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Press releases 9 November 2007

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(1) Most UK citizens susceptible to hepatitis B infection
(2) Should drugs be decriminalised?
(3) Study reveals high death toll after severe urinary complications in men over 45
(4) Warning for women who binge drink

(1) Most UK citizens susceptible to hepatitis B infection
(Hepatitis B vaccination)
http://www.bmj.com/cgi/content/full/335/7627/950
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The failure of the UK to introduce universal hepatitis B immunisation means that most UK citizens are susceptible to infection, warns an infectious diseases expert in this week's BMJ.

The UK is one of the few developed countries that still does not routinely immunise children against hepatitis B, despite a call by the World Health Organisation for the global introduction of vaccine prevention programmes by 1997, writes Andrew Pollard, Reader in Paediatric Infection and Immunity at Oxford University.

Earlier this year, the BMA also called upon the Department of Health "to introduce the hepatitis B vaccine into the childhood schedule without further delay".

The main argument against introducing universal immunisation is the relatively low incidence of disease in the UK compared with other countries. However, 180,000 people in the UK are chronically infected with hepatitis B virus and 7,700 new cases of chronic infection are detected each year.

Growing travel and migration also put the UK population at risk of exposure from abroad.

Up to 40% of infections are transmitted from mother to child during birth, or in early childhood through contact with blood or body fluids. Fortunately, the virus can be controlled and, possibly, eventually eliminated by immunisation, says Pollard.

Indeed, countries that have introduced universal childhood immunisation in the past 15 years now have a new generation of adolescents and young adults among whom transmission is being interrupted.

The UK government currently favours a targeted immunisation strategy to prevent transmission of the virus from mother to child. But the easiest and cheapest way to protect UK children is to add hepatitis B vaccine to the current UK primary immunisation schedule in early infancy, says Pollard. This approach is already widely used in Europe.

However, at this time, infant immunisation alone is also insufficient to limit transmission of the virus, because of ongoing transmission among the non-immune adult population and the difficulty in identifying and reaching people at risk. For this reason, Pollard argues that the current targeted programme aimed at high risk groups (injecting drug users, prisoners etc) needs strengthening to reduce the burden of new infections until those in a universal immunisation programme reach adulthood.

He also says that the recent proposal to introduce vaccination to prevent cervical cancer in pre-adolescents from next year could provide a vehicle for implementing a concomitant adolescent hepatitis B programme to prevent liver cancer. This, he suggests, would generate a group of immune individiuals more quickly than universal infant immunisation alone and hasten the control of the hepatitis B virus in the UK.

Contact:
Andrew Pollard, Reader in Paediatric Infection and Immunity, Oxford Vaccine Group, Department of Paediatrics, University of Oxford, UK
Email: andrew.pollard{at}paediatrics.ox.ac.uk 

(2) Should drugs be decriminalised?
(Head to Head: Should drugs be decriminalised?)
Yes: www.bmj.com/cgi/content/full/335/7627/966
No: www.bmj.com/cgi/content/full/335/7627/967

Recent government figures suggest that the UK drug treatment programmes have had limited success in drug rehabilitation, leading to calls for decriminalisation from some parties.

In this week's BMJ, two experts debate the issue.

A sensible policy of regulation and control would reduce burglary, cut gun crime, bring women off the streets, more than halve the prison population, and raise billions in tax revenue, argues Kailash Chand, a general practitioner in Lancashire. Yet politicians would never dare to suggest it.

Prohibition as a policy has failed, he says. It is the violent criminal gangs - and not the governments - that control this trade and it is their turf wars that fuel gun crime. The policy drives young women into prostitution and fuels crime among desperate low income addicts.

He believes that drugs could easily be regulated in the same manner that alcohol and tobacco are regulated and, more importantly, heavily taxed. The revenue generated could then be funnelled into education and other rehabilitation programmes.

Legislation would also mean that drug users could buy from places where they could be sure the drugs had not been cut with other substances, he adds. There would be clear information about the risks involved and guidance on how to seek treatment.

It is time to allow adults the freedom to make decisions about the harmful substances they consume, he concludes.

But Joseph Califano, Chairman of the National Center on Addiction and Substance Abuse at Columbia University argues that neither legislation nor decriminalisation is the answer. Rather, more resources and energy should be devoted to research, prevention, and treatment, and each citizen and institution should take responsibility to combat all substance misuse and addiction.

Decriminalisation will also make illegal drugs cheaper, easier to obtain, and more acceptable to use, he says. For example Italy, where personal possession of a few doses of drugs like heroin has generally been exempt from criminal sanction, has one of the highest rates of heroin addiction in Europe.

