A survey targeting ASPHER members was launched in 2010/11, being a first initiative in improving ethics education in European Schools of Public Health. An 8-items questionnaire collected information on teaching of ethics in public health. A 52% response rate (43/82) revealed that almost all of the schools (95% out of 40 respondents with valid data) included the teaching of ethics in at least one of its programmes. They also expressed the need of support, (e.g.: a model curriculum (n=25), case studies (n=24)), which indicates further work to be met by the ASPHER Working Group on Ethics and Values in Public Health.

Aim: The aim in this survey was to study the clinical characteristics of infections caused by Borrelia genospecies in patients with erythema migrans where Borrelial origin was confirmed by polymerase chain reaction. The aim was also to study factors influencing the clinical appearance of erythema migrans. Methods: The study was conducted in southern Sweden from May 2001 to December 2003 on patients 18 years and older attending with erythema migrans at outpatient clinics. All erythema migrans were verified by polymerase chain reaction, photographed and categorized into “annular” or “non-annular” lesions. A logistic regression model was used to analyze relations between the appearance of the erythema migrans (i.e., annular or non-annular) and factors that influenced its clinical appearances. Results: A total of 118 patients, 54 women (45.8%) and 64 men (54.2%), fulfilled the inclusion criteria. Of these patients, 74% were infected by B. afzelii, 26% by B. garinii ( p < 0.001). A total of 45% (38/85) of the erythema migrans were annular, 46% (39/85) were non-annular and 9.4% (8/85) were atypical. For men infected by B. afzelii the odds ratio of developing non-annular erythema migrans was 0.09 (95% CI: 0.03 - 0.33) in comparison with women with the same infection. Conclusions: In this prospective study of a large series of erythema migrans, where infecting genospecies were confirmed by polymerase chain reaction, the sex of patients infected with B. afzelii had a strong influence on the appearance of the rash. Patients infected by B. garinii more often had non-annular erythema migrans and a more virulent infection with more individuals presenting with fever, raised levels of C-reactive protein and seroreactivity in the convalescence sera.

Background: The aim of this study was to describe and categorize the different predominant patterns of PCR confirmed erythema migrans (EM) and to study possible correlations according to the clinical pictures and Borrelia substrains. Methods: Patients over 18 years old, seeking care with tick exposure and an EM were consecutively included during a study period of three years. We evaluated clinical and laboratory findings with regard to Borrelia burgdorferi s.l. spirochetes detected with nested Osp A PCR in skin biopsy specimens. Laboratory and serology testing were done acute, after 6 weeks and after 6 months. The patients were clinically evaluated at the initial visit and repeatedly after 14 days unitl recovery. Results: 118 patients (women=54, men=64) with a positive B. Burgdorferi s.l. PCR analysis were included. In this area totally 73.7% of the EM were caused by B. afzelii and 26.3% by B. garinii (p=0.0001). Leisons caused by B. garinii had a shorter duration from tick bite to the initial visit (p= 0.001) but there were no differences between the sizes of the EM, indicating a faster development of lesions caused by B. garinii. Patients with lesions caused by B. garinii to a greater extent had presented with fever at the initial visit (p=0.02). Also patients with B. garinii lesions to a greater extent had elevated levels of CRP at the initial visit (p=0.006). 45% of the EM were categorized as “annular”, 27% as “homogeneous”, 19% as “central erythemas” and 9% as “atypical”. The lesions caused by B. afzelii were predominately “annular” and the lesions caused by B. gaarinii were predominately “homogeneous”. Conclusions: In this study most EM were caused by B. afzelii. Leisons caused by B. garinii developed faster and the patients to a greater extent presented with fever and elevated levels of CRP at the initial visit. Leisons caused by B. garinii were mostly homogenous and by B. afzelii were mostly annular.

The aim is to highlight the influence of patients’ gender on Lyme borreliosis and especially erythema migrans (EM), focusing on exposure to tick bites, epidemiology, and the clinical picture. All studies were conducted in the county of Blekinge, located in southeastern Sweden. A prospective study was conducted in 235 individuals (women, n=110; men, n=125) engaged in recreational or occupational activities focusing on exposure to tick bites. A retrospective epidemiological study evaluating 123,495 electronic patients´ records (women, n=61,712; men, n=61,783) and a prospective clinical study including 118 patients (women, n=54; men, n=64) 18 years or older seeking care for EM > 5 cm in diameter with genospecies verified by polymerase chain reaction were conducted. Results: Women 40 years or older had a 48% higher risk than men 40 years or older and 42% higher risk than women younger than 40 years of attracting tick bites (0.0188 versus 0.0127 and 0.0188 versus 0.0132 tick bites respectively per hour). Additionally they had a 96% higher risk than men younger than 40 years of attracting tick bites (0.0188 versus 0.0096). The annual incidence rate of EM in women was 506 and in men 423 cases per 100,000 inhabitants (p<0.001). Significant differences in incidence rates occurred in those 40 years or older. Odds ratios for males infected with Borrelia afzelii developing nonannular EM were 0.09 (95% confidence interval [CI] 0.03 to 0.33) in comparison with females infected by Borrelia afzelii. Conclusions: Significant gender differences in the risk of contracting tick bites, incidence rates, and clinical picture of EM have been observed. Exposure to tick bites alone may not explain these observations and further studies need to be done to clarify the biologic, immunologic, and sociological mechanisms causing these differences.

