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Background and Aims: Although much has been written about the conventional cardiovascular risk factor correlates of the extent of coronary artery calcification (CAC), few studies have been carried out on symptomatic patients. This paper assesses the potential ability of risk factors to associate with an increasing CAC score.Methods: From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and the USA. All had conventional cardiovascular risk factor assessment and CT scanning for CAC scoring.Results: Among all patients, male sex (OR = 4.85, p<0.001) and diabetes (OR = 2.36, p<0.001) were the most important risk factors of CAC extent, with age, hypertension, dyslipidemia and smoking also showing a relationship. Among patients with CAC, age, diabetes, hypertension and dyslipidemia were associated with an increasing CAC score in males and females, with diabetes being the strongest dichotomous risk factor (p<0.001 for both). These results were echoed in quantile regression, where diabetes was consistently the most important correlate with CAC extent in every quantile in both males and females. To a lesser extent, hypertension and dyslipidemia were also associated in the high CAC quantiles and the low CAC quantiles respectively.Conclusion: In addition to age and male sex in the total population, diabetes is the most important correlate of CAC extent in both sexes. [ABSTRACT FROM AUTHOR]

Wind damage to commercial plantations and natural forests is a serious concern for forest owners and managers all over the world, with notable losses having been reported in the last few decades in Europe, the Americas, and Oceania. Wind-risk models such as ForestGALES allow for a good understanding of the dynamics involved in wind damage, and for calculations of risk to be made, therefore providing vital information on the best practices to minimise such risk. In this paper we parameterise ForestGALES for Eucalyptus globulus (Labill.), arguably one the most widespread and commercially important species for pulp and biomass production, with tree-pulling data obtained in Asturias, Spain. Despite the scarce data on tree and stand characteristics available for wind damaged stands of Eucalyptus spp., we provide an evaluation of our model’s performance under different stocking densities by comparing our simulations with real wind damage data acquired from the literature. We show that ForestGALES is able to accurately model the critical wind speeds responsible for Eucalypts stand damage, hence extending the model’s applicability to this important commercial genus. In line with good modelling practice, we present the results of a sensitivity analysis of the model, performed with a Global variance-based method. Our sensitivity analysis confirmed the main role of Dbh , stocking density, and tree height in driving the model outputs, and highlighted the importance of accurately knowing the size of any upwind gaps adjacent to a stand to reduce uncertainty in model predictions. [ABSTRACT FROM AUTHOR]

A ‘yes’ vote, though unlikely, would fundamentally alter the British Isles, and potentially Europe as well. [ABSTRACT FROM PUBLISHER]

Background: Shortly after the H1N1 influenza virus reached pandemic status in June 2009, the benefit–risk project team at the European Medicines Agency recognized this presented a research opportunity for testing the usefulness of a decision analysis model in deliberations about approving vaccines soon based on limited data or waiting for more data. Undertaken purely as a research exercise, the model was not connected to the ongoing assessment by the European Medicines Agency, which approved the H1N1 vaccines on 25 September 2009. Methods: A decision tree model constructed initially on 1 September 2009, and slightly revised subsequently as new data were obtained, represented an end-of-September or end-of-October approval of vaccines. The model showed combinations of uncertain events, the severity of the disease and the vaccines’ efficacy and safety, leading to estimates of numbers of deaths and serious disabilities. The group based their probability assessments on available information and background knowledge about vaccines and similar pandemics in the past. Results: Weighting the numbers by their joint probabilities for all paths through the decision tree gave a weighted average for a September decision of 216 500 deaths and serious disabilities, and for a decision delayed to October of 291 547, showing that an early decision was preferable. Conclusions: The process of constructing the model facilitated communications among the group’s members and led to new insights for several participants, while its robustness built confidence in the decision. These findings suggest that models might be helpful to regulators, as they form their preferences during the process of deliberation and debate, and more generally, for public health issues when decision makers face considerable uncertainty. [ABSTRACT FROM PUBLISHER]

