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BACKGROUND: Dengue fever (DF) is a growing public health problem in Vietnam. The disease burden in Vietnam has been increasing for decades. In Hanoi, in contrast to many other regions, extrinsic drivers such as weather have not been proved to be predictive of disease frequency, which limits the usefulness of such factors in an early warning system. AIMS: The purpose of this research was to review the epidemiology of DF transmission and investigate the role of weather factors contributing to occurrence of DF cases. METHODS: Monthly data from Hanoi (2002-2010) were used to test the proposed model. Descriptive time-series analysis was conducted. Stepwise multivariate linear regression analysis assuming a negative binomial distribution was established through several models. The predictors used were lags of 1-3 months previous observations of mean rainfall, mean temperature, DF cases, and their interactions. RESULTS: Descriptive analysis showed that DF occurred annually and seasonally with an increasing time trend in Hanoi. The annual low occurred from December to March followed by a gradual increase from April to July with a peak in September, October. The amplitude of the annual peak varied between years. Statistically significant relationships were estimated at lag 1-3 with rainfall, autocorrelation, and their interaction while temperature was estimated as influential at lag 3 only. For these relationships, the final model determined a correlation of 92% between predicted number of dengue cases and the observed dengue disease frequencies. CONCLUSIONS: Although the model performance was good, the findings suggest that other forces related to urbanization, density of population, globalization with increasing transport of people and goods, herd immunity, government vector control capacity, and changes in serotypes are also likely influencing the transmission of DF. Additional research taking into account all of these factors besides climatic factors is needed to help developing and developed countries find the right intervention for controlling DF epidemics, and to set up early warning systems with high sensitivity and specificity. Immediate action to control DF outbreak in Hanoi should include an information, communication, and education program that focuses on training Hanoi residents to more efficiently eliminate stagnant puddles and water containers after each rainfall to limit the vector population growth. ; Special Issue: Climate Change and Health in Vietnam

Exposure to traffic pollution is increasing worldwide as people move to cities, and as more vehicles join the roads, creating longer journeys and more traffic jams. Most traffic pollutants are odourless and invisible, which hides exposure from the public. If traffic pollution had a distinctive smell it would enable people to avoid exposure, and increase the political will for difficult policy changes. A smell may also instigate longer-term changes, such as switching to active transport for school pick-ups. A smell could be added using a fuel additive or a temporary device attached to vehicle exhausts.

Background: Three major international agreements signed in 2015 are key milestones for transitioning to more sustainable and resilient societies: the UN 2030 Agenda for Sustainable Development; the Sendai Framework for Disaster Risk Reduction; and the Paris Agreement under the United Nations Framework Convention on Climate Change. Together, these agreements underscore the critical importance of understanding and managing the health risks of global changes, to ensure continued population health improvements in the face of significant social and environmental change over this century. Body: Funding priorities of major health institutions and organizations in the U.S. and Europe do not match research investments with needs to inform implementation of these international agreements. In the U.S., the National Institutes of Health commit 0.025 % of their annual research budget to climate change and health. The European Union Seventh Framework Programme committed 0.08 % of the total budget to climate change and health; the amount committed under Horizon 2020 was 0.04 % of the budget. Two issues apparently contributing to this mismatch are viewing climate change primarily as an environmental problem, and therefore the responsibility of other research streams; and narrowly framing research into managing the health risks of climate variability and change from the perspective of medicine and traditional public health. This reductionist, top-down perspective focuses on proximate, individual level risk factors. While highly successful in reducing disease burdens, this framing is insufficient to protect health and well-being over a century that will be characterized by profound social and environmental changes. Conclusions: International commitments in 2015 underscored the significant challenges societies will face this century from climate change and other global changes. However, the low priority placed on understanding and managing the associated health risks by national and international research institutions and organizations leaves populations poorly prepared to cope with changing health burdens. Risk-centered, systems approaches can facilitate understanding of the complex interactions and dependencies across environmental, social, and human systems. This understanding is needed to formulate effective interventions targeting socio-environmental factors that are as important for determining health burdens as are individual risk factors.

