Association of PM2.5 mass and its components with ovarian reserve in a northern peninsular province, China: The critical exposure period and components

BACKGROUND

A possible role of PM2.5 components on ovarian reserve has not been adequately unexplored.

OBJECTIVE

To evaluate the association between PM2.5 components and women' ovarian reserve over critical exposure periods in northern China, where the level of air pollution is among the nation's highest.

METHODS

We included 15,102 women with serum anti-Müllerian hormone (AMH) measurements from the Center for Reproductive Medicine of Shandong University during 2015-2019. Concentrations of PM2.5 and its five major components (0.1° × 0.1°), including sulfate, nitrate, ammonium, organic matter, and black carbon, were assigned to each residential address. Multivariable linear mixed effect models combined with constituent-residual models were performed to estimate the effect sizes of essential components over six short- to long-term exposure periods.

RESULTS

The strength of association was stronger during the process from primary to small antral follicle compared with other longer windows. For every interquartile range increase in PM2.5 mass was associated with - 8.7% (95%CI: -12.3%, -4.9%) change in AMH and the effect size was greatest for sulfate. Women with the lower level of attained education and those living inland were more susceptible compared with other population subgroups.

CONCLUSION

Exposure to specific components of air pollution during critical exposure windows is associated with a decline in ovarian reserve. These data add to the growing body of evidence that environmental factors have adverse effects on reproductive health, particularly for vulnerable population subgroups.

The influence of the Great Recession on perinatal health-an ecological study on the trend changes and regional differences in Portugal

Background

Few studies examine the relationship between socioeconomic factors and trends in mortality in high-income European countries. Due to the lack of regional-level data, most recent studies on social inequality in Portugal do not investigate regional differences. This study analyses time trends and regional disparities in the evolution of perinatal mortality (PMR) and infant mortality (IMR) associated with demographic and socioeconomic indicators following Portugal's 2008 economic and financial crisis.

Methods

Associations were assessed using generalised linear models. A Poisson joinpoint regression model was applied to identify relevant PMR and IMR changes between 2000 and 2018. Country regional disparities were analysed using Mixed Effect Multilevel models.

Findings

IMR and PMR significantly decreased in the pre-crisis period but not in the post-crisis period. The significant differences between regions in IMR and PMR in 2000 were followed by a different evolution of regional IMR after 2008. PMR and IMR were not significantly associated with socioeconomic indicators. A significant positive association with maternal age at first birth was identified.

Interpretation

Results confirm the influence of the crisis on PMR and IMR trends in Portugal, taking into account recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility, and stagnation of IMR and PMR. Regional inequalities confirm the internal variability of the crisis influence and persistent spatial inequalities affecting IMR patterns.

Funding

FCT, under the Institute of Public Health of the University of Porto (ISPUP)-EPIUnit (UIDB/04750/2020) and ITR (LA/P/0064/2020), Maastricht University's external PhD programme under the Care and Public Health Research Institute (CAPHRI), and the RECAP preterm project (grant agreement no 733280).

Adverse short-term effects of ozone on cardiovascular mortalities modified by season and temperature: a time-series study

Introduction

Ambient ozone pollution becomes critical in China. Conclusions on the short-term effects of ozone on cardiovascular mortality have been controversial and limited on cause-specific cardiovascular mortalities and their interactions with season and temperature. This research aimed to investigate the short-term effects of ozone and the modifications of season and temperature on cardiovascular mortality.

Methods

Cardiovascular death records, air pollutants, and meteorological factors in Shenzhen from 2013 to 2019 were analyzed. Daily 1-h maximum of ozone and daily maximum 8-h moving average of ozone were studied. Generalized additive models (GAMs) were applied to evaluate their associations with cardiovascular mortalities in sex and age groups. Effect modifications were assessed by stratifying season and temperature.

Results

Distributed lag impacts of ozone on total cardiovascular deaths and cumulative effects on mortality due to ischemic heart disease (IHD) were most significant. Population under 65 years old was most susceptible. Majority of significant effects were found in warm season, at high temperature, and at extreme heat. Ozone-associated risks in total deaths caused by hypertensive diseases reduced in warm season, while risks in IHD in males increased at high temperature. Extreme heat enhanced ozone effects on deaths caused by CVDs and IHD in the population under 65 years old.

Discussion

The revealed cardiovascular impacts of ozone below current national standard of air quality suggested improved standards and interventions in China. Higher temperature, particularly extreme heat, rather than warm season, could significantly enhance the adverse effects of ozone on cardiovascular mortality in population under 65 years old.

Systems thinking methods: a worked example of supporting emergency medical services decision-makers to prioritize and contextually analyse potential interventions and their implementation

BACKGROUND

Systems thinking can be used as a participatory data collection and analysis tool to understand complex implementation contexts and their dynamics with interventions, and it can support the selection of tailored and effective implementation actions. A few previous studies have applied systems thinking methods, mainly causal loop diagrams, to prioritize interventions and to illustrate the respective implementation context. The present study aimed to explore how systems thinking methods can help decision-makers (1) understand locally specific causes and effects of a key issue and how they are interlinked, (2) identify the most relevant interventions and best fit in the system, and (3) prioritize potential interventions and contextually analyse the system and potential interventions.

METHODS

A case study approach was adopted in a regional emergency medical services (EMS) system in Germany. We applied systems thinking methods following three steps: (1) a causal loop diagram (CLD) with causes and effects (variables) of the key issue "rising EMS demand" was developed together with local decision-makers; (2) targeted interventions addressing the key issue were determined, and impacts and delays were used to identify best intervention variables to determine the system's best fit for implementation; (3) based on steps 1 and 2, interventions were prioritized and, based on a pathway analysis related to a sample intervention, contextually analysed.

RESULTS

Thirty-seven variables were identified in the CLD. All of them, except for the key issue, relate to one of five interlinked subsystems. Five variables were identified as best fit for implementing three potential interventions. Based on predicted implementation difficulty and effect, as well as delays and best intervention variables, interventions were prioritized. The pathway analysis on the example of implementing a standardized structured triage tool highlighted certain contextual factors (e.g. relevant stakeholders, organizations), delays and related feedback loops (e.g. staff resource finiteness) that help decision-makers to tailor the implementation.

CONCLUSIONS

Systems thinking methods can be used by local decision-makers to understand their local implementation context and assess its influence and dynamic connections to the implementation of a particular intervention, allowing them to develop tailored implementation and monitoring strategies.

2008 economic crisis impact on perinatal and infant mortality in Southern European countries

INTRODUCTION

The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession's impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems' response to the protection of the health of the most vulnerable groups.

OBJECTIVE

To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain.

METHODS

Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models.

RESULTS

IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018.

CONCLUSION

Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population's health from the earliest days.

A scoping review on the impact of austerity on healthcare access in the European Union: rethinking austerity for the most vulnerable

BACKGROUND

There is consensus that the 2008 financial and economic crisis and related austerity measures adversely impacted access to healthcare. In light of the growing debt caused by the COVID-19 crisis, it is uncertain whether a period of austerity will return.

OBJECTIVE

This study aims to provide a structured overview of the impact of austerity policies in the EU-28 zone, applied in response to the Great Recession, on access to health care for the adult population, using the five access dimensions by Levesque et al. (2013).

METHODS

This study followed the PRISMA extension for Scoping Reviews guideline. Medline (PubMed) and Web of Science were searched between February 2021 and June 2021. Primary studies in the English language published after the 1st of January 2008 reporting on the possible change in access to the healthcare system for the adult population induced by austerity in an EU28 country were included.

RESULTS

The final search strategy resulted in 525 articles, of which 75 studies were reviewed for full-text analysis, and a total of 21 studies were included. Results revealed that austerity policy has been primarily associated with a reduction in access to healthcare, described through four main categories: i) Increase in rates of reported unmet needs (86%); ii) Affordability (38%); iii) Appropriateness (38%); iv) and Availability and Accommodation (19%). Vulnerable populations were more affected by austerity measures than the general population when specific safeguards were not in place. The main affected adult vulnerable population groups were: patients with chronic diseases, elderly people, (undocumented) migrants, unemployed, economically inactive people and individuals with lower levels of education or socioeconomic status.

CONCLUSION

Austerity measures have led to a deterioration in access to healthcare in the vast majority of the countries studied in the EU-28 zone. Findings should prompt policymakers to rethink the fiscal agenda across all policies in times of economic crisis and focus on the needs of the most vulnerable populations from the health perspective.

Patient characteristics and dispatch responses of urinary tract infections in a prehospital setting in Copenhagen, Denmark: a retrospective cohort study

BACKGROUND

Urinary tract infection (UTI) is particularly common in young women and the elderly. The Emergency Medical Services (EMS) in Copenhagen, Denmark can be reached by calling either of two dedicated telephone lines: 1-1-2 in case of an emergency and 1813 during general practitioner's (GP) out-of-office hours (OOH). This study investigated characteristics of patients with symptoms of UTI calling the Copenhagen EMS and the response they received.

