- Email: [email protected]
Congenital rubella: down but not out
CORRESPONDENCE
would help to focus attention on the need for research. Jennifer Worth The White House, St John’s Road, Boxmoor, Hertfordshire HP1 1PQ, UK 1
2
3
4
Cherry N, Mackiness M, Durrington P, et al. Paraoxonase (PON1) polymorphisms in farmers attributing ill health to sheep dip. Lancet 2002; 359: 763–64. The Control of Substances Hazardous to Health Regulations 1988. http://www.hmso.gov.uk/si/si1988/Uksi_198 81657_en_1.htm (accessed March 19, 2002). Royal College of Physicians and Royal College of Psychiatrists. Report of a joint working party of the Royal College of Physicians and the Royal College of Psychiatrists. November, 1998. CR67. Organophosphate information network. http://www.op-infonet.org (accessed March 19, 2002).
Congenital rubella: down but not out Sir—In a report on congenital rubella, E Sheridan and colleagues (Feb 23, p 674)1 focus on one of about 40 infants reported to the National Congenital Rubella Surveillance Programme (NCRSP) in the UK since 1991. More than 60 terminations for rubella disease or contact in pregnancy were reported in England and Wales in the same period.2 In 1991–96, about 60% of the mothers of infants reported to have congenital rubella had been born abroad. Most had come to the UK as adults, and had not been offered rubella vaccination. 25% of the maternal infections were acquired abroad (imported cases), mostly in Asia, but also one each in the Republic of Ireland, Poland, and Spain.3 No baby born with congenital rubella was reported in 1997 or 1998, one was reported in 1999, and seven more since then. Five of these eight babies were born to women who were infected early in pregnancy in Africa or Asia, before coming to the UK. Another mother acquired her infection in Scotland, although it was epidemiologically linked to an outbreak in Greece in 1999.4 The remaining two maternal infections were acquired in London, one by a UK-born woman, and the other by a Sri Lankan woman who had been in the UK for several years. Almost all infants reported in the past decade had typical rubella defects recognisable at birth or soon after. Congenital rubella is probably underdiagnosed, especially among affected children who have sensorineural hearing loss as the only defect. Before
the start of measles-mumps-rubella (MMR) vaccination, rubella antibodies were useful as a marker for congenital rubella in very young deaf children, since they were unlikely to have acquired natural infection in the first 2–3 years of life. Awareness of congenital rubella is currently low, few younger health professionals will ever have seen a case, and by the time hearing loss has been recognised and investigated, many children already have rubella antibodies from MMR vaccination. As Sheridan and colleagues report, rubella infection in the first 16 weeks of pregnancy can have devastating consequences. The best defence is high uptake of MMR in young children. MMR uptake in the UK has declined notably with substantial variation around the country.5 The current measles outbreaks should serve as a warning that rubella may also be poised to make a comeback. Particular attention should be paid to protecting people who have recently arrived in the UK, and others who are likely to have missed vaccination. Meanwhile, contact with suspected rubella in a susceptible pregnant woman, or rubella-like symptoms in any pregnant woman (irrespective of her recorded rubella status), must be investigated appropriately. If rubella infection is confirmed, women can be advised about the risks, and offered the option of termination of pregnancy if appropriate. Any infant or young child with suspected or confirmed congenital rubella, with or without typical rubella defects, should be reported through the British Paediatric Surveillance Unit’s active reporting scheme for rare disorders of childhood, or direct to the NCRSP. I thank the British Paediatric Surveillance Unit and particularly to paediatricians and all other colleagues who have provided data to the NCRSP. The Public Health Laboratory Service pays for the inclusion of congenital rubella on the BPSU’s orange card.
Pat Tookey National Congenital Rubella Surveillance Programme, Institute of Child Health, London WC1N 1EH, UK (e-mail: [email protected]) 1
2 3
4
5
Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002; 359: 674–75. Abortion Statistics 2000: series AB No 27. London: Stationery Office, 2001. Tookey PA, Peckham CS. Surveillance of congenital rubella in Great Britain, 1971–96. BMJ 1999; 318: 769–70. Tookey P, Molyneaux P, Helms P. UK case of congenital rubella can be linked to Greek cases. BMJ 2000; 321: 766–67. PHLS. COVER programme: October to December 2001—vaccination coverage statistics for children up to five years of age
THE LANCET • Vol 360 • September 7, 2002 • www.thelancet.com
in the United Kingdom. http://www.phls.co.uk/publications/CDR %20Weekly/pages/immunisation.html (accessed April 12, 2002).
