Trends in smoking prevalence and attributable mortality in China, 1991–2011

ObjectiveChina is the largest producer of tobacco worldwide. We assessed secular trends in prevalence of smoking, average cigarettes per day, mean age of initiation, and mortality attributable to smoking among the Chinese population between 1991 and 2011.DesignData came from the China Health and Nutrition Survey, conducted eight times between 1991 and 2011. A total of 83,447 participants aged 15 years or older were included in this study. Trends in smoking were stratified by sex, age, and region (urban vs. rural).ResultsIn 2011, 311 millions individuals were current smokers in China, with 295 million men and 16 million women, respectively. Between 1991 and 2011, the prevalence of current smoking decreased from 60.6% to 51.6% in men, and from 4.0% to 2.9% in women. However, during this period, the average number of cigarettes smoked per day per smoker increased from 15.0 to 16.5 in males, and from 8.5 to 12.4 in females. Further, age of smoking initiation decreased from 21.9 to 21.4 years in men and from 31.4 to 28.4 years in women. In 2011, 16.5% of all deaths in men and 1.7% in women were due to smoking. Between 1991 and 2011, the total number of deaths caused by smoking increased from 800,000 to 900,000.ConclusionsDuring the past 20 years, a slight decrease in smoking prevalence was observed in the Chinese population. However, cigarette smoking remains a major cause of death in China, especially in men.     

The evolution of breast cancer mortality and morbidity in Spain (1977–1988)

A study of breast cancer mortality and cancer morbidity has been carried out in Spain recently for the period 1977–1988, covering the population of the 17 Autonomous Communities and 50 provinces of the country. Data was obtained from INE, Instituto Nacional de Estadistica (National Institute of Statistics), with age standardization using the indirect method. The different Autonomous Communities and provinces were compared in order to establish possible significant differences. The crude mean mortality rate was 21 cases per 100,000 inhabitants/year; Las Palmas, Gerona, Barcelona, the Balearic Islands, Navarra and Zaragoza have the highest mortality rates, with a proportional increment of 54% in that period. The crude national mean morbidity rate for the considered period was 64.0 cases per 100,000 inhabitants, and the proportional increment 180%. According to provincial figures, Alava had the highest fitted mean morbidity rate, 135 cases per 100,000 inhabitants, whilst the highest fitted mean rate was Las Palmas (28 cases/100,000 inhabitants), and the highest proportional increment was the rate for the province of Huesca (169%). When using the ANOVA test on the mean rate of the period, for mortality as well as morbidity, we observed significant differences among provinces and among Autonomous Communities (p 0.05).     

Decrease in the incidence and in hospital mortality of community-acquired pneumonia among children in Spain (2001–2014)

ObjectivesTo describe trends in the incidence and outcomes of community-acquired pneumonia (CAP) hospitalizations among Spanish children from 2001 to 2014 and to assess the effect of the pneumococcal vaccination (PCV) coverage in this period.MethodsThis study was conducted using the Spanish National Hospital Database from 2001 to 2014 including subjects <18 years. We selected discharges with a primary diagnosis of CAP.Study variable included age, sex, comorbid conditions, procedures, isolated pathogens and hospital outcome variables.In order to estimate the effect of coverage of pneumococcal vaccination in hospitalizations for CAP, we used the number of commercialized doses of PCV (PCV7 PCV10, and PCV13) for each year.Incidence rates of admissions for CAP were calculated by dividing the number of admissions per year, sex, and age group by the corresponding number of people in that population group according to the census data.ResultsWe identified 194,419 admissions for CAP. Incidence rate was highest among children younger than 2 years and decreased significantly by 3.67% per year over the study period in this age group. Among children aged 2–4 years incidence of CAP seem to decrease after year 2009. S. pneumoniae isolations decreased significantly over time but virus isolations increased. In children aged <2 years and 2–4 years increase in PVC was associated to a decrease in the incidence of CAP hospitalizations.Overall crude in hospital mortality following CAP fell significantly from 4.1‰ in 2001–2003 to 2.8‰ in 2012–2014.ConclusionsCAP incidence rates decreased significantly among children <2 years of age from 2001 to 2014. S. pneumoniae isolations decreased significantly over time but virus isolations increased. In hospital mortality paralleling CAP fell significantly in children and adolescents from 2001 to 2014. Improvement in vaccination coverage seems to have a mitigating effect on hospitalizations and outcomes for CAP in children.     

