Charles Parry

THE RELATION BETWEEN DIFFERENT DIMENSIONS OF ALCOHOL CONSUMPTION AND BURDEN OF DISEASE - AN OVERVIEW

AIMS As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease. METHODS Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses. RESULTS Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden. CONCLUSIONS Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

The association between alcohol use, alcohol use disorders and tuberculosis (TB). A systematic review.

BackgroundIn 2004, tuberculosis (TB) was responsible for 2.5% of global mortality (among men 3.1%; among women 1.8%) and 2.2% of global burden of disease (men 2.7%; women 1.7%). The present work portrays accumulated evidence on the association between alcohol consumption and TB with the aim to clarify the nature of the relationship.MethodsA systematic review of existing scientific data on the association between alcohol consumption and TB, and on studies relevant for clarification of causality was undertaken.ResultsThere is a strong association between heavy alcohol use/alcohol use disorders (AUD) and TB. A meta-analysis on the risk of TB for these factors yielded a pooled relative risk of 2.94 (95% CI: 1.89-4.59). Numerous studies show pathogenic impact of alcohol on the immune system causing susceptibility to TB among heavy drinkers. In addition, there are potential social pathways linking AUD and TB. Heavy alcohol use strongly influences both the incidence and the outcome of the disease and was found to be linked to altered pharmacokinetics of medicines used in treatment of TB, social marginalization and drift, higher rate of re-infection, higher rate of treatment defaults and development of drug-resistant forms of TB. Based on the available data, about 10% of the TB cases globally were estimated to be attributable to alcohol.ConclusionThe epidemiological and other evidence presented indicates that heavy alcohol use/AUD constitute a risk factor for incidence and re-infection of TB. Consequences for prevention and clinical interventions are discussed.

Substance Use, Sexual Risk, and Violence: HIV Prevention Intervention with Sex Workers in Pretoria

This paper describes an HIV prevention intervention designed in the US that was adapted and implemented in South Africa. Using an experimental design, 93 women who reported recent substance use and sex trading were randomly assigned to a modified Standard HIV intervention or to a Woman-Focused HIV prevention intervention. Eighty women completed the one-month follow-up interview. Participants reported high rates of sexual risk and violence at baseline. At follow-up, findings showed decreases in the proportion of women reporting unprotected sex and the daily use of alcohol and cocaine. Daily alcohol and cocaine use decreased more for women receiving the Woman-Focused intervention. Although violence continued to be a problem, at follow-up Woman-Focused participants reported being victimized less often than women receiving the Standard intervention. This study demonstrates the feasibility of implementing cross-cultural behavioral HIV prevention interventions, and supports the need for future studies of womens contextual issues and the effectiveness of targeted interventions.

Alcohol consumption and non-communicable diseases: Epidemiology and policy implications

AIMS This paper summarizes the relationships between different patterns of alcohol consumption and various on non-communicable disease (NCD) outcomes and estimates the percentage of NCD burden that is attributable to alcohol. METHODS A narrative review, based on published meta-analyses of alcohol consumption-disease relations, together with an examination of the Comparative Risk Assessment estimates applied to the latest available revision of Global Burden of Disease study. RESULTS Alcohol is causally linked (to varying degrees) to eight different cancers, with the risk increasing with the volume consumed. Similarly, alcohol use is related detrimentally to many cardiovascular outcomes, including hypertension, haemorrhagic stroke and atrial fibrillation. For other cardiovascular outcomes the relationship is more complex. Alcohol is furthermore linked to various forms of liver disease (particularly with fatty liver, alcoholic hepatitis and cirrhosis) and pancreatitis. For diabetes the relationship is also complex. Conservatively, of the global NCD-related burden of deaths, net years of life lost (YLL) and net disability adjusted life years (DALYs), 3.4%, 5.0% and 2.4%, respectively, can be attributed to alcohol consumption, with the burden being particularly high for cancer and liver cirrhosis. This burden is especially pronounced in countries of the former Soviet Union. CONCLUSIONS There is a strong link between alcohol and non-communicable diseases, particularly cancer, cardiovascular disease, liver disease, pancreatitis and diabetes, and these findings support calls by the World Health Organization to implement evidence-based strategies to reduce harmful use of alcohol.

