Cold indoor temperatures and their association with health and well-being: a systematic literature review

OBJECTIVE

The study aimed to identify, appraise and update evidence on the association between cold temperatures (i.e. <18°C) within homes (i.e. dwellings) and health and well-being outcomes.

STUDY DESIGN

This study was a systematic review.

METHODS

Seven databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL, APA PsycInfo, Applied Social Sciences Index and Abstracts, Coronavirus Research Database) were searched for studies published between 2014 and 2022, which explored the association between cold indoor temperatures and health and well-being outcomes. Studies were limited to those conducted in temperate and colder climates due to the increased risk of morbidity and mortality during winter in those climatic zones. Studies were independently quality assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

Of 1209 studies, 20 were included for review. Study outcomes included cardiovascular (blood pressure, electrocardiogram abnormalities, blood platelet count), respiratory (chronic obstructive pulmonary disease symptoms, respiratory viral infection), sleep, physical performance and general health. Seventeen studies found exposure to cold indoor temperatures was associated with negative effects on health outcomes studied. Older individuals and those with chronic health problems were found to be more vulnerable to negative health outcomes.

CONCLUSION

Evidence suggests that indoor temperatures <18°C are associated with negative health effects. However, the evidence is insufficient to allow clear conclusions regarding outcomes from specific temperature thresholds for different population groups. Significant gaps in the current evidence base are identified, including research on the impacts of cold indoor temperatures on mental health and well-being, studies involving young children, and the long-term health effects of cold indoor temperatures.

The Health and wellbeing impacts of Home and agile working in Wales: A HIA Approach

The SARS-COV-02 pandemic has globally resulted in a number of policies and interventions to address and reduce the transmission of the disease throughout the population. Mitigation measures have ranged from ‘Staying at Home' or ‘Lockdowns' to social distancing policies and requirements to work from home when you can. Whilst there are a number of papers which discuss the effects of home or remote working on employees and their families the large scale shift, accelerated pace and wider impacts of such a shift has not been well explored in the literature or has been focussed on specific topics, for example, productivity. HIA is promoted as a beneficial tool to identify the wider impacts of a policy, plan or intervention across a population and as such is well placed to examine and articulate who in a population may be affected and how, and the inequalities that may be created by an intervention such as home working. Using the lens of social determinants and equity focussed-HIA, this work examines the wider impact of home working in Wales during the COVID-19 pandemic. It provides a coherent overview of the major impacts on health and the particular populations affected. It articulates the process followed, the key evidence based findings, discusses the gaps in the evidence base that require further exploration and the impact and influence it has had to date. Finally, it shares the transferable learning, which will be of use to researchers, policy and decision makers, organisations and public health agencies.

Adverse childhood experiences during childhood and academic attainment at age 7 and 11 years: an electronic birth cohort study

OBJECTIVES

Adverse childhood experiences (ACEs) have a negative impact on childhood health, but their impact on education outcomes is less well known. We investigated whether or not ACEs were associated with reduced educational attainment at age 7 and 11 years.

STUDY DESIGN

The study design used in the study is a population-based electronic cohort study.

METHODS

We analysed data from a total population electronic child cohort in Wales, UK. ACEs (exposures) were living with an adult household member with any of (i) serious mental illness, (ii) common mental disorder (CMD), (iii) an alcohol problem; (iv) child victimisation, (v) death of a household member and (vi) low family income. We used multilevel logistic regression to model exposure to these ACEs and not attaining the expected level at statutory education assessments, Key Stage (KS) 1 and KS2 separately, adjusted for known confounders including perinatal, socio-economic and school factors.

RESULTS

There were 107,479 and 43,648 children included in the analysis, with follow-up to 6-7 years (KS1) and 10-11 years (KS2), respectively. An increased risk of not attaining the expected level at KS1 was associated with living with adult household members with CMD (adjusted odds ratio [aOR]: 1.13 [95% confidence interval [CI]: 1.09-1.17]) or an alcohol problem (adjusted odds ratio [aOR]: 1.16 [95% confidence interval [CI]: 1.10-1.22]), childhood victimisation (adjusted odds ratio [aOR]: 1.58 [95% confidence interval [CI]: 1.37-1.82]), death of a household member (adjusted odds ratio [aOR]: 1.14 [95% confidence interval [CI]: 1.04-1.25]) and low family income (adjusted odds ratio [aOR]: 1.92 [95% confidence interval [CI]: 1.84-2.01]). Similar results were observed for KS2. Children with multiple adversities had substantially increased odds of not attaining the expected level at each educational assessment.

CONCLUSION

The educational potential of many children may not be achieved due to exposure to adversity in childhood. Affected children who come in to contact with services should have relevant information shared between health and care services, and schools to initiate and facilitate a coordinated approach towards providing additional support and help for them to fulfil their educational potential, and subsequent economic and social participation.

Health and mass unemployment events-developing a framework for preparedness and response

BACKGROUND

Mass unemployment events are not uncommon yet the impact on health is not well recognised. There is a need for a preparedness and response framework, as exists for other events that threaten population health.

