Bulletin of the World Health Organization最新文献

Objective: To calculate the total life-course expenditure of smokers on cigarettes alone, before or without accounting for any economic losses as a result of smoking-attributable death and disease.

Method: We used data from Global Adult Tobacco Surveys to calculate annual cigarette consumption and expenditure in 15 low- and middle-income countries. We extracted data on average earnings from the ILOSTAT database of the International Labour Organization. We calculated life-course cigarette expenditures using cohort life expectancies and inflation, and converted these expenditures into net present value terms using a 3% social discount rate.

Findings: The average age of adult cigarette smokers in our sample was 40 years, and their average expenditure on cigarettes was equivalent to 7.2% of annual average earnings. Given an average life expectancy of 55 years at the age of 15 years, we estimated an average life-course consumption of 217 752 cigarettes and a full life-course expenditure of 8481 United States dollars (US$) in net present value terms, more than twice the current average annual earnings of workers. However, by quitting, current adult smokers can avoid an average of US$ 6612 in expenditure on cigarettes over their remaining life-course.

Conclusion: The affordability of cigarettes is an important determinant of cigarette use and tax policies can have a large effect on consumers, especially young adults. These costs will only increase over time as governments continue to raise taxes to address the market failures inherent within the tobacco market.

Objective: To develop new methods to analyse the distributions of diarrhoea, pneumonia and measles deaths in children younger than 5 years across wealth quintiles.

Methods: We used Demographic and Health Surveys conducted since 2013 from 21 sub-Saharan African countries. We implemented multidimensional optimization techniques to estimate the joint impact of risk factors (that is, stunting, wasting, underweight, vitamin A deficiency and unsafe sanitation), immunization coverage and treatment utilization, on the distribution of deaths from diarrhoea, pneumonia and measles across wealth quintiles in each country. For each country, we created wealth-related gradients to show the risk of dying from either diarrhoea, pneumonia or measles.

Findings: Across all countries and diseases, the risks of dying from diarrhoea, pneumonia and measles decrease with increasing household wealth: children in the wealthiest quintile are at the lowest risk (set to 1), except in a few rare instances. Yet, the magnitudes of these estimated risk gradients varied considerably across diseases and countries, from under 2 to above 10. Wealth-related risks of dying seemed to be unrelated to the countries' levels of under-5 mortality.

Conclusion: We estimate that inequalities in deaths from diarrhoea, pneumonia and measles are large in many countries of sub-Saharan Africa, with more deaths occurring among children in the poorest wealth quintiles compared with the richest. Our new and generalizable methods can help research on health disparities to explore new directions.

Problem: In sub-Saharan Africa, hypertension prevalence is usually estimated from participant recall. We assessed the accuracy of self-reported hypertension in women of reproductive age.

Approach: In PRECISE (PREgnancy Care Integrating translational Science, Everywhere), an observational prospective cohort study, we recruited 1825 non-pregnant women of reproductive age, 610 in the Gambia, 609 in Kenya and 606 in Mozambique. We compared self-reported and measured hypertension (systolic blood pressure ≥ 140mmHg or diastolic blood pressure ≥ 90mmHg). We adjusted hypertension prevalence for age, body mass index, education, parity, and antihypertensive medicine and oral contraceptive use.

Local setting: PRECISE was conducted in both urban and rural hospitals or clinics.

Relevant changes: The women were generally in their late twenties and parous. Adjusted measured hypertension prevalence was higher in Mozambique (10.4%; 95% confidence interval, CI: 7.9-12.7) and the Gambia (9.3%; 95% CI: 6.6-12.6) than in Kenya (4.6%; 95% CI: 3.0-6.6). Self-reported hypertension prevalence was highest in the Gambia (12.9%; 95% CI: 10.2-15.9) versus Mozambique (4.2%; 95% CI: 2.8-5.7) or Kenya (6.7%; 95% CI: 5.0-8.6). Sensitivity of self-reported (versus measured) hypertension was less than 45% in all countries, with specificities more than 89%. Positive likelihood ratios were fair in the Gambia (3.70; 95% CI: 2.47-5.54), and good in Kenya (5.79; 95% CI: 3.36-9.98) and Mozambique (5.18; 95% CI: 2.56-10.46). All negative likelihood ratios were poor (≥ 0.20).

Lessons learnt: Self-reported hypertension is unsuitable for population hypertension estimates among women of reproductive age in these countries.

Objective: To understand why caesarean sections are performed for stillborn babies by investigating caesarean section rates and indications in sub-Saharan African countries and to examine whether fetal vital status at admission is associated with caesarean section.

