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Network authors: Portugal - Raquel Guiomar, Pedro Pechirra, National Influenza Reference Laboratory, Infectious Diseases Department, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal Background: The 2018/2019 influenza season in the WHO European Region was dominated by influenza A (H1N1)pdm09 and (H3N2) viruses, with very few influenza B viruses detected. Methods: Countries in the European Region reported virus characterization data to The European Surveillance System for weeks 40/2018 to 20/2019. These virus antigenic and genetic characterization and haemagglutinin (HA) sequence data were analysed to describe and assess circulating viruses relative to the 2018/2019 vaccine virus components for the northern hemisphere. Results: Thirty countries reported 4776 viruses characterized genetically and 3311 viruses antigenically. All genetically characterized A(H1N1)pdm09 viruses fell in subclade 6B.1A, of which 90% carried the amino acid substitution S183P in the HA gene. Antigenic data indicated that circulating A(H1N1)pdm09 viruses were similar to the 2018/2019 vaccine virus. Genetic data showed that A(H3N2) viruses mostly fell in clade 3C.2a (75%) and 90% of which were subclade 3C.2a1b. A lower proportion fell in clade 3C.3a (23%) and were antigenically distinct from the vaccine virus. All B/Victoria viruses belonged to clade 1A; 30% carried a double amino acid deletion in HA and were genetically and antigenically similar to the vaccine virus component, while 55% carried a triple amino acid deletion or no deletion in HA; these were antigenically distinct from each other and from the vaccine component. All B/Yamagata viruses belonged to clade 3 and were antigenically similar to the virus component in the quadrivalent vaccine for 2018/2019. Conclusions: A simultaneous circulation of genetically and antigenically diverse A(H3N2) and B/Victoria viruses was observed and represented a challenge to vaccine strain selection. Highlights: Co-circulation of different clades/subclades of influenza A viruses in 2018/2019 in the Region; Most circulating A(H1N1)pdm09 viruses (6B.1A) carried S183P in hemagglutinin; Genetically heterogeneous A(H3N2) viruses, with co-circulation of clades 3C.2a and 3C.3a; Antigenically distinct A(H3N2) clade 3C.3a viruses were increasingly detected until 02/2019 and then decreased; Co-circulation of genetically and antigenically diverse A(H3N2) strains challenges vaccine strain selection. info:eu-repo/semantics/publishedVersion

Purpose: The purpose of the study was to examine the trends between 2002 and 2018 in school pressure and school satisfaction among 15-year-old students, across countries and by gender, in the WHO European region and North America, and explore whether there are variations between countries and by gender in the co-occurrence of school pressure and school satisfaction. Methods: Data from the 32 countries that participated in the Health Behaviour in School-aged Children study (HBSC) study between 2002 and 2018 were used. Statistical analyses included ttests, binary logistic regression analyses, and chi-square tests, as required by each of the study aims. Results: School satisfaction tended to increase over the period 2002e2018 among boys, whereas school pressure increased among girls. Also, gender differences tended to dissipate in school satisfaction and generally increase in school pressure. The co-occurrence of school satisfaction and school pressure in 2017/2018 shows that the majority of students are found in the “not pressured enot highly satisfied” and “pressuredenot highly satisfied” groups. There were more boys in the former group and more girls in the latter group. Conclusion: Few students in the 32 countries belonged to the “not pressuredehighly satisfied” group, which from a public health perspective may be seen as the most desirable group. The increases in school pressure in girls from 2002 to 2018 and their overrepresentation in the pressured groups require further attention. Ministerio de Ciencia, Innovación y Universidades RYC-2017e 21626

The area affected by wildfires is experiencing an overall decrease in the Mediterranean European region. However, there is no clear trend associated to the incidence of large fire events, which continue to pose an important threat to assets-at-risk, while debates on control by meteorological or fuel drivers are ongoing. Understanding the underlying spatial and temporal patterns of large-fire drivers is of critical importance for a more efficient and science-based management, and specifically for improving wildfire season definition and informing fuel management. Taking advantage of the reliable wildfire data available in Spain, we analyzed large fires (>100 ha) in the period 2010–2015 to outline homogenous spatial-temporal regions in terms of the influence of the main drivers of large-fire activity: temperature, wind speed, slope, distance to populated places and roads, and proximity to agricultural lands. We combined Geographically Weighted Logit Regression (GWLR) models to parameterize the marginal influence of the drivers, with optimized hierarchical clustering to define uniform regions in terms of the underlying driving factors. These regions were subsequently analyzed for monthly distribution of fire occurrence and associated fuel models. We identified four different zones in terms of drivers' features, capturing dissimilar intra-annual patterns of fire activity and affected fuels: one covering the Mediterranean and two along the northern coast, and a fourth aggregation in the hinterlands that seems to act as transition area. The Mediterranean and hinterland were linked to weather-related summer ignitions, late and early summer respectively. The northern cluster gathers most winter fires starting in remote locations under steep slopes and strong wind conditions. The northwestern cluster accounts for most of the fire activity in Spain, related to complex relief and shrub-type fuels.