METHODS

Framework informed by a narrative review of the impact of mass unemployment on health (studies published in English from 1990 to 2016), and qualitative data from 23 semi-structured interviews with individuals connected to historical national and international events, addressing gaps in published literature on lessons learnt from past responses.

RESULTS

Economic and employment shock triggered by mass unemployment events have a detrimental impact on workers, families and communities. We present a public health informed response framework which includes (i) identify areas at risk, (ii) develop an early warning system, (iii) mobilise multi-sector action including health and community, (iv) provision of support across employment, finance and health (v) proportionate to need, (vi) extend support to family members and (vii) communities and (viii) evaluate and learn.

CONCLUSION

Mass unemployment events have an adverse impact on the health, financial and social circumstances of workers, families, and communities. This is the first framework for action to mitigate and address the detrimental impact of mass unemployment events on population health.

Step-by-step process of making the case for sustainable investment in wellbeing and health equity

Issue

Urgent action is needed to address the growing health, inequity, economic and planetary challenges that threaten the wellbeing of present and future generations. Business as usual has proven unsustainable with high human, social, economic and environmental costs. Coordinated policy action on the determinants of health combined with well-designed and implemented governance and innovative investment approaches can have a dual effect: a) reducing the health gap; and b) improving overall population health.

Description

The WHO Collaborating Centre on Investment for Health and Wellbeing has developed a practical step-by-step guide, outlining the process of how to synthesise, translate and communicate public health and economics evidence into policy and practice, in order to make the case for investment in wellbeing and health equity. It aims to: 1) prevent disinvestment in health; 2) increase investment in prevention / public health; and 3) mainstream cross-sector investment to address the wider determinants of health and equity, driving prosperity for all.

Building on the Knowledge-to-Action framework and an extensive international multi-disciplinary consultation, four key phases are described: 1) Project scoping and planning; 2) Evidence gathering, synthesis and design; 3) Dissemination and communication; and 4) Monitoring and evaluation. Key messages, different products and a number of practical tools and tips are highlighted. An essential element is using health economics approaches and tools to build the case, showing the burden of inaction in parallel with available sustainable solutions, which can bring ‘social return on investment’.

Results/Lessons

The result of the above-described process is the development of evidence-informed, context-tailored advocacy documents and tools, enabling healthy policy- and decision-making across different sectors, levels of government and country settings.

Measuring the relationships between adverse childhood experiences and educational and employment success in England and Wales: findings from a retrospective study

OBJECTIVES

Educational and employment outcomes are critical elements in determining the life course of individuals, yet through health and other mechanisms, those who suffer adverse childhood experiences (ACEs) may experience barriers to achieve in these domains. This study examines the association between ACEs and poor educational outcomes, before considering the impact of ACEs and education on employment in adulthood.

STUDY DESIGN

Retrospective cross-sectional surveys were conducted in England and Wales using a random stratified sampling methodology.

METHODS

During face-to-face household interviews (n = 2881), data were collected on demographic factors, ACEs, self-rated childhood affluence, the highest qualification level attained and the current employment status.

RESULTS

While respondents with ≥4 ACEs were significantly more likely to have no formal qualifications (adjusted odds ratio [AOR] = 2.18; P < 0.001), among those who did achieve secondary level qualifications, the presence of ACEs did not further impact subsequent likelihood of going on to attain college or higher qualifications. However, results suggest a persisting independent impact of high (≥4) ACEs, which were found to be significantly associated with both current unemployment (AOR = 2.52, P < 0.001) and long-term sickness and disability (AOR = 3.94, P < 0.001). Modelled levels of not being in employment ranged from as little as 3% among those with 0 or 1 ACE and higher qualifications to 62% among those with no qualifications and ≥4 ACEs (adjusted for age, gender and childhood affluence effects).

CONCLUSIONS

Compulsory education may play a pivotal role in mitigating the effects of adversity, supporting the case for approaches within schools that build resilience and tackle educational inequalities. However, adults with ACEs should not be overlooked and efforts should be considered to support them in achieving meaningful employment.

Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey

BACKGROUND

ACE (adverse childhood experience) studies typically examine the links between childhood stressors and adult health harming behaviours. Using an enhanced ACE survey methodology, we examine impacts of ACEs on non-communicable diseases and incorporate a proxy measure of premature mortality in England.

METHODS

A nationally representative survey was undertaken (n = 3885, aged 18-69, April-July 2013). Socio-demographically controlled proportional hazards analyses examined the associations between the number of ACE categories (<18 years; e.g. child abuse and family dysfunction such as domestic violence) and cancer, diabetes, stroke, respiratory, liver/digestive and cardiovascular disease. Sibling (n = 6983) mortality was similarly analysed as a measure of premature mortality.