Sir—We agree with Sheridan and colleagues’ conclusion1 that, despite the success of the UK rubella immunisation programme, congenital rubella syndrome may re-emerge, and that targeted immunisation is required for groups with higher susceptibility rates. They report a rubella susceptibility rate of 6% among Asian women from east London, but our data suggest that the situation in south London may be even worse. After we noticed an unusually high number of rubella-susceptible women from Sri Lanka in 1998, we undertook an audit of rubella susceptibility in pregnant women receiving antenatal care at St George’s Hospital, London, in that year. The overall susceptibility rate was 111 (3%) per 3500, but we noted large variations by country of birth. Of the 142 Sri Lankan women, 23 (16%) of 142 were susceptible compared with 16 (8%) of 195 and 24 (9%) of 276 South Asian and African women, respectively. Only 1% of women born in the UK were susceptible. In a review of the obstetric records for these women, two-thirds from countries without rubella vaccination programmes had already made a total of 85 contacts with obstetric and gynaecology services in the UK before becoming pregnant and testing rubella susceptible in 1998. Moreover, 17% of susceptible Sri Lankan women had previously had terminations done in the UK, yet were not tested for rubella before the procedure. The Sri Lankan women in particular were further disadvantaged by language difficulties, registering with over-worked, singlehanded family physicians more commonly than women of other ethnic origins, and by failures in postpartum immunisation. Despite rubella susceptibility being indicated by laboratory testing, only 85% of women were immunised after birth. The main reason for not being immunised was incorrect recording of rubella status as immune in the notes. With falling rates of MMR uptake in infants and an increase in migration to the UK from resource-poor countries, we are still failing these women in not adhering to the Department of Health’s recommendation that every effort should be made to identify and immunise seronegative women.2 If we are to avoid the re-emergence of congenital rubella syndrome, accurate data on local and national rubella
803
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
susceptibility rates among different groups are needed. Ruby Devi, David Muir, *Philip Rice
2
Department of Medical Microbiology, St George’s Hospital, London SW17 0QT, UK (e-mail: [email protected]) 1
2
Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002; 359: 674–75. Salisbury DM, Begg NT, eds. Immunisation against infectious disease. London: HM Stationery Office, 1996.
3
4
5
Sir—The issue of potential high susceptibility to rubella in women of childbearing age and consequent high risk of congenital rubella syndrome, as highlighted by E Sheridan and colleagues,1 is not limited to immigrants and visitors from parts of the world without vaccination programmes. Such women from countries with poorly implemented rubella immunisation programmes may be at an even higher risk. The presence of a universal childhood rubella vaccination programme will increase susceptibility in women of childbearing age unless coverage exceeds the prevaccination level of immunity. This level varies from country to country, but is frequently 75–90%.2 In practice, infant coverage must be high, combined with effective targeted programmes, to avoid any risks. There are suboptimum rubella immunisation programmes in developing and developed countries, including some in western Europe. High levels of seronegativity to rubella among women aged 15–19 years are reported in France (12%), Italy (10%), and Germany (8%), compared with only 1–3% in the UK, Netherlands, and Finland.3 These high susceptibility levels may raise the risk of congenital rubella syndrome. In Greece, coverage of the infant immunisation programme started in the 1970s was suboptimum. Consequently, major rubella epidemics affected women of childbearing age in 1993, which led to the largest number of cases of congenital rubella syndrome ever reported in the country.4 A further epidemic in Greece occurred in 1998, and affected other European countries, including the UK. One infant with congenital rubella syndrome was linked to these outbreaks.5 Thus great care should be taken before and after embarking on childhood rubella vaccination. *A Nardone, N J Gay, W J Edmunds Immunisation Division, PHLS Communicable Disease Surveillance Centre, London NW9 5EQ, UK (e-mail: [email protected]) 1
Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella
804
syndrome: a risk in immigrant populations. Lancet 2002; 359: 674–75. Edmunds WJ, Gay NJ, Kretzschmar M, Pebody RG, Wachmann H. The prevaccination epidemiology of measles, mumps and rubella in Europe: implications for modelling studies. Epidemiol Infect 2001 125: 635–50. Pebody RG, Edmunds WJ, Conyn M, et al. The seroepidemiology of rubella in Western Europe. Epidemiol Infect 2000; 125: 347–57. Panagiotopoulos T, Antoniadou I, Valassi-Adam E. Increase in congenital rubella occurrence after immunisation in Greece: retrospective survey and systematic review. BMJ 1999; 319: 1462–67. Tookey P, Molyneaux P, Helms P. UK case of congenital rubella can be linked to Greek cases. BMJ 2000; 321: 766–67.
