European Regional Office Research Articles

Breakfast Cereals Intended for Children: Opportunities for Reformulation and Potential Impact on Nutrient Intake.

Ready-to-eat cereals (RTECs) have become a popular breakfast option claiming to provide important nutrients to children’s diets, despite being a source of excess sugar and, therefore, a health concern. Thus, food reformulation constitutes an important public health strategy that could benefit from inputs provided by nutrient profiling. This study aimed to assess the adequacy of the RTECs for children available in Portuguese supermarkets, applying three nutrient profile models (NPMs)—the nutrient profile model of the World Health Organization’s Regional Office for Europe (WHO-EURO), the profile of the private-sector EU Pledge (EU-Pledge), and the national model developed by the Directorate-General of Health (NPM-PT)—in order to explore the potential for reformulation of the RTECs identified as not adequate and evaluate the impact of RTECs’ reformulation on the nutritional quality of Portuguese children’s diets. In total, 78 RTECs intended for children were assessed and two scenarios—current (not considering reformulation) and alternative (considering reformulation to accomplish the nutrient profile requirements)—were considered to assess the impact of reformulation on nutritional quality. Across all RTECs, only 5.1% could be promoted to children according to the considered NPMs. The most common nutrients requiring reformulation were sugar, saturated fatty acids (SFA), salt, and dietary fiber. The scenarios of reformulation considered could reduce the RTECs average content of total sugars, SFA, and salt by 43%, 8.7%, and 1.1%, respectively, and dietary fiber intake could be increased by 34%. Thus, these results support policies to implement reformulation strategies for developing healthier food products to be promoted to children.

A comparison of 2020 health policy responses to the COVID-19 pandemic in Canada, Ireland, the United Kingdom and the United States of America

This paper compares health policy responses to COVID-19 in Canada, Ireland, the United Kingdom and United States of America (US) from January to November 2020, with the aim of facilitating cross-country learning. Evidence is taken from the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, which has documented country responses to COVID-19 using a structured template completed by country experts. We show all countries faced common challenges during the pandemic, including difficulties in scaling-up testing capacity, implementing timely and appropriate containment measures amid much uncertainty and overcoming shortages of health and social care workers, personal protective equipment and other medical technologies. Country responses to address these issues were similar in many ways, but dissimilar in others, reflecting differences in health system organization and financing, political leadership and governance structures. In the US, lack of universal health coverage have created barriers to accessing care, while political pushback against scientific leadership has likely undermined the crisis response. Our findings highlight the importance of consistent messaging and alignment between health experts and political leadership to increase the level of compliance with public health measures, alongside the need to invest in health infrastructure and training and retaining an adequate domestic health workforce. Building on innovations in care delivery seen during the pandemic, including increased use of digital technology, can also help inform development of more resilient health systems longer-term.

Variations in the Consumption of Antimicrobial Medicines in the European Region, 2014-2018: Findings and Implications from ESAC-Net and WHO Europe.

Background: Surveillance of antimicrobial consumption (AMC) is important to address inappropriate use. AMC data for countries in the European Union (EU) and European Economic Area (EEA) and Eastern European and Central Asian countries were compared to provide future guidance. Methods: Analyses of 2014–2018 data from 30 EU/EEA countries of the European Surveillance of Antibiotic Consumption network (ESAC-Net) and 15 countries of the WHO Regional Office for Europe (WHO Europe) AMC Network were conducted using the Anatomical Therapeutic Chemical (ATC) classification and Defined Daily Dose (DDD) methodology. Total consumption (DDD per 1000 inhabitants per day) of antibacterials for systemic use (ATC group J01), relative use (percentages), trends over time, alignment with the WHO Access, Watch, Reserve (AWaRe) classification, concordance with the WHO global indicator (60% of total consumption should be Access agents), and composition of the drug utilization 75% (DU75%) were calculated. Findings: In 2018, total consumption of antibacterials for systemic use (ATC J01) ranged from 8.9 to 34.1 DDD per 1000 inhabitants per day (population-weighted mean for ESAC-Net 20.0, WHO Europe AMC Network 19.6, ESAC-Net Study Group, and WHO Europe AMC Network Study Group). ESAC-Net countries consumed more penicillins (J01C; 8.7 versus 6.3 DDD per 1000 inhabitants per day), more tetracyclines (J01A; 2.2 versus 1.2), less cephalosporins (J01D; 2.3 versus 3.8) and less quinolones (J01M; 1.7 versus 3.4) than WHO Europe AMC Network countries. Between 2014 and 2018, there were statistically significant reductions in total consumption in eight ESAC-Net countries. In 2018, the relative population-weighted mean consumption of Access agents was 57.9% for ESAC-Net and 47.4% for the WHO Europe AMC Network. For each year during 2014–2018, 14 ESAC-Net and one WHO Europe AMC Network countries met the WHO global monitoring target of 60% of total consumption being Access agents. DU75% analyses showed differences in the choices of agents in the two networks. Interpretation: Although total consumption of antibacterials for systemic use was similar in the two networks, the composition of agents varied substantially. The greater consumption of Watch group agents in WHO Europe AMC Network countries suggests opportunities for improved prescribing. Significant decreases in consumption in several ESAC-Net countries illustrate the value of sustained actions to address antimicrobial resistance.

