Jonathan Gardner

Improvements in women's health worldwide are being held back by inequalities in income and social status, discriminatory delivery systems, and a failure of leaders to tailor health care for women, a World Health Organization report shows.

The report, published in early November, said reproduction and sexuality remain distinctive features of women's health. Complications during pregnancy and birth were considered the leading cause of death among females aged 15–19 in developing countries and HIV/AIDS was named the world's leading cause of death of all women of reproductive age (15–44).

According to the report, women of all ages are harmed by preventable causes of death, such as communicable disease in developing countries, chronic diseases in both developing and developed nations, and disparities in treatment of men and women in health delivery systems. “As the report reveals, the obstacles to good health for women are not principally technical in nature. They are social and political,” Dr. Margaret Chan, director general of WHO, said in a press briefing. “While it is tempting to think that poverty is the single most important determinant, this report shows otherwise.”

According to the report:

▸ Lower respiratory infections are the leading killers of girls from birth to age 9 years in the world (17.6% of deaths) and in low-income countries (18.8%), but prematurity and low birthweight are the most common killers in middle-income countries (14.6%) and congenital anomalies in high-income countries (21.7%).

▸ Lower respiratory infections also take the most lives of girls aged 10–19 worldwide (8.9%) and in low-income countries (10.6%), but road traffic accidents are the biggest killers in middle-income (9.9%) and high-income (28.9%) countries.

▸ HIV/AIDS is the biggest killer worldwide of women of child-bearing age (19.2%), and also in low- and middle-income countries (22.3% and 15.4%), while road traffic accidents take the most lives in that age group in high-income countries (10.2%).

▸ Among women aged 20–59, HIV/AIDS still is the leading cause of deaths worldwide (13.3%) and in low- (18.2%) and middle-income (8.9%) countries, but in high-income countries breast cancer (11.5%) is the leading cause.

▸ Among women 60 and older, ischemic heart disease is the leading cause of death worldwide (19.2%) and in both low- (19.9%) and high-income countries (17.1%), although stroke is the leading cause in middle-income countries (21.7%).

Women often have longer life expectancies than men because of biological and behavioral differences and the reduction of maternal-related deaths in many parts of the world. However, gender-based discrimination overrides the biological advantages of women in other countries. A failure to have tailored treatments for women for conditions that affect both sexes is also a factor in female death rates.

The deficiencies in women's health also have a detrimental effect on health care systems, where women predominantly care for the sick, and on their children, who are harmed if their mothers suffer from such conditions as malnutrition and infectious disease, the report states.

Improvements in women's health worldwide are being held back by inequalities in income and social status, discriminatory delivery systems, and a failure of leaders to tailor health care for women, a World Health Organization report shows.

The report, published in early November, said reproduction and sexuality remain distinctive features of women's health. Complications during pregnancy and birth were considered the leading cause of death among females aged 15–19 in developing countries and HIV/AIDS was named the world's leading cause of death of all women of reproductive age (15–44).

According to the report, women of all ages are harmed by preventable causes of death, such as communicable disease in developing countries, chronic diseases in both developing and developed nations, and disparities in treatment of men and women in health delivery systems. “As the report reveals, the obstacles to good health for women are not principally technical in nature. They are social and political,” Dr. Margaret Chan, director general of WHO, said in a press briefing. “While it is tempting to think that poverty is the single most important determinant, this report shows otherwise.”

According to the report:

▸ Lower respiratory infections are the leading killers of girls from birth to age 9 years in the world (17.6% of deaths) and in low-income countries (18.8%), but prematurity and low birthweight are the most common killers in middle-income countries (14.6%) and congenital anomalies in high-income countries (21.7%).

▸ Lower respiratory infections also take the most lives of girls aged 10–19 worldwide (8.9%) and in low-income countries (10.6%), but road traffic accidents are the biggest killers in middle-income (9.9%) and high-income (28.9%) countries.

▸ HIV/AIDS is the biggest killer worldwide of women of child-bearing age (19.2%), and also in low- and middle-income countries (22.3% and 15.4%), while road traffic accidents take the most lives in that age group in high-income countries (10.2%).

▸ Among women aged 20–59, HIV/AIDS still is the leading cause of deaths worldwide (13.3%) and in low- (18.2%) and middle-income (8.9%) countries, but in high-income countries breast cancer (11.5%) is the leading cause.

▸ Among women 60 and older, ischemic heart disease is the leading cause of death worldwide (19.2%) and in both low- (19.9%) and high-income countries (17.1%), although stroke is the leading cause in middle-income countries (21.7%).

Women often have longer life expectancies than men because of biological and behavioral differences and the reduction of maternal-related deaths in many parts of the world. However, gender-based discrimination overrides the biological advantages of women in other countries. A failure to have tailored treatments for women for conditions that affect both sexes is also a factor in female death rates.

The deficiencies in women's health also have a detrimental effect on health care systems, where women predominantly care for the sick, and on their children, who are harmed if their mothers suffer from such conditions as malnutrition and infectious disease, the report states.

Improvements in women's health worldwide are being held back by inequalities in income and social status, discriminatory delivery systems, and a failure of leaders to tailor health care for women, a World Health Organization report shows.

The report, published in early November, said reproduction and sexuality remain distinctive features of women's health. Complications during pregnancy and birth were considered the leading cause of death among females aged 15–19 in developing countries and HIV/AIDS was named the world's leading cause of death of all women of reproductive age (15–44).

According to the report, women of all ages are harmed by preventable causes of death, such as communicable disease in developing countries, chronic diseases in both developing and developed nations, and disparities in treatment of men and women in health delivery systems. “As the report reveals, the obstacles to good health for women are not principally technical in nature. They are social and political,” Dr. Margaret Chan, director general of WHO, said in a press briefing. “While it is tempting to think that poverty is the single most important determinant, this report shows otherwise.”

According to the report:

▸ Lower respiratory infections are the leading killers of girls from birth to age 9 years in the world (17.6% of deaths) and in low-income countries (18.8%), but prematurity and low birthweight are the most common killers in middle-income countries (14.6%) and congenital anomalies in high-income countries (21.7%).

▸ Lower respiratory infections also take the most lives of girls aged 10–19 worldwide (8.9%) and in low-income countries (10.6%), but road traffic accidents are the biggest killers in middle-income (9.9%) and high-income (28.9%) countries.

