- Email: [email protected]
Congenital rubella: down but not out
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.
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.