Education in Occupational Health: with Special Emphasis on Eight Asian Countries

A study project of the Asian Association of Occupational Healthin eight Asian countries (Hong Kong, Indonesia, Korea, Malaysia,the Philippines, Singapore, Sri Lanka and Thailand) was conductedin 1981-83. Among other objectives, a study on OccupationalHealth Education was included. It was found that in all thesecountries there was teaching of occupational health in medicalschools. However, there was little teaching of nurses. Few countrieshad formal training of safety engineers. Specialist trainingin occupational health was available in six countries. The findingsare compared with the known situation in other countries. Possibleways to promote more cooperation and improvements in Asia arethen discussed. Professor W. O. Phoon, Department of Social Medicine and Public Health, National University of Singapore, Outram Hill, Singapore 0316, Republic of Singapore.     

Education in Occupational Health: with Special Emphasis on Eight Asian Countries

A study project of the Asian Association of Occupational Healthin eight Asian countries (Hong Kong, Indonesia, Korea, Malaysia,the Philippines, Singapore, Sri Lanka and Thailand) was conductedin 1981-83. Among other objectives, a study on OccupationalHealth Education was included. It was found that in all thesecountries there was teaching of occupational health in medicalschools. However, there was little teaching of nurses. Few countrieshad formal training of safety engineers. Specialist trainingin occupational health was available in six countries. The findingsare compared with the known situation in other countries. Possibleways to promote more cooperation and improvements in Asia arethen discussed. Professor W. O. Phoon, Department of Social Medicine and Public Health, National University of Singapore, Outram Hill, Singapore 0316, Republic of Singapore.     

Changes in serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates from adult patients in Asia: Emergence of drug-resistant non-vaccine serotypes

This study was performed to investigate the serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae in Asian countries. A prospective surveillance study on S. pneumoniae collected from adult patients (≥50 years old) with invasive pneumococcal disease or community-acquired pneumonia was performed at 66 hospitals in Asian countries (Korea, China, Malaysia, Singapore, the Philippines, and Thailand) in 2012-2017. Serotyping and antimicrobial susceptibility tests of 850 pneumococcal isolates were performed. The proportions of isolates with serotypes covered by 13-valent pneumococcal conjugate vaccine (PCV13) were 37.0% in Korea, 53.4% in China, 77.2% in Malaysia, 35.9% in the Philippines, 68.7% in Singapore, and 60.2% in Thailand. Major serotypes were 19F (10.4%), 19A (10.1%), and 3 (8.5%) in 2012-2017, with different serotype distributions in each country. Macrolide resistance in pneumococci was high (66.8%) and prevalence of multidrug resistance (MDR) also remained high (50.8%). MDR non-PCV13 serotypes such as 11A, 15A, 35B, and 23A have emerged in Asian countries. This study showed the persistent prevalence of 19F and 19A with a noteworthy increase of certain non-PCV13 serotypes in Asian countries. High prevalence of macrolide resistance and MDR was also found in pneumococcal isolates. These data emphasize the need for continued surveillance of pneumococcal epidemiology in Asia in the post-pneumococcal vaccine era.     

A cross-country comparative overview of the asbestos situation in ten Asian countries

Information about asbestos issues at the national level was compiled for ten Asian countries (China, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, Thailand, and Vietnam) regarding 1) bans and consumption levels; 2) occupational exposure limits (OELs) and medical follow-up schemes; and 3) statistics and compensation status of asbestosis and mesothelioma victims. Only Singapore and recently Japan have adopted a total ban an asbestos. China, a major producer of chrysotile, showed an increasing consumption trend, which was typical of the less industrialized countries. Considerable differences between countries existed in OELs (0.1 to 5.0 fibers/mL) and medical follow-up of exposed workers. National statistics for asbestosis and mesothelioma were available for only the industrialized countries, where reported cases as well as compensated cases were relatively few. There is need to improve the quality and quantity of information, but the available information attests to unfavorable conditions in the less industrialized countries. Hence the experience of industrialized countries regarding asbestos and its use should be utilized to the fullest to improve the situation worldwide.     