▸ HIV/AIDS is the biggest killer worldwide of women of child-bearing age (19.2%), and also in low- and middle-income countries (22.3% and 15.4%), while road traffic accidents take the most lives in that age group in high-income countries (10.2%).

▸ Among women aged 20–59, HIV/AIDS still is the leading cause of deaths worldwide (13.3%) and in low- (18.2%) and middle-income (8.9%) countries, but in high-income countries breast cancer (11.5%) is the leading cause.

▸ Among women 60 and older, ischemic heart disease is the leading cause of death worldwide (19.2%) and in both low- (19.9%) and high-income countries (17.1%), although stroke is the leading cause in middle-income countries (21.7%).

Women often have longer life expectancies than men because of biological and behavioral differences and the reduction of maternal-related deaths in many parts of the world. However, gender-based discrimination overrides the biological advantages of women in other countries. A failure to have tailored treatments for women for conditions that affect both sexes is also a factor in female death rates.

The deficiencies in women's health also have a detrimental effect on health care systems, where women predominantly care for the sick, and on their children, who are harmed if their mothers suffer from such conditions as malnutrition and infectious disease, the report states.

LONDON — International health officials have declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer assigned ultraviolet ray–emitting tanning devices to their group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said that a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 years raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices.

“Therefore, the Working Group raised the classification of the use of UV-emitting tanning devices to Group 1, “carcinogenic to humans,” the report said (Lancet Oncology 2009;10:751-2).

“The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category,” Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

“Given the dangers of sunbeds, we want to the government to act now to ban under-18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers,” she said.

Based on animal studies, exposure to ultraviolet radiation was also added to the group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors of the report.

The working group also reaffirmed that internally deposited radionuclides that emit alpha or beta particles, such as radon, are group 1 carcinogenic agents. Humans can be exposed to radon through soil and building materials.

Also included in group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

LONDON — International health officials have declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer assigned ultraviolet ray–emitting tanning devices to their group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said that a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 years raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices.

“Therefore, the Working Group raised the classification of the use of UV-emitting tanning devices to Group 1, “carcinogenic to humans,” the report said (Lancet Oncology 2009;10:751-2).

“The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category,” Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

“Given the dangers of sunbeds, we want to the government to act now to ban under-18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers,” she said.

Based on animal studies, exposure to ultraviolet radiation was also added to the group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors of the report.

The working group also reaffirmed that internally deposited radionuclides that emit alpha or beta particles, such as radon, are group 1 carcinogenic agents. Humans can be exposed to radon through soil and building materials.

Also included in group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

LONDON — International health officials have declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer assigned ultraviolet ray–emitting tanning devices to their group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said that a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 years raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices.

“Therefore, the Working Group raised the classification of the use of UV-emitting tanning devices to Group 1, “carcinogenic to humans,” the report said (Lancet Oncology 2009;10:751-2).

“The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category,” Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

“Given the dangers of sunbeds, we want to the government to act now to ban under-18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers,” she said.

Based on animal studies, exposure to ultraviolet radiation was also added to the group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors of the report.

The working group also reaffirmed that internally deposited radionuclides that emit alpha or beta particles, such as radon, are group 1 carcinogenic agents. Humans can be exposed to radon through soil and building materials.

Also included in group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

LONDON — International health officials declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer raised the ultraviolet ray-emitting tanning devices to their Group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices. "Therefore, the working group raised the classification of the use of UV-emitting tanning devices to Group 1, carcinogenic to humans," the report noted (Lancet Oncol. 2009;10:751–2).

"The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category," Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

"Given the dangers of sunbeds, we want the government to act now to ban under 18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers," she noted.

Based on animal studies, exposure to ultraviolet radiation was also added to the Group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors.

The working group also reaffirmed as Group 1 carcinogenic agents internally deposited radionuclides that emit alpha or beta particles, such as radon. Humans can be exposed to radon through soil and building materials. Also in Group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

The carcinogenic classification probably will not be enough to convince hard-core tanners to abandon their bronzing, said Mark Leary, Ph.D., director of the social psychology program at Duke University in Durham, N.C.

"I suspect that some people will rethink the importance of a tan with the new labeling, but I don't expect it to make a great difference," Dr. Leary said. "The perceived value of being tanned in terms of enhancing one's appearance and social acceptance is simply too strong."

Another reason that die-hard tanners probably won't quit—the short-term benefits of looking good carry more weight than the possibility of skin cancer 20–30 years down the road, Dr. Leary added.

He explained that tanning behaviors aren't likely to change unless the norms of attractiveness change so that paler skin becomes preferable. In the 1800s, for example, being tanned was a signal that you were a farmer or outdoor laborer, while pale skin signaled that you had an indoor, professional job, Dr. Leary said.

"Only after the Industrial Revolution moved much of the working class inside factories [where they developed pale skin] did being tanned signal status," he said.

The carcinogen message alone is unlikely to discourage teens and young adults from tanning, Dr. Leary added.

But Dr. Leary's previous research showed that an essay about the negative effects of tanning on appearance was more effective in reducing tanning than an essay about skin cancer. A publicity campaign featuring images of wrinkled, saggy skin in relatively young people might make an impact, he said.

LONDON — International health officials declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer raised the ultraviolet ray-emitting tanning devices to their Group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices. "Therefore, the working group raised the classification of the use of UV-emitting tanning devices to Group 1, carcinogenic to humans," the report noted (Lancet Oncol. 2009;10:751–2).

"The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category," Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

"Given the dangers of sunbeds, we want the government to act now to ban under 18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers," she noted.

Based on animal studies, exposure to ultraviolet radiation was also added to the Group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors.

The working group also reaffirmed as Group 1 carcinogenic agents internally deposited radionuclides that emit alpha or beta particles, such as radon. Humans can be exposed to radon through soil and building materials. Also in Group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

The carcinogenic classification probably will not be enough to convince hard-core tanners to abandon their bronzing, said Mark Leary, Ph.D., director of the social psychology program at Duke University in Durham, N.C.

"I suspect that some people will rethink the importance of a tan with the new labeling, but I don't expect it to make a great difference," Dr. Leary said. "The perceived value of being tanned in terms of enhancing one's appearance and social acceptance is simply too strong."

