Global assessment of El Niño's disaster burden

BACKGROUND

Natural disasters have profound effects on health and require medical intervention as part of relief operations. The world's populations are becoming increasingly vulnerable to extreme weather events, which are responsible for most natural disasters. The El Niño Southern Oscillation (ENSO) is the most prominent global climate system associated with year-to-year weather variability and extreme events. We have estimated the burden on human health of natural disasters associated with ENSO.

METHODS

We used time-series regression analysis of the relation between El Niño years and the annual rates of persons affected by natural disasters per 1000 population during 1964-93, globally and also by region and disaster type. Correlations between sea-surface temperature (SST) anomalies (index of ENSO) and the rates of persons affected by natural disasters per 1000 population were determined globally, by region and by disaster type.

FINDINGS

The rate of persons affected by natural disasters worldwide is strongly associated with ENSO; rates are greater during the first El Niño year (p = 0.05) and the following year (p = 0.01) than in the pre-Niño year. The correlation between rates of persons affected by natural disasters and SST anomalies in the Eastern Pacific (a key ENSO indicator) is highest in the last quarter of the previous year (r = 0.53, p < 0.01). These associations are strongest in South Asia, the region where more than 50% of all disaster victims live. Worldwide, rates of persons affected by drought/famine (half of all disaster victims) and by volcanic eruptions show significant associations with the ENSO cycle, being highest in the post-Niño year and El Niño year, respectively, and being significantly associated with SST anomalies.

INTERPRETATION

The strong relation between ENSO and populations affected by natural disasters can be described as a "natural disaster cycle". Determining the phase in this cycle, using SST from the Eastern Equatorial Pacific, could benefit disaster preparedness on a global scale, for South Asia in particular, and for all populations affected by drought/famine and volcanic disasters.

Thunderstorm-associated asthma: the effect on GP consultations

Evidence shows that asthma attacks can be brought on by adverse weather conditions such as those experienced during a thunderstorm; a prime example of such an occasion being a thunderstorm episode on 24 June 1994, which resulted in a well-documented increase in medical attendances made by those suffering with asthma and respiratory disorders. However, most of these studies have concerned admissions to accident and emergency departments. The aim of this paper was to ascertain whether a similar increase in consultations was observed in the primary care setting.

Promoting clinically effective practice: general practitioners' awareness of sources of research evidence

BACKGROUND

Practitioners are being encouraged to base their clinical practice on research evidence. In order to do this, they must be aware of and use the sources of evidence.

METHODS

A questionnaire survey was undertaken to establish GPs' awareness of research evidence in their clinical practice and, in fundholding practices, its influence on purchasing plans. Questionnaires were sent to 360 lead fundholders in North Thames Region and 440 of a random sample of the remaining general practitioners in the region for comparison.

RESULTS

Questionnaires were returned by 62% of lead fundholders and 63% of GPs in the random sample. There was limited use of the electronic sources of clinical effectiveness. There was greater reported awareness of published sources of research evidence and fundholding GPs were significantly more likely to have referred to publications summarizing research evidence.

CONCLUSIONS

GPs seem to make more use of published clinical effectiveness sources than the electronic databases. Consequently, they need educational and technical support if they are to make full use of the available sources of research evidence available in other media.

Comparison of two methods of screening for genital chlamydial infection in women attending in general practice: cross sectional survey

OBJECTIVES

To estimate the prevalence of Chlamydia trachomatis in asymptomatic women attending general practice: to assess the potential of the ligase chain reaction as a screening tool; and to evaluate selective screening criteria.

DESIGN

Cross sectional survey.

SETTING

Four general practices in northeast London.

SUBJECTS

890 women aged 18-35 years attending general practice for a cervical smear or a "young well woman" check between October 1994 and January 1996. The women were tested for C trachomatis with confirmed enzyme immunoassay (endocervical specimens) and ligase chain reaction assay on urine specimens.

MAIN OUTCOME MEASURES

Prevalence of C trachomatis infection in women aged 18-35 on the basis of each test; sensitivity and specificity of both tests in this population.

RESULTS

Prevalence of confirmed infection was 2.6% (95% confidence interval 1.6% to 3.6%) in all women. Prevalence on the basis of enzyme immunoassay was 1.6% (0.8% to 2.7%), with a sensitivity of 60% and a specificity of 100%. Prevalence on the basis of ligase chain reaction was 2.5% (1.5% to 3.9%), with 90% sensitivity and 99.8% specificity. Screening all women aged < or = 25 and all women who had had two or more partners in the past year would have detected 87% (20/23) of infections.