Ebola in the Netherlands, 2014–2015: costs of preparedness and response

The recent epidemic of Ebola virus disease (EVD) resulted in countries worldwide to prepare for the possibility of having an EVD patient. In this study, we estimate the costs of Ebola preparedness and response borne by the Dutch health system. An activity-based costing method was used, in which the cost of staff time spent in preparedness and response activities was calculated based on a time-recording system and interviews with key professionals at the healthcare organizations involved. In addition, the organizations provided cost information on patient days of hospitalization, laboratory tests, personal protective equipment (PPE), as well as the additional cleaning and disinfection required. The estimated total costs averaged €12.6 million, ranging from €6.7 to €22.5 million. The main cost drivers were PPE expenditures and preparedness activities of personnel, especially those associated with ambulance services and hospitals. There were 13 possible cases clinically evaluated and one confirmed case admitted to hospital. The estimated total cost of EVD preparedness and response in the Netherlands was substantial. Future costs might be reduced and efficiency increased by designating one ambulance service for transportation and fewer hospitals for the assessment of possible patients with a highly infectious disease of high consequences.     

Epidemiological trends of sepsis in the twenty-first century (2000–2013): an analysis of incidence,mortality, and associated costs in Spain

Background

Sepsis has represented a substantial health care and economic burden worldwide during the previous several decades. Our aim was to analyze the epidemiological trends of hospital admissions, deaths, hospital resource expenditures, and associated costs related to sepsis during the twenty-first century in Spain.

Methods

We performed a retrospective study of all sepsis-related hospitalizations in Spanish public hospitals from 2000 to 2013. Data were obtained from records in the Minimum Basic Data Set. The outcome variables were sepsis, death, length of hospital stay (LOHS), and sepsis-associated costs. The study period was divided into three calendar periods (2000–2004, 2005–2009, and 2010–2013).

Results

Overall, 2,646,445 patients with sepsis were included, 485,685 of whom had died (18.4%). The incidence of sepsis (events per 1000 population) increased from 3.30 (2000–2004) to 4.28 (2005–2009) to 4.45 (2010–2013) (p?<?0.001). The mortality rates from sepsis (deaths per 10,000 population) increased from 6.34 (2000–2004) to 7.88 (2005–2009) to 7.89 (2010–2013) (p?<?0.001). The case fatality rate (CFR) or proportion of patients with sepsis who died decreased from 19.1% (2000–2004) to 18.4% (2005–2009) to 17.9% (2010–2013) (p?<?0.001). The LOHS (days) decreased from 15.9 (2000–2004) to 15.7 (2005–2009) to 14.5 (2010–2013) (p?<?0.001). Total and per patient hospital costs increased from 2000 to 2011, and then decreased by the impact of the economic crisis.

Conclusions

Sepsis has caused an increasing burden in terms of hospital admission, deaths, and costs in the Spanish public health system during the twenty-first century, but the incidence and mortality seemed to stabilize in 2010–2013. Moreover, there was a significant decrease in LOHS in 2010–2013 and a decline in hospital costs after 2011.

     

How many deaths are attributable to smoking in the United States? Comparison of methods for estimating smoking-attributable mortality when smoking prevalence changes

Background

The number of smoking-attributable deaths is commonly estimated using current and former smoking prevalences or lung cancer mortality as an indirect metric of cumulative population smoking. Neither method accounts for differences in the timing with which relative risks (RRs) for different diseases change following smoking initiation and cessation. We aimed to develop a method to account for time-dependent RRs.

