Cancer incidence among Chernobyl cleanup workers from Estonia: A 34-year follow-up.

From 1986 to 1991, 4831 men from Estonia were sent to clean up radioactively contaminated areas near Chernobyl (Chornobyl). Their cancer incidence during 1986 to 2019 was compared to that of the male population of Estonia. The cohort of cleanup workers was linked to national population and cancer registers based on unique personal identification numbers. Nineteen (0.4%) workers could not be traced. A total of 4812 men contributing 120 770 person-years of follow-up were eligible for the analyses. Standardized incidence ratios (SIR) and adjusted relative risks (ARR, expressed as ratios of SIRs) with 95% confidence intervals (CI) were calculated. A total of 687 incident cancer cases were registered in the cohort (SIR 1.11, 95% CI 1.03-1.19). Presumptive radiation-related cancers combined were in excess, but not when smoking- and alcohol-related cancers were excluded (SIR 0.92, 95% CI 0.71-1.18). For smoking-related cancers, the SIR was 1.24 (95% CI 1.13-1.36) and for alcohol-related cancer the SIR was 1.53 (95% CI 1.31-1.75). Less educated workers had a higher risk of all cancers (ARR = 1.21, 95% CI 1.02-1.44) and smoking-related cancers (ARR = 1.42, 95% CI 1.14-1.76). An elevated risk of alcohol-related cancers was evident 15 to 24 years (vs <15 years) after return from the Chernobyl area. This updated register-based follow-up of Chernobyl cleanup workers from Estonia revealed an excess of radiation-related cancer sites combined, but the excess was not apparent after excluding cancers associated with smoking and alcohol.

Suicide and other causes of death among Chernobyl cleanup workers from Estonia, 1986 - 2020: an update.

Mortality was studied in a cohort of 4831 men from Estonia who participated in the environmental cleanup of the radioactively contaminated areas around Chernobyl in 1986-1991. Their mortality in 1986-2020 was compared with the mortality in the Estonian male population. A total of 1503 deaths were registered among the 4812 traced men. The all-cause standardized mortality ratio (SMR) was 1.04 (95% CI 0.99-1.09). All-cancer mortality was elevated (SMR 1.16, 95% CI 1.03-1.28). Radiation-related cancers were in excess (SMR 1.20, 95% CI 1.03-1.36); however, the excesses could be attributed to tobacco and alcohol consumption. For smoking-related cancers, the SMR was 1.20 (95% CI 1.06-1.35) and for alcohol-related cancers the SMR was 1.56 (95% CI 1.26-1.86). Adjusted relative risks (ARR) of all-cause mortality were increased among workers who stayed in the Chernobyl area ≥ 92 days (ARR 1.20, 95% CI 1.08-1.34), were of non-Estonian ethnicity (ARR 1.33, 95% CI 1.19-1.47) or had lower (basic or less) education (ARR 1.63, 95% CI 1.45-1.83). Suicide mortality was increased (SMR 1.31, 95% CI 1.05-1.56), most notably among men with lower education (ARR 2.24, 95% CI 1.42-3.53). Our findings provide additional evidence that unhealthy behaviors such as alcohol and smoking play an important role in shaping cancer mortality patterns among Estonian Chernobyl cleanup workers. The excess number of suicides suggests long-term psychiatric and substance use problems tied to Chernobyl-related stressors, i.e., the psychosocial impact was greater than any direct carcinogenic effect of low-dose radiation.

Trends in teenage delivery and abortion rates in Estonia over more than two decades: a nationwide register-based study.

BACKGROUND: In the last 30 years, Estonia has undergone major socio-economic changes, including profound educational and healthcare reforms. The study aimed to analyse trends in teenage delivery and induced abortion rates among younger and older teens, including Estonians and non-Estonians, and to study trends in repeat teenage pregnancies in more detail. METHODS: The register-based study included data on 29 818 deliveries (1992-2019) and 25 865 (1996-2019) induced abortions among 15-19-year-old girls. Delivery and abortion rates per 1000 girls were calculated by age group, ethnicity and reproductive history. Poisson regression models were applied to estimate average annual percentage changes in delivery and abortion rates over the whole period and in two sub-periods with change points in the trend in 2007. RESULTS: The delivery rate decreased by 5.3% per year, from 49.9 in 1992 to 8.4 in 2019; the abortion rate decreased by 6.0% per year, from 42.4 in 1996 to 8.6 in 2019. A faster decline in delivery rates took place among Estonians than non-Estonians, but the opposite trend occurred in abortion rates. Delivery rates for first and repeat pregnancies decreased nearly at the same pace, while abortion rates for repeat pregnancies decreased faster than those for first pregnancies. CONCLUSIONS: A decreasing trend in teenage births is evident in parallel with society becoming wealthier. A remarkable decline in teenage abortions occurs when young people's rights to safe abortion, contraception, mandatory sexuality education and youth-friendly services are ensured. There always remains a small group of adolescents who repeatedly become pregnant.