In contrast, Sweden offers an example of a successful restrictive drug policy. Faced with rising drug use in the 1990s, the government tightened drug control, stepped up police action, mounted a national action plan, and created a national drug coordinator. The result: Drug use is just a third of the European average.

Meanwhile, evidence that cannabis use can cause serious mental illness is also mounting.

Drugs are not dangerous because they are illegal; they are illegal because they are dangerous, he argues. Legalisation and decriminalisation - policies certain to increase illegal drug availability and use among our children - hardly qualify as public health approaches.

Contacts:
Kailash Chand, General Practitioner, Ashton under Lyne, Lancashire, UK
Email: kailash.chand{at}gp-P89609.nhs.uk 
Joseph A. Califano, Jr., Chairman and President, The National Center on Addiction and Substance Abuse at Columbia University, New York, USA
Email: info{at}casacolumbia.org 

(3) Study reveals high death toll after severe urinary complications men over 45
(Mortality in men with acute urinary retention admitted to hospital)
www.bmj.com/cgi/content/full/bmj.39377.617269.55v1
(Editorial: Mortality in men admitted to hospital with acute urinary retention)
www.bmj.com/cgi/content/full/bmj.39384.556725.80v1

As many as one in four men admitted to hospital with acute urinary retention will die within a year, finds a study published on bmj.com today.

The risk of death in men after acute urinary retention is close to that seen in patients who had a broken hip. The problem is set to get worse as the population ages, warn the researchers.

Acute urinary retention (AUR) is the sudden inability to pass urine and is often a progression of benign prostatic hyperplasia (an increase in size of the prostate in middle-aged and elderly men which can interfere with the normal flow of urine). It is a medical emergency and is thought to be linked to the presence of other disorders such as high blood pressure and diabetes.

So to investigate the risk of death associated with AUR, researchers analysed data on all men aged over 45 years who were admitted to NHS hospitals in England with a first episode of AUR between 1998 and 2005. Mortality in the first year after AUR was compared to mortality among the general male population of similar age.

During the study period, 176,046 men over 45 were admitted to hospital with primary AUR.

Mortality among these men was very high. One in seven men with spontaneous AUR (no evidence of precipitating factors other than benign prostatic hyperplasia) and one in four with precipitated AUR died in the first year.

The risk of dying increased with age and the presence of other disorders (comorbidity). Consequently, about half the men aged over 85 years with comorbid conditions died within the first year after AUR.

Overall mortality at one year in men admitted to hospital for AUR was two to three times higher than for the general male population. However, in men aged between 45 and 54 years with precipitated AUR, there was an almost 24-fold increase in mortality compared to the general population.

The authors conclude that mortality of hospitalised men with AUR is high and increases strongly with age and the presence of other conditions. As a result, patients with AUR may benefit from urgent multi-disciplinary care to identify and treat comorbidity early.

An accompanying editorial discusses the importance of this study and supports the call for multidisciplinary care in these men.

Contact:
G James Rubin, Lecturer, King's College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK
Email: g.rubin{at}iop.kcl.ac.uk 

(4) Warning for women who binge drink
(Lesson of the Week: Lower abdominal pain in women after binge drinking)
www.bmj.com/cgi/content/full/335/7627/992

As levels of binge drinking in the UK rise, doctors in this week’s BMJ report three cases of bladder rupture in women who attended hospital with lower abdominal pain.

Although rare, this condition has previously only been seen in men after excessive alcohol intake.

Alcohol misuse is costing the NHS up to £3bn a year, with over 28,000 hospital admissions cause by alcohol dependence or poisoning and 22,000 premature deaths each year caused by problems related to alcohol.

Women have now caught up with men in their alcohol consumption, and health concerns that were initially raised about drinking habits in men now seem to affect women as well.

Dr Mohantha Dooldeniya and colleagues describe three women who presented to Pinderfields Hospital with lower abdominal pain after excessive alcohol consumption.

The first two patients presented with symptoms consistent with urinary infection (sepsis) and were initially treated with antibiotics and rehydration. In the third woman, doctors initially suspected appendicitis because of the localisation of the pain.

After further investigation, bladder rupture was confirmed and all women underwent surgery to repair the bladder.

In all these cases, diuresis (increased discharge of urine) and the dulling effect of alcohol, without the relief of bladder voiding, was thought to be the cause.

Alcohol consumption increases the volume of urine held within the bladder and dulls the senses such that the patient has a reduced urge to void despite the increased bladder volume, say the authors. Minor trauma, such as from a fall, will further increase the pressure and can cause rupture.

They suggest that with the increase in alcohol consumption in women today, the complications previously seen only in men should now also be considered.

Contact:
Mohantha D Dooldeniya, Specialist Registrar in Urology, Castlehill Hospital, UK
Email: modool{at}btinternet.com 


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