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

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

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

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

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

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

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

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

An entomological review of invasive mosquitoes in Europe.

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

Practices to optimise gastrointestinal nematode control on sheep, goat and cattle farms in Europe using targeted (selective) treatments.

Due to the development of anthelmintic resistance, there have been calls for more sustainable nematode control practices. Two important concepts were introduced to study and promote the sustainable use of anthelmintics: targeted treatments (TT), where the whole flock/herd is treated based on knowledge of the risk, or parameters that quantify the severity of infection; and targeted selective treatments (TST), where only individual animals within the grazing group are treated. The aim of the TT and TST approaches is to effectively control nematode-induced production impacts while preserving anthelmintic efficacy by maintaining a pool of untreated parasites in refugia. Here, we provide an overview of recent studies that assess the use of TT/TST against gastrointestinal nematodes in ruminants and investigate the economic consequences, feasibility and knowledge gaps associated with TST. We conclude that TT/TST approaches are ready to be used and provide practical benefits today. However, a major shift in mentality will be required to make these approaches common practice in parasite control.

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

Despite the availability of safe and effective hepatitis B virus (HBV) vaccines for more than 30 years, the burden of hepatitis B disease is still substantial. In 1992, the WHO recommended the inclusion of HBV vaccination in all national vaccination programmes. As of 2012, 47 of the 53 European countries (89%) had implemented a universal hepatitis B vaccination programme. The most recent countries to follow the recommendation were Ireland (in 2008) and the Netherlands (in 2011). Still, six countries (Denmark, Finland, Iceland, Norway, Sweden and the UK) adopt risk-group-targeted vaccination only, instead of adding a universal vaccination programme. However, changing demography, increasing immigration and the current vaccine costs make the cost­benefit ratios in these remaining low endemicity countries strongly in favour of universal HBV vaccination. Global efforts, including a cohesive European vaccination policy, are essential to control and prevent hepatitis B.

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

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

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

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

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

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

Relative importance of management, meteorological and environmental factors in the spatial distribution of Fasciola hepatica in dairy cattle in a temperate climate zone.

Fasciola hepatica, a trematode parasite with a worldwide distribution, is the cause of important production losses in the dairy industry. Diagnosis is hampered by the fact that the infection is mostly subclinical. To increase awareness and develop regionally adapted control methods, knowledge on the spatial distribution of economically important infection levels is needed. Previous studies modelling the spatial distribution of F. hepatica are mostly based on single cross-sectional samplings and have focussed on climatic and environmental factors, often ignoring management factors. This study investigated the associations between management, climatic and environmental factors affecting the spatial distribution of infection with F. hepatica in dairy herds in a temperate climate zone (Flanders, Belgium) over three consecutive years. A bulk-tank milk antibody ELISA was used to measure F. hepatica infection levels in a random sample of 1762 dairy herds in the autumns of 2006, 2007 and 2008. The infection levels were included in a Geographic Information System together with meteorological, environmental and management parameters. Logistic regression models were used to determine associations between possible risk factors and infection levels. The prevalence and spatial distribution of F. hepatica was relatively stable, with small interannual differences in prevalence and location of clusters. The logistic regression model based on both management and climatic/environmental factors included the factors: annual rainfall, mowing of pastures, proportion of grazed grass in the diet and length of grazing season as significant predictors and described the spatial distribution of F. hepatica better than the model based on climatic/environmental factors only (annual rainfall, elevation and slope, soil type), with an Area Under the Curve of the Receiver Operating Characteristic of 0.68 compared with 0.62. The results indicate that in temperate climate zones without large climatic and environmental variation, management factors affect the spatial distribution of F. hepatica, and should be included in future spatial distribution models.

A summer school on vaccinology: Responding to identified gaps in pre-service immunisation training of future health care workers.

Immunisation is one of the corner stones of public health. Most health care consumers see the health care worker as their major source of information on immunisation and vaccine safety. Doctors, nurses and midwives should be appropriately and timely trained for that role. Within the Vaccine Safety, Attitudes, Training and Communication (VACSATC) EU-project a specific work package focused on the possible improvements of pre-service training of future health care workers. Surveys to assess current pre-service training about knowledge, skills and competences towards immunisation were distributed to students and curriculum managers of medical schools, universities and nursing training institutions in seven EU countries. In all responding institutions training on vaccines and immunisation is disseminated over a wide range of courses over several academic years. Topics as immunology and vaccine-preventable diseases are well covered during the pre-service training but major gaps in knowledge and competences were identified towards vaccine safety, communication with parents, addressing anti-vaccine arguments and practical skills. This assessment underlined the rationale for adequate pre-service training and identified opportunities for improvement of pre-service training. A prototype of an accurate pre-service immunisation curriculum was developed, implemented and evaluated in the summer of 2009 with a group of 36 students from 19 countries during a summer school on vaccinology at the Antwerp University, Belgium.

