Public Health

The Duke University School of Law following its practice of devoting whole issues of its quarterly to a single topic has turned its attention to population problems.2 The two hundred and fifty pages are loaded with factual information-some of it new-, and also some controversy. What foHows is an attempt to review what seem to be to the present writer some of the more salient features of the material assembled. The following discussion does not claim to be a balanced presentation of the problem, because the issues raised in the quarterly are too uncertain and the information presented too selective. It is not clear to this reviewer how far this uncertainty and selectivity are intentional and how far the function of the ready availability to Durham of scholars with the necessary knowledge.

An outbreak of 12 cholera cases, caused by Vibrio cholerae eltor inaba, occurred in Hong Kong during a three week period in June-July 1994. Only adults of both sexes were affected. Epidemiological investigations showed linkage in all cases with consumption of seafood, including shellfish, mantis shrimps and crabs. Microbiological findings demonstrated that contaminated seawater in fish tanks used for keeping alive these seafoods is the most likely vehicle of transmission. Aggressive control measures, promptly instituted, included prohibition of use of contaminated typhoon shelter water in fish tanks, use of seawater with E. coli counts below 610 organisms/100 ml, and the banning of unlicensed food sampans in typhoon shelters. These measures, coupled with public announcements and an active health education campaign on food safety and personal hygiene, abruptly terminated the outbreak. Places which practise the use of seawater, from probable contaminated sources, to keep alive their seafood for human consumption should be alerted to the possibility of transmission of Vibrio cholerae through this route.

An outbreak of E.coli 0111 infection occuring in a mother and baby residential home and the obstetric department of a hospital is described. Swift control of the spread of the infection was due to co-operation between staff of the home, the obstetric department and the local Medical Officer of Health.

Numerous studies have reported adverse effects of traffic pollution on respiratory health. Exposure to power plants emissions has not been as comprehensively studied. The prevalence of asthma and respiratory symptoms was investigated among 15-17 year-olds in communities in the vicinity of power plants in Cyprus in relation to the rest of the island. Cross-sectional study METHODS: Based on responses of 5817 participants to the ISAAC questionnaire, study outcomes were: active asthma (i.e. report of asthma and current symptoms), inactive asthma and respiratory symptoms without a diagnosis. Associations in terms of the distance of the participants' community to any of the three power plants were investigated in logistic models before and after adjusting for known confounders. At 7.4% (95% CI: 4.5, 11.3), the prevalence of active asthma in communities at 5 km of power plants appeared elevated but reduced to national levels of 5% at longer distances. Adjusted odds ratio for active asthma was 1.83 (95% CI: 1.04, 3.24) in the 5 km zone compared to 30 km away. No clear pattern was observed for inactive asthma while the odds ratio of respiratory symptoms in the absence of diagnosis was 0.76 (95% CI: 0.58, 1.01) in the affected communities. Higher prevalence of active asthma was observed in the vicinity of power plants, with no evidence of a distance-response relationship. With less than 5% of this age-group residing in close proximity to power plants, this corresponds to a small fraction of active asthma attributable to power plant emissions.

A questionnaire was designed to assess teenagers' knowledge, habits and beliefs in a variety of health education topics. 1,418 (74%) fourth year secondary school pupils participated. The results on smoking, alcohol, drugs, diet and exercise are presented, together with teenagers' own suggestions for improvements in the methods of acquisition of health education messages. A change of emphasis is necessary and an advisory role for the school health service is suggested.

Iran like other middle east countries has a large number of major thalassaemics. Due to religious restrictions on abortion, the routine prevention of the birth of thalassaemic children by this means is not possible. The aim of this study is to describe an alternative means to prevent the birth of thalassaemic children. From January 1993 to January 1996, 10,000 people preparing for marriage were screened for the thalassaemia trait, using CBC and HbA2 level measurement. High risk couples were referred for further consultation regarding the disease and the means of its prevention. The proposed actions of the couples regarding thalassaemia prevention were evaluated immediately after consultation and then re-evaluated three months later. After the project had been running for three years the average of high risk couple initially deciding not to marry was 90% and no new cases of thalassemia were detected in the children of the screened population. Where both members of the couple were trait-positive their preferred choice was not to marry, rather than to marry and use other or no methods of preventing a thalassemia affected child being born to them. Cultural and religious ideas can affect such decisions and in some Islamic countries the establishment and use of a genetic counselling centre can help prevent most of new thalassaemia cases.

