Diarmuid O'Donovan

Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study.

Abstract Objectives To compare exposure to secondhand smoke and respiratory health in bar staff in the Republic of Ireland and Northern Ireland before and after the introduction of legislation for smoke-free workplaces in the Republic. Design Comparisons before and after the legislation in intervention and control regions. Setting Public houses in three areas in the Republic (intervention) and one area in Northern Ireland (control). Participants 329 bar staff enrolled in baseline survey; 249 (76%) followed up one year later. Of these, 158 were non-smokers both at baseline and follow-up. Main outcome measures Salivary cotinine concentration, self reported exposure to secondhand smoke, and respiratory and sensory irritation symptoms. Results In bar staff in the Republic who did not themselves smoke, salivary cotinine concentrations dropped by 80% after the smoke-free law (from median 29.0 nmol/l (95% confidence interval 18.2 to 43.2 nmol/l)) to 5.1 nmol/l (2.8 to 13.1 nmol/l) in contrast with a 20% decline in Northern Ireland over the same period (from median 25.3 nmol/l (10.4 to 59.2 nmol/l) to 20.4 nmol/l (13.2 to 33.8 nmol/l)). Changes in self reported exposure to secondhand smoke were consistent with the changes in cotinine concentrations. Reporting any respiratory symptom declined significantly in the Republic (down 16.7%, −26.1% to −7.3%) but not in Northern Ireland (0% difference, −32.7% to 32.7%). After adjustment for confounding, respiratory symptoms declined significantly more in the Republic than in Northern Ireland and the decline in cotinine concentration was twice as great. Conclusion The smoke-free law in the Republic of Ireland protects non-smoking bar workers from exposure to secondhand smoke.

Maternal plasma viral RNA levels determine marked differences in mother-to-child transmission rates of HIV-1 and HIV-2 in The Gambia.

ObjectivesTo determine the rates of, and risk factors for, mother-to-child transmission (MCT) of HIV-1 and HIV-2 infection in The Gambia. DesignA blinded, prospective, community-based cohort study of 29 549 pregnant women attending the eight largest antenatal clinics in The Gambia. MethodsWomen were tested for HIV-1 and HIV-2 infection. Infected subjects and a group of HIV-seronegative women were followed with their babies until 18 months after delivery. Maternal CD4 cell count percentages were measured before and 18 months after delivery, and the antenatal plasma viral load was determined. Babies were tested for HIV by the polymerase chain reaction and/or serology at 2, 9 and 18 months of age. ResultsThe study enrolled 144 women positive for HIV-1 and 294 for HIV-2 plus 565 seronegative pregnant women: the mean antenatal percentage CD4 cell counts of 96 HIV-1-positive, 223 HIV-2-positive and 125 HIV-seronegative mothers were 31% [95% confidence interval (CI) 28–33], 41% (95% CI 39–42) and 47% (95% CI 45–49), respectively. The geometric mean antenatal plasma viral load of 94 HIV-1-infected women was 15 100 copies×103ml (95% CI 10 400–19 000) which was much higher than that of 60 randomly selected HIV-2-infected women, which was 410 copies×103ml (95% CI 150–910) (P < 0.001). The estimated transmission rate of HIV-1 was 24.4% (95% CI 14.6–33.9) and that of HIV-2 was 4.0% (95% CI 1.9–7.4). Five of 17 HIV-1-positive and three of eight HIV-2-positive babies were infected after 2 months of age. Birth in the rainy season [odds ratio (OR) 2.9; 95% CI 1.2–7.2], a low postnatal CD4 cell percentage (OR for a 10% fall 2.4; 95% CI 1.1–5.1) and a high maternal plasma viral load (OR for a 10-fold increase 2.9; 95% CI 1.1–7.8) were risk factors for transmission that applied equally to both viruses. ConclusionLow maternal HIV-2 RNA levels, which on average are 37-fold less than in HIV-1 infection, relate to the low MCT rate of HIV-2.OBJECTIVES To determine the rates of, and risk factors for, mother-to-child transmission (MCT) of HIV-1 and HIV-2 infection in The Gambia. DESIGN A blinded, prospective, community-based cohort study of 29.549 pregnant women attending the eight largest antenatal clinics in The Gambia. METHODS Women were tested for HIV-1 and HIV-2 infection. Infected subjects and a group of HIV-seronegative women were followed with their babies until 18 months after delivery. Maternal CD4 cell count percentages were measured before and 18 months after delivery, and the antenatal plasma viral load was determined. Babies were tested for HIV by the polymerase chain reaction and/or serology at 2, 9 and 18 months of age. RESULTS The study enrolled 144 women positive for HIV-1 and 294 for HIV-2 plus 565 seronegative pregnant women: the mean antenatal percentage CD4 cell counts of 96 HIV-1-positive, 223 HIV-2-positive and 125 HIV-seronegative mothers were 31% [95% confidence interval (CI) 28-33], 41% (95% CI 39-42) and 47% (95% CI 45-49), respectively. The geometric mean antenatal plasma viral load of 94 HIV-1-infected women was 15,100 copies x 10(3) ml (95% CI 10,400-19,000) which was much higher than that of 60 randomly selected HIV-2-infected women, which was 410 copies x 10(3) ml (95% CI 150-910) (P < 0.001). The estimated transmission rate of HIV-1 was 24.4% (95% CI 14.6-33.9) and that of HIV-2 was 4.0% (95% CI 1.9-7.4). Five of 17 HIV-1-positive and three of eight HIV-2-positive babies were infected after 2 months of age. Birth in the rainy season [odds ratio (OR) 2.9; 95% CI 1.2-7.2], a low postnatal CD4 cell percentage (OR for a 10% fall 2.4; 95% CI 1.1-5.1) and a high maternal plasma viral load (OR for a 10-fold increase 2.9; 95% CI 1.1-7.8) were risk factors for transmission that applied equally to both viruses. CONCLUSION Low maternal HIV-2 RNA levels, which on average are 37-fold less than in HIV-1 infection, relate to the low MCT rate of HIV-2.