Methods

We used birth cohort lung cancer mortality and its change over time to characterize time-varying cumulative smoking exposure. We analyzed data from the American Cancer Society Cancer Prevention Study II to estimate RRs for disease-specific mortality associated with current and former smoking, and change in RRs over time after cessation.

Results

When lung cancer was used to measure cumulative smoking exposure, 254,700 male and 227,000 female deaths were attributed to smoking in the US in 2005. A modified method in which RRs for different diseases decreased at different rates after cessation yielded similar but slightly lower estimates [251,900 (male) and 221,100 (female)]. The lowest estimates resulted from the method based on smoking prevalence [225,800 (male) and 163,700 (female)].

Conclusions

Although all methods estimated a large number of smoking attributable deaths, future efforts should account for temporal changes in smoking prevalence and in accumulation/reversibility of disease-specific risks.     

Long-term trends in ambient particulate matter,chemical composition,and associated health risk and mortality burden in Hong Kong (1995–2016)

Hong Kong is one of the special administrative regions in China and a densely populated city with poor air quality. The impact of high pollutant concentrations, especially ambient particulate matter (PM), on human health is of major concern. This study reported the temporal trends of PM masses and chemical components and assessed the PM pollution-related health risk and mortality burden in Hong Kong over a 22-year period (1995–2016). The results showed that the ambient PM increased before 2005 and then decreased gradually with overall downward trends of ??0.61 μg m^?3 year^?1 for inhalable PM (PM₁₀) and ??1.30 μg m^?3 year^?1 for fine PM (PM_2.5). No statistically significant changes were observed for secondary inorganic components (SO₄^2?, NO₃^?, and NH₄⁺), while significant decreasing trends were found for total carbon (TC) and other water-soluble irons (Na⁺, Cl^?, and K⁺). The long-term variabilities of the trace elements differed greatly with species. A health risk assessment revealed that the annual inhalational carcinogenic risk from As, Cd, Ni, Cr, and Pb was always lower than the accepted criterion of 10^?6, whereas the total noncarcinogenic risk from As, Cd, Ni, Cr, and Mn frequently exceeded the safe level of 1. Further, a health burden assessment indicated that the annual mean number of premature mortalities attributable to PM_2.5 exposure was 2918 (95% CI: 1288, 4279) cases during the period of 2001–2016. Both health risk and mortality burden presented constant reductions in recent years, confirming the health benefits of air pollution control measures and the importance of further mitigation efforts.     

The relevance of spatial aggregation level and of applied methods in the analysis of geographical distribution of cancer mortality in mainland Portugal (2009–2013)

Background

Knowledge regarding the geographical distribution of diseases is essential in public health in order to define strategies to improve the health of populations and quality of life.The present study aims to establish a methodology to choose a suitable geographic aggregation level of data and an appropriated method which allow us to analyze disease spatial patterns in mainland Portugal, avoiding the “small numbers problem.” Malignant cancer mortality data for 2009–2013 was used as a case study.

Methods

To achieve our aims, we used official data regarding the mortality by all malignant cancer, between 2009 and 2013, and the mainland Portuguese resident population in 2011. Three different spatial aggregation levels were applied: Nomenclature of Territorial Units for Statistics, level III (28 areas), municipalities (278 areas), and parishes (4050 areas).Standardized Mortality Ratio (SMR) and relative risk (RR) were computed with Besag, York and Mollié model (BYM) for the evaluation of geographic patterns of mortality data. We also estimated Global Moran’s I, Local Moran’s I, and posterior probability (PP) for the spatial cluster analysis.