Problem Improving pandemic planning and preparedness is a challenge in Europe, a diverse region whose regional bodies (the Regional Office for Europe of the World Health Organization [WHO], the European Commission and the European Centre for Disease Prevention and Control) have overlapping roles and responsibilities. Approach European pandemic preparedness indicators were used to develop an assessment tool and procedure based on the 2005 global WHO checklist for pandemic preparedness. These were then applied to Member States of WHO's European Region, initially as part of structured national assessments conducted during short visits by external teams. Local setting Countries in WHO's European Region. Relevant changes From 2005 to 2008, 43 countries underwent a pandemic preparedness assessment that included a short external assessment visit by an expert team. These short visits developed into a longer self-assessment procedure involving an external team but "owned" by the countries, which identified gaps and developed plans for improving preparedness. The assessment tool and procedure became more sophisticated as national and local pandemic preparedness became more complex. The 2009 pandemic revealed new gaps in planning, surveillance communications and immunization. Lessons learnt Structured national self-assessments with support from external teams allow individual countries to identify gaps in their pandemic preparedness plans and enable regional bodies to assess the regional and global resources that such plans require. The 2009 pandemic revealed additional problems with surveillance, pandemic severity estimates, the flexibility of the response, vaccination, involvement of health-care workers and communication. European national plans are being upgraded and global leadership is required to ensure that these plans are uniformly applied across the region. INSET: Box 1. Summary of lessons learnt. [ABSTRACT FROM AUTHOR]

If European countries are to build capabilities that match the significant amounts they spend on defence, effective cooperation on investments, force structures and equipment is necessary. [ABSTRACT FROM PUBLISHER]

In this article we explore the relationship of care of a group of health care workers in elderly care, through their descriptions of themselves and their work. We have an interest in how relationships of care may be explored and characterised in and across disparate vocational settings. This is a critical response to policy discourses of citizenship that are currently emerging for re-emphasis in Europe through citizenship education and the idea of the active citizen. We mobilise two notions to help us in the analysis of interview transcripts. First, 'calling' is used as a figure of thought. Past religious and secular discourses of calling to God and nursing provide us with glimpses of past relations of vocation and care through which to consider present descriptions. The term 'technology of the self' is one drawing specifically from the work of Michel Foucault, through which we theorise the calling to care emerging from our interviewee descriptions as such a technology. Our analysis indicates that a specific calling to care and technology is mobilised by these health care workers in elderly care. We conclude that it is through such stabilisations of description that the health care workers' shape context-specific subjectivities, as caring citizens. [ABSTRACT FROM AUTHOR]

Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the 'known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring (Component 3) for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) (Component 4) is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of Component 4) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2-4, resourcing them realistically and devising new ways of sharing analyses. [ABSTRACT FROM AUTHOR]

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Background: Breast feeding is beneficial for mothers and children and in all countries breast feeding should be encouraged, protected and promoted. Levels of breast feeding in Europe are lower than elsewhere, but there are few recent data on breast feeding policies and progress against international standards. Design: Questionnaire survey of national European non-governmental organizations (NGOs). Materials and Methods: Questionnaires were sent to NGOs in 41 European countries. Reports were received of policy and practice for 32 countries (a 76% response rate). Comparison with an independent World Health Organization/United Nations Children's Fund (WHO/UNICEF) survey showed good result validity. Results: Only 50% of the western European countries had a national breast feeding programme, while these were reported for nearly 90% of eastern Europe. Less than 50% of the countries monitored their programme's progress, only 40% communicated official policies to staff advising mothers on breast feeding and less than 60% reported routine antenatal breast feeding education. Although employment laws supporting breast feeding are common, these may be ineffective because women work outside the formal sector, especially in eastern Europe. Not all countries reported enactment of the International Code of Marketing Breast Milk Substitutes and this had been agreed with the food industry in less than 50%. Regular breast feeding surveys were uncommon and non-standardized. Although 50% of the countries routinely collected data on breast feeding, these data were not necessarily used. The results standardized well against the WHO survey. Conclusion: National breast feeding policies and practices remain inadequate in Europe, where there are considerable weaknesses in the protection, promotion and monitoring of breast feeding. NGOs are a useful complementary source of data and should be used more widely in international surveys and monitoring. [ABSTRACT FROM AUTHOR]

Examines national trends in diagnosed HIV infections, gonorrhea, and infectious syphilis from 1995 to 2000, using published routine data and studies in Europe. Data showing an increase in sexually acquired HIV infections, gonorrhea, and syphilis in men having sex with men; Indication that people might be taking sexual risks and are complacent over HIV prevention; Suggestion that public health surveillance of sexually transmitted infections other than HIV be introduced at the European level.

