Finding the real case-fatality rate of H5N1 avian influenza.

BACKGROUND: Accurate estimation of the case-fatality (CF) rate, or the proportion of cases that die, is central to pandemic planning. While estimates of CF rates for past influenza pandemics have ranged from about 0.1% (1957 and 1968 pandemics) to 2.5% (1918 pandemic), the official World Health Organization estimate for the current outbreak of H5N1 avian influenza to date is around 60%. METHODS AND RESULTS: The official estimate of the H5N1 CF rate has been described by some as an over-estimate, with little relevance to the rate that would be encountered under pandemic conditions. The reasons for such opinions are typically: (i) numerous undetected asymptomatic/mild cases, (ii) under-reporting of cases by some countries for economic or other reasons, and (iii) an expected decrease in virulence if and when the virus becomes widely transmitted in humans. Neither current data nor current literature, however, adequately supports these scenarios. While the real H5N1 CF rate could be lower than the current estimate of 60%, it is unlikely that it will be at the 0.1-0.4% level currently embraced by many pandemic plans. We suggest that, based on surveillance and seroprevalence studies conducted in several countries, the real H5N1 CF rate should be closer to 14-33%. CONCLUSIONS: Clearly, if such a CF rate were to be sustained in a pandemic, H5N1 would present a truly dreadful scenario. A concerted and dedicated effort by the international community to avert a pandemic through combating avian influenza in animals and humans in affected countries needs to be a global priority.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon.

BACKGROUND: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. METHODS: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. RESULTS: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. CONCLUSION: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

A simple approximate mathematical model to predict the number of severe acute respiratory syndrome cases and deaths.

BACKGROUND: Severe acute respiratory syndrome (SARS) is currently spreading in many countries. This paper proposes a simple approximate mathematical model for public health practitioners to predict the number of SARS cases and deaths. METHODS: The model is based on four parameters: R(o) (basic reproductive number), F (case-fatality rate), i (incubation period), and d (duration of disease). The calculations can be done by hand or by using a computer spreadsheet. RESULTS: The best parameters to fit Canadian data as of 6 April 2003 (before infection controls took effect) are R(o) = 1.5, F = 30%, i = 5 days, d = 14 days. On 6 April (day 40) there were 74 cases and 7 deaths. If this trend continues, SARS numbers in Canada are predicted to be as follows: 387 cases and 34 deaths by 26 April (day 60), 4432 cases and 394 deaths by 26 May (day 90), and 50 500 cases and 4489 deaths by 25 June (day 120). By comparison, the best parameters to fit Hong Kong data as of 10 April 2003 are R(o) = 2.0, F = 20%, i = 5 days, d = 14 days. CONCLUSIONS: Using the proposed mathematical model, it was estimated that about 1.5 to 2 new infectious cases were produced per infectious case every five days. Also, about 20% to 30% of the cases die within 14 days. The case-fatality may therefore be considerably higher than initially thought. The model indicates that SARS can spread very fast when there are no interventions.

Lessons for surveillance in the 21st century: a historical perspective from the past five millennia.

This paper reviews some major epidemics in the past 5,000 years in human history and derives 12 lessons in the context of epidemiologic surveillance. The corresponding 12 challenges proposed in this paper could be used to guide us in building a better and more comprehensive surveillance system in the 21st century. This will be achieved by: continuing the evolvement and improvement of surveillance; maintaining on an ongoing basis; being systematic; being population-based; including risk and intervention indicators in the data base; more efficient data analysis; stimulating etiologic research; improving forecasting capability; linking to development of intervention; evaluating the intervention; better ways of information dissemination; and dissemination without prejudice.

Health and social costs of tobacco use in Ontario, Canada, 1979 and 1988.

STUDY OBJECTIVE: This study aimed to estimate the health and social costs of tobacco use in Ontario, Canada. DESIGN: This was a cost-benefit analysis based on cross sectional data in 1988, stratified by age and sex, using an attributable risk model. The total cost of the consequences of tobacco use in the society included those costs attributed to extra deaths, disability, hospitalisation, physician visits, and fire losses, from tobacco use. PARTICIPANTS: The general population of Ontario, Canada. MAIN RESULTS: The total cost of tobacco use in Ontario, Canada in 1988 was estimated to be $3.623 billion--$721 million more than the total customer expenditure on tobacco products. Tobacco use was also found to be responsible for 14% of all adult deaths, 5% of all adult disability days, 14% of all days of hospitalisation, and 3% of all physician visits. Compared with previous results for Ontario (1979) the cost of the consequences of tobacco use had increased by about 25% and consumer expenditure by about 35% over the period, while the excess of consequences over expenditure fell slightly by about 3%. CONCLUSIONS: The annual excess of the social costs of tobacco use over total consumer expenditure is staggering. It is suggested that similar cost-benefit analysis of smoking be carried out at regular intervals to monitor smoking trends in the society, to estimate health and social costs, and to provide information for the setting of targets for tobacco control and healthy public policies.

A nested case-control study on alcohol drinking, tobacco smoking, and cancer.

A nested case-control study was conducted to investigate the effect of alcohol consumption and tobacco smoking on cancers of various sites. The study population was based on 887 cases and 1774 controls, selected from a cohort of 17,200 male participants of a gastric mass survey in 1984, who were followed up for 9 years by the Chiba Cancer Registry, Japan. The odds ratio (OR) of colon cancer was significantly elevated in alcohol drinkers of one cup of sake-equivalent (27 ml ethanol) per day (OR = 3.5), and three cups of sake-equivalents per day (OR = 3.2) compared with nondrinkers, but its dose-response was not clear since two cups of sake-equivalents per day had an OR of 1.9, which was nonsignificant. Cancer risk elevation was especially predominant in the proximal colon, again showing no dose-response: OR = 30.7 for one cup of sake-equivalent per day, OR = 12.4 for two or more cups per day. Lung cancer showed a dose-response relationship with alcohol consumption, independent of tobacco smoking. A synergistic effect of alcohol intake and tobacco smoking was observed for upper aerodigestive tract and bladder cancer. Both alcohol drinking and tobacco smoking were found not to be associated with stomach cancer.

Effects of mailing strategies on response rate, response time, and cost in a questionnaire study among nurses.

We conducted a pilot study to determine the most efficient mailing strategy for a postal questionnaire study among nurses in Ontario, Canada. Five mailing strategies involving types of stamps on the return envelopes were considered: no stamp, business-reply stamp, metered stamp, small regular stamp, and large commemorative stamp. We found that paper stamps, especially large commemorative stamps, on return envelopes increased the response rate and reduced the response time, as compared with other mailing strategies. Business-reply stamps had the lowest cost per response received and a low total cost.