In this paper an audio processing solution for video conference based aerobics is presented. The proposed solution leaves the workout music unaltered by separating it from the speech and processing each signal separately. The speech signal processing is also performed at a lower sample rate, which saves computational power. Real time evaluation of the system shows that high quality music as well as a good two-way communication is maintained during the aerobic session.

The objective of this follow-up study was to determine the long-term outcome of strictly classified cases of neuroborreliosis treated with antibiotics. A one-year prospective population-based survey of Lyme borreliosis was conducted in southern Sweden, between 1992 and 1993. A total of 349 identified cases with suspected neuroborreliosis were followed up 5 years later. Medical records were reviewed and all participants filled in a questionnaire. Of those classified with definite neuroborreliosis 114/130 completed the follow-up, of whom 111 had completed the initial antibiotic treatment. Of the 114 patients followed up, 86 (75%) had recovered completely and 70 (61%) had recovered within 6 months. Residual neurological symptoms such as facial palsy, concentration disorder, paresthesia and/or neuropathy were reported by 28/114. No significant differences between different antibiotic treatments were observed in terms of occurrence of sequelae. To conclude, we found that 25% (95% confidence interval 17-33%) of the patients suffered from residual neurological symptoms 5 years post-treatment. However, the clinical outcome of treated neuroborreliosis is favourable as only 14/114 (12%) of the patients had sequelae that influenced their daily activity post-treatment. Early diagnosis and treatment would seem to be of great importance in order to avoid such sequelae.

The objective of this follow-up study was to determine the long-term outcome in patients treated with antibiotics for strictly classified cases of neuroborreliosis. A one-year prospective population-based survey of Lyme borreliosis was conducted in southern Sweden, 1992-1993. Totally 349 identified cases with suspected neuroborreliosis were registered. Of those, 130 were classified as definitively neuroborreliosis and followed up five years later. Medical records were reviewed and all participants filled in a questionnaire. Totally, 114/130 (88%) completed the follow-up of whom 111/114 (97%) had fulfilled the initial antibiotic treatment. Of these, 86/114 (75%) had recovered completely and 70 (61%) recovered within six months. However 28/114 (25%) suffered from remaining neurological symptoms such as facial palsy, concentration disorder, paresthesia and/or neuropathy. The longer the duration from the neurological symptoms onset to antibiotic treatment the higher was the rate of sequelae. Of those who were treated within 30 days 5/32 (16%) and of those who were treated after 30 days 16/41 (39%) respectively, reported sequelae. Women suffered significantly more from sequelae compared to men, this difference was not seen among the children. No significant differences between the different antibiotic treatments given and experience of sequelae were seen. To conclude, we found that 25% (95% CI 17% to 33%) of the patients suffered from remaining neurological symptoms five years post treatment. However, the clinical outcome of treated neuroborreliosis is favourable as only 14/114 (12%) of the patients had sequelae that influenced their daily activity post treatment and early diagnosis and treatment seems to be of great importance to possibly avoid also these cases.

Today schools and departments of public health (SDPHs), as well as public health professionals are searching for interface and synergies between public health science and practice. They are increasingly relying on partnerships in order to achieve common goals. To collect more information on the fragmented institutional landscape the Association of Schools of Public Health in the European Region (ASPHER) organised a survey among its full institutional 81 members with the core objective to assess the exit competences of master of public health graduates according to the new Essential Public Health Operations (EPHO) of WHO-EURO. The survey results indicate that usually European SDPHs are small units, funded from tax money. A total of 130 academic programmes released 3035 graduates per last year All selected competences within each EPHO showed high reliability and high internal consistency (alpha>0.75, p<0.01). SDPH assess their best teaching output to be in the field of health promotion, followed by disease prevention and identification of priority health problems and health hazards in the community, while they see the least success regarding preparedness and planning for public health emergencies. Given the fragmentation of the institutional infrastructure, the harmonization of programme content and thinking is impressive. Even more surprising is the observation that the determination of the desired performance by employers of public health professionals for most EPHOs (6 out of 10) is almost congruent with the estimated output of SDPHs. The main objective of the workshop was to continue with permanent dialogue on innovation and good practice in public health education, continuing training and lifelong learning and to strengthen everlasting collaboration of European schools in efforts to improve public health performance.

The aim of the presentation and the following paper was to stimulate debate on the state of a public health profession in Europe and measures and actions which need to be taken to authorise public health professionals based on their competencies.

The aim of this short communication is to stimulate a discussion on the state of a public health profession in Europe and actions which need to be taken to authorise public health professionals based on their competencies. While regulated professions such as medical doctors, nurses, lawyers, and architects can enjoy the benefits of the 2005/ 36/EC Directive amended by 2013/55/EU Directive on the recognition of professional qualifications, public health professionals are left out from these elite. Firstly, we use the profession traits theory as a framework in arguing whether public health can be a legitimate profession in itself, second, we explain who public health professionals are and what usually is required for shaping the public health profession, and thirdly, we attempt to sketch the road to the authorisation or licencing of public health professionals. Finally, we will propose some recommendation.

