Many developing countries are experiencing the epidemiological transition, with the majority of deaths attributed to cardiovascular disease, cancer, Type 2 diabetes (T2DM) and others. In some countries, large proportional mortality attributed to diabetes is evident in official mortality statistics, with Mauritius and Fiji rated as the highest in the world.

In view of erroneous type 2 diabetes prevalence reported in 3 small Pacific Island countries, a study was conducted to investigate whether this error occurred in other countries which have conducted WHO STEPS surveys associated with glucose thresholds for point‐of‐care (POC) measuring devices calibrated to plasma.

This study estimates type 2 diabetes (T2DM) incidence in Samoans aged 25–64 years from sequential, irregularly spaced, cross-sectional population prevalence surveys.

Aims: To estimate the overweight (OW) and obesity (Ob) prevalence and associated socio-demographic risk factors in New Caledonian adults aged 18-67 years.

Methods: From a randomly selected cross-sectional population survey, self-reported (n=2513) and measured (n=736) height and weight data were collected. Separate linear regression analyses for measured weight and height were performed, using cases with both self-reported weight and height and socio-demographic variables. The final weight and height assigned to each case was either measured or predicted from the regression (n=2075). OW prevalence was defined as: Body Mass Index (BMI) ≥25 and <30kg/m-2; and Ob: BMI ≥30kg/m-2. Samples were weighted to the general adult population. Prevalence and Odds ratios (ORs) were calculated by gender, and adjusted for socio-demographic variables, to assess differentials in OW, Ob and OW-Ob, using multinomial and logistic regressions.

Results: Male (M) OW was 35% (95% CI: 31-38), Ob 29% (95% CI: 26-32) and OW-Ob 64% (95% CI: 60-67); female (F) OW was 26% (95% CI: 23-28), Ob 34% (95% CI: 31-37) and OW-Ob 60% (95% CI: 57-63). Compared to Melanesians (OR=1.0) for male/female: Polynesians had the highest prevalence of OW (1.7/1.5), Ob (4.7/3.5), and OW-Ob (3.0/2.5); New Caledonian-born Europeans had greater OW, Ob and OW-Ob (0.3/0.4) than immigrant Europeans (0.2/0.2).

Conclusions: Findings contribute to obesity comparisons with other Pacific Islands, and they establish trends in New Caledonia for targeting policies and strategies of prevention.

Population surveys of Type 2 diabetes mellitus and obesity conducted in Samoa over three decades have used varying methodologies and definitions. This study standardizes measures, and trends of Type 2 diabetes mellitus and obesity for 1978–2013 are projected to 2020 for adults aged 25–64 years.

Disparate population surveys of type 2 diabetes mellitus (T2DM) have been conducted in Tonga for 4 decades. This study standardizes these surveys to enable assessment of T2DM and obesity trends in Tongans aged 25 to 64 years over 1973-2012, and projects T2DM prevalence to 2020 based on demographic and population weight changes. Eight surveys were standardized to the nearest census to produce nationally representative estimates. Linear period trends and prevalence projections to 2020 were produced using random-effects meta-regression. Over 1973-2012, T2DM prevalence increased from 5.2% to 19.0% (1.9%/5 years) and obesity prevalence from 56.0% to 70.2% (2.7%/5 years). T2DM prevalence period projection to 2020 is 22.3%. Based on modeling using body mass index, T2DM prevalence in 2020 could have been 12.7% and 16.8% in 2020 had mean population weight been 1 to 4 kg lower than 2012 levels.

https://www.ncbi.nlm.nih.gov/pubmed/27122623

Background: No systematic comparison has been conducted in Fiji using all suitable surveys of type 2 diabetes mellitus (T2DM) and obesity prevalence after standardizing methodology and definitions.

Methods: Unit records from six surveys of Fiji adults were variously adjusted for age, ethnicity (Fiji Melanesians, i-Taukei, and Fijians of Asian Indian descent [Indians]) and urban–rural by sex to previous censuses. Trends were assessed using meta-regression (random effect models) and estimates projected to 2020. Poisson regression of strata was used to assess the effect of body mass index (BMI) increases on T2DM period trends.

Results: Over 1980–2011, T2DM prevalence increased in i-Taukei men (3.2% to 11.1%; 1.32%/5 years) and women (5.3% to 13.6%; 1.40%/5 years) and Indian men (11.1% to 17.9%; 1.24%/5 years) and women (11.2% to 19.9%; 1.71%/5 years). Projected T2DM prevalence in 2020 is 13.3% and 16.7% in i-Taukei men and women, and 23.4% and 24.1% in Indian men and women, respectively. Obesity prevalence increased in i-Taukei men (12.6% to 28.9%; 2.99%/5 years) and women (30.1% to 52.9%; 3.84%/5 years) and in Indian men (2.8% to 9.4%; 1.21%/5 years) and women (13.2% to 26.6%; 2.61%/ 5 years). Projected obesity prevalence in 2020 is 34.0% and 60.0% in i-Taukei and women, and 11.4% and 31.0% in Indian men and women, respectively. After age-adjustment, an estimated 27%, 25%, 16% and 18% of the T2DM period trend is attributable to BMI in i-Taukei men and women and Indian men and women, respectively.

Conclusions: Prevalence of T2DM in Fiji is projected to continue increasing, driven by rising obesity, with consequences for premature mortality and life expectancy.

https://www.ncbi.nlm.nih.gov/pubmed/26201444

Background: Type 2 diabetes mellitus (T2DM) incidence is traditionally derived from cohort studies that are not always feasible, representative, or available. The present study estimates T2DM incidence in Fijian adults from T2DM prevalence estimates assembled from surveys of 25–64 year old adults conducted over 30 years (n = 14,288).

Objective: To assemble standardized estimates of abnormal glucose tolerance in adults in diverse communities worldwide and provide guidelines for the derivation of comparable estimates in future epidemiological studies.

Research design and methods: The project was limited to population-based investigations that had used current WHO criteria for diagnosis and classification of abnormal glucose tolerance. Raw data were obtained by WHO from surveys conducted during 1976-1991 of over 150,000 persons from 75 communities in 32 countries. Data within the truncated age range of 30-64 yr were adjusted to the standard world population of Segi. Age-specific prevalences also are reported for selected populations.

Results: Within the chosen age range, diabetes was absent or rare (< 3%) in some traditional communities in developing countries. In European populations, age-standardized prevalence varied from 3 to 10%. Some Arab, migrant Asian Indian, Chinese, and Hispanic American populations were at higher risk with prevalences of 14-20%. The highest prevalences were found in the Nauruans (41%) and the Pima/Papago Indians (50%). Age-standardized prevalence of IGT was low (< 3%) in some Chinese, traditional American Indian, and Pacific island populations. Moderate (3-10%) or high (11-20%) prevalences of IGT were observed in many populations worldwide. The highest estimates for prevalence of IGT were seen in female Muslim Asian Indians in Tanzania (32%) and in urban male Micronesians in Kiribati (28%). Prevalence of diabetes rose with age in all populations in which age-specific data were examined. This trend was most pronounced in those at moderate to high risk. The ratio of prevalence of diabetes in men versus women varied markedly between populations with little discernable trend, although IGT was generally more common in women. In most communities, at least 20% of diabetes cases were unknown before the survey, and in many communities, > 50% were previously undiagnosed. In both Chinese and Indian migrant populations, relative prevalence was high when compared with indigenous communities.

Conclusions: Diabetes in adults is now a global health problem, and populations of developing countries, minority groups, and disadvantaged communities in industrialized countries now face the greatest risk. https://www.ncbi.nlm.nih.gov/pubmed/8123057

Objective: To determine the prevalence of non-communicable disease, specifically hypertension, diabetes and obesity, amongst populations at different levels of urbanisation in Vanuatu, and to relate the frequency of these conditions to the modernisation of way of life.