Another reason that die-hard tanners probably won't quit—the short-term benefits of looking good carry more weight than the possibility of skin cancer 20–30 years down the road, Dr. Leary added.

He explained that tanning behaviors aren't likely to change unless the norms of attractiveness change so that paler skin becomes preferable. In the 1800s, for example, being tanned was a signal that you were a farmer or outdoor laborer, while pale skin signaled that you had an indoor, professional job, Dr. Leary said.

"Only after the Industrial Revolution moved much of the working class inside factories [where they developed pale skin] did being tanned signal status," he said.

The carcinogen message alone is unlikely to discourage teens and young adults from tanning, Dr. Leary added.

But Dr. Leary's previous research showed that an essay about the negative effects of tanning on appearance was more effective in reducing tanning than an essay about skin cancer. A publicity campaign featuring images of wrinkled, saggy skin in relatively young people might make an impact, he said.

LONDON — International health officials declared UV-emitting tanning devices a human carcinogen after reviewing epidemiologic studies that indicate an association with cutaneous melanomas.

A working group of the International Agency for Research on Cancer raised the ultraviolet ray-emitting tanning devices to their Group 1 list of carcinogens, joining tobacco and tobacco smoke, asbestos, and human papillomaviruses.

The working group said a meta-analysis of 20 epidemiologic studies has shown that use of tanning devices before age 30 raises the risk of cutaneous melanomas by 75%. In addition, case-control studies indicate an increased risk of ocular melanoma when using these devices. "Therefore, the working group raised the classification of the use of UV-emitting tanning devices to Group 1, carcinogenic to humans," the report noted (Lancet Oncol. 2009;10:751–2).

"The link between sunbeds and skin cancer has been convincingly shown in a number of scientific studies now, and so we are very pleased that IARC have upgraded sunbeds to the highest risk category," Jessica Harris, health information officer with Cancer Research UK, said in a written statement.

"Given the dangers of sunbeds, we want the government to act now to ban under 18s from using sunbeds, close salons that aren't supervised by trained staff, and ensure information about the risks of using sunbeds is given to all customers," she noted.

Based on animal studies, exposure to ultraviolet radiation was also added to the Group 1 list, and exposure to solar radiation was reaffirmed as carcinogenic, according to the authors.

The working group also reaffirmed as Group 1 carcinogenic agents internally deposited radionuclides that emit alpha or beta particles, such as radon. Humans can be exposed to radon through soil and building materials. Also in Group 1 are x-rays, gamma radiation, phosphorus-32, radium-224, and a number of other radioactive materials involved in medicine or manufacturing.

The carcinogenic classification probably will not be enough to convince hard-core tanners to abandon their bronzing, said Mark Leary, Ph.D., director of the social psychology program at Duke University in Durham, N.C.

"I suspect that some people will rethink the importance of a tan with the new labeling, but I don't expect it to make a great difference," Dr. Leary said. "The perceived value of being tanned in terms of enhancing one's appearance and social acceptance is simply too strong."

Another reason that die-hard tanners probably won't quit—the short-term benefits of looking good carry more weight than the possibility of skin cancer 20–30 years down the road, Dr. Leary added.

He explained that tanning behaviors aren't likely to change unless the norms of attractiveness change so that paler skin becomes preferable. In the 1800s, for example, being tanned was a signal that you were a farmer or outdoor laborer, while pale skin signaled that you had an indoor, professional job, Dr. Leary said.

"Only after the Industrial Revolution moved much of the working class inside factories [where they developed pale skin] did being tanned signal status," he said.

The carcinogen message alone is unlikely to discourage teens and young adults from tanning, Dr. Leary added.

But Dr. Leary's previous research showed that an essay about the negative effects of tanning on appearance was more effective in reducing tanning than an essay about skin cancer. A publicity campaign featuring images of wrinkled, saggy skin in relatively young people might make an impact, he said.

More than half of children prescribed oseltamivir in three London schools with outbreaks of the novel virus influenza A(H1N1) experienced side effects, according to a survey.

Researchers from the British Health Protection Agency (HPA) and the European Centre for Disease Prevention and Control (ECDC) said 45 of 85 (53%) respondents prescribed prophylactic oseltamivir (Tamiflu) reported side effects from the antiviral medication (Euro. Surveill. 2009;14:19287). The most common side effect was nausea, reported in 29% of cases (25 of 85), according to the researchers.

Frequent side effects reduce compliance and raise the risk of promoting antiviral resistance if lower drug concentrations only partly block virus replication, suggesting that governments in a disease containment mode not rely too much on antiviral drugs.

“The study findings formed part of the body of growing evidence that contributed to policy change in the U.K.,” wrote the researchers, led by Aileen Kitching of the HPA London epidemiology unit and ECDC's European Program for Intervention Epidemiology Training. “Current U.K. advice is to limit antiviral prophylaxis in schools to the small number of contacts considered most at risk.”

With a stockpile of 30 million doses of antiviral medication, the United Kingdom continued its containment strategy until July 2, 3 weeks after the World Health Organization declared a global pandemic. Until July 2, British physicians were offering oseltamivir to both patients and all exposed contacts.

Researchers asked the children at one primary school and two secondary schools, or their parents, to fill out an online survey form on side effects from oseltamivir. They sought responses from 256 children, of whom 103 responded. Of the respondents, 95 were estimated to have been offered oseltamivir, and 85 took any of the medication.

Of those 85, 56 respondents (66%) said they did or would complete the full course. A gastrointestinal side effect was reported by 40% of those on the medication. Nearly 18% reported at least one mild neuropsychiatric side effect (poor concentration/unable to think clearly, problems sleeping, feeling dazed/confused, bad dreams/nightmares, strange behavior). Neuropsychiatric side effects were more commonly reported by secondary (20%) than primary (13%) schoolchildren, the report noted.

The researchers said their findings are limited by a low response rate, which occurred because they asked for a response by the end of the day via a Web link that was sent to the families.

More than half of children prescribed oseltamivir in three London schools with outbreaks of the novel virus influenza A(H1N1) experienced side effects, according to a survey.

Researchers from the British Health Protection Agency (HPA) and the European Centre for Disease Prevention and Control (ECDC) said 45 of 85 (53%) respondents prescribed prophylactic oseltamivir (Tamiflu) reported side effects from the antiviral medication (Euro. Surveill. 2009;14:19287). The most common side effect was nausea, reported in 29% of cases (25 of 85), according to the researchers.

