Hepatitis-B-Virus-Infektionen und impfinduzierte Immunität: die Rolle von soziodemografischen Determinanten

Hintergrund und Ziel: Trotz niedriger Prävalenz der Hepatitis-B-Virus-(HBV-)Infektion in Deutschland ist es wichtig, vulnerable Gruppen und Ansatzpunkte für die Prävention zu identifizieren. In ersten Analysen der „Studie zur Gesundheit Erwachsener in Deutschland“ (DEGS1, 2008–2011) waren HBV-Infektion und -Impfung mit sozidemografischen Determinanten assoziiert. In dieser Arbeit werden die Ergebnisse im Detail untersucht. Material und Methoden: In DEGS1 lag für 7046 Teilnehmende (Alter: 18–79 Jahre) eine HBV-Serologie vor. Die stattgehabte HBV-Infektion war durch Antikörper gegen das Hepatitis-B-Core-Antigen (Anti-HBc) definiert, die impfinduzierte Immunität durch alleinigen Nachweis von Antikörpern gegen das Hepatitis-B-Surface-Antigen (Anti-HBs). Seroprävalenzen von HBV-Infektions- und -Impfstatus wurden geschlechtsstratifiziert geschätzt und Assoziationen mit Alter, Gemeindegröße, Einkommen, formaler Bildung, Krankenversicherung und Migrationsgeneration in logistischen Regressionen analysiert. Ergebnisse: Die HBV-Infektion war bei Männern und Frauen unabhängig mit den Altersgruppen 34–64 und ≥ 65 Jahre, erster Migrationsgeneration und Leben in größeren Gemeinden assoziiert, zudem bei Männern mit niedrigem Einkommen und bei Frauen mit niedriger Bildung. Die impfinduzierte Immunität war bei Männern und Frauen unabhängig mit den Altersgruppen 18–33 und 34–64 Jahre, mittlerer und hoher Bildung und hohem Einkommen assoziiert, darüber hinaus bei Männern mit mittlerem Einkommen und privater Krankenversicherung und bei Frauen mit fehlendem Migrationshintergrund. Diskussion: Die Berücksichtigung von Migrationsstatus, Einkommen und Bildung könnte zur zielgenauen Ausrichtung der HBV-Prävention beitragen.Background and objective: Even though the prevalence of hepatitis B virus (HBV) infection in Germany is low, it is important to identify vulnerable groups and targeted approaches for infection prevention. Previous analyses from the “German Health Interview and Examination Survey for Adults” (DEGS1, 2008–2011) have shown that HBV infections and vaccination are associated with sociodemographic determinants. This paper examines the results in detail. Materials and methods: In the DEGS1, HBV serology was available for 7046 participants aged 18–79 years. HBV infection was defined by antibodies to hepatitis B core antigen (anti-HBc), vaccine-induced immunity by antibodies to hepatitis B surface antigen (anti-HBs) in the absence of other markers. Seroprevalences of HBV infection and vaccine-induced immunity were estimated stratified by sex, and associations with age, municipality size, income, formal education, health insurance and migration generation were analysed by logistic regression. Results: In both sexes, HBV infection was independently associated with age groups 34–64 and ≥ 65 years, first migrant generation and living in larger municipalities as well as low income in men and low education in women. Vaccine-induced immunity was independently associated with age groups 18–33 and 34–64 years, middle and high education and high income in both sexes, middle income and private health insurance in men and having no migration background in women. Conclusions: HBV prevention measures should take into account migration status, income and education in order to focus prevention measures.Peer Reviewe

Historische Kohortenstudie zum Einfluss von Dieselmotoremissionen auf die Lungenkrebssterblichkeit im Kalibergbau : zweite Follow-Up-Untersuchung und Validierungsstudie