Singleton pregnancies after in vitro fertilization in Estonia: a register-based study of complications and adverse outcomes in relation to the maternal socio-demographic background.

BACKGROUND: An increased risk of adverse conditions related to in vitro fertilization (IVF) pregnancies has been repeatedly reported. Our study aimed to summarize outcome differences between pregnancies after IVF and after spontaneous conception (SC) in Estonia. METHODS: Data on all liveborn singletons to primiparas women aged 25-40 years during the period 2005-2014 were obtained from the Estonian Medical Birth Registry. There were 1778 and 33,555 newborns in the IVF and SC cohort, respectively. The relative risk of pregnancy-related complications and adverse pregnancy outcomes in the IVF cohort in comparison with the SC cohort was quantified by prevalence proportion ratios (RR) with 95% confidence intervals (CI) using modified Poisson regression models adjusted for maternal age, education, ethnicity, marital status and study period. RESULTS: The cohort of IVF singletons experienced a higher risk of preterm birth (RR 1.51; 95% CI 1.28-1.78), iatrogenic preterm birth (RR 1.62; 95% CI 1.32-1.98), very preterm birth (RR 1.49; 95% CI 1.00-2.23), low birthweight (RR 1.47; 95% CI 1.20-1.80), congenital anomalies (RR 1.51; 95% CI 1.08-2.11), and admission to a neonatal intensive care unit (RR 1.13; 95% CI 1.01-1.26). Somewhat elevated risk of spontaneous preterm birth did not reach statistical significance (RR 1.32; 95% CI 0.97-1.80). IVF mothers were at increased risk of placenta previa (RR 7.15; 95% CI 4.04-12.66), placental abruption (RR 2.12; 1.43-3.14) and cesarean section (RR 1.28; 95% CI 1.20-1.37). The risk of pre-eclampsia was borderline (RR 1.25; 95% CI 0.98-1.59). Adjustment for maternal age attenuated the associations between IVF and adverse outcomes. Maternal education, ethnicity and marital status had no effect on the magnitude of the risk estimates. CONCLUSIONS: The increased risk of pregnancy-related complications and adverse pregnancy outcomes was observed in the Estonian cohort of IVF singletons in comparison with the cohort of SC singletons. The relative risk estimates grew with maternal age but were not influenced by the maternal education, ethnicity and marital status. To monitor the efficacy and safety of the used assisted reproductive technology, a specialized country-wide register should be created in Estonia.

Quality of IVF status registration in the Estonian Medical Birth Registry: a national record linkage study.

BACKGROUND: Information regarding in vitro fertilization (IVF) as a pregnancy risk factor (yes/ no) is stored in each birth record of the Estonian Medical Birth Registry (EMBR). This study aimed to assess the validity of registration of newborns' IVF status in the EMBR. METHODS: To identify the newborns conceived by IVF, the birth records in the EMBR were compared to individual records on the embryo transfer procedures in the Estonian Health Insurance Fund (EHIF) database as a reference. Maternal age was restricted to 40 years, the age limit for IVF treatment covered by the EHIF. The embryo transfer procedures, that dated up to eight weeks before pregnancy, were additionally checked in the infertility treatment clinics. The validity of IVF status was measured by sensitivity, specificity, positive and negative predictive values (PPV and NPV). Relative risk (RR) of unrecorded IVF status among IVF mothers by socio-demographic characteristics and birth plurality was estimated using modified Poisson regression models. RESULTS: There were 3198 newborns identified as conceived by IVF in the EMBR in 2005-2014. Eight of them were incorrectly entered as born after IVF. The record linkage with the EHIF database revealed 1014 newborns with unrecorded IVF status in the EMBR. A total of 4204 newborns were verified as conceived by IVF, 24.1% of them were not categorized as born after IVF. The sensitivity of the IVF status registration was poor (75.9%), specificity (100.0%), PPV (99.8%) and NPV (99.3%) were high. The misclassifications were significantly more common among mothers of younger age or non-Estonians or with singleton birth. CONCLUSION: Information based on mother's self-report or her antenatal chart does not accurately identify the newborn's IVF status. The lack of a specialized country-wide assisted reproductive technology register in Estonia requires routine record linkage of the EMBR, EHIF and the infertility treatment clinics' databases to obtain adequate information regarding IVF status in the EMBR. Electronic record linkages between databases would help considerably to improve the validity of data to be used in medical decision making, in research and for statistical purposes.