METHODS

A retrospective observational cohort study was conducted in which 7.5 years of telephone data on UTI from the EMS in Copenhagen were analyzed. Descriptive statistics and multinomial logistic regression were used to analyze patient characteristics, the timing of the incident and response. Patients' age and gender were assessed and the use of urinary catheters, the timing of the incident, and the impact on the response were evaluated.

RESULTS

A total of 278.961 calls were included (78% female, mean age 47), with an average of 120 patients with UTI symptoms calling each day. Most people contacted the 1813-medical helpline (98%) and of those, the majority were referred to the emergency department (ED)(37%). Patients were more likely to be referred to the ED during the weekend compared to a weekday and less likely during OOH compared to in-office hours (IH). Patients with a urinary catheter were more likely to receive specialized care referred to as 'other'. For the smaller proportion of patients calling 1-1-2, most people got a B (urgent) response (1.5%). The most likely response to be given was an A (emergency) or F (non-emergency) response during OOH compared to IH and on weekends compared to weekdays. Patients with a urinary catheter were more likely to receive a D (unmonitored transport) response.

CONCLUSIONS

Since 2015, there was a decrease in 1813 antibiotic prescription rates and a subsequent increase in referral to the ED of UTI patients. Patients were referred less to the ED during OOH as they were likely to be sent to their GP the next day. During the weekend, patients were referred more to the ED for the likely reason that their GP is closed.

Zwei Jahre Pilotphase Gemeindenotfallsanitäter in der Region Oldenburg (Niedersachsen)

Hintergrund

Steigende Einsatzzahlen im Rettungsdienst, demografischer Wandel sowie Veränderungen bei der Morbidität und in den Strukturen der Akutversorgung erfordern eine Weiterentwicklung der Versorgungsoptionen an den Sektorengrenzen zwischen ambulanter und stationärer Versorgung. Zur Erprobung von Gemeindenotfallsanitätern (G-NFS) als eine unterstützende Ressource des Rettungsdienstes wird in der Region Oldenburg seit 2019 ein Modellprojekt mit wissenschaftlicher Begleitung durchgeführt.

Methodik

Im Rahmen einer Mixed-Methods-Studie wurden Fokusgruppeninterviews mit den vier regionalen G‑NFS-Gruppen (Stadt Oldenburg und die Kreise Vechta, Cloppenburg und Ammerland) durchgeführt. Die Interviews (Teilnahme ca. 56,7 % aller G‑NFS) wurden jeweils durch eine kurze anonyme Online-Umfrage (Teilnahme ca. 53,3 % aller G‑NFS) mit denselben Teilnehmern ergänzt. Interviews und Online-Befragung zielten auf die persönlichen Einsatzerfahrungen vor und während der Coronapandemie ab. Die Interviewergebnisse wurden anhand thematischen Codierens analysiert und ausgewertet.

Ergebnisse

An den Interviews und der anschließenden Umfrage nahmen 17 bzw. 16 G-NFS teil. Aus Sicht der G‑NFS ergänzt die Ressource das bisherige Reaktionsspektrum des Rettungsdienstes in Form von Rettungswagen (RTW) oder Krankentransportwagen (KTW) um eine sinnvolle und fachgerechte Komponente, die insbesondere zur erforderlichen Entlastung der Einsatzmittel der Notfallversorgung beiträgt. Die notwendige sektorenübergreifende Zusammenarbeit mit anderen Diensten verläuft in Abhängigkeit von den jeweiligen lokalen Gegebenheiten unterschiedlich, aber insgesamt zielgerichtet und effizient; Gleiches gilt für die Zusammenarbeit mit den zuständigen Rettungsleitstellen. G‑NFS wurden in den Hochphasen der Pandemie in die Triagierung von COVID-Verdachtsfällen einbezogen und haben zur dringend gebotenen Entlastung des Rettungssystems in der Region beigetragen.

Diskussion

Das G‑NFS-Konzept hat sich aus Sicht der Mitarbeiter in der bisherigen Projektlaufzeit bewährt. Die vorliegenden Erfahrungen bieten eine gute Grundlage für die konzeptionelle Weiterentwicklung des G‑NFS.

Impact of integrating out-of-hours services into Emergency Medical Services Copenhagen: a descriptive study of transformational years

Background

Many emergency medical services and out-of-hours systems are facing an increasing demand for primary, ambulance, and secondary care services caused by population aging and a higher prevalence of long-term and complex conditions. In order to ensure safety and efficiency for future demands, many systems are changing their dispersed healthcare services towards a more integrated care system. Therefore, an evaluation of the production and performance over time of such a unified system is desirable.

Methods

This retrospective quantitative study was performed with dispatch and financial accounting data of Copenhagen Emergency Medical Services for the period 2010–2019. Copenhagen Emergency Medical Services operates both an emergency number and a medical helpline for out-of-hours services. The number of calls to the emergency number, the centralized out-of-hours medical helpline, the number of dispatches, and the annual expenditure of the system are described for both the periods before and after the major reforms. Production of the emergency number and the centralized medical helpline were analyzed separately.

Results

The average number of dispatches increased from 328 per 10,000 inhabitants in 2010 to 361 per 10,000 inhabitants in 2019. The newly initiated medical helpline received 533 calls per 10,000 inhabitants in its first year and 5 years later 548 calls per 10,000 inhabitants. A cost increase of 10% was observed in the first year after the reforms, but it decreased again to 8% in the following year.

Conclusions

There is a population demand for a centralized telephone access point for (semi-)emergency medical services. A more integrated EMS system is promising for a sustainable healthcare provision for a growing population with complex healthcare demands and multi-morbidities.

Artificial intelligence in Emergency Medical Services dispatching: assessing the potential impact of an automatic speech recognition software on stroke detection taking the Capital Region of Denmark as case in point

BACKGROUND AND PURPOSE

Stroke recognition at the Emergency Medical Services (EMS) impacts the stroke treatment and thus the related health outcome. At the EMS Copenhagen 66.2% of strokes are detected by the Emergency Medical Dispatcher (EMD) and in Denmark approximately 50% of stroke patients arrive at the hospital within the time-to-treatment. An automatic speech recognition software (ASR) can increase the recognition of Out-of-Hospital cardiac arrest (OHCA) at the EMS by 16%. This research aims to analyse the potential impact an ASR could have on stroke recognition at the EMS Copenhagen and the related treatment.

METHODS

Stroke patient data (n = 9049) from the years 2016-2018 were analysed retrospectively, regarding correlations between stroke detection at the EMS and stroke specific, as well as personal characteristics such as stroke type, sex, age, weekday, time of day, year, EMS number contacted, and treatment. The possible increase in stroke detection through an ASR and the effect on stroke treatment was calculated based on the impact of an existing ASR to detect OHCA from CORTI AI.

RESULTS

The Chi-Square test with the respective post-hoc test identified a negative correlation between stroke detection and females, the 1813-Medical Helpline, as well as weekends, and a positive correlation between stroke detection and treatment and thrombolysis. While the association analysis showed a moderate correlation between stroke detection and treatment the correlation to the other treatment options was weak or very weak. A potential increase in stroke detection to 61.19% with an ASR and hence an increase of thrombolysis by 5% in stroke patients calling within time-to-treatment was predicted.

CONCLUSIONS

An ASR can potentially improve stroke recognition by EMDs and subsequent stroke treatment at the EMS Copenhagen. Based on the analysis results improvement of stroke recognition is particularly relevant for females, younger stroke patients, calls received through the 1813-Medical Helpline, and on weekends.

TRIAL REGISTRATION

This study was registered at the Danish Data Protection Agency (PVH-2014-002) and the Danish Patient Safety Authority (R-21013122).

Impacts and Lessons Learned of the First Three COVID-19 Waves on Cross-Border Collaboration in the Field of Emergency Medical Services and Interhospital Transports in the Euregio-Meuse-Rhine: A Qualitative Review of Expert Opinions

Background

In the Euregio-Meuse-Rhine (EMR), cross-border collaboration is essential for resource-saving and needs-based patient care within the emergency medical service (EMS) systems and interhospital transport (IHT). However, at the onset of the novel coronavirus SARS-COV-2 (COVID-19) pandemic, differing national measures highlighted the fragmentation within the European Union (EU) in its various approaches to combating the pandemic. To assess the consequences of the pandemic in the EMR border area, the aim of this study was to analyze the effects and “lessons learned” regarding cross-border collaboration in EMS and IHT.

Method

A qualitative study with 22 semi-structured interviews was carried out. Experts from across the EMR area, including the City of Aachen, the City region of Aachen, the District of Heinsberg (Germany), South Limburg (The Netherlands), and the Province of Limburg, as well as Liège (Belgium), took part. The interviews were coded and analyzed according to changes in cross-border collaboration before and during the pandemic, as well as lessons learned and recommendations.