Providing health services effectively during the first wave of COVID-19: A cross-country comparison on planning services, managing cases, and maintaining essential services

The COVID-19 pandemic triggered abrupt challenges for health care providers, requiring them to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Since March 2020, the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, has documented country responses to COVID-19 using a structured template which includes a section on provision of care. Using the information available on the platform, this paper analyzes how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and ambulatory settings. Despite very real differences in the organization of health and care services, there were many similarities in country responses. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

Dietary Patterns for Health and Sustainability: From Experts’ Opinions to Action for the WHO European Region

Background: To reduce the negative impact of diets on human and planetary health, healthy and sustainable ones need to be adopted. Food systems account for a quarter of greenhouse gas emissions. ‘Dietary Patterns for Health and Sustainability’ is a World Health Organization project that aims to build consensus among international food, health, and sustainability experts and policymakers on actions and policies that could be implemented in the WHO European Region. Methods: Online interviews were conducted with 19 experts from European countries to elicit their views on multiple dimensions of food sustainability and health. Interviews were followed by a Nominal Group Technique and focus groups carried out during a participatory workshop with 32 experts. Findings: The aspects emphasised in the individual interviews and during the workshop were: the need for a multi-stakeholder approach and for simultaneous implementation of aligned and coherent policies at both local and regional levels; the call for a shift towards plant-based diets with a reduction in food waste; and the importance of adapting recommendations to each context (local, regional or national).Interpretation The study findings will be key to helping policymakers make decisions on improving dietary patterns for citizens’ health and wellbeing, in line with the European Programme of Work (EPW) and the Sustainable Development Goals in the European Region. Funding: This research was funded by the WHO Regional office for Europe. Funding for the publication was received from the Government of the Russian Federation within the context of the WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office). Declaration of Interest: The authors report no conflicts of interest.

Weight status in the 6- to 9-year-old school population in Spain: results of the ALADINO 2019 Study

Introduction: childhood obesity is a public health problem whose prevalence has grown steadily in recent decades. Objective: to describe the weight status of schoolchildren aged 6 to 9 years in Spain in 2019, and their associated factors. Methods: ALADINO is a cross-sectional study in schoolchildren aged 6 to 9 years, representative of the Spanish population, and aligned with the Child Obesity Surveillance Initative of the WHO Regional Office for Europe. Participants' weight, height, and abdominal circumference were measured, defining weight status according to different standards (WHO, IOTF, and Orbegozo). A questionnaire on lifestyle and socio-demographic characteristics was administered to parents. Results: a total of 16,665 schoolchildren from 276 schools were measured. Excess weight was observed in 40.6 %: 23.3 % overweight and 17.3 % obesity, with obesity being more prevalent in boys and overweight in girls, both increasing with age. The prevalence of abdominal obesity was 22.6 %. Excess weight decreased by 3.9 percentage points since 2011, mainly due to overweight in boys. Obesity remained stable. Excess weight was more prevalent in schoolchildren with less healthy eating and physical activity habits, and in families with a lower socioeconomic status. Conclusions: the prevalence of excess weight is high, although it has declined since 2011 and remains stable since 2015 among schoolchildren aged 6-9 years in Spain, this reduction being mainly due to a decrease in overweight in children. It is necessary to continue promoting healthy habits from the earliest stages of life, thus reducing health inequalities.

Coronavirus transmission mitigation behaviors

BACKGROUND AND OBJECTIVE: The spread of COVID-19 across the globe develops psychological disturbance to the population. People are always trying to protect themselves from this pandemic through transmission mitigation behavioral (TMBs) practices. The understanding and practice of the exemplary coronavirus TMBs will help the population to fight the disease effectively and efficiently. This study draws the exemplary coronavirus TMBs among the Indian population and constructs a viable model to study these behaviors. METHODS: Data collected from 238 valid respondents through online were the sample of this study. TMB items were collected from the publications of the Ministry of Health and Family Welfare, Government of India, and World Health Organization, Regional Office for Europe. AMOS, SPSS, and Microsoft Excel were used for statistical calculations. Confirmatory Factor Analysis (CFA), Bartlett's Test of sphericity and Keiser–Meyer Olkin (KMO) test, Cronbach's alpha, Principal Component Analysis (PCA), Average Variance Extracted (AVE), and composite reliability (CR) were calculated for the analysis of data. RESULTS, INTERPRETATION, AND CONCLUSIONS: Based on the existing literature, three out of 14 TMB items was dropped, and CFA was run for the remaining 11 items. The result of CFA identified a 5-component structure. Bartlett's test of sphericity was significant at P < 0.001, and KMO measure was acceptable at 0.83. The model fit indices (λ2/df = 1.43, goodness of fit index = 0.953, adjusted goodness of fit index = 0.925, normed fit index = 0.914, Tucker-Lewis Index = 0.962, comparative fit index = 0.972, and root mean square error of approximation = 0.043) and convergent validity (AVE = 0.41 and CR = 0.88) were acceptable. Based on the statistical results, the hypothesized model is fit to examine the 11 TMB items. The 3-factor model with 11 TMB items can be adopted for further replication study, and effective practice of these items is the first-line intervention to fight the spread of coronavirus.