Design: A cross-sectional population-based comparative study of indicative cluster samples.

Setting: Republic of Vanuatu (south-west Pacific). A relatively undeveloped malarious island country.

Participants: Adult (aged greater than or equal to 20 years) Melanesian ni-Vanuatu of both sexes. An occupation-based (civil servants) urban sample (n = 623) and area-based semi-rural (n = 349) and rural (n = 397) samples were employed. Response rates were 78%-92%.

Interventions: Cases detected were referred for assessment and treatment by local medical staff.

Main outcome measures: Body mass index, triceps skinfold thickness, blood pressure, plasma glucose (fasting and 2 hours after 75 g glucose), plasma cholesterol and triglyceride levels.

Results: Modernity scores confirmed that the three locations represented different levels of acculturation. Prevalences of non-communicable disease were relatively low compared to other Pacific Island communities and industrialised countries. These conditions were nevertheless more common in the urban sample and least common in the rural sample. Non-communicable disease correlated positively with modernity scores and negatively with physical activity scores. Obesity correlated with blood pressure in the urban sample, and there was indirect evidence (urine sodium concentration) of higher salt intake with modernisation. Mean plasma cholesterol levels were lowest in the rural group.

Conclusion: Prevalences of non-communicable disease are relatively low in Vanuatu, although rural-urban differentials are present, and likely to increase with continued development. The evidence presented is consistent with non-communicable disease being related to the modernisation of way of life; specifically: decreased exercise, obesity, and dietary change. Preventive activities should commence now. https://www.ncbi.nlm.nih.gov/pubmed/1857313

The prevalence of diabetes mellitus in the traditional-living population of Wallis Island was low and comparable with that found in other rural Polynesian societies. The diabetes prevalence was 1.9% in men and 3.5% in women; impaired glucose tolerance occurred in 5.0% of men and 8.4% of women. The prevalence of obesity was significantly greater in women than in men (37.4% versus 12%, respectively, were equal to or greater than 140% ideal weight). Subjects with diabetes tended to be more obese and less active than normal subjects, but these differences, although appreciable, were not usually statistically significant. The population engages in considerable physical activity, and this, along with the traditional diet, may be responsible for the relatively low diabetes prevalence. https://www.ncbi.nlm.nih.gov/pubmed/6617409

Objective: To investigate the impact of population mammography screening on breast cancer incidence trends in New Zealand.

Objective: To investigate trends in breast cancer mortality in New Zealand women, to corroborate or negate a causal association with service screening mammography.

Background: To summarize data on long-term ipsilateral local recurrence (LR) and breast cancer death rate (BCDR) for patients with ductal carcinoma in situ (DCIS) who received different treatments.

Methods: Systematic review and study-level meta-analysis of prospective (n = 5) and retrospective (n = 21) studies of patients with pure DCIS and with median or mean follow-up time of ≥10 years. Meta-regression was performed to assess and adjust for effects of potential confounders - the average age of women, period of initial treatment, and of bias - follow-up duration on recurrence- and death-rates in each treatment group. LR and BCDR rates by local treatment used were reported. Outside of randomized trials, remaining studies were likely to have tailored patient treatment according to the clinical situation.

Results: Nine thousand four hundred and four DCIS cases in 9391 patients with 10-year follow-up were included. The adjusted meta-regression LR rate for mastectomy was 2.6 % (95 % CI, 0.8-4.5); breast-conserving surgery with radiotherapy (RT), 13.6 % (95 % CI, 9.8-17.4); breast-conserving surgery without RT, 25.5 % (95 % CI, 18.1-32.9); and biopsy-only (residual predominately low-grade DCIS following inadequate excision), 27.8 % (95 % CI, 8.4-47.1). RT + tamoxifen (TAM) in conservation surgery (CS) patients resulted in lower LR compared to one or no adjuvant treatments: LR rate for CS + RT + TAM, 9.7 %; CS + RT(no TAM), 14.1 %; CS + TAM(no RT), 24.7 %; CS(alone), 25.1 % (linear trend for treatment P < 0.0001). Compared to CS + RT + TAM, a significantly higher invasive LR was observed for CS(alone), odds ratio (OR) 2.61 (P < 0.0001); CS + TAM(no RT), OR 2.52 (P = 0.001); CS + RT(no TAM), OR 1.59 (P = 0.022). BCDR was similar for mastectomy, breast-conserving surgery with or without RT (1.3-2.0 %) and non-significantly higher for biopsy-only (2.7 %). Additionally, the 15-year follow-up was reported where all like-studies had ≥ 15-year data sets; the biopsy-only patients had a meta-analysed total LR rate of 40.2 % and the invasive LR rate was 28.1 %. The biopsy-only patients had a ≥ 15-year BCDR (that included women with metastatic disease) of 17.9 %; the ≥ 15-year BCDR was 55.2 % for those with invasive LR.

Conclusions: More local intervention was associated with greater local control for patients with DCIS at long-term follow-up. For patients undergoing breast-conservation, invasive LR was significantly lower when two rather than one adjuvant treatment modalities were given

The purpose of this study was to demonstrate the feasibility of VIA screening with cryotherapy and to record normative values for indicators anticipated in similar low resource settings. Women aged 30-49 years were targeted, resulting in 1961 women screened and treated at two primary health care (PHC) centres near Suva, Fiji. Recruitment was through provision of information, education and communication (IEC). Referrals to a gynaecology outpatient department (OPD) at a referral hospital occurred throughout the screening pathway. Participation was 32% (95%CI 31-33%), higher in iTaukei (Melanesians) women (34%, 95%CI 33-36) compared to Fijians of Indian descent (26%, 95%CI 24-28). Regression analysis, adjusted for confounders, indicated significantly lower participation in those of Indian descent, and age groups 35-39 and 45-49 years. Of those examined by VIA, 190 were positive with aceto-white lesions (9.9%), within the expected range of 8-15%, with minor geographic and ethnic variation. Positive VIA results were more common in the peri-urban area, and in those aged 35-39 years. Of women aged 30-49 years, 59 received cryotherapy (none of whom had significant complications), 91 were referred to OPD, two cervical carcinomas were identified and eight cervical intra-epithelial neoplasms (CIN) II-III were diagnosed. These results provide normative findings from a community-based VIA screening program for other similar low resource settings.

Objective: To quantify the population attributable risk of key modifiable risk factors associated with breast cancer incidence in Queensland, Australia.

Study design: Population attributable fractions (PAFs) for high body mass index (BMI), use of hormone replacement therapy (HRT), alcohol consumption and inadequate physical activity were calculated, using prevalence data from a representative survey of women attending mammographic screening at BreastScreen Queensland in 2008 and relative risk estimates sourced from published literature. Attributable cancers were calculated using 'underlying' breast cancer incidence data for 2008 based on Poisson regression models, adjusting for the inflation of incidence due to the effects of mammographic screening.

Main outcome measures: Attributable burden of breast cancer due to high body mass index (BMI), use of hormone replacement therapy (HRT), alcohol consumption and inadequate physical activity.

Results: In Queensland women aged 45-69 years, an estimated 12.1% (95% CI: 11.6-12.5%) of invasive breast cancers were attributable to high BMI in post-menopausal women who have never used HRT; 2.8% (95% CI: 2.7-2.9%) to alcohol consumption; 7.6% (95% CI: 7.4-7.9%) to inadequate physical activity in post-menopausal women and 6.2% (95% CI: 5.5-7.0%) to current use of HRT after stratification by BMI and type of HRT used. Combined, just over one quarter (26.0%; 95% CI: 25.4-26.6%) of all invasive breast cancers in Queensland women aged 45-69 years in 2008 were attributable to these modifiable risk factors.

