Tobacco endgame measures and their adaptation in selected European countries: A narrative review synthesis

Due to the continued detrimental effects of tobacco use, a growing number of countries are embracing the idea of tobacco endgame, meaning ending the tobacco epidemic instead of controlling it. This narrative review aims to synthesize and update the evidence from earlier scientific reviews on effective tobacco endgame measures, as well as to assess their integration to current national strategies among European countries with official tobacco endgame goals. The synthesis of the prior scientific literature found most evidence on product-focused and some evidence for supply-focused policies. Little evidence was detected for user- and institutional-focused measures. An update for the tobacco-free generation measure showed uncertainty in reducing smoking prevalence, especially for adolescents' reactions to age-restrictive laws. All the countries that established a tobacco endgame strategy have included product standards in their measures, predominantly based on European Union regulations on conventional tobacco products, yet standards above this level and considering other products were also common. Cessation measures were given strong emphasis in strategies, yet none of the countries linked these to specific endgame measures. Despite commonly mentioning vulnerable groups, such as youth and pregnant women, adoption of measures to reduce tobacco use among these groups was scarce. Lastly, the decline in tobacco use seems to be modest, implying challenges in meeting the endgame goals. To meet these goals, European countries should reinforce the implementation of known effective tobacco control measures such as tax increases. Furthermore, new innovative strategies and measures to meet the objective of an endgame should be explored.

Tobacco endgame in the WHO European Region: Feasibility in light of current tobacco control status

INTRODUCTION

To assess the feasibility of developing World Health Organization (WHO) European Region countries' goals and measures in line with tobacco endgame objectives, information on the current tobacco control context and capacity is needed. The aim of this study was to assess the implementation of the Framework Convention on Tobacco Control (WHO FCTC) and MPOWER measures in the region.

METHODS

In this cross-sectional study we used data from the WHO FCTC implementation reports and MPOWER from 2020 in 53 WHO European Region countries. Six domains (i.e. capacity, taxation and price policies, other national key regulations, public awareness raising and communication, tobacco use cessation, and monitoring) were formed. Subsequently, available indicators under these domains were scored and the level of implementation was computed for each country. Mann-Whitney tests were carried out to compare the scores between the group of countries with and without official endgame goals.

RESULTS

Overall, implementation of the WHO FCTC with the selected indicators at the country level ranged from 28% to 86%, and of MPOWER from 31% to 96%. Full implementation was achieved by 28% of WHO FCTC Parties in the region in taxation and price policies, 12% in public awareness raising and communication, and 42% in monitoring. In capacity, tobacco use cessation and other national key regulations, none of the Parties in the region reached full implementation. Overall median WHO FCTC scores were significantly higher in countries with official endgame goals than in those without (p<0.001).

CONCLUSIONS

There is unequal implementation of both WHO FCTC and MPOWER measures among WHO European Region countries. MPOWER and WHO FCTC provide all the measures for the necessary first steps, followed by innovative measures, to accomplish tobacco endgame goals.

Comparative effectiveness and durability of COVID-19 vaccination against death and severe disease in an ongoing nationwide mass vaccination campaign

As national coronavirus disease 2019 (COVID-19) mass vaccination campaigns are rolled out, monitoring real-world Vaccine Effectiveness (VE) and its durability is essential. We aimed to estimate COVID-19 VE against severe disease and death in the Greek population, for all vaccines currently in use. Nationwide active surveillance and vaccination registry data during January-December 2021 were used to estimate VE via quasi-Poisson regression, adjusted for age and calendar time. Interaction terms were included to assess VE by age group, against the "delta" severe acute respiratory syndrome coronavirus 2 variant and waning of VE over time. Two doses of BNT162b2, mRNA-1273, or ChAdOx1 nCov-19 vaccines offered very high (>90%) VE against both intubation and death across all age groups, similar against both "delta" and previous variants, with one-dose Ad26.COV2.S slightly lower. VE waned over time but remained >80% at 6 months, and three doses increased VE again to near 100%. Vaccination prevented an estimated 19 691 COVID-19 deaths (95% confidence interval: 18 890-20 788) over the study period. All approved vaccines offer strong and also durable protection against COVID-19 severe disease and death. Every effort should be made to vaccinate the population with at least two doses, to reduce the mortality and morbidity impact of the pandemic.

