Category: Disease

It is vital to emphasize that what is important in this exer­cise is not the absolute number of points given to a disease, but rather the relative position of the disease to others, and the cut-off point chosen. After ranking the scores, the subcom­mittee chose a cut-off of 13 points to recommend a disease for national surveillance. This decision was based on the experi­ence of the raters with regards to the practical considerations of time, effort and money.

The results of the priority-setting exercise are presented in Table 1. The diseases on this list constitute the list of diseases that are under national surveillance; reporting of these diseases is effective January 1,2000. The ‘top five’ diseases were HIV, AIDS, laboratory-confirmed influenza, tuberculosis and measles. Of the ‘newly proposed’ diseases, two did not make the list: Reye syndrome and hemolytic uremic syndrome. The subcommittee decided that Lyme disease and legionellosis re­quire monitoring but on a ‘need-to-know’ basis. The following diseases from the current list did not make the cut-off point, and consequently, will no longer warrant national surveil­lance: ‘meningitis, other bacterial’, listeriosis, gonococcal opthalmia neonatorum, trichinosis, chancroid, ‘meningitis, viral’, and amoebiasis.

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The definition of ‘potential to drive public health policy’ implies that other criteria of incidence, severity, risk percep­tion and preventability should be considered in determining the potential to drive public health policy. The factor is divided into three levels: ‘low’ with a score of 1; ‘medium’ with a score of 2; and ‘high’ with a score of 3. A score of 0 is assigned if the disease has no potential to influence public health policy. For in­stance, a score of 0 was assigned to yellow fever, cholera, ma­laria and leprosy. The highest score of three was awarded to HIV, AIDS, laboratory-confirmed influenza, tuberculosis, hepatitis A and C, CJD, invasive pneumococcal disease and salmonello- sis.

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disease surveillance: SEVERITY

Severity is defined as ‘most likely outcome’ and classified into three groups. One point is assigned to the disease if it is of short duration and the patient completely recovers. Five points are assigned if the most likely outcome is death; for ex­ample, HIV, AIDS and rabies were each assigned a score of 5.

POTENTIAL TO SPREAD TO THE GENERAL POPULATION

A score of 0 is assigned to a disease if there is no potential threat of spread to the general population. A score of 1 is as­signed if the potential for spread is localized and managed on a case-by-case basis. A score of 3 is assigned for ‘local’ out­breaks, and a score of 5 is assigned if the outbreak is national. For example, influenza, measles and chickenpox were each assigned 5 points. HIV was assigned 3 points, rabies was as­signed 1 point and CJD was assigned 0 points.

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The World Health Organization (WHO) is interested in all communicable diseases to some extent; however, cholera, plague and yellow fever are subject to international health regulations. Canada must collect and report information about cases of these diseases as an international duty. Five points were awarded to the three diseases. Five points were awarded to measles because of the provincial and territorial commitment to eliminate measles in Canada by the year 2005, and to poliomyelitis and acute flaccid paralysis because of the global polio eradication initiative.

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Before 1987, there was no mechanism in place to evaluate newly emerging diseases and compare them with the diseases that were being reported. Accordingly, in 1987, ACE estab­lished a subcommittee on communicable diseases to develop a systematic process to determine which communicable dis­eases should be monitored at the national level. The subcom­mittee asked which diseases should be routinely monitored, how should they be monitored and whether they should be monitored at all. These are important questions that have led to a priority setting exercise with the following objectives: to ensure national surveillance of major infectious diseases that threaten the health of Canadians; to support the development and evaluation of programs that are currently in place and those which have been proposed; to ensure the participation of Canada in the global surveillance of specific health threats; and to determine the best use of human and financial resources in the prevention and control of communicable diseases.

The priority setting process involves several steps: estab­lishing the criteria; subdividing each criterion into levels; as­signing points to each level within each criterion; summing the points and assigning a total score to each disease; ranking the diseases from highest to lowest score; and determining a cut-off point that would allow the inclusion and exclusion of diseases. The list of diseases for national surveillance that re­sulted from the 1988 priority setting exercise remained un­changed until the second iteration, with the exception of hepa­titis C, which was added in 1991, and a more extensive breakdown for syphilis in 1992.

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Establishing priorities for national communicable disease surveillance

The federal government has collected information on communicable diseases since 1924, under the legisla­tive authority of the Statistics Canada Act and the Health Canada Act. Aggregate data on communicable diseases was initially collected and collated by The Dominion Bureau of Statistics (later changed to Statistics Canada), but this respon­sibility, with the exception of tuberculosis, was transferred to the Laboratory Centre for Disease Control (LCDC) in 1988. Responsibility for tuberculosis was subsequently transferred to the LCDC in 1995. Currently, information on communicable diseases under national surveillance is managed by the Divi­sion of Disease Surveillance within the Bureau of Infectious Diseases, LCDC.

The delivery of health care and public health services is identified in the Canadian Constitution as a provincial power. The federal government has powers over the provision of safe food and the importation of communicable diseases, and has the power to assist in a crisis such as an infectious disease outbreak.

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The treatment of Paget's: Available specific therapies part 2

Alendronate. Alendronate is available for the treatment of Paget’s disease in most western countries (Fosamax 40). The recommended dose is 40 mg daily for 6 months to be taken with a large glass of water (>200 ml) on getting up in the morn­ing after an overnight fast. The patient is instructed not to take anything else orally (except more water) and not to lie down for at least 30 minutes after ingesting the dose. With this dosing schedule, a single course of alendronate was found to nor­malise bALP in over 63% of patients with biochemical remis­sion lasting for more than 12 months. Biopsy speci­mens from patients treated with alendronate revealed normal patterns of deposition of new bone and radiological improve­ment. The overall tolerability profile is good, although up­per gastrointestinal discomfort, nausea, or the less common but more serious complication of oesophageal ulceration, are not rare.

Risedronate. Risedronate 30 mg (Actonel 30) was approved by both FDA and EMEA in 1998 for the treatment of Paget’s dis­ease. Studies of risedronate have described the efficacy of a 30-mg dose given for 2 or 3 months to patients with moderately active disease. These short courses of therapy led to a nearly 80% reduction in bALP and normalisation of bone turnover markers in 50-70% of patients. The 30-mg risedronate dose is taken with 200 ml of water on getting up in the morning after an overnight fast, with no other oral intake (except water) and no lying down for 30 minutes after the dose. Gastrointesti­nal side effects of varying degrees of severity are expected in a minority of patients.

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