AccessMod 3.0: computing geographic coverage and accessibility to health care services using anisotropic movement of patients

Background Access to health care can be described along four dimensions: geographic accessibility, availability, financial accessibility and acceptability. Geographic accessibility measures how physically accessible resources are for the population, while availability reflects what resources are available and in what amount. Combining these two types of measure into a single index provides a measure of geographic (or spatial) coverage, which is an important measure for assessing the degree of accessibility of a health care network. Results This paper describes the latest version of AccessMod, an extension to the Geographical Information System ArcView 3.×, and provides an example of application of this tool. AccessMod 3 allows one to compute geographic coverage to health care using terrain information and population distribution. Four major types of analysis are available in AccessMod: (1) modeling the coverage of catchment areas linked to an existing health facility network based on travel time, to provide a measure of physical accessibility to health care; (2) modeling geographic coverage according to the availability of services; (3) projecting the coverage of a scaling-up of an existing network; (4) providing information for cost effectiveness analysis when little information about the existing network is available. In addition to integrating travelling time, population distribution and the population coverage capacity specific to each health facility in the network, AccessMod can incorporate the influence of landscape components (e.g. topography, river and road networks, vegetation) that impact travelling time to and from facilities. Topographical constraints can be taken into account through an anisotropic analysis that considers the direction of movement. We provide an example of the application of AccessMod in the southern part of Malawi that shows the influences of the landscape constraints and of the modes of transportation on geographic coverage. Conclusion By incorporating the demand (population) and the supply (capacities of heath care centers), AccessMod provides a unifying tool to efficiently assess the geographic coverage of a network of health care facilities. This tool should be of particular interest to developing countries that have a relatively good geographic information on population distribution, terrain, and health facility locations.

A Vaccine Encoding Conserved Promiscuous HIV CD4 Epitopes Induces Broad T Cell Responses in Mice Transgenic to Multiple Common HLA Class II Molecules

Current HIV vaccine approaches are focused on immunogens encoding whole HIV antigenic proteins that mainly elicit cytotoxic CD8+ responses. Mounting evidence points toward a critical role for CD4+ T cells in the control of immunodeficiency virus replication, probably due to cognate help. Vaccine-induced CD4+ T cell responses might, therefore, have a protective effect in HIV replication. In addition, successful vaccines may have to elicit responses to multiple epitopes in a high proportion of vaccinees, to match the highly variable circulating strains of HIV. Using rational vaccine design, we developed a DNA vaccine encoding 18 algorithm-selected conserved, ""promiscuous"" ( multiple HLA-DR-binding) B-subtype HIV CD4 epitopes - previously found to be frequently recognized by HIV-infected patients. We assessed the ability of the vaccine to induce broad T cell responses in the context of multiple HLA class II molecules using different strains of HLA class II-transgenic mice (-DR2, -DR4, -DQ6 and -DQ8). Mice displayed CD4+ and CD8+ T cell responses of significant breadth and magnitude, and 16 out of the 18 encoded epitopes were recognized. By virtue of inducing broad responses against conserved CD4+ T cell epitopes that can be recognized in the context of widely diverse, common HLA class II alleles, this vaccine concept may cope both with HIV genetic variability and increased population coverage. The vaccine may thus be a source of cognate help for HIV-specific CD8+ T cells elicited by conventional immunogens, in a wide proportion of vaccinees.

Hospitalizations for ambulatory care-sensitive conditions, Minas Gerais, Southeastern Brazil, 2000 and 2010

OBJECTIVE To analyze hospitalization rates and the proportion of deaths due to ambulatory care-sensitive hospitalizations and to characterize them according to coverage by the Family Health Strategy, a primary health care guidance program. METHODS An ecological study comprising 853 municipalities in the state of Minas Gerais, under the purview of 28 regional health care units, was conducted. We used data from the Hospital Information System of the Brazilian Unified Health System. Ambulatory care-sensitive hospitalizations in 2000 and 2010 were compared. Population data were obtained from the demographic censuses. RESULTS The number of ambulatory care-sensitive hospitalizations declined from 20.75/1,000 inhabitants [standard deviation (SD) = 10.42) in 2000 to 14.92/thousand inhabitants (SD = 10.04) in 2010 Heart failure was the most frequent cause in both years. Hospitalizations rates for hypertension, asthma, and diabetes mellitus, decreased, whereas those for angina pectoris, prenatal and birth disorders, kidney and urinary tract infections, and other acute infections increased. Hospitalization durations and the proportion of deaths due to ambulatory care-sensitive hospitalizations increased significantly. CONCLUSIONS Mean hospitalization rates for sensitive conditions were significantly lower in 2010 than in 2000, but no correlation was found with regard to the expansion of the population coverage of the Family Health Strategy. Hospitalization rates and proportion of deaths were different between the various health care regions in the years evaluated, indicating a need to prioritize the primary health care with high efficiency and quality.

