Hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia: An ecological study

BackgroundWidespread increases in facility delivery have not substantially reduced neonatal mortality in sub-Saharan Africa and South Asia over the past 2 decades. This may be due to poor quality care available in widely used primary care clinics. In this study, we examine the association between hospital delivery and neonatal mortality.Methods and findingsWe used an ecological study design to assess cross-sectional associations between the share of hospital delivery and neonatal mortality across country regions. Data were from the Demographic and Health Surveys from 2009 to 2018, covering 682,239 births across all regions. We assess the association between the share of facility births in a region that occurred in hospitals (versus lower-level clinics) and early (0 to 7 days) neonatal mortality per 1,000 births, controlling for potential confounders including the share of facility births, small at birth, maternal age, maternal education, urbanicity, antenatal care visits, income, region, and survey year. We examined changes in this association in different contexts of country income, global region, and urbanicity using interaction models.Across the 1,143 regions from 37 countries in sub-Saharan Africa and South Asia, 42%, 29%, and 28% of births took place in a hospital, clinic, and at home, respectively. A 10-percentage point higher share of facility deliveries occurring in hospitals was associated with 1.2 per 1,000 fewer deaths (p-value < 0.01; 95% CI: 0.82 to 1.60), relative to mean mortality of 22. Associations were strongest in South Asian countries, middle-income countries, and urban regions. The study’s limitations include the inability to control for all confounding factors given the ecological and cross-sectional design and potential misclassification of facility levels in our data.ConclusionsRegions with more hospital deliveries than clinic deliveries have reduced neonatal mortality. Increasing delivery in hospitals while improving quality across the health system may help to reduce high neonatal mortality.

In an ecological study, Anna D Gage and colleagues examine the association between hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia.     

Impacts of pollution on marine life in Southeast Asia

Pollutants, originating from both land and sea, are responsible for significant lethal and sub-lethal effects on marine life. Pollution impacts all trophic levels, from primary producers to apex predators, and thus interferes with the structure of marine communities and consequently ecosystem functioning. Here we review the effects of sediments, eutrophication, toxics and marine litter. All are presently major concerns in Southeast Asia (SE Asia) and there is little indication that the situation is improving. Approximately 70% of SE Asia’s human population lives in coastal areas and intensive farming and aquaculture, rapid urbanization and industrialisation, greater shipping traffic and fishing effort, as well as widespread deforestation and nearshore development, are contributing towards the pollution problem. As SE Asia encompasses approximately 34% of the world’s reefs and between a quarter and a third of the world’s mangroves, as well as the global biodiversity triangle formed by the Malay Peninsular, the Philippines, and New Guinea, the need to reduce the impacts of marine pollution in this region is all the more critical.     

Socioeconomic status and adiposity in childhood: a systematic review of cross-sectional studies 1990-2005

Background: Sobal and Stunkard's review (1989) of 34 studies from developed countries published after 1941, found inconsistent relationships between socioeconomic status (SES) and childhood adiposity. Inverse associations (36%), no associations (38%), and positive associations (26%) were found in similar proportions. In view of the trends in pediatric obesity, the relationship between SES and adiposity may have changed. Objective: To describe the cross‐sectional association between SES and adiposity in school‐age children from western developed countries in epidemiological studies since 1989. Methods and Procedures: PubMed database was searched to identify potentially relevant publications. Epidemiological studies from western developed countries presenting cross‐sectional data on the bivariate association between an SES indicator and objectively measured adiposity in childhood (5–18 years), carried out after 1989 were included. SES indicators included parental education, parental occupation, family income, composite SES, and neighborhood SES. Results: Forty‐five studies satisfied the review criteria. SES was inversely associated with adiposity in 19 studies (42%), there was no association in 12 studies (27%), and in 14 studies (31%) there was a mixture of no associations and inverse associations across subgroups. No positive SES‐adiposity associations were seen in unadjusted analyses. With parental education as the SES indicator, inverse associations with adiposity were found in 15 of 20 studies (75%). Discussion: Research carried out within the past 15 years finds that associations between SES and adiposity in children are predominately inverse, and positive associations have all but disappeared. Research is needed to understand the mechanisms through which parental social class influences childhood adiposity.     

