The state of health in the European Union (EU-27) in 2019: a systematic analysis for the Global Burden of Disease study 2019.

BACKGROUND: The European Union (EU) faces many health-related challenges. Burden of diseases information and the resulting trends over time are essential for health planning. This paper reports estimates of disease burden in the EU and individual 27 EU countries in 2019, and compares them with those in 2010. METHODS: We used the Global Burden of Disease 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardised death, years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life years (DALYs) rates for Level 2 causes, as well as life expectancy and healthy life expectancy (HALE). RESULTS: In 2019, the age-standardised death and DALY rates in the EU were 465.8 deaths and 20,251.0 DALYs per 100,000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases in age-standardised death and YLL rates across EU countries. However, YLD rates remained mainly unchanged. The largest decreases in age-standardised DALY rates were observed for "HIV/AIDS and sexually transmitted diseases" and "transport injuries" (each -19%). "Diabetes and kidney diseases" showed a significant increase for age-standardised DALY rates across the EU (3.5%). In addition, "mental disorders" showed an increasing age-standardised YLL rate (14.5%). CONCLUSIONS: There was a clear trend towards improvement in the overall health status of the EU but with differences between countries. EU health policymakers need to address the burden of diseases, paying specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.

Predicting Covid-19 infection and death rates among E.U. minority populations in the absence of racially disaggregated data through the use of US data comparisons.

BACKGROUND: The E.U.'s lack of racially disaggregated data impedes the formulation of effective interventions, and crises such as Covid-19 may continue to impact minorities more severely. Our predictive model offers insight into the disparate ways in which Covid-19 has likely impacted E.U. minorities and allows for the inference of differences in Covid-19 infection and death rates between E.U. minority and non-minority populations. METHODS: Data covering Covid-19, social determinants of health and minority status were included from 1 March 2020 to 28 February 2021. A systematic comparison of US and E.U. states enabled the projection of Covid-19 infection and death rates for minorities and non-minorities in E.U. states. RESULTS: The model predicted Covid-19 infection rates with 95-100% accuracy for 23 out of 28 E.U. states. Projections for Covid-19 infection and mortality rates among E.U. minority groups illustrate parallel trends to US rates. CONCLUSIONS: Disparities in Covid-19 infection and death rates by minority status likely exist in patterns similar to those observed in US data. Policy Implications: Collecting data by race/ethnicity in the E.U. would help document health disparities and craft more targeted health interventions and mitigation strategies.

Impacts and mitigation of excess diesel-related NOx emissions in 11 major vehicle markets.

Vehicle emissions contribute to fine particulate matter (PM2.5) and tropospheric ozone air pollution, affecting human health, crop yields and climate worldwide. On-road diesel vehicles produce approximately 20 per cent of global anthropogenic emissions of nitrogen oxides (NOx), which are key PM2.5 and ozone precursors. Regulated NOx emission limits in leading markets have been progressively tightened, but current diesel vehicles emit far more NOx under real-world operating conditions than during laboratory certification testing. Here we show that across 11 markets, representing approximately 80 per cent of global diesel vehicle sales, nearly one-third of on-road heavy-duty diesel vehicle emissions and over half of on-road light-duty diesel vehicle emissions are in excess of certification limits. These excess emissions (totalling 4.6 million tons) are associated with about 38,000 PM2.5- and ozone-related premature deaths globally in 2015, including about 10 per cent of all ozone-related premature deaths in the 28 European Union member states. Heavy-duty vehicles are the dominant contributor to excess diesel NOx emissions and associated health impacts in almost all regions. Adopting and enforcing next-generation standards (more stringent than Euro 6/VI) could nearly eliminate real-world diesel-related NOx emissions in these markets, avoiding approximately 174,000 global PM2.5- and ozone-related premature deaths in 2040. Most of these benefits can be achieved by implementing Euro VI standards where they have not yet been adopted for heavy-duty vehicles.

Relaxing restrictions at the pace of vaccination increases freedom and guards against further COVID-19 waves.