Influenza vaccine effectiveness against hospitalization with laboratory-confirmed influenza in Greece: A pooled analysis across six seasons, 2013-2014 to 2018-2019

BACKGROUND

Monitoring seasonal influenza Vaccine Effectiveness (VE) is key to inform vaccination strategies and sustain uptake. Pooling data across multiple seasons increases precision and allows for subgroup analyses, providing more conclusive evidence. Our aim was to assess VE against hospitalization with laboratory-confirmed influenza in Greece over six seasons, from 2013 to 2014 to 2018-2019, using routinely collected surveillance data.

METHODS

Swab samples from hospitalized patients across the country were tested for influenza by RT-PCR. We used the test-negative design, with patients testing positive for influenza serving as cases and those testing negative serving as controls. VE was calculated as one minus the Odds Ratio (OR) for influenza vaccination, estimated by mixed-effects logistic regression and adjusted for age, sex, hospitalization type (being in intensive care or not), time from symptom onset to swabbing, and calendar time. Stratified estimates by age and hospitalization type were obtained, and also subgroup estimates by influenza type/subtype and season. Antigenic and genetic characterization of a subset of circulating influenza strains was performed.

RESULTS

A total of 3,882 test-positive cases and 5,895 test-negative controls were analyzed. Across all seasons, adjusted VE was 45.5% (95% CI: 31.6-56.6) against all influenza, 62.8% against A(H1N1)pdm09 (95% CI: 40.7-76.7), 28.2% against A(H3N2) (95% CI: 12.0-41.3) and 45.5% against influenza B (95% CI: 29.1-58.1). VE was slightly lower for patients aged 60 years and over, and similar between patients hospitalized inside or outside intensive care. Circulating A(H1N1)pdm09 and B strains were antigenically similar to the vaccine strains, whereas A(H3N2) were not.

CONCLUSION

Our results confirm the public health benefits from seasonal influenza vaccination, despite the suboptimal effectiveness against A(H3N2) strains. Continued monitoring of VE is essential, and routinely collected surveillance data can be valuable in this regard.

Anxiety and Charles Bonnet Syndrome

Introduction

Some persons with Charles Bonnet syndrome (CBS) suffer significant anxiety because of their visual hallucinations, while others do not. The aim of the study presented here was to compare levels of anxiety in persons with low vision with and without CBS.

Methods

This retrospective study compared the level of anxiety in 31 persons with CBS and 26 persons without CBS. These participants were recruited voluntarily from senior centers, a low vision support group, and an ophthalmology practice in October and November 2010. All were administered surveys to measure cognitive function (TICS: Telephone Interview for Cognitive Status), anxiety (STAI: State and Trait Anxiety Inventory), and general health (GHQ: General Health Questionnaire). The responses of the two groups were compared.

Results

The participants with CBS exhibited higher levels of anxiety than did those without CBS on both the STAI and GHQ surveys, but this difference did not reach statistical significance. The proportion of participants who were pharmacologically treated for anxiety was four times higher in the CBS cohort than in the cohort without CBS: CBS: 36% (11 of 31), those without CBS: 9% (2 of 22), p value = .03. The participants with CBS who took medication for anxiety scored higher on the STAI and GHQ than did those without CBS, but these differences did not reach statistical significance.

Discussion

The findings indicate that persons with CBS have higher levels of anxiety than do those without CBS. The highest levels of anxiety occurred in the participants with CBS who were being treated for anxiety with medications. Although the findings did not reach statistical significance, they suggest that anxiety is an important consideration when treating individuals with CBS.

Implications for practitioners

Persons with CBS who have difficulty tolerating visual hallucinations may benefit from interventions that are directed at managing anxiety, such as counseling, visual rehabilitation, and pharmacological treatment.

455. Epidemiological Surveillance in Points of Care for Refugees/Migrants: The 2016–2017 Experience in Greece

Background

In 2016 and 2017, 535,000 refugees/migrants crossed the Mediterranean Sea to reach Europe, with 203,000 arriving in Greece. To address enhanced epidemiological surveillance needs, in May 2016 Greece established an ad hoc surveillance system in points of care for refugees/migrants in hosting centers, complementary to routine surveillance.

