Public Health

Learning from the Noughties

F. Sim, P. Mackie — 2010-01-01

Well, we have left the noughties behind us and are approaching the teens of the twenty-first century. The past decade seems to have rushed past, though that perhaps reflects an era when time rarely seems to be “spare”. Who recalls the predictions based loosely on the work of Nostradamus, at the eve of the Millennium? We were warned that the world was about to end, or at least that there would be severe disruption of communications due to crashes of information technology. In the event, the Millennium transition was relatively smooth, at least in terms of technology. But what followed, including major terrorist atrocities, wars, and natural disasters which may or may not have been preventable, all wreaked havoc with the world's wellbeing, in addition to the impact of personal tragedies for the many people directly affected. Most recently, we have found ourselves in economic recession, which is likely to be associated with additional challenges to individual and population health and wellbeing.

Pandemic influenza: learning from the present

John McConnell — 2010-01-01

Infectious disease epidemics can be thought of as natural disasters, acute public health emergencies in the same vein as earthquakes or hurricanes. These events are inevitable, yet their arrival is unpredictable. We can, however, make prevision to ameliorate the emergencies when they do arrive. Unlike disasters of geology or weather, the cause of a infectious disease outbreak is often not immediately obvious. Scientific investigation is required before the cause of an epidemic can be identified and effective public health interventions delivered. Such was the case with severe acute respiratory syndrome (SARS) in 2002–03. Nevertheless, with dramatic advances in our ability to identify the cause of diseases, SARS was attributed to a coronavirus with weeks of the outbreak coming to global attention. Similarly, the source of the outbreak of acute respiratory illness that began in Mexico in March of 2009 was identified within days as a new variant of the influenza A H1N1 virus.

Influenza pandemic preparedness and severity assessment of pandemic (H1N1) 2009 in South-east Asia

T. Kamigaki, H. Oshitani — 2009-12-25

Summary: Pandemic (H1N1) 2009 poses a serious global health threat. However, the global impact of this new pandemic remains uncertain. Past pandemics had different impacts on mortality which varied between countries. Several countries in South-east Asia have already developed their national pandemic preparedness plans. However, these plans have focused on surveillance for and response to the highly pathogenic avian influenza (H5N1), including the rapid containment of H5N1. The newly emerged pandemic (H1N1) 2009 is different from H5N1 in terms of severity and requires different approaches. There are several factors that can potentially affect the severity of pandemic (H1N1) 2009, including a population's vulnerability and response capacity. The pattern of severity appears to be changing with the spread of pandemic (H1N1) 2009, which can be conceptualized in a step-wise manner based on observation of the current situation. The overall impact of pandemic (H1N1) 2009 remains unknown and it is difficult to assess its severity. However, there is an urgent need to assess its potential severity based on the available data so that appropriate responses can be provided in order to mitigate its impact.

Getting back to basics during a public health emergency: a framework to prepare and respond to infectious disease public health emergencies

A.T. Craig, T. Kasai, A. Li, S. Otsu, Q.Y. Khut — 2009-12-25

Summary: This paper describes a simple framework developed by the World Health Organization, used to convey the concept of comprehensive and integrated public health response structures and to identify core public health capacity development needs. The framework highlights five core components of a response: surveillance, healthcare response, public health intervention, communication and command. This paper notes that to mount an effective public health response, each component requires sufficient capacity to meet demand, and effective relationships and mechanisms need to be established between components that support coordination, communication and collaboration.

Experience and lessons from surveillance and studies of the 2009 pandemic in Europe

2010-01-01

Summary: Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the ‘known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring () for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) () is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of ) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2–4, resourcing them realistically and devising new ways of sharing analyses.

