Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000-17: a financial modelling study

BACKGROUND

Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17.

METHODS

We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$.

FINDINGS

Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (-2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8-75·8) of tuberculosis spending in 2017.

INTERPRETATION

Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending.

FUNDING

Bill & Melinda Gates Foundation.

Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years

OBJECTIVE

To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload.

DESIGN

Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB).

SETTING

Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres.

PARTICIPANTS

The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers.

PRIMARY OUTCOME MEASURE

Volume and nature of surgical workload of different anaesthesia providers.

RESULTS

Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%.

CONCLUSION

Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.

[Prescription of Yellow Fever Vaccine: The Experience of the International Vaccination Centre of the Loures-Odivelas Health Centre Group]

INTRODUCTION

Yellow fever is a vector-borne disease in sub-Saharan Africa and tropical South America regions which is preventable by an effective and safe vaccine. In some cases, it may cause serious adverse effects and should therefore be prescribed only to individuals at risk of exposure to the yellow fever virus or those traveling to countries requiring proof of vaccination. The aim of this study was to analyze the prescriptions of yellow fever vaccine, based on travel destination and type of referring consultation, according to the international recommendations of the World Health Organization.

MATERIAL AND METHODS

The database of the International Vaccination Centre of the International Vaccination Centre of the Loures-Odivelas Health Centre Group was used to analyze data concerning the year of 2016. Travelers who were prescribed and administered the yellow fever vaccine were grouped based on travel destination and type of referring consultation (travelers' medical consultations or non-specialist consultations).

RESULTS

A total of 517 yellow fever vaccines were administered, with the highest proportion in female (53%) and in individuals aged 40 - 49 years (20.7%). One hundred and thirteen (22.6%) of the 499 individuals with known-destinations were travelling to non-endemic/non-epidemic countries and a greater proportion of those were prescribed in non-specialist consultations (27.3%) than in travel medicine consultations (8.8%).

DISCUSSION/CONCLUSION

The highest percentage of yellow fever vaccines that were administered to individuals travelling to non-endemic/non-epidemic countries were prescribed in non-specialist consultations.

The indirect impact of antiretroviral therapy: Mortality risk, mental health, and HIV-negative labor supply

To reduce the burden of the HIV/AIDS epidemic, international donors recently began providing free antiretroviral therapy (ART) in parts of Sub-Saharan Africa. ART dramatically prolongs life and reduces infectiousness for people with HIV. This paper shows that ART availability increases work time for HIV-negative people without caretaker obligations, who do not directly benefit from the medicine. A difference-in-difference design compares people living near and far from ART, before and after treatment becomes available. Next we explore the possible reasons for this pattern. Although we cannot pinpoint the mechanism, we find that ART availability substantially reduces subjective mortality risk and improves mental health. These results show an undocumented economic consequence of the HIV/AIDS epidemic and an important externality of medical innovation. They also provide the first evidence of a link between the disease environment and mental health.

International Variation in Female Breast Cancer Incidence and Mortality Rates

BACKGROUND

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer-related death among women worldwide. Herein, we examine global trends in female breast cancer rates using the most up-to-date data available.

METHODS

Breast cancer incidence and mortality estimates were obtained from GLOBOCAN 2012 (globocan.iarc.fr). We analyzed trends from 1993 onward using incidence data from 39 countries from the International Agency for Research on Cancer and mortality data from 57 countries from the World Health Organization.

RESULTS

Of 32 countries with incidence and mortality data, rates in the recent period diverged-with incidence increasing and mortality decreasing-in nine countries mainly in Northern/Western Europe. Both incidence and mortality decreased in France, Israel, Italy, Norway, and Spain. In contrast, incidence and death rates both increased in Colombia, Ecuador, and Japan. Death rates also increased in Brazil, Egypt, Guatemala, Kuwait, Mauritius, Mexico, and Moldova.

CONCLUSIONS

Breast cancer mortality rates are decreasing in most high-income countries, despite increasing or stable incidence rates. In contrast and of concern are the increasing incidence and mortality rates in a number of countries, particularly those undergoing rapid changes in human development. Wide variations in breast cancer rates and trends reflect differences in patterns of risk factors and access to and availability of early detection and timely treatment.

IMPACT

Increased awareness about breast cancer and the benefits of early detection and improved access to treatment must be prioritized to successfully implement breast cancer control programs, particularly in transitioning countries.