Frequent side effects reduce compliance and raise the risk of promoting antiviral resistance if lower drug concentrations only partly block virus replication, suggesting that governments in a disease containment mode not rely too much on antiviral drugs.

“The study findings formed part of the body of growing evidence that contributed to policy change in the U.K.,” wrote the researchers, led by Aileen Kitching of the HPA London epidemiology unit and ECDC's European Program for Intervention Epidemiology Training. “Current U.K. advice is to limit antiviral prophylaxis in schools to the small number of contacts considered most at risk.”

With a stockpile of 30 million doses of antiviral medication, the United Kingdom continued its containment strategy until July 2, 3 weeks after the World Health Organization declared a global pandemic. Until July 2, British physicians were offering oseltamivir to both patients and all exposed contacts.

Researchers asked the children at one primary school and two secondary schools, or their parents, to fill out an online survey form on side effects from oseltamivir. They sought responses from 256 children, of whom 103 responded. Of the respondents, 95 were estimated to have been offered oseltamivir, and 85 took any of the medication.

Of those 85, 56 respondents (66%) said they did or would complete the full course. A gastrointestinal side effect was reported by 40% of those on the medication. Nearly 18% reported at least one mild neuropsychiatric side effect (poor concentration/unable to think clearly, problems sleeping, feeling dazed/confused, bad dreams/nightmares, strange behavior). Neuropsychiatric side effects were more commonly reported by secondary (20%) than primary (13%) schoolchildren, the report noted.

The researchers said their findings are limited by a low response rate, which occurred because they asked for a response by the end of the day via a Web link that was sent to the families.

More than half of children prescribed oseltamivir in three London schools with outbreaks of the novel virus influenza A(H1N1) experienced side effects, according to a survey.

Researchers from the British Health Protection Agency (HPA) and the European Centre for Disease Prevention and Control (ECDC) said 45 of 85 (53%) respondents prescribed prophylactic oseltamivir (Tamiflu) reported side effects from the antiviral medication (Euro. Surveill. 2009;14:19287). The most common side effect was nausea, reported in 29% of cases (25 of 85), according to the researchers.

Frequent side effects reduce compliance and raise the risk of promoting antiviral resistance if lower drug concentrations only partly block virus replication, suggesting that governments in a disease containment mode not rely too much on antiviral drugs.

“The study findings formed part of the body of growing evidence that contributed to policy change in the U.K.,” wrote the researchers, led by Aileen Kitching of the HPA London epidemiology unit and ECDC's European Program for Intervention Epidemiology Training. “Current U.K. advice is to limit antiviral prophylaxis in schools to the small number of contacts considered most at risk.”

With a stockpile of 30 million doses of antiviral medication, the United Kingdom continued its containment strategy until July 2, 3 weeks after the World Health Organization declared a global pandemic. Until July 2, British physicians were offering oseltamivir to both patients and all exposed contacts.

Researchers asked the children at one primary school and two secondary schools, or their parents, to fill out an online survey form on side effects from oseltamivir. They sought responses from 256 children, of whom 103 responded. Of the respondents, 95 were estimated to have been offered oseltamivir, and 85 took any of the medication.

Of those 85, 56 respondents (66%) said they did or would complete the full course. A gastrointestinal side effect was reported by 40% of those on the medication. Nearly 18% reported at least one mild neuropsychiatric side effect (poor concentration/unable to think clearly, problems sleeping, feeling dazed/confused, bad dreams/nightmares, strange behavior). Neuropsychiatric side effects were more commonly reported by secondary (20%) than primary (13%) schoolchildren, the report noted.

The researchers said their findings are limited by a low response rate, which occurred because they asked for a response by the end of the day via a Web link that was sent to the families.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintain a functioning health care system and prevent infection with the pandemic influenza A (H1N1) virus in people who have pre-existing illnesses, Dr. Marie-Paule Kieny, director of WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children depending on each country's domestic needs, Dr. Kieny said. For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The expert panel made its recommendations after a meeting in July, and WHO Director-General Dr. Margaret Chan, endorsed the recommendations.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an “urgent need” to collect more safety data on subgroups, Dr. Kieny said.

New adjuvants are being used in some of the pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective, according to the panel.

In addition, the panel said that data on immunogenicity and postmarketing safety and surveillance studies need to be shared among the countries to allow for adjustments in immunization policy, she said.

The panel added that countries in the Northern Hemisphere should proceed with their plans for seasonal influenza vaccination as if there were no pandemic because production of the seasonal vaccine is almost complete, Dr. Kieny added.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintain a functioning health care system and prevent infection with the pandemic influenza A (H1N1) virus in people who have pre-existing illnesses, Dr. Marie-Paule Kieny, director of WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children depending on each country's domestic needs, Dr. Kieny said. For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The expert panel made its recommendations after a meeting in July, and WHO Director-General Dr. Margaret Chan, endorsed the recommendations.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an “urgent need” to collect more safety data on subgroups, Dr. Kieny said.

New adjuvants are being used in some of the pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective, according to the panel.

In addition, the panel said that data on immunogenicity and postmarketing safety and surveillance studies need to be shared among the countries to allow for adjustments in immunization policy, she said.

The panel added that countries in the Northern Hemisphere should proceed with their plans for seasonal influenza vaccination as if there were no pandemic because production of the seasonal vaccine is almost complete, Dr. Kieny added.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintain a functioning health care system and prevent infection with the pandemic influenza A (H1N1) virus in people who have pre-existing illnesses, Dr. Marie-Paule Kieny, director of WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children depending on each country's domestic needs, Dr. Kieny said. For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The expert panel made its recommendations after a meeting in July, and WHO Director-General Dr. Margaret Chan, endorsed the recommendations.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an “urgent need” to collect more safety data on subgroups, Dr. Kieny said.

New adjuvants are being used in some of the pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective, according to the panel.

In addition, the panel said that data on immunogenicity and postmarketing safety and surveillance studies need to be shared among the countries to allow for adjustments in immunization policy, she said.

The panel added that countries in the Northern Hemisphere should proceed with their plans for seasonal influenza vaccination as if there were no pandemic because production of the seasonal vaccine is almost complete, Dr. Kieny added.

