Low-incidence Areas Research Articles

Characteristics and outcome of multidrug-resistant tuberculosis in a low-incidence area

ObjectivesTo characterize multidrug-resistant tuberculosis (MDR-TB) patients treated in a low endemic area in France and to determine risk factors for resistance. We also analyzed the efficacy and tolerability of tuberculosis (TB) treatment. MethodsBetween 2002–2013, all MDR-TB patients diagnosed in western France (hospitals belonging to the GERICCO group) were retrospectively included, with a follow-up period running until 2016. A case-control study (1:2), matched according to age, sex, and year of diagnosis, was performed to assess socio-demographic and clinical data, treatment strategies, and outcomes for the MDR-TB patients and controls treated for drug-susceptible tuberculosis during the same period. ResultsOf 134 TB patients, 44 were MDR-TB and 90 were drug-susceptible TB. Of the 44 MDR-TB patients (35 MDR and nine extensively drug-resistant [XDR]), 33 (75%) were males; the median age was 33 years; and 27 (61%) were born in Eastern Europe. Prior treatment failure was more frequently reported for XDR-TB (8/9) in Georgian patients. In multivariate analysis, risk contacts and prior TB history were associated with MDR-TB. Treatment failure was associated with MDR/XDR-TB and miliary TB. ConclusionIn western France, MDR-TB more frequently occurred in recent migrants from high-risk countries with a previous history of at-risk contact with other MDR-TB patients or previous TB treatment failure.

Surveillance of premalignant gastric lesions: a multicentre prospective cohort study from low incidence regions

ObjectiveInternational guidelines recommend endoscopic surveillance of premalignant gastric lesions. However, the diagnostic yield and preventive effect require further study. We therefore aimed to assess the incidence of neoplastic progression and...

Moving Closer to Tuberculosis Elimination through Institutional Scientific Collaboration: Opportunities for Cuba and the USA.

Global efforts to eliminate tuberculosis by 2050 continue to challenge health systems. In countries with low reported tuberculosis incidence, such as the USA (3.1/100,000 population) and Cuba (6.9/100,000), differences in classification by income level and health systems' overall organizational structure are evident. However, the two countries' low tuberculosis incidence, geographic proximity, robust research capacity and shared health priority for tuberculosis elimination provide fertile territory to strengthen collaboration for tuberculosis control in clinical, laboratory and community settings. Two tuberculosis symposia in Cuba-one at the Cuba Salud Convention in 2015 and the other at the International Forum on Hygiene and Epidemiology in 2016-were instrumental in stimulating dialogue on continued efforts towards eliminating tuberculosis by 2050. In this article, we describe tuberculosis burden in the USA and Cuba, critically analyze strengths and challenges experienced in areas of low tuberculosis incidence and provide recommendations for future institutional collaboration to support tuberculosis elimination and improved population health. KEYWORDS Tuberculosis/epidemiology, Mycobacterium tuberculosis, prevention, communicable disease control, disease eradication, disease elimination, international cooperation, Cuba, USA.

Investigation of Dietary Factors and Esophageal Cancer Knowledge: Comparison of Rural Residents in High- and Low-incidence Areas

To compare the differences in dietary status and knowledge of esophageal cancer (EC) between residents of high- and low-incidence areas. We investigated dietary conditions and EC knowledge among residents in high- and low-EC incidence areas (Yanting and Qingzhen counties). Residents in Yanting consumed more pickled vegetables, salted meat and barbecued food (P < 0.05). Analysis of the past ten-year trend in Yanting consumed fresh vegetables/fruits, beans, sauerkraut, hot food, and barbecued food had gradually increased, and the trend was less than that in Qingzhen County. However, the gradual increasing trend in consumption of pickled vegetables, pickled meat, and spicy food over the past 10 years was greater (P < 0.05). Drinking water in Yanting County was healthier than that in Qingzhen County (P < 0.05). In terms of EC knowledge, the proportions of residents in Yanting who had a clear understanding, knowledge or had heard of EC or knew the common causes, primary symptoms, therapeutic measures, preventive measures, and government interventions for EC were all higher than in Qingzhen (P < 0.05). Residents in Yanting had greater EC knowledge but more harmful dietary habits than those in Qingzhen.

