Progress towards antibiotic use targets in eight high-income countries

ObjectiveTo compare antibiotic sales in eight high-income countries using the 2019 World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification and the target of 60% consumption of Access category antibiotics.MethodsWe analysed data from a commercial database of sales of systemic antibiotics in France, Germany, Italy, Japan, Spain, Switzerland, United Kingdom of Great Britain and Northern Ireland, and United States of America over the years 2013–2018. We classified antibiotics according to the 2019 AWaRe categories: Access, Watch, Reserve and Not Recommended. We measured antibiotic sales per capita in standard units (SU) per capita and calculated Access group sales as a percentage of total antibiotic sales.FindingsIn 2018, per capita antibiotic sales ranged from 7.4 SU (Switzerland) to 20.0 SU (France); median sales of Access group antibiotics were 10.9 SU per capita (range: 3.5–15.0). Per capita sales declined moderately over 2013–2018. The median percentage of Access group antibiotics was 68% (range: 22–77 %); the Access group proportion increased in most countries between 2013 and 2018. Five countries exceeded the 60% target; two countries narrowly missed it (> 55% in Germany and Italy). Sales of Access antibiotics in Japan were low (22%), driven by relatively high sales of oral cephalosporins and macrolides.ConclusionWe have identified changes to prescribing that could allow countries to achieve the WHO target. The 60% Access group target provides a framework to inform national antibiotic policies and could be complemented by absolute measures and more ambitious values in specific settings.     

Urban/rural inequalities in suicide in Scotland, 1981–1999

Although suicide accounts for a small percentage of deaths in Scotland (1.4% in 1999), it has been steadily increasing over the last two decades. In the US, Australia, England and Wales the greatest rises in suicide for this time period, occurred in rural areas. This study describes the pattern and magnitude of urban/rural variation in suicide in Scotland, examines methods of suicide within differing geographies and looks at trends in suicides over time.Scotland is split into four rurality types. Suicide data for all areas of Scotland (apart from Grampian which underwent changes in postcode sector boundaries in 1996) are investigated using Standardised Mortality Ratios (SMRs) and multilevel Poisson modelling, adjusting for age, sex and deprivation. SMRs for 1981–85, 1989–93 and 1995–99 are created across the four geographies, using the populations of Scotland in 1983, 1991 and 1997 as the standard populations (SMR=100). The highest rates in 1995–99 are seen in “remote rural” areas, SMR=125 (95% confidence interval 107–146). Models adjusted for age and deprivation show significantly greater risk of male suicide in remote rural areas relative to urban areas and significantly lower risk of female suicide in accessible rural areas. The method of suicide varies across ruralities for both males and females. The study considers how the relationship between suicides and rurality varies over time and how methods of suicide vary across different ruralities. The steepest rises in suicide amongst men, adjusting for age and deprivation, were seen to occur in accessible rural areas, however highest rates remain in remote rural areas.     

Influence of socio-economic crisis on epidemiological characteristic of suicide in the region of Nis (southeastern part of Serbia, Yugoslavia)

It is well known that gross social crises greatly influence the change in epidemiological features of suicide. The aim of this study is to determine whether the social-economic crisis in Yugoslavia influenced the change in epidemiological features of suicide in the region of Nis (southeastern Serbia). The material included death certificates for 1987–1999. The rates were calculated per 100,000 inhabitants (1991 Census) and standardization was performed by direct method (Segi's world population was used as standard population). Generally, trends for suicide rates in the region of Nis from 1987 to 1999 have decreasing tendency among both sexes. The average annual suicide rate in the region during the period 1987/1989 (relatively economically and politically stable) was 14.8 among males, and 6.8 among females. In 1999 (maximum influence of socio-economical and political crisis) suicide rate among males was 13.8 and among females it was 3.7. The decrease in suicide rate in females can be observed in all age groups, and in males in the age groups 15–29 and 50–64. During 1999, compared to 1987/1989, the increase in the number of suicides is perceived in the summer months (1999 – 41.5%; 95% CI: 30.8–52.2%; 1987/1989 – 23.8%; 95% CI: 18.9–28.7%), as well as the decrease of suicide on Monday (1987/1989 – 21.2%; 95% CI: 16.2–26.1%; 1999 – 9.8%; 95% CI: 3.4–16.2%). During 1999 the rate of suicides committed by fire arms increased (from 8.1 to 14.5%), while there was a decrease in poisoning, in both males (from 26.3 to 9.7%; p < 0.05) and females (from 39.1 to 10.0%; p < 0.05). During 1999 significant changes in epidemiological features of suicide were registered, compared to 1987/1989. These changes were probably enhanced by changed socio-economic factors (primarily war action and the bombing of Serbia, as well as the decline of standard of living and other aspects of economic and political crisis), which requires additional, more complete and thorough research.     