Hepatitis B epidemiology in Asia, the Middle East and Africa

Asia and Africa have previously been classified as areas of high endemicity for hepatitis B virus (HBV), but in some countries highly effective vaccination programmes have shifted this pattern towards intermediate or low endemicity. Thus, China is now the only country in Asia where HBV endemicity is high. Countries with intermediate endemicity include India, Korea, the Philippines, Taiwan and Thailand, and those with low endemicity include Japan, Pakistan, Bangladesh, Singapore, Sri Lanka and Malaysia. Most countries in Africa have high HBV endemicity, with the exceptions of Tunisia and Morocco, which have intermediate endemicity. Zambia has borderline intermediate/high endemicity. In the Middle East, Bahrain, Iran, Israel and Kuwait are areas of low endemicity, Cyprus, Iraq and the United Arab Emirates have intermediate endemicity, and Egypt, Jordan, Oman, Palestine, Yemen and Saudi Arabia have high endemicity. All of these Middle East countries reach a large proportion of their population with hepatitis B vaccination, which is reducing the infection rate, particularly in Saudi Arabia. The vaccination programme in Taiwan has also greatly reduced the HBV infection rate. Future vaccination programmes must take into account the mode of transmission of HBV, the healthcare infrastructure to deliver vaccination, and the socioeconomic and political factors in each individual country, to determine the most cost-effective way of infection control.     

Mortality trends of young children in developing countries

The findings of a World Fertility Survey of infant and early childhood mortality trends in 29 countries in Africa, the Americas, and Asia are reported. The national surveys, carried out in 1974-79, utilized the synthetic cohort method. Analysis of the infant and child mortality 0-4 years before the data of each survey revealed wide variation. A moderate percentage (4-8%) of children died before reaching age 5 in 10 of the 29 countries studied: Costa Rica, Fiji, Guyana, Jamaica, Jordan, Korea, Malaysia, Panama, Trinidad and Tobago, and Venezuela. A moderate to high percentage (8-12%) of infant and child deaths was noted in Colombia, Mexico, Paraguay, Philippines, Sri Lanka, Syria, and Thailand. Mortality in this age group was high (12-15%) in Dominican Republic, Indonesia, Kenya, Peru, and Sudan; very high (16-20%) in Haiti, Lesotho, and Turkey; and extremely high (20% or more) in Bangladesh, Nepal, Pakistan, and Senegal. Even the countries with the lowest mortality levels have more than twice the mortality of developed countries. The neonatal death rate has been the most difficult to control. To determine time trends, children born to women ages 20-29 at time of the survey were further analyzed. Mortality has declined over time in all countries studied. There was an average of 43 fewer deaths under the age of 5 years per 1000 births in the period 0-4 years before the surveys than 15-19 years earlier, for an overall 28% decrease. Per 1000 births, 20 infant, 10 toddler, and 13 preschooler deaths were averted. However, the declines have not been equal or consistent across countries. When the countries were grouped by region, Western Asia recorded the greatest decline, with an average of 93 fewer infant and early childhood deaths in the period 0-4 years before survey than 15-19 years earlier. With 26 fewer deaths per 1000 births, the countries of Africa demonstrated the least fall. Asia (excluding Western Asia) and the Americas showed average declines of 34 and 45 deaths, respectively. There is some indication of a slowdown in the rate of decline of mortality, and 4 countries have shown increases in the recent period. This finding must be interpreted with caution, however, since recently born children may have been better reported.     

Modeling the hepatitis A epidemiological transition in Thailand

BackgroundIn most low- and middle-income countries, hepatitis A virus (HAV) is shifting or expected to shift from high endemicity to intermediate or low endemicity. A decreased risk of HAV infection will cause an increase in the average age at infection and will therefore increase the proportion of infections that results in severe disease. Mathematical models can provide insights into the factors contributing to this epidemiological transition.MethodsAn MSLIR compartmental dynamic transmission model stratified by age and setting (rural and urban) was developed and calibrated with demographic, environmental, and epidemiological data from Thailand. HAV transmission was modeled as a function of urbanization and access to clean drinking water. The model was used to project various epidemiological measures.ResultsThe age at midpoint of population immunity remains considerably younger in rural areas than in urban areas. The mean age of symptomatic hepatitis A infection in Thailand has shifted from childhood toward early adulthood in rural areas and is transitioning from early adulthood toward middle adulthood in urban areas. The model showed a significant decrease in incidence rates of total and symptomatic infections in rural and urban settings in Thailand over the past several decades as water access has increased, although the overall incidence rate of symptomatic HAV is projected to slightly increase in the coming decades.ConclusionsModeling the relationship between water, urbanization, and HAV endemicity is a novel approach in the estimation of HAV epidemiological trends and future projections. This approach provides insights about the shifting HAV epidemiology and could be used to evaluate the public health impact of vaccination and other interventions in a diversity of settings.     