Analysis of the Incidence of Hepatitis B and Hepatitis C and Association with Socio-Economic Factors in Various Regions in China

The incidence of liver cancer in China accounts for more than half of the world, and the majority of them is caused by hepatitis B and hepatitis C. China is known as a great contributor to hepatitis. The Chinese government has implemented a series of preventive measures to solve this problem, especially the policy of free hepatitis B vaccination for newborn babies and effectively reduced the incidence of hepatitis. The incidence of infectious diseases is often related to socio-economic factors. Therefore, we used data on the incidence of hepatitis B and C and socioeconomic factors to analyze and find out the relationship among them in various regions. There were high incidence areas and low incidence areas in China, and the high incidence area of hepatitis B was also the high incidence area of hepatitis C. Especially in Xinjiang, the highest incidence of hepatitis B and hepatitis C was observed at the same time. The incidence of hepatitis B and hepatitis C was more affected by regional economic factors. The economic factors in low incidence areas of hepatitis were better than those in high incidence areas. There was a negative correlation between economic factors and the incidence of hepatitis. In conclusion, in economically developed areas, the government has invested more money and resources in public health and people’s health awareness in comparison to underdeveloped areas. In the future, various preventive strategies should be carried out according to the background of different regions.

Moving Closer to Tuberculosis Elimination through Institutional Scientific Collaboration: Opportunities for Cuba and the USA.

Global efforts to eliminate tuberculosis by 2050 continue to challenge health systems. In countries with low reported tuberculosis incidence, such as the USA (3.1/100,000 population) and Cuba (6.9/100,000), differences in classification by income level and health systems' overall organizational structure are evident. However, the two countries' low tuberculosis incidence, geographic proximity, robust research capacity and shared health priority for tuberculosis elimination provide fertile territory to strengthen collaboration for tuberculosis control in clinical, laboratory and community settings. Two tuberculosis symposia in Cuba-one at the Cuba Salud Convention in 2015 and the other at the International Forum on Hygiene and Epidemiology in 2016-were instrumental in stimulating dialogue on continued efforts towards eliminating tuberculosis by 2050. In this article, we describe tuberculosis burden in the USA and Cuba, critically analyze strengths and challenges experienced in areas of low tuberculosis incidence and provide recommendations for future institutional collaboration to support tuberculosis elimination and improved population health. KEYWORDS Tuberculosis/epidemiology, Mycobacterium tuberculosis, prevention, communicable disease control, disease eradication, disease elimination, international cooperation, Cuba, USA.

Economic evaluation of 2014 cholera outbreak in Ghana: a household cost analysis

IntroductionGhana experienced its worst cholera outbreak in three decades in 2014. Evidence of cholera economic costs on affected households has been limited. This study aimed at determining economic costs on households affected by the cholera outbreak in a Coastal Region of Ghana.MethodsTwo districts; High and Low Incidence Areas (HIA and LIA) were selected in comparative cost analysis and disease impact on affected households assessed based on scientifically documented economic indicators. A total of 418 (282 HIA and 136 LIA) households that experienced at least one case of cholera infection were interviewed. Direct and indirect costs were estimated. Correlates of household’s cholera infection were estimated using Tobit Regression model in STATA 13.ResultsAverage direct cost to households in HIA amounted to USD 106.88, almost 2 folds higher than LIA (USD 62.02). Potential cost saving of an episode of cholera is USD 99,201.28 in LIA and raises almost 8 folds in HIA (USD 782,611.60). Households in lowest income category had the highest incidence of cholera (0.073) compared to other categories plus other factors were significant in explaining cholera incidence.ConclusionsThe study showed considerable differences in HIA and LIA costs with higher household economic impact of cholera on the lowest income category. Results underscore the need for pragmatic policy interventions to avert recurrent outbreaks and emphasis huge potential cost saving with reducing cholera cases.

Differences in agricultural activities related to incidence of scrub typhus between Korea and Japan.

