Zubair Kabir

ABSTRACT Background Coronary heart disease (CHD) death rates have been falling across most of Europe in recent decades. However, CHD remains the leading cause of mortality. Furthermore, substantial risk factor reductions have been achieved in some European countries, but not in others. This partly reflects rather patchy implementation of the most effective prevention policies. Our study therefore aimed to quantify the potential impact of future policy scenarios (reducing smoking, diet and physical inactivity) on future CHD mortality in diverse countries across Europe. Methods We updated previously validated IMPACT CHD mortality models in nine countries (Czech Republic, Finland, Iceland, Italy, Ireland, Northern Ireland, Poland, Scotland and Sweden). Using recent risk factor data, these models were extended from 2010 (baseline year) to predict potential reductions in CHD mortality to 2020 (in people aged 25–74 years). We then modelled the mortality reductions in each country expected with future policies to decrease cardiovascular risk factors. We compared three alternative policy scenarios: conservative, intermediate and optimistic improvements for smoking prevalence (absolute decreases of 5%, 10% and 15%), dietary saturated fat intake (1%, 2% and 3% decreases in energy, replaced by unsaturated fats), dietary salt (decreases of 10%, 20% and 30%), and physical activity (absolute increases of 5%, 10% and 15%). Probabilistic sensitivity analyses were then conducted. Results Under the conservative, intermediate and optimistic policy scenarios, we estimated approximately 11%, 21% and 29% fewer CHD deaths respectively in 2020 in these countries. Depending on the future mortality trends assumed, this represented between 11,000 and 18,500 fewer CHD deaths for the optimistic scenario. For the conservative scenario, 5% absolute reductions in smoking prevalence could decrease CHD deaths in each country by 2–3% (e.g. approximately 40–80 fewer deaths in Ireland, 460–760 fewer deaths in Poland). Salt intake reductions of 10% could decrease CHD deaths by approximately 1.2–2.5%; and 1% reductions in saturated fat intake might decrease CHD deaths by some 1.5–2.2%. The 5% absolute increases in physical activity levels might decrease CHD deaths by just 0.8–1.4% (approximately 20–40 fewer deaths in Ireland, approximately 220–370 fewer deaths in Poland). These projections remained stable under a wide range of probabilistic sensitivity analyses. Conclusion Modest and feasible policy-based reductions in cardiovascular risk factors (already been achieved in some other countries) could translate into substantial reductions in future CHD deaths across Europe. However, this would require the European Union to more effectively implement powerful evidence-based prevention policies.

To investigate whether population based primary prevention (risk factor reduction in apparently healthy people) might be more powerful than current government initiatives favouring risk factor reduction in patients with coronary heart disease (CHD) (secondary prevention). The IMPACT model was used to synthesise data for England and Wales describing CHD patient numbers, uptake of specific treatments, trends in major cardiovascular risk factors, and the mortality benefits of these specific risk factor changes in healthy people and in CHD patients. Between 1981 and 2000, CHD mortality rates fell by 54%, resulting in 68,230 fewer deaths in 2000. Overall smoking prevalence declined by 35% between 1981 and 2000, resulting in approximately 29,715 (minimum estimate 20 035, maximum estimate 44,675) fewer deaths attributable to smoking cessation: approximately 5035 in known CHD patients and approximately 24,680 in healthy people. Population total cholesterol concentrations fell by 4.2%, resulting in approximately 5770 fewer deaths attributable to dietary changes (1205 in CHD patients and 4565 in healthy people) plus 2135 fewer deaths attributable to statin treatment (1990 in CHD patients, 145 in people without CHD). Mean population blood pressure fell by 7.7%, resulting in approximately 5870 fewer deaths attributable to secular falls in blood pressure (520 in CHD patients and 5345 in healthy people) plus approximately 1890 fewer deaths attributable to antihypertensive treatments in people without CHD. Approximately 45,370 fewer deaths were thus attributable to reductions in the three major risk factors in the population: some 36 625 (81%) in people without recognised CHD and 8745 (19%) in CHD patients. Compared with secondary prevention, primary prevention achieved a fourfold larger reduction in deaths. Future CHD policies should prioritise population-wide tobacco control and healthier diets.

