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PubMed1991

Prevalence of HIV infection in childbearing women in the United States. Surveillance using newborn blood samples.

A national, population-based survey was initiated in 1988 to measure the prevalence of human immunodeficiency virus (HIV) infection in women giving birth to infants in the United States. Following standardized procedures, residual dried-blood specimens collected on filter paper for newborn metabolic screening were tested anonymously in state public health laboratories for maternal antibody to HIV. As of September 1990, annual survey data were available from 38 states and the District of Columbia. The highest HIV seroprevalence rates were observed in New York (5.8 per 1000), the District of Columbia (5.5 per 1000), New Jersey (4.9 per 1000), and Florida (4.5 per 1000). Nationwide, an estimated 1.5 per 1000 women giving birth to infants in 1989 were infected with HIV. Assuming a perinatal transmission rate of 30%, we estimate that approximately 1800 newborns acquired HIV infection during one 12-month period. Preventing transmission of HIV infection to women and infants is an urgent public health priority.

Anonymous Testing↗
PubMed1995

Efficacy of BCG vaccination of the newborn: evaluation by a follow-up study of contacts in Bangui.

BACKGROUND: The efficacy of Bacillus of Calmette and Guérin (BCG) vaccination given at birth is still controversial. We therefore conducted a study in Bangui (Central African Republic) to estimate the protection afforded over the first seven years of life by BCG administered at birth. METHODS: One thousand children who had lived in contact with a recently diagnosed case of contagious tuberculosis were followed up for a period of 6 months in order to detect the occurrence of tuberculosis. Diagnosis of tuberculosis was made through a scoring system. Vaccine efficacy (VE) was calculated on the basis of the relative risk of contracting tuberculosis according to vaccination status. RESULTS: The efficacy of BCG was estimated to be 71% (95% confidence interval: 56-81%). This result remained practically the same after changing the definition used for tuberculosis cases (VE = 75% for a threshold with a score of 15 instead of 6, VE = 74% when only confirmed cases were considered). There was no difference between the two groups in the variables measuring intensity of contact with the source of contamination, but there was a difference in age distribution. Vaccine efficacy adjusted for this factor was the same as the crude VE. CONCLUSION: This study, based on a methodology that controls for most of the risks of bias inherent to field efficacy measurement, confirms the protective capacity of neonatal BCG against childhood tuberculosis. Therefore BCG vaccination at birth must remain a public health priority especially in countries with high incidence of the disease.

BCG Vaccine↗
PubMed2001

The effect of middle- and old-age body mass index on short-term mortality in older people.

OBJECTIVES: To determine the effect of body mass index (BMI) at old age and at age 50 on short-term survival among persons age 65 and older. DESIGN: Cross-sectional, using the 4,791 respondents to the community interview of the 1994 National Long Term Care Survey (NLTCS). SETTING: United States of America. PARTICIPANTS: Persons age 65 and older who lived in community settings as of the 1994 NLTCS interview. MEASUREMENTS: Short-term mortality was measured from the date of the 1994 NLTCS through year-end 1995. BMI (kg/m2) (at three points: 1994 NLTCS, 1 year before, age 50) and all other variables, including three other modifiable risk factors known to be related to mortality--cigarette smoking, alcohol consumption, and exercise--were based on self-report. RESULTS: Both the unadjusted and adjusted nadirs of mortality in relation to BMI at old age were found in older persons with a BMI between 30 and 34.9; this was true for males and females in all age groups. The highest mortality rates were found for older persons with very low BMI (<18.5). In contrast, BMI at age 50 was positively related to mortality, with those in the lowest BMI category (<18.5) at age 50 having the lowest mortality. Persons who were obese at age 50 and who were no longer obese at the 1994 NLTCS had lower mortality than persons with stable weight. CONCLUSIONS: Weight reduction by middle-aged persons who are obese should be reinforced as a public health priority, because there is evidence that long-term weight loss results in better short-term survival. Further study of healthy older survivors to determine why they are not harmed by heavier weight in old age may provide useful insights into successful aging.

Aged↗
PubMed2001

The rising prevalence of asthma in young Melbourne adults is associated with improvement in treatment.

