Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services.

PURPOSE: The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS. METHODS: Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations. RESULTS: Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. CONCLUSION: Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

[Parents of suicidal young persons and transitional psychiatry: therapeutic and ethical challenges]. / Ouders van suïcidale jongeren en transitiepsychiatrie; ethische en therapeutische uitdagingen.

BACKGROUND: Young people aged 15-25 with mental health problems often experience discontinuity of care during the transition from child to adult mental health services. Furthermore, suicide is one of the most common causes of death in this age category. Although it is known that parents are important in the care process of suicidal youth, parental participation faces various challenges.
AIM: To investigate the ethical, therapeutic and practical aspects regarding parents of a suicidal young person during the mental health care transition.
METHOD: A literature search in the most important literature databases.
RESULTS: We found no studies that specifically examined the role of parents of suicidal youth during the transition. However, there is enough scientific evidence suggesting that including parents during treatment of suicidal young persons has a positive effect on outcome and quality of life. Regarding transition, parents are also important. Nevertheless, several bottlenecks impede their involvement.
CONCLUSION: Parental participation during transitional care is hampered by ethical, therapeutic and practical issues. Taking these into account, parents should be involved as much as possible in the care for their child. Furthermore, sufficient attention must be paid to the concerns and needs of the parents themselves.

An entomological review of invasive mosquitoes in Europe.

Among the invasive mosquitoes registered all over the world, Aedes species are particularly frequent and important. As several of them are potential vectors of disease, they present significant health concerns for 21st century Europe. Five species have established in mainland Europe, with two (Aedes albopictus and Aedes japonicus) becoming widespread and two (Ae. albopictus and Aedes aegypti) implicated in disease transmission to humans in Europe. The routes of importation and spread are often enigmatic, the ability to adapt to local environments and climates are rapid, and the biting nuisance and vector potential are both an ecomonic and public health concern. Europeans are used to cases of dengue and chikungunya in travellers returning from the tropics, but the threat to health and tourism in mainland Europe is substantive. Coupled to that are the emerging issues in the European overseas territorities and this paper is the first to consider the impacts in the remoter outposts of Europe. If entomologists and public health authorities are to address the spread of these mosquitoes and mitigate their health risks they must first be prepared to share information to better understand their biology and ecology, and share data on their distribution and control successes. This paper focusses in greater detail on the entomological and ecological aspects of these mosquitoes to assist with the risk assessment process, bringing together a large amount of information gathered through the ECDC VBORNET project.

Sampling strategies for phlebotomine sand flies (Diptera: Psychodidae) in Europe.

The distribution of phlebotomine sand flies is widely reported to be changing in Europe. This can be attributed to either the discovery of sand flies in areas where they were previously overlooked (generally following an outbreak of leishmaniasis or other sand fly-related disease) or to true expansion of their range as a result of climatic or environmental changes. Routine surveillance for phlebotomines in Europe is localized, and often one of the challenges for entomologists working in non-leishmaniasis endemic countries is the lack of knowledge on how to conduct, plan and execute sampling for phlebotomines, or how to adapt on-going sampling strategies for other haematophagous diptera. This review brings together published and unpublished expert knowledge on sampling strategies for European phlebotomines of public health concern in order to provide practical advice on: how to conduct surveys; the collection and interpretation of field data; suitable techniques for the preservation of specimens obtained by different sampling methods; molecular techniques used for species identification; and the pathogens associated with sand flies and their detection methods.

Changes in species richness and spatial distribution of mosquitoes (Diptera: Culicidae) inferred from museum specimen records and a recent inventory: a case study from Belgium suggests recent expanded distribution of arbovirus and malaria vectors.

Mosquito (Diptera: Culicidae) distribution data from a recent inventory of native and invading mosquito species in Belgium were compared with historical data from the period 1900-1960 that were retrieved from a revision of the Belgian Culicidae collection at the Royal Belgian Institute of Natural Sciences. Both data sets were used to investigate trends in mosquito species richness in several regions in Belgium. The relative change in distribution area of mosquito species was particularly important for species that use waste waters and used tires as larval habitats and species that recently shifted their larval habitat to artificial larval habitats. More importantly, several of these species are known as vectors of arboviruses and Plasmodium sp. and the apparent habitat shift of some of them brought these species in proximity to humans. Similar studies comparing current mosquito richness with former distribution data retrieved from voucher specimens from collections is therefore encouraged because they can generate important information concerning health risk assessment at both regional and national scale.

Nationwide inventory of mosquito biodiversity (Diptera: Culicidae) in Belgium, Europe.