Mass vaccination offers a promising exit strategy for the COVID-19 pandemic. However, as vaccination progresses, demands to lift restrictions increase, despite most of the population remaining susceptible. Using our age-stratified SEIRD-ICU compartmental model and curated epidemiological and vaccination data, we quantified the rate (relative to vaccination progress) at which countries can lift non-pharmaceutical interventions without overwhelming their healthcare systems. We analyzed scenarios ranging from immediately lifting restrictions (accepting high mortality and morbidity) to reducing case numbers to a level where test-trace-and-isolate (TTI) programs efficiently compensate for local spreading events. In general, the age-dependent vaccination roll-out implies a transient decrease of more than ten years in the average age of ICU patients and deceased. The pace of vaccination determines the speed of lifting restrictions; Taking the European Union (EU) as an example case, all considered scenarios allow for steadily increasing contacts starting in May 2021 and relaxing most restrictions by autumn 2021. Throughout summer 2021, only mild contact restrictions will remain necessary. However, only high vaccine uptake can prevent further severe waves. Across EU countries, seroprevalence impacts the long-term success of vaccination campaigns more strongly than age demographics. In addition, we highlight the need for preventive measures to reduce contagion in school settings throughout the year 2021, where children might be drivers of contagion because of them remaining susceptible. Strategies that maintain low case numbers, instead of high ones, reduce infections and deaths by factors of eleven and five, respectively. In general, policies with low case numbers significantly benefit from vaccination, as the overall reduction in susceptibility will further diminish viral spread. Keeping case numbers low is the safest long-term strategy because it considerably reduces mortality and morbidity and offers better preparedness against emerging escape or more contagious virus variants while still allowing for higher contact numbers (freedom) with progressing vaccinations.

Healthcare indicators associated with COVID-19 death rates in the European Union.

OBJECTIVES: Identification of environmental and hospital indicators that may influence coronavirus disease 2019 (COVID-19) mortality in different countries is essential for better management of this infectious disease. STUDY DESIGN: Correlation analysis between healthcare system indicators and COVID-19 mortality rate in Europe. METHODS: For each country in the European Union (EU), the date of the first diagnosed case and the crude death rate for COVID-19 were retrieved from the John Hopkins University website. These data were then combined with environmental, hospital and clinical indicators extracted from the European Health Information Gateway of the World Health Organization. RESULTS: The COVID-19 death rate in EU countries (mean 1.9 ± 0.8%) was inversely associated with the number of available general hospitals, physicians and nurses. Significant positive associations were also found with the rate of acute care bed occupancy, as well as with the proportion of population who were aged older than 65 years, overweight or who had cancer. Total healthcare expenditure, public sector health expenditure and the number of hospital and acute care beds did not influence COVID-19 death rate. CONCLUSIONS: Some common healthcare system inadequacies, such as limited numbers of general hospitals, physicians and nurses, in addition to high acute care bed occupancy, may be significant drivers of nationwide COVID-19 mortality rates in EU countries.

Burden of disease from breast cancer attributable to smoking and second-hand smoke exposure in Europe.

Smoking and second-hand smoke (SHS) exposure have been recently linked to a higher risk of breast cancer in women. The aim of this work is to estimate the number of deaths and disability-adjusted life years (DALYs) from breast cancer attributable to these two risk factors in the European Union (EU-28) in 2017. The comparative risk assessment method was used. Data on prevalence of smoking and SHS exposure were extracted from the Eurobarometer surveys, relative risks from a recent meta-analysis, and data on mortality and DALYs from breast cancer were estimated from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 82 239 DALYs and 3354 deaths from breast cancer in the EU-28 could have been avoided by removing exposure to these two risk factors (smoking and SHS exposure). The proportion of DALYs from breast cancer lost respectively from smoking and SHS exposure was 2.6% and 1.0%, although geographically distributed with significant heterogeneity. These results represent the first estimates of breast cancer burden in women attributable to smoking and SHS exposure for the EU-28. It is important to increase awareness among women, health professionals and wider society of the association between smoking, SHS exposure and breast cancer, a relationship that is not widely recognised or discussed.

Mortality from abdominal aortic aneurysm: trends in European Union 15+ countries from 1990 to 2017.