OBJECTIVESThe purpose of this study was to establish a basis for improving or strengthening the preventive strategy against scrub typhus in Korea by comparing and analyzing the difference of prevention behaviors contributing to the occurrence of scrub typhus in Japan and Korea.METHODSThe survey was carried out in Jeollabuk-do, which is a high risk and high incidence area, and Fukuoka Prefecture, which is a high risk and low incidence area. The study included 406 Korean farmers and 216 Japanese farmers. Data were collected through face-to-face surveys by interviewers who had completed standardized education.RESULTSKorean farmers have a higher percentage of agricultural working posture that involved contact with weeds than Japanese farmers (p<0.05). The frequency and proportion of weeding were lower in Korean farmers than in Japanese farmers (p<0.05). The level of knowledge about scrub typhus was significantly higher among Korean farmers than among Japanese farmers (p<0.05). Mostly, the behavior of agriculture work was more appropriate for Japanese farmers than for Korean farmers (p<0.05). The total average level of agricultural work was lower in Korea than in Japan, lower in men than women, and lower in part-time farmers than full-time farmers (p<0.05).CONCLUSIONSThis study suggests that it is reasonable to develop and provide a program that can improve the level of preventive behavior taking into consideration the characteristics of the subject in order to reduce the incidence of diseases in high-risk areas for scrub typhus.

Investigation of human T-cell lymphocytic leukemia virus infections among voluntary blood donors in Foshan City

Objective To investigate the infection status of human T lymphocyte leukemia virus (HTLV) in voluntary blood donors in Foshan City of Guangdong Province, and to evaluate the risk of HTLV transmission through blood, in order to ensure safety of clinical blood transfusion in Foshan City. Methods From February to December 2016, a total of 69 275 blood donors in Foshan City were selected as study objects. Enzyme-linked immunosorbent assay(ELISA)was conducted to detect HTLV-Ⅰ/-Ⅱ antibodies in plasma from all blood donors, then reactivity samples were double-hole re-examined. The samples which were reactive by double-hole re-examined were determined primary screening results of HTLV-Ⅰ/-Ⅱ antibodies positive. And finally confirmed by Western blotting detection. The primary screening positive rates of HTLV-Ⅰ/-Ⅱ antibodies of blood donors from different gender, age, education degrees, household registration and times of blood donation were measured and compared by statistical method. Results ① In these 69 275 blood donors, HTLV-Ⅰ/-Ⅱ antibodies of 17 donors were positive, and primary screening positive rate of HTLV-Ⅰ/-Ⅱ antibodies was 0.025%. Among them, only 2 samples were identified as positive for HTLV-Ⅰ/-Ⅱ antibodies by Western blotting, and confirmed positive rate was 0.003%. ② The primary screening positive rate of HTLV-Ⅰ/-Ⅱ antibodies in female donors was 0.042% (11/26 291), which was higher than that of male donors (0.014%, 6/42 984) , and the difference was statistically significant (χ2=5.17, P=0.023). The primary screening positive rate of HTLV-Ⅰ/-Ⅱ antibodies in 46-55 years old blood donors was the highest as 0.084% (4/4 768) among donors of different ages, and the total difference of HTLV-Ⅰ/-Ⅱ antibodies primary screening positive rates in donors of different ages was statistically significant (χ2=8.09, P= 0.044). The blood donors with junior middle school education or below has the highest primary screening positive rate of HTLV-Ⅰ/-Ⅱ antibodies (0.063%, 7/11 113) among donors of different education degrees, and the total difference of primary screening positive rates was statistically significant (χ2=7.97, P=0.047). The primary screening positive rate of HTLV-Ⅰ/-Ⅱ antibodies in nonlocal registered blood donors (0.033%, 15/45 274) was higher than that of local registered donors (0.008%, 2/24 001), and the difference was statistically significant (χ2=3.93, P=0.047). The primary screening positive rate of HTLV-Ⅰ/-Ⅱ antibodies in multipe blood donors (0.034%, 16/46 414) who donated blood twice or more, was higher than that of the first blood donors (0.004%, 1/22 861), and the difference was statistically significant (χ2=5.65, P=0.017). Conclusions The results show that Foshan City belongs to low-incidence or non-endemic area of HTLV infection among voluntary blood donors. The risk of infection with HTLV was higher among female, elderly, low education, nonlocal registered and multipe blood donors. In view of blood transfusion safety, it is recommended that HTLV-Ⅰ/-Ⅱ antibodies of all voluntary donors should be detected before blood donation, and the blood should deal with filter to remove white blood cells. Key words: HTLV-Ⅰantibodies; HTLV-Ⅱ antibodies; Blood donors; Enzyme-linked immunosorbent assay; Blotting, Western; Blood safety

Long-term follow-up reveals high incidence of colorectal cancer in Indian patients with inflammatory bowel disease.