Chronotype correlates with developmental index,intelligence and academic achievement: A study based on nationwide indicators

Chronotype or morningness–eveningness (M/E) is an individual trait with a biological basis. In this study, I analysed the relationship between M/E and nationwide available data, such as economic variables, school achievement, intelligence and conscientiousness, which is a personality trait. These variables have been chosen because, first, they are linked on the individual level with circadian preference, and, second these associations have been found based on meta-analyses, which gives these findings a high plausibility. In addition, economic status has also been proposed to be related to M/E. Higher developed countries showed a lower morningness, based on both, the ranking of countries as well as on the HDI value. Similarly, GNI was related to morningness, while higher intelligence and performance in PISA were related to eveningness. Conscientiousness was related to morningness, although the results failed the significance level marginally. When using IQ as a control variable in partial correlations, the relationship between GNI and morningness disappeared, as did the correlation between eveningness and PISA results.     

National Economic Development Status May Affect the Association between Central Adiposity and Cognition in Older Adults

Background

Obesity is becoming a global problem, rather than one found only in developed countries. Although recent studies have suggested a detrimental effect of obesity on cognition, studies of the relationship between obesity and cognition among older adults have been limited to developed countries. We aimed to examine the associations between central obesity, as measured by waist circumference, and cognition level in adults aged 50 years and older in England and Indonesia.

Methods

We used linear regression models to analyse these associations and multiple imputation to manage missing data. The 2006 English Longitudinal Study of Ageing Wave 3 is the source of data from England, while data from Indonesia is sourced from the 2007 Indonesian Family Life Survey Wave 4.

Findings

Centrally obese respondents had lower cognition levels than non-centrally obese respondents in England. In contrast, central adiposity had a statistically significant positive association with cognition in Indonesia. Higher levels of education and higher economic status were associated with higher cognitive ability, while age was associated with lower cognition in both countries. Elevated C-reactive protein (CRP) concentrations and smoking behaviour, both linked to higher risk of obesity, were negatively associated with cognitive ability among older adults in England, but they had no statistically significant association with cognition among Indonesians.

Interpretation

The contradictory findings on obesity and cognition in England and Indonesia not only create a puzzle, but they may also have different policy implications in these countries. Reducing the prevalence of obesity may be the main focus in England and other developed countries to maintain older adults’ cognition. However, Indonesia and other developing countries should place more emphasis on education, in addition to continued efforts to tackle the double burden of malnutrition, in order to prevent cognitive impairment among older adults.     

Association between healthy life expectancy at birth and consanguineous marriages in 63 countries

In order to investigate the association between mean inbreeding coefficient (α) and healthy life expectancy at birth (HALE; years) the present ecological study on 63 countries was done. Statistical analysis showed that HALE negatively and positively correlated with log(10)α and log(10)GNI per capita, respectively (p<0.001). It should be noted that log(10)α and log(10)GNI per capita were significantly correlated with each other (p<0.001). After controlling for log(10)GNI per capita, significant negative correlations between log(10)α and HALE were observed. The countries were stratified according to their GNI per capita into low- and high-income countries. In countries with high income, after controlling for log(10)GNI per capita, the correlation between HALE at birth and log(10)α was significant (for males r=-0.399, df=32, p=0.001; for females r=-0.683, df=32, p<0.001). In high-income Asian and African countries, where consanguineous marriage is common, after controlling for log(10)GNI per capita, the correlation between HALE at birth and log(10)α was significant (for males r=-0.819, df=8, p=0.004; for females r=-0.936, df=8, p<0.001). It seems that consanguinity influences HALE independent of country income.     

