Geneva Health Forum Archive

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The Gait and Balance of Patients with Diabetes Can Be Improved: A Randomised Controlled Trial in Switzerland

Author(s): Lara Allet1, R. A. de Bie1, S. Armand2, A. Golay1
Affiliation(s): 1Geneva University Hospital and University of Geneva, Maastricht University and  Caphri Research School, Maastricht, the Netherlands
1st country of focus: Switzerland
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): This randomised controlled trial evaluates the effect of a specific training programme on gait and balance of diabetic patients. A group of 71 diabetic patients was recruited and randomly assigned to an intervention (n=35) or a control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function orientated strengthening (twice weekly over 12 weeks). The control group received no treatment. The authors conclude that specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients.
Background (max 200 words): Type 2 diabetes mellitus and its common complication, peripheral neuropathy, affect a large population. Peripheral neuropathy leads to sensory and motor deficits, which often results in mobility-related dysfunction, alterations in gait characteristics and balance impairments. Diabetic patients with peripheral neuropathy have lower gait velocity, decreased cadence, shorter stride length, increased stance time and higher step to step variability compared with healthy controls. These gait alterations increase on irregular surfaces. In addition, diabetic patients are known to suffer from increased risk of injurious falls. Fall-related injuries are often assumed to trigger a vicious circle because of their potentially detrimental influence on the physical activity levels of affected patients. Public Health guidelines for diabetes management recommend that patients perform at least 30 min of physical activity a day six times a week, requiring adequate gait security and balance. However, little is known about treatment strategies that could improve patients’ gait and balance, thereby also reducing the risk of falls.
Objectives (max 100 words): This study evaluates the effect of specific training programme on gait and balance of diabetic patients.
Methodology (max 400 words): This was a randomised controlled trial (n=71) with an intervention (n=35) and control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up.
Results (max 400 words): After training, the intervention group increased habitual walking speed by 0.149 m/s (p<0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength.
Conclusion (max 400 words): Although our study showed positive results, clinicians should be aware of possible adverse events. Two patients developed pain in their Achilles tendon, obliging us to slow down the progression for ‘toe walking’ and ‘one leg stance’exercises. More moderate progression and a longer warm up could possibly avoid such incidents. To the best of our knowledge, this is one of the first randomised controlled trials to describe an effective physiotherapy training programme geared to concurrently improve the balance and gait of diabetic patients. Future studies should examine the effect of exercise regimens on patient groups differentiated by neuropathy status (patients without, with mild or with severe peripheral neuropathy, identified by a more complex instrument for peripheral neuropathy screening). In addition, outcomes such as functional capacity, the number of falls or physical activity level should be considered in order to draw meaningful conclusions about exercise efficacy among patients with diabetes, thereby facilitating medical and clinical decision-making. Overall we can conclude that specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients.