Countries with existing cases of pandemic virus influenza A(H1N1) should stop widespread laboratory testing and move to wider indicators of disease, a top World Health Organization official said.

Dr. Keiji Fukuda, the WHO's interim assistant director-general for health, security, and environment, said in a telephone press conference that eliminating laboratory testing would ease the burden on national health departments dealing with widespread outbreaks of the virus.

Tailored testing of influenza cases will assist epidemiologists in estimating the incidence of pandemic H1N1 cases in the community, Dr. Fukuda said. He said the WHO will recommend testing of unusually severe cases, unusual clusters, or unusual symptoms.

Countries without cases should continue with laboratory testing of suspected cases of the pandemic virus, he said.

Speaking on cases of oseltamivir-resistant pandemic virus H1N1, Dr. Fukuda said there is no evidence of widespread transmission of the mutated virus.

The three separate cases in Denmark, Japan, and Hong Kong appear to have the same spontaneous mutation but do not appear to have reassorted with seasonal influenza viruses, he said.

The WHO does not recommend any changes to clinical treatment protocols for oseltamivir-resistant cases, Dr. Fukuda said.

He added that the WHO and national epidemiological agencies continue to watch for more sustained transmission of the resistant virus.

Countries with existing cases of pandemic virus influenza A(H1N1) should stop widespread laboratory testing and move to wider indicators of disease, a top World Health Organization official said.

Dr. Keiji Fukuda, the WHO's interim assistant director-general for health, security, and environment, said in a telephone press conference that eliminating laboratory testing would ease the burden on national health departments dealing with widespread outbreaks of the virus.

Tailored testing of influenza cases will assist epidemiologists in estimating the incidence of pandemic H1N1 cases in the community, Dr. Fukuda said. He said the WHO will recommend testing of unusually severe cases, unusual clusters, or unusual symptoms.

Countries without cases should continue with laboratory testing of suspected cases of the pandemic virus, he said.

Speaking on cases of oseltamivir-resistant pandemic virus H1N1, Dr. Fukuda said there is no evidence of widespread transmission of the mutated virus.

The three separate cases in Denmark, Japan, and Hong Kong appear to have the same spontaneous mutation but do not appear to have reassorted with seasonal influenza viruses, he said.

The WHO does not recommend any changes to clinical treatment protocols for oseltamivir-resistant cases, Dr. Fukuda said.

He added that the WHO and national epidemiological agencies continue to watch for more sustained transmission of the resistant virus.

Countries with existing cases of pandemic virus influenza A(H1N1) should stop widespread laboratory testing and move to wider indicators of disease, a top World Health Organization official said.

Dr. Keiji Fukuda, the WHO's interim assistant director-general for health, security, and environment, said in a telephone press conference that eliminating laboratory testing would ease the burden on national health departments dealing with widespread outbreaks of the virus.

Tailored testing of influenza cases will assist epidemiologists in estimating the incidence of pandemic H1N1 cases in the community, Dr. Fukuda said. He said the WHO will recommend testing of unusually severe cases, unusual clusters, or unusual symptoms.

Countries without cases should continue with laboratory testing of suspected cases of the pandemic virus, he said.

Speaking on cases of oseltamivir-resistant pandemic virus H1N1, Dr. Fukuda said there is no evidence of widespread transmission of the mutated virus.

The three separate cases in Denmark, Japan, and Hong Kong appear to have the same spontaneous mutation but do not appear to have reassorted with seasonal influenza viruses, he said.

The WHO does not recommend any changes to clinical treatment protocols for oseltamivir-resistant cases, Dr. Fukuda said.

He added that the WHO and national epidemiological agencies continue to watch for more sustained transmission of the resistant virus.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintaining a functioning health care system and preventing infection with the pandemic influenza A(H1N1) virus in people who have preexisting illnesses, Dr. Marie-Paule Kieny, director of the WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children, depending on each country's domestic needs, Dr. Kieny said.

For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an “urgent need” to collect more safety data on subgroups, Dr. Kieny said.

New adjuvants are being used in some pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective, according to the panel.

In addition, the panel said data on immunogenicity and postmarketing safety and surveillance studies need to be shared among the countries to allow for adjustments in immunization policy, Dr. Kieny said.

The panel also recommended that countries in the Northern Hemisphere should proceed with plans for seasonal influenza vaccination as if there were no pandemic, because production of the seasonal vaccine is almost complete, according to Dr. Kieny.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintaining a functioning health care system and preventing infection with the pandemic influenza A(H1N1) virus in people who have preexisting illnesses, Dr. Marie-Paule Kieny, director of the WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children, depending on each country's domestic needs, Dr. Kieny said.

For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an “urgent need” to collect more safety data on subgroups, Dr. Kieny said.

New adjuvants are being used in some pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective, according to the panel.

In addition, the panel said data on immunogenicity and postmarketing safety and surveillance studies need to be shared among the countries to allow for adjustments in immunization policy, Dr. Kieny said.

The panel also recommended that countries in the Northern Hemisphere should proceed with plans for seasonal influenza vaccination as if there were no pandemic, because production of the seasonal vaccine is almost complete, according to Dr. Kieny.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintaining a functioning health care system and preventing infection with the pandemic influenza A(H1N1) virus in people who have preexisting illnesses, Dr. Marie-Paule Kieny, director of the WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children, depending on each country's domestic needs, Dr. Kieny said.

For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an “urgent need” to collect more safety data on subgroups, Dr. Kieny said.

New adjuvants are being used in some pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective, according to the panel.

In addition, the panel said data on immunogenicity and postmarketing safety and surveillance studies need to be shared among the countries to allow for adjustments in immunization policy, Dr. Kieny said.

The panel also recommended that countries in the Northern Hemisphere should proceed with plans for seasonal influenza vaccination as if there were no pandemic, because production of the seasonal vaccine is almost complete, according to Dr. Kieny.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintain a functioning health care system and prevent infection with the pandemic influenza A (H1N1) virus in people who have pre-existing illnesses, Dr. Marie-Paule Kieny, director of WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children depending on each country's domestic needs, Dr. Kieny said. For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an "urgent need" to collect more safety data on subgroups, Dr. Kieny said. New adjuvants are being used in some pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective.

