Lights, camera…research! Short film and social media to recruit to HIV research in Indonesia

Introduction

HIV prevalence among men who have sex with men has increased in Indonesia, amid reports of growing stigma against lesbian, gay, bisexual and transgender individuals and policies that have pushed back public health outreach to these groups.

Methods

We assessed the utility of tailored short film and targeted social media engagement to recruit men who have sex with men in Indonesia to HIV social science research. A short HIV testing promotion film, anonymised short survey and invite to a wider research study was embedded on a website platform and disseminated using geo and social/community group targeting for 1 month via a social networking app and social media platforms.

Results

From 3 January 2021 to 3 February 2021, there were over 2200 hits of the website within Indonesia. A total of 177 male web users who identified as men who have sex with men or preferred not to declare their sexuality, engaged by watching the short film and completing the survey, they were aged between 17 and 60 years old, of Indonesian nationality and living in Indonesia. Of these, 88% indicated having at least one HIV test in their lifetime, 66% had felt shame with respect to their sexuality and 53% indicated feeling afraid to have a HIV test. Ninety (51%) of the 177 validated using their email or mobile phone number demonstrating willingness to be contacted to join a further study. Twenty-three eligible men who have sex with men, aged 21–55 years old, joined a further social science research study. Participants were from diverse backgrounds and included men born in provinces outside Bali, of different socio-economic and employment backgrounds and diverse relationship contexts.

Discussion

Engaging, empowering digital media involving key health messaging can provide health education in more effective ways, build trust and bring communities together. Targeted digital and social media approaches could reach increasingly marginalised and vulnerable communities to promote individual and public health and enable recruitment to valuable medical research.

Rapid initiation of antiretroviral therapy in those with newly diagnosed HIV infection in London, UK

OBJECTIVES

In July 2016, as a result of patient demand, we introduced a rapid initiation option (RIO) to offer a first medical appointment and antiretroviral therapy (ART) initiation within 2 days of HIV diagnosis at 56 Dean Street (56DS) , a combined sexual health and HIV treatment service in London, UK.

METHODS

We performed a retrospective case-note review of patients newly diagnosed with HIV infection at 56DS following the introduction of the new RIO from July to October 2016. In order to assess the effect of the new service on ART uptake, we chose a comparison group of newly diagnosed patients at 56DS from 1 year earlier: July to October 2015.

RESULTS

In the 4 months following RIO introduction, there was a reduction in the median time from HIV diagnosis to the first medical appointment (7 versus 15 days; P < 0.00001) and to ART initiation (8 versus 21 days; P < 0.00001) compared with the same 4-month period 1 year previously. Uptake of ART at first appointment also significantly increased from 60% to 76% (P = 0.0074).

CONCLUSIONS

By increasing our clinic capacity and awareness of staff and patients of the RIO service, we were able to fulfil the aim of the service to offer ART more quickly following HIV diagnosis.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

InterPrEP: internet-based pre-exposure prophylaxis with generic tenofovir disoproxil fumarate/emtrictabine in London - analysis of pharmacokinetics, safety and outcomes

OBJECTIVES

The National Health Service in England (NHS England) does not provide pre-exposure prophylaxis (PrEP) against HIV, forcing people to purchase generic versions on the internet. However, there are concerns about the authenticity of medicines purchased online. We established an innovative service offering plasma tenofovir (TFV) and emcitrabine (FTC) therapeutic drug monitoring for people buying generic PrEP online, to ensure that drug concentrations in vivo were consistent with those of propriety brands and previously published data.

METHODS

TFV/FTC concentrations were measured by ultra-performance liquid chromatography ultraviolet detection. Evaluation of renal function and testing for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) were also carried out, at baseline and every 3-6 months, with risk reduction advice.

RESULTS

A total of 293 individuals presented having purchased PrEP on the internet: 85% were white, 84% were taking daily PrEP, and 16% were event-driven. Most were on generic TFV disoproxil fumarate (TDF)/FTC from Cipla Ltd. Median (range) TFV and FTC plasma concentrations were 104 (21-597) ng/mL and 140 (17-1876) ng/mL, respectively. All concentrations were above our established plasma TFV and FTC targets, based on previously published data. Renal function was normal in all evaluable individuals and no new cases of HIV, HBV or HCV infection were seen.