Prevention of impulsive suicide with antidepressants in outpatients

Self-poisoning is a common method of suicide, for which various medications are used, including antidepressants. A non-systematic review of Russian-language and English-language publications, by keywords, in the databases: ELibrary.ru, PubMed, Cochrane Database of Systematic Reviews. The purpose of the review was to analyze the literature on new risk factors and methods of their reduction in suicides with self-poisoning with antidepressants. Every fifth (20%) self-poisoning performed with antidepressants. In self-poisoning attempts, one drug used in 55% of cases, and more than one drug was used in 45% of cases. Impulsive suicides account for up to half of all suicide cases. Risk factors for impulsive suicides include the presence of impulsive character traits, female gender, young age, and the use of psychostimulants. The WHO Regional Office for Europe's mhGAP-IG guidelines recommend limiting access to a patient at risk of suicide to a weekly dose of an antidepressant. Preferably, the use of antidepressants from the group of SSRIs in small forms of release.

The 2021 WHO Catalogue of <i>Mycobacterium Tuberculosis</i> Complex Mutations Associated with Drug Resistance: A New Global Standard for Molecular Diagnostics

Background: Molecular diagnostics are considered the most promising route to achieving rapid, universal drug susceptibility testing for Mycobacterium tuberculosis . There is currently no WHO endorsed catalogue of mutations to serve as a global standard for interpreting molecular information for drug resistance prediction. Methods: A candidate gene approach was used to identify mutations as associated with resistance, or consistent with susceptibility, for 13 WHO endorsed anti-tuberculosis drugs. 38,215 M. tuberculosis isolates with paired whole-genome sequencing and phenotypic drug susceptibility data were amassed from 41 countries. Mutations were graded according to their odds ratio and associated false discovery rate corrected p-value, and their positive predictive value for phenotypic resistance. A series of expert rules were applied for final confidence grading of each mutation. Findings: 15,667 associations were computed for 13,211 unique mutations linked to one or more drugs. 1,149/15,667 (7·3%) mutations were classified as associated with phenotypic resistance and 107/15,667 (0·7%) were deemed consistent with susceptibility. For rifampicin, isoniazid, ethambutol, fluoroquinolones, and streptomycin, the mutations’ pooled sensitivity was >80%. Specificity was over 95% for all drugs except ethionamide (91·4%), moxifloxacin (91·6%) and ethambutol (93·3%). Only two resistance mutations were classified for bedaquiline, delamanid, clofazimine, and linezolid as prevalence of phenotypic resistance was low for these drugs. Interpretation: This first WHO endorsed catalogue of molecular targets for M. tuberculosis drug susceptibility testing provides a global standard for resistance interpretation. It will be expanded as data emerge on phenotypically resistant isolates, including for new and repurposed drugs. Funding: UNITAID, Wellcome, MRC, BMGF. Declaration of Interest: C.U.K. is a consultant Becton Dickinson, the Foundation for Innovative New Diagnostics and the TB Alliance. C.U.K. is collaborating with PZA Innovation and Thermo Fisher Scientific. C.U.K. worked as a consultant for QuantuMDx, the Stop TB Partnership, the World Health Organization (WHO) Global TB Programme and the WHO Regional Office for Europe. C.U.K. gave a paid educational talk for Oxford Immunotec. Hain Lifescience covered C.U.K.’s and accommodation to present at a meeting. C.U.K. is an unpaid advisor to BioVersys and GenoScreen. E.R. is employed by Public Health England and holds an honorary contract with Imperial College London. I.F.L. is Director of the Scottish Mycobacteria Reference Laboratory. S.N. receives funding from German Center for Infection Research, Excellenz Cluster Precision Medicine in Chronic Inflammation, Leibniz Science Campus Evolutionary Medicine of the LUNG (EvoLUNG)tion EXC 2167. P.S. is a consultant at Genoscreen. T.R. is funded by NIH and DoD and receives salary support from the non-profit organization FIND. T.R. is a cofounder, board member and shareholder of Verus Diagnostics Inc, a company that was founded with the intent of developing diagnostic assays. Verus Diagnostics was not involved in any way with data collection, analysis or publication of the results. T.R. has not received any financial support from Verus Diagnostics. UCSD Conflict of Interest office has reviewed and approved T.R.’s role in Verus Diagnostics Inc. T.R. is a co-inventor of a provisional patent for a TB diagnostic assay (provisional patent #: 63/048.989). T.R. is a co-inventor on a patent associated with the processing of TB sequencing data (European Patent Application No. 14840432.0 & USSN 14/912,918). T.R. has agreed to “donate all present and future interest in and rights to royalties from this patent” to UCSD to ensure that he does not receive any financial benefits from this patent. S.S. is working and holding ESOPs at HaystackAnalytics Pvt. Ltd. (Product: Using whole genome sequencing for drug susceptibility testing for Mycobacterium tuberculosis). G.F.G. is listed as an inventor on patent applications for RBDdimer- based CoV vaccines. No other authors declare a conflict of interest. Ethical Approval: Approval for CRyPTIC study was obtained by Taiwan Centers for Disease Control IRB No. 106209, University of KwaZulu Natal Biomedical Research Ethics Committee (UKZN BREC) (reference BE022/13) and University of Liverpool Central University Research Ethics Committees (reference 2286), Institutional Research Ethics Committee (IREC) of The Foundation for Medical Research, Mumbai (Ref nos. FMR/IEC/TB/01a/2015 and FMR/IEC/TB/01b/2015), Institutional Review Board of P.D. Hinduja Hospital and Medical Research Centre, Mumbai (Ref no. 915-15-CR [MRC]), scientific committee of the Adolfo Lutz Institute (CTC-IAL 47-J / 2017) and in the Ethics Committee (CAAE: 81452517.1.0000.0059) and Ethics Committee review by Universidad Peruana Cayetano Heredia (Lima, Peru) and LSHTM (London, UK).