To advance our restricted knowledge on mosquito biodiversity and distribution in Belgium, a national inventory started in 2007 (MODIRISK) based on a random selection of 936 collection points in three main environmental types: urban, rural and natural areas. Additionally, 64 sites were selected because of the risk of importing a vector or pathogen in these sites. Each site was sampled once between May and October 2007 and once in 2008 using Mosquito Magnet Liberty Plus traps. Diversity in pre-defined habitat types was calculated using three indices. The association between species and environmental types was assessed using a correspondence analysis. Twenty-three mosquito species belonging to traditionally recognized genera were found, including 21 indigenous and two exotic species. Highest species diversity (Simpson 0.765) and species richness (20 species) was observed in natural areas, although urban sites scored also well (Simpson 0.476, 16 species). Four clusters could be distinguished based on the correspondence analysis. The first one is related to human modified landscapes (such as urban, rural and industrial sites). A second is composed of species not associated with a specific habitat type, including the now widely distributed Anopheles plumbeus. A third group includes species commonly found in restored natural or bird migration areas, and a fourth cluster is composed of forest species. Outcomes of this study demonstrate the effectiveness of the designed sampling scheme and support the choice of the trap type. Obtained results of this first country-wide inventory of the Culicidae in Belgium may serve as a basis for risk assessment of emerging mosquito-borne diseases.

Human-induced expanded distribution of Anopheles plumbeus, experimental vector of West Nile virus and a potential vector of human malaria in Belgium.

For the majority of native species, human-created habitats provide a hostile environment that prevents their colonization. However, if the conditions encountered in this novel environment are part of the fundamental niche of a particular species, these low competitive environments may allow strong population expansion of even rare and stenotopic species. If these species are potentially harmful to humans, such anthropogenic habitat alterations may impose strong risks for human health. Here, we report on a recent and severe outbreak of the viciously biting and day-active mosquito Anopheles plumbeus Stephens, 1828, that is caused by a habitat shift toward human-created habitats. Although historic data indicate that the species was previously reported to be rare in Belgium and confined to natural forest habitats, more recent data indicate a strong population expansion all over Belgium and severe nuisance at a local scale. We show that these outbreaks can be explained by a recent larval habitat shift of this species from tree-holes in forests to large manure collecting pits of abandoned and uncleaned pig stables. Further surveys of the colonization and detection of other potential larval breeding places of this mosquito in this artificial environment are of particular importance for human health because the species is known as a experimental vector of West Nile virus and a potential vector of human malaria.

Juvenile-onset systemic lupus erythematosus: different clinical and serological pattern than adult-onset systemic lupus erythematosus.

OBJECTIVE: To investigate differences in clinical signs and symptoms, and in antinuclear antibodies (ANA), between patients with juvenile-onset and adult-onset systemic lupus erythematosus (SLE). METHODS: Clinical and serological data of 56 patients with juvenile-onset SLE were compared with data of 194 patients with adult-onset SLE. ANA were determined by line immunoassay and by indirect immunofluorescence on Crithidia luciliae. RESULTS: Renal involvement, encephalopathy and haemolytic anaemia were seen, and anti-dsDNA, anti-ribosomal P and antihistone antibodies found, significantly more often in juvenile-onset SLE. Anti-dsDNA antibodies were directly associated, and anti-ribosomal P antibodies inversely associated, with renal involvement in juvenile-onset SLE. In juvenile patients with SLE and anti-dsDNA and without anti-ribosomal P antibodies the odds ratio for glomerulonephritis was 9.00; no patients with anti-ribosomal P but without anti-dsDNA had renal involvement. CONCLUSION: Patients with juvenile-onset SLE more often have renal involvement and encephalopathy than patients with adult-onset SLE. Anti-ribosomal P, anti-dsDNA and antihistone antibodies are more often found in patients with juvenile-onset SLE.

Has the time come to control hepatitis A globally? Matching prevention to the changing epidemiology.

For the first time a global meeting on hepatitis A virus (HAV) infection as vaccine preventable disease was organized at the end of 2007. More than 200 experts from 46 countries gathered to investigate the changing global HAV epidemiology reflecting the increasing numbers of persons at risk for severe clinical disease and mortality from HAV infection. The benefits of childhood and adult hepatitis A (HepA) vaccination strategies and the data needed by individual countries and international health organizations to assess current HepA prevention strategies were discussed. New approaches in preventing HAV infection including universal HepA vaccination were considered. This introductory paper summarizes the major findings of the meeting and describes the changing epidemiology of HAV infections and the impact of HepA vaccination strategies in various countries. Implementation of HepA vaccination strategies should take into account the level of endemicity, the level of the socio-economic development and sanitation, and the risk of outbreaks. A stepwise strategy for introduction of HepA universal immunisation of children was recommended. This strategy should be based on accurate surveillance of cases and qualitative documentation of outbreaks and their control, secure political support on the basis of high-quality results, and comprehensive cost-effectiveness studies. The recognition of the need for increased global attention towards HepA prevention is an important outcome of this meeting.