Results

Each EU member country within the EMR area, addressed the pandemic individually with national measures. Cross-border collaboration between regional actors was hardly or not at all addressed at the national level during political decision- or policymaking. Previous direct communication at the personal level was replaced by national procedures, which made regular cross-border collaboration significantly more difficult. The cross-border transfer regulations of patients with COVID-19 proved to be complex and led, among other things, to patients being transported to hospitals far outside the border region. Collaboration continues to be seen as valuable and Euregional emergency services including hospitals work well together, albeit to different degrees. The information and data exchange should, however, be more transparent to use resources more efficiently.

Conclusion

Effective Euregional collaboration of emergency services is imperative for public safety in a multi-border region with strong economic, cultural, and social cross-border links. Our findings indicate that existing (pre-pandemic) structures which included regular meetings of senior managerial staff in the region and a number of thematic working groups were helpful to deal with and to compensate for the disruptions during the crisis. Regional cross-border agreements that are currently based on mutual but more or less informal arrangements need to be formalized and better promoted and recognized also at the national and EU level to increase resilience. The continuous determination of synergies and good and best practices are further approaches to support cross-border collaboration especially in preparation for future crises.

The “unclear problem” category: an analysis of its patient and dispatch characteristics and its trend over time

Background

An effective emergency medical dispatch process is vital to provide appropriate prehospital care to patients. It increases patient safety and ensures the sustainable use of medical resources. Although Copenhagen has a sophisticated emergency medical services (EMS) system with a significant focus on public welfare, more than 10% of emergency cases are still being categorized as an "unclear problem category" (UPC) and are thus not categorized as "symptom-specific". Therefore, the objective of this research is to gain a better understanding of the patient and dispatch characteristics of emergency cases categorized as "unclear".

Methods

This register-based study based on medical emergency cases data describes patient and dispatch characteristics of emergency cases categorized as “unclear” through the use of numbers and proportions. Moreover, these cases were compared to non UPC cases. Use of UPC was stratified by month to determine the impact of alerting medical dispatchers to reduce its use.

Results

From 296,398 included cases UPC accounted for 11.4% of the cases. The median age of those triaged with the UPC was 66 years vs 58 years for individuals triaged with other symptom-specific categories.

Moreover, after having been triaged with the UPC, 9,661 (34.7%) of the dispatched EMS vehicles ended up being cancelled. Sensitizing medical dispatchers about the use of the UPC likely contributed to the decreased use of the UPC over time.

Conclusion

The UPC has different dispatch characteristics than the symptom-specific categories, with potential negative effects on the medical dispatch process. Moreover, the median age of individuals triaged with the UPC is higher than those triaged with symptom-specific categories. Nonetheless, the use of the UPC decreased throughout the study period after the medical dispatchers were alerted about the implications of its use.

Composition and sources of particulate matter in the Beijing-Tianjin-Hebei region and its surrounding areas during the heating season

This paper aimed to analyze the composition and pollution sources of particulate matter (PM) in the Beijing-Tianjin-Hebei region and its surrounding areas (henceforth the BTH region) during the heating season to support the mitigation and control of regional air pollution. Manual monitoring data from the China National Environmental Monitoring Network for Atmospheric PM in the BTH region were collected and analyzed during the 2016 and 2018 heating seasons. The positive definite matrix factor analysis (PMF) model was used to analyze the PM sources in BTH cities during the heating season. The main PM components were organic matter (OM), nitrate (NO₃^-), sulfate (SO₄^2-) and ammonium salt (NH₄⁺). Direct emission sources have decreased since 2016, indicating the effectiveness of governmental controls on these sources; however, secondary pollution showed an increasing trend, suggesting control measures should be strengthened. Daily regional average concentrations of OM, SO₄^2-, NH₄⁺, elemental carbon (EC), chloride (Cl^-) and trace elements all showed similar trends. When air quality worsened, the concentrations of the main PM components increased, but trends of change varied among components. In 2018, concentrations of OM and chloride were highest in the Taihang Mountains, and NO₃ concentrations were highest in Anyang, Hebi, Jiaozuo and Xinxiang. The SO₄^2- concentration was highest in the southern section of the Taihang Mountains. The NH₄⁺ and EC concentrations were generally highest in the central and southern regions. The concentration of crustal substances was highest in some cities in the north and central parts of the BTH region. In the 2018 heating season, the pollution level of five transmission channels showed an increasing trend in the Northwest, Southeast, Yanshan, South and Taihang Mountain channels. These findings provide a scientific basis for the continued management of atmospheric PM pollution.

Acute effects of ambient nitrogen oxides and interactions with temperature on cardiovascular mortality in Shenzhen, China

BACKGROUND

Though inconsistent, acute effects of ambient nitrogen oxides on cardiovascular mortality have been reported. Whereas, interactive roles of temperature on their relationships and joint effects of different indicators of nitrogen oxides were less studied. This study aimed to extrapolate the independent roles of ambient nitrogen oxides and temperature interactions on cardiovascular mortality.

METHODS

Data on mortality, air pollutants, and meteorological factors in Shenzhen from 2013 to 2019 were collected. Three indicators including nitric oxide (NO), nitrogen dioxide (NO₂), and nitrogen oxides (NO_X) were studied. Adjusted generalized additive models (GAMs) were applied to analyse their associations with cardiovascular mortality in different groups.

RESULTS

The average daily concentrations of NO, NO₂, and NO_X were 11.7 μg/m³, 30.7 μg/m³, and 53.2 μg/m³, respectively. Significant associations were shown with each indicator. Cumulative effects of nitrogen oxides were more obvious than distributed lag effects. Males, population under 65 years old, and population with stroke-related condition were more susceptible to nitrogen oxides. Adverse effects of nitrogen oxides were more significant at low temperature. Impacts of NO₂ on cardiovascular mortality, and NO on stroke mortality were the most robust in the multi-pollutant models, whereas variations were shown in the other relationships.

CONCLUSIONS

Low levels of nitrogen oxides showed acute and adverse impacts and the interactive roles of temperature on cardiovascular mortality. Cumulative effects were most significant and joint effects of nitrogen oxides required more attention. Population under 65 years old and population with stroke-related health condition were susceptible, especially days at lower temperature.

Land use and land cover change and its impacts on dengue dynamics in China: A systematic review

Background

Dengue is a prioritized public health concern in China. Because of the larger scale, more frequent and wider spatial distribution, the challenge for dengue prevention and control has increased in recent years. While land use and land cover (LULC) change was suggested to be associated with dengue, relevant research has been quite limited. The “Open Door” policy introduced in 1978 led to significant LULC change in China. This systematic review is the first to review the studies on the impacts of LULC change on dengue dynamics in China. This review aims at identifying the research evidence, research gaps and provide insights for future research.

Methods

A systematic literature review was conducted following the PRISMA protocol. The combinations of search terms on LULC, dengue and its vectors were searched in the databases PubMed, Web of Science, and Baidu Scholar. Research conducted on China published from 1978 to December 2019 and written in English or Chinese was selected for further screening. References listed in articles meeting the inclusion criteria were also reviewed and included if again inclusion criteria were met to minimize the probability of missing relevant research.

Results

28 studies published between 1978 and 2017 were included for the full review. Guangdong Province and southern Taiwan were the major regional foci in the literature. The majority of the reviewed studies observed associations between LULC change factors and dengue incidence and distribution. Conflictive evidence was shown in the studies about the impacts of green space and blue space on dengue in China. Transportation infrastructure and urbanization were repeatedly suggested to be positively associated with dengue incidence and spread. The majority of the studies reviewed considered meteorological and sociodemographic factors when they analyzed the effects of LULC change on dengue. Primary and secondary remote sensing (RS) data were the primary source for LULC variables. In 21 of 28 studies, a geographic information system (GIS) was used to process data of environmental variables and dengue cases and to perform spatial analysis of dengue.

Conclusions

The effects of LULC change on the dynamics of dengue in China varied in different periods and regions. The application of RS and GIS enriches the means and dimensions to explore the relations between LULC change and dengue. Further comprehensive regional research is necessary to assess the influence of LULC change on local dengue transmission to provide practical advice for dengue prevention and control.

Dengue is a major public health concern in China. The rapid development of urbanization along with climate change increases the challenge for dengue prevention and control. Previous research has mainly focused on the meteorological variables whereas land use and land cover (LULC) change received comparatively less attention. Our review identified that the regional research hotspots of dengue epidemics in China were Guangdong Province and southern Taiwan. Though inconsistent, most included studies somehow observed associations between at least one of the LULC change factors and dengue. A geographical information system (GIS) was widely used to perform spatial analysis in the selected literature. Its application provided a novel view to describe the relationships between environmental factors and the situation of dengue, which enabled scholars to explore more characteristics of dengue transmission. Meanwhile, the use of remote sensing (RS) enriched the means of environmental monitoring. However, there are research gaps in the area of dengue and LULC change, such as the less consideration of dengue vector study, the lack of interplays between factors, and the lack of considering interventions and policies. Furthermore, because of different research settings, results from these studies were difficult to compare. Thus, further comprehensive and comparable investigations are necessary to better understand the effects of LULC change on dengue in China. This review is the first to expound the studies on the associations between LULC change and dengue dynamics in China. It demonstrates the findings and methodologies and provided insights for future research.