Urbanization in Southeast Asia: Assessing Policy Process and Progress toward Sustainability

In investigating the relationship between urbanization and sustainability in cities of developing countries, many researchers have looked to rising incomes as a driver for environmental improvement. This article challenges the transition and evolutionary models of urban environmental development that suggest that as cities grow in per capita income, their local environmental problems will diminish. The transition model is outcomes-based, and a competing model based on greater attention to participation in setting sustainability goals and assessing the progress toward those goals is presented.
Consensus on appropriate sustainability indicators is a key element, albeit a challenging one, in the task of pursuing urban sustainability. This is due to the contested nature of the concept of sustainability and also the fact that much of the work done on sustainability has been conducted among countries or on a national scale. A brief review of health, urban transport, air quality, and sewerage indicators suggests that cities do not necessarily see more progress as the per capita income increases. Low-income cities in Southeast Asia that are performing well are likely to see a deterioration in standards with rapid economic and population growth.     

Public Health Risks of Multiple-Drug-Resistant Enterococcus spp. in Southeast Asia

Enterococci rank as one of the leading causes of nosocomial infections, such as urinary tract infections, surgical wound infections, and endocarditis, in humans. These infections can be hard to treat because of the rising incidence of antibiotic resistance. Enterococci inhabiting nonhuman reservoirs appear to play a critical role in the acquisition and dissemination of antibiotic resistance determinants. The spread of antibiotic resistance has become a major concern in both human and veterinary medicine, especially in Southeast Asia, where many developing countries have poor legislation and regulations to control the supply and excessive use of antimicrobials. This review addresses the occurrence of antibiotic-resistant enterococci in Association of Southeast Asian Nations countries and proposes infection control measures that should be applied to limit the spread of multiple-drug-resistant enterococci.     

Cardiovascular Disease Risk Factor Profiles of 263,356 Older Australians According to Region of Birth and Acculturation,with a Focus on Migrants Born in Asia

Risk factors for cardiovascular disease (CVD), such as obesity, diabetes, hypertension and physical inactivity, are common in Australia, but the prevalence varies according to cultural background. We examined the relationship between region of birth, measures of acculturation, and CVD risk profiles in immigrant, compared to Australian-born, older Australians. Cross-sectional data from 263,356 participants aged 45 and over joining the population-based 45 and Up Study cohort from 2006–2008 were used. Prevalence ratios for CVD risk factors in Australian- versus overseas-born participants were calculated using modified Poisson regression, adjusting for age, sex and socioeconomic factors and focusing on Asian migrants. The association between time resident in Australia and age at migration and CVD risk factors in Asian migrants was also examined. Migrants from Northeast (n = 3,213) and Southeast Asia (n = 3,942) had lower levels of overweight/obesity, physical activity and female smoking than Australian-born participants (n = 199,356), although differences in prevalence of overweight/obesity were sensitive to body-mass-index cut-offs used. Compared to Australian-born participants, migrants from Northeast Asia were 20–30% less likely, and from Southeast Asia 10–20% more likely, to report being treated for hypertension and/or hypercholesterolaemia; Southeast Asian migrants were 40–60% more likely to report diabetes. Northeast Asian-born individuals were less likely than Australian-born to have 3 or more CVD risk factors. Diabetes, treated hypertension and hypercholesterolaemia occurred at relatively low average body-mass-index in Southeast Asian migrants. The CVD risk factor profiles of migrants tended to approximate those of Australian-born with increasing acculturation, in both favourable (e.g., increased physical activity) and unfavourable directions (e.g., increased female smoking). Minimizing CVD risk in migrant populations may be achieved through efforts to retain the healthy facets of the traditional lifestyle, such as a normal body mass index and low prevalence of smoking in women, in addition to adopting healthy aspects of the host country lifestyle, such as increased physical activity.     