The role of socioeconomic indicators on non-alcohol and alcohol-associated suicide mortality among women in Finland. A register-based follow-up study of 12 million person-years

This study was to analyse the effects and interrelationships of three socioeconomic indicators – education, occupation-based social class and income – on non-alcohol and alcohol-associated suicide mortality among women in Finland. The register data used comprised the 1990 census records linked to the death register for the years 1991–2001 for women who were 25–64 years old in 1990. Adjusted relative mortality rates and the relative index of inequality (RII) were estimated using Poisson regression. The study population experienced 1926 suicides, of which 563 (29%) had alcohol intoxication as a contributory cause. The age-adjusted effects of education on non-alcohol associated suicide were modest, while social class and income related inversely and strongly. The effect of social class was partly mediated by income, and social class explained income differences to some extent. The associations between these socioeconomic indicators and alcohol-associated suicide were stronger, and following adjustment for each other large effects were left for education, social class and income. Further adjustment for living arrangements had little effect on socioeconomic differences in both types of suicide, but practically all of the effects of income and some of education and social class were mediated by employment status. In conclusion, current material factors are hardly the main underlying drivers of socioeconomic differences in suicide among Finnish women. Low social class proved to be an important determinant of suicide risk, but the strong independent effect of education on alcohol-associated suicide indicates that the roots of these differences are probably established in early adulthood when educational qualifications are obtained and health-behavioural patterns set.     

Do antidepressants reduce suicide rates?

Investigators from a number of countries have linked temporal declines in the rate of completed suicide in children and adults to the increasing utilization of selective serotonin reuptake inhibitor (SSRI) antidepressants. They suggest that the relationship is causal. We undertook a thorough literature search of the rates of completed suicide using data from 1980 onwards, from the World Health Organization, the US National Center for Health Statistics, and related studies, in order to ascertain if a broad array of epidemiological evidence would or would not support a consistent association between suicide completion and SSRI utilization. The major findings were: (1) within and between countries, suicide rates vary prominently by age group; (2) national differences are marked with respect to a temporal association between rates of completed suicide and SSRI utilization; (3) in nearly half of the countries of the world, the decline in the suicide rate preceded the onset of the use of SSRIs; (4) suicide rates have fluctuated dramatically over the last century; and (5) the association between declining rates of completed suicides and increased SSRI use in the USA between 1990 and 1999 was no longer present between 2000 and 2004. We conclude that available ecological evidence does not support an inverse temporal relationship between rates of completed suicide and SSRI utilization.     

Social inequalities in ischaemic heart and cerebrovascular disease mortality in men: Spain and France, 1980–1982 and 1988–1990

In this study we analyse the trend in socio-economic differences in mortality from ischaemic heart and cerebrovascular diseases in the economically active male population aged 25–64 years in Spain and France. The data used were taken from deaths from these two causes in 1980–1982 and 1988–1990; in the case of Spain the data came from the Eight Provinces Study. Individuals were grouped into four categories — professional/managerial, clerical/sales/service workers, farmers, and manual workers — and the mortality rate ratio was estimated with reference to the professional/managerial group. For ischaemic heart disease in 1980–1982, professionals and managers aged 25–44 years had the lowest risk of mortality in Spain, and the highest risk of mortality in France; in 1988–1990 the socio-economic differences in mortality in Spain increased, whereas the relation was inverted in France. In 1980–1982, professionals and managers aged 45–64 years had higher mortality from ischaemic heart disease than the other occupational groups in both countries; in 1988–1990 this relation was inverted, except in the case of clerical/sales/service workers in Spain. For cerebrovascular disease, manual workers experienced the highest mortality in the 25–44 year age group in 1980–1982, and the differences increased in 1988–1990 in all groups with respect to professionals and managers in both places. Professionals and managers in France and manual workers in Spain had the highest mortality between 45 and 64 years in 1980–1982; in contrast, in 1988–1990 professionals and managers had the lowest risk of mortality from this disease in both Spain and France, although in Spain the magnitude was similar to that of clerical/sales/service workers. In general terms, mortality from each disease was different in professionals and managers than in clerical/sales/service workers. Thus, the pattern of mortality and its evolution in different socio-economic groups cannot be analysed accurately when the two occupational groups are combined in a single large group of non-manual workers.     

