Geographical variations in deaths related to drug misuse in England and Wales, 1993-2006

Drug misuse is a significant public health issue in England and Wales. This article examines geographical variations in drug misuse mortality in England and Wales over the period 1993 t 2006. Geographical variations in deaths related to drug misuse have generally persisted over this period, one of substantial change in these deaths (with a peak in 2001 and numbers in 2006 being almost double those in 1993), although there were some significant changes to the regional level pattern. The regions with the highest mortality rates aggregated over the whole time period were the North West, Yorkshire and The Humber, and London, although by 2004/06 the rate in London was among the lowest and the rate in the North East was higher than the North West. Three Drug Action Teams (DATs), Brighton and Hove, Blackpool, and Camden, consistently had the highest drug misuse mortality rates. Urban areas tended to have the highest rates, but the rate in the most sparsely populated areas was similar to those of towns. The mortality rate in the most deprived parts of England and Wales was five times the rate in the least deprived areas. Areas with low rates were generally large, mostly rural areas, as well as areas in outer London and the south east of England.

Paracetamol (acetaminophen) pack size restrictions and poisoning severity: time trends in enquiries to a UK poisons centre

BACKGROUND AND OBJECTIVE

In September 1998, legislation was introduced in the United Kingdom to limit paracetamol pack sizes to 16 tablets of 500 mg at general sales outlets and 32 tablets of 500 mg at pharmacies. The effect of the regulations on severity of paracetamol poisoning is unclear. The aim of this study was to describe trends in the severity of paracetamol poisoning and to assess the impact of the 1998 Regulations on the enquiries to a UK poisons centre.

METHODS

We extracted data about the age, sex and number of tablets or capsules of paracetamol ingested by patients notified to Guy's and St Thomas' Poisons Unit (London, UK) between 1996 and 2004.

RESULTS AND DISCUSSION

During the study period, there were approximately 140 000 patients with suspected paracetamol poisoning, accounting for around 11% of all patients reported to the poisons unit. The median number of tablets fell from 25 to 20 for males and 20 to 16 for females after 1998. There was also a reduction in the proportion of patients who ingested 17-32 tablets (from 36% to 30%) and 33-100 tablets (from 25% to 19%).

CONCLUSION

Following the 1998 Regulations there was a decline in the severity, but not frequency, of paracetamol poisoning cases reported to Guy's and St Thomas' Poisons Unit. It is unclear whether the decline in severity was a direct consequence of the regulations.

Public information needs after the poisoning of Alexander Litvinenko with polonium-210 in London: cross sectional telephone survey and qualitative analysis

OBJECTIVES

To identify public perceptions of the risk to health after the poisoning of Alexander Litvinenko with polonium-210 (210Po) in London and to assess the impact of public health communications.

DESIGN

Cross sectional telephone survey and qualitative interviews.

SETTING

London, United Kingdom.

PARTICIPANTS

1000 people completed the cross sectional survey and 86 potentially exposed people completed the qualitative interviews.

MAIN OUTCOME MEASURES

Perception of risk to personal health after the 210Po incident. Qualitative interviews were analysed with an emphasis on information needs.

RESULTS

11.7% of the survey sample (n=117) perceived their health to be at risk. Aside from personal variables the main predictors of perceived risk to health were believing that the incident was related to terrorism (odds ratio 2.7, 95% confidence interval 1.5 to 4.6) rather than to espionage, that it was targeted at the wider public rather than one person (5.9, 3.2 to 10.9), and that it could affect people who had not been in the contaminated area (3.2, 2.1 to 5.1). Participants in the qualitative interviews were generally satisfied with the information they had received, although they would have preferred more information about their individual risk of exposure, the results of their urine tests, and the health implications of the incident.

CONCLUSIONS

Perceptions of the public that the 210Po incident in London in 2006 was related to espionage helped to reassure them that the risks to personal health were low. In the event of future incidents it is important to ensure that detailed, comprehensible information about the risks of any exposure is available.