Modelling local dispersal of bluetongue virus serotype 8 using random walk.

The knowledge of the place where a disease is first introduced and from where it later spreads is a key element for the understanding of an epizootic. For a contagious disease, the main method is back tracing. For a vector-borne disease such as the Bluetongue virus serotype 8 epizootic that occurred in 2006 in North-Western Europe, the efficiency of tracing is limited because many infected animals are not showing clinical signs. In the present study, we propose to use a statistical approach, random walk, to model local spread in order to derive the Area of First Infection (AFI) and spread rate. Local spread is basically described by the random movements of infected insect vectors. Our model localised the AFI centre, origin of the infection, in the Netherlands, South of Maastricht. This location is consistent with the location of the farms where the disease was first notified in the three countries (Netherlands, Belgium, and Germany) and the farm where retrospectively the earliest clinical signs were found. The derived rate of spread of 10-15 km/week is consistent with the rates observed in other Bluetongue epizootics. In another article Mintiens (2008), the AFI definition has then been used to investigate possible ways of introduction (upstream tracing) and to study the effect of animal movements from this area (downstream tracing).

Impact of human interventions on the spread of bluetongue virus serotype 8 during the 2006 epidemic in north-western Europe.

Bluetongue virus (BTV) can be spread by movement or migration of infected ruminants. Infected midges (Culicoides sp.) can be dispersed with livestock or on the wind. Transmissions of infection from host to host by semen and trans-placental infection of the embryo from the dam have been found. As for any infectious animal disease, the spread of BTV can be heavily influenced by human interventions preventing or facilitating the transmission pathways. This paper describes the results of investigations that were conducted on the potential role of the above-mentioned human interventions on the spread of BTV-8 during the 2006 epidemic in north-western Europe. Data on surveillance and control measures implemented in the affected European Union (EU) Member States (MS) were extracted from the legislation and procedures adopted by the national authorities in Belgium, France, Germany, and The Netherlands. The impact of the control measures on the BTV-incidence in time and space was explored. Data on ruminant transports leaving the area of first infection (AFI) to other areas within and beyond the affected MS were obtained from the national identification and registration systems of the three initially affected MS (Belgium, Germany, The Netherlands) and from the Trade Control and Expert System (TRACES) of the European Commission. The association between the cumulative number of cases that occurred in a municipality outside the AFI and the number of movements or the number of animals moved from the AFI to that municipality was assessed using a linear negative binomial regression model. The results of this study indicated that the control measures which were implemented in the affected MS (in accordance with EU directives) were not able to fully stop further spread of BTV and to control the epidemic. This finding is not surprising because BT is a vector-borne disease and it is difficult to limit vector movements. We could not assess the consequences of not taking control measures at all but it is possible, if not most likely, that this would have resulted in even wider spread. The study also showed an indication of the possible involvement of animal movements in the spread of BTV during the epidemic. Therefore, the prevention of animal movements remains an important tool to control BTV outbreaks. The extension of the epidemic to the east cannot be explained by the movement of animals, which mainly occurred in a north-western direction. This indicates that it is important to consider other influential factors such as dispersal of infected vectors depending on wind direction, or local spread.

Possible routes of introduction of bluetongue virus serotype 8 into the epicentre of the 2006 epidemic in north-western Europe.

