Ascaris suum - A zoonosis in Bali, Indonesia

Background

Ascariasis is a common disease in humans and pigs. In previous reports, it has been known that ascariasis in humans is not only caused by Ascaris lumbricoides but also by Ascaris suum which is known to originate from pigs.

Aims and Objectives

This research aims to identify the species of Ascaris that infect traditional pig farmers in Bali, Indonesia.

Materials and Methods

To achieve this, an observational study was conducted, in which 239 feces samples were collected from traditional pig farmers. The collected samples were then divided into two parts, with one part stored in a pot containing 10% formalin for microscopic testing, and the other part stored in 70% ethanol for molecular testing. In cases where Ascaris infection was observed during the microscopic examination, a further test was conducted using the polymerase chain reaction (PCR) method for molecular examination. The DNA derived from the PCR was then subjected to DNA sequencing.

Results

The result was compared to A. suum gene data previously published in the Gene Bank. The results of the microscopic examination showed that 22 farmers were infected with Ascaris. However, PCR testing and DNA sequencing indicated that three infections were caused by A. suum.

Conclusion

Therefore, it can be concluded that A. suum is a zoonosis in Bali. Thus, efforts to control ascariasis must pay attention to the presence of pigs around it. Handling of ascariasis is not only carried out in humans but also in pigs and the environment.

The silent, rapidly unfolding threat of mpox spread via international travel to Southeast Asia: Are we ready?

The 2022 mpox (monkeypox) outbreak has been surprisingly large and has raised several novel questions about this disease. New information, such as atypical clinical manifestations and transmission via sexual activities, have been identified. These pose a potential risk of widespread outbreaks due to unusual clinical manifestations and failure to consider mpox as a diagnosis by physicians and the sexual behaviours of some tourists in Southeast Asia. Since Southeast Asia is a popular tourist destination, there is substantial potential for the silent spread of mpox in this region. Consequently, there is an urgent need for effective surveillance measures at points of entry of international travelers to identify suspected cases and their close contacts in order to limit the spread of mpox in Southeast Asia.

Diagnostic test of Immature Granulocyte Ratio (IG Ratio) to detect Early-Onset Neonatal Sepsis (EONS)

Background: Based on the onset of events, the most common neonatal sepsis is early-onset neonatal sepsis (EONS), which occurs within the first 72 hours of life. Blood culture is the gold standard for EONS, but this examination takes a long time to provide the results. However, the latest method is obtained to determine the shift to the left granulocytic image by counting Immature Granulocyte (IG). This study aims to evaluate the accuracy of the IG Ratio for diagnosing EONS in neonates suspected of having sepsis. Methods: A cross-sectional observational study was conducted among 60 EONS patients consecutively, who met the inclusion criteria from January to June 2022 at Prof. dr. I.G.N.G Ngoerah Hospital, Bali. Variables assessed in this study included age, gender, delivery methods, birth status, birthweight, blood culture, complete blood count (CBC), I/T ratio, and IG ratio. Data were analyzed using SPSS version 23 for Windows. Results: The cut-off point of the IG Ratio was 2.21 (AUC=0.670 (0,490-0,851); p=0.041; OR: 8.021 (2.283-28.185); p=0.001), which had a sensitivity of 64.7% and a specificity of 81.4% for diagnosing EONS in neonates suspected of having sepsis. The results also obtained a Negative Predictive Value (NPV) of 85.35 and a Positive Predictive Value (PPV) of 57.89. Conclusion: The cut-off point of the IG Ratio of 2.21 has a risk factor of 8.021 times higher for diagnosing EONS in neonates with sepsis.

The first report on the prevalence of soil-transmitted helminth infections and associated risk factors among traditional pig farmers in Bali Province, Indonesia

Background and Aim:

Pigs are the main livestock commodity in Bali Province, Indonesia, where traditional farming practices are widely used. Traditional pig farmers are often closely associated with poverty and a perceived lack of knowledge regarding health and hygiene. Data on soil-transmitted helminthiasis (STH) and risk factors associated with STH worm infection among traditional pig farmers in Bali were previously unavailable. This study aimed to analyze the prevalence and risk factors for STH infections among traditional pig farmers in Bali Province, Indonesia.

Materials and Methods:

This study involved the fecal examination of 238 traditional pig farmers from all areas of Bali Province in Indonesia. In addition, several pig feces samples were combined into one pooled sample belonging to each farm. All fresh fecal samples were stored in a 5% formaldehyde solution before being analyzed using concentration flotation techniques. Subsequently, risk factors were determined through an interview and a questionnaire. The odds ratio (OR) and Chi-square tests were used to determine the risk factors associated with STH infections.

