Burden of Tick-Borne Encephalitis, Sweden.

In recent decades, the incidence of tick-borne encephalitis (TBE) in Sweden has increased. To calculate the burden of disease over a 17-year period, we analyzed data from the Swedish National Health Data Register for TBE cases diagnosed during 1998-2014. We compared healthcare use and sick leave associated with 2,429 persons with TBE with a referent cohort of 7,287 persons without TBE. Patients with TBE were hospitalized for significantly more days during the first year after disease onset (11.5 vs. 1.1 days), logged more specialist outpatient visits (3.6 vs. 1.2 visits), and logged more sick leave days (66 vs. 10.7 days). These differences generally increased over time. The case-fatality rate for TBE was 1.1%. Our calculated cost of TBE to society provides a baseline for decisions on immunization programs. Analyzing register data, our study adds to clinical studies of smaller cohorts and model-based studies that calculate disease burden.

Spatial tick bite exposure and associated risk factors in Scandinavia.

Tick-borne diseases are emerging and re-emerging threats causing public health concerns in Europe and North America. Prevention and control requires understanding of human exposure and behaviour. The aim was to measure exposure to tick bites across Scandinavia, its spatial distribution and the associated risk factors. Methods We sent a web-based survey to a randomly chosen population and analysed answers by Principal Component Analysis and Chi-Square. Individual responses were aggregated at the municipality level to assess the spatial distribution of bites. Results Nearly 60% of adults reported bites at low levels (1-5 bites); however, the majority were not in their resident municipality. We found two spatial profiles: In their home municipalities, people were most often bitten in less, but not the least, urbanized areas. When visiting other municipalities, people were most frequently bitten in peri-urban areas. Running/walking in the forest, gardening, and paddling/rowing were activities most strongly associated with bites. Conclusion Tick bites affect the entire Scandinavian population, with a higher risk in Sweden compared to Denmark and Norway. The frequency of observation of ticks in the environment or on pets might be used as a proxy for the actual risk of exposure to tick bites. Our results indicates that urban-dwelling outdoor enthusiasts and inhabitants of rural areas must be equally targeted for prevention campaigns.

Who is afraid of ticks and tick-borne diseases? Results from a cross-sectional survey in Scandinavia.

BACKGROUND: In Scandinavia, the distribution of ticks is expanding and tick-borne diseases constitute growing health risks. While the probability of getting a tick-borne disease after a tick bite is low, the health impacts can be large. This, as well as other characteristics of these diseases make tick-related risks difficult for laypeople to assess and perceived risk may differ substantially from actual risk. Understanding risk perceptions is important since it is the perceived risk, rather than actual risk, that determine behaviour and even more so for new and emerging risks. The aim of this study is to investigate knowledge and risk perceptions related to tick bites and the tick-borne diseases Lyme borreliosis (LB) and tick-borne encephalitis (TBE). By analysing risk perceptions and knowledge, the study helps inform the development of public health strategies in response to the increasing incidence of these diseases in Scandinavia. METHODS: Two thousand, six hundred sixty-eight respondents in Denmark, Norway and Sweden answered an online questionnaire with 48 questions, including 7 questions on risk perceptions and 9 knowledge questions. Chi-squared tests were used to analyse statistical differences between country sub-samples, gender and age groups. A multivariate regression model was used to analyse factors associated with risk perceptions. RESULTS: Risk perceptions were on average high in comparison with scientific estimates, with respondents grossly overrating the probability of contracting LB or TBE if bitten by a tick. Also, the average perceived seriousness of a single tick bite and of getting LB or TBE was high. Knowledge on the other hand was low, especially among men and the youngest age group (18-29 years). Higher levels of knowledge about tick-borne diseases were associated with lower perceived seriousness of tick bites and LB and higher perceived seriousness of TBE. Also, having been diagnosed with LB was negatively associated with the perceived seriousness of LB. CONCLUSIONS: Our results indicate that informing about ticks and tick-borne diseases would be a relevant public health strategy as it could make risk perceptions better aligned with actual risk. Should the TBE virus spread further in Denmark and Norway, increasing knowledge about TBE vaccination would be especially important.

