isolates, influenza viruses are also genotyped by sequencing to determine whether viruses in circulation have a pandemic potential. We communicate our findings to professionals (epidemiologists, virologists, cli- nics) and the general public (websites). Our data is essential for professionals to implement measures to control the annual influenza epidemic. We report the data to ECDC and WHO, and with our isolates we contribute to the global database of viruses available for the production of vaccines. Our isolate A/Slove- nia/2903/2015 (H1N1) was used in the FluMist Quad- rivalent Influenza Vaccine. 120 The path to eradication of measles, rubel a and mumps Katarina Prosenc Trilar One of the important goals of ECDC and WHO is to control vaccine preventable diseases. In addition to vaccination and epidemiological monitoring, laboratory confirmation of suspected cases is essential for disease management. This helps in assessing the effectiveness and success of vaccination, setting up further vaccination strategies and finding pockets of population with low rates of vaccinations. The eradication of measles and congenital rubella is one of the WHO’s most important goals. The WHO's goal of eliminating (eradicating) measles laboratories to provide data (they are only required in Europe by 2020 has not been achieved. The number to report positive cases of notifiable diseases) does of measles patients is still high in Europe because the not provide support for epidemiology, nor does it vaccination rate with two doses of measles vaccine is require diagnostic laboratories to maintain a parti- too low in many places. Outbreaks of measles occur cular method. The Laboratory for Public Health Viro- in groups that are reluctant to vaccination or difficult logy provides systematic monitoring and response to reach due to their particular lifestyle. The epidemi- to exceptional situations when measles, rubella or ological situation in Europe dictates close monitoring mumps occur. Since 2012, the laboratory has been of febrile diseases with rash, especially those whose performing genotyping, which enables molecular clinical picture corresponds to measles. Close moni- epidemiological clarification of outbreaks. Further- toring of mumps is also defined in the Programme for more, the laboratory has been running an incentive the Protection of the Population against Infectious programme for the differential diagnosis of febrile Diseases. illness with rash and parotitis for years. As data on the vaccination rate are not sufficient to offer a good Slovenia had no cases of measles between 1999 and assessment of the population's immune status, peri- 2009. Since 2010, there have been individual impor- odic sero-epidemiological studies are necessary. ted cases or outbreaks caused by imported cases. The last sero-epidemiological study for the presence Attention on the occurrence of measles is there- of antibodies against measles, rubella and mumps fore especially important. The NLZOH Laboratory was performed in the Slovenian population on serum for Public Health Virology is the national reference samples collected in 2018. laboratory for measles and rubella, and confirms its status through annual prescribed activities. Legi- slation that does not require diagnostic and other 121 Europe is polio free, but the global risk remains Katarina Prosenc Trilar Polio caused by polio viruses is the first disease since smallpox that we have a chance to eradicate by vaccination that prevents the spread. Even when the disease no longer occurs, it takes years of monitoring and confirmation to establish that the circulation of the virus has indeed stopped. The NLZOH Laboratory for Public Health Virology maintains the required methods and, in cooperation with the WHO, carries out virological control over the occurrence of polio viruses in Slovenia. Before the introduction of vaccination against polio as far as possible, providing equipment and means viruses, the pathogens that still caused polio, in the for diagnosing and storing polio viruses in an accre- mid-1950s, this disease was widespread throughout dited laboratory, managing relevant data and perfor- the world. Vaccination has effectively reduced the ming analyses. The eradication programme provides number of those infected. Eradication of polio is public health microbiology support for the epidemi- possible by stopping the transmission of polio viru- ological surveillance of polio, maintains and updates ses in the population. The WHO European Region was the methods, and through its reference role sets declared free of polio viruses in 2002. Wild strains are tasks for the exchange of information and data in still being confirmed today in Pakistan and Afghanis- the country, in the European Community (ECDC) and tan, therefore the absence of polio viruses in all other with with international organizations (WHO). At the areas needs to be constantly checked and con- same time, the programme provides opportunities for firmed. The strategy in the post-eradication period studying the circulation of polio viruses and tracking and the population protection programme to prevent their properties and characteristics that are impor- the re-spread of polio viruses are coordinated by the tant for the implementation of measures in the field NIJZ and NLZOH, which has the only WHO-accredited of infectious diseases. Therefore, in addition to the reference laboratory for the diagnosis of polio viruses mandatory isolation of polio viruses in cell cultures, in Slovenia, and are based on the following elements: we also introduced molecular detection and genoty- high vaccination rate against polio, advanced epide- ping of enteroviruses and polio viruses in 2018. miological monitoring of the disease, i.e. detection and throughout diagnosis of all suspected cases of polio (a key element is full epidemiological monito- ring of acute flaccid paralysis – AFP) with prescribed methods, preparing an accurate inventory of mate- rials containing polio viruses and their destruction 122 Surveil ance of whooping cough Tamara Kastrin, Metka Paragi The Ljubljana Department of Public Health Microbiology under the auspices of the NLZOH performs the tasks of a reference laboratory for monitoring diseases prevented by vaccination, including whooping cough, diphtheria and diphtheria-like diseases, and tetanus. Surveillance of these pathogens is important to detect their presence early, detect outbreaks, and evaluate the effectiveness of management programmes, especially the vaccination programme. Whooping cough is a highly contagious acute respi- introduced in 2009. Over the many years of our work, ratory disease caused by the bacterium Bordetella we have succeeded in introducing more sensitive pertussis. The disease is prevented by vaccination, molecular methods to show the actual epidemio- which was introduced in Slovenia in 1959. In its typi- logical situation of whooping cough in Slovenia. We cal form, the disease occurs in unprotected babies, have shown that, despite the high vaccination rate, for whom it is very dangerous and can even lead to whooping cough still occurs, especially in certain death. Despite the high vaccination rate, whooping age groups (Kastrin et al., 2019). Another task of cough remains endemic and is one of the worst the public health laboratory is to explain and limit managed diseases that are preventable by vaccina- outbreaks, which, characteristically for this disease, tion. The disease is on the rise in Europe and occurs occur frequently. For the purposes of public health cyclically with higher incidences every 2 to 5 years. monitoring, we carry out isolation of the bacterium Factors that have contributed to the increased inci- in culture. In this way we can determine the antimi- dence of whooping cough in the last decade include crobial susceptibility and antigenic properties of the improved national epidemiological surveillance, the bacterium, type the bacterium, study its genome and introduction of more sensitive molecular diagno- assess the suitability of vaccines. By using the esta- stic methods, genetic changes in the bacteria and blished methodology, we also participate in European antigenic divergence from vaccines, lack of booster studies and are members of the European Reference vaccinations and changes in vaccine composition or Laboratory Network for Pertussis under the auspices vaccination schedules. of the ECDC (European Centre for Disease Preven- tion and Control). In 2021, we took over the organi- Within the public health laboratory of the NLZOH in zation of the European congress EUPertStrain 2021. Ljubljana we are a reference laboratory and imple- ment all microbiological methods for rapid detection and confirmation of whooping cough: isolation in culture, molecular and serological diagnostics. The Kastrin T, Barkoff A-M, Paragi M, Grgič-Vitek, M, Mertsola, J, He Q. High pre-occurrence of whooping cough has been actively valence of currently circulating Bordetella pertussis isolates not producing vaccine antigen pertactin in Slovenia. Clinical microbiology and infection. monitored since 1998 in order to show the actual 2019; 25 (2):258-60. DOI: 10.1016/j.cmi.2018.10.005. situation in Slovenia and at the same time evalu- ate the booster dose for children, which was newly 123 Surveil ance of invasive diseases caused by S. pneumoniae, N. meningitidis and H. influenzae in Slovenia Tamara Kastrin, Metka Paragi The bacteria S. pneumoniae, N. meningitidis and H. influenzae are among the most common causes of bacterial invasive diseases. The Department of Public Health Microbiology in Ljubljana has been conducting prospective laboratory surveillance of these invasive bacteria at the national level since 1993. The surveillance system represents a national database of serotypes, genotypes, antibiotic susceptibility and other relevant clinical and epidemiological data. In 1993, we started a national project in Slovenia to vaccination into the vaccination programme. In this monitor invasive diseases caused by the bacte- way we can monitor the impact of vaccination on ria Neisseria meningitidis, Heamophilus influenzae the occurrence of invasive pneumococcal disea- and Streptococcus pneumoniae. Surveillance is ses, on the possible decrease in resistance and on important in terms of public health, mainly because the change in the serotype population, mainly due of the possibility of preventing these diseases by to the possibility of the occurrence of replacement vaccination, the possibility of epidemics occurring, serotypes not covered by the vaccine. The results of assessing the effectiveness of vaccination and also our national monitoring of invasive diseases caused the high mortality rate in the case of invasive menin- by the H. influenzae bacterium have shown that the gococcal disease. Further cases can be prevented Hib vaccine is very effective in preventing this inva- by surveillance and laboratory and epidemiological sive disease. Invasive meningococcal disease occurs treatment of each case. Invasive meningococcal endemically in Slovenia. All invasive isolates are disease belongs to the 1st group of infectious dise- typed phenotypically as well as molecularly by the ases according to the Communicable Diseases Act whole genome sequencing method. We have proved and the Communicable Disease Reporting Rules, so that the isolates are genetically heterogeneous, and it is necessary to report it to the NIJZ and treat it in at the same time we have proved the presence of accordance with the meningococcal algorithm. In our important hypervirulent clonal complexes. Detailed laboratory we perform rapid diagnostics and further, molecular laboratory based surveillance is essential detailed identification of bacteria, typing, molecular to monitor and at the same time prevent and control typing, determination of antimicrobial resistance and this dangerous bacterium. finally the use of more advanced technology, such as whole genome sequencing. Following the introduction of regular vaccination Kastrin T, Paragi M, Erčulj V, Žohar Čretnik, T, Bajec, T, Čižman, M. Lack of against H. influenzae serotype b (Hib) at the end of correlation between reduced outpatient consumption of macrolides and resistance of invasive Streptococcus pneumoniae isolates in Slovenia during 1999, pneumococci became the main causes of inva-1997 to 2017. Journal of global antimicrobial resistance. 2018; 16: 242-248 DOI: sive bacterial diseases that are preventable by vacci-10.1016/j.jgar.2018.10.022. nation. In addition to the increase in incidence, we are Kastrin T, Gubina M, Paragi M, Kolman J, Čižman M, Kraigher A, Ribič H, Sadowy E, Hryniewicz W, et al. Macrolide resistance among invasive Streptococcus also facing an increase in antimicrobial resistance pneumoniae in Slovenia. Journal of antimicrobial chemotherapy. 2008; 62 (3): (Kastrin et al., 2018; Kastrin et al., 2008). 628-9. DOI: 10.1093/jac/dkn202. Determination of pneumococcal serotypes is essen- tial for a high-quality surveillance system, in par- ticular due to the introduction of pneumococcal 124 Surveillance of diphtheria Verica Mioč The last case of diphtheria in Slovenia was recorded in 1967. Although the disease is rare in developed parts of the world, surveillance of diphtheria remains essential due to it still being present in many parts of the world. Potentially toxicogenic strains are tested for toxicity in the Department of Public Health Microbiology in Ljubljana (OJM Ljubljana, NLZOH). We also perform serological tests for the presence of vaccine antibodies. Diphtheria is a rare infectious disease caused by In order to establish effective laboratory and epide- toxigenic species of bacteria of the genus Coryneba- miological monitoring of diphtheria, Slovenia par- cterium (C. diphtheriae, C. ulcerans, C. pseudotuber- ticipates in the European Diphtheria Surveillance culosis). In Slovenia the last case of diphtheria in Slo- Network – EDSN, which operates within the ECDC. venia was detected in 1967. Although the disease is Fast and efficient diagnostics and proof of toxigeni- rare in developed countries, surveillance of diphthe- city of pathogenic strains of corynebacteria (Coryne- ria remains essential due to it still being present in bacterium diphteriae – 4 biotypes, Corynebacterium many parts of the world. The disease still occurs in ulcerans and Corynebacterium pseudotuberculosis) Indonesia, India, the Philippines, Nigeria, Brazil and are particularly important for early detection and elsewhere. Travellers and emigrants from endemic prevention of the spread of the disease. Potentially and epidemic areas are an important factor. Trans- toxicogenic strains are tested for toxicity in our labo- mission of diphtheria is possible if a person has not ratory. We also perform serological tests for the pre- been vaccinated or several years have passed since sence of vaccine antibodies. their booster dose. Vaccination remains the only pre- ventive control measure that is effective. 125 Surveil ance of bacterial pathogens causing food and waterborne infectious diseases Marija Trkov The Department of Public Health Microbiology in Ljubljana (OJM Ljubljana) monitors various pathogens of infectious diseases that are transmitted through food and water. Such diseases are most commonly caused by bacteria of the genera Campylobacter, Salmonella, Listeria and E. coli species. The European Centre for Disease Prevention and Control treats them under the Food and Waterborne Diseases and Zoonoses programme in which our laboratory has been involved from the very beginning. The most common route of infection with Campylo- already involved at the time of its creation. In colla- bacter, Salmonella, Listeria, E. coli is by eating con- boration with the NLZOH laboratories, the Institute taminated food. These pathogens cause individual of Microbiology and Immunology (IMI), medical labo- cases of infection and outbreaks. Campylobacte- ratories of some hospitals and the National Institute riosis and salmonellosis are the most commonly of Public Health (NIJZ), we collect and type isolates reported bacterial zoonoses. Infections with Liste- from all over the country. We use some phenotypic ria are less common, as mostly only invasive infecti- methods, but mostly various molecular methods. ons are reported. The symptoms of the disease are We are constantly keeping up with the development long-lasting and severe, and the hospitalization of newer methods, which enables the comparabi- rate and mortality of patients are high. Surveillance lity of our data with the data of other Slovenian and of diarrhoeagenic E. coli (DEC) is important beca- European laboratories. The typing methods which use of their great diversity. Some pathogenic types were once widely used have been replaced in recent (e.g. VTEC) can cause very severe diseases, and due years or supplemented by next-generation sequen- to the variability of these bacteria, new pathogenic cing methodology. This methodology has also been types emerge with a combination of virulence factors employed in our laboratory since the beginning of and consequently increased pathogenicity. This is 2019, and the sequences are uploaded to the ECDC evidenced by the outbreak of infections with ente- database. Prior to that, for the purposes of surve- roaggregative/verotoxigenic E. coli O104:H4 in 2011, illance and international outbreaks investigation, for which our laboratory was well prepared due to sequencing of Listeria isolates was supported by the the timely introduction of a number of detection and ECDC. typing methods for DEC. Through many years of collecting isolates and typing In Europe, the ECDC is responsible for surveillance of them, we have created valuable national collections these diseases in humans and international outbre- that serve pathogens surveillance and comparison of aks investigation. EU Member States, including Slo- isolates from food, animals, animal feed and the envi- venia, contribute epidemiological and laboratory ronmental samples to identify sources of infection data, and this