RESULTS

Of the total, 46.4% of respondents reported ≥1 and 8.3% ≥4 ACEs. Disease development was strongly associated with increased ACEs (e.g. hazard ratios, HR, 0 versus ≥4 ACEs; cancer, 2.38 (1.48-3.83); diabetes, 2.99 (1.90-4.72); stroke, 5.79 (2.43-13.80, all P < 0.001). Individuals with ≥4 ACEs (versus no ACEs) had a 2.76 times higher rate of developing any disease before age 70 years. Adjusted HR for mortality was strongly linked to ACEs (≥4 versus 0 ACEs; HR, 1.97 (1.39-2.79), P < 0.001).

CONCLUSIONS

Radically different life-course trajectories are associated with exposure to increased ACEs. Interventions to prevent ACEs are available but rarely implemented at scale. Treating the resulting health costs across the life course is unsustainable.

Views and experiences of hepatitis C testing and diagnosis among people who inject drugs: systematic review of qualitative research

BACKGROUND

Many developed countries are facing a major challenge to improve identification of individuals acutely and chronically infected with hepatitis C virus (HCV) infection. We explored the views and experiences of people who inject drugs (PWID) in relation to HCV testing, and diagnosis through a review and synthesis of qualitative research.

METHODS

Based on the thematic synthesis of qualitative research. Searches were conducted in 14 databases and supplemented by reference checking, hand searching of selected journals, and searches of relevant websites. Studies of any qualitative design that examined the views and experiences of, and attitudes towards, HCV testing and diagnosis among PWID or practitioners involved in their care were included. Key themes and sub-themes were systematically coded according to the meaning and content of the findings of each study which proceeded to the preparation of a narrative account of the synthesis.

RESULTS

28 qualitative studies were identified. We identified a number of overarching descriptive themes in the literature, finding overall that PWID hold complex and differing views and experiences of testing and diagnosis. Three major themes emerged: missed opportunities for the provision of information and knowledge; shifting priorities between HCV testing and other needs; and testing as unexpected and routine. Evidence of missed opportunities for the provision of knowledge and information about HCV were clear, contributing to delays in seeking testing and providing a context to poor experiences of diagnosis. Influenced by the nature of their personal circumstances, perceptions of the risk associated with HCV and the prioritisation of other needs acted both to encourage and discourage the uptake of HCV testing. Undergoing HCV testing as part of routine health assessment, and an unawareness of being testing was common. An unexpected positive diagnosis exacerbated anxiety and confusion.

CONCLUSION

This review has identified that there are modifiable factors that affect the uptake of HCV testing and experiences of HCV diagnosis among PWID. Intervention development should focus on addressing these factors. There is a need for further research that engages PWID from a diverse range of populations to identify interventions, strategies and approaches that they consider valuable.

Traffic risk behaviors at nightlife: drinking, taking drugs, driving, and use of public transport by young people

Road traffic crashes associated with nightlife alcohol and recreational drug use are a major health problem for young people.

OBJECTIVES

This study explores use of different forms of transport to and from nightlife environments and the relationships between traffic risk behaviors, drunkenness, and drug consumption.

METHODS

1363 regular nightlife users from nine European cities in 2006 completed a self-administered and anonymous questionnaire. Sampling utilized a variation of respondent-driven sampling.

RESULTS

Private car was the most frequent form of transport used when going out, especially by males and older individuals. Drug use was related to crashes and traffic risk behaviors, including having a lift from someone drunk or driving drunk or driving having taken drugs; drunkenness was related to risk behaviors but not to crashes (possibly because drunk people tend to use the private car less). Males showed higher levels of drunkenness and drug consumption, traffic risk behaviors, and traffic crashes. Age is not related to the traffic risk behaviors, but older individuals had less crashes.

CONCLUSIONS

There are serious health problems related to transport and recreational nightlife activities. It is necessary to improve later public transport services, complemented by actions that deter the use of private cars. The relationships of both drunkenness and cannabis/cocaine use with traffic risk behaviors should be addressed and programs implemented to change risk perceptions on the effects of illegal drugs on driving.

Contribution of violence to health inequalities in England: demographics and trends in emergency hospital admissions for assault

INTRODUCTION

Violence is increasingly recognised as a major public health issue yet health data are underutilised for describing the problem or developing responses. We use English emergency hospital admissions for assault over four years to examine assault demography and contribution to health inequalities.

METHODS

Geodemographic cross-sectional analyses utilising records of all individuals in England (n = 120 643) admitted between 1 April 2002 and 31 March 2006.

RESULTS

Over 4 years, rates of admission increased by 29.56% across England. Admissions peaked on Saturdays (22.34%) and Sundays (20.38%). Higher rates were associated with deprivation across all ages, including those <15 years, with a sixfold increase in admission rates between the poorest and wealthiest quintiles of residence. Logistic regression analyses indicate males are 5.59 times more likely to be admitted to hospital for assault and such admissions peak in those aged 15-29 years. Modelling based on national assault admissions and limited Accident and Emergency (A&E) data suggest that while more serious assaults requiring hospital admission have increased, assault attendances at A&Es have fallen.