The European Single Market program has put in place legislation that provides the free circulation of goods, capital, and people. Further, the recent implementation of monetary union provides a single currency and a common monetary policy in 11 out of the 15 Member States. Yet significant practical barriers to European integration remain. Legislation concerning taxation and company law is still primarily nationally based. More fundamentally from a business perspective, the European environment continues to be characterized by divergent industry structures and national cultures. Although there is considerable momentum for political and economic integration at present, this deep-seated national diversity remains strong and can hinder businesses from adopting an integrated approach toward the European Union. [ABSTRACT FROM AUTHOR]

Looks at the budgetary affairs of the European Community (EC) in 1985. Maximum rate of increase of non-compulsory expenditure (NCE); Financial gap for 1985 in the budgetary finances; European Commission's budgetary compensation in favour of Great Britain.

In this article, the authors reflect on the 2009 influenza outbreak in Europe and how European authorities understand and evaluate advantages and possible risks of the pandemic. The authors mention factors that lessen its impact including cross-immunity of older Europeans to similar virus which spared them from the disease. They say that the characteristics of the pandemic established a challenge for people engaged in infection transmission.

Focuses on breast feeding programs in Europe. Data on the national survey of infant feeding in Great Britain; Link between infant feeding and health outcomes; Economic implications of breast feeding.

Due to climate change, forests are likely to face new hazards, which may require adaptation of our existing silvicultural practices. However, it is difficult to imagine a forest management approach that can simultaneously minimize all risks of damage. Multicriteria decision analysis (MCDA) has been developed to help decision makers choose between actions that require reaching a compromise among criteria of different weights. We adapted this method and produced a multicriteria risk analysis (MCRA) to compare the risk of damage associated with various forest management systems with a range of management intensity. The objective was to evaluate the effect of four forest management alternatives (FMAs) (i.e., close to nature, extensive management with combined objectives, intensive even-aged plantations, and short-rotation forestry for biomass production) on biotic and abiotic risks of damage in eight regional case studies combining three forest biomes (Boreal, Continental, Atlantic) and five tree species (Eucalyptus globulus, Pinus pinaster, Pinus sylvestris, Picea sitchensis, and Picea abies) relevant to wood production in Europe. Specific forest susceptibility to a series of abiotic (wind, fire, and snow) and biotic (insect pests, pathogenic fungi, and mammal herbivores) hazards were defined by expert panels and subsequently weighted by corresponding likelihood. The PROMETHEE ranking method was applied to rank the FMAs from the most to the least at risk. Overall, risk was lower in short-rotation forests designed to produce wood biomass, because of the reduced stand susceptibility to the most damaging hazards. At the opposite end of the management intensity gradient, close-to-nature systems also had low overall risk, due to lower stand value exposed to damage. Intensive even-aged forestry appeared to be subject to the greatest risk, irrespective of tree species and bioclimatic zone. These results seem to be robust as no significant differences in relative ranking of the four FMAs were detected between the combinations of forest biomes and tree species. [ABSTRACT FROM AUTHOR]

Within the Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE) project we conducted a multicentre case–control study in eight European Union (EU) Member States to estimate the 2011/12 influenza vaccine effectiveness against medically attended influenza-like illness (ILI) laboratory-confirmed as influenza A(H3) among the vaccination target groups. Practitioners systematically selected ILI / acute respiratory infection patients to swab within seven days of symptom onset. We restricted the study population to those meeting the EU ILI case definition and compared influenza A(H3) positive to influenza laboratory-negative patients. We used logistic regression with study site as fixed effect and calculated adjusted influenza vaccine effectiveness (IVE), controlling for potential confounders (age group, sex, month of symptom onset, chronic diseases and related hospitalisations, number of practitioner visits in the previous year). Adjusted IVE was 25% (95% confidence intervals (CI): -6 to 47) among all ages (n=1,014), 63% (95% CI: 26 to 82) in adults aged between 15 and 59 years and 15% (95% CI: -33 to 46) among those aged 60 years and above. Adjusted IVE was 38% (95%CI: -8 to 65) in the early influenza season (up to week 6 of 2012) and -1% (95% CI: -60 to 37) in the late phase. The results suggested a low adjusted IVE in 2011/12. The lower IVE in the late season could be due to virus changes through the season or waning immunity. Virological surveillance should be enhanced to quantify change over time and understand its relation with duration of immunological protection. Seasonal influenza vaccines should be improved to achieve acceptable levels of protection.