Conclusion: There is benefit in targeting prevention strategies to modify lifestyle behaviours around BMI, physical activity, HRT use and alcohol consumption, as a reduction in these risk factors could decrease invasive breast cancer incidence in the Queensland population. http://www.ncbi.nlm.nih.gov/pubmed/24113278

Background: Evidence that mammography screening reduces breast cancer mortality derives from trials, with observational studies broadly supporting trial findings. The purpose of this study was to evaluate the national mammographic screening programme, BreastScreen Australia, using aggregate screening and breast cancer mortality data.

Method: Breast cancer mortality from 1990 to 2004 in the whole Australian population was assessed in relation to screening exposure in the target of women aged 50-69 years. Population cohorts were defined by year of screening (and diagnosis), five-year age group at screening (and diagnosis), and local area of residence at screening (and diagnosis). Biennial screening data for BreastScreen Australia were related to cumulated mortality from breast cancer in an event analysis using Poisson regression, and in a time-to-event analysis using Cox proportional hazards regression. Results were adjusted for repeated measures and the potential effects of mammography outside BreastScreen Australia, regionality, and area socio-economic status.

Results: From the adjusted Poisson regression model, a 22% (95% CI:12-31%) reduction in six-year cumulated mortality from breast cancer was predicted for screening participation of approximately 60%, compared with no screening; 21% (95% CI:11-30%) for the most recently reported screening participation of 56%; and 25% (95% CI:15-35%) for the programme target of 70% biennial screening participation. Corresponding estimates from the Cox proportional hazard regression model were 30% (95% CI:17-41%), 28% (95% CI:16-38%) and 34% (95% CI:20-46%).

Conclusion: Despite data limitations, the results of this nationwide study are consistent with the trial evidence, and with results of other service studies of mammography screening. With sufficient participation, mammography screening substantially reduces mortality from breast cancer. http://www.ncbi.nlm.nih.gov/pubmed/22345322

Background: Previous studies indicate that cervical cancer is the second most frequent cancer and most common cause of cancer mortality among women in Fiji. There is little published data on the epidemiology of cervical cancer in Pacific countries. AIMS: To determine the incidence 2003-2009 of, and mortality 2003-2008 from, cervical cancer by ethnicity and period in Fiji, identify evidence of secular change and relate these data to other Pacific countries, Australia and New Zealand.

Method: Counts of incident cervical cancer cases (2003-2009) and unit record mortality data (2003-2008) from the Fiji Ministry of Health were used to calculate age-standardised (to the WHO World Population) cervical cancer incidence and mortality rates, and cervical or uterine cancer mortality rates, by ethnicity, with 95% confidence intervals. On the basis of comparison of cervical cancer mortality with cervical or uterine cancer mortality in Fiji with similar populations, misclassification of cervical cancer deaths is unlikely.

Results: There is no evidence of secular change in cervical cancer incidence and mortality rates for the study period. For women of all ages and ethnicities, the age-standardised incidence rate of cervical cancer (2003-2009) was 27.6 per 100,000 (95% CI 25.4-29.8) and the age-standardised mortality rate (2003-2008) was 23.9 per 100,000 (95% CI 21.5-26.4). The mortality/incidence ratio was 87%. Fijians had statistically significant higher age-standardised incidence and mortality rates than Indians. Fiji has one of the highest estimated rates of cervical cancer incidence and mortality in the Pacific region.

Conclusion: Cervical cancer screening in Fiji needs to be expanded and strengthened. http://onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.2012.01461.x/abstract

Background and Objective: Little is known about cervical cancer (CC) in the Democratic People's Republic of Korea (DPRK). This study examines the knowledge, attitudes and practices (KAP) concerning CC and screening among female health care practitioners (HCPs), and whether differences exist between rural and urban HCPs.

Method: In a descriptive cross-sectional study, a purposive sample of 200 women HCPs from 128 health care centers in 6 provinces of DPRK was interviewed using a standardized questionnaire.

Results: 98% of HCPs were aware of CC. Awareness of the national CC policy was significantly lower in rural (44%) than urban (62%) respondents (p<0.05). Fewer rural (71%) than urban (89%) HCPs knew of cervical cytology (p<0.05). Around 30% of HCPs were aware of the association between CC and human papillomavirus infection. Only 13% of HCPs had ever had a cervical cytology smear. Only 4% of rural and 21% of urban practitioners (p<0.05) provided cytology; all used unaided visual inspection of the cervix without staining to determine whether cytology testing was indicated. For all, screening intervals depended on presence of symptoms.

Conclusion: Misconceptions and ineffective clinical practices regarding screening need to be urgently addressed among both rural and urban HCPs. There are no major differences between rural and urban HCPs regarding their KAP. http://www.ncbi.nlm.nih.gov/pubmed/22393984

Background: This study assessed women from the Democratic People's Republic of Korea for: (i) their level of knowledge of cervical cancer and attitudes and practices concerning cervical screening (KAP); and (ii) differences in KAP between rural and urban groups.

Methods: In a descriptive cross-sectional study, a purposive sample of 200 women in 6 provinces of DPRK (rural: n=99, urban: n=101) were interviewed using a standardized questionnaire. Differences between proportions were assessed using the χ2 test. Significance was defined as p<0.05.

Results: 63% of rural and 60% of urban participants had heard of cervical cancer (p>0.05). 42% knew that it is the most common cancer of the female reproductive tract, 55% knew that all women are at risk, but only 36% were aware of cervical cancer's preventability. Some 13% of rural and 29% of urban respondents had heard of cervical cytology testing (p<0.001). Only 6% of participants had ever received a cervical cytology smear. Among the reasons for not screening, 48% mentioned a lack of awareness of cervical cytology; 47% their dislike of pelvic examinations; 17% of rural and 31% of urban interviewees reported the absence of symptoms (p<0.05); and 62% of rural and 0% of urban women mentioned travelling long distances to service delivery points (p<0.001).

Conclusion: There is a reasonable level of knowledge of cervical cancer among North Korean women; however, there are major gaps regarding awareness of its preventability and actual uptake of cytology screening services. There are no significant differences between rural and urban women with regard to their KAP. Large scale health promotion campaigns are needed to educate women and the community about cervical cancer and its preventability through screening. The national health care system needs to ensure that screening services are effective, accessible, feasible and acceptable to women. http://www.ncbi.nlm.nih.gov/pubmed/22393985

Objective: This study combines population changes in hormone therapy (HT) use with reported relative risks to estimate directly the impact of reductions in HT use on US breast cancer incidence.

Method: Using breast cancer incidence rates and prevalence estimates of HT use, the breast cancer incidence in HT users and non-users was derived. Attributable fraction calculations used risk data from the Million Women Survey (MWS), Collins' meta-analysis (CMA), and the initial or later data from the Women's Health Initiative (WHI) study.

Results: Between 2000 and 2005, HT use fell from 25.0 to 11.3%. The reported breast cancer incidence (in women aged 40-79) fell 8.8%. Derived incidence rates among non-users of HT remained unchanged (MWS or later WHI data) or slightly lower (initial WHI and CMA data), suggesting reductions in incidence are almost entirely (MWS or later WHI data) or partially (initial WHI or CMA data) due to reduced HT use.

Conclusion: Changes in reported breast cancer incidence may be partially or largely explained by changes in HT use in the US population. http://www.ncbi.nlm.nih.gov/pubmed/19795215

Objective: This study examined whether offering annual mammography screening for women with the risk factor of a family history of breast cancer resulted in more favorable prognostic indicators of diagnosed cancers than the usual approach of biennial screening.