Neumeyer-Gromen A. Historische Kohortenstudie zum Einfluss von Dieselmotoremissionen auf die Lungenkrebssterblichkeit im Kalibergbau : zweite Follow-Up-Untersuchung und Validierungsstudie. Bielefeld (Germany): Bielefeld University; 2007.Einleitung/Hintergrund: Dieselmotoremissionen (DME) sind nach IARC als "wahrscheinlich humankanzerogen" eingestuft. Epidemiologische Forschungslücken bestehen in der Quantifizierung der Exposition, der Kontrolle von Confounding (v.a. Rauchen) und der Untersuchung besonders hochbelasteter Populationen, zu denen Bergarbeiter zählen (Hauptemittenten von DME sind Großlader und Sprenglochbohrwagen). Primäres Ziel der Studie ist die Untersuchung des Zusammenhangs zwischen DME und Lungenkrebsmortalität. Material/Methoden: In einer historischen Kohortenstudie wurden 6079 Kalibergarbeiter aus dem Südharzrevier von 1970 bis 2001 verfolgt. Einschlusskriterium war eine mindestens einjährige Berufstätigkeit nach 1969 (Umstellung auf Dieseltechnologie). Die Berufsvorgeschichten und das Rauchverhalten wurden aus arbeitsmedizinischen Akten erhoben und zusätzlich bei 3087 Teilnehmern durch Interviews validiert. Repräsentative Dieselrußkonzentrationen in den Tätigkeitsgruppen wurden mit den Tätigkeitsjahren multipliziert (kumulative Exposition). In der Auswertung erfolgte ein externer Vergleich der Mortalität der Kohorte mit der Allgemeinbevölkerung (standardisierte Mortalitätsratio/SMR) und ein interner Vergleich hoch- und niedrigbelasteter Tätigkeitsgruppen (Cox-/Poisson-Regression). Im internen Vergleich ist für das relative Risiko (RR) ein Cutpoint von 4.9 [mg/m³]*Jahre definiert, was einer 20jährigen Exposition in der am höchsten belasteten Tätigkeitsgruppe entspricht. Die RR sind nach Alter und Rauchverhalten adjustiert und zusätzlich auf der Grundlage von Dosis-Terzilen und -Quintilen berechnet. Ergebnisse: Die Erfassung von Vitalstatus und Todesursachen liegt bei 98,1 Prozent. Die Validierung der Exposition zeigt insgesamt eine gute Übereinstimmung, während die Rauchangaben eher auf Unterschätzung durch die Aktendaten schließen lassen. Die SMR-Analyse ergibt keine Risikoerhöhung für Lungenkrebs. Im internen Vergleich zeigen sich überwiegend moderate Risikoerhöhungen für die Lungenkrebssterblichkeit, die bei dichotomer Exposition bis zu 1.5 [0.7-3.1] in der Gesamtkohorte und 1.8 [0.8-4.0] in der Subkohorte reichen. Bei zusätzlicher Adjustierung der Länge des Follow-Up steigen die RR signifikant an. Die Analyse mit Dosis-Terzilen bestätigt die Befunde durch eine nicht-signifikante Dosis-Wirkungsbeziehung in einer Subkohorte mit besonders gut beschriebener Exposition (N=3335), in der überdies eine 10jährige Latenzzeit berücksichtigt wird. Die Quintilenberechnungen zeigen bereits ab der kumulativen Exposition (CE) von 2.7 [mg/m³]*Jahre grenzwertig signifikante Risikoerhöhungen über die Risikoverdopplung hinaus (RR 2.5 [1.0-6.0]). Diskussion/Schlussfolgerungen: Die Befunde sind mit der Literatur konsistent. Die Ergebnisse dieser Studie sprechen aus probabilistischer Sicht für humankanzerogene Wirkungen durch DME, da sie in allen Berechnungen und Sensitivitätsprüfungen des maßgeblichen internen Vergleichs Risikoerhöhungen zeigen. Sie geben Anlass, Präventionsmaßnahmen zur Senkung von Partikelemissionen zu forcieren

Diesel motor emissions and lung cancer mortality-Results of the second follow-up of a cohort study in potash miners