Natural vitamin C intake and the risk of head and neck cancer: A pooled analysis in the International Head and Neck Cancer Epidemiology Consortium

Evidence of associations between single nutrients and head and neck cancer (HNC) is still more limited and less consistent than that for fruit and vegetables. However, clarification of the protective mechanisms of fruit and vegetables is important to our understanding of HNC etiology. We investigated the association between vitamin C intake from natural sources and cancer of the oral cavity/pharynx and larynx using individual-level pooled data from ten case-control studies (5,959 cases and 12,248 controls) participating in the International Head and Neck Cancer Epidemiology (INHANCE) consortium. After harmonization of study-specific exposure information via the residual method, adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated using unconditional multiple logistic regression models on quintile categories of 'non-alcohol energy-adjusted' vitamin C intake. In the presence of heterogeneity of the estimated ORs among studies, we derived those estimates from generalized linear mixed models. Higher intakes of vitamin C were inversely related to oral and pharyngeal (OR = 0.54, 95% CI: 0.45-0.65, for the fifth quintile category versus the first one, p for trend<0.001) and laryngeal cancers (OR = 0.52, 95% CI: 0.40-0.68, p for trend = 0.006), although in the presence of heterogeneity among studies for both sites. Inverse associations were consistently observed for the anatomical subsites of oral and pharyngeal cancer, and across strata of age, sex, education, body mass index, tobacco, and alcohol, for both cancer sites. The inverse association of vitamin C intake from foods with HNC may reflect a protective effect on these cancers; however, we cannot rule out other explanations.

The development of education indicators for measuring quality in the English-speaking Caribbean: how far have we come?

Education evaluation has become increasingly important in the English-speaking Caribbean. This has been in response to assessing the progress of four regional initiatives aimed at improving the equity, efficiency, and quality of education. Both special interest groups and local evaluators have been responsible for assessing the progress of education and providing an overall synthesis and summary of what is taking place in the English-speaking Caribbean. This study employed content analysis to examine the indicators used in these education evaluation studies since the declaration of the Caribbean Plan of Action 2000-2015 to determine these indicators' appropriateness to the Caribbean context in measuring education progress. Findings demonstrate that the English-speaking Caribbean has made strides in operationalizing quality input, process, and output indicators; however quality outcome indicators beyond test scores are yet to be realized in a systematic manner. This study also compared the types of collaborative partnerships in conducting evaluation studies used by special interest groups and local evaluators and pinpointed the one that appears most suitable for special interest groups in this region.

Perspective in supportive care--practical experiences in Georgia

Authors describe the first steps of Palliative Care development in Georgia, including policy, educational issues, drug availability and services. It is underlined the importance and effectiveness of collaboration of Governmental institutions, NGOs and international organizations and experts to create the basis for Palliative care system in the Country. Georgian experience on revealing of problems of adequate pain control gained by survey with participation of advanced patients and their family members is also discussed. All current activities in the sphere of Palliative Care as well as the future models of Palliative Care provision in the capital and regions of Georgia is shown.

WNA's worldwide overview on front-end nuclear fuel cycle growth and health, safety and environmental issues

This paper presents the WNA's worldwide nuclear industry overview on the anticipated growth of the front-end nuclear fuel cycle from uranium mining to conversion and enrichment, and on the related key health, safety, and environmental (HSE) issues and challenges. It also puts an emphasis on uranium mining in new producing countries with insufficiently developed regulatory regimes that pose greater HSE concerns. It introduces the new WNA policy on uranium mining: Sustaining Global Best Practices in Uranium Mining and Processing-Principles for Managing Radiation, Health and Safety and the Environment, which is an outgrowth of an International Atomic Energy Agency (IAEA) cooperation project that closely involved industry and governmental experts in uranium mining from around the world.

Utilization of antiepileptic drugs during pregnancy: comparative patterns in 38 countries based on data from the EURAP registry

We assessed the utilization of antiepileptic drugs (AEDs), 1999-2005, in 4,798 prospective epilepsy pregnancies from 38 countries participating in EURAP, an international AED and pregnancy registry. Prominent differences in utilization patterns were observed across the various countries. Exposure to second-generation AEDs ranged from 3.5% in India and 7.3% in Italy to 75% in Denmark. Even wider variation was recorded in exposure to individual AEDs. The utilization of second-generation AEDs increased over time (for lamotrigine, from 9.9% of all pregnancies before 2001 to 29.6% after 2003). The differences in use of individual AEDs across countries probably reflect lack of evidence concerning the optimal treatment of epilepsy in women of childbearing age, as well as variation in country-specific traditions, medication costs, and drug promotion. Our observations underscore the need for comparative studies to investigate the factors influencing the prescription of AEDs during pregnancy, as well as their influence on pregnancy outcome.