Mental health and alcohol problems among Estonian cleanup workers 24 years after the Chernobyl accident.

PURPOSE: To study the long-term mental health consequences of the 1986 Chernobyl nuclear accident among cleanup workers from Estonia. METHODS: In 2010, 614 Estonian Chernobyl cleanup workers and 706 geographically and age-matched population-based controls completed a mail survey that included self-rated health, the Posttraumatic Stress Disorder Checklist (PCL), alcohol symptoms (AUDIT), and scales measuring depressive, anxiety, agoraphobia, fatigue, insomnia, and somatization symptoms. Respondents were dichotomized into high (top quartile) and low symptom groups on each measure. RESULTS: Logistic regression analysis detected significant differences between cleanup workers and controls on all measures even after adjustment for ethnicity, education, marital status, and employment status. The strongest difference was found for somatization, with cleanup workers being three times more likely than controls to score in the top quartile (OR = 3.28, 95% CI 2.39-4.52), whereas for alcohol problems the difference was half as large (OR = 1.52, 95% CI 1.16-1.99). Among cleanup workers, arrival at Chernobyl in 1986 (vs. later) was associated with sleep problems, somatization, and symptoms of agoraphobia. CONCLUSION: The toll of cleanup work was evident 24 years after the Chernobyl accident among Estonian cleanup workers indicating the need for focused mental health interventions.

Chernobyl cleanup workers from Estonia: cohort description and related epidemiological research.

The Estonian study of Chernobyl cleanup workers was one of the first investigations to evaluate the possible health consequences of working in the Chernobyl area (the 30 km exclusion zone and/or adjacent territories) after the 1986 reactor accident. The cohort consists of 4831 men who were dispatched in 1986-1991 for tasks involving decontamination, construction of buildings, transport, radiation measurement, guard duty or other activities. By 31 December 2012, the follow-up of the cohort yielded 102 158 person-years of observation. Exposure and health data were collected by postal questionnaires, biodosimetry evaluations, thyroid screenings, and record-linkages with cancer, causes of death and health insurance reimbursement registers and databases. These data cover socio-demographic factors, employment history, aspects of health behaviour, medical history, work and living conditions in the Chernobyl area, biomarkers of exposure, cancer and non-cancer disease occurrence and causes of death. Cancer incidence data were obtained for 1986-2008, mortality data for 1986-2011 and non-cancer morbidity data for 2004-2012. Although the cohort is relatively small, it has been extensively examined and benefited from comprehensive nationwide population and health registers. The major finding was an increased risk of suicide. Thyroid examinations did not reveal an association with thyroid nodular disease and radiation dose, but did indicate the importance of accounting for screening when making comparisons with unscreened populations. No risk of leukaemia was observed and risks higher than 2.5-fold could be excluded with 95% confidence. Biodosimetry included GPA analyses and chromosomal translocation analyses and indicated that the Estonian cleanup workers experienced a relatively low mean exposure of the order of 0.1 Gy. One value of the Estonian study is in the methodologic processes brought to bear in addressing possible health effects from the Chernobyl accident. Twenty-five years of research are summarised and opportunities for the future listed.

Chernobyl cleanup workers from Estonia: follow-up for cancer incidence and mortality.

