Factors influencing rising caesarean section rates in China between 1988 and 2008

Objective

To identify factors driving the rapid increase in caesarean section in China between 1988 and 2008.

Methods

Data from four national cross-sectional surveys (1993, 1998, 2003 and 2008) and modified Poisson regression were used to determine whether changes in household income, access to health insurance or women’s education accounted for the rise in caesarean sections in urban and rural areas.

Findings

In 2008, 64.1% of urban women and 11.3% of women in the poorest rural region reported giving birth by caesarean section. A fast rise was occurring in all socioeconomic groups. Between 1993 and 2008, the risk of caesarean section had increased more than threefold in urban areas (relative risk, RR: 3.63; 95% confidence interval, CI: 2.61–5.04) and more than 15-fold in rural areas (RR: 15.46; 95% CI: 10.46–22.86). After adjustment for improvements in income, education and access to health insurance over the study period, the RR dropped minimally in urban areas (RR: 3.07; 95% CI: 2.32–4.07), which suggests that these factors do not explain the rise; in rural areas, the adjusted RR dropped to 7.18 (95% CI: 4.82–10.69), which shows that socioeconomic change is only partly responsible for the rise. Socioeconomic region of residence was a more important driver of the caesarean section rate than individual socioeconomic status.

Conclusion

The large variation in caesarean section rate by socioeconomic region – independent of individual income, health insurance or education – suggests that structural factors related to service supply have influenced the increasing rate more than a woman’s ability to pay.     

Heterogeneity in host risk factors for incident melanoma and non-melanoma skin cancer in a cohort of US women

Background

Melanoma, squamous cell carcinoma (SCC), and basal cell carcinoma (BCC) are 3 types of skin cancer that have distinct biologic characteristics and prognoses. We evaluated phenotypic differences in the risk of these cancers in US women.

Methods

We conducted a prospective study of 113 139 female nurses from 1984 to 2002. Over the 18 years of follow-up, there were 375 cases of melanoma, 495 cases of SCC, and 9423 cases of BCC.

Results

Women with melanoma were more likely to have a family history of melanoma (melanoma: RR 1.94, 95% confidence interval [CI] 1.36–2.76; SCC: RR 0.82, 95% CI 0.58–1.37; BCC: RR 1.49, 95% CI 1.38–1.62) and 6 or more moles on the left arm (melanoma: RR 3.66, 95% CI 2.15–6.24; SCC: RR 1.53, 95% CI 0.83–2.79; BCC: RR 1.48, 95% CI 1.28–1.72). Polytomous logistic regression analysis showed that age at diagnosis (P < 0.0001), family history of melanoma (P = 0.016), and number of moles on the left arm (P = 0.007) were significantly different across the 3 cancers.

Conclusions

This prospective observational study demonstrated that known phenotypic factors for skin cancer have a differential impact on the risk of melanoma, SCC, and BCC.Key words: melanoma, squamous cell carcinoma, basal cell carcinoma, phenotype     

Maternal multiple micronutrient supplementation and pregnancy outcomes in developing countries: meta-analysis and meta-regression

Objective

To systematically review randomized controlled trials comparing the effect of supplementation with multiple micronutrients versus iron and folic acid on pregnancy outcomes in developing countries.

Methods

MEDLINE and EMBASE were searched. Outcomes of interest were birth weight, low birth weight, small size for gestational age, perinatal mortality and neonatal mortality. Pooled relative risks (RRs) were estimated by random effects models. Sources of heterogeneity were explored through subgroup meta-analyses and meta-regression.

Findings

Multiple micronutrient supplementation was more effective than iron and folic acid supplementation at reducing the risk of low birth weight (RR: 0.86, 95% confidence interval, CI: 0.79–0.93) and of small size for gestational age (RR: 0.85; 95% CI: 0.78–0.93). Micronutrient supplementation had no overall effect on perinatal mortality (RR: 1.05; 95% CI: 0.90–1.22), although substantial heterogeneity was evident (I² = 58%; P for heterogeneity = 0.008). Subgroup and meta-regression analyses suggested that micronutrient supplementation was associated with a lower risk of perinatal mortality in trials in which > 50% of mothers had formal education (RR: 0.93; 95% CI: 0.82–1.06) or in which supplementation was initiated after a mean of 20 weeks of gestation (RR: 0.88; 95% CI: 0.80–0.97).