also includes our laboratory. In 2012, and routes of transmission. the ECDC established the Tessy MSS (Molecular Surveillance Service) database, which was intended for collecting data on molecular typing of Salmonella, Listeria and E. coli, in which the OJM Ljubljana was 126 Diversity of Clostridioides difficile ribotypes Maja Rupnik Clostridioides difficile is one of the main causes of gastrointestinal infections in Slovenia. Since we started with the surveillance of C. difficile ribotypes in Slovenia in 2008, the diversity of ribotypes has changed. Since 2011, the ribotypes 027 and 014/020 have been predominant. Other hypervirulent ribotypes are uncommon. Slovenia is one of the few countries with a well-documented diversity of ribotypes in humans and in all other reservoirs that are important from the One Health point of view of. Infections with the bacterium Clostridioides (Clostri- Tracking ribotypes is particularly important in con- dium) difficile in Slovenia represent a significant trolling outbreaks. In order to improve the time to portion of gastrointestinal infections. According to obtain results, we have developed ribotyping that the current published epidemiological report, ente- can be performed independently of the isolation of rocolitis caused by C. difficile was the second most the pathogen (Janezic et al., 2011). The strains within common diagnosis of all infectious diseases among a ribotype are still genetically diverse, so we also hospitalized patients and the most common of inte- introduced typing at the whole genome level, which stinal infectious diseases in 2018. The number of we also use for research purposes. reported cases almost doubled from 2014 to 2018, when there were 668 infections. Slovenia is one of the few countries with well-chara- cterized strains from all reservoirs where C. difficile Within the C. difficile species, strains are classified spores are found, including animals, the environment into different ribotypes, marked with a three-digit and food (Tkalec et al., 2020). This places us at the number according to the international ECDC/Leeds/ top of public health research in the field of C. difficile Leiden classification. The steep increase in infecti- and the One Health approach. ons in Slovenia could be associated with outbreaks or the spread of more virulent types. In Slovenia, the NLZOH has been performing ribotyping of a small set of strains since 2008. During certain periods, strains from all Slovenian laboratories were systematically Rupnik M, Beigot Glaser S, Andlovic A, Berce I, Čretnik T, Drinovec B, Harlander T, Orešič N, Ravnik M, Štrumbelj I. Diversity of C. difficile PCR ribotypes isola-collected. A total of 149 strains from all Slovenian ted from hospitalised patients in Slovenia during two-winter-month period. laboratories were typed for the two-month period Zdravniški Vestnik, 2021; 82(11). Available from: https://vestnik.szd.si/index. php/ZdravVest/article/view/990. December 2011/January 2012. They were classified Janezic S, Strumbelj I, Rupnik M. Use of modified PCR ribotyping for direct into 35 ribotypes, but 57.7% of the strains were classi-detection of Clostridium difficile ribotypes in stool samples. Journal of Clinical fied into just two ribotypes (027 and 014/020). In this Microbiology. 2011; 49(8): 3024-5. doi: 10.1128/JCM.01013-11. period, ribotype 027 was strongly predominant only Tkalec V, Jamnikar-Ciglenecki U, Rupnik M, Vadnjal S, Zelenik K, Biasizzo in north-eastern Slovenia (Rupnik et al., 2021) For M. Clostridioides difficile in national food surveillance, Slovenia, 2015 to 2017. Euro Surveillance, 2020. 25(16): 1900479. doi: 10.2807/1560-7917. 2018, a total of 561 strains of C. difficile were typed, ES.2020.25.16.1900479. which were classified into 76 ribotypes. Despite this apparent diversity, ribotypes 027 (n = 107) and 014/020 (n = 104) were still predominant. Ribotype 027 appeared almost throughout the country during this period, but was not detected by two of the seven laboratories in that year. 127 Monitoring and control of bacterial resistance Helena Ribič The results of research and monitoring of antimicrobial resistance make an important contribution to decisions for the experiential treatment of infections, the rational use of antimicrobials and the control of infections at the regional and national levels. The identification, study and monitoring of National Antimicrobial Susceptibility Testing Com-resistance are important priority areas at the Nati- mittee (SKUOPZ). Annual reports from the SKUOPZ onal Laboratory of Health, Environment and Food have been available online since 2011. The reports are (NLZOH). Within the Centre for Medical Microbio- extensive, and the report for 2017 contains data for logy, seven diagnostic laboratories, a public health 19 bacterial species (Štrumbelj et al., 2017). laboratory and a research microbiological labora- tory are involved in this. Laboratories with data on Laboratories regularly monitor the resistance of bacterial susceptibility participate in ECDC networks bacteria and fungi in individual hospitals and coope- and research, including the European Antimicro- rate intensively with hospitals in the management of bial Resistance Surveillance Network (EARS-Net), resistant bacteria. networks for monitoring Salmonella, Campylobacter, Individual laboratories perform detailed molecular Meningococcus, and in detailed molecular testing of diagnostics of resistance mechanisms in Strep- bacteria for carbapenemases – the European Anti- tococcus pneumoniae, Staphylococcus aureus, microbial Resistance Genes Surveillance Network bacteria with ESBL enzymes, carbapenemases and (EURGen-Net) and others. others. From 2016 to 2019, research for monitoring The coordination of EARS-Net, database editing the resistance of pathogens of uncomplicated uri- and correspondence with the ECDC for Slovenia are nary tract infections was performed through outpa- carried out by the National Institute of Public Health tient clinics at the primary healthcare level (Ribič et (NIJZ). The results from recent years are favourable al., 2019b). for Slovenia and show the success of many activi- ties to limit resistance (Ribič et al., 2019). In 2019, the resistance of monitored invasive bacteria in Slove- Ribič H, Pirš M, Mueller Premru M, Glavan U, the EARS-Net network. Monitoring of resistance trends of invasive bacteria within the EARS-Net network. 11. nia was close to the European average and decrea- Baničevi dnevi – Sepsa in invazivne okužbe, 2019a, proceedings of the profesed statistically significantly in six of a total of eight ssional meeting. In print. bacterial species. The EARS-Net data for 2015 were Cassini A, Högberg LD, Plachouras D, Quattrocchi A, Hoxha A, Simonsen GS, et al. Attributable deaths and disability-adjusted life-years caused by infections the basis for a study by Cassini et al. (2019), which with antibiotic-resistant bacteria in the EU and the European Economic Area estimated that each year in Slovenia 2,280 people in 2015: a population-level modelling analysis. Lancet Infectious Diseas, 2019; 19(1): 56-66. become infected with resistant bacteria, 96 patients die, and patients lose 100 to 120 years of healthy life Štrumbelj I, Pirš M, Berce I, et al. Slovenian National Antimicrobial Susceptibility Testing Committee. Pregled občutljivosti bakterij za antibiotike – 2017. due to infection with resistant bacteria. Available at: http://www.imi.si/strokovna-zdruzenja/skuopz/dokumenti/ skoupz_porocilo_2017_CIP.pdf. NLZOH laboratories, together with other microbio- Ribič H, Dermota U, Štrumbelj I, et al. 2019. Nezapletene okužbe sečil v Slove-logical laboratories, participate in the national moni- niji. In: Pirš M (editor), Maver Vodičar P (editor). Okužbe sečil. Ljubljana: Medi-cinski razgledi, 2019b. toring of bacterial resistance within the Slovenian 128 National system of antimicrobial susceptibility testing Iztok Štrumbelj Until 2010, antimicrobial susceptibility testing in Slovenia took place without national coordination. In November 2010, the Slovenian National Antimicrobial Susceptibility Testing Committee (SKUOPZ) was established. Representatives of all clinical microbiological labo- All SKUOPZ laboratories participate in monitoring ratories participate in the SKUOPZ; the NLZOH with the resistance of important bacterial species with seven diagnostic laboratories, public health labora- nationally established methods, as part of Euro- tories and research microbiological laboratories, and pean projects organized by the ECDC. Since 2010, the Institute of Microbiology of the Medical Faculty in the SKUOPZ Committee has published eight natio- Ljubljana play a key role in the creation of all SKUOPZ nal annual resistance surveillance reports covering guidelines and reports. all isolates of the main bacteria, not just invasive ones; data are for as many as 19 bacterial groups for The SKUOPZ reported on resistance rates in Slovenia all first clinical isolates (Štrumbelj et al., 2017). The for the first time in 2011 on Antibiotic Awareness Day. data complement the EARS-Net data and in addition In 2013, the Committee published national guidelines to the percentages of resistance also report a natio- for the detection of bacteria with the most concer- nal assessment of the burden of the most resistant ning significant forms of resistance, namely broad- bacteria – in 2017, we isolated 3,750 of the first isola- -spectrum beta-lactamases and carbapenemases. tes with significant resistance. These bacteria are especially important as they are resistant to many antibiotics and resistance is usu- The NLZOH actively participated in the development ally acquired on mobile elements. After intensive of the National Strategy “One Health” for the con- one-year preparations, Slovenia switched from Ame- trol of microbial resistance (2019–2024), which was rican to European guidelines for susceptibility testing adopted by the Slovenian Government in September of bacteria to antibiotics; all laboratories apart from 2019, with the action plan for 2019–20211. one hospital laboratory switched to EUCAST gui- delines in April 2014. Since 2020, EUCAST has been used by all laboratories (Štrumbelj et al., 2019). In 2015, the SKUOPZ, together with NAKOBO, issued a uniform national classification of resistant gram-ne- Štrumbelj I, Mueller Premru M, Pirš M. Slovenian National Antimicrobial gative bacteria (definitions and labels for “significant Susceptibility Testing Committee. Osnove antibiograma po smernicah EUCAST [web]. Slovenian National Antimicrobial Susceptibility Testing Com-resistance”), which greatly facilitated the participa- mittee; 2019. Available from: http://www.imi.si/strokovna-zdruzenja/skuopz. tion of microbiologists and staff in the prevention of Štrumbelj I, Pirš M, Berce I, et al. Slovenian National Antimicrobial Suscepti-healthcare-associated infections. The NLZOH has bility Testing Committee. Pregled občutljivosti bakterij za antibiotike – 2017. Available from: http://www.imi.si/strokovna-zdruzenja/skuopz. already partly introduced and is still rapidly introdu- cing the electronic ordering of tests and issuing of results, which shortens the time from the comple- 1_National Strategy “One health” for the control of microbial resistance (2019–2024). Available from: https://www.gov.si/novice/nov-vlada-spreje-tion of an antibiogram to availability of the results in la-drzavno-strategijo-eno-zdravje-za-obvladovanje-odpornosti-mikrobov-health institutions. -2019-2024-z-akcijskim-nacrtom-za-obdobje-2019-2021/. 129 Molecular determination of carbapenemases Andrej Golle Bacteria that produce carbapenemase enzymes are among the major health threats due to their resistance to carbapenems, which are antibiotics with the broadest spectrum of activity. The infections they cause occur mainly in hospitals and pose the greatest threat to seriously ill patients and those in intensive care units. Few antibiotics are available to treat these infections, and infections are associated with higher mortality due to delayed treatment. The problem is global, bacteria with carbapenema- In addition to identifying the carbapenemase type, ses are appearing all over the world and are being typing is also important for international classifica- transmitted between countries by travellers. Early tion of the epidemiological situation regarding the detection and molecular characterization of carba- occurrence of multidrug resistance, which enables penemases are important for immediate action and tracking of the spread of strains through time and for effective containment, especially in healthcare space and thus epidemiological, geographical and facilities. evolutionary research on the spread of isolates. In cooperation with the NLZOH Department of Micro- Carbapenems are β-lactam antibiotics and are usu- biological Research, we conducted a study for 2014, ally the treatment of last resort for infections caused in which we showed the occurrence of carbapenem- by multi-resistant bacteria. However, especially -resistant strains of Pseudomonas aeruginosa from among Gram-negative bacteria, resistance to car-the environment and from clinical isolates (patients' bapenems also occurs, which nullifies their efficacy. isolates) in the Maribor region by typing based on Resistance is the result of various mechanisms, the multilocus sequences (MLST) and comparing whole most important from an epidemiological point of view genomes (Golle et al., 2017). Based on MLST, we iden- being resistance due to the action of carbapene- tified 98 known sequence types and 12 new types. mases, enzymes that break down carbapenems and The data were transmitted to the PubMLST interna- prevent their action (Meletis et al., 2012). tional database. The presence of carbapenemase In order to provide detailed molecular identification, genes was found in 6.5% of clinical strains and in 27% the NLZOH Centre for Medical Microbiology introdu- of environmental strains. Carbapenemase encoding ced and validated methods for determining genes genes were found in three sequential types of P.ae- with coding for many types of carbapenemases. ruginosa (ST111, ST235, and ST654), which also occur These methods regularly confirm the presence of frequently in neighbouring countries (Guzvinec et carbapenemases in those strains of multiresistant al., 2014). bacteria where, based on phenotypic susceptibility testing, the isolate is suspected to be less sensitive or to be resistant to carbapenems. In the years 2019 Meletis G, Exindari M, Vavatsi N, et al. Mechanisms responsible for the emer-gence of carbapenem resistance in Pseudomonas aeruginosa. Hippokratia. to 2020, we confirmed in this way the presence of 2012;16(4):303-7. carbapenemases in 2661 bacterial strains isolated Golle A, Janezic S, Rupnik M. Low overlap between carbapenem resistant from infection samples of 2216 individuals. Pseudomonas aeruginosa genotypes isolated from hospitalized patients and wastewater treatment plants. PLoS One 2017;12(10):e0186736. Guzvinec M, Izdebski R, Butic I, Jelic M, Abram M, Koscak I, et al. Sequence types 235, 111, and 132 predominate among multidrug-resistant pseudomo-nas aeruginosa clinical isolates in Croatia. Antimicrob Agents Chemother 2014;58(10):6277-83. 130 Monitoring airborne pol en Andreja Kofol Seliger, Anja Simčič We monitor allergenic pollen within the National Laboratory of Health, Environment and Food as the only laboratory of its kind in Slovenia. We upgrade the quality of our routine work by developing the profession, informing the public about pollen levels, and offering short-term forecasts, information and tools that help users implement preventive measures and understand allergic diseases. Allergic rhinitis is a global health problem, and pollen the Pollen Diary, intended for users to simultaneou- as an inhalation allergen is one of the risk factors for sly obtain information on exposure and self-assess its occurrence. their health status. The database is also used to evaluate pollen forecasting models developed within The Aerobiology Group within the NLZOH performs the Copernicus Atmosphere Monitoring Service year-round measurements of pollen at the national (CAMS) and the European Centre for Medium-Range level, in accordance with the SIST EN 16868:2019 Weather Forecasts (ECMWF). standard, which defines the sampling and analysis of pollen grains based on Hirst's volumetric method. In the field of invasive species, the greatest emp- hasis is placed on ragweed. An analysis of the mea- Pollen information is intended to help the general surements confirmed the air pollen count gradient in public understand the disease and adhere to preven- a West-East direction, where it reaches the highest tive behaviours. They are published on the NLZOH pollen counts in Europe. We cooperated with the website, where a newly created pollen calendar is Hungarian National Public Health Centre (NPHC) on a also available. It shows information on the average project aimed at creating the Ragweed Pollen Alarm start, duration and end of the pollen season in the System (R-PAS) in the Danube region. area where measurements are made. An important part of the information is short-term forecasts for During the epidemic, we participated in an internatio- the country's continental lowlands and for the coas- nal study on the association between airborne pollen tal area. exposure and SARS-CoV-2 infection (Damialis A. et al., 2021). In cooperation with the Slovenian Environment Agency (ARSO), we publish monthly inspections of pollen levels in their newsletter Naše okolje. We are in a transitional period when new methods for bioa- erosol measurement are gradually being introduced. In connection with ARSO, which is a member of the European Meteorological Services Network (EUME- TNET), we are involved in the AutoPollen programme, which aims to develop guidelines for the transition from manual to automatic bioaerosol measurement in real time. We are involved in COST action CA18226 – New approaches in detection of pathogens and aeroallergens. We cooperate with the Medical University of Vienna, which owns the European Aeroallergen Network Damialis A., Gilles S., Sofiev M., Sofieva V., Kolek K., Bayr D., Plaza M.P., Leier- – EAN, where we send the results of our measure- -Wirtz V., ments. The database is managed, operated and Kaschuba S., Ziska L.H., Bielory L., Makra L., Trigo M., COVID-19/POLLEN study developed by the research unit Aerobiology and group, Traidl-Hoffmann C. 2021.Higher airborne pollen concentrations correlated with increased SARS-CoV-2 infection rates, as evidenced from 31 cou-Pollen Information. This database is also the basis of ntries across the globe. 