Trends and patterns of tuberculosis: interpretations and prospects of tuberculosis control in Vojvodina, Yugoslavia, 1987-2000.

AIM: To assess the trends and pattern of tuberculosis in Vojvodina, Yugoslavia. METHODS: Using a retrospective design, data on 393 diagnosed TB cases were investigated for the years 1987, 1993 and 2000. RESULTS: TB case notification has been increasing in Vojvodina. The number of reported TB cases was 146 in 1987, 101 in 1993 and 146 in 2000; cases were predominantly in the age group 20-39 years (44.5%) in 1987, compared to the 40-59 year age group in 1993 and 2000 (38.6% and 45.9%, respectively). The majority of patients belonged to lower socio-economic groups. Manifestations of TB such as cough, weight loss and exhaustion were common. With the increasing trend of alcoholism from 1987 to 2000, delays in reporting were noticed. TB-related mortality was 1.4% in 1987 and 4.1% in 2000. Resistance to TB drugs among previously treated cases was 2.7% in 1987, 0.9% in 1993 and 2.7% in 2000. With respect to the increasing resistance, the levels of detection and surveillance were poor. The implementation of the DOTS strategy remained fairly low. CONCLUSION: TB is a chronic problem in Vojvodina. Prompt community-oriented actions need to be taken to improve case detection and cure rates through DOTS.

The epidemiology of hepatitis A infection in Palestine: a universal vaccination programme is not yet needed.

In Palestine, there has been an increase in the reported incidence of acute hepatitis A virus (HAV) infection since 1995. Since overt clinical disease occurs only among adults, questions were raised whether or not a shift in the epidemiology of HAV has occurred. This is generally characterized by a decrease in the overall incidence rate and a shifting in the mean age of infection towards adolescence and early adulthood. The need for a vaccination programme is being discussed. To resolve this issue, we examined the prevalence of anti-HAV in a representative sample of 396 school children in the Gaza Strip. The prevalence of anti-HAV was 93.7% (95% CI: 91.3, 96.1%). Stratifying the prevalence by age showed that 87.8% (95% CI: 78.6, 97%) were HAV antibody positive by the age of 6. By the age of 14, almost 98% (95% CI: 92.7, 100%) were HAV antibody positive. This means that the majority of HAV infection is still taking place in early childhood, when it is usually asymptomatic and of little clinical significance. The results refuted the shifting epidemiology theory and we recommend that a vaccination programme against HAV infection is not yet needed. Alternative explanations for the increase in reported cases are discussed.

Public health training and research collaboration in South Eastern Europe.

The health care systems in South Eastern Europe are characterized by a predominantly curative orientation. During the last decade public health became insufficient due to war as well as economic and political changes. Today there is a lack of competence in public health above all in health management and strategy development, but also in the fields of health surveillance and prevention. The great need for a sustainable collaboration and support in advanced training and continuous education of qualified professionals to reach required conditions was recognized. Therefore, the project for the development of training modules and research capabilities in public health in South Eastern European countries (SEE) was proposed to the Stability Pact (PH-SEE Project). The project is to support the reconstruction of postgraduate public health training through development of teaching materials in English for the Internet. A regional network of lecturers in the health sciences will be established. The up to date texts should be of international standard but also be of regional specificity.

Can a decline in the population means of cardiovascular risk factors reduce the number of people at risk?

OBJECTIVE: To prove the possibility of shifting distribution of cardiovascular risk factors for a whole population over time and thereby to influence the prevalence of the corresponding disease states, according to the theory stated by Geoffrey Rose in 1985. DESIGN: Examination of standardised data from the German Cardiovascular Prevention Study (GCP), a seven year long, population-based, multicentre intervention trial, concerned with decreasing risk factors for cardiovascular disease. SETTING AND SUBJECTS: three cross sectional surveys of a population 25 to 69 years old in six study regions, and three nationwide cross sectional surveys in the former West Germany in 1984, 1988 and 1991. MAIN OUTCOME MEASURES: The relation between the population mean for systolic and diastolic blood pressure, total serum cholesterol, body mass index, and alcohol intake, and the prevalence of the corresponding disease states, as are systolic (> or =140 and > or =160 mm Hg) and diastolic hypertension (> or =90 and > or =95 mm Hg), hypercholesterolaemia (> or =250 and > or =300 mg/dl), overweight (body mass index > or =30 kg/m2), and heavy drinking (weekly alcohol intake > or =300 g/week). Results are expressed as linear regression equations and Pearson correlation coefficients. RESULTS: The correlation between the mean population values and prevalence of disease was close for blood pressures and body mass index. The Pearson coefficients, corrected for the influence of values increased above borderlines, were 0.86 and 0.81 respectively for systolic blood pressure, 0.88 and 0.91 for diastolic blood pressure, 0.28 and 0.52 for cholesterol, and 0.86 for the body mass index. The coefficient for alcohol intake was 0.55. CONCLUSIONS: It seems possible to shift the risk distribution of a population for some physiological parameters over time with the effect of changing the disease prevalence. This strategy can be used successfully for specific preventive measures, as was strongly advocated by Geoffrey Rose.

