Estimating the birth prevalence and pregnancy outcomes of congenital malformations worldwide.

Congenital anomaly registries have two main surveillance aims: firstly to define baseline epidemiology of important congenital anomalies to facilitate programme, policy and resource planning, and secondly to identify clusters of cases and any other epidemiological changes that could give early warning of environmental or infectious hazards. However, setting up a sustainable registry and surveillance system is resource-intensive requiring national infrastructure for recording all cases and diagnostic facilities to identify those malformations that that are not externally visible. Consequently, not all countries have yet established robust surveillance systems. For these countries, methods are needed to generate estimates of prevalence of these disorders which can act as a starting point for assessing disease burden and service implications. Here, we describe how registry data from high-income settings can be used for generating reference rates that can be used as provisional estimates for countries with little or no observational data on non-syndromic congenital malformations.

Universal newborn screening: A roadmap for action.

Newborn screening (NBS) prevents morbidity and mortality by screening babies for selected disorders in the first days of life so that early diagnosis and treatment can be initiated. Congenital disorders impact an estimated 8 million or 6% of annual births worldwide, and of the top five that contribute 25% to the global burden of these disorders, three can be identified and managed by NBS. There are determined pockets of activity in Latin America, Sub-Saharan Africa, and the Asia Pacific region, where partnerships among government, non-governmental organizations, academia, the private sector and civil society are developing novel NBS programs that are both saving lives and preventing disability in those who survive.

Perspectives and needs for health in the 21st century: 20th-century paradigms in 21st-century science.

Countries in both the developed and developing world are expected to experience an unprecedented growth in the number of their elderly and decline in the number of their youth. This extraordinarily rapid aging of the world's population is a phenomenon without precedence in human history. Additionally, there is an increasing gap between the rich and poor both among and within nations. Both trends will not only constitute the primary health issues of the first decades of the 21st century but will also profoundly alter the world's economic, political, and social landscapes.

The pursuit of global health: the relevance of engagement for developed countries.

The globalisation of the world economy and the consequent increase in commerce, travel, and communication have brought benefits to virtually every country. But these changes also bring risks that cannot be addressed adequately within traditional national borders. These risks include emerging infectious diseases, resulting in part from increased prevalence of drug-resistant pathogens; exposure to dangerous substances, such as contaminated foodstuffs, and banned and toxic substances; and violence, including chemical and bioterrorist attack. By investing in global health, industrialized countries will not only benefit populations in desperate and immediate need of assistance, but also themselves--through protecting their people, improving their economies, and advancing their international interests. This paper describes the rationale for involvement of industrialised countries in global health, and suggests a means for its coordination.

The life span approach to female morbidity and mortality: an application to female health in sub-Saharan Africa.

PIP: Women play a central and increasingly complex role in most societies of the world. That role, however, has been poorly reflected in the fields of medicine and public health. Scientific attention and preventive health efforts have almost focused exclusively upon women's health as it affects their reproductive functions and offspring. Women have been treated as mothers or wives, rather than as individual female human beings with more comprehensive needs. This narrow perspective has adverse consequences for women's health and the social and economic well-being of the communities and societies in which they live. A study was undertaken to elaborate and test a more inclusive way of thinking about illness and to provide a unified documentary base for use in developing a systematic agenda for research and health policy formulation around female health in sub-Saharan Africa. The authors chose a life span model taking health and illness as cumulative products of synergy among different diseases and conditions, and between those diseases and conditions and the circumstances of real life. The Board on International Health of the Institute of Medicine study demonstrates the general utility of the life span model to the study of male and female health worldwide.^ieng

Acute encephalopathy and chronic neurological damage after pertussis vaccine.

In August 1991, the Institute of Medicine released a report entitled Adverse Effects of Pertussis and Rubella Vaccines, which examined, among others, the relation between immunization with whole-cell diphtheria-tetanus-pertussis (DTP) vaccine and both acute encephalopathy and chronic neurological damage. The committee reviewed information from a wide range of both professional and lay sources and found that the evidence is consistent with a possible causal relation between DTP vaccine and acute encephalopathy, although it is insufficient to establish causality. The range of excess risk of acute encephalopathy following DTP immunization is consistent with that estimated from the National Childhood Encephalopathy Study: 0.0 to 10.5 cases per million immunizations. The committee concluded that the evidence is insufficient to indicate either the presence or absence of a causal relationship between DTP vaccine and permanent neurological damage. The evaluative methods used by the committee are briefly described and the evidence underlying its conclusions presented.

Chronic arthritis after rubella vaccination.

