How EU policies could reduce nutrient pollution in European inland and coastal waters.

Intensive agriculture and densely populated areas represent major sources of nutrient pollution for European inland and coastal waters, altering the aquatic ecosystems and affecting their capacity to provide ecosystem services and support economic activities. Ambitious water policies are in place in the European Union (EU) for protecting and restoring aquatic ecosystems under the Water Framework Directive and the Marine Strategy Framework Directive. This research quantified the current pressures of point and diffuse nitrogen and phosphorus emissions to European fresh and coastal waters (2005-2012), and analysed the effects of three policy scenarios of nutrient reduction: 1) the application of measures currently planned in the Rural Development Programmes and under the Urban Waste Water Treatment Directive (UWWTD); 2) the full implementation of the UWWTD and the absence of derogations in the Nitrates Directive; 3) high reduction of nutrient, using best technologies in wastewaters treatment and optimal fertilisation in agriculture. The results of the study show that for the period 2005-2012, the nitrogen load to European seas was 3.3-4.1 TgN/y and the phosphorus load was 0.26-0.30 TgP/y. Policy measures supporting technological improvements (third scenario) could decrease the nutrient export to the seas up to 14% for nitrogen and 20% for phosphorus, improving the ecological status of rivers and lakes, but widening the nutrient imbalance in coastal ecosystems (i.e. increasing nitrogen availability with respect to phosphorus), affecting eutrophication. Further nutrient reductions could be possible by a combination of measures especially in the agricultural sector. However, without tackling current agricultural production and consumption system, the reduction might not be sufficient for achieving the goals of EU water policy in some regions. The study analysed the expected changes and the source contribution in different European regional seas, and highlights the advantages of addressing the land-sea dynamics, checking the coherence of measures taken under different policies.

An innovative approach to the assessment of hydro-political risk: A spatially explicit, data driven indicator of hydro-political issues.

Competition over limited water resources is one of the main concerns for the coming decades. Although water issues alone have not been the sole trigger for warfare in the past, tensions over freshwater management and use represent one of the main concerns in political relations between riparian states and may exacerbate existing tensions, increase regional instability and social unrest. Previous studies made great efforts to understand how international water management problems were addressed by actors in a more cooperative or confrontational way. In this study, we analyze what are the pre-conditions favoring the insurgence of water management issues in shared water bodies, rather than focusing on the way water issues are then managed among actors. We do so by proposing an innovative analysis of past episodes of conflict and cooperation over transboundary water resources (jointly defined as "hydro-political interactions"). On the one hand, we aim at highlighting the factors that are more relevant in determining water interactions across political boundaries. On the other hand, our objective is to map and monitor the evolution of the likelihood of experiencing hydro-political interactions over space and time, under changing socioeconomic and biophysical scenarios, through a spatially explicit data driven index. Historical cross-border water interactions were used as indicators of the magnitude of corresponding water joint-management issues. These were correlated with information about river basin freshwater availability, climate stress, human pressure on water resources, socioeconomic conditions (including institutional development and power imbalances), and topographic characteristics. This analysis allows for identification of the main factors that determine water interactions, such as water availability, population density, power imbalances, and climatic stressors. The proposed model was used to map at high spatial resolution the probability of experiencing hydro-political interactions worldwide. This baseline outline is then compared to four distinct climate and population density projections aimed to estimate trends for hydro-political interactions under future conditions (2050 and 2100), while considering two greenhouse gases emission scenarios (moderate and extreme climate change). The combination of climate and population growth dynamics is expected to impact negatively on the overall hydro-political risk by increasing the likelihood of water interactions in the transboundary river basins, with an average increase ranging between 74.9% (2050 - population and moderate climate change) to 95% (2100 - population and extreme climate change). Future demographic and climatic conditions are expected to exert particular pressure on already water stressed basins such as the Nile, the Ganges/Brahmaputra, the Indus, the Tigris/Euphrates, and the Colorado. The results of this work allow us to identify current and future areas where water issues are more likely to arise, and where cooperation over water should be actively pursued to avoid possible tensions especially under changing environmental conditions. From a policy perspective, the index presented in this study can be used to provide a sound quantitative basis to the assessment of the Sustainable Development Goal 6, Target 6.5 "Water resources management", and in particular to indicator 6.5.2 "Transboundary cooperation".

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe.

BACKGROUND: Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001. METHODS: Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)-infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0. RESULTS: The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%-9.5%) in 2008-2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones. CONCLUSIONS: Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Corrigendum: Control and Eradication Programs for Six Cattle Diseases in the Netherlands.