BACKGROUND: Asthma is a common source of morbidity and is now recognized as a national health priority in Australia. Although a number of epidemiologic studies have been conducted in Australia to determine the prevalence of asthma in adults, it is unclear whether the prevalence is changing. OBJECTIVES: To determine the prevalence in 1998 of self-reported asthma and respiratory symptoms among young adults and changes in prevalence between 1990 and 1999. METHODS: Cross-sectional postal survey to 4,455 young adults (aged 20 to 44 years) randomly selected from the electoral rolls of the inner southeastern suburbs of metropolitan Melbourne. The survey instrument was the validated European Community Respiratory Health Survey screening questionnaire, which gathered data on self-reported respiratory symptoms, including whether asthma had been diagnosed. Identically worded questions from similar surveys conducted in 1990, 1992, and 1999 were used to compare changes in prevalence. RESULTS: A response rate of 72% was achieved in 1998 after three mailings and telephone followup. Forty-two percent reported nasal allergies, 26% wheezed within the past 12 months, and 20% ever had asthma. The prevalence of doctor-diagnosed asthma was 18%, whereas 10% reported using asthma medications within the past 12 months. Nine percent of respondents reported an asthma attack within the past 12 months. The prevalence of having ever had asthma, doctor-diagnosed asthma, and using asthma medications had increased significantly since 1990. However, the prevalence of respiratory symptoms did not significantly change over this time. CONCLUSIONS: The prevalence of asthma is likely to be rising, but the symptoms of asthma are being better managed in young Melbourne adults.

Adult↗
PubMed2005

Mycobacterium tuberculosis transmission in a newborn nursery and maternity ward--New York City, 2003.

Evaluating young children recently exposed to airborne Mycobacterium tuberculosis is a public health priority. If infected, children aged <2 years are at high risk for severe tuberculosis (TB) disease (e.g., TB meningitis). In December 2003, infectious pulmonary TB disease was diagnosed in a foreign-born nurse working in the newborn nursery and maternity ward of a New York City hospital (hospital A); the nurse had declined treatment for latent TB infection (LTBI) after testing positive 11 years earlier. An investigation including medical evaluation of contacts in the nursery and maternity ward was conducted by the Bureau of TB Control (BTBC) at the New York City Department of Health and Mental Hygiene, hospital A, and CDC. This report summarizes the results of that investigation, which determined that approximately 1,500 patients had been exposed to the nurse but the majority could not be located for evaluation. Among those who were tested, four infants had positive tuberculin skin test (TST) results, likely attributable to recent transmission of M. tuberculosis. The findings emphasize the difficulty of conducting contact investigations in certain settings and the importance of effective LTBI testing and treatment programs for health-care workers (HCWs) to prevent TB disease and subsequent health-care--associated transmission.

Adult↗
PubMed2005

Preventing suicidal behaviour in a general hospital psychiatric service: priorities for programming.

PURPOSE: General hospital psychiatric services are able to provide leadership and coordinate the development of suicide prevention programs for individuals serviced in general hospital settings. We completed this literature review to suggest priorities for programming. METHODS: Our procedure was to update the review by Gunnell and Frankel that guided priorities for Health of the Nation, the national suicide prevention strategy in the UK. We completed a search, using the terms suicide prevention and control, of all English-language research and clinical trials conducted between January 1, 1994, and May 1, 2004. RESULTS: We identified 82 papers. Of these, 48 were excluded and the remaining 34 were grouped by secondary care setting categories. We found no articles on screening tools for predicting risk of suicide, 16 articles on interventions for individuals with suicidal behaviour, 14 articles on the treatment of major psychiatric disorders, 1 article and 1 published abstract on discharge from hospital, and 2 articles on reducing access to means. CONCLUSIONS: Based on a review of each category, we make several program and policy recommendations, including regularly updating clinical assessment skills, using guidelines for assessment of patients following a suicide attempt, assessing the risk of suicide 24 to 48 hours before discharge from hospital, and incorporating education about reducing access to means into routine psychiatric care.

Health Planning Guidelines↗
PubMed2004

Changing the medical world order with technological advances: the future has only begun.

It is a great honor to contribute in a small way to this book which in a way celebrates the continued evolution of telemedicine in Kosova. I was privileged to visit this brave land on several occasions in the last years. Severe circumstances were repeatedly resolved through great personal and professional sacrifice. Revolutionary solutions have been applied where evolutionary development was simply too slow in the realization of a new land in a complex world. In some ways telemedicine is emblematic of such struggle and success. We aspire to world health when world peace is elusive and hunger haunts us in the midst of plenty. Telecommunications have made it easy to report the failings of medicine, the injustice of health care and the unmet promise of political endeavor. It is the promise of telemedicine to use those same channels of information to empower, unify and advance the cause of health rather than only report the failings. Telemedicine entails the use of telecommunications and information technology to support the delivery of health care at a distance. There are critics who believe telemedicine is a waste of precious resources, which are needed urgently for higher health priorities. Telemedicine is dismissed as an expensive irrelevance, another distraction from the real needs of medicine in a chaotic world. That is patently ridiculous. Telemedicine is a part of the wider phenomenon of information and information is arguably the strongest change agent in play for medicine and other societal elements as well. A well-informed public armed with the tools for self-determination and the evidence for efficient action cannot be corrupted. Telemedicine is a part of the great change information brings to the world order, a drastic change toward a better world of health and justice.