The panel added that Northern Hemisphere countries should proceed with plans for seasonal influenza vaccination as if there were no pandemic, because production of the seasonal vaccine is almost complete, she added.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintain a functioning health care system and prevent infection with the pandemic influenza A (H1N1) virus in people who have pre-existing illnesses, Dr. Marie-Paule Kieny, director of WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children depending on each country's domestic needs, Dr. Kieny said. For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an "urgent need" to collect more safety data on subgroups, Dr. Kieny said. New adjuvants are being used in some pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective.

The panel added that Northern Hemisphere countries should proceed with plans for seasonal influenza vaccination as if there were no pandemic, because production of the seasonal vaccine is almost complete, she added.

Health care workers should be the top priority to receive immunization with the pandemic influenza vaccine, and individual countries should take their nations' domestic needs into account when determining how to prioritize inoculating subgroups vulnerable to the virus, a top international health panel has decided.

The World Health Organization's Strategic Advisory Group of Experts on Immunization has said that vaccinating health care workers is necessary to maintain a functioning health care system and prevent infection with the pandemic influenza A (H1N1) virus in people who have pre-existing illnesses, Dr. Marie-Paule Kieny, director of WHO's initiative for vaccine research, said in a press teleconference.

Countries are advised to prioritize the vaccination of such vulnerable groups as the chronically ill and children depending on each country's domestic needs, Dr. Kieny said. For example, countries whose first priority is reducing sickness and death may choose to focus on inoculating the elderly and chronically ill first, while those countries whose priority is reducing the spread of infection may decide to inoculate schoolchildren first, she said.

The panel also concluded that at this time there is no concern regarding the safety of the tested pandemic influenza vaccine, but there is still an "urgent need" to collect more safety data on subgroups, Dr. Kieny said. New adjuvants are being used in some pandemic vaccines that have not been fully tested, so postmarketing surveillance must also be effective.

The panel added that Northern Hemisphere countries should proceed with plans for seasonal influenza vaccination as if there were no pandemic, because production of the seasonal vaccine is almost complete, she added.

Aspirin and antioxidants are not effective in primary prevention of cardiovascular events in patients with diabetes and asymptomatic peripheral arterial disease, according to a Scottish clinical trial published online in BMJ.

In a multiarm interventional study, researchers in the multicenter prevention of progression of arterial disease and diabetes trial found that subjects in the two arms taking aspirin and in the two arms taking antioxidants did not experience significantly fewer myocardial infarctions, strokes, or other cardiovascular events than did subjects in placebo arms.

Aspirin in particular carries with it risks of gastrointestinal bleeding and other adverse events, so physicians may want to avoid prescribing it for primary prevention, given that it does not seem to be effective in the population studied.

“Although the calculated risk of major bleeding is relatively small, the number of people taking aspirin is relatively large, and therefore in population terms, aspirin-induced bleeding is a major problem,” said Dr. Jill Belch of the Institute of Cardiovascular Research at the University of Dundee (Scotland) and her associates. “Aspirin should, however, still be given for secondary prevention of cardiovascular disease in people with diabetes mellitus, when the evidence base is convincing, and the results of this study must not detract from this important standard of care.”

The researchers randomized 1,276 patients aged 40 years or older at 16 hospitals in Scotland. The patients had type 1 or 2 diabetes and asymptomatic peripheral artery disease; they were randomized into groups taking aspirin and antioxidants, aspirin plus a placebo, antioxidants plus a placebo, or two placebos.

The aspirin groups took 100 mg daily and the antioxidant groups took a capsule of 200 mg alpha-tocopherol, 100 mg ascorbic acid, 25 mg pyridoxine, 10 mg zinc, 10 mg nicotinamide, 9.4 mg lecithin, and 0.8 mg selenite, according to researchers. Patients were followed up every 6 months for a median of 6.7 years, for a total of 8,127 patient-years of follow-up, according to the researchers (BMJ 2008 Oct. 17 [doi:10.1136/bmj.a1840]).

The researchers selected a composite end point of death from coronary heart disease or stroke, nonfatal myocardial infarction or stroke, or above-ankle amputation for critical limb ischemia.

In the two aspirin groups, 18.2% (116 of 638) experienced one of the composite end point events, compared with 18.3% (117 of 638) in the no-aspirin groups, a nonsignificant difference. In the two antioxidant groups, 18.3% (117 of 640) experienced one of those events, compared with 18.2% (116 of 636) in the no-antioxidant groups, also a nonsignificant difference, the researchers said.

They added that one reason aspirin may have been ineffective in primary prevention is the emergence of statin therapy in the diabetic population, which was allowed as standard therapy at the discretion of investigators and other clinicians. At two of the participating centers, researchers have found a drop-off in the mean total cholesterol level of 6 mmol/L in 1996 to 4.3 mmol/L in 2007 in a total of 10,000 diabetic patients. They added that future research should consider whether aspirin provides benefit in addition to that of statins.

“Studies evaluating the possible benefits of aspirin for primary prevention in patients without cardiovascular disease have been consistently negative,” commented Dr. William R. Hiatt of the University of Colorado at Denver in an accompanying editorial (BMJ 2008 Oct. 17 [doi:10.1136/bmj.a1806]).

“The assumption is that the positive findings of aspirin in patients with symptomatic coronary or cerebrovascular disease can be extrapolated to these high-risk populations without clinical evidence of cardiovascular disease,” Dr. Hiatt said.

The researchers disclosed no conflicts of interest.

Dr. Hiatt reported having served on the Food and Drug Administration's cardiovascular and renal drugs advisory committee, which reviewed aspirin in 2003.

Aspirin and antioxidants are not effective in primary prevention of cardiovascular events in patients with diabetes and asymptomatic peripheral arterial disease, according to a Scottish clinical trial published online in BMJ.

In a multiarm interventional study, researchers in the multicenter prevention of progression of arterial disease and diabetes trial found that subjects in the two arms taking aspirin and in the two arms taking antioxidants did not experience significantly fewer myocardial infarctions, strokes, or other cardiovascular events than did subjects in placebo arms.

Aspirin in particular carries with it risks of gastrointestinal bleeding and other adverse events, so physicians may want to avoid prescribing it for primary prevention, given that it does not seem to be effective in the population studied.

