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).

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.

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.

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.

Comparing Vector-Borne Disease Surveillance and Response in Beijing and the Netherlands.

Background: Climate change, environmental change, and globalization affect the geographical distribution of vector-borne diseases. Temperate regions should be prepared for emerging diseases and learn from each other's experiences. Objectives: The vector-borne disease preparedness in two regions, Beijing and the Netherlands, were compared in order understand their similarities and differences leading to learning points on this complex topic. Methods: A comparative study was performed using interviews with vector-borne disease experts from Beijing and the Netherlands and supplemented by literature. Findings: In Beijing, syndromic surveillance is a priority for the identification of suspected vector-borne disease cases. In the Netherlands, the main surveillance emphasis is on laboratory confirmed vector-borne disease cases. Vector-surveillance at potential points of entry and other high-risk locations is performed according to the International Health Regulation (2005) in both settings. Beijing controls invasive and native mosquitos, which is not the case in the Netherlands. In Beijing, vector surveillance is performed to measure mosquito density around hospitals, this is not observed in the Dutch setting. Health risks posed by ticks are a priority in urban areas in the Netherlands, and the public is educated in self-protection. In contrast, ticks seem to occur less often in Beijing's urban areas. Conclusions: The vector-borne disease context framework allowed us to compare the vector-borne disease preparedness between Beijing and the Netherlands, despite differences in vector-borne disease challenges. We can learn valuable lessons concerning surveillance and early detection of emerging vector-borne diseases when comparing the preparedness between different regions.

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 (SO42-) 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, SO42-, 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 SO42- 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 (NOX) 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 NOX 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.

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.

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.

Exploring Vector-Borne Disease Surveillance and Response Systems in Beijing, China: A Qualitative Study from the Health System Perspective.

BACKGROUND: Climate change may contribute to higher incidence and wider geographic spread of vector borne diseases (VBDs). Effective monitoring and surveillance of VBDs is of paramount importance for the prevention of and timely response to outbreaks. Although international regulations exist to support this, barriers and operational challenges within countries hamper efficient monitoring. As a first step to optimise VBD surveillance and monitoring, it is important to gain a deeper understanding of system characteristics and experiences in to date non-endemic regions at risk of becoming endemic in the future. Therefore, this study qualitatively analyses the nature and flexibility of VBD surveillance and response in Beijing. METHODS: In this qualitative study, eleven experts working in Beijing's vector-borne diseases surveillance and response system were interviewed about vector-borne disease surveillance, early warning, response, and strengths and weaknesses of the current approach. RESULTS: Vector-borne disease surveillance occurs using passive syndromic surveillance and separate vector surveillance. Public health authorities use internet reporting networks to determine vector-borne disease risk across Beijing. Response toward a vector-borne disease outbreak is uncommon in this setting due to the currently low occurrence of outbreaks. CONCLUSIONS: A robust network of centralised institutions provides the continuity and flexibility needed to adapt and manage possible vector-borne disease threats. Opportunities exist for population-based health promotion and the integration of environment and climate monitoring in vector-borne disease surveillance.

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.