BACKGROUND: This observational study assessed trends in abdominal aortic aneurysm (AAA) death rates in European Union (EU) 15+ countries for the years 1990 to 2017. METHODS: Age-standardized death rates (ASDRs) were extracted from the Global Burden of Disease Study Global Health Data Exchange. Trends were analysed using joinpoint regression analysis. RESULTS: Between 1990 and 2017, ASDRs from AAA decreased in all 19 EU15+ countries for women, and in 18 of 19 countries for men. Increasing AAA mortality was observed only for men in Greece (+5·3 per cent). The largest relative decreases in ASDR between 1990 and 2017 were observed in Australia (men -65·6 per cent, women -50·4 per cent) and Canada (men -60·8 per cent, women -48·6 per cent). Over the 28-year interval, the smallest decreases in ASDR for women were noted in Greece (-2·3 per cent) and in Italy (-2·5 per cent). In 2017, the highest mortality rates were observed in the UK for both men and women (7·5 per 100 000 and 3·7 per 100 000 respectively). The lowest ASDR was observed in Portugal for men (2·8 per 100 000) and in Spain for women (1·0 per 100 000). ASDRs for AAA in 2017 were higher for men than women in all 19 EU15+ countries. The most recent trends demonstrated increasing AAA ASDRs in 14 of 19 countries for both sexes; the increases were relatively small compared with the improvements in the preceding years. CONCLUSION: This observational study identified decreasing mortality from AAA across EU15+ countries since 1990. The most recent trends demonstrated relatively small increases in AAA mortality across the majority of EU15+ countries since 2012.

ANTECEDENTES: Este estudio observacional evalúa las tendencias en las tasas de mortalidad del aneurisma de aorta abdominal (abdominal aortic aneurysm, AAA) en los 19 países integrantes del acrónimo conocido como EU15+ en los aóos 1990-2017. MÉTODOS: Se obtuvieron las tasas de mortalidad estandarizadas por la edad del Global Burden of Disease Study Global Health Data Exchange. Las tendencias se analizaron utilizando el análisis de regresión por puntos de inflexión (joinpoint). RESULTADOS: Entre 1990 y 2017, las tasas de muerte estandarizadas por edad (age-standardized death rates, ASDR) del AAA disminuyeron en todos los 19 EU15+ países para las mujeres, y en 18 de los 19 países para los varones. Solamente se observó un incremento de la mortalidad del AAA para los varones en Grecia (+5,3%). El mayor descenso relativo de ASDR entre 1990-2017 se observó en Australia (varones -65,6%, mujeres -50,4%) y Canadá (varones -60,8%, mujeres -48,6%). A lo largo del periodo de 28 aóos, en el caso de las mujeres, los menores descensos en ASDR se observaron en Grecia (-2,3%) y en Italia (-2,5%). En 2017, las tasas de mortalidad más elevadas se observaron en el Reino Unido tanto para varones como para mujeres (7,5/100.000 y 3,7/100.000 para varones y mujeres, respectivamente). La ASDR más baja se observó en Portugal para varones (2,8/100.000) y Espaóa para mujeres (1,0/100.000). Las ASDRs para AAA en 2017 fueron más altas para varones que para mujeres en todos los 19 países EU15+. Las tendencias más recientes demostraron aumentos de las ASDRs por AAA en 14 de 19 países para varones y mujeres; los aumentos fueron relativamente pequeóos cuando se compararon con las mejorías observadas dentro de los aóos precedentes. CONCLUSIÓN: En este estudio observacional de los países EU15+, se ha identificado una disminución en la mortalidad de los AAA entre los países integrantes de EU15+ desde 1990. Las tendencias más recientes demuestran aumentos relativamente pequeóos de la mortalidad del AAA en la mayoría de los países EU15+ desde 2012.

How is migration background considered in the treatment and care of people? A comparison of national dementia care guidelines in Europe.