The human leukocyte antigen class I genes in nasopharyngeal carcinoma risk

Nasopharyngeal carcinoma (NPC) is a virally associated cancer which is highly prevalent in Southeast Asia and North Africa. Several linkage analysis studies suggested the association of susceptibility HLA (Human Leukocyte Antigen) alleles and haplotypes with NPC development. The HLA system is very polymorphic and according to the ethnic group studied, it has been found to have the capacity to confer susceptibility or resistance to NPC. Our aim was to review the most important described genetic associations of HLA class I in NPC and to comment on the inconsistent associations found in the different NPC incidence areas. We believe that the mechanisms of these associations may involve HLA genes through the differential capacity of each allele to present antigens. However, because HLA genes contain various linked candidate genes, HLA-NPC associations should be carefully interpreted.     

Urbanicity and Lifestyle Risk Factors for Cardiometabolic Diseases in Rural Uganda: A Cross-Sectional Study

Background

Urban living is associated with unhealthy lifestyles that can increase the risk of cardiometabolic diseases. In sub-Saharan Africa (SSA), where the majority of people live in rural areas, it is still unclear if there is a corresponding increase in unhealthy lifestyles as rural areas adopt urban characteristics. This study examines the distribution of urban characteristics across rural communities in Uganda and their associations with lifestyle risk factors for chronic diseases.

Methods and Findings

Using data collected in 2011, we examined cross-sectional associations between urbanicity and lifestyle risk factors in rural communities in Uganda, with 7,340 participants aged 13 y and above across 25 villages. Urbanicity was defined according to a multi-component scale, and Poisson regression models were used to examine associations between urbanicity and lifestyle risk factors by quartile of urbanicity. Despite all of the villages not having paved roads and running water, there was marked variation in levels of urbanicity across the villages, largely attributable to differences in economic activity, civil infrastructure, and availability of educational and healthcare services. In regression models, after adjustment for clustering and potential confounders including socioeconomic status, increasing urbanicity was associated with an increase in lifestyle risk factors such as physical inactivity (risk ratio [RR]: 1.19; 95% CI: 1.14, 1.24), low fruit and vegetable consumption (RR: 1.17; 95% CI: 1.10, 1.23), and high body mass index (RR: 1.48; 95% CI: 1.24, 1.77).

Conclusions

This study indicates that even across rural communities in SSA, increasing urbanicity is associated with a higher prevalence of lifestyle risk factors for cardiometabolic diseases. This finding highlights the need to consider the health impact of urbanization in rural areas across SSA. Please see later in the article for the Editors'' Summary     

Association of Household and Community Socioeconomic Position and Urbanicity with Underweight and Overweight among Women in Pakistan

Background

Similar to other developing countries, Pakistan is going through a rapid nutrition transition where shift from underweight to overweight and obesity is occurring. In this paper, we report on the relationship of household socioeconomic position (SEP), community SEP and urbanicity with under- and over-weight categories of BMI among Pakistani women.

Methods

We analyzed data on 4,767 women ages 15-49 years enrolled in a nationally representative Pakistan Demographic Health Survey (PDHS) conducted in 2012-13 that employed a multistage, stratified cluster sampling design. We assessed the association of urbanicity, household and community SEP derived from household assets and utilities, with categories of body mass index (BMI) using multinomial regression analysis where normal weight (BMI 18.6-22.5) was the reference category.

Results

Thirteen percent of women were underweight (BMI <18.5), 15% pre-overweight (BMI: 22.6-24.9), 25% overweight (BMI: 25.0–29.9) and 14% were obese (BMI≥30). Pre-overweight, overweight and obesity among women increased across household wealth quintiles (HWQs) in a graded fashion whereas there was no significant difference in underweight by household wealth. Women in urban areas were more likely to be obese. There was a pronounced increase in adjusted odds ratios (aORs) for overweight/obesity across HWQs within urban areas compared to rural areas. There was a steeper gradient in aORs for obesity from 1st to 5th HWQs in high income communities compared to the middle- and low income communities. In community-level analyses, communities in urban areas were more likely to have higher levels of obesity while in rural areas, especially in Sindh, more communities were more likely to have a higher level of underweight.