Young women's decisions to accept chlamydia screening: influences of stigma and doctor- patient interactions

BackgroundAn understanding of the factors that encourage young women to accept, and discourage them from accepting, STI (sexually transmitted infection) testing is needed to underpin opportunistic screening programs for the STI Chlamydia trachomatis (opportunistic screening involves healthcare professionals offering chlamydia tests to people while they are attending health services for reasons that are usually unrelated to their sexual health). We conducted a qualitative study to identify and explore: how young women would feel about being offered opportunistic tests for chlamydia?; how young women would like to be offered screening, and who they wanted to be offered screening by?; and what factors would influence young womens partner notification preferences for chlamydia (who they would notify in the event of a positive diagnosis of chlamydia, how they would want to do this).MethodsSemi-structured interviews with 35 young women between eighteen and twenty nine years of age. The study was conducted in the Dublin and Galway regions of the Republic of Ireland. Young adults were recruited from General Practice (GP) practices, Third Level College health services, Family Planning clinics and specialist STI treatment services.ResultsRespondents were worried that their identities would become stigmatised if they accepted screening. Younger respondents and those from lower socio-economic backgrounds had the greatest stigma-related concerns. Most respondents indicated that they would accept screening if it was offered to them, however; accepting screening was seen as a correct, responsible action to engage in. Respondents wanted to be offered screening by younger female healthcare professionals. Respondents were willing to inform their current partners about positive chlamydia diagnoses, but were more ambivalent about informing their previous partners.ConclusionsIf an effort is not put into reducing young womens stigma-related concerns the population coverage of Chlamydia screening might be reduced.

Length of stay and associated costs of obesity related hospital admissions in Ireland

BackgroundObesity is the cause of other chronic diseases, psychological problems, obesity shortens the lifespan and puts strain on health systems. The risk associated with childhood obesity in particular, which will accelerate the development of adult morbidity and mortality, has been identified as an emerging public health problem.MethodsTo estimate the length of stay and associated hospital costs for obesity related illnesses a cost of illness study was set up. All discharges from all acute hospitals in the Republic of Ireland from 1997 to 2004 with a principal or secondary diagnostic code for obesity for all children from 6 to 18 years of age and for adults were collected.A discharge frequency was calculated by dividing obesity related discharges by the total number of diagnoses (principal and secondary) for each year. The hospital costs related to obesity was calculated based on the total number of days care.ResultsThe discharge frequency of obesity related conditions increased from 1.14 in 1997 to 1.49 in 2004 for adults and from 0.81 to 1.37 for children. The relative length of stay (number of days in care for obesity related conditions per 1000 days of hospital care given) increased from 1.47 in 1997 to 4.16 in 2004 for children and from 3.68 in 1997 to 6.74 in 2004 for adults.Based on the 2001 figures for cost per inpatient bed day, the annual hospital cost was calculated to be 4.4 Euromillion in 1997, increasing to 13.3 Euromillion in 2004. At a 20% variable hospital cost the cost ranges from 0.9 Euromillion in 1997 to 2.7 Euromillion in 2004; a 200% increase.ConclusionThe annual increase in the proportion of hospital discharges related to obesity is alarming. This increase is related to a significant increase in economic costs. This paper emphasises the need for action at an early stage of life. Health promotion and primary prevention of obesity should be high on the political agenda.