APPROACHING THE PREVALENCE OF THE FULL SPECTRUM OF FETAL ALCOHOL SPECTRUM DISORDERS IN A SOUTH AFRICAN POPULATION-BASED STUDY

BACKGROUND The prevalence and characteristics of fetal alcohol spectrum disorders (FASD) were determined in this fourth study of first-grade children in a South African community. METHODS Active case ascertainment methods were employed among 747 first-grade pupils. The detailed characteristics of children within the continuum of FASD are contrasted with randomly selected, normal controls on (i) physical growth and dysmorphology; (ii) cognitive/behavioral characteristics; and (iii) maternal risk factors. RESULTS The rates of specific diagnoses within the FASD spectrum continue to be among the highest reported in any community in the world. The prevalence (per 1,000) is as follows: fetal alcohol syndrome (FAS)-59.3 to 91.0; partial fetal alcohol syndrome (PFAS)-45.3 to 69.6; and alcohol-related neurodevelopmental disorder (ARND)-30.5 to 46.8. The overall rate of FASD is therefore 135.1 to 207.5 per 1,000 (or 13.6 to 20.9%). Clinical profiles of the physical and cognitive/behavioral traits of children with a specific FASD diagnosis and controls are provided for understanding the full spectrum of FASD in a community. The spectral effect is evident in the characteristics of the diagnostic groups and summarized by the total (mean) dysmorphology scores of the children: FAS = 18.9; PFAS = 14.3; ARND = 12.2; and normal controls, alcohol exposed = 8.2 and unexposed = 7.1. Documented drinking during pregnancy is significantly correlated with verbal (r = -0.253) and nonverbal ability (r = -0.265), negative behaviors (r = 0.203), and total dysmorphology score (r = 0.431). Other measures of drinking during pregnancy are significantly associated with FASD, including binge drinking as low as 3 drinks per episode on 2 days of the week. CONCLUSIONS High rates of specific diagnoses within FASD were well documented in this new cohort of children. FASD persists in this community. The data reflect an increased ability to provide accurate and discriminating diagnoses throughout the continuum of FASD.

The 3‐Metros Study of Drugs and Crime in South Africa: Findings and Policy Implications

This study examined the drug–crime nexus by investigating the prevalence of recent drug use among persons arrested by the police. Data were gathered during August/September 2000 from 1050 adult arrestees in eight police stations in Cape Town, Durban, and Johannesburg (South Africa). Measures included urinalysis results for cannabis, methaqualone (Mandrax), opiates, cocaine, amphetamines, and benzodizepines, and a questionnaire designed to assess socioeconomic and demographic backgrounds of arrestees, history of prior arrests and imprisonment, current arrest information, profile of substance use, etc. Results of the study show high levels of drug use among arrestees, with 45% testing positive for at least one drug (mainly cannabis and Mandrax). A greater proportion of arrestees in Cape Town tested positive for drugs than in the other sites. Data were also analyzed in terms of gender, age, race, location (site and police station), and offense category. Persons arrested on charges of housebreaking or for drugs/alcohol offenses were particularly likely to test positive for drugs. Drug positive arrestees were more likely to have had a prior arrest. Among the conclusions of the study are that 1) strategies to reduce drug use and drug related crime must be area specific, 2) particular attention needs to focus on young offenders, 3) police need to be trained to recognize particular symptoms and to establish protocols on handling arrestees under the influence of drugs, and 4) diversion to treatment of drug using offenders deserves more consideration.

Seasonal variation of suicide in South Africa

Seasonal trends in South African suicide incidence were investigated with a view to ascertaining whether they are consistent with those in the northern hemisphere regarding: (1) the existence of the expected pattern; (2) this pattern being more pronounced for less urbanized groups; and (3) the presence of a secondary fall peak for youth and females. Log-linear modelling was performed to investigate the effect of month and relevant demographic variables on the suicide counts. The 16,389 nationally registered suicide deaths during 1980-1989 were analysed. The expected pattern, with a peak in the spring (that is, in September/October) or summer and a trough in winter, was present. This pattern was more pronounced for a sub-group that is less urbanized and for another sub-group with a relatively low standard of living. The secondary peak in autumn was not present for youth or females. In the northern hemisphere, this secondary peak has been ascribed to sociodemographic factors associated with the commencement of the academic year and (for females) bioclimatic factors associated with gender-specific biological circannual rhythms. The fact that the academic year commences in summer in South Africa indicates that the present findings are consistent with the former explanation.