THE STATE OF BROWN CARPATHIAN AND BROWN CAUCASIAN CATTLE BREEDS ON FAO PROJECT TCP/RER/3604 “CONSERVATION AND DEVELOPMENT OF DUAL-PURPOSE CATTLE BREEDS IN EASTERN EUROPE”

During 2018–2019 Ukraine took part in the project of Food and Agriculture Organization (FAO) «Conservation and development of double-purpose cattle breeds in Eastern Europe» (TCP/RER/3604). The project covered Brown Carpathian and Brown Caucasian breeds of Armenia, Georgia and Ukraine. On the results of the project, experts from the FAO Regional Office for Europe and Central Asia, international experts prepared reports on gender, social and economic characteristics of the studied regions, genomic analysis of samples and provided recommendations for breeding in the regions with the breeds. It was considered expedient to present these results to the general scientific community.
 At each country FAO have chosen service-provider (organization), which should make survey on productive environment of targeted breed (in Ukraine – Brown Carpathian), conclude the general state of the breed, visit at least 100 farms where Caucasian/Carpathian Brown cattle breed was kept, collect information from 300 cows and 20 bulls, and genetic samples from at least 100 cows and 20 bulls kept for breeding. Service-provider in Ukraine was M.V.Zubets Institute of Animal Breeding and Genetics, NAAS.
 Scientists of M.V.Zubets Institute of Animal Breeding and Genetics and other sub-contracting organizations during February-June, 2019 investigated 265 heads of cattle in 31 villages 5 districts of the Transcarpathian region, phenotypically classified as Brown Carpathian breed, including 6 breeding bulls of mating age (1.5–2 years). Each animal was photographed, linearly descriptive features of the exterior were evaluated, the necessary body measurements were taken with the help of appropriate tools, live weight and constitutional features were determined, and samples were taken for genetic testing.
 A total of 554 hair samples were taken from the project (123 – from Armenia, 141 – from Georgia and 290 – from Ukraine).
 The basis for classifying the animals as Brown Carpathian was phenotypic examination and strict compliance with the main characteristics of the breed: uniform grey or brown colour with different shades of it, general conformation typical for the breed, lighter belt along the back, black muzzle with lighter hair around it, black hooves and horn tips, lighter "glasses" around the eyes, thick light hair inside outer ears.
 To form the genetic passport of the population, hair was selected from the tail switch of selected animals using equipment provided by FAO, sent to the laboratories of the International Atomic Energy Agency, Austria. In the laboratory in the district of Siebersdorf, DNA was isolated from the obtained samples, the genetic diversity of populations, the degree of inbreeding and their effective number, kinship between populations were assessed and the genetic structure and level of influence of other breeds were analysed.
 DNA was extracted from each hair follicle using a MasterPure kit (Biozym, Illumina, USA) according to the protocol of the Association of Public Health Laboratories (APHL). The isolated DNA was subjected to a two-step quality control procedure before preparation for wide-genome typing. DNA samples were measured using a Nanodrop spectrophotometer to obtain a concentration with a ratio of 260/280 and 260/230. According to the results obtained using a spectrophotometer, DNA samples were diluted to measure high-quality double-stranded DNA (dsDNA) by PicoGreen Assay. The final working DNA was prepared based on PicoGreen measurements and stored at – 20°C for further processing.
 Sample genotyping was performed using a third-generation 384-cell matrix to assess Bovine individuals on the Affymetrix-Axiom platform (Axiom Bovine Genotyping v3 array). Within the project, 48 individuals of Austrian Simmental and 18 – Ayrshire breeds were also genotyped for comparison. The matrix included 64.000 SNPs, providing a high probability of covering genomic variations of the Bos taurus and Bos indicus breeds.
 Intra-breed genetic diversity was assessed using PLINK v1.09 to calculate actual heterozygosity (H0) and inbreeding coefficient (FIS).
 Analysis of genetic parameters of population diversity evidenced a rather low inbreeding rate of Brown Carpathian breed and a fairly high effective population size compared to European breeds, which can indicate a very limited practice of artificial insemination and lack of selection among bulls.
 Analysis of genetic differentiation and relationship between populations, principal components analysis and determination of admixtures of other breeds proved the uniqueness of the Brown Carpathian breed from a genetic point of view.
 Based on the conducted genomic analysis of populations, consultations with project participants, reports of service providers of each country, an international consultant on animal genetic resources, chairman of the ICAR working group on functional traits, formed a breeding program for the studied populations. The breeding program included proposals for further selection work, calculation of basic selection-genetic parameters, selection effect, number of bulls and heifers for selection nucleus, number of doses to maintain genetic diversity of the population, cost of population restoration, breeding work of breeding centre and work plan by years to implement a breeding program.
 Gender analysis of service providers' reports showed some gender differentiation in livestock care, processing and everyday life of owners of Brown Carpathian cattle.