Neumeyer-Gromen A, Razum O, Kersten N, Seidler A, Zeeb H. Diesel motor emissions and lung cancer mortality-Results of the second follow-up of a cohort study in potash miners. INTERNATIONAL JOURNAL OF CANCER. 2009;124(8):1900-1906.International health authorities have graded diesel motor emissions (DME) as probably cancerogenic in human beings. There are gaps in epidemiological evidence regarding exact exposure quantification, confounder control and the investigation of highly exposed populations. We investigated the association of DME ana lung cancer mortality in a historical cohort study of 5,862 German potash miners who were followed from 1970 to 2001. Cumulative exposure (CE) was measured by representative concentrations of total carbon multiplied with exposure years from the mines' medical records. Exposure and smoking behavior were validated by interviews of 3,087 participants. We computed standardized mortality ratios (SMR, external comparison) and performed Cox regression (internal comparison). The relative risk estimates (RR) with 95%-confidence intervals were adjusted for age and smoking. Vital status and causes of death were confirmed for 98.1% of participants. Sixty-one lung cancer deaths occurred. SMR-analysis showed lower than expected lung cancer mortality (healthy-worker-effect). Internal comparisons revealed risk elevations from moderate to risk doubling depending oil the exposure categories used (dichotomized: up to RR 1.43[0.67-3.03] for a CE of 4.90[mg/m(3)]*years as compared with less exposure; quintiles: RR 1.13[0.46-2.75], 2.47[1.02-6.02], 1.50[0.56-4.04] and 2.28[0.87-5.97] for a CE up to 2.04, 2.73, 3.90 and >3.90, respectively, as compared with the reference of <1.29[mg/m(3)] *years). Additional adjustment of length of follow-up leads to further RR increases and indicates healthy-worker-survivor-phenomena. The analyses of a sub-cohort (n = 3,335) with particularly accurate exposure measurement revealed a nonsignificant dose-response-relationship. Our results support an association of DME and lung cancer mortality. (C) 2008 Wiley-Liss, Inc

Interventions to improve return to work in depressed people

BACKGROUND: Work disability such as sickness absence is common in people with depression. OBJECTIVES: To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders. SEARCH METHODS: We searched CENTRAL (The Cochrane Library), MEDLINE, Embase, CINAHL, and PsycINFO until April 4th 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-RCTs of work-directed and clinical interventions for depressed people that included days of sickness absence or being off work as an outcome. We also analysed the effects on depression and work functioning. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data and rated the certainty of the evidence using GRADE. We used standardised mean differences (SMDs) or risk ratios (RR) with 95% confidence intervals (CI) to pool study results in studies we judged to be sufficiently similar.  MAIN RESULTS: In this update, we added 23 new studies. In total, we included 45 studies with 88 study arms, involving 12,109 participants with either a major depressive disorder or a high level of depressive symptoms. Risk of bias The most common types of bias risk were detection bias (27 studies) and attrition bias (22 studies), both for the outcome of sickness absence. Work-directed interventions Work-directed interventions combined with clinical interventions A combination of a work-directed intervention and a clinical intervention probably reduces days of sickness absence within the first year of follow-up (SMD -0.25, 95% CI -0.38 to -0.12; 9 studies; moderate-certainty evidence). This translates back to 0.5 fewer (95% CI -0.7 to -0.2) sick leave days in the past two weeks or 25 fewer days during one year (95% CI -37.5 to -11.8). The intervention does not lead to fewer persons being off work beyond one year follow-up (RR 0.96, 95% CI 0.85 to 1.09; 2 studies, high-certainty evidence). The intervention may reduce depressive symptoms (SMD -0.25, 95% CI -0.49 to -0.01; 8 studies, low-certainty evidence) and probably has a small effect on work functioning (SMD -0.19, 95% CI -0.42 to 0.06; 5 studies, moderate-certainty evidence) within the first year of follow-up.  Stand alone work-directed interventions A specific work-directed intervention alone may increase the number of sickness absence days compared with work-directed care as usual (SMD 0.39, 95% CI 0.04 to 0.74; 2 studies, low-certainty evidence) but probably does not lead to more people being off work within the first year of follow-up (RR 0.93, 95% CI 0.77 to 1.11; 1 study, moderate-certainty evidence) or beyond (RR 1.00, 95% CI 0.82 to 1.22; 2 studies, moderate-certainty evidence). There is probably no effect on depressive symptoms (SMD -0.10, 95% -0.30 CI to 0.10; 4 studies, moderate-certainty evidence) within the first year of follow-up and there may be no effect on depressive symptoms beyond that time (SMD 0.18, 95% CI -0.13 to 0.49; 1 study, low-certainty evidence). The intervention may also not lead to better work functioning (SMD -0.32, 95% CI -0.90 to 0.26; 1 study, low-certainty evidence) within the first year of follow-up.   Psychological interventions A psychological intervention, either face-to-face, or an E-mental health intervention, with or without professional guidance, may reduce the number of sickness absence days, compared with care as usual (SMD -0.15, 95% CI -0.28 to -0.03; 9 studies, low-certainty evidence). It may also reduce depressive symptoms (SMD -0.30, 95% CI -0.45 to -0.15, 8 studies, low-certainty evidence). We are uncertain whether these psychological interventions improve work ability (SMD -0.15 95% CI -0.46 to 0.57; 1 study; very low-certainty evidence). Psychological intervention combined with antidepressant medication Two studies compared the effect of a psychological intervention combined with antidepressants to antidepressants alone. One study combined psychodynamic therapy with tricyclic antidepressant (TCA) medication and another combined telephone-administered cognitive behavioural therapy (CBT) with a selective serotonin reuptake inhibitor (SSRI). We are uncertain if this intervention reduces the number of sickness absence days (SMD -0.38, 95% CI -0.99 to 0.24; 2 studies, very low-certainty evidence) but found that there may be no effect on depressive symptoms (SMD -0.19, 95% CI -0.50 to 0.12; 2 studies, low-certainty evidence). Antidepressant medication only Three studies compared the effectiveness of SSRI to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Improved care Overall, interventions to improve care did not lead to fewer days of sickness absence, compared to care as usual (SMD -0.05, 95% CI -0.16 to 0.06; 7 studies, moderate-certainty evidence). However, in studies with a low risk of bias, the intervention probably leads to fewer days of sickness absence in the first year of follow-up (SMD -0.20, 95% CI -0.35 to -0.05; 2 studies; moderate-certainty evidence). Improved care probably leads to fewer depressive symptoms (SMD -0.21, 95% CI -0.35 to -0.07; 7 studies, moderate-certainty evidence) but may possibly lead to a decrease in work-functioning (SMD 0.5, 95% CI 0.34 to 0.66; 1 study; moderate-certainty evidence). Exercise Supervised strength exercise may reduce sickness absence, compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54; one study, low-certainty evidence). However, aerobic exercise probably is not more effective than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24; 2 studies, moderate-certainty evidence). Both studies found no differences between the two conditions in depressive symptoms. AUTHORS' CONCLUSIONS: A combination of a work-directed intervention and a clinical intervention probably reduces the number of sickness absence days, but at the end of one year or longer follow-up, this does not lead to more people in the intervention group being at work. The intervention may also reduce depressive symptoms and probably increases work functioning more than care as usual. Specific work-directed interventions may not be more effective than usual work-directed care alone. Psychological interventions may reduce the number of sickness absence days, compared with care as usual. Interventions to improve clinical care probably lead to lower sickness absence and lower levels of depression, compared with care as usual. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. Further research is needed to assess which combination of work-directed and clinical interventions works best