Rapid assessment of drug-related HIV risk among men who have sex with men in three South African cities

The current assessment was undertaken to examine the link between drug use and sexual risk behavior among men who have sex with men (MSM) in locations known to have high prevalence rates of drug use and sexual risk behavior in Cape Town, Durban and Pretoria, South Africa. Street intercepts and purposive snowball sampling were used to recruit drug-using MSM. A rapid assessment was undertaken which included observation, mapping, key informant interviews and focus group interviews with MSM. Drug using key informants were tested for HIV. The use of drugs like crack cocaine, cannabis and methamphetamine to specifically facilitate sexual encounters was evident. Drugs led to inconsistent condom use and other high-risk sexual activities despite HIV risk knowledge being high. Many injecting drug-using MSM shared needles and reused equipment. Among MSM who agreed to HIV testing, one-third tested positive. Views about drug and HIV treatment and preventive services and their efficacy were mixed. Various barriers to accessing services were highlighted including homosexual stigmatization and availability of drugs in treatment facilities. Recommendations include addressing the gap between HIV-risk knowledge and practice, extending VCT services for MSM, increasing the visibility of drug abuse services within communities, addressing concerns about drug availability in treatment centers as well as reintegration issues and the need for after-care services, reducing stigmatization in drug and HIV services for MSM and finally, strengthening the link between drug treatment services and HIV prevention by integrating HIV/drug-related risks into HIV prevention efforts and HIV risks into drug use prevention efforts.

Alcohol, cannabis, and methamphetamine use and other risk behaviours among Black and Coloured South African women: A small randomized trial in the Western Cape

BACKGROUND There is a pressing need for brief behavioural interventions to address the intersection of high HIV prevalence, increasing substance use, and high-risk sex practices among South African women. The primary aim of this pilot, randomized trial was to examine whether an adapted evidence-based intervention would be equally, more, or less effective at reducing HIV risk behaviours when delivered using an individual or group format. The secondary aim was to examine differences between Black and Coloured South African women across pre- and post-intervention measures of alcohol and illicit drug use and sex risk behaviours. METHODS The Cape Town Womens Health CoOp was adapted from an evidence-based intervention known as the Womens CoOp. Study participants included Black (n=60) and Coloured (n=52) women living in the township communities of Cape Town, South Africa, who reported using illicit drugs and alcohol. RESULTS Coloured women reported greater methamphetamine use (13 days in the past 30 days) and Black women reported mostly cannabis use (27 days in the past 30 days). Although both groups reported having unprotected sex under the influence of alcohol and/or other drugs, Black women reported greater condom use and having one partner; Coloured women reported having more than one sex partner. One-month post-intervention assessments indicated significant reductions in substance use and sex risk behaviours. After controlling for baseline measures, there were no significant differences between the two intervention conditions. CONCLUSION Significant differences in risk behaviours were observed between Black and Coloured South African women. However, both ethnic groups were responsive to the adapted intervention and no differences were found by intervention assignment. These findings support the assertion that group interventions may be more cost-effective in reaching at-risk women in resource-scarce environments. Larger studies are needed to show efficacy and effectiveness of woman-focused group prevention interventions.

Maternal alcohol consumption producing fetal alcohol spectrum disorders (FASD): Quantity, frequency, and timing of drinking

BACKGROUND Concise, accurate measures of maternal prenatal alcohol use are needed to better understand fetal alcohol spectrum disorders (FASD). METHODS Measures of drinking by mothers of children with specific FASD diagnoses and mothers of randomly-selected controls are compared and also correlated with physical and cognitive/behavioral outcomes. RESULTS Measures of maternal alcohol use can differentiate maternal drinking associated with FASD from that of controls and some from mothers of alcohol-exposed normals. Six variables that combine quantity and frequency concepts distinguish mothers of FASD children from normal controls. Alcohol use variables, when applied to each trimester and three months prior to pregnancy, provide insight on critical timing of exposure as well. Measures of drinking, especially bingeing, correlate significantly with increased child dysmorphology and negative cognitive/behavioral outcomes in children, especially low non-verbal IQ, poor attention, and behavioral problems. Logistic regression links (p<.001) first trimester drinking (vs. no drinking) with FASD, elevating FASD likelihood 12 times; first and second trimester drinking increases FASD outcomes 61 times; and drinking in all trimesters 65 times. Conversely, a similar regression (p=.008) indicates that drinking only in the first trimester makes the birth of a child with an FASD 5 times less likely than drinking in all trimesters. CONCLUSIONS There is significant variation in alcohol consumption both within and between diagnostic groupings of mothers bearing children diagnosed within the FASD continuum. Drinking measures are empirically identified and correlated with specific child outcomes. Alcohol use, especially heavy use, should be avoided throughout pregnancy.