The international standards for neurological classification of spinal cord injury: intra-rater agreement of total motor and sensory scores in the pediatric population

BACKGROUND

The International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) is the gold standard for evaluating and classifying the neurological consequence of spinal cord injury (SCI).

OBJECTIVE

To determine the within-rater agreement for total scores of light touch (LT), pin prick (PP), and total motor (TM) in children and youth.

DESIGN

Part of a larger cross-sectional study to determine the intra-rater reliability of the standards when applied to children and youth.

PARTICIPANTS/METHODS

A total of 187 subjects participated in 2 repeated examinations performed by the same rater. A total of 7 raters participated in this study. Intraclass correlations coefficients (ICCs), with 95% CI were calculated to determine agreement between the 2 examinations for LT, PP, and TM.

RESULTS

With the exception of subjects younger than 6 years, agreement on repeated total PP, LT, and TM scores were good to excellent, as shown by ICC values of 0.92 or higher. Although agreement was high for the youngest age group for LT (ICC = 0.920), PP (ICC = 0.957), and TM (ICC = 0.971), all of the lower 95% CI values fell well below 0.66, indicating poor precision. All subgroups had good to high agreement for total PP, LT, and TM scores, as indicated by ICC values of 0.87 and higher. There were lower 95% CI (LCI) values for the 6- to 11-year-old group with incomplete paraplegia due to the low number of subjects in that subgroup (N=4). The LCI values were poor for PP for the subgroups with 6- to 11-year-olds with incomplete tetraplegia (LCI = 0.675) and the 12- to 15-year-old group with incomplete paraplegia (LCI = 0.707) and for TM for 16- to 21-year-old group with complete paraplegia (LCI = 0.706).

CONCLUSIONS

In children as young as 6 years, within-rater agreement on LT, PP, and TM exceeded recommended values for clinical measures. With the exception of 6- to 11-year-olds with incomplete injuries, type of injury and severity of injury were not factors in agreement. Although more work is needed to define the lower age limit in which the ISCSCI have utility, these data represent growing evidence supporting the use of the ISCSCI when evaluating the neurological consequence of SCI in children.

How few whales were there after whaling? Inference from contemporary mtDNA diversity

Reconstructing the history of exploited populations of whales requires fitting a trajectory through at least three points in time: (i) prior to exploitation, when abundance is assumed to be at the maximum allowed by environmental carrying capacity; (ii) the point of minimum abundance or 'bottleneck', usually near the time of protection or the abandonment of the hunt; and (iii) near the present, when protected populations are assumed to have undergone some recovery. As historical abundance is usually unknown, this trajectory must be extrapolated according to a population dynamic model using catch records, an assumed rate of increase and an estimate of current abundance, all of which have received considerable attention by the International Whaling Commission (IWC). Relatively little attention has been given to estimating minimum abundance (N(min)), although it is clear that genetic and demographic forces at this point are critical to the potential for recovery or extinction of a local population. We present a general analytical framework to improve estimates of N(min) using the number of mtDNA haplotypes (maternal lineages) surviving in a contemporary population of whales or other exploited species. We demonstrate the informative potential of this parameter as an a posteriori constraint on Bayesian logistic population dynamic models based on the IWC Comprehensive Assessment of the intensively exploited southern right whales (Eubalaena australis) and published surveys of mtDNA diversity for this species. Estimated historical trajectories from all demographic scenarios suggested a substantial loss of mtDNA haplotype richness as a result of 19th century commercial whaling and 20th century illegal whaling by the Soviet Union. However, the relatively high rates of population increase used by the IWC assessment predicted a bottleneck that was implausibly narrow (median, 67 mature females), given our corrected estimates of N(min). Further, high levels of remnant sequence diversity (theta) suggested that pre-exploitation abundance was larger than predicted by the logistic model given the catch record, which is known to be incomplete. Our results point to a need to better integrate evolutionary processes into population dynamic models to account for uncertainty in catch records, the influence of maternal fidelity on metapopulation dynamics, and the potential for inverse density dependence (an 'Allee effect') in severely depleted populations.

How, and how not, to stop AIDS in Africa

A review of Helen Epstein's book, "The invisible cure: Africa, the West, and the fight against AIDS."

