Public Health

A better tool for measuring the health of Canadians

The Medical Outcomes Study 36-item Short Form (SF-36) is a widely cited measure of health-related quality of life that is used in approximately 40 countries. A team of scientists has established the first Canadian normative data for the SF-36 by using data from the Canadian Multicentre Osteoporosis Study, a prospective cohort study involving 9,423 men and women. The normative data are the key to determining whether a group or an individual scores above or below the average for their country. The authors report that men scored higher than women on all parts of the SF-36 and that Canadians scored higher than US and UK counterparts in several domains. CMAJ 2000;163(3):265-71.

A new tool to reduce antibiotic prescriptions?

Three years ago, a national consensus conference on antibiotic resistance recommended antimicrobial prescriptions be reduced "by 25% within three years by focusing on community-acquired respiratory infection." To assess how well we’re doing, researchers evaluated their previously published clinical score for the management of infections of the upper respiratory tract accompanied by sore throat and the potential impact of the clinical score on the prescribing of antibiotics in community-based medicine. The authors surveyed 97 family physicians in 49 Ontario communities who assessed children and adults with a new infection of the upper respiratory tract and compared their prescribing decisions with previously published results for patients seen at an academic family medicine centre. The authors also compared the physicians’ prescribing practices and their recommendations for obtaining throat swabs with score-based recommendations.

The authors report that physicians prescribed antibiotics in 173 out of 619 cases (27.9%) and of the 173 prescriptions, 109 (63%) were given to patients with culture-negative results for group A Streptococcus.

They add that using the clinical score to determine management would have reduced prescriptions to culture-negative patients by 63.7%) and overall antibiotic prescriptions by 52.3%. "This approach could substantially reduce unnecessary prescribing of antibiotics by family physicians and is consistent with national recommendations for limiting antibiotic resistance," conclude the authors. CMAJ 2000;163(7):811.

Anemia in Cree infants

Authors of a study of nine-month-old Cree infants living in northern Quebec report that one-third of these children were anemic and that this was more of a problem among breast-fed babies than formula-fed infants. Six Cree communities in the James Bay region introduced a screening program in 1995 to identify anemia in infants. Researchers reviewed the charts of 386 of these children and discovered 31.9% were anemic. To understand the cause of the anemia, they tested the association between hemoglobin (Hb) concentration and mean cell volume at nine months of age, weight gain between birth and nine months, and type of milk consumed when the infant visited the nine-month well-baby clinic.

The authors reported that babies fed formula at nine months had a higher mean Hb concentration than those exclusively breast-fed or cow’s milk. Since research shows that iron-deficiency anemia is associated with psychomotor impairment, the authors warn the high prevalence among Cree infants should be considered a serious health problem. CMAJ 2000;162(3):323-6.

A related editorial warns that this study has important implications for public health and nutrition programs. While stating that "breast is best," the editorialist recommends supplying additional sources of iron to breast-fed infants after 6 months of age as a way to avoid the severe neurologic and developmental effects associated with iron-deficiency anemia. CMAJ 2000;162(3):343.

Curb use of drugs in farm animals, WHO advises

The World Health Organization wants farmers to curtail and monitor their use of antimicrobial chemicals in food animals in an effort to show the proliferation of drug-resistant forms of disease-causing bacteria. The tough new measures call for obligatory prescriptions for all antimicrobial agents used for disease control in farm animals, as well as national systems to monitor the use of these products. CMAJ 2000;163(6):751.

Doctors lobby for hockey masks

The Canadian Ophthalmological Society and Canadian Dental Association are supporting a campaign to encourage major hockey bodies, like the NHL, to make full facial protection mandatory. The campaign is led by the 500-member Ottawa Academy of Medicine, a branch of the Ontario Medical Association. The Canadian Standards Association says more eye injuries are sustained in hockey than in any other sport. Between 1972 and 1997, 1,860 such injuries were recorded with 298 resulting in at least partial blindness. CMAJ 2000;163(4):433.

Driving: How old is too old?