COPD Prevalence among Women due To Indoor Air Pollution: South India

Author(s): Priscilla Johnson1, Padmavathi Ramaswamy2, Kalpana Balakrishnan2, Santu Ghosh2
Affiliation(s): 1Department of Physiology, Sri Ramachandra University, Chennai, India, 2Department of Environmental Health Engineering, Sri Ramachandra University, Chennai, India
1st country of focus: India
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Chronic obstructive pulmonary disease (COPD) is the 4th leading cause of death and 13th leading cause of burden of diseases worldwide. Although smoking remains the predominant risk factor, exposure to solid fuel smoke has also been identified as a risk factor for COPD, with rural women in developing countries bearing most of this disease burden.  Despite the importance of this disease, the fact is that the prevalence of COPD is not well measured due to the uncertainties in the prevalence estimation. Most of the previous studies have focused on prevalence of COPD in men and primarily addressing smoking as a risk factor and relatively few studies have attempted to assess prevalence amongst non-smoking rural women. Moreover, estimates of COPD prevalence were diverse either due to variation in the type of assessment or due to inconsistent physician recognition of COPD. In this study a meticulous diagnostic approach was chosen for identification of the COPD cases, including a complete clinical evaluation with spirometry before and after bronchodilation. Further, a previously developed predicted equation using  a log linear multiple regression model was used for understanding the likely household concentrations experienced by the women dwelling in different type of rural household which may be applied in future to generate exposure response for the development of COPD.
Background (max 200 words): COPD is the 4th leading cause of death and 13th leading cause of burden of diseases worldwide with projected increases in its contributions over the next decade. Active smoking is the major risk factor for COPD. Other risk factors include air pollution, passive smoking, heredity etc., More recently exposure to biomass smoke resulting from household combustion of solid fuels has also been identified as a risk factor for COPD. Solid fuel combustion results in high levels of pollutants like respirable particulate matter, carbon monoxide, oxides of nitrogen and sulphur, formaldehyde, benzo(a)pyrene and benzene which are a  major source of  respiratory irritants in the etiopathogenesis of COPD. Evidence from recent studies which have made contributions to examining temporal, spatial, or multi-pollutant patterns, in addition to day-to-day or seasonal variability in household concentrations,  show that persons in solid fuel using settings experience extremely high levels of noxious pollutants. Moreover, WHO’s Comparative Risk Assessment estimated that about 650,000 premature deaths of women from COPD and lung cancer occurred as a result of these exposures. Despite the importance of this disease, the fact is that the prevalence of COPD is not well measured is due to the uncertainties in the prevalence estimation.
Objectives (max 100 words): The primary aim of this cross sectional study was to estimate the prevalence of COPD among the rural women above 30 years through a primary household level, clinical and spirometric assessment. The secondary objective was to explore the different household level variables that may influence the development of COPD. The additional objective was focused at understanding the likely household concentrations experienced by the women dwelling in different type of rural household which may be applied in future to generate a exposure response for the development of COPD.
Methodology (max 400 words): This cross sectional study was conducted among 900 women from 45 different rural villages in Tiruvallur, a rural district in the state of Tamilnadu in India. The study was approved by the Institutional Ethics committee and was conducted between January and May 2007. The study subjects were selected through cluster sampling using probability proportion to size criteria.  This approach resulted in the selection of 45 out of 612 small villages with populations less than 10,000 in Tiruvallur district. The selection criteria included women aged 30 yrs and above who have been residents of the villages in Tiruvallur District for a minimum period of five years who did not report a history of bronchial asthma, pulmonary tuberculosis, cardiac diseases, pregnancy, diabetes and cancer. Informed written consent was obtained before recruiting any person into the study.  Then, the questionnaire was administered that collected information on known risk factors for COPD, details on type of fuel, duration of cooking etc. A detailed clinical history on respiratory symptoms was also obtained.  All symptomatic women were then subjected to pulmonary function tests. COPD cases were diagnosed based on the three criteria given by the GOLD diagnostic guidelines. Pulmonary function test was performed following American Thoracic Society guidelines using a portable data logging Spiro meter (MIR Spirobank).  This test was performed in a sitting position and the subject was then asked to inhale completely and rapidly and exhale maximally until no more air can be expelled while maintaining an upright posture. The same was repeated for a minimum of three manoeuvres and not more than eight was done for acceptability and repeatability. A complete flow-volume loop was obtained from the Spiro meter. The data were compared with individual predictive values based on age, sex, body weight, standing height and interpreted to arrive at the diagnosis. Spirometry with broncho dilation testing after inhalation of 200 µg of Salbutamol, was carried out in order to confirm COPD. Statistical analysis was performed using “R” Version 2. Prevalence was expressed in terms of percentage. Logistic regression analysis was performed to examine the association between selected risk factors and COPD. The Odds Ratios were calculated. Further, a previously developed predicted equation using  a log linear multiple regression model by Santu Ghosh  et al 2011 that predicts household level concentrations in relation to the household level determinants was assigned to the solid fuel and the clean fuel using households of the study population.
Results (max 400 words): The overall prevalence of COPD in this study was found to be 2.44% (95% CI 1.43- 3.45). COPD prevalence was higher in solid fuel users than the clean fuel users 2.5% vs 2 %, (OR 1.24; 95% CI 0.36 – 6.64) and it was two times higher (3%) in women who spend 2hours/day in the kitchen involved in cooking. Logistic regression analysis was performed to examine the association between COPD and use of solid fuel for cooking. Logistic regression analysis has shown increased risk of COPD in women using solid fuel for cooking, in older women, in women involved in cooking for longer duration, in women living in kutcha houses, and in women with history of passive smoking, though not significant. The concentration of particulate matter (PM2.5 ) of solid fuel using households was found to be 237.4 µg/m3 which was significantly higher than the households using clean fuel (50 µg/m3)
Conclusion (max 400 words): Accurate prevalence information is vital for several reasons such as documentation of COPD’s impact on the morbidity, mortality and economic burden and also for public health planning. This population based cross-sectional study used a meticulous diagnostic approach for the identification of the COPD cases, including a complete clinical evaluation with spirometry before and after bronchodilation, and estimated the COPD prevalence in a non-smoking rural women population primarily using solid fuel. The estimates generated in this study will contribute significantly to the growing database of available information on COPD prevalence and to refine the attributable burden of disease estimates. Besides, this information will help researchers to monitor trends, including the success or failure of control efforts. Moreover, this study has incorporated a previously developed model to assign exposure status in terms of quantitative value for  the categorical variables namely solid fuel and clean fuel using households of the study population which in turn may be applied to generate exposure response relationship with relevant to the development of COPD.

Sex Differences in the Association between Serum Uric Acid and Adiposity Markers in the Population-Based CoLaus Study