Outbreak of Salmonella Enteritidis phage type 13a: case-control investigation in Hertsmere, United Kingdom

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Outbreak of measles among Irish Travellers in England, March to May 2007

The Health Protection Agency (HPA) in England has been investigating an outbreak of measles in the Irish Traveller community. Between 23 March and 26 May 2007, 92 cases have been reported from six of England’s nine regions: London, East of England, South East, South West, East Midlands, and Yorkshire and the Humber.

Legionnaires' disease: when an 'outbreak' is not an outbreak

During August 2006, there was a large increase in non-travel related legionella cases throughout England and in the Netherlands.

Association between availability of heroin and methadone and fatal poisoning in England and Wales 1993–2004

BACKGROUND

The UK heroin market is the biggest in Europe and approximately 70% of heroin deaths are due to fatal poisoning. Methadone treatment for heroin addiction in the UK, the 'British system', is unique as it is largely provided by General Practitioners.

METHODS

The Office for National Statistics provided data on deaths, the Home Office provided law enforcement data on drug seizures and the Department of Health data on prescriptions. For methadone treatment we calculated the death rate per 1000 patient years. We used Spearman's rank correlation to assess the association between illicit drug seizures for heroin and methadone and deaths.

RESULTS

Between 1993 and 2004 there were 7072 deaths involving heroin/morphine (86% males) and 3298 deaths involving methadone (83% male). From 1993-1997, directly age-standardized mortality rates for males were similar for both drugs, increasing from approximately 5 to 15 per million. Mortality rates for heroin continued to increase until 2000, subsequently decreasing from 30 to 20 per million by 2003, and rising again to 24 per million in 2004. In contrast, mortality rates for methadone decreased between 1997 and 2004 to just above 1993 levels. Among females the mortality rate for both drugs was lower than for males throughout the study period, remaining relatively stable. Methadone deaths per 1000 patient years remained similar between 1993 and 1997, after which they fell by three quarters. For both heroin/morphine and methadone, deaths were strongly associated with seizures (Spearmans' coefficient for males: heroin, P = 0.95, P < 0.001 and methadone, P = 0.83, P = 0.0013).

CONCLUSIONS

Our study suggests the 'British System' can deliver substantial expansion of treatment without increased mortality risk. The fall in heroin/morphine deaths since 2000 may also be an indication of success of increasing methadone treatment. Data on mortality risk is needed to determine whether increased methadone treatment has reduced drug-related deaths.

Trends in deaths related to drug misuse in England and Wales, 1993-2004

In this article we report trends in deaths related to drug misuse in England and Wales from 1993 to 2004, looking particularly at the period between 1999 and 2004, for which there was a Government target to reduce these deaths by 20 per cent. Although there was an overall decline in deaths related to drug misuse between 1999 and 2004, the percentage reduction, at 9 per cent, was less than the Government target. There was an increase in deaths between 2003 and 2004, largely accounted for by deaths involving heroin/methadone and morphine. Mortality rates were highest in young adults and an increase in mortality rates within this group appears to have been the driver behind rising mortality trends during the 1990s.

Measuring deprivation in England and Wales using 2001 Carstairs scores

Carstairs scores, first calculated in the 1980s based on data from the 1981 Census, were designed as a summary measure of relative deprivation within small populations. They were based on four indicators from the census which were considered to represent material disadvantage, and have since been widely used to examine the relationship between deprivation and health. This article describes how Carstairs scores were calculated for England and Wales based on data from the 2001 Census and also presents the resulting geographical patterns of deprivation.