Results

Our results show that the occurrence of lower and higher extreme values of the standardized mortality ratio tend to increase with the decrease of data spatial aggregation. In addition, the number of local clusters is higher at small spatial aggregation levels, although the area of each cluster is generally smaller. Regarding global clustering, data forms clusters at all considered levels.Relative risk (RR) computed by Besag, York and Mollié model, in turn, also shows different results at the municipalities and parishes levels. However, the difference is smaller than the difference obtained by SMR computation. This statement is supported by the coefficient variation values.

Conclusions

Our findings show that the choice of spatial data aggregation level has high importance in the research results, as different aggregation levels can lead to distinct results.In terms of the case study, we conclude that for the period of 2009–2013, cancer mortality in mainland Portugal formed clusters. The most suitable applicable spatial scale and method seemed to be at the municipalities level and Besag, York and Mollié model, respectively. However, further studies should be conducted in order to provide greater support to these results.

     

The burden of disease from air pollution in Israel: How do we use burden estimates to advance public health?

In an article recently published in the IJHPR, Ginsberg and colleagues from Israel’s Public Health Services estimate the disease burden from airborne particulate matter in Israel. Using national data on the concentration of PM_2.5 (particulate matter less than 2.5 μm in aerodynamic diameter) and risk estimates from meta-analyses, they calculate that about 2000 deaths (4.7% of total deaths) are attributable to air pollution. Although inherently subject to uncertainty, such estimates are useful for motivating public health protection and gauging the stringency of any needed regulations. However, Israel does not yet have an evidence-based process for air quality regulation comparable to that of the United States, which has evolved over the 45 years since passage of the Clean Air Act. In fact, Israel has only recently promulgated a national standard for airborne particulate matter and quantitative risk assessment has not been an element of regulatory decision-making. The report by Ginsberg and colleagues represents a useful beginning and should initiate discussion of the role of burden estimation and risk assessment more broadly in regulations intended to advance environmental health in Israel.     

The burden of invasive meningococcal disease in the Netherlands, 2011–2020

IntroductionRepresentative information on disease course and outcome of invasive meningococcal disease (IMD) is important because of the shift in meningococcal epidemiology that recently occurred in the Netherlands. With this study, we update earlier research on the burden of IMD in the Netherlands.Material and methodsWe performed a retrospective study using Dutch surveillance data on IMD from July 2011 to May 2020. Clinical information was collected from hospital records. The effect of age, serogroup, and clinical manifestation on disease course and outcome was assessed in multivariable logistic regression analyses. Grouping of infecting isolates was performed by Ouchterlony gel diffusion or by PCR.ResultsClinical information was collected for 278 IMD cases of which the majority had IMD-B (55%), followed by IMD-W (27%), IMD-Y (13%), and IMD-C (5%). Most patients presented with meningitis (32%) or sepsis (30%). Hospitalisation for ≥ 10 days was most frequent among 24–64 year olds (67%). ICU admission was highest among 24–64 year olds (60%), and in case of sepsis (70%), or sepsis plus meningitis (61%). Sequelae at discharge was lower for patients with mild meningococcaemia compared to patients with sepsis plus meningitis (OR: 0.19, 95% CI: 0.07–0.51). The overall case fatality rate was 7%, and was highest for IMD-Y (14%) and IMD-W (13%) patients.ConclusionsIMD remains a disease with high morbidity and mortality. Sepsis (with or without meningitis) is associated with a more severe disease course and outcome compared to other clinical manifestations. The high disease burden can be partly prevented by meningococcal vaccination.     

The increase in cancer prevalence and hospital burden in Western Australia, 1992–2011

Purpose

To describe cancer prevalence and hospital service utilization by prevalent cancer patients in Western Australia from 1992 to 2011.

Methods

This study was a population-based cohort study using the Western Australia (WA) Cancer Registry (1982 to 2011) as the source of incident cancer cases. These data were linked to mortality (1982 to 2011) and hospital morbidity (1998 to 2011) records via the WA Data Linkage System to ascertain complete and limited-duration prevalence and cancer-related hospitalizations over time. Prevalence rates were calculated using estimated residential population data from the Australian Bureau of Statistics.

