Health burden and costs attributable to the carbon footprint of the health sector in the European Union.

BACKGROUND: The healthcare sector has an environmental impact of around 4.6% of global CO2 emissions, contributing to aggravating the climate crisis. However, the impact of the health sector's emissions on human health is not regularly assessed. We aim to estimate the health burden and associated costs of the health sector's carbon footprint within the European Union (EU). METHODS: We calculated disability-adjusted life years (DALYs) and associated costs based on human health damage factors (DALYs/kg-CO2e) by considering four scenarios. Three scenarios for shared socioeconomic pathways (S1 - high growth, S2 - baseline, and S3 - low growth) represented variations of global society, demographics, and economics until 2100. A fourth scenario (S4) considered the current EU's 55% reduction goal of greenhouse gas emissions. The healthcare sector's emissions per capita (in CO2-equivalent) in 2019 were extracted from the Lancet Countdown, and population data were retrieved from Eurostat for the same year. RESULTS: In the EU, 365,047 DALYs (95%CI: 194,692-535,403) are expected to be caused by the health sector's emissions at baseline (S2). In an S1 scenario, the burden would slightly decrease to 316,374 DALYs (95%CI: 170,355-462,393), whereas a S3 scenario would increase 486,730 DALYs (95%CI: 243,365-681,422). If EU's carbon goals are met, the burden could be substantially reduced to 164,271 DALYs (95%CI: 87,611-240,931). Costs can amount to 25.6 billion euros, when considering DALYs monetisation. CONCLUSION: CO2 emissions from the health sector are expected to significantly impact human health. Therefore, it is important to ensure that EU climate policies for public buildings are in line with the Paris Agreement, increase funding for climate mitigation programs within the healthcare sector, and review clinical practices at the local level.

Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009-19: an ecological study.

BACKGROUND: Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic. METHODS: In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models. FINDINGS: Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]). INTERPRETATION: Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA. FUNDING: Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

Medical residency in Portugal: a cross-sectional study on the working conditions.

Objectives: The current European crisis in human resources in health has opened the debate about working conditions and fair wages. This is the case with Resident doctors, which have faced challenges throughout Europe. In Portugal, they account for about a third of the doctors in the Portuguese National Health Service. No studies to date objectively demonstrate the working conditions and responsibilities undertaken. This study aims to quantify the residents' workload and working conditions. Methods: Observational, retrospective cross-sectional study which involved a survey on the clinical and training activity of Portuguese residents, actively working in September 2020. The survey was distributed through e-mail to residents' representatives and directly to those affiliated with the Independent Union of Portuguese Doctors. The descriptive analysis assessed current workload, and logistic regression models analyzed associations with geographical location and residency seniority. Results: There were a total of 2,012 participants (19.6% of invited residents). Of the residents giving consultations, 85.3% do so with full autonomy. In the emergency department, 32.1% of the residents work 24 h shifts and 25.1% work shifts without a specialist doctor present. Regarding medical training, 40.8% invest over EUR 1,500 annually. Autonomy in consultations was associated with being a Family Medicine resident (OR 4.219, p < 0.001), being a senior resident (OR 5.143, p < 0.001), and working in the Center (OR 1.685, p = 0.009) and South regions (OR 2.172, p < 0.001). Seniority was also associated with investing over EUR 1,500 in training annually (OR 1.235, p = 0.021). Conclusion: Residents work far more than the contracted 40 h week, often on an unpaid basis. They present a high degree of autonomy in their practice, make a very significant personal and financial investment in medical training, with almost no time dedicated to studying during working hours. There is a need to provide better working conditions for health professionals, including residents, for the sake of the sustainability of health systems across Europe.

Assessment of the Implementation of the International Health Regulations during the COVID-19 Pandemic: Portugal as a Case Study.