Conclusion

A shift to higher overweight and obesity than underweight in Pakistan is associated with high household and community wealth as well as living in urban areas. Clustering of obesity and underweight in distinct communities afford opportunity for tailored intervention programs.     

Vitamin D status and nutrition in Europe and Asia

Vitamin D status is highly different in various countries of Europe, the Middle East and Asia. For this review, vitamin D deficiency is defined as serum 25-hydroxyvitamin D (25(OH)D) <25 nmol/l. Within European countries, serum 25(OH)D is <25 nmol/l in 2–30% of adults, increasing in the elderly and institutionalized to more than 80% in some studies. A north-south gradient was observed for serum 25(OH)D in the Euronut and MORE studies with higher levels in Scandinavia and lower levels in Italy and Spain and some Eastern European countries. This points to other determinants than sunshine, e.g. nutrition, food fortification and supplement use. Mean vitamin D intake in Scandinavia is 200–400 IU/d, twice that in other European countries. Very low serum 25(OH)D levels have been reported in the Middle East, e.g. Turkey, Lebanon, Jordan and Iran. In these countries serum 25(OH)D was lower in women than in men and associated with clothing habits. In a Lebanese survey, vitamin D deficiency was observed in the majority and occurred mainly in veiled women. In India, vitamin D deficiency was observed in more than 30%, vitamin D status being poor in school children, pregnant women and large cities. Vitamin D status was much better in Malaysia and Singapore, but lower serum 25(OH)D was observed in Japan and China. Rickets and osteomalacia appear quite common in India, but precise data are lacking. Immigrants in Europe from the Middle East and Asia carry a high risk for vitamin D deficiency, pregnant women being especially at risk. Comparison of vitamin D status between countries is hampered by interlaboratory variation of serum 25(OH)D measurement. In addition, there is a need of population-based data. In conclusion, vitamin D deficiency is common in Southern Europe, the Middle East, India, China and Japan. It is less common in Northern Europe and Southeast Asia. Risk groups are young children, the elderly, pregnant women and non-western immigrants in Europe. Important determinants are skin type, sex, clothing, nutrition, food fortification, supplement use, BMI and degree of urbanization.     

Japanese encephalitis vaccines--needs, flaws and achievements

Japanese encephalitis causes serious health problems in countries in Southeast Asia, where the causative virus is endemic. Whereas most adults living in this region have acquired immunity, children are at high risk of infection. Childhood mass immunization programs with first-generation mouse brain-derived vaccines efficiently reduced Japanese encephalitis incidence in affected countries, but immunization recommendations have mostly been abolished in Japan owing to the occurrence of severe side effects. Thus, there is a pressing need for safer vaccines to keep the disease under control. The safety profile of the current vaccines, together with the relatively low incidence, makes the risk/benefit ratio unfavorable for immunization of travelers to Southeast Asia, despite the high mortality once the clinical disease has developed. As Asian countries become increasingly popular travel destinations, the availability of well-tolerated vaccines would likely shift the ratio towards immunization. Currently, there is one second-generation inactivated cell-culture-grown vaccine in late-stage clinical development that is approaching licensing in developed countries.     