Results

In 2011, one in every 27 people living in WA had been diagnosed with cancer at some time in their lifetime, and one in 68 had been diagnosed within the previous five years. Between 1992 and 2011, complete cancer prevalence in Western Australia increased by a magnitude of 2.5-fold. Forty-five and 44% of the increase in complete cancer prevalence in males and females between 1992 and 2011 can be attributed to prostate and breast cancer, respectively. The absolute number of cancer-related bed days increased 81 and 74% in males and females, respectively, diagnosed within one year, between 1998 and 2011.

Conclusions

The prevalence of cancer and the burden it places on hospitals continues to rise, demanding ongoing efforts to prevent cancer through modifiable risk factors and better, more efficient use of health resources. Steps should to be taken to understand and address overdiagnosis and overtreatment.

     

The average age of smoking onset in Germany – trends and correlates

Summary Objectives:  Germany is rated among the countries with the highest prevalence of tobacco use in Europe. This paper analyzes whether the age of smoking onset has decreased in recent years. Methods:  Multivariable event data analyses were performed on the basis of the representative national cross-sectional study “Drug Affinity among Young People in the Federal Republic of Germany 2004”. The survey involved a total net sample of 3032 individuals aged 12 to 25. Results:  Socioeconomic groups starting to smoke at significantly earlier age include those from the economically deprived areas in eastern Germany, low educational achievers and subjects in households with adult smokers. Conclusions:  The average age of smoking onset has decreased further in the 1978–1992 birth cohorts. Submitted: 18 November 2006; Revised: 23 January 2008, 18 March 2008; Accepted: 19 March 2008     

The dynamics of tobacco smoking among male educated youths in Aleppo–Syria

Understanding the dynamics of the smoking habit among youths at different stages of their development is crucial for the adoption of effective tobacco control policies. We looked at the smoking habits of 576 male university students and compared it with previously studied 555 male high school students in Aleppo–Syria, stratified into four groups with 2-year interval each. The prevalence of current smoking among 1st and 3rd year university students is 18.2% and 29.4% respectively, compared to 10.5% and 22.6% among 10th and 12th year high school students respectively. This study shows a late onset initiation of regular forms of smoking compared to patterns seen in developed countries.     

Continuities and changes in spatial patterns of under-five mortality at the district level in India (1991–2011)

Background

India has the largest number of under-five deaths globally, and large variations in under-five mortality persist between states and districts. Relationships between under-five mortality and numerous socioeconomic, development and environmental health factors have been explored at the national and state levels, but the possible spatial heterogeneity in these relationships has seldom been investigated at the district level. This study seeks to unravel local variation in key determinants of under-five mortality based on the 1991 and 2011 censuses.

Methods

Using geocoded district-level data from the last two census rounds (1991 and 2011) and ordinary least squares and geographically weighted regressions, we identify district-specific relationships between under-five mortality rate and a series of determinants for two periods separated by 20 years (1986–1987 and 2006–2007). To identify spatial groupings of coefficients, we perform a cluster analysis based on t-values of the geographically weighted regression.

Results

The geographically weighted regression analysis shows that relationships between the under-five mortality rate and factors for socioeconomic, development, and environmental health factors vary spatially in terms of direction, strength, and extent when considering: female literacy and labor force participation; share of scheduled castes and scheduled tribes; access to electricity; safe water and sanitation; road infrastructure; and medical facilities. This spatial heterogeneity is accompanied by significant changes over time in the roles that these factors play in under-five mortality. Important local determinants of under-five mortality in 2011 were female literacy, female labor force participation, access to sanitation facilities and electricity; while the key local determinants in 1991 were road infrastructure, safe water, and medical facilities. We identify six different clusters based on geographically weighted regression coefficients that broadly encompass the same districts in both periods; but these clusters do not follow the regional boundaries suggested by the previous studies. In particular, the high mortality states of India that are often typically classified as high focus states were classified into three different clusters based on the relationship of the factors associated with under-five mortality.