Bigger And Better? Scaling Up And Innovation In Health Aid

As the volume of health aid to developing countries increases and allocations shift toward specific disease burdens, issues of allocation efficiency become more important to the achievement of better health outcomes. This paper examines (1) whether health aid--traditional and innovative--corresponds to recipients' needs and priorities and (2) how the terms of aid affect its efficiency. We find that there is considerable scope for improvement through consolidation, improvement of terms, and increased attention to the efficient allocation of the marginal dollar of aid.

The International Standards for Neurological Classification of Spinal Cord Injury: reliability of data when applied to children and youths

STUDY DESIGN

Intra-rater reliability study, cross-sectional design.

OBJECTIVES

To determine reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory exam in children.

SETTING

Nonprofit pediatric hospital.

METHODS

In all, 74 subjects had two trials of the motor and sensory exams. Intraclass correlation coefficients (ICC), 95% confidence intervals (CI) were generated for total motor (TM), pin prick (PP) and light touch (LT) scores for the entire sample, four age groups, severity and type of injury. Coefficients >0.90=high reliability; 0.75-0.90=moderate reliability and <0.75=inadequate reliability.

RESULTS

Children <four years (N=7) were unable to participate in the exams. TM ICC, CI=0.888, 0.821-0.93 (N=73); PP ICC, CI=0.975, 0.96-0.98 (N=67) and LT ICC, CI=0.974, 0.974-0.985 (N=68). When age was considered, 4-5 year: TM ICC, CI=0.917, 0.69-0.98 (N=11), PP=0.912, 0.49-0.985 (N=7), LT=0.948, 0.63-0.993 (N=6); for 6-11 year: TM ICC, CI=0.711, 0.226-0.892 (N=18), PP=0.952, 0.867-0.983 (M=17), LT=0.952, 0.867-0.983 (N=17); for 12-15 year: TM ICC, CI=0.893, 0.723-0.959 (N=19), PP=0.982, 0.953-0.993 (N=19), LT=0.982, 0.953-0.993 (N=19); for 16-21 year: TM ICC, CI=0.912, 0.80-0.961 (N=25), PP=0.98, 0.954-0.991 (N=25), LT=0.98, 0.954-0.991 (N=25). ICC for severity and type of injury >0.90 except for TM in complete injuries (0.808).

CONCLUSION

The ISCSCI exams may have poor utility in children under 4 years. While reliability values for the motor and sensory exams met or exceeded recommended values, wide CI suggest poor precision of the motor exam in children under 15 years of age and sensory exams in children under 5 years.

Interlaboratory comparison of assessments of Alzheimer disease-related lesions: a study of the BrainNet Europe Consortium

This interlaboratory study evaluated the reproducibility of the assessments of neuritic plaques and neurofibrillary tangles (NFTs)--the hallmark lesions of Alzheimer disease--and compared the staining between the BrainNet Europe centers. To reduce the topography-related inconsistencies in assessments, we used a 2-mm tissue microarray (TMA) technique. The TMA block included 42 core samples taken from 21 paraffin blocks. The assessments were done on Bielschowsky and Gallyas silver stains using an immunohistochemical (IHC) method with antibodies directed to beta-amyloid (IHC/Abeta) and hyperphosphorylated tau (IHC/HPtau). The staining quality and the assessments differed between the participants, being most diverse with Bielschowsky (good/acceptable stain in 53% of centers) followed by Gallyas (good/acceptable stain in 57%) and IHC/Abeta (good/acceptable stain in 71%). The most uniform staining quality and assessment was obtained with the IHC/HPtau method (good/acceptable stain in 94% of centers). The neuropathologic diagnostic protocol (Consortium to Establish a Registry for Alzheimer Disease, Braak and Braak, and the National Institute of Aging and Reagan [NIA-Reagan] Institute) that was used significantly influenced the agreement, being highest with NIA-Reagan (54%) recommendations. This agreement was improved by visualization of NFTs using the IHC/HPtau method. Therefore, the IHC/HPtau methodology to visualize NFTs and neuropil threads should be considered as a method of choice in a future diagnostic protocol for Alzheimer disease.

State size as measured in terms of public spending and world health, 1990-2000

OBJECTIVE

To determine the relationship between state size (measured in terms of public spending) and public health indicators in a sample of countries representing all regions of the world and from 1990-2000.

METHODS

An ecological study was performed using data on Central Government Spending (CGS) and per capita Gross National Product (GNP) obtained from the International Monetary Fund, and on life expectancy, maternal, and infant mortality, provided by the World Health Organization. A multiple linear regression model was fitted to estimate the effect of CGS on health, which also took into consideration per capita GNP and geographical region.