[The second stage of the Nursing Insurance Act and its effects on the institutional care within welfare for the elderly]. / Auswirkungen der 2. Stufe des Pflegeversicherungsgesetzes auf die Versorgung im stationären Bereich der Altenhilfe.

OBJECTIVE: The intention of the recently introduced compulsory nursing care insurance in Germany has been to support patients as well as relatives, and to reduce the burden on the social insurance system in financing professional services. In this study we examine the consequences of the 2nd stage of this legislation upon the care in old people's homes. METHODS: The investigation covered 5 institutions comprising two components: 1) Analysis of the records kept by the administration (N = 369), and 2) analysis of the volume of nursing care in a sample of N = 121 (including basic care as well as psychosocial support) provided by the staff over a period of 14 days. RESULTS: The required volume of basic nursing care (SGB XI) determines the classification of patients according to their need for nursing. Although by law the amount of nursing in stage 0 should be none, nevertheless 20 minutes of basic care in average are provided each day here. In stages II and III the observed nursing-time exceeded the allowed values slightly. In stage III realized nursing was far below the legal provision, although the private co-payments were highest. CONCLUSION: The agreement between nursing providers and nursing insurance aiming at comprehensive care, under the given circumstances cannot be executed satisfactorily. This is true especially for stage III patients in old people's homes.

[The effect of diagnosis-related groups on hospital care]. / Der Einfluss von Fallpauschalen auf die stationäre Versorgung.

OBJECTIVE: The implementation of Diagnosis Related Groups (DRG's) is intended to lead to a shortening of hospital days. DRG's therefore may endanger the quality of hospital care or cause a transfer of services from inward to ambulatory care. In this study the consequences of two selected DRG's are examined: operations of patients with varicosis and with hernia. METHODS: A retrospective comparison of 875 patient files in 6 hospitals in Northrhine-Westphalia (NRW) and a follow-up questionnaire to the patients themselves (N = 510). RESULTS: Between 1995 and 1997 average hospital days have been reduced by 2 days (varicosis) and 1 day (hernia) respectively. However, the standard stay according to an expert commission of the MOH is still exceeded. The shortening of inward care leads to an increase of ambulatory care. Also the patients indicate a worse subjective health status at discharge although this does not carry through the ambulatory phase. CONCLUSION: For the two DRG's examined the reduction of hospital services due to shorter inward periods is mostly compensated during ambulatory care. An additional shortening of hospital days, however, is likely to lead to negative effects on the health status of patients.

[Epidemiologic evidence in the treatment of cardiovascular risk factors in Germany]. / Zur epidemiologischen Evidenz der Behandlung kardiovaskulärer Risikofaktoren in Deutschland.

Up to now, approaches neither in primary nor in secondary prevention led to a relevant decline in prevalences of hypertension and hypercholesterolemia. On the contrary, prevalence of hypercholesterolemia increased from 38 to 40% (p < 0.001) while the hypertension prevalence stagnated (at nearly 20%) in the 30 to 69 years old population in West Germany between 1984/85 and 1991/92. The potential of medical advice is not sufficiently used, the compliance of patients regarding medical recommendations to change health behavior is limited. Subsequently the scientific consensus with regard to benefits from normalization of hypertension and hypercholesterolemia does not become effective at the population level. Evidence based medicine needs more efficient evaluation of continued medical education and quality assurance.

[The German Cardiovascular Disease Prevention Study: social gradient in use of drugs with a potentially addictive nature. An analysis of selected indications groups]. / Die Deutsche Herz-Kreislauf-Präventionsstudie (DHP): Sozialer Gradient beim Konsum von Medikamenten mit potentiell suchtgefährdendem Charakter. Eine Analyse ausgewählter Indikationsgruppen.