Dispelling disaster myths about dead bodies and disease: the role of scientific evidence and the media

For decades, after nearly every natural disaster, fear of disease has encouraged communities, local authorities, and governments to rapidly dispose of the bodies of the victims without first identifying them. In May 2004 this journal published the first-ever review article to comprehensively assess the scientific evidence on the infectious disease risks of dead bodies following natural disasters, along with an editorial commenting on the persistence of myths concerning the dangers allegedly posed by dead bodies. This paper assesses the impact that the review article and the editorial have had on the way that health risks from dead bodies have been reported by the media over the following year, especially focusing on the South Asian tsunami disaster of December 2004. While some media outlets have reported erroneous information, hundreds of other news stories have accurately reported that dead bodies pose no public health risk, and have explained the priority for properly identifying the deceased. Nevertheless, publication of scientific evidence alone is insufficient to bring about public health action. International agencies need to continue their work on producing standards, guidelines, and practical guidance on managing dead bodies. There needs to be a community-centered approach to informing communities about the management of the dead following disasters and the rights of individuals to be treated respectfully after death. Nongovernmental organizations should be encouraged to provide expertise and technical support in identifying and burying large numbers of dead. There also needs to be ongoing assessment of the technical processes involved in the recovery, identification, and disposal of dead bodies, as well as the effectiveness of disaster preparedness plans and communication with the affected population.

Revisiting the tsunami: health consequences of flooding

Morgan and colleagues critically review the evidence on the health consequences of flooding disasters, and consider what interventions are appropriate.

Approaches to increase physical activity: reviewing the evidence for exercise-referral schemes

OBJECTIVE

To review current evidence of effectiveness for exercise-referral schemes.

METHODS

Studies were identified from MEDLINE 1966-2002, EMBASE 1980-2002 and CINHAL 1982-2002 and bibliographies of relevant papers.

INCLUSION CRITERIA

Interventions providing access to exercise activities and/or facilities, experimental or quasi-experimental studies, studies with a control group, interventions based in a primary care setting, and interventions including an exercise component with measures of physical activity levels.

CONCLUSIONS

Exercise-referral schemes appear to increase physical activity levels in certain populations, namely individuals who are not sedentary but already slightly active, older adults and those who are overweight (but not obese). However, increases in the level of physical activity may not be sustained over time. Further studies are required to assess effectiveness in a range of populations and for different activities, and to find strategies to increase long-term adherence.

Restricting paracetamol in the United Kingdom to reduce poisoning: a systematic review

BACKGROUND

Paracetamol poisoning is implicated in about 150-200 poisoning deaths per year in England and Wales. We review previous studies assessing the effectiveness of regulations introduced in 1998 to restrict sales of paracetamol and reduce paracetamol poisoning.

METHODS

We searched the following electronic databases: MEDLINE, EMBASE, CINHAL, HIMIC, COCH, APC, CENTRAL and DARE. English language publications between 1998 and 2003 were included. Studies were included if they took place in the United Kingdom and assessed changes in any aspect of paracetamol poisoning following the introduction of the 1998 regulations.

RESULTS

Twelve studies were identified, which examined several different outcomes. Three studies examined admissions to liver transplant units; all reported reductions. Eight studies evaluated severity of paracetamol poisoning; three reported reductions but five did not. Five out of six studies reported reductions in hospital admissions. One study reported reduced mortality in England and Wales after 1 year while another found no difference in Scotland 2 years after the regulations were introduced. Two studies observed a significant reduction in over-the-counter sales. Studies suffered from several limitations including short follow-up periods, no case definition for paracetamol poisoning and lack of comparison groups.

CONCLUSIONS

The limitations of these studies makes it difficult to draw firm conclusions. They do, however, suggest that the 1998 regulations may have been associated with reduced admissions to liver units and liver transplants, reduced hospital attendance due to paracetamol poisoning and reduced sales of paracetamol. Further research is needed to fully evaluate the impact of the 1998 regulations. In the future, formal evaluation of the impact of similar interventions should be an integral part of policy formation.

Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study

BACKGROUND

About 500 drug poisoning deaths involving paracetamol (acetaminophen) occur every year in England and Wales. To reduce the number of deaths, regulations were introduced in 1998 to restrict the sale of paracetamol. In this paper, we evaluate the impact of these regulations.

METHODS

Mortality data for England and Wales were provided by the Office for National Statistics. Deaths were defined as due to compound paracetamol (paracetamol in combination with another analgesic, a low dose opioid or other ingredients) or paracetamol only, with or without alcohol or other drugs. The Department of Health provided data on all hospital admissions with a primary diagnosis of paracetamol poisoning.

RESULTS

Mortality rates for paracetamol only were similar for males and females, and decreased from about 4.5 to 2.8 per million between 1997 and 1999 and again from about 3.1 to 2.2 per million between 2001 and 2002. These falls may be attributable to random variation in the rates. Deaths involving compound paracetamol, which were not subject to the 1998 regulations, remained relatively constant over the study period. There was evidence of a decreasing trend in paracetamol only mortality rates and this followed overall trends for other drug poisoning excluding opioids and drugs of misuse. Hospital admissions due to paracetamol poisoning increased from about 27 000 to 33 000 between 1995/1996 and 1997/1998 and then decreased to 25 000 in 2001/2002. There were almost 50 per cent more admissions for females than males, with the highest admission rates amongst females aged 15-24 years old.

CONCLUSIONS

Between 1993 and 2002, mortality rates and hospital admissions due to paracetamol poisoning declined. However, the contribution of the 1998 regulations to this decline is not clear. Paracetamol poisoning continues to be an important public health issue in England and Wales and represents significant workload for the NHS in England.

Geographical variations in fatal poisoning due to antidepressant drugs in England and Wales 1993-2003

This article examines geographical variations in fatal poisoning due to antidepressant drugs in England and Wales between 1993 and 2003. The analysis looks at mortality rates for Government Office Regions and Wales and Strategic Health Authorities in England. Mortality rates were also considered in relation to antidepressant prescribing and deprivation. Throughout England and Wales, mortality rates due to antidepressant poisoning varied by area (Government Office Region and Strategic Health Authority), and were positively associated with area deprivation.

Infectious disease risks from dead bodies following natural disasters

OBJECTIVE

To review existing literature to assess the risks of infection from dead bodies after a natural disaster occurs, including who is most at risk, what precautions should be taken, and how to safely dispose of the bodies.

METHODS

Disease transmission requires the presence of an infectious agent, exposure to that agent, and a susceptible host. These elements were considered to characterize the infectious disease risk from dead bodies. Using the PubMed on-line databases of the National Library of Medicine of the United States of America, searching was done for relevant literature on the infection risks for public safety workers and funeral workers as well as for guidelines for the management of the dead and prevention of infection. A small but significant literature was also reviewed regarding the disposal of the dead and the contamination of groundwater by cemeteries.

RESULTS

Victims of natural disasters usually die from trauma and are unlikely to have acute or "epidemic-causing" infections. This indicates that the risk that dead bodies pose for the public is extremely small. However, persons who are involved in close contact with the dead-such as military personnel, rescue workers, volunteers, and others-may be exposed to chronic infectious hazards, including hepatitis B virus, hepatitis C virus, HIV, enteric pathogens, and Mycobacterium tuberculosis. Suitable precautions for these persons include training, use of body bags and disposable gloves, good hygiene practice, and vaccination for hepatitis B and tuberculosis. Disposal of bodies should respect local custom and practice where possible. When there are large numbers of victims, burial is likely to be the most appropriate method of disposal. There is little evidence of microbiological contamination of groundwater from burial.

CONCLUSIONS

Concern that dead bodies are infectious can be considered a "natural" reaction by persons wanting to protect themselves from disease. However, clear information about the risks is needed so that responsible local authorities ensure that the bodies of disaster victims are handled appropriately and with due respect. This paper provides a source of information for those who are in the unfortunate position of managing those bodies.