Conclusion

Maternal education or gestational age at initiation of supplementation may have contributed to the observed heterogeneous effects on perinatal mortality. The safety, efficacy and effective delivery of maternal micronutrient supplementation require further research.     

Twenty-year trends in the prevalence of disability in China

Objective

To evaluate changes in the age-adjusted prevalence of disability in transitional China from 1987 to 2006.

Methods

Data from nationally representative surveys conducted in 1987 and 2006 were used to calculate age-adjusted disability prevalence rates by applying appropriate sample weights and directly adjusting to the age distribution of the 1990 Chinese population. Trends were assessed in terms of average annual percentage change.

Findings

The estimated number of disabled people in China in 1987 and 2006 was 52.7 and 84.6 million, respectively, corresponding to a weighted prevalence of 4.9% and 6.5%. The age-adjusted prevalence of disability decreased by an average of 0.5% per year (average annual percentage change, AAPC: −0.5%; 95% confidence interval, CI: −0.7 to −0.4) during 1987–2006. However, it increased by an average of 0.3% (AAPC: 0.3%; 95% CI: 0.1 to 0.5) per year in males and by an average of 1.0% (AAPC: 1.0%; 95% CI: 0.8 to 1.2) per year among rural residents, whereas among females it showed an average annual decrease of 1.5% (AAPC: −1.5%; 95% CI: −1.7 to −1.3) and among urban residents, an average annual decrease of 3.9% (AAPC: −3.9%; 95% CI: −4.3 to −3.5). Despite significant declining trends for hearing and speech, intellectual and visual disabilities, the annual age-adjusted prevalence of physical and mental disabilities increased by an average of 11.2% (AAPC: 11.2%; 95% CI: 10.5 to 11.9) and 13.3% (AAPC: 13.3%; 95% CI: 10.7 to 16.2), respectively.

Conclusion

In China, the age-adjusted prevalence of disability has declined since 1987, with inconsistencies dependent on the type of disability. These findings call for continuing and specific efforts to prevent disabilities in China.     

Disseminated bacille Calmette�CGu��rin disease in HIV-infected South African infants

Objective

To determine the population-based incidence of disseminated bacille Calmette–Guérin (BCG) disease in HIV-infected infants (aged ≤ 1 year) in a setting with a high burden of tuberculosis and HIV infection coupled with a well-functioning programme for the prevention of HIV infection in infants.

Methods

The numerator, or number of new cases of disseminated BCG disease, was derived from multicentre surveillance data collected prospectively on infants with a confirmed HIV infection during 2004–2006. The denominator, or total number of HIV-infected infants who were BCG-vaccinated, was derived from population-based estimates of the number of live infants and from reported maternal HIV infection prevalence, vertical HIV transmission rates and BCG vaccination rates.

Findings

The estimated incidences of disseminated BCG disease per 100 000 BCG-vaccinated, HIV-infected infants were as follows: 778 (95% confidence interval, CI: 361–1319) in 2004 (vertical HIV transmission rate: 10.4%); 1300 (95% CI: 587–2290) in 2005 (transmission rate: 6.1%); and 1013 (95% CI: 377–1895) in 2006 (transmission rate: 5.4%). The pooled incidence over the study period was 992 (95% CI: 567–1495) per 100 000.

Conclusion

Multicentre surveillance data showed that the risk of disseminated BCG disease in HIV-infected infants is considerably higher than previously estimated, although likely to be under-estimated. There is an urgent need for data on the risk–benefit ratio of BCG vaccination in HIV-infected infants to inform decision-making in settings where HIV infection and tuberculosis burdens are high. Safe and effective tuberculosis prevention strategies are needed for HIV-infected infants.     

Under-registration of deaths in Thailand in 2005-2006: results of cross-matching data from two sources

Objective

To estimate the magnitude of under-registration of deaths, by age and sex, in Thailand.

Methods

The data in this study were derived from two sources: the Thai Survey of Population Changes (SPC) 2005–2006, a consecutive multi-round household survey conducted over a 12-month period, and Thailand’s vital registration records. SPC death entries for people of all ages were matched to 2005–2006 death records from vital registration. The principles of a dual records system were applied to estimate the magnitude of under-registration of deaths, classified by age and sex, using the Chandrasekaran-Deming formula.