Results:

The result showed that there was a high prevalence of STH infections among traditional pig farmers and pig farms in Bali, with rates of 21.8% and 76.5%, respectively. This could be due to risk factors, such as personal hygiene (OR: 5.756; confidence interval [CI]: 2.96-11.193; p=0.00), sanitation (OR: 1.914; CI: 1.024-3.576; p=0.042), education level (OR: 7.579; CI: 2.621-21.915; p=0.00), household income (OR: 2.447; CI: 1.122-5.338; p=0.025), and occupation (OR: 2.95; CI: 1.356-6.415; p=0.006).

Conclusion:

The infections seen in farmers were distributed among hookworm, Ascaris spp., and Trichuris spp., at 15.1%, 9.2%, and 4.2%, respectively. The risk factors associated with infections of STH and Ascaris spp. were personal hygiene, home sanitation, education level, household income, and having a primary occupation as a traditional pig farmer. In contrast, personal hygiene, education level, and primary occupation were the only risk factors for hookworm infection, while personal hygiene and home sanitation were the risk factors associated with Trichuris spp. infection. The limitation of this study was that the number of samples was relatively small due to the difficulty of obtaining stool samples from traditional pig farmers, with many individuals refusing to provide their stool for inspection. We suggest that future research focus on identifying the species of worms that infect traditional pig farmers and to better identify the zoonotic link of STH transmission from pigs to humans.

The effect of an application-based educational intervention with a social cognitive theory model on pregnant women in Denpasar, Bali, Indonesia: a randomized controlled trial

Objectives

The aim of this study was to elucidate the effect of application-based antenatal education based on social cognitive theory (SCT) on Health Promoting Lifestyle Profile II (HPLP II) scores, compliance with iron tablet consumption, and readiness for childbirth and complications among pregnant women in Denpasar, Bali, Indonesia.

Methods

This randomized controlled trial included 71 pregnant women in the treatment group and 74 pregnant women in the control group. The treatment group application-based antenatal education based on SCT, while the control group attended a conventional pregnancy class. Iron tablet consumption was verified by counting the remaining iron tablets. Information on participants’ lifestyles was collected using the HPLP II questionnaire with the help of an assistant. The collected data were statistically analyzed using IBM SPSS ver. 24.0.

Results

The antenatal education intervention effectively increased the HPLP II score by 0.32 points (2.62±0.331 before the intervention and 2.94±0.273 after). Meanwhile, the control group had a 0.13-point increase (p=0.001), from 2.67±0.336 to 2.80±0.275. There was no significant difference in iron tablet consumption (p=0.333) or readiness for delivery and complications (p=0.557) between the treatment and control groups.

Conclusion

Application-based antenatal education with SCT effectively increased the HPLP II scores of pregnant women in Denpasar, Bali. Although there was no significant difference in iron tablet consumption or readiness for delivery and complications, the values increased to a greater extent in the treatment group than in the control group. This education model is more suited to urban pregnant women who employed and have good internet access.

A Health Belief Model-Based Motivational Interviewing for Medication Adherence and Treatment Success in Pulmonary Tuberculosis Patients

Medication adherence behavior plays a central role in the success of tuberculosis (TB) treatment. Conventional motivation is not optimal in strengthening long-term medication adherence. A motivational interviewing (MI) communication motivation model based on the Health Belief Model (HBM) was designed with the main objective of improving medication adherence and treatment success. This study used an experimental design with a randomized posttest-only control group design. The intervention and control groups consisted of 107 TB patients each, who were selected by random cluster sampling. The study was conducted from November 2020 to June 2021 at 38 public health centers in Bali Province. The HBM-based MI model intervention was given in seven counseling sessions, pill count percentages were used to measure medication adherence, and treatment success was based on sputum examination results. Logistic regression was used to assess the effect of the intervention on medication adherence and treatment success. Logistic regression analysis showed that MI-based HBM and knowledge were the most influential variables for increasing medication adherence and treatment success. Medication adherence was 4.5 times greater (ARR = 4.51, p = 0.018) and treatment success was 3.8 times greater (ARR = 3.81, p < 0.038) in the intervention group compared to the control group, while the secondary outcome of knowledge of other factors together influenced medication adherence and treatment success. The conclusion is that the HBM-based MI communication motivation model creates a patient-centered relationship by overcoming the triggers of treatment barriers originating from the HBM construct, effectively increasing medication adherence and treatment success for TB patients, and it needs further development by involving families in counseling for consistent self-efficacy of patients in long-term treatment.