118 (12) e2019034118; DOI: 10.1073/pnas.2019034118. 131 Food safety as a public health factor Vesna Viher Hrženjak, Barbara Škrjanc, Katja Zelenik, Jernejka Franko, Jerica Ivanoš Healthy foods are one of the basic external factors for maintaining and improving individual health and public health. The National Laboratory of Health, Environment and Food (NLZOH) is involved in food safety processes in Slovenia at all stages of food production, processing and distribution through sampling, laboratory testing, evaluations, suggestions for improvement, awareness raising and research work. Healthy foods are one of the basic external factors In the field of ensuring food safety, we also provide for maintaining and improving individual health professional assistance to food business operators. and public health. For foodstuffs to be healthy, the We participate in the verification of HACCP systems adequacy of their composition in terms of the con- in public institutions, as well as perform chemical and tent of vital nutrients that affect the biological and microbiological testing of foods for various partners. energy value is important, as is food safety. We participate in education and raising awareness among professional public and consumers through Ensuring food safety is one of the strategic activities contributions at conferences at home and abroad as of the NLZOH. As a supporting professional institu- well as at professional meetings, and publications in tion of the Administration for Food Safety, Veterinary various media. We participate in national and interna- Sector and Plant Protection (UVHVVR) and the Health tional research projects in the field of food safety. Inspectorate of the Republic of Slovenia (ZIRS), we are involved in food safety processes in Slovenia at We are distinguished by well-equipped laborato- all stages of food production, processing and distri- ries, high professional qualifications of staff and bution. We participate in the preparation of national a large number of different testing methods. With control programmes, perform food sampling, che- activities accredited according to the SIST EN ISO/ mical and microbiological testing of foods, assess IEC 17025:2017 standard, we ensure internationally food labels and, based on the results, produce con- recognized independence and professional qualifi- formity, safety and risk assessments. We prepare cations, confidence in test results and international annual reports and, in cooperation with the respon- recognition of our issued reports. sible authorities, report data on the methods and results of food testing to the European Food Safety Our work in the field of ensuring food safety contri- Authority. We are the national reference laboratory butes to maintaining and improving public health. for performing sets of chemical tests on foods of plant and/or animal origin (pesticide and PAH residues, heavy metals, mycotoxins, mercury, residues of certain veterinary drugs, dioxins and PCBs, organic phosphorus compounds) and for testing of materials coming into con- tact with food. In addition, we are the appoin- ted official laboratory to perform chemical and microbiological tests on foods of plant and/or animal origin (contaminants, additives, aller- gens, quality and chemical composition) and food sampling. 132 Monitoring of drinking water and the MPV information system Sandra Mertik, Darja Repnik At a time when much of the world is facing water scarcity, the developed world sets the criteria for assessing the characteristics of drinking water that are important to humans. The National Laboratory of Health, Environment and Food (NLZOH) is the provider of drinking water monitoring in Slovenia. The results of monitoring are recorded in the monitoring information system and thus converted into useful information. In the period from 2007 to 2021, we noticed a marked improvement in the quality of drinking water. At a time when much of the world is facing a scarcity of drinking water and risk assessments, and pro- of drinking water, the developed world sets the crite- pose the most appropriate ways to reduce the risk ria for assessing the characteristics of drinking water to human health. that are important to humans. Drinking water is being monitored in Slovenia in accordance with the Rules The results of drinking water monitoring are trac- on Drinking Water (Official Gazette of the Republic of ked in the Drinking Water Monitoring Information Slovenia, No. 19/2004, 35/2004, 26/2006, 92/2006, System (MPV IS). The providers of measurements 25/2009, 74/2015 and 51/2017) in order to protect and testing report the results to the IS MPV thro- human health from the harmful effects of any pollu- ugh their laboratory information systems. All results tion of drinking water. The provider of monitoring is are verified by the system administrator before final the National Laboratory of Health, Environment and entry. The IS MPV enables different ways of querying Food (NLZOH). The drinking water monitoring pro- data and the consistency of results can be checked gramme is prepared annually and defines sampling from different spatial and temporal aspects. This points, sampling frequency, sampling methodology converts the data on the test results into useful and physical, chemical and microbiological tests. information, which was one of the basic principles Drinking water sampling is performed at consu- guiding the update performed in 2012. mers' water taps. Tests determine the presence of Drinking water tests provide important informa- bacteria and various chemical substances, such tion about the state of the environment in which as pesticides, metals, nitrates, drug residues and we live and the water we drink. After many years of others, and we also monitor the content of minerals monitoring drinking water, we can establish that and other microelements. Based on the results, we good quality drinking water is available in Slove- make conformity and health suitability assessments nia. In the period from 2007 to 2021, we noticed a marked improvement in the quality of drinking water. In 2007, bacteria of faecal origin were detected in 20% of samples, while this share is currently 2.2%. Chemical consis- tency of water is achieved in 98% of samples. Monitoring of drinking water is among the factors that have contributed to good results. 133 Quality of ambient air with PM particles in Maribor 10 Uroš Lešnik, Benjamin Lukan Polluted air is the leading environmental cause of premature death in the EU, killing ten times more people than road traffic accidents.1 Effective reduction of pollutant levels requires as much knowledge as possible about the pollutants. We researched this issue in Maribor as part of the PMinter project2 with partners from Klagenfurt and Lipnica in the years 2010–2013. Polluted air has a major impact on the health of Euro- Figure 1 shows the average annual concentrations of pean citizens. For 2018, estimates of the impact of PM10 particles in Maribor. The data show a declining exposure to PM2.5 particles in Europe show around trend, which was interrupted in 2014–2018. The air in 417,000 premature deaths, 55,000 for nitrogen dio- Maribor, at least as far as PM10 particles are concer- xide and 20,600 for ozone3. Certain groups of the ned, was the cleanest in 2020 in the entire measured population (e.g. in urban areas) are more exposed to period 2001–2020. The findings of the PMinter pro- polluted air than others. The negative impact of pol- ject as well as other factors (natural replacement of luted air is also reflected in other areas, such as the older vehicles with newer and cleaner ones, renova- impact on vegetation and on water and soil quality. tion of buildings with insulating façades, replacement Deposition of nitrogen compounds can cause eut- of building fixtures, replacement of obsolete heating rophication, which leads to changes in diversity and devices with newer and cleaner ones), and undou- invasion of new species. btedly the situation due to the COVID-19 epidemic all contributed to this reduction. This work should Measurements of PM particles in Maribor from 2002 10 be continued, as in 2020 the measured levels of PM to 2007 showed that the prescribed limit value was 10 particles are still higher than the WHO recommended exceeded, and the reasons for this situation were value. still insufficiently researched at that time. The main goal of the PMinter project was to develop methods and plans for ambient air quality which would enable permanent improvement of ambient air quality and reduce the health risk for the residents of Maribor, Lipnica and Klagenfurt. The emphasis was on rese- arch of small wood biomass combustion units and their impact on quality with PM particles in ambient 10 air. We showed that the concentrations of PM10 par- ticles can be reduced, but it is necessary to know the detailed situation regarding the contribution of indi- vidual groups of pollutants. Based on this, it is possi- ble to select measures and target them at the most influential sources of pollutants, taking into account Figure: Icons from the graphic image of the programme, which illustrate the local characteristics. Nevertheless, the effective-basic recommendations for protection against UV radiation. ness of measures also depends on the behaviour of individuals and the involvement of national authori- ties. The findings were used in drafting the Ordinance on the air quality plan for the area of the Municipality 1_http://www.mojzrak.si/vpliv-na-zdravje/ of Maribor. 2_Operational Programme Slovenia–Austria 2007–2013, Interreg project: PMinter – interregional impact of measures for protection of ambient air against pollution with particles from road traffic and small combustion units in the border region between Slovenia and Austria. 3_Air quality in Europe – 2020 report, European Environment Agency. 2020 (9). Available from: https://www.eea.europa.eu/publications/air-quality-in-e-urope-2020-report. 134 The role of NLZOH in environmental emergencies Vesna Viher Hrženjak, Emil Žerjal The response of public health institutions to extraordinary environmental events is important for the protection of people’s health in the affected area and, in the case of large-scale events, also of public health. The Mobile Unit of the Ecological Laboratory (MEEL) operates within the National Laboratory of Health, Environment and Food (NLZOH) for the purposes of immediate response. Once the acute danger is no longer present, NLZOH measurements and results form the basis for environmental measures and recommendations for the population. Extraordinary environmental events (fires, floods, environment, depending on the type of emergency. dumping or spillage of unknown substances, indu- Further analyses of the samples are performed in the strial accidents), pose risks to individual health and laboratory. public health in addition to the risk to the environment and wild organisms. They can cause pollution of air, Once the acute threat is no longer present, the water (surface and groundwater, drinking water), NLZOH cooperates with stakeholders in all sectors soil, crops, objects and more. The response of public in environmental remediation measures and the pre- health institutions to extraordinary environmental vention of harmful consequences for the health of events is extremely important for the protection of the population. For the purpose of monitoring the the health of the people in the affected area and, in state of the environment after the event, we perform the case of large-scale events, also of public health. sampling and measurement of various elements of the environment (most often surface and groundwa- At the NLZOH, we actively respond to emergencies in ter, drinking water, soil, crops), perform chemical and several ways. The Mobile Unit of the Ecological Labo- microbiological tests in laboratories and provide esti- ratory (MEEL) operates for the purposes of imme- mates. We have a competent team of experts from diate response. The basic tasks of MEEL are main- various fields involved in deciding when, what, where taining constant readiness, rapid departure to the and how much to sample based on a preliminary risk place of the event, performing field and laboratory assessment, knowledge, literature data and past chemical and biological tests, and taking measure- experience. Our measurements and results form the ments and participating in call-to-action measures basis for environmental measures and recommenda- in the event of natural or environmental disasters tions for the population. and terrorist actions. MEEL is activated by the nati- onal notification centre. In recent years, MEEL has The coordinated work of cross-sectoral experts been activated on average 5 to 10 times a year, most reduces the tendency to sample absolutely eve- often due to the dumping or spillage of an unknown rything (due to requests from different sectors and substance or fire. At the time of an accident, there others) to the optimal number of samples and analy- is most commonly a need to take measurements ses required for risk assessment, preparation of of air pollution (in the case of fires), take measure- measures and proposals for remediation. ments and collect samples of various elements of the 135 Microbiological analyses for public health protection Tatjana Rupel The sanitary microbiological laboratories of the National Laboratory of Health, Environment and Food (NLZOH) analyse food, water and environmental samples. We have a long history, a lot of experience and our mission is to help protect the population from infections caused by inadequate water, food and the environment. We improve our knowledge and methods by participating in research, projects and international expert groups in order to provide fast and reliable results. As part of the unified institute, which was created We offer professional internships to high school stu- by merging the regional Institutes of Public Health in dents and university students, specialisation interns 2014, the NLZOH laboratories have been better con- and trainees. In this way, we help with education and nected, combining knowledge and energy to provide transfer our specific knowledge. a wide range of analyses. We are accredited accor- ding to the ISO 17025 standard and maintain a certi- The laboratories are now focusing their knowledge ficate of good manufacturing practice (GMP), which on solving the problems caused by the epidemic. We allows us to participate in national monitoring and evaluate the suitability of products used to disinfect ensures confidence in our results. As the appoin- hands and surfaces. The risk of infection with legi- ted official laboratory, we participate in the zoonosis onella and other microbiological factors has incre- monitoring programme and undergo supervision by ased due to the long-term closure of catering esta- the Administration for Food Safety, Veterinary Sector blishments and tourist accommodations, therefore and Plant Protection, as well as supervision by the additional monitoring and demonstration of adequ- Health Inspectorate of the Republic of Slovenia. We acy through microbiological analyses is required are a key laboratory to detect infectious pathogens before reopening. and food and water poisoning agents in collaboration Laboratories for microbiological analysis of food, with the National Institute of Public Health. water and other environmental samples are an The laboratories perform more than 400,000 tests indispensable part of prevention, and their work pro- per year for government institutions, industries, the vides the people of Slovenia with the information hospitality sector and individuals. Furthermore, we they need to prevent infections from food, water or participate in several research projects that study the environment. During the epidemic, we proved the appropriate environment in schools, sanitary that we are able to adapt and provide our services drinking water and antimicrobial activity of various even in emergency situations, thus ensuring approp- materials and plant extracts. Cooperation with vari- riate results based on which users decide on safety ous Slovenian and foreign experts provides us with a measures. Our operation will be particularly impor- high level of knowledge. tant in the future as we face the consequences of a changed lifestyle due to the epidemic. As part of the European Microbiology Expert Group (EMEG) for drinking and bathing water we exchange opinions, experiences and knowledge that provide key data for the drafting of EU legislative require- ments. 