This study examined cancer incidence (1986-2008) and mortality (1986-2011) among the Estonian Chernobyl cleanup workers in comparison with the Estonian male population. The cohort of 4810 men was followed through nationwide population, mortality and cancer registries. Cancer and death risks were measured by standardised incidence ratio (SIR) and standardised mortality ratio (SMR), respectively. Poisson regression was used to analyse the effects of year of arrival, duration of stay and time since return on cancer and death risks. The SIR for all cancers was 1.06 with 95% confidence interval 0.93-1.20 (232 cases). Elevated risks were found for cancers of the pharynx, the oesophagus and the joint category of alcohol-related sites. No clear evidence of an increased risk of thyroid cancer, leukaemia or radiation-related cancer sites combined was apparent. The SMR for all causes of death was 1.02 with 95% confidence interval 0.96-1.08 (1018 deaths). Excess mortality was observed for mouth and pharynx cancer, alcohol-related cancer sites together and suicide. Duration of stay rather than year of arrival was associated with increased mortality. Twenty-six years of follow-up of this cohort indicates no definite health effects attributable to radiation, but the elevated suicide risk has persisted.

Diminishing trend in alcohol poisoning mortality in Estonia: reality or coding peculiarity?

AIMS: To examine whether the changes in coding practice could reduce alcohol poisoning mortality rates in Estonia. METHODS: Individual death records in 1983-2009 (age at death 25-64) were used to calculate the 3-year moving averages of age-standardized mortality rates. From 2000 onwards, there was a sharp increase in mortality from mental disorders due to alcohol, and at the same time a remarkable decrease in alcohol poisoning mortality. We calculated expected alcohol poisoning mortality rates for 2000-2009, assuming that mortality rate ratio of alcohol poisoning and mental disorders due to alcohol remained stable. RESULTS: Alcohol poisoning mortality rates fluctuated considerably, being the lowest in 1988 and the highest in 1994-1995. A sharp decline started in 2000. Expected alcohol poisoning mortality rates continued their growth from 2000 onwards with a small decrease in 2006-2009. Mortality rates of mental disorders due to alcohol followed the same curve as alcohol poisoning rates up to 1999, being roughly 10 times lower than alcohol poisoning rates in both genders. From 2000 onwards, mortality from mental disorders due to alcohol increased rapidly, exceeding alcohol poisoning mortality in 2006. CONCLUSION: This study demonstrates an obvious misclassification in coding of alcohol poisoning and mental disorders due to alcohol as underlying causes of death in the Estonian Causes of Death Registry.

Gender differences in factors associated with sexual intercourse among Estonian adolescents.

AIMS: To examine factors associated with early sexual intercourse among 15 to 16-year-old adolescents by gender. METHODS: The data were collected from a random sample of Estonian basic schools' ninth grade pupils in 1999 using self-completed questionnaires. A multivariate logistic regression analysis for boys and girls was used to test for associations between sexual intercourse, and personal gender role-related attitudes, attitudes towards sexual intercourse, pubertal timing, smoking status and experience of drunkenness. RESULTS: Of the respondents, 14.6% of boys and 13.1% of girls had experienced sexual intercourse. Traditional gender role-related attitudes were associated with sexual intercourse among girls, but not among boys. Smoking and experience of drunkenness was strongly associated with sexual intercourse for both genders. CONCLUSIONS: Gender differences in the association between gender role-related attitudes and early sexual intercourse were observed among 15 to 16-year-olds in Estonia. Smoking and experience of drunkenness were strongly related to sexual intercourse for both genders.

Dramatic increase in alcoholic liver cirrhosis mortality in Estonia in 1992-2008.

AIMS: The aim of the study was to describe trends in alcoholic liver cirrhosis mortality rates in 1992-2008 and to examine socio-demographic differences in alcoholic liver cirrhosis mortality. METHODS: Individual records of deaths from alcoholic liver cirrhosis among 25-64-year olds in 1992-2008 in Estonia were analysed. Age-standardized mortality rates for men and women aged 25-44 and 45-64 were calculated. Association between alcoholic liver cirrhosis mortality and socio-demographic variables (age, education and ethnicity) for the data of the years around the census in 2000 was measured by mortality rate ratios using Poisson regression models. RESULTS: In 1992-2008, alcoholic liver cirrhosis mortality rates were higher among men than that in women and that in the older than in the younger age group. Over the whole study period, mortality from alcoholic liver cirrhosis increased steeply. The increase was sharper among men and women in the older age group. In 1998-2001, higher alcoholic liver cirrhosis mortality rates occurred in non-Estonians and those with lower levels of education. CONCLUSION: Alcoholic liver cirrhosis mortality has increased steadily in Estonia, and is reflected in an increase in heavy drinking. National alcohol policies should address all strata of society. However, in order to reduce alcohol-related damage in the population most effectively, special attention should be paid to non-Estonians and people with low levels of education.

