in this study, we performed the first European wide training needs assessment from a POE perspective. This training needs assessment aimed to gain insight into the training needs on infectious disease management among dedicated staff at designated airports, ports, and ground-crossings in Europe. Handling ill travelers, public health measures at PoE, and routine inspections have the highest priority for training among ports, airports and ground-crossings together. Combining the moderate to high training needs, the low percentage of respondents that received recent training, and the few real events that were experienced, we call for additional training efforts to enhance the workforce preparedness at European POEs.
The Covid-19 pandemic
Between the data collection and reporting of this study, the COVID-19 pandemic has confronted many European POEs with the response to infectious disease threats on an unprecedented scale. News reports, first scientific publications and the authors’ experiences indicate that indeed several POEs perceived enormous challenges to handle cruise ships with cases on board [17, 18], implement public health measures at airports and on land-borders . These events again emphasize, how important the capacity of personnel and organization and the necessary training at PoEs are. The results of this study outline the starting point from which, in January and February 2020, Europe’s POEs started the required ad hoc preparations for the COVID-19 crisis. This crisis, however, inevitable has lead to new insights on what kind of training is required for effective infectious disease management in the near and more distant future. It is too early to capture these new insights since these will keep on changing till the entire international community has recalibrated its position towards prevention of international spread of infectious diseases in the light of a highly globalized world, and the subsequent roles for POEs.
What remains, however, is the need for a well prepared workforce at POEs both on the individual and the collective level to face COVID-19, other conventional infectious diseases such as influenza, tuberculosis, and measles, as well as any new Disease X. This geographically spread and divided workforce with widely varying needs will be one of the key players in restarting international travel and trade again. Focus on essential roles and tasks and a collaborative policy will be of utmost importance in the coming 18 months of European COVID-19 recovery. Our findings draw attention to this crucial resource and provides a starting point for this collective approach, which, however, needs to be combined with the emerging needs of our fast-changing international society.
Interpretation of the results
Our results are univocal regarding issues that are both important and have high training needs, such as the handling of ill travelers and several public health measures. Here, according to our sample, additional training efforts should be made. However, less clear is the conclusion for issues that are considered little or not important, such as handling animals, or health risks from a chemical or radiological essence. Since these issues are derived from the core capacity list as stated by the IHR and recent landmark guidelines, considering these issues as little important is remarkable. Several interpretations are possible. First, they might be scored less important relative to the other topics instead of not being important at all in an absolute sense. Or second, respondents may be unaware of these issues being important or do not consider it a POE problem. The little experience from prior training, exercise and real cases that we identified prudently supports this second interpretation. Because if the workforce is not trained to focus on an issue, and no direct consequences follow from a lack of attention, one can concede to attribute little importance to it. If this is the case, however, these issues still require training attention.
Also, the diverging training needs among respondents needs further attention. For many topics, we saw high training needs as well as low training needs. This incongruence indicates varying perspectives on infectious disease preparedness among POEs, which is not explained by differentiating between ports, airports and ground-crossings. Again, this is in line with the generally low and widely varying level of preparedness among POEs, as shown by the results of our study, the IHR self-assessment , and the Joint External Evaluations of IHR core capacities. In the light of increasing travel with and within Europe  and the experiences of the current COVID-19 pandemic, it is of utmost importance that the awareness for the role POEs in cross-border disease preparedness and control, and subsequently, the development of a prepared workforce is being implemented.
We identified a very low number of infectious disease events at POEs, with few exceptions reporting several events a year. This finding correlates with the results of a literature review conducted in 2013 in which less than 70 events were identified between 1990 and 2013 in the categories ‘European ports’, ‘the Mediterranean Sea’, or ‘worldwide’ . The latter is named here because European crew and ships might be involved. The workforce’s little experience raises the question to what extent the training needs merely indicate a gut feeling, or are a reliable estimation related to real practice. Also, the low and highly varying number of events suggests an incomplete identification and notification of infectious disease signals at several POEs.
Airports, ports and ground-crossings perceive slightly different needs. Airports and ports have the highest training needs in PHEIC situations. This difference can be explained by several events. First, the large Ebola outbreak of 2014-2015 led to enhanced screening at ports and airports worldwide [22, 23]. In addition, in the meantime, major EU Joint Actions AIRSAN and SHIPSAN supported countries extensively with the development of effective infectious disease control at ports and airports [24, 25]. Ground-crossings, however, have received less attention since they only had a minor role in the spreading of Ebola and have not had a EU Joint Action aimed at enhancing their preparedness. However, a recent report shows a substantial and growing number of travelers that enter Europe via train and roadways and a suboptimal prepared workforce for dealing with infectious disease threats. In combination with the current COVID-19 pandemic, we expect more attention for and awareness at ground-crossings on infectious disease management shortly.
The high preference for presentations as training methodology is hard to resolve with currently leading educational theories, such as the Adult Learning Theory. This theory promotes interactive, problem-based learning in real environments to be most effective . Future organizers of training programs should note this discrepancy in preferences between our respondents and leading theories, and consider consulting didactic professionals during training development. Even more, because the literature on training in infectious disease control mostly leaves us here, as is shown in a recent but still unpublished literature review on effective training methods performed by this study’s authors. However, very promising tools have been developed and tested to enhance active learning and interaction during presentations, such as the use of audience response systems  and online methodologies. (Online) E-modules are the other preferred methodology and already better suited for problem-based learning and limited interaction among learners. Since there is a need for European-wide training at POEs, this might be a very suitable method to reach this geographically spread target group. Locally at POEs, however, our respondents simulation exercises for practical skills such as the use of personal protective equipment and the handling of ill persons.