Background: To calculate a pooled estimate of relative risk (RR) of lung cancer associated with exposure to passive smoking in never smoking women exposed to smoking spouses. This study is an updated meta-analysis that also assesses the differences between estimated risks according to continent and study type using meta-regression.

Method: From a total of 101 primary studies, 55 studies are included in this meta-analysis, of which, 7 are cohort studies, 25 population-based case-control and 23 non-population-based case-control studies. Twenty previously published meta-analyses are also reviewed. Fixed and random effect models and meta-regression are used to obtain pooled estimates of RR and P-value functions are used to demonstrate consistency of results.

Results: The pooled RR for never-smoking women exposed to passive smoking from spouses is 1.27 (95% CI 1.17-1.37). The RR for North America is 1.15 (95% CI 1.03-1.28), Asia, 1.31 (95% CI 1.16-1.48) and Europe, 1.31 (1.24-1.52). Sequential cumulative meta-analysis shows no trend. There is no strong evidence of publication bias.

Conclusion: The abundance of evidence, consistency of finding across continent and study type, dose-response relationship and biological plausibility, overwhelmingly support the existence of a causal relationship between passive smoking and lung cancer. http://www.ncbi.nlm.nih.gov/pubmed/17690135

Background: To examine time trends in cervical cancer incidence and mortality in NSW women aged yen20 years in relation to important health service initiatives and programs.

Method: Data on cervical cancer incidence and mortality were obtained from the NSW Central Cancer Registry for 1972-2001, and corresponding annual populations obtained from the Australian Bureau of Statistics. Direct age-standardised rates in the yen20 year population were calculated using the 2001 NSW census population as standard. Proportional reductions in incidence and mortality since 1972-1974 were also calculated and related to key health service factors and to published NSW 5-year cervical cancer relative survival for similar periods.

Results: Declines in cervical cancer incidence (-10%) and mortality (-20%), and increased degree-of-spread specific survival following the introduction of universal health care in 1975 suggest effects of greater access to Pap screening, earlier access to diagnosis and treatment services, and improved effectiveness of treatment. Incidence plateaued during the 1980s, but mortality fell further (-7%) due to an increased proportion of localised cancers (without change to degree-of-spread specific survival). The 1980s mortality reduction was a consequence of earlier diagnosis and/or secondary prevention, not improved treatment effectiveness or reduced incidence. A marked and sustained incidence decline to 2001 (-35%) occurred after the introduction of the NSW Cervical Screening Program in 1992. This was followed 3 years later by a sustained mortality decline (-20%). During the 1990s survival across all degrees of spread remained unchanged and the mortality reduction was due entirely to reduction in incidence.

Conclusion: The substantial reduction of cervical cancer incidence and mortality in NSW over the last 3 decades is associated with important health service interventions that relate to control of cervical cancer, particularly the implementation of a population-based organised cervical screening program. http://www.ncbi.nlm.nih.gov/pubmed/16489537

Objective: To analyse breast cancer incidence trends in New South Wales (NSW), Australia, in relation to population-based mammography screening targeting women aged 50 to 69 years.

Method: Trends in age-specific incidence of invasive breast cancers in NSW women aged > or = 40 years were examined in relation to mammography screening rates and screening cancer detection rates.

Results: Incidence of invasive breast cancer in NSW women increased in all age-groups over 1972 to 2002. The incidence trend for women aged 50 to 69 years showed that the steepest rise was associated with increased participation in population-based mammography screening, which was implemented from 1988 and achieved state-wide coverage in 1995. The elevated incidence of invasive cancer significantly exceeded pre-screening levels, and persisted after rates of initial screens declined. This elevated incidence was sustained by the contribution of cancers diagnosed through subsequent screening, and resulted from increased cancer detection rates in subsequent screens.

Conclusion: The recent increase in invasive breast cancer incidence in NSW is associated with mammography screening, and occurred mostly in the target age-group women. Persistence of higher incidence after 1994 was not explicable by inflation of cancer incidence due to detection of prevalent screen cases, but was associated with a trend of increased cancer detection rates in subsequent screening rounds, probably consequent to quality improvements in mammography screening diagnosis. http://www.ncbi.nlm.nih.gov/pubmed/16425093

Objective:To determine the effectiveness of three recruitment strategies to encourage women to attend for an initial mammography screen, and to compare results with similar service studies. Interventions were: (1) an invitation letter; (2) two invitation letters; and (3) an invitation letter plus a follow-up telephone call.

Method: All women aged 50-54 years in two BreastScreen New South Wales (BSNSW) Screening and Assessment Service catchment areas (n=3,144) were recruited from the Australian Electoral Roll and randomised to the four groups. Response rates for each intervention were compared relative to standard practice (one invitation letter) at 12-weeks follow-up. Marginal cost-effectiveness for each condition was calculated. Other similar randomised trials were also meta-analysed.

Results: The screening rate for two letters was 8.5% (OR=1.61, 95% CI 1.08-2.40) and 7.8% (OR=1.46, 95% CI 0.97-2.18) for one letter plus a telephone call, compared with 5.5% for standard practice (one letter) (OR=1.00). The response rate in the one letter plus a phone call group was 13.3% (OR=2.65, 95% CI 1.76-4.00) for women where a phone number was located.

Conclusion: Initial screening rates after a 12-week follow-up were significantly higher in the women receiving a second invitation letter, compared with standard practice (one letter). Marginal cost-effectiveness favoured the two-letter approach.

Implications: A follow-up invitation letter is more cost-effective than one invitation letter plus a follow-up telephone call in the BSNSW program. However, an invitation letter plus follow-up phone call is more cost-effective in recruiting women to BSNSW only if a phone number is located.
http://www.ncbi.nlm.nih.gov/pubmed/16681329

Method: Primary studies and meta-analyses examining the relationship between passive smoking and lung cancer were identified through a computerised literature search of Medline and Embase, secondary references, and experts in the field of passive smoking. Primary studies meeting the inclusion criteria were meta-analysed.

Results: From 1981 to the end of 1999 there have been 76 primary epidemiological studies of passive smoking and lung cancer, and 20 meta-analyses. There were 43 primary studies that met the inclusion criteria for this meta-analysis; more studies than previous assessments. The pooled relative risk (RR) for never-smoking women exposed to environmental tobacco smoke (ETS) from spouses, compared with unexposed never-smoking women was 1.29 (95% CI 1.17-1.43). Sequential cumulative meta-analysed results for each year from 1981 were calculated: since 1992 the RR has been greater than 1.25. For Western industrialised countries the RR for never-smoking women exposed to ETS compared with unexposed never-smoking women, was 1.21 (95% CI 1.10-1.33). Previously published international spousal meta-analyses have all produced statistically significant RRs greater than 1.17.

Conclusion: The abundance of evidence in this paper, and the consistency of findings across domestic and workplace primary studies, dosimetric extrapolations and meta-analyses, clearly indicates that non-smokers exposed to ETS are at increased risk of lung cancer.

Implications: The recommended public health policy is for a total ban on smoking in enclosed public places and work sites. http://www.ncbi.nlm.nih.gov/pubmed/11494987

Design: An actuarial analysis using cross-sectional all-cause mortality and smoking data for the mid to late 1980s. Age-specific mortality rates in never­ smokers were estimated using the age­ specific population rates and the aetiological fraction for tobacco smoking determined by the indirect method. Relative risks for smokers versus never­ smokers were used to calculate age­ specific rates in various categories of smoker.

Setting: New South Wales (NSW), Australia. Mid 1980s to 1990.

Subjects: State population: 5.8 million in 1990: 15-year-old male smokers: 8816 in 1990.

Main outcome measures: The parameters calculated for smokers and never smokers were: life expectancy (at age 15 years); actuarial cumulative risk for all­ cause mortality for the age range 15-74 years; and excess deaths and person­ years of life lost by age 74 years due to tobacco smoking in yearly cohorts of 15-year-old boys in NSW.