Background: Despite considerable global attention to the issues of climate change, relatively little priority has been given to the likely effects on human health of current and future changes in the global climate. We identify three major societal determinants that influence the impact of climate change on human health, namely the application of scholarship and knowledge; economic and commercial considerations; and actions of governments and global agencies. Discussion: The three major areas are each discussed in terms of the ways in which they facilitate and frustrate attempts to protect human health from the effects of climate change. Academia still pays very little attention to the effects of climate on health in poorer countries. Enterprise is starting to recognise that healthy commerce depends on healthy people, and so climate change presents long-term threats if it compromises health. Governments and international agencies are very active, but often face immovable vested interests in other sectors. Overall, there tends to be too little interaction between the three areas, and this means that potential synergies and co-benefits are not always realised. Conclusion: More attention from academia, enterprise, and international agencies needs to be given to the potential threats the climate change presents to human health. However, there needs to also be much closer collaboration between all three areas in order to capitalise on possible synergies that can be achieved between them.

Climate change is one of today's most pressing global issues. Policies to guide mitigation and adaptation are needed to avoid the devastating impacts of climate change. The health sector is a significant contributor to greenhouse gas emissions in developed countries, and its climate impact in low-income countries is growing steadily. This paper reviews and discusses the literature regarding health sector mitigation potential, known and hypothetical co-benefits, and the potential of health information technology, such as eHealth, in climate change mitigation and adaptation. The promising role of eHealth as an adaptation strategy to reduce societal vulnerability to climate change, and the link's between mitigation and adaptation, are also discussed. The topic of environmental eHealth has gained little attention to date, despite its potential to contribute to more sustainable and green health care. A growing number of local and global initiatives on 'green information and communication technology (ICT)' are now mentioning eHealth as a promising technology with the potential to reduce emission rates from ICT use. However, the embracing of eHealth is slow because of limitations in technological infrastructure, capacity and political will. Further research on potential emissions reductions and co-benefits with green ICT, in terms of health outcomes and economic effectiveness, would be valuable to guide development and implementation of eHealth in health sector mitigation and adaptation policies.

Climate change is one of today's most pressing global issues. Policies to guide mitigation and adaptation are needed to avoid the devastating impacts of climate change. The health sector is a significant contributor to greenhouse gas emissions in developed countries, and its climate impact in low-income countries is growing steadily. This paper reviews and discusses the literature regarding health sector mitigation potential, known and hypothetical co-benefits, and the potential of health information technology, such as eHealth, in climate change mitigation and adaptation. The promising role of eHealth as an adaptation strategy to reduce societal vulnerability to climate change, and the link's between mitigation and adaptation, are also discussed. The topic of environmental eHealth has gained little attention to date, despite its potential to contribute to more sustainable and green health care. A growing number of local and global initiatives on 'green information and communication technology (ICT)' are now mentioning eHealth as a promising technology with the potential to reduce emission rates from ICT use. However, the embracing of eHealth is slow because of limitations in technological infrastructure, capacity and political will. Further research on potential emissions reductions and co-benefits with green ICT, in terms of health outcomes and economic effectiveness, would be valuable to guide development and implementation of eHealth in health sector mitigation and adaptation policies.

Countries of lower Mekong regions are highly alarmed by the spread of fish-borne trematode infections, i.e., small liver flukes and minute intestinal flukes especially in Thailand, Lao People's Democratic Republic (Lao PDR), Vietnam, Cambodia and Myanmar. Moreover; the incidence of cholangiocarcinoma has also been increasing in the endemic area of liver fluke infections. Only a few reports have been published concerning the fish-borne trematodes infections in the central region of Myanmar. However; there is still a lack of information regarding the status of trematodes infections in second intermediate hosts in the Mekong region of Myanmar. Therefore, we conducted surveillance on the distribution of trematode metacercariae in small cyprinoid fishes collected from the Mekong region of Myanmar. A total of 689 fishes (12 different species of cyprinoid fishes) have been collected and examined by pepsin digestion methods. We discovered four species of fish-borne trematode metacercariae infections, i.e., carcinogenic liver fluke, Opisthorchis viverrini; minute intestinal flukes, Haplorchis taichui; Haplorchis pumilio and Haplorchoides sp. in Tachileik, the Mekong Region of Myanmar. The outcome of this study could be a useful index for the fish-borne zoonotic trematode epidemiology in the Mekong area. Besides, the results of our study contribute to filling the gap of information necessary for the control and prevention of fish-borne trematode zoonotic infections in the Mekong region.