Author(s): Tanica Lyngdoh1, Pascal Bovet1, Pedro Marques-Vidal1, Gerard Waeber1, Peter Vollenweider1, Murielle Bochud1
Affiliation(s): Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Women and men differ in their serum uric acid (SUA) levels and fat distribution. As very few large scale population-based studies have systematically assessed sex differences in the relationship between SUA and markers of adiposity, we explored these associations in the CoLaus study. Our study supports previous findings that an elevated serum uric acid is closely associated with measures of adiposity. We present additional information on the differential effects of sex on the relationship. Our findings seem to suggest that the observed sex-differences are, in large part, explained by leptin.
Background (max 200 words): High serum uric acid (SUA) is known to co-exist with the different components of metabolic syndrome including obesity. Epidemiological and clinical studies have established positive associations between SUA and different adiposity markers including waist circumference, body mass index, waist-hip ratio, visceral fat, subcutaneous fat and total body fat. Sex is an important determinant underlying the relationship between SUA and metabolic syndrome. This is evident by the finding that the association is stronger in females than in males. Furthermore, recent findings suggest the role of leptin as a plausible explanation for the sex differences observed in the metabolic pathways involved in metabolic syndrome. Although SUA concentrations, serum leptin, and body fat distribution show obvious sex differences, very few studies have tried to systematically assess sex-differences in the relationship between serum uric acid and the different markers of adiposity.
Objectives (max 100 words): The objective of the current study was to explore sex differences in the relationship of serum uric acid with markers of adiposity and to assess if leptin could be a factor underlying the relationship between serum uric acid and adiposity.
Methodology (max 400 words): In 6184 participants aged 35 to 75 years randomly selected from the general population in Lausanne, we measured SUA, leptin and anthropometric variables including weight, height, body mass index (BMI),  waist circumference (WC), and fat and lean mass (using bioimpedance), and assessed lifestyle behaviors using a questionnaire. Fasting venous blood were collected after an overnight fasting.  Uric acid was measured by uricase-PAP and leptin by ELISA. Multiple median regressions were used to test the association of SUA with the different adiposity markers (as dependent variable) one at a time. We tested the interaction of SUA with sex by adding a multiplicative interaction term in the model.
Results (max 400 words): Mean SUA was higher in men (361.1 ± 75.7 µmol/L) than in women (270.6 ± 67.2 µmol/L). Men had higher mean weight, height, BMI and WC, while women had higher fat mass (p values <0.0001 for all). Positive correlations of SUA with weight, BMI, WC, and fat mass were stronger in women than in men (Spearman r:  0.35, 0.37, 0.40, and 0.41 in women, and 0.26, 0.30, 0.31, and 0.30 in men, respectively, p<0.0001 for all). In univariate analysis, SUA was strongly associated with weight, BMI, WC and fat mass in both men and women and the regression coefficients were almost twice as large in women than in men (p<0.001 for all associations). The associations remained significant upon adjustment for age, alcohol intake, smoking, Modification of the diet in Renal Disease (MDRD), diabetes, hypertension and the use of diuretics (regression coefficients ±SE for weight, BMI, WC and fat mass was 3.35 ±0.38; 1.25±0.10; 3.43±0.30; 2.00±0.15 in men and 5.61±0.38; 2.18±0.13; 6.21±0.32; 4.13±0.22 in women respectively, p<0.001 for all). In models including men and women together, there was a statistically significantly interaction by sex for all the associations between SUA and adiposity markers (p<0.001 for all). The interaction by sex was unaltered upon adjustment for insulin but was no longer significant upon adjustment for leptin.
Conclusion (max 400 words): In this population-based study of Caucasians aged 35 to 75 years, we found a strong association between SUA and markers of adiposity, with women showing stronger associations than men. We observe the sex difference to be largely explained by leptin, consistent with a leptin resistance in maintaining higher fat mass in women.

Effects of Particulate Matters on Inflammatory Markers in the General Adult Population

Author(s): Dai-Hua Tsai1,2, Nadia Amyai3, Pedro Marques-Vidal1, Jia-Lin Wang2, Michael Riediker4, Vincent Mooser5, Fred Paccaud1, Gerard Waeber3, Peter Vollenweider3, Murielle Bochud1
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Epalinges, Switzerland, 2Department of Chemistry, National Central University, Taoyuan County, Taiwan,  3Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland, 4 Institute for Work and
Health (IST), Lausanne, Switzerland, 5 Department of Genetics, GlaxoSmithKline, Philadelphia, PA, USA
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Particulate air pollution is associated with increased cardiovascular risk. The induction of systemic inflammation following particle inhalation represents a plausible mechanistic pathway. The purpose of this study was to assess the associations of short-term exposure to ambient particulate matters of aerodynamic diameter less than 10 μm (PM10) with circulating inflammatory markers in 6183 adults in Lausanne, Switzerland. The results show that short-term exposure to PM10 was associated with higher levels of circulating IL-6 and TNF-α. The positive association of PM10 with markers of systemic inflammation materializes the link between air pollution and cardiovascular risk.
Background (max 200 words): Variations in short-term exposure to particulate matters (PM) have been repeatedly associated with daily all-cause mortality. Particle-induced inflammation has been postulated to be one of the important mechanisms for increased cardiovascular risk. Experimental in-vitro, in-vivo and controlled human studies suggest that interleukin 6 (IL-6) and tumor-necrosis-factor alpha (TNF-α) could represent key mediators of the inflammatory response to PM. The associations of short-term exposure to ambient PM with circulating inflammatory markers have been inconsistent in studies including specific subgroups so far. The epidemiological evidence linking short-term exposure to ambient PM and systemic inflammation in the general population is scarce. So far, large-scale population-based studies have not explored important inflammatory markers such as IL-6, IL-1β or TNF-α. We therefore analyzed the associations between short-term exposure to ambient PM10 and circulating levels of high-sensitive CRP (hs-CRP), IL-6, IL-1β and TNF-α in the population-based CoLaus study.
Objectives (max 100 words): To assess the associations of short-term exposure to ambient particulate matters of aerodynamic diameter less than 10 μm (PM10) with circulating inflammatory markers, including hs-CRP, IL-6, IL-1β and TNF-α, in adults aged 35 to 75 years from the general population.
Methodology (max 400 words): All study subjects were participants to the CoLaus study (www.colaus.ch) and the baseline examination was carried out from 2003 to 2006. Overall, 6184 participants were included. For the present analysis, 6183 participants had data on at least one of the four measured circulating inflammatory markers.  The monitoring data was obtained from the website of Swiss National Air Pollution Monitoring Network (NABEL). We analyzed data on PM10 as well as outside air temperature, pressure and humidity. Hourly concentrations of PM10 were collected from 1 January 2003 to 31 December 2006.   Robust linear regression (PROC ROBUSTREG) was used to evaluate the relationship between cytokine inflammatory and PM10. We adjusted all analyses for age, sex, body mass index, smoking status, alcohol consumption, diabetes status, hypertension status, education levels, zip code, and statin intake. All data were adjusted for the effects of weather by including temperature, barometric pressure, and season as covariates in the adjusted models. We performed simple and multiple logistic regression analyses. Descriptive statistical analysis used the Wilcoxon rank sum test (for medians). All data analyses were performed using SAS software (version 9.2; SAS Institute Inc., Cary, NC, USA), and a two-sided significance level of 5% was used.
Results (max 400 words): PM10 levels averaged over 24 hours were significantly and positively associated with continuous IL-6 and TNF-α levels, in the whole study population both in unadjusted and adjusted analyses. For each cytokine, there was a similar seasonal pattern, with wider confidence intervals in summer than during the other seasons, which might partly be due to the smaller number of participants examined in summer. The associations of PM10 with IL-6 and TNF-α were also found after having dichotomized these cytokines into high versus low levels, which suggests that the associations of PM10 with the continuous cytokine levels are very robust to any distributional assumption and to potential outlier values. In contrast with what we observed for continuous IL-1β levels, high PM10 levels were significantly associated with high IL-1β. PM10 was significantly associated with IL-6 and TNF-α in men, but with TNF-α only in women. However, there was no significant statistical interaction between PM10 and sex. For IL-6 and TNF-α, the associations tended to be stronger in younger people, with a significant interaction between PM10 and age groups for IL-6. PM10 was significantly associated with IL-6 and TNF-α in the healthy group and also in the “non-healthy” group, although the statistical interaction between healthy status and PM10 was not significant.
Conclusion (max 400 words): In summary, we found significant independent positive associations of short-term exposure to PM10 with circulating levels of IL-6 and TNF-α in the adult population of Lausanne. Our findings strongly support the idea that short-term exposure to PM10 is sufficient to induce systemic inflammation on a broad scale in the general population. From a public health perspective, the reported association of elevated inflammatory cytokines with short-term exposure to PM10 in a city with relatively clean air such as Lausanne supports the importance of limiting urban air pollution levels.