Two methodologies are used for describing and estimating influenza-related mortality: Individual-based methods, which use death certification and laboratory diagnosis and predominately determine patterns and risk factors for mortality, and population-based methods, which use statistical and modelling techniques to estimate numbers of premature deaths. The total numbers of deaths generated from the two methods cannot be compared. The former are prone to underestimation, especially when identifying influenza-related deaths in older people. The latter are cruder and have to allow for confounding factors, notably other seasonal infections and climate effects. There is no routine system estimating overall European influenza-related premature mortality, apart from a pilot system EuroMOMO. It is not possible at present to estimate the overall influenza mortality due to the 2009 influenza pandemic in Europe, and the totals based on individual deaths are a minimum estimate. However, the pattern of mortality differed considerably between the 2009 pandemic in Europe and the interpandemic period 1970 to 2008, with pandemic deaths in 2009 occurring in younger and healthier persons. Common methods should be agreed to estimate influenza-related mortality at national level in Europe, and individual surveillance should be instituted for influenza-related deaths in key groups such as pregnant women and children.

Annual epidemics of seasonal (inter-pandemic) influenza represent a significant burden on society in terms of morbidity, mortality, hospitalizations and lost working time. The impact of influenza depends on a mix of direct and indirect effects and is not easy to assess. Nevertheless there is a consensus in considering influenza prevention and mitigation high priorities for public health. We review the available evidence to assess the impact of influenza prevention focusing especially on vaccines and immunization strategies.

The 2011 influenza season (May to October) in the southern hemisphere was dominated by the A(H1N1) viruses that emerged during the 2009 influenza A(H1N1) pandemic and influenza B viruses, although the proportion of these two varied between and within countries. Some influenza A(H3N2) viruses were also seen. We discuss here the preliminary implications for Europe of the 2011 influenza season in five temperate southern hemisphere countries.

Providing guidance on risk and target groups for seasonal influenza immunisation is difficult for the 2010-11 season since there is no experience with the new influenza A(H1N1) virus in its seasonal form. Arguments exist for offering immunisation to people with chronic illness and older people, and also for other risk and target groups including pregnant women. A more rigorous approach is being developed to produce annual evidence-based guidance on risk and target groups for influenza vaccination.

During the 2007-08 influenza season, high levels of oseltamivir resistance were detected among influenza A(H1N1) viruses ina number of European countries. We used surveillance data to describe influenza A(H1N1) cases for whom antiviral resistance testing was performed. We pooled data from national studies to identify possible risk factors for infection with a resistant virus and to ascertain whether such infections led to influenza illness of different severity. Information on demographic and clinical variables was obtained from patients or their physicians. Odds ratios for infection with an oseltamivir resistant virus and relative risks for developing certain clinical outcomes were computed and adjusted through multivariable analysis. Overall, 727 (24.3%) of 2,992 tested influenza A(H1N1) viruses from 22 of 30 European countries were oseltamivir-resistant. Levels of resistance ranged from 1% in Italy to 67% in Norway. Five countries provided detailed case-based data on 373 oseltamivir resistant and 796 susceptible cases. By multivariable analysis, none of the analysed factors was significantly associated with an increased risk of infection with anoseltamivir-resistant virus. Similarly, infection with an oseltamivir-resistant virus was not significantly associated with a different risk of pneumonia, hospitalisation or any clinical complication. The large-scale emergence of oseltamivir-resistant viruses in Europe calls for a review of guidelines for influenza treatment.

Europe has experienced more than two months of the first transmissions and outbreak of the 2009 pandemic of A(H1N1)v. This article summarises some of the experience to date and looks towards the expected autumn increases of influenza activity that will affect every country. To date the distribution of transmission has been highly heterogenous between and within countries, with one country the United Kingdom (UK) experiencing the most cases and the highest transmission rates. Most infections are mild but there are steadily increasing numbers of people needing hospital care and more deaths are being reported. An initial difference in practice between Europe and North America was over case-finding and treatment with some authorities in Europe using active case-finding, contact tracing and treatment/prophylaxis with antivirals to try and delay transmission. This article details the history of this practice in the past two months and explains how and why countries are moving to mitigation, especially treating with antivirals those at higher risk of experiencing severe disease.

