Human and animal rabies prevention and control cost in Bhutan, 2001–2008: The cost–benefit of dog rabies elimination

The objective of this study was to estimate the cost of various interventions and to quantify the economic impacts of rabies in Bhutan. Cost–benefit of dog rabies elimination versus human post exposure treatment cost was also assessed. The average direct medical cost of human post-exposure treatment (using rabies vaccine only) was estimated to be Nu. 1615 (US$ 35.65) per 5-dose Essen regimen per patient. The cost would increase to Nu. 2497 (US$ 55.13) and Nu. 19,633 (US$ 433.41) per patient when one dose of either equine rabies immunoglobulin (ERIG) or human rabies immunoglobulin (HRIG) is administered, respectively. The societal cost (direct medical and indirect patient expenses) per patient was estimated to be Nu. 2019 (US$ 45), Nu. 2901 (US$ 64) and Nu. 20,037 (US$ 442) using vaccine only, vaccine with ERIG and vaccine with HRIG, respectively. The average cost per dog vaccination and sterilization were estimated to be Nu. 75 (US$ 1.66) and Nu. 288 (US$ 6.36), respectively. The total direct cost of rabies and various interventions between 2001 and 2008 was estimated to be Nu. 46.95 million (US$ 1.03 million). The direct cost for intensified human PET was estimated to be Nu. 5.85 million (US$ 0.11 million) per year with a cumulated estimated costs of Nu. 35.10 million (US$ 0.70 million) while the cost of mass dog vaccination with at least 70% coverage is estimated to be approximately Nu. 10.31 million (US$ 0.21 million) at the end of 6 years. The combined cost of mass dog vaccination and human PET was estimated to be greater than the cost of human PET alone during the first 2 years of the campaign, and then would be lower than human PET cost alone after the 5th year of the campaign. The total cumulated cost of the combined strategy was estimated to be Nu. 34.14 million (US$ 0.73 million) and would be lower than the cumulated cost of human PET alone (Nu. 35.10 million, US$ 0.77 million) at the end of 6 years. Rabies represents a substantial economic impact to the Bhutanese society. Well-planned and implemented mass dog vaccination would result in elimination of rabies reservoirs in the domestic dog population and would eliminate human rabies cases. It would also reduce the recurrent expenditure on human post-exposure treatment.     

Value of exercise capacity and physical activity in the prevention of cardiovascular diseases—brief review of the current literature

A low level of physical activity and decreased exercise capacity are independent risk factors for cardiovascular and all-cause mortality. The assessment of the level of physical activity and its improvement following preventive procedures is methodologically difficult. In population studies, subjective methods, such as questionnaires, activity records and other somewhat imperfect measures (accelerometers, pedometers, and pulse monitors), are used. Direct and especially indirect assessment of physical capacity with exercise tests has become increasingly more accessible and cheap. Both methods have been proved to have high prognostic value. Assessment of physical capacity enables objectification of information on the level and effects of a subjects physical activity acquired via a questionnaire. Taking into account the above-mentioned issues, the role of the assessment of exercise capacity and its improvement is not adequately appreciated. Routine evaluation of exercise capacity has not been included in the current statements on epidemiology and prevention, even in those with an increased Framingham or SCORE risk index in whom low exercise tolerance has been proved to have an unfavorable influence on prognosis. The importance of an increase in the level of physical activity resulting in an improvement in exercise capacity in different population groups should be verified in the near future, but in our opinion there is indirect but strong evidence that actions to improve exercise capacity should become the main goals in the prevention of cardiovascular and all-cause mortality, such as cessation of cigarette smoking, body weight reduction, correction of lipid and carbohydrate metabolism disturbances, and a decrease in blood pressure.     

A study of the current knowledge base in treating snake bite amongst doctors in the high-risk countries of India and Pakistan: does snake bite treatment training reflect local requirements?

The call for greater production of better quality anti-snake venom (ASV) is a major thrust in the effort to reduce snake bite mortality. However, snake bite mortality has many causes and these should also be addressed. A key feature of efficient ASV usage is ensuring that doctors are trained to administer ASV only when it is required and in amounts that are necessary to neutralize venom. The need for better snake bite management training has been referred to, but little attention has been paid to how effectively medical education actually prepares doctors to treat snake bite. The objective of this study is to evaluate the current level of knowledge amongst doctors in India and Pakistan, two countries with the highest snake bite mortality in absolute terms. Results show that the use of current textbooks and medical education do not adequately prepare doctors to treat snake bite, particularly in the areas of use of ASV, dealing with adverse reactions to ASV and specific measures to deal with neurotoxic bites. The central conclusion of the paper is that local protocols and training are required to adequately prepare doctors to improve treatment and reduce mortality.     