Risk Perception of COVID-19 in Indonesia During the First Stage of the Pandemic

Community perceptions of early-stage pandemics may have significant implications for subsequent disease control and management. Perceptions of COVID-19 among Indonesian citizens were assessed 2 months after the first reported case in the country. The study used an online survey tool, which was adapted from a standardized questionnaire for risk perception of an infectious disease outbreak. The questions of the survey involved respondents' perceived level of knowledge, preparedness, efficacy of control measures, newness, infectiousness, seriousness, motivating and hindering factors, and effectiveness of prevention methods, as well as questions that assessed actual level of knowledge of respondents such as causative agents, modes of transmission, number of total cases, and available control measures. A total of 1,043 respondents participated in this study. The main sources of information of respondents were social media (85.2%) and online news (82.2%). Nearly all respondents were aware that COVID-19 is a viral disease with saliva droplets (97.1%) and contaminated surfaces (86.5%) being its main modes of transmission. Participants showed a good level of knowledge pertaining to control measures, an adequate level of belief toward their efficacy, and a willingness to implement such measures. More than 95% of the respondents perceived COVID-19 to be either serious or very serious. However, the level of anxiety among respondents was moderate, suggesting the presence of risk tolerance in the community. Individual characteristics such as gender, educational background, and occupation were found to have a statistically significant relationship with risk perception and tolerance, but voluntary participation in control measures was high and similar. This indicates that the COVID-19 health campaign during early pandemic in Indonesia was a success. This research also revealed certain areas where health promotion, education, and awareness might be improved.

The Exploration of Antenatal Education Method and its Problems in Denpasar Regency, Indonesia: A Qualitative Study

BACKGROUND: Antenatal education is a process giving health information to pregnant women as a part of antenatal care. Antenatal education influences knowledge and behavior which indirectly give impact to the health of mothers and children. In implementing several antenatal education methods, several countries have experienced some obstacles. AIM: The present study aimed to explore the implementation and problems of antenatal education in Denpasar Bali. METHODS: Descriptive qualitative exploration design was used in the study. The respondents were ten midwives in primary health-care clinics and private midwifery clinics in all districts of Denpasar city. The sample was selected using purposive sampling. Data analysis was using thematic approach by QSR Nvivo 12 Plus. RESULTS: The result of this study found two main themes; those were maternity class method and individual/face to face method. Midwives reported that on maternity class method the delivered information was felt more complete since it was in accordance with curriculum, pregnant women could hare with each other, and they could integrate with other professions. However, its weakness was low participation of pregnant women due to busyness. Meanwhile, face-to-face method had advantages since pregnant women felt free to express their personal problems and midwives could offer solutions for the identified problems during antenatal visits. Nevertheless, it has many disadvantages such as, very limited information was provided, problem with human resource management, time management, and pregnant women visitation management. CONCLUSION: In conclusion, both of antenatal education methods have advantages and disadvantges. Maternity class method is considered as a better method yet pregnant women participation to the class is relatively low. Face-to-face method is considered not comprehensive in delivering antenatal information as its problem with time management, human resource management, and patient management.

Financial Risk Protection for Neurosurgical Care in Indonesia and the Philippines: A Primer on Health Financing for the Global Neurosurgeon

Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.

Risk Factors of Needlestick and Sharp Injuries among Health Care Workers at Sanglah Tertiary Hospital

Background: Needlestick and sharp injuries (NSIs) remain one of the main occupational hazards among health care workers (HCWs) that lead to blood-borne pathogen exposure. Purpose: This study examined the risk factors for NSIs among HCWs at a tertiary referral hospital in Bali. Methods: A case-control study was conducted at Sanglah General Hospital, Bali, involving 171 HCWs, divided into 81 cases and 90 control subjects. The sample was selected using a simple random sampling technique. Data were collected using questionnaires and analyzed using multiple logistic regression. Results: The majority of respondents had experienced NSIs once, in the morning shift, and had affected an individual’s hands. The most frequent activity leading to NSIs was giving an injection and most of the situations causing NSIs involved accidental self-action, and recapping needles. Factors associated with the incidence of NSIs were work career or experience of <5 years (p < 0.01; adjusted odds ratio [AOR]=5.04; 95% confidence interval [CI] = 2.04–12.42), non-compliance with working procedures (p = 0.01; AOR = 2.47; 95%CI= 1.26–4.82), female HCWs (p = 0.03; AOR = 2.21; 95% CI = 1.01–4.55), and unsafe workplace conditions (p = 0.04; AOR = 2.23; 95% CI = 1.01–4.92). Conclusion: Personal and environmental factors such as gender, work experience, compliance with working procedures, and workplace conditions are among the risk factors for NSIs. Occupational health and safety policies and programs focusing on the relevant factors, accompanied by adequate supervision, are necessary to reduce the risk of NSIs occurring.