In August 2006, bluetongue (BT) was notified in The Netherlands on several animal holdings. This was the onset of a rapidly spreading BT-epidemic in north-western Europe (latitude >51 degrees N) that affected cattle and sheep holdings in The Netherlands, Belgium, Germany, France and Luxembourg. The outbreaks were caused by bluetongue virus (BTV) serotype 8, which had not been identified in the European Union before. Bluetongue virus can be introduced into a free area by movement of infected ruminants, infected midges or by infected semen and embryos. In this study, information on animal movements or transfer of ruminant germ plasms (semen and embryos) into the Area of First Infection (AFI), which occurred before and during the onset of the epidemic, were investigated in order to establish the conditions for the introduction of this virus. All inbound transfers of domestic or wild ruminants, non-susceptible mammal species and ruminant germ plasms into the AFI during the high-risk period (HRP), registered by the Trade Control and Expert System (TRACES) of the EC, were obtained. Imports originating from countries with a known or suspected history of BTV-incidence of any serotype were identified. The list of countries with a reported history of BTV incidence was obtained from the OIE Handistatus II for the period from 1996 until 2004. No ruminants were imported from a Member State (MS) with a known history of BTV-8 or from any other country with a known or suspected history of BTV incidence of any serotype. Of all non-susceptible mammal species only 233 horses were transported directly into the AFI during the HRP. No importations of semen or embryos into the AFI were registered in TRACES during the period of interest. An obvious source for the introduction of BTV-8, such as import of infected ruminants, could not be identified and the exact origin and route of the introduction of BTV-8 thus far remains unknown. However, the absence of legal import of ruminants from outside the EU into the AFI and the absence of BTV-8 in southern Europe suggest that, the introduction of the BTV-8 infection into the north-western part of Europe took place via another route. Specifically, in relation to this, the potential for Culicoides to be imported along with or independently of the import of animals, plants or other 'materials', and the effectiveness of measures to reduce such a possibility, merit further study.

Building capacity for improved veterinary epidemiosurveillance in southern Africa.

A workshop to produce recommendations on training requirements for improved epidemiosurveillance of livestock diseases in southern Africa was organised at the Department of Veterinary Tropical Diseases in the Veterinary Faculty of the University of Pretoria. It was attended by 23 persons representing 10 different southern African countries. The majority of the participants were actively involved in veterinary epidemiosurveillance and many of them were members of the SADC Epidemiology and Informatics Subcommittee. Discussions focused on (i) epidemiosurveillance networks and their 2 main components, i.e. (ii) diagnosis and (iii) information flow. The debates were guided by 3 questions; (i) what are the requirements for an effective network, (ii) what cannot be achieved with existing capacity and (iii) how can the current capacity be improved. Workshop participants developed lists of realistic capacity building needs, which were divided into structural needs and training requirements. Structural needs mainly concerned communication means and quality assurance. With regard to training, the need for appropriate continuing education of all actors at the various disease management levels (non-professional, para-professional, professional) was expressed. Special emphasis was put on capacity building at the lowest level, i.e. the livestock owner and the para-professionals at the community level. At the international level, it was felt that special emphasis should be put on building capacity to improve the understanding of international agreements on trade in animals and animal products and to improve the capacity of negotiating such agreements.

Description of Events Where African Buffaloes (Syncerus caffer) Strayed from the Endemic Foot-and-Mouth Disease Zone in South Africa, 1998-2008.

African buffaloes (Syncerus caffer) are reservoir hosts of Southern African Territories (SAT) foot-and-mouth disease (FMD) virus strains. In South Africa, infected buffaloes are found in the FMD-infected zone comprising the Kruger National Park (KNP) and its adjoining reserves. When these buffaloes stray into livestock areas, they pose a risk of FMD transmission to livestock. We assessed 645 records of stray buffalo events (3124 animals) from the FMD infected zone during 1998-2008 for (i) their temporal distribution, (ii) group size, (iii) age and gender composition, (iv) distance from the infected zone fence and (v) outcome reported for each event. A maximum entropy model was developed to evaluate spatial predictors of stray buffalo events and assess current disease control zones. Out of all buffaloes recorded straying, 38.5% escaped from the FMD infected zone during 2000/2001, following floods that caused extensive damage to wildlife fences. Escape patterns were not apparently influenced by season. The median size of stray groups was a single animal (IQR [1-2]). Adult animals predominated, comprising 90.4% (620/686) of the animals for which age was recorded. Of the 315 events with accurate spatial information, 204 (64.8%) were recorded within 1 km from the FMD infected zone. During late winter/spring (June-October), stray buffaloes were found significantly closer to the FMD infected zone (median = 0.3 km, IQR [0.1-0.6]). Less than 13% (40/315) of stray groups reached the FMD protection zone without vaccination, posing a higher risk of spreading FMD to these more susceptible livestock. Model outputs suggest that distance from the FMD infected zone, urban areas and permanent water sources contributed almost 85% to the spatial probability of stray buffalo events. Areas with a high probability for stray buffalo events were well covered by current disease control zones, although FMD risk mitigation could be improved by expanding the vaccination zone in certain areas.

Spatial trypanosomosis management: from data-layers to decision making.