BACKGROUND: Dengue has become a major public health problem in Sri Lanka with a considerable economic burden. As a response, in June, 2014, the Ministry of Health initiated a proactive vector control programme in partnership with military and police forces, known as the Civil-Military Cooperation (CIMIC) programme, that was targeted at high-risk Medical Officer of Health (MOH) divisions in the country. Evaluating the effectiveness and cost-effectiveness of population-level interventions is essential to guide public health planning and resource allocation decisions, particularly in resource-limited health-care settings. METHODS: Using an interrupted time series design with a non-linear extension, we evaluated the impact of vector control interventions from June 22, 2014, to Dec 29, 2016, in Panadura, a high-risk MOH division in Western Province, Sri Lanka. We used dengue notification and larval survey data to estimate the reduction in Breteau index and dengue incidence before and after the intervention using two separate models, adjusting for time-varying confounding variables (ie, rainfall, temperature, and the Oceanic Niño Index). We also assessed the cost and cost-effectiveness of the CIMIC programme from the perspective of the National Dengue Control Unit under the scenarios of different levels of hospitalisation of dengue cases (low [25%], medium [50%], and high [75%]) in terms of cost per disability-adjusted life-year averted (DALY). FINDINGS: Vector control interventions had a significant impact on combined Breteau index (relative risk reduction 0·43, 95% CI 0·26 to 0·70) and on dengue incidence (0·43, 0·28 to 0·67), the latter becoming prominent 2 months after the intervention onset. The mean number of averted dengue cases was estimated at 2192 (95% CI 1741 to 2643), and the total cost of the CIMIC programme at 2016 US$271 615. Personnel costs accounted for about 89% of the total cost. In the base-case scenario of moderate level of hospitalisation, the CIMIC programme was cost-saving with a probability of 70% under both the lowest ($453) and highest ($1686) cost-effectiveness thresholds, resulting in a net saving of $20 247 (95% CI -57 266 to 97 790) and averting 176 DALYs (133 to 226), leading to a cost of -$98 (-497 to 395) per DALY averted. This was also the case for the scenario with high hospitalisation levels (cost per DALY averted -$512, 95% CI -872 to -115) but with a higher probability of 99%. In the scenario with low hospitalisation levels (cost per DALY averted $690, 143 to 1379), although the CIMIC programme was cost-ineffective at the lowest threshold with a probability of 77%, it was cost-effective at the highest threshold with a probability of 99%. INTERPRETATION: This study suggests that communities affected by dengue can benefit from investments in vector control if interventions are implemented rigorously and coordinated well across sectors. By doing so, it is possible to reduce the disease and economic burden of dengue in endemic settings. FUNDING: None.

Background: Dengue has become a major public health problem in Sri Lanka with a considerable economic burden. As a response, in June, 2014, the Ministry of Health initiated a proactive vector control programme in partnership with military and police forces, known as the Civil-Military Cooperation (CIMIC) programme, that was targeted at high-risk Medical Officer of Health (MOH) divisions in the country. Evaluating the effectiveness and cost-effectiveness of population-level interventions is essential to guide public health planning and resource allocation decisions, particularly in resource-limited health-care settings. Methods: Using an interrupted time series design with a non-linear extension, we evaluated the impact of vector control interventions from June 22, 2014, to Dec 29, 2016, in Panadura, a high-risk MOH division in Western Province, Sri Lanka. We used dengue notification and larval survey data to estimate the reduction in Breteau index and dengue incidence before and after the intervention using two separate models, adjusting for time-varying confounding variables (ie, rainfall, temperature, and the Oceanic Niño Index). We also assessed the cost and cost-effectiveness of the CIMIC programme from the perspective of the National Dengue Control Unit under the scenarios of different levels of hospitalisation of dengue cases (low [25%], medium [50%], and high [75%]) in terms of cost per disability-adjusted life-year averted (DALY). Findings: Vector control interventions had a significant impact on combined Breteau index (relative risk reduction 0·43, 95% CI 0·26 to 0·70) and on dengue incidence (0·43, 0·28 to 0·67), the latter becoming prominent 2 months after the intervention onset. The mean number of averted dengue cases was estimated at 2192 (95% CI 1741 to 2643), and the total cost of the CIMIC programme at 2016 US$271 615. Personnel costs accounted for about 89% of the total cost. In the base-case scenario of moderate level of hospitalisation, the CIMIC programme was cost-saving with a probability of 70% under both the lowest ($453) and highest ($1686) cost-effectiveness thresholds, resulting in a net saving of $20 247 (95% CI −57 266 to 97 790) and averting 176 DALYs (133 to 226), leading to a cost of −$98 (−497 to 395) per DALY averted. This was also the case for the scenario with high hospitalisation levels (cost per DALY averted −$512, 95% CI −872 to −115) but with a higher probability of 99%. In the scenario with low hospitalisation levels (cost per DALY averted $690, 143 to 1379), although the CIMIC programme was cost-ineffective at the lowest threshold with a probability of 77%, it was cost-effective at the highest threshold with a probability of 99%. Interpretation: This study suggests that communities affected by dengue can benefit from investments in vector control if interventions are implemented rigorously and coordinated well across sectors. By doing so, it is possible to reduce the disease and economic burden of dengue in endemic settings. Funding: None.

