Epidemiological evaluation of the use of genetics to improve the predictive value of disease risk factors.

The prevention of common diseases relies on identifying risk factors and implementing intervention in high-risk groups. Nevertheless, most known risk factors have low positive predictive value (PPV) and low population-attributable fraction (PAF) for diseases (e.g., cholesterol and coronary heart disease). With advancing genetic technology, it will be possible to refine the risk-factor approach to target intervention to individuals with risk factors who also carry disease-susceptibility allele(s). We provide an epidemiological approach to assess the impact of genetic testing on the PPV and PAF associated with risk factors. Under plausible models of interaction between a risk factor and a genotype, we derive values of PPV and PAF associated with the joint effects of a risk factor and a genotype. The use of genetic testing can markedly increase the PPV of a risk factor. PPV increases with increasing genotype-risk factor interaction and increasing marginal relative risk associated with the factor, but it is inversely proportional to the prevalences of the genotype and the factor. For example, for a disease with lifetime risk of 1%, if all the risk-factor effect is confined to individuals with a susceptible genotype, a risk factor with 10% prevalence and disease relative risk of 2 in the population will have a disease PPV of 1.8%, but it will have a PPV of 91.8% among persons with a genotype of 1% prevalence. On the other hand, genetic testing and restriction of preventive measures to those susceptible may decrease the PAF of the risk factor, especially at low prevalences of the risk factor and genotype.(ABSTRACT TRUNCATED AT 250 WORDS)     

Epidemiology of Alzheimer disease and related disorders

Alzheimer's disease and related disorders (dementia) are a major public health problem due to the number of cases in the general population, the projections for the future, and the consequences of these diseases. We can estimate that about 850 000 cases of dementia were present in France in 2005 and this number will increase to 1,200,000 in 2020 and 2,100,000 in 2040 if the incidence and the duration of the disease did not change. The development of prevention is therefore necessary. Four ways of prevention are credible. The most important is the treatment of vascular risk factors and particularly hypertension. Other ways are nutritional factors, stimulating leisure activities and depression.     

Critical developmental periods in the pathogenesis of hypertension

Hypertension is one of the major risk factor of cardiovascular diseases, but after a century of clinical and basic research, the discrete etiology of this disease is still not fully understood. One reason is that blood pressure is a quantitative trait with multifactorial determination. Numerous genes, environmental factors as well as epigenetic factors should be considered. There is no doubt that although the full manifestation of hypertension and other cardiovascular diseases usually occurs predominantly in adulthood and/or senescence, the roots can be traced back to early ontogeny. The detailed knowledge of the ontogenetic changes occurring in the cardiovascular system of experimental animals during particular critical periods (developmental windows) could help to solve this problem in humans and might facilitate the age-specific prevention of human hypertension. We thus believe that this approach might contribute to the reduction of cardiovascular morbidity among susceptible individuals in the future.     

Cerebral small vessel disease: genetic risk assessment for prevention and treatment

Cerebrovascular disease is a major burden to individuals and their communities worldwide. Stroke is one of the leading causes of death and disability, and the prevention and treatment of stroke can be improved with a better understanding of its causation. Cerebral small vessel disease (SVD) is a subset of cerebrovascular disease, and has an equally large impact on an individual's quality of life. Although many risk factors are involved, we propose that genetics has a significant role in the pathogenesis of SVD through a complex interplay of environmental and multigenetic factors. Advances in molecular technology have enabled the human genome to be investigated both at a population and, more recently, an individual level. A better understanding of the molecular basis of SVD will enable the development of therapies to help in its prevention and treatment. This review assesses the molecular genetics underlying cerebral SVD.     