Results: In males, conditional life expectancy for 15-year-olds was 77.2 years in never-smokers, 73.1 years in ever­ smokers, and 71.6 years in heavy smokers (defined as smokers of more than one packet per day). The risk of premature death (before age 75 years) in 15-year-old boys was 35% in never-smokers (1 in 3), 50% in ever-smokers (1 in 2), and 56 % in heavy smokers (1 in 1.8). A one-year cohort of 15-year-old male smokers (8816) can be expected to pro­ duce 1292 to 1841 excess deaths and 23485 to 33895 extra person-years of life lost to age 74 years, for ever-smokers and heavy smokers, respectively. Using data on brand preference, 569 to 810 of these excess deaths will occur in 15-year-olds who presently smoke Winfield cigarettes (for ever-smokers and heavy smokers, respectively), with lesser numbers apportioned to Peter Jackson, Benson and Hedges, and Longbeach.

Conclusion: Plausible estimates can be made for absolute risk from tobacco smoking using cross-sectional data on mortality and smoking prevalence. Number of future excess deaths and person-years of life lost in current smokers can also be estimated. Projections describe what will happen if the current situation does not change.

Background: Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data.

Objectives: An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture-recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture-recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35-44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37-46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147-391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146-389). Conclusion Application of capture-recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.

Background: Young adult (aged 20-34) males experience higher mortality than females, and in age groups immediately younger and older, and with considerable variation in death rates over time. Trends in mortality and the cause structure of deaths among young adult Australian males over 1979-2011 are investigated, with a focus on suicide and drug overdose.

Background:Kiribati is an atoll country of 103,058 (2010 Census) situated in the central Pacific. Previous mortality estimates have been derived from demographic analyses of census data. This is the first mortality analysis based on reported deaths.

Methods: Recorded deaths were from the Ministry of Health and the Civil Registration Office for 2000–2009; populations were from the 2000, 2005, and 2010 censuses. Duplicate death records were removed by matching deaths within and between data sources using a combination of names, date of death, age, sex, island of residence, and cause of death. Probability of dying <5 years (5q0) and 15–59 years (45q15), and life expectancy (LE) at birth, were computed with 95 % confidence intervals. These data were compared with previous census analyses.

Results: There were 8,681 unique deaths reported over the decade 2000–2009 in Kiribati. The reconciled mortality data indicate 5q0 for both sexes of 64 per 1,000 live births in 2000–2004, and 51 for 2005–2009 (assuming no under-enumeration), compared with 69 and 59 for comparable periods from the 2005 and 2010 census analyses (children ever-born/children surviving method). Based on reconciled deaths, LE at birth (e0) for males was 54 years for 2000–2004 and 55 years in 2005–2009, five years lower than the 2005 and 2010 census estimates for comparable periods of 59 and 58 years. Female LE was 62 years for 2000–2004 and 63 years for 2005–2009, two-three years less than estimates for comparable periods of 63 and 66 years from the 2005 and 2010 census analyses. Adult mortality (45q15) was 47-48 % in males and 27-28 % in females from reconciled mortality over 2000–2009, higher than census estimates of 34-38 % in males and 21-26 % in females for the same periods. The reconciled data are very likely to be incomplete and actual mortality higher and life expectancy lower than reported here.

Conclusion: This analysis indicates higher mortality than indirect demographic methods from the 2005 and 2010 Censuses. Reported deaths are most likely under-reported; especially 5q0, as many early neonatal deaths are probably classified as stillbirths. These analyses suggest that the health situation in Kiribati is more serious and urgent than previously appreciated.

Background: The population of the Pacific Melanesian country of Vanuatu was 234,000 at the 2009 census. Apart from subsistence activities, economic activity includes tourism and agriculture. Current completeness of vital registration is considered too low to be usable for national statistics; mortality and life expectancy (LE) are derived from indirect demographic estimates from censuses/surveys. Some cause of death (CoD) data are available to provide information on major causes of premature death.

Methods: Deaths 2001–2007 were coded for cause (ICDv10) for ages 0–59 years from: hospital separations (HS) (n = 636), hospital medical certificates (MC) of death (n = 1,169), and monthly reports from community health facilities (CHF) (n = 1,212). Ill-defined causes were 3 % for hospital deaths and 20 % from CHF. Proportional mortality was calculated by cause (excluding ill-defined) and age group (0–4, 5–14 years), and also by sex for 15–59 years. From total deaths by broad age group and sex from 1999 and 2009 census analyses, community deaths were estimated by deduction of hospital deaths MC. National proportional mortality by cause was estimated by a weighted average of MC and CHF deaths.

Results: National estimates indicate main causes of deaths <5 years were: perinatal disorders (45 %) and malaria, diarrhea, and pneumonia (27 %). For 15–59 years, main causes of male deaths were: circulatory disease 27 %, neoplasms 13 %, injury 13 %, liver disease 10 %, infection 10 %, diabetes 7 %, and chronic respiratory disease 7 %; and for females: neoplasms 29 %, circulatory disease 15 %, diabetes 10 %, infection 9 %, and maternal deaths 8 %. Infection included tuberculosis, malaria, and viral hepatitis. Liver disease (including hepatitis and cancer) accounted for 18 % of deaths in adult males and 9 % in females. Non-communicable disease (NCD), including circulatory disease, diabetes, neoplasm, and chronic respiratory disease, accounted for 52 % of premature deaths in adult males and 60 % in females. Injuries accounted for 13 % in adult males and 6 % in females. Maternal deaths translate into an annual maternal mortality ratio of 130/100,000 for the period.

Conclusion: Vanuatu manifests a double burden of disease with significant proportional mortality from perinatal disorders and infection/pneumonia <5 years and maternal mortality, coupled with significant proportional mortality in adults (15–59 years) from cardiovascular disease (CVD), neoplasms, and diabetes.

Background: Significant variation exists in published Aboriginal mortality and life expectancy (LE) estimates due to differing and evolving methodologies required to correct for inadequate recording of Aboriginality in death data, under-counting of Aboriginal people in population censuses, and unexplained growth in the Aboriginal population attributed to changes in the propensity of individuals to identify as Aboriginal at population censuses. The objective of this paper is to analyse variation in reported Australian Aboriginal mortality in terms of LE and infant mortality rates (IMR), compared with all Australians.

Methods: Published data for Aboriginal LE and IMR were obtained and analysed for data quality and method of estimation. Trends in reported LE and IMR estimates were assessed and compared with those in the entire Australian population.

Results: LE estimates derived from different methodologies vary by as much as 7.2 years for the same comparison period. Indirect methods for estimating Aboriginal LE have produced LE estimates sensitive to small changes in underlying assumptions, some of which are subject to circular reasoning. Most indirect methods appear to under-estimate Aboriginal LE. Estimated LE gaps between Aboriginal people and the overall Australian population have varied between 11 and 20 years.

Latest mortality estimates, based on linking census and death data, are likely to over-estimate Aboriginal LE.

Temporal LE changes by each methodology indicate that Aboriginal LE has improved at rates similar to the Australian population overall. Consequently the gap in LE between Aboriginal people and the total Australian population appears to be unchanged since the early 1980s, and at the end of the first decade of the 21st century remains at least 11–12 years.

In contrast, focussing on the 1990–2010 period Aboriginal IMR declined steeply over 2001–08, from more than 12 to around 8 deaths per 1,000 live births, the same level as Australia overall in 1993–95. The IMR gap between Aboriginal people and the total Australian population, while still unacceptable, has declined considerably, from over 8 before 2000 to around 4 per 1,000 live births by 2008.

