End-stage renal disease in Taiwan: a case-control study.

BACKGROUND: Taiwan has the highest incidence of end-stage renal disease (ESRD) in the world. The epidemiologic features of ESRD, however, have not been investigated. In this case-control study, we evaluated the risk of ESRD associated with a number of putative risk factors. METHODS: We studied 200 patients among whom ESRD had been newly diagnosed between 1 January 2005 and 31 December 2005; 200 controls were selected from among relatives of patients treated in the general surgery unit. Using a structured questionnaire, we collected information related to socioeconomic factors, history of disease, regular blood or urine screening, lifestyle, environmental exposure, consumption of vitamin supplements, and regular drug use at 5 years before disease onset. RESULTS: Our primary multivariate risk models indicated that low socioeconomic status was a strong predictor of ESRD (education: odds ratio [OR], 2.78; 95% confidence interval [CI], 1.49-5.19; income: OR, 2.86, 95% CI, 1.48-5.52), even after adjusting for other risk factors. Other significant predictors for ESRD were a history of hypertension (OR, 3.63-3.90), history of diabetes (OR, 3.85-5.50), and regular intake of folk remedies or over-the-counter Chinese herbs (OR, 10.84-12.51). Regular intake of a multivitamin supplement 5 years before diagnosis was associated with a decreased risk of ESRD (OR, 0.12-0.14). CONCLUSIONS: Our findings indicate that low socioeconomic status, history of hypertension, diabetes, and regular use of folk remedies or over-the-counter Chinese herbs were significant risk factors for ESRD, while regular intake of a multivitamin supplement was associated with a decreased risk of ESRD.

Private doctors' practices, knowledge, and attitude to reporting of communicable diseases: a national survey in Taiwan.

BACKGROUND: Epidemiological surveillance of infectious diseases through the mandatory-reporting system is crucial in the planning and evaluation of disease control and prevention program. This study investigated the reporting behavior, knowledge, and attitude to reporting communicable disease in private doctors in Taiwan. The differences between the reporting and non-reporting doctors were also explored. METHODS: A total of 1250 clinics were randomly sampled nationwide by a 2-stage process. Data were collected from 1093 private doctors (87.4% response rate) using a self-administered structured questionnaire. Four hundred and six (37.2%) doctors reported having diagnosed reportable communicable diseases. Among them, 340 (83.5%) have the experiences of reporting. RESULTS: The most common reasons for not reporting were "do not want to violate the patient's privacy", "reporting procedure is troublesome", and "not sure whether the diagnosed disease is reportable". Significantly higher proportions of the non-reporting doctors considered the reporting system inconvenient or were not familiar with the system. The highest percentage (65.2%) of the non-reporting doctors considered that a simplified reporting procedure, among all measures, would increase their willingness to report. In addition, a significantly higher proportion of the non-reporting doctors would increase their willingness to report if there has been a good reward for reporting or a penalty for not reporting. CONCLUSION: The most effective way to improve reporting rate may be to modify doctor's attitude to disease reporting. The development of a convenient and widely-accepted reporting system and the establishment of a reward/penalty system may be essential in improving disease reporting compliance in private doctors.

SNP combinations in chromosome-wide genes are associated with bone mineral density in Taiwanese women.

Osteoporosis is a major public health problem, mainly quantified by low BMD. Eleven polymorphisms were investigated in this study; TNFalpha-857 (rs1799724), TGFbeta1-509 (rs1800469), osteocalcin (rs1800247), TNFalpha-308 (rs1800629), PTH BstB I (rs6254), PTH Dra II (rs6256), IL-1ra (VNTR), HSP70 hom (rs2227956), HSP 70-2 (rs1061581), CTR (rs1801197), and BMP-4 (rs17563). The relationship between the combined polymorphisms in different genomic regions and BMD variation was investigated. Among the female subjects, the proportion of subjects with low BMD in low BMI group (< or = 18.50) was significantly higher than that of the middle (18.51-22.99) and high (> or = 23.00) BMI groups (P < 0.05). In post-menopausal women, there was a significant association between low BMD and genotypes ranging from 2 to approximately 7 SNPs. For two combined SNPs, the portion of subjects with low BMD was significantly higher in those with CC-AA genotypes in rs1799724-rs1800629, compared to those with non-CC-AA genotypes in post-menopausal women and the combination of all women. Similarly, part of the combined SNPs with rs1799724-rs1800629-rs6254-rs6256-IL-1ra-rs2227956-rs1801197 was significantly associated with reduced BMD. After controlling for age and BMI, post-menopausal women with certain specific SNP combination had a 3.54- to 4.68-fold increased risk for low BMD, comparing to other SNP combinations. In conclusion, our data suggest that several gene polymorphisms may be cooperatively involved in the development of osteoporosis.