Delivery of Health Care↗
PubMed1998

Measuring the burden of disease: healthy life-years.

OBJECTIVES: This paper presents the background and rationale for a composite indicator, healthy life-year (HeaLY), that incorporates mortality and morbidity into a single number. HeaLY is compared with the disability-adjusted life-year (DALY) indicator, to demonstrate the relative simplicity and ease of use of the former. METHODS: Data collected by the Ghana Health Assessment team from census records, death certificates, medical records, and special studies were used to create a spreadsheet. HeaLYs lost as a result of premature mortality and disability from 56 conditions were estimated. RESULTS: Two thirds of HeaLYs lost in Ghana were from maternal and communicable diseases and were largely preventable. The age weighting in DALYs leads to a higher value placed on deaths at younger ages than in HeaLYs. This spreadsheet can be used as a template for assessing changes in health status attributable to interventions. CONCLUSIONS: HeaLY can aid in setting health priorities and identifying disadvantaged groups. The disaggregated approach of the HeaLY spreadsheet tool is simpler for decision makers and useful for country application.

Cost of Illness↗
PubMed2006

Prioritisation by physicians in the Netherlands--the growth hormone example in drug reimbursement decisions.

Drug treatment and reimbursement is an area of ever growing complexity in health priority setting. This paper assesses the National Registry of Growth Hormone Treatment (LRG) responsible for making prioritisation decisions in the Dutch drug reimbursement system in the treatment of growth hormone, using the framework for fairness. We used qualitative research consisting of semi-structured interviews and focus group sessions combined with quantitative methods to audit the decisions of the forum. The rationing decisions of the forum demonstrate accountability for reasonableness by the conditions for transparency, relevance, and appeal. Most rationales for the decisions are public and transparent. The patients and paediatricians see decisions made by the LRG as clinical and therefore relevant decisions. They also refer to extensive appeal procedures. The case also raises important issues regarding the legitimacy of expert-based priority setting as the cyclic nature of guideline development conflicts with the need for maintaining strict rationing criteria. In 13% of the patients, the sick funds did cover treatment as the forum advised them to do, but according to guideline criteria it may be unlikely that these patients have growth hormone deficiency. According to the LRG, however, only 2% of the decisions are inconsistent with the guidelines, as some criteria on what to do in case of more uncertainty, shifted. For the forum, it seems rather unthinkable to go against the professional norms, in spite of formal national regulations. For the Health Care Insurance Board (CVZ), it was not considered possible to go against national regulations, especially as professional norms have shifted without informing policy makers and patient representatives.

Choice Behavior↗
PubMed2004

[Burden of disease in Spanish population under 15 years old in 1999].

BACKGROUND AND OBJECTIVE: Burden of disease (DALYs) can help define health priorities. Our objective was to assess DALYs of those illnesses most important in Spanish children and teenagers. MATERIAL AND METHOD: We calculated DALYs components (YLL, YLD) by age groups and sex. Sources used were Spanish mortality data and WHO DALY's estimates. RESULTS: Total DALYs was 46.57/1000 habitants and it was highest in children aged less than 1 year. The first cause was represented by non-communicable diseases and the second by communicable-perinatal diseases in less than 1 year and 1-4 years and injuries in 5-14 years. CONCLUSIONS: DALYs is a good indicator to define health's population.

Adolescent↗
PubMed1990

Impact of HIV on tuberculosis in Zambia: a cross sectional study.

OBJECTIVE: To examine the contribution of HIV infection to the apparently increasing incidence of tuberculosis in central Africa. DESIGN: Cross sectional study. SETTING: Outpatient clinic in teaching hospital, Lusaka, Zambia. PATIENTS: 346 Adult patients with tuberculosis. RESULTS: Overall, 206 patients (60%; 95% confidence interval 54% to 65%) were positive for HIV: in one or both assays used. The peaks for both tuberculosis and HIV infection were among men aged 25-34 years and women aged 14-24 years. Of patients with confirmed pulmonary tuberculosis, 73/149 (49%; 41% to 57%) were positive for HIV; 67/83 (81%; 70% to 89%) patients with pleural disease and 16/19 (84%; 60% to 97%) patients with pericardial disease were positive. HIV positive patients with positive sputum culture were less likely to have had a positive sputum smear, and their chest x ray films less often showed classic upper zone disease or cavitation. Of 72 patients who fulfilled clinical criteria for AIDS, 17 were negative for HIV. CONCLUSIONS: The high prevalence of HIV in patients with tuberculosis suggests that an epidemic of reactivating tuberculosis is arising in those who are infected with HIV. The redirection of public health priorities towards tuberculosis would focus on a major treatable and preventable complication of the AIDS epidemic.