Epidemiological studies on aging in France: from the PAQUID study to the Three-City study

Follow-up of cohorts recruited in general population with active screening and diagnosis of incident cases, is the most appropriate epidemiological design for studying incidence and risk factors of Alzheimer disease and other types of dementia. In France, people considered in the PAQUID study, then in the EVA study, have been the first cohorts on dementia. They have prepared the way for the Three-City (3C) study, conducted in Bordeaux, Dijon and Montpellier. About 9500 persons aged 65 years and over have been recruited in these three cities and will be followed-up during four years. The main objective of the 3C study is to investigate the relation between vascular risk and neurodegenerative diseases. The 3C study will provide essential data for defining strategies for dementia prevention. To measure the impact of the strategies on the incidence of dementia and the social burden of this disease will be an important public health objective in the near future.     

The use of mortality data in setting priorities for disease prevention

The examination of specific disease mortality by five-year age groups helps identify health problems as problems of people and how they live. Traditional methods of examining data in broad classifications tend to obscure etiological factors and the importance of behaviour. Violence, a major cause of death in young adults, gives way to so-called diseases of indulgence in middle age, especially among men who have a much higher death rate than women. Male life expectancy at age 40 has increased only marginally in the past 40 years. Health-related human behaviour must be considered within an ecological framework since social, cultural and physical environmental differences as well as personal factors influence life-style. The responsibility for prevention rests more with the individual and society at large than with health workers. Probability tables, Health Hazard Appraisal (a system of personal risk assessment) and personal counselling can reinforce healthful life-styles and help correct hazardous ones.     

Genetic markers of osteoarticular disorders: facts and hopes

Osteoarthritis and osteoporosis are the two most common age-related chronic disorders of articular joints and skeleton, representing a major public health problem in most developed countries. Apart from being influenced by environmental factors, both disorders have a strong genetic component, and there is now considerable evidence from large population studies that these two disorders are inversely related. Thus, an accurate analysis of the genetic component of one of these two multifactorial diseases may provide data of interest for the other. However, the existence of confounding factors must always be borne in mind in interpreting the genetic analysis. In addition, each patient must be given an accurate clinical evaluation, including family history, history of drug treatments, lifestyle, and environment, in order to reduce the background bias. Here, we review the impact of recent work in molecular genetics suggesting that powerful molecular biology techniques will soon make possible both a rapid accumulation of data on the genetics of both disorders and the development of novel diagnostic, prognostic, and therapeutic approaches.     

Environmental hazards to children's health in the modern world

Patterns of illness in children have changed dramatically in the last century, and will continue to change in this century. The major diseases confronting children are now chronic and disabling conditions termed the "new pediatric morbidity"-asthma, leukemia and brain cancer, neurodevelopmental dysfunction and neurobehavioral abnormality, reproductive and systemic developmental problems. Chemical toxicants in the environment, poverty, and little or no access to health care are all factors contributing to life-threatening pediatric diseases; children are uniquely vulnerable to chemical toxicants because of their disproportionately heavy exposures and their inherent biological growth and development. Genetic susceptibility and environmental exposures during vulnerable periods of development are also important contributors to the etiologies of many diseases of childhood. It is vital that we develop a better understanding of the mechanisms and interactions between nutrition, infectious disease, environmental exposures, and genetic predisposition in order to develop better prevention methods. This paper briefly examines modern contributors to children's environmental health problems, efforts to date on both the regional and international level to address these challenges, and reflects upon major research needs that must be addressed in order to close the gaps that exist in our understanding of the relationship between environmental exposures and children's health.     

Epidemiological aspects of ageing.

A major societal challenge is to improve quality of life and prevent or reduce disability and dependency in an ageing population. Increasing age is associated with increasing risk of disability and loss of independence, due to functional impairments such as loss of mobility, hearing and vision; a major issue must be how far disability can be prevented. Ageing is associated with loss of bone tissue, reduction in muscle mass, reduced respiratory function, decline in cognitive function, rise in blood pressure and macular degeneration which predispose to disabling conditions such as osteoporosis, heart disease, dementia and blindness. However, there are considerable variations in different communities in terms of the rate of age-related decline. Large geographic and secular variations in the age-adjusted incidence of major chronic diseases such as stroke, hip fracture, coronary heart disease, cancer, visual loss from cataract, glaucoma and macular degeneration suggest strong environmental determinants in diet, physical activity and smoking habit. The evidence suggests that a substantial proportion of chronic disabling conditions associated with ageing are preventable, or at least postponable and not an inevitable accompaniment of growing old. Postponement or prevention of these conditions may not only increase longevity, but, more importantly, reduce the period of illnesses such that the majority of older persons may live high-quality lives, free of disability, until very shortly before death. We need to understand better the factors influencing the onset of age-related disability in the population, so that we have appropriate strategies to maintain optimal health in an ageing population.     