Protective practices against tick bites in Denmark, Norway and Sweden: a questionnaire-based study.

BACKGROUND: Tick-borne infections are of emerging and increasing concern in the Scandinavian countries Denmark, Norway and Sweden. Only few studies have investigated protective practices against tick bites in the general population. The aim of this multi-country study was to assess the use of protective practices and the perception of the efficacy of them. METHODS: We surveyed the extent of using protective practices against tick bites, using the same questionnaire in three local languages. In addition, we surveyed perceptions of how good a protection the different practices provide. Altogether 783 individuals from Denmark, 789 from Norway and 1096 from Sweden participated in the study by completing an extensive online questionnaire in October 2016. RESULTS: Altogether 1011 respondents (37.9%) reported using at least three different protective practices either often or always when in areas where there are ticks, while 522 (19.6%) reported using none. Female gender was among the factors identified as positively associated with using several of the specific practices often or always when in areas where there are ticks. The gender-difference in extent of using protective practices against tick bites was particularly pronounced in Sweden. Based on a multivariable logistic regression model, being female, being from Sweden, and having experienced one or more tick bites were positively associated with using at least three different protective practices against tick bites either often or always when in areas where there are ticks (odds ratios 1.90, 1.87 and 1.88, respectively). CONCLUSIONS: The results of our study, especially the observed differences by country and by gender, can be useful in targeting future information to the public. In particular, our results suggest that men across all ages should be considered a specific target group for this information.

Learning to live with ticks? The role of exposure and risk perceptions in protective behaviour against tick-borne diseases.

The purpose of this study is to analyse the role of risk perceptions and exposure for protective behaviour against tick bites and the related diseases Lyme borreliosis (LB) and tick-borne encephalitis (TBE), both of which are growing health concerns. We use data from a national survey in Sweden with respondents in geographical areas with substantial differences in both abundance of ticks and incidence of LB and TBE. We find that the share of respondents who frequently use protective clothing (64%), perform tick checks (63%) or avoid tall grass while in areas with ticks (48%) is relatively high. However, the use of protective measures is uneven and a considerably lower share tuck their trousers into their socks (18%), use repellent against ticks (16%) or use a combination of protective measures. Thirty-one per cent of the respondents report one or more tick bites in the last year and 68% report one or more lifetime tick bites, indicating that it is difficult to protect oneself from tick bites. There is a strong positive association between exposure and checking the skin for ticks, but exposure is only weakly associated with other protective measures. Tick bites are perceived as a serious health risk by as many as 43% of the respondents. The perception that a single tick bite is serious is negatively associated with actual exposure to ticks, while the opposite is true for the perception that tick bites constitute a serious lifetime health risk. This indicates a learning effect in relation to risk perceptions and the performance of tick checks, but not in relation to other protective measures. Recommendations include informing people of the risks associated with tick bites, the efficacy of various protective measures and the importance of combining multiple types of protection. Given the high exposure to tick bites, the growing incidence of TBE and LB, and the difficulties in preventing tick bites, other preventive measures should be further discussed, including vaccination programmes.

Hairdressers' skin exposure to hair dyes during different hair dyeing tasks.

BACKGROUND: The high risk of occupational skin disease among hairdressers, caused by skin exposure to irritants and sensitizers, such as hair dye substances, is of great concern. OBJECTIVES: The aim of the present study was to assess how the various tasks involved in hair dyeing contribute to hairdressers' exposure to hair dye, in order to enable the formulation of well-founded recommendations on working routines that will reduce exposure and prevent occupational disease. METHODS: Skin exposure to hair dye was measured for 20 hairdressers applying highlights and all-over hair colour with the hand rinsing technique. Resorcinol was used as a proxy for hair dye exposure. RESULTS: Applying hair dye and cutting the newly dyed hair were the tasks that contributed most to exposure in treatments for highlights. After cutting all-over-coloured hair, all hairdressers had measurable amounts of hair dyes on both hands. CONCLUSIONS: Hairdressers are exposed to hair dye ingredients during all steps of the hair dyeing procedure. Cutting newly dyed hair contributes significantly to exposure. For the prevention of occupational disease resulting from hair dye exposure, we suggest cutting hair before dyeing it, and wearing gloves during all other work tasks.