Nutritional insults experienced by the mother have a life-long imprint on organ size and function of the fetus. Infant low birth weight (LBW) is one of the consequences of such maternal undernutrition. The physiological consequences of nutritional insults can lead to adverse metabolic consequences after birth, including hypertension, diabetes and dyslipidemia. The objective of this study was to determine the association and contribution of LBW to serum concentration of lipoprotein(a) [Lp(a)] in a representative sample of white and black American children aged 5-11 y. Data (n=666) from the Third US National Health and Nutrition Examination Survey were used in this investigation. Racial/ethnic-specific trends in mean values of Lp(a) were compared across tertile distribution of birth weight. Multiple linear regression analysis was employed to determine the association of birth weight with Lp(a), controlling for age, sex and sum of four skinfold thicknesses (SUM). A consistent trend of increasing values of Lp(a) with decreasing birth weight emerged for both white and black children (P<0.001). Black children presented with higher values of serum concentrations of Lp(a) at each level of birth weight distributions than white children (P<0.01). Black race/ethnicity was associated with approximately 0.4 mg/dl greater serum concentration of Lp(a) than white, adjusting for birth weight, age, sex and SUM (P<0.001). LBW sub-population in black children appeared to be relevant to elevated Lp(a) concentration, while a similar scenario did not appear in white children. Since interactions between in utero factors and risk exposures after birth are likely, definitive studies evaluating these interactions are warranted.

A questionnaire on smoking behaviour and certain family and school factors was administered to over 700 11–12 year olds attending nine schools in the Western Area of Northern Ireland. The results showed that over 7% of the children smoked regularly and a further 6% smoked occasionally. The children's smoking behaviour was related to the smoking behaviour and attitude to children smoking of their parents, siblings and friends. There was a sex linking in these relationships. Smoking behaviour was not related to type of school, location of school or whether the school included anti-smoking education in the curriculum. But boys who reported trouble at school and girls who thought their teachers had a permissive attitude to children smoking were more likely to smoke.

To evaluate whether unemployment is a risk factor in suicide. This study was designed as a follow-up study of a cross-sectional sample. People in years at risk were calculated from the date of the interview until death, or for those who survived, until the end of the follow-up period at 31 December 1993. Information on the dependent variable, was obtained from the Cause of Death Register by the Swedish personal registration number. The data were analysed by a proportional hazard model in order to estimate relative risks (RR) of suicide with 95% confidence intervals (CI). The background variables were added one by one to the model according to their casual order, namely, sex, age, marital status, form of tenure and health status. Sweden. The present study is focused on a simple random cross-sectional sample of 37789 people aged 20-64 y. The data is collected only once from each person. Suicide and undetermined deaths (E950-959 and E980-989 according to ICD-8 and ICD-9 1987). The high relative risk for suicide for unemployment/sickness pension decreased from 3.86 to 1.93 (1.63-3.67) when adding the variables sex, age, marital status, form of tenure and health status one by one into the model. People living alone, form of tenure (renting an apartment) and those who reported poor health had high suicide risks in the final model varied between 1.66 and 3.39. Unemployment is an important social variable associated with increased suicide risk. Socio-economic position defined as form of tenure is important for social patterning in suicide. Self-rated poor health is also strongly related to suicide.

To examine the association between socio-economic status (SES) and liver cancer mortality among Korean men. Prospective cohort study Data were acquired from a large, prospective cohort study that included 548,530 civil service workers aged 30-59 years who had undergone health examination in 1998 provided by the Korean National Health Insurance System. Information on lifestyle and demographic characteristics was acquired through self-administered questionnaires. The main outcome event was mortality from liver cancer. Cox proportional hazards model was used to estimate relative risks (RRs) and 95% confidence intervals (95% CIs) after adjusting for age, body mass index, fasting serum glucose, alcohol consumption, smoking and hepatitis B surface antigen (HBsAg) status. Liver cancer mortality differentials relating to SES were statistically significant and consistent in the fully adjusted model. Compared with the highest SES category, excess risk associated with liver cancer mortality was observed with decreasing SES levels: the RRs in the upper middle, lower middle and low SES categories were 1.35 (95% CI 1.13-1.61), 1.54 (95% CI 1.28-1.86) and 1.72 (95% CI 1.45-2.04), respectively. There was no effect modification by HBsAg status on the association between SES and liver cancer mortality. This study demonstrated an inverse association between SES and liver cancer mortality, suggesting that SES is an independent predictor of liver cancer mortality. The policies and interventions regarding prevention of liver cancer need to focus on disadvantaged groups in order to reduce health disparities related to liver cancer.