Qualitative and quantitative procedures for health risk assessment.

Numerous reactive mutagenic electrophiles are present in the environment or are formed in the human body through metabolizing processes. Those electrophiles can directly react with DNA and are considered to be ultimate carcinogens. In the past decades more than 200 in vitro and in vivo genotoxic tests have been described to identify, monitor and characterize the exposure of humans to such agents. When the responses of such genotoxic tests are quantified by a weight-of-evidence analysis, it is found that the intrinsic potency of electrophiles being mutagens does not differ much for the majority of the agents studied. Considering the fact that under normal environmental circumstances human are exposed to low concentration of about a million electrophiles, the relation between exposure to such agents and adverse health effects (e.g., cancer) will become a 'Pandora's box'. For quantitative risk assessment it will be necessary not only to detect whether the agent is genotoxic, but also understand the mechanism of interaction of the agent with the DNA in target cells needs to be taken into account. Examples are given for a limited group of important environmental and carcinogenic agents for which such an approach is feasible. The groups identified are agents that form cross-links with DNA or are mono-alkylating agents that react with base-moieties in the DNA strands. Quantitative hazard ranking of the mutagenic potency of these groups of chemical can be performed and there is ample evidence that such a ranking corresponds with the individual carcinogenic potency of those agents in rodents. Still, in practice, with the exception of certain occupational or accidental exposure situations, these approaches have not be successful in preventing cancer death in the human population. However, this is not only due to the described 'Pandora's box' situation. At least three other factors are described. Firstly, in the industrial world the medical treatment of cancer in patients occurs with high levels of extremely mutagenic agents. Actually, both in number of persons and in exposure levels such medical treatment is the single largest exposure of humans to known carcinogens. Although such treatments are very effective in curing the tumor as present in the patient, the recurrence of cancer in those patients later in life is very high. In other words: "curing cancer is not the same as preventing cancer death in the human population". Secondly, the rate of cancer death in the human population is also determined by the efficacy in which other major causes of death are prevented. For instance, cardiovascular diseases are the major cause of death in humans in the industrialized world. There is evidence that the treatment of cardiovascular diseases is more successful than that of cancer. On a population level this will result in increase of cancer being the ultimate death cause. Finally, the improvement of medical treatment of diseases together with an improved quality of life will lead to increase average age of the population. Because the onset of most cancer is long after the exposure to carcinogens-in human often more than 30 years-cancer is predominantly a disease of the old age. This means that if the average age of human increases, there will be a selective preference of cancer becoming an even more important cause of death. This especially will be pronounced in those countries were the age distribution in a population is abnormal.     

Global approach to reducing lead exposure and poisoning

Lead poisoning is an important environmental disease that can have life-long adverse health effects. Most susceptible are children, and most commonly exposed are those who are poor and live in developing countries. Studies of children's blood-lead levels (BLLs) are showing cognitive impairment at increasingly lower BLLs. Lead is dangerous at all levels in children. The sources of lead exposure vary among and within countries depending on past and current uses. Sources of lead may be from historic contamination, recycling old lead products, or from manufacturing new products. In all countries that have banned leaded gasoline, average population BLLs have declined rapidly. In many developing countries where leaded gasoline is no longer used, many children and workers are exposed to fugitive emissions and mining wastes. Unexpected lead threats, such as improper disposal of electronics and children's toys contaminated with lead, continue to emerge. The only medical treatment available is chelation, which can save lives of persons with very high BLLs. However, chelating drugs are not always available in developing countries and have limited value in reducing the sequelae of chronic low dose lead exposure. Therefore, the best approach is to prevent exposure to lead. Because a key strategy for preventing lead poisoning is to identify and control or eliminate lead sources, this article highlights several major sources of lead poisoning worldwide. In addition, we recommend three primary prevention strategies for lead poisoning: identify sources, eliminate or control sources, and monitor environmental exposures and hazards.     