Adolescent↗
PubMed1995

Slowing heterosexual HIV transmission.

HIV-1 is spreading rapidly through heterosexual intercourse in many societies. Slowing the transmission of this virus is the most urgent global public health priority. Our understanding of the biologic differences between societies that account for most vacancies in heterosexual HIV transmission are now understood. Effective interventions to slow transmission must be designed, implemented, and evaluated. Human and fiscal resources must be provided through a shared global effort. The consequences of failing to do so will lead to a world catastrophe of unprecedented magnitude.

Developing Countries↗
PubMed2000

Estimating the burden of disease in one Swiss canton: what do disability adjusted life years (DALY) tell us?

BACKGROUND: Examining life expectancy and general mortality rates, the health of the population of Geneva can be described as one of the best in the world. However, in some areas Geneva fares worse than the rest of Switzerland or Europe. To re-appraise the current health priorities of the Genevan population, we analysed the relative importance of specific diseases and injuries calculating DALYs. METHODS: We followed the procedures developed for the Global Burden of Disease (GBD) study to ensure comparability. Some adaptations were made for mortality coding. Disability was estimated based on data for countries classified as Established Market Economies (EME) in the GBD study. RESULTS: Non-communicable diseases accounted for 79% of the disability adjusted life years (DALY), injuries represented 12%, and communicable diseases and other disorders 9%. Ischaemic heart disease was the largest single contributor to DALY, followed by unipolar major depression. Neuropsychiatric disorders and mental health accounted for more than 23% of DALY. CONCLUSIONS: Some of the most important problems identified-depression, osteoarthritis and alcohol abuse-would have been overlooked in an analysis based solely on mortality data. The most striking finding is the importance of mental health problems. The main limitation is the lack of morbidity data for Geneva.

Adolescent↗
PubMed2005

[Health consequences of the tobacco epidemic in West African French-speaking countries and current tobacco control].

The burden of disease due to tobacco for each country will depend on the prevalence of tobacco use and the duration of the epidemic. Given that the tobacco epidemic in West African Francophone countries is relatively recent, the burden of disease due to tobacco use is currently low. However, tobacco related burden of disease in Francophone West African countries is increasing as the number of smokers continues to increase and the population has been smoking for a longer period of time. If the current trends continue, West African countries will be suffering the massive consequences of tobacco use in two or three decades. Apart from the classical health consequences of tobacco consumption such as certain types of cancer and cardiovascular diseases, there are some conditions of special importance in low income African countries such as the increased risk of tuberculosis infection and mortality amongst smokers, low birth weight for babies of smoking mothers, and tobacco consumption associated malnutrition especially amongst women. Furthermore, developing countries, with inadequate resources and other important health issues, cannot afford the costs of the chronic degenerating conditions caused by tobacco use, as these are very expensive to treat. Tobacco control in Francophone African countries is still deficient Human and financial resources which are often scarce in West African countries are dedicated to other health issues since tobacco is normally not amongst the public health priorities. Legislation in Francophone African countries is limited and not adequately enforced. A major reason for governments' inaction on tobacco is their fear of creating unemployment and loss of revenue from tobacco taxes. This fear is derived mainly from the arguments of the tobacco industry. Apart from lobbying governments, the tobacco industry uses all kinds of strategies to market their products in these countries and faces practically no barriers to their business in these countries. It is essential that Francophone African countries take immediate action and develop and implement comprehensive multisectoral tobacco control programmes. These programmes must be integrated into the existing public health programmes and make use of existing infrastructure and resources in order to stop the tobacco epidemic from expanding. In February 2005, the WHO Framework Convention for Tobacco Control (WHO FCTC) entered into force. Most Francophone African countries have signed the treaty thus expressing their intention to become Parties in the future. WHO urges these countries to become Parties as soon as possible and to implement the WHO FCTC provisions in order to control the tobacco epidemic. WHO in turn will provide guidelines and assistance for the process of becoming Parties to the treaty and implementing tobacco control measures outlined therein.

Africa, Northern↗
PubMed2005

[Evaluation of a university hospital unit specialising in treating adults at risk of suicide].