Among sub-Saharan Africans in general, a generation or so ago, there was very little gain in weight, or in blood pressure, with age. Even at present, in most populations, especially in the indigent masses, obesity prevalence remains very low, at 1-5%. However, in South Africa and some neighbouring countries, Botswana, Namibia and Zimbabwe, with rise in socio-economic status, urbanization, and diminishing physical activity, the proportion affected has increased. Rises, as noted in Cape Town, have been only slight in men, to 8%; but in women much more so, to 34%, ie to a level similar to that of African-American women. Dietarily, energy intake has increased slightly, that from fat from 15-20% to 25-30%. However, there have been falls in dietary fibre intake, to 20-25 g and 15-20 g daily, in rural and urban areas, respectively. Evidence suggests that the health disadvantage of obesity in African women is less than that in white women, and would seem to have little influence on their proneness to hypertension, coronary heart disease and breast cancer. Traditionally, and even currently, sociologically, the disorder carries little opprobrium. As to the future, the prevalence in women may well increase still further. Regarding treatment, unfortunately among African women desirous of losing weight, sustained reducing measures are near impossible; moreover, pharmacological treatment is too costly to implement.

To estimate the prevalence of domestic violence among women presenting to primary health care facilities in Lebanon; to identify presenting symptoms and responses to varied forms of violence; and to examine variables associated with domestic violence. A cross-sectional survey of all women presenting to four primary health care centres in different geographic areas of Lebanon from September 2002 to October 2002. A questionnaire was administered in interview format. The following information was collected from participants: demographic characteristics, perceived health status, prior exposure and responses to domestic violence, and characteristics of the perpetrators. Of the 1418 participants, 494 (35%) reported experiencing domestic violence and 307 (22%) had family members who had been exposed to domestic violence. Among the women exposed to violence, verbal abuse or insult was most common (88%) followed by physical violence (66%); 57% reported their experiences to family, friends or authorities, whereas the remainder kept silent. Women who were exposed to domestic violence had higher frequencies of reported physical symptoms than those who were not exposed. Generally, the perpetrators were spouses who had demographic backgrounds comparable to their wives. Multiple regression analyses showed that women's education levels, work status, health status, and familial violence predicted domestic violence. Women readily talk about their abuse when asked. The rate of domestic violence is high among Lebanese women and is a significant health issue. Additional research is needed to better understand the extent of the problem and to develop more effective reporting methods.

To describe the frequency and determinants of alcohol use in a representative sample of 13 years old adolescents, and to analyse qualitatively how adolescents perceive this issue. Cross-sectional study with quantitative and qualitative components. Two thousand and thirty-six adolescents attending schools in a city in Portugal were surveyed using a self-reported, structured questionnaire. The qualitative component of the study included 30 semi-structured interviews that intended to assess the reasons for and consequences of drinking as perceived by adolescents, and also the preventive strategies they suggested. Overall, 50.0% of girls and 44.9% of boys reported that they had experimented with alcohol, and 4.7% of girls and 6.6% of boys drink alcohol at least once per month. Most adolescents recognised that drinking alcohol is harmful and an addiction which is difficult to treat, but this perception was not associated with their own behaviour. Adolescents only identified minor and temporary consequences of drinking alcohol, usually related to very high and acute consumption. In order to prevent alcohol abuse and its consequences, adolescents proposed measures based on strict control, legal restrictions and economic measures, some of which are already in place in Portugal. A high proportion of adolescents had experimented with alcohol by 13 years of age, showing the importance of starting prevention at an early life stage. The results also reflect the importance of reviewing prevention programmes in schools, highlighting the importance of families.

Evaluation of the routine medical examination of 1500 13-year-old schoolboys revealed four main advantages. First, the examination educates the school doctor by giving him the experience to define normality in this age group. Second, it provides the epidemiologist with information on the incidence and treatment of disease. Third, and more importantly, it enables the doctor to provide a better quality of medical care. Fourth, it enhances the doctor-parent relationship.

