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The greatest threat to women's health
CORRESPONDENCE
Moreover, in Asian countries, education about the relation between smoking and health still has a valuable effect on morbidity. A worldwide approach and a regional approach will be needed to reduce the burden of the disease and increase health status in both Asian and European countries.5 This study was supported by research grants from the Japanese Ministry of Health and Welfare and the Japan Arteriosclerosis Prevention Fund.
*Shinji Teramoto, Hiroshi Yamamoto, Yasuhiro Yamaguchi, Takeshi Matsuse, Yasuyoshi Ouchi *Department of Geriatric Medicine, Tokyo University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan (ST, HY, YY, YO); Department of Pulmonary Medicine, Yokohama City University, Yokohama, Japan (TM) (e-mail: [email protected]) 1
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Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet 2003; 362: 1053–61. Zhang H, Cai B. The impact of tobacco on lung health in China. Respirology 2003; 8: 17–21. Fukuchi Y, Nishimura M, Ichinose M, et al. Prevalence of chronic obstructive pulmonary disease in Japan: results from the NIPPON COPD epidemiology (NICE) study. Eur Respir J 2001; 18: 275s. Trupin L, Earnest G, San Pedro M, et al. The occupational burden of chronic obstructive pulmonary disease. Eur Respir J 2003; 22: 462–69. Teramoto S, Fukuchi Y. Bullous emphysema. Curr Opin Pulm Med 1996; 2: 90–96.
The greatest threat to women’s health Sir—Your Oct 11 Editorial1 fuels the hype surrounding heart disease in women. The reason that four in five women have not discussed heart disease is that it is not important to them—nor should it be! Cause of death and other cumulative lifetime incidence statistics are quite misleading and have long been used by lobbyists to improve funding for cardiovascular disease. The greatest threat to women’s health worldwide is poor social standing. We made this point in our paper in the 1997 Lancet supplement on women’s health.2 This paper generated no correspondence and no discussion. I urge your readers to re-examine this perspective. Jonathan Silberberg Stationmaster’s Cottage, 92 Scott Street, Newcastle, New South Wales 2300, Australia (e-mail: [email protected]) 1 2
The Lancet. The greatest threat to women’s health. Lancet 2003; 362: 1165. Newnham H, Silberberg J. Women’s hearts are hard to break. Lancet 1997; 349 (suppl): sI3–sI6.
High-titre measles vaccine and female mortality Sir—In their Commentary (June 28, p 2169),1 F Cutts and P Fine suggest that the difference in mortality noted by us2 between girls and boys who received a high-titre measles vaccine (HTMV) could be a result of chance. First, Cutts and Fine suggest that the increased female-to-male mortality ratio could be due to unexpectedly low mortality among boys vaccinated with DTP-IPV (diphtheria-tetanuspertussis and inactivated poliovirus; 2·9% vs 5·0% for those not vaccinated). We suggest that the more conscientious mothers, who generally have healthier children, took their infants to the 10-month vaccination session where they received DTP-IPV; attending children were also examined and given malaria prophylaxis for 2 months.3 Those who attended would, hence, be expected to have lower mortality rates, as seen for boys. From this perspective, we cannot explain why mortality was slightly higher for girls who attended the 10month session and received DTP-IPV than for those who did not (5·2% vs 4·5%, respectively). The three trials we assessed were designed to compare HTMV with standard-titre measles vaccine (STMV). Results of a meta-analysis4 had suggested that girls were more likely to die than boys after vaccination with HTMV and more likely to die than girls vaccinated with STMV. These findings we tried to explain with the new analysis, emphasising the role of DTP-IPV.2 This finding was confirmed by our results.2 Though it might be interesting that boys who received HTMV plus DTP-IPV had slightly lower mortality rates than girls, the main problem was increased female mortality rather than reduced male mortality. Second, Cutts and Fine suggest that none of our hypotheses explain the delay in raised female mortality, which only arose 2–3 years after the original vaccinations.4 Compared with girls given STMV,3 those who received HTMV had higher mortality immediately after the DTP-IPV vaccination (mortality rate age 10–23 months 2·08 [1·05–4·13] and age 2–3 years 2·43 [1·05–5·60]; unpublished data available on request). However, boys who received HTMV could have benefited initially from the DTP-IPV combination (0·76 [0·41-1·41]). This effect waned, and by age 2–3 years, the boys had a mortality rate of 1·37 (0·67–2·82).