Diabetes prevalence and projections in South Asia Sir—In your March 9 news item1 on cardiovascular disease in South Asia, you note diabetes mellitus as a risk factor. We have assessed prevalence and case-load projections for type 2 diabetes for the next 25 years in the South Asian Association for Regional Cooperation (SAARC) countries.2 Individual country projections are derived from a 1998 publication on global burden of diabetes, 1995–2025, developed by WHO, the Prudential Center for Health Care Research, and the University of Michigan.3 The type 2 diabetes pandemic is fuelled by globalisation, rural-to-urban shifts, and dietary and physical activity changes.2,3 Since type 2 diabetes mostly starts in adulthood, the trend is compounded by demographic ageing; even if rates were stable, demography alone would increase case load. By 2025, more than 80% of people with type 2 diabetes (>240 million) will live in developing countries. The top three countries in 1995 and 2025 are: India, China, and the USA, but, in this time, Pakistan moves from eighth to fourth position. For the five SAARC countries with population-based surveys (Bangladesh, India, Nepal, Pakistan, and Sri Lanka) rates are all higher than the WHO value
for developing countries (3·5%) in 2000 (table). The Nepal data are preliminary survey results (D L Singh, M D Bhattaria, personal communication). No data are available for Bhutan and the Maldives, but the small populations imply little impact on overall SAARC estimates. In 2000, the adult SAARC population (age ⭓20 years) included 33 million people with type 2 diabetes, which will rise to 77 million by 2025. This number is, however, underestimated because population data are unavailable for younger people. Around 80% of cases now and in 2025 are in people aged 20–64 years. Pakistan, with an adult prevalence of 10·6%, and India, with an urban adult prevalence of 12·1%, are among the top ten countries for rates and case load. However, India’s rate, because of its large population, yields the largest case load. In addition, Indians and Pakistanis have a high prevalence of impaired glucose tolerance (10–14%) such that incidence rates for diabetes will increase over the next decade. In SAARC populations there is generally a male preponderance for type 2 diabetes, that compares with a malefemale ratio of 1:1 in developing countries as a whole, and contrasts with developed countries, where type 2 diabetes is 1·5 times more common in women than in men. We purport that this sex difference reflects mainly underlying transitional biosocial factors; in urban India a significant difference is no longer seen.4 Since diabetes complications have high health-care costs, waiting for the pandemic to run its course is unsatisfactory. South Asian countries cannot afford the increasing burden of chronic renal failure and blindness. The large poor population has lower prevalence rates than the rich, but have higher rates of complications because of later diagnosis, inaction on risk factors, and poor management.5 SAARC countries must increase health promotion, and primary and secondary prevention while the pandemic is still in an early phase. *Franklin White, Ghazala Rafique
Prevalence of Male/female type 2 diabetes (%) rate ratio
Country Bangladesh India Nepal* Pakistan Sri Lanka
Urban
Rural
7·9% 12·1% 14·1% 10·8% –5·0
3·8% 2·9% 2·9% 6·5% –2·0
1·15 1·05 1·31 1·32 2·13
*Preliminary results. No data available from Bhutan and Maldives.
Type 2 diabetes prevalence in SAARC countries
Community Health Sciences, Aga Khan University, PO Box 3500, Karachi 74800, Pakistan (e-mail: [email protected]) 1
2
Srivastava R. South Asia’s governments exhorted to focus on CVD. Lancet 2002; 359: 858. White F, Rafique G. Diabetes prevalence and projections in South Asia: an emerging public health priority for the 21st century. Selected proceedings of the 9th International Congress of the World Federation of Public Health Associations, Sept 2–6, 2000, Beijing, China. Washington: APHA, 2001: 118–20.