Findings

Overall under-registration of deaths during 2005–2006 was 9.00% (95% confidence interval, CI: 8.95–9.05) for males and 8.36% (95% CI: 8.31–8.41) for females. For both males and females, under-registration decreased as age increased. Under-registration was greatest among people of either sex aged 1–4 years, whereas it was < 10% among people 60 years of age and older, both males and females.

Conclusion

These findings provided correction factors that can be used for adjusting mortality data from the registration system.     

High-sensitivity C-reactive protein and cancer

Background

High-sensitivity C-reactive protein (hs-CRP) is a commonly used inflammatory marker. The association between hs-CRP and cancer is less consistent than that between hs-CRP and cardiovascular diseases. This study explored the association between hs-CRP and cancer, using a large database of Korean health examination records.

Methods

A total of 80 781 Koreans who visited the health promotion center of a general hospital were included. There were 729 cases of cancer of any primary site during a 3-year period. Subjects with a known cancer or a condition capable of affecting hs-CRP were excluded.

Results

Serum hs-CRP was significantly higher in cancer cases (2.9 mg/L) than in non-cases (1.4 mg/L; P < 0.0001). With the lowest hs-CRP category (<1 mg/L) as reference, the crude odds ratios (ORs) for cancer were 1.36 (95% confidence interval [CI] = 1.16–1.62) for the second highest category (1–3 mg/L) and 2.49 (95% CI = 2.02–3.07) for the highest category (>3 mg/L), and the adjusted ORs for cancer were 1.16 (95% CI = 0.95–1.42) for the second highest category and 1.94 (95% CI = 1.51–2.51) for the highest category. After excluding cancer cases detected within 1 year after the check-up, the associations remained, although the reduced number of cancer cases (n = 88) attenuated the significance of the associations.

Conclusions

Serum hs-CRP was positively associated with the risk of cancer, although causality cannot be inferred in this cross-sectional study. The results support the hypothesis that chronic inflammation plays a role in cancer.Key words: high-sensitivity C-reactive protein, cancer, inflammation     

Association between frequency of drinking alcohol and chronic kidney disease in men

Objectives

Chronic kidney disease (CKD) is a major public health problem. Epidemiological studies of the relationship between alcohol intake and CKD are scarce in Japan. This cross-sectional study aims to investigate the relationship between frequency of drinking alcohol and CKD in Japanese men.

Methods

The subjects were 9,196 men (mean ± standard deviation age, 57.9 ± 5.1 years) who underwent a health check-up. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m². Frequency of alcohol drinking was obtained from questionnaire and divided into five categories: nondrinkers, once or twice a week, three or four times a week, five or six times a week, and everyday drinkers.

Results

Multivariable-adjusted [age, body mass index, hypertension, diabetes, hyper-low-density lipoprotein (LDL) cholesterolemia, smoking, and physical activity] odds ratios and 95% confidence intervals (CIs) were calculated using logistic regression analysis. Compared with the results for the nondrinkers, the multivariable-adjusted odds ratios of CKD were as follows: 0.76 (95% CI 0.60–0.95) for 1–2 drinks per week, 0.74 (95% CI 0.59–0.93) for 3–4 drinks per week, 0.79 (95% CI 0.64–0.97) for 5–6 drinks per week, and 0.60 (95% CI 0.51–0.71) for everyday drinkers. There was a significant inverse trend across increasing frequency of drinking alcohol (p = 0.001 for trend).

Conclusions

An inverse association was found between frequency of drinking alcohol and CKD in apparently healthy men.     

Risk factors associated with sexual violence towards girls in Swaziland

Objective

To explore risk factors for sexual violence in childhood in a nationally representative sample of females aged 13 to 24 years in Swaziland.

Methods

During a household survey respondents were asked to report any experiences of sexual violence before the age of 18 years. The association between childhood sexual violence and several potential demographic and social risk factors was explored through bivariate and multivariate logistic regression.