THE LANCET • Vol 362 • November 22, 2003 • www.thelancet.com
Hence, in Senegal, the combined result for both sexes indicated that HTMV excess mortality was seen most strongly at age 2–3 years (1·78 [1·04–3·07]). The pattern was similar in Guinea-Bissau. Hence, consistent with our hypothesis,2 there is no delay in DTP-IPV being associated with increased mortality among girls vaccinated with HTMV. Third, the commentators suggest that the observed patterns in the HTMV trials were unexpected and of only borderline statistical importance, and hence could have been due to chance.1 Borderline significance was the result of combining the effects of HTMV in boys and girls. The hightitre trials displayed a significant vaccine-sex interaction4 and the mortality rate ratio of 1·86 (1·28–2·70) for girls was hardly borderline. Similar sex-specific tendencies have been reproduced in other studies as reviewed elsewhere.2,5 The previous hypotheses did not explain several other contradictions, including why girls vaccinated with HTMV had higher mortality than boys and why the results of some studies showed no negative effect of HTMV.5 By emphasising the potentially negative effect of DTP-IPV in girls and by suggesting that HTMV was not harmful, our hypothesis is consistent with the original studies and these additional contradictions.5 Hence, the new hypothesis has created increasing consistency in existing data, which suggest that causal processes might be involved. This consistency across different studies should reduce the likelihood of chance as an explanation. *Peter Aaby, Henrik Jensen, Hilton Whittle *Projecto de Saúde de Bandim, Danish Epidemiology Science Centre, Apartado 861, Bissau, Guinea-Bissau (PA, HJ); UR 24 Epidemiology and Prevention Research Unit, IRD, Dakar, Senegal (PA); MRC Laboratories, Banjul, The Gambia (HW) (e-mail: [email protected]) 1 2
3
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5
Cutts FT, Fine PEM. Caution—mortality ratios ahead. Lancet 2003; 361: 2169–70. Aaby P, Jensen H, Samb B, et al. Differences in female-male mortality after high-titre measles vaccine and association with subsequent vaccination with diphtheria-tetanus-pertussis and inactivated poliovirus: reanalysis of the West African studies. Lancet 2003; 361: 2183–88. Aaby P, Samb B, Simondon F, et al. Sex specific mortality after high titre measles vaccines in rural Senegal. Bull World Health Organ 1994; 72: 761–70. Knudsen KM, Aaby P, Whittle H, et al. Child mortality following standard, medium and high titre measles vaccination in West Africa. Int J Epidemiol 1996; 25: 665–73. Aaby P, Jensen H, Simondon F, Whittle H. High-titre measles vaccination before 9 months of age and increased female mortality: do we have an explanation? Semin Pediatr Infect Dis 2003; 14: 220–32.
1765
For personal use. Only reproduce with permission from The Lancet publishing Group.
Moreover, in Asian countries, education about the relation between smoking and health still has a valuable effect on morbidity. A worldwide approach and a regional approach will be needed to reduce the burden of the disease and increase health status in both Asian and European countries.5 This study was supported by research grants from the Japanese Ministry of Health and Welfare and the Japan Arteriosclerosis Prevention Fund.
*Shinji Teramoto, Hiroshi Yamamoto, Yasuhiro Yamaguchi, Takeshi Matsuse, Yasuyoshi Ouchi *Department of Geriatric Medicine, Tokyo University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan (ST, HY, YY, YO); Department of Pulmonary Medicine, Yokohama City University, Yokohama, Japan (TM) (e-mail: [email protected]) 1
2
3
4
5
Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet 2003; 362: 1053–61. Zhang H, Cai B. The impact of tobacco on lung health in China. Respirology 2003; 8: 17–21. Fukuchi Y, Nishimura M, Ichinose M, et al. Prevalence of chronic obstructive pulmonary disease in Japan: results from the NIPPON COPD epidemiology (NICE) study. Eur Respir J 2001; 18: 275s. Trupin L, Earnest G, San Pedro M, et al. The occupational burden of chronic obstructive pulmonary disease. Eur Respir J 2003; 22: 462–69. Teramoto S, Fukuchi Y. Bullous emphysema. Curr Opin Pulm Med 1996; 2: 90–96.
The greatest threat to women’s health Sir—Your Oct 11 Editorial1 fuels the hype surrounding heart disease in women. The reason that four in five women have not discussed heart disease is that it is not important to them—nor should it be! Cause of death and other cumulative lifetime incidence statistics are quite misleading and have long been used by lobbyists to improve funding for cardiovascular disease. The greatest threat to women’s health worldwide is poor social standing. We made this point in our paper in the 1997 Lancet supplement on women’s health.2 This paper generated no correspondence and no discussion. I urge your readers to re-examine this perspective. Jonathan Silberberg Stationmaster’s Cottage, 92 Scott Street, Newcastle, New South Wales 2300, Australia (e-mail: [email protected]) 1 2
The Lancet. The greatest threat to women’s health. Lancet 2003; 362: 1165. Newnham H, Silberberg J. Women’s hearts are hard to break. Lancet 1997; 349 (suppl): sI3–sI6.
