Can economic indicators predict infectious disease spread? A cross-country panel analysis of 13 European countries.

Aims: It is unclear how economic factors impact on the epidemiology of infectious disease. We evaluated the relationship between incidence of selected infectious diseases and economic factors, including economic downturn, in 13 European countries between 1970 and 2010. Methods: Data were obtained from national communicable disease surveillance centres. Negative binomial forms of the generalised additive model (GAM) and the generalised linear model were tested to see which best reflected transmission dynamics of: diphtheria, pertussis, measles, meningococcal disease, hepatitis B, gonorrhoea, syphilis, hepatitis A and salmonella. Economic indicators were gross domestic product per capita (GDPpc), unemployment rates and (economic) downturn. Results: GAM models produced the best goodness-of-fit results. The relationship between GDPpc and disease incidence was often non-linear. Strength and directions of association between population age, tertiary education levels, GDPpc and unemployment were disease dependent. Overdispersion for almost all diseases validated the assumption of a negative binomial relationship. Downturns were not independently linked to disease incidence. Conclusions: Social and economic factors can be correlated with many infections. However, the trend is not always in the same direction, and these associations are often non-linear. Economic downturn or recessions as indicators of increased disease risk may be better replaced by GDPpc or unemployment measures.

Health assessments for health governance-concepts and methodologies.

Background: For better supporting the science-governance interface, the potential of health assessments appears underrated. Aims: To identify what various types of health assessment have in common; how they differ; which assessment(s) to apply for which purpose; and what needs and options there are for future joint development. Methods: This review is based on five types of health assessment: monitoring/surveillance/reporting, assessment of health impact, of health technology, of health systems performance, health-related economic assessment. The approach is exploratory and includes: applying an agreed set of comparative criteria; circulating and supplementing synoptic tables; and interpreting the results. Results: Two of the assessments deal with the question 'Where do we stand?', two others with variants of 'What if' questions. Economic Assessment can take place in combination with any of the others. The assessments involve both overall 'procedures' and a variety of 'methods' which inescapably reflect some subjective assumptions and decisions, e.g. on issue framing. Resources and assistance exist for all these assessments. The paper indicates which type of assessment is appropriate for what purpose. Conclusions: Although scientific soundness of health assessments is not trivial to secure, existing types of health assessment can be interpreted as a useful 'toolkit' for supporting governance. If current traces of 'silo' thinking can be overcome, the attainability of a more unified culture of health assessments increases and such assessments might more widely be recognized as a prime, 'tried and tested' way to voice Public Health knowledge and to support rational governance and policy-making.

Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening.

BACKGROUND: Treatment for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is improving but not benefiting individuals unaware to be infected. To inform screening policies we assessed (1) the hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV-Ab) prevalence for 34 European countries; and (2) the cost-effectiveness of screening for chronic HBV and HCV infection. METHODS: We searched peer-reviewed literature for data on HBsAg and anti-HCV-Ab prevalence and cost-effectiveness of screening of the general population and five subgroups, and used data for people who inject drugs (PWID) and blood donors from two European organizations. Of 1759 and 468 papers found in the prevalence and cost-effectiveness searches respectively, we included 124 and 29 papers after assessing their quality. We used decision rules to calculate weighted prevalence estimates by country. RESULTS: The HBsAg and anti-HCV-Ab prevalence in the general population ranged from 0.1%-5.6% and 0.4%-5.2% respectively, by country. For PWID, men who have sex with men and migrants, the prevalence of HBsAg and anti-HCV-Ab was higher than the prevalence in the general population in all but 3 countries. There is evidence that HCV screening of PWID and HBsAg screening of pregnant women and migrants is cost-effective. CONCLUSION: The prevalence of chronic HBV and HCV infection varies widely between European countries. Anti-HCV-Ab screening of PWID and HBsAg screening of pregnant women and migrants have European public health priority. Cost-effectiveness analyses may need to take effect of antiviral treatment on preventing HBV and HCV transmission into account.

Measles outbreak in Bulgaria: poor maternal educational attainment as a risk factor for medical complications.

BACKGROUND: An 8-year era of interrupted indigenous measles transmission in Bulgaria came to an end in April 2009 when a large epidemic occurred that would eventually claim 24,253 cases and 24 deaths; infants, children and young adults of the Roma community were disproportionally affected. Compared with Western Europe, case-fatality rate and proportion of medical complications were uncharacteristically high. METHODS: To disentangle underlying drivers of the outbreak and reasons for these medical complications, we assembled a number of national ecologic variables as well as regional individual-level data for 206 measles cases, randomly selected from national medical records. We conducted a logit regression analysis of data from individuals with medical complications. RESULTS: Ecologic socio-economic predictors were not associated with measles cases by region, although the proportion of medical complications differed considerably. Individual-level data from a region with high medical complications revealed that mother's education [odds ratio (OR) 0.79; 95% confidence interval (CI) 0.68-0.92], immunization status of the child (OR 0.28; 95% CI 0.08-0.94) and households declaring an income (OR 0.31; 95% CI 0.10-0.93) decreased the risk for developing severe medical complications such as pneumonia or encephalitis from a measles infection. DISCUSSION: The extent of this outbreak with a high case-fatality rate and high proportion of medical complications calls for resolute public health action. We found vaccination and maternal education to be crucial conduits of curbing medical complications from measles infections. Ultimately, the goal is measles elimination in Europe by 2015, and these data hint at intervention entry points.