Alcohol consumption in Estonia and Finland: Finbalt survey 1994-2006.

BACKGROUND: Alcohol consumption has been regarded as an important contributor to the high premature mortality rates. The objective of this paper was to provide an overview and comparison of alcohol consumption and its socio-demographic determinants among adults in Estonia and Finland. METHODS: The study was based on a 25-64-year-old subsample of nationally representative postal cross-sectional surveys conducted in Estonia (n = 10,340) and Finland (n = 19,672) during 1994-2006. Abstinence, frequency, and the amount of alcohol consumed were examined. Logistic regression models were used to test the socio-demographic differences in alcohol consumption at least once a week. The effect of socio-demographic factors on pure alcohol consumed per week was calculated using linear regression. RESULTS: The proportion of abstainers was 1.5 times higher among women than men in both countries. Throughout the study period, the amount of alcohol consumed per week increased for both genders in Estonia and for women in Finland, but was stable for men in Finland. In the final study year, medium risk amount of alcohol consumed per week was nearly 1.5 times higher among men in Estonia than in Finland, but about half that among women in Estonia than in Finland. Compared to ethnic majority in Estonia, alcohol consumption at least once a week was lower among men, but amount of pure alcohol drunk per week was higher among women of ethnic minority. In Finland, alcohol consumption at least once a week was more prevalent among women of ethnic minority, but the amount of pure alcohol drunk per week was lower for both gender groups of ethnic minority. Compared to married/cohabiting respondents, alcohol consumption at least once a week was less pronounced among single respondents in Finland, divorced or separated women in both countries, and widowed respondents in Estonia. Greater amount of alcohol consumed per week was more prevalent among single and divorced or separated respondents in Finland, but only among divorced or separated men in Estonia. Frequency of alcohol consumption was lower among less educated than higher educated respondents in Finland, but not in Estonia. The amount of consumed alcohol per week was higher among less educated men in Estonia, but lower among women with basic education in Finland. CONCLUSIONS: Alcohol consumption has increased in Estonia and Finland. National alcohol policies should reflect findings of alcohol epidemiology in order to introduce measures that will reduce alcohol related harm in the population effectively.

The fall and rise of cancer registration in Estonia: The dangers of overzealous application of data protection.

BACKGROUND: The population-based Estonian Cancer Registry (ECR) has maintained a database of cancer cases since 1968. Between 2001 and 2007 the ECR was prohibited from linking cancer records to death certificates. In January 2008, the prohibition was lifted, and two years later the ECR was able to begin tracing back unmatched deaths. This paper estimates the effect of the linkage ban on reported cancer incidence and survival. METHODS: Incident cancers in 2001-2007 were extracted from the ECR database in May 2018 to allow for late registrations. Two datasets were created: one with all incident cases and another without death-certificate-initiated (DCI) cases. Using both datasets, age-standardised incidence rates (ASIR) and their ratios; age-standardised five-year relative survival ratios (ARSR) and excess mortality rate ratios were calculated. RESULTS: In 2001-2007, 46,535 incident cancers were registered in the ECR. Of them, 2299 (4.9 %) were DCI cases. The inclusion of DCI cases increased the ASIR for overall cancer by 6 % in men and 3 % in women. An increase ≥10 % in ASIR for lung, liver and pancreatic cancer was observed. The effect of accrued DCI cases to the ARSR was minor. Excess mortality in the dataset without DCI cases was 4 % underestimated in men and 3 % in women. CONCLUSION: Biases in cancer incidence and survival measures generated by the temporary record linkage ban were largely correctable by using trace-back procedures when this became possible. Nevertheless, this type of ban and the arguments put forward to justify it, harm disease registration and register-based research.

Contrasts in alcohol-related mortality in Estonia: education and ethnicity.