Findings

Participants totalled 1244. Compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence (crude odds ratio, COR: 1.89; 95% CI: 1.14–3.14), as did those who had had no relationship with her at all (COR: 1.93; 95% CI: 1.34–2.80). In addition, greater odds of childhood sexual violence were noted among respondents who were not attending school at the time of the survey (COR: 2.26; 95% CI: 1.70–3.01); who were emotionally abused as children (COR: 2.04; 95% CI: 1.50–2.79); and who knew of another child who had been sexually assaulted (COR: 1.77; 95% CI: 1.31–2.40) or was having sex with a teacher (COR: 2.07; 95% CI: 1.59–2.69). Childhood sexual violence was positively associated with the number of people the respondent had lived with at any one time (COR: 1.03; 95% CI: 1.01–1.06).

Conclusion

Inadequate supervision or guidance and an unstable environment put girls at risk of sexual violence. Greater educational opportunities and an improved mother-daughter relationship could help prevent it.     

Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa

Objective

To investigate trends in adult mortality in a population serviced by a public-sector antiretroviral therapy (ART) programme in rural South Africa using a demographic surveillance system.

Methods

Verbal autopsies were conducted for all 7930 deaths observed between January 2000 and December 2006 in a demographic surveillance population of 74 500 in the Umkhanyakude district of northern KwaZulu-Natal province, South Africa. Age-standardized mortality rate ratios (SMRRs) were calculated for adults aged 25 to 49 years, the group most affected by HIV, for the 2 years before 2004 and the 3 subsequent years, during which ART had been available.

Findings

Between 2002–2003 (the period before ART) and 2004–2006 (the period after ART), HIV-related age-standardized mortality declined significantly, from 22.52 to 17.58 per 1000 person-years in women 25–49 years of age (P < 0.001; SMRR: 0.780; 95% confidence interval, CI: 0.691–0.881), and from 26.46 to 18.68 per 1000 person-years in men 25–49 years of age (P < 0.001; SMRR: 0.706; 95% CI: 0.615–0.811). On sensitivity analysis the results were robust to the possible effect of misclassification of HIV-related deaths.

Conclusion

Overall population mortality and HIV-related adult mortality declined significantly following ART roll-out in a community with a high prevalence of HIV infection. A clear public health message of the benefits of treatment, as revealed by these findings, should be part of a multi-faceted strategy to encourage people to find out their HIV serostatus and seek care.     

Estimated incidence of influenza-virus-associated severe pneumonia in children in El Salvador, 2008�C2010

Objective

To estimate the incidence of influenza-virus-associated severe pneumonia among Salvadorian children aged < 5 years.

Methods

Data on children aged < 5 years admitted with severe pneumonia to a sentinel hospital in the western region were collected weekly. Nasal and oropharyngeal swab specimens were collected from a convenience sample of case patients for respiratory virus testing. A health-care utilization survey was conducted in the hospital catchment area to determine the proportion of residents who sought care at the hospital. The incidence of influenza-virus-associated severe pneumonia among all Salvadorian children aged < 5 years was estimated from surveillance and census data, with adjustment for health-care utilization. Influenza virus strains were characterized by the United States Centers for Disease Control and Prevention to determine their correspondence with northern and southern hemisphere influenza vaccine formulations.

Findings

Physicians identified 2554 cases of severe pneumonia. Samples from 608 cases were tested for respiratory viruses and 37 (6%) were positive for influenza virus. The estimated incidence of influenza-virus-associated severe pneumonia was 3.2 cases per 1000 person–years (95% confidence interval, CI: 2.8–3.7) overall, 1.5 cases per 1000 person–years (95% CI: 1.0–2.0) during 2008, 7.6 cases per 1000 person–years (95% CI: 6.5–8.9) during 2009 and 0.6 cases per 1000 person–years (95% CI: 0.3–1.0) during 2010. Northern and southern hemisphere vaccine formulations matched influenza virus strains isolated during 2008 and 2010.

Conclusion

Influenza-virus-associated severe pneumonia occurred frequently among young Salvadorian children during 2008–2010. Antigens in northern and southern hemisphere influenza vaccine formulations corresponded to circulating strains.     

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in the United Republic of Tanzania

Objective

To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011.

Methods

We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models.