DISCUSSION

Hospital admission and A&E data identify a direct contribution made by violence to health inequalities. Levels of violence inhibit other interventions to improve people's health through, for instance, outdoor exercise or delivery of health-related services in affected areas. With disproportionate exposure to violence in poorer areas even in those under 15, early life primary prevention initiatives are required in disadvantaged communities to reduce childhood harm and the development of adult perpetrators and victims of violence.

Adults at 12? Trends in puberty and their public health consequences

Adults at 12?

The ability of two commercially available quick test kits to detect drug-facilitated sexual assault drugs in beverages

AIMS

Assessment of the sensitivity and specificity of two commercially available 'drug-facilitated sexual assault' drug detector kits, Drink Guard and Drink Detective.

DESIGN

Experimental.

SETTING

Laboratory.

MEASUREMENTS

Gamma hydroxybutyrate (GHB) sodium salt, ketamine hydrochloride, temazepam, flunitrazepam and diazepam were dissolved (Tween added to benzodiazepine solutions) as separate stock solutions and added to 330 ml samples of cola (Pepsi Max), beer (Stella Artois), 'alcopop' (Bacardi Breezer) and placebo (distilled water). The doses used are reported to be common in cases of intoxication. Each kit was tested 10 times for each drink/drug combination. Two blind, independent observers scored each test (presence/absence of drug) in accordance with kit instructions; chi 2 was used to compare the proportion of times raters scored tests correctly and incorrectly. Sensitivity and specificity were calculated overall, for each drink, and sensitivity was calculated for each drug. Inter-observer agreement was evaluated using the kappa statistic.

FINDINGS

While both raters were able to score significantly more tests correctly than incorrectly using Drink Detective, and one rater scored similarly using Drink Guard, the overall sensitivity of Drink Detective and Drink Guard was 69.0% (95% CI 64.2-73.5%) and 37.5% (95% CI 30.1-45.5%), respectively. Sensitivity was drink-dependent. Drink Detective was unable to detect our dose of GHB in water, with all tests scored negatively by both raters for this drink/drug combination (n = 20 negative scores). Overall, specificity was 76.6% (95% CI 71.5-81.0%) and 87.9% (95% CI 83.0-91.6%) for Drink Guard and Drink Detective, respectively, but was affected by the beverage. Inter-rater agreement was poor for Drink Guard (kappa = 0.278 +/- 0.069) but excellent for Drink Detective (kappa = 0.894 +/- 0.245). Inter-observer agreement was drug-dependent.

CONCLUSIONS

Use of drug detector kits by the public in the night-time environment needs further investigation and may create a false sense of security (false negatives) and undue concern (false positives) among kit users.

Elevated mortality following diagnosis with a treatable disease: tuberculosis

OBJECTIVE

To determine whether previous diagnosis with tuberculosis (TB) increases the risk of mortality.

DESIGN

A retrospective survey of 439 TB patients in the city of Liverpool, population 439500, over an 8-year period.

OUTCOMES

Mortality compared with the general population; cause of death as identified from death certificates.

RESULTS

A total of 104 (23.7%) TB cases had died within the follow-up period. For 45-54 year olds, the standardised mortality ratio (SMR) was 1101, an 11-fold higher mortality than expected from the Liverpool population. The SMR then declined with age, but remained higher in males than in females. Death certificates showed that 34 (30.8%) died from TB and 26 (21%) from bronchopneumonia. Malignancy was the cause of death in 24 cases (28%), including 16 with lung tumours, all in patients aged under 75 years. This gave a 30-fold greater mortality from lung cancer compared with the general population aged under 75.

CONCLUSIONS

TB increases the risk of mortality compared with the general population, with unexpectedly high mortality from lung cancer in cases aged under 75. Older patients die from TB itself or other chest diseases. Common risk factors for the Liverpool population probably contribute to elevated mortality from all chest-related diseases, including TB.

Effects of nightlife activilty on health

This article aims to increase understanding of nightlife health and the potential for nurses to reduce some of the negative health consequences associated with nightlife activity.

Relationship between the use of hospital services and deprivation score of place of residence among HIV-positive individuals in the north west of England

We used routine surveillance data to investigate whether deprivation relates to hospital admission in a HIV-positive population. HIV-positive individuals living in the poorest areas were more likely to have spent one or more nights in hospital for HIV-related care (adjusted odds ratio = 1.6, p = 0.009, after controlling for infection route, disease stage and demographic variables). This implies that healthcare networks in poorer areas may incur disproportionately greater costs.

Behind the mask. Journey through an epidemic: some observations of contrasting public health responses to SARS

SARS has been called the first global epidemic of the 21st century and has been the cause of a massive and varied public health response in many countries of the world. This report describes observations made by two authors on a journey from Manchester in the United Kingdom to Chiang Mai in Thailand during the peak of global transmission. The public response to SARS, particularly characterised by the wearing of face masks, seemed to outstrip official guidance. Though of uncertain protective benefit, the wearing of masks may have contributed to the awareness of the collective and personal responsibility in combating infectious disease. Active and empowered involvement of the general public in implementing and cooperating with public health control measures supported by national and international authorities has clearly helped to bring SARS under control. The public health significance of such potent symbols as the face mask may be considered in strategies to tackle other emerging infections.