Variable levels of oseltamivir resistance among seasonal influenza A(H1N1) isolates have been reported in Europe during the 2007-8 northern Hemisphere influenza season. It has been questioned whether oseltamivir use could have driven the emergence and predominance of resistant viruses. This study aimed at describing the levels of use of oseltamivir in 12 European Union (EU) Member States and European Economic Area (EEA)/European Free Trade Area (EFTA) countries. The data were converted into prescription rates and compared with the national proportions of resistant influenza A(H1N1) viruses through regression analysis. Overall use of oseltamivir in European countries between 2002 and 2007 was low compared to e.g. the use in Japan. High variability between the countries and over time was observed. In eight of the 12 countries, there was a peak of prescriptions in 2005, coinciding with concerns about a perceived threat from an influenza pandemic which might have lead to personal stockpiling. Ecological comparison between national levels of use of oseltamivir in 2007 and the proportions of A(H1N1) viruses that were resistant to oseltamivir showed no statistical association. In conclusion, our results do not support the hypothesis that the emergence and persistence of these viruses in 2007-8 was related to the levels of use of oseltamivir in Europe. Further investigation is needed to elucidate the reasons for different level of use between the countries.

The coordination of influenza pandemic preparedness planning within Europe is especially important for Germany with 10 out of 16 Länder (regions) bordering neighbouring countries. The language barrier presents only one of the challenges to overcome. Creating a European early warning system by linking national surveillance structures and the development of a communication network are important initial achievements. Several instruments have been designed and the European Centre for Disease Prevention and Control has already played a major role in the coordination of this process. It has also led the assessment of preparedness and planning by Member States. The speed of the European Member States in preparing for and the foci they have chosen when dealing with an influenza outbreak are heterogeneous. The simultaneous analysis presented here from European, national and regional points of view aims to identify both opportunities and risks of this diversity in Europe for coping with a new pandemic. Regional and local initiatives for cross-border measures and crisis management will play a central role in achieving successful influenza pandemic preparedness in Europe.

The influenza season 2008-9 started in week 49 of 2008 and is so far characterised by influenza virus type A subtype H3N2. Isolates of this subtype that were tested proved susceptible to neuraminidase inhibitors, but resistant to M2 inhibitors. The circulating A(H3N2) viruses are antigenically similar to the component in the current northern hemisphere influenza vaccine.

This paper summarises the scientific evidence supporting selection of risk groups that would benefit from annual seasonal influenza immunisation in European Union (EU) countries. Risk groups are defined restrictively as persons in Europe at higher than average risk of adverse outcomes should they be infected with seasonal influenza and for whom use of vaccine is demonstrated to be effective in reducing the risk of those outcomes. Existing evidence indicate that older people and those with chronic disease are at higher risk of severe adverse outcome and that immunisation reduces this risk. There is thus good scientific evidence for routinely offering annual immunisation to all older people (at least those aged 65 years and older), and people with certain groups of chronic medical conditions. We estimated that these two groups account for between 19% and 28% of the population of EU countries. Thus in 2006, an estimated 84 million older people aged 65 years and over and 41 million people younger than 65 years of age with chronic conditions were living in these countries. There is also strong evidence for immunising staff caring for patients belonging to these two risk groups in residential (care home) settings in order to protect the patients. There are as yet no strong data on whether or not immunising other healthcare workers and carers protect patients though immunisation of healthcare workers can be justified on occupational health grounds. At present the scientific evidence for immunising other suggested risk groups, notably children and pregnant women is not strong for Europe though equally there is no evidence against immunising these groups.

The emergence of avian influenza A/H5N1 viruses has driven pandemic preparations to become government priorities across Europe. To date these viruses have remained poorly adapted to humans and the risk of a pandemic based on H5N1 is unquantifiable. However, the risk of a future pandemic is 100%. Preparations are essential and without these many avoidable deaths will occur. Children will be affected at least as much as adults and may play an important role in amplifying transmission. Pharmacological and public health interventions focused on children will save lives through suggested community measures such as pre-emptive closures of schools, and need to be considered carefully, balancing benefits against negative consequences. Child health services will be hugely stressed by any pandemic but also have the potential to save many lives. The challenge will be to deliver core services in the face of major staff illnesses. Detailed local business continuity planning will be essential.

In this weeks issue of Eurosurveillance, Zambon and colleagues describe the first findings of the European Union-funded European Surveillance Network for Vigilance Against Viral Resistance (VIRGIL) of some seasonal influenza viral isolates resistant to the antiviral drug oseltamivir in Europe.

Progress has been made in influenza pandemic preparedness in Europe in the past six month.