Perception of childbirth experiences of Japanese women in Bali, Indonesia: a qualitative study

Background

Maternal healthcare services in Indonesia have seen dramatic improvements over the past 25 years and yet there is still room for improvement. The perception, by the women, of the perinatal care provided, is a vital input to further improving these services. This study examines how the perinatal care provided is experienced by Japanese women in Bali, using an interview survey.

Methods

We conducted semi-structured interviews, from August to October 2017, with 14 Japanese women living in Badung Regency and Denpasar City in Bali Province, Indonesia to report their perception of the perinatal care they experienced during their pregnancies. The interview guide included among others, the reasons for choosing specific (perinatal care) health facilities and their satisfaction with their experience of using the antenatal, delivery, and postnatal care services. The data were analysed using the qualitative content analysis method.

Results

From the interview data, 12 categories across five themes were extracted. Participants reported experiencing various concerns during their pregnancies such as difficulty in obtaining perinatal care related information. From the beginning of their pregnancies, participants gradually established trusting relationships with midwives, but in many situations, they were disappointed with their childbirth experiences, as they felt that the care provided was not woman-centred. Through their own efforts and with the support of family members and other Japanese residents, many women were able to eventually regard their childbirth experiences as positive. Nevertheless, some women could not overcome their negative impressions even years after childbirth.

Conclusions

Participants desired close attention and encouragement from nurses and midwives. Our results suggest that Japanese women in Bali expected a woman-centred perinatal care and active support from nursing/midwifery staff during their pregnancies and postnatal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03466-x.

Cardiovascular Risk Factor Modification in Asymptomatic Adults and Implications for Pilots

This study aims to examine the available evidence that supports a more aggressive approach to managing asymptomatic people with low to intermediate cardiovascular risks; to evaluate the appropriate threshold for initiating pharmacologic interventions to treat hyperglycaemia, hyperlipidaemia, and hypertension; and to describe the implications for airline pilots. A systematic search was performed employing an OvidSP interface, including all EBM Reviews, EMBASE, and Ovid MEDLINE databases. Data, including sixteen randomised controlled trials, on the appropriate threshold for initiating pharmacologic interventions were extracted. Studies on the treatment of hyperlipidaemia indicated that the threshold for initiation of intervention in intermediate-risk people is a LDL-C level of 3.36 mmol/l (130 mg/dl). There was no lower limit or optimal LDL-C level below which further reduction was no longer beneficial. Studies on the treatment of hyperglycaemia suggested that a threshold of fasting plasma glucose of ≥5.3 mmol/l (95 mg/dl) and 2-hour postprandial glucose level of 7.8 mmol/l (140 mg/dl) is reasonable for initiating pharmacologic intervention. Initiating treatment to people with a blood pressure of ≥130/≤89 mmHg or ≤139/≥85 mmHg significantly reduced the risk of developing stage 1 hypertension. Multifactorial intervention studies showed that, in hypertensive patients (BP ≥160/≥100 mmHg), initiating treatment to those with a total cholesterol of 6.5 mmol/l (251.35 mg/dl) or higher resulted in a significant reduction in the risk of developing fatal and non-fatal cardiovascular events. The available evidence from large quality trials supports a more aggressive approach to managing hyperglycaemia, hyperlipidaemia, and hypertension in asymptomatic pilots with a 5-year CVD risk of 5-10% and 10-15%.

HIV testing uptake among pregnant women attending private midwife clinics: challenges of scaling up universal HIV testing at the private sectors in Indonesia

INTRODUCTION

Being ranked seventh among countries with the highest number of new pediatric HIV infection, around 3% of new pediatric HIV infection worldwide occurs in Indonesia. UNAIDS has set a goal of elimination of mother-to-child HIV transmission, and private sector plays a critical role in achieving this goal. More than half of pregnant women in Indonesia seek antenatal care (ANC) services at private sectors, particularly at private midwife clinics. However, no published data is available on the rates of HIV testing uptake among pregnant women at these clinics, reflecting important gap on prevention of mother to child HIV transmission programmatic data.