Genetic susceptibility to ageing-associated diseases

The constant and rapid increase of life expectancy in western countries is associated with a major ageing of our populations. In these conditions, we can expect an epidemic progression of most chronic diseases, especially cardiovascular, neurodegenerative and metabolic disorders, the main causes of death in the world. The global burden of these diseases will have a dramatic impact on the health and on the socio-economical context of our societies. From a global point of view, the occurrence and progression of these multifactorial diseases rely upon the nature and intensity of the environmental determinants we are exposed to all life long, but also to our individual genetic susceptibility. Through the determination of this higher susceptibility to an environmental risk factor and the understanding of its mechanisms of action, prevention and management efforts will be better focused. In such multifactorial affections, the development and the transmission of the disease do not follow the simple laws of monogenic Mendelian models. The complexity of this transmission is associated with the influence, at various degrees, of several genes and of a close interaction between this particular genetic susceptibility and environmental risk factors. With the recent development of automated and high throughput molecular biology techniques and their use in epidemiological studies, gene expression regulation and post genomic studies, the determination of sub-groups facing a higher individual genetic susceptibility has begun. This determination will offer new clues for a better-targeted disease management.     

Free anonymous screening consultation and clinical management of HIV infection

In France, since 1988, anonymous and free consultations (called CDAG) have been settled in the country to facilitate an individual and volunteer approach for HIV screening. At the time, there are more than 380 CDAG with newly defined objectives. CDAG are supposed to encourage early screening, facilitate access to precarious persons and persons at risk for sexually transmitted diseases, and reinforce prevention, helping consultants to define a personal preventive strategy. CDAG are also supposed to play a role in prevention of both hepatitis B and C, and syphilis. They may help to link screening and healthcare. Their activity is increasing and the rate of positive test is twice that of private laboratories. Patients consulting those facilities are younger and more at risk than general population. Between 1000 and 2000 HIV positive tests are detected in CDAG each year (11 % of positive tests in the country). The real impact on prevention and screening at the national level is unknown, in part because of anonymity. To improve the characterization of consultants, data collection will be modified in 2004, and a network of selected and volunteer centres will collect continuously more accurate data.     

Analytical Relationship between Family History and Genetic and Environmental risks,with Application to Female Breast Cancer

It is well established in genetic epidemiology that family history is an important indicator of familial aggregation of disease in a family. A strong genetic risk factor or an environmental risk factor with high familial correlation can result in a strong family history. In this paper, family history refers to the number of first‐degree relatives affected with the disease. Cui and Hopper (Journal of Epidemiology and Biostatistics 2001; 6 : 331–342) proposed an analytical relationship between family history and relevant genetic parameters. In this paper we expand the relationship to both genetic and environmental risk factors. We established a closed‐form formula for family history as a function of genetic and environmental parameters which include genetic and environmental relative risks, genotype frequency, prevalence and familial correlation of the environmental risk factor. The relationship is illustrated by an example of female breast cancer in Australia. For genetic and environmental relative risks less than 10, most of the female breast cancer cases occur between the age of 40 and 60 years. A higher genetic or environmental relative risk will move the peak of the distribution to a younger age. A more common disease allele or more prevalent environmental risk factor will move the peak to an older age. For a proband with breast cancer, it is most likely (with probability ≥80%) that none of her first‐degree relatives is affected with the disease. To enable the probability of having a positive family history to reach 50%, the environmental relative risks must be extremely as high as 100, the familial correlation as high as 0.8 and the prevalence as low as 0.1. For genetic risk alone, even the relative risk is as high as 100, the probability of having a positive family history can only reach about 30%. This suggests that the environmental risk factor seems to play a more important role in determining a strong family history than the genetic risk factor. (© 2004 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Prevention of type 2 diabetes: the strategic approach for implementation