[This corrects the article DOI: 10.3389/fvets.2021.670419.].

Control and Eradication Programs for Six Cattle Diseases in the Netherlands.

Within the European Union, infectious cattle diseases are categorized in the Animal Health Law. No strict EU regulations exist for control, evidence of disease freedom, and surveillance of diseases listed other than categories A and B. Consequently, EU member states follow their own varying strategies for disease control. The aim of this study was to provide an overview of the control and eradication programs (CPs) for six cattle diseases in the Netherlands between 2009 and 2019 and to highlight characteristics specific to the Dutch situation. All of these diseases were listed as C,D or E in the New Animal Health Law. In the Netherlands, CPs are in place for six endemic cattle diseases: bovine viral diarrhea, infectious bovine rhinotracheitis, salmonellosis, paratuberculosis, leptospirosis, and neosporosis. These CPs have been tailored to the specific situation in the Netherlands: a country with a high cattle density, a high rate of animal movements, a strong dependence on export of dairy products, and a high-quality data-infrastructure. The latter specifically applies to the dairy sector, which is the leading cattle sector in the Netherlands. When a herd enters a CP, generally the within-herd prevalence of infection is estimated in an initial assessment. The outcome creates awareness of the infection status of a herd and also provides an indication of the costs and time to achieve the preferred herd status. Subsequently, the herd enrolls in the control phase of the CP to, if present, eliminate the infection from a herd and a surveillance phase to substantiate the free or low prevalence status over time. The high-quality data infrastructure that results in complete and centrally registered census data on cattle movements provides the opportunity to design CPs while minimizing administrative efforts for the farmer. In the CPs, mostly routinely collected samples are used for surveillance. Where possible, requests for proof of the herd status are sent automatically. Automated detection of risk factors for introduction of new animals originating from a herd without the preferred herd status i.e., free or unsuspected, is in place using centrally registered data. The presented overview may inspire countries that want to develop cost-effective CPs for endemic diseases that are not (yet) regulated at EU level.

Incorporating hydrology into climate suitability models changes projections of malaria transmission in Africa.

Continental-scale models of malaria climate suitability typically couple well-established temperature-response models with basic estimates of vector habitat availability using rainfall as a proxy. Here we show that across continental Africa, the estimated geographic range of climatic suitability for malaria transmission is more sensitive to the precipitation threshold than the thermal response curve applied. To address this problem we use downscaled daily climate predictions from seven GCMs to run a continental-scale hydrological model for a process-based representation of mosquito breeding habitat availability. A more complex pattern of malaria suitability emerges as water is routed through drainage networks and river corridors serve as year-round transmission foci. The estimated hydro-climatically suitable area for stable malaria transmission is smaller than previous models suggest and shows only a very small increase in state-of-the-art future climate scenarios. However, bigger geographical shifts are observed than with most rainfall threshold models and the pattern of that shift is very different when using a hydrological model to estimate surface water availability for vector breeding.

Relationship between ecological condition and ecosystem services in European rivers, lakes and coastal waters.

We quantify main ecosystem services (i.e. the contribution of ecosystems to human well-being) provided by rivers, lakes, coastal waters and connected ecosystems (riparian areas and floodplains) in Europe, including water provisioning, water purification, erosion prevention, flood protection, coastal protection, and recreation. We show European maps of ecosystem service capacity, flow (actual use), sustainability and efficiency. Then we explore the relationship between the services and the ecosystem condition at the European scale, considering the ecological status of aquatic ecosystems, reported under the EU Water Framework Directive, as a measure of the ecosystem integrity and biodiversity. Our results indicate that a higher delivery of the regulating and cultural ecosystem services analysed is mostly correlated with better conditions of aquatic ecosystems. Conversely, the use of provisioning services can result in pressures on the ecosystem. This suggests the importance of maintaining good ecological condition of aquatic ecosystems to ensure the delivery of ecosystem services in the future. These results at the continental scale, although limited to the ecosystem services under analysis, might be relevant to consider when investing in the protection and restoration of aquatic ecosystems called for by the current EU water policy and Biodiversity Strategy and by the United Nations Sustainable Development Goals.

Physical water scarcity metrics for monitoring progress towards SDG target 6.4: An evaluation of indicator 6.4.2 "Level of water stress".