The state and conservation of Southeast Asian biodiversity

Southeast Asia is a region of conservation concern due to heavy losses of its native habitats. In this overview, we highlight the conservation importance of Southeast Asia by comparing its degree of species endemism and endangerment, and its rate of deforestation with other tropical regions (i.e., Meso-America, South America, and Sub-Saharan Africa). Southeast Asia contains the highest mean proportion of country-endemic bird (9%) and mammal species (11%). This region also has the highest proportion of threatened vascular plant, reptile, bird, and mammal species. Furthermore, not only is Southeast Asia’s annual deforestation rate the highest in the tropics, but it has also increased between the periods 1990–2000 and 2000–2005. This could result in projected losses of 13–85% of biodiversity in the region by 2100. Secondary habitat restoration, at least in certain countries, would allow for some amelioration of biodiversity loss and thus potentially lower the currently predicted extinction rates. Nonetheless, urgent conservation actions are needed. Conservation initiatives should include public education, sustaining livelihoods, and ways to enhance the sustainability of agriculture and increase the capacity of conservation institutions. Furthermore, these actions should be country-specific and not ignore areas heavily populated by humans, as they can also harbour high numbers of threatened species. We urge that cooperative conservation initiatives be undertaken and support (e.g., capacity-building) be given by more developed countries in the region and beyond.     

Molecular phylogeography and genetic diversity of East Asian goats

The domestic goat is one of the most important livestock species, but its origins and genetic diversity still remain uncertain. Multiple highly divergent maternal lineages of goat have been reported in previous studies. Although one of the mitochondrial DNA lineages, lineage B, was detected only in eastern and southern Asia, the geographic distribution of these lineages was previously unclear. Here, we examine the genetic diversity and phylogeographic structure of Asian goats by mitochondrial DNA sequences and morphological characteristics. The analyses of a total of 1661 Asian goats from 12 countries revealed a high frequency of lineage B in Southeast Asia. The frequency of this lineage tended to be higher in mountain areas than in plain areas in Southeast Asian countries, and there was a significant correlation between its frequency and morphological traits. The results suggest an original predominance of lineage B in Southeast Asia and the recent infiltration of lineage A into Southeast Asian goats.     

Molecular database for classifying Shorea species (Dipterocarpaceae) and techniques for checking the legitimacy of timber and wood products

The extent of tropical forest has been declining, due to over-exploitation and illegal logging activities. Large quantities of unlawfully extracted timber and other wood products have been exported, mainly to developed countries. As part of the export monitoring effort, we have developed methods for extracting and analyzing DNA from wood products, such as veneers and sawn timbers made from dipterocarps, in order to identify the species from which they originated. We have also developed a chloroplast DNA database for classifying Shorea species, which are both ecologically and commercially important canopy tree species in the forests of Southeast Asia. We are able to determine the candidate species of wood samples, based on DNA sequences and anatomical data. The methods for analyzing DNA from dipterocarp wood products may have strong deterrent effects on international trade of illegitimate dipterocarp products. However, the method for analyzing DNA from wood is not perfect for all wood products and need for more improvement, especially for plywood sample. Consequently, there may be benefits for the conservation of tropical forests in Southeast Asia.     

Quantifying the biophysical and socioeconomic drivers of changes in forest and agricultural land in South and Southeast Asia

South and Southeast Asia (SSEA) has been a hotspot for land use and land cover change (LULCC) in the past few decades. The identification and quantification of the drivers of LULCC are crucial for improving our understanding of LULCC trends. So far, the biophysical and socioeconomic drivers of forest change have not been quantified at the regional scale, particularly for SSEA. In this study, we quantify the biophysical and socioeconomic drivers of forest change on a country‐by‐country basis in SSEA using an integrated quantitative methodology, which systematically accounts for previously published driver information and regional datasets. We synthesize more than 200 publications to identify the drivers of the forest change at different spatial scales in SSEA. Subsequently, we collect spatially explicit proxy data to represent the identified drivers. We quantify the dynamics of forest and agricultural land from 1992 to 2015 using the Climate Change Initiative (CCI) land cover data developed by the European Space Agency (ESA). A geographically weighted regression method is employed to quantify the spatially heterogeneous drivers of forest change. Our results show that socioeconomic drivers are more important than biophysical drivers for the conversion of forest to agricultural land in South Asia and maritime Southeast Asia. In contrast, biophysical drivers are more important than socioeconomic drivers for the conversion of agricultural land to forest in maritime Southeast Asia and less important in South Asia. Both biophysical and socioeconomic drivers contribute approximately equally to both changes in the mainland Southeast Asia region. By quantifying the dynamics of forest and agricultural land and the spatially explicit drivers of their changes in SSEA, this study provides a solid foundation for LULCC modeling and projection.     