A review of the status of foot and mouth disease in South-East Asia and approaches to control and eradication

The author presents reports of foot and mouth disease (FMD) submitted between 1996 and 2001 to the Office International des Epizooties (OIE: World organisation for animal health) Sub-Commission for FMD in South-East Asia. Of the ten countries in South-East Asia, FMD is endemic in seven (Cambodia, Laos, Malaysia, Myanmar, the Philippines, Thailand and Vietnam) and three are free of the disease (Brunei, Indonesia and Singapore). Part of the Philippines is also recognised internationally as being free of FMD. From 1996 to 2001, serotype O viruses caused outbreaks in all seven of the endemically infected countries. On the mainland, three different type O lineages have been recorded, namely: the South-East Asian (SEA) topotype, the pig-adapted or Cathay topotype and the pan-Asian topotype. Prior to 1999, one group of SEA topotype viruses occurred in the eastern part of the region and another group in the western part. However, in 1999, the pan-Asian lineage was introduced to the region and has become widespread. The Cathay topotype was reported from Vietnam in 1997 and is the only FMD virus currently endemic in the Philippines. Type Asia 1 has never been reported from the Philippines but was reported from all countries on the mainland except Vietnam between 1996 and 2001. Type A virus has not been reported from east of the Mekong River in the past six years and seems to be mainly confined to Thailand with occasional spillover into Malaysia. The distribution and movement of FMD viruses in the region is a reflection of the trade-driven movement of livestock. There is great disparity across the region in the strength and resources of the animal health services and this has a direct impact on FMD control. Regulatory environments are not well developed and enforcement of regulations can be ineffectual. The management of animal movement is quite variable across the region and much market-driven transboundary movement of livestock is unregulated. Formal quarantine approaches are generally not supported by traders or are not available. Vaccination is not used widely as a control tool because of the expense. However, it is applied by the Veterinary Services in Malaysia to control incursions of the disease and there is a mass vaccination programme for large ruminants in Thailand where the Government produces and distributes vaccine. Vaccination is also used by the commercial pig sector, particularly in the Philippines and Thailand.     

East Asia Review, 1973. To sum up

Observations are made related to the review of family planning activities in East Asia in 1973. The number of new acceptors for the region increased from 2.7 million in 1972 to 3.4 million in 1973. The leaders were Indonesia, which almost doubled its achievement of calendar year 1972, the Philippines, and Korea. In Thailand, the number of new acceptors dropped by about 10%. South Vietnam is the only country in the region without an official policy. Most couples still think that the ideal number of children is 4, with at least 2 sons. Some religious opposition does exist, particularly with reference to sterlization and abortion. More attention is being paid to women in their 20s. Sterilization and condoms are becoming more popular. Korea reports a sharp increase in vasectomies. Better methods and continuation rates should be stressed. In Taiwan a couple who start with 1 method and continue to practice some method lower their reproduction rate by 80%. More responsibility is being delegated to nurses and midwives, but too slowly. In Indonesia, the number of field workers rose from 3774 in 1972 to 6275 in 1973. The Philippines and Thailand are experimenting to see what kind of workers get best results and under what kind of salary and incentive arrangements. In-service training tends to be neglected, but preservice training is improving. Costs, in general, have risen, though in Korea the cost per acceptor has dropped from US$8.00 to US$7.80. Korea and Taiwan have reduced their annual population growth rates by more than 1/3 in 10 years, from 30 to 19-20 per 1000 each. Singapore's rate is 17 and Hong Kong's 14 (exclusive of inmigration). The number of couples currently practicing contraception in Singapore is 71%. Target systems assigning quotas to clinics are generally used except in Thailand and Malaysia, where programs emphasize maternal and child health, rather than population planning. Most programs require about 10 years to get the annual growth rate down to 2% by voluntary family planning. To get it down to 1.5% will probably take another 10 years.     

Enterovirus type 70: the etiologic agent of pandemic acute haemorrhagic conjunctivitis

A new enterovirus, now classified as enterovirus type 70, was isolated from the conjunctiva of patients with acute haemorrhagic conjunctivitis during the 1971 epidemics that occurred in Japan, Singapore, and Morocco. These epidemics were parts of a pandemic involving Africa (Algeria, Ghana, Morocco, Nigeria, and Tunisia), Asia (Cambodia, China (Province of Taiwan), Hong Kong, India, Indonesia, Japan, Malaysia, the Philippines, Singapore, and Thailand), and England during 1969-71. A representative strain from each of the three epidemic areas was studied cooperatively. The strains exhibited the physicochemical characteristics of enteroviruses. Cross-neutralization tests showed that these viruses were distinct from all known human enterovirus immunotypes, but that they were antigenically closely related. The human origin of the viruses was demonstrated by the appearance of homologous neutralizing antibodies during convalescence in patients with acute haemorrhagic conjunctivitis.     