A stalagmitic flowstone deposit from the Beke Cave (called Nagy-tufa deposit), East-Central Europe is characterized by complex, climate related textural and geochemical records as documented from a drill core (BNT-2 core) covering the period of 4 to 1 ka cal BP. The core location was monitored in an earlier study. Based on monitoring, textural and chemical relationships, it has been hypothesized that the stable carbon isotope signal of the flowstone deposit is a regional humidity record, indicating wet periods 3.8 to 3.4, 3.0 to 2.8 and 2.0 to 1.6 ka cal BP, and a prominent dry period between 2.1 and 2.7 ka cal BP. Furthermore, stable H isotope data of inclusion-hosted water were used to reconstruct the atmospheric temperatures that fit independent regional paleotemperature records, indicating warm conditions around 2.7 ka BP and a relatively cold period between 2.5 and 1.5 ka BP. Comparisons with regional speleothem records and reconstructed North Atlantic Oscillation data indicate that the Late Holocene paleohumidity changes recorded by the BNT-2 stable carbon isotope record can be detected in the entire Western-Central European region with further links to the North Atlantic realm.

A literature study was carried out with respect to the release and accumulation of formaldehyde indoors. With reference to representative emission data, exposure scenarios were calculated on the basis of the European Reference Room with the aid of Monte-Carlo methods. Furthermore, data concerning formaldehyde concentrations in indoor and outdoor air, as well as data on air exchange, were collected for the European region. Various permanent, intermitting and temporary emission sources were compared under the specified conditions of the Reference Room. It was thereby necessary to bear in mind that, for example, the emission tests for raw wood-based materials and mineral wool do not take place under realistic conditions, as these products are not applied open in indoor areas. It is demonstrated that coatings and coverings drastically reduce the release of formaldehyde into the room air. Moreover, it becomes clear that the Reference Room concept allows a comparison of emission sources but also greatly overestimates the formaldehyde concentrations in indoor areas when diverse sources are simply added together. In view of the discussed aspects, as well as taking into account outdoor air conditions and diverse secondary sources, the potential problem of exposure to high formaldehyde concentrations in indoor areas can therefore not be solved through the further tightening of already existing regulations, in particular because peak concentrations and therefore high exposures would remain largely uninfluenced. Due to the fact that formaldehyde is a compound with a threshold effect, this aspect is of considerable importance. Consequently, an appropriate risk management option would be to primarily address the peak concentrations originating from temporary and intermitting sources.

Learning rates enable the generation of first-order estimates of the cost of a technology as cumulative production grows, and play an important role in energy-economic modelling. This paper extends the component-based approach to estimating future learning rates to the case of a technology with multiple variants. It sets out a bottom-up method for estimating the composite learning rate including the situation where the proportional contribution of the different variants changes as cumulative production increases. The method is demonstrated for carbon storage using representative cost and distribution data from recent studies of storage in the European region. Carbon storage comprises four technology variants defined by the nature of the storage reservoir – (onshore or offshore) depleted oil & gas reservoirs and (onshore or offshore) saline aquifers – and each variant has a different learning rate reflecting its different cost structure. Moreover, the proportional contribution of each variant to total storage is likely to change with the growth of global storage capacity. The composite learning rate for carbon storage is estimated for scenarios in which the relative contributions change: a negative learning rate is determined in one scenario.

The diurnal course of daylight (exterior illuminance) during winter and summer in a central European town, Bratislava, Slovakia, is studied. By using multivariate statistical methods (Factor and Cluster Analysis), the most significant types of the diurnal variations of illuminance are determined. The database used consists of mean 5-min values of global horizontal illuminance for the 14-year period 1994–2007. Two sets of data (sunrise-noon, noon-sunset) are utilized for each season, consisting of the anomalies of the semi-diurnal courses of illuminance with respect to the mean semi-diurnal course on each calendar day of the year. For winter, six typical semi-diurnal courses for sunrise-noon and nine for noon-sunrise are found, and for summer, six for sunrise-noon and seven for noon-sunset. For each type of semi-diurnal course, the most representative day is selected. Finally, for a verification of the results the atmospheric circulation patterns near the surface and at the 500-hPa level, the distribution of precipitation over Europe as well as the meteorological observations are presented, for these days. The purpose of the present study is to achieve an objective determination of the main diurnal daylight courses observed in a central European region. The results can be useful to engineers for a rational use of daylight in buildings, which may significantly contribute towards energy saving.