Plenary: After key note presentation by Elke Jakubowski, the plenary session continued as panel discussion dedicated to innovation and good-practice in public health education based on interface between public health operations, competences and performance.

After months of inaction and neglect from the international community, the Ebola epidemic in west Africa has now spiralled utterly out of control. Today, the virus is a threat not only to the countries where the outbreak has overwhelmed the capacity of national health systems, but also to the entire world. We urge our governments to mobilise all possible resources to assist west Africa in controlling this horrific epidemic. Based on our expertise in public health and emergency response, this open letter describes believes and measures particularly effective to take into actions.

The current protracted economic crisis is giving rise to the scarcity of public health resources across Europe. In response to budgetary pressures and the Eurozone public debt crisis, decision-makers resort to a short-term solution: the introduction of austerity measures in diverse policy fields. Health and social policy tend to be easy targets in this regard and budget cuts often include a reduction of healthcare expenditure or social welfare benefits. We suggest incorporating discussions from the field of ethics in policy making processes and in the academic debate on austerity. This includes recognising procedural justice as a social value. On the road to economic recovery, governments are compelled to resort to fiscal consolidation and austerity packages but decisions taken to save our European ships in crisis should be anchored in values such as (procedural) justice, equity and solidarity.

The participation in physical activity (PA) can change during the life time. Parenthood has been found to be a life event that is associated with decreased PA, especially among women, but studies in the field are sparse. The aim of this study was to investigate performance in outdoor recreational PA, and factors influencing participation among parents and non-parents from a gender perspective. Methods This study included 432 individuals, 224 women and 208 men from Karlskrona municipality in the south eastern part of Sweden. Data collection was carried out during the years 2008-09. We measured the self-reported amount of outdoor recreational PA performed during the last year and analysed the dependency of the probability of performing this PA on 25 variables covering individual and socio-economic factors. Results A total of 76% of the women and 65% of the men had performed outdoor recreational PA during the last 12 months before one month prior to pregnancy. Men were affected by a greater number of factors than women. Performing PA indoors and dog or horse ownership emerged as the most important factors associated with the probability of performing outdoor recreational PA. Conclusions Those active in PA were active independent of indoor or outdoor activities, i.e. to be physical active seems to have a special connection to the personality and lifestyle. Becoming a parent is a life-changing event that affects participation in PA. By offering family-oriented PA choices that involve both parfents and children, midwives and health promoters can courage parents to be active and to support each other. The promotion of outdoor recreational PA, which also has restorative effects on well-being, needs to focus on activities which are attractive and affordable for the majority of both women and men.

Objectives: Follow changing physical activity (PA) patterns among women and men during pregnancy compared to before pregnancy. Study design: Longitudinal study. Methods: The study involved 280 individuals, 145 women and 135 men (who were partners to the women), from the municipality of Karlskrona, Sweden. Data were collected during 2008–2009. We measured the self-reported amount of PA performed outdoors and indoors during the 12 months before pregnancy and throughout the entire pregnancy. Results: Among both women and men, we found changes in PA patterns during pregnancy compared to before pregnancy. Women and men were more physically active before pregnancy than during pregnancy. Similar patterns were found among women and men with regard to the type of activity, with both groups taking more exercise and pursuing aquatic sports, indoor PA and non-strenuous activities before pregnancy and more strolling/walking during pregnancy. Conclusions: Our findings contribute new knowledge about changes in men’s PA patterns from pre-pregnancy to pregnancy that is an unexplored field. Changes in the women’s activity patterns during pregnancy also affect the men. Women seem to adjust their activity patterns during the pregnancy. The changes in activity patterns among the men are more tentative but follow the pattern for the women, which could be explained by the couples sharing their everyday lives. Midwives should consider providing information to men about the importance of being physically active during pregnancy and informing them about their role in encouraging women to be physically active.

Background Due to health effects from participating in physical activity (PA) it is from a public health perspective important to study how participation PA may change over a lifetime and how different life events impact on the participation. Although studies in the field are sparse, parenthood has been found to be a life event associated with decreased PA, especially among women. We studied physical activities performed among women and men with and without children. Methods This study includes data for from parents-to-be, 224 women and 208 men, from Karlskrona municipality, situated in the south eastern part of Sweden. Data collection was carried out during 2008–2009. When contacting the antenatal clinics in the municipality all expectant parents were asked by the midwife about participation in the study. Respondents completed a questionnaire about age, socioeconomic status, level of education, previous children, smoking and alcohol habits, Body Mass Index, self estimated health, and participation in different kinds of outdoor and indoor recreational PA. We measured the self-reported amount of outdoor recreational PA undertaken during the last year. Results Both women and men without children performed more outdoor and indoor PA compared to those who had children. Women walked significantly more (p = 0.017) than men irrespective of whether or not they had children. Women with children participated in significantly more gardening (p = 0.009) and winter sports (p = 0.013) than women without children, and women without children participated in significantly more PA indoors (p = 0.001) than women with children. Men with children participated in significantly more gardening (p = 0.001) than men without children, and men without children participated in significantly more PA indoors (p = 0.006). Conclusions Becoming a parent is a life event that affects participation in PA, both concerning duration and the kind of activities performed. To gain deeper understanding and more insight about reasons for these changed patterns of PA as well as the effects on the outcome of the parents health in a short- and long term would be important to follow prospectively.