Completeness of suspected measles reporting in a southern district of Nigeria

C.C. Odega, A.A. Fatiregun, G.K. Osagbemi — 2010-01-11

Summary: Objective: To determine the completeness of reporting of suspected measles cases to a local health authority in southern Nigeria.Study design: Retrospective.Methods: Suspected measles cases were identified in all 23 health facilities in Aniocha South Local Government Area (LGA) of Delta State, Southern Nigeria by retrospective review of the health facilities' registers and the LGA surveillance records between 1 January 2007 and 30 June 2008. A capture–recapture method was used to obtain an estimate of the total number of measles cases expected for the study area within the study period. The completeness of reporting was calculated as a ratio of the number of measles cases reported to the LGA by hospitals to the number of cases estimated by the capture–recapture method.Results: An estimate of 87 measles cases was obtained with the capture–recapture method. The overall completeness of reporting was 11.5% (95% confidence interval 8.1–19.6%).Conclusion: The number of suspected measles cases seems to have been grossly under-reported in this area.

Short-term effect of concentrations of fine particulate matter on hospital admissions due to cardiovascular and respiratory causes among the over-75 age group in Madrid, Spain

C. Linares, J. Díaz — 2010-01-11

Summary: Objectives: This study sought to analyse the effect of daily mean concentrations of fine particulate matter (diameter <2.5μm; PM2.5) on hospital admissions due to circulatory and respiratory causes among an elderly population (>75 years) in Madrid between 2003 and 2005.Study design: Ecological longitudinal time-series study.Methods: The dependent variable used was the daily number of emergency hospital admissions registered at the Gregorio Marañón University Teaching Hospital. The following causes were analysed: all causes [International Classification of Diseases 9th Version (ICD-9:1-799)], respiratory causes (ICD-9: 460–519) and circulatory causes (ICD-9: 390–459). Analysis focused on subjects over 75 years of age. Daily records of mean concentrations of PM2.5, PM10, NO2, NOx, SO2 and O3 in Madrid were used as independent variables. The control variables were seasonalities, trend, influenza epidemics, noise and pollen concentrations. Poisson regression models were constructed to calculate the relative risk (RR) and attributable risk (AR). Analyses were performed for the entire year and for the winter and summer.Results: PM2.5 was the single primary pollutant that proved statistically significant in all models. The functional relationship with hospital admissions was linear and had no threshold. Taking the year as a whole, the RRs among people over 75 years of age for an increase of 10μg/m3 in PM2.5 concentrations were: 1.038 [95% confidence interval (CI) 1.022–1.053] for all causes at lag 0; 1.062 (95% CI 1.036–1.089) for circulatory causes at lag 0; and 1.049 (95% CI 1.019–1.078) for respiratory causes at lag 3. The ARs were 3.6%, 5.9% and 4.6%, respectively. These risks increased in winter and no statistically significant associations were observed in summer. PM2.5 was the only primary pollutant that showed a statistically significant association with hospital admissions among people over 75 years of age in Madrid across the study period.Conclusion: Measures should be implemented to reduce PM2.5 concentrations in Madrid.

Aspects to be considered in extreme-temperature prevention plans in the light of new research

J.C. Montero, C. Linares, I.J. Mirón, J.J. Criado, J. Díaz — 2009-12-25

A heat wave struck Europe in the summer of 2003, leading to an estimated 70,000 deaths. The vast majority of European cities viewed this as a public health priority, and those that had not already done so proceeded to implement prevention plans to mitigate the health effects of extremely hot days. As a result, by the summer of 2004, practically all European cities had their own prevention plans. These plans were undoubtedly necessary, and the assessment made in France of the heat wave of 2006 demonstrates the effectiveness of the measures performed. However, recent studies have revealed some weaknesses in these plans which must be considered. In many cases, such plans were drawn up hurriedly and were not based on solid studies addressing the biological mechanisms that influence the relationship between heat waves and health, given that such studies were practically non-existent.

Impact of education, income and chronic disease risk factors on mortality of adults: does ‘a pauper-rich paradox’ exist in Latin American societies?