The European Union and Public Health Emergencies: Expert Opinions on the Management of the First Wave of the COVID-19 Pandemic and Suggestions for Future Emergencies

Objective: The first wave of the coronavirus SARS-COV-2 pandemic has revealed a fragmented governance within the European Union (EU) to tackle public health emergencies. This qualitative study aims: 1) to understand the current EU position within the field of public health emergencies taking the case of the COVID-19 as an example by comparing and contrasting experiences from EU institutions and experts from various EU Member States at the beginning of the pandemic; and, 2) to identify and to formulate future EU pandemic strategies and actions based on experts' opinions. Methods: Eighteen semi-structured interviews were conducted with public health experts from various European Member States and European Commission officials from May 2020 until August 2020. The transcripts were analyzed by Thematic Content Analysis (TCA), mainly a manifest content analysis. Results: This study demonstrated that the limited EU mandate in health hinders proper actions to prevent and tackle infectious disease outbreaks, such as the COVID-19 pandemic. The results showed that this limitation significantly impacted the ECDC, as the Member States' competence did not allow the agency to have more capacity. The European Commission has fulfilled its role of coordinating and supporting the Member States by facilitating networks and information exchange. However, EU intra- and inter-communication need further improvement. Although diverse EU instruments and mechanisms were found valid, their implementation needed to be faster and more efficient. The results pointed out that underlying political challenges in EU decision-making regarding health emergencies hinder the aligned response. It was stated that the Member States were not prepared, and due to the restriction of their mandate, EU institutions could not enforce binding guidelines. Additionally, the study explored future EU pandemic strategies and actions. Both, EU institutions and national experts suggested similar and clear recommendations regarding the ECDC, the investment, and future harmonized preparedness tools. Conclusion: The complex politics of public health at the EU level have led to the fragmentation of its governance for effective pandemic responses. This ongoing pandemic has shed light on the fragility of the political and structural systems in Europe in public health emergencies. Health should be of high importance in the political agenda, and robust health reforms at the local, regional, national, and EU levels are highly recommended.

Use of Ambulance Dispatch Calls for Surveillance of Severe Acute Respiratory Infections

Ambulance dispatches for respiratory syndromes reflect incidence of influenza-like illness in primary care. Associations are highest in children (15%–34% of respiratory calls attributable to influenza), out-of-office hours (9%), and highest urgency-level calls (9%–11%). Ambulance dispatches might be an additional source of data for severe influenza surveillance.

Climate Action at Public Health Schools in the European Region

Climate change is putting the achievement of all Sustainable Development Goals at risk and leads to negative impacts on human health and well-being. Consequently, tremendous social responsibility lies with public health professionals and their associations. Therefore, this study addressed the following question: “How can the Association of Schools of Public Health in the European Region (ASPHER) best support the goals of the European Green Deal through its network of public health schools and departments?” This study looked at the implementation of climate education in public health schools in the European region and climate action taken by these public health schools. An online survey among ASPHER members with a 51% overall response rate (excluding non-European members) shows that 64% of the responding schools provide climate-health educational offerings, while 63% consider these for the future. Additionally, most climate actions taken by the schools were ad hoc actions. These findings show that a systematic approach is missing, and there is a general lack of strategy in most schools. We consequently recommend that schools invest in climate and health education in their curricula and become exemplars for climate action to actively contribute to the achievement of Europe’s climate goals.

Impact of macro-socioeconomic determinants on sustainable perinatal health care in Portugal: a qualitative study on the opinion of healthcare professionals and experts

BACKGROUND

The WHO identified the importance of macro-socioeconomic determinants and political context as interlinked key factors affecting healthcare quality and health equity. As a response to the recent economic and financial crisis, Portugal approved in 2011 the Economic Adjustment Programme (EAP) to obtain financial assistance from the Troika in order to reduce public debt. This study aims to analyse the impact of the economic crisis and the EAP on perinatal healthcare quality for very preterm (VPT) and/or very low birth weight (VLBW) infants, as perceived by healthcare professionals and experts, within the health administrative regions of the two major metropolitan areas in Portugal.

METHODS

A qualitative approach was applied to receive an in-depth understanding and accomplish perspective variability. A purposive sampling technique was used. Semi-structured interviews were conducted with twenty-one healthcare professionals and experts between October 2018-July 2019. Inductive thematic analysis was performed which encompassed a five-step categorization procedure. Data analysis was undertaken by utilizing Nvivo2011 software. Evolved themes were then associated with WHO's Quality Standards on Maternal and New-born Care. A framework on the impact of macro-socioeconomic determinants on perinatal health care quality was developed.

RESULTS

Although participants did not perceive the quality of perinatal care had deteriorated, the analysis of their accounts on work experience revealed that it was indeed adversely modified in all WHO Quality Standards. Health care provision was perceived as detrimental in five main areas: 1) Availability of human resources; 2) Functional referral systems; 3) Competent and motivated human resources; 4) Emotional support; and 5) Essential physical resources available. Policy reforms by the EAP resulted in reduced timeliness of care, increased waiting times, cuts in sequence and duration of consultations, and deficiencies in follow-up care for VPT/VLBW infants and their mothers. The EAP directly influenced working environment of healthcare professionals by causing stress, burnout, work absence, and brain drain.

CONCLUSION

An interrelation between macro-socioeconomic determinants and perinatal health care quality was disclosed. The economic crisis and EAP have adversely modified equitable perinatal health care quality for VPT/VLBW infants and their mothers. Our findings underlined the negative impact of austerity policies on vulnerable populations.

Urban environmental health interventions towards the Sustainable Development Goals

The aim of the UN Sustainable Development Goals (SDGs) is to achieve a better and more sustainable future for all by 2030. Since the majority of the global population lives in cities, it is crucial to identify, evaluate and implement urban interventions (such as zero carbon housing, active transport, better urban connectivity, air pollution control, clean household fuels, and protection from heat and flood events) that will improve health and wellbeing and make our natural and built environment more sustainable. This Virtual Special Issue (VSI) comprises of 14 diverse case studies, methods and tools that provide suggestions for interventions which directly or indirectly support the achievement of the UN SDGs.

Utility of emergency call centre, dispatch and ambulance data for syndromic surveillance of infectious diseases: a scoping review

BACKGROUND

Syndromic surveillance can supplement conventional health surveillance by analyzing less-specific, near-real-time data for an indication of disease occurrence. Emergency medical call centre dispatch and ambulance data are examples of routinely and efficiently collected syndromic data that might assist in infectious disease surveillance. Scientific literature on the subject is scarce and an overview of results is lacking.

METHODS

A scoping review including (i) review of the peer-reviewed literature, (ii) review of grey literature and (iii) interviews with key informants.

RESULTS

Forty-four records were selected: 20 peer reviewed and 24 grey publications describing 44 studies and systems. Most publications focused on detecting respiratory illnesses or on outbreak detection at mass gatherings. Most used retrospective data; some described outcomes of temporary systems; only two described continuously active dispatch- and ambulance-based syndromic surveillance. Key informants interviewed valued dispatch- and ambulance-based syndromic surveillance as a potentially useful addition to infectious disease surveillance. Perceived benefits were its potential timeliness, standardization of data and clinical value of the data.

CONCLUSIONS

Various dispatch- and ambulance-based syndromic surveillance systems for infectious diseases have been reported, although only roughly half are documented in peer-reviewed literature and most concerned retrospective research instead of continuously active surveillance systems. Dispatch- and ambulance-based syndromic data were mostly assessed in relation to respiratory illnesses; reported use for other infectious disease syndromes is limited. They are perceived by experts in the field of emergency surveillance to achieve time gains in detection of infectious disease outbreaks and to provide a useful addition to traditional surveillance efforts.

Ambulance dispatch calls attributable to influenza A and other common respiratory viruses in the Netherlands (2014-2016)

BACKGROUND

Ambulance dispatches could be useful for syndromic surveillance of severe respiratory infections. We evaluated whether ambulance dispatch calls of highest urgency reflect the circulation of influenza A virus, influenza B virus, respiratory syncytial virus (RSV), rhinovirus, adenovirus, coronavirus, parainfluenzavirus and human metapneumovirus (hMPV).

METHODS

We analysed calls from four ambulance call centres serving 25% of the population in the Netherlands (2014-2016). The chief symptom and urgency level is recorded during triage; we restricted our analysis to calls with the highest urgency and identified those compatible with a respiratory syndrome. We modelled the relation between respiratory syndrome calls (RSC) and respiratory virus trends using binomial regression with identity link function.

RESULTS

We included 211 739 calls, of which 15 385 (7.3%) were RSC. Proportion of RSC showed periodicity with winter peaks and smaller interseasonal increases. Overall, 15% of RSC were attributable to respiratory viruses (20% in out-of-office hour calls). There was large variation by age group: in <15 years, only RSV was associated and explained 11% of RSC; in 15-64 years, only influenza A (explained 3% of RSC); and in ≥65 years adenovirus explained 9% of RSC, distributed throughout the year, and hMPV (4%) and influenza A (1%) mainly during the winter peaks. Additionally, rhinovirus was associated with total RSC.