Conclusions: Regardless of estimation method used, mortality and LE gaps between Aboriginal and non-Aboriginal people are substantial, but remain difficult to estimate accurately.

Background: People with limited health literacy are more likely to be socioeconomically disadvantaged and have risk factors for preventable chronic diseases. General practice is the ideal setting to address these inequalities however these patients engage less in preventive activities and experience difficulties navigating health services. This study aimed to compare primary care patients with and without sufficient health literacy in terms of their lifestyle risk factors, and explore factors associated with receiving advice and referral for these risk factors from their GPs.

Methods: A mailed survey of 739 patients from 30 general practices across four Australian states was conducted in 2012. Health literacy was measured using the Health Literacy Management Scale. Patients with a mean score of <4 within any domain were defined as having insufficient health literacy. Multilevel logistic regression was used to adjust for clustering of patients within practices.

Results: Patients with insufficient health literacy (n = 351; 48%) were more likely to report being overweight or obese, and less likely to exercise adequately. Having insufficient health literacy increased a patient’s chance of receiving advice on diet, physical activity or weight management, and referral to and attendance at lifestyle modification programs. Not speaking English at home; being overweight or obese; and attending a small sized practice also increased patients’ chances of receiving advice on these lifestyle risks. Few (5%, n = 37) of all patients reported being referred to lifestyle modification program and of those around three-quarters had insufficient health literacy. Overweight or obese patients were more likely to be referred to lifestyle modification programs and patients not in paid employment were more likely to be referred to and attend lifestyle programs.

Conclusions: Patients with insufficient health literacy were more likely to report receiving advice and being referred by GPs to attend lifestyle modification. Although the number of patients referred from this sample was very low, these findings are positive in that they indicate that GPs are identifying patients with low health literacy and appropriately referring them for assistance with lifestyle modification. Future research should measure the effectiveness of these lifestyle programs for patients with low health literacy.

Objectives: Infant mortality rates (IMR) and under-five mortality rates (U5MR) in Tuvalu (2010 population 11,149) for 1990–2011 were evaluated to determine best estimates of levels and trends.

Method: Estimates were graphed over time to identify trends/inconsistencies, and censored for reliability/plausibility. Where possible, 95% confidence intervals (CIs) and tests for linear trend were calculated.

Results: Ministry of Health (MoH) data indicates IMR and U5MR (per 1,000 live births) declined over 1990–2008: IMR 62 (95%CI 46-81) for 1991–93 (51 deaths) to 19 (95%CI 10-33) for 2006–08 (12 deaths); U5MR 67 (95%CI 50-87) for 1991–93 (55 deaths) to 19 (95%CI 10-33) for 2006–08 (12 deaths). The 2007 Demographic and Health Survey (DHS) suggests recent trends are increasing: IMR 24 for 1998–2002 to 31 (95%CI 20-42) for 2003–07; U5MR 29 for 1998–2002 to 36 (95%CI 30-43) for 2003–07 (deaths not provided). Tests for linear trend and 95%CIs indicate MoH declines are statistically significant, but recent increased estimates from DHS are not, and could be affected by recall bias.

Conclusion: Small populations provide challenges in interpretation of IMR/U5MR trends. To ensure the correct interpretation of rates, CIs (95%) and tests for trend should be calculated. Tuvalu has experienced steady decline in IMR/U5MR over the past 20 years.< /p>

https://www.ncbi.nlm.nih.gov/pubmed/24750434

Background: Although all-cause mortality in Sri Lanka decreased significantly from 1950 to 1970, subsequent declines have been more modest with divergent trends by age and sex. This study investigates these trends through cause of death analysis for 1950–2006 in adults aged 15–64 years.

Method: Deaths were obtained from the World Health Organisation (WHO) mortality database for 1950 to 2003, and the Department of Census and Statistics Sri Lanka for 1992–95 and 2004–06 where WHO data was unavailable. Adult deaths were categorised by age (15–34 and 35–64 years) and sex into: infectious diseases; external-causes; circulatory diseases; cancers; digestive diseases; respiratory diseases; pregnancy-related; ill-defined; and other-causes. Cause-specific mortality rates were directly age-standardised to the 2001 Sri Lankan Census population.

Results: Mortality declined in females aged 15–34 years by 85% over 1950–2006, predominantly due to sharp declines in infectious disease and pregnancy-related mortality over 1950–70. Among males aged 15–34 years the mortality decline was less at 47%, due to a rise in external-cause mortality during 1970–2000. In females aged 35–64 years mortality declined by 67% over 1950–2006, predominantly due to a sharp decline in infectious disease, ill-defined and other cause mortality over 1950–70. Among males aged 35–64 years, decline in mortality is evident to 1960 (19%) from decline in infectious disease mortality, followed by increased mortality from circulatory diseases and external cause mortality, despite continued decline in infectious disease mortality. All-cause mortality in males 35–64 years has stagnated since 1970, with fluctuating increases. Circulatory diseases were the leading cause of death among adults 35–64 years in 2002–06, with the male rate almost three times higher than females.

Conclusion: Significant disparities are demonstrated in Sri Lankan cause-specific adult mortality by sex and age group for 1950–2006. Female mortality progressively declined while male mortality demonstrated periods of increase and stagnation. Among males aged 15–34 years this coincides with periods of civil conflict over 1970–2000. Among males aged 35–64 years the increased mortality from non-communicable disease and external causes are the main reasons for stagnation in all-cause mortality since the 1970’s.
https://www.biomedcentral.com/1471-2458/14/644

Background: Published estimates of Aboriginal mortality and life expectancy (LE) for the eastern Australian states are derived from demographic modelling techniques to estimate the population and extent of under-recording of Aboriginality in death registration. No reliable empirical information on Aboriginal mortality and LE exists for New South Wales (NSW), the most populous Australian state in which 29% of Aboriginal people reside. This paper estimates mortality and LE in a large, mainly metropolitan cohort of Aboriginal clients from the Aboriginal Medical Service (AMS) Redfern, Sydney, NSW.

Methods: Identifying information from patient records accrued by the AMS Redfern since 1980 of definitely Aboriginal clients, without distinction between Aboriginal and Torres Strait Islander (n=24,035), was extracted and linked to the National Death Index (NDI) at the Australian Institute of Health and Welfare (AIHW). Age-specific mortality rates and LEs for each sex were estimated using the AMS patient population as the denominator, discounted for deaths. Directly age-standardised mortality and LEs were estimated for 1995–1999, 2000–2004 and 2005–2009, along with 95% confidence intervals. Comparisons were made with other estimates of Aboriginal mortality and LE and with the total Australian population.

Results: Mortality declined in the AMS Redfern cohort over 1995–2009, and the decline occurred mostly in the ≤44 year age range. Male LE at birth was estimated to be 64.4 years (95%CI:62.6-66.1) in 1995–1999, 65.6 years (95%CI:64.1-67.1) in 2000–2004, and 67.6 years (95%CI:65.9-69.2) for 2005–2009. In females, these LE estimates were 69.6 (95%CI:68.0-71.2), 71.1 (95%CI:69.9-72.4), and 71.4 (95%CI:70.0-72.8) years. LE in the AMS cohort was 11 years lower for males and 12 years lower for females than corresponding all-Australia LEs for the same periods. These were similar to estimates for Australian Aboriginal people overall for the same period by the Aboriginal Burden of Disease for 2009, using the General Growth Balance (GGB) model approach, and by the Australian Bureau of Statistics (ABS) for 2005–2007. LE in the AMS cohort was somewhat lower than these estimates for NSW Aboriginal people, and higher than ABS 2005–2007 estimates for Aboriginal people from Northern Territory, South Australia, and Western Australia.

Conclusions: The AMS Redfern cohort has provided the first empirically based estimates of mortality and LE trends in a large sample of Aboriginal people from NSW.