A growing need exists to deliver effective and affordable prevention programs and to take urgent action to address the major public health challenge that diabetes represents. Achieving prevention of type 2 diabetes requires moving through a series of steps from basic science discovery to widespread distribution of effective interventions. Understanding the cellular level influences on diabetes prevention will help target particular interventions to those who may be most responsive. Several randomized controlled trials conducted throughout the world have demonstrated that type 2 diabetes can be prevented or delayed. Subsequent real-world translation studies have provided important information necessary to reduce cost and increase access. Ultimately achieving a population impact in diabetes prevention requires widespread distribution of effective interventions, which is supported by policies that help achieve sustainability and reach. The use of a global stakeholder network can help to share experiences and build on partner knowledge gained.     

Koch is dead

Although the foundation of Koch's postulates, that "if an agent is the cause of disease in one individual it should be capable of causing disease in a second individual," is basically sound, the ritual that has evolved into present day experimental studies has obscured almost completely what occurs in natural processes outside the laboratory. Through a series of examples, it is emphasized that just bringing the host and the parasite together is not enough, but that the circumstances under which this is done is equally important. These circumstances include: the prior history of the host; the host's behavioral patterns, environmental conditioning, and disease history; the circumstances of exposure; and the environmental factors related to the host and the parasite. Of equal importance is the individual variation (genetic, physiologic, immunologic, etc.) of the host and the individual variation (strains, immunogenicity, pathogenicity, virulence, etc.) of the parasite. Because the rigor of the present day "scientific method" demands clearcut and reproducible results and investigations require predictable performance of the parasite in an evenly maintained host that is in a highly constrained environment, we should not wonder why we cannot produce the events of nature. If we are going to understand diseases of wildlife, we must consider the genetic heterogenicity of the host and parasite population, and recognize the complexity of the environment in which both exist. Koch's postulates, in the narrow sense, will help us to identify parasitisms but will not provide us with an understanding of information about diseases in wildlife; the real significance of these parasitisms to the health of the individual and to the size of the population.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lexis Diagram and Illness-Death Model: Simulating Populations in Chronic Disease Epidemiology

Chronic diseases impose a tremendous global health problem of the 21st century. Epidemiological and public health models help to gain insight into the distribution and burden of chronic diseases. Moreover, the models may help to plan appropriate interventions against risk factors. To provide accurate results, models often need to take into account three different time-scales: calendar time, age, and duration since the onset of the disease. Incidence and mortality often change with age and calendar time. In many diseases such as, for example, diabetes and dementia, the mortality of the diseased persons additionally depends on the duration of the disease. The aim of this work is to describe an algorithm and a flexible software framework for the simulation of populations moving in an illness-death model that describes the epidemiology of a chronic disease in the face of the different times-scales. We set up a discrete event simulation in continuous time involving competing risks using the freely available statistical software R. Relevant events are birth, the onset (or diagnosis) of the disease and death with or without the disease. The Lexis diagram keeps track of the different time-scales. Input data are birth rates, incidence and mortality rates, which can be given as numerical values on a grid. The algorithm manages the complex interplay between the rates and the different time-scales. As a result, for each subject in the simulated population, the algorithm provides the calendar time of birth, the age of onset of the disease (if the subject contracts the disease) and the age at death. By this means, the impact of interventions may be estimated and compared.     