RESULTS

CGS varied little over the study period, with convergence around an average of 28%, but within a relatively wide range (7.80-53.0%); the countries with the strongest economies (according to per capita GNP) had the highest levels of CGS. The influence of this factor was particularly relevant for the infant mortality rate (r = 0.40; beta = -1.327; EE = 0.237; t = -5.590; p < 0.001). Per capita GNP and geographic location were also associated with variations in health; health indicators tended to be worse for poorer countries in Africa and Asia. In the adjusted model, CGS was statistically significant with regard to infant and maternal mortality rates.

CONCLUSION

The study suggests that state size (in terms of public spending) has an important influence upon health and particularly upon mortality. Although it is important to bear in mind the limitations of this study and the reduced time window used, these results should be taken into consideration in the current political and epidemiological debate.

Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE)

The International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE) have come to consensus definitions for the terms epileptic seizure and epilepsy. An epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure.

Mefloquine increases the risk of serious psychiatric events during travel abroad: a nationwide case-control study in the Netherlands

BACKGROUND

Psychiatric events during travel abroad account for a large percentage of medical repatriations arranged by insurance companies. Several risk factors have been proposed for such events, one of these being use of mefloquine. We investigated the risk of psychiatric events during use of mefloquine.

METHOD

We performed a nationwide case control study using medical records from 4 large alarm centers in the Netherlands. Cases were patients contacting the alarm centers because of psychiatric events, according to International Code Primary Care code P (all psychiatric symptoms) or International Classification of Diseases, Ninth Edition, codes 290-319 (all psychiatric syndromes). To every case we matched up to 6 controls by alarm center, calendar time, and continent of travel. All controls had contacted the alarm centers because of nonpsychiatric medical reasons. Shortly after the anticipated day of return, cases and controls received a questionnaire regarding travel characteristics, gender, age, marital status, education, weight, height, general health, history of psychiatric diseases, use of medicines, smoking status, alcohol intake, coffee intake, and use of malaria prophylaxis. Dates of travel for the source population were between September 1, 1997, and June 1, 2000.

RESULTS

The study population consisted of 111 cases and 453 controls. The risk of psychiatric events during the use of mefloquine was 3.5 (95% CI = 1.4 to 8.7). In females, the risk was strongly increased, with an odds ratio of 47.1 (95% CI = 3.8 to 578.6). Stratification for history of psychiatric diseases showed that the risk of psychiatric events during use of mefloquine in cases without a history of psychiatric diseases was 3.8 (95% CI = 1.4 to 10.1), whereas the risk in cases with a history of psychiatric diseases was 8.0 (95% CI = 1.8 to 35.8).

CONCLUSION

The use of mefloquine is associated with an increased risk of psychiatric events in females and in patients with a history of psychiatric diseases.

Global estimates of fatal occupational accidents

Data on occupational accidents are not available from all countries in the world. Furthermore, underreporting, limited coverage by reporting and compensation schemes, and non-harmonized accident recording and notification systems undermine efforts to obtain worldwide information on occupational accidents. This paper presents a method and new estimated global figures of fatal accidents at work by region. The fatal occupational accident rates reported to the International Labour Office are extended to the total employed workforce in countries and regions. For areas not covered by the reported information, rates from other countries that have similar or comparable conditions are applied. In 1994, an average estimated fatal occupational accident rate in the whole world was 14.0 per 100,000 workers, and the total estimated number of fatal occupational accidents was 335,000. The rates are different for individual countries and regions and for separate branches of economic activity. In conclusion, fatal occupational accident figures are higher than previously estimated. The new estimates can be gradually improved by obtaining and adding data from countries where information is not yet available. Sectoral estimates for at least key economic branches in individual countries would further increase the accuracy.