A conceptual framework to assess the effectiveness of HIV prevention

Aim: The relative effectiveness of different methods of prevention of HIV transmission is a subject of debate that is renewed with the integration of each new method. The relative weight of values and evidence in decision-making is not always clearly defined. Debate is often confused, as the proponents of different approaches address the issue at different levels of implementation. This paper defines and delineates the successive levels of analysis of effectiveness, and proposes a conceptual framework to clarify debate. Method / Issue: Initially inspired from work on contraceptive effectiveness, a first version of the conceptual framework was published in 1993 with definition of the Condom Effectiveness Matrix (Spencer, 1993). The framework has since integrated and further developed thinking around distinctions made between efficacy and effectiveness and has been applied to HIV prevention in general. Three levels are defined: theoretical effectiveness (ThE), use-effectiveness (UseE) and population use-effectiveness (PopUseE). For example, abstinence and faithfulness, as proposed in the ABC strategy, have relatively high theoretical effectiveness but relatively low effectiveness at subsequent levels of implementation. The reverse is true of circumcision. Each level is associated with specific forms of scientific enquiry and associated research questions: basic and clinical sciences with ThE; clinical and social sciences with UseE; epidemiology and social, economic and political sciences with PopUseE. Similarly, the focus of investigation moves from biological organisms, to the individual at the physiological and then psychological, social and ecological level, and finally takes as perspective populations and societies as a whole. The framework may be applied to analyse issues on any approach. Hence, regarding consideration of HIV treatment as a means of prevention, examples of issues at each level would be: ThE: achieving adequate viral suppression and non-transmission to partners; UseE: facility and degree of adherence to treatment and medical follow-up; PopUseE: perceived validity of strategy, feasibility of achieving adequate population coverage. Discussion: Use of the framework clarifies the questions that need to be addressed at all levels in order to improve effectiveness. Furthermore, the interconnectedness and complementary nature of research from the different scientific disciplines and the relative contribution of each become apparent. The proposed framework could bring greater rationality to the prevention effectiveness debate and facilitate communication between stakeholders.