Epidemiology of poisoning due to pharmaceutical products, Poison Control Centre, Seville, Spain

A retrospective study of telephone calls concerning poisoning due to pharmaceutical products, attended by the Toxicological Information Service in Seville (Spain), is presented. The years 1993 and 1994 were analized. Demographic data including the age and sex of the patient, route of exposure, cause, type of poisoning and the therapeutic group, was obtained. The great majority were cases of acute poisoning due to domestic accident, attempted suicide took second place. Ingestion was the principal route of entry, and more males than females were affected. 35.2% were children under two. In general, the medicines most frequently involved were those affecting the nervous system (28.1%) – principally analgesics, anxiolytics and antidepressants – followed by dermatological agents (13.7%) – such as antiseptics and disinfectants – and those affecting the respiratory (medicines to treat common cold, bronchodilators, antitussives) and digestive systems (laxatives, antiacids). It is hoped that with knowledge of data from as many poisons centres as possible, an improvement may gradually be seen in the prevention of the such poisoning in the future.     

Spatio-temporal Distribution of Suicide Risk in Iran: A Bayesian Hierarchical Analysis of Repeated Cross-sectional Data

ObjectivesWe aimed to estimate the space-time distribution of the risk of suicide mortality in Iran from 2006 to 2016.MethodsIn this repeated cross-sectional study, the age-standardized risk of suicide mortality from 2006 to 2016 was determined. To estimate the cumulative and temporal risk, the Besag, York, and Mollié and Bernardinelli models were used.ResultsThe relative risk of suicide mortality was greater than 1 in 43.0% of Iran’s provinces (posterior probability >0.8; range, 0.46 to 3.93). The spatio-temporal model indicated a high risk of suicide in 36.7% of Iran’s provinces. In addition, significant upward temporal trends in suicide risk were observed in the provinces of Tehran, Fars, Kermanshah, and Gilan. A significantly decreasing pattern of risk was observed for men (β, −0.013; 95% credible interval [CrI], −0.010 to −0.007), and a stable pattern of risk was observed for women (β, −0.001; 95% CrI, −0.010 to 0.007). A decreasing pattern of suicide risk was observed for those aged 15–29 years (β, −0.006; 95% CrI, −0.010 to −0.0001) and 30–49 years (β, −0.001; 95% CrI, −0.018 to −0.002). The risk was stable for those aged >50 years.ConclusionsThe highest risk of suicide mortality was observed in Iran’s northwestern provinces and among Kurdish women. Although a low risk of suicide mortality was observed in the provinces of Tehran, Fars, and Gilan, the risk in these provinces is increasing rapidly compared to other regions.     

Are there social correlates to suicide?