Findings

The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3–147.4) in 2000 to 66.2 (95% CI: 59.0–74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1–130.7) in 2000 to 76.2 (95% CI: 66.7–86.9) in 2011. Combining both sites, in 2000–2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08–1.92) higher than for children of mothers who had received education beyond primary school and in 2010–2011, the HR was 1.18 (95% CI: 0.90–1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99–1.47) in 2000–2001 to 1.48 (95% CI: 1.15–1.89) in 2010–2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09–1.55) to 1.15 (95% CI: 0.95–1.39) in the same period.

Conclusion

While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.     

Effect on road traffic injuries of criminalizing road traffic offences: a time-series study

Objective

To determine the effect of criminalizing some traffic behaviours, after the reform of the Spanish penal code in 2007, on the number of drivers involved in injury collisions and of people injured in traffic collisions in Spain.

Methods

This study followed an interrupted times–series design in which the number of drivers involved in injury collisions and of people injured in traffic collisions in Spain before and after the criminalization of offences were compared. The data on road traffic injuries in 2000–2009 were obtained from the road traffic collision database of the General Traffic Directorate. The dependent variables were stratified by sex, age, injury severity, type of road user, road type and time of collision. Quasi-Poisson regression models were fitted with adjustments for time trend, seasonality, previous interventions and national fuel consumption.

Findings

The overall number of male drivers involved in injury collisions dropped (relative risk, RR: 0.93; 95% confidence interval, CI: 0.89–0.97) after the reform of the penal code, but among women no change was observed (RR: 0.99; 95% CI: 0.95–1.03). In addition, 13 891 men (P < 0.01) were prevented from being injured. Larger reductions were observed among young male drivers and among male motorcycle or moped riders than among the drivers of other vehicles.

Conclusion

The findings suggest that criminalizing certain traffic behaviours can improve road safety by reducing both the number of drivers involved in injury collisions and the number of people injured in such collisions.     

Increased paediatric hospitalizations for empyema in Australia after introduction of the 7-valent pneumococcal conjugate vaccine

Objective

To examine rates of paediatric hospitalization for empyema and pneumonia in Australia before and after the introduction of the seven-valent pneumococcal conjugate vaccine (PCV7).

Methods

Rates of paediatric hospitalization for empyema and pneumonia (bacterial, viral and all types) were calculated following the codes of the International Classification of Diseases, tenth revision (ICD-10) as a principal diagnosis. The expected number of hospitalizations after the PCV7 was introduced was estimated on the basis of the observed number of hospitalizations before the introduction of the PCV7. Incidence rate differences (IRDs) and incidence rate ratios (IRRs) were calculated. Hospitalization incidence in each study period was expressed as the number of hospitalizations per million (10⁶) person–years. The population of children aged 0–19 years in Australia from 1998 to 2004 and from 2005 to 2010, as reported by the Australian Bureau of Statistics, was used to calculate the number of person–years in each period.

Findings

In the 5 years following the introduction of the PCV7, hospitalizations for pneumonia were fewer than expected (15 304 fewer; 95% confidence interval, CI: 14 646–15 960; IRD: −552 per 10⁶ person–years; 95% CI: −576 to −529 per 10⁶ person–years; IRR: 0.78; 95% CI: 0.77–0.78). Hospitalizations for empyema, on the other hand, were more than expected (83 more; 95% CI: 37–128; IRD: 3 per 10⁶ person–years; 95% CI: 1–5 per 10⁶ person–years; IRR: 1.35; 95% CI: 1.14–1.59). Reductions in hospitalizations were observed for all ICD-10 pneumonia codes across all age groups. The increase in empyema hospitalizations was only significant among children aged 1 to 4 years.

Conclusion

The introduction of the PCV7 in Australia was associated with a substantial decrease in hospitalizations for childhood pneumonia and a small increase in hospitalizations for empyema.     

Risk Factors for Community-Based Reports of Gastrointestinal,Respiratory, and Dermal Symptoms: Findings From a Cohort Study in Australia

Background

Although gastrointestinal (GI), respiratory, and dermal symptoms are common, few studies have conducted concurrent and comparative prospective analyses of risk factors for these 3 morbidity outcomes.

Methods

We used data from a community-based randomized controlled trial among 277 South Australian families to analyze GI (diarrhea, vomiting), respiratory (sore throat, runny nose, cough) and dermal (rash, generalized itch, dermal infection) symptoms.