Research has given a comprehensive picture of the negative health consequences of unemployment without offering sufficient comparison between different age groups. The aim of this study was to analyse whether the associations between ill health, particularly poor psychological health and smoking, and unemployment differ between young and adult men and women. A 14-year follow-up study of graduates of compulsory school in an industrial town in northern Sweden was undertaken. The subjects were analysed at ages 16, 21 and 30 years. Complete data on the cohort were collected for 1044 individuals with the aid of a comprehensive questionnaire. The response rate was 96.4%. The main health measurements used in this study were poor psychological health and smoking, analysed by multivariate logistic regression. After controlling for several background variables, associations between long-term unemployment and poor psychological health were found in young men and women, and adult men. Long-term unemployment was only associated with smoking in young people. The association between long-term unemployment and psychological health, as well as smoking, seemed to be stronger in young people than adults.

Although numerous studies have demonstrated a socio-economic gradient in health, there is still a lack of research about the mechanisms behind this gradient. The aim of this study was to analyse possible mechanisms from adolescence to adulthood to explain the socio-economic gradient in somatic symptoms among men and women in the Northern Swedish Cohort. A prospective cohort study was performed, in which all pupils (n = 1083) in the last year of compulsory school were followed for 14 years. The response rate was high, with 96.6% still participating after 14 years. The data were mainly collected through repeated comprehensive self-administered questionnaires. The main dependent variable was a combination of socio-economic position and somatic health at 30 years of age. Multivariate multinomial and bivariate logistic regression analyses were undertaken. After controlling for parental working-class position and health-related selection, the authors identified mechanisms from adolescence to adulthood for the socio-economic gradient in health that were related to social relations (poor relationship with father and unemployed friends among men, violence among women), labour market experiences (unemployment among men and women, physically heavy work among women), economic hardship (among women) and poor health behaviour. These analyses contribute to the development of epidemiological methods for analysing mechanisms for the socio-economic gradient in health.

This study of drug and solvent misuse and knowledge of the HIV link amongst 934 secondary school students, completes a third survey concerned with prevalence of drug misuse. Drug and/or solvent misuse was found in 16% of the sample including 5% who use hard drugs, which since 1985 represents a 3% decline, but a 1% increase in the use of hallucinogens. The misusers were compared with the non-users with regard to their social characteristics, other illegal behaviour and their knowledge of HIV and other public health concerns. There were some surprises concerning the gender results. Misusers were found to be more socially disadvantaged and more involved in other negative behaviour. Despite reasonable knowledge about HIV-related matters, the misuser group were less accurate on all public health issues, appearing to 'deny' the potential risks associated with drug misuse.

A questionnaire-based investigation was performed to elucidate factors with possible influence on smoking status in 557 14-17-year-old boarding school pupils. A representative sample of boarding school pupils in Denmark participated. Before entering boarding school an increased risk of being a smoker was present if a majority of one's schoolmates were smokers (odds ratio 5.9; P < 0.0001); if parents were not living together (odds ratio 2.1; P < 0.005); if older brother or sister was a smoker (odds ratio 3.1; P < 0.0001); and if both parents smoked (odds ratio 1.9; P < 0.01). After changing to boarding school there was an increased risk of starting to smoke if a majority of the schoolmates were smokers (odds ratio 4.6; P < 0.0001). Believing that smoking causes damage to the smokers' own health decreased the risk (odds ratio 2.9; P < 0.01). More efficient smoking prevention programmes should be created by aiming particularly at the special problems encountered in certain age groups, and possibly through a better understanding of the influence that psycho-social factors may have on youngsters' risk of becoming smokers.

OBJECTIVES: To analyse the associations between unemployment and suboptimal self-rated health as well as high alcohol consumption, and to examine the role of possible mediating factors explaining the associations from a gender perspective. STUDY DESIGN: The sample, from a 14-year longitudinal study with a 96.4% response rate, consisted of 386 women and 478 men who were either employed or unemployed at 30 years of age. METHODS: The health outcomes studied were suboptimal self-rated health and high alcohol consumption at 30 years of age. Logistic regression was used for analysis, and the relational theory of gender was used to discuss the findings. RESULTS: A strong relationship was found between unemployment and suboptimal self-rated health among women, and unemployment and high alcohol consumption among men, even after controlling for health-related selection, potential mediators and background factors. All mediating factors in the model were attributable to suboptimal self-rated health among unemployed women. Two mediating factors were also substantially related to high alcohol consumption among unemployed men. CONCLUSIONS: Long-term unemployment at a young age could have various health effects in men and women. At present, the mechanisms behind the health consequences are better understood among women. Research would benefit from developing theories in order to explain how youth unemployment leads to gendered health consequences.