WHO Europe Heat Health Action Plan guidance: an update of the evidence ten years on.

Backround: Future climate change and the increasing frequency and intensity of heat waves poses a serious health threat to populations worldwide and the need to promote adaptation strategies. The European Centre for Environmental Health - WHO Regional Office for Europe, has carried out an update of the scientific evidence and a survey on European heat health plans currently in place. Our aim is to update the WHO Heat Health Action Plans (HHAP) guidance document.Methods/results. The document includes most relevant evidence from recent epidemiological research and lessons learned from implementation in practice. The evidence update is focused on the eight core components of a HHAP as defined by the WHO: Lead body, warning systems, information plan, reduction in indoor heat exposure, particular care for vulnerable subgroups, preparedness of the health and social services, long-term urban planning, surveillance and evaluation.The survey was disseminated via national focal points and WHO EURO Country Offices, members of the WHO EURO working group and subnational networks. Results from the survey provide an overview of current plans in place among European Member States. Over 80% of HHAPs are either a formal part or mentioned in national Climate Change policy. Most plans identify a lead body, have an information plan and a warning system in place. The latter, helps raise awareness on the health risk during heat waves at population level, while ensuring the timely planning of prevention and emergency measures. Plans acknowledge the need to target vulnerable subgroups, however who these are and what specific measures are adopted is very much heterogeneous. The formal inclusion of long-term policy addressing indoor heat reduction or urban planning has the lowest level of coverage in current HHAPs. Conclusion: The WHO document will help promote the update of HHAPs taking into account the changing climate, shifting demographics and urbanization.

Tuberculosis in Poland in 2018.

To evaluate the main features of tuberculosis (TB) epidemiology in 2018 in Poland and to compare with the situation in the EU/EEA countries. Analysis of case- based data on TB patients from National TB Register, data on anti-TB drug susceptibility testing results in cases notified in 2018, data from National Institute of Public Health- National Institute of Hygiene on HIV-positive subjects for whom TB was an AIDS-defining disease, data from Central Statistical Office on deaths from tuberculosis based on death certificates, data from the report " European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2020- 2018 data. Stockholm: European Centre for Disease Prevention and Control, 2020". In 2018, 5487 TB cases were reported in Poland. The incidence rate was 14.3 cases per 100000, with large variability between voivodeships from 7.3 to 23.4 per 100 000. The mean annual decrease of TB incidence in 2014- 2018 was 3.8%. In 2018, 4852 cases were newly diagnosed with no history of previous treatment i.e. 12.6 per 100 000. 635 cases i.e. 1.7 per 100 000 - 11.6% of all registered subjects were previously treated for tuberculosis. In 2018, the number of all pulmonary tuberculosis cases was 5224 i.e. 13.7 per 100000. Pulmonary cases represented 95.2% of all TB cases. In 2018, 243 extrapulmonary TB cases were found i.e. 0.6 per 100 000. In the whole country there were 52 pediatric cases of tuberculosis. TB in children represented 0.9% of all cases notified in Poland in 2018. The incidence rates of tuberculosis were growing along with the age group from 0.9 per 100 000 among children to 24.7 per 100 000 among subjects in the age group 45-64 years (the highest incidence rate). In 2018, the incidence rate in the age group ≥65 years was 21.3 per 100 000. The TB incidence among men i.e. 21.0 per 100 000 was 2.6 times higher than among women i.e. 8.0 per 100 000. The biggest difference in the TB incidence between the two sex groups occurred in persons aged 55 to 59 years - 44.9 vs. 9.8 and in age group 60- 64 years - 43.7 vs. 10.2. The TB incidence in rural population was lower than in urban, respectively 13.4 per 100 000 and 14.9 per 100 000. The number of all registered culture positive TB cases was 4075. Pulmonary tuberculosis was bacteriologically confirmed in 3935 subjects. Cases confirmed by culture represented 74.3% of all TB cases and 75.3% of all pulmonary TB cases. The number of smear-positive pulmonary TB cases reported in 2018 was 2324 i.e. 6.1 per 100 000 accounting for 44.3% of all pulmonary TB cases and 59.1% of pulmonary TB cases confirmed by culture. In all patients with tuberculosis in Poland in 2018 there were 48 cases with MDR-TB (among them 14 foreigners) and 83 patients with resistance to isoniazid only, representing respectively 1.3% and 2.2% of cases with known DST results (DSTs were available in 90.7% of all culture-confirmed TB cases). In 2018, there were 97 patients of foreign origin among all cases of tuberculosis in Poland. TB was AIDS-indicative disease in 14 subjects with HIV co-infection. There were 490 deaths due to tuberculosis reported in 2017 - 1.3 per 100 000; 468 people died from pulmonary and 22 from extrapulmonary tuberculosis. Mortality among males - 2.1 per 100 000 - was 3.6 X higher than among females - 0.5. 40.2% of all TB deaths were cases 65 years old and older - 3.1 per 100 000. In 2017, there was no death from tuberculosis in children and no deaths in adolescents. In 2017, tuberculosis represented 0.1% of total mortality in Poland and 25.4% of mortality from infectious and parasitic diseases. In 2018, the incidence of tuberculosis in Poland was lower than in 2017. Despite a continuous decline it is still higher than the average in the EU/EEA countries. The highest incidence rates were observed in older age groups. The participation of pediatric cases is smaller than average in the EU/EEA countries. The incidence in males was more than 2 times higher than in females. The impact of migration on the characteristics of tuberculosis in Poland is not substantial. In Poland, MDR-TB is less common than the average in the EU/EEA countries.