Cardiovascular Disease Mortality Trends in a Rapidly Developing Country in the African Region

Author(s): Silvia Stringhini1, Flavie Sinon2, Joaquim Didon2, Jude Gedeon2, Fred Paccaud1 Pascal Bovet1,2,
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland, 2Ministry of Health, Victoria, Republic of Seychelles
1st country of focus: Seychelles
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Cardiovascular diseases (CVD) mortality is declining in high income countries. In low and middle income countries (LMIC), the total CVD burden is expected to increase due to demographic transition, but few reliable data allow assessing trends in age-adjusted cause-specific CVD rates. The Republic of Seychelles, a middle-income small island state located east to Kenya, is one of the few countries in the African region where vital statistics are obtained for the whole population. We examined trends in all-cause, CVD, stroke and myocardial infarction (MI) mortality between 1989-91 and 2008-10. Despite the increasing and aging population between 1989 and 2010, the total number of stroke deaths did not change over time and the number of MI deaths decreased. The age-adjusted mortality rates decreased by (men/women) 26%/25% for stroke and 39%/43% for MI between 1889 and 2010. Decreasing age-adjusted CVD mortality rates underlie reduced incidence (improved risk factors levels in the population) and/or improve case-fatality (improved case management). However, while MI mortality rates are low, stroke mortality rates remain high which is consistent with the high prevalence of hypertension in Seychelles. This emphasizes the need to further strengthen CVD prevention and control.
Background (max 200 words): CVD mortality has decreased markedly over the past three decades in high income countries. In contrast, the total CVD burden (i.e. the total number of CVD deaths) is expected to increase in LMICs due to increasing and aging populations (demographic transition). However, few reliable data are available on age-adjusted mortality rates in LMICs, because of the paucity of vital statistics or otherwise reliable population-based information systems in these countries, in particular in the African region. The Republic of Seychelles, a rapidly developing country, represents a unique opportunity to examine trends in cause-specific mortality in the African region, as all deaths are medically certified along vital statistics (numerator), the age- and sex-distribution of the population is known (denominator), and barriers to health care access are limited due to free health care. Assessing age-adjusted trends is important in order to monitor the epidemiological situation and to inform prevention and treatment strategies.
Objectives (max 100 words): The objective of this study was to examine trends in crude and age-adjusted mortality for CVD, stroke and MI in the Seychelles between 1989 and 2010. The emphasis is on stroke and MI, which are diagnoses that rely on minimal investigations and are likely to have been reported fairly reliably during the 22-year investigation period.
Methodology (max 400 words): All deaths recorded in the vital statistics between 1989 and 2010 were reviewed and manually coded. We considered stroke and MI as the cause of death if these diagnoses were reported in any of the 4 fields for underlying and concomitant causes of death. This approach (vs. considering only the first underlying cause of death) limits misclassification since the sequences of the underlying causes of death were recorded without formal validation. This approach also limits biases related to changing coding practices over time. However, the ascertainment of causes of death based on diagnoses appearing in any of 4 fields slightly overestimates the true MI and stroke mortality rates. The estimation of changes over time is unbiased. The yearly distribution of the population was available from census data, regularly updated by civil status authorities. Mortality rates for each year were directly standardized to the WHO 2001 standard population. In view of the small size of the country, and the relatively small number of deaths, we pooled events within 3-year groups. Trends in mortality were based on yearly analysis and examined using Poisson regression.
Results (max 400 words): Between 1989-91 and 2008-10, the population increased by 27% (from 204’854 to 261’033 people) and the proportion aged ≥70 years increased from 4% to 6%. A total of 13’163 deaths (7560 men and 5603 women) occurred in 22 years. The mortality rates (crude/age-adjusted, per 100’000) were 947/1625 for men and 684/704 for women in 1989-91 and 1083/1456 for men and 519/657 for women in 2008-10. CVD mortality represented 46% of all deaths in 1989-91 (762 cases) and 42% in 2008-10 (846 cases). Stroke and MI were reported as a cause of death in 17% and 7% of all death certificates in 1989-91 and in 14% and 5% in 2008-10. The total number of CVD deaths increased by 11% in 2008-10 compared to 1989-91; the number of stroke deaths was virtually unchanged (285 cases in 1989-91 and 290 in 2007-10); and the total number of MI deaths decreased (116 cases in 1989-91 and 97 in 2008-10). Comparing 1989-91 to 2008-10, age-standardized mortality rates (men/women, per 100,000) decreased from 764/343 to 565/310 for CVD; from 255/144 to 190/108 (a decrease of 26%/25%) for stroke; and from 119/52 to 79/30 (a decrease of 39%/43%) for MI. Based on yearly analysis, the decline in CVD, stroke and MI mortality was monotonous (an annual decrease (men/women) of 3.3%/2.7% for stroke and 3.0%/3.8% for MI, all p<0.001).
Conclusion (max 400 words): The total numbers of stroke and MI deaths in Seychelles did not increase over time despite the rapidly aging and growing population, and age-adjusted mortality rates decreased by approximately 25% for stroke and approximately 40% for MI between 1989 and 2010. This marked decline in CVD, which is consistent with the situation in high income countries and in some middle-income countries (e.g. Argentina or Brazil) underlie reduced incidence and/or improved case-fatality (e.g. decreasing prevalence of smoking, improved treatment for hypertension, better case management of acute cases, etc). While mortality rates of MI are fairly low by international standards, mortality rates for stroke remain high and are consistent with the high prevalence of several major risk factors in Seychelles, particularly hypertension.  This emphasizes the need to strengthen primary and secondary CVD prevention.