基因组时代的新视野: 东南亚哺乳动物类群在第四纪冰河时期多样性的起源与分化

东南亚地区东起菲律宾群岛, 西至印度次大陆, 北及中国中部, 南至巽他群岛, 涵盖了世界上25个最重要的生物多样性热点地区之中的6个, 具有极其重要的全球生物多样性保护的战略意义。该地区复杂的地质地貌和气候历史使其动植物的种类和数量都极为丰富。经典的生物地理分界线华莱士线和克拉地峡将该地区进一步划分出包括部分巽他群岛和马来半岛在内的南部巽他区和北部印度支那区两个生物多样性热点地区。主要基于形态学的生物地理学研究认为巽他区和印度支那区通过马来半岛陆地相连, 并且第四纪大部分时间海平面下降形成大陆桥, 直到一万年前该地区的众多岛屿仍与大陆连接, 促进了哺乳动物的种群迁徙与基因交流, 因此物种种群间的差别将很细微。然而近来分子遗传学研究表明, 由于其他生态因素制约, 哺乳动物的迁移能力可能比以往认为的低, 大陆桥的存在并不一定导致迁徙的发生, 许多种群的隔离早在200万年前便已形成, 并且没有因为后来冰川期海平面降低而恢复种群交流, 而距今7.3万年前发生的苏门答腊多巴超级火山爆发也可能进一步影响了物种间和物种内多样性的形成和分化。通过已有的东南亚哺乳动物种群遗传学研究结果, 我们认为物种间或种群间的差异主要表现为三个层次: 巽他区种群与印度支那区种群间约百万年尺度的分化, 巽他区不同岛屿种群间约数十万年尺度的分化, 以及发生于晚更新世的分化事件。已有的东南亚种群遗传学研究主要采用线粒体及核基因多位点数据进行分析, 而种群基因组学分析则使得获得详尽的种群历史动态成为可能, 并使我们可以进一步了解东南亚哺乳动物类群所经历的物种形成过程。     

Independent associations of anti-cyclic citrullinated peptide antibodies and rheumatoid factor with radiographic severity of rheumatoid arthritis

Several recent publications have established a strong association between anti-cyclic citrullinated peptide antibody (anti-CCP)-positive rheumatoid arthritis (RA) and carriage of shared epitope (SE) alleles. Although anti-CCP have also been associated with more severe RA, the issue of whether this is independent of rheumatoid factor (RF) has not been addressed. To identify associations between RF, anti-CCP, SE status and radiological damage, we studied a large cross-sectional cohort with longstanding RA. Individuals (n = 872) enrolled in the study all fulfilled the American College of Rheumatology criteria for RA, had a minimum disease duration of 3 years, and at least one definite radiographic erosion was present in hands or feet. Radiographs were scored blind at study entry by a single musculoskeletal radiologist using a modified Larsen's score. Anti-CCP and RF levels were determined using enzyme-linked immunosorbent assay, and DRB1 typing was performed using polymerase chain reaction based methodology. Both anti-CCP and RF levels were strongly associated with radiographic severity (P < 0.0001). In subgroups stratified for both anti-CCP and RF status, evidence of independent associations of both antibodies with radiographic outcome was found (P < 0.0001). An association of SE alleles with radiographic severity was present only in RF-negative individuals. Anti-CCP positivity was associated with SE status with evidence of a gene-dose effect, most markedly in RF-negative individuals (P < 0.01). Anti-CCP and RF status are independent severity factors for RA, with SE alleles playing at most a secondary role. Our data support the view that previously described associations between SE and radiological severity, especially in RF-negative patients, may be indirect and due to an association with anti-CCP.