Methods

Data on number of cases per age group for 14 syndromes of public health (PH) interest were collected daily from primary healthcare units of refugee/migrant hosting centers in the country, along with the number of consultations from any cause. Additional information enabling case-finding was collected for syndromes representing diseases that require PH measures at an individual level. Observed daily proportional morbidity (PM) was compared with expected PM using a quasi-Poisson regression model. PM ≥2 standard deviations from expected was defined as a “warning signal.” “Warning signals” appearing for ≥2 consecutive days were considered “alert signals.” Signals were evaluated daily and public health measures were implemented as necessary.

Results

The number of centers participating in the system ranged between 27 and 51. Mean weekly reporting rate reached 96%. From 16 May 2016 to 31 December 2017, 500,166 consultations from any cause were reported, with 28,300 cases of the syndromes under surveillance (5.6%). Syndromes with the higher PM were respiratory infections with fever (3.3%), gastroenteritis (1.3%), suspected scabies (0.6%), and rash with fever (0.3%, of whom 95.1% were varicella cases, with no measles or rubella identified). Two hundred fifteen cases of suspected tuberculosis were referred to hospitals for further diagnostic testing and treatment. Of 92 cases of jaundice with acute onset, 85% were verified as hepatitis A, triggering interventions such as vaccination. None of the produced signals corresponded to a major PH incident, all being of low severity and duration.

Conclusion

Infections represented a small proportion of refugees’ health problems. Syndromic surveillance in hosting centers guided PH action and confirmed no major PH event.

Disclosures

All authors: No reported disclosures.

Clinical assessment is a neglected component of outbreak preparedness: evidence from refugee camps in Greece

BACKGROUND

Refugees may have an increased vulnerability to infectious diseases, and the consequences of an outbreak are more severe in a refugee camp. When an outbreak is suspected, access to clinical information is critical for investigators to verify that an outbreak is occurring, to determine the cause and to select interventions to control it. Experience from previous outbreaks suggests that the accuracy and completeness of this information is poor. This study is the first to assess the adequacy of clinical characterisation of acute medical illnesses in refugee camps. The objective is to direct improvements in outbreak identification and management in this vulnerable setting.

METHODS

We collected prospective data in 13 refugee camps in Greece. We passively observed consultations where patients presented with syndromes that might warrant inclusion into an existing syndromic surveillance system and then undertook a structured assessment of routine clinical data collection to examine the extent to which key clinical parameters required for an outbreak response were ascertained and then documented.

RESULTS

A total of 528 patient consultations were included. The most common presenting condition was an acute respiratory illness. Clinicians often made a comprehensive clinical assessment, especially for common syndromes of respiratory and gastrointestinal conditions, but documented their findings less frequently. For fewer than 5% of patients were a full set of vital signs ascertained and so the severity of patient illnesses was largely unknown. In only 11% of consultations was it verified that a patient who met the case criteria for syndromic surveillance reporting based on an independent assessment was reported into the system.

DISCUSSION

Opportunities exist to strengthen clinical data capture and recording in refugee camps, which will produce a better calibrated and directed public health response.

CONCLUSION

Information of significant utility for outbreak response is collected at the clinical interface and we recommend improving how this information is recorded and linked into surveillance systems.

Serum Tumor Markers in Non-Hodgkin's Lymphomas and Chronic Lymphocytic Leukemia

The levels of soluble interleukin-2 receptors (sIL-2R), beta-2 microglobulin (β-2M), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured in the serum of 50 previously untreated patients with non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukemia (CLL) as well as in 25 age and sex-matched normal controls. Compared to normal controls, mean serum levels of sIL-2R and β-2M were significantly increased in both NHL and CLL (p < 0.001) while the increase in ESR and CRP was less marked (p < 0.01 and p < 0.05, respectively). Comparison of these tumor markers with histologic grading showed statistically significant differences only for CRP between low, intermediate and high-grade lymphomas (p < 0.001 and p < 0.05). More advanced stages exhibited higher mean values of all serum markers than early stages (p < 0.001 for sIL-2R, β-2M and ESR and p < 0.05 for CRP). An association with the presence of b-symptoms was observed only for sIL-2R (p < 0.05). In addition, sIL-2R as well as β-2M were able to predict time to progression in patients with diffuse large-cell lymphomas.