10.C. Round table: European public health week: how to unite a continent to celebrate healthy populations

The first two editions of the European Public Health Week (EUPHW) took place in May 2019 and May 2020. Both exceeded all expectations, registering more than 140 events in more than 30 countries each year - despite the pandemic context and a fully online format in 2020. In this session we will share insights from both editions, with the round table format allowing for a wider discussion of experiences with other countries from around the world.Under the motto “celebrating healthy populations” in 2019 and “joining forces for healthier populations” in 2020, EUPHW aims to raise awareness about public health, maximise existing messages around the five themes that are set each year, and encourage collaboration among all professionals contributing to public health at local, national, regional and European level. Amid the COVID-19 public health emergency, the importance of ensuring that populations remain healthy and that the public health community joins forces gained momentum.The five days of the 2020 edition were dedicated to the Sustainable Development Goals, primary care in the digital age, staying together for mental health, equal health for all, and healthy ageing - under the exceptional overarching theme of 'COVID-19 Collaboration, Coordination, Communication'. Last year's edition covered physical activity, healthy environments, the healthcare workforce, healthy and sustainable diets, and youth mental health.The EUPHW Coordinator will explain what the initiative consists of and reveal key figures from both editions. The different types of involvement in the EUPHW will also be described: Event host, Disseminator and Participant. Three panelists will represent the EUPHW Steering Committee, providing important insights into the backstage preparation of this large-scale initiative. One is the communications coordinator of the EUPHAnxt network, representing contributions from the young generation of public health professionals in Europe. A second panelist will not only share the experience of hosting EUPHW events but also represent EUPHA Sections, which play an important role in fact-checking resources and messages about each of the annual themes. The fourth panelist will share their experiences at country level through the Austrian Public Health Association and its own National Public Health Week. The final panelist will share examples of activities hosted by the community of public health schools across Europe.Although the focus of the EUPHW is the European region, its online reach enables the participation from anywhere in the world. In fact, both editions saw registered activities in Brazil, USA, South Africa, Kenya, Australia and Colombia.The EUPHW is an initiative by the European Public Health Association (EUPHA), receives co-funding under an operating grant from the European Union's Health Programme (2014-2020) and is supported by the WHO Regional Office for Europe.Key messages The European Public Health Week brings together a continent to raise awareness about important public health issues.The workshop unveils how public health themes are explored on different contexts, across different cultures and in different formats. Panelists: Debora Miranda EUPHA, PortugalContact: debbiemiranda@gmail.com Thomas Dorner Austrian Public Health Association, AustriaContact: thomas.dorner@meduniwien.ac.atNicole RosenkötterNRW Centre for Health - Health Information, GermanyContact: Nicole.Rosenkoetter@lzg.nrw.de Pasquale Cacciatore EUPHAnxt, ItalyContact: pasqualecacciatore@gmail.com Robert Otok AASPHER, BelgiumContact: robert.otok@aspher.org

Conversion of industrial contaminated sites into residential areas –safeguarding health and wellbeing

Abstract Across Europe, urban settlements are changing and expanding. Due to lack of land resources, urban development often relies on the re-use and conversion of former industrial areas - land which has had special functions before but now is being used for urban, public, recreational and residential functions. This challenge is often referred to as land recycling or brownfield conversion, and is associated with urban processes labelled e.g. urban sprawl, renewal, revitalization, regeneration or redevelopment. Urban revitalization and the use of former non-residential land for urban functions raise potential challenges related to health, wellbeing and equity. The use of former industrial areas can be associated with contamination which, if not fully remediated, can pose health risks to new residents. With increasing urbanization in many countries there is a need for cities to provide new residential areas. The WHO Regional Office for Europe is developing a compilation of health impacts of such urban land-take processes - including a review of lessons learned and a collection of practical experiences - that can provide better understanding of the scope of the problem, related health challenges and guidance for action for countries and cities where such conversion projects take place. The work will contribute to achieving SDG 11 by discussion practical processes for multi-stakeholder engagement in all stages of urban development that build consensus, inclusion, resilience and sustainability when converting former industrial areas into residential areas. The presentation will focus on environmental, social and health implications and experiences of urban and residential use of land resources with formerly different functions. The presentation will include lessons learned regarding the assessment of risk associated with land contamination etc.