The use of bulk-tank milk ELISAs to assess the spatial distribution of Fasciola hepatica, Ostertagia ostertagi and Dictyocaulus viviparus in dairy cattle in Flanders (Belgium).

Fasciola hepatica, Ostertagia ostertagi and Dictyocaulus viviparus are helminth parasites with a wide distribution and an important economic impact in cattle in temperate climates. This paper describes the spatial distribution of F. hepatica, O. ostertagi and D. viviparus in dairy herds in Flanders (Belgium). One thousand eight hundred herds were selected at random from the Flemish dairy population (n=7002), stratified on community level to obtain a sample representative for the entire study area. From each herd, a bulk milk sample collected in autumn 2006 was analysed with previously described antibody-ELISAs in order to identify herds where the parasite infection level is likely to cause production loss (F. hepatica and O. ostertagi) (defined as economic infections) or where patent infections have been present over the past grazing season (D. viviparus). The herd prevalence of economic infections with F. hepatica and O. ostertagi was 37.3% (95% Confidence Interval (CI): 35.1-39.7) and 59.1% (95%CI: 56.8-61.4), respectively. The herd prevalence of D. viviparus was 19.6% (95%CI: 17.7-21.6). On 28.9% (CI 26.8-31.3) of the herds, low levels of infection were observed for all three of the helminths. The presence of clustering of (economic) infections was studied using Moran's I, whereas the location and size of the clusters were studied using the spatial scan statistic, the Local Indicator of Spatial Association and Kernel density plotting. A marked clustering in the spatial distribution of F. hepatica and a mild clustering in the spatial distribution of O. ostertagi were observed. D. viviparus infections were spread evenly over Flanders. Knowledge of locations of high risk areas can lead to increased awareness and may be the start of the development of regionally adapted control measures.

The impact of habitat fragmentation on tsetse abundance on the plateau of eastern Zambia.

Tsetse-transmitted human or livestock trypanosomiasis is one of the major constraints to rural development in sub-Saharan Africa. The epidemiology of the disease is determined largely by tsetse fly density. A major factor, contributing to tsetse population density is the availability of suitable habitat. In large parts of Africa, encroachment of people and their livestock resulted in a destruction and fragmentation of such suitable habitat. To determine the effect of habitat change on tsetse density a study was initiated in a tsetse-infested zone of eastern Zambia. The study area represents a gradient of habitat change, starting from a zone with high levels of habitat destruction and ending in an area where livestock and people are almost absent. To determine the distribution and density of the fly, tsetse surveys were conducted throughout the study area in the dry and in the rainy season. Landsat ETM+ imagery covering the study area were classified into four land cover classes (munga, miombo, agriculture and settlements) and two auxiliary spectral classes (clouds and shadow) using a Gaussian Maximum Likelihood Classifier. The classes were regrouped into natural vegetation and agricultural zone. The binary images were overlaid with hexagons to obtain the spatial spectrum of spatial pattern. Hexagonal coverage was selected because of its compact and regular form. To identify scale-specific spatial patterns and associated entomological phenomena, the size of the hexagonal coverage was varied (250 and 500 m). Per coverage, total class area, mean patch size, number of patches and patch size standard deviation were used as fragmentation indices. Based on the fragmentation index values, the study zone was classified using a Partitioning Around Mediods (PAM) method. The number of classes was determined using the Wilks' lambda coefficient. To determine the impact of habitat fragmentation on tsetse abundance, the correlation between the fragmentation indices and the index of apparent density of the flies was determined and habitat changes most affecting tsetse abundance was identified. From this it followed that there is a clear relationship between habitat fragmentation and the abundance of tsetse flies. Heavily fragmented areas have lower numbers of tsetse flies, but when the fragmentation of natural vegetation decreases, the number of tsetse flies increases following a sigmoidal-like curve.

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

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

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

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

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

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

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

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