A Proposed Minimum Standard Set of Outcome Measures for Cataract Surgery.

IMPORTANCE: Aligning outcome measures for cataract surgery, one of the most frequently performed procedures globally, may facilitate international comparisons that can drive improvements in the outcomes most meaningful to patients. OBJECTIVE: To propose a minimum standard set of outcome measures for cataract surgery that enables global comparisons. DESIGN, SETTING, AND PARTICIPANTS: A working group of international experts in cataract outcomes and registries was convened, along with a patient advocate, to agree on a consensus of outcome measures for cataract surgery. In a modified Delphi process, the group met regularly between November 10, 2012, and November 21, 2013, to discuss which outcomes to include in a standard set. Included factors were based on extant literature, existing registries, and the experience of group members. Similarly, a series of consensus discussions were held to determine a set of risk factors to be gathered for each patient. The final shortlist was compiled into a standard set. Analysis was performed from November 22, 2013, to April 5, 2014. MAIN OUTCOMES AND MEASURES: Development of a recommended standard set encompassing preoperative metrics including patient risk factors, intraoperative factors including surgical complications, and postoperative cataract surgery outcomes. RESULTS: The recommended standard set encompasses all patients treated for cataracts by 1 of 4 surgical approaches (phacoemulsification, sutured manual extracapsular cataract extraction, sutureless manual extracapsular cataract extraction, or intracapsular cataract extraction). The recommended metrics to be recorded preoperatively include demographics, ocular history and comorbidities, preoperative visual acuity, and patient-reported visual function. The recommended outcomes were split into intraoperative and postoperative metrics. Intraoperative outcomes include capsule-related problems, dislocation of lens nucleus fragments into the vitreous, and other complications. Postoperative outcomes include visual acuity, refractive error, patient-reported visual function, and early and late complications of surgery. The suggested follow-up for collection of postoperative outcomes is up to 3 months. CONCLUSIONS AND RELEVANCE: A minimum standard set of outcome measures for cataract surgery is important for meaningful comparison across contexts. The proposed data set is a compromise between all useful data and the practicalities of data collection.

The influence of hydrogen peroxide on the permeability of protective gloves to resorcinol in hairdressing.

BACKGROUND: Hairdressers are exposed to hair dye chemicals, for example resorcinol and hydrogen peroxide. Adequate skin protection is an important preventive measure against occupational skin disease. OBJECTIVES: To examine whether hydrogen peroxide may cause deterioration of protective gloves. METHODS: Permeation of resorcinol through gloves of polyvinylchloride (PVC) (n = 8), natural rubber latex (NRL) (n = 5) and nitrile rubber (NR) (n = 5) was studied in a two-compartment cell, with resorcinol as an indicator for hair dyes. The amount of resorcinol that had permeated was analysed with a high-performance liquid chromatography instrument. Cumulative breakthrough time and permeation rate were compared for hydrogen peroxide-pretreated and untreated gloves. RESULTS: The cumulative breakthrough time was > 1 hr but < 4 hr for all tested gloves. Pretreatment of PVC gloves resulted in a slightly decreased breakthrough time, and pretreatment of NRL gloves decreased the permeation rate. No change was recorded in NR gloves. CONCLUSIONS: Treatment with hydrogen peroxide had a minor effect on permeation in the tested gloves. NR gloves provided the best protection. However, taking the allergy risk of rubber gloves into account, plastic gloves are recommended in hairdressing. PVC gloves may be used, but not for > 1 hr. Disposable gloves should never be reused, regardless of material.

Exposure of hairdressers to ortho- and meta-toluidine in hair dyes.