136 Testing for the presence of drugs Roman Kranvogl Testing is intended for drug users in order to reduce the risk of overdosing and other complications associated with the use of unknown substances. The service of testing illicit psychoactive substances is provided within the project Development and upgrading of a network of mobile units for implementing preventive action and programmes to reduce harm in the area of illicit drugs. Acceptance of samples of psychoactive substances In the stationary laboratory, we use four different is anonymous and is possible at various reception analytical techniques for determining psychoactive points throughout Slovenia. Upon acceptance of the substances: FTIR-ATR spectroscopy (FTIR-ATR), high sample, users are also provided with information on pressure liquid chromatography with DAD analyser drug-related harm reduction and advice on drug-re- (HPLC-DAD), gas chromatography with mass analy- lated problems. ser (GC-MS) and liquid chromatography with mass analyser based on ion transit time (LC-MS-QTOF) Analyses of psychoactive substances are performed to identify new psychoactive substances. The user in the laboratory of the National Laboratory of Health, receives the results of the analysis within a few days. Environment and Food (NLZOH) using appropriate instrumentation, and in a mobile unit in the field. The mobile laboratory consists of three departments. We report on the results of performed analyses and The first department is intended for photographing provide advice and basic information on reducing and weighing samples, the second for sample prepa- the risks of using new psychoactive substances. We ration and the third for the analytical part (FTIR-ATR guarantee the performance of accurate analyses. and HPLC-DAD). The analysis takes 20 minutes from We work continuously to ensure development of the receipt of the sample to issuing the result. service from an analytical point of view. 137 Official quality control of medicines Andrej Golmajer Medicines, which are of particular importance to society as a whole, must demonstrate quality, safety and efficacy before being granted a marketing authorization. The Official Control Laboratory for the quality control of medicines operates within the National Laboratory of Health, Environment and Food (NLZOH). 450 medicines were analysed in 2020. This ensures a high level of quality control of medicines on the market and contributes to the protection of public health. Medicines, which are of particular importance to • collaborative studies of Ph. Eur. monographs; society as a whole, must demonstrate quality, safety and efficacy before being granted a marketing autho- • quality control of medicines authorized under rization. After medicines are placed on the market, the mutual recognition procedure (MRP) or the market surveillance is performed by the Official Con- decentralized procedure (DCP). trol Laboratory to confirm that the quality of a medici- Four types of official quality control of medicines are nes is met and maintained throughout shelf-life. The required by the Medicinal Products Act. The main beginnings of official quality control of medicines in activity of UKL is regular quality control of medicines Slovenia date back to 1955 with the establishment of on the market, which includes sampling of medici- the Institute for Pharmacy and Drug Research in Lju- nes (usually in pharmacies or wholesalers), analyti- bljana, at Ptujska ulica 21, where the Official Control cal testing of medicines and assessment of label- Laboratory (UKL) of the NLZOH still operates today. ling and patient information leaflet. The number of The UKL is included in the European Network of Offi- tested medicines as part of regular quality control is cial Control Laboratories (OMCL Network) at the gradually increasing over the years – 450 medicines European Directorate for the Quality of Medicines were analysed in 2020 – which ensures a high level of (EDQM). The quality of UKL's work is monitored thro- quality control of medicines on the market. ugh periodic audits of the quality system carried out by EDQM. Our work involves independent quality con- Special quality control of medicines, which is carried trol of medicines, which is necessary to ensure the out for each batch of blood products and vaccines, presence of quality medicines for human and veteri- proved to be a very important aspect of the official nary use in Slovenia and the consequent protection quality control of medicines, especially during the of public health. UKL actively participates in the fol- pandemic. This is related to the national release of lowing activities of the OMCL Network, which ensure these types of medicines, the number of which sig- a high quality of work: nificantly increased especially in 2021 due to the • intercomparison studies organized by EDQM; COVID-19 vaccines. In the case of COVID-19 vacci- nes, regular cooperation with the NIJZ and JAZMP • quality control of centrally authorized medicines was necessary to ensure that logistics, national rele- (CAP) available on the European market; ase and vaccination were implemented as quickly as possible. 138 08 MONITORING AND DEVELOPMENT OF HEALTH CARE 8.1 Thirty years of the health care system in Slovenia 8.2 Self-assessment of the Essential Public Health Operations in Slovenia 8.3 Development of a demand projection model for specialist doctors in Slovenia 8.4 Achievements in emergency medical care 8.5 Slovenia primary health care model 8.6 Slovenian health system performance assessment 8.7 National clinical cancer registries 8.8 Monitoring the consumption of prescription medicines in hospitals 8.9 Experience of patients in the Slovenian healthcare system 8.10 The economic burden of public health problems 8.11 National Mental Health Program 2018 - 2028, MIRA Program and mental health centers 8.12 Intersectoral Regional Council for Public Health of Goriška region Thirty years of the health care system in Slovenia Tit Albreht The health care system in Slovenia is a mixed system both in means of ownership and service delivery, formed by public institutions like community primary healthcare centers, public hospitals and public institutes, with the involvement of private concessionaires. Public health measures, implemented in collaboration between public health institutions and stakeholders and the primary healthcare level, have contributed to reducing premature mortality and the burden of lifestyle-related risk factors. Hospital inpatient treatments have become shorter and more intensive and more focused on outcomes, quality, and patient satisfaction. In the last 30 years, the Slovenian state has steered chronic patients, screening for non-communicable the development of the health care system through diseases risk factors and counselling about healthy several planning and strategic documents and chan- lifestyle. ges to the basic health legislation, which outlined the system in 1992. Related to health care organization and financing, a key innovation was the introduction of payment for hospital treatment according to the diagnosis-rela- ted groups (DRG) system. This way, we significan- tly shortened the average length of stay in hospi- tal, which at the time of independence in 1992 was 11.5 days, and has since been reduced to 7.7 days (Zdravstveni statistični letopis, 2019). This shift was underpinned by the financial incentives for daily hospitalizations, i.e., those in which the patient does not stay overnight in the hospital. Institutional public health was transformed by merger of the Institute of Public Health of the Republic of Slo- venia and nine regional institutes of health care into The health care system contributed considerably to the National Institute of Public Health (www.nijz.si) the extension of life expectancy, reaching 81.6 years and the National Laboratory for Health, Environment in 2019, which puts Slovenia at the level of Germany and Food (www.nlzoh.si). and Denmark (OECD, 2019). From the public health Finally, it is worth mentioning the significant scale point of view, the most important changes were up of medical education and nursing education with the introduction of new health education, promo- opening of the second medical faculty at the Uni- tion, prevention and screening programs and public versity of Maribor in 2003 and a number of faculties health measures at the population level (legislation, of health sciences. Despite these measures, Slove- intersectoral health programs and measures to pro- nia still lacks a significant number of key health pro- tect and promote health by addressing health deter- fessionals. minants, and national programs to reduce the burden of selected priority diseases - cancer, diabetes, obe- More information on health system in Slovenia is sity, HIV / AIDS, rare diseases, mental health). With available in the publication Slovenia: Health system the latter, we were able to significantly reduce the review. Health Systems in Transition, 2021; 23 (1): burden of premature mortality, mainly of cardiovas- pp.i-188. cular disease and suicide. This was followed by the successful introduction of three cancer screening OECD/European Observatory on Health Systems and Policies, Slovenija: programs (ZORA, DORA, Svit Program). These public Zdravstveni profil leta 2019, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels, 2019. Available from: https://www. health measures were upgraded with programs oecd.org/publications/slovenija-zdravstveni-profil-leta-2019-62a79a00-sl. addressing the four risk factors related to lifestyle - htm. first through the development of health education Zdravstveni statistični letopis 2019, Available from: https://www.nijz.si/ centres, and in the second decade by introduction of sites/www.nijz.si/files/uploaded/publikacije/letopisi/2019/6.2_bolnisnicne_ obravnave_2019.pdf the so-called reference practices - family medicine practices with additional half-time registered nurse, who is responsible for monitoring well-managed 1_The first Faculty of Medicine was established in the year 1919 at the University of Ljubljana. 140 Self-assessment of the Essential Public Health Operations in Slovenia Pia Vračko, Eva Murko In Slovenia, we have a long tradition of a well-developed public health system. However, despite the remarkable development over the last twenty years, the country has not yet adopted a national strategy for the development of the public health system, as envisaged by the Resolution on the National Health Care Plan 2016-2025. The COVID-19 pandemic has shown that the need to strengthen the public health system in Slovenia is now greater than ever. The Self-assessment of the Essential Pubic Health Operations (EPHO) in Slovenia presents the key findings of the current state assessment and sets out the recommendations for the development of the system that have emerged in this participatory process. Between 2017 and 2019, the Ministry of Health of The uniqueness of the EPHO self-assessment is the Republic of Slovenia, in cooperation with the that it emphasizes the importance of a process that, WHO Regional Office for Europe, the WHO Slovenia with appropriate guidance from managers, triggers Country Office and the NIJZ, conducted a compre- thinking and dialogue and the search for solutions hensive self-assessment of the 10 EPHOs. The eva- within the broadest understanding of the role of luation process was carried out systematically and each EPHO. The result of the process is a set of har- was guided by the tool of the WHO European Region monized recommendations for action aimed at for- (WHO, 2015). Special attention was paid to the areas mulating health policy, as well as promoting improve- of financing public health activities and ofhuman ments and reaching consensus among stakeholders resources development in public health. Over 130 on priorities. The EPHO self-assessment process has experts from various institutions and organizations enabled the development and renewal of partner- performing public health activities were involved in ships at all levels and between different stakeholders the implementation of the process and prepared a to protect and promote health and to promote inve- detailed description of the strengths of the public stment in the health of the population. The results of health system as well as areas to be strengthened or the EPHO process lay the objective foundations on redeveloped (Vračko et al., 2018). which the strategy for the development of the public health system in the Republic of Slovenia will be pre- Posebnost ocenjevanja EPHO je, da v ospredje pared. postavlja pomen procesa, ki ob ustreznem usmer- janju s strani vodij sproži razmišljanje in dialog ter iskanje rešitev v okviru najširšega razumevanja vloge posamezne funkcije. Rezultat procesa je nabor WHO Euro. Self-assessment tool for the evaluation of essential public health usklajenih priporočil za ukrepanje, ki so namenjena operations in the WHO European Region. Copenhagen, WHO Regional Office oblikovanju zdravstvene politike, pa tudi spodbujanju for Europe, 2015. Available from: https://www.euro.who.int/__data/assets/ pdf_file/0018/281700/Self-assessment-tool-evaluation-essential-public-izboljšav ter doseganju soglasja med deležniki o pri- -health-operations.pdf. oritetah. Proces ocenjevanja EPHO je omogočil razvoj P Vracko, E Murko, M Marcoulli, MP Krayer von Krauss, VK Petric, D Sedlakova, in obnovo partnerstev na vseh ravneh in med različ- EPHO self-assessment process in Slovenia (2017 – 2018), European Journal of Public Health, 2018; 28 (4). https:/ doi.org/10.1093/eurpub/cky218.083. nimi deležniki za varovanje in promocijo zdravja ter za spodbujanje vlaganja v zdravje prebivalstva. Rezul- tati postopka EPHO postavljajo objektivne temelje, na katerih bo pripravljena strategija razvoja sistema javnega zdravja v Republiki Sloveniji. 141 Development of a demand projection model for specialist doctors in Slovenia Petra Ogrin Rehberger, Blaž Povž, Stane Marn In cooperation with the Ministry of Health and with international technical support, the National Institute of Public Health (NIJZ) has developed a demand projection model for specialist doctors designed for planning the development of the health workforce. In the model, we focused on the supply of doctors Structural Reform Support Service (SRSS) and the (number of doctors, number of FTEs, retirement), National Institute of Public Health (NIJZ) as the car- demand for health services (number of citizens and rier of activities on the Slovenian side. The NIJZ has treatments by age and gender, regional characte- taken on the task of introducing this model, which is ristics) and gaps (staff shortage or surplus) in indi- based on the expected development of the existing vidual types of healthcare activities by medical spe- supply (both the network of providers and human cializations. Based on the analyses, we prepared the resources) and future demand for health services, results and findings for 25 specializations regarding into regular use for strategic personnel planning the need for doctors for the entire country of Slo- in healthcare. During the process of modelling the venia, as well as for its statistical regions (for the need for doctors, the NIJZ continued with a detai- secondary and tertiary levels of health services) or led analysis of data sources in healthcare, some of for administrative units (for primary healthcare), in which have already been connected and used, while the period from 2020 to 2035. others are still being prepared for use. Projections of the need for doctors are a continuous process based The results of the model-based approach to deter- on the assumptions defined within the project and mining the need for specialist doctors for individual the assumptions that we have identified based on types of health activities and specializations repre- subsequent findings. The model is open to change sent a starting point for discussion and coordination based on population, socio-economic, institutional among stakeholders in the health system (MH, ZZS, and political developments. SZD sections and associations, RSK and ZZZS). We believe that this data will have a signifi- cant impact on the quality of decision- -making on the need for doctors in Slove- nian healthcare. The demand projection model for spe- cialist doctors was developed as part of the two-year project Planning and Mana- gement of the Public Health Service Network. The Ministry of Health imple- mented it between 2017 and 2019 with the help of the European Commission's 142 Achievements in emergency medical care Darko Čander The system of emergency medical care (hereinafter: EMC) represents one of the key elements of a modern healthcare system. It has been proven that an effective system of EMC, in terms of positive economic effects, exceeds several times the costs of the actual operation of the EMC service, and is viewed around the world as extremely cost-effective. In line with the strategies for developing healthcare, specifically the urgent examination unit, observation in the period since the last amendments to the Rules room and triage. on the EMC Service (2008), the EMC network has been updated and enhanced in the following areas: Pre-hospital EMC took into account the public debate of 2015 in maintaining the existing network 1. The construction and organisation of emergency of EMC units and thereby access to health servi- centres at two University Medical Centres and in ces. In agreement with the partners, the Ministry of nine general hospitals. Health secured an increase in funding to enhance 2. Setting up a medical dispatcher service. the network and separate out the work of physicians between individual work sites (work in family medi- 3. Strengthening the primary network and separa- cine clinic, EMC and post-mortem examination ser- ting out the concurrent work of physicians on the vice). Currently activities are underway on arranging primary level. the post-mortem examination service, and we are cooperating actively with the Medical Chamber of 4. Introducing first responders into the EMC system. Slovenia regarding an overhaul of the EMC network, 5. Arranging for healthcare provision at events. which will involve a new definition of the role of the family practitioner within the EMC system. 