INTRODUCTION: The International Health Regulations (IHR) were developed to prepare countries to deal with public health emergencies. The spread of SARS-CoV-2 underlined the need for international coordination, although few attempts were made to evaluate the integrated implementation of the IHR's core capacities in response to the COVID-19 pandemic. The aim of this study was to evaluate whether IHR shortcomings stem from non-compliance or regulatory issues, using Portugal as a European case study due to its size, organization, and previous discrepancies between self-reporting and peer assessment of the IHR's core capacities. METHODS: Fifteen public health medical residents involved in contact tracing in mainland Portugal interpreted the effectiveness of the IHR's core capabilities by reviewing the publicly available evidence and reflecting on their own field experience, then grading each core capability according to the IHR Monitoring Framework. The assessment of IHR enforcement considered efforts made before and after the onset of the pandemic, covering the period up to July 2021. RESULTS: Four out of nine core IHR capacities (surveillance; response; risk communication; and human resource capacity) were classified as level 1, the lowest. Only two were graded level 3 (preparedness; and laboratory), the highest. The remaining three) (national legislation, policy & financing; coordination and national focal point communication; and points of entry) were classified as level 2. CONCLUSION: Portugal exemplifies the extent to which implementation of the IHR was not fully achieved, which has resulted in the underperformance of several core capacities. There is a need to improve preparedness and international cooperation in order to harmonize and strengthen the global response to public health emergencies, with better political, institutional, and financial support.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study.

BACKGROUND: Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest. METHODS: DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries. RESULTS: Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low. CONCLUSIONS: The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Burden of lung cancer and predicted costs of occupational exposure to hexavalent chromium in the EU - The impact of different occupational exposure limits.

BACKGROUND: Exposure to hexavalent chromium [Cr(VI)] occurs widely in occupational settings across the EU and is associated with lung cancer. In 2025, the occupational exposure limit is set to change to 5 µg/m3. Current exposure limits are higher, with 10 µg/m3 as a general limit and 25 µg/m3 for the welding industry. We aimed to assess the current burden of lung cancer caused by occupational exposure to Cr(VI) and to evaluate the impact of the recently established EU regulation by analysing different occupational exposure limits. METHODS: Data were extracted from the literature, the Global Burden of Disease 2019) study, and Eurostat. We estimated the cases of cancer attributable to workplace exposure to Cr(VI) by combining exposure-effect relationships with exposure data, and calculated related DALYs and health costs in scenarios with different occupational exposure limits. RESULTS: With current EU regulations, 253 cases (95%UI 250.96-255.71) of lung cancer were estimated to be caused by Cr(VI) in 2019, resulting in 4684 DALYs (95%UI 4683.57-4704.08). In case the welding industry adopted 10 µg/m3, a decrease of 43 cases and 797 DALYs from current values is expected. The predicted application of a 5 µg/m3 limit would cause a decrease of 148 cases and 2746 DALYs. Current costs are estimated to amount to 12.47 million euros/year (95%UI 10.19-453.82), corresponding to 39.97 million euros (95%UI 22.75-70.10) when considering costs per DALY. The limits implemented in 2025 would lead to a decrease of 23.35 million euros when considering DALYs, with benefits of introducing a limit value occurring after many decades. Adopting a 1 µg/m3 limit would lower costs to 1.04 million euros (95%UI 0.85-37.67) and to 3.33 million euros for DALYs (95%UI 1.89-5.84). DISCUSSION: Assessing different scenarios with different Cr(VI) occupational exposure limits allowed to understand the impact of EU regulatory actions. These findings make a strong case for adapting even stricter exposure limits to protect workers' health and avoid associated costs.

Impact of the COVID pandemic on mental health and training opportunities of Public Health Residents from 4 European countries: A cross-sectional study.