BACKGROUND: Carcinogenic aromatic amines derived from hair dyes have recently received new attention. One of these is ortho (o)-toluidine, which is classified as carcinogenic to humans. OBJECTIVES: To clarify exposure of hairdressers to potentially carcinogenic aromatic amines, including o-toluidine. METHODS: We measured eight potentially carcinogenic aromatic amines in the blood of 295 hairdressers, 32 users of hair dyes and 60 controls. The study was restricted to female non-smokers. Lifestyle data were collected for all participants using self-administered questionnaires. Blood samples were taken for analysis of ortho-, meta (m)- and para (p)-toluidine; 2-, 3- and 4-ethylaniline, 2,3- and 3,4-dimethylaniline as haemoglobin adducts. The samples were analysed with gas chromatography-tandem mass spectrometry. RESULTS: Generally, adduct concentrations were in the range of 0-200 pg/g haemoglobin. A comparison of the adduct concentrations found in hairdressers, consumers and controls showed no statistically significant differences. However, for hairdressers, o- and m-toluidine concentrations increased significantly with the weekly number of hair waving (p=0.020) and permanent hair dyeing treatments (p=0.026), respectively. o-Toluidine and m-Toluidine concentrations also tended (p=0.076 and 0.080, respectively) to increase with the frequency of light-colour permanent hair dye treatments. CONCLUSIONS: Hairdressers who use light-colour permanent hair dyes, other permanent hair dyes and hair waving treatments seem to be exposed to o- and m-toluidine as indicated by associations with the number of treatments performed. Analyses of hair waving and hair dye products should be performed to identify the possible sources of exposure to o- and m-toluidine.

Predicting the absorption of chemical vapours.

The focus of this review is on the systemic absorption of vapours via skin, including experimental data as well as regression and pharmacokinetic models. Dermal contribution ratios (DCR), i.e. amount absorbed through skin relative to total intake (skin and inhalation) at specified conditions, could be identified or calculated from published data for 33 chemical vapours. The ratios vary from ~0.0002 (vinyl chloride) to ~0.8 (2-butoxyethanol), with hydrophilic chemicals having a higher ratio than lipophilic ones. Multiple regression analysis of these data suggests that the DCR is largely explained by the octanol:water partition coefficient, vapour pressure and molecular weight (R(2)=0.69). Several physiologically-based pharmacokinetic models were identified; however, all describe the absorption of single substances. Regarding predictive models, only two models were found. In conclusion, dermal uptake of chemical vapours needs more attention, as such exposures are common, data are scarce and few predictive models exist.

Primary prevention of latex allergy in healthcare-spectrum of strategies including the European glove standardization.

IgE-mediated allergy to natural rubber latex was first noted from rubber gloves in 1979. The initial reports in dermatological journals described contact urticarial reactions; later, severe generalized allergic reactions and asthma were documented. A considerable proportion of the people involved in medical and dental care were found to be sensitized to latex. This article describes and surveys a broad range of primary prevention measures at the local and national levels. Examples are given from paediatrics, dental education, and medical care. National strategies and position papers on latex allergy are presented in which medical professionals, manufacturers and public authorities have cooperated. Special reference is paid to the European work to standardize medical gloves, which led to document EN 455:3.

The critical review of methodologies and approaches to assess the inherent skin sensitization potential (skin allergies) of chemicals. Part I.

To critically review currently available methods, or methods under development (in vivo, in vitro, in silico, etc.) used in the evaluation of skin sensitization potential and their applicability in the derivation of quantitative 'safety thresholds'.

The critical review of methodologies and approaches to assess the inherent skin sensitization potential (skin allergies) of chemicals. Part II.

To identify specific cases, classes or specific use situations of chemicals for which 'safety thresholds' or 'safety limits' were set (in regulations, standards, in scientific research/clinical work, etc.) and critically review the scientific and methodological parameters used to set those limits.

The critical review of methodologies and approaches to assess the inherent skin sensitization potential (skin allergies) of chemicals. Part III.