Pigs are an important source of human infections with Salmonella, one of the most common causes of sporadic gastrointestinal infections and foodborne outbreaks in the European region. Feed has been estimated to be a significant source of Salmonella in piggeries in countries of a low Salmonella prevalence. To estimate Salmonella risk to consumers via the pork production chain, including feed production, a quantitative risk assessment model was constructed. The Salmonella prevalence in feeds and in animals was estimated to be generally low in Finland, but the relative importance of feed as a source of Salmonella in pigs was estimated as potentially high. Discontinuation of the present strict Salmonella control could increase the risk of Salmonella in slaughter pigs and consequent infections in consumers. The increased use of low risk and controlled feed ingredients could result in a consistently lower residual contamination in pigs and help the tracing and control of the sources of infections.

Highlights • Mean city centre winter UHI intensity was +2.3 °C reaching maximum of +9.9 °C. • Winter UHI reduces cold-related mortality by 15% (266 deaths avoided). • This compares with increased mortality of 36% (96 deaths) in summer. • Winter UHI continues to have a protective effect in future climate., Exposure to heat has a range of potential negative impacts on human health; hot weather may exacerbate cardiovascular and respiratory illness or lead to heat stroke and death. Urban populations are at increased risk due to the Urban Heat Island (UHI) effect (higher urban temperatures compared with rural ones). This has led to extensive investigation of the summertime UHI and its effects, whereas far less research focuses on the wintertime UHI. Exposure to low temperature also leads to a range of illnesses, and in fact, in the UK, annual cold-related mortality outweighs heat-related mortality. It is not clearly understood to what extent the wintertime UHI may protect against cold related mortality. In this study we quantify the UHI intensity in wintertime for a heavily urbanized UK region (West Midlands, including Birmingham) using a regional weather model, and for the first time, use a health impact assessment (HIA) to estimate the associated impact on cold-related mortality. We show that the population-weighted mean winter UHI intensity was +2.3 °C in Birmingham city center, and comparable with that of summer. Our results suggest a potential protective effect of the wintertime UHI, equivalent to 266 cold-related deaths avoided (~15% of total cold-related mortality over ~11 weeks). When including the impacts of climate change, our results suggest that the number of heat-related deaths associated with the summer UHI will increase from 96 (in 2006) to 221 in the 2080s, based on the RCP8.5 emissions pathway. The protective effect of the wintertime UHI is projected to increase only slightly from 266 cold-related deaths avoided in 2009 to 280 avoided in the 2080s. The different effects of the UHI in winter and summer should be considered when assessing interventions in the built environment for reducing summer urban heat, and our results suggest that the future burden of temperature-related mortality associated with the UHI is likely to increase in summer relative to winter.

Objectives The proportion of tuberculosis (TB) cases occurring in migrants in Europe is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality, yet its extent in migrant populations is unclear. We assessed patterns of extrapulmonary TB in migrants across the European Union (EU)/European Free Trade Association (EFTA). We investigated the proportion of extrapulmonary TB cases among migrants versus non-migrants, and variations by specific site of disease, reporting European region, and migrant region of origin. Methods We carried out a cross-sectional secondary database analysis, utilizing 23 years of data collected between 1995 and 2017 from the European Surveillance System of the European Centre for Disease Prevention and Control for 32 EU/EFTA countries. Results In total, 1 270 896 TB cases were included, comprising 326 987 migrants (25.7%) and 943 909 non-migrants (74.3%). Of TB cases among migrants, 45.2% (n = 147 814) were extrapulmonary compared to 21.7% (n = 204 613) among non-migrants (p

Background This study aims to examine the relationship between weather changes (atmospheric pressure and temperature) and incidence of rupture of abdominal aortic aneurysm (AAA). Methods All patients with ruptured infrarenal AAA and who were referred to our institution between August 1998 and August 2015 were prospectively entered into a database of which a retrospective review of a ruptured AAA was performed. The needed information about the daily atmospheric pressure and air temperature could be extracted from the meteorological unit in Cologne. Results During the study period (6,225 days), a total number of 154 patients with confirmed ruptured AAA were identified. Basic patients' characteristics are tabulated. The mean daily atmospheric pressure during the study was 1,004.04 ± 8.79 mBar ranging from 965.40–1031.80 mBar. The mean atmospheric pressure on the days of rupture was 1,004.03 vs. 1,004.68 on those days when no rupture occurred ( P = 0.34). The mean atmospheric pressure on the day of rupture and that on the preceding day was not significantly different (1,004.78 vs. 1,005.44 with P = 0.13). The air temperature (10.62 ± 6.25 vs. 10.77 ± 6.83°C, P = 0.787) was equally distributed between days of rupture events and control days. Conclusions The present study could not show a significant association between the monthly and seasonal difference in atmospheric pressure and the prevalence of AAA rupture as it has been supposed by previous studies.