Interventions to improve return to work in depressed people

Work disability such as sickness absence is common in people with depression. To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders. We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO until January 2014. We included randomised controlled trials (RCTs) and cluster RCTs of work-directed and clinical interventions for depressed people that included sickness absence as an outcome. Two authors independently extracted the data and assessed trial quality. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to pool study results in the studies we judged to be sufficiently similar. We used GRADE to rate the quality of the evidence. We included 23 studies with 26 study arms, involving 5996 participants with either a major depressive disorder or a high level of depressive symptoms. We judged 14 studies to have a high risk of bias and nine to have a low risk of bias. Work-directed interventions We identified five work-directed interventions. There was moderate quality evidence that a work-directed intervention added to a clinical intervention reduced sickness absence (SMD -0.40; 95% CI -0.66 to -0.14; 3 studies) compared to a clinical intervention alone.There was moderate quality evidence based on a single study that enhancing the clinical care in addition to regular work-directed care was not more effective than work-directed care alone (SMD -0.14; 95% CI -0.49 to 0.21).There was very low quality evidence based on one study that regular care by occupational physicians that was enhanced with an exposure-based return to work program did not reduce sickness absence compared to regular care by occupational physicians (non-significant finding: SMD 0.45; 95% CI -0.00 to 0.91). Clinical interventions, antidepressant medication Three studies compared the effectiveness of selective serotonin reuptake inhibitor (SSRI) to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Clinical interventions, psychological We found moderate quality evidence based on three studies that telephone or online cognitive behavioural therapy was more effective in reducing sick leave than usual primary or occupational care (SMD -0.23; 95% CI -0.45 to -0.01). Clinical interventions, psychological combined with antidepressant medication We found low quality evidence based on two studies that enhanced primary care did not substantially decrease sickness absence in the medium term (4 to 12 months) (SMD -0.02; 95% CI -0.15 to 0.12). A third study found no substantial effect on sickness absence in favour of this intervention in the long term (24 months).We found high quality evidence, based on one study, that a structured telephone outreach and care management program was more effective in reducing sickness absence than usual care (SMD - 0.21; 95% CI -0.37 to -0.05). Clinical interventions, exercise We found low quality evidence based on one study that supervised strength exercise reduced sickness absence compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54). We found moderate quality evidence based on two studies that aerobic exercise was no more effective in reducing sickness absence than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24). We found moderate quality evidence that adding a work-directed intervention to a clinical intervention reduced the number of days on sick leave compared to a clinical intervention alone. We also found moderate quality evidence that enhancing primary or occupational care with cognitive behavioural therapy reduced sick leave compared to the usual care. A structured telephone outreach and care management program that included medication reduced sickness absence compared to usual care. However, enhancing primary care with a quality improvement program did not have a considerable effect on sickness absence. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. More studies are needed on work-directed interventions. Clinical intervention studies should also include work outcomes to increase our knowledge on reducing sickness absence in depressed worker