For those chemicals identified in point 2 above, to collect and critically analyse clinical and statistical evidence on the incidence and morbidity (clinical picture) of skin contact allergy (contact dermatitis) cases in the EU before (at least 3 years) and after the limits were set, so as to allow an assessment of the possible effect of the limits in the reduction/prevention of the incidence and morbidity of contact dermatitis.

p-Phenylenediamine and other hair dye sensitizers in Spain.

BACKGROUND: Oxidative hair dyes are important skin sensitizers, causing contact allergy and dermatitis in hairdressers and consumers. OBJECTIVES: To study the prevalence of hair dye substances, categorized as potent skin sensitizers, in consumer-available oxidative hair dye products on the market of a southern European country and to compare it with that in Sweden. METHODS: Ingredient labels of 105 oxidative hair dye products from 19 brands were studied, and the prevalence and use pattern of hair dye substances, categorized as potent skin sensitizers, was assessed. Network diagrams were used to display results. RESULTS: According to the labelling, all 105 products contained hair dye substances categorized as potent skin sensitizers. A total of 25 different hair dye substances categorized as potent skin sensitizers were identified. Eighty-seven per cent of the products contained at least four such substances. Either p-phenylenediamine, toluene-2,5-diamine or toluene-2,5-diamine sulfate was present in 103 products. CONCLUSIONS: Hair dye substances categorized as potent skin sensitizers were used in all studied hair dye products on the Spanish market. The prevalence of p-phenylenediamine was higher in the present study than in a similar study in Sweden. More than 20 potent sensitizers were identified in each country. Not only p-phenylenediamine should be used to diagnose allergy to hair dyes.

Preservatives and fragrances in selected consumer-available cosmetics and detergents.

BACKGROUND: Preservatives and fragrances are important and frequent skin sensitizers, found in a wide range of products intended for personal and occupational use. OBJECTIVES: To examine the use of preservatives and fragrances in certain cosmetics and detergents on the market. The product types studied were shampoos, hair conditioners, liquid soaps, wet tissues, washing-up liquids, and multi-purpose cleaners. MATERIALS/METHODS: Ingredient labels of 204 cosmetic products and ingredient data sheets of 97 detergents, available on company websites, were examined. RESULTS: The preservatives most frequently identified were phenoxyethanol, methylparaben, sodium benzoate, propylparaben, and methylchloroisothiazolinone/methylisothiazolinone. Parabens were found in 44% of cosmetics and 9% of detergents; formaldehyde-releasers in 25% of cosmetics and 8% of detergents; and isothiazolinones in 23% of cosmetics and 28% of detergents. The fragrances most frequently identified were linalool, limonene, hexyl cinnamal, butylphenyl methylpropional, and citronellol. Eighty-eight per cent of the products contained fragrances, and any of the 26 fragrances requiring labelling were found in half of the cosmetics and one-third of the detergents. CONCLUSIONS: Several preservatives and fragrances with well-known skin-sensitizing potential were common in the examined product types. Such products may be used several times a day by consumers and workers.

Efficacy and Safety of Percutaneous Epiphysiodesis Operation around the Knee to Reduce Adult Height in Extremely Tall Adolescent Girls and Boys.

Objective. The aim was to determine efficacy and safety of a surgical method to reduce adult height in extremely tall adolescents. Methods. Data for all girls (n = 12) and boys (n = 9) in our center subjected to bilateral percutaneous epiphysiodesis around the knee who had reached final height were included. Final height predictions were based on hand and wrist X-rays before surgery. Results. When compared to prediction, adult height was reduced by 4.1 ± 0.7 cm in treated girls (P < .001) and 6.4 ± 0.7 cm in treated boys (P < .001) corresponding to a 33.6 ± 3.4% and 33.6 ± 4.2% reduction of remaining growth, respectively. Besides mild to moderate postoperative pain reported in 9 operated individuals, no other side effects were reported. Postoperative X-rays confirmed growth plate closure and absence of leg angulations. Conclusions. Bilateral epiphysiodesis is an effective and safe method to reduce adult height in extremely tall girls and boys.