Target 6.4 of the recently adopted Sustainable Development Goals (SDGs) deals with the reduction of water scarcity. To monitor progress towards this target, two indicators are used: Indicator 6.4.1 measuring water use efficiency and 6.4.2 measuring the level of water stress (WS). This paper aims to identify whether the currently proposed indicator 6.4.2 considers the different elements that need to be accounted for in a WS indicator. WS indicators compare water use with water availability. We identify seven essential elements: 1) both gross and net water abstraction (or withdrawal) provide important information to understand WS; 2) WS indicators need to incorporate environmental flow requirements (EFR); 3) temporal and 4) spatial disaggregation is required in a WS assessment; 5) both renewable surface water and groundwater resources, including their interaction, need to be accounted for as renewable water availability; 6) alternative available water resources need to be accounted for as well, like fossil groundwater and desalinated water; 7) WS indicators need to account for water storage in reservoirs, water recycling and managed aquifer recharge. Indicator 6.4.2 considers many of these elements, but there is need for improvement. It is recommended that WS is measured based on net abstraction as well, in addition to currently only measuring WS based on gross abstraction. It does incorporate EFR. Temporal and spatial disaggregation is indeed defined as a goal in more advanced monitoring levels, in which it is also called for a differentiation between surface and groundwater resources. However, regarding element 6 and 7 there are some shortcomings for which we provide recommendations. In addition, indicator 6.4.2 is only one indicator, which monitors blue WS, but does not give information on green or green-blue water scarcity or on water quality. Within the SDG indicator framework, some of these topics are covered with other indicators.

Flood risk mapping at European scale.

The aim of this article is to illustrate a framework for flood risk mapping at pan-European scale produced by the Weather-Driven Natural Hazards (WDNH) action of the EC-JRC-IES. Early results are presented in the form of flood risk index maps. We assess several flood risk factors that contribute to the occurrence of flood disasters. Among the causal factors of a flood disaster one is triggering a natural event in the form of extreme precipitation and consequently extreme river discharge and extreme flood water levels. The threatening natural event represents the hazard component in our assessment. Furthermore exposure and vulnerability are anthropogenic factors that contribute also to flood risk. In the proposed approach, flood risk is considered on the light of exposure, vulnerability and hazard. We use a methodology with a marked territorial approach for the assessment of the flood risk. Hence, based on mathematical calculations, risk is the product of hazard, exposure and vulnerability. Improvements on datasets availability and spatial scale are foreseen in the next phases of this study. This study is also a contribution to the discussion about the need for communication tools between the natural hazard scientific community and the political and decision making players in this field.

Five-year immunological outcome of highly active antiretroviral treatment in a clinical setting: results from a single HIV treatment centre.

Our objective was to study the evolution of CD4 cell count five years after starting highly active antiretroviral treatment (HAART) in a clinical setting. The study was performed at the HIV outpatient clinic, Institute of Tropical Medicine, Antwerp. All patients (n = 225) who started HAART in 1997, who had a CD4 cell count within six months prior to starting HAART and who were subsequently followed for at least two years were included. Change in CD4 cell count after start of HAART and the influence of patient and clinical factors were investigated using graphical exploration, endpoint analysis and mixed-effects linear regression. The mean CD4 cell count at start of HAART was 280 cells/mm(3). At the five-year endpoint of the study the mean increase in CD4 cell count was 333 cells/mm(3), while 79% of the patients had a viral load less than 400 copies/mL. There was a significant negative correlation between increase in CD4 cell count at five years and time since first positive HIV test at start of HAART (P = 0.021). Patients who ever had a HAART interruption of more than seven days had a significantly lower increase in CD4 cell count than those who did not (225 cells/mm(3) compared with 438 cells/mm(3); P < 0.001). A mixed-effects linear regression model additionally suggested a significant impact of exposure to antiretrovirals prior to HAART (P = 0.03). Overall, the recovery of CD4 cell count after five years of HAART is good, although therapy interruptions have an important negative impact.

The role of non-viral load surrogate markers in HIV-positive patient monitoring during antiviral treatment.

Monitoring the efficacy of highly active antiretroviral treatment (HAART) is crucial if disease progression and the emergence of viral mutants are to be avoided. Classical viral load monitoring is too expensive for large-scale use in resource-limited settings. Three alternative measures, CD4 count, total lymphocyte count (TLC) and haemoglobin, were evaluated as surrogate markers of treatment success (viral load below detection level) among 710 HIV-positive patients who started HAART in an HIV treatment centre in Belgium. TLC correlated well with changes in CD4 counts during HAART, but an increase in TLC alone was a poor predictor of treatment success. A combination of increases in both haemoglobin levels and TLC proved a reliable predictor of successful treatment outcome comparable to the increase in CD4 count, but its specificity and sensitivity were low.