Purpose To evaluate the framework of drug information produced by public health and regulatory institutions in Europe. Materials and methods We carried out a short survey asking editors of ISDB bulletins of the European region to indicate the main sources of drug information provided by public health and regulatory authorities in their countries, the specific kind of information produced and their opinions about strengths and weaknesses of such information. The availability of evaluations about the added therapeutic value of drugs and of tools facilitating the implementation of such information were particularly addressed and checked on the websites of those institutions. Results Answers pertaining to eight countries were available. Regulatory information and safety alerts are generally available, but just UK and Germany stand out by showing quite an advanced framework of evidence-based, comparative drug information for health professionals, decision-makers and for the general public. National plans to implement evidence-based drug information seem lacking. Conclusion More efforts are warranted to develop sharp formats to make evidence-based drug information easier to access, understand and put in context, showing the place in therapy of medicines and their added therapeutic value. Harmonization of different sources, also at European level, would be important to favor their access and limit dispersion. Appropriate tools and specific plans are then necessary to favor implementation of information materials.

There is increasing consensus that limiting consumption of meat and dairy products can contribute to lowering the environmental impact of diets. At the same time, the market for ultra-processed plant-based substitutes for meat and dairy (ie. ‘milk’, ‘cheese’ and ‘yoghurt’) is expanding to meet changing consumer demands. This shift far outpaces the revision of dietary guidelines and other nutritional guidance. Here, we identify significant knowledge gaps in the nutritional composition of meat and dairy substitutes as well as the extent to which they comprise modern diets in many countries in the WHO European Region. We also highlight that most dietary models are not based on real-life dietary patterns.

The aim of this study was to analyze 26 various illicit drugs, psychopharmaceuticals and metabolites thereof in sewer from 17 selected wastewater treatment plants (WWTPs) in the Slovak and Czech Republics. Urinary bio-markers used were analyzed using liquid chromatography coupled with the tandem mass spectrometry (LC-MS/MS). We then compared our results with data obtained in other parts of Europe and the world. The present study shows that the Slovak and Czech Republics have one of the highest methamphetamine consumption rates in Europe. Within Slovakia, the highest level of methamphetamine consumption was found in Dunajská Streda with the mean specific load of the drug in sewage being up to 479mg/day/1000 inhabitants; the next highest load was detected in Trnava (354mg/day/1000 inhabitants). The methamphetamine, ecstasy and cannabis consumptions in our study were comparable to those found in other European cities, whereas cocaine consumption was lower. Among all of the studied psychopharmaceuticals, tramadol and venlafaxine were represented in the highest concentrations. The highest mean specific load of tramadol was detected in the spa town of Piešťany (371mg/day/1000 inhabitants) and Košice (372mg/day/1000 inhabitants), while the highest mean loads of venlafaxine were recorded for the towns of Trenčín (230mg/day/1000 inhabitants) and Piešťany (108mg/day/1000 inhabitants).

This paper provides a snapshot of the implementation of the WHO European Food and Nutrition Action Plan 2015–2020 among Member States in the WHO European Region. The focus is on the level and degree of implementation of selected policies recommended in this regional framework to promote healthy nutrition and prevent diet related noncommunicable diseases including obesity. Data was gathered through online and off-line versions of the Global Nutrition Policy Review questionnaire in 2017, through appointed focal points from the ministries of health. Almost all (94%) countries in the European region responded to the questionnaire, although not all responses were equally detailed. Significant progress has been made in some areas of public health nutrition, such as within school food policies, product reformulation, and implementation of trans fat regulations. However, if countries are to achieve global NCD targets, more ambitious policies with appropriate breadth and depth are needed. This is mainly the case for consumer-friendly front-of-package labelling, restrictions on marketing of foods to children as well as policies to protect, promote and support exclusive breastfeeding and appropriate complementary feeding practices. Lastly, it is crucial to prioritize robust monitoring, surveillance and evaluation systems in order to understand the effect of these actions and to guide timely and appropriate adjustment of policies.

Using a sample of 312 bank M&As announced between 1998 and 2016 in the EU-27 countries, this paper investigates the impact of market concentration and the European sovereign debt crisis on the way investors react to these corporate events. In Western European countries, we find results which contrast the conventional wisdom that acquiring banks lose around the merger announcement date. In fact, since 2009, acquiring banks shareholders gain approximately $34 million around the announcement, a $56 million improvement compared to the pre-crisis period. These documented shareholder gains are also accompanied by significant improvements in post-merger profitability. Markedly, we link this superior performance of the post-2008 acquirers with the degree of market concentration in the Western European region. Finally, results for the Eastern European countries indicate that the crisis did not have a significant impact on the quality of bank M&As in the region.