30.L. Workshop: European burden of disease network: strengthening the collaboration

Abstract The burden of disease (BoD) approach has become one of the foundations of descriptive epidemiology. Central to this approach is the use of the Disability-Adjusted Life Year as a comprehensive and comparable summary measure of population health. Driven by the impact of the Global Burden of Disease (BoD) study, several researchers and health institutes across the world have adopted the BoD approach to assess the health impact of diseases and risk factors, supporting a more rational allocation of available resources. Despite the increasing prominence of the BoD approach, several challenges remain. The BoD methodology is complex and highly data intensive, which has led to major disparities across researchers and nations in their capacity to perform BoD studies, to interpret the soundness of available BoD estimates, or to advocate for the use of BoD methods. Often, these disparities follow geographical boundaries–for instance, over half of all published BoD studies in Europe were set in the Netherlands, Spain and UK, while only 15% were set in eastern European countries. BoD as a generally standardized approach nonetheless requires different methodological choices, and lack of harmonization in these may hamper comparisons across studies. This is further aggravated by the fact that different BoD initiatives have remained scattered–there is for instance little interaction between infectious disease, nutritional and environmental epidemiologists, even though several methodological issues transcend the boundaries of diseases and risk factors. Finally, many BoD researchers are struggling to find optimal ways to translate their findings and communicate them adequately and comprehensively to decision makers and other stakeholders. In response to these needs, several countries and BoD researchers have set up ad hoc partnerships. In 2016, the WHO Regional Office for Europe (WHO-EURO) launched a European BoD network, aiming to intensify links between WHO, IHME and the WHO-EURO member states. In 2019, our group has launched a COST Action that aims to serve as a technical platform to integrate and strengthen capacity in BoD assessment across Europe and beyond. At the moment of writing, the “burden-eu” COST Action joins over 200 participants from 38 European countries, as well as several observers from non-European countries and international organizations. In this workshop, we give an overview of the current status and initial accomplishments of the COST Action, with a focus on the key challenges that the Action aims to address - i.e., increased interaction between existing efforts, methodological advances and technical capacity building at country level, and an actionable understanding of the process underlying knowledge translation. The different sessions will include interactions with the audience to learn about the needs and expectations of the attendees, and how these can be addressed by the COST Action. Key messages The burden of disease approach is increasingly used to generate comparable and comprehensive estimates of the health impact of diseases and risk factors. The 'burden-eu' COST Action offers a technical platform for integrating and strengthening capacity in burden of disease assessment across Europe and beyond.

Knowledge translation and health policy for burden of disease

Abstract A key goal of most Burden of Disease (BoD) studies is to support public health policies. However, while the concepts of BoD and Disability Adjusted Life years have been introduced more than 25 years, BoD researchers are still struggling to find better ways to translate their findings and communicate them to the relevant decision makers and other stakeholders. To address this gap, the burden-eu COST Action aims to generate better guidance of the use of BoD metrics in policy-making processes. In collaboration with experts in knowledge translation and risk communication, the Action will compile good practices in knowledge translation and develop a roadmap to integrate knowledge translation in national BOD studies. To support these objectives, collaborations have been established with knowledge translation experts from the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Public Health Association. During an initial meeting of the “knowledge translation” working group, 29 participants identified elements in the pathway from evidence generation to practice that need to be addressed. Building on the outcomes of this meeting and the inputs from the knowledge translation experts, this presentation will introduce the knowledge translation framework, and address some of the challenges in identifying best routes to reach out to the public and policy-makers. Specific emphasis will be placed in profiling the context, actors and processes of each country within the policy triangle, and drawing on best and worst example case studies. Additionally, the process will be discussed to co-create a toolkit or guide for using BoD evidence in policy and practice. The session will conclude with an interaction with the audience to learn about the perceived barriers for implementing knowledge translation within the BoD framework.

25.G. Round table: Public health codes of ethical professional conduct for effective practice

Abstract One of the major outputs of the WHO Regional Office for Europe “Coalition of Partners” initiative has been the development of the “Road map for professionalization of the public health workforce in Europe.” Public health ethics was considered as one of the key pillars for practice for the workforce. The report highlighted the case and urgent need for development of Public Health Codes of ethics and professional conduct (CoC) as an essential part of workforce development strategies. The development of CoCs is considered essential to pursue the mission and moral mandate of public health and to clarify the purpose of professional activities in public health. Scotland has been working as an initial pilot site in Europe to consider developing a CoC for its workforce as part of its public health reform program. The purpose of this roundtable workshop is to share and reflect on the learning from the process, experience and findings from development of the Scottish CoC as the first pilot site in Europe and implications for development of such codes in other public health systems. The workshop will also share the evidence, rationale and background to CoC with research and learning from around the world on the issue. The Roundtable will include brief presentations by an experienced expert panel of senior public health leaders, ethicists and academics who have been working on development of public health Codes of professional conduct. This will be followed by reflection, consultation and debate with participants around the case, nature and options for development of codes of practice and distinguishing features for public health practice. There are issues to whether there is need for country specific, regional or global codes of ethics taking account core public health values and implications for practice. One of the key issues identified is fundamental importance of ensuring such work is linked to a strategy and activities to build competency and capacity around public health ethics and law and to ensure resources, systems and robust education and training activities are put in place for a sustainable development of the issue. Key messages The Development of CoCs is important in order to support the workforce, pursue the mission and moral mandate of public health and clarify the purpose of professional activities. There is need to develop activities and strategy for building competency and capacity in public health ethics alongside development of Code of ethics and professional conduct.