2009-12-28

Summary: Objectives: To test the hypothesis that an inverse association exists between socio-economic position and all-cause mortality in a developing country in Latin America.Study design: Prospective cohort study carried out in Chile using data from a simple random sample of 920 apparently healthy subjects (weighted population 11,600 aged 30–89 years) followed for 8 years.Methods: Education level (0–8 years, 9–12 years and ≥13 years) and income quartiles were established at the outset of the study, along with behavioural and biological risk factors for chronic diseases: smoking, alcohol use, obesity, diabetes, hypertension, lipids and family history of death by cardiovascular disease. Relative risks of all-cause mortality were estimated using age-adjusted Cox regression models.Results: During the follow-up period, 46 deaths were observed. Adjusting for age, gender, and behavioural and biological risk factors, the mortality risk for increasing categories of education after controlling for income was 1.0, 0.76 and 0.33 (P for trend<0.01). In contrast, the relative risk for increasing levels of income after controlling for education was 1.0, 0.98, 1.33 and 1.17 (P for trend=0.07).Conclusion: While education level had a protective effect on mortality risk of Chilean adults, income had a slightly unfavourable effect on survival. This finding is described as suggestive of a ‘pauper-rich paradox’, since the higher income quantiles in this study correspond with the lower income levels in most developed countries. Nevertheless, due to the small number of deaths, additional research is required to assess the validity of these findings.

Association of secular trends in unemployment with suicide in Taiwan, 1959–2007: A time-series analysis

S.-S. Chang, J.A.C. Sterne, W.-C. Huang, H.-L. Chuang, D. Gunnell — 2009-12-09

Summary: Objective: Despite the wealth of research investigating the association of unemployment with suicide in the West, few studies have investigated the association in non-Western countries. This study aimed to investigate the relationship between secular trends in unemployment and suicide in Taiwan.Study design: Time-series analysis.Methods: Overall and age-specific suicide rates (1959–2007) for Taiwanese men and women aged 15 years or above were calculated from national population and mortality statistics. The association of secular trends in unemployment with suicide was investigated graphically and using time-series modelling (Prais-Winsten regression).Results: Rises in unemployment were associated with an increase in male suicide rates, but evidence for an association in females was limited. In the model controlling for changes in gross domestic product (GDP) per capita, GDP growth, divorce and female labour force participation, for every 1% rise in unemployment, male suicide rates increased by 3.1 (95% confidence interval 1.4–4.8) per 100,000. There is no evidence for a difference in the strength of association between men of different ages.Conclusion: Trends in suicide, particularly for adult males, appear to be influenced by unemployment. The results have implications for suicide prevention, in particular for societies facing acute rises in unemployment during recessions.

Public health governance: views of key stakeholders

L. Marks, S. Cave, D.J. Hunter — 2009-12-28

Summary: Objectives: To identify views of key stakeholders on public health governance.Study design: Focus groups and interviews.Methods: Key national and regional stakeholders in England were invited to participate in focus groups. Three focus groups and four additional interviews were transcribed and a thematic analysis was carried out.Results: Focus groups and interviewees identified points of transition in public health governance including changes in the notion of stewardship, governance across a local public health system and a shift from organizational governance to ‘governance of place’.Conclusions: Different governance arrangements and approaches to governance can influence health outcomes through their impact on commissioning strategies, public health practice and performance management regimes. Failure to address these issues will hamper the development of a stewardship role in local organizations and across a local public health system.

Ensuring Value for Money in Healthcare – The role of health technology assessment in the European Union

Philip Rutledge — 2009-12-25

During a period of economic recession and impending public spending cuts policy makers are increasingly focusing on value for money. This short book is a timely reminder of the importance of health technology assessment (HTA). This report is the result of a year long project set up to consider the concepts and controversy surrounding HTA in Europe, and discusses the use of HTA guidance in priority-setting, decision-making and health-care provision.

Beyond anthrax – The weaponization of infectious diseases

Andrew Riley — 2009-12-25

This book is intended to be a primer for clinicians and epidemiologists, a collection of contributions aimed at increasing knowledge of bioterrorism. An albeit highly specialised field, but one which from time to time touches mainstream specialties and ordinary practitioners in sometimes surprising ways. My own experience is a prime example when, in 2006, being obliged to undertake a public health response to a fatal case of anthrax in a rural Scottish health setting.