Sexual behaviour of young people in international tourist resorts

BACKGROUND/OBJECTIVES

Increasingly, young people travel abroad to experience nightlife in international resorts. Although media coverage of such resorts suggests high levels of sexual activity, little empirical data are currently available. We have measured: 3 year trends in sexual behaviour of young people visiting Ibiza, levels of sexual risk taking, and their relation to substance use. Additionally, in 2002 we identified levels of homosexual sex and sexual interactions between UK residents and individuals from other countries.

METHODS

Data were collected from visitors to Ibiza between 2000 and 2002 just before they left the island. Information on sexual health was surveyed using a short anonymous questionnaire.

RESULTS

Over half of individuals (56.0%) visiting Ibiza had sex with at least one person, with 26.2% of males and 14.5% of females having sex with more than one individual. However, of those arriving without sexual partners (75.5%) just under half (47.5%) have sex in Ibiza and most of these (62.4%) always used condoms. Having any sex abroad was associated with using illicit drugs and having more sexual partners in the 6 months before visiting Ibiza. However, having unprotected sex or sex with more than one person was associated with smoking as well as having higher numbers of sexual partners before their visit. Overall, 8.6% of individuals had sex with a non-UK resident in Ibiza although such individuals were no more likely to have sex without condoms.

CONCLUSIONS

Substantial numbers of individuals visiting international nightlife resorts have unprotected sex with people they meet while abroad. This poses an increasing threat to the sexual health of UK residents but as yet little attention has been paid to developing interventions that might reduce sexual risk taking among young people holidaying abroad.

An investigation into the microflora of heroin

In 2000, an unusual increase of morbidity and mortality among illegal injecting drug users in the UK and Ireland was reported and Clostridium novyi was identified as the likely source of the serious infection, although infections due to C. botulinum and Bacillus cereus were also reported. Because heroin was a possibile source of infection, this study investigated the microflora of heroin samples seized in England during 2000 and 2002. Two methods were developed for the examination of the microflora of heroin. The first consisted of suspension of the drug in maximum recovery diluent (MRD) which was inoculated directly into Clostridium Botulinum Isolation Cooked Meat Broth (CBI). The second method rendered the heroin soluble in citric acid, concentrated particulate material (and bacterial cells) by filtration and removed heroin residues by washing with citric acid and phosphate-buffered saline before placing the filter in CBI broth. Duplicate CBI broths from both methods were incubated without heating and after heating at 60 degrees C for 30 min. Subcultures were made after incubation for 7 and 14 days on to eight different solid media. The methods were evaluated with heroin samples spiked with either C. botulinum or C. novyi spore suspensions; recovery of 10 spores in the original sample was demonstrated. Fifty-eight heroin samples were tested by citric acid solubilisation and 34 by the MRD suspension technique. Fifteen different gram-positive species of four genera were recognised. No fungi were isolated. Aerobic endospore-forming bacteria (Bacillus spp. and Paenibacillus macerans) were the predominant microflora isolated and at least one species was isolated from each sample. B. cereus was the most common species and was isolated from 95% of all samples, with B. licheniformis isolated from 40%. Between one and five samples yielded cultures of B. coagulans, B. laterosporus, B. pumilus, B. subtilis and P. macerans. Staphylococcus spp. were isolated from 23 (40%) samples; S. warneri and S. epidermidis were the most common and were cultured from 13 (22%) and 6 (10%) samples respectively. One or two samples yielded cultures of S. aureus, S. capitis and S. haemolyticus. The remainder of the flora detected comprised two samples contaminated with C. perfringens and two samples with either C. sordellii or C. tertium. Multiple bacterial species were isolated from 43 (74%) samples, a single species from the remaining 15. In 13 samples B. cereus alone was isolated, in one B. subtilis alone and in one sample B. pumilus alone. C. botulinum and C. novyi were not isolated from any of the heroin samples. Recommendations for the optimal examination of the microflora of heroin are given.

A case-control study of lifestyle risk factors associated with tuberculosis in Liverpool, North-West England

The aim of this study was to identify the subtle influences of exposure and individual lifestyles on the risk of developing tuberculosis. A retrospective case-control study (with matching by sex, age, postcode and ethnicity) of all tuberculosis cases notified over a 7-yr period in Liverpool, UK, was carried out. Multiple logistic regression showed that, before diagnosis, cases were 7.4 times more likely to have had visitors from abroad; 4.0 times more likely to have been born abroad; and 3.8 times more likely to have lived with someone with tuberculosis. Subtle socioeconomic factors were also evident with cases 4.0 times less likely to have additional bathrooms. Lifestyle factors emerged with cases 2.3 times more likely to have smoked for at least 30 yrs, 3.8 times less likely to eat dairy products every week and 2.6 times less likely to have had high blood pressure. At interview, these factors were still evident, but cases, unlike controls, had reduced their smoking and alcohol consumption and were less likely to go out of the home or exercise than before their illness. Within individuals, lifestyle consequences of tuberculosis lead to a "healthier" lifestyle on the one hand (less smoking and alcohol consumption), but a reduced quality of life (social activity) on the other.