A structural-sociological approach to suicide research holds that an aggregate-level cause of suicide should correlate with the suicide rates in a population. In 1980, Sainsbury, Jenkins, and Levey published the article “The Social Correlates of Suicide in Europe” which related the suicide rates in 1961–1963 and the changes in them in the following 11 years to 15 social variables in 18 European countries. Its main findings were that the changes in suicide rates could be attributed to specific changes in the social environment. Complementary discriminant analyses showed that it was possible accurately to divide the countries into low- and high-change suicide rate groups on the basis of a combination of the social variables.Although criticized for its method, the study has been widely quoted and sometimes presented as the most definitive current study on the subject. In order to see whether its results held for similar data 16 years later it was replicated for 1977–1979 and the ensuing 11 years, with data and method as similar as possible to the original.The results agreed with those of the original study on only one point: the correlations between the levels of the social variables and those of the suicide rates were similar in both periods. However, changes in the suicide rates were unrelated to either the levels of the social variables or the changes in them: correlations found in the original study tended to change profoundly or disappear. Moreover, the results of the original discriminant analyses were a property of the method employed and thus independent of the data.Statistical artefacts or social processes such as changing expectations are unlikely to explain the suddenly changing or vanishing correlations. The original correlations seem to have been largely spurious and dependent on the fact that the more modern countries in Europe experienced a “suicide boom” in the 1960s. As the boom waned in these, it was beginning in the less modern countries: the correlations between the processes indicated by the social variables and the suicide rates were reversed or disappeared.The results call the existence of clear relations between these “suicidogenic” social circumstances and the suicide rates into question. Since many of the variables used are traditional “Durkheimian” indicators of the integration of society, a critique of this still-dominant view of the relationship between society and suicide mortality, or its common operationalization, is implied.     

Forging an Agenda for Suicide Prevention in the United States

Suicide prevention must be transformed by integrating injury prevention and mental health perspectives to develop a mosaic of common risk public health interventions that address the diversity of populations and individuals whose mortality and morbidity contribute to the burdens of suicide and attempted suicide. Emphasizing distal preventive interventions, strategies must focus on people and places—and on related interpersonal factors and social contexts—to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years—the age with the greatest overall burden. We need scientific and social processes that define priorities and assess their potential for reducing what has been a steadily increasing rate of suicide during the past decade.Preventing suicide is very challenging, especially when seeking to shift the modal behaviors of large populations.1,2 Talented, dedicated people have made extraordinary efforts to reduce suicide in the United States during these first years of the 21st century, but the overall rate has risen steadily. The 1990s was a decade of decline; the crude suicide rate was 10.46 per 100 000 people in 1999, with an age-adjusted rate of 10.48.3 In 2008 suicide became the 10th leading cause of death in our nation, up from its long-held position of 11th. In 2010 suicide accounted for 38,364 deaths, with a crude rate of 12.43 and an age-adjusted rate of 12.08 per 100 000, respectively,4 the latter being 15.26% higher than the comparable 1999 figure. Preliminary reports indicate 38,235 deaths in 2011. By comparison, there were 37,233 lives lost in 2010 from transportation accidents.5 Suicide far surpasses more publically noted challenges, such as homicide—the 16th leading cause of death—which took 16 259 lives in 2010.In 2010 suicide was the third leading cause of death for those aged 15 to 24 years (4600), after unintentional injury (12 341) and homicide (4678); second among those aged 25 to 34 years (5735), between unintentional injury (14 573) and homicide (4258); and fourth (6571) among those aged 35 to 44 years. For those aged 35 to 64 years, there have been steady annual increases in age-adjusted rates from 1999 to 2010: men climbed from 21.48 to 27.64 suicides per 100 000 and women from 6.19 to 8.21, for a combined change in those ages from 13.70 to 17.75 per 100 000, an increase of nearly 30%.3This far outweighed all other changes in rates during the same period. For those aged 10 to 24 years, rates tended to remain relatively stable during the first decade of the 21st century: males had an age-adjusted rate of 11.64 in 1999 and 11.56 in 2010, whereas females had rates of 2.17 and 2.83, respectively. Among those aged 25 to 34 years, males had rates of 20.74 in 1999 and 22.50 in 2010, an increase of 8.5%, with comparable rates for females of 4.58 and 5.34 (16.6% more). The age-adjusted suicide rate for those aged 65 years and older declined from 15.81 in 1999 (33.80 for men; 4.34 for women) to 14.89 per 100 000 in 2010 (29.00 for men; 4.19 for women), a drop of 5.8%.3 Although the use of firearms as a method of suicide remained relatively stable from 1999 to 2010 (age-adjusted rates of 5.96 in 1999 and 6.06 in 2010, with a brief dip in mid-decade), the rate of poisoning suicides grew steadily (1.76 in 1999 and 2.06 in 2010), with the greatest increase in the middle years.Taken together, these statistics only hint at the devastation wreaked by suicide on the lives of families, friends, coworkers, and communities. Between 2000 and 2010,3 suicide was the fifth leading cause of years of potential life lost (YPLL) for those younger than 65 years in the United States (5.9% of the total; nearly 8.23 million YPLL), more than homicide (5.0%; 6.94 million), and following unintentional injury (18.9%), malignant neoplasms (16.2%), heart disease (12.1%), and deaths during the perinatal period (7.9%). By 2010, suicide accounted for 6.9% of YPLL (764,776 of 11,043,870) for those younger than 65 years whereas homicide was 4.7% (522,701) of YPLL, reflecting the continued changes in the distribution of these premature deaths. Furthermore, fundamental factors that contribute to the contexts for suicide, especially during the early and middle years of life, also relate to unintentional deaths owing to alcohol poisoning, drug overdose, and motor vehicle accidents as well as to interpersonal violence and homicide.2 Identifying and mitigating or preventing such common risks potentially serve as the foundation for public health and injury prevention approaches to preventing suicide and attempted suicide.The costs of suicide and attempted suicide are economic as well as personal and social. For 2005, the estimated cost of suicide was more than $34.6 billion arising from 32 637 deaths and including medical costs and inferred lost work3; by comparison, that same year 18 124 homicides were projected to cost about $25.3 billion. Since then, suicides have risen by nearly 6000 and homicides have declined by nearly 2000, obviously altering the cost projections further toward a greater burden from the less-attended problem. The hospitalization and emergency department costs arising from self-harm in 2005 were nearly $6.4 billion. Thus, suicide and attempted suicide, in addition to involving deaths, damaged lives, and broad ramifications for family and friends, damage our collective economic well-being.     