Conservation Genetics of Exploited Finnish Salmonid Fishes

Genetic diversity is one of the levels of biodiversity that the World Conservation Union (IUCN) has recognized as being important to preserve. This is because genetic diversity is fundamental to the future evolution and to the adaptive flexibility of a species to respond to the inherently dynamic nature of the natural world. Therefore, the key to maintaining biodiversity and healthy ecosystems is to identify, monitor and maintain locally-adapted populations, along with their unique gene pools, upon which future adaptation depends. Thus, conservation genetics deals with the genetic factors that affect extinction risk and the genetic management regimes required to minimize the risk. The conservation of exploited species, such as salmonid fishes, is particularly challenging due to the conflicts between different interest groups. In this thesis, I conduct a series of conservation genetic studies on primarily Finnish populations of two salmonid fish species (European grayling, Thymallus thymallus, and lake-run brown trout, Salmo trutta) which are popular recreational game fishes in Finland. The general aim of these studies was to apply and develop population genetic approaches to assist conservation and sustainable harvest of these populations. The approaches applied included: i) the characterization of population genetic structure at national and local scales; ii) the identification of management units and the prioritization of populations for conservation based on evolutionary forces shaping indigenous gene pools; iii) the detection of population declines and the testing of the assumptions underlying these tests; and iv) the evaluation of the contribution of natural populations to a mixed stock fishery. Based on microsatellite analyses, clear genetic structuring of exploited Finnish grayling and brown trout populations was detected at both national and local scales. Finnish grayling were clustered into three genetically distinct groups, corresponding to northern, Baltic and south-eastern geographic areas of Finland. The genetic differentiation among and within population groups of grayling ranged from moderate to high levels. Such strong genetic structuring combined with low genetic diversity strongly indicates that genetic drift plays a major role in the evolution of grayling populations. Further analyses of European grayling covering the majority of the species’ distribution range indicated a strong global footprint of population decline. Using a coalescent approach the beginning of population reduction was dated back to 1 000-10 000 years ago (ca. 200-2 000 generations). Forward simulations demonstrated that the bottleneck footprints measured using the M ratio can persist within small populations much longer than previously anticipated in the face of low levels of gene flow. In contrast to the M ratio, two alternative methods for genetic bottleneck detection identified recent bottlenecks in six grayling populations that warrant future monitoring. Consistent with the predominant role of random genetic drift, the effective population size (N_e) estimates of all grayling populations were very low with the majority of N_e estimates below 50. Taken together, highly structured local populations, limited gene flow and the small N_e of grayling populations indicates that grayling populations are vulnerable to overexploitation and, hence, monitoring and careful management using the precautionary principles is required not only in Finland but throughout Europe. Population genetic analyses of lake-run brown trout populations in the Inari basin (northernmost Finland) revealed hierarchical population structure where individual populations were clustered into three population groups largely corresponding to different geographic regions of the basin. Similar to my earlier work with European grayling, the genetic differentiation among and within population groups of lake-run brown trout was relatively high. Such strong differentiation indicated that the power to determine the relative contribution of populations in mixed fisheries should be relatively high. Consistent with these expectations, high accuracy and precision in mixed stock analysis (MSA) simulations were observed. Application of MSA to indigenous fish caught in the Inari basin identified altogether twelve populations that contributed significantly to mixed stock fisheries with the Ivalojoki river system being the major contributor (70%) to the total catch. When the contribution of wild trout populations to the fisheries was evaluated regionally, geographically nearby populations were the main contributors to the local catches. MSA also revealed a clear separation between the lower and upper reaches of Ivalojoki river system – in contrast to lower reaches of the Ivalojoki river that contributed considerably to the catch, populations from the upper reaches of the Ivalojoki river system (>140 km from the river mouth) did not contribute significantly to the fishery. This could be related to the available habitat size but also associated with a resident type life history and increased cost of migration. The studies in my thesis highlight the importance of dense sampling and wide population coverage at the scale being studied and also demonstrate the importance of critical evaluation of the underlying assumptions of the population genetic models and methods used. These results have important implications for conservation and sustainable fisheries management of Finnish populations of European grayling and brown trout in the Inari basin.

Fluoride concentration in public water supply: 72 months of analysis

Known as one of the ten most important advances on Public Health in the 20th century, fluoridation of public water supply is a measure of wide population coverage, which is effective on caries control. The city of Araçatuba, in the Northwest region of the São Paulo state, Brazil, started public water supply fluoridation in 1972 and, based on the average annual highest temperature, has kept the fluoride concentration between 0.6 to 0.8 mgF/L. The purpose of this study was to analyze monthly the fluoride concentration in public water supply in the city of Araçatuba during 72 months. Water samples were collected monthly on weekdays, directly from the water distribution network, on pre-established locations and analyzed in duplicate between November 2004 and October 2010 at the Research Laboratory of the Nucleus for Public Health (NEPESCO) of the Public Health Graduate Program from Araçatuba Dental School/UNESP, Brazil, using an fluoride-specific electrode connected to an ion analyzer. From the total of samples (n=591), 67.2% (n=397) presented fluoride concentration between 0.6 and 0.8 mgF/L; 20.6% (n=122) below 0.6 mgF/L; 11.5% (n=68) between 0.8 and 1.2 mgF/L and 0.7% (n=4) above 1.2 mgF/L. Most samples showed fluoride levels within the recommended parameters. Minimal variation was observed among the analyzed collection locations, showing that the city has been able to control the fluoride levels in the public water supply and reinforcing the importance of surveillance and constant monitoring to assure the quality of the water delivered to the population.

The role of insurance in social protection

Includes bibliography

Cobertura populacional do Sistema de Vigilância Alimentar e Nutricional no Estado de São Paulo, Brasil