Pancreas transplants for United States (US) and non-US cases as reported to the International Pancreas Transplant Registry (IPTR) and to the United Network for Organ Sharing (UNOS)

As of November 1997 more than 9,800 pancreas transplants had been reported to the IPTR, including more than 7,400 US and more than 2,400 non-US cases. Cases reported since the inception of UNOS in 1987 (more than 6,800 in the US and more than 2,000 from outside the US) were analyzed, with emphasis on 1994-97 cases. In the US, for all 1994-97 SPK transplants (n = 2,585), one-year patient, pancreas and kidney graft survival rates were 94%, 82% and 90%, respectively; for all PAK cases (n = 230), patient and graft survival rates at one year were 95% and 71%; and for all PTA cases (n = 117), patient and graft survival rates at one year were 93% and 62%, respectively. The 1994-97 pancreas survival rates in all categories were significantly higher than in previous eras. Analysis of bladder versus enteric drainage (BD vs ED) was made only for 1994-97 SPK cases since there were too few solitary ED cases for a comparison. One-year pancreas survival rates (all causes of failure included) were 83% for BD (n = 1,995) versus 80% for ED (n = 456) cases (p = NS). However, nearly 20% of SPK BD grafts had been converted to ED by 2 years. The pancreas retransplant success rates have also significantly increased over time. For 1994-97 pancreas retransplants (n = 92), the one-year graft survival rate was 72%. The technical failure (TF) rate for pancreas transplants has declined over time. For 1994-96 BD cases, the TF rate was 8% in SPK (n = 1,995), 13% in PAK (n = 174) and 11% in PTA (n = 90) cases. For SPK ED cases (n = 456) the TF rate was 11% (p = 0.06 vs SPK BD). The most common cause of technical loss was graft thrombosis, 5.5% for SPK, 10.2% for PAK and 6.7% for PTA. The TF rates were significantly higher in grafts from older (> 45 yrs) donors and donors who died from cardiovascular disease. The immunological graft loss rate has also significantly declined in all categories. For 1994-97, technically successful (TS) cases (DWFG censored), the rejection loss rate at one year was 2% in the SPK (n = 2,234), 9% in the PAK (n = 154), and 16% in the PTA (n = 78) categories. Cox multivariate analyses were done in each recipient category to assess for factors that influence risks of pancreas graft loss. Increasing donor age was a risk factor in all categories. HLA mismatching was important only in the solitary (PAK and PTA) categories. FK506 use was associated with a positive effect in all categories, as was MMF in the SPK category.

Problems and possible solutions in finding an unrelated bone marrow donor. Results of consecutive searches for 240 Dutch patients

To evaluate the efficiency of our protocol for finding an HLA matched unrelated bone marrow donor, search results obtained between 1990 and 1995 for 240 Dutch patients were analyzed. The percentage of patients for whom, according to information given by the registries, a fully split-HLA antigen matched donor is available, increased from 24% in 1990 to over 70% in 1995. As a result the percentage of patients transplanted rose from about 24% in 1990-1991 to 44% in 1994-1995. The median time between the start of the search and transplantation was about 6 months. The systematic use of Bone Marrow Donors Worldwide (BMDW) which comprises the HLA groups of all volunteer bone marrow donors in Europe, Israel, South Africa, North America, Canada, India, Australia and New Zealand has been essential in this context. While searching for a suitable donor several problems were encountered such as unavailability of donors (12%) and discordant typing results (8%; range < 1% to > 25%). Thus it is advisable to select several donors for a patient. For 86% of patients with at least one HLA identical donor on the serological level for HLA-A,-B,-DR,-DQ, an HLA-DRB1/3/4/5, and -DQB1 identical donor could be identified. As expected, patients with two frequent haplotypes in strong linkage disequilibrium had the best chance of obtaining an HLA matched donor. Unexpectedly, patients with only one such haplotype had an almost similar chance. It could be calculated that HLA-DR typing of HLA-A,-B identical donors was rarely cost-effective after 1992. Only 12 of the 75 transplanted patients (16%) typeable at DNA level for class II, turned out to be completely matched for HLA-A,-B,-C,-DRB1/3/4/5,-DQB1,-DPB1 and had a negative MLC test. In the group of patients transplanted with a fully matched donor and for whom a CTLp test was performed, only 7% (4/54) of the tests were negative. Search results for patients of non-European origin were dismal, with only four of 26 patients referred being transplanted. In summary, of the 240 patients for whom the Europdonor office searched for a donor, about one-third were transplanted, one-third had a potential donor but did not reach transplantation, while for the remaining one-third of patients no suitable donor could be found.

Measuring the relationship between income and NHEs (national health expenditures)

This article uses recently published time series data for the Organization for Economic Cooperation and Development countries to estimate income elasticities for health care expenditures. Several different models and alternative specifications are examined to determine the sensitivity and robustness of the estimated relationships. Income is the dominant-determinant of health care spending and longrun income elasticity for health care is significantly greater than unity. This implies that health care is a luxury good, and expenditures will tend to rise with the level of national income. There is little evidence that the degree of public finance reduces the level of health care expenditures.