In France, suicide prevention has been a public health priority since 1992. Half of all suicide attempts are repeated attempts made by people who have already tried to commit suicide, and the risk of death increases by 1% after the first attempt. Today, hospitalisation has become an unavoidable consequence for those who have attempted suicide, and recommendations for best practice were recently issued in France (1998). The objective of this study was two-fold: 1) to assess the quality of management and care provided for patients hospitalised in a university hospital in Angers after having attempted suicide, an evaluation that was based in part on the criteria of the National Agency on Health Accreditation and Evaluation (ANAES); and 2) the demonstrate the value and high utility of such a unit specialising in caring for patients recovering from attempted suicide. The unit has now been in existence for over 5 years, and has treated 42% of such patients who require hospitalisation. One investigator was responsible for asking 251 patients (on the day of their release) who had been hospitalised anytime during the given 6 month period (November 2002 - May 2003) to complete a questionnaire containing approximately 100 items. In order to be eligible for the study, patients had to be older than 16 years and hospitalised for at least 48 hours. 155 questionnaires were completed (62%), and there were 96 patients were notable to participate on the day of their release. Nine of the 14 criteria recommended by the ANAES were met in over 65% of the cases, and three in less than 40%. Following the analysis of the data through logic regression, it remained clear that unit specialising in the care of people who have attempted suicide was better able and equipped to meet the standards of the ANAES' recommendations than a standard hospital medical unit. Visits with a psychiatrist or psychiatric nurse occurred more frequently in the specialised unit (p < 0.04), interviews with the patients' family members were more frequent (p < 0.01), the confidentiality of the discussions from the interviews was more often respected and maintained (p < 0001), and the information provided by the caregivers and staff was more effective in the specialised unit (p < 0.03). One of the main benefits and results of these aforementioned differences is that the patients in the suicide unit more often perceived a distinct improvement in their depression (p < 0.007). All of these arguments indicate that hospitalisation in a special unit provides real benefits to patients, and the results of this study advocate strongly in favour of increasing the capacity of the unit, which is currently limited to only 6 beds.

Adolescent↗
PubMed2006

Cultural aspects of communication in cancer care.

Cancer is increasing in incidence and prevalence worldwide, and the WHO has recently included cancer and its treatments as a health priority in developed and developing countries. The cultural diversity of oncology patients is bound to increase, and cultural sensitivity and competence are now required of all oncology professionals. A culturally competent cancer care leads to improved therapeutic outcome and it may decrease disparities in medical care. Cultural competence in medicine is a complex multilayered accomplishment, requiring knowledge, skills and attitudes whose acquisition is needed for effective cross-cultural negotiation in the clinical setting. Effective cultural competence is based on knowledge of the notion of culture; on awareness of possible biases and prejudices related to stereotyping, racism, classism, sexism; on nurturing appreciation for differences in health care values; and on fostering the attitudes of humility, empathy, curiosity, respect, sensitivity and awareness. Cultural competence in healthcare relates to individual professionals, but also to organizations and systems. A culturally competent healthcare system must consider in their separateness and yet in there reciprocal influences social, racial and cultural factors. By providing a framework of reference to interpret the external world and relate to it, culture affects patients' perceptions of disease, disability and suffering; degrees and expressions of concern about them; their responses to treatments and their relationship to individual physicians and to the healthcare system. Culture also influences the interpretation of ethical norms and principles, and especially of individual autonomy, which can be perceived either as synonymous with freedom or with isolation depending on the cultural context. This, in turn, determines the variability of truth-telling attitudes and practices worldwide as well as the different roles of family in the information and decision-making process of the cancer patient. Finally, culture affects individual views of the patient-doctor relationship in different contexts.

Communication↗
PubMedDate not supplied

The use of formal and informal health care by female adolescents in eastern Nepal.

I am presenting the background and interim results of an ongoing study in Eastern Nepal where at present the adolescent females do not use the formal health sector to the same extent as men. Suggested reasons for this include lack of awareness (literacy rates among women are 17%), lack of access, lack of time, and the cost and the quality of services offered. Women are more likely to visit traditional health practitioners, and very little research has been done to find out why this is the case. I also examine the access of rural adolescent females to health services and the policy process. The researcher involves the women in the research so that they can actively participate in the decision-making process and in setting health priorities. The research is based on a reconstituted form of participatory rural appraisal (PRA) known as participatory appraisal of needs and development of action (PANDA). This is a framework which has been developed out of PRA and has been used in developing countries to enable local people to obtain, share, and analyze their life conditions and to plan and act according to that knowledge.

Adolescent↗