Warming temperatures may increase the geographic spread of vector-borne diseases into temperate areas. Although a tropical mosquito-borne viral disease, a dengue outbreak occurred in Madeira, Portugal, in 2012; the first in Europe since 1920s. This outbreak emphasizes the potential for dengue re-emergence in Europe given changing climates. We present estimates of dengue epidemic potential using vectorial capacity (VC) based on historic and projected temperature (1901–2099). VC indicates the vectors' ability to spread disease among humans. We calculated temperature-dependent VC for Europe, highlighting 10 European cities and three non-European reference cities. Compared with the tropics, Europe shows pronounced seasonality and geographical heterogeneity. Although low, VC during summer is currently sufficient for dengue outbreaks in Southern Europe to commence–if sufficient vector populations (either Ae. aegypti and Ae. albopictus) were active and virus were introduced. Under various climate change scenarios, the seasonal peak and time window for dengue epidemic potential increases during the 21st century. Our study maps dengue epidemic potential in Europe and identifies seasonal time windows when major cities are most conducive for dengue transmission from 1901 to 2099. Our findings illustrate, that besides vector control, mitigating greenhouse gas emissions crucially reduces the future epidemic potential of dengue in Europe. ; This study is part of the DengueTools project funded by the European Union Seventh Framework Programme FP7/2007-2013 under grant agreement no. 282589. Originally included in thesis 1 as submitted manuscript.

Recurrent health emergencies threaten global health security. International Health Regulations (IHR) aim to prevent, detect and respond to such threats, through increase in national public health core capacities, but whether IHR core capacity implementation is necessary and sufficient has been contested. With a longitudinal study we relate changes in national IHR core capacities to changes in cross‐border infectious disease threat events (IDTE) between 2010 and 2016, collected through epidemic intelligence at the European Centre for Disease Prevention and Control (ECDC). By combining all IHR core capacities into one composite measure we found that a 10% increase in the mean of this composite IHR core capacity to be associated with a 19% decrease (p = 0.017) in the incidence of cross‐border IDTE in the EU. With respect to specific IHR core capacities, an individual increase in national legislation, policy & financing; coordination and communication with relevant sectors; surveillance; response; preparedness; risk communication; human resource capacity; or laboratory capacity was associated with a significant decrease in cross‐border IDTE incidence. In contrast, our analysis showed that IHR core capacities relating to point‐of‐entry, zoonotic events or food safety were not associated with IDTE in the EU. Due to high internal correlations between core capacities, we conducted a principal component analysis which confirmed a 20% decrease in risk of IDTE for every 10% increase in the core capacity score (95% CI: 0.73, 0.88). Globally (EU excluded), a 10% increase in the mean of all IHR core capacities combined was associated with a 14% decrease (p = 0.077) in cross‐border IDTE incidence. We provide quantitative evidence that improvements in IHR core capacities at country‐level are associated with fewer cross‐border IDTE in the EU, which may also hold true for other parts of the world.