The paper presents how a combination of two progressive technologies - high-voltage direct current (HVDC) and wide area monitoring system (WAMS), can contribute towards secure power system operation and enable flexible power flows control. A new control algorithm based on WAMS for HVDC connection has been proposed and tested on a dynamic model of the future Central East European region.

Eight datasets of 1-h?black carbon (BC) concentrations measured in Warsaw agglomeration (Poland), at urban background and sub-urban sites, and in Raciborz, a small town in Upper Silesia district (regional background site) were analyzed to evaluate BC levels, daily profiles and statistical distributions of concentrations in Central-Eastern European region. The observed mean levels ranged from 1483?ng?m-3 in suburban site during summer to 3358?ng?m-3 in regional background site in winter. Observed diurnal patterns were bimodal in the locations dominated by traffic emissions, but unimodal, with elevated evening peak in individually heated residential area. Three theoretical frequency distributions were applied to fit analyzed datasets separately. The lognormal distribution was the most appropriate to represent the middle-range values, while the high concentrations were satisfactorily predicted by the type I two-parameter exponential distribution which was used to estimate the return periods of extreme concentrations for winter months. BC concentrations in Warsaw are higher than in Western European capitals.Regional background BC levels in Upper Silesia district are high, especially during winter.One or two daily peaks are observed depending on the dominating emission source and season.Lognormal distribution presents the best fit to the middle-range BC concentrations.Return periods of extreme BC wintertime concentrations were estimated.

Measles is a rash illness of moderate severity and high risk of serious complications, with recovery in several weeks. It is a viral disease caused by one of the most infectious and contagious pathogens that exists, whose only known reservoir is human. In 1998, the European Region of the WHO set a target of eliminating measles by 2010. This goal has not been achieved. Furthermore, it has been observed the resurgence of the disease in some parts of Europe. We review the disease and its vaccines as well as the epidemiological and social factors that have so far prevented the total control of the disease.

Cosmogenic nuclide surface exposure ages have been widely used to constrain glacial chronologies in the European regions. This paper brings new evidence that the Romanian Carpathians sheltered mountain glaciers in their upper valleys and cirques until the end of the last glaciation. Twenty-four 10Be surface exposure ages were obtained from boulders on moraine crests in the central area of the Parâng Mountains, Southern Carpathians. Exposure ages were used to constrain the timing of the deglaciation events during the Late Glacial. The lowest boulders yielded an age of 13.0 ± 1.1 (1766 m) and final deglaciation occurred at 10.2 ± 0.9 ka (2055 m). Timing of the Late Glacial events and complete deglaciation reported in this study are consistent with, and confirm, previously reported ages of deglaciation within the Carpathian and surrounding European region.

Drug-resistant tuberculosis (TB) has increased at an alarming rate in the WHO European Region. Of the 27 countries worldwide with a high burden of multidrug resistant-TB (MDR-TB), 15 are in the European Region. An estimated 78,000 new cases of MDR-TB occur annually in the Region, of which approximately 10% are extensively drug-resistant (XDR)-TB. In response, the WHO Regional Office for Europe developed a Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-resistant Tuberculosis (2011-2015). Our objective was to analyse the cost-effectiveness of implementing the plan, with the expected achievements of diagnosing 85% of estimated MDR-TB cases and treating at least 75% successfully. A transmission model, using epidemiological data reported to WHO was developed to calculate expected achievements. WHO-CHOICE database was used for cost analyses. The highly cost-effective plan is expected to prevent the emergence of 250,000 new MDR-TB and 13,000 XDR-TB patients respectively, saving US$7 billion and 120,000 lives. The plan and accompanying Resolution were fully endorsed by the sixty-first session of the WHO Regional Committee for Europe in 2011. Member States need to continuously improve health system performance and address TB determinants. Research and development of new medicines, tools and patient-friendly services are also crucial.

While Clostridium difficile epidemiology is well documented in many European countries, data are largely missing for South Eastern European region. Here we report the PCR ribotype distribution of 249 C. difficile isolates received for typing from six hospital settings from Croatia, Bosnia and Herzegovina, Republic of Macedonia and Serbia in time period from 2008 to 2015. Twenty-four PCR ribotypes were detected. The majority of strains from Bosnia and Herzegovina and Serbia belonged to PCR ribotype 027 (65.8%). Other three dominating PCR ribotypes were 176 (18 strains ; Croatia), 001/072 (15 strains ; all countries) and 014/020 (15 strains ; all countries).