PURPOSE

A longitudinal study was conducted to examine the rates of HIV testing uptake among pregnant women attending private midwife clinics in Bali and were referred to Voluntary HIV counselling and testing (VCT) clinics for a HIV test.

METHODS

Seventy midwives from private clinics were asked to suggest women, who were deemed to be at risk of HIV, to seek HIV testing at the nominated VCT clinics and to provide the women with a referral. Data were then analyzed to identify the percentage of women who took HIV testing at the VCT clinics among those referred by the midwives.

RESULTS

The midwives referred 619 women to VCT clinics. Of the referred women, only 321 (52%; 95% CI, 47.8%-55.9%) took a HIV test at the appointed clinics. Among these who tested, three (0.9%) were HIV positive. This study identified a challenge in scaling up HIV testing coverage among women seeking ANC services at private sectors. Implications and recommendations are discussed.

Travel agent and tour guide perceptions on travel health promotion in Bali

The increasing number of travelers to Bali has been accompanied by the increased risks of travel-related health problems. Travel agents and tour guides are in a key position to inform travelers about these matters; nonetheless, little evidence was found on their role in the promotion of travel health. This article aims to assess travel agent and tour guide perceptions on their possible involvement in promoting travel health measures in Bali. A cross-sectional study was conducted between July and October 2015, involving 500 respondents (250 travel agents and 250 tour guides), who were chosen systematically from the Bali-based members of the Association of the Indonesian Tours and Travel Agencies. Data were collected using questionnaires, and perception indicators were developed using concepts from social learning theory and health belief model. Both groups have good levels of knowledge of general travel health issues, with mean percentages (SD) of 67.1 (11.9) and 66.2 (10.0) for travel agents and tour guides, respectively. Tour guides were more likely than travel agents to deliver information on health risks [PR (95%CI) = 1.31 (1.10–1.56); p = 0.003]; and on safety hazards during travel [PR (95%CI) = 1.22 (1.01–1.46), p = 0.04]. Overall, the majority of respondents (&gt;68%) have positive and very positive perceptions of possible involvement in travel health and safety programs, although tour guides have statistically better perceptions (z = −2.2, p = 0.03). Based on perception levels, previous experiences and levels of knowledge, travel agents and tour guides have great potential to be involved in travel health promotion programs in Bali.

Microbiological Quality, Hygiene, and Sanitation of the Production Processes of a Traditional Beverage at Tourism Areas in Bali

Loloh Cemcem, a traditional beverage containing Cemcem leaves of (Spondias pinnata (L.f.) Kurz) from the tourism area of Penglipuran, has been widely distributed across Bali. This study aims to examine the microbiological quality of Loloh Cemcem and its association with hygiene and the sanitation of its production processes. A cross-sectional study was conducted, involving all home industries that produce Loloh Cemcem and its handlers, four water depots, and three samples of water source in Penglipuran, Bali. Observations and interviews were conducted to obtain data on hygiene and sanitation. Samples were tested for microbiological qualities, including total plate count (TPC), most probable number (MPN) method for coliform, and Escherichia coli (E. coli) contamination. A polymerase chain reaction (PCR) examination was conducted to identify virulent genes. The water source was contaminated with enterotoxigenic E. coli (ETEC), and about 25% of water depots and 43.3% of Loloh Cemcem samples were also contaminated with E. coli. This indicates E. coli viability under an acidic medium (average pH of 2.8). Of the 30 home industries, 76.7% of sanitation facilities met the safety standards, while the conditions were considerably lower for instrument sanitation (60.0%), personal hygiene of the handlers (50.0%), and production site sanitation (43.3%). Poor personal hygiene of the handlers was associated with the microbiological quality of Loloh Cemcem with an adjusted odds ratio (AOR) of 15.02 (95%CI: 1.32-171.56, P = 0.029). Ongoing monitoring is warranted to improve personal hygiene and sanitation of the production processes. Microbiological research is essential to understand the nature of E. coli, including its viability in acidic environments.

Cardiovascular Tests for Risk Assessment in Asymptomatic Adults and Implications for Pilots

BACKGROUND

This study aims to examine which marker or testing protocols have been suggested for cardiovascular disease (CVD) risk assessment in asymptomatic populations, at which CVD risk level, and how this can be implemented for CVD risk assessment in pilot populations.