Physical activity in the second half of life—current situation in Switzerland

Over the past several decades, there has been a gradually growing awareness among health care professionals and policy makers of the impact of physical activity (PA) in the second half of life. Implementation of PA recommendations among the most inactive members in the community aged 50+ has been the subject of considerable discussion in Switzerland. A vital step towards promoting good exercise habits in populations is to describe the current PA behavior of both the sedentary and physically active. According to previous findings about PA behavior (sports, exercise, habitual PA) in the Swiss population aged 50+ and associated sociodemographic variables, health status, and health orientation, habitual PA seems to have the greatest potential for increasing overall guideline-compliant activity levels. The findings suggest a behavioral/cognitive and political/environmental approach to improving PA. Nevertheless, since the findings were obtained from cross-sectional analyses, the information provided has to be considered with reservation. PA promotion campaigns targeting the 50+ age groups can be rendered more effective if relevant information (such as current and previous lifestyles that also have impact on PA behavior in the second half of life) can be gathered through data-differentiated multi-item cross-sectional studies and/or cohort studies.     

Do local inhabitants want to participate in community injury prevention?: a focus on the significance of local identities for community participation

During the 1980s the community became the object of new interest and enthusiasm among many health promotion practitioners and researchers, and the principle of community participation was put on the research agenda. However, recent evaluations of major community health promotion programs have questioned the value of community interventions. This paper argues that the community level need not be of less importance in future health promotion initiatives. It is discussed whether the cultural dimension and the significance of local identities, neglected in most community health promotion programs, should receive more attention when local inhabitants are invited to participate in health promotion or disease prevention activities. Results from a study of injury prevention projects in small Norwegian municipalities indicate that the inhabitants' identification with local spatial subarenas might play an important role when they decide to become involved in injury prevention. Contemporary sociological approaches to the community, focusing on developments of local identities in processes of globalization, have formed a theoretical frame of reference in this study.     

A food‐based systems approach to improve the nutritional status of Australian aborigines: A focus on zinc

Several studies have identified impaired zinc status in remote Australian Aboriginal communities, which contributes to poor growth, low immunity and recurrent episodes of diarrhoea in children. Indigenous foods were identified for inclusion into a community or household garden which would include fruit and vegetables and lead to their availability, affordability, freshness and quality. Suitable indigenous foods which provide zinc include Brachychiton para‐doxum (zinc 7.9 mg/100g), Sterculia quadrifida (zinc 6.5 mg/100 g), Portulaca oleracealintraterranea (zinc 6.5 mg/100 g), and Acacia coriacea (zinc 5.8 mg/ 100 g). A brief review of the literature on zinc bioavailability is presented and an attempt is made to estimate and improve the bioavailability of zinc from these indigenous foods. This includes food processing techniques which reduce the content of zinc inhibitors, mainly phytate, and the consumption of zinc absorption facilitators with meals. Concomitantly, adequate health and hygiene is suggested in order to minimise the infection‐malnutrition cycle that can result from a reduced zinc status and recurrent episodes of infection. An education program, which includes nutrition, gardening and cooking skills, could form the basis of a sustainable approach to combating impaired zinc status in this population.     

Background paper to the revised recommendation for hepatitis B vaccination of persons at particular risk and for hepatitis B postexposure prophylaxis in Germany