Methods: The study involved registry data on 105 872 babies weighing 1000 g or more born to women aged 13 to 50 years at 16 hospitals in Benin, Malawi, Uganda and United Republic of Tanzania between 1 July 2021 and 30 June 2023. We assessed caesarean section rates and indications, and used multivariable logistic regression analyses to estimate associations between fetal heartbeat at admission and caesarean section, by birth outcome.

Findings: The caesarean section rate was 28.0% (29 640/105 872) overall, 40.9% (858/2098) for intrapartum stillbirths and 19.0% (322/1694) for antepartum stillbirths. Previous caesarean section was among the top three indications across birth outcomes. Information on fetal heartbeat at admission was unavailable for 24.7% (7312/29 640) of caesarean section births. Multivariable analysis showed that the odds of a caesarean section was significantly higher when fetal heartbeat was not reported compared with the detection of a heartbeat among both antepartum (adjusted odds ratio, aOR: 2.55; 95% confidence interval, CI: 1.53-4.26) and intrapartum (aOR: 2.08; 95% CI: 1.51-2.87) stillbirths.

Conclusion: Unknown fetal heartbeat at admission was associated with a higher odds of caesarean section, possibly due to attempts to provide optimum care given diagnostic uncertainty. Decision-making processes on the mode of birth need to be better understood and feasible fetal monitoring recommendations are required for low-resource settings.

Objective: To estimate the financial and economic costs and the cost-effectiveness of thermal ablation compared to cryotherapy and loop diathermy within a screen-and-treat approach to cervical cancer screening in Zambia.

Methods: We analysed costs within a randomized controlled trial in which women eligible for ablative treatment after cervical cancer screening were assigned to one of three treatment arms: thermal ablation, cryotherapy or loop diathermy. We used a microcosting approach to calculate programme, personnel, equipment and consumable costs for two groups: women treated without follow-up (screened-and-treated) and women who completed follow-up (follow-up-completed). We also estimated trial costs and projected costs if the screen-and-treat approach were to be integrated into routine cervical cancer services. To assess how cost-effective the treatments were, we used a decision tree model.

Findings: Out of the 3124 women who were screened-and-treated, 2386 (76.4%) completed follow-up. In the trial scenario, costs for thermal ablation were lower than cryotherapy and loop diathermy, both per screened-and-treated woman (39.6 United States dollars (US$) versus US$ 42.3 and US$ 50.6, respectively) and per follow-up-completed woman (US$ 55.1 versus US$ 57.9 and US$ 66.2, respectively). In the routine scenario, costs for thermal ablation were also lower than for other treatments (US$ 12.7 versus US$ 15.6 and US$ 34.9, respectively, for screen-and-treat) due to significantly lower personnel costs. Thermal ablation was cost-effective compared to cryotherapy and loop diathermy.

Conclusion: Our study suggests that thermal ablation is a cost-effective option for the screen-and-treat approach to cervical cancer screening compared with cryotherapy and loop diathermy.

Objective: To investigate the associations between national breast cancer screening programmes and breast cancer mortality globally.

Methods: We collected data on breast cancer screening programmes and breast cancer mortality from the World Health Organization's Global Health Observatory, the Global Burden of Diseases 2021 study and the Eurostat database. We assessed differences in breast cancer mortality between countries with regular and irregular screening programmes, adjusting for sociodemographic index. We calculated annual changes in breast cancer mortality from 2015 to 2021 and assessed differences in mortality changes between countries with regular and irregular screening programmes.

Findings: Between 2015 and 2021, 94 of 194 countries reported having national breast cancer screening programmes. In 2021, countries with regular breast cancer screening programmes had 3.74 fewer deaths (95% uncertainty interval, UI: 1.69-5.81) per 100 000 population than countries with irregular screening programmes. This difference was more pronounced in women aged 50-74 years: 10.13 fewer deaths (95% UI: 4.47-15.80) per 100 000. From 2015 to 2021, the age-standardized mortality rate decreased by 1.02% (95% UI: 0.71-1.36) annually in countries with regular breast cancer screening programmes, whereas countries with irregular programmes had an annual increase of 0.45% (95% UI: 0.23-0.69). Higher breast cancer screening coverage rates were associated with lower mortality in the European region.

Conclusion: Countries with breast cancer screening programmes had a significant reduction in breast cancer mortality. Reducing breast cancer mortality globally will require adopting national breast cancer screening programmes and increasing screening coverage, particularly among women aged 50-74 years.