Long-term persistence of anti-diphtheria toxin antibodies among adults in Israel

Vaccination against diphtheria has essentially led to the disappearance of the disease in Israel. However, in other countries with high immunization coverage, isolated cases and small outbreaks have occurred in adults. Immunity following vaccination or natural exposure to toxigenic strains ofC. diphtheriae is conferred by serum antibodies to diphtheria toxin. Since booster doses of diphtheria toxoid are recommended every ten years in adults, this raises the question of persistence of protective levels Of anti-diphtheria toxin antibodies. In this study we assessed a possible age-related decline in anti-diphtheria toxin antibodies among adults in Israel. The study population comprised random samples in three age groups: 263 male recruits aged 18–19 years, 116 male reserve soldiers aged 25–35 years and 153 aged 41–51 years. Anti-diphtheria toxin antibody levels were measured by means of ELISA. Results indicate that 64.3% (95% CI=58.5–70.1%) of those aged 18–19 had anti-diphtheria toxin levels in excess of 0.1 IU ml^–1, whereas the corresponding figures for ages 25–35 and 41–51 were 32.8% (95% CI=24.2–41.3%) and 15% (95% CI=9.4–20.7%). However, even in the oldest age group, 95.4% (95% CI=90.8–98.1%) had antibodies above the presumed protective level of 0.01 IU ml^–1. Although these results indicate a significant age-related decline in anti-diphtheria toxin antibodies in vaccinated subjects, most had apparently protective levels. The absence of cases suggests that vaccine-induced immunity is long-lasting. However the immune status of the population should be carefully monitored.     

Association of long working hours with accidents and suicide mortality in Korea

Objectives:The deleterious health effects of long working hours have been previously investigated, but there is a dearth of studies on mortality resulting from accidents or suicide. This prospective study aims to examine the association between working hours and external-cause mortality (accidents and suicide) in Korea, a country with some of the longest working hours in the world.Methods:Employed workers (N=14 484) participating in the Korean National Health and Nutrition Examination Survey (KNHANES) were matched with the Korea National Statistical Office’s death registry from 2007–2016 (person-years = 81 927.5 years, mean weighted follow-up duration = 5.7 years). Hazard ratios (HR) for accident (N=25) and suicide (N=27) mortality were estimated according to weekly working hours, with 35–44 hours per week as the reference.Results:Individuals working 45–52 hours per week had higher risk of total external cause mortality compared to those working 35–44 hours per week [HR 2.79, 95% confidence interval (CI) 1.22–6.40], adjusting for sex, age, household income, education, occupation, and depressive symptoms. Among the external causes of death, suicide risk was higher (HR 3.89, 95% CI 1.06–14.29) for working 45–52 hours per week compared to working 35–44 hours per week. Working >52 hours per week also showed increased risk for suicide (HR 3.74, 95% CI 1.03–13.64). No statistically significant associations were found for accident mortality.Conclusions:Long working hours are associated with higher suicide mortality rates in Korea.     