Objectives: There is little evidence on the impact of the COVID-19 pandemic on Public Health Residents' (PHR) mental health (MH). This study aims at assessing prevalence and risk factors for depression, anxiety and stress in European PHR during the COVID-19 pandemic. Methods: Between March and April 2021, an online survey was administered to PHR from France, Italy, Portugal and Spain. The survey assessed COVID-19 related changes in working conditions, training opportunities and evaluated MH outcomes using the Depression Anxiety Stress Scales-21. Multivariable logistic regressions were applied to identify risk factors. Results: Among the 443 respondents, many showed symptoms of depression (60.5%), anxiety (43.1%) and stress (61.2%). The main outcome predictors were: female gender for depression (adjOR = 1.59, 95%CI [1.05-2.42]), anxiety (adjOR = 2.03, 95%CI [1.33-3.08]), and stress (adjOR = 2.35, 95%CI [1.53-3.61]); loss of research opportunities for anxiety (adjOR = 1.94, 95%CI [1.28-2.93]) and stress (adjOR = 1.98, 95%CI [1.26-3.11]); and COVID-19 impact on training (adjOR = 1.78, 95%CI [1.12-2.80]) for depression. Conclusions: The pandemic had a significant impact on PHR in terms of depression, anxiety and stress, especially for women and who lost work-related opportunities. Training programs should offer PHR appropriate MH support and training opportunities.

Burden of infectious disease studies in Europe and the United Kingdom: a review of methodological design choices.

This systematic literature review aimed to provide an overview of the characteristics and methods used in studies applying the disability-adjusted life years (DALY) concept for infectious diseases within European Union (EU)/European Economic Area (EEA)/European Free Trade Association (EFTA) countries and the United Kingdom. Electronic databases and grey literature were searched for articles reporting the assessment of DALY and its components. We considered studies in which researchers performed DALY calculations using primary epidemiological data input sources. We screened 3053 studies of which 2948 were excluded and 105 studies met our inclusion criteria. Of these studies, 22 were multi-country and 83 were single-country studies, of which 46 were from the Netherlands. Food- and water-borne diseases were the most frequently studied infectious diseases. Between 2015 and 2022, the number of burden of infectious disease studies was 1.6 times higher compared to that published between 2000 and 2014. Almost all studies (97%) estimated DALYs based on the incidence- and pathogen-based approach and without social weighting functions; however, there was less methodological consensus with regards to the disability weights and life tables that were applied. The number of burden of infectious disease studies undertaken across Europe has increased over time. Development and use of guidelines will promote performing burden of infectious disease studies and facilitate comparability of the results.

Mortality in COVID-19 patients after proximal femur fracture surgery: a systematic review and meta-analysis.

BACKGROUND: COVID-19 infection first emerged in December 2019 in China and has since rapidly spread to become a worldwide pandemic. Orthopaedic surgery suffered a significant decline in the volume of surgical cases, while the orthopaedic trauma services maintained or increased the activity. Emergency operations for proximal femur fractures (PFF) in the elderly population assumed levels comparable to before the pandemic, with the 1-year mortality rate ranging from 14% to 36%. AIMS: To determine whether patients with PFF affected by COVID-19 have a higher risk of postoperative mortality through a systematic review and meta-analysis. METHODS: PubMed, Web of Science, Scopus and BMC were searched from January 2020 to January 2021 to identify original studies reporting the mortality in COVID-19 patients after PFF surgery. Study and participants' characteristics, mortality rate and odds ratio (OR) were extracted. Risk of bias assessment was carried, and visual inspection of the funnel plot was used to assess publication bias. A random-effects model for meta-analysis was adopted. RESULTS: Among 656 articles that came from the search query and hand-search, 10 articles were eligible after applying inclusion and exclusion criteria. Overall, the sum of the study participants was 1882, with 351 COVID-19 positive patients (18.7%) and a total number of 117 deaths, with an overall mortality rate of 33.3%. The mortality rate of COVID-19 positive patients varied from 14.8% to 60% and was higher than of those without COVID-19, with OR ranging from 2.424 to 72.00. The inverse variance method showed an OR = 3.652. All studies showed a statistically significant p-value. CONCLUSIONS: The postoperative mortality in hip fracture patients with concomitant COVID-19 was 3.65 times higher than the mortality in non-COVID patients. The currently available literature demonstrates that COVID-19 infection represents a substantial risk factor for postoperative mortality in the already susceptible hip fracture population.