6. Introducing checks of competence and systema- tic training of EMC units in the area of natural and The medical dispatcher service, established under other disasters. the aegis of the University Medical Centre Ljubljana, has been embedded in the EMC system. It represents Along with the changes, adjustments were also the primary entry point for EMC, and its operation can made to the legal basis for the operation of the EMC affect the outcome of each individual intervention. system, with the issuing of new Rules on the Emer- Setting up and operating the medical dispatcher gency Medical Care Service (2015), Rules on the service in Slovenia signals one step further towards Conditions of Operation of Rapid Emergency Medi- equal access to services and an improvement in the cal Care (2016) and Rules on the Medical Dispatcher quality of EMC services for all inhabitants, an impro- Service (2017). vement in the quality of non-emergency and medical transportation of patients, and an improvement in With the construction of emergency centres there the preparedness of the health system to function in was a need to reorganise the existing system of special and emergency situations. duty services into a single system that offers pati- ents accessible, high-quality and safe treatment of The Ministry of Health drafted and published two key emergency conditions for all inhabitants of Slovenia. documents in this area, the textbook Medical Dispa- At emergency centres, patients are placed at the tcher Service (Fink and Kolar, 2015), which is aimed at centre of attention regarding their state of health, educating personnel to work in dispatcher centres, without any unnecessary prior examinations or con- and Slovenian EMC Index, which is the basic decision- tingencies in caring for emergency conditions on the -making tool for medical dispatchers. Using this tool, secondary level. For the purpose of setting up and medical dispatchers can quickly determine the level organising the operation of emergency centres in of urgency for intervention, and activate an appropri- accordance with the guidelines Single methodology ate type of EMC team, and can also give instructions for organising emergency centres in the Republic or guidelines to a caller over the telephone, until the of Slovenia, the Ministry of Health allocated for pro- EMC team arrives. viders additional funds for financing two activities, 143 First responders, who are activated via the system units was conducted under the system of charging called ReCO 1121, are in practice members of pro- for the services of specific activities. The Ministry of tection and rescue forces, and work within the fra- Health actively embarked on rearranging the system mework of volunteer firefighting societies or other of funding EMC activities, and thus in the period from organisations. In several local environments, good 2015 to 2021 secured additional funds for the deve- practices have been established through the coope- lopment of activities in the amount of almost EUR 40 ration of EMC services with local communities in rapid million. On the primary level, cofinancing of municipa- response in the area of cardiac arrest and activation lities is carried out for those that established health of first responders with automatic external defibrilla- centres, for the procurement of equipment such as tors (AED). Results indicate that this is an important AED, ambulances (46), vehicles for emergency ser- building block in attaining access times and thereby vice physicians (35) and other vital equipment for improving survival rates following cardiac arrest. providing EMC. In the Rules on the EMC Service we systemically Further development of the EMC system will require arranged the area of AED devices in public places. The the short-term addressing principally of challenges Medical Dispatcher Service will keep records. This will which, on the appearance of the epidemic, have poin- serve to facilitate regular and comprehensive moni- ted to systemic deficiencies in the operation of the toring of this substantively important area. system. A key challenge at the moment is the earli- est possible conclusion of investment to include all In accordance with the third paragraph of Article 21 of EMC units in the operation of the medical dispatcher the Rules on the EMC Service the Ministry of Health, system, strengthening the activities of emergency aiming to establish a uniform standard of knowledge centres at hospitals and an overhaul of the network and qualifications of providers of EMC outside hospi- of mobile units and duty stations in Slovenia, with the tals, organises through a selected provider tests of aim of: knowledge for all health workers involved in the EMC service. The testing of knowledge and qualifications • completely eliminating the concurrent work of is substantively separated into a set for testing quali- physicians at several work sites; fications for physicians and a set for graduate health • improving the access of mobile EMC teams and workers and emergency health workers. At the same physicians in special vehicles in the field; time regular annual training is provided for EMC units for cases of responding to major disasters, and tra- • ensuring high-quality responding in the field – of ining for health team responses in the event of radi- the physician to patients in terms of providing ological, chemical, biological and nuclear accidents. urgent medical services at home, including palli- The training has been shown to be very useful, par- ative care, and ticularly so with the occurrence of the SARS-CoV-2 epidemic, where the majority of EMC unit members • ensuring high-quality and comprehensive care were familiarised with the proper use of protective under the EMC system at strategic points (satel- equipment. lite emergency centres). During the crisis and the period of cutting costs, due to the reduction in the prices of services the EMC Fink A, Kolar M. Dispečerska Služba Zdravstva: Učbenik Za Usposabljanje system lost nearly EUR 4 million at the pre-hospital Zdravstvenih Dispečerjev. Ljubljana: Republic of Slovenia, Ministry of Health, level. A similar thing happened in the area of funding 2015. emergency activities in hospitals, which up until the introduction of emergency centres as autonomous 1_ Regional notification centres, which respond to 112 emergency calls. 144 Slovenia primary health care model Pia Vračko, Tatjana Krajnc Nikolić Multidisciplinary, integrated, patient-centred Primary Health Care (PHC) forms the foundation of the Slovenian health system. It is the entry point into the health system and provides universal access to health services to address most of the population’s health care needs in one place, covered by compulsory social health insurance. As such, the model closely resembles the Declaration of Astana vision of »comprehensive, integrated, accessible« care, which is »affordable to everyone and everywhere«, and puts into practice the principle of universal health coverage (UHC). PHC is provided by the network of 63 community services, including cervical cancer screening, prena- health centres (CHCs), complemented by private tal care and family planning. Children from birth until providers – so-called concessionaires – contracted 19 years of age receive preventive and curative health with the Health Insurance Institute of Slovenia. It pro- services from a personal paediatrician in their CHCs. vides access to a wide range of promotional, preven- Preventive health checks include the monitoring of tive, diagnostic, curative, rehabilitative and palliative child growth and development as well as a schedule health services to address the population's health of recommended and mandatory vaccinations. As needs across the life course. It also provides emer- part of a national oral health programme, a paediatric gency medical care. As an entry point into the health- dental practice is situated on the premises of primary care system, PHC has an effective goalkeeping role, schools, and a visiting CHC-based nurse provides giving primary care specialists a good position to repetitive oral health promotion services to children serve as coordinators of their patients' care (WHO, in the first three grades. Innovative approaches to 2020; Johansen, 2020). promoting oral health in children include an annual competition where classes of school children com- PHC services in Slovenia are delivered by multi-pro- pete for having the best oral health in Slovenia. file teams that evidence suggests are needed to effectively care for a population whose burden of Aiming at better managing the burden of chro- disease is dominated by NCDs. Slovenia's multi-di- nic diseases associated with unhealthy lifestyles, sciplinary teams comprise a variety of health profe- health education centers were established in 2002, ssionals including: general practitioners (GPs), who and since 2016 they have been gradually upgraded are specialists in family medicine; paediatricians, to health promotion centers (HPCs)2. HPC is cha- gynaecologists and dentists; community nurses and racterized by multidisciplinary teams of experts, a family medicine nurse, midwives; physiotherapists, programmed way of working and the implementation occupational therapists, kinesiologists, psychologi- of a community approach to health - the »whole of sts, pharmacists, dietitians and other health profe- society approach«. They provide preventive health ssionals. programs, including collaboration with partners in the local community by implementing tailored outre- Adults are registered with their chosen family medi- ach approaches for vulnerable groups. An important cine specialists, where in addition to the treatment activity of CHCs is the implementation of health of acute and chronic medical conditions, performed education programs for various target populations. by physician, graduate nurses perform periodic scre- Community nurses play an important role in preven- ening for the most common chronic diseases and risk tive care, and also provide home care, palliative care factors and monitor well-managed chronic patients1. and long-term care. In addition, CHCs reside some Women have access to a personal gynaecologist at secondary level specialist outpatient clinics, to faci- the CHCs and receive a variety of reproductive health litate access to these services closer to person's 145 home. Large CHCs provide comprehensive outpa- tient health care, from health promotion through program-based health education for all population groups, to early detection of risk factors and their appropriate management, to diagnosis, treatment and rehabilitation. Part of the structural changes to the PHC is the establishment of a national network of mental health centers for children and ado- lescents and for adults, which provide better access to psychological and outpatient psychiatric servi- ces, which in some places complement community mental health services. In 2019, in collaboration with the WHO regional Office for Europe, an analysis of PHC was conducted, which resulted in recommendations to address the system challenges that threaten the sustainability of Slove- nia's impressive PHC achievements. The recommen- dations are the basis for the designing a compre- hensive strategy for the development of primary health care in Slovenia, which is envisaged by the National Health Care Plan 2016-2025. Health promotion and disease prevention at PHC in Integrated, person-centred primary health care produces results: case study from Slovenia. Copenhagen: WHO Regional Office for Europe; 2020. Available Slovenia is based on programs aimed at managing from: https:/ apps.who.int/iris/bitstream/handle/ major public health problems (early detection of 10665/336184/9789289055284-eng.pdf risk factors, health education, community appro- Johansen A S, Vracko, P, West R. (2020). The evolution of community-based ach for health of the vulnerable population groups) primary health care, Slovenia. Bulletin of the World Health Organization, 98 (5), 353 - 359. World Health Organization, 2020b. http:/ dx.doi.org/10.2471/ and immediate action and improving the health of BLT.19.239616 all population groups (including pregnant women, children, adolescents and adults). All programs are 1_The family medicine nurse’s role in primary health care management of implemented uniformly across the country, their fun-patients with non-communicable diseases in Slovenia. https://www.euro. ding is solid, their performance is monitored, and are who.int/__data/assets/pdf_file/0007/441916/case-study-family-medicine- -specialist-nurse.pdf available free of charge to all residents. 2_Health promotion centres in Slovenia: Integrating population and individual services to reduce health inequalities at community level. https://www.euro. Through PHC, Slovenia has achieved UHC in all three who.int/__data/assets/pdf_file/0004/377428/hss-ncd-policy-brief-sloveni-dimensions: service coverage, financial protection a-eng.pdf?ua=1 and population coverage. Particularly, success- ful cooperation between public health and primary health care is an example of good practice for cou- ntries that want to place primary health care as »the cornerstone of a sustainable health system for uni- versal health coverage (UHC) and health-related Sustainable Development Goals (SDG)«. 146 Slovenian health system performance assessment Denis Perko, Blashko Kasapinov In the period 2017–2019, the first assessment of various aspects of the Slovenian health care system was performed. We have developed a framework with clear domains and relevant indicators. It turned out that the Slovenian health care system works well or very well, in certain areas, but radical changes are needed in other areas. This was a positive process that offered us the opportunity to recognize the weaknesses and strengths of the Slovenian health care system. Health care system vary in different countries. One 2055 indicators were considered in the selection of the key tools for evaluating the performance process, and 69 indicators and 26 sub-indicators of the system is the Health System Performance were included in the final list. The results of indivi- Assessment (HSPA), which is increasingly used by dual indicators were presented in graphical, tabular many countries as a means of monitoring the quality, or other form. Each indicator was presented separa- accessibility, efficiency, economy and other impor- tely, followed by a comment. Some indicators were tant areas of the health care system (WHO, 2008; not assessed due to missing data (Figure). WHO, 2000). The year 2016 was chosen as the base year. Accor- In March 2016, Slovenia adopted a Resolution on ding to the indicator, the time analysis was done for the National Health Care Plan 2016–2025 “Together at least 10-15 years, depending on the availability of for a Society of Health”, which recognized the need data. Depending on availability, EU28, EU15, OECD for a more comprehensive approach to monitoring and WHO data were used for international compari- the operation of the health care system. In 2017, an son. application was submitted to obtain funding from the Structural Reform Support Program for the deve- None of the domains were ranked as very good or lopment and implementation of the HSPA. The con- very bad. Four domains (health, quality and safety, tract was signed in the fall of 2017. The project star- efficiency, equality and accessibility) were classified ted running in late October 2017 and ended with the as good, three (resource creation and management, production of a report in the Summer of 2019. responsiveness and focus on the person, health pro- motion and disease prevention) as satisfactory and The objectives set were to develop a framework for two (sustainability of funding, determinants health) the HSPA, to produce the first HSPA report and to as poor. build capacity for the future implementation of the HSPA without additional external support. It can be concluded that the Slovenian health care system is performing well, while facing many challen- The Donabedian model was chosen as the framework ges that call for its adjustments. of the assessment of the health care system. It inclu- des three sets of assessment: inputs, processes, and outputs. It consists of selected domains: deter- minants of health, sustainability of funding, creation and management of resources, health promotion and disease prevention, efficiency, quality and safety, equality and accessibility, responsiveness and focus Tallinn Charter on Health systems for health and wealth. World Health Organisation. s.l.: WHO European Region, 2008. on the person and population health status. The World Health Organization. The world health report 2000: Health systems: domains were mapped to the model according to the improving performance. Geneva: World Health Organization, 2000. three sets. 147 National clinical cancer registries Vesna Zadnik, Katarina Lokar, Ana Mihor Clinical cancer registries enable the monitoring of indicators to evaluate the quality of care for cancer patients. In Slovenia, within the population-based Slovenian Cancer Registry national clinical registries are being set up for skin melanoma, lung, breast, colorectal and prostate cancer. A national clinical registry for childhood cancer is also being established for surveillance of late effects of cancer treatment in childhood. Short- and long-term monitoring of quality of care data; in particular, it already has a system in place for indicators for cancer patients is only possible if pre- obtaining a core set of data on cancer patients and cise and detailed data on the type of disease, method the legal basis for its operations. of diagnosis, treatment procedures and response to treatment are available. These data are gathered in Clinical registries allow for ongoing monitoring of what are called clinical registries. Data on diagnosis, quality indicators in the diagnosis and treatment of treatment and disease progression are quite sparse common cancers throughout the entire cancer pati- in population-based cancer registries. ent pathway, from diagnosis to treatment. They also monitor compliance of treatment with current guide- The National Cancer Control Plan 2017−2021 envisa- lines, the number of annual treatments by individual ged the establishment of national clinical registries providers, treatment complications, survival and so for breast, prostate, colorectal, lung cancer, and skin forth. The analysed data provide invaluable feedback melanoma. These are the five most common cancers to clinicians, allowing them to identify and correct which account for more than half of all cancers in the systemic deviations, as well as to verify that the set Slovenian population. Stepwise establishment of the criteria for the network of oncology centres are met. five clinical registries was planned. The national Cli- nical Registry of Skin Melanoma was set up in 2017; it was for skin melanoma that a professional consensus was reached first on the set of data that should be recorded to monitor the quality of care. In 2019, the national Clinical Registry of Lung Cancer was esta- blished, and in 2021 the remaining three are being set up – breast, colorectal and prostate cancer regi- stries. Parallel to this, a national Childhood Cancer Clinical Registry is being established to monitor and prevent late effects of cancer treatment in childhood and adolescence more effectively and systematically at the individual level. The Slovenian national clinical cancer registries are set up as part of the population-based Slovenian Cancer Registry, which already has population- and health system-specific knowledge on the collection, Figure: First report by the national Clinical processing, storage and analysis of cancer patient Registry of Skin Melanoma. 