BACKGROUND: Not only prescription but also turnover of medicines are well established by documentary evidence. However, there is a lack of information regarding the usage of drugs in different social classes. MATERIALS AND METHODS: Within the scope of the German Cardiovascular Prevention Study (GCP), a cross-sectional community-based multicenter intervention study, (t0 = 1984/5, t1 = 1988 und t2 = 1991/2) the usage of drugs was examined. Four groups of drugs with a potentially addictive character (analgesics, sedatives, sleeping drugs, psychotropics) were analyzed with regard to socioeconomic differences in consumption. RESULTS: A gradient was found for all analyzed groups of drugs. The data analysis of the 3 pooled surveys (t0, t1, t2) regarding analgesics yields an OR of 1.67 (95%-CI: 1.41 to 1.98) for the middle class (mc) and 2.33 (95%-CI: 1.95 to 2.80) for the lower class (lc) (reference being the upper class). For psychotropics the values are OR = 1.40 (95%-CI: 1.12 to 1.75) (mc) and OR = 2.01 (95%-CI: 1.58 to 2.55) (lc), for sleeping drugs OR = 1.31 (95%-CI: 1.05 to 1.65) (mc) and OR = 1.54 (95%-CI: 1.37 to 1.96) (lc) and for sedatives OR = 1.40 (95%-CI: 1.19 to 1.64) (mc) and OR = 1.94 (95%-CI: 1.63 to 2.30) (lc). CONCLUSION: Considering possible indicators of different drug utilization (age, sex, occupation, individual health, last medical care, mental distress) the gradient was diminished but--especially for the lower class--remained at significant OR's between 1.37 and 1.65.

Reduction of coronary heart disease risk factors in the German cardiovascular prevention study.

BACKGROUND: In six regions of former West Germany, a community-oriented prevention program for coronary heart disease (CHD) was conducted over a 7-year period. METHODS: In the intervention regions, CHD prevention activities were performed with special emphasis on healthy nutrition, increased physical activity, and reduction of smoking, hypertension, and hypercholesterolemia. The impact of these activities on CHD risk factor trends was observed in three independent samples of the intervention regions. Three independent representative samples of the total West German population were used as a reference. Linear regression models with interaction terms to represent the intervention effects were used to test for differences in risk factor trends. RESULTS: In the pooled intervention regions, a net reduction in mean values of systolic (-2.0%) and diastolic (-2.0%) blood pressure, total serum cholesterol (-1.8%), as well as the percentage of smokers (-6.7%) was observed compared with the nationwide trend. From the major CHD risk factors, only body mass index was not influenced in the intervention population. CONCLUSIONS: The community-oriented German Cardiovascular Prevention program can effectively be used to reduce CHD risk factors in a broad population.

[The German Cardiovascular Prevention Study: social gradient for the net effects in prevention of hypercholesterolemia]. / Die Deutsche Herz-Kreislauf-Präventionsstudie (DHP): sozialer Gradient bei den Nettoeffekten in der Prävention der Hypercholesterinämie.

Hypercholesterolemia is considered an important risk factor for cardiovascular disease. The net effects of 7 years of a community prevention programme using principally a high-risk strategy (screening, referrals to general practitioner) in the German Cardiovascular Prevention Study (GCP) are analysed according to socioeconomic status (SES). Cholesterol was measured in three subsequent cross-sectional population samples of adults (ages 25-69 years) in 1984-1985, 1988 and 1991-1992 in the regions of Berlin, Bremen, Stuttgart, Karlsruhe with Bruchsal/Mosbach, and Traunstein (n = 11,548, 8743, 8636), in the region of Stuttgart only (n = 1791, 1437, 1313) and in the entire West German population (n = 4790, 5335, 5311) as reference. SES was determine by an additive, multiple index. Variations of means for phases and regions and resultant net differences were calculated. From 1984-1985 to 1991-1992 cholesterol declined from 232.7 to 231.8 mg/dl in the overall regions, from 232.0 to 230.5 mg/dl in Stuttgart, but increased from 233.5 to 236.9 mg/dl in the reference region. In the combined regions net differences according to SES were -4.2%***1) for the upper class, -1.6%** for the middle class and -0.3% for the lower class. Similar results were found comparing Stuttgart with the reference region (-5.4%***, -1.4%, -0.1%). The GCP intervention for hypercholesterolemia was successful basically only for the upper class, if net differences for the means are calculated. Prevention of hypercholesterolemia increased the social gradient in the pooled intervention regions and in Stuttgart.