Predictive Value of Elevated Blood Pressure during Childhood: Seychelles

Author(s): Arnaud Chiolero1, Gilles Paradis2, Georges Madeleine3, Pascal Bovet1
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland, 2Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada, 3Ministry of Health and Social Services, Victoria, Seychelles
1st country of focus: Seychelles
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Hypertension has roots in childhood and screening for elevated BP beginning in children is advocated.  However, having elevated blood pressure (BP) in childhood may not be associated with a high probability of elevated BP later in life.  Using data collected in school children of the Seychelles, we showed that having an elevated BP on one occasion in childhood is a weak predictor of sustained elevated BP 3-4 years later.
Background (max 200 words): Screening of elevated blood pressure (BP) in children has been advocated to early identify hypertension. However, identification of children with sustained elevated BP is challenging due to the high BP variability.  The value of an elevated BP measure during childhood and adolescence for the prediction of future elevated BP is not well described.
Objectives (max 100 words): We assessed the positive (PPV) and negative (NPV) predictive value of high BP for sustained elevated BP in cohorts of children of the Seychelles, a rapidly developing island state in the African region.
Methodology (max 400 words): Serial school-based surveys of weight, height, and BP were conducted yearly between 1998-2006 among all students of the country in four school grades (kindergarten [G0, mean age (SD): 5.5 (0.4) yr], G4 [9.2 (0.4) yr], G7 [12.5 (0.4) yr] and G10 (15.6 (0.5) yr].  We constituted three cohorts of children examined twice at 3-4 years interval:  4,557 children examined at G0 and G4, 6,198 at G4 and G7, and 6,094 at G7 and G10.  The same automated BP measurement devices were used throughout the study.  BP was measured twice and averaged at each exam. Obesity and elevated BP were defined using the CDC (BMI 95th sex-, and age-specific percentile) and the NHBPEP criteria (BP 95th sex-, age-, and height specific percentile), respectively.
Results (max 400 words): Prevalence of obesity was 6.1% at G0, 7.1% at G4, 7.5% at G7, and 6.5% at G10.  Prevalence of elevated BP was 10.2% at G0, 9.9% at G4, 7.1% at G7, and 8.7% at G10.  Among children with elevated BP at initial exam, the PPV of keeping elevated BP was low but increased with age: 13% between G0 and G4, 19% between G4 and G7, and 27% between G7 and G10, respectively.   Among obese children with elevated BP, the PPV was higher: 33%, 35% and 39% respectively. Overall, the probability for children with normal BP to remain in that category 3-4 years later (NPV) was 92%, 95%, and 93%, respectively.  By comparison, the PPV for children initially obese to remain obese was much higher at 71%, 71%, and 62% (G7-G10), respectively.  The NPV (i.e. the probability of remaining at normal weight) was 94%, 96%, and 98%, respectively.
Conclusion (max 400 words): During childhood and adolescence, having an elevated BP at one occasion is a weak predictor of sustained elevated BP 3-4 years later.  In obese children, it is a better predictor.