Objective The aim of this study is to assess the level of protection of secondhand smoke in outdoor locations among countries belonging to the WHO European Region. Method This cross-sectional study measures the level of protection provided by laws in outdoor locations. A protocol to evaluate the outdoor smoke-free legislation was developed according to the recommendations provided by the WHO Guidelines for implementing smoke-free outdoor places. For each law 6 main sectors and 28 outdoor locations were evaluated. Results 68 laws from 48 countries were reviewed, totally assessing 1758 locations. Overall 3.1% of the locations specified 100% smoke-free outdoor regulation without exceptions, 2.5% permitted smoking in designated outdoor areas, 37.5% allowed smoking everywhere, and 56.9% did not provide information about how to deal with smoking in outdoor places. In the Education sector 17.8% of the laws specified smoke-free outdoor regulation, mainly in the primary and secondary schools. Three pioneering laws from recreational locations and two from general health facilities specified 100% outdoor smoke-free regulation. Conclusion Outdoor smoke-free policies among countries belonging to the WHO European Region are limited and mainly have been passed in the primary and secondary schools, which protect minors from the hazards of secondhand smoke in educational settings.

Introduction The concurrent use of multiple tobacco products (i.e., poly-tobacco use) might hinder efforts to reduce overall tobacco use, particularly considering that use of some non-cigarette tobacco products may be popular in some regions due to social, cultural, or economic reasons. This study assessed poly-tobacco use patterns among persons aged â?¥15 years old from 44 countries. Methods Data from 44 countries in all six World Health Organization regions were obtained from the 2008-2012 Global Adult Tobacco Surveys (n = 19 countries), and the Special Eurobarometer 385 (77.1) survey, 2012 (n = 25 countries). Correlates of poly-tobacco use were assessed using multivariate logistic regression analyses (p < 0.05). Results Overall prevalence of poly-tobacco use ranged from 0.8% (Mexico) to 11.9% (Denmark). In 28 countries, 20% or more of current smokers of manufactured cigarettes concurrently used at least one other tobacco product and this proportion was highest in India (66.2%) and lowest in Argentina (4.4%). After adjusting for other factors, the likelihood of being a poly-tobacco user among all respondents was lower among females (aOR = 0.09; 95%CI:0.08-0.11), and among respondents from upper-middle-income (aOR = 0.53, 95%CI:0.43-0.66), and lower-middle-income countries (aOR = 0.64; 95%CI:0.51-0.81) compared to high income countries. Increased likelihood of poly-tobacco use was observed among respondents from the South-East Asian region compared to those from the European region (aOR = 1.58, 95%CI:1.35-1.85), as well as among respondents aged â?¥65 years (aOR = 2.10; 95%CI:1.73-2.54), compared to those aged

Despite the availability of safe and effective hepatitis B virus (HBV) vaccines for more than 30years, the burden of hepatitis B disease is still substantial. In 1992, the WHO recommended the inclusion of HBV vaccination in all national vaccination programmes. As of 2012, 47 of the 53 European countries (89%) had implemented a universal hepatitis B vaccination programme. The most recent countries to follow the recommendation were Ireland (in 2008) and the Netherlands (in 2011). Still, six countries (Denmark, Finland, Iceland, Norway, Sweden and the UK) adopt risk-group-targeted vaccination only, instead of adding a universal vaccination programme. However, changing demography, increasing immigration and the current vaccine costs make the cost-benefit ratios in these remaining low endemicity countries strongly in favour of universal HBV vaccination. Global efforts, including a cohesive European vaccination policy, are essential to control and prevent hepatitis B.

The publisher regrets that the co-authors in the “European region influenza surveillance network” were not tagged correctly. The full and complete list of authors and their affiliations for this article is given above. The publisher would like to apologise for any inconvenience caused.

In electricity storage valuation studies, the lack of the (efficient) aggregation of applications in a single operation strategy is usually identified as a major barrier. Determining the true value of storage requires the aggregation of applications while accounting for the interdependence between revenue streams. Individual applications cannot simply be added together, but need to be co-optimized since they can interfere with each other. This article's contributions are threefold. First, we provide model formulations to aggregate multiple arbitrage opportunities, and to quantify the accompanying potential arbitrage value. Whereas the storage arbitrage literature focuses on the capturing of price differences over time for the day-ahead market, we consider all three short-term markets, i.e., the day-ahead, intra-day, and real-time markets, and we consider the opportunity to capture three types of price differences: (1) over time in each individual market, (2) over the three markets for the same time step, and (3) over time over the three markets. Second, an important assumption in arbitrage models is related to whether storage operators recognize that their actions may affect those prices. This price-effect of storage actions has been considered before for the day-ahead market, but not for the intra-day and real-time markets. We study the price-effect with high detail for all three short-term markets, based on real-world price and volume data. Third, we apply the developed models to the four market zones of the Central Western European region, i.e., the Belgian, French, German, and Dutch market zones, while elaborating on the price-effect for the Belgian zone. As such, this article provides insight in the extent to which the three short-term markets, and their combination, in these market zones are potentially interesting for storage arbitrage. This assists improved decision-making of market participants in storage investment and operation, and informs policy-makers about the impact of market design on the potential storage value.