CONCLUSIONS

In a population at high risk of HIV acquisition, who cannot yet access PrEP on the NHS, concentrations of TFV and FTC in generic formulations purchased over the internet were similar to (or slightly higher than) those measured in phase I studies with the original formulation from Gilead (Truvada™), which has demonstrated high levels of protection against HIV infection in previous PrEP clinical trials.

High HIV incidence in men who have sex with men attending for postexposure prophylaxis: a service evaluation

BACKGROUND/AIMS

There are limited outcome data for men who have sex with men (MSM) who have received HIV postexposure prophylaxis (PEP). The objective of this service evaluation was to determine HIV incidence and repeat PEP use among MSM PEP recipients in London, UK.

METHODS

Retrospective electronic case-note review of all MSM who were prescribed PEP between January and April 2013 at a central London sexual health service.

RESULTS

530 MSM received PEP between 1 January and 30 June 2013. Of these, 449 had more than 30 days subsequent follow-up at our service. Median age was 31 years. PEP indication was unprotected anal intercourse, 98% (receptive 88% and insertive 10%) and other, 2%. Up to 1 November 2015, total follow-up was 756 person-years. 183 users received repeat PEP. The total number of repeat PEP courses was 442. 57 MSM newly acquired HIV: the HIV incidence was 7.6 per 100 person-years.

CONCLUSIONS

PEP was associated with a high risk of subsequent HIV seroconversion in this cohort; this group may be appropriate candidates for pre-exposure prophylaxis.

Distinct Urban Mines: Exploiting secondary resources in unique anthropogenic spaces

Fear of scarcity of resources highlight the need to exploit secondary materials from urban mines in the anthroposphere. Analogous to primary mines rich in one type of material (e.g. copper, gold, etc.), some urban mines are unique/distinct. We introduce, illustrate and discuss the concept of Distinct Urban Mines (DUM). Using the example of a university DUM in the UK, analogous to a primary mine, we illustrate potential product/material yields in respect of size, concentration and spatial location of the mine. Product ownership and replacement cycles for 17 high-value electrical and electronic equipment (EEE) among students showed that 20 tonnes of valuable e-waste were in stockpile in this DUM and a further 87 tonnes would 'soon' be available for exploitation. We address the opportunities and challenges of exploiting DUMs and conclude that they are readily available reservoirs for resource recovery. Two original contributions arise from this work: (i) a novel approach to urban mining with a potential for maximising resource recovery within the anthroposphere is conceptualised; and (ii) previously unavailable data for high-value products for a typical university DUM are presented and analysed.

Does dropping day 5 PEP follow-up affect outcomes? An audit of HIV post-exposure prophylaxis at a central London sexual health clinic

UK post-exposure prophylaxis (PEP) guidelines were updated by the British Association for Sexual Health and HIV (BASHH) in 2011. In 2013, we changed policy to omit day 5 PEP follow-up at 56 Dean Street as it was felt clinically unnecessary. This audit compares our performance against BASHH standards for PEP attenders during June 2012 and June 2013. We identified 162 PEP prescriptions; PEP assessment and appropriate sexually transmitted infection testing was done well. PEP completion rates and post-PEP HIV testing were lower than BASHH standards. Following omission of day 5 review, documentation that results have been checked was poor; however, attendance at follow-up was not adversely affected.

Blood glucose and risk of cardiovascular disease in the Asia Pacific region

OBJECTIVE

To assess the shape and strength of the association between usual blood glucose and cardiovascular disease (CVD) in Asian and Australasian cohorts and to determine the impact of adjusting for other determinants of CVD risk and excluding people with diabetes.

RESEARCH DESIGN AND METHODS

Relative risk estimates and 95% CIs were calculated from Cox models, stratified by sex and cohort, and adjusted for age at risk on individual participant data from 17 cohort studies. Repeat measurements of blood glucose were used to adjust for regression dilution bias.