The use of geographical information systems (GIS) in the management of African animal trypanosomosis in sub-Saharan Africa offers potential in assisting decisions on allocation of resources, prioritization of control areas, and planning and management of field operations. Here, Guy Hendrickx and colleagues review approaches being used to develop reliable data-layers and to incorporate these data into GIS models. They argue that techniques should be further refined to produce more-detailed data layers and to include a dynamic element, a problem rarely addressed until now.

The area-wide epidemiology of bovine trypanosomosis and its impact on mixed farming in subhumid West Africa; a case study in Togo.

This paper reports on an area wide study of all major variables determining the expression of trypanosomosis in cattle in the subhumid eco-zone of West Africa, taking Togo as an example. To enable systematic area-wide sampling, the country was divided in 311 grid-squares of 0.125 x 0.125 sides. Cross-sectional surveys were then conducted to generate maps or digital layers on cattle density, herd structure, ownership and breed. These data layers, except for the breed data, were subjected to a cluster analysis in order to define spatial patterns in animal husbandry systems. This analysis revealed two main systems: one is oriented towards integration with crop-agriculture and a second towards investment in cattle. These two systems could be further characterised by incorporating breed data. Zebu cattle and their crossbreeds are more favoured in the second system. The breed distribution map shows the actual situation but also serves to predict the outcome of progressive crossbreeding. An area wide trypanosomosis survey allowed the production of prevalence maps for Trypanosoma congolense, T. vivax and the associated packed cell volume (PCV) values. A simple curvi-linear relationship was established between vector density and disease prevalence. The regression between disease prevalence and PCV for taurine and zebu plus crossbreeds separately, revealed that taurine cattle maintain a comparatively high PCV level particularly in high prevalence scenarios. The relationship between the average herd PCV and cattle density suggests that herd PCV value may provide a mirror for the number of animals not kept because of the prevailing risk. The regression between agricultural intensity and cattle density subsequently in areas with decreasing herd PCV values reveals that the level of integration of cattle in crop production decreases with a decreasing PCV. Thus, despite the presence of taurine animals in Togo, the omnipresence of tsetse in particular Glossina tachinoides, remains a major obstacle to cattle raising and indirectly mixed farming development and intensification. It is argued that only with the present type of wide scale, spatial studies it becomes possible to clarify all the major variables influencing the expression of trypanosomosis. Spatial epidemiological studies at a macro level may form the basis for area wide trypanosomosis control in West Africa.

Tsetse flies and their control.

The authors use a quantitative modelling framework to describe and explore the features of the biology of tsetse flies (Glossina spp.) which are important in determining the rate of transmission of the African trypanosomiases between hosts. Examples are presented of the contribution of previous research on tsetse to quantified epidemiological and epizootiological understanding, and areas of current ignorance are identified for future study. Spatial and temporal variations in risk are important (but rarely-studied) determinants of the impact of trypanosomiasis on humans, domestic animals and agricultural activities. Recent grid-based sampling surveys to Togo provide valuable data sets on tsetse, cattle and trypanosomiasis throughout the country. A combination of ground-based meterological and remotely-sensed satellite data, within linear discriminant analytical models, enables description of the observed distributions of the five species of tsetse occurring in Togo, with accuracies of between 72% (Glossina palpalis and G. tachinoides) and 98% (G. fusca). Abundance classes of the two most widespread species, G. palpalis and G. tachinoides, are described with accuracies of between 47% and 83%. This is especially remarkable given the relatively small differences between the average values of the predictor variables in areas of differing fly abundance. Similar analyses could be used to predict the occurrence and abundance of flies in other areas, which have not been surveyed to date, in order to plan tsetse control campaigns or explore development options. Finally, some recent tsetse control campaigns are briefly reviewed. The shift of emphasis from fly eradication to fly control is associated with a devolution of responsibility for control activities from central government to local areas, communities or even individuals. The future role of central governments will remain crucial, however, in determining the areas in which different control options are practised, in facilitating control by local communities and in protecting controlled areas from re-invasion by flies from other areas.

The macrocephaly-cutis marmorata telangiectatica congenita syndrome. Long-term follow-up data in 4 children and adolescents.

We present the clinical history and findings in 4 children and adolescents with the association of macrocephaly and cutis marmorata telangiectatica congenita (Macrocephaly-CMTC syndrome). This syndrome has recently been delineated within the general group of patients with manifestations of cutis marmorata telangiectatica-Klippel-Trenaunay-Weber syndrome as a clinically recognisable entity.

A cohesive European policy for hepatitis B vaccination, are we there yet?

Despite the availability of safe and effective hepatitis B virus (HBV) vaccines for more than 30 years, 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 cost­benefit 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.