AIMS: The aims of this study were to examine socio-demographic differences in alcohol-related mortality in Estonia, and how they changed over time. METHODS: Individual death records (age at death 25-64) in Estonia from the late Soviet era (1983-1991) to Estonian re-independence (1992-2005) were analysed using a case-control design. Cases were deaths from alcohol-related causes (7981 deaths). Controls were deaths (13,820) from those neoplasms that are considered not to show variation in death risk according to the socio-demographic variables (that is, excluding cancer of the upper aero-digestive tract, lung, stomach, colon and female breast). Differences in alcohol-related mortality between socio-demographic groups were measured by mortality odds ratio. RESULTS: In the study period as a whole, in both genders, an inverse relationship between the educational level and risk of alcohol-related death was apparent. Non-Estonians were more likely to die from alcohol-related causes than Estonians. Risk of alcohol-related death varied over time, being lowest just before Estonia regained its independence, and highest in the most recent period. In men, the educational gradient in the mortality odds ratio almost disappeared in 1988-1991, but reappeared in the transition period, while the impact of ethnicity remained stable over time. In women, educational contrasts in the risk of death existed throughout all subperiods, and ethnical inequalities widened in the re-independence period. CONCLUSION: Rapid societal changes had profound effects on alcohol-related mortality. Strategies to prevent alcohol misuse should include all sections in society, paying special attention to less educated and non-Estonians.

Individual and familial factors associated with teenage pregnancy: an interview study.

BACKGROUND: The determinants of teenage sexual health, including pregnancies, can be addressed from social, familial and individual level perspectives. The main objective of this study was to examine whether pregnancy among 18 years old and younger girls were associated with selected individual (age at coitarche, score of sexual health knowledge, dislike of school) and family (mother's education) and family functioning (alcohol abuse in the family, parents' acceptance of sexual relationship) characteristics. METHODS: An interview survey in two medical institutions in Estonia among 279 18 year old and younger girls, who: (i) used contraception, had been sexually active for at least 6 months and had not pregnancies--(148 girls); (ii) came for termination of pregnancy--abortion group; (iii) planned to deliver and came for prenatal care--delivery group. The last two groups were analysed together as the 'pregnancy group'--131 girls. Multivariate analysis, by means of logistic regression models, was used to explore whether the associations were sustained after adjusting for other variables. Crude odds ratios (ORs), adjusted ORs and their 95% confidence intervals (CIs) were estimated, with girls having no pregnancies as the reference group. RESULTS: Risk factors associated with teenage pregnancy were low score of sexual health knowledge (adjusted ORs 3.07; 95% CIs 1.73-5.46), dislike of school (adjusted ORs 1.96; 95% CIs 1.08-3.54), alcohol abuse by family members (adjusted ORs 2.03; 95% CIs 1.16-3.54). CONCLUSION: Sexual knowledge of teenagers, their attitude towards school, alcohol abuse in the family are factors associated with teenage pregnancies.

Sex disparities in premature adult mortality in Estonia 1995-2016: a national register-based study.

OBJECTIVES: To quantify sex disparities in cause-specific premature adult mortality in Estonia, to determine the causes of death with the largest differences, to provide insight into related behaviours and to offer some guidance to public health policy-makers based on the results of the study. DESIGN: A national register-based study. SETTING: Estonia. DATA: Individual records of deaths at ages 20-69 years in 1995-2016 from the Estonian causes of death register; data on tobacco smoking and alcohol consumption in the adult population in 1996-2016 from the biennial postal survey of health behaviour. MAIN OUTCOME MEASURES: Overall and cause-specific age-standardised mortality rates, average annual percentage changes in mortality, and cause-specific men-to-women mortality rate ratios were calculated. In addition, the age-standardised prevalence proportions of tobacco smoking and alcohol consumption and men-to-women prevalence rate ratios were determined. RESULTS: Overall premature adult mortality decreased considerably during 1995-2016, but no reduction was observed with respect to the large relative sex disparities. In circulatory disease mortality, the disparities widened significantly over time. Extremely high mortality rate ratios were observed for cancer of the upper aerodigestive tract and for lung cancer. There was a stable, more than fivefold male excess mortality from external causes. A fourfold male disadvantage was evident for alcohol poisoning, mental disorders due to alcohol and alcohol-related degeneration of the nervous system as a group. The prevalence of tobacco smoking and harmful alcohol consumption among men exceeded that among women by factors of two and six, respectively. CONCLUSIONS: Even though premature adult mortality has markedly decreased over time, there has been no success in diminishing the large sex differences in the mortality patterns, mostly associated with smoking and excessive alcohol consumption, both more prevalent among men. Estonia needs a comprehensive and consistent alcohol policy while maintaining and further developing antitobacco measures.