148 Monitoring the consumption of prescription medicines in hospitals Tatja Kostnapfel In accordance with the Databases Act and in addition to the already established collection of data on the consumption of medicines prescribed on green and white prescription forms, the National Institute of Public Health (NIJZ) has also begun the systematic collection of data on the consumption of medicines prescribed in all hospitals. The report was supplemented with the consumption of expensive hospital medicines (List B) and the consumption of ampoules and other medicines for outpatient treatment within the framework of materials that are billed separately (List A). In this way, we established a comprehensive overview of the consumption of prescribed medicines. Appropriate prescribing of medicines, which takes The analysis of medicines is prepared in three sets into account both professional and economic factors, – separately for general, specialized and psychiatric has an important social role, and constant monito- hospitals. ring of the consumption of medicines contributes to the more responsible handling and proper use of The Anatomical Therapeutic Chemical (ATC) Classi- medicines. This is one of the areas of public health fication System is used to monitor the prescribing of whose long-term objective is to prevent disease, and medicines. The consumption of medicines is shown to protect and improve health as well as raise the as the number of defined daily doses (DDD) and the quality of life. Monitoring and analysis of data on the number of defined daily doses per 1,000 inhabitants consumption of medicines in accordance with the per day (DDD/TID) at the five levels of the ATC classi- Databases Act in the field of healthcare for national fication (WHO, 2020). purposes is being carried out by the National Insti- The Resolution on the National Healthcare Plan tute of Public Health (NIJZ) as an independent orga- (ResNPZV) 2016–2025 “Together for Healthy Soci- nization by using two databases, specifically NIJZ 64 ety” plans to ensure the correct and safe use of medi- – Register of Consumption of Prescription Medicines cines and equal access to quality and safe healthcare and NIJZ 66 – Register of Hospital Use of Medicines for all, along with comprehensive treatment taking (Official Gazette of the Republic of Slovenia, 2020). into account the health needs of the ageing popula- The main purposes of the analysis of data on the tion, user orientation and user empowerment while consumption of medicines are to provide informa- maintaining cost-effectiveness. Various measures tion on the supply of medicines and on morbidity, to based on this resolution ensure the rational use of draw attention to the role of responsible prescribing medicines and better access to quality pharmaceu- of medicines, and promote the efficient use of reso- tical care. urces. Monitoring of data is also the basis for moni- With the support of a comprehensive analysis of toring and planning of the healthcare system. The prescribing and dispensing of medicines, we also information obtained through the analysis of data on ensure the optimization of prescribing of medicines. consumption of medicines is also useful for identi- fying which groups of patients are prescribed parti- cular medicines, which can also be used to evaluate the adequacy of therapeutic guidelines. The NIJZ has also established a system for monito- Healthcare Databases Act. Official Gazette of the Republic of Slovenia, 2000; ring the consumption of medicines in hospitals on 65/00, 31/18). the basis of data provided by 30 hospitals, of which Guidelines for ATC classification and DDD assignment. WHO Collaborating Centre for Drug Statistics Methodology, 2020 Oslo: WHO Collaborating 26 are public and three are publicly funded private Centre for Drug Statistics Methodology. Available from: https://www.whocc. hospitals (Diagnostic Center Bled, Surgical centre no/atc_ddd_index_and_guidelines/guidelines/. Rožna dolina, Medicor), along with the public health Resolution on the National Healthcare Plan 2016–2025: “Together for a Healthy Society”. Official Gazette of the Republic of Slovenia No. 25/2016. institution Youth Climatic Health Resort Rakitna. 149 Experience of patients in the Slovenian healthcare system Eva Murko, Marcel Kralj, Nina Ropret The experience of patients with medical treatment is becoming increasingly recognized as an important indicator of the quality of healthcare in developed societies. Political documents and commitments in Slovenia also emphasize the importance of patient-centred healthcare. The National Institute of Public Health has, since 2019, been conducting national surveys on patient experience at the secondary and tertiary levels of healthcare. The experience of patients with medical treatment results at the level of the outpatient clinic, the clinical PREMs (Patient Reported Experience Measures) is activity and at the level of Slovenia (Figure 1). Based becoming increasingly recognized as an important on the results, they were able to introduce improve- indicator of the quality of healthcare –– and is often ments in the quality of health services, as well as of mentioned in national and international health poli- their equipment, inventory, etc. Both PREMs surveys cies in developed societies (Gleeson, 2016; Klazinga were very well received by most providers. and Fujisawa, 2017). A PREMS website was created on the web portal of Between 2006 and 2012, the Ministry of Health con- the National Institute of Public Health (NIJZ) – My ducted a national survey on the experience of pati- Experience, Our Healthcare: Survey on the Experi- ents in acute and psychiatric hospitals in Slovenia. ence of Patients with Medical Treatment (https:// In 2017–2019, the National Institute of Public Health www.nijz.si/sl/prems), which offers the visitor key (NIJZ) participated in a project of developing and information about PREMs surveys. upgrading tools and building capacities for monito- ring the experience of adult patients in outpatient In 2020, the NIJZ repeated the national survey in spe- specialist care and acute hospital care with providers cialist outpatient clinics, but this time for other clini- involved in the public health system network. As part cal activities. We are also conducting both surveys in of the project, the first national surveys were con- 2021. With the implementation of this type of rese- ducted in 2019 in specialist outpatient clinics and in arch, Slovenia ranks among those advanced coun- acute hospitals. The survey in specialist outpatient tries that have a developed system for monitoring clinics was responded to by over 8,000 patients, who healthcare from the point-of-view of patient experi- had visited 149 specialist outpatient clinics perfor- ence. ming six different types of healthcare activities. The clinics were rated with an average score of 9.25 on a scale of 0 to 10. Based on these results, Slovenia will be able to report patient experience indicators for the Gleeson H. Systemic review of approaches to using patient experience data first time in the OECD publicationHealth at a Glance for quality improvement in healthcare settings. BMJ Open 2016; 6: e011907, doi: 10.1136. for the year 2021. Based on the data from other OECD Klazinga, N. and R. Fujisawa , “Measuring patient experiences (PREMS): Pro-member states published in the same publication for gress made by the OECD and its member countries between 2006 and 2016”, 20193, we estimate that Slovenia's results are slightly OECD Health Working Papers, 2017:102.http:/ dx.doi.org/10.1787/893a07d-2-en. above the average of countries that report such data to the OECD. OECD. Health at a glance 2019, OECD Indicators. Dostopano 7.6. 2021 na nas-lednji spletni strani: https://www.oecd.org/health/health-systems/health-at- -a-glance-19991312.htm. Healthcare providers have received an individualized document reporting the quantitative and qualitative 150 The economic burden of public health problems Sabina Sedlak The National Institute of Public Health (NIJZ) assesses the economic burden of certain diseases and health conditions using a methodology of direct and indirect costs. The purpose of the calculation is to provide information on how much a certain disease or health condition burdens the healthcare system, and to highlight the importance and cost-effectiveness of investing in prevention. This can reduce the incidence of premature retirement and death and improve the quality of life for both the individual and Slovenian society as a whole. Public health problems such as risky and harmful Period 2015–2017 (https://www.nijz.si/sl/publikacije/ alcohol consumption, smoking, suicidality, and con- ekonomske-posledice-demence-v-sloveniji-v-ob- ditions such as dementia, musculoskeletal and con- dobju-2015-2017), are intended for all residents of nective tissue diseases represent a major burden Slovenia, and particularly for the professional public, on health systems. The reports, which were created as each public health problem is also presented from in cooperation with the Faculty of Economics of the the financial point of view. Research on the cost of University of Ljubljana, have been prepared at the disease in other countries also shows what a country National Institute of Public Health since 2017. Data gains from managing to reduce the incidence or eli- used for the analysis of the economic and social con- minate a particular disease or health condition. Early sequences of diseases and health conditions are detection and identification of certain diseases, war- obtained from the databases of the National Insti- ning of risky behaviours and the dangers of alcohol tute of Public Health (NIJZ) and from the Pension consumption and use of tobacco products, suppor- and Disability Insurance Institute (ZPIZ). All burden ted by financial data, contribute to raising awareness estimates are based on the calculation of direct and and the better understanding of public health goals indirect cross-sectional costs incurred within one aimed at improving the quality of life of individuals year. Direct costs are related to medical treatment, and Slovenian society in the future. while indirect costs are related to loss of produ- ctivity due to absence from work and loss of future earnings or income due to premature retirement. Various cost analyses, such as the report titled Eco- 1_Available from: https://www.nijz.si/sl/publikacije/ekonomske-posledice-de-nomic Consequences of Dementia in Slovenia in the mence-v-sloveniji-v-obdobju-2015-2017 151 National Mental Health Program 2018 - 2028, MIRA Program and mental health centers Jožica Maučec Zakotnik, Mojca Zvezdana Dernovšek In March 2018, the Parliament of the Republic of Slovenia unanimously adopted the Resolution on the National Mental Health Program 2018-2028 (NPDZ18-28), which sets out a development strategy for mental health care in Slovenia. The national program is called MIRA Program. In the first action plan of NPDZ 18-20, we focused mainly on establishing a network of mental health centers (CDZ) in order to increase accessibility to mental health services at the primary level of health care. The MIRA Program is action-oriented, it responds The MIRA program envisages the establishment of to key mental health challenges and fills gaps in the 25 Mental Health Centers for Adults (CDZO) and 27 mental health care system. Mental Health Centers for Children and Adolescents (CDZOM). CDZs represent major advances in com- The identified mental health challenges are: munity and outpatient care, provided by a multidisci- • to introduce community approaches to mental plinary team of professionals, and are designed for health care in the local environment geographic areas with a certain population size. They • to establish supportive environments for mental provide local access to assistance and connect with health and introduce preventive and promotion various stakeholders within the network of mental programs to support mental health in all envi- health services with the aim of integrated and con- ronments tinued care for people with mental health problems. During the first action plan, we exceeded the origi- • to reduce the number of suicides and provide nally planned number of 3 CDZO and 3 CDZOM and support to those who have attempted suicide and established 11 CDZOM and 10 CDZO. their relatives The COVID-19 epidemic has increased mental health • to improve the availability of care at the primary problems for the entire population, and especially for level of health care children and adolescents. To address the urgently increased need for hospitalizations of children and • to support deinstitutionalisation in the field of adolescents with mental health problems during the mental health COVID-19 epidemic, we established, in cooperation • to reduce stigma and discrimination and to incre- with the Ministry of Health, additional hospital beds ase mental health literacy and a day hospital. • to ensure the quality of programs and services, In order to increase the availability of assistance in monitoring, evaluation, research and develo- 2021, the CDZ network with additional 10 CDZOM (a pment in the field of mental health care total of 21 out of 27 required) and 4 CDZO (a total of 14 out of 25), which include existing mental health Activities aimed at strengthening mental health and dispensaries and mental health specialists already prevention in the first action plan NPDZ18-20 were working in community primary healthcare centers. not carried out to the planned extent due to lack of Currently, most CDZs operate with minimal teams. support from decision-makers and financial reso- In order to achieve standard interdisciplinary teams urces and the outbreak of the Covid-19 epidemic, in CDZ, it is necessary to accelerate the provision of which greatly changed priorities. However, we exce- staff with clinical specialization, which can be achie- eded the plan in the number of established CDZs. ved by increasing the number of spec ializations and redeploying staff from psychiatric hospitals to CDZ. Health education/ health promotion centres Adult mental Social work Primary healthcare Community- health centre centres based treatment coordinators Mental health centre for children and Emergency adolescents Anti-stigma service Mental health advocates Indivtiduals Psychiatric and families hospitals, in the subpatient teams community Community- based social care programmes Protocols of Family- cooperation Institutional support NIJZ care programmes Figure 2: Mental health Local Counselling Professional Figure 1: Map of the network communities, services at User-run services at services network. associations education associations residential and institutions counselling centres 152 Intersectoral Regional Council for Public Health of Goriška Marko Vudrag On 10 May 2010, the Intersectoral Regional Council for Public Health (Medregijski svet za javno zdravje, MRSJZ) was established at the Institute of Public Health, which was the predecessor of the current Nova Gorica Regional Office of the National Institute of Public Health (NIJZ). It is an informal and voluntary association of repre- enables the target populations, especially vulnerable sentatives of public and non-governmental sta- groups, to be reached effectively through prevention keholders in the region (healthcare, local self-go- programmes and campaigns. We have also prepared vernment, education, sports, culture, social work an Implementation Plan For The Reduction Of Health institutions, development agencies, business, NGOs, Inequalities, so that in 2011 the Strategy for the Redu- disability organizations…), where twice yearly dis- ction of Health Inequalities by Strengthening Health cussions are held on critical health and social issues, in the Goriška Region was created. Our methodologi- as well as related topics that are important to the cal approach is an example of good practice in cross- local community. At the first meeting, we defined the -sectoral cooperation – Health in all policies. This is purpose, objectives, tasks and methods of monito- one of the reasons why we in the Goriška region have ring and reporting on the measures that would be been successful in three screening programmes for adopted in consensus with the decisions made at early detection of cancer (ZORA, DORA, Svit) – as a later meetings. The basic objectives of the Council region we have the best results in the country. Nota- are: 1) to emphasize the importance of the horizon- ble successes in preventive health were also achie- tal integration and (co)operation of all stakeholders ved with the Healthy Schools project. We have carried in society to strengthen health, 2) to establish joint out numerous public campaigns, including events programme cooperation to reduce public health pro- and the public signing by all 13 mayors of several con- blems in the region, such