O objetivo deste artigo é estimar a cobertura populacional do Sistema de Vigilância Alimentar e Nutricional (SISVAN) nos diferentes estágios de vida e avaliar seu funcionamento no estado de São Paulo. O estudo incluiu 65 municípios divididos em 14 regiões do estado. A cobertura do SISVAN foi estimada a partir de dados de monitoramento do estado nutricional disponíveis nos relatórios públicos, e do número de usuários que frequentam os serviços públicos de saúde. O total de usuários foi obtido pela diferença entre o total de habitantes e o número de beneficiários de planos de saúde privados. A maioria das regiões apresentou uma cobertura reduzida (<10%). Cerca de 57% revelaram cobertura entre 5 e 10%. Constatou-se uma preponderância de registros do estado nutricional de crianças para todas as regiões do Estado. Chama a atenção a reduzida cobertura entre os idosos, que é inexistente ou próxima de zero na maioria das regiões. Apesar dos esforços empreendidos pelo governo visando à ampliação e à qualificação do SISVAN, o monitoramento nutricional no estado de São Paulo ainda é insuficiente. Esta condição compromete sua utilização na elaboração de políticas efetivas na área de alimentação e nutrição.

Private and Public Dental Care in the City of Sao Paulo in the First Decade of the XXI Century

Two concomitant movements occur in the first decade of the XXI century within the private and public dental services in Brazil: the entrance of oral health on the agenda of political priorities of the federal government and the vigorous growth of additional dental care. We analyzed the occurrence of these phenomena in the city of Sao Paulo, by seeking information in official documents and electronic databases in the Municipality of Sao Paulo, the Ministry of Health and National Health Agency (ANS), and also in scientific literature. During the studied period - January 2000 to December 2009 - and with basis on indicators such as coverage of First Consultation Program and Dental coverage Population Potential, percentages were found that characterize low public assistance and a situation far short of the constitutional principle of universal access to dental care. The growing number of beneficiaries of additional services through exclusively dental coverage insurance plans and other types of private insurance plans in the same period was significant, accounting for a major expansion of population coverage in this mode of care. It was found that, compared to the overall national framework, the city of Sao Paulo offers poor access to public dental care, with reduced supply of services to adults and aged people. Furthermore, considering the limitations of market additional services to provide dental care to all Brazilians, it reinforces the need for continuity and expansion of Brasil Sorridente, which is the programmatic expression of the National Oral Health Politics.

Broad and Cross-Clade CD4(+) T-Cell Responses Elicited by a DNA Vaccine Encoding Highly Conserved and Promiscuous HIV-1 M-Group Consensus Peptides

T-cell based vaccine approaches have emerged to counteract HIV-1/AIDS. Broad, polyfunctional and cytotoxic CD4(+) T-cell responses have been associated with control of HIV-1 replication, which supports the inclusion of CD4(+) T-cell epitopes in vaccines. A successful HIV-1 vaccine should also be designed to overcome viral genetic diversity and be able to confer immunity in a high proportion of immunized individuals from a diverse HLA-bearing population. In this study, we rationally designed a multiepitopic DNA vaccine in order to elicit broad and cross-clade CD4(+) T-cell responses against highly conserved and promiscuous peptides from the HIV-1 M-group consensus sequence. We identified 27 conserved, multiple HLA-DR-binding peptides in the HIV-1 M-group consensus sequences of Gag, Pol, Nef, Vif, Vpr, Rev and Vpu using the TEPITOPE algorithm. The peptides bound in vitro to an average of 12 out of the 17 tested HLA-DR molecules and also to several molecules such as HLA-DP, -DQ and murine IA(b) and IA(d). Sixteen out of the 27 peptides were recognized by PBMC from patients infected with different HIV-1 variants and 72% of such patients recognized at least 1 peptide. Immunization with a DNA vaccine (HIVBr27) encoding the identified peptides elicited IFN-gamma secretion against 11 out of the 27 peptides in BALB/c mice; CD4(+) and CD8(+) T-cell proliferation was observed against 8 and 6 peptides, respectively. HIVBr27 immunization elicited cross-clade T-cell responses against several HIV-1 peptide variants. Polyfunctional CD4(+) and CD8(+) T cells, able to simultaneously proliferate and produce IFN-gamma and TNF-alpha, were also observed. This vaccine concept may cope with HIV-1 genetic diversity as well as provide increased population coverage, which are desirable features for an efficacious strategy against HIV-1/AIDS.