Ethical Responsibility in Environmentally Sustainable Health Care / Responsabilidad Ética en la Sostenibilidad Ambiental del Cuidado de la Salud / Responsabilidade Ética na Sustentabilidade Ambiental dos Cuidados de Saúde

Environmental issues gained momentum in recent years, with consequences of climate change already being felt across the world. As the environment worsens health, human activities also influence the environment, by worsening this process, creating an uninterrupted cycle which might speed up climate change. The health sector plays a role as important as the other sectors, as one of the human activities with high impact on the environment, owing to the high consumption of resources, water and energy, and the production of millions of tons of waste daily across the world, overall contributing to high levels of greenhouse gases. This is especially important as health care institutions need to operate 24/7 to satisfy medical needs of the populations. However, few green measures have been implemented in this field, as it is perceived as costly and ineffective. Ethical concerns arise from this scenario, as corporate social responsibility and accountability weight in the decision of investing in green infrastructures. Efficiency and optimal financial management play a role on minimizing costs of existing activities, while trying to provide the best care to patients. This paper explores the rationale for implementing green measures, reviewing the current status of environmental sustainability within the health care sector, as it discusses different perspectives on ethical issues emerging when managing health institutions and how these can be instrumental to drive policy-based change.

Los problemas ambientales cobraron impulso en los últimos años, y las consecuencias del cambio climático ya se sienten en todo el mundo. A medida que el medio ambiente empeora la salud, las actividades humanas también influyen en el medio ambiente, al empeorar este proceso, creando un ciclo ininterrumpido que podría acelerar el cambio climático. El sector salud juega un papel tan importante como los demás sectores, como una de las actividades humanas con alto impacto en el medio ambiente, debido al alto consumo de recursos, agua y energía, y la producción de millones de toneladas de desechos diariamente en todo el mundo. mundo, contribuyendo en general a los altos niveles de gases de efecto invernadero. Esto es especialmente importante ya que las instituciones de atención médica deben operar las 24 horas del día, los 7 días de la semana para satisfacer las necesidades médicas de las poblaciones. Sin embargo, se han implementado pocas medidas verdes en este campo, ya que se percibe como costoso e ineficaz. Las preocupaciones éticas surgen de este escenario, ya que la responsabilidad social corporativa y la rendición de cuentas pesan en la decisión de invertir en infraestructuras verdes. La eficiencia y la gestión financiera óptima desempeñan un papel en la minimización de los costos de las actividades existentes, mientras se intenta brindar la mejor atención a los pacientes. Este documento explora la justificación para implementar medidas ecológicas, revisando el estado actual de la sostenibilidad ambiental dentro del sector de la atención de la salud, ya que analiza diferentes perspectivas sobre los problemas éticos que surgen al administrar las instituciones de salud y cómo pueden ser fundamentales para impulsar el cambio basado en políticas.

As questões ambientais ganharam força nos últimos anos, com as consequências das mudanças climáticas já sendo sentidas em todo o mundo. À medida que o meio ambiente piora a saúde, as atividades humanas também influenciam o meio ambiente, agravando esse processo, criando um ciclo ininterrupto que pode acelerar as mudanças climáticas. O setor da saúde desempenha um papel tão importante quanto os demais setores, como uma das atividades humanas com alto impacto no ambiente, devido ao alto consumo de recursos, água e energia, e à produção de milhões de toneladas de resíduos diariamente em todo o mundo, contribuindo globalmente para altos níveis de gases de efeito estufa. Isso é especialmente importante, pois as instituições de saúde precisam operar 24 horas por dia, 7 dias por semana, para atender às necessidades médicas das populações. No entanto, poucas medidas verdes foram implementadas neste campo, pois é percebido como caro e ineficaz. As preocupações éticas surgem deste cenário, pois a responsabilidade social corporativa e a prestação de contas pesam na decisão de investir em infraestruturas verdes. A eficiência e a gestão financeira otimizada desempenham um papel na minimização dos custos das atividades existentes, ao mesmo tempo em que se tenta oferecer o melhor atendimento aos pacientes. Este artigo explora a lógica para a implementação de medidas verdes, revisando o status atual da sustentabilidade ambiental no setor de saúde, discutindo diferentes perspectivas sobre questões éticas emergentes na gestão de instituições de saúde e como elas podem ser instrumentais para impulsionar mudanças baseadas em políticas.