as the rise of cancer and crete collaborations in the implementation of public chronic diseases, and 3) to raise public awareness of health activities. the importance of prevention and establish a working group to prepare a regional strategy to reduce health The operation of the MRSJZ is of great strategic inequalities. importance for the planning of sustainable develo- pment at the regional level, as cross-sectoral health- In the previous period, we organized 18 meetings of care, together with investment in health and health- the MRSJZ, and the 19th meeting will follow in June care, makes an important contribution to economic, 2021, at which we will reflect on the broader social and social and environmental development. Such colla- health effects of COVID-19. The MRSJZ meetings are borations and innovative bottom-up approaches are attended by representatives of many departments also valued as examples of good practice by interna- and organizations in the region, not only representa- tional standards. tives of the health and social departments, because a network of stakeholders with predefined activities 153 09 NGOs IN PUBLIC HEALTH 9.1 NGOs in public health NGOs in public health Kerstin Vesna Petrič, Samra Mušić In the developed world it is already a tradition that NGOs cooperate in carrying out public health activities. They operate in sensitive areas in which the state’s measures, for various reasons, cannot fully or appropriately meet people’s needs. NGOs are the first to recognise the consequences of social and other changes for the well-being of individuals, populations and social groups, thus drawing attention to them and being the first to react. By means of public tenders, the Ministry of Health Co-financed programmes are being carried out co-finances programmes in different areas of public across the entire country and cover all fields of public health such as preventing addiction to illegal and health. The programmes involve different population legal drugs and non-chemical addictions; improving groups with different needs, often including the most mental health; empowering and raising awareness of vulnerable population groups. patients with chronic noncommunicable diseases; the environment and health; nutrition and physical Here are some examples of the operation of NGOs activity; preventing and controlling infections with and public institutions in the field of public health: HIV and other sexually transmitted diseases; and 1. The Incredible Years programme is carried out by preventing infectious diseases by promoting vacci- Javni zavod Mala ulica (public institution) in coopera- nation. tion with the Paediatric Clinic. The programme helps By co-financing the activities of NGOs in the field young parents who have children aged between 3 of health, the Ministry also ensures additional and 9 years who have problems growing up. employment, above all for young experts in the field 2. The Slovenian Union of Autism NGOs, the ASPI of public health and others who are interested in Association, društvo ASPI, offers support and help this field of work. In this way we have improved the to parents and children with autism or other special expertise of programme providers in the field of needs. public health and enabled constructive cooperation between professionals and civil society. New tools 3. The Advisory Centre for Children and Ado- have been created such as mobile applications to lescents treats children and adolescents experien- support the promotion of a healthy way of life, nume- cing mental health problems together with psycho- rous consultations and trainings have been carried logists and psychiatrists. out, campaigns to raise awareness have been organi- 4. The Centre for Psychological Counselling, sed and guidelines for work with different population Posvet, offers psychological advice to individuals, groups have been prepared. couples and families experiencing emotional distress In 2019 the first national conference took place at and needing expert help. which NGOs and public institutions operating in 5. Beli Obroč Slovenije – the Association for public health programmes, both locally and on a nati- Assistance to Victims of Crime offers support to onal level, were presented according to their field of victims of violence and psycho-social and legal help activity, and this showed that the greatest strength to victims of crime. of NGOs in the field of health is their involvement in the local environment and their ability to adapt rapi- 6. Društvo UP, Projekt Človek, and ŠENT are associ- dly to the needs of people where they live. ations that offer advice to parents and young people who are having problems connected to illegal drug This form of operation gives good results. In recent use. years, many NGOs that are co-financed by the Mini- stry have received international awards and reco- 7. IZRIIS, IPoP, the Slovenian Association for Public gnition for their projects and programmes, including Health, the Environment and Tobacco Control, from the European Commission and the WHO. Some Mladinsko združenje Brez izgovora (No Excuse), projects have also been listed as examples of good ARS VITAE, Association for Preventive Work, UTRIP, practice on an EU level. Zavod 7, Zavod Etnika, Društvo Vesela kuhinja, Inštitut ROK, the Association of Slovenian Socie- 157 ties of Cured Alcoholics, ISA Inštitut, the Federa- -raising in the field of chronic non-communicable ill- tion of Slovenian Anti-Cancer Societies, Slovenian nesses and provide support for patients with chronic Diabetes Association, University of Primorska, illnesses. Associations of Bonding Psychotherapists, NIJZ, Higher School of Applied Sciences, Debeli Rtič 13. Kralji Ulice, Anton Trstenjak Institute, Društvo Youth Health and Holiday Centre, Diabetes Edu- Stigma, Društvo Žarek Upanja, Zavod Vozim, Zavod cation Institution, and Slovenian Caritas are only Varna pot, ZA SRCE, Zavod NORA, Zavod Etnika, some of the NGOs and public institutions organising Center Šteker, ABSTINENT – the Association for workshops for children in schools to raise awareness an Ordered Life, Association of Slovenian Bon- about a healthy lifestyle and the risk factors they are ding Psychotherapists, and Association of Slove- exposed to. nian Societies of Cured Alcoholics, Vesele nogice, Humanitarno društvo Reto center - prijatelj upanja, 8. Slovenian Caritas Maribor and various youth MAKROBIOS PANONIJA so. p., Permakulturni center associations (IMZTR, BREZ IZGOVORA, eMC PLAC, za boljšo kvaliteto življenja in za pot k samozado- DrogArt, SKAVTI) prepare and carry out healthy life- stnost organise programmes to prevent and reduce style workshops for young people outside the school the use of illegal and legal drugs and non-chemical environment in organised groups of young people. addictions to address the needs of the most vulne- This is mostly a peer-to-peer approach, which rable groups that usually do not ask for help from demands the training of a certain number of young health institutions, but due to different life stories people. and problems rather look for help elsewhere. 9. Legebitra, ŠKUC, DIH, and the Association of 14. Društvo Zdrava pot and the STOPINJE INSTI- Medical Students implement activities for the pre- TUTE for logotherapy, mediation, education and vention of infection with HIV, hepatitis and sexually research help to female illegal drug addicts and their transmitted diseases, including work with hidden children (the Zdrava pot association) and implement groups such as men who have sexual relations with programs for detainees and their children, partners men, and drug addicts. Slovenia is one of the rare and family. countries not to have suffered an AIDS epidemic. 15. The Slovene Consumers’ Association, Slovenian 10. The Association of Medical Students organi- Society for Cardiovascular Health, Nutrition Insti- ses activities to increase the number of vaccinated tute, Društvo Vesela kuhinja, Urban Planning Insti- people in Slovenia and to promote vaccination. It tute of the Republic of Slovenia, Institute for Spatial regularly cooperates with NIJZ. Policies, Jožef Stefan Institute, School of Health Association, Association for a Culture of Inclu- 11. The Association of Friends of Youth Moste-Polje, sion, Caritas of the Archdiocese of Maribor and the ZRC SAZU, and the Association for Perinatal Medi- Chamber of Commerce and Industry of Slovenia, cine implement counselling programmes for couples, UNICEF, Slovenian Red Cross – Federation individuals and families in distress. of Associations prepare programmes above all 12. The Cancer Patients Association of Slovenia, to raise awareness about a healthy diet and physical Europa Donna - Slovenian Association Against activity amongst different population groups – chil- Breast Cancer, Slovenian Association of Patients dren, young people, adults and the elderly. with Lymphomas and Leukaemia L&L, EuropaCo- 16. The Institute of Oncology, Slovenian Associ- lon Slovenija Association, Slovenian Osteoporosis ation for Clinical Nutrition, Novo Mesto General Association, Association of Slovenian Coronary Hospital and the Clinical Department of Haemato- Societies and Clubs, Federation of Slovenian Anti- logy UMCL operate in the field of patient and clinical -Cancer Societies, Društvo League Against Epi- nutrition. lepsy, Association Against Cancer and Other Chro- nic Illnesses ko-RAK.si, ”Trepetlika” Parkinson’s 17. IMZRT, UIRS, and the Adult Education Centre Disease Society of Slovenia, Emonicum Institute, Ormož carry out programmes for the cooperation Slovenian Celiac Disease Association, Slovenian of young people who are active in the fields of envi- Diabetes Association, Centre for Health and Deve- ronment and health on the basis of the Strategies lopment Murska Sobota, Sinapsa, Association for of the Republic of Slovenia for the health of chil- Chronic Inflammatory Bowel Disease, Institute for dren and adolescents in connection with the envi- Research, Education and Sustainability Develo- ronment 2012–2020 and the implementation of the pment Celje, Chamber of Nursing and Midwifery of Ostrava Declaration (Better Health and a Better Envi- Slovenia, Slovenian Stroke Support Society imple- ronment). ment programmes of empowerment and awareness- 158 List of co-financed NGOs and public institutions 2019–2022 Ord. Organisation No. 1. "Trepetlika" Parkinson’s Disease Society of Slovenia 2. "UP" Association Helping Addicts and Their Families 3. ARS VITAE - Society for the Development and Implementation of Programmes 4. Beli obroč Slovenije, Association Helping Victims of Crime 5. Centre for Health and Development Murska Sobota 6. Centre for Psychological Counselling, Posvet 7. ASPI ASSOCIATION Association Helping Adults with an Autism Spectrum Disorder - Asperger’s Syndrome 8. Društvo DIH - equal under the rainbow 9. Društvo Ključ - the Centre Working Against Human Trafficking 10. Association for culture, information and counsel ing, Centre LEGEBITRA 11. Društvo League Against Epilepsy 12. Cancer Patients Association of Slovenia 13. Društvo Projekt Človek 14. Društvo ŠKUC 15. School of Health Association 16. Association of Medical Students Maribor 17. Society of Medical Students of Slovenia 18. Društvo Vesela kuhinja 19. Association Against Cancer and Other Chronic Il nesses ko-RAK.si 20. Chronic Inflammatory Bowel Disease Association 21. Association for a Culture of Inclusion 22. Youth Association IndiJanez (Šteker Center) 23. Association for the Help and Self-help of Homeless People Kralji ulice 24. Association for Help and Self-help in Addiction Zdrava pot 25. HAPPY FEET Association for Care of Persons with Developmental Disorders 26. Association for Preventive Work 27. ABSTINENT - Association for an Ordered Life 28. Slovenian Society for Cardiovascular Health 29. Stigma - Association for the Reduction of Harm due to Drug Abuse, 30. Association Ray of Hope 31. Europa Donna - Slovenian Association Against Breast Cancer 32. Chamber of Commerce and Industry of Slovenia - Chamber of Agricultural and Food Production Companies 33. Humanitarian Association Reto Center - Friend of Hope 34. Jožef Stefan Institute 35. Anton Trstenjak Institute for Gerontology and Intergenerational Coexistence 36. Emonicum Institute, Institute for an Active and Healthy Life 37. INSTITUTE STOPINJE for Logotherapy, Mediation, Education and Research 38. Institute for Youth Participation, Health and Sustainable Development (IMZTR) 39. Nutrition Institute 40. Institute for Research and Development “Utrip” 41. Institute for Developing Personal Quality - ROK 42. IPoP – Institute for Spatial Policies 43. ISA institute - Institute for Psychological Counsel ing and Educational Development Projects 44. Public Institute Mala ulica - Centre for Children and Families in Ljubljana Figure 1: List of co-financed NGOs and public institutions 2019–2022 159 45. Clinical Department for Haematology, UMCL Ljubljana 46. Adult Education Centre Ormož 47. MAKROBIOS PANONIJA so. p., Permaculture Centre for a Better Quality of Life and the Path to Self-sufficiency 48. Youth Network no Excuse Slovenia 49. Debeli Rtič Youth Health and Holiday Centre 50. National Institute of Public Health – NIJZ 51. Caritas of the Archdiocese of Maribor 52. Institute of Oncology 53. Union of Slovenian Red Cross Associations 54. SiNAPSA, Slovenian Neuroscience Association 55. Slovenian UNICEF Foundation 56. Slovenian Caritas Maribor 57. Slovenian Association for Public Health, the Environment and Tobacco control – SZOTK 58. Slovenian Celiac Disease Association 59. Slovenian Association of Patients with Lymphomas and Leukaemia, L&L 60. Slovenian Association for Clinical Nutrition (SZKP) 61. Slovenian Suicide Prevention Association 62. Slovenian Association for Reducing the Harmful Consequences of Drug Abuse – DrogArt 63. Novo Mesto General Hospital 64. Counselling Centre for Children, Adolescents and Parents Ljubljana 65. ŠENT - Slovenian Asociation for Mental Health 66. University of Primorska (UP IAM) 67. Urban Planning Institute of the Republic of Slovenia 68. VARNA POT Institute for Help for Road Accident Victims, Prevention, Education and Training 69. Higher School of Applied Sciences Ljubljana, Independent Higher Education Institution 70. VOZIM - Institute for Innovative Education 71. ZAVOD 7, Design and Implementation of Socially Responsible Programmes Nova Gorica 72. Zavod eMCe plac, Zavod mladine šaleške doline 73. Zavod Etnika 74. Zavod IZRIIS 75. Zavod Nora, Centre for Modern Addictions (LOGOUT) 76. NewPrevent Institute for Education and Prevention 77. Diabetes Education Institution 78. Institute for Research, Education and Sustainable Development Celje 79. Nurses and Midwives Association of Slovenia - Union of Professional Associations of Nurses and Midwives of Slovenia, Section for Nurses in Endocrinology 80. Slovenian Stroke Support Society 81. Associations of Bonding Psychotherapists 82. Slovenian Catholic Girl Guides and Boy Scouts Association 83. Association for the Fight Against Colorectal Cancer – Europacolon Slovenija 84. Research Centre of the Slovenian Academy of Sciences and Arts 85. Slovenian Osteoporosis Association 86. Slovenian Diabetes Association 87. Association of Slovenian Societies of Cured Alcoholics 88. Association of Slovenian Coronary Societies and Clubs 89. Association of Slovenian Autism NGOs 90. Slovenian Consumers’ Association 91. Slovenian Association of Friends of Youth Ljubljana Moste-Polje 92. Federation of Slovenian Anti-Cancer Societies Figure 1: List of co-financed NGOs and public institutions 2019–2022 160 10 SLOVENIA'S CONTRIBUTION TO INTERNATIONAL HEALTH AGENDA 10.1 Membership of the World Health Organization Executive Board 10.2 Coordination of European cancer projects Membership of the World Health Organization Executive Board Kerstin Vesna Petrič Since becoming an official member in 1992, the Republic of Slovenia (RS) has established a long-standing successful and constructive cooperation with the World Health Organization (WHO). The international community’s acknowledgement of Slovenia’s efforts in fulfilling the vision and commitment to attaining more just, sustainable and responsible development in confronting the challenges now facing humanity in the field of health is also reflected in the election of Kerstin Vesna Petrič as a member of the WHO Executive Board for the period 2021–2023. This is a prestigious and respected function in one of the most senior decision-making bodies of the WHO, which allows a country to cooperate directly in deciding about the WHO’s priority fields of work, and indirectly contribute to the work of this international organisation. Cooperation between Slovenia and the WHO is a The other historical milestone was the first WHO two-way process, where Slovenia benefits from the global conference on a high level to reduce inequa- technical support of the WHO while at the same time lities in health in 2019, at which the Ljubljana State- making an important contribution at the highest ment on Health Equity was adopted (WHO, 2019). As possible level to shaping WHO priorities, realising a leading country in the field of managing inequali- health policies and international strategic com- ties in health, Slovenia hosted an event which focu- mitments, while on a professional level it helps in pre- sed on the importance of appropriate investment in paring new guidelines, tools, mechanisms and in the policies and interventions, which together influence exchange of experience and good practice. the basic conditions for healthy living in the following areas: health services; income security and social In the course of its WHO membership, Slovenia has protection; living conditions; social and human capi- hosted numerous WHO meetings and consultations. tal; and decent work and employment. The confe- We should mention two of the most important inter- rence also served as a basis for further preparations national WHO events in Slovenia which represented for the ten-year European action plan to increase important milestones and helped the development equity in