As the magnitude of sporadic colorectal cancer (CRC) in India is low, magnitude of CRC in ulcerative colitis (UC) is also considered low. As a result, screening for CRC in UC although advocated may not be followed everywhere. We report our data of UC-related CRC from a low-incidence area of sporadic CRC. A total of 1012 patients with left-sided colitis/pancolitis having more than one full-length colonoscopy performed at least a year after the onset of symptoms were included in retrospective analysis of prospectively maintained case records. In addition, 136 patients with duration of disease >10 years underwent surveillance white-light colonoscopy prospectively during the study period. A total of 1012 individuals were finally included (6542 person-years of follow-up, 68.5% males, disease duration: 6.4 ± 6.8 years). Twenty (1.97%) patients developed CRC. Two (10%) patients developed CRC during the first decade, 10/20 (50%) during the second and 8/20 (40%) after the second decade of disease. The cumulative risk of developing CRC was 1.5%, 7.2% and 23.6% in the first, second and third decade, respectively. Of 136 high-risk UC cases, five (3.6%) had CRC on screening colonoscopy. Disease duration and increasing age of onset were associated with higher risk of CRC. Cumulative risk of CRC in Indian UC patients is as high as 23.6% at 30 years. The risk of CRC increases with increasing age of onset and increasing duration of disease. A low risk of sporadic CRC does not confer a low risk of UC-related CRC, and regular screening is warranted.

Analysis on spatial distribution of tuberculosis in China, 2012-2014

Objective: To analyze the spatial distribution of the incidence of tuberculosis (TB) in China from 2012 to 2014 and provide evidence for the prevention and control of TB. Methods: The database of TB in China from 2012 to 2014 was established by using geographical information system, the spatial distribution map was drawn, trend analysis and spatial autocorrelation analysis were conducted to explore the spatial distribution pattern of TB and identify hot areas. Results: The trend surface analysis showed that the incidence of TB decreased gradually from the west to the east in China, and the U type curve could reflect the TB distribution from the south to the north; Global spatial autocorrelation analysis showed the 2012-2014 global Moran's I were 0.366, 0.364 and 0.358 (P<0.01), suggesting that the incidence of TB had a spatial clustering in China; Local Getis-OrdG(i) spatial autocorrelation analysis by ArcGIS software showed that there was 11 cluster areas, 3 high incidence areas (Xinjiang, Tibet, Qinghai) and 8 low incidence areas (Beijing, Tianjin, Shanghai, Hebei, Inner Mongolia, Shanxi, Shandong, Jiangsu). Conclusion: The incidence of TB had obviously spatial clustering characteristic, the areas at high risk were mainly in the northwestern and plateau area in China.

Functional PIN1 promoter polymorphisms associated with risk of nasopharyngeal carcinoma in Southern Chinese populations

Our previous work reported the association between two single nucleotide polymorphisms (SNPs) in PIN1 promoter and nasopharyngeal carcinoma (NPC) risk with a small sample size in a low incidence area. This study investigated the association between the two SNPs and NPC risk in 733 patients and 895 controls from a high incidence area. The results indicated the genotype and allele frequencies of -842G > C and -667C > T were both significantly different between patients and controls even using the resampling statistics. The -842GC and -667TT genotypes showed a significantly increased risk of NPC (OR = 1.977, 95% CI = 1.339–2.919, P = 0.001 and OR = 1.438, 95% CI = 1.061–1.922, P = 0.019, respectively). Compared to the most common -842G-667C haplotype, -842G-667T haplotype and -842C-667C haplotype showed a significantly increased risk of NPC (OR = 1.215, 95% CI = 1.053–1.402, P = 0.008 and OR = 2.268, 95% CI = 1.530–3.362, P = 0.001, respectively). Further reporter gene expression suggested that variant -842C-667C and -842G-667T were associated with an enhanced transcriptional activity. In conclusion, our findings suggest that -842G > C and -667C > T in PIN1 promoter are associated with NPC risk; as well as the promoter activity is mediated by functional PIN1 variants.