Age-specific seroprevalence of hepatitis A infection among children visited in pediatric hospitals of Tehran, Iran

BACKGROUND: Hepatitis A is an enterically transmitted disease that still remains endemic in many developing countries. In some countries improvements in living conditions have recently led to changing in epidemiology of hepatitis A virus (HAV) infection. In our country there are very few reports on prevalence of HAV infection. OBJECTIVE: To determine the seroprevalence of anti-HAV IgG among children visited in pediatric hospitals of Tehran, Iran. METHODS: The study group included 1018 children who were 6 months-14.9 years of age. These children were visited in four major pediatric hospitals of Tehran. The children were separated to three age groups: Group 1 (6 months-4.9 years; n = 469), Group 2 (5.0-9.9 years; n = 290), and Group 3 (10.0-14.9 years; n = 259). Serum anti-HAV IgG was tested with commercial ELISA kits. The data were tested for statistical significance with chi2 test. RESULTS: In all subjects, seroprevalence of hepatitis A was 22.3% (95% CI: 19.7, 24.9). There was no significant difference between genders (22.2% vs. 22.5% in males and females, respectively) and among age groups (Group I was 22.1% and Group 3 was 25.9; p > 0.05). CONCLUSIONS: In summary, it seems that HAV infection is not highly endemic at least in some urban areas of Iran. On the basis of this epidemiologic data, post exposure prophylaxis would be necessary for children and young adults, and hepatitis A vaccination strategy should be revised.     

Current status of nutrition labelling and claims in the South-East Asian region: are we in harmony?

This review includes the situation of nutrition labelling and claims in six countries in South-East Asia: Brunei, Indonesia, Malaysia, Philippines, Singapore and Thailand. With the exception of Malaysia, there is no mandatory nutrition labelling requirements for foods in these countries except for special categories of foods and when nutritional claims are made for fortified or enriched foods. Nevertheless, several food manufacturers, especially multinationals, do voluntarily label the nutritional content of a number of food products. There is, therefore, increasing interest among authorities in countries in the region to start formulating regulations for nutrition labelling for a wider variety of foods. Malaysia has proposed new regulations to make it mandatory to label a number of foodstuffs with the four core nutrients, protein, carbohydrate, fat and energy. Other countries have preferred to start with voluntary labelling by the manufacturers, but have spelt out the requirements for this voluntary labelling. The format and requirements for nutrition labelling differ widely for countries in the region. Some countries, such as Malaysia, closely follow the Codex guidelines on nutrition labelling in terms of format, components to be included and mode of expression. Other countries, such as the Philippines and Thailand, have drafted nutrition labelling regulations very similar to those of the Nutrition Labeling and Education Act (NLEA) of the United States. Nutrition and health claims are also not specifically permitted under food regulations that were enacted before 1998. However, various food products on the market have been carrying a variety of nutrition and health claims. There is concern that without proper regulations, the food industry may not be certain as to what claims can be made. Excessive and misleading claims made by irresponsible manufacturers would only serve to confuse and mislead the consumer. In recent years, there has been efforts in countries in the region to enact regulations on nutrition claims. Recently enacted regulations or amendments to existing regulations of almost all the countries reviewed have included provisions for nutrition claims. Malaysia is in the process of gazetting regulations to clearly stipulate the permitted nutrition claims and the conditions required to make these claims along the guidelines of Codex Alimentarius Commission. Only two countries in the region permit health claims to be made - Indonesia and Philippines. Other countries in the region are following developments in Codex and examining the need for allowing these claims. There are more differences than similarities in the regulations on nutrition labelling and claims among countries in the South-East Asian region as no previous efforts have been made to address these. Hopefully, through this first regional meeting, countries can initiate closer interaction, with a view to working towards greater harmonization of nutrition labelling and health claims in the region.     