Health sciences as an interdisciplinary challenge: the development of a new scientific field.

Health sciences in Central Europe have been established in recent years as the academic complement to public health. Unlike the situation outside Europe the link between academia, administration and practical application has become a distinct characteristic of this European philosophy. In this article the two questions are posed: 1. as to which structural problems characterize research into health and illness today and 2. how far can the establishment of an interdisciplinary sphere of "health sciences" provide adequate solutions? The authors also sketch the outlines of the new health sciences as an intergrating and "trans-paradigmatical" teaching and research field and they consider the relationships of health sciences to practice in general, and their relevance to the health services in particular. The challenges in the future for public health and therefore for the health sciences will be enormous. A breakthrough in this field will probably not be achieved until the research interests of clinical specialists and researchers oriented towards social and behavioural sciences are linked over a broad front. It is also hoped that from this connection-embeded in open scientific discourse-"health sciences" will arise, not as part of medicine, and not as part of this social sciences, but with their own claims and specific conceptions as to how the problems of our health system can be resolved.

[Benefits and costs of early detection and treatment of hypercholesterolemia]. / Nutzen und Kosten bei Früherkennung und Frühbehandlung der Hypercholesterinämie.

Hypercholesterolemia is the epidemiologically most relevant parameter of hyperlipoproteinemia 1) for its high prevalence of almost 40% > = 250 mg/dl in the adult German population (30-65 years) and 2) because of a relative risk of 3 and more for coronary heart disease. An estimate of the cost to benefit relation of early diagnosis and therapy requires epidemiological, clinical, and economic analysis. A synopsis of the present scientific discussion leads to more restricted recommendations for treatment than before, i.e., limited to males aged 40-65, of high cardiovascular risk and cholesterol of at least > = 250 mg/dl. An even more conservative approach especially with regard to screening programs is not justified yet. However, careful monitoring of forthcoming trials and meta-analyses is mandated. The costs for an indicated cholesterol-lowering medication are not extreme, but there are large differences between different drugs on the German market. Overtreatment of the aged population occurs together with undertreatment of hypercholesterolemic men of medium age.

Economic evaluation of lenograstim (glycosylated rHuG-CSF) in the treatment of inflammatory breast cancer for Germany and Italy.

Data from a French placebo-controlled double-blind trial in 120 female patients treated with high dose fluorouracil, epirubicin and cyclophosphamide (HD-FEC) chemotherapy for inflammatory breast cancer were used to assess the economic impact of adjunctive lenograstim therapy. The analysis compared direct costs of treatment, with or without lenograstim, with reference to the Social Security (Germany) or to the National Health Service (Italy). Resource utilisation differed between the 2 treatment groups. The lenograstim group reported 32% fewer antibiotic therapy days (9.8 days vs 14.6; p = 0.01) and 24% fewer inpatient days for any reason other than chemotherapy (7.4 'excess' days vs 9.8). By reducing infection-related morbidity associated with a high dose chemotherapy regimen, lenograstim decreased treatment costs by DM 1794 and ItL 1.2 million, excluding the cost of lenograstim itself. Since lenograstim patients reported fewer chemotherapy delays (16.4 vs 30.5%) and, hence, benefited from 1.2 (p = 0.04) more chemotherapy days, the related cost was DM 1519 and ItL 0.9 million higher than for the placebo group. This cost difference would be expected to be smaller if the placebo group patients had been followed until completion of their full chemotherapy regimen. Assuming that the costs of chemotherapy were the same for both groups, the direct cost saving for the lenograstim group would be 30% in Germany and 34% in Italy.

Blood pressure in childhood: pooled findings of six European studies.

In an attempt to study and prevent the development of hypertension, there is a growing interest in measuring blood pressure in children. The aim of this is to detect and monitor those with a relatively high level of blood pressure. Until now, reference values on blood pressure in children are based on data from North-American youngsters. The present study provides percentile charts based on pooled data from studies on blood pressure conducted in six North-West European countries among 28,043 children. These blood pressure centiles are presented as age-, height- and gender-specific. Brief guidelines for blood pressure measurements in childhood and for detection of children with a relatively high blood pressure are included.