The German Standing Committee on Vaccination (Ständige Impfkommission, STIKO) recommends vaccinating risk groups against hepatitis B and gives advice for postexposure prophylaxis. STIKO has recently revised this recommendation, focusing on: (i) classification of risk groups, (ii) duration of protection after primary immunization, and (iii) anti-HBs threshold that defines successful hepatitis B vaccination. Orientating literature reviews were performed for the first objective. Examples of population subgroups at increased risk were identified and classified into three indication groups. Systematic reviews on the duration of vaccine-induced protection identified one randomized controlled trial (RCT) and nine cohort studies. When applying the grading of recommendation, assessment, development, and evaluation (GRADE) methodology, evidence from RCTs was considered of very low quality regarding the question of whether hepatitis B can be prevented for 15 years after successful primary vaccination (anti-HBs ≥?10 IU/l) with a vaccine efficacy of 96?% against chronic hepatitis, 89?% against HBsAg positivity, and 73?% against isolated anti-HBc positivity. However, seven cohort studies showed that no cases of clinical hepatitis B or HBsAg positivity occurred during a maximum follow-up period of 10 years in settings comparable to the situation in Germany when anti-HBs ≥?10 IU/l was used to indicate vaccination success. Less than 1?% of vaccinated study participants had isolated anti-HBc positivity. GRADE assessment of two cohort studies revealed that evidence of very low quality exists that the use of anti-HBs ≥?100 IU/l to measure vaccination success leads to a lower frequency of anti-HBc positivity during follow-up than the use of anti-HBs ≥?10 IU/l. The recommendation was revised according to this evidence.     

Supervisors’ views on employer responsibility in the return to work process. A focus group study

Background: Supervisors’ attitudes and measures have been pointed out by employees to influence the return to work process. The purpose of this study was to explore supervisors’ views on employer responsibility in the return to work process and factors influencing the support of sick-listed employees. Method: The focus group method was used. Six groups were conducted and each group met on one occasion. Twenty-three supervisors experienced in managing sick-listed employees participated. Result: Two different themes emerged; In “The Supervisor is the Key Person” the participants found themselves as being key persons, carrying the main responsibility for the rehabilitation of the sick-listed employees and for creating a good working environment, thus preventing ill health and sick-listing among the employees. In the second theme “Influential Factors in Rehabilitation Work” the participants described the rehabilitation work as a part of a greater whole influenced by society, demands and resources of the workplace and the interplay between all parties involved. Conclusion: The study gives us the supervisors’ perspective on the complexity of the return to work rehabilitation. This knowledge could be invaluable and be used to improve the possibilities for developing successful collaboration in occupational rehabilitation.     

Influence of Behavioral and Environmental Factors on the Development of Obesity in Three-year-old Children —A Case-Control Study Based on Toyama Study—

Obesity in children seems to be a risk factor for chronic diseases in adulthood. From the viewpoint of preventive medicine, factors influencing the development of obese children should be removed early in life. The purpose of this study was to the elucidate relationship between obesity in 3-year-old children and both behavioral and environmental factors by conducting a case-control study. Subjects were selected from the Toyama study. Matched-pair comparisons were performed between obese children whose Kaup’s index was 18 or more (N=117) and control children (N=234) . Multivariate stepwised logistic regression analysis also applied to assess influence of confounding factors. The results indicated that the following 6 factors significantly influenced the development of obese 3-year-old children in exact Fisher’s method analysis (p<0.05): person other than the mother responsible for taking care of the child, short sleep duration (9 hours or less), physical inactivity, eating snacks irregularly, overweight father (BMI≥24), and overweight mother (BMI≥24). For both sexes, after adjusting for confounders by multivariate stepwise logistic analysis, overweight mother (OR 2.54, 95 % CI 1.64-3.95), birth overweight (birth weight≥3,500g; OR 1.76, 95 % CI 1.15-2.69), the mother not responsible for taking care of the child (OR 1.65, 95% CI 1.10-2.48), overweight father (OR 1.62, 95%CI 1.09-2.40), eating snacks irregularly (OR 1.56, 95% CI 1.04-2.33), and gender (female;OR 0.51, 95% CI 0.34-0.77) had significant relationships with obesity in childhood. For boys, overweight mother (OR 2.53, 95 % CI 1.47-4.35), birth overweight (OR 2.03, 95%CI 1.22-3.39), eating snacks irregularly (OR 1.94, 95 %CI 1.19-3.18), and birth month (36-41 months; OR 0.47, 95 % CI 0.23-0.96) had significant relationships. For girls, overweight mother (OR 2.62, 1.28-5.35), and short sleep duration (OR 2.24, 1.11-4.52) had significant relationships. In neither Fisher’s exact method nor multivariate logistic models, time to wake up, bedtime, duration of playing outdoors, regularity of meals, care about salty food, or frequency of eating snacks had significant relations with obesity in 3-year-old children (p<0.05).     