Hepatitis A shifting epidemiology in Latin America

In the past, Latin America was considered to be an area of high endemicity for hepatitis A virus (HAV) infection, with most people infected in early childhood. A seroepidemiological study was recently undertaken in six countries to determine whether this pattern has changed. The highest seroprevalence of antibodies to HAV (anti-HAV) was found in Mexico and the Dominican Republic. Analysis of the different age groups showed that at age 6-10 years, 30% of children in Chile and 54-55% in Brazil, Venezuela and Argentina had been infected, compared with almost 70% in Mexico and 80% in the Dominican Republic. At age 11-15 years, nearly 90% in Mexico and 91% in the Dominican Republic had been infected, compared with 54% in Argentina, 62% in Venezuela, 60% in Brazil and 70% in Chile. By age 31-40 years, over 80% of the populations in all six countries had been exposed to HAV. In all of the countries except Brazil and Venezuela, the seroprevalence of anti-HAV was significantly higher in females than in males. In Mexico, Argentina and Brazil, anti-HAV seroprevalence was significantly higher in the low socioeconomic groups than in the middle/high socioeconomic groups. The results show that there has been a shift from high to medium endemicity of HAV infection throughout Latin America, which may result in more clinical cases in adolescents and adults and a greater potential for outbreaks. The vaccination strategy for hepatitis A should thus be reviewed.     

Occupational Rehabilitation in Singapore and Malaysia

Introduction: Asia is the new and favored magnet of economic attention and foreign investments after it made an almost uneventful rebound from the depths of financial crisis of 2008/2009. Not many Western observers fully understand the diversity that is Asia other than perhaps its 2 growing economic giants of China and India. Indeed many smaller countries like Singapore and Malaysia in South East Asia along with Australia and Hong Kong (a Special Administrative Region within China) look to symbiotic relationships with these two economic giants. The purpose of this discussion paper is to examine the current issues related to the development and provision of occupational rehabilitation services in Singapore and Malaysia with a forward-looking view of how Asia’s different developing societies could potentially benefit from better alignment of occupational rehabilitation practices and sharing of expertise through international collaboration and dialogue platforms. Methods: Seven therapists and one physician who are frequently involved in occupational rehabilitation services in their home countries critically reviewed the current issues in Singapore and Malaysia which included analysis of the prevalence and cost of occupational injury; overview of workers’ compensation system; current practices, obstacles, and challenges in providing occupational rehabilitation and return to work practices. They also offered opinions about how to improve the occupational rehabilitation programs of their two home countries. Conclusion: Even though Malaysia and Singapore are two different countries, in many ways their current provision of occupational rehabilitation services and the problems they face with are very similar. There is a lot of room for systemic improvements that require government support and action. Most prominently, the training of more healthcare professionals in the assessment and rehabilitation of the injured worker should be encouraged. There could be better liaison between the many stakeholders and more funding made available to develop resources and to jump start strategic programs. As these two countries are witnessing rapid economic growth, more resources should be allocated to establish holistic care of the injured workers emphasizing early interventions and prevention of chronic disabilities.     

Vaccination strategies against hepatitis A in southern Europe

Hepatitis A virus (HAV) infection is decreasing in southern European countries, where epidemiological conditions vary among regions depending on the social and health-care system development. In high endemic settings, HAV infection has not heavy social and economic weight while in countries with a moderate/low degree of endemia there is a call for targeted vaccination policy. In countries, like Spain and in Italy, where several studies confirm an increase in susceptible adults, vaccination strategies have been applied and recommendations have been published about hepatitis A prevention. Universal hepatitis A immunization seems economically unattractive and most evidences for targeted vaccination have not yet been sufficiently investigated. Vaccine should be used to protect travellers to countries where HAV infection is a major risk and in preventing secondary cases and outbreaks.     

A new method for imputing country-level estimates of hepatitis A virus endemicity levels in the Eastern Mediterranean region

Background

Few country-level estimates for hepatitis A virus (HAV) seroprevlance are available for the 23 countries in the Eastern Mediterranean region (EMRO) of the World Health Organization.

Methods

We used a three-stage approach to assign an HAV endemicity level to each country in North Africa and the Middle East based on the age at midpoint of population immunity. First, we conducted a systematic review to identify all age–seroprevalence studies conducted within the past 10 years. Second, for countries without first-stage evidence we searched for incidence data and older seroprevalence data. Third, for countries with no hepatitis A data, we estimated HAV endemicity based on socioeconomic and water indicators.

Results

This three-stage method allowed us to estimate country-specific endemicity levels for every country in EMRO even though first-stage evidence was only available for nine countries and for three countries only third-stage evidence was available. The region has a heterogeneous hepatitis A risk profile, with 13 countries having very high endemicity (an age at midpoint of population immunity in early childhood), three having high endemicity (late childhood), and seven having intermediate endemicity (early adulthood).