Perceived Overweight, BMI, and Risk for Suicide Attempts: Findings from the 2007 Youth Risk Behavior Survey

Among U.S. youth (N = 14,041), perceived (odds ratio [OR]adj. = 1.45, 95% confidence interval [CI]: 1.18–1.72) and actual overweight (ORadj. = 1.31, 95% CI: 1.07–1.60) were associated with suicide attempts in analyses controlling for demographic characteristics and potential confounders. There is a need to better understand associations between perceived and actual overweight and risk for suicide attempts and to develop appropriate strategies for prevention.     

2006－2013年全国伤害监测系统中自残/自杀病例特征分析

目的 了解全国伤害监测系统(NISS)自残/自杀门/急诊病例的分布特征,为制定相关政策提供依据.方法 利用2006-2013年NISS监测数据,分析自残/自杀病例占伤害病例构成趋势、人口社会学特征、自残/自杀事件基本情况及临床信息构成情况.结果 监测期间因自残/自杀就诊人数占所有伤害就诊人数的比例呈下降趋势.2013年因自残/自杀就诊女性病例占58.6％,文化程度为初中者占42.1％;76.2％的自残/自杀发生在家中;因自残/自杀就诊者中56.1％采用中毒的方式自伤,其次为锐器;60.8％的自残/自杀就诊者治疗后观察/住院/转院.结论 自残/自杀行为干预应加强农药/毒麻药品的管制,利用自杀未遂者在院期间开展再次自杀的预防工作.     

Helicobacter pylori infection: A seroepidemiological study in Gipuzkoa, Basque Country, Spain

Helicobacter pylori is one of the most common bacterial infections worldwide. To evaluate the prevalence of this infection in Gipuzkoa (Basque Country, Spain) we studied the presence of antibodies against Helicobacter pylori (HPAb) using a second-generation EIA (Cobas Core). The study was performed on two groups of subjects: a middle-class group, 2–78 years-old (n = 1335) and a group of slum dwellers, 2–15 years-old (n = 89). In the middle-class group the prevalence of HPAb in children under 6 was 3.1% (3/96); the prevalence was significantly greater in older compared to younger age groups, reaching 84.3% (102/121) in adults 50–59 years. The geometric mean of the titer in seropositive subjects was also greater in older age groups. By logistic regression analysis the prevalence of HPAb was associated with age, educational level and geographic origin but not with sex, smoking, alcohol consumption, or use of nonsteroid anti-inflammatory drugs. The prevalence of HPAb was much higher in the slum-dwelling group 2–15 years-old (55.5% of children 2– 5 years-old). The results indicate that H. pylori infection was more common in adult people from our geographic region than in those from other developed countries and show that socioeconomically deprived children constitute at present a group at high risk of acquiring infection in our region.     

The predictive value of cholesterol in young men for anelevated cholesterol ten to twelve years later

We reviewed the charts of 322 randomly selected male Airforce personnel with no known illnesses, who were first seen between 1970–1974 when aged 20–24 years. The results of all annual determinations of fasting serum total cholesterol (TC) during the following 10–12 years ending 1980–1984 were compiled. The cut-off point separating ‘normal’ from ‘elevated’ TC was arbitrarily set at the upper decile. The predictive value of the TC at entry for an elevated TC on follow-up was calculated. Subjects aged 20–24 years with a single elevated serum TC on entry had a 25% probability of having a similarly elevated TC 10–12 years later. Most of the decrease in positive predictive value could be accounted for by intra-individual variation. Subjects with elevated TC on 2 of 3 annual examinations after entry had a 50% probability of having a similarly elevated TC on 2 of 3 annual examinations 7–10 years later. We conclude that tracking of individuals with elevated TC is improved by multiple sampling.