Background: A physically active life promotes both physical and mental health, increasing well-being and quality of life. Physical activity (PA) performed outdoors has been found to be particularly good for promoting well-being. However, participation in PA can change during the course of a lifetime. Parenthood has been found to be a life event associated with decreased PA, especially among women, although studies in the field are sparse. The aim of this study was to investigate participation in outdoor recreational PA, and factors influencing participation among parents-to-be, with and without previous children, from a gender perspective. Methods: This study included baseline data from parents-to-be, 224 women and 208 men, from the municipality of Karlskrona in south-east Sweden. Data collection was carried out during 2008-2009. We measured the self-reported amount of outdoor recreational PA undertaken during the last year and analysed the probability of participating in this PA using 25 variables covering individual and socioeconomic factors. Results: Seventy-six per cent of the women and 65% of the men had participated in outdoor recreational PA, varying from several times per month to every day, over a 12-month period prior to one month before pregnancy. Participation in PA indoors and owning a dog or a horse emerged as the most important factors associated with the probability of participation in outdoor recreational PA. Men were affected by a greater number of factors than women, for example men who had a family situation that permitted outdoor recreational PA participated in activities to a greater extent than men without such a family situation. The physical aspect, i.e. improved physical condition, staying power and vigour, also played a significant role with regard to participation among men. Conclusions: Becoming a parent is a life-changing event that affects participation in PA. By offering family-oriented PA choices that involve both parents and children, midwives and health promoters can encourage parents to be active and to support each other. The promotion of outdoor recreational PA, which also has restorative effects on well-being, needs to focus on activities which are attractive and affordable for the majority of both women and men.

Background Physical activity (PA) is part of a healthy lifestyle and prevents many chronic health problems, in addition to promoting mental health. PA performed outdoors has been found particularly good for promoting one's well-being. The aim of this study was to investigate the extent to which outdoor recreational PA was carried out during 1 year, and the factors influencing such activities from a gender perspective among persons ≥ 60 years of age. Methods This study included 999 individuals 60-96 years of age living in the south eastern part of Sweden. Data collection was carried out during the years of 2001-2003. We measured the amount of regular light and/or intense outdoor recreational PA performed during the last year and determined the probability of performing PA as a function of 10 variables covering individual and socioeconomic factors. Results Our results suggest that being independent physically and healthy enough to manage one's personal hygiene and having access to areas for country walks were the most important factors associated with the probability of engaging in outdoor recreational PA for both men and women. Despite the level of performance being almost equal for the sexes as two-thirds of both had performed outdoor recreational PA during the preceding year more factors, i.e., living alone, being unable to cover an unexpected cost, fear of being violated, and fear of falling, were associated with the possibilities of engaging in outdoor recreational PA among women. Also increasing age seems to affect activities among women negatively to a higher extent than men. Conclusion Men and women seem to have different opportunities and needs with respect to performing PA. These considerations do not seem to be sufficiently taken into account today and improvements could be made concerning e.g., health-promoting activities suggested to the elderly by healthcare personnel and spatial planning within society. Promoting outdoor recreational PA that has restorative effects on well-being needs to focus on activities which are attractive and affordable for the majority of both men and women.

Background The elderly population in the world are increasing. Health promoting activities aiming at a long healthy life among the elderly is a central public health issue. Regular outdoor recreation physical activity is associated with physical and mental health benefits, also if starting late in life. We studied outdoor recreation physical activities and factors influencing such activities, among persons aged >60 years. Methods The study was performed within the longitudinal Swedish National Study on Aging and Care. Baseline data were collected between 2001 and 2003. Respondents completed a questionnaire about sex, age, outdoor physical activities during the last year, access to recreational areas, socioeconomic status, social network, anxiety of falling or being assaulted outdoors and capability to have a shower by themselves. A binary logistic regression was used to determine differences in variables constituting on factors enhancing the probability on performing outdoor recreation physical activities. Results In total, 999/1402 (71 %) respondents aged 60-96 years answered all the questions in the questionnaire. Of those, 659/999 (66 %) had performed outdoor recreation physical activities several times/week during the last year. The probability on performing activities was significantly higher among women when compared to men. The activities decreased significantly when becoming >80 years, especially among women. Also, being a woman with poor economy decreased the probability significantly compared to men in the same situation. Other factors which significantly increased the performance were; access to a recreational area, if respondents were not anxious of falling and if respondents were capable to have a shower by themselves. Conclusions To facilitate outdoor physical activities among elderly, extra support seems important for men <80 years and for both sexes when becoming >80 years. Also, those anxious of falling and women with a poor economy need support. Access to recreational areas is of importance.