RESULTS

Fasting blood glucose data were available for 237,468 participants, and during approximately 1.2 million person-years of follow-up, there were 1,661 stroke and 816 ischemic heart disease (IHD) events. Data were also available on 27,996 participants with nonfasting glucose measurements. Continuous positive associations were demonstrated between usual fasting glucose and the risks of CVD down to at least 4.9 mmol/l. Overall, each 1 mmol/l lower usual fasting glucose was associated with a 21% (95% CI 18-24%) lower risk of total stroke and a 23% (19-27%) lower risk of total IHD. The associations were similar in men and women, across age-groups, and in Asian compared with Australasian (Australia and New Zealand) populations. Adjusting for potential confounders or removing those with diabetes as baseline did not substantially affect the associations. Associations for nonfasting glucose were weaker than those with fasting glucose.

CONCLUSIONS

Fasting blood glucose is an important determinant of CVD burden, with considerable potential benefit of usual blood glucose lowering down to levels of at least 4.9 mmol/l.

Serum triglycerides as a risk factor for cardiovascular diseases in the Asia-Pacific region

BACKGROUND

The importance of serum triglyceride levels as a risk factor for cardiovascular diseases is uncertain.

METHODS AND RESULTS

We performed an individual participant data meta-analysis of prospective studies conducted in the Asia-Pacific region. Cox models were applied to the combined data from 26 studies to estimate the overall and region-, sex-, and age-specific hazard ratios for major cardiovascular diseases by fifths of triglyceride values. During 796,671 person-years of follow-up among 96,224 individuals, 670 and 667 deaths as a result of coronary heart disease (CHD) and stroke, respectively, were recorded. After adjustment for major cardiovascular risk factors, participants grouped in the highest fifth of triglyceride levels had a 70% (95% CI, 47 to 96) greater risk of CHD death, an 80% (95% CI, 49 to 119) higher risk of fatal or nonfatal CHD, and a 50% (95% CI, 29% to 76%) increased risk of fatal or nonfatal stroke compared with those belonging to the lowest fifth. The association between triglycerides and CHD death was similar across subgroups defined by ethnicity, age, and sex.

CONCLUSIONS

Serum triglycerides are an important and independent predictor of CHD and stroke risk in the Asia-Pacific region. These results may have clinical implications for cardiovascular risk prediction and the use of lipid-lowering therapy.

Motor vehicle driver injury and marital status: a cohort study with prospective and retrospective driver injuries

OBJECTIVE

To investigate the association of marital status with risk of motor vehicle driver injury.

DESIGN

A cohort study with prospective and retrospective outcomes.

SETTING

New Zealand.

PARTICIPANTS

A total of 10,525 adults (a volunteer sample of a multi-industry workforce, n = 8008; and a random sample of urban electoral rolls, n = 2517). EXPOSURE VARIABLE: Self reported marital status, assessed from a questionnaire administered in 1992-93 (baseline).

MAIN OUTCOME MEASURE

Motor vehicle driver injury resulting in admission of the driver to hospital and/or the driver's death, during the period 1988-98; hospitalisation and mortality data were obtained by record linkage to national health databases.

RESULTS

During 108 741 person-years of follow up, 139 driver injury cases occurred (85 before baseline, 54 after). After adjustment for age, sex, and study cohort, never married participants had twice the risk of driver injury (hazard ratio [HR] 2.06, 95% confidence interval [CI] 1.35 to 3.16) as married participants (HR 1.00). The relative risk for never married participants was slightly higher (HR 2.29), though less precise (95% CI 1.39 to 3.76), after further adjustment for alcohol intake, driving exposure, area of residence, body mass index, and occupational status.

CONCLUSIONS

After taking age, sex, and other variables into account, never married people had a substantially higher risk of driver injury than married people. While requiring corroboration, these findings imply that it may be appropriate for driver injury countermeasures to be targeted to never married people.

Vitamin B12 and folate deficiency in later life

OBJECTIVES

to examine the prevalence of vitamin B12 deficiency and folate deficiency in later life in representative samples of the elderly population in the United Kingdom.