CONCLUSION

Ligase chain reaction on urine samples performs at least as well as enzyme immunoassay on cervical specimens in this low prevalence population. It offers potential as a non-invasive screening tool. A simple selective screening strategy might be appropriate and would be able to detect most cases of infection. However, a rigorous economic evaluation of possible screening strategies is needed first.

A randomized trial of the impact of telephone and recorded delivery reminders on the response rate to research questionnaires

BACKGROUND

A range of factors have been shown to affect the response rate to mailed questionnaires, but particular strategies to improve patients' response in trials conducted in general practice require further study.

METHODS

Non-responders in a larger trial were randomized to receive a telephone or recorded delivery reminder on the third contact. The cost of administration of each method was estimated.

RESULTS

Significantly more patients returned completed questionnaires when sent questionnaires by recorded delivery, although the cost per patient contacted was nearly three times more than for contact by telephone.

CONCLUSION

Our study indicates that sending reminders by recorded delivery, although more expensive, is more effective than telephone reminders for recruiting patients to a study in general practice using research questionnaires.

Promoting clinical effective practice. Attitudes of fundholding general practitioners to the role of commissioning

Aims to evaluate the acceptability of commissioning to improve clinical effectiveness in secondary care and explore the conditions under which fundholders would be willing to use commissioning in this way. Describes how fundholders in two contrasting districts in North Thames Region were interviewed in 1995-1996. Respondents were selected from a list of all fundholders in the district with few fundholding practices and from lists of fundholders holding contracts with specified hospitals in the district with many fundholders. Interviews were analysed using the constant comparison method of content analysis. All fundholders in the districts were eligible. The sample represented a broad range of fundholders, containing all fundholding waves and large and small practices. Managers and general practitioners from multifunds outside the districts were also interviewed to assess whether they faced different issues from single practice fundholders. Many respondents felt unable to use commissioning to improve clinically effectiveness despite their awareness of the policy. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use fundholding to challenge hospital practice. Respondents from early wave fundholding practices and those with training in critically appraising research literature expressed more readiness to review research evidence, but only a few early wave fundholders said they would consider evidence-based commissioning. Concludes that steps should be taken to educate fundholders in clinical effectiveness and provide appropriate information to them. Also, they must be persuaded that clinical effectiveness is not a politically-driven policy or they will resist it.

The science of perpetual change

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Setting priorities for research and development in the NHS: a case study on the interface between primary and secondary care

Since 1991 the NHS has attempted to identify and prioritise its needs for research and development in a systematic manner. This has not been done before and there is little evidence on which to draw. Multidisciplinary expert groups have identified priorities in different topics using explicit criteria and after widespread consultation within the NHS and research community to identify pressing problems and opportunities for research. This paper focuses on a review completed in 1993 to identify research and development priorities for the NHS in relation to the interface between primary and secondary care. The review covered several recent developments which require evaluation. The authors describe the process used to identify research and development priorities in this complex subject and examine the strengths and weaknesses of the approach. This case study should help to stimulate a wider debate on methods of identifying priorities, particularly those using participatory approaches, in research and non-research contexts.

Commissioning a national programme of research and development on the interface between primary and secondary care

The first call for applications to the NHS research and development programme on the interface between primary and secondary care was advertised in February 1994. A total of 674 outline proposals were submitted and 54 (8%) secured funding. Projects have been commissioned in 16 of the 21 priority areas and around 6m pounds has been committed. Analysis shows that multidisciplinary applications are more likely to be funded and that the odds for a successful application are on average nearly doubled for each discipline represented up to five. A survey of applicants and peer reviewers found satisfaction with much of the commissioning process, but peer review and feedback were subject to criticism, particularly by unsuccessful applicants. The programme shows that it is possible to commission a large number of projects in an innovative area of research and development and has identified refinements that will further increase the efficiency and acceptability of the process.

The potential health impacts of climate change: an overview

Climate change would have a range of impacts on human health. Health impacts would be caused by the direct effect of climatic factors on human health, such as heat stress, and possible changes in the frequency and intensity of extreme weather events such as storms, floods and droughts. Impacts on health would also be mediated by the indirect effects of climate change, such as changes in availability of food and water and the distribution of vector-borne diseases. The majority of health impacts would be adverse and would depend greatly on the vulnerability of populations.