Recurrent health emergencies threaten global health security. International Health Regulations (IHR) aim to prevent, detect and respond to such threats, through increase in national public health core capacities, but whether IHR core capacity implementation is necessary and sufficient has been contested. With a longitudinal study we relate changes in national IHR core capacities to changes in cross‐border infectious disease threat events (IDTE) between 2010 and 2016, collected through epidemic intelligence at the European Centre for Disease Prevention and Control (ECDC). By combining all IHR core capacities into one composite measure we found that a 10% increase in the mean of this composite IHR core capacity to be associated with a 19% decrease (p=0.017) in the incidence of cross‐border IDTE in the EU. With respect to specific IHR core capacities, an individual increase in national legislation, policy & financing; coordination and communication with relevant sectors; surveillance; response; preparedness; risk communication; human resource capacity; or laboratory capacity was associated with a significant decrease in cross‐border IDTE incidence. In contrast, our analysis showed that IHR core capacities relating to point‐of‐entry, zoonotic events or food safety were not associated with IDTE in the EU. Due to high internal correlations between core capacities, we conducted a principal component analysis which confirmed a 20% decrease in risk of IDTE for every 10% increase in the core capacity score (95% CI: 0.73, 0.88). Globally (EU excluded), a 10% increase in the mean of all IHR core capacities combined was associated with a 14% decrease (p=0.077) in cross‐border IDTE incidence. We provide quantitative evidence that improvements in IHR core capacities at country‐level are associated with fewer cross‐border IDTE in the EU, which may also hold true for other parts of the world.

BACKGROUND: While the COVID-19 outbreak in China now appears suppressed, Europe and the USA have become the epicentres, both reporting many more deaths than China. Responding to the pandemic, Sweden has taken a different approach aiming to mitigate, not suppress, community transmission, by using physical distancing without lockdowns. Here we contrast the consequences of different responses to COVID-19 within Sweden, the resulting demand for care, intensive care, the death tolls and the associated direct healthcare related costs. METHODS: We used an age-stratified health-care demand extended SEIR (susceptible, exposed, infectious, recovered) compartmental model for all municipalities in Sweden, and a radiation model for describing inter-municipality mobility. The model was calibrated against data from municipalities in the Stockholm healthcare region. RESULTS: Our scenario with moderate to strong physical distancing describes well the observed health demand and deaths in Sweden up to the end of May 2020. In this scenario, the intensive care unit (ICU) demand reaches the pre-pandemic maximum capacity just above 500 beds. In the counterfactual scenario, the ICU demand is estimated to reach ∼20 times higher than the pre-pandemic ICU capacity. The different scenarios show quite different death tolls up to 1 September, ranging from 5000 to 41 000, excluding deaths potentially caused by ICU shortage. Additionally, our statistical analysis of all causes excess mortality indicates that the number of deaths attributable to COVID-19 could be increased by 40% (95% confidence interval: 0.24, 0.57). CONCLUSION: The results of this study highlight the impact of different combinations of non-pharmaceutical interventions, especially moderate physical distancing in combination with more effective isolation of infectious individuals, on reducing deaths, health demands and lowering healthcare costs. In less effective mitigation scenarios, the demand on ICU beds would rapidly exceed capacity, showing the tight interconnection between the healthcare demand and physical distancing in the society. These findings have relevance for Swedish policy and response to the COVID-19 pandemic and illustrate the importance of maintaining the level of physical distancing for a longer period beyond the study period to suppress or mitigate the impacts from the pandemic.

Effort to control dengue transmission requires community participation to ensure its sustainability. We carried out a knowledge attitude and practice (KAP) survey of dengue prevention to inform the design of a vector control intervention. A cross-sectional survey was conducted in June⁻August 2014 among 521 households in two villages of Yogyakarta, Indonesia. Demographic characteristics and KAP questions were asked using a self-managed questionnaire. Knowledge, attitudes and practice scores were summarized for the population according to sex, age, occupation and education. The average knowledge score was rather poor-3.7 out of 8-although both attitude and practice scores were good: 25.5 out of 32 and 9.2 out of 11 respectively. The best knowledge within the different groups were found among women, the age group 30⁻44 years, people with a university degree and government employees. Best practice scores were found among retired people and housewives. There were several significant gaps in knowledge with respect to basic dengue symptoms, preventive practices and biting and breeding habits of the Aedes mosquito. In contrast, people's practices were considered good, although many respondents failed to recognize outdoor containers as mosquito breeding sites. Accordingly, we developed a vector control card to support people's container cleaning practices. The card was assessed for eight consecutive weeks in 2015, with pre-post larvae positive houses and containers as primary outcome measures. The use of control cards reached a low engagement of the community. Despite ongoing campaigns aiming to engage the community in dengue prevention, knowledge levels were meagre and adherence to taught routines poor in many societal groups. To increase motivation levels, bottom-up strategies are needed to involve all community members in dengue control, not only those that already comply with best practices.