Background. In 2002, 2 cases of tick-borne encephalitis were diagnosed among inhabitants living in a tick endemic area on the island of Aspö in south-eastern Sweden. During the previous 25 years, only 2 additional cases had been diagnosed in that region of Sweden. To study presence and evolution of seroprevalence of antibodies to the tick-borne encephalitis virus we carried out a follow-up study, comparing inhabitants´ immunoglobulin G antibody levels against the virus in blood samples drawn in 1991 and 2002. Method. The island of Aspö is located in the south-eastern archipelago by the Baltic Sea in the county of Blekinge, Sweden. Due to the confirmed cases of tick-borne encephalitis, permanent and part-time residents were offered tick-borne encephalitis vaccination in the autumn of 2002. Blood samples were collected and analyzed by the two-step enzyme-linked immunosorbent assay to detect immunoglobulin G antibodies against tick-borne encephalitis virus. Also, questionnaires including questions about sex, age, earlier history of and previous vaccination against tick-borne encephalitis, residency on Aspö, history of observed tick-bites and earlier history of Lyme borreliosis and human granulocytic erhlichiosis, was filled in. All those individuals who had participated in a study on LB performed in 1991, and where available blood samples made it possible to compare tick-borne encephalitis immunoglobulin G seroprevalence, were included in the follow-up. Results. A significant increase in immunoglobulin G levels was seen during the follow-up with 24 (12.0%) of 200 blood samples being seropositive in 2002 versus 7 (3,5%) of 200 blood samples in 1991. However, only five participants converted from seronegative level during the 11 y follow-up and one of these participants had been vaccinated against tick-borne encephalitis during the observation period. In only four of all positive sera from 2002 and in no sera from 1991, were neutralizing antibodies against tick-borne encephalitis virus demonstrated. Compared with women, significantly more men were seropositive. In comparison with other age groups the greatest increase was seen in the age group 20 to 29 years. However, most seropostive levels were seen among those >50 years. Conclusion. Although we found seropositive blood samples in this area already in 1991, the existence of tick-borne encephalitis virus at that time is doubtful since no neutralizing antibodies against tick-borne encephalitis virus were demonstrated. During the 11 years follow-up an obvious increase of tick-borne encephalitis immunoglobulin G seropositive levels in humans was seen. Recommending preventing measures, including vaccination against tick-borne encephalitis is of importance for people regularly staying in this endemic area.

The incidence and variety of diseases associated with ticks have increased world-wide and ticks are currently considered to be second only to mosquitoes as vectors of human infectious diseases in the world. In the northern hemisphere, Ixodes ricinus, the most common tick, transmits diseases caused by several infectious pathogens, including different types of bacteria, virus and protozoa. In Sweden, Lyme borreliosis, tick-borne encephalitis and erlichiosis are established, and more than 10.000 people are infected each year. This thesis focuses on aspects of risks associated with tick bites, the risk of contracting tick borne diseases including long-term outcome, and preventive measures and behaviour among people living in tick endemic areas. The first study describes the long-term outcome in patients treated with antibiotics due to neuroborreliosis. At the follow up, 75% of the patients had recovered completely and 25% (95% confidence interval; 17% - 33%) suffered from residual neurological symptoms such as facial palsy, concentration disorder, paresthesia and/or neuropathy. In order to avoid sequelae, early diagnosis and treatment are of great importance. The second study investigated the exposure and contraction of tick-bites with the risk of developing Lyme borreliosis from these tick-bites. Results showed that among people well aware of tick-borne diseases and who inspect their skin daily for ticks, the monthly rate of being tick bitten was 0.04 (95% confidence interval; 0.02-0.06) per 10 hours spent out of doors. Within six months, 3% had contracted Lyme borreliosis, i.e. the risk of developing this disease was 0.5% (95% confidence interval; 0.44-0.56) per tick-bite. The third (experimental) study was aimed at determining whether light-coloured or dark-coloured clothing had the least attractive effect on Ixodes ricinus. The overall found ticks between the both colours differed significantly, with 62% (95% confidence interval; 59% - 65%) of the ticks found on light-coloured clothing. Dark-coloured clothing seems to attract fewer ticks. The fourth study describes tick preventive measures, and their predictors, taken among highly exposed people. In total, 69% of the participants regularly took preventive measures, personally and/or in the environment. When analysing gender and preventive measure solely, women took more preventive measures compared to men. When analysing all risk variables together, spending less time in tick endemic area and being tick bitten the same tick season significantly increased the probability of taking any preventive measures. After being tick bitten, men increased their performance of preventive measures more than women.

One of the challenges in research and education is to be innovative in helping society to develop sustainable applied technology, i.e. applied health technology that keeps pace with the need in society, both nationally and internationally for technology development in health promotion and prevention as well as in healthcare and social services. The School of Health Science at Blekinge Institute of Technology (BTH) has the stated aim of moving in that direction as new areas of research and education are formulated. The School has defined Health and Technology and Sustainable Active Ageing as the two main focal areas for research and education. To emphasise the importance of bringing research and education into line with each another, a “Bachelor programme in Public Health Science aligned to Community Planning”, was established and started in 2009.