Maternal HIV-1 and HIV-2 infection and child survival in The Gambia.

ObjectiveTo compare the survival of children born to HIV-1 or HIV-2 seropositive mothers with that of children born to HIV-seronegative mothers and to evaluate risk factors for mortality. DesignPhysician-blinded prospective study. MethodsOne hundred and one HIV-1-seropositive, 243 HIV-2-seropositive pregnant women, and 468 HIV-seronegative women (control group) matched by age, parity, and health centre, were followed up in a study of mother-to-child transmission of HIV. Mothers and children were seen at 2 and 6 months of age and subsequently followed at 3-monthly intervals up to 18 months of age. HIV infection in children was diagnosed by polymerase chain reaction at 2, 9 or 18 months and by antibody assays at 18 months. ResultsFifteen per cent of children born to HIV-1-infected mothers died compared with 7% of children born to HIV-2-infected mothers [hazard ratio, 2.3; 95% confidence interval (CI), 1.1–4.7;P = 0.02], and 6% of HIV-seronegative mothers (hazard ratio, 2.6; 95% CI, 1.4–5.0;P = 0.003). Six of the 17 children known to be HIV-1 infected died compared with none among the eight HIV-2-infected children (P = 0.13). High proviral load in the babies, high antenatal maternal RNA plasma viral load, and maternal death increased child mortality significantly. ConclusionsMore children born to HIV-1-infected mothers died in comparison with those born to HIV-2-infected mothers or to mothers from the control group. This effect was due to excess death in HIV-1-infected infants which was associated with a high viral load in the affected mother and child.

Why don't young women go for Chlamydia testing? A qualitative study employing Goffman's stigma framework

Many women who might be at risk of having the sexually transmitted infection (STI) Chlamydia trachomatis either delay going, or do not go, for testing. We aimed to examine the factors that either prevent or discourage Irish young women from going for Chlamydia testing. We conducted in-depth interviews with 35 women in the Republic of Ireland who were between 18 and 29 years of age. Accounts were analysed using Goffmans stigma framework. Study respondents strongly associated Chlamydia and Chlamydia testing with stigma and felt that only irresponsible, promiscuous risk takers were at risk of contracting the infection. Respondents saw themselves as responsible, moral actors who avoided risk and took good care of their bodies; they were therefore not at risk of having Chlamydia. Going for Chlamydia testing was seen as a risky activity that could shift respondents identities into a negative ‘Other’ category. Respondents feared that if they found themselves in this ‘Other’ category they would open themselves to bullying and ostracism. While a negative act from a medical perspective, for respondents the act of not testing was seen as a positive activity that helped to reinforce their identities as good, ‘worthy’ individuals and avoided negative social consequences that might otherwise arise from the testing process.

The cost and cost-effectiveness of opportunistic screening for Chlamydia trachomatis in Ireland

Objective The objective of this study was to estimate the cost and cost-effectiveness of opportunistic screening for Chlamydia trachomatis in Ireland. Methods Prospective cost analysis of an opportunistic screening programme delivered jointly in three types of healthcare facility in Ireland. Incremental cost-effectiveness analysis was performed using an existing dynamic modelling framework to compare screening to a control of no organised screening. A healthcare provider perspective was adopted with respect to costs and included the costs of screening and the costs of complications arising from untreated infection. Two outcome measures were examined: major outcomes averted, comprising cases of pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility in women, neonatal conjunctivitis and pneumonia, and epididymitis in men; and quality-adjusted life-years (QALY) gained. Uncertainty was explored using sensitivity analyses and cost-effectiveness acceptability curves. Results The average cost per component of screening was estimated at €26 per offer, €66 per negative case, €152 per positive case and €74 per partner notified and treated. The modelled screening scenario was projected to be more effective and more costly than the control strategy. The incremental cost per major outcomes averted was €6093, and the incremental cost per QALY gained was €94 717. For cost-effectiveness threshold values of €45 000 per QALY gained and lower, the probability of the screening being cost effective was estimated at <1%. Conclusions An opportunistic chlamydia screening programme, as modelled in this study, would be expensive to implement nationally and is unlikely to be judged cost effective by policy makers in Ireland.