Natural History of Adult Ulcerative Colitis in Population-based Cohorts: A Systematic Review

A comprehensive knowledge of the natural history of ulcerative colitis (UC) helps understand disease evolution, identify poor prognostic markers and impact of treatment strategies, and facilitates shared decision-making. We systematically reviewed the natural history of UC in adult population-based cohort studies with long-term follow-up. Through a systematic literature review of MEDLINE through March 31, 2016, we identified 60 studies performed in 17 population-based inception cohorts reporting the long-term course and outcomes of adult-onset UC (n= 15,316 UC patients). Left-sided colitis is the most frequent location, and disease extension is observed in 10%-30% of patients. Majority of patients have a mild-moderate course, which is most active at diagnosis and then in varying periods of remission or mild activity; about 10%-15% of patients experience an aggressive course, and the cumulative risk of relapse is 70%-80% at 10 years. Almost 50% of patients require UC-related hospitalization, and 5-year risk of re-hospitalization is ∼50%. The 5-year and 10-year cumulative risk of colectomy is 10%-15%; achieving mucosal healing is associated with lower risk of colectomy. About 50% of patients receive corticosteroids, although this proportion has decreased over time, with a corresponding increase in the use of immunomodulators (20%) and anti-tumor necrosis factor (5%-10%). Although UC is not associated with an increased risk of mortality, it is associated with high morbidity and work disability, comparable to Crohn's disease. UC is a disabling condition over time. Prospective cohorts are needed to evaluate the impact of recent strategies of early use of disease-modifying therapies and treat-to-target approach with immunomodulators and biologics. Long-term studies from low-incidence areas are also needed.

HPV-negative penile squamous cell carcinoma: disruptive mutations in the TP53 gene are common.

The majority of penile squamous cell carcinomas is caused by transforming human papilloma virus (HPV) infection. The etiology of HPV-negative cancers is unclear, but TP53 mutations have been implicated. Archival tissues of 108 invasive squamous cell carcinoma from a single pathology institution in a low-incidence area were analyzed for HPV-DNA and p16ink4a overexpression and for TP53 mutations by ion torrent next-generation sequencing. Library preparation failed in 32/108 squamous cell carcinomas. Institutional review board approval was obtained. Thirty of 76 squamous cell carcinomas (43%; average 63 years) were HPV-negative with 8/33 squamous cell carcinomas being TP53 wild-type (24%; average 63 years). Twenty-five of 33 squamous cell carcinomas (76%; average 65 years) showed 32 different somatic TP53 mutations (23 missense mutations in exons 5-8, 6 nonsense, 1 frameshift and 2 splice-site mutations). Several hotspot mutations were detected multiple times (R175H, R248, R282, and R273). Eighteen of 19 squamous cell carcinomas with TP53 expression in immunohistochemistry had TP53 mutations. Fifty percent of TP53-negative squamous cell carcinomas showed mostly truncating loss-of-function TP53 mutations. Patients without mutations had longer survival (5 years: 86% vs 61%; 10 years: 60% vs 22%), but valid clinically relevant conclusions cannot be drawn due to different tumor stages and heterogeneous treatment of the cases presented in this study. Somatic TP53 mutations are a common feature in HPV-negative penile squamous cell carcinomas and offer an explanation for HPV-independent penile carcinogenesis. About half of HPV-negative penile cancers are driven by oncogenic activation of TP53, while a quarter is induced by loss of TP53 tumor suppressor function. Detection of TP53 mutations should be carried out by sequencing, as immunohistochemical TP53 staining could not identify all squamous cell carcinomas with TP53 mutations.

Prevalence of asymptomatic submicroscopic malaria in eastern Indonesia: a cross sectional survey and spatial analysis