CONCLUSION

High urgency ambulance dispatches reflect the burden of different respiratory viruses and might be useful to monitor the respiratory season overall. Influenza plays a smaller role than other viruses: RSV is important in children while adenovirus and hMPV are the biggest contributors to emergency calls in the elderly.

Monitoring history and change trends of ambient air quality in China during the past four decades

This study summarized the history of ambient air quality monitoring and air pollution prevention and control, and it analyzed the spatiotemporal patterns of ambient air pollutants during 1981-2017 in China. The results showed that monitoring of ambient air quality has changed dramatically in terms of determinants, sampling methods, monitoring extent, and evaluation basis during the previous four decades. Annual average concentrations of total suspended particulates, PM₁₀ and SO₂ have shown obvious decreasing trends during the studied period. These improvements have been closely related to the considerable efforts and various approaches undertaken to prevent and control air pollution. However, although policy implementation has been decisive and, at least in part, it has been enforced effectively, significant challenges remain. Air pollution control cannot be accomplished without a long-term strategy designed to achieve clean air in all parts of China.

The Role of Cohesion Policy Funds in Decreasing the Health Gaps Measured by the EURO-HEALTHY Population Health Index

Social, economic, and environmental differences across the European Union significantly affect opportunities to move forward in achieving greater equity in health. Cohesion Policy (CP) funds can contribute positively through investments in the main determinants of health. The aim of this study is to analyze to what extent the planned investments for 2014-2020 are addressing the regional health gaps, in light of the population health index (PHI), a multidimensional measure developed by the EURO-HEALTHY project. The operational programs of all regions were analyzed, namely, the CP planned investments by field of intervention. Analysis of variance was performed to examine whether the regional scores in the PHI dimensions were statistically different across regions with different levels of development (measured by gross domestic product (GDP)). Results show that 98% of regions with worse performances on the PHI are less developed regions. Overall, all regions present planned investments in intervention fields linked to dimensions appraised within the PHI (e.g., employment, income, education, pollution). Yet, more needs to be done to focus regional investments in health determinants where regions still lag behind. The PHI has the potential to inform future CP restructuring, providing evidence to extend the current eligibility criteria to other dimensions beyond the GDP.

Q fever: Evidence of a massive yet undetected cross-border outbreak, with ongoing risk of extra mortality, in a Dutch-German border region

Background

Following outbreaks in other parts of the Netherlands, the Dutch border region of South Limburg experienced a large‐scale outbreak of human Q fever related to a single dairy goat farm in 2009, with surprisingly few cases reported from neighbouring German counties. Late chronic Q fever, with recent spikes of newly detected cases, is an ongoing public health concern in the Netherlands. We aimed to assess the scope and scale of any undetected cross‐border transmission to neighbouring German counties, where individuals unknowingly exposed may carry extra risk of overlooked diagnosis.

Methods

(A) Seroprevalence rates in the Dutch area were estimated fitting an exponential gradient to the geographical distribution of notified acute human Q fever cases, using seroprevalence in a sample of farm township inhabitants as baseline. (B) Seroprevalence rates in 122 neighbouring German postcode areas were estimated from a sample of blood donors living in these areas and attending the regional blood donation centre in January/February 2010 (n = 3,460). (C) Using multivariate linear regression, including goat and sheep densities, veterinary Q fever notifications and blood donor sampling densities as covariates, we assessed whether seroprevalence rates across the entire border region were associated with distance from the farm.

Results

(A) Seroprevalence in the outbreak farm's township was 16.1%. Overall seroprevalence in the Dutch area was 3.6%. (B) Overall seroprevalence in the German area was 0.9%. Estimated mean seroprevalence rates (per 100,000 population) declined with increasing distance from the outbreak farm (0–19 km = 2,302, 20–39 km = 1,122, 40–59 km = 432 and ≥60 km = 0). Decline was linear in multivariate regression using log‐transformed seroprevalence rates (0–19 km = 2.9 [95% confidence interval (CI) = 2.6 to 3.2], 20 to 39 km = 1.9 [95% CI = 1.0 to 2.8], 40–59 km = 0.6 [95% CI = −0.2 to 1.3] and ≥60 km = 0.0 [95% CI = −0.3 to 0.3]).

Conclusions

Our findings were suggestive of widespread cross‐border transmission, with thousands of undetected infections, arguing for intensified cross‐border collaboration and surveillance and screening of individuals susceptible to chronic Q fever in the affected area.

Impact of macro-socioeconomic determinants on perinatal healthcare quality for very preterm infants

Key messages

The added value is the disclosure of an in-depth understanding on the interrelation of macro-socioeconomic determinants and healthcare permitting a distinct representation from quantitative methods. The non-linearity between policy response and expected outcomes chiefly complements its comprehension and demonstrates its relevance for further research on assessing effects of austerity measures.

Influenza vaccine effectiveness estimates against influenza A(H3N2) and A(H1N1) pdm09 among children during school-based outbreaks in the 2016-2017 season in Beijing, China

Background: Since 2007, trivalent inactivated influenza vaccine (TIV) has been provided free-of-charge to primary, middle school and high school students in Beijing. However, there have been few school-based studies on influenza vaccine effectiveness (VE). In this report, we estimated influenza VE against laboratory-confirmed influenza illness among school children in Beijing, China during the 2016-2017 influenza season.Methods: The VE of 2016-2017 TIV against laboratory-confirmed influenza virus infection among school-age children was assessed through a case-control design. Conditional logistic regression was conducted on matched case-control sets to estimate VE. The effect of prior vaccination on current VE was also examined.Results: All 176 samples tested positive for influenza A virus with the positive rate of 55.5%. The average coverage rate of 2016-2017 TIV among students across the 37 schools was 30.6%. The fully adjusted VE of 2016-2017 TIV against laboratory-confirmed influenza was 69% (95% CI: 51 to 81): 60% (95% CI: -15 to 86) for influenza A(H1N1)pdm09 and 73% (95% CI: 52 to 84) for influenza A(H3N2). The overall VE for receipt of 2015-2016 vaccination only, 2016-2017 vaccination only, and vaccinations in both seasons was 46% (95% CI: -5 to 72), 77% (95% CI: 58 to 87), and 57% (95%CI: 17 to 78), respectively.Conclusions: Our study during school outbreaks found that VE of 2016-2017 TIV was moderate against influenza A(H3N2) as well as A(H1N1)pdm09 viruses.

Evaluation of data availability on population health indicators at the regional level across the European Union

BACKGROUND

The ability to measure regional health inequalities across Europe and to build adequate population health indices depends significantly on the availability of reliable and comparable data at the regional level. Within the scope of the EU-funded project EURO-HEALTHY, a Population Health Index (PHI) was built. This model aggregates 39 indicators considered relevant by experts and stakeholders to evaluate and monitor population health on the regional level within the European Union (269 regions). The aim of this research was to assess the data availability for those indicators. As a subsequent aim, an adequate protocol to overcome issues arising from missing data will be presented, as well as key messages for both national and European statistical authorities meant to improve data collection on population health.

METHODS

The methodology for the study includes three consecutive phases: (i) assessing the data availability for the respective indicators at the regional level for the last year available (ii) applying a protocol for missing data and completing the database and (iii) developing a scoring system ranging from 0 (no data available; worst) to 1 (all data available; best) to evaluate the availability of data by indicator and EU region.

RESULTS

Although the missing data on the set of the PHI indicators was significant, the mean availability score for the EURO-HEALTHY PHI indicators is 0.8 and the regional availability score is 0.7, which reveal the strength of the indicators as well as the data completeness protocol for missing data.

CONCLUSIONS

This study provides a comprehensive data availability assessment for population health indicators from multiple areas of concern, at the EU regional level. The results highlight that the data completeness protocol and availability scores are suitable tools to apply on any indicator's data source mapping. It also raises awareness to the urgent need for sub-national data in several domains and for closing the data gaps between and within countries. This will require policies clearly focused on improving equity between regions and a coordinated effort from the producers of data (the EU28 national statistics offices and EUROSTAT) and the stakeholders who design policies at EU, regional and local level.

The 2015-2016 influenza epidemic in Beijing, China: Unlike elsewhere, circulation of influenza A(H3N2) with moderate vaccine effectiveness

BACKGROUND

While the 2015-2016 influenza season in the northern hemisphere was dominated by A(H1N1)pdm09 and B/Victoria viruses, in Beijing, China, there was also significant circulation of influenza A(H3N2) virus. In this report we estimate vaccine effectiveness (VE) against influenza A(H3N2) and other circulating viruses, and describe further characteristics of the 2015-2016 influenza season in Beijing.

METHODS

We estimated VE of the 2015-2016 trivalent inactivated vaccine (TIV) against laboratory-confirmed influenza virus infection using the test-negative study design. The effect of prior vaccination on current VE was also examined.