We conclude that of the four tumor markers tested sIL-2R and β-2M more frequently showed increased serum levels and were associated with clinical stage and/or presence of b-symptoms. Both sIL-2R and β-2M were also found to have prognostic significance for survival.

Splenic abscess. An old disease with new interest

BACKGROUND/AIMS

To study the demographics, signs and symptoms, causes, risk factors, imaging findings, bacteriologic profile, treatment and outcome of patients with splenic abscess.

METHOD

The medical records of 17 patients with splenic abscess at two tertiary-care hospitals between 1989 and 1997 were retrospectively reviewed. The demographic data, physical and radiological findings, treatment, bacteriology reports and outcome of treatment were reviewed.

RESULTS

The mean age of patients was 43 years (range 7-79 years). Fever and abdominal pain were the most prominent signs. Seven patients were immunocompromised, three had abscessed hydatic cysts, two were drug users and three suffered from splenic trauma, infarction, and endocarditis, respectively. No predisposing factor was identified in 2 patients. In all cases, CT demonstrated the splenic lesion(s). Staphylococcus species and Bacteriodes were the most common microbes, identified in the blood and abscess cultures. Thirteen patients underwent splenectomy, two medical therapy and two no therapy with respective survival rates of 92, 100 and 0%.

CONCLUSION

Splenic abscess is a rare surgical entity encountered mostly in immunocompromised patients. CT scan is the gold standard for the definite diagnosis. Splenectomy is the treatment of choice, while medical therapy should be reserved for unusual pathogens provided that an effective antimicrobial agent is available.

Severe hypothyroidism in patients dependent on prolonged thyroxine infusion through a jejunostomy

BACKGROUND AND AIMS

Enteral absorption of thyroxine (T4) is variable; the duodenum and jejunum appear to be the most important sites of absorption. Our objective is to demonstrate that T4 infused via a standard jejunostomy may occasionally be poorly absorbed.

METHODS

Two patients underwent esophagolaryngeal resection for carcinoma of the cervical esophagus. The procedure was accompanied by complete removal of the thyroid and parathyroid glands. A neck fistula at the gastropharyngeal anastomosis led to a restriction of oral intake; daily requirements of T4 and nutrients were given via the jejunostomy. T4 plasma levels deteriorated and thyroid-stimulating hormone (TSH) levels increased and in the third postoperative week, T4 (300 microg) was administered via a nasogastric tube.

RESULTS

Although given a high dose (300 microg) of T4, both patients developed severe hypothyroidism. Infusion of T4 through the nasogastric tube precipitated the normalization of T4 and TSH plasma levels. Both patients (cases 1 and 2) resumed oral intake during the fifth and sixth postoperative weeks respectively.

CONCLUSION

T4 malabsorption may occur in patients dependent on prolonged T4 infusion via a standard jejunostomy.

Glucose-based versus fat-based total parenteral nutrition (TPN): Effects on hepatic function in septic patients complicated with cholestatic jaundice

A prospective study of two types of total parenteral nutrition (TPN) was carried out in 34 patients suffering from sepsis and complicated liver dysfunction. Group 1 (18 patients) received non-protein energy as glucose plus fat emulsion in a caloric ratio of 19:1, while group 2 (16 patients) received the same energy intake but with a ratio of 1:1. Group 1 exhibited higher levels of bilirubin and alkaline phosphatase with values of 93.5 +/- 25.5 mumol/l and 160 +/- 30 IU/l respectively compared to Group 2, in which the corresponding values were 81.6 +/- 32.3 mumol/l and 120 +/- 10 IU/l (p < 0.05). On the other hand, group 1 had lower levels of serum albumin and serum transferrin with values 25 +/- 1.3 g/l and 40 +/- 20% of normal, compared to group 2 in whom the corresponding values were 28 +/- 8 g/l and 48 +/- 30% of normal (p < 0.05). There were no differences between the two groups, in the absolute number of T-lymphocytes and in transaminase levels. In sepsis complicated by liver dysfunction a 50:50 glucose: fat regimen caused less disturbance of liver function than one consisting almost entirely of glucose.