The amphibian microbiome: natural range of variation,pathogenic dysbiosis,and role in conservation

Recent research in humans, livestock, and wildlife using high-throughput next-generation sequencing (NGS) has identified that resident microbiota play an essential role in disease resistance, host health, and adaptation to biotic and abiotic stressors. Since amphibians are currently facing population declines and extinctions attributable to anthropogenic pressures and emerging diseases, an understanding of the effects of microbiome dysbiosis and mitigation is a prerequisite for amphibian conservation and disease management. Interest is now growing with regard to understanding the influence of unfavorable environmental conditions on the amphibian microbiome and the effects of dysbiosis on the susceptibility to pathogenic infections. Here, we summarize information on the amphibian microbiome, specifically concerning intrinsic and extrinsic factors that shape the skin and gut microbiome. We explore diverse types of unfavorable environmental perturbations and the ways in which they can impact the microbiota of an individual so that we can better comprehend the consequences of stressors and dysbiosis on pathogen emergence and health. We discuss the role of the microbiome in amphibian conservation and identify gaps of knowledge that need to be filled if we are to achieve a meta-organism conservation approach. NGS studies should be complemented with other high-throughput “-omic” approaches to target microbiome functionality. Understanding the microbiome might be the missing piece in the overall strategy that will help maintain the health of amphibians in a world with highly affected environments and that will prevent/mitigate emerging infectious diseases.     

Prevention and treatment of type 2 diabetes in youth

Parallel to the increase in obesity worldwide, there has been a rise in the prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents. The etiology of T2DM in youth, similar to adults, is multifactorial including genetic and environmental factors, among them obesity, sedentary lifestyle, family history of the disease, high-risk ethnicity and insulin resistance phenotype playing major roles. Treatment of T2DM should not have a glucocentric approach; it should rather target improving glycemia, dyslipidemia, hypertension, weight management and the prevention of short- and long-term complications. Prevention strategies, especially in high-risk groups, should focus on environmental change involving participation of families, schools, the food and entertainment industries and governmental agencies. Presently, limited pharmacotherapeutic options need to be expanded both for childhood T2DM and obesity. The coming decades will prove very challenging for healthcare providers battling socioeconomic waves conducive to obesity and T2DM. Evidence-based research and clinical experience in pediatrics, possibly modeled after adult trials, need to be developed if this public health threat is to be contained.     

Cardiovascular disease, risk factors and heart rate variability in the elderly general population: Design and objectives of the CARdiovascular disease, Living and Ageing in Halle (CARLA) Study

Background

The increasing burden of cardiovascular diseases (CVD) in the ageing population of industrialized nations requires an intensive search for means of reducing this epidemic. In order to improve prevention, detection, therapy and prognosis of cardiovascular diseases on the population level in Eastern Germany, it is necessary to examine reasons for the East-West gradient of CVD morbidity and mortality, potential causal mechanisms and prognostic factors in the elderly. Psychosocial and nutritional factors have previously been discussed as possible causes for the unexplained part of the East-West gradient. A reduced heart rate variability appears to be associated with cardiovascular disease as well as with psychosocial and other cardiovascular risk factors and decreases with age. Nevertheless, there is a lack of population-based data to examine the role of heart rate variability and its interaction with psychosocial and nutritional factors regarding the effect on cardiovascular disease in the ageing population. There also is a paucity of epidemiological data describing the health situation in Eastern Germany. Therefore, we conduct a population-based study to examine the distribution of CVD, heart rate variability and CVD risk factors and their associations in an elderly East German population. This paper describes the design and objectives of the CARLA Study.

Methods/design

For this study, a random sample of 45–80 year-old inhabitants of the city of Halle (Saale) in Eastern Germany was drawn from the population registry. By the end of the baseline examination (2002–2005), 1750 study participants will have been examined. A multi-step recruitment strategy aims at achieving a 70 % response rate. Detailed information is collected on own and family medical history, socioeconomic, psychosocial, behavioural and biomedical factors. Medical examinations include anthropometric measures, blood pressure of arm and ankle, a 10-second and a 20-minute electrocardiogram, a general physical examination, an echocardiogram, and laboratory analyses of venous blood samples. On 200 participants, a 24-hour electrocardiogram is recorded. A detailed system of quality control ensures high data quality. A follow-up examination is planned.

Discussion

This study will help to elucidate pathways to CVD involving autonomic dysfunction and lifestyle factors which might be responsible for the CVD epidemic in some populations.