Chlamydia trachomatis infection and sexual behaviour among female students attending higher education in the Republic of Ireland

BackgroundThere are no prevalence data on Chlamydia trachomatis relating to female students attending higher education available for the Republic of Ireland. This information is required to guide on the necessity for Chlamydia screening programmes in higher education settings. This research aimed to determine the prevalence of and predictive risk factors for Chlamydia trachomatis genital infection among female higher education students in Ireland.MethodsAll females presenting during one-day periods at Student Health Units in three higher education institutions in two cities in the Republic of Ireland were invited to participate. Participants completed a questionnaire on lifestyle and socio-demographic factors and provided a urine sample. Samples were tested for C. trachomatis DNA by a PCR based technique (Cobas Amplicor, Roche). To examine possible associations between a positive test and demographic and lifestyle risk factors, a univariate analysis was performed. All associations with a p value < 0.05 were included in a multivariate logistic regression analysis.ResultsOf the 460 sexually active participants 22 tested positive (prevalence 4.8%; 95% CI 3.0 to 7.1%). Variables associated with significantly increased risk were current suggestive symptoms, two or more one-night stands and three or more lifetime sexual partners. The students displayed high-risk sexual behaviour.ConclusionThe prevalence of C. trachomatis infection and the lack of awareness of the significance of suggestive symptoms among sexually experienced female students demonstrate the need for a programme to test asymptomatic or non-presenting higher education students. The risk factors identified by multivariate analysis may be useful in identifying those who are most likely to benefit from screening. Alcohol abuse, condom use, sexual behaviour (at home and abroad) and, knowledge of sexually transmitted infections (STIs) (including asymptomatic nature or relevant symptoms) were identified as target areas for health promotion strategies. These strategies are needed in view of the high-risk sexual activity identified.

Men's attitudes towards chlamydia screening: a narrative review

OBJECTIVES Chlamydia trachomatis is a sexually transmissible infection (STI) that affects significant numbers of men. Research on mens perspectives on chlamydia screening (or testing) has been limited. We conducted a narrative review to examine: (1) what factors encourage or discourage men from attending health services for chlamydia screening, and/or from accepting screening once it has been offered to them, and (2) where men want chlamydia screening services to be located. METHODS A narrative review of the recent peer-reviewed literature (published between 1999 and 2009) on mens attitudes towards chlamydia screening. To be included, articles had to explore mens perspectives on screening (which could be ascertained through quantitative or qualitative studies, or from relevant discussion papers or reviews). RESULTS Forty-eight articles were included in all. Mens attitudes towards chlamydia screening are influenced by their knowledge about the infection, their perceived vulnerability to the infection, the degree of embarrassment and shame that they associate with screening and the stigma that they associate with screening. Men prefer to be offered urine testing for chlamydia. Men want to be offered screening by non-judgemental professionals. Mens attitudes towards screening for chlamydia in general practice, genito-urinary medicine clinics, home and outreach settings are also explored in this review. CONCLUSIONS Several factors influence mens attitudes towards screening. Two central themes underlie and influence many of these factors: mens needs to make positive impressions on others, and mens identification with particular ideals of masculinity. The review concludes with suggestions for future research on this topic.

The farming population in Ireland: mortality trends during the 'Celtic Tiger' years.

BACKGROUND Although the Irish farming population is a significant occupational group, analysis of their mortality patterns is limited. This study compared mortality trends with other occupational groups and assessed the impact of socio-economic factors. METHODS Population and mortality data (2000-06) were obtained to calculate standardized mortality ratios (SMRs) by cause of death and matched with socio-economic data. The extent to which variation in mortality was explained by variations in the socio-economic data was determined using multiple regression. RESULTS Farmers and agricultural workers experienced the highest levels of mortality for all causes of death (2000-06). Farmers are 5.14 times more likely and agricultural workers are 7.35 times more likely to die from any cause of death than the lowest risk group. Circulatory disease is a significant cause of mortality among farmers [SMR = 215.91, 95% confidence interval (CI) = 201.83-229.98]. Other significant causes include cancers (SMR = 156.60, CI = 146.73-166.48) and injuries and poisonings (SMR = 149.69, CI = 135.44-163.93). Agricultural workers have similar mortality trends: circulatory disease (SMR = 226.27; CI = 192.45-260.08), cancers (SMR = 221.44; CI = 193.88-249.00), and injuries and poisonings (SMR = 353.90; CI = 302.48-405.32). From 2000 to 2006, SMRs increased incrementally. Multiple regression identified farm size and income poverty risk as predictors of mortality. CONCLUSION Irish farmers and agricultural workers have experienced a reversal of mortality trends compared to the 1980s and 1990 s. Policies should target them as a high-risk group.