METHODS

A systematic search was performed using Systematic Reviews Subset on PubMed; the OvidSP interface, including all EBM reviews and EMBASE databases; and the G-I-N International Guideline Library. From each recommendation, we extracted data on consideration of the use of a marker or test for cardiovascular risk assessment in asymptomatic populations.

RESULTS

Included were 45 guidelines, systematic reviews, or meta-analyses relevant to cardiovascular risk assessment in asymptomatic populations. The majority (9/12) of the citations recommend coronary artery calcium score (CACS) for CVD risk assessment in intermediate-risk (10-yr CVD risk score of 10-20%) asymptomatic adults. Other cardiac and vascular tests that may also be considered include the measurements of carotid-intima media thickness, supplemented by carotid plaque, and the ankle brachial index for prevention of peripheral artery disease and stroke. Stress myocardial perfusion scan is the potential cardiac functional test to be used with pilots with 5-yr risk of ≥15%. Among laboratory markers, only hs-CRP has a potency to be used in CVD risk assessment in intermediate-risk asymptomatic adults; however, the strength of the recommendation is not adequate.

DISCUSSION

Among the cardiac and vascular testing available, CACS is the most frequently suggested test. The implications of findings for CVD risk assessment in airline pilots are highlighted in this paper.Wirawan IMA, Griffiths RF, Larsen PD. Cardiovascular tests for risk assessment in asymptomatic adults and implications for pilots. Aerosp Med Hum Perform. 2018; 89(7):648-656.

Cardiovascular investigations of airline pilots with excessive cardiovascular risk

BACKGROUND

This study examined the prevalence of airline pilots who have an excessive cardiovascular disease (CVD) risk score according to the New Zealand Guideline Group (NZGG) Framingham-based Risk Chart and describes their cardiovascular risk assessment and investigations.

METHODS

A cross-sectional study was performed among 856 pilots employed in an Oceania based airline. Pilots with elevated CVD risk that had been previously evaluated at various times over the previous 19 yr were reviewed retrospectively from the airline's medical records, and the subsequent cardiovascular investigations were then described.

RESULTS

There were 30 (3.5%) pilots who were found to have 5-yr CVD risk score of 10-15% or higher. Of the 29 pilots who had complete cardiac investigations data, 26 pilots underwent exercise electrocardiography (ECG), 2 pilots progressed directly to coronary angiograms and 1 pilot with abnormal echocardiogram was not examined further. Of the 26 pilots, 7 had positive or borderline exercise tests, all of whom subsequently had angiograms. One patient with a negative exercise test also had a coronary angiogram. Of the 9 patients who had coronary angiograms as a consequence of screening, 5 had significant disease that required treatment and 4 had either trivial disease or normal coronary arteries.

CONCLUSION

The current approach to investigate excessive cardiovascular risk in pilots relies heavily on exercise electrocardiograms as a diagnostic test, and may not be optimal either to detect disease or to protect pilots from unnecessary invasive procedures. A more comprehensive and accurate cardiac investigation algorithm to assess excessive CVD risk in pilots is required.

Cardiovascular risk score and cardiovascular events among airline pilots: a case-control study

BACKGROUND

A cardiovascular risk prediction score is routinely applied by aviation authorities worldwide. We examined the accuracy of the Framingham-based risk chart used by the New Zealand Civil Aviation Authority in predicting cardiovascular events among airline pilots.

METHODS

A matched case-control design was applied to assess the association of 5-yr cardiovascular risk score and cardiovascular events in Oceania-based airline pilots. Cases were pilots with cardiovascular events as recorded on their medical records. Each case was age and gender matched with four controls that were randomly selected from the pilot population. To collect data before the events, 5-yr retrospective evaluations were conducted.

RESULTS

Over a 16-yr study period we identified 15 cases of cardiovascular events, 9 (60%) of which were sudden clinical presentations and only 6 (40%) of which were detected using cardiovascular screening. There were 8 cases (53%) and 16 controls (27%) who had a 5-yr risk of > or = 10-15%. Almost half of the events (7/15) occurred in pilots whose highest 5-yr risk was in the 5-10% range. Cases were 3.91 times more likely to have highest 5-yr risk score of > or =10-15% than controls (OR = 3.91, 95% CI 1.04-16.35). The accuracy of the highest risk scores were moderate (AUC = 0.723, 95% CI 0.583-0.863). The cutoff point of 10% is valid, with a specificity of 0.73, but low sensitivity (0.53).

CONCLUSION

Despite a valid and appropriate cutoff point, the tool had low sensitivity and was unable to predict almost half of the cardiovascular events.