Predictors of hepatitis B and C infection in injecting drug users both in and out of drug treatment

AIMS

To assess prevalence of, and behavioural risk factors for, hepatitis B and C in drug users both in and out of contact with drugs services.

DESIGN

Cross-sectional survey of hepatitis B and C prevalence using blood samples and self-completed risk factor questionnaires.

PARTICIPANTS

Three hundred and sixty injecting drug users (IDUs) in treatment for their drug use, attending syringe exchange schemes (SES), and not in contact with any services in Wirral and Manchester between 1997 and 1999, for whom test results were available for 334 (hepatitis B) and 341 (hepatitis C).

FINDINGS

Hepatitis B prevalence differed between groups, from 19% of those not in contact to 41% of those presenting to request a test (p = 0.040). Prevalence of hepatitis C ranged from 48% (SES) to 62% among those presenting for a test (p = 0.233). After multivariate adjustment, hepatitis B was predicted by prison stays (p = 0.030) and injecting for longer (p = 0.003). For hepatitis C, length of injecting career (p = 0.036), having been to prison (p = 0.034), having injected more than one drug type (p < 0.001) and being female (p = 0.037) predicted infection. Overall, 38% had shared some form of injecting equipment in the previous 4 weeks. People recently starting injecting were more likely to share, and sharing was more likely to occur when injecting with only one other user rather than in larger groups. Those who had previously presented for a hepatitis C test, regardless of the result, were less likely to have recently shared injecting equipment.

CONCLUSIONS

Behaviours associated with transmission of hepatitis B and C are common among IDUs. In particular, sharing of injecting equipment was more likely in small groups and in those recently beginning injecting. More broadly, chaotic drug use and time in prison were also risk factors for hepatitis infections. When assessing prevalence of hepatitis B and C, our results suggest that figures cannot be extrapolated from those in service contact to those in the wider drug-using population.

Re-emerging syphilis in the UK: a behavioural analysis of infected individuals

In-depth interviews with 27 individuals infected with syphilis in a recent UK outbreak (out of a total of 58 diagnosed between May 1999 and August 2000 in three city hospitals) were carried out to examine behaviour and attitudes. Most (23/27) participants were homosexual men, seven of whom were HIV positive. Between them, the 23 gay men had 1,494 different contacts in the twelve months prior to their awareness of having syphilis, but only 10% of these contacts could be named. While oral sex (usually unprotected) was the most prevalent behaviour (median = 30 partners per year), only 39% perceived unprotected oral sex as a syphilis risk (c.f. 70% for anal sex). Many gay men (61%) used gamma hydroxybutyrate (GHB) during sex as an aphrodisiac. This syphilis-infected subset of the population had high levels of unprotected and anonymous sex, which brings into question the usefulness of contact tracing to control syphilis outbreaks. The majority of partners were casual oral sex partners. More awareness is urgently needed around syphilis symptoms and risks, and risks of using drugs to reduce sexual inhibitions.

Hidden need for drug treatment services: measuring levels of problematic drug use in the North West of England

BACKGROUND

In the North West of England, data on drug users are routinely collected from a variety of agencies including specialist treatment centres, police and probation services. However, the covert nature of drug use means that alone, these conventional monitoring systems cannot provide the epidemiology required to target and develop drug treatment and prevention initiatives.

METHODS

Utilizing surveillance data and capture-recapture techniques we estimate the rates of problematic drug users by age and sex in five North West health authorities and one local authority.

RESULTS

Analyses show concentrations of problematic drug use in large metropolitan areas (Liverpool and Manchester) with levels as high as 34.5 and 36.5 per 1000 population (ages 15-44), respectively, and, for males, levels exceed 50 per 1000 in three authorities. Patterns of prevalence for those aged 25 and over differed from those in the younger age groups, with disproportionate levels of young users outside metropolitan areas. The proportion of young users already in treatment (21.3 per cent) was lower (older users, 35.3 per cent), with overall proportions in treatment varying between health authorities (range 26.2-46.5 per cent).

CONCLUSION

With a multi-agency approach, established monitoring systems can be used to measure hidden populations of drug users. Estimates of the current populations of such users in the North West of England suggest that planned increases of people in treatment by 100 per cent would fail to accommodate even current level of problematic users. A holistic approach to new initiatives must ensure that the high level of relapse once drug users are discharged are reduced and that the needs of young users are addressed before prolonged treatment is required.