RESULTS

Of 11,000 eligible patients included in the study, 2969 (27.0%) were influenza positive. Vaccination coverage was 4.2% in both cases and controls. Adjusted VE against all influenza was 8% (95% CI: -16% to 27%): 18% (95% CI: -38% to 52%) for influenza A(H1N1)pdm09, 54% (95% CI: 16% to 74%) for influenza A(H3N2), and -8% (95% CI: -40% to 18%) for influenza B/Victoria. The overall VE for receipt of 2015-2016 vaccination only, 2014-2015 vaccination only, and vaccinations in both seasons was -15% (95% CI: -63% to 19%), -25% (95% CI: -78% to 13%), and 18% (95% CI: -11% to 40%), respectively.

CONCLUSIONS

Overall the 2015-2016 TIV was protective against influenza infection in Beijing, with higher VE against the A(H3N2) viruses compared to A(H1N1)pdm09 and B viruses.

Diurnal temperature range in relation to death from stroke in China

BACKGROUND

Stroke is the second leading cause of death in the world. It has multiple risk factors of which some, such as ambient temperature, are less well documented.

OBJECTIVE

We aimed to examine the association between diurnal temperature range (DTR) and stroke mortality, and to test the possible effect modification of this association according to gender, age and educational level.

METHODS

Daily data on weather and stroke mortality from 16 provincial capital cities in China for the years 2007-2013 were obtained, with a total of 788,783 deaths from stroke. A quasi-Poisson generalized linear regression combined with a distributed lag non-linear model was used to examine the city-specific DTR effect on stroke mortality. The pooled effects of DTR on stroke mortality were then obtained using a meta-analysis, which was based on restricted maximum likelihood estimation.

RESULTS

The DTR impacts were generally limited to a period of eight days, while significant effects during lag 0-8 days were only found in the cities of Beijing, Zhengzhou, Nanjing, Hefei, Chongqing and Changsha. The DTR effects were significantly and negatively associated with latitudes at lag 0-10 days (r_s = - 0.640, P = 0.008). An increase of 1 °C in DTR was associated with pooled estimate of 0.66% (95%CI: 0.28-1.05%), 0.12% (- 0.26% to 0.51%) and 0.67% (0.26-1.07%) increases in stroke mortality at lag 0-10 days during the total, hot and cold days, respectively. The impact of DTR was much higher in southern China than in northern China [1.02% (0.62% to 1.43%) versus 0.10% (-0.27% to 0.47%) ]. For the individual characteristics, only females, the elderly aged ≥ 65 years, and those with lower educational attainment were vulnerable to DTR.

CONCLUSIONS

DTR has considerable effects on risk of mortality from stroke in various cities in China, especially among the elderly, females, those with low educational level, and people living in southern China. The results can inform decisions on developing programs to protect vulnerable subpopulations from adverse impacts of DTR.

Migrants' access to healthcare services within the European Union: a content analysis of policy documents in Ireland, Portugal and Spain

Background

The current migration flow into Europe is leading to a growing ethnically diverse population in many European countries. Now more than ever, those populations have different healthcare needs, languages, traditions, and previous level of care. This higher level of diversity is likely to increase health inequalities that might challenge healthcare systems if not addressed. In this context, this study aims at reviewing the policy framework for migrants’ access to healthcare in Spain, Portugal and Ireland, countries with a long history of immigration, to identify lessons to be learned for policies on migrants’ health.

Methods

A content analysis of official policy documents was undertaken and the conceptual framework developed by Mladowsky was adapted to classify the actions indicated in the policies.

Results

The content analysis revealed that the policy aim for all three analysed countries is the improvement of the health status of the immigrant population based on equity and equality principles. The main strategies are the adaptation of services through actions targeting patients and providers, such as the implementation of cultural mediators and trainings for health professionals.

Conclusion

The three countries propose a great range of policies aiming at improving access to healthcare services for immigrants that can inspire other European countries currently welcoming refugees. Developing inclusive policies, however does not necessarily mean they will be implemented or felt on the ground. Inclusive policies are indeed under threat due to the economic and social crises and due to the respective nationalistic attitudes towards integration. The European Union is challenged to take a more proactive leadership and ensure that countries effectively implement inclusive actions to improve migrant’s access to health services.

Interventions to improve immigrant health. A scoping review

Background: Disparities in health between immigrants and their host populations have been described across countries and continents. Hence, interventions for improving health targeting general populations are not necessarily effective for immigrants. Aims: To conduct a systematic search of the literature evaluating health interventions for immigrants; to map the characteristics of identified studies including range of interventions, immigrant populations and their host countries, clinical areas targeted and reported evaluations, challenges and limitations of the interventions identified. Following the results, to develop recommendations for research in the field. Methods: A scoping review approach was chosen to provide an overview of the type, extent and quantity of research available. Studies were included if they empirically evaluated health interventions targeting immigrants and/or their descendants, included a control group, and were published in English (PubMed and Embase from 1990 to 2015). Results: Most of the 83 studies included were conducted in the USA, encompassed few immigrant groups and used a randomized controlled trial (RCT) or cluster RCT design. Most interventions addressed chronic and non-communicable diseases and attendance at cancer screening services, used individual targeted approaches, targeted adult women and recruited participants from health centres. Outcome measures were often subjective, with the exception of interventions for cardiovascular risk and diabetes. Generally, authors claimed that interventions were beneficial, despite a number of reported limitations. Conclusions: Recommendations for enhancing interventions to improve immigrant health are provided to help researchers, funders and health care commissioners when deciding upon the scope, nature and design of future research in this area.

Taking Action on Air Pollution Control in the Beijing-Tianjin-Hebei (BTH) Region: Progress, Challenges and Opportunities

Due to rapid urbanization, industrialization and motorization, a large number of Chinese cities are affected by heavy air pollution. In order to explore progress, remaining challenges, and sustainability of air pollution control in the Beijing-Tianjin-Hebei (BTH) region after 2013, a mixed method analysis was undertaken. The quantitative analysis comprised an overview of air quality management in the BTH region. Semi-structured expert interviews were conducted with 12 stakeholders from various levels of government and research institutions who played substantial roles either in decision-making or in research and advising on air pollution control in the BTH region. The results indicated that with the stringent air pollution control policies, the air quality in BTH meets the targets of the Air Pollution Prevention and Control Action Plan. However, improvements vary across the region and for different pollutants. Although implementation has been decisive and was at least in parts effectively enforced, significant challenges remained with regard to industrial and traffic emission control, and national air quality limits continued to be significantly exceeded and competing development interests remained mainly unsolved. There were also concerns about the sustainability of the current air pollution control measures especially for industries due to the top-down enforcement, and the associated large burden of social cost including unemployment and social inequity resulting industrial restructuring. Better mechanisms for ensuring cross-sectoral coordination and for improved central-local government communication were suggested. Further suggestions were provided to improve the conceptual design and effective implementation of respective air pollution control strategies in BTH. Our study highlights some of the major hurdles that need to be addressed to succeed with a comprehensive air pollution control management for the Chinese mega-urban agglomerations.

New insights into biodrying mechanism associated with tryptophan and tyrosine degradations during sewage sludge biodrying

Sewage sludge biodrying is a treatment that uses bio-heat generated from organic degradation to remove water from sewage sludge. Dewatering is still limited during biodrying, due to the presence of extracellular polymeric substances (EPS) in sludge. To study the biodrying mechanism associated with EPS compositions tryptophan and tyrosine degradations, this study investigated the microbial function in sludge biodrying material. This study conducted a taxonomic analysis of biodrying material; determined the most abundant genetic functions; analyzed the functional microorganisms involved in the degradations of tryptophan and tyrosine; and summarized the metabolic pathways. The results indicated efficient degradations of tryptophan and tyrosine were observed during the initial thermophilic phase; functional microorganisms were mainly from the phyla Firmicutes, Actinobacteria, and Proteobacteria, enriched with genes involved in amino acid transport and metabolism. These findings highlight the potentially important microorganisms and typical pathways that may help improve dewaterability during biodegradation.

Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal

BACKGROUND

The recent economic and financial crisis in Portugal urged the Portuguese Government in April 2011 to request financial assistance from the troika austerity bail out program to get aid for its government debt. The troika agreement included health reforms and austerity measures of the National Health Service (NHS) in Portugal to save non-essential health care costs. This research aimed to identify potential barriers among the elderly population (aged 65 and above) to healthcare access influenced by the economic crisis and the troika agreement focussing on the Memorandum of Understanding on Specific Economic Policy Conditionality (MoU) in Lisbon metropolitan area, Portugal.

METHODS

The qualitative study is including 13 semi-structured interviews of healthcare experts, municipality authority, health care providers, negotiator of the troika agreement, hospital managers, health economists and elderly. A content analysis was performed to evaluate the interviews applying Nvivo2011 software. The barriers identified were clustered towards the five areas of the 'Conceptual framework on health care access' by Levesque et al. (Int J Equity Health 12:18, 2013).

