Objective To assess whether immunosuppressive drugs increase mortality.

Design Retrospective cohort study evaluating overall and cancer mortality in relation to immunosuppressive drug exposure among patients with ocular inflammatory diseases. Demographic, clinical, and treatment data derived from medical records, and mortality results from United States National Death Index linkage. The cohort’s mortality risk was compared with US vital statistics using standardised mortality ratios. Overall and cancer mortality in relation to use or non-use of immunosuppressive drugs within the cohort was studied with survival analysis.

Setting Five tertiary ocular inflammation clinics.

Patients 7957 US residents with non-infectious ocular inflammation, 2340 of whom received immunosuppressive drugs during follow up.

Exposures Use of antimetabolites, T cell inhibitors, alkylating agents, and tumour necrosis factor inhibitors.

Main outcome measures Overall mortality, cancer mortality.

Results Over 66 802 person years (17 316 after exposure to immunosuppressive drugs), 936 patients died (1.4/100 person years), 230 (24.6%) from cancer. For patients unexposed to immunosuppressive treatment, risks of death overall (standardised mortality ratio 1.02, 95% confidence interval [CI] 0.94 to 1.11) and from cancer (1.10, 0.93 to 1.29) were similar to those of the US population. Patients who used azathioprine, methotrexate, mycophenolate mofetil, ciclosporin, systemic corticosteroids, or dapsone had overall and cancer mortality similar to that of patients who never took immunosuppressive drugs. In patients who used cyclophosphamide, overall mortality was not increased and cancer mortality was non-significantly increased. Tumour necrosis factor inhibitors were associated with increased overall (adjusted hazard ratio [HR] 1.99, 95% CI 1.00 to 3.98) and cancer mortality (adjusted HR 3.83, 1.13 to 13.01).

Conclusions Most commonly used immunosuppressive drugs do not seem to increase overall or cancer mortality. Our results suggesting that tumour necrosis factor inhibitors might increase mortality are less robust than the other findings; additional evidence is needed.

Design Cross sectional telephone survey using random digit dialling.

Setting Interviews by telephone between 8 and 12 May.

Participants 997 adults aged 18 or more who had heard of swine flu and spoke English.

Main outcome measures Recommended change in behaviour (increases in handwashing and surface cleaning or plans made with a "flu friend") and avoidance behaviours (engaged in one or more of six behaviours such as avoiding large crowds or public transport).

Results 37.8% of participants (n=377) reported performing any recommended behaviour change "over the past four days . . . because of swine flu." 4.9% (n=49) had carried out any avoidance behaviour. Controlling for personal details and anxiety, recommended changes were associated with perceptions that swine flu is severe, that the risk of catching it is high risk, that the outbreak will continue for a long time, that the authorities can be trusted, that good information has been provided, that people can control their risk of catching swine flu, and that specific behaviours are effective in reducing the risk. Being uncertain about the outbreak and believing that the outbreak had been exaggerated were associated with a lower likelihood of change. The strongest predictor of behaviour change was ethnicity, with participants from ethnic minority groups being more likely to make recommended changes (odds ratio 3.2, 95% confidence interval 2.0 to 5.3) and carry out avoidance behaviours (4.1, 2.0 to 8.4).

Conclusions The results support efforts to inform the public about specific actions that can reduce the risks from swine flu and to communicate about the government’s plans and resources. Tackling the perception that the outbreak has been "over-hyped" may be difficult but worthwhile. Additional research is required into differing reactions to the outbreak among ethnic groups.

Design Prospective population based study with an average follow-up of 21 years.

Setting Kuopio and Joensuu regions in eastern Finland.

Participants Participants were derived from random, population based samples previously investigated in 1972, 1977, 1982, or 1987; 1449 individuals (73%), aged 65-79, underwent re-examination in 1998.

Main outcome measures Alzheimer’s disease and mild cognitive impairment.

Results People cohabiting with a partner in mid-life (mean age 50.4) were less likely than all other categories (single, separated, or widowed) to show cognitive impairment later in life at ages 65-79. Those widowed or divorced in mid-life and still so at follow-up had three times the risk compared with married or cohabiting people. Those widowed both at mid-life and later life had an odds ratio of 7.67 (1.6 to 40.0) for Alzheimer’s disease compared with married or cohabiting people. The highest increased risk for Alzheimer’s disease was in carriers of the apolipoprotein E e4 allele who lost their partner before mid-life and were still widowed or divorced at follow-up. The progressive entering of several adjustment variables from mid-life did not alter these associations.

Conclusions Living in a relationship with a partner might imply cognitive and social challenges that have a protective effect against cognitive impairment later in life, consistent with the brain reserve hypothesis. The specific increased risk for widowed and divorced people compared with single people indicates that other factors are needed to explain parts of the results. A sociogenetic disease model might explain the dramatic increase in risk of Alzheimer’s disease for widowed apolipoprotein E e4 carriers.

Design Plausibility study using three nationally representative cross sectional household and health facility surveys, timed to take place early, mid-way, and at the end of the roll out of the national programme.

Setting The Tanzania National Voucher Scheme was implemented in antenatal services, and phased in on a district by district basis from October 2004 covering all of mainland Tanzania in May 2006.

Participants 6115, 6260, and 6198 households (in 2005, 2006, and 2007, respectively) in a representative sample of 21 districts (out of a total of 113).

Interventions A voucher worth $2.45 (£1.47, 1.74) to be used as part payment for the purchase of a net from a local shop was given to every pregnant woman attending antenatal services.

Main outcome measures Insecticide treated net coverage was measured as household ownership of at least one net and use of a net the night before the survey. Socioeconomic distribution of nets was examined using an asset based index.

Results Steady increases in net coverage indicators were observed over the three year study period. Between 2005 and 2007, household ownership of at least one net (untreated or insecticide treated) increased from 44% (2686/6115) to 65% (4006/6198; P<0.001), and ownership of at least one insecticide treated net doubled from 18% (1062/5961) to 36% (2229/6198) in the same period (P<0.001). Among infants under 1 year of age, use of any net increased from 33% (388/1180) to 56% (707/1272; P<0.001) and use of an insecticide treated net increased from 16% (188/1180) to 34% (436/1272; P<0.001). After adjusting for potential confounders, household ownership was positively associated with time since programme launch, although this association did not reach statistical significance (P=0.09). Each extra year of programme operation was associated with a 9 percentage point increase in household insecticide treated net ownership (95% confidence interval –1.6 to 20). In 2005, only 7% (78/1115) of nets in households with a child under 1 year of age had been purchased with a voucher; this value increased to 50% (608/1211) in 2007 (P<0.001). In 2007, infants under 1 year in the least poor quintile were more than three times more likely to have used an insecticide treated net than infants in the poorest quintile (54% v 16%; P<0.001).

Conclusions The Tanzania National Voucher Scheme was associated with impressive increases in the coverage of insecticide treated nets over a two year period. Gaps in coverage remain, however, especially in the poorest groups. A voucher system that facilitates routine delivery of insecticide treated nets is a feasible option to "keep up" coverage.