Results

Log-binomial regression analysis revealed similar risks of GI (adjusted risk ratio [RR], 1.65; 95% CI, 1.05–2.58) and respiratory (RR, 1.68; 95% CI, 1.31–2.15) symptoms among childcare/kindergarten attendees. Swimming in public pools/spas in the current or previous week was associated with all 3 symptom complexes, conferring similar risk for each (RR for GI: 1.33; 95% CI, 0.99–1.77; respiratory: 1.20; 95% CI, 1.04–1.38; dermal: 1.41; 95% CI, 1.08–1.85). Pet ownership was not associated with symptoms. Household clustering of GI and respiratory symptoms was common, and clustering of respiratory symptoms correlated with number of individuals per household.

Conclusions

This simultaneous examination of risk factors for 3 health outcomes yielded new comparative data that are useful for developing prevention strategies.Key words: risk factors, respiratory symptoms, gastrointestinal symptoms, dermal symptoms, swimming, swimming pools, household clustering     

Arsenic exposure in pregnancy increases the risk of lower respiratory tract infection and diarrhea during infancy in Bangladesh

Background

Previous studies have reported associations between prenatal arsenic exposure and increased risk of infant mortality. An increase in infectious diseases has been proposed as the underlying cause of these associations, but there is no epidemiologic research to support the hypothesis.

Objective

We evaluated the association between arsenic exposure in pregnancy and morbidity during infancy.

Methods

This prospective population-based cohort study included 1,552 live-born infants of women enrolled during 2002–2004 in Matlab, Bangladesh. Arsenic exposure was assessed by the concentrations of metabolites of inorganic arsenic in maternal urine samples collected at gestational weeks 8 and 30. Information on symptoms of lower respiratory tract infection (LRTI) and diarrhea in infants was collected by 7-day recalls at monthly home visits.

Results

In total, 115,850 person-days of observation were contributed by the infants during a 12-month follow-up period. The estimated risk of LRTI and severe LRTI increased by 69% [adjusted relative risk (RR) = 1.69; 95% confidence interval (CI), 1.36–2.09)] and 54% (RR = 1.54; 95% CI, 1.21–1.97), respectively, for infants of mothers with urinary arsenic concentrations in the highest quintile (average of arsenic concentrations measured in early and late gestation, 262–977 μg/L) relative to those with exposure in the lowest quintile (< 39 μg/L). The corresponding figure for diarrhea was 20% (RR = 1.20; 95% CI, 1.01–1.43).

Conclusions

Arsenic exposure during pregnancy was associated with increased morbidity in infectious diseases during infancy. Taken together with the previous evidence of adverse effects on health, the findings strongly emphasize the need to reduce arsenic exposure via drinking water.     

Surveillance of anti-tuberculosis drug resistance in the world: an updated analysis, 2007-2010

Objective

To present a global update of drug-resistant tuberculosis (TB) and explore trends in 1994–2010.

Methods

Data on drug resistance among new and previously treated TB patients, as reported by countries to the World Health Organization, were analysed. Such data are collected through surveys of a representative sample of TB patients or surveillance systems based on routine drug susceptibility testing. Associations between multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection and sex were explored through logistic regression.

Findings

In 2007–2010, 80 countries and 8 territories reported surveillance data. MDR-TB among new and previously treated cases was highest in the Russian Federation (Murmansk oblast, 28.9%) and the Republic of Moldova (65.1%), respectively. In three former Soviet Union countries and South Africa, more than 10% of the cases of MDR-TB were extensively drug-resistant. Globally, in 1994 to 2010 multidrug resistance was observed in 3.4% (95% confidence interval, CI: 1.9–5.0) of all new TB cases and in 19.8% (95% CI: 14.4–25.1) of previously treated TB cases. No overall associations between MDR-TB and HIV infection (odds ratio, OR: 1.4; 95% CI: 0.7–3.0) or sex (OR: 1.1; 95% CI: 0.8–1.4) were found. Between 1994 and 2010, MDR-TB rates in the general population increased in Botswana, Peru, the Republic of Korea and declined in Estonia, Latvia and the United States of America.

Conclusion

The highest global rates of MDR-TB ever reported were documented in 2009 and 2010. Trends in MDR-TB are still unclear in most settings. Better surveillance or survey data are required, especially from Africa and India.     