BACKGROUND: People with a migration background are vulnerable to dementia. Due to problems such as underdiagnosis or access barriers, the care of this population is a public health challenge in Europe. Many countries are issuing care guidelines, but a systematic overview of their references to migration groups is lacking. This study aims to analyze national dementia care guidelines regarding their focus on people with a migration background, what specific actions to ensure healthcare have been undertaken at the national level, and whether recommendations for action are made for this population. METHODS: This study is a systematic analysis of national dementia care guidelines of the EU and EFTA (European Free Trade Association) countries. Using the discourse analysis model by Keller (2011), 43 documents from 24 EU and 3 EFTA countries were systematically screened for migration references via keyword and context analysis. The content of the migration-related section was paraphrased, memos and comments were added, and the individual text passages were coded using the strategy of open coding. RESULTS: Twenty-seven of the 35 EU and EFTA countries have guidelines or similar documents on care for people with dementia, and 12 refer to migration. Norway, Sweden, and Northern Ireland refer to this topic in detail. The focus of the migration-related guidelines is on the early detection and diagnosis of dementia. The main message is that standardized diagnostic tools such as the MMSE (Mini-Mental State Examination) or the clock test are not suitable for linguistic minorities. Nine countries make recommendations for the care of people with a migration background and dementia, but only Norway, Sweden, and Denmark point to available healthcare services. A key recommendation is that the linguistic and cultural background of people should be considered when selecting diagnostic tests. Several countries refer to the validity of the RUDAS (Rowland Universal Dementia Assessment Scale) for migrants. CONCLUSIONS: The topic of migration plays a subordinate role in the dementia care guidelines of European countries. Almost all countries lack appropriate diagnostic tools and healthcare services for people with a migration background. Consequently, this group is vulnerable to underdiagnosis and a lower level of care.

Happiness as fairness: The relationship between national life satisfaction and social justice in EU countries.

Despite growing interest in the relation between social justice and life satisfaction, there is a paucity of quantitative investigations linking these two constructs, even in the field of Community Psychology. To bridge this gap, we tested the relationship between the EU Social Justice Index (SJI; 2008-2017) and life satisfaction across 28 European Union (EU) countries, in a series of multilevel multinomial logistic regression models with cumulative logit link function. The SJI proved one of the strongest predictors of national life satisfaction, after controlling for time variation and other well-established country-level determinants. Our findings lend support to the hypothesis that social justice is highly related to life satisfaction. We invite scholars to explore this relationship further. We also recommend that EU governments strive to promote fairer social conditions to increase national happiness.

Estimating dementia cases amongst migrants living in Europe.

BACKGROUND AND PURPOSE: The phenomenon of dementia amongst migrants and ethnic minorities represents an emerging concern for European healthcare systems, posing additional challenges in terms of clinical approach, access to care and resource utilization. The aim of the present study was to estimate the cases of dementia amongst immigrant older subjects living in Europe and in each European country. METHODS: The estimated cases of dementia amongst older (i.e. 65+) migrants living in the European Union (EU-28) and European Free Trade Association member states were calculated by multiplying the number of migrants (obtained through the data provided by Eurostat) with the age- and sex-specific prevalence rates (derived by a recent meta-analysis). RESULTS: Overall, 6 507 360 older migrants lived in Europe in 2017. In addition, 1 204 671 migrants were registered in Germany in 2010. Nearly 475 000 dementia cases (329 028 women, 147 410 men) were estimated in this population by applying age- and sex-specific prevalence rates. When considering each European country, the number of estimated cases ranged from 108 (Iceland) to 119 161 (France). In parallel, the proportion of dementia cases occurring in migrants ranged from 0.9% (Czech Republic) to 51.2% (Liechtenstein). CONCLUSIONS: The issue of dementia in migrants and ethnic minorities is emerging but already relevant for European healthcare systems. The magnitude of this phenomenon and its complexities reinforce the need for coordinated initiatives both at a national and continental level. These epidemiological data should ideally be integrated with those coming from 'real world' services in order to better calibrate these actions.

Achieving orphan designation for placental insufficiency: annual incidence estimations in Europe.