Temporal trends in paediatric encounters for otitis media (OM) were last characterised and observed to be steadily increasing from 1975 to the mid-1990 s. The present study uses an ecological design to quantify trends in paediatric encounters for OM concurrent with a period of decline of an important risk factor, secondhand smoke (SHS) exposure among children. Annual paediatric ambulatory visit and hospital discharge rates for children ≤ 6 years with OM as primary diagnosis were computed with nationally representative data for 1993-2006. Percentages of households with children ≤ 6 years and no-smoking rules were computed using Tobacco Use Supplement to the Current Population Survey data. Average annual percentage changes were determined for covariate-adjusted rates of paediatric encounters for OM using joinpoint analysis. While percentages of homes with children and no-smoking rules increased by 89% from 45.5% in 1993 to 86.1% in 2006, average annual covariate-adjusted paediatric encounters for OM decreased by 4.6% (95% CI 4.5% to 4.8%) for ambulatory visits and by 9.8% (95% CI 9.1% to 10.6%) for hospital discharges. Coverage by 7-valent pneumococcal conjugate vaccination (PCV7) increased since 2002, while little variation occurred in other potentially associated risk factors. Paediatric encounter rates for OM decreased steadily over a 13-year period reversing a previously reported long-term increasing trend reported. Reduced SHS exposure, PCV7 coverage since 2002 and other factors may have contributed to the decline. Further research is needed to provide direct estimates of paediatric encounter rates in exposed and unexposed populations for causal inference.

This study utilises an ecological design to analyse the relation between concurrent temporal trends in sudden infant death syndrome (SIDS) rates and prevalence of smoke-free households with infants in the USA, controlling for an important risk factor, infant supine sleep position. Annual state-specific SIDS cases were computed using period linked birth/infant death files; the prevalence of 100% smoke-free homes with infants using Tobacco Use Supplement to the Current Population Survey data, and percentage of infants in supine sleep position from National Infant Sleep Position data, for years 1995-2006. Incidence rate ratios relating trends in SIDS cases and risk factors were determined using time-series negative binomial regression. Population-level health effects were assessed with secondhand smoke (SHS) exposure population attributable fractions and excess attributable SIDS deaths. For every 1% absolute increase in the prevalence of smoke-free homes with infants, SIDS rates decreased 0.4% from 1995 to 2006, controlling for supine sleep position. Nationally, it is possible that 20% of the 1326 total SIDS cases were attributable to childhood SHS exposure at home in 2006 with potentially 534 fewer infant deaths attributable to SHS exposure in 2006 than in 1995, owing to an increasing prevalence of 100% smoke-free homes with infants. Cumulatively, 4402 (lower 95% CI) to 6406 (upper 95% CI) excess SIDS cases may have been attributable to SHS exposure in the home over the 12-year study period. The uptake of voluntary restrictions on smoking inside the home may present a public health benefit for infants in their first year of life. In light of inherent ecological study design limitations, these results warrant further individual level research linking postnatal SHS exposure and SIDS.

Coronary heart disease (CHD) mortality rates have been decreasing in many industrialized countries since the 1980s. Up to half this decrease can be attributed to evidence-based medical and surgical cardiology interventions. However, recent studies suggest that modern cardiology treatment uptake levels remain disappointingly low in many patient categories. To determine the potential for further reductions in CHD mortality in Ireland from increasing the number of eligible patients receiving cardiology treatments. A previously validated, cell-based IMPACT CHD mortality model was used to integrate large amounts of data describing CHD patient numbers, and the effectiveness and uptake levels of specific medical and surgical treatments. The CHD mortality reductions potentially achievable through the increased use of specific treatments were then calculated, stratified by age and gender and tested using sensitivity analyses. In 2000, medical and surgical coronary disease treatments together prevented or postponed approximately 1950 CHD deaths in the adult population aged 25-84. However, increasing treatment levels to reach 80% of eligible patients might have prevented or postponed a further 2280 CHD deaths in 2000 (minimum estimate 860, maximum estimate 4000). The biggest gain was from maximizing the treatment uptake of eligible heart failure patients, followed by those receiving statins and secondary prevention therapies. Many eligible patients are currently not receiving appropriate evidence-based treatments that would reduce CHD mortality and morbidity. Our results suggest that increasing cardiology treatment uptake in Ireland could at least double the current therapeutic reduction in CHD mortality.