In August 1991 the Institute of Medicine released a report entitled "Adverse Effects of Pertussis and Rubella Vaccines" that examined, among other relations, the relation between immunization with the RA 27/3 rubella vaccine strain and chronic arthritis. The committee spent 20 months reviewing a wide range of information sources including case series and individual case reports published in peer-reviewed journals and reported by vaccine manufacturers; unpublished case reports from physicians, parents, and other concerned persons; epidemiological studies; and laboratory studies. There were no animal studies available. The committee found that the evidence is consistent with a causal relation between the RA 27/3 rubella vaccine strain and chronic arthritis in adult women, although the evidence is limited in scope. Proving that rubella vaccination can cause chronic arthritis will require a better understanding of pathogenetic mechanisms and additional well-designed studies. We briefly describe the committee's evaluative methods and present the evidence underlying its conclusion.

Adverse events following pertussis and rubella vaccines. Summary of a report of the Institute of Medicine.

In August 1991, the Institute of Medicine released a report entitled Adverse Effects of Pertussis and Rubella Vaccines, which examined 18 adverse events in relation to diphtheria-tetanus-pertussis (DTP) vaccine and four adverse events in relation to the currently used rubella vaccine strain, RA 27/3. The committee spent 20 months reviewing a wide range of information sources, including case series and individual case reports, both published and unpublished, epidemiologic studies, studies in animals, and other laboratory studies. The committee found that the evidence indicates a causal relation between DTP vaccine and anaphylaxis and between the pertussis component of DTP vaccine and extended periods of inconsolable crying or screaming. The committee also reported that the evidence indicates a causal relation between the rubella vaccine and acute arthritis in adult women. The committee found the available evidence weaker but still consistent with a causal relation between DTP vaccine and two conditions--acute encephalopathy and hypotonic, hyporesponsive episodes--and between rubella vaccine and chronic arthritis in adult women. Estimated incidence rates of these adverse events following vaccination are provided, where possible. The committee found that the evidence does not indicate a causal relation between the DTP vaccine and infantile spasms, hypsarrhythmia, Reye's syndrome, and sudden infant death syndrome. The committee found insufficient evidence to indicate either the presence or absence of a causal relation between DTP vaccine and chronic neurologic damage, aseptic meningitis, erythema multiforme or other rash, Guillain-Barré syndrome, hemolytic anemia, juvenile diabetes, learning disabilities and attention-deficit disorder, peripheral mononeuropathy, or thrombocytopenia, and between rubella vaccine and radiculoneuritis and other neuropathies or thrombocytopenic purpura. The committee's evaluative methods are briefly described and a summary of research needs is provided.

Beer consumption and rectal cancer.

The association of beer drinking with cancer of the rectum was investigated in a case-control study of 130 male and 88 female rectal cancer cases and 336 male and 249 female controls. Information was obtained on consumption of beer, wine, and hard liquor throughout adulthood (quantity and duration), as well as on smoking and sociodemographic characteristics. Beer intake was not significantly associated with estimated risk of rectal cancer in females but was in males, with an increasing gradient in the odds ratio (OR) with increasing beer consumption. For drinkers of 32 or more ounces of beer per day, the OR was 3.5 (95% CI 1.8-7.0). No association was seen with duration of beer drinking. Wine and hard liquor consumption showed no association with the development of rectal cancer. In multiple logistic regression analyses, the relative risk for beer drinking was reduced slightly when potential confounding variables were included in the model (RR adjusted for religion and education: 2.7, 95% CI 1.3-5.7). The study results are discussed in the light of other epidemiological studies of rectal cancer and beer drinking. We conclude from the aggregate evidence that the association of beer drinking with rectal cancer is probably not causal and that the slightly elevated OR's observed for males in this study are most likely due to incomplete control for confounding variables.

Body weight, serum cholesterol, and stage of primary breast cancer.

To determine if body weight and serum cholesterol are associated with advanced primary breast cancer, the authors compared levels of both by TNM stage and estrogen receptor protein (ERP) concentration in a population of 148 premenopausal and 167 postmenopausal white women with histologically confirmed Stage I, II, and IIIa breast cancer. The women were admitted to Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City between 1982 and 1984. Overweight, whether measured as body weight in pounds, Quetelet index, or body surface area, was not found to be associated with TNM tumor stage, tumor size, extent of axillary node disease, or ERP concentration at mastectomy. Elevated serum cholesterol, either alone or in combination with overweight, also showed no association. When assessed in light of earlier studies, the study findings suggest that if overweight, as defined in this study, and/or elevated serum cholesterol do influence early breast cancer recurrence, they do so other than through an association with advanced primary disease. Suggestions for future research are proposed.

Appendectomy and subsequent cancer risk.

Although earlier epidemiologic studies reported a positive association between appendectomy and certain cancers, interest was limited due to lack of confidence in the study findings. However, recent morphologic studies on the immune structure of the vermiform appendix in the rabbit and man argue for a reevaluation of the appendectomy--cancer association. This paper reviews briefly the morphologic and epidemiologic literature on the subject to date. The validity of the earlier epidemiologic findings is discussed and avenues for further research assessing the relationship of appendectomy to subsequent cancer risk are proposed.