OBJECTIVE: To determine whether a novel therapy for placental insufficiency could achieve orphan drug status by estimating the annual incidence of placental insufficiency, defined as an estimated fetal weight below the 10th centile in the presence of abnormal umbilical artery Doppler velocimetry, per 10 000 European Union (EU) population as part of an application for European Medicines Agency (EMA) orphan designation. DESIGN: Incidence estimation based on literature review and published national and EU statistics. SETTING AND POPULATION: European Union. METHODS: Data were drawn from published literature, including national and international guidelines, international consensus statements, cohort studies and randomised controlled trials, and published national and EU statistics, including birth rates and stillbirth rates. Rare disease databases were also searched. RESULTS: The proportion of affected pregnancies was estimated as 3.17% (95% CI 2.93-3.43%), using a weighted average of the results from two cohort studies. Using birth rates from 2012 and adjusting for a pregnancy loss rate of 1/100 gave an estimated annual incidence of 3.33 per 10 000 EU population (95% CI 3.07-3.60 per 10 000 EU population). This fell below the EMA threshold of 5 per 10 000 EU population. CONCLUSIONS: Maternal vascular endothelial growth factor gene therapy for placental insufficiency was granted EMA orphan status in 2015 after we demonstrated that it is a rare, life-threatening or chronically debilitating and currently untreatable disease. Developers of other potential obstetric therapies should consider applying for orphan designation, which provides financial and regulatory benefits. TWEETABLE ABSTRACT: Placental insufficiency meets the European Medicines Agency requirements for orphan disease designation.

Tax harmonisation and tobacco product prices in the European Union, 2004-2015.

OBJECTIVES: The European Commission has formally opened a process of revision of its tobacco tax directive. The purpose of this study is to analyse the evolution of cigarette and roll-your-own (RYO) tobacco prices in order to identify avenues for the improvement of public health goals. METHODS: Pooled cross-sectional data on prices and taxes on cigarettes and RYO tobacco in the Member States over 2004-2015 is used to track the distributions of the most popular price category and the weighted average price of these products and to relate them to the underlying tax structure. RESULTS: The inflation-adjusted prices for the two products have increased over the period, but the dispersion of prices across Member States has remained constant. Throughout the period, there was a pervasive price gap between cigarettes and RYO tobacco within the Member States. Such features are explained by the underlying tax design. DISCUSSION: The current tax stance has been successful at increasing both cigarette and RYO tobacco prices. To further enhance the public health impact of the European Union tax directive, the revision should promote the convergence of prices across Member States and aim at closing the price gap between cigarettes and RYO tobacco. These objectives call for increasing the mandatory minimum levels of excise duty on the two products, preferably linking them to the evolution of a European weighted average price. The pace of increase should be faster for RYO tobacco in order to close the gap with respect to cigarette prices.

Informal employees in the European Union: working conditions, employment precariousness and health.

BACKGROUND: The aim of this study is to estimate the prevalence of informal workers and their working conditions and employment precariousness in the EU-27; and to explore the association of different contract arrangements with health outcomes and how they are influenced by working and employment conditions. METHODS: A sample of 27 245 working-age employees from the fifth European Working Condition Survey of 2010 was analysed. Logistic regression models were fitted to estimate the contribution of different contract arrangement (permanent, temporary and informal) and working and employment precariousness variables on health outcomes (psychosocial well-being and self-rated health). RESULTS: Prevalence of informal employees in the EU-27 is 4.1% among men and 5.1% among women. Although informal employees have the poorest working conditions and employment precariousness, they did not seem to reflect poorer health. Precariousness employment variables have a greater impact than working conditions variables in reducing the association between health outcomes and type of contract arrangement, especially in the case of informal employees. CONCLUSIONS: Informal employment in the EU-27 is characterized by worse working conditions and employment precariousness than the conditions for formal employees. There is no evidence at all that being in informal employment implies better health outcomes compared to permanent employees.

Nicotine dependence among adolescents in the European Union: How many and who are affected?