The reconstruction of past atmospheric circulation is crucial for the understanding of natural climate change and its driving factors. A recent reconstruction suggests that, during Medieval times, the European region was dominated by a persistent positive phase of the North Atlantic Oscillation (NAO), followed by a shift to a more oscillatory behavior. We test this hypothesis and the concept underlying the reconstruction in a pseudo-proxy approach using instrumental records, reanalysis data sets and millennial simulations with four different climate models. While a shift from a more positive to a more negative phase of the NAO seems to be likely, the amplitude and persistence of the reconstructed positive phase cannot be reproduced by models. The analysis further reveals that proxy locations that were used in the reconstruction are not always sufficient to describe the NAO. This is reflected in a failure of the reconstruction to verify against instrumental records of the NAO in the 19th century. By adding complementary proxies, the robustness of an NAO reconstruction can be improved to the degree that it would withstand the tests presented here.

BACKGROUND: The "Tallinn Charter: Health Systems, Health and Wealth" signed by 53 member states of the WHO European Region provides guidance for strengthening health systems. OBJECTIVES: A systematic search was conducted to compare studies and actions related to the commitments of the Tallinn Charter. MATERIALS AND METHODS: Target keywords were identified directly from the Charter. Structured web search was conducted on Pubmed/Google. Results for 2007-2010 were analyzed as frequencies before/after the end of the year of signature and classified by relevance and category of content. RESULTS: Searches for 2007-2010 extracted N=717 papers in Medline and N=634 links in Google using combined keywords. Additional N=165 direct links to the Charter were found by Google for 2008-2010. An increase by 18% (scientific literature) and 10% (grey literature) was observed after 2008. DISCUSSION: The number of conceptual, methodological, analytical or system evaluation reports related to the themes of the Charter increased after 2008, while benchmarking and cross-country comparisons were less frequent. Opposite trends were observed for the grey literature. CONCLUSIONS: The implementation of the Tallinn Charter is supported by more information available on the topic. The methodology used to perform a rapid search may be usefully repeated to monitor the process.

The lessons learned from a review of thirteen existing European bio-economic models used in the evaluation of EU policies are presented. How these models compare and differ in terms of their biological and economic components, the integration between the components, which indicators are selected and how they are used, are described and analysed. The article concludes that the multitude of construction differences reflects the necessity of adapting the modelling approach to answer different questions. Since real life questions in fisheries are so diverse, answering them requires a diversity of models.

The European principles of Integrated Coastal Zone Management (ICZM) are often viewed as central, defining features of the EC approach to ICZM, enshrined within the EC Recommendation (2002/413/EC) and endorsed by the European Commission in its Communication on ICZM (COM(2007) 308 final). This paper presents the findings of COREPOINT surveys which evaluated the extent to which the ICZM principles are addressed and interpreted across the North West European region. An interpretation of these findings is undertaken in order to provide an assessment of local ICZM development against the European ICZM Progress Indicator. The surveys revealed rather mixed adherence to with the EC ICZM principles at national, regional and local levels, although there were some promising results related to the principles of local specificity and stakeholder engagement. The principles providing the greatest challenge were those promoting the broad holistic approach, the long-term approach and adaptive management. The surveys demonstrated the value of using a structured, clearly designed ‘expert’ survey for providing an insight into operational aspects of the ICZM principles and provided a means of assessing ICZM progress. As such, this paper provides a useful contribution to the ongoing European and wider debate about the principles and their evaluation.

The aim of this paper is to investigate various aspects of the International Reference Ionosphere (IRI) performance in European area and to evaluate its accuracy and efficiency for: long term prediction of the critical frequencies foF2 and the maximum usable frequencies (MUF); using storm-time correction option (ST); the total electron content (TEC) and the maximum observable frequency (MOF) updating. Data of foF2, TEC, MOF are related to 2005. It is obtained that median values of foF2 can be predicted with the mean error σ(med)∼ 0.49 MHz. For median values of MUF absolute σ was 1.39 MHz and relative σr was 8.8%. For instanteneous values estimates are increased to 1.58σ(med) MHz for foF2 and could reach 3.84 MHz for MUF. Using correction ST-option and TEC values provided ∼30% improvement but TEC seems to be more preferable. However, from considered parameters of the IRI updating (ST-factor, TEC, MOF) the best results were demonstrated by MOF. Using the IRI2007 to calculate TEC gives 20–50% improvement of TEC correspondence to experimental values but this improvement is not enough to treat TEC without the IRI model adaptation.