“Although the calculated risk of major bleeding is relatively small, the number of people taking aspirin is relatively large, and therefore in population terms, aspirin-induced bleeding is a major problem,” said Dr. Jill Belch of the Institute of Cardiovascular Research at the University of Dundee (Scotland) and her associates. “Aspirin should, however, still be given for secondary prevention of cardiovascular disease in people with diabetes mellitus, when the evidence base is convincing, and the results of this study must not detract from this important standard of care.”

The researchers randomized 1,276 patients aged 40 years or older at 16 hospitals in Scotland. The patients had type 1 or 2 diabetes and asymptomatic peripheral artery disease; they were randomized into groups taking aspirin and antioxidants, aspirin plus a placebo, antioxidants plus a placebo, or two placebos.

The aspirin groups took 100 mg daily and the antioxidant groups took a capsule of 200 mg alpha-tocopherol, 100 mg ascorbic acid, 25 mg pyridoxine, 10 mg zinc, 10 mg nicotinamide, 9.4 mg lecithin, and 0.8 mg selenite, according to researchers. Patients were followed up every 6 months for a median of 6.7 years, for a total of 8,127 patient-years of follow-up, according to the researchers (BMJ 2008 Oct. 17 [doi:10.1136/bmj.a1840]).

The researchers selected a composite end point of death from coronary heart disease or stroke, nonfatal myocardial infarction or stroke, or above-ankle amputation for critical limb ischemia.

In the two aspirin groups, 18.2% (116 of 638) experienced one of the composite end point events, compared with 18.3% (117 of 638) in the no-aspirin groups, a nonsignificant difference. In the two antioxidant groups, 18.3% (117 of 640) experienced one of those events, compared with 18.2% (116 of 636) in the no-antioxidant groups, also a nonsignificant difference, the researchers said.

They added that one reason aspirin may have been ineffective in primary prevention is the emergence of statin therapy in the diabetic population, which was allowed as standard therapy at the discretion of investigators and other clinicians. At two of the participating centers, researchers have found a drop-off in the mean total cholesterol level of 6 mmol/L in 1996 to 4.3 mmol/L in 2007 in a total of 10,000 diabetic patients. They added that future research should consider whether aspirin provides benefit in addition to that of statins.

“Studies evaluating the possible benefits of aspirin for primary prevention in patients without cardiovascular disease have been consistently negative,” commented Dr. William R. Hiatt of the University of Colorado at Denver in an accompanying editorial (BMJ 2008 Oct. 17 [doi:10.1136/bmj.a1806]).

“The assumption is that the positive findings of aspirin in patients with symptomatic coronary or cerebrovascular disease can be extrapolated to these high-risk populations without clinical evidence of cardiovascular disease,” Dr. Hiatt said.

The researchers disclosed no conflicts of interest.

Dr. Hiatt reported having served on the Food and Drug Administration's cardiovascular and renal drugs advisory committee, which reviewed aspirin in 2003.

Aspirin and antioxidants are not effective in primary prevention of cardiovascular events in patients with diabetes and asymptomatic peripheral arterial disease, according to a Scottish clinical trial published online in BMJ.

In a multiarm interventional study, researchers in the multicenter prevention of progression of arterial disease and diabetes trial found that subjects in the two arms taking aspirin and in the two arms taking antioxidants did not experience significantly fewer myocardial infarctions, strokes, or other cardiovascular events than did subjects in placebo arms.

Aspirin in particular carries with it risks of gastrointestinal bleeding and other adverse events, so physicians may want to avoid prescribing it for primary prevention, given that it does not seem to be effective in the population studied.

“Although the calculated risk of major bleeding is relatively small, the number of people taking aspirin is relatively large, and therefore in population terms, aspirin-induced bleeding is a major problem,” said Dr. Jill Belch of the Institute of Cardiovascular Research at the University of Dundee (Scotland) and her associates. “Aspirin should, however, still be given for secondary prevention of cardiovascular disease in people with diabetes mellitus, when the evidence base is convincing, and the results of this study must not detract from this important standard of care.”

The researchers randomized 1,276 patients aged 40 years or older at 16 hospitals in Scotland. The patients had type 1 or 2 diabetes and asymptomatic peripheral artery disease; they were randomized into groups taking aspirin and antioxidants, aspirin plus a placebo, antioxidants plus a placebo, or two placebos.

The aspirin groups took 100 mg daily and the antioxidant groups took a capsule of 200 mg alpha-tocopherol, 100 mg ascorbic acid, 25 mg pyridoxine, 10 mg zinc, 10 mg nicotinamide, 9.4 mg lecithin, and 0.8 mg selenite, according to researchers. Patients were followed up every 6 months for a median of 6.7 years, for a total of 8,127 patient-years of follow-up, according to the researchers (BMJ 2008 Oct. 17 [doi:10.1136/bmj.a1840]).

The researchers selected a composite end point of death from coronary heart disease or stroke, nonfatal myocardial infarction or stroke, or above-ankle amputation for critical limb ischemia.

In the two aspirin groups, 18.2% (116 of 638) experienced one of the composite end point events, compared with 18.3% (117 of 638) in the no-aspirin groups, a nonsignificant difference. In the two antioxidant groups, 18.3% (117 of 640) experienced one of those events, compared with 18.2% (116 of 636) in the no-antioxidant groups, also a nonsignificant difference, the researchers said.

They added that one reason aspirin may have been ineffective in primary prevention is the emergence of statin therapy in the diabetic population, which was allowed as standard therapy at the discretion of investigators and other clinicians. At two of the participating centers, researchers have found a drop-off in the mean total cholesterol level of 6 mmol/L in 1996 to 4.3 mmol/L in 2007 in a total of 10,000 diabetic patients. They added that future research should consider whether aspirin provides benefit in addition to that of statins.

“Studies evaluating the possible benefits of aspirin for primary prevention in patients without cardiovascular disease have been consistently negative,” commented Dr. William R. Hiatt of the University of Colorado at Denver in an accompanying editorial (BMJ 2008 Oct. 17 [doi:10.1136/bmj.a1806]).

“The assumption is that the positive findings of aspirin in patients with symptomatic coronary or cerebrovascular disease can be extrapolated to these high-risk populations without clinical evidence of cardiovascular disease,” Dr. Hiatt said.

The researchers disclosed no conflicts of interest.