The aim of the survey was to study the risk of tick-bites when exposed during daily activities in a tick endemic region in the south-eastern part of Sweden, between May 2000-March 2001. All the participants were well aware of ticks and tick-borne diseases and every day from May until September inspected their skin and filled in a diary sheet, registering e.g. visited geographical places, time out-of-doors and observed tick-bites. In addition, questionnaires were filled in when entering and at the end of the study. They included questions, e.g. about earlier history of tick-bites or previous undergone tick-borne diseases and out-of-door activities during the studied period. Of the participants, 197/235 (84%) were bitten during the observation period of whom 47/235 (20%) were bitten at = 10 occasions. The incidence was 0.04 (95% CI 0.02-0.06) tick-bitten participants per 10 hours spent out-of-doors. Totally, the participants registered 1767 tick-bites, i.e. an incidence of 0.14 (95% CI 0.10-0.18) tick-bites per 10 hours spent out-of-doors. There were no significant differences of the distribution of tick-bitten participants between children and adults (p=0.19), nor when taking in consider gender (p=0.09). Within six months after the registration period, 8/235 (3%) had been treated for a physician diagnosed Lyme borreliosis (LB). To conclude, we found a risk of 4% to be tick-bitten per 10 hours spent out-of-doors in this region. Although the participants consciousness we found a population at high risk to be tick-bitten. The risk to acquire LB was 1/221 tick-bites. If the participants not have performed such a meticulously daily tick inspection the risk of developing LB would probably increased. However, our study further strengthens the opinion to not recommend routinely prophylactic treatment for observed tick-bites.

It is common belief that ticks are more visible and easier to detect on light clothing in comparison with dark clothing. We studied which of the clothing, light or dark, had the least attractive effect on Ixodes ricinus, thus minimizing exposure and thereby in theory help to prevent tick borne diseases in humans. Ten participants, exposed by walking in tick endemic areas, wore alternately light and dark clothing before every new exposure. Nymphal and adult ticks on the clothing were collected and counted. Totally, 886 nymphal ticks were collected. The overall mean in found ticks between the both groups differed significantly, with 20.8 more ticks per person on light clothing. All participants had more ticks on light clothing in all periods of exposure. Dark clothing seems to attract fewer ticks.

Comments and reply on; Stjernberg L, Berglund J. Garlic as an insect repellent

Objectives: To study if Swedish marine conscripts are a population of high risk to tick-bites and tick-borne diseases and if tick-bites could be prevented by consumption of garlic. Design: Prospective, randomised double blind intervention trial. Subjects: 100 individuals from south-eastern Sweden in military service during 1998. Interventions: The survey participants consumed 1200 mg Allium sativum/placebo for eight weeks, had a wash-out period then changed to placebo/Allium sativum consumption for another ten weeks. All participants had uniform clothes, the same diet, participated in similar activities, stayed equal time in tick-endemic nature etceteras. Main outcome measures: Tick-bites were registered in a diary-sheet after daily inspection of the skin. Results: Totally 286 tick-bites were registered by the participants. On average the participants registered 0.2 tick-bites per week during military service compared to 0.03 tick-bites during leave. Results shows significant reduction in tick-bites when consuming garlic compared to placebo (p<0.05). Furthermore, during placebo consumption, a greater number of the participants were bitten by ticks (incidence per 10 weeks = garlic, intention to treat 0.5, per protocol 0.6, placebo, intention to treat 0.5, per protocol 0.7). Swedish marine conscripts are at high risk of tick bites during military service. Preventive measures, including vaccinations against tick-transmitted diseases, should be considered. However, our results suggest that garlic may be considered as a tick repellent for individuals and populations at high risk for tick bite, rather than other agents that might have more adverse effects.

The incidence and the temporal pattern of tick bites were studied in a population frequently out-of-doors in a tick endemic area in south-eastern Sweden between May 2000-March 2001. The participants, who were well aware of tick-borne diseases, inspected their skin daily from May until September and completed a diary sheet, registering visited geographical places, time out-of-doors, observed tick-bites, etc. The participants were also given questionnaires in both the initial and final stages of the study, asking questions about their earlier history of tick-bites, previous tick-borne diseases and out-of-door activities. The incidence was 0.04 (95% confidence interval 0.02-0.06) tick-bitten participants/10 h spent out-of-doors. In total, the participants registered 1767 tick bites, i.e. an incidence of 0.14 (95% CI 0.10-0.18) tick-bites/10 h spent out-of-doors. Within 6 months after the registration period, 8/235 (3%) had been treated for physician-diagnosed Lyme borreliosis. In conclusion, this study found a 4% risk to be tick-bitten per 10 h spent out-of-doors. The risk of contracting Lyme borreliosis was 1/221 tick bites (0.5%, 95% CI 0.44-0.56). Thus, our results indicate a low risk of acquiring Lyme borreliosis when using daily tick checks and we underline the opinion of not recommending routine prophylactic treatment for observed tick-bites.