Evaluation of the National Notifiable Disease Surveillance System in Taiwan: an example of varicella reporting.

Despite the mandatory reporting by laws, the incompleteness of notifiable infectious disease reporting is well-documented in many countries for various diseases. The purpose of this study is to investigate the completeness of varicella reporting in Taiwan. Annual reports of National Notifiable Disease Surveillance System in Taiwan were compared to the annual outpatient claims of National Health Insurance (NHI) in the years of 2000, 2001, and 2002. Age and area-specific reporting rates of varicella were calculated by dividing the respective reported cases by the number of incidence cases. The reporting rate was the highest in aged 0 year in all years, followed by the 20-29- and 30-39-year groups. The reporting rate in each age group increased gradually during the study period. Other than Taipei City, the reporting rates in all regions were below 9% during this period. This study suggested that varicella reporting rate is very low in Taiwan. In addition, the reporting rates were inconsistent in 2000-2002, making the estimation of prevalence and vaccine efficacy using data from the National Notifiable Disease Surveillance System almost impossible. This study indicated that the physicians in Taiwan should improve their knowledge and attitude toward notifiable infectious diseases.

Seroepidemiology study of rubella antibodies among pregnant women from seven Asian countries: evaluation of the rubella vaccination program in Taiwan.

During 2003-2004, approximately 13% of birth in Taiwan was given by foreign-born females. The aims of this study were to compare the seroprevalence of rubella antibodies between Taiwan-born and foreign-born pregnant women and evaluate the effect of rubella vaccination program in Taiwan. We reviewed the rubella antibody test results of 5007 women during routine pregnancy check-ups at Fooyin University Hospital during 1999-2002. In Taiwan-born women, rubella antibody was undetectable in 29.2%, 7.3%, and 8.3% of the cohorts born before 1971, between 1971 and 1976, and after 1976, respectively. In the cohorts born between 1971 and 1976 and after 1976, pregnant women born in China, Vietnam, Indonesia, and Philippines had significant higher chances of being susceptible. Our results suggested that the voluntary adult vaccination program was not as effective as the school or wipe-out programs. Both Taiwanese women born before 1971 and foreign-born women were more likely to be susceptible to rubella. The introduction of 'catch-up' immunization program and enforcement of the checking of immunization record and/or blood test before pregnancy for these women are necessary in preventing CRS.

Use of National Health Insurance database to evaluate the impact of public varicella vaccination program on burden of varicella in Taiwan.

The aims of this study were to investigate the epidemiology of varicella and evaluate the effect of varicella vaccination on the burden of varicella in Taiwan. The outpatient and hospitalization claims made to the National Health Insurance (NHI) in public and private vaccination areas were compared during 2000-2002. In 2002, the outpatient visit rates for 1- to 5-year-old children in public vaccination areas were 66-78% lower than their counterparts in private vaccination areas. The reduction in outpatient visit rate was the greatest among preschool children. The reductions also occurred in every age group including infants and adults. This study showed significant evidence of vaccine impact with a marked decline in clinical cases in the short term.

Accessibility assessment of the Health Care Improvement Program in rural Taiwan.