Mapping of Trachoma and Risks Factors: Northern Ivory Coast

Author(s): Brama Kone1, Guéladio Cissé2, Marie-Madelaine Kouakou3, Doulaye Sacko4
Affiliation(s): 1Swiss Centre for Scientific Research in Côte d'Ivoire, Korhogo University, Abidjan, Ivory Coast, 2Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland, 3Programme National de Lutte contre la Cécité in Ivory Coast,  4Organisation Ouest Africaine de la Santé (OOAS), Bobo-Dioulasso, Burkina Faso
1st country of focus: Ivory Coast
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): A mapping of trachoma in northern Côte d'Ivoire in 2008 illustrates a relative high prevalence in few villages. In those villages, it’s urgent to treat and sensitize affected communities and, help clean up and improve their living environment.
Background (max 200 words): Trachoma is endemic in Mali and Burkina Faso, two boundary countries of Côte d’Ivoire in its northern part. However, there is no data available on the disease in that country.
Objectives (max 100 words): In order to achieve trachoma cartography in West Africa a survey was conducted in northern Côte d’Ivoire in 2008.
Methodology (max 400 words): A cross sectional community-based survey was conducted. From six prefectural areas, a total of 31 clusters of at least 60 children of 1 to 9 years old per cluster were selected by a multistage cluster random sampling technique. Subjects more than 9 years old from each cluster were also selected. A total of 3978 people (2066 children of 1-9 years old) were assessed for signs of trachoma. Ophthalmic nurses used a simplified clinical grading system to assess stages of trachoma while environmentalists assessed risk factors for trachoma.
Results (max 400 words): Prevalence of active trachoma (TA) in children aged 1-9 years was 3.1% (95% CI= 2.4- 4.0). Among them, TF= 2.9% (95% CI= 2.2-3.7) and TI=0.2 (95% CI= 0.1-0.5).  Two villages had the highest prevalence of TA (10.7% and 25.0%) while the majority others had less than 2%. Three (3) women aged more than 40 years had trachomatous trichiasis (TT) representing 0.7% (95% CI= 0.2-2.3) of that age group. TA prevalence was not different between children male and female but was more prevalent, for example, in children whose faces were dirty (OR = 3.4; 95% CI = 1.9-6.4) or weren’t washed on waking up (OR = 5.5; 95% CI = 1.8-13.9) and those who were living in houses without electricity (OR = 2.6; 95% CI= 1.4-5.4). The presence of cows in the household seemed to be a protecting factor against TA (OR = 2.8; 95% CI = 1.6-5.5).
Conclusion (max 400 words): Apart from some villages, trachomatous doesn't seem to be a public health problem in the north of Côte d’Ivoire. However, due to its relative high prevalence in those villages, it’s urgent to treat and sensitize affected communities and help improve their living environment in order to contribute to the objective of eradicating Thrachoma until 2020.

Chronic Hepatitis B among Sub-Saharan Africa Immigrants in Southern Spain

Author(s): Joaquin Salas-Coronas1, J. Vázquez-Villegas, MT Cabezas-Fernández, MJ Soriano-Pérez,I. Cabeza-Barrera, AB Lozano-Serrano, JM Fernández-Peláez, I. Pérez-Camacho, E. Fernández-Fuertes
Affiliation(s): 1Hospital de Poniente, El Ejido, Almeria, Spain
1st country of focus: Spain
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): Chronic hepatitis B infection affects 350 million people worldwide, of which 50 million are in Africa. In sub-Saharan Africa, where the disease is endemic, the population of some countries has a prevalence that reaches 98% for markers of infection for hepatitis B virus (HBV). The transmission of the virus occurs in these countries at very early stages of life, which often determines the chronicity of the disease. The complications of chronic HBV infection, such as liver cirrhosis or hepatocellular carcinoma (HCC), are in fact a major cause of mortality in the population of these countries.
Background (max 200 words): Chronic hepatitis B infection affects 350 million people worldwide, of which 50 million are in Africa. In sub-Saharan Africa, where the disease is endemic, the population of some of these countries has a prevalence that reaches 98% for markers of infection for hepatitis B virus (HBV). The transmission of the virus occurs in these countries at very early stages of life, which often determines the chronicity of the disease. The complications of chronic HBV infection, such as liver cirrhosis or hepatocellular carcinoma (HCC), are in fact a major cause of mortality in the population of these countries
Objectives (max 100 words): The aim of this study was to investigate the prevalence of HBV (hepatitis B virus) markers and chronic B hepatitis in sub-Saharan Africa immigrants referred to a Tropical Unit Medicine between October 2004 and November 2011
Methodology (max 400 words): Patients were deemed to have active hepatitis B if they had HBsAg positive result, while past infection was presumed when only anti-HBc and/or anti-HBs were present. In patients with a solely anti-HBc positive, anti-HBc-IgM was determinate to rule out acute infection. In HBsAg carriers were determined HBeAg, anti-HBe and HBV-DNA testing by nested-PCR.
Results (max 400 words): HBV markers were tested in 1.434 of 1.451 subjects (98.8%). 91.4% were males and the mean age was 29.8 yr. Most of them were born in countries from West Africa (Senegal 31.6%, Mali 22.1%, Guinea-Bissau 15.4% and Mauritania 7.6%). The mean time spent in Spain was 40.65 months. Among 1.434 patients studied, 1.293 (90.16%) presented serologic markers for HBV infection. 378 (26.35%) were chronic carriers (HBsAg +). There were no significant differences in serologic HBV profile between different countries.  After determination of HBV- DNA in HBsAg + patients, 219 were classified as inactive chronic carriers, 112 patients as HBeAg negative chronic hepatitis B and 47 patients as HBeAg positive chronic hepatitis B. Genotype E was the most frequent (78.7%). 9 patients had liver cirrhosis and 2 hepatocellular carcinoma.
Conclusion (max 400 words): We found a very high prevalence of HVB infection in sub-Saharan Africa immigrants patients referred to the Tropical Medicine Unit in Hospital de Poniente (Spain). More than 26% were HBsAg chronic carriers. HBV carriage in black Africans is largely established in early childhood, and induces other diseases, especially hepatocellular carcinoma and cirrhosis. It is necessary to closely follow these patients to prevent the development of these significant illnesses. HVB markers must be requesting all patients coming from sub-Saharan Africa countries.