Dr. Hiatt reported having served on the Food and Drug Administration's cardiovascular and renal drugs advisory committee, which reviewed aspirin in 2003.

In an eight-nation survey of people with chronic conditions, patients in the Netherlands were most positive about their country's health care system—reporting affordable, accessible care with low rates of errors—while U.S. patients were the most likely to say their system was in need of major revision.

The study, published online, showed that patients in all nations report gaps in care when being discharged from the hospital, such as providing written care plans and follow-up care.

The survey included more than 9,000 patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States from March through May 2008. Patients had hypertension, heart disease, diabetes, arthritis, chronic lung conditions, depression, or cancer, and the share of patients with two or more conditions ranged from 51% in New Zealand to 71% in the United States, according to the survey.

The researchers, from the Commonwealth Fund, a New York-based charitable foundation, said just 9% of patients in the Netherlands called for health care restructuring, significantly less than the 33% of the respondents in the United States (Health Aff. 2008 Nov. 13 [doi 10.1377/hlthaff.28.1.w1]).

“It goes back to primary care as the core of [the Dutch] system,” Robin Osborn, vice president of the International Program in Health Policy and Practice at the Commonwealth Fund, said in a teleconference to discuss the findings. “Patients register with a doctor. There is gatekeeping. The benefit is great. Eighty percent of the patients had been with their doctors for 5 years or more.” In the United States, just 53% of subjects had been with their physicians 5 years or more.

U.S. patients faced the greatest cost and access issues, with 41% spending more than $1,000 out of pocket, significantly more than the seven other countries, with France (5%) and the United Kingdom (4%) paying the lowest.

U.S. patients were significantly more likely (43%) than those in all other countries to skip doses of prescribed medicine or not fill prescriptions because of costs.

The United States scored comparatively well on care when patients transition from hospital care to the community. In the United States, 38% of hospital patients reported deficiencies; the highest rate was in France, with 71% of hospital patients reporting gaps, the report said.

The United States scored well on waiting times, the researchers found. Of patients needing to see a specialist, 74% waited less than 4 weeks, with Germany (68%) and the Netherlands (69%) also having short waits. Forty-two percent of Canadians reported waits of 2 months or longer, significantly higher than all other countries, according to the survey.

In an eight-nation survey of people with chronic conditions, patients in the Netherlands were most positive about their country's health care system—reporting affordable, accessible care with low rates of errors—while U.S. patients were the most likely to say their system was in need of major revision.

The study, published online, showed that patients in all nations report gaps in care when being discharged from the hospital, such as providing written care plans and follow-up care.

The survey included more than 9,000 patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States from March through May 2008. Patients had hypertension, heart disease, diabetes, arthritis, chronic lung conditions, depression, or cancer, and the share of patients with two or more conditions ranged from 51% in New Zealand to 71% in the United States, according to the survey.

The researchers, from the Commonwealth Fund, a New York-based charitable foundation, said just 9% of patients in the Netherlands called for health care restructuring, significantly less than the 33% of the respondents in the United States (Health Aff. 2008 Nov. 13 [doi 10.1377/hlthaff.28.1.w1]).

“It goes back to primary care as the core of [the Dutch] system,” Robin Osborn, vice president of the International Program in Health Policy and Practice at the Commonwealth Fund, said in a teleconference to discuss the findings. “Patients register with a doctor. There is gatekeeping. The benefit is great. Eighty percent of the patients had been with their doctors for 5 years or more.” In the United States, just 53% of subjects had been with their physicians 5 years or more.

U.S. patients faced the greatest cost and access issues, with 41% spending more than $1,000 out of pocket, significantly more than the seven other countries, with France (5%) and the United Kingdom (4%) paying the lowest.

U.S. patients were significantly more likely (43%) than those in all other countries to skip doses of prescribed medicine or not fill prescriptions because of costs.

The United States scored comparatively well on care when patients transition from hospital care to the community. In the United States, 38% of hospital patients reported deficiencies; the highest rate was in France, with 71% of hospital patients reporting gaps, the report said.

The United States scored well on waiting times, the researchers found. Of patients needing to see a specialist, 74% waited less than 4 weeks, with Germany (68%) and the Netherlands (69%) also having short waits. Forty-two percent of Canadians reported waits of 2 months or longer, significantly higher than all other countries, according to the survey.

In an eight-nation survey of people with chronic conditions, patients in the Netherlands were most positive about their country's health care system—reporting affordable, accessible care with low rates of errors—while U.S. patients were the most likely to say their system was in need of major revision.

The study, published online, showed that patients in all nations report gaps in care when being discharged from the hospital, such as providing written care plans and follow-up care.

The survey included more than 9,000 patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States from March through May 2008. Patients had hypertension, heart disease, diabetes, arthritis, chronic lung conditions, depression, or cancer, and the share of patients with two or more conditions ranged from 51% in New Zealand to 71% in the United States, according to the survey.

The researchers, from the Commonwealth Fund, a New York-based charitable foundation, said just 9% of patients in the Netherlands called for health care restructuring, significantly less than the 33% of the respondents in the United States (Health Aff. 2008 Nov. 13 [doi 10.1377/hlthaff.28.1.w1]).

“It goes back to primary care as the core of [the Dutch] system,” Robin Osborn, vice president of the International Program in Health Policy and Practice at the Commonwealth Fund, said in a teleconference to discuss the findings. “Patients register with a doctor. There is gatekeeping. The benefit is great. Eighty percent of the patients had been with their doctors for 5 years or more.” In the United States, just 53% of subjects had been with their physicians 5 years or more.

U.S. patients faced the greatest cost and access issues, with 41% spending more than $1,000 out of pocket, significantly more than the seven other countries, with France (5%) and the United Kingdom (4%) paying the lowest.

U.S. patients were significantly more likely (43%) than those in all other countries to skip doses of prescribed medicine or not fill prescriptions because of costs.

The United States scored comparatively well on care when patients transition from hospital care to the community. In the United States, 38% of hospital patients reported deficiencies; the highest rate was in France, with 71% of hospital patients reporting gaps, the report said.

The United States scored well on waiting times, the researchers found. Of patients needing to see a specialist, 74% waited less than 4 weeks, with Germany (68%) and the Netherlands (69%) also having short waits. Forty-two percent of Canadians reported waits of 2 months or longer, significantly higher than all other countries, according to the survey.