Capture recapture as a method of determining the completeness of tuberculosis notifications

Notification of tuberculosis cases is often incomplete but combining data from several sources can provide a more accurate estimate of the number of cases. Data for the city of Liverpool were collected over an eight-year period from three sources: notifications, microbiological records and in-patient discharge coding data. Capture-recapture (CR) techniques were used to estimate the total number (including unreported cases) of tuberculosis cases in the city. By creating a log-linear model from the pattern of case replication between data sets, a model of best fit was created from which the number of cases present in the population, but not identified in any of the data sets, was estimated. False positive diagnoses were found in 67/516 (13%) of notifications and in 65/241 (27%) of in-patient codings. After excluding these, the total combined number of cases from all data sources was 473. CR methods identified only twelve extra cases (2.5%) making the estimated number of true cases total 485. Of these, in-patient codings identified 36.3%, microbiological records 56.3% and notifications 92.6%. It was concluded that notification of tuberculosis is very complete in Liverpool. Capture-recapture methods can be used to assess completeness of notification data in other settings.

Mercury contamination incident

BACKGROUND

The aim of this paper is to describe an incident where elemental mercury led to widespread contamination and the exposure of 225 individuals and confirmed toxicity in 19 individuals. The paper describes the incident and difficulties found in trying to assess the risk to individuals and to identify and decontaminate the residences involved.

METHODS

All individuals exposed to elemental mercury in the incident were followed up for 15 months.

RESULTS

Thirty-seven individuals were found to be 'at risk' and 13 were symptomatic of mercury poisoning. Five patients required chelation therapy. The incident was closed when the risk of poisoning and re-exposure was minimized.

CONCLUSION

Incident management depends on early effective communication and collaboration between all agencies involved.

Knowing the risk: relationships between risk behaviour and health knowledge

Communicating risk is a key public health strategy. The implicit assumptions are that the public interprets risk information in a logical fashion and adopts behavioural changes to reduce risk. We assessed risk behaviour, and knowledge and perception of voluntary and involuntary risks using an anonymous questionnaire completed by 472 students. Risk-taking behaviour was measured as the number of different risk behaviours undertaken in the previous 12 months. Knowledge and perception were measured by the extent to which subjects agreed with statements of risk-related information. These varied in complexity from simple statements linking a behaviour with a health risk to numerical statements describing the strength of such relationships. Risk-taking behaviour was highest amongst younger people, males, people whose parents were in non-manual occupations, and people who believed in God (risk-taking behaviour was not related to voting preference or birth order). Overall, knowledge was not significantly related to risk-taking behaviour (P=0.889). However, risk-taking was positively related to more accurate responses to numerical risk questions (P<0.001) and risk-takers were also more likely to perceive both voluntary and involuntary risks as less risky (P<0.05). At least in this cohort, more information about risk is not related to lower risk behaviour. In fact, those individuals with a better understanding of the precise risk associated with certain behaviours were more likely to be higher risk-takers while those who consistently over-estimated risks were low risk-takers. Overall, knowledge and perception of risk explained relatively little of the variance in behaviour. Although these findings need further examination within the general population, public health measures should not assume that information campaigns will necessarily lead to a reduction in risk behaviour.

How many data sources are needed to determine diabetes prevalence by capture-recapture?

BACKGROUND

Capture-recapture (CR) methods are increasingly used to estimate the size of human populations, including those with diabetes. Few studies have examined the demographic details needed to match patients on the lists used in these techniques, or to determine the optimum number of lists.

METHODS

Six lists of known diabetic patients attending different medical settings during the study year were obtained. The effects on total enumeration after aggregation of these lists were examined using increasing numbers of demographic data items as patient identifiers. The CR estimates of prevalence were obtained using 15 different combinations of two lists. Estimates were obtained after log-linear modelling for interdependence between different combinations of three and four lists, and after combining the six available lists into three logical lists.

RESULTS

For matching patients, adding date of birth to first name and family name as matching criteria increased the total of identified patients from 2500 to 2585 (3% increase), corresponding to a period prevalence of 1.5% (95% CI : 1.41-1.52). Addition of further identifiers, such as partial postcode, only increased the estimate by a further 15 patients (0.5%), and more detailed matching with full postcode introduced uncertainty. The use of two-list CR yielded widely varying estimates of the total diabetic population from 1379 (95% CI : 435-2273) to 9554 (95% CI : 7291-10 983). Log-linear modelling using different combinations of three and four lists produced estimates of 5074 (95% CI : 4417-5947) and 5578 (95% CI : 4918-7081), respectively, after compensating for statistical interdependence between the lists used. The appropriate condensation of six available lists into three lists for modelling yielded estimates of 5492 (95% CI : 4870-6285), corresponding to a CR-adjusted period prevalence of 3.1% (95% CI : 3.03-3.19%).

CONCLUSIONS

In a Western population, the only demographic data required for matching patients on lists used for CR methods are first name, family name and date of birth, if unique identifiers such as social security numbers are not available. Two lists alone do not produce reliable data, and at least three lists are needed to allow for modelling for 'dependence' between datasets. The use of more than three lists does not substantially alter the absolute value or confidence of enumeration, and multiple lists (if available) should be condensed into three lists for use in CR calculations.

Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort

Background: Each year more young people travel to international resorts where levels of substance use, sex and associated health risks are unknown. This study measures changes in levels of substance use and sexual behaviour of young people from the UK when on holiday in a youth orientated international resort, Ibiza. Methods: Data were collected through a cross-sectional survey collecting matched information on individuals' behaviour in the UK and abroad. Questionnaires were administered to 846 individuals aged between 15 and 35 at Ibiza Airport prior to their returning to the UK. Results: Young visitors to Ibiza significantly alter patterns of drug, alcohol and tobacco use. For ecstasy, in the UK 2.9% of users (9/313) used 5 or more days a week, while in Ibiza this rises to 42.6% (127/298). Fewer individuals use amphetamine, ketamine, cannabis, LSD, cocaine and GHB (gamma-hydroxybutyrate) in Ibiza although those continuing to use in Ibiza consume at substantially higher rates than when in the UK (P<0.001). Using multiple drugs over a 1 or 2 week stay was common (31.9%). Most individuals (53.8%) had sex while in Ibiza; 26.2% had sex without a condom and 23.2% had more than one sexual partner. Overall, 7.3% of individuals went to hospital or to see a doctor while in Ibiza with male (P<0.001), older (P<0.05) and staying for shorter times (P<0.005) being the key risk factors. Conclusions: While the potential for substance related ill health is dramatically elevated in Ibiza, harm minimisation measures in such resorts remain scarce. Equally, although holiday companies attract a sexually active cohort, safe sex messages are either absent or ineffective. Coordinated information campaigns to protect the health of young people are urgently needed and will require European cooperation across both public and private organisations.

Historical declines in tuberculosis in England and Wales: improving social conditions or natural selection?

OBJECTIVES

A reinvestigation of the relationship between the decline of tuberculosis and improvement in social conditions in England and Wales during Victorian times.

DESIGN

A retrospective study using data published in the annual reports of the Registrar General from 1853 to 1910. MEASURES ASSESSED: The diseases studied, in addition to tuberculosis were dysentery and cholera, including their total and infant mortality. Social conditions were evaluated from earnings and population density per house.

RESULTS

Tuberculosis mortality declined at an annual average rate of 1.71% (95% confidence interval [Cl] 0.77-2.63), whereas total mortality, infant mortality and mortality from cholera and dysentery and house population density showed no statistically significant decline over the same period. Real earnings increased by 1.05% (95% CI 0.29-1.81).

CONCLUSION

Improving social conditions do not provide the total explanation for the decline in tuberculosis during Victorian times. Other factors, principally natural selection, probably played a role. Part of the current increase in tuberculosis may be caused by effective drug therapy eliminating natural selection.

Capture-recapture-adjusted prevalence rates of type 2 diabetes are related to social deprivation

We examined the prevalence of type 2 diabetes and social deprivation in one urban district in Liverpool from October 1995 to September 1996 inclusive. This area has a stable Caucasian population of 176, 682. Lists were made of all known diabetics attending six different medical points of contact during the year, and were condensed and aggregated to eliminate duplicates. From postcode data, each patient was assigned to residence in one of the 14 electoral wards in the district, for which demographic structure and standardized measures of social deprivation were known (Townsend index). The crude period prevalences of type 1 and type 2 diabetes were estimated for each ward. Crude prevalence data were then corrected by applying capture-recapture (CR) techniques to the different patient datasets to allow for undercount. The crude period prevalence (95%CI) of diabetes was 1.5% (1.4-1.5%), or 2585/176, 682. The mean age of people with diabetes was not significantly different between electoral wards. The crude period prevalence of type 2 diabetes within individual wards ranged from 0.4% (0.3-0.6%) in the least deprived area to 4.1% (3.6-4.6%) in the most deprived area. The corresponding range of CR-adjusted period prevalence rates of type 2 diabetes was from 3.2% (2.8-3.6%) to 6.7% (6.1-7.4%), and there was strong correlation between both crude and CR-adjusted prevalence and social deprivation in each ward (r=0.76, p<0.001 for crude; and r=0. 49, p<0.005 for CR-adjusted prevalence). There was no correlation between the crude or CR-adjusted period prevalence rates of type 1 diabetes and Townsend index (r=0.14, p=NS). This strong correlation between the prevalence of type 2 diabetes and social deprivation has important implications for the planning of health-care delivery.

Historical declines in tuberculosis in England and Wales: improving social conditions or natural selection?

A reinvestigation of the relationship between the decline of tuberculosis and improvement in social conditions in England and Wales during Victorian times.

DESIGN

A retrospective study using data published in the annual reports of the Registrar General from 1853 to 1910. The diseases studied, in addition to tuberculosis were, dysentery and cholera including their total and infant mortality. Social conditions were evaluated from earnings and population density per house. Tuberculosis mortality declined at an annual average rate of 1.71% (95%CI 0.77 to 2.63) whereas total mortality, infant mortality and mortality from cholera and dysentery and house population density showed no statistically significant decline over the same period. Real earnings increased by 1.05% (C10.29 to 1.81). Improving social conditions do not provide the total explanation for the decline in tuberculosis during Victorian times. Other factors, principally natural selection, probably played a role. Part of the current increase in tuberculosis may be caused by effective drug therapy eliminating natural selection.