Transport Canada statistics show that Canadians over the age of 65 have a much higher annual fatality rate (14.5 per 100,000) than those between the ages of 35 and 64 (8.2 deaths per 100,000). Young Canadians (age 15-34) come close to matching the fatality rate of seniors (14.1 per 100,000). The rate of injury, however, declines with age. A May 2000, Gallup poll reveals that 85% of Canadians favour mandatory testing of elderly drivers. CMAJ 2000;163(10):1334.

Injection drug use and harm reduction

New research compares the morbidity and mortality rates among injection drug users in Canadian and Western European jurisdictions during 1988–1999 and explores their correlation with harm reduction programs. Whereas expanded harm reduction initiatives in the Netherlands, Switzerland and Germany correlated with a decrease in morbidity and mortality rates, the rates among drug users in Canada have increased. The authors attribute this increase to the limited range and penetration of harm reduction initiatives in Canada. CMAJ 2000;162(12):1709-13.

But a related commentary examines specific jurisdictions and finds the above conclusion is an oversimplification. CMAJ 2000;162(12):1695-6.

Food safety standards

In 1998 an outbreak of 39 cases of Escherichia coli O157:H7 in southern Ontario resulted in the national recall of Genoa salami. A case–control study identified that this product, produced by fermenting and drying raw meat, was the likely source. Samples obtained from the most commonly identified supplier tested positive for E. coli O157:H7. Only two-thirds of the people infected recalled eating salami in the week preceding their illness, but 95% said that they had consumed a sliced deli product, implicating the slicer as a possible source of contamination. A similar outbreak reported in the United States in 1994 led to more stringent US production standards. CMAJ 2000;162(10):1409-13.

A related editorial finds that dry fermented sausages have been recognized as a risk for E. coli since 1994 and the US Department of Agriculture required that significant manufacturing changes be made 2 years later. Unfortunately similar action was not taken in Canada until another serious outbreak occurred in British Columbia and Alberta in 1999.meaningful changes to Canada’s food safety standards were not initiated until 1999. CMAJ 2000;162(10):1429-30.

Forest fungus makes its way to the city

No one would have predicted that anyone would catch the rare and life-threatening fungal disease blastomycosis within the city limits of Toronto. Contracted through inhalation of inoculum from contaminated material, primarily in rural and woodland areas, the fungus is usually found in the Great Lakes region and the Mississippi and Ohio river valleys in the US. However, Toronto researchers report that two patients acquired skin abscesses caused by this fungus without travelling to an area where blastomycosis is endemic. CMAJ 2000;163(10):1309-1312.

These cases are bolstered further by a report of a similar case that appeared in New Brunswick. These authors warn that, while still rare, blastomycosis may be found further afield than traditionally believed and that physicians should be prepared to at least consider blastomycosis in the diagnosis of unexplained granulomatous pulmonary or cutaneous disease. CMAJ 2000;163(10):1303-5.

More high school students on drugs

During the 1990s, rates of nonmedical drug use among adolescents rose in most industrialized countries. Researchers used data from the Ontario Student Drug Use Survey to learn more about this trend and what implications it may hold for the future. The survey, done every two years since 1977, asked students enrolled in grades seven, nine, 11 and 13 whether or not they had used any of 17 drugs, including alcohol and tobacco, in the 12 months preceding the survey. Using the self-reported rates of drug use over the survey’s last five cycles (1991-1999), the authors discovered an upward trend between 1993 and 1999 in the proportion of students reporting drug use. This increase was found in the number using tobacco (up from 23.8% to 28.3%), alcohol (56.5% to 65.7%), cannabis (12.7% to 29.2%), glue (1.6% to 3.8%) and other solvents (2.3% to 7.3%), hallucinogens (3.1% to 13.6%) and cocaine (1.5% to 4.1%). The numbers also reflect increased use of the drug ecstasy (0.6% to 4.8%), which is popular among those who attend raves.

The authors report that, from a public health perspective, the survey findings are mixed. On a positive front, there was no evidence that the proportion of students who use tobacco, alcohol or cannabis by age 9 is increasing. And despite overall increases in drug use, a sizable proportion of the students do not use drugs. However, they caution that episodes of heavy drinking among young people and the marked upswing in drug use between 1993 and 1999 are major causes for concern. CMAJ 2000:162(12):1677-80.