RESULTS

Healthcare access for the elderly was found inadequate in four areas of the framework: availability; appropriateness; approachability; and affordability. The fifth area on acceptability was not identified since the study neither followed a gender nor ethnic specific purpose. The main identified barriers were: current financial situation and pension cuts; insufficient provision and increased user fees in primary care; inadequate design and availability of hospital care service; lack of long-term care facilities; increased out-of-pocket-payment on pharmaceuticals; limitations in exemption allowances; cuts in non-emergent health transportation; increased waiting time for elective surgery; and poor unadapted housing conditions for elderly.

CONCLUSIONS

The health reforms and health budget cuts in the MoU implemented as part of the troika agreement have been associated with increasing health inequalities in access to healthcare services for the elderly population. The majority of responses disclosed an increasing deficiency across the entire National Health Service (NHS) to collaborate, integrate and communicate between the different healthcare sectors for providing adequate care to the elderly. An urgent necessity of restructuring the health care system to adapt towards the elderly population was implied.

Predictors, help-seeking behaviour and treatment coverage for depression in adults in Sehore district, India

BACKGROUND

National Mental Health Survey found that in India, the point prevalence of major depressive disorder (MDD) was 2.7% and the treatment gap was 85.2%, whereas in Madhya Pradesh the point prevalence of MDD was 1.4% and the treatment gap was 80%.

AIMS

To describe the baseline prevalence of depression among adults, association of various demographic and socioeconomic variables with depression and estimation of contact coverage for the same.

METHOD

Population-based cross-sectional survey of 3220 adults in Sehore district of Madhya Pradesh, India. The outcome of interest was a probable diagnosis of depression that was measured using the Patient Health Questionnaire (PHQ-9) and the proportion of individuals with depression (PHQ-9>9) who sought care for the same. The data were analysed using simple and multiple log-linear regression.

RESULTS

Low educational attainment, unemployment and indebtedness were associated with both moderate/severe depression (PHQ-9 score >9) and severe depression only (PHQ-9 score >14), whereas age, caste and marital status were associated with only moderate or severe depression. Religion, type of house, land ownership and amount of loan taken were not associated with either moderate/severe or only severe depression. The contact coverage for moderate/severe depression was 13.08% (95% CI 10.2-16.63).

CONCLUSIONS

There is an urgent need to bridge the treatment gap by targeting individuals with social vulnerabilities and integrating evidence-based interventions in primary care.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Comparing national infectious disease surveillance systems: China and the Netherlands

BACKGROUND

Risk assessment and early warning (RAEW) are essential components of any infectious disease surveillance system. In light of the International Health Regulations (IHR)(2005), this study compares the organisation of RAEW in China and the Netherlands. The respective approaches towards surveillance of arboviral disease and unexplained pneumonia were analysed to gain a better understanding of the RAEW mode of operation. This study may be used to explore options for further strengthening of global collaboration and timely detection and surveillance of infectious disease outbreaks.

METHODS

A qualitative study design was used, combining data retrieved from the literature and from semi-structured interviews with Chinese (5 national-level and 6 provincial-level) and Dutch (5 national-level) experts.

RESULTS

The results show that some differences exist such as in the use of automated electronic components of the early warning system in China ('CIDARS'), compared to a more limited automated component in the Netherlands ('barometer'). Moreover, RAEW units in the Netherlands focus exclusively on infectious diseases, while China has a broader 'all hazard' approach (including for example chemical incidents). In the Netherlands, veterinary specialists take part at the RAEW meetings, to enable a structured exchange/assessment of zoonotic signals.

CONCLUSION

Despite these differences, the main conclusion is that for the two infections studied, the early warning system in China and the Netherlands are remarkably similar considering their large differences in infectious disease history, population size and geographical setting. Our main recommendations are continued emphasis on international corporation that requires insight into national infectious disease surveillance systems, the usage of a One Health approach in infectious disease surveillance, and further exploration/strengthening of a combined syndromic and laboratory surveillance system.

Is the current pertussis incidence only the results of testing? A spatial and space-time analysis of pertussis surveillance data using cluster detection methods and geographically weighted regression modelling

BACKGROUND

Despite high vaccination coverage, pertussis incidence in the Netherlands is amongst the highest in Europe with a shifting tendency towards adults and elderly. Early detection of outbreaks and preventive actions are necessary to prevent severe complications in infants. Efficient pertussis control requires additional background knowledge about the determinants of testing and possible determinants of the current pertussis incidence. Therefore, the aim of our study is to examine the possibility of locating possible pertussis outbreaks using space-time cluster detection and to examine the determinants of pertussis testing and incidence using geographically weighted regression models.

METHODS

We analysed laboratory registry data including all geocoded pertussis tests in the southern area of the Netherlands between 2007 and 2013. Socio-demographic and infrastructure-related population data were matched to the geo-coded laboratory data. The spatial scan statistic was applied to detect spatial and space-time clusters of testing, incidence and test-positivity. Geographically weighted Poisson regression (GWPR) models were then constructed to model the associations between the age-specific rates of testing and incidence and possible population-based determinants.

RESULTS

Space-time clusters for pertussis incidence overlapped with space-time clusters for testing, reflecting a strong relationship between testing and incidence, irrespective of the examined age group. Testing for pertussis itself was overall associated with lower socio-economic status, multi-person-households, proximity to primary school and availability of healthcare. The current incidence in contradiction is mainly determined by testing and is not associated with a lower socioeconomic status.

DISCUSSION

Testing for pertussis follows to an extent the general healthcare seeking behaviour for common respiratory infections, whereas the current pertussis incidence is largely the result of testing. More testing would thus not necessarily improve pertussis control. Detecting outbreaks using space-time cluster detection is feasible but needs to adjust for the strong impact of testing on the detection of pertussis cases.

Do the risk factors for type 2 diabetes mellitus vary by location? A spatial analysis of health insurance claims in Northeastern Germany using kernel density estimation and geographically weighted regression

BACKGROUND

The provision of general practitioners (GPs) in Germany still relies mainly on the ratio of inhabitants to GPs at relatively large scales and barely accounts for an increased prevalence of chronic diseases among the elderly and socially underprivileged populations. Type 2 Diabetes Mellitus (T2DM) is one of the major cost-intensive diseases with high rates of potentially preventable complications. Provision of healthcare and access to preventive measures is necessary to reduce the burden of T2DM. However, current studies on the spatial variation of T2DM in Germany are mostly based on survey data, which do not only underestimate the true prevalence of T2DM, but are also only available on large spatial scales. The aim of this study is therefore to analyse the spatial distribution of T2DM at fine geographic scales and to assess location-specific risk factors based on data of the AOK health insurance.

METHODS

To display the spatial heterogeneity of T2DM, a bivariate, adaptive kernel density estimation (KDE) was applied. The spatial scan statistic (SaTScan) was used to detect areas of high risk. Global and local spatial regression models were then constructed to analyze socio-demographic risk factors of T2DM.

RESULTS

T2DM is especially concentrated in rural areas surrounding Berlin. The risk factors for T2DM consist of proportions of 65-79 year olds, 80 + year olds, unemployment rate among the 55-65 year olds, proportion of employees covered by mandatory social security insurance, mean income tax, and proportion of non-married couples. However, the strength of the association between T2DM and the examined socio-demographic variables displayed strong regional variations.

CONCLUSION

The prevalence of T2DM varies at the very local level. Analyzing point data on T2DM of northeastern Germany's largest health insurance provider thus allows very detailed, location-specific knowledge about increased medical needs. Risk factors associated with T2DM depend largely on the place of residence of the respective person. Future allocation of GPs and current prevention strategies should therefore reflect the location-specific higher healthcare demand among the elderly and socially underprivileged populations.

Structure modification and extracellular polymeric substances conversion during sewage sludge biodrying process

Biodrying, an economical and energy-saving biomass waste treatment, removes water from waste using the biological heat generated by organic matter degradation. Technical limitations associated with dewatering complicate the biodrying of sewage sludge. This study investigated the sludge alteration associated with its water removal, focusing on sludge form, extracellular polymeric substances, and free water release. An auto-feedback control technology was used for the biodrying; a scanning electron microscope was used to record the morphological change; three-dimensional excitation-emission matrix fluorescence spectroscopy was used to analyze extracellular polymeric substances (EPS) variation, and time domain reflectometry was used to assess the free water release. Over the 20-day biodrying, there was a 62% water removal rate during the first thermophilic phase. Biodrying created a hollow and stratified sludge structure. Aromatic proteins and soluble microbial byproducts in the EPS were significantly degraded. The thermophilic phase was the phase resulting in the greatest free water release.

Regional aging and longevity characteristics in China

The factors that influence the length of human life are complex and longevity remains a controversial topic, particularly in China. This paper demonstrates the spatial patterns and changes of the elderly group (65 years old and over), the oldest old (80 years old and over) and the centenarians in China in the last decade, analyzes the influence of economic development on aging, and in the end, using a case study, explores the characteristics of the centenarians' behavior. The results indicate that high elderly and the oldest old proportions are more common in regions with higher socio-economic development and that have a favorable climate. Centenarian distribution pattern is less influenced by economic but only for few regions. Lifestyle factors, such as sufficient sleep, positive mental state and a light diet are also largely found among the centenarian group.