To ascertain, using a combination of epidemiological, environmental and microbiological methods of investigation, a possible link between two outbreaks of salmonella food poisoning. Case-control studies were carried out on the known at-risk populations. Environmental investigations took place in the food preparation areas used for the social functions and microbiological examinations were carried out on faecal specimens obtained from cases, environmental swabs, and food specimens when these were available. In both outbreaks, illness was associated with the consumption of sesame prawn toast (outbreak one P<0.004; outbreak two P<0.0001). Salmonella enteritidis phage type 14b was cultured from the faecal specimens of cases in both outbreaks and from a packet of sesame prawn toast used for the second outbreak function. Molecular typing methods indicated that the salmonella cultures obtained in both outbreaks were indistinguishable from each other and from cultures obtained from imported Spanish eggs in a previous survey. Imported Spanish eggs were used in the manufacture of the sesame prawn toast. Adequate cooking must take place of raw food products, which should be clearly labelled as such. Manufacturers should consider, when possible, the use of pasteurized egg in the preparation of food products.

To assess levels of physical activity in the general population and amongst the 'healthy', and to identify factors associated with this important health behaviour. Population-based cross-sectional study. North-west England. Adults (aged at least 18 years) registered with a general practitioner with a residential address within two local administrative districts (local authorities). Less than one-third of adults performed adequate amounts of physical activity for health protection, and this differed little when analyses were restricted to 'healthy' people. Lower levels of physical activity were observed amongst women, older people, ethnic groups, those with obesity and in each increased quintile of social deprivation. Current smokers, but not previous smokers, were less likely to be physically active, as were those not eating at least five portions of fruit and vegetables per day. Lack of physical activity was associated with poor general health and a history of, or current, chronic disease. Concerted efforts are required by the Government, society and individuals to overturn our predominantly physically inactive adult population. Interventions may be needed which specifically target certain groups, especially the most socially deprived, and that consider individuals and societal barriers to becoming physically active. Evidence of the effectiveness of individual and population-based interventions remains scant and this needs to be addressed urgently.

The smoking habits of adolescents of 16 years in the National Child Development Study were examined in relation to social and other variables. The data, collected in 1974, suggested that frequencies had not changed substantially over the previous decade and supported the findings of other studies of strong connections with certain factors such as social activities. They thus confirm, in a more recent national sample, the social and demographic patterns of smoking among British adolescents.

A short resume is presented on the incidence of disease amongst children at the Provincial Hospital at Quang Ngai, South Vietnam. Case figures and fatality rates are given. The most common causes of morbidity were pneumonia, plague, bacillarydy sentery, encephalitis, malnutrition, chronic chest disease and typhoid fever. Encephalitis is the most common cause of death followed by pneumonia, malnutrition, bacillary dysentery, plague and convulsions.

In recent years a number of research projects have reported on the level of alcohol use by young people. The research to date, however, has tended to overlook the ethnic origins of the young people as a factor associated with the level of alcohol use. Against this background, this paper reports findings on the use of alcohol by 15-16-year-olds in Leicestershire with specific reference to ethnic group. A survey of over 1000 young people revealed significant differences between ethnic groups in terms of their attitudes to alcohol consumption and the frequency of alcohol consumption. As expected, South Asians tended to hold less favourable attitudes to drinking alcohol than their White counterparts and reported a far lower frequency of alcohol consumption. The extent of the divergence between the two ethnic groups is detailed, revealing a stark contrast between the groups at age 15-16 years.

PIP A questionnaire was administered to 2444 male and female adolescents in Northern Ireland to ascertain the general level of knowledge among them concerning reproduction and child care. Knowledge of both child care and reproduction was at a low level. Girls knew more about reproduction than boys and grammer school pupils scored higher than secondary school pupils. Pupils who had studied either biology or home economics scored higher on the reproduction questions than those who had not studied either subject. Child care knowledge was even lower in the sampling than reproduction knowledge. The study of home economics and biology made some differences in the scores but not to the same extent that it did on reproduction. It is recommended that pupils who do not study biology be assigned courses on human physiology. It was felt that all pupils could benefit from a course on parenthood.