THE LANCET • Vol 360 • September 7, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
would help to focus attention on the need for research. Jennifer Worth The White House, St John’s Road, Boxmoor, Hertfordshire HP1 1PQ, UK 1
2
3
4
Cherry N, Mackiness M, Durrington P, et al. Paraoxonase (PON1) polymorphisms in farmers attributing ill health to sheep dip. Lancet 2002; 359: 763–64. The Control of Substances Hazardous to Health Regulations 1988. http://www.hmso.gov.uk/si/si1988/Uksi_198 81657_en_1.htm (accessed March 19, 2002). Royal College of Physicians and Royal College of Psychiatrists. Report of a joint working party of the Royal College of Physicians and the Royal College of Psychiatrists. November, 1998. CR67. Organophosphate information network. http://www.op-infonet.org (accessed March 19, 2002).
Congenital rubella: down but not out Sir—In a report on congenital rubella, E Sheridan and colleagues (Feb 23, p 674)1 focus on one of about 40 infants reported to the National Congenital Rubella Surveillance Programme (NCRSP) in the UK since 1991. More than 60 terminations for rubella disease or contact in pregnancy were reported in England and Wales in the same period.2 In 1991–96, about 60% of the mothers of infants reported to have congenital rubella had been born abroad. Most had come to the UK as adults, and had not been offered rubella vaccination. 25% of the maternal infections were acquired abroad (imported cases), mostly in Asia, but also one each in the Republic of Ireland, Poland, and Spain.3 No baby born with congenital rubella was reported in 1997 or 1998, one was reported in 1999, and seven more since then. Five of these eight babies were born to women who were infected early in pregnancy in Africa or Asia, before coming to the UK. Another mother acquired her infection in Scotland, although it was epidemiologically linked to an outbreak in Greece in 1999.4 The remaining two maternal infections were acquired in London, one by a UK-born woman, and the other by a Sri Lankan woman who had been in the UK for several years. Almost all infants reported in the past decade had typical rubella defects recognisable at birth or soon after. Congenital rubella is probably underdiagnosed, especially among affected children who have sensorineural hearing loss as the only defect. Before
the start of measles-mumps-rubella (MMR) vaccination, rubella antibodies were useful as a marker for congenital rubella in very young deaf children, since they were unlikely to have acquired natural infection in the first 2–3 years of life. Awareness of congenital rubella is currently low, few younger health professionals will ever have seen a case, and by the time hearing loss has been recognised and investigated, many children already have rubella antibodies from MMR vaccination. As Sheridan and colleagues report, rubella infection in the first 16 weeks of pregnancy can have devastating consequences. The best defence is high uptake of MMR in young children. MMR uptake in the UK has declined notably with substantial variation around the country.5 The current measles outbreaks should serve as a warning that rubella may also be poised to make a comeback. Particular attention should be paid to protecting people who have recently arrived in the UK, and others who are likely to have missed vaccination. Meanwhile, contact with suspected rubella in a susceptible pregnant woman, or rubella-like symptoms in any pregnant woman (irrespective of her recorded rubella status), must be investigated appropriately. If rubella infection is confirmed, women can be advised about the risks, and offered the option of termination of pregnancy if appropriate. Any infant or young child with suspected or confirmed congenital rubella, with or without typical rubella defects, should be reported through the British Paediatric Surveillance Unit’s active reporting scheme for rare disorders of childhood, or direct to the NCRSP. I thank the British Paediatric Surveillance Unit and particularly to paediatricians and all other colleagues who have provided data to the NCRSP. The Public Health Laboratory Service pays for the inclusion of congenital rubella on the BPSU’s orange card.
Pat Tookey National Congenital Rubella Surveillance Programme, Institute of Child Health, London WC1N 1EH, UK (e-mail: [email protected]) 1
2 3
4
5
Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002; 359: 674–75. Abortion Statistics 2000: series AB No 27. London: Stationery Office, 2001. Tookey PA, Peckham CS. Surveillance of congenital rubella in Great Britain, 1971–96. BMJ 1999; 318: 769–70. Tookey P, Molyneaux P, Helms P. UK case of congenital rubella can be linked to Greek cases. BMJ 2000; 321: 766–67. PHLS. COVER programme: October to December 2001—vaccination coverage statistics for children up to five years of age
THE LANCET • Vol 360 • September 7, 2002 • www.thelancet.com
in the United Kingdom. http://www.phls.co.uk/publications/CDR %20Weekly/pages/immunisation.html (accessed April 12, 2002).