High-titre measles vaccine and female mortality Sir—In their Commentary (June 28, p 2169),1 F Cutts and P Fine suggest that the difference in mortality noted by us2 between girls and boys who received a high-titre measles vaccine (HTMV) could be a result of chance. First, Cutts and Fine suggest that the increased female-to-male mortality ratio could be due to unexpectedly low mortality among boys vaccinated with DTP-IPV (diphtheria-tetanuspertussis and inactivated poliovirus; 2·9% vs 5·0% for those not vaccinated). We suggest that the more conscientious mothers, who generally have healthier children, took their infants to the 10-month vaccination session where they received DTP-IPV; attending children were also examined and given malaria prophylaxis for 2 months.3 Those who attended would, hence, be expected to have lower mortality rates, as seen for boys. From this perspective, we cannot explain why mortality was slightly higher for girls who attended the 10month session and received DTP-IPV than for those who did not (5·2% vs 4·5%, respectively). The three trials we assessed were designed to compare HTMV with standard-titre measles vaccine (STMV). Results of a meta-analysis4 had suggested that girls were more likely to die than boys after vaccination with HTMV and more likely to die than girls vaccinated with STMV. These findings we tried to explain with the new analysis, emphasising the role of DTP-IPV.2 This finding was confirmed by our results.2 Though it might be interesting that boys who received HTMV plus DTP-IPV had slightly lower mortality rates than girls, the main problem was increased female mortality rather than reduced male mortality. Second, Cutts and Fine suggest that none of our hypotheses explain the delay in raised female mortality, which only arose 2–3 years after the original vaccinations.4 Compared with girls given STMV,3 those who received HTMV had higher mortality immediately after the DTP-IPV vaccination (mortality rate age 10–23 months 2·08 [1·05–4·13] and age 2–3 years 2·43 [1·05–5·60]; unpublished data available on request). However, boys who received HTMV could have benefited initially from the DTP-IPV combination (0·76 [0·41-1·41]). This effect waned, and by age 2–3 years, the boys had a mortality rate of 1·37 (0·67–2·82).
THE LANCET • Vol 362 • November 22, 2003 • www.thelancet.com
Hence, in Senegal, the combined result for both sexes indicated that HTMV excess mortality was seen most strongly at age 2–3 years (1·78 [1·04–3·07]). The pattern was similar in Guinea-Bissau. Hence, consistent with our hypothesis,2 there is no delay in DTP-IPV being associated with increased mortality among girls vaccinated with HTMV. Third, the commentators suggest that the observed patterns in the HTMV trials were unexpected and of only borderline statistical importance, and hence could have been due to chance.1 Borderline significance was the result of combining the effects of HTMV in boys and girls. The hightitre trials displayed a significant vaccine-sex interaction4 and the mortality rate ratio of 1·86 (1·28–2·70) for girls was hardly borderline. Similar sex-specific tendencies have been reproduced in other studies as reviewed elsewhere.2,5 The previous hypotheses did not explain several other contradictions, including why girls vaccinated with HTMV had higher mortality than boys and why the results of some studies showed no negative effect of HTMV.5 By emphasising the potentially negative effect of DTP-IPV in girls and by suggesting that HTMV was not harmful, our hypothesis is consistent with the original studies and these additional contradictions.5 Hence, the new hypothesis has created increasing consistency in existing data, which suggest that causal processes might be involved. This consistency across different studies should reduce the likelihood of chance as an explanation. *Peter Aaby, Henrik Jensen, Hilton Whittle *Projecto de Saúde de Bandim, Danish Epidemiology Science Centre, Apartado 861, Bissau, Guinea-Bissau (PA, HJ); UR 24 Epidemiology and Prevention Research Unit, IRD, Dakar, Senegal (PA); MRC Laboratories, Banjul, The Gambia (HW) (e-mail: [email protected]) 1 2
3
4
5
Cutts FT, Fine PEM. Caution—mortality ratios ahead. Lancet 2003; 361: 2169–70. Aaby P, Jensen H, Samb B, et al. Differences in female-male mortality after high-titre measles vaccine and association with subsequent vaccination with diphtheria-tetanus-pertussis and inactivated poliovirus: reanalysis of the West African studies. Lancet 2003; 361: 2183–88. Aaby P, Samb B, Simondon F, et al. Sex specific mortality after high titre measles vaccines in rural Senegal. Bull World Health Organ 1994; 72: 761–70. Knudsen KM, Aaby P, Whittle H, et al. Child mortality following standard, medium and high titre measles vaccination in West Africa. Int J Epidemiol 1996; 25: 665–73. Aaby P, Jensen H, Simondon F, Whittle H. High-titre measles vaccination before 9 months of age and increased female mortality: do we have an explanation? Semin Pediatr Infect Dis 2003; 14: 220–32.
1765
For personal use. Only reproduce with permission from The Lancet publishing Group.