Effects of long duration centrifugation on head movements and a psychomotor task.

Previous investigations suggest strong similarities between aftereffects of an 1.5-hour 3 gx centrifuge run (Sickness Induced by Centrifugation; SIC) and the Space Adaptation Syndrome (SAS). Head movements proved to be especially nauseogenic in both cases. Until recently, during SIC experimentation, the performance of head movements was not adequately operationalized, which hampered a statistical evaluation. For this purpose, a test was designed by which head movements in four directions (left, right, up, and down) were provoked and registered, once before and once after a 1-h 3 g centrifuge run. Subjects had to execute these head movements in order to perform well on a psychomotor task. The results indicate that the test described is sensitive in discriminating between subjects who are seriously affected after a long duration centrifugation and those who are not. Because differences in performance were found only on those parts of the task in which head movements were involved, objective evidence is obtained in favour of a vestibular cause in the etiology of SIC.

Understanding the central-local relationship in health care: a new approach.

One of the basic assumptions of governmental health planning policy is that the government can effectively take final responsibility for the development of the health care system. Failure to reach policy goals is explained in terms of inadequate planning technology and instruments to control implementation. In this article an alternative explanation is offered, based on the theory of strategic organizational behavior. According to this theory, the government must be seen as but one actor in a complex interorganizational network. From this, a different perspective on effective health planning policy is developed. Policies will fail if they are not based on a valid analysis of the policy space of health care institutions and the interdependencies between government and health care organizations. This article starts with an outline of the nature of the central-local relationship as seen from the perspective of strategic organizational behavior theory. Next, this theory is used to frame two cases in which Dutch health care institutions successfully pursued their own strategies that ran counter to the existing health planning policies. The article ends with a discussion of the implications of the theory of strategic organizational behavior for the development of effective central health care policies. This development starts with a thorough analysis of the policy space and interdependencies of all relevant actors in the health system, the government included. Following, policy makers can set the governmental goals and then have to start negotiations with health care institutions about mutual adaptation of their strategies and the governmental goals. The result is a negotiated health care order.

Hospital policy in The Netherlands: the parameters of structural stalemate.

The Dutch hospital sector has recently been the subject of two divergent national policy initiatives. Following a mixed experience with regulation in the mid-1980s, the national government has now taken the first steps in a radical shift toward market-based competition. This article suggests that neither official strategy can address the fundamental structural and cultural factors that shape institutional behavior in the Dutch hospital system. Drawing upon empirical evidence from two 1987 hospital case studies, this article contends that Dutch hospital management reflects a precentralized insularity which, in turn, sharply reduces the likelihood that either publicly or privately framed decentralized strategies can be successfully implemented.

A nasal septum perforation caused by a Varicella zoster infection in an AIDS patient.

A nasal septum perforation caused by a Varicella Zoster Infection in an AIDS patient. A patient with an acquired immune deficiency syndrome is described who developed a nasal septum perforation. This perforation was probably caused by frequently scratching chronic zoster lesions inside the nose.

Antibodies to gonococcal pili in women with asymptomatic gonorrhoea. Diagnostic value of the ELISA for testing women attending an STD clinic.

The diagnostic efficacy of an enzyme-linked immunosorbent assay (ELISA) using gonococcal pili 6650 as antigen was studied in asymptomatic women attending an STD clinic. Of the 182 women studied, gonorrhoea was diagnosed in 29%. The value of the ELISA was calculated on the basis of four arbitrary cut-off points in the test. The best predictive values for a positive result (PV(+)) were obtained at an absorbance value of A greater than or equal to 1.15 and A greater than or equal to 1.30 and that for a negative result at A greater than or equal to 0.85. When patients with a history of gonorrhoea were excluded, the PV(+) rose only at A greater than or equal to 1.15 (not at A greater than or equal to 1.30) and the PV(-) rose slightly. To be of use in the diagnosis of gonorrhoea in asymptomatic patients the ELISA should be used as follows: the result is positive at A greater than or equal to 1.15 and negative at A less than 0.85, the PV(+) then being 0.52 and the PV(-) 0.85. Whenever sera give a result between A = 0.85 and A = 1.15, the test should be repeated.