Sir—We agree with Sheridan and colleagues’ conclusion1 that, despite the success of the UK rubella immunisation programme, congenital rubella syndrome may re-emerge, and that targeted immunisation is required for groups with higher susceptibility rates. They report a rubella susceptibility rate of 6% among Asian women from east London, but our data suggest that the situation in south London may be even worse. After we noticed an unusually high number of rubella-susceptible women from Sri Lanka in 1998, we undertook an audit of rubella susceptibility in pregnant women receiving antenatal care at St George’s Hospital, London, in that year. The overall susceptibility rate was 111 (3%) per 3500, but we noted large variations by country of birth. Of the 142 Sri Lankan women, 23 (16%) of 142 were susceptible compared with 16 (8%) of 195 and 24 (9%) of 276 South Asian and African women, respectively. Only 1% of women born in the UK were susceptible. In a review of the obstetric records for these women, two-thirds from countries without rubella vaccination programmes had already made a total of 85 contacts with obstetric and gynaecology services in the UK before becoming pregnant and testing rubella susceptible in 1998. Moreover, 17% of susceptible Sri Lankan women had previously had terminations done in the UK, yet were not tested for rubella before the procedure. The Sri Lankan women in particular were further disadvantaged by language difficulties, registering with over-worked, singlehanded family physicians more commonly than women of other ethnic origins, and by failures in postpartum immunisation. Despite rubella susceptibility being indicated by laboratory testing, only 85% of women were immunised after birth. The main reason for not being immunised was incorrect recording of rubella status as immune in the notes. With falling rates of MMR uptake in infants and an increase in migration to the UK from resource-poor countries, we are still failing these women in not adhering to the Department of Health’s recommendation that every effort should be made to identify and immunise seronegative women.2 If we are to avoid the re-emergence of congenital rubella syndrome, accurate data on local and national rubella
803
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
susceptibility rates among different groups are needed. Ruby Devi, David Muir, *Philip Rice
2
Department of Medical Microbiology, St George’s Hospital, London SW17 0QT, UK (e-mail: [email protected]) 1
2
Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002; 359: 674–75. Salisbury DM, Begg NT, eds. Immunisation against infectious disease. London: HM Stationery Office, 1996.
3
4
5
Sir—The issue of potential high susceptibility to rubella in women of childbearing age and consequent high risk of congenital rubella syndrome, as highlighted by E Sheridan and colleagues,1 is not limited to immigrants and visitors from parts of the world without vaccination programmes. Such women from countries with poorly implemented rubella immunisation programmes may be at an even higher risk. The presence of a universal childhood rubella vaccination programme will increase susceptibility in women of childbearing age unless coverage exceeds the prevaccination level of immunity. This level varies from country to country, but is frequently 75–90%.2 In practice, infant coverage must be high, combined with effective targeted programmes, to avoid any risks. There are suboptimum rubella immunisation programmes in developing and developed countries, including some in western Europe. High levels of seronegativity to rubella among women aged 15–19 years are reported in France (12%), Italy (10%), and Germany (8%), compared with only 1–3% in the UK, Netherlands, and Finland.3 These high susceptibility levels may raise the risk of congenital rubella syndrome. In Greece, coverage of the infant immunisation programme started in the 1970s was suboptimum. Consequently, major rubella epidemics affected women of childbearing age in 1993, which led to the largest number of cases of congenital rubella syndrome ever reported in the country.4 A further epidemic in Greece occurred in 1998, and affected other European countries, including the UK. One infant with congenital rubella syndrome was linked to these outbreaks.5 Thus great care should be taken before and after embarking on childhood rubella vaccination. *A Nardone, N J Gay, W J Edmunds Immunisation Division, PHLS Communicable Disease Surveillance Centre, London NW9 5EQ, UK (e-mail: [email protected]) 1
Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella
804
syndrome: a risk in immigrant populations. Lancet 2002; 359: 674–75. Edmunds WJ, Gay NJ, Kretzschmar M, Pebody RG, Wachmann H. The prevaccination epidemiology of measles, mumps and rubella in Europe: implications for modelling studies. Epidemiol Infect 2001 125: 635–50. Pebody RG, Edmunds WJ, Conyn M, et al. The seroepidemiology of rubella in Western Europe. Epidemiol Infect 2000; 125: 347–57. Panagiotopoulos T, Antoniadou I, Valassi-Adam E. Increase in congenital rubella occurrence after immunisation in Greece: retrospective survey and systematic review. BMJ 1999; 319: 1462–67. Tookey P, Molyneaux P, Helms P. UK case of congenital rubella can be linked to Greek cases. BMJ 2000; 321: 766–67.