Abstract Background In 2013 in Indonesia, 4·8 million people were infected with malaria, and 23 483 malaria-related deaths were reported. Most infections were reported in eastern Indonesia, with two dominant species of malarial parasite: Plasmodium falciparum (62%) and P vivax (33%). Annual parasite incidence was 15·6 per 1000 population. In 2016, the Indonesian Ministry of Health announced that Indonesia would reach the WHO-defined pre-elimination stage for malaria by 2020, and be free of malaria transmission by 2030. Unfortunately, real data on incidence, surveillance, and mapping of malaria cases is scarce. This study will assess whether East Nusa Tenggara Province in eastern Indonesia should proceed with the malaria pre-elimination stage activities. Methods We did a survey of 555 people who were systematically selected from five districts in eastern Indonesia. We included healthy participants aged 14 years and older who had a blood haemoglobin concentration ≥100 g/L. We recorded baseline characteristics and risk factors for malaria infection via a standardised questionnaire, and blood samples were taken for analysis. All participants were examined by a local medical doctor. A malaria case was defined as the presence of Plasmodium spp in blood detected with nested PCR (nPCR) or microscopy. Data were collected by standard questionnaire, physical examination and laboratory tests (haemoglobin concentration measurements, microscopic analysis, and nPCR). We mapped nPCR-confirmed cases of malaria using ArcGIS 9.1 spatial and SaTScan analysis. We used univariate and bivariate statistical analysis for statistical analysis. Findings Between August, 2013, and September, 2014, we included 555 samples in our survey. 181 (32·6%) samples tested positive for malaria with n-PCR: only nine (1·6%) of these cases were detected by microscopy. P vivax was the most common Plasmodium spp detected (94 cases [51·9%]). Not using bednets was the most important risk factors for malaria in our population (OR 2·34, 95% CI 1·98–4·83); fever, which is the most commonly presented symptom, was noted in only five cases (0·9%). Results of spatial analysis showed three distinct and significant clusters: 13 cases (7·2%, p=0·0041), 54 cases (29·9%, p=0·0025), and 87 cases (48·1%, p=0·001). However, all malaria clusters were in areas of low malaria incidence. Interpretation A malaria pre-elimination programme in eastern Indonesia should be delayed. Routine treatment to stop silent transmission of malaria, and improved laboratory surveillance, are needed. Funding Asia Pacific Malaria Elimination Network (APMEN) Project number 103-02 as part of the APMEN Country Partner Technical Development Program Round-X. Major funding for APMEN is provided by Australian Government Department of Foreign Affair and Trade, alongside funds received from Bill and Melinda Gates Foundation.

Control of bovine tuberculosis in a farmed red deer herd in England

This report describes how Mycobacterium bovis infection was controlled and eventually eradicated in a farmed red deer herd in the north of England, following sustained tuberculin skin testing supplemented with...

Association of genotypes of rs671 withinALDH2 with risk for gastric cardia adenocarcinoma in the Chinese Han population in high- and low-incidence areas.

Objective: This study aimed to determine if gastric cardia adenocarcinoma (GCA) risk was associated with the lys (A or *2) allele at the rs671 (glu504lys) polymorphism within the aldehyde dehydrogenase 2 (ALDH2) gene in a Chinese Han population. We also aimed to investigateALDH2 genotypic distributions between subjects from high- and low-incidence areas for both GCA and esophageal squamous cell carcinoma (ESCC). Methods: We designed a case-control study including 2,686 patients with GCA and 3,675 control subjects from high- and low-incidence areas for both GCA and ESCC in China. TaqMan allele discrimination assay was used to genotype the rs671 polymorphism.χ2 test and binary logistic regression analysis were used to estimate the odds ratios for the development of GCA, and multivariate ordinal logistic regression was used to analyzeALDH2 genotypic distributions among different groups. Results: Compared withALDH2*1/*1 homozygotes,ALDH2*1/*2 andALDH2*2/*2 carriers did not increase the risk for GCA in the Chinese Han population (P>0.05). Interestingly, the ratio of homozygous or heterozygousALDH2 *2 carriers in high-incidence areas for both GCA and ESCC was lower than that in low-incidence areas (P<0.001). Conclusions: Genotypes of rs671 atALDH2 may not increase GCA susceptibility in Chinese Han populations. In addition, theALDH2 genotypic distribution differs between Chinese Han populations from high- and low-incidence areas for both GCA and ESCC. Our findings may shed light on the possible genetic mechanism for the dramatic geographic differences of GCA occurrence in China.