Three different diagnostic criteria for primary progressive MS were recently proposed for Caucasian population of Western European region.The objective of the study was to apply these criteria to a series of Brazilian patients with high ethnic diversity background to evaluate reproducibility and reliability.52 patients classified as form of the disease that is progressive from onset and followed between 2000 and 2006 were included. Thompson, McDonald and Polman criteria were applied based in clinical date and complementary exams.72% fulfilled all three criteria with moderate agreement (p0.001). Ten patients fulfilled at least one criterion and four failed to fulfill any of the three criteria. Strong agreement was found between Thompson and McDonald criteria (p0.001), agreement was moderate between Thompson and Polman criteria (p0.001) and weak agreement occurred between McDonald and Polman criteria (p=0.042).The main difference between these criteria is the change in the role of CSF, previously a prerequisite for diagnosis. Rigid diagnostic criteria as Thompson have higher specificity, should be used in clinical research protocols, while more flexible criteria as Polman facilitate the diagnosis of PPMS in neurological practice, particularly in initial stages of the disease, because of their potentially higher sensitivity.

The current paper analyses the potential for prescribed burning techniques for mitigating carbon dioxide (CO2) emissions from forest fires and attempts to show quantitatively that it can be a means of achieving a net reduction of carbon emissions in the context of the Kyoto Protocol. The limited number of available studies suggests that significant reductions in CO2 emissions can be obtained and that prescribed burning can be a viable option for mitigating emissions in fire-prone countries. The present analysis shows that the potential reduction attained by prescribed burning as a percentage of the reduction in emissions required by the Kyoto Protocol varies from country to country. Out of the 33 European countries investigated, only in one the requirements of the Kyoto Protocol could potentially be achieved by applying prescribed burning, while three other nations showed a potential net CO2 emissions reduction of about 4–8% of the Kyoto requirements and the majority showed a reduction of less than 2%. This implies that prescribed burning can only make a significant contribution in those countries with high wildland fire occurrence. Over a 5-year period the emissions from wildfires in the European region were estimated to be approximately 11 million tonnes of CO2 per year, while with prescribed burning application this was estimated to be 6 million tonnes, a potential reduction of almost 50%. This means that for countries in the Mediterranean region it may be worthwhile to account for the reduction in emissions obtained when such techniques are applied.

There are clear indications that in the future the Alpine region will increasingly suffer from droughts. In this paper, a simple method is devised for determining probability of drought occurrence and exceedance of severity thresholds. A reconstruction of drought occurrence during the past 100 yr indicates that the method is able to detect major events and also to correctly gauge their relative severity. The procedure is used in conjunction with climate simulations for the European region valid for 2071–2100 to study the impact of climate change on the likelihood and severity of droughts. The climate scenario used for the analysis refers to a SRES A2 emission pathway and specifies in particular a decrease in the frequency of wet days of about 20% with respect to the growing season of summer crops (April to September). Under these conditions the frequency of droughts is shown to increase from about 15% to more than 50%. In addition, the results indicate an overall shift in the distribution toward higher severity scores. The average severity increases by a factor of two, but also at the upper end of the spectrum severity increases by more than 20%. It is argued that this will affect the perception of extreme droughts, i.e. of those events rarer than the 10th percentile of the distribution. If this scenario comes true, by the end of the 21st century droughts comparable in severity to the 2003 event would represent the norm rather than the exception.

New ionospheric activity indices are derived from automatically scaled online data from several European ionosonde stations. These indices are used to distinguish between normal ionospheric conditions expected from prevailing solar activity and ionospheric disturbances caused by specific solar and atmospheric events (flares, coronal mass ejections, atmospheric waves, etc.). The most reliable indices are derived from the maximum electron density of the ionospheric F 2layer expressed by the maximum critical frequency foF 2. Similar indices derived from ionospheric M(3000)F 2 values show a markedly lower variability indicating that the changes of the altitude of the F 2-layer maximum are proportionally smaller than those estimated from the maximum electron density in the F 2-layer. By using the ionospheric activity indices for several stations the ionospheric disturbance level over a substantial part of Europe (341N–601N; 51W–401E) can now be displayed online. r 2006 Elsevier Ltd. All rights reserved.