Diabetes prevalence and projections in South Asia Sir—In your March 9 news item1 on cardiovascular disease in South Asia, you note diabetes mellitus as a risk factor. We have assessed prevalence and case-load projections for type 2 diabetes for the next 25 years in the South Asian Association for Regional Cooperation (SAARC) countries.2 Individual country projections are derived from a 1998 publication on global burden of diabetes, 1995–2025, developed by WHO, the Prudential Center for Health Care Research, and the University of Michigan.3 The type 2 diabetes pandemic is fuelled by globalisation, rural-to-urban shifts, and dietary and physical activity changes.2,3 Since type 2 diabetes mostly starts in adulthood, the trend is compounded by demographic ageing; even if rates were stable, demography alone would increase case load. By 2025, more than 80% of people with type 2 diabetes (>240 million) will live in developing countries. The top three countries in 1995 and 2025 are: India, China, and the USA, but, in this time, Pakistan moves from eighth to fourth position. For the five SAARC countries with population-based surveys (Bangladesh, India, Nepal, Pakistan, and Sri Lanka) rates are all higher than the WHO value
for developing countries (3·5%) in 2000 (table). The Nepal data are preliminary survey results (D L Singh, M D Bhattaria, personal communication). No data are available for Bhutan and the Maldives, but the small populations imply little impact on overall SAARC estimates. In 2000, the adult SAARC population (age ⭓20 years) included 33 million people with type 2 diabetes, which will rise to 77 million by 2025. This number is, however, underestimated because population data are unavailable for younger people. Around 80% of cases now and in 2025 are in people aged 20–64 years. Pakistan, with an adult prevalence of 10·6%, and India, with an urban adult prevalence of 12·1%, are among the top ten countries for rates and case load. However, India’s rate, because of its large population, yields the largest case load. In addition, Indians and Pakistanis have a high prevalence of impaired glucose tolerance (10–14%) such that incidence rates for diabetes will increase over the next decade. In SAARC populations there is generally a male preponderance for type 2 diabetes, that compares with a malefemale ratio of 1:1 in developing countries as a whole, and contrasts with developed countries, where type 2 diabetes is 1·5 times more common in women than in men. We purport that this sex difference reflects mainly underlying transitional biosocial factors; in urban India a significant difference is no longer seen.4 Since diabetes complications have high health-care costs, waiting for the pandemic to run its course is unsatisfactory. South Asian countries cannot afford the increasing burden of chronic renal failure and blindness. The large poor population has lower prevalence rates than the rich, but have higher rates of complications because of later diagnosis, inaction on risk factors, and poor management.5 SAARC countries must increase health promotion, and primary and secondary prevention while the pandemic is still in an early phase. *Franklin White, Ghazala Rafique
Prevalence of Male/female type 2 diabetes (%) rate ratio
Country Bangladesh India Nepal* Pakistan Sri Lanka
Urban
Rural
7·9% 12·1% 14·1% 10·8% –5·0
3·8% 2·9% 2·9% 6·5% –2·0
1·15 1·05 1·31 1·32 2·13
*Preliminary results. No data available from Bhutan and Maldives.
Type 2 diabetes prevalence in SAARC countries
Community Health Sciences, Aga Khan University, PO Box 3500, Karachi 74800, Pakistan (e-mail: [email protected]) 1
2
Srivastava R. South Asia’s governments exhorted to focus on CVD. Lancet 2002; 359: 858. White F, Rafique G. Diabetes prevalence and projections in South Asia: an emerging public health priority for the 21st century. Selected proceedings of the 9th International Congress of the World Federation of Public Health Associations, Sept 2–6, 2000, Beijing, China. Washington: APHA, 2001: 118–20.
THE LANCET • Vol 360 • September 7, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.