DESIGN

a population-based cross-sectional analysis of 3,511 people aged 65 years or older from three studies was used to estimate the age-specific prevalence of vitamin B12 deficiency and of folate deficiency. Vitamin B12 deficiency is conventionally diagnosed if serum vitamin B12 < 150 pmol/l ('low vitamin B12'). We defined 'metabolically significant vitamin B12 deficiency' as vitamin B12 < 200 pmol/l and blood total homocysteine >20 micro mol/l. Folate deficiency, which usually refers to serum folate <5 nmol/l, was defined as 'metabolically significant' if serum folate was <7 nmol/l and homocysteine >20 micro mol/l.

RESULTS

the prevalence of vitamin B12 deficiency, whether defined as low vitamin B12 or metabolically significant vitamin B12 deficiency increased with age in all three studies, from about 1 in 20 among people aged 65-74 years to 1 in 10 or even greater among people aged 75 years or greater. The prevalence of folate deficiency also increased with age, and was similar to that for vitamin B12 deficiencies, but only about 10% of people with low vitamin B12 levels also had low folate levels.

CONCLUSION

the high prevalence of vitamin B12 and folate deficiency observed in older people indicates a particular need for vigilance for deficiency of these vitamins. Reliable detection and treatment of vitamin deficiency could reduce the risk of deficiency-related disability in old age.

Motor vehicle driver injury and socioeconomic status: a cohort study with prospective and retrospective driver injuries

STUDY OBJECTIVE

To investigate the association between motor vehicle driver injury and socioeconomic status.

DESIGN

Cohort study with prospective and retrospective outcomes.

SETTING

New Zealand.

PARTICIPANTS

10 525 adults (volunteer sample of a multi-industry workforce, n=8008; and a random sample of urban electoral rolls, n=2517).

OUTCOME MEASURE

Motor vehicle driver injury resulting in admission of the driver to hospital or the driver's death, or both, during the period 1988-98; hospitalisation and mortality data were obtained by record linkage to national health databases.

MAIN RESULTS

After adjustment for age and sex, driver injury risk was inversely associated with both occupational status (p for linear trend <0.0001) and educational level (p for linear trend =0.007). Participants in the lowest approximate quartile of occupational status were four times as likely (HR 4.17, 95% CI 2.31 to 7.55) to have experienced a driver injury during follow up as participants in the highest approximate quartile. Participants who had been to secondary school for less than two years were twice as likely (HR 2.26, 95% CI 1.34 to 3.81) to have experienced a driver injury as those who had been to university or polytechnic. There was little evidence that driver injury risk was associated with neighbourhood income (p for linear trend =0.12) CONCLUSIONS: Occupational status and educational level seem to be important determinants of driver injury risk. Driver injury countermeasures should be targeted to people in low status occupations, as well as to people with comparatively little formal education.

Random errors in the measurement of 10 cardiovascular risk factors

Random errors in the measurement of 10 commonly investigated cardiovascular risk factors (systolic and diastolic blood pressure, blood cholesterol, blood glucose, pulse rate, body mass index (BMI), cigarette consumption, passive smoking, alcohol intake and physical exercise) were assessed in a general population cohort (n = 2517) and a workforce cohort (n = 8008). Random errors were estimated from regression dilution ratios (lower ratios imply greater random error, and a ratio of one implies no random error). All of the risk factors, except for BMI (which had regression dilution ratios of 0.93 and 0.98 in the two cohorts), were measured with substantial levels of random error. Particularly low regression dilution ratios were observed for physical exercise (0.28 and 0.39) and pulse rate (0.47 and 0.56). For each of these risk factors, with the possible exception of BMI, associations with long-term average values could be importantly biased toward the null unless appropriate corrections are made.

The New Zealand Blood Donors' Health Study: baseline findings of a large prospective cohort study of injury

INTRODUCTION

Cohort studies have contributed important scientific knowledge regarding the determinants of chronic diseases. Despite the need for etiologic investigations, this design has been infrequently used in injury prevention research.