CONTEXT: An experimental Health Care Improvement Program (HCIP) was initiated by the Bureau of National Health Insurance in 1997 to improve the accessibility of health care in several rural, mountainous districts. PURPOSE: This longitudinal study evaluated service availability, utilization patterns, and effectiveness of services under the HCIP in the A-Li Mountain District. METHODS: Outpatient claims made by residents in the A-Li Mountain District were extracted from the database of the National Health Insurance program. Changes in utilization pattern and volume were analyzed. Satisfaction levels were assessed by 2-stage face-to-face interviews with local residents. FINDINGS: After the HCIP, the average population served by each doctor decreased 75%, and total outpatient visits increased 15.4%. The total number of in-district outpatient visits increased 83.6%. The proportion of in-district outpatient visits to all visits increased from 22.1% to 35.1%. The total in-district outpatient visit fee claimed increased 100.2%, and the total out-of-district outpatient visit fee claimed increased only 7.2%. About 60.4% of the residents were not satisfied with overall health care services before the HCIP. The proportion decreased to 32.4% after the HCIP. CONCLUSIONS: The HCIP improved accessibility, enriched local medical care resources, changed the utilization pattern of some residents, and increased residents' satisfaction level. A well-managed program with stabilized financial resources is more likely to succeed if it also respects cultural differences and responds to community needs.

Seroepidemiology study of Japanese encephalitis neutralizing antibodies in southern Taiwan: a comparative study between urban city and country townships.

BACKGROUND: Japanese encephalitis (JE) occurs all over Asia, especially in southeastern regions. The aim of this study was to evaluate the current JE vaccination regimen in Taiwan by assessing the neutralizing antibody among people of various age groups from different living environments. METHODS: From 1998 to 1999, 2365 (1016 male, 1349 female) students and home-visit volunteers were recruited from an industrialized city (Kaohsiung), and 712 (290 male, 422 female) students and volunteers from hospital outpatient and physical check-up units were recruited from country townships (Pintung County) for this study. Participants were between 6 and 74 years old. Serum JE neutralizing antibody was measured by the plaque reduction neutralization test with a 50% reduction as seroconversion. Incidence cases from 1971 to 1999 were collected from an active surveillance system run by the Center for Disease Control in Taiwan. RESULTS: Seropositive prevalence peaked immediately after the second booster in first-grade students and declined as age increased. For those born before 1963, seropositive prevalence was significantly associated with age, sex, and living area. In the 1990s, the incidences of confirmed JE in Kaohsiung and Pintung County were 0.11 and 0.14 per 100,000 population, with only 2 and 1 patient age 10 years or younger, respectively. All but 2 patients had never been vaccinated. CONCLUSIONS: Seropositive prevalence decreased gradually after vaccination. A third booster (the fifth shot) before age 18 years may further enhance the antibody titers, especially if the odds of natural infections have significantly reduced. Follow up studies on the changes of antibody titers over time among immunized populations are warranted in Asian countries where natural infections become less common.

Varicella vaccine safety, incidence of breakthrough, and factors associated with breakthrough in Taiwan.

BACKGROUND: Varicella vaccine was first available in Taiwan in 1997. The aims of this study were to investigate varicella vaccine safety and occurrence of breakthrough in Taiwan during the first 3 years. The adverse events, incidence of breakthrough, and factors associated with breakthrough were analyzed. METHODS: A personal interview using a structured questionnaire was conducted for the parents of 1248 children less than 12 years old who were vaccinated between 1998 and 2000. Incidence of adverse events and breakthrough were presented and factors associated with breakthrough were estimated by logistic regression. RESULTS: There were 27 (2.16%) breakthrough cases occurring during the maximum follow up period of 31 months, including 22 very mild or mild cases, 3 moderately severe cases, and 2 severe cases. Compared with those who did not have confirmed history of varicella exposure after vaccination, children with such exposure were approximately 28 times as likely to have breakthrough varicella develop (adjusted odds ratio = 27.75, 95% confidence interval: 6.12-125.78, P =.00). There were 91 (7.3%) reported cases of adverse events, including rash, fever, and pain or swelling, occurring within 2 weeks of vaccination. CONCLUSIONS: Although rare adverse events cannot be well-quantified in this study, the results suggest that, at least in the short term, varicella vaccine is well-tolerated and effective in Taiwan. Long-term monitoring program is necessary to ensure the safety of this vaccine.