Objective: To examine trends in infant mortality rate (IMR), adult mortality and life expectancy (LE) in the two major Fijian ethnic groups since 1975.

Method: Estimates of IMR, adult mortality (15-59 years) and LE by ethnicity are calculated from previously unreported Fiji Ministry of Health data and extracted from published sources.

Results: Over 1975-2008: IMR decreased from 33 to 20 deaths/1,000 live births in i-Taukei (Fiji Melanesians); and 38 to 18 in Fijians of Indian descent. Increased adult male mortality among i-Taukei and decline among Fijians of Indian descent led to an equal probability of dying in 2007 of 29%; while in female adults the probability trended upwards in i-Taukei to 25%, and declined in Fijians of Indian descent to 17%. Life expectancy in both ethnicities increased until 1985 (to 64 years for males; 68 for females) then forming a plateau in males of both ethnicities, and Fijian females of Indian descent, but declining in i-Taukei females to 66 years in 2007.

Conclusion: Despite IMR declines over 1975-2008, LE for i-Taukei and Fijians of Indian descent has not increased since 1985, and has actually decreased in i-Taukei women, consistent with trends in adult mortality (15-59 years). Mortality analyses in Fiji that consider the entire population mask divergent trends in the major ethnic groups. This situation is most likely a consequence of non-communicable disease mortality, requiring further assessment and a strengthened response.
https://www.ncbi.nlm.nih.gov/pubmed/24892148

Background: Mortality statistics are essential for population health assessment. Despite limitations in data availability, Pacific Island Countries are considered to be in epidemiological transition, with non-communicable diseases increasingly contributing to premature adult mortality. To address rapidly changing health profiles, countries would require mortality statistics from routine death registration given their relatively small population sizes.

Method: This paper uses a standard analytical framework to examine death registration systems in Fiji, Kiribati, Nauru, Palau, Solomon Islands, Tonga and Vanuatu.

Results: In all countries, legislation on death registration exists but does not necessarily reflect current practices. Health departments carry the bulk of responsibility for civil registration functions. Medical cause-of-death certificates are completed for at least hospital deaths in all countries. Overall, significantly more information is available than perceived or used. Use is primarily limited by poor understanding, lack of coordination, limited analytical skills, and insufficient technical resources.

Conclusion: Across the region, both registration and statistics systems need strengthening to improve the availability, completeness, and quality of data. Close interaction between health staff and local communities provides a good foundation for further improvements in death reporting. System strengthening activities must include a focus on clear assignment of responsibility, provision of appropriate authority to perform assigned tasks, and fostering ownership of processes and data to ensure sustained improvements. These human elements need to be embedded in a culture of data sharing and use. Lessons from this multi-country exercise would be applicable in other regions afflicted with similar issues of availability and quality of vital statistics.
https://www.ncbi.nlm.nih.gov/pubmed/22694936

Background: Detailed cause of death data by age group and sex are critical to identify key public health issues and target interventions appropriately. In this study the quality of local routinely collected cause of death data from medical certification is reviewed, and a cause of death profile for Tonga based on amended data is presented.

Methods: Medical certificates of death for all deaths in Tonga for 2001 to 2008 and medical records for all deaths in the main island Tongatapu for 2008 were sought from the national hospital. Cause of death data for 2008 were reviewed for quality through (a) a review of current tabulation procedures and (b) a medical record review. Data from each medical record were extracted and provided to an independent medical doctor to assign cause of death, with underlying cause from the medical record tabulated against underlying cause from the medical certificate. Significant associations in reporting patterns were evaluated and final cause of death for each case in 2008 was assigned based on the best quality information from the medical certificate or medical record. Cause of death data from 2001 to 2007 were revised based on findings from the evaluation of certification of the 2008 data and added to the dataset. Proportional mortality was calculated and applied to age- and sex-specific mortality for all causes from 2001 to 2008. Cause of death was tabulated by age group and sex, and age-standardized (all ages) mortality rates for each sex by cause were calculated.

Results: Reported tabulations of cause of death in Tonga are of immediate cause, with ischemic heart disease and diabetes underrepresented. In the majority of cases the reported (immediate) cause fell within the same broad category as the underlying cause of death from the medical certificate. Underlying cause of death from the medical certificate, attributed to neoplasms, diabetes, and cardiovascular disease were assigned to other underlying causes by the medical record review in 70% to 77% of deaths. Of the 28 (6.5%) deaths attributed to nonspecific or unknown causes on the medical certificate, 17 were able to be attributed elsewhere following review of the medical record. Final cause of death tabulations for 2001 to 2008 demonstrate that noncommunicable diseases are leading adult mortality, and age-standardized rates for cardiovascular diseases, neoplasms, and diabetes increased significantly between 2001 to 2004 and 2005 to 2008. Cause of death data for 2001 to 2008 show increasing cause-specific mortality (deaths per 100,000) from 2001-2004 to 2005-2008 from cardiovascular (194-382 to 423-644 in 2005-2008 for males and 108-227 to 194-321 for females) and other noncommunicable diseases that cannot be accounted for by changes in the age structure of the population. Mortality from diabetes for 2005 to 2008 is estimated at 94 to 222 deaths per 100,000 population for males and 98 to 190 for females (based on the range of plausible all-cause mortality estimates) compared with 2008 estimates from the global burden of disease study of 40 (males) and 53 (females) deaths per 100,000 population.

Discussion: Certification of death was generally found to be the most reliable data on cause of death in Tonga available for Tonga, with 93% of the final assigned causes following review of the 2008 data matching those listed on the medical certificate of death. Cause of death data available in Tonga can be improved by routinely tabulating data by underlying cause and ensuring contributory causes are not recorded in Part I of the certificate during data entry to the database. There is significantly more data on cause of death available in Tonga than are routinely reported or known to international agencies.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378436/

Background: Accurate measures of mortality level by age group, gender, and region are critical for health planning and evaluation. These are especially required for a country like Tonga, which has limited resources and works extensively with international donors. Mortality levels in Tonga were examined through an assessment of available published information and data available from the four routine death reporting systems currently in operation.

Methods: Available published data on infant mortality rate (IMR) and life expectancy (LE) in Tonga were sought through direct contact with the Government of Tonga and relevant international and regional organizations. Data sources were assessed for reliability and plausibility of estimates on the basis of method of estimation, original source of data, and data consistency. Unreliable sources were censored from further analysis and remaining data analysed for trends. Mortality data for 2001 to 2009 were obtained from both the Health Information System (based on medical certificates of death) and the Civil Registry. Data from 2005 to 2009 were also obtained from the Reproductive Health System of the Ministry of Health (MoH) (based on community nursing reports), and for 2005–2008, data were also obtained from the Prime Minister’s office. Records were reconciled to create a single list of unique deaths and IMR and life tables calculated. Completeness of the reconciled data was examined using the Brass growth-balance method and capture-recapture analysis using two and three sources.

Results: Published IMR estimates varied significantly through to the late 1990s when most estimates converge to a narrower range between 10 and 20 deaths per 1,000 live births. Findings from reconciled data were consistent with this range, and did not demonstrate any significant trend over 2001 to 2009.
Published estimates of LE from 2000 onwards varied from 65 to 75 years for males and 68 to 74 years for females, with most clustered around 70 to 71 for males and 72 to 73 for females. Reconciled empirical data for 2005 to 2009 produce an estimate of LE of 65.2 years (95% confidence interval [CI]: 64.6 - 65.8) for males and 69.6 years (95% CI: 69.0 – 70.2) for females, which are several years lower than published MoH and census estimates. Adult mortality (15 to 59 years) is estimated at 26.7% for males and 19.8% for females. Analysis of reporting completeness suggests that even reconciled data are under enumerated, and these estimates place the plausible range of LE between 60.4 to 64.2 years for males and 65.4 to 69.0 years for females, with adult mortality at 28.6% to 36.3% and 20.9% to 27.7%, respectively.