OBJECTIVES

To describe the baseline findings of the New Zealand Blood Donors' Health Study, a large prospective study designed to investigate relationships between lifestyle, psychosocial factors, and serious injury due to road crashes, falls, self harm, assault, work, sport, and recreation.

METHODS

Participants were recruited from fixed and mobile collection sites of a voluntary non-profit blood donor program. Baseline exposure data (for example risk taking behaviors, alcohol and marijuana use, sleep habits, and depression) were collected using a self administered questionnaire. Outcome data regarding serious injury will be collected prospectively through computerized record linkage of participants' unique identifiers to national morbidity and mortality databases.

RESULTS

In total, 22 389 participants enrolled in the study (81% response rate). The diverse study population included 36% aged 16-24 years, 20% rural residents, and large variability in exposures of interest. For example, in the 12 months before recruitment, 21% had driven a motor vehicle when they considered themselves over the legal limit for alcohol, and 11% had been convicted of traffic violations (excluding parking infringements). Twelve per cent had seriously considered attempting suicide sometime in their life.

CONCLUSIONS

This is the first, large scale cohort study investigating determinants of serious injury in New Zealand and among the largest worldwide. Preliminary findings from prospective analyses that can inform injury prevention policy are expected within five years.

A case of infectious tuberculosis on two long-haul aircraft flights: contact investigation

AIM

During a five-week period in 1996, a passenger with highly infectious tuberculosis travelled on five long-haul aircraft flights. We investigated passengers and crew on two of these flights to identify whether transmission of Mycobacterium tuberculosis had occurred.

METHODS

Crew and passengers were identified from airline and immigration records. Contacts were notified of their exposure and invited to attend their local public health clinic. At the clinic, a questionnaire was administered by a public health worker, and a Mantoux skin test was performed. When indicated, a second test was carried out twelve weeks later. Test positivity and conversion were defined according to the 1996 New Zealand tuberculosis control guidelines.

RESULTS

Data were obtained on 206 (87%) of the 238 contacts. Twenty four contacts had a positive Mantoux test result, four of which were conversions. All of these contacts had at least one other major risk factor for a positive result, such as a previous BCG vaccination (n=17) or having lived in a country in which tuberculosis is endemic (n=15). To our knowledge, no contacts have subsequently developed tuberculosis disease.

CONCLUSIONS

The investigation produced inconclusive evidence about the hypothesis that Mycobacterium tuberculosis was transmitted on one or both of these flights.

Japanese and Western diet and risk of idiopathic sudden deafness: a case-control study using pooled controls

BACKGROUND

One of the proposed aetiological mechanisms for idiopathic sudden deafness is vascular disease. However, it is not known whether traditional cardiovascular risk factors, such as particular dietary factors, are associated with this condition.

METHODS

A case-control study using pooled controls was conducted in Japan to investigate the relationship between idiopathic sudden deafness and diet. An m:n matched-pairs method was used to obtain age-, gender- and residential district-matched controls from a nationwide database of pooled controls. Food intake was assessed from a self-administered usual food frequency questionnaire that asked about intake of 35 foods (including four drinks). Participants were classified according to the frequency of intake of Western foods and the frequency of intake of traditional Japanese foods. Subgroup analyses were performed using audiometric subtypes of idiopathic sudden deafness.

RESULTS

Data were obtained for 164 cases and 20,313 controls. An increased risk of sudden deafness was observed among participants who frequently consumed Western foods (OR = 1.82, 95% CI : 1.14--2.89), and a decreased risk of this condition was observed among participants who frequently consumed Japanese foods (OR = 0.52, 95% CI : 0.33--0.82). A direct association of sudden deafness with Western food intake was evident for flat-type hearing loss.

CONCLUSIONS

This study suggests that a largely Western diet might be a risk factor for idiopathic sudden deafness, a traditional Japanese diet might be a preventive factor for this condition, or both. These findings are consistent with the hypothesis that vascular factors are an important cause of idiopathic sudden deafness, although the possibility of residual confounding by unmeasured confounders such as socioeconomic status cannot be ruled out.