INTRODUCTION To prevent tick bites, personal precautions such as wearing light-coloured clothing, are generally recommended. It is believed that ticks are easier to detect on light-coloured clothing in comparison with dark-coloured clothing. Studies confirming this supposition have not been found and we do not know whether colour of clothing influences the tick´s choice of hosts. The aim of this study was to determine which colour of clothing had the least attractive effect on Ixodes ricinus and thus help to prevent tick borne diseases in humans. PROCEDURES The study was performed in the archipelago of the south-eastern Sweden. Ten participants, randomised into two standardised groups, were exposed by walking in squares measuring 25x25 meters. They were exposed 12 times, twice in each square; once with light-coloured and once with dark-coloured clothing. The nymphs and adult ticks on the clothing were collected and counted. FINDINGS Totally, 892 nymphal ticks were collected and of these 552 were found on light-coloured clothing and 340 on dark-coloured clothing. The total mean found number of ticks between the both groups differed significantly, with 21.2 more ticks per person on light-coloured clothing (p=0.003, 95% CI 9.37-33.03). CONCLUSIONS All participants had more ticks on light-coloured clothing in all periods of exposure. In view of these straight results, the recommendation to use light-coloured clothing as a personal precaution in tick endemic areas must be questioned. Dark-coloured clothing seems to attract fewer ticks.

Background: To describe environmental and personal tick preventive measures and their predictors, taken by a population living in a highly tick-endemic area. Methods: Due to the recent confirmation of human tick-borne encephalitis cases, vaccination against tick-borne encephalitis was offered to the population living in the endemic area through the use of leaflets and media campaigns. At the time for the initial dose, information and enrollment to this cohort study was carried out. Participants´ characteristics, frequency of tick-bites and preventive measures were included in questionnaires. Logistic analysis was used to determine behavioural differences in activities taken in order to prevent tick-bites. Results: In total, 70% of the permanent residents had themselves vaccinated before the next tick-season. Of the studied participants 356/517 (69%) regularly took preventive measures in their environment (i.e. affecting the surroundings and towards animals) and/or personally (i.e. avoidance of extensive tick-areas, use of naturopathic medicine, use of repellents, clothing/boots, body examination, bath/shower). Of those taking personally preventive measures, 46% limited their time spent out-of-doors in carrying out leisure activities. Women in particular, and those previously treated for a tick-borne disease took significantly more preventive measures. When analysing all variables together, spending less time in tick-endemic area and being tick-bitten the latest tick-season significantly increased the probability of taking preventive measures. After being tick-bitten, men were more inclined to start taking preventive measures than women. Conclusion: Awareness of the risks caused by living in a high endemic area to ticks influenced the participant’s daily life through preventive activities. Public health action should be considered thus encouraging out-of-door activities for the population, without anxiety for risks for contracting tick-borne disease after being tick-bitten.

Aims: To describe environmental and personal tick preventive measures and their predictors, taken by a population living in a highly tick-endemic area. Methods: Due to the recent confirmation of human tick-borne encephalitis cases, vaccination against tick borne encephalitis was offered to the population living in the endemic area through the use of leaflets and media campaigns. At the time for the initial dose, information and enrollment to this cohort study was carried out. Participants´ characteristics, frequency of tick-bites and preventive measures were included in questionnaires. Logistic analysis was used to determine behavioural differences in activities taken in order to prevent tick-bites. Conclusion: In total, 70% of the permanent residents had themselves vaccinated before the next tick-season. Of the studied participants 356/517 (69%) regularly took preventive measures in their environment and/or personally. Women in particular, and those previously treated for a tick-borne disease took significantly more preventive measures. When analysing all variables together, spending less time in tick-endemic area and being tick-bitten the latest tick-season significantly increased the probability of taking preventive measures. After being tick-bitten, men were more inclined to start taking preventive measures than women. Awareness of the risks caused by living in a high endemic area to ticks influenced the participant’s daily life through preventive activities. Public health action should be considered thus encouraging out-of-door activities for the population, without anxiety for risks for contracting tick-borne disease after being tick-bitten.

INTRODUCTION AND PURPOSE Lyme borreliosis is in Sweden the most common vector-borne disease with approximately 10.000 individuals affected each year. Previous studies have suggested that conscripts compose a population of high risk to tick-bites and others have linked tick attachment to different body odour. In several countries the peasant population have observed that garlic keep the cattle free from ticks. The purpose of this study was to determine if Swedish conscripts are a population of high risk to tick-bites and thereby tick-borne diseases and to study if tick-bites can be prevented by garlic consumption. METHODS The survey participants, n=100 (50 in each group) consumed garlic / placebo for eight weeks, had a wash-out period, then changed to placebo / garlic consumption for another ten weeks. The study drug contained 1200 mg Allium sativum, administrated 600 mg twice daily. During the study period the conscripts performed a daily inspection of their skin and filled in a diary-sheet. Questionnaires including questions on e.g. smoking habits, other medication, adverse events and tick-borne disease manifestations were answered when; entering the study, before and after the wash-out period and at the end of the study. RESULTS The total amount of registered tick-bites during the study period was 286. On average the participants registered 0.2 bites per week during military service compared to 0.03 bites per week during leave. Two of the participants developed an erythema migrans. When consuming garlic, results show a significant reduction in tick-bites, included and excluded a participant who reported 86 tick-bites on one occasion, compared to consuming placebo. Also, the incidence was lower when taking account the reported number of bitten participants both in intention to treat and per protocol. CONCLUSIONS Swedish marine conscripts are a population of high risk to tick-bites during their military service and preventive measures including vaccinations against diseases transmitted by ticks should be considered. Garlic had a preventive effect against tick-bites, however significantly differences were not seen in intention to treat calculations and more studies are needed.