Überlegungen zum Berner Stichprobenplan

Fritschi, Meyer und Schweizer haben vor drei Jahrzehnten in der Schweizerischen Zeitschrift für Soziologie ein elegantes Stichprobenverfahren für ein gesamtschweizerisches Sample vorgeschlagen, bei dem die Befragungspersonen mit Hilfe kommunaler Wahl- oder Einwohnerregister bestimmt werden. Ungeachtet der Vorzüge dieser Methode beruhen heute die meisten Bevölkerungsumfragen in der Schweiz aber auf Telefonregisterstichproben, die bezüglich der Abdeckung der Grundgesamtheit als problematisch anzusehen sind. Sozusagen als Wiederbelebungsversuch möchte ich deshalb hier einige Überlegungen zum Stichprobenplan von Fritschi et al. präsentieren. Die theoretischen Eigenschaften des Stichprobenplans werden besprochen und ein vereinfachtes Verfahren, die ex ante geteilte Stichprobe, wird vorgeschlagen. Mit Hilfe einer Simulationsstudie werden sodann die Vorzüge des "Berner Stichprobenplans" gegenüber einer einfachen Klumpenstichprobe illustriert.

Providing 30Mbit/s to Spain’s final third. -A techno-economic assessment.

Since the Digital Agenda for Europe released the Europe2020 flagship, Member States are looking for ways of fulfilling their agreed commitments to fast and ultrafast internet deployment. However, Europe is not a homogenous reality. The economic, geographic, social and demographic features of each country make it a highly diverse region to develop best practices over Next Generation Access Networks (NGAN) deployments. There are special concerns about NGAN deployments for “the final third”, as referred to the last 25% of the country’s population who, usually, live in rural areas. This paper assesses, through a techno-economic analysis, the access cost of providing over 30 Mbps broadband for the final third of Spain`s population in municipalities, which are classified into area types, referred to as geotypes. Fixed and mobile technologies are compared in order to determine which is the most cost-effective technology for each geotype. The demographic limit for fixed networks (cable, fibre and copper) is also discussed. The assessment focuses on the supply side and the results show the access network cost only. The research completes a previous published assessment (Techno-economic analysis of next generation access networks roll-out. The case of platform competition, regulation and public policy in Spain) by including the LTE scenario. The LTE scenario is dimensioned to provide 30 Mbps (best effort) broadband, considering a network take-up of 25%. The Rocket techno-economic model is used to assess a ten-year study period deployment. Nevertheless, the deployment must start in 2014 and be completed by 2020, in order to fulfil the Digital Agenda’s goals. The feasibility of the deployment is defined as the ability to recoup the investment at the end of the study period. This ability is highly related to network take-up and, therefore, to service adoption. Network deployment in each geotype is compared with the cost of the deployment in the Urban geotype and broadband expected penetration rates for clarity and simplicity. Debating the cost-effective deployments for each geotype, while addressing the Digital Agenda’s goals regarding fast and ultrafast internet, is the main purpose of this paper. At the end of the last year, the independent Spanish regulation agency released the Spain broadband coverage report at the first half of 2013. This document claimed that 59% and 52% of Spain’s population was already covered by NGAN capable of providing 30 Mbps and 100 Mbps broadband respectively. HFC, with 47% of population coverage, and FTTH, with 14%, were considered as a 100 Mbps capable NGAN. Meanwhile VDSL, with 12% of the population covered, was the only NGAN network considered for the 30 Mbps segment. Despite not being an NGAN, the 99% population coverage of HSPA networks was also noted in the report. Since mobile operators are also required to provide 30 Mbps broadband to 90% of the population in rural areas by the end of 2020, mobile networks will play a significant role on the achievement of the 30 Mbps goal in Spain’s final third. The assessment indicates the cost of the deployment per cumulative households coverage with 4 different NGANs: FTTH, HFC, VDSL and LTE. Research shows that an investment ranging from €2,700 (VDSL) to €5,400 (HFC) million will be needed to cover the first half of the population with any fixed technology assessed. The results state that at least €3,000 million will be required to cover these areas with the least expensive technology (LTE). However, if we consider the throughput that fixed networks could provide and achievement of the Digital Agenda’s objectives, fixed network deployments are recommended for up to 90% of the population. Fibre and cable deployments could cover up to a maximum of 88% of the Spanish population cost efficiently. As there are some concerns about the service adoption, we recommend VDSL and mobile network deployments for the final third of the population. Despite LTE being able to provide the most economical roll-out, VDSL could also provide 50 Mbps from 75% to 90% of the Spanish population cost efficiently. For this population gap, facility based competition between VDSL providers and LTE providers must be encouraged. Regarding 90% to 98.5% of the Spanish population, LTE deployment is the most appropriate. Since costumers in less populated the municipalities are more sensitive to the cost of the service, we consider that a single network deployment could be most appropriate. Finally, it has become clear that it is not possible to deliver 30Mbps to the final 1.5% of the population cost-efficiently and adoption predictions are not optimistic either. As there are other broadband alternatives able to deliver up to 20 Mbps, in the authors’ opinion, it is not necessary to cover the extreme rural areas, where public financing would be required.