health. of further WHO processes for faster progress in ensuring better health. At the first WHO ministerial Slovenia's visibility on the international level is evident conference on health systems in 1996 in Ljubljana, also in the numerous national models adopted at a one of the key documents for the strengthening of local level, which also serve as case studies for other health systems was adopted: The Ljubljana Charter countries, e.g. integration programmes between the on Reforming Health Care in Europe (WHO, 1996). primary and secondary levels; enhancing primary The conference also resulted in the foundation of health care by founding centres for health improve- the European Observatory on Health Systems and ment; multidisciplinary teams for providing support Policies, of which Slovenia is a partner. During Slove- to chronic patients; and various projects in which the nia's Presidency of the Council of the EU in 2008, the emphasis is on intersectoral cooperation with work, Ljubljana Charter was upgraded by the Tallinn Char- social security, education, the environment, etc., and ter (WHO, 2008), which was then supplemented in in partnership with local communities and civil soci- 2018. It should be emphasised that reforms and solu- ety. tions for adapting health systems to new challenges always respect the values and principles written in Slovenia is a pilot country in many fields of the these two charters. WHO's operation, and has carried out many activi- ties and projects in joint agreement with the WHO. 162 Numerous analyses and assessments were carried Slovenia has so far had one representative on the out in the period 2008–2021 with the aim of revi- WHO Executive Board, Dr. Božidar Voljč (2006–2009). ewing and improving the functioning of the national Through its membership in the WHO Executive Board health system in individual health sectors depen- in the period 2021–2023, Slovenia will also have more ding on the altered health needs of the population. say in negotiations for global health as part of Slove- The most significant ones include: an analysis of nia's Presidency of the Council of the EU. Slovenia has the health system in Slovenia (2015); a joint external gained the opportunity to further improve its active assessment of Slovenia's capacity to prevent and act role and international visibility, upgrade cooperation in the event of biological, chemical and/or nuclear in international initiatives and networks and more threats to health which have a potential cross-bor- actively co-create global politics and focus on rea- der effect (2017), which significantly contributed lising jointly agreed international commitments in to connecting different sectors and stakeholders dealing with humanity's current challenges in the for readiness in the event of health threats such as field of global health. Slovenia's representative, Ker- COVID-19; two assessments addressing mental ill- stin Vesna Petrič, will actively contribute to promoting nesses and the quality of institutional care for adults the WHO's values and strategic policies and to more with psychosocial and intellectual limitations in Slo- in-depth sustainable and systematic approaches to venia (2015, 2019); an assessment of the system introducing innovative solutions for resilient health for collecting and exchanging health information systems and the creation of capacities both in the and data (2019); an analysis of the organisation and WHO and in individual countries. Improving health as financing of primary healthcare services (2019); and the highest value and placing health at the centre of an analysis is now being prepared on key functions the world agenda remains the common theme, which in public health. Analyses include comparisons and runs throughout, from the first Presidency onwards, good practices of other countries, an estimate of and remains Slovenia's most important contribution Slovenia's capacities, and proposals for further deve- to international efforts for health. lopment. The performance of the analyses always includes professional representatives from Slovenia, which alongside the analysis further contributes to improving the professional capacities in areas short WHO. Ljubljana Charter on reforming health care in Europe. WHO Regional Office for Europe, 1996. Available online at: https://www.euro.who.int/__data/ of professional staff. assets/pdf_file/0010/113302/E55363.pdf. WHO. The Tallin Charter: Health Systems for Health and Wealth. WHO Regional Office for Europe, 2008. Available online at: https://www.euro.who.int/__ data/assets/pdf_file/0008/88613/E91438.pdf. WHO. The Ljubljana Statement on Health Equity. WHO Regional Office for Europe, 2019. Available online at: https://www.euro.who.int/__data/assets/ pdf_file/0010/403939/190325_HealthEquityConferenceOutcomeStatement.pdf. 163 Coordination of European cancer projects Tit Albreht, Marjetka Jelenc Slovenia has been recognized in the field of cancer policies since 2008, when fight against cancer was priori-tized during its presidency of the Council of Europe. Based on successful activities in the field of cancer, the European Commission has entrusted Slovenia and the National Institute of Public Health (NIJZ) the management of three projects from the group of joint action projects: European Partnership for Action Against Cancer JA-EPAAC JA, Cancer Control JA-CANCON JA and Innovative Partnership for Action Against Cancer JA-iPAAC JA. The EPAAC JA project1, which ended in 2014, involved The products of the ongoing iPAAC JA project will all Member States of the European Union, Norway undoubtedly benefit the Slovenian and European and Iceland. The project lasted for three years, very population and cancer patients, who are present successfully, and the project products were remar- and active in most of the decisions made as part of kable and are practically useful in all participating the project work. The people of Slovenia and Europe countries. One of the very useful products of the will certainly benefit from the results of the preven- project is the European Guide for Quality National tion package, the updated European Code against Cancer Control Programs2, a guide to developing Cancer and screening programs. high quality national cancer plans. All JA projects bring together a large number of sta- CANCON JA project3 took place from 2014 to 2017, keholders, such as European countries, healthcare its results will undoubtedly help to improve the ove- professionals, medical professionals, patient repre- rall management of cancer in various health areas, sentatives, civil society representatives, NGOs and from improving the quality of screening programs, industry. Despite progress in recent years, cancer to better integration of oncology health care thro- remains an important cause of morbidity in the Euro- ugh models of comprehensive cancer care networks, pean Union and a major burden on society, which all different approaches to primary care cancer care and European countries and the European Commission a psychosocial approach to solving the problem of are aware of. cured cancer patients, as well as in the field of pal- liative care. Based on the joint work of the project partners, a European Guide for Improvement in Com- prehensive Cancer Control4 was published, intended 1_http://www.epaac.eu/images/OF_Ljubljana/Cancer_book_web_version. pdf for European Member States, policy makers and the professional public. Another result of the project are 2_https://cancercontrol.eu/archived/uploads/images/European_Guide_ for_Quality_National_Cancer_Control_Programmes_web.pdf the recommendtions the Cancer Control Joint Action 3_https:/ cancercontrol.eu/archived/ Policy Papers5. 4_https://cancercontrol.eu/archived/uploads/images/Guide/pdf/CanCon_ Guide_FINAL_Web.pdf 5_https://cancercontrol.eu/archived/uploads/PolicyPapers27032017/ CanCon_Policy_Papers_FINAL_Web.pdf 164 Authors in alphabetical order Albreht Tit, National Institute of Public Health Golmajer Andrej, National Laboratory of Health, Environment and Food Belščak Čolaković Andreja, National Institute of Public Health Grašek Manja, National Institute of Public Health Beović Bojana, Medical Chamber of Slovenia and Gregorič Matej, National Institute of Public Health University Clinical Centre Ljubljana, Clinic for infectious diseases and fever conditions Grilc Eva, National Institute of Public Health Bevc Mojca, National Institute of Public Health Grmek Košnik Irena, National Institute of Public Health Beznec Peter, Centre for Health and Development Murska Sobota Hafner Alenka, National Institute of Public Health, Regional Office Kranj Blažko Nataša, Ministry of Health of the Republic of Slovenia Hladnik Marjana, National Institute of Public Health Blaznik Urška, National Institute of Public Health Hočevar Grom Ada, National Institute of Public Health Bric Nika, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana Hočevar Tadeja, National Institute of Public Health Cugmas Marjan, Faculty of Social Sciences Horvat Tadeja, National Institute of Public Health Čander Darko, Ministry of Health of Republic of Hovnik Keršmanc Marjetka, National Institute of Slovenia Public Health Dernovšek Mojca Zvezdana, Community Health Ivanoš Jerica, National Laboratory of Health, Center Sevnica Environment and Food Domen Kralj, National Institute of Public Health, Ivanuš Urša, Institute of Oncology Ljubljana Regional Office Celje Ivartnik Matej, National Institute of Public Health, Dravec Sonja, National Institute of Public Health Regional Office Ravne na Koroškem Drev Andreja, National Institute of Public Health Jandl Mateja, National Institute of Public Health Drglin Zalka, National Institute of Public Health Janežič Sandra, National Laboratory of Health, Environment and Food Eržen Ivan, National Institute of Public Health Jarm Katja, Institute of Oncology Ljubljana Fafangel Mario, National Institute of Public Health Jelenc Marjetka, National Institute of Public Health Fajdiga Turk Vida, National Institute of Public Health Jeriček Klanšček Helena, National Institute of Public Farkaš Lainščak Jerneja, General Hospital Murska Health Sobota Kasapinov Blashko, National Institute of Public Franko Jernejka, National Laboratory of Health, Health Environment and Food Kastrin Tamara, National Laboratory of Health, Gabrijelčič Blenkuš Mojca, National Institute of Environment and Food Public Health Kavka Daša, National Laboratory of Health, Gabrovec Branko, National Institute of Public Health Environment and Food Galičič An, National Institute of Public Health Klavs Irena, National Institute of Public Health Golle Andrej, National Laboratory of Health, Kofol Bric Tatjana, National Institute of Public Health Environment and Food 165 Kofol Seliger Andreja, National Laboratory of Health, Maučec Zakotnik Jožica, National Institute of Public Environment and Food Health Konec Juričič Nuša, National Institute of Public Mertik Sandra, National Laboratory of Health, Health, Regional Office Celje Environment and Food Kopilović Boris, National Institute of Public Health, Mezinec Andreja, National Institute of Public Health Regional Office Koper Mihevc Ponikvar Barbara, National Institute of Public Koprivnikar Helena, National Institute of Public Health Health Mihor Ana, Epidemiology and Cancer Registry, Kostnapfel Tatja, National Institute of Public Health Institute of Oncology Ljubljana Kovač Nataša, Slovenian Environment Agency Mioč Verica, National Laboratory of Health, Environment and Food Kožar Jerneja, National Institute of Public Health Mozetič Matija, National Institute of Public Health Krajc Mateja, Institute of Oncology Ljubljana Murko Eva, National Institute of Public Health Krajnc Nikolić Tatjana, National Institute of Public Health, Regional Office Murska Sobota Samra Mušić, Ministry of Health of the Republic of Slovenia Kralj Marcel, National Institute of Public Health Novak Mlakar Dominika, National Institute of Public Kranvogl Roman, National Laboratory of Health, Health Environment and Food Novaković Srdjan, Institute of Oncology Ljubljana Krek Milan, National Institute of Public Health Ogrin Rehberger Petra, National Institute of Public Kuhar Doroteja, National Institute of Public Health, Health Regional Office Novo Mesto Oikonomidis Christos, National Institute of Public Kvaternik Ines, National Institute of Public Health, Health, Regional Office Maribor Regional Office Koper Oprešnik Denis, National Institute of Public Health Lavtar Darja, National Institute of Public Health Otorepec Peter, National Institute of Public Health Leban Eva, National Institute of Public Health Paragi Metka, National Laboratory of Health, Lekić Ksenija, National Institute of Public Health, Environment and Food Regional Office Celje Paulin Mojca, Slovene Medical Informatics Lešnik Uroš, National Laboratory of Health, Association Environment and Food Paulin Sonja, National Institute of Public Health Letnar Žbogar Nives, National Institute of Public Health, Regional Office Ljubljana Pečan Erna, National Institute of Public Health Lokar Katarina, Epidemiology and Cancer Registry, Peperko Marjeta, National Institute of Public Health, Institute of Oncology Ljubljana Regional Office Celje Lovrečič Barbara, National Institute of Public Health Perharič Lucija, National Institute of Public Health Lovrečič Mercedes, National Institute of Public Perko Denis, National Institute of Public Health Health Petraš Teodora, National Institute of Public Health, Lukan Benjamin, National Laboratory of Health, Regional Office Murska Sobota Environment and Food Petrič Kerstin Vesna, Ministry of Health of the Marn Stane, National Institute of Public Health Republic of Slovenia Marta Grgič Vitek, National Institute of Public Health Pibernik Tjaša, National Institute of Public Health Matetić Vedrana, National Institute of Public Health Pirnat Nina, National Institute of Public Health 166 Pohar Majda, National Institute of Public Health Simčič Anja, National Laboratory of Health, Environment and Food Poličnik Jožica, Ministry of Health of the Republic of Slovenia Simončič Mojca, National Institute of Public Health Poličnik Rok, National Institute of Public Health Stanimirović Dalibor, National Institute of Public Health Pollak Pavel, National Institute of Public Health Šimac Nataša, National Institute of Public Health, Povhe Jemec Katja, Ministry of Health of the Regional Office Nova Gorica Republic of Slovenia Šinkovec Zorko Nadja, National Institute of Public Povž Blaž, National Institute of Public Health Health Prijon Ticijana, National Institute of Public Health Škrjanc Barbara, National Laboratory of Health, Prosenc Trilar Katarina, National Laboratory of Environment and Food Health, Environment and Food Štanta Marko, National Institute of Public Health, Pucelj Vesna, National Institute of Public Health Regional Office Nova Gorica Radoš Krnel Sandra, National Institute of Public Štrumbelj Iztok, National Laboratory of Health, Health Environment and Food Ranfl Martin, National Institute of Public Health, Šubelj Maja, National Institute of Public Health Regional Office Murska Sobota Tacol Alenka, National Institute of Public Health, Rant Živa, National Institute of Public Health external associate Ražman Nevenka, National Institute of Public Health, Tomšič Sonja, Epidemiology and Cancer Registry, Regional Office Koper Institute of Oncology Ljubljana Rebec Andreja, National Institute of Public Health, Tovornik Teja, National Institute of Public Health Regional Office Koper Tratnjek Petra, National Institute of Public Health, Rehberger Maruša, National Institute of Public Regional Office Celje Health Trkov Marija, National Laboratory of Health, Repnik Darja, National Laboratory of Health, Environment and Food Environment and Food Trop Skaza Alenka, National Institute of Public Ribič Helena, National Laboratory of Health, Health, Regional Office Celje Environment and Food Truden Dobrin Polonca, National Institute of Public Robnik Levart Monika, National Institute of Public Health Health Učakar Veronika, National Institute of Public Health Rok Simon Mateja, National Institute of Public Health Uršič Simona, National Institute of Public Health Ropret Nina, National Institute of Public Health Vardič Damjana, National Institute of Public Health Roškar Maja, National Institute of Public Health Veninšek Perpar Irena, National Institute of Public Roškar Saška, National Institute of Public Health Health Rupel Tatjana, National Laboratory of Health, Vidovič Maruška, National Institute of Public Health Environment and Food Viher Hrženjak Vesna, National Laboratory of Health, Rupnik Maja, National Laboratory of Health, Environment and Food Environment and Food Vinko Matej, National Institute of Public Health Sedlak Sabina, National Institute of Public Health Vračko Pia, National Institute of Public Health Serec Maša, Ministry of Health of Republic of Vrbovšek Sanja, National Institute of Public Health Slovenia 167 Vrdelja Mitja, National Institute of Public Health Žerjal Živa, National Institute of Public Health, Regional Office Koper Vudrag Marko, National Institute of Public Health, Regional Office Nova Gorica Zimet Zlatko, National Institute of Public Health, Regional Office Maribor Zadnik Vesna, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana Žmak Vanja, National Institute of Public Health, Regional Office Maribor Zakotnik Branko, Cancer Registry, Institute of Oncology Ljubljana Žohar Čretnik Tjaša, National Laboratory of Health, Environment and Food Zaletel Jelka, National Institute of Public Health Zaletel Kragelj Lijana, Faculty of Medicine, University of Ljubljana Zaletel Metka, National Institute of Public Health Zdolšek Barbara, National Laboratory of Health, Environment and Food Zelenik Katja, National Laboratory of Health, Environment and Food Zupanič Saša, National Institute of Public Health Zupanič Tina, National Institute of Public Health Žagar Janina, National Institute of Public Health Žagar Tina, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana Žerjal Emil, National Laboratory of Health, Environment and Food 168