Is a poor pregnancy outcome related to young maternal age? A study of teenagers in Estonia during the period of major socio-economic changes (from 1992 to 2002).

OBJECTIVE: To assess the risk of low birth weight, preterm birth, stillbirth, neonatal and postneonatal death among primiparous teenagers having singleton births, compared to a similar group of women aged 20-24 years in Estonia during the period of major socio-economic changes. STUDY DESIGN: Registry study using the data from the Estonian Medical Birth Registry (EMBR) for years 1992-2002; EMBR data were linked with infant deaths in the Estonian Mortality Database. Study population included 51,890 women aged 13-24 years, arranged into three groups: < or =17, 18-19, and 20-24. Crude odds ratios (OR), adjusted ORs and their 95% confidence intervals (CI) for the different outcomes were estimated using multiple logistic regression analysis. RESULTS: Compared with women aged 20-24 years, the risk of low birth weight and preterm birth was higher among teenagers. The risk of low birth weight and preterm birth within the study group as a whole did not change during the study period. Increased risks in neonatal and postneonatal death among younger teenagers of an age of 17 years and less seem to be a result of prematurity. CONCLUSIONS: Despite major socio-economic changes resulting in improvements in obstetric care and growth in incomes, teenagers remained a higher risk group.

Mental disorders among Chernobyl cleanup workers from Estonia: A clinical assessment.

OBJECTIVE: To assess, at a clinical level, the mental health of former Chernobyl cleanup workers from Estonia by comparing them with same-age controls. METHOD: The Mini International Neuropsychiatric Interview (MINI) was administered during 2011-2012 to 99 cleanup workers and 100 population-based controls previously screened for mental health symptoms. RESULTS: Logistic regression analysis showed that cleanup workers had higher odds of current depressive disorder (odds ratio [OR] = 3.07, 95% confidence interval [CI: 1.34, 7.01]), alcohol dependence (OR = 3.47, 95% CI [1.29, 9.34]), and suicide ideation (OR = 3.44, 95% CI [1.28, 9.21]) than did controls. Except for suicide ideation, associations with Chernobyl exposure became statistically nonsignificant when adjusted for education and ethnicity. CONCLUSION: A quarter of a century after the Chernobyl accident, Estonian cleanup workers were still at increased risk of mental disorders, which was partly attributable to sociodemographic factors. (PsycINFO Database Record

Suicide risk among Chernobyl cleanup workers in Estonia still increased: an updated cohort study.

PURPOSE: The aim of the study is to examine the mortality experience among Chernobyl cleanup workers. METHODS: A cohort study of 4786 men from Estonia who participated in the Chernobyl cleanup from 1986 to 1991 and were traced until December 31, 2002. Standardized mortality ratio (SMR) and adjusted mortality rate ratio (RR) derived through Poisson regression analysis were calculated. RESULTS: During follow-up, 550 deaths occurred, yielding an SMR of 1.01 (95% confidence interval [CI], 0.92-1.09). Increased risks were observed for suicide alone (SMR, 1.32; 95% CI, 1.03-1.67) and suicide combined with undetermined injury (SMR, 1.29; 95% CI, 1.03-1.60). One leukemia death occurred, and no thyroid cancer deaths were found. Elevated mortality also was observed for brain cancer (SMR, 2.78; 95% CI, 1.02-6.05). The adjusted RR for suicide remained stable over the time passed since return from the Chernobyl area, showing RRs of 1.09 (95% CI, 0.56-2.10) for 5 to 9 years and 1.00 (95% CI, 0.48-2.05) for 10 or more years compared with less than 5 years. CONCLUSIONS: During the 17 years after the accident, suicide risk in the cohort was greater than in the general male population. No elevated risk in overall mortality and radiation-related cancers was observed. The long-term nature of this elevated risk provides concrete evidence that psychological consequences represent the largest public health problem caused by the accident to date.