Objective. To describe the users of herbal medicine products and food supplements with respect to age and gender specifically among persons aged ≥60 years. Design. A descriptive study with baseline data from a longitudinal study of the elderly, stratified into different age cohorts (60-69, 70-79, 80-89 and ≥90 years). Setting. Blekinge county, situated in the southeastern Sweden. Subjects. Totally 1380 persons aged 60-96 years (median age 78 years). Main outcome measures. Current use of herbal medicine products and the use of food supplements. Results. Of the participants, 264/1380 (19.1%) used at least one herbal medicine product, 184/1380 (13.3%) used at least one food supplement and 382/1380 (27.7%) used herbal medicine products and/or food supplements. In all regression models, women had a higher probability to use herbal medicine and/or food supplements in comparison with men. Focusing on the use of herbal medicine products alone and in the combination of using herbal medicine and/or food supplement, a decreased use was seen with increasing age. However, 27.9% were still users of herbal medicine products and/or food supplements in the age group 80-89 years. In comparison, 14% were users in the age group ≥90 years. Age did not have an impact on the probability of taking food supplements. Conclusion. General practitioners need to consider the high use of herbal medicine product and food supplements among elderly when making decisions about treatment.

In 2002, two cases of tick-borne encephalitis (TBE) were diagnosed in inhabitants of a tick endemic area on the island of Aspö in southeastern Sweden. During the previous 25 y, only two other cases of TBE had been diagnosed in that region of Sweden. To investigate the presence and evolution of seroprevalence of antibodies to TBE virus (TBEV), we compared inhabitants´ anti-TBEV immunoglobulin G (IgG) levels in blood samples drawn in 1991 and 2002. A significant increase in IgG antibody levels was observed in 24/200 (12.0%) 2002 blood samples compared to 7/200 (3.5%) 1991 samples. However, neutralizing antibodies were detected in only 4 of the two-step enzyme-linked immunosorbent assay (ELISA) IgG positive sera against TBEV, corresponding to a TBEV neutralizing test (NT) prevalence of 2%. Significantly more men than women were seropositive for TBEV antibodies. Compared to other age groups, the greatest increase in TBEV antibody levels was observed in the 20-29 y age group. However, the majority of seropositive samples were from participants >50 y of age. Recommending preventative measures, including vaccination against TBE, to individuals who reside in or regularly visit TBEV endemic areas is suggested.

Background: In order to increase the current levels of physical activity new strategies have been suggested where it is incorporated into daily routines, such as commuting to and from school/work. Active commuting i.e. cycling or walking to and from school/work is an excellent strategy to increase the overall activity levels. Even though the health benefits of active commuting are well documented, non-active modes of transportation (i.e. cars, bus, train) remain the main mode of transportation. The purpose of the present study is to examine the prevalence and what factors are influencing participation in active commuting in the municipality of Karlskrona, Sweden. Method: A cross-sectional study, including base-line data from parents-to- be was carried out, including 432 participants. Questionnaires were filled in and data collection was conducted during a year in 2008 and 2009. The results were calculated using multivariate logistic regression with odds ratios (OR) and 95% confidence interval (CI). Results: The main mode of commuting was motorised vehicle (63.0%), whilst active commuters were a minority (8.3%). The regression model demonstrated a negative association between being Swedish and AC; as such immigrants were more likely to be active commuters (CI 0.08-0.80). The variable mostly associated with AC was the type of residential area. Participants living in an urban area had 5.4 times higher odds of AC compared to participants living in a rural area (CI 1.51-18.54). Being surrounded by a green-space environment decreased the probability of engaging in AC compared to being surrounded by buildings the majority of time (CI 0.07-0.60). Another important variable was outdoor recreational PA, were engaging resulted in 3.9 times higher odds of AC compared to those not engaging in outdoor recreational PA (CI 1.31-11.71). Although the variable pet-ownership remained in the last step of the model non-significant, it explains some of the variance in the model (0.10-1.24). Conclusions: The number of people being active are modest and are instead using other modes of transportation. This study found several factors both facilitating and impeding active commuting, signifying the importance of applying a broad health promotional approach to active commuting.

Aim: The purpose of the present study is to examine the prevalence of active commuting and factors associated with participation in active commuting in the municipality of Karlskrona, Sweden. Active commuting is defined here as walking or cycling to and from school/work for at least 15 min one-way. Method: A cross-sectional study was carried out, which included baseline data from parents-to-be. Pregnant females and their partners were invited to participate in the study when they contacted either of the municipality’s two antenatal clinics. Data collection ran from March 2008 to February 2009. When completing the questionnaire, the participants were asked to reflect on their situation one month before the female became pregnant. The final sample consisted of 432 participants (response rate 51.9% for females and 85.0% for males). Results: The main mode of commuting was motor vehicle (63.0%), with active commuters forming a minority (8.3%). The main facilitating factor for active commuting was living in an urban as opposed to a rural area. Regular participation in outdoor recreational physical activity was significantly positively associated with active commuting. Being Swedish and being surrounded by a green space environment were significantly negatively associated with active commuting. Conclusions: This study found that the number of people who are active commuters is modest and other modes of transportation are preferred. Several facilitating and impeding factors associated with active commuting were also found, indicating the importance of applying a broad health-promoting approach to encouraging active commuting.