Iodine status in late pregnancy and psychosocial determinants of iodized salt use in rural northern Viet Nam

Objective

To establish iodine status among pregnant women in rural northern Viet Nam and explore psychosocial predictors of the use of iodized salt in their households.

Methods

This prospective study included pregnant women registered in health stations in randomly-selected communes in Ha Nam province. At recruitment (< 20 weeks of gestation), sociodemographic factors, reproductive health, intimate partner relationship, family violence, symptoms of common mental disorders and use of micronutrient supplements were assessed. During a second assessment (> 28 weeks of gestation) a urine specimen was collected to measure urinary iodine concentration (UIC) and iodized salt use was assessed. Predictors were explored through univariable analyses and multivariable linear and logistic regression.

Findings

The 413 pregnant women who provided data for this study had a median UIC of 70 µg/l; nearly 83% had a UIC lower than the 150 µg/l recommended by the World Health Organization; only 73.6% reported using iodized salt in any form in their households. Iodized salt use was lower among nulliparous women (odds ratio, OR: 0.56; 95% confidence interval, CI: 0.32–0.96); less educated women (OR: 0.34; 95% CI: 0.16–0.71); factory workers or small-scale traders (OR: 0.52; 95% CI: 0.31–0.86), government workers (OR: 0.35; 95% CI: 0.13–0.89) and women with common mental disorders at recruitment (OR: 0.61; 95% CI: 0.38–0.98).

Conclusion

The decline in the use of iodized salt in Viet Nam since the National Iodine Deficiency Disorders Control Programme was suspended in 2005 has placed pregnant women and their infants in rural areas at risk of iodine deficiency disorders.     

Identification of Abnormal Screening Mammogram Interpretation Using Medicare Claims Data

Objective

To develop and validate Medicare claims-based approaches for identifying abnormal screening mammography interpretation.

Data Sources

Mammography data and linked Medicare claims for 387,709 mammograms performed from 1999 to 2005 within the Breast Cancer Surveillance Consortium (BCSC).

Study Design

Split-sample validation of algorithms based on claims for breast imaging or biopsy following screening mammography.

Data Extraction Methods

Medicare claims and BCSC mammography data were pooled at a central Statistical Coordinating Center.

Principal Findings

Presence of claims for subsequent imaging or biopsy had sensitivity of 74.9 percent (95 percent confidence interval [CI], 74.1–75.6) and specificity of 99.4 percent (95 percent CI, 99.4–99.5). A classification and regression tree improved sensitivity to 82.5 percent (95 percent CI, 81.9–83.2) but decreased specificity (96.6 percent, 95 percent CI, 96.6–96.8).

Conclusions

Medicare claims may be a feasible data source for research or quality improvement efforts addressing high rates of abnormal screening mammography.     

Measles incidence and reporting trends in Germany, 2007–2011

Objective

We aimed to quantify progress towards measles elimination in Germany from 2007 to 2011 and to estimate any potential underreporting over this period.

Methods

We determined the annual incidence of notified cases of measles – for each year – in northern, western, eastern and southern Germany and across the whole country. We then used measles-related health insurance claims to estimate the corresponding incidence.

Findings

In each year between 2007 and 2011, there were 6.9–19.6 (mean: 10.8) notified cases of measles per million population. Incidence decreased with age and showed geographical variation, with highest mean incidence – 20.3 cases per million – in southern Germany. Over the study period, incidence decreased by 10% (incidence rate ratio, IRR: 0.90; 95% confidence interval, CI: 0.85–0.95) per year in western Germany but increased by 77% (IRR: 1.77; 95% CI: 1.62–1.93) per year in eastern Germany. Although the estimated incidence of measles based on insurance claims showed similar trends, these estimates were 2.0- to 4.8-fold higher than the incidence of notified cases. Comparisons between the data sets indicated that the underreporting increased with age and was generally less in years when measles incidence was high than in low-incidence years.

Conclusion

Germany is still far from achieving measles elimination. There is substantial regional variation in measles epidemiology and, therefore, a need for region-specific interventions. Our analysis indicates underreporting in the routine surveillance system between 2007 and 2011, especially among adults.