Conclusion

This study demonstrates the utility of combining geographically weighted regression and cluster analyses as a methodological approach to study local-level variation in public health indicators, and it could be applied in any country using aggregate-level information from census or survey data. Identifying local predictors of under-five mortality is important for designing interventions in specific districts. Additional reduction in under-five mortality will only be possible with intervention programs designed at the local level, which take into consideration local level determinants of under-five mortality.

     

The use of population attributable risk to estimate the impact of prevention and early detection of type 2 diabetes on population‐wide mortality risk in US males

The Population Attributable Risk (PAR) represents the proportion of the deaths (in a specified time) in the whole population that may be preventable if a cause of mortality were totally eliminated. This population‐based measure was used to assess the potential impact of three public health interventions for type 2 diabetes (early detection + standard therapy; early detection + intensive therapy; and primary prevention) on the mortality risk from all causes and from cardiovascular (CVD) diseases. Potential reduction in mortality risks for several levels of compliance or implementation (25%, 50%, 75%, 100%) for each intervention were also estimated. Results suggest that among males aged 45–74 years, the interventions may have greater population‐wide impact on total deaths among black males, and greater impact on the CVD deaths among white males. Overall, primary prevention (reduction in all‐cause mortality 6.2–10.0%, and CVD mortality 7.9–9.0%) may offer greater marginal benefit than screening and early treatment (reduction in all‐cause mortality 3.5–8.3%, and CVD mortality 2.8–8.6%). Often the question facing policy makers is not simply whether to but how much of an intervention is worth implementing? Estimated benefits for various intensities of intervention (as provided) may be useful to assess the likely marginal benefits of each intervention, and can be especially useful if combined with estimated marginal costs.     

The effects of weight and waist change on the risk of long-term mortality in older adults- The Bambuí (Brazil) Cohort Study of Aging

Objective

We aimed to investigate the risk of long-term mortality associated with weight and waist circumference (WC) change among older adults, particularly the overweight and obese ones.

Design

Cohort Study.

Setting

The Bambuí (Brazil) Cohort Study of Aging.

Participants

Community-dwelling elderly (n=1138).

Measurements

Weight and WC were reassessed three years after baseline. Mortality risk associated with a 5% weight/WC loss and gain was compared to that of weight/WC stability by Cox models adjusted for clinical, behavioral and social known risk factors for death (age, gender, BMI, smoking, diabetes, total cholesterol, hypertension, Chagas disease, major electrocardiographic changes, physical activity, B-type natriuretic peptide, C-reactive protein, creatinine, education and household income).

Results

Female sex was predominant (718; 63.1%). Mean age was 68 (6.7) years. Weight stability (696; 61.1%) was more common than weight loss (251; 22.1%) or gain (191; 16.8%). WC remained stable in 422 (37.3%), decreased in 418 (37.0%) and increased in 291 (25.7%) participants. There were 334 (29.3%) deaths over a median follow-up time of 8.0 (6.4-8.0) years from weight/WC reassessment. Weight loss (HR 1.69; 95% CI 1.30-2.21) and gain (HR 1.37; 95% CI 1.01-1.85) were associated with increased mortality, except in those who were physically active in which weight gain was associated with decreased mortality. Results were similar for participants who were overweight/ obese or with abdominal obesity at baseline (HR 1.41; 95%CI 1.02-1.97 and HR 2.01; 95%CI 1.29-3.12, for weight loss and gain, respectively). WC change was not significantly associated with mortality.

Conclusion

Although weight loss has been recommended for adults with excessive weight regardless of age, weight change might be detrimental in older adults. Rather than weight loss, clinical interventions should target healthy lifestyle behaviors that contribute to weight stability, particularly physical activity in overweight and obese older adults.