HIV incidence fall in Italy: a –20% fall in 2018 to be explained

Abstract Background HIV is still a critical public health threat in Europe, especially in some at-risk populations. Stigma keeps undermining access to prevention, diagnosis, and care. Treatment as Prevention (TasP) and Pre-Exposure Prophylaxis (PrEP) have spread heterogeneously across the continent. The study aimed to compare recent HIV incidence trends in five European countries (Italy, Spain, Germany, France, UK), and to speculate about TasP and PrEP's relative contribution as preventive measures in Italy. Methods We collected incidence data by consulting the ECDC HIV/AIDS Surveillance Report 2019, and a preliminary Italian 2019 report issued by the National Institute of Health. We used the latest ECDC Continuum of HIV care data to appraise European trends in HIV viral suppression. Results All the considered European countries reported a decreasing trend in 2018, compared to 2017. In Italy, according to raw preliminary data, the number of new HIV infections dropped from 3,561 (5.9/100,000) to 2,847 (4.7/100,000), thus resulting in a -20% fall. Interestingly, Spain shows an even sharper decrease of -22%, dropping from 3,795 new cases in 2017 to 2,527 in 2018, that is from a rate of 8.2/100,000 to 6.4/100,000. Conclusions Since 2008, when the coordinated ECDC/WHO Regional Office for Europe HIV/AIDS surveillance system was set up, Italy has never witnessed such a sharp yearly fall in incident cases, thus representing, together with Spain, an epidemiological peculiarity in the European context. TasP could have played a major role in Italy. Indeed, Continuum of HIV care data show a positive trend in viral suppression in European countries. PrEP has been introduced in the Italian guidelines in 2016 and is nowadays adopted in a few urban areas, as a co-pay, on-demand service for high-risk populations with limited diffusion. It is thus plausible that PrEP carries a much lower epidemiologic weight in the Italian 2018 incidence reduction. Key messages We need to spread PrEP, TasP and screening programs, especially in at-risk populations. We must search for a causal association between preventive measures and decreasing incidence.

WHO European Health Literacy Action Plan

Abstract Background Grounded in the last decade's health literacy developments; the work of the European health literacy action networks on measurement and NCDs as well as the newly adopted European Health Literacy Roadmap and resolution agreed upon by their 53 Member States in 2019, the WHO European Region continues its investment in health literacy. A WHO European health literacy action plan is under development to be launched in 2021. The action plan implies concrete actions for Member States on how to develop health literate populations and societies. Methods Based on co-creation principles, the development of the action plan is conducted by stakeholders from a wide range of fields and disciplines. Lead by the WHO European Regional Office, the process includes an initial stakeholder meeting, iterative technical consultations with experts and the wider stakeholder community and Member State consultations. The analytical methods integrate a SWOT-analysis, future scenario thinking and long-sight action planning approaches as well as application of health literacy analytics. Results The results of the initial analytical steps will be presented such as the SWOT analysis, the future scenarios and associated recommendations on how to create health literate populations and societies in Europe. Additionally, the outline of the draft of the European health literacy action plan will be open for discussion and input. Conclusions Through an iterative process, the European health literacy action plan is co-produced by multiple actors through a series of consultations facilitating ownership and accountability. The European health literacy action plan can be an inspiration and a model for other world regions.

10.F. Round table: Transforming food and agricultural systems and addressing food insecurity in Europe

Abstract This roundtable will follow up from the Workshop on Planetary Healthy Diets for All and explore practical solutions to tie increased sustainability of food systems to reductions in food insecurity in Europe. There is a disconnect between the level of scientific evidence supporting the need for action on food and agricultural systems and the willingness to uptake it at the national and local level. Countries' reluctance to implement evidence-based policy options often results from the perception that the data and solutions do not reflect their national realities. At the same time, there is a rising trend in food insecurity in Europe. Part of it is driven by the food system itself and part of it by social determinants that exacerbate the effects of elements such as food prices or the availability of affordable healthy foods. In terms of the current response to food insecurity in Europe, there is enough evidence that it is inadequate. The most notable example of inadequacy are food banks: they are unsustainable and perpetuate deficiencies of the foods system, such as waste. At the same time, food banks contribute to widening health inequities because they are stigmatizing, and the quality and reliability of the food they offer exacerbates health problems. They also mask failures of social protection and of food policy to protect those at the bottom. Yet, they are proliferating all around Europe. The WHO European Regional Office for Europe will share practical steps that it is taking to assist policy makers at national level to bridge evidence and action. WHO will present a novel on-line, readily accessible tool that public health officials from Member States can use to guide policy decisions. This tool uses a food systems model considering food consumption, food production, environmental impacts and health impacts to identify practical solutions for countries to create food systems that both have a lower impact on the climate and promote healthier diets. The roundtable will also highlight the transformative example of Copenhagen's public food procurement strategy, which, starting from a target on organic food in public canteens, has evolved into a comprehensive approach to achieve tasty, healthy, sustainable meals with social added value and without increasing procurement costs. In sum, against the backdrop of both nutritional and environmental challenges to food systems in Europe, participants at the roundtable will share barriers and opportunities to the uptake of evidence-based solutions to transform food systems and tackle food insecurity at the national and local levels, including in the context of the ongoing reform of the EU's Common Agricultural Policy (CAP) and the new 'Farm to Fork' Strategy for sustainable food. This discussion will allow participants to share their insights and enrich each other's understanding of the issues at stake and the tools and opportunities on offer to support, in an action-oriented way, a sustainable food systems transition that overcomes food insecurity. Key messages Global reference diets need application on a national and subnational level. Food insecurity, can be major barrier to the uptake of healthy diets and must be tackled as such. The new data platform and training materials will empower policymakers within countries to develop and introduce national level initiatives, such as sustainable and healthy public procurement.