N-nitrodimethlyamine in natural and drinking water of high cancer incidence regions of Guangdong, China

The Guangdong province of China contains the most clearly described high-incidence of hepatocellular carcinoma (HCC) and nasopharyngeal carcinoma (NPC) areas in the world. The geographical heterogeneity of cancer incidence in the region suggests that many carcinogenic risk factors might be present in the regional geochemical environment. This paper presents the concentrations of a wide range of known carcinogens in two high cancer incidence areas in Guangdong and compared them to a low cancer incidence area in the same province. N-Nitrosamines, NO3−, NO2−, and ammonium were detected in groundwater, surface water, and drinking-water. The concentrations of the 7 trace metal and metalloid elements As, Cd, Ni, Cu, Pb, Zn, and Hg were determined in surface soil samples and all water samples. The results show that, compared with the guidelines or limit values for drinking-water quality in the world, the high cancer incidence areas have hazardous high levels of N-nitrodimethlyamine (NDMA) in all kinds of water. Oppositely, the low cancer incidence area has a safe low level of NDMA in water bodies. The levels of NO3−, NO2−, and ammonium in water have the same character, although they have different expression between the two high-risk areas. The distribution of the 7 tested trace elements in surface soil has no significant correlation with cancer incidence. On the other hand, high concentrations of carcinogenic N-Nitrosamines in drinking-water and natural water bodies were identified for the first time in the high NPC and HCC incidence area.

Spatial transmission and meteorological determinants of tuberculosis incidence in Qinghai Province, China: a spatial clustering panel analysis.

BackgroundTuberculosis (TB) is the notifiable infectious disease with the second highest incidence in the Qinghai province, a province with poor primary health care infrastructure. Understanding the spatial distribution of TB and related environmental factors is necessary for developing effective strategies to control and further eliminate TB.MethodsOur TB incidence data and meteorological data were extracted from the China Information System of Disease Control and Prevention and statistical yearbooks, respectively. We calculated the global and local Moran’s I by using spatial autocorrelation analysis to detect the spatial clustering of TB incidence each year. A spatial panel data model was applied to examine the associations of meteorological factors with TB incidence after adjustment of spatial individual effects and spatial autocorrelation.ResultsThe Local Moran’s I method detected 11 counties with a significantly high-high spatial clustering (average annual incidence: 294/100 000) and 17 counties with a significantly low-low spatial clustering (average annual incidence: 68/100 000) of TB annual incidence within the examined five-year period; the global Moran’s I values ranged from 0.40 to 0.58 (all P-values < 0.05). The TB incidence was positively associated with the temperature, precipitation, and wind speed (all P-values < 0.05), which were confirmed by the spatial panel data model. Each 10 °C, 2 cm, and 1 m/s increase in temperature, precipitation, and wind speed associated with 9 % and 3 % decrements and a 7 % increment in the TB incidence, respectively.ConclusionsHigh TB incidence areas were mainly concentrated in south-western Qinghai, while low TB incidence areas clustered in eastern and north-western Qinghai. Areas with low temperature and precipitation and with strong wind speeds tended to have higher TB incidences.Electronic supplementary materialThe online version of this article (doi:10.1186/s40249-016-0139-4) contains supplementary material, which is available to authorized users.

The work of negotiating HIV as a chronic condition: a qualitative analysis

ABSTRACTLiving with human immunodeficiency virus (HIV) in the industrialised world has for over a decade been conceptualised as living with a chronic illness. People living with HIV now are amongst the first to live and age with the virus. Drawing on a qualitative longitudinal study in a low-incidence area in a low-incidence country, this paper investigates the nuanced ways that people negotiate this condition. While it has been argued that HIV is a condition like any other chronic disease, our thematic analysis reveals some similarities and particularities around living with the condition. In comparing themselves to others with the condition, high levels of diversity of experience were identified that extended well beyond length of time from diagnosis. In comparing their illness with other illnesses, the location, for example, of their specialist service within a clinic for those with acute sexually transmitted diseases was identified as problematic. The work involved in maintaining a coherent sense of self in the face of existing and shifting challenges as a result of their infection was a second strong theme. The final theme involved flux and flex work in the ways people sought to gain and maintain control over various aspects of their lives. All of these experiences are mediated by place; that is the experience is not the same as that of those who live where there is a much higher incidence of infection. The work involved in negotiating this condition in low-incidence environments deserves more attention, but aspects of these findings are significant in higher incidence contexts as well; in particular, passivity in face of infection as one ages and the potential for medication refusal as a means of maintaining control over life and death.