BACKGROUND: Nicotine dependence during adolescence increases the risk of continuing smoking into adulthood. The magnitude of nicotine dependence among adolescents in the European Union (EU) has not been established. We aimed to estimate the number of nicotine dependent 15-year-old adolescents in the EU, and identify high-risk groups. METHODS: The number of nicotine dependent 15-year-olds in the EU was derived combining: (i) total number of 15-year-olds in the EU (2013 Eurostat), (ii) smoking prevalence among 15-year-olds (2013/2014 HBSC survey) and (iii) proportion of nicotine dependent 15-year-olds in six EU countries (2013 SILNE survey). Logistic regression analyses identified high-risk groups in the SILNE dataset. RESULTS: We estimated 172 636 15-year-olds were moderately to highly nicotine dependent (3.2% of all 15 years old; 35.3% of daily smokers). In the total population, risk of nicotine dependence was higher in males, adolescents with poor academic achievement, and those with smoking parents or friends. Among daily smokers, only lower academic achievement and younger age of smoking onset were associated with nicotine dependence. CONCLUSION: According to our conservative estimates, more than 172 000 15-year-old EU adolescents were nicotine dependent in 2013. Prevention of smoking initiation, especially among adolescents with poor academic performance, is necessary to prevent a similar number of adolescents getting addicted to nicotine each consecutive year.

Psychological intimate partner violence against women in the European Union: a cross-national invariance study.

BACKGROUND: Intimate partner violence against women (IPVAW) is a worldwide public health problem. One of the most frequent forms of this type of violence in western societies is psychological IPVAW. According to the European Union (EU) Fundamental Rights Association (FRA) the prevalence of psychological IPVAW in the EU is 43%. However, the measurement invariance of the measure addressing psychological IPVAW in this survey has not yet been assessed. METHODS: The aim of this study is to ensure the cross-national comparability of this measure, by evaluating its measurement invariance across the 28 EU countries in a sample of 37,724 women, and to examine how the levels of this type of violence are distributed across the EU. RESULTS: Our results showed that the psychological IPVAW measure presented adequate psychometric properties (reliability and validity) in all countries. A latent structure of one factor was supported and scalar invariance was established in all countries. The average levels of psychological IPVAW were higher in countries like Finland, Latvia, Lithuania, and Sweden compared to the rest of the EU countries. In many of the other countries the levels of this type of violence overlapped. CONCLUSION: Our findings underlined the importance of using appropriate statistical methods to make valid cross-national comparisons in large population surveys.

Factors associated with Legionnaires' disease recurrence in hotel and holiday rental accommodation sites.

BackgroundThe detection of a cluster of travel-associated Legionnaires' disease (TALD) cases in any European Union/European Economic Area (EU/EEA) country prompts action at the accommodation, follow-up by health authorities and reporting of measures taken. Some accommodations incur further cases despite presumed implementation of adequate control measures.AimTo identify factors associated with the occurrence of a further TALD case after the implementation of control measures.MethodsWe conducted a retrospective cohort study of hotel and holiday rental accommodations in the EU/EEA associated with two or more TALD cases with onset dates less than 2 years apart (a 'cluster') and notification between 1 June 2011-31 December 2016. We fitted Cox regression models to estimate the association between accommodation characteristics and the occurrence of a further case, defined as any case with onset date after the report on measures taken.ResultsOf the 357 accommodations in the analysis, 90 (25%) were associated with at least one further case after the report on measures taken (12.4/100 accommodation-years). Accommodations associated with two or more cases before the cluster notification were more likely to be associated with a further case, compared with those not previously associated with any case (adjusted hazard ratio 1.85; 95% confidence interval: 1.14-3.02). Neither the detection of Legionella in the water system nor the type of disinfection were found to be associated with the risk of a further case.ConclusionAccommodation size and previous TALD cases were predictive of further Legionnaires' disease cases after implementation of control measures.

HIV among women in the WHO European Region - epidemiological trends and predictors of late diagnosis, 2009-2018.

Human immunodeficiency virus (HIV) transmission among women remains an issue in the WHO European Region, with nearly 50,000 women diagnosed in 2018 and over half (54%) diagnosed late. Although new HIV diagnoses declined between 2009 and 2018 in the West of the Region, they increased in the Centre and East. Understanding the characteristics of women diagnosed with HIV can inform gender-sensitive prevention services including pre-exposure prophylaxis and early testing and linkage to care.