Rubus occidentalis: The black raspberry—its potential in the prevention of cancer

Rubus occidentalis is a black-fruited raspberry originating from North America. Its popularity and demand has been growing over the years, as studies outline its high anthocyanin and ellagitannin content and significance for human health. Interaction between chemical composition and pharmacological activity, mechanisms of action at cellular and molecular levels are all active areas of study. The vast majority of research concerning black raspberries is focused on chemoprevention and anticancer effects. This review summarizes the data on chemical composition and anticancer activity of black raspberry fruits throughout the years.     

Sensory functions in the foot soles in victims of generalized torture,in victims also beaten under the feet (falanga) and in healthy controls – A blinded study using quantitative sensory testing

Background

Falanga torture (beatings on the foot soles) produces local chronic pain and severe walking difficulties. We have previously reported signs of neuropathic pain in the feet of falanga victims. The objective here was to clarify underlying pain mechanisms by quantifying sensory impairments in the feet of torture victims who had experienced both generalized torture and those who had been exposed to falanga in addition. An ethnically matched control group was available.

Methods

We employed quantitative sensory testing (QST) by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain as were interview data on sensory symptoms. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli in the foot soles. Clinical data on anxiety and depression were retrieved.

Results

Almost all falanga victims had moderate or strong pain in their feet and in twice as large an area of their foot soles as other torture victims. One-third of the latter had no pain in their feet and many reported slight pain; in spite of this, there were no differences in foot sole QST data between the tortured groups. A comparison with normal data indicated that both tortured groups had hypoesthesia for all cutaneous sensory fibre groups except those transmitting cold and heat pain, in addition to deep mechano-nociceptive hyperalgesia.

Conclusion

A comparison of the QST data between victims having been exposed to generalized torture and victims who in addition had been exposed to falanga, showed no differences on the group level. The sensory disturbances in relation to our control group are compatible with central sensitization and de-sensitization, pointing to a core role of central mechanisms. A further analysis to create individual sensory profiles from our measurements is in progress.

     

Modeling the impact of prevention policies on future diabetes prevalence in the United States: 2010–2030

Background

Although diabetes is one of the most costly and rapidly increasing serious chronic diseases worldwide, the optimal mix of strategies to reduce diabetes prevalence has not been determined.

Methods

Using a dynamic model that incorporates national data on diabetes prevalence and incidence, migration, mortality rates, and intervention effectiveness, we project the effect of five hypothetical prevention policies on future US diabetes rates through 2030: 1) no diabetes prevention strategy; 2) a “high-risk” strategy, wherein adults with both impaired fasting glucose (IFG) (fasting plasma glucose of 100–124 mg/dl) and impaired glucose tolerance (IGT) (2-hour post-load glucose of 141–199 mg/dl) receive structured lifestyle intervention; 3) a “moderate-risk” strategy, wherein only adults with IFG are offered structured lifestyle intervention; 4) a “population-wide” strategy, in which the entire population is exposed to broad risk reduction policies; and 5) a “combined” strategy, involving both the moderate-risk and population-wide strategies. We assumed that the moderate- and high-risk strategies reduce the annual diabetes incidence rate in the targeted subpopulations by 12.5% through 2030 and that the population-wide approach would reduce the projected annual diabetes incidence rate by 2% in the entire US population.

Results

We project that by the year 2030, the combined strategy would prevent 4.6 million incident cases and 3.6 million prevalent cases, attenuating the increase in diabetes prevalence by 14%. The moderate-risk approach is projected to prevent 4.0 million incident cases, 3.1 million prevalent cases, attenuating the increase in prevalence by 12%. The high-risk and population approaches attenuate the projected prevalence increases by 5% and 3%, respectively. Even if the most effective strategy is implemented (the combined strategy), our projections indicate that the diabetes prevalence rate would increase by about 65% over the 23 years (i.e., from 12.9% in 2010 to 21.3% in 2030).

Conclusions

While implementation of appropriate diabetes prevention strategies may slow the rate of increase of the prevalence of diabetes among US adults through 2030, the US diabetes prevalence rate is likely to increase dramatically over the next 20 years. Demand for health care services for people with diabetes complications and diabetes-related disability will continue to grow, and these services will need to be strengthened along with primary diabetes prevention efforts.