Immunoinformatic evaluation of multiple epitope ensembles as vaccine candidates:E coli 536

Epitope prediction is becoming a key tool for vaccine discovery. Prospective analysis of bacterial and viral genomes can identify antigenic epitopes encoded within individual genes that may act as effective vaccines against specific pathogens. Since B-cell epitope prediction remains unreliable, we concentrate on T-cell epitopes, peptides which bind with high affinity to Major Histacompatibility Complexes (MHC). In this report, we evaluate the veracity of identified T-cell epitope ensembles, as generated by a cascade of predictive algorithms (SignalP, Vaxijen, MHCPred, IDEB, EpiJen), as a candidate vaccine against the model pathogen uropathogenic gram negative bacteria Escherichia coli (E-coli) strain 536 (O6:K15:H31). An immunoinformatic approach was used to identify 23 epitopes within the E-coli proteome. These epitopes constitute the most promiscuous antigenic sequences that bind across more than one HLA allele with high affinity (IC50 <50nM). The reliability of software programmes used, polymorphic nature of genes encoding MHC and what this means for population coverage of this potential vaccine are discussed.

Identifiying human MHC supertypes using bioinformatic methods

Classification of MHC molecules into supertypes in terms of peptide-binding specificities is an important issue, with direct implications for the development of epitope-based vaccines with wide population coverage. In view of extremely high MHC polymorphism (948 class I and 633 class II HLA alleles) the experimental solution of this task is presently impossible. In this study, we describe a bioinformatics strategy for classifying MHC molecules into supertypes using information drawn solely from three-dimensional protein structure. Two chemometric techniques–hierarchical clustering and principal component analysis–were used independently on a set of 783 HLA class I molecules to identify supertypes based on structural similarities and molecular interaction fields calculated for the peptide binding site. Eight supertypes were defined: A2, A3, A24, B7, B27, B44, C1, and C4. The two techniques gave 77% consensus, i.e., 605 HLA class I alleles were classified in the same supertype by both methods. The proposed strategy allowed “supertype fingerprints” to be identified. Thus, the A2 supertype fingerprint is Tyr9/Phe9, Arg97, and His114 or Tyr116; the A3-Tyr9/Phe9/Ser9, Ile97/Met97 and Glu114 or Asp116; the A24-Ser9 and Met97; the B7-Asn63 and Leu81; the B27-Glu63 and Leu81; for B44-Ala81; the C1-Ser77; and the C4-Asn77. action fields calculated for the peptide binding site. Eight supertypes were defined: A2, A3, A24, B7, B27, B44, C1, and C4. The two techniques gave 77% consensus, i.e., 605 HLA class I alleles were classified in the same supertype by both methods. The proposed strategy allowed “supertype fingerprints” to be identified. Thus, the A2 supertype fingerprint is Tyr9/Phe9, Arg97, and His114 or Tyr116; the A3-Tyr9/Phe9/Ser9, Ile97/Met97 and Glu114 or Asp116; the A24-Ser9 and Met97; the B7-Asn63 and Leu81; the B27-Glu63 and Leu81; for B44-Ala81; the C1-Ser77; and the C4-Asn77.

Future trends in cystic fibrosis demography in 34 European countries

Median survival has increased in people with cystic fibrosis (CF) during the past six decades, which has led to an increased number of adults with CF. The future impact of changes in CF demographics has not been evaluated. The aim of this study was to estimate the number of children and adults with CF in 34 European countries by 2025. Data were obtained from the European Cystic Fibrosis Society Patient Registry. Population forecasts were performed for countries that have extensive CF population coverage and at least 4 years of longitudinal data by modelling future entering and exiting flows in registry cohorts. For the other countries, population projections were performed based on assumptions from knowledge of current CF epidemiology. Western European countries' forecasts indicate that an increase in the overall number of CF patients by 2025, by approximately 50%, corresponds to an increase by 20% and by 75% in children and adults, respectively. In Eastern European countries the projections suggest a predominant increase in the CF child population, although the CF adult population would also increase.It was concluded that a large increase in the adult CF population is expected in the next decade. A significant increase in adult CF services throughout Europe is urgently required.