Community Empowerment – Intervention of Non Communicable Diseases in Luanti Baru Village District of Ranau, Sabah, Malaysia

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Author(s): Koay TengKhoon1, Rahim Bin Sulong1, Chin Kim Ling2, Saibi Modusin2
Affiliation(s): 1Tuaran Area Health Office, Sahah, Malaysia, 2Ranau Health Office, Ranau, Malaysia
1st country of focus: Malaysia
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This paper presents the results of ongoing intervention programmes for non-communicable diseases (NCD) through community empowerment in "Luanti Baru" Village, district of Ranau
Background (max 200 words): Non-communicable diseases have increased in Malaysia where we are face an epidemiological transition. There is a need for affordable and effective community based preventive programs. By empowering the community, it is possible to make the prevention of non-communicable diseases more affordable, accessible and effective.
Objectives (max 100 words): The objective of this paper is to describe and evaluate ongoing intervention programmes for non-communicable diseases through community empowerment in “Luanti Baru” Village, Ranau.
Methodology (max 400 words): Pre assessment was completed with a universal sample to evaluate the Body Mass Index (BMI), Blood Pressure (BP) and Blood Glucose for the community aged 13 years and above. We used a self administered questionnaire to collect data about socio-demographic characteristics, eating and physical activities, cigarette smoking and alcohol consumption habits.  The intervention program commenced in November 2010. The intervention program consists of educative sessions on healthy diet, physical activity, cardiovascular diseases, tobacco & alcohol uses and mental health. A total of 14 community members were selected and trained to be NCDs facilitator to facilitate the intervention program. Physical activities session, health counselling clinic, and healthy cooking demonstrations were  also carried out.
Results (max 400 words): The total number of participants was 89. The proportion of males and female was 48.3% and 51.7% respectively. The age group of 13-34 years was 44.9% and 35 years & above was 55.1%. A proportion 62.9% was overweight or obese, 10.8% were found to have borderline blood sugar, 76.4% were found to be either borderline or hypertensive and 72% was smokers. Based on food intake assessment score, 51.3% were excellent, 39.5% were good and 9.2% were fair. Physical activity status for the past 1 week based on MET (Metabolic Equivalent for physical activity) reviewed that 56.6% was inactive.  After 6 months intervention, a total of 29 (64.4%) out of 45 residents participated in the intervention recorded weight reduction, 5 (62.5%) out of 8 borderline blood sugar became normal, 5 (11%) out of 44 participants became normal blood pressure and three residents successfully quit smoking.
Conclusion (max 400 words): Intervention through community empowerment is important and could possibly lead to prevention of non communicable diseases in the community.