Smoking, alcohol, sleep and risk of idiopathic sudden deafness: a case-control study using pooled controls

Sudden deafness sometimes has an identifiable cause, but in most cases the cause is unknown (idiopathic sudden deafness). Vascular impairment has been proposed as an aetiological mechanism for this condition, but it is unclear whether traditional cardiovascular risk factors, such as smoking or alcohol intake, are associated with this condition. We accordingly investigated associations of idiopathic sudden deafness with smoking, alcohol intake and sleep duration in a case-control study. Cases were consecutive patients diagnosed with idiopathic sudden deafness between October 1996 and August 1998 at collaborating hospitals in Japan. Controls were obtained from a nationwide database of pooled controls, with matching for age, gender and residential district. Exposure variables were assessed from a self-administered questionnaire. Subgroup analyses were performed using audiometric subtypes of sudden deafness. Data were obtained for 164 cases and 20,313 controls. Increased risks of idiopathic sudden deafness were observed among participants who consumed two or more units of alcohol per day (OR=1.90, 95% CI=1.12-3.21), and among participants who slept less than seven hours per night (OR=1.61, 95% CI=1.09-2.37). The direct association with alcohol intake was particularly strong for the participants with profound hearing loss. There was little evidence of an association with smoking. This study suggests that alcohol intake and short sleep duration might be risk factors for idiopathic sudden deafness.

The role of driver sleepiness in car crashes: a systematic review of epidemiological studies

To assess the available evidence for a causal role of driver sleepiness in car crashes or car crash injury, and to quantify the effect, a systematic review of the international literature was conducted. The review included all studies with a fatigue-related exposure measure, a crash or crash injury outcome measure and a comparison group, regardless of publication status, language or date of the study. Eighteen cross-sectional studies and one case-control study fulfilled the inclusion criteria. The fatigue-related exposures investigated in these studies were sleep disorders (n = 14), shift work (n = 2), sleep deprivation/fragmentation (n = 1), and excessive daytime sleepiness (n = 2). Only one study used an injury outcome measure. Studies were limited in their ability to establish a causal relationship by their design, by biases, and in many cases, by small sample sizes. The better quality cross-sectional studies were suggestive of a positive relationship between fatigue and crash risk, but could not provide reliable estimates of the strength of the association. The case-control study provided moderately strong evidence for an association between sleep apnoea and risk of driver injury, with an adjusted odds ratio of 7.2 (95% confidence interval 2.4-21.8). We conclude that the direct epidemiological evidence for a causal role of fatigue in car crashes is weak, but suggestive of an effect. To estimate the burden of injury due to fatigue-related crashes in the population, information is required from well-designed observational epidemiological studies about the prevalence of fatigue in the car driving population and the size of the risk this confers.

Association of environmental tobacco smoke exposure with socioeconomic status in a population of 7725 New Zealanders

OBJECTIVE

To test the hypothesis that environmental tobacco smoke (ETS) exposure is inversely associated with socioeconomic status.

DESIGN

Survey.

SETTING

General community, New Zealand.

PARTICIPANTS

7725 non-smoking adults (volunteer sample of a multi-industry workforce, n = 5564; and a random sample of urban electoral rolls, n = 2161), including 5408 males; mean age 45 years.

MAIN OUTCOME MEASURES

ETS exposure was assessed as self-reported number of hours per week spent near someone who is smoking, and as prevalence of regular exposure to some ETS. Socioeconomic status was assessed as educational level, occupational status, and median neighbourhood household income.

RESULTS

Both measures of ETS exposure were steeply and inversely associated with all three indicators of socioeconomic status (all p < 0.0001). Geometric mean ETS exposure ranged from 16 minutes per week among university-educated participants to 59 minutes per week in the second lowest occupational quintile (95% confidence intervals: 14-18 minutes per week and 54-66 minutes per week). The associations with occupational status and educational level were steeper than those with neighbourhood income. The socioeconomic gradients of ETS exposure were steeper among participants aged less than 35 years than among participants aged over 50 years, among men than women, and among Maori than Europeans.

CONCLUSIONS

In this study population, ETS exposure was inversely associated with socioeconomic status. Greater ETS exposure might therefore contribute to the higher risks of disease and death among low socioeconomic groups. These results provide a further rationale for targeting tobacco control measures to people in low socioeconomic groups.