Interventions to improve return to work in depressed people

Background Work disability such as sickness absence is common in people with depression. Objectives To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders. Search methods We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO until January 2014. Selection criteria We included randomised controlled trials (RCTs) and cluster RCTs of work-directed and clinical interventions for depressed people that included sickness absence as an outcome. Data collection and analysis Two authors independently extracted the data and assessed trial quality. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to pool study results in the studies we judged to be sufficiently similar. We used GRADE to rate the quality of the evidence. Main results We included 23 studies with 26 study arms, involving 5996 participants with either a major depressive disorder or a high level of depressive symptoms. We judged 14 studies to have a high risk of bias and nine to have a low risk of bias. Work-directed interventions We identified five work-directed interventions. There was moderate quality evidence that a work-directed intervention added to a clinical intervention reduced sickness absence (SMD-0.40; 95% CI -0.66 to -0.14; 3 studies) compared to a clinical intervention alone. There was moderate quality evidence based on a single study that enhancing the clinical care in addition to regular work-directed care was not more effective than work-directed care alone (SMD -0.14; 95% CI -0.49 to 0.21). There was very low quality evidence based on one study that regular care by occupational physicians that was enhanced with an exposure-based return to work program did not reduce sickness absence compared to regular care by occupational physicians (nonsignificant finding: SMD 0.45; 95% CI -0.00 to 0.91). Clinical interventions, antidepressant medication Three studies compared the effectiveness of selective serotonin reuptake inhibitor (SSRI) to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Clinical interventions, psychological We found moderate quality evidence based on three studies that telephone or online cognitive behavioural therapy was more effective in reducing sick leave than usual primary or occupational care (SMD -0.23; 95% CI -0.45 to -0.01). Clinical interventions, psychological combined with antidepressant medication We found low quality evidence based on two studies that enhanced primary care did not substantially decrease sickness absence in the medium term (4 to 12 months) (SMD -0.02; 95% CI -0.15 to 0.12). A third study found no substantial effect on sickness absence in favour of this intervention in the long term (24 months). We found high quality evidence, based on one study, that a structured telephone outreach and care management program was more effective in reducing sickness absence than usual care (SMD -0.21; 95% CI -0.37 to -0.05). Clinical interventions, exercise We found low quality evidence based on one study that supervised strength exercise reduced sickness absence compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54). We found moderate quality evidence based on two studies that aerobic exercise was no more effective in reducing sickness absence than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24). Authors' conclusions We found moderate quality evidence that adding a work-directed intervention to a clinical intervention reduced the number of days on sick leave compared to a clinical intervention alone. We also found moderate quality evidence that enhancing primary or occupational care with cognitive behavioural therapy reduced sick leave compared to the usual care. A structured telephone outreach and care management program that included medication reduced sickness absence compared to usual care. However, enhancing primary care with a quality improvement program did not have a considerable effect on sickness absence. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. More studies are needed on work-directed interventions. Clinical intervention studies should also include work outcomes to increase our knowledge on reducing sickness absence in depressed workers