Conclusions

The three-stage estimation approach enables the creation of a complete country-level map of HAV risk in EMRO. Given the heterogeneity of HAV endemicity levels in the region and the likelihood of transitions to lower incidence rates and greater adult susceptibility in the near future, enhanced surveillance for hepatitis A would strengthen decisions about vaccination policy in the region.     

Age-specific prevalence of hepatitis A virus antibody in Thailand

Serum specimens drawn at random from three geographically defined populations of healthy Thais were tested for antibody to the hepatitis A virus (anti-HAV) by radioimmunoassay. A total of 746 specimens were tested. The age by which 50 per cent were antibody positive was 4-5 years for residents of an urban Bangkok housing project, 8-9 years for rural villagers, and 10-11 years for urban Bangkok government school pupils. Overall, specimens from 97 per cent of Thai adults 16 years of age or older were anti-HAV positive. These data suggest widespread distribution of HAV in Thailand.     

Was the economic crisis 1997–1998 responsible for rising suicide rates in East/Southeast Asia? A time–trend analysis for Japan,Hong Kong,South Korea,Taiwan, Singapore and Thailand

In 1997–1998 a widespread economic crisis hit the economies of many East/Southeast Asian countries; its impact on suicide rates across the region has not been systematically documented. We investigated the impact of the Asian economic crisis (1997–1998) on suicide in Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Suicide and population data for the period 1985–2006 were extracted from the World Health Organisation's mortality database and Taiwanese mortality statistics. Sex-specific age-standardised suicide rates for people aged 15 years or above were analysed using joinpoint regression. Trends in divorce, marriage, unemployment, gross domestic product (GDP) per capita and alcohol consumption were compared with trends in suicide rates graphically and using time-series analysis. Suicide mortality decreased in the late 1980s and early 1990s but subsequently increased markedly in all countries except Singapore, which had steadily declining suicide rates throughout the study period. Compared to 1997, male rates in 1998 rose by 39% in Japan, 44% in Hong Kong and 45% in Korea; rises in female rates were less marked. Male rates also rose in Thailand, but accurate data were incomplete. The economic crisis was associated with 10,400 more suicides in 1998 compared to 1997 in Japan, Hong Kong and Korea. Similar increases in suicide rates were not seen in Taiwan and Singapore, the two countries where the economic crisis had a smaller impact on GDP and unemployment. Time-series analyses indicated that some of the crisis's impact on male suicides was attributable to increases in unemployment. These findings suggest an association of the Asian economic crisis with a sharp increase in suicide mortality in some, but not all, East/Southeast Asian countries, and that these increases were most closely associated with rises in unemployment.     

Changing epidemiology of hepatitis A infection in Izmir, Turkey

The seroprevalence study was conducted in order to determine the current seroepidemiology hepatitis A in Izmir, Turkey and to evaluate the epidemiological shift in HAV serostatus. Blood samples collected from 595 subjects aged 1-60 years were analyzed for anti-HAV IgG antibodies. The current study results were compared with those of a previous study conducted in 1998 involving the same location. There was a marked decrease in the prevalence of anti-HAV between 1998 and 2008. While anti-HAV seroprevalence rates in the current study were 4.6% in children aged 1-4 years, 23% in children aged 10-14 years, and 85% in young adults aged 20-29 years, the prevalence rates were 36% in the 1-4 years age group, 65% in the 10-14 years age group, and 95% in young adults in the previous study, indicating a shift in HAV seroprevalence from the younger to the higher age groups. As HAV infection in childhood is decreasing, the pool of susceptible adolescents and young adults is increasing in Izmir, Turkey. The majority of adolescent population is susceptible to HAV infection. The potential risk of HAV epidemics still exists. The situation of Turkey, suggested to need for mass immunization. Also, introduction of hepatitis A vaccination into the national immunization schedule of Turkey should be considered.     

A Paradigm Shift in Regulating and Running Nursing Homes in Singapore

Singapore faces a rapidly aging population. By 2030, 19% of her population will be aged 65 years and above. Other Asian countries face similar problems, with South Korea having the fastest aging population worldwide, followed by China and Thailand. With Singapore possessing an advanced aging population, its policy provides a useful case study of eldercare to cater to evolving population demographics. This article will focus specifically on nursing homes and analyze current policies toward them, synthesize recommendations to improve long-term care, and justify a paradigm shift toward more holistic, humanistic, and multidimensional care.