The determinants of fat intake in a multi-ethnic New Zealand population. Fletcher Challenge--University of Auckland Heart and Health Study Management Committee

BACKGROUND

The New Zealand diet is high in total and saturated fat and this is likely to be contributing to the increasing prevalence of obesity and relatively high rates of coronary heart disease in New Zealand. The identification of subgroups with a high-fat intake will enable nutrition-related public health strategies to be better targeted.

METHODS

Subjects from two surveys were included in the study: 7574 employees from a large multinational workforce survey and 2447 people aged 35-84 years selected from a stratified random sample of the electoral roll in central Auckland. Fat and saturated fat intake were assessed by short questionnaire which gave a dietary fat habits (DFH) score and supplemented by a six-item food frequency questionnaire.

RESULTS

The DFH scores were higher in males than in females at all ages, and there was an inverse relationship with age which was stronger for males. Age-adjusted scores showed significantly higher DFH scores for Maori than for Europeans. Lower socioeconomic status was associated with higher DFH scores in males. Current smoking and heavy drinking (in males) were associated with significantly higher DFH scores after controlling for socioeconomic status. The results of the limited food frequency questionnaire supported the trends in DFH scores.

CONCLUSIONS

The subgroups with high total and saturated fat intakes which should be a priority for public health action are young and middle-aged males, Maori and lower socioeconomic status males. The clustering of high-fat intake with smoking and heavy drinking should be considered when developing preventative strategies.

Socioeconomic distribution of smoking in a population of 10,529 New Zealanders

AIMS

This study aimed to investigate the associations of several smoking variables with socioeconomic status.

METHODS

Cross-sectional analyses of data about smoking behaviour and socioeconomic status (education, occupation and neighbourhood income) were performed using baseline data from the Fletcher Challenge-University of Auckland Heart and Health Study (10,529 participants).

RESULTS

After adjustment for age and sex, lower educational level was associated with: (1) higher frequency of ever having smoked (65% of participants who had attended secondary school for fewer than two years, versus 43% of participants who had attended university; 2p < 0.0001); (2) lower likelihood of having quit (46% versus 71%; 2p < 0.0001); (3) higher likelihood of being a current smoker (35% versus 12%; 2p < 0.0001); (4) higher tobacco consumption per smoker (13 manufactured cigarettes/day versus 8 manufactured cigarettes/day; 2p < 0.0001); and (5) higher tobacco consumption per participant (1980 cigarette-equivalents/year versus 450 cigarette-equivalents/year; 2p < 0.0001). Similar, but shallower, associations of these smoking variables were observed with occupation and neighbourhood income (with the exception that tobacco consumption per smoker was not associated with neighbourhood income). The socioeconomic gradients of tobacco consumption per study participant with all three socioeconomic indicators were particularly steep among younger participants, men and Maori.

CONCLUSIONS

Participants of low socioeconomic status consumed a disproportionately large amount of tobacco. Policies that prevent smoking initiation and promote smoking cessation in low socioeconomic groups are therefore needed. These should include targeting of mass media messages to low socioeconomic groups, public subsidisation of nicotine replacement therapy and higher taxes on tobacco.

Blood pressure lowering for the prevention of cognitive decline in patients with cerebrovascular disease. PROGRESS Management Committee. Perindopril Protection Against Recurrent Stroke Study

Cerebrovascular disease and high blood pressure both appear to increase the risk of vascular dementia. PROGRESS aims to investigate whether blood pressure lowering with an angiotensin coverting enzyme inhibitor-based regimen will reduce the risk of cognitive impairment in patients with a history of stroke or transient ischaemic attack. A total of at least 6000 patients will be randomised to receive perindopril (+/- indapamide) or matching placebo(s), with treatment and follow-up scheduled to continue for at least 4 years. Substudies will investigate the effects of treatment on cognitive decline in subgroups defined by apo-E genotype and on white matter lesions assessed by magnetic resonance imaging. Final results from the study should be available in 2001.