The health of the homeless

In the first of three articles on the health care system and homeless people, researchers interviewed 50 homeless people with diabetes in Toronto shelters and found that 72% had difficulties managing their diabetes. The authors report that, by at least some measures, the access to health care was relatively good since most were regularly seeing a physician for diabetes care. Forty% of respondents reported a history of mental illness and 38% showed signs of alcohol abuse, but the most commonly cited barriers to their diabetes care were related to the quality of the diet in shelters and to the logistics of scheduling and administering medication. The authors recommend that shelters establish secure areas for diabetic patients to self-administer insulin, as well as the provision of safe storage areas for the medication. The authors also recommend that an objective assessment of shelter meals be carried out to determine whether subjective reports of dietary problems are justified. CMAJ 2000;163(2):161-5.

A related commentary cites a Philadelphia example of how the use of restaurant school students to staff the kitchens of homeless shelters can result in healthier food choices. The author adds, however, that care management, shelter modification and other strategies are all well and good, but effective disease prevention or treatment of homeless people also requires effective prevention of homelessness. CMAJ 2000;163(2):172-3.

Another article examines the billing records of three physicians providing medical care at three separate homeless shelters and found that physicians only received payment for 54% of treatment encounters. The authors state that even though care for the homeless can be professionally and personally fulfilling for physicians, special arrangements may need to be considered if health care outreach programs for the homeless are to be sustained. CMAJ 2000;163(2):170-1.

The politics of gambling

In 1985 Canadian provinces were given exclusive control over gambling and legalized computer, video and slot betting devices. By 1997/98 Canadians were spending $6.8 billion every year on some form of government-run gambling activity, and the provinces were spending $14 million on support services for people with gambling problems.

A review article comments on the dual role governments play in both encouraging gambling and protecting the public interest. The author discusses the economic impact of gambling, identifies vulnerable populations and cautions that "there is a need for enhanced awareness on the part of health care professionals about the potential impact of gambling on vulnerable, at-risk individuals and special populations." CMAJ 2000;163(1):61-4.

The sobering burden of substance abuse

Canadian researchers have determined that the use and misuse of alcohol, tobacco and illicit drugs were responsible for one in five deaths and almost 10% of hospital admissions in Canada in 1995. The researchers updated earlier estimates of the number and proportion of deaths and hospital admissions attributable to substance use in Canada. They estimate that in 1995, 34,728 deaths and 194,072 admissions to hospital were attributable to tobacco. This was followed by alcohol (6,507 deaths, 82,014 hospital admissions) and illicit drug use (805 deaths, 6,940 admissions).

The new estimates presented by the authors update the 1992 data. Although lower than those figures, they still show that alcohol, tobacco and illicit drug use represent a major source of death and illness in Canada. One of the most significant finding is that accidents and other acute causes accounted for 47% of all alcohol-attributed deaths; previously, a much higherpercentage were attributed to chronic conditions related to alcohol use. CMAJ 2000:162(12):1669-75.

Ticks on the wing

The blacklegged tick Ixodes scapularis is a principal vector of Borrelia burgdorferi, the spirochete that causes Lyme disease. Researchers report that, of 139 I. scapularis ticks collected from Ontario dogs between 1997 and 1998, nine were carrying B. burgdorferi. Some of the dogs were in areas where the tick species is not endemic. CMAJ 2000;162(11):1567-9.

An accompanying commentary explained that these were likely "adventitious" ticks that arrived in immature stages on birds migrating from endemic areas and that their density in the environment is quite low. CMAJ 2000;162(11):1573-4.

Type 2 diabetes worsens among Canada’s First Nations

Diabetes, once rare in Aboriginal peoples, is now a significant health problem for them, accompanied as it is by high rates of retinopathy, renal disease and infection. Researchers describe the prevalence of diabetes in Canada’s First Nations and current hypotheses for its emergence, from the "thrifty genotype" to lifestyle changes. They also outline particular considerations for health care providers, including the need to ensure access for patients living in remote areas and the need for culturally appropriate education and treatment programs. Traditional medicines are a yet-unexplored source of potential therapies. CMAJ 2000;163(5):561-6.

Copyright 2000 Canadian Medical Association or its licensors