Conclusions: The level of LE at a relatively low IMR and high adult mortality suggests that non-communicable diseases are having a profound limiting effect on health status in Tonga. There has been a sustained history of incomplete and erroneous mortality estimates for Tonga. The findings highlight the critical need to reconcile existing data sources and integrate reporting systems more fully to ensure all deaths in Tonga are captured and the importance of local empirical data in monitoring trends in mortality.
https://www.ncbi.nlm.nih.gov/pubmed/22891707

This article aims to examine the epidemiological transition in Nauru through analysis of available mortality data. Mortality data from death certificates and published material were used to construct life tables and calculate age-standardized mortality rates (from 1960) with 95% confidence intervals. Proportional mortality was calculated from 1947. Female life expectancy (LE) varied from 57 to 61 years with no significant trend. Age-standardized mortality for males (15-64 years) doubled from 1960-1970 to 1976-1981 and then decreased to 1986-1992, with LE fluctuating since then from 49 to 54 years. Proportional mortality from cardiovascular disease and diabetes increased substantially, reaching more than 30%. Nauru demonstrates a very long period of stagnation in life expectancy in both males and females as a consequence of the epidemiological transition, with major chronic disease mortality in adults showing no sustained downward trends over 40 years. Potential overinterpretation of trends from previous data due to lack of confidence intervals was highlighted.
https://www.ncbi.nlm.nih.gov/pubmed/21169596

Objective: Mortality level and cause of death trends are evaluated to chart the epidemiological transition in Fiji. Implications for current health policy are discussed.

Method: Published data for infant mortality rate (IMR), life expectancy (LE) and causes of death for 1940-2008 were assessed for quality, and compared with mortality indices generated from recent Ministry of Health death recording. Trends in credible mortality estimates are compared with trends in proportional mortality for cause of death.

Results: IMR declined from 60 deaths (per 1,000) in 1945 to below 20 by 2000. IMR for 2006-08 is estimated at 18-20 deaths per 1,000 live births. Excessive LE estimates arise by imputing from the IMR using inappropriate models. LE increased, but has been stable at 64 years for males and 69 years for females since the late 1980s and early 1990s respectively. Proportional mortality from diseases of the circulatory system has increased from around 20% in the 1960s to more than 45%. Extensive variation in published mortality estimates was indentified, including clearly incompatible ranges of IMR and LE.

Conclusions: Mortality decline has stagnated. Relatively low IMR and proportional mortality trends suggest this is largely due to chronic diseases (especially cardiovascular) in adults. Implications: Reconciliation of mortality data in Fiji to reduce uncertainty is urgently needed. Fiji's health services and donor partners should place continued and increased emphasis on effective control strategies for cardiovascular disease.
https://www.ncbi.nlm.nih.gov/pubmed/21973247

The purposes of the present article are to: (a) document levels of uncertainty in mortality estimates in Pacific island countries, (b) identify the major quality and analytical problems affecting estimates of mortality in Pacific island countries, and (c) provide best possible estimates based on an assessment of published data and application of demographic techniques. The scope of the current exercise is limited to total mortality levels from the 1990s to 2005 and is an update of previously published studies. A similar assessment of causes of death data and causes of death estimates is essential to help determine the need for priority health programmes. The present study focuses on: Melanesia which refers commonly to Fiji, New Caledonia, Papua New Guinea, Solomon Islands, Vanuatu; Micronesia: Federated States of Micronesia, Guam, Kiribati, the Marshall Islands, Nauru, the Northern Mariana Islands, and Palau; Polynesia: American Samoa, Cook Islands, French Polynesia, Niue, Samoa (formerly Western Samoa), Tokelau, Tonga, Tuvalu, Wallis and Futuna.

Background: The Pacific Island countries are at different stages of the demographic and epidemiological transitions. The availability of accurate and current mortality data is of vital importance for priority setting in health. Available mortality data generally underestimate death rates among both children and adults. In many Pacific Island populations, little is reliably known about levels and causes of death, particularly among adults.

Method: The results of two comprehensive approaches to obtaining mortality estimates are reported. First, a systematic review of available life expectancy and infant mortality information reported by countries from 1990 onwards was undertaken and evaluated with respect to quality, and a final "best estimate" was established. Methods were based on registered deaths and indirect demographic methods. The second approach consisted of a demographic evaluation of vital registration data for completeness, with death rates adjusted accordingly, or where vital registration was not available, the application of new model life table methods to generate life tables from estimates of child mortality, as used by the World Health Organisation (WHO).

Results: This analysis reveals substantial uncertainty about mortality conditions in Pacific Island populations. In some countries, life expectancy variations of 10 years or more were recorded in the 1990s, depending on the source. Best approaches suggest that life expectancy (at birth) varied considerably, from levels of around 55-60 years in some Melanesian and Micronesian states to levels above 70 years in low-mortality countries. The principal issues with regard to uncertainty around mortality levels include underenumerated vital registration data; annual stochastic fluctuations in mortality in small populations; errors in the imputation of adult mortality from infant and childhood rates; implausible results from indirect demographic methods; use of possibly inappropriate model life tables to adjust death data or for indirect methods; and inadequately described and implausible projections. The WHO model life table method based on adjusted vital registration generally yielded results similar to those suggested by an evaluation of published data, with some exceptions, which are further discussed.

Conclusion: This study indicates the urgent need to improve infrastructure, training, and resources for routine mortality estimation in many Pacific Island countries in order to better inform and evaluate health and public policy.
https://www.ncbi.nlm.nih.gov/pubmed/15465904

Objectives:To examine trends from 1980 to 2011 in daily tobacco smoking by sex, ethnicity, age, and urban/rural in Fiji Melanesian (i-Taukei) and Indian adults aged 25–64 years.

Background: The island country of Samoa (population 188,000 in 2011) forms part of Polynesia in the South Pacific. Over the past several decades Samoa has experienced exceptional modernization and globalization of many sectors of society, with noncommunicable diseases (NCD) now the leading cause of morbidity and mortality. The evolution of risk factor prevalence underpinning the increase in NCDs, however, has not been well described, including tobacco smoking which is related to cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease.

Methods: The present study examines tobacco smoking in relation to different forms and effects of globalization in Samoa using 7 population-based surveys (n = 9223) over 1978-2013.

Results: The prevalence of daily tobacco smoking steadily decreased over 1978-2013 from 76% to 36% in men, and from 27% to 15% in women (p < 0.0001 both sexes). During 1991-2013, current tobacco smoking also steadily decreased from 64% to 40% in men (p < 0.0001), and from 21% to 17% in women (p < 0.05). Declines were similar in younger (25-44 years) and older (45-64 years) men and women. Colonial globalization facilitated the introduction and prolific spread of tobacco trade and consumption in the Pacific Islands from the sixteenth century, with many populations inexorably pulled into trade relations and links to the global economy. It has also been a different globalization which may have led to the decline in smoking prevalence in Samoa in recent decades, through global dissemination since the 1950s of information on the harmful effects of tobacco smoking derived from research studies in the USA and Europe.

Conclusions: Over the past 35 years tobacco smoking has steadily declined among Samoan adults; the only NCD risk factor to demonstrate marked declines during this period. By 2013 tobacco smoking in women had decreased to levels similar to Australia and New Zealand (ANZ), however in men smoking prevalence remained more than three times higher than ANZ. The impact on smoking prevalence of the variety of tobacco control interventions that have been implemented so far in Samoa need to be evaluated in order to determine the most effective initiatives that should be prioritized and strengthened.