Scaling Up Cancer Care for Non-Insured Children in Developing Countries: Mexico

Author(s): Ricardo Pérez Cuevas1, Svetlana V. Doubova2, Marta Zapata-Tarres3, Sergio Flores-Hernández, Lindsay Frazier, Carlos Rodríguez-Galindo, Gabriel Cortes-Gallo, Salomon Chertorivski-Woldenberg, Onofre Muñoz-Hernández
Affiliation(s): 1Ministry of Health, Mexico City, Mexico, 2Epidemiology and Health Services Research Unit Mexican Institute of Social Security, 3Hospital Infantil de Mexico Federico Gomez
1st country of focus: Mexico
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): Objective: to evaluate the progress of coverage and survival experience of non-insured children with cancer whose treatment was financed by the System of Social Protection for Health in Mexico. Methods: A retrospective cohort study was conducted in 47 public hospitals.  Results: 3,821 patients were analyzed. In 3 years, coverage increased from 3.3% to 55.3%. Principal diagnoses were acute lymphoblastic leukemia (46.4%), central nervous system tumors (8.2%) and acute myeloid leukemia (7.4%). The survival rates showed wide variability in the country.  Conclusion: Access to healthcare for children with cancer increased; yet capability of public hospitals must improve to increase life expectancy.
Background (max 200 words): Mexico is investing in expanding equitable pediatric cancer care, which is the second most common cause of death among children aged 1-14 years. In the country there are differences in childhood cancer mortality rates according to the geographic area of residence. The poorest states have reported the highest mortality rates. Access to health care is limited by the costs of treatment and deficient health services infrastructure; children without social security have a 30% greater risk of delayed diagnosis of cancer; furthermore, caring for a child with cancer represents a significant risk of impoverishment for families.  To mitigate the burden of pediatric cancer, since 2004, the Mexican government implemented the Fund for Protection against Catastrophic Expenditures (FPGC) as part of the System of Social Protection for Health “Seguro Popular”. FPGC is a tax-based fund that financially supports health care by pooling the risks of high cost and low-prevalence diseases. FPGC allocates financial resources directly to accredited public hospitals that provide care for cancer patients. This paper analyzes the progress of this policy to increase access to care for children with cancer.
Objectives (max 100 words): This study had three objectives: to investigate the progress in coverage of new patients suffering from childhood cancer, to describe their socio-demographic, clinical characteristics and health outcomes, and to analyze their survival experience.
Methodology (max 400 words): A retrospective cohort study was conducted from October 2008 to November 2009. The study population was children and adolescents with newly diagnosed cancer who were cared for at 47 public hospitals. The scientific review board and the ethics committee approved the study protocol.  To investigate the progress of coverage, the estimated number of eligible patients to receive care was used. The country was divided into five geographical regions: West, Northwest, Central, East and Southeast. The regions were based on the human development index. The expected number of patients for all types of cancer was estimated by multiplying the number of eligible children to receive care by 121.5 per 1,000,000 children/years. This is the age–standardized incidence rate for all types of cancer for individuals aged 0–14 years reported in Mexico. The resulting number was divided by 1,000,000. The amount of new cancer patients from Seguro Popular registries was identified, and the proportion of cancer cases funded in relation to the expected number of cases was calculated.  To describe the socio-demographic and clinical characteristics and analyze the survival experience, the analysis concerned the registries of the claims made by affiliated hospitals, and information from clinical charts. The variables were: socio-demographic characteristics, children’s characteristics: sex, age at diagnosis, previous disease, cancer type and risk group of cancer according its prognosis and stage at diagnosis, relapse and adverse events (AE). The high-risk cancer children were those suffering from high-risk ALL, high-risk acute myeloid leukemia (AML), high-risk Central Nervous System (CNS) tumors such as astrocytoma, and stage III and IV solid tumors or those with metastasis. The classification of AE was in accordance with the National Cancer Institute. AE appeared after diagnosis, regardless of treatment provision. Only AE graded between two and five were recorded.  Survival was measured from the time of initial diagnosis to the date of death from any cause or to the last date of follow-up or last contact. The Kaplan-Meier (KM) method was used. The survival analysis included the 2006-2009 period when Seguro Popular funded care for children with cancer. Censored patients were children with incomplete information concerning their follow-up, and patients with other or unknown causes of death. The log-rank test was used to compare survival curves. To determine the impact of the program on the survival experience in terms of geographical region and other covariates, univariate and multivariate analysis (Cox proportional hazard regression model) were performed.
Results (max 400 words): Data were collected from 47 hospitals, accounting for 4,065 patients. The final analysis comprised 3,821 patients.  Table 1 demonstrates the progress of coverage per region. The central and south-southeast regions had the highest expected numbers; yet the highest increase of coverage was in the northwest (2006: 2.2%, 2008: 77.7%), the lowest in the south-southeast (2006: 1.6%, 2008: 37.8%).  Table 2 depicts the characteristics of the study population. Acute lymphoblastic leukemia (ALL) was the most frequent (46.4%), followed by CNS tumors (8.2%) and AML (7.4%); 58.6% of patients were at high-risk. Relapse occurred in 10.7%; 44.9% had AE. 68.1% were alive, 23.7% had died, 6.7% had abandoned the treatment regime and 2% had missing data. Figure 1 depicts the unadjusted KM survival curves of cases with hematologic malignancies: ALL 60%, AML 33%, Hodgkin’s lymphoma 81.5% and Non-Hodgkin’s lymphoma 52%. Figure 2 presents the unadjusted KM survival curves of cases with solid tumors: CNS tumors 40%, renal tumors 73.4%, bone tumors 47% and retinoblastoma 73%.  Figure 3 concentrates on the estimated survival function of leukemia by region. The KM curve for the south-southeast was consistently lower than KM curves for other regions. After 12 months, as the number of follow-up months increased, the KM curves grew farther apart. The 3-year survival rates calculated in terms of geographical region were: west 58.1%, northwest 69.1%, east 68.2%, center 64.1% and south-southeast 29.8%. Children with cancer in the south-southeast region had poorer survival prognosis than children from the other regions.  Figure 4 displays the estimated survival function of CNS tumors by region. Patients from the northwest and south-southeast had lower unadjusted survival estimates than the other regions. The 3-year survival rates by region were: east 82.3%, center 69.3%, west 61.3%, northwest 37.6% and south-southeast 10.4%. The log-rank test was p<0.001.  Table 3 summarizes the Cox proportional hazards model in three groups: all types of cancer, leukemia and CNS tumors. The group "all types of cancer" showed that children from all regions, when compared with the central region, had a significant risk of death; the east and south-southeast regions had the highest risk. Patients with CNS tumors and bone tumors were at higher risk of death than individuals diagnosed with other cancers. The analysis for leukemia demonstrated similar risks. The analysis of CNS tumors showed higher risk of death in children in the northwest region and the south-southeast.
Conclusion (max 400 words): Mexican policies aimed at improving access to and coverage of cancer care for children are gaining momentum. Seguro Popular is a strategy to help reduce disparities in the treatment of children with cancer. The policy of funding all childhood cancer treatments through Seguro Popular is relatively new and being gradually introduced into the country. Therefore, it will require time and additional resources to achieve reasonable outcomes. This study demonstrated that the institutional capacity should be strengthened to improve the overall survival rate of sufferers of childhood cancer. The findings could be used to build on the knowledge derived from a middle-income country’s experience concerning the possible causes of not reaching the health outcomes that cancer care protocols are reaching in developed countries where extensive studies take place. It is advisable to develop pediatric cancer care services in the poorest regions to decrease the uneven distribution of resources available, and to implement studies to analyze the economic impact of Seguro Popular and measure adherence and quality of care for patients. The results of these studies will assist in the development of policies and to be used for better-targeted interventions aimed at increasing the effectiveness of cancer care.