Success Factors of European Syndromic Surveillance Systems: A Worked Example of Applying Qualitative Comparative Analysis

INTRODUCTION

Syndromic surveillance aims at augmenting traditional public health surveillance with timely information. To gain a head start, it mainly analyses existing data such as from web searches or patient records. Despite the setup of many syndromic surveillance systems, there is still much doubt about the benefit of the approach. There are diverse interactions between performance indicators such as timeliness and various system characteristics. This makes the performance assessment of syndromic surveillance systems a complex endeavour. We assessed if the comparison of several syndromic surveillance systems through Qualitative Comparative Analysis helps to evaluate performance and identify key success factors.

MATERIALS AND METHODS

We compiled case-based, mixed data on performance and characteristics of 19 syndromic surveillance systems in Europe from scientific and grey literature and from site visits. We identified success factors by applying crisp-set Qualitative Comparative Analysis. We focused on two main areas of syndromic surveillance application: seasonal influenza surveillance and situational awareness during different types of potentially health threatening events.

RESULTS

We found that syndromic surveillance systems might detect the onset or peak of seasonal influenza earlier if they analyse non-clinical data sources. Timely situational awareness during different types of events is supported by an automated syndromic surveillance system capable of analysing multiple syndromes. To our surprise, the analysis of multiple data sources was no key success factor for situational awareness.

CONCLUSIONS

We suggest to consider these key success factors when designing or further developing syndromic surveillance systems. Qualitative Comparative Analysis helped interpreting complex, mixed data on small-N cases and resulted in concrete and practically relevant findings.

Spatiotemporal patterns of particulate matter (PM) and associations between PM and mortality in Shenzhen, China

Background

Most studies on air pollution exposure and its associations with human health in China have focused on the heavily polluted industrial areas and/or mega-cities, and studies on cities with comparatively low air pollutant concentrations are still rare. Only a few studies have attempted to analyse particulate matter (PM) for the vibrant economic centre Shenzhen in the Pearl River Delta. So far no systematic investigation of PM spatiotemporal patterns in Shenzhen has been undertaken and the understanding of pollution exposure in urban agglomerations with comparatively low pollution is still limited.

Methods

We analyze daily and hourly particulate matter concentrations and all-cause mortality during 2013 in Shenzhen, China. Temporal patterns of PM (PM_2.5 and PM₁₀) with aerodynamic diameters of 2.5 (10) μm or less (or less (including particles with a diameter that equals to 2.5 (10) μm) are studied, along with the ratio of PM_2.5 to PM₁₀. Spatial distributions of PM₁₀ and PM_2.5 are addressed and associations of PM₁₀ or PM_2.5 and all-cause mortality are analyzed.

Results

Annual average PM₁₀ and PM_2.5 concentrations were 61.3 and 39.6 μg/m³ in 2013. PM_2.5 failed to meet the Class 2 annual limit of the National Ambient Air Quality Standard. PM_2.5 was the primary air pollutant, with 8.8 % of days having heavy PM_2.5 pollution. The daily PM_2.5/PM₁₀ ratios were high. Hourly PM_2.5 concentrations in the tourist area were lower than downtown throughout the day. PM₁₀ and PM_2.5 concentrations were higher in western parts of Shenzhen than in eastern parts. Excess risks in the number of all-cause mortality with a 10 μg/m³ increase of PM were 0.61 % (95 % confidence interval [CI]: 0.50–0.72) for PM₁₀, and 0.69 % (95 % CI: 0.55–0.83) for PM_2.5, respectively. The greatest ERs of PM₁₀ and PM_2.5 were in 2-day cumulative measures for the all-cause mortality, 2-day lag for females and the young (0–65 years), and L02 for males and the elder (>65 years). PM_2.5 had higher risks on all-cause mortality than PM₁₀. Effects of high PM pollution on mortality were stronger in the elder and male.

Conclusions

Our findings provide additional relevant information on air quality monitoring and associations of PM and human health, valuable data for further scientific research in Shenzhen and for the on-going discourse on improving environmental policies.

Global health and domestic policy - What motivated the development of the German Global Health Strategy?

In 2013, the German government published its national Global Health Strategy, outlining principles and focal topics for German engagement in global health. We asked the question of why Germany has decided to establish a national policy framework for global health at this point in time, and how the development process has taken place. The ultimate goal of this study was to achieve better insights into the respective health and foreign policy processes at the national level. This article reports on the results of semi-structured interviews with those actors that were responsible for initiating and drafting the German Global Health Strategy (GGHS). Our study shows that a series of external developments, stakeholders, and advocacy efforts created an environment conducive to the creation of the strategic document. In addition, a number of internal considerations, struggles, and capacities played a decisive role during the development phase of the GGHS. Understanding these factors better can not only provide substantial insights into global health related policy processes in Germany, but also contribute to the general discourse on the role of the nation state in global health governance.

Ambient air quality and the effects of air pollutants on otolaryngology in Beijing

To investigate temporal patterns, pollution concentrations and the health effects of air pollutants in Beijing we carried out time-series analyses on daily concentrations of ambient air pollutants and daily numbers of outpatient visits for otolaryngology over 2 years (2011-2012) to identify possible health effects of air pollutants. The results showed that PM10 was the major air pollutant in Beijing and that air quality was slightly better in 2012 than in 2011. Seasonal differences were apparent for SO2 and NO2. Both the background and urban areas of Beijing experienced particulate matter pollution in 2011. In addition to local air pollution, Beijing was also affected by pollutants transported from other regions, especially during heavy air pollution episodes. PM10, NO2, and SO2 concentrations showed positive associations with numbers of outpatient visits for otolaryngology during winter. NO2 and SO2 also had adverse ear, nose, and throat health effects outside of winter. The ear, nose, and throat health risks caused by air pollutants were higher during the winter than during the summer. NO2 had stronger influence on increased the likelihood of outpatient visits than SO2. The findings provide additional information about air quality and health effects of air pollution in Beijing.

Meeting the International Health Regulations (2005) surveillance core capacity requirements at the subnational level in Europe: the added value of syndromic surveillance

Background

The revised World Health Organization’s International Health Regulations (2005) request a timely and all-hazard approach towards surveillance, especially at the subnational level. We discuss three questions of syndromic surveillance application in the European context for assessing public health emergencies of international concern: (i) can syndromic surveillance support countries, especially the subnational level, to meet the International Health Regulations (2005) core surveillance capacity requirements, (ii) are European syndromic surveillance systems comparable to enable cross-border surveillance, and (iii) at which administrative level should syndromic surveillance best be applied?

Discussion

Despite the ongoing criticism on the usefulness of syndromic surveillance which is related to its clinically nonspecific output, we demonstrate that it was a suitable supplement for timely assessment of the impact of three different public health emergencies affecting Europe. Subnational syndromic surveillance analysis in some cases proved to be of advantage for detecting an event earlier compared to national level analysis. However, in many cases, syndromic surveillance did not detect local events with only a small number of cases.

The European Commission envisions comparability of surveillance output to enable cross-border surveillance. Evaluated against European infectious disease case definitions, syndromic surveillance can contribute to identify cases that might fulfil the clinical case definition but the approach is too unspecific to comply to complete clinical definitions. Syndromic surveillance results still seem feasible for comparable cross-border surveillance as similarly defined syndromes are analysed.

We suggest a new model of implementing syndromic surveillance at the subnational level. In this model, syndromic surveillance systems are fine-tuned to their local context and integrated into the existing subnational surveillance and reporting structure. By enhancing population coverage, events covering several jurisdictions can be identified at higher levels. However, the setup of decentralised and locally adjusted syndromic surveillance systems is more complex compared to the setup of one national or local system.

Summary

We conclude that syndromic surveillance if implemented with large population coverage at the subnational level can help detect and assess the local and regional effect of different types of public health emergencies in a timely manner as required by the International Health Regulations (2005).

Estimating the spatial distribution of acute undifferentiated fever (AUF) and associated risk factors using emergency call data in India. A symptom-based approach for public health surveillance

The System for Early-warning based on Emergency Data (SEED) is a pilot project to evaluate the use of emergency call data with the main complaint acute undifferentiated fever (AUF) for syndromic surveillance in India. While spatio-temporal methods provide signals to detect potential disease outbreaks, additional information about socio-ecological exposure factors and the main population at risk is necessary for evidence-based public health interventions and future preparedness strategies. The goal of this study is to investigate whether a spatial epidemiological analysis at the ecological level provides information on urban-rural inequalities, socio-ecological exposure factors and the main population at risk for AUF. Our results displayed higher risks in rural areas with strong local variation. Household industries and proximity to forests were the main socio-ecological exposure factors and scheduled tribes were the main population at risk for AUF. These results provide additional information for syndromic surveillance and could be used for evidence-based public health interventions and future preparedness strategies.