Social determinants of tuberculosis in Europe: a prospective ecological study.

Tuberculosis (TB) is considered to be a disease of poverty, since its incidence is exacerbated by socioeconomic factors, inconsistent or partial treatment practices, and immigration from endemic countries. A prospective country level study, using a comprehensive dataset of TB incidence and prevalence taken from countries within the World Health Organization (WHO) European region, was conducted. We employed quintile regression to investigate the prospective association between baseline (measured in 2000) and a nation's wealth, level of egalitarianism, migration rate, health-related lifestyle and social capital with TB incidence and prevalence over a 10-yr period (2000-2009). We found that ∼50% of TB variation is accounted for by a nation's wealth and level of egalitarianism. We observed a negative prospective association between logged gross domestic product and TB rates, and a positive prospective association between income inequality and TB. National income levels per capita and income inequality are important predictors for TB incidence and prevalence in the WHO European region. They account for 50% of country-level variation, indicating the importance of a combined absolute and relative socioeconomic disadvantage in the development of TB. These findings also provide a tool for forecasting potential fluctuations in the level of TB epidemics in the WHO European region, with respect to socioeconomic changes.

Lung cancer mortality in France. Trend analysis and projection between 1975 and 2012, using a Bayesian age-period-cohort model.

INTRODUCTION: Lung cancer is currently the most common cancer in the world and as such is an important public health concern. One of the main challenges is to foresee the evolution of trends in lung cancer mortality rates in order to anticipate the future burden of this disease as well as to plan the supply of adequate health care. The aim of this study is to propose a quantification of future lung cancer mortality rates by gender in France until the year 2012. METHODS: Lung cancer mortality data in France (1978-2002) were extracted from the National Statistics of Death and analyzed by 5-year age-groups and periods, using a Bayesian age-period-cohort model. DISCUSSION: Between 1978 and 2002, female lung cancer mortality rate rises by 3.3%year(-1). For men, a slow increase is observed until 1988-1992 followed by a declining trend. In 1998-2002, age-standardized mortality rates were, respectively, 45.5 and 7.6 per 100000 for males and for females. By 2008-2012 these figures would reach 40.8 (95% credibility interval (CI): 32.7, 50.0) and 12.1 (CI: 11.7, 12.6) per 100000, respectively, which represents among women a 4.7% annual increase (CI: 4.5, 5.0). RESULTS: Our results highlight the relevance of pursuing public health measures in order to cope more actively with tobacco smoking in the prevention strategy against lung cancer specifically among women.

School life expectancy and risk for tuberculosis in Europe.

OBJECTIVE: This study aims to investigate the effect of country-level school life expectancy on Tuberculosis (TB) incidence to gain further understanding of substantial variation in TB incidence across Europe. METHODS: An ecological study examined the prospective association between baseline country-level education in 2000 measured by school life expectancy and TB incidence in 2000-2010 in 40 countries of the WHO European region using quantile regression. Subsequently, to validate the ecological associations between education and TB incidence, an individual-level analysis was performed using case-based data in 29 EU/EEA countries from the European Surveillance System (TESSy) and simulating a theoretical control group. RESULTS: The ecological analysis showed that baseline school life expectancy had a negative prospective association with TB incidence. We observed consistent negative effects of school life expectancy on individuals' TB infections prospectively. CONCLUSIONS: These findings suggests that country-level education is an important determinant of individual-level TB infection in the region, and in the absence of a social determinants indicator that is routinely collected for reportable infectious diseases, the adoption of country-level education for reportable infectious diseases would significantly advance the field.

Environmental burden of disease in Europe: assessing nine risk factors in six countries.

BACKGROUND: Environmental health effects vary considerably with regard to their severity, type of disease, and duration. Integrated measures of population health, such as environmental burden of disease (EBD), are useful for setting priorities in environmental health policies and research. This review is a summary of the full Environmental Burden of Disease in European countries (EBoDE) project report. OBJECTIVES: The EBoDE project was set up to provide assessments for nine environmental risk factors relevant in selected European countries (Belgium, Finland, France, Germany, Italy, and the Netherlands). METHODS: Disability-adjusted life years (DALYs) were estimated for benzene, dioxins, secondhand smoke, formaldehyde, lead, traffic noise, ozone, particulate matter (PM2.5), and radon, using primarily World Health Organization data on burden of disease, (inter)national exposure data, and epidemiological or toxicological risk estimates. Results are presented here without discounting or age-weighting. RESULTS: About 3-7% of the annual burden of disease in the participating countries is associated with the included environmental risk factors. Airborne particulate matter (diameter ≤ 2.5 µm; PM2.5) is the leading risk factor associated with 6,000-10,000 DALYs/year and 1 million people. Secondhand smoke, traffic noise (including road, rail, and air traffic noise), and radon had overlapping estimate ranges (600-1,200 DALYs/million people). Some of the EBD estimates, especially for dioxins and formaldehyde, contain substantial uncertainties that could be only partly quantified. However, overall ranking of the estimates seems relatively robust. CONCLUSIONS: With current methods and data, environmental burden of disease estimates support meaningful policy evaluation and resource allocation, including identification of susceptible groups and targets for efficient exposure reduction. International exposure monitoring standards would enhance data quality and improve comparability.