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PubMed2002

Some biological cardiovascular risk factors and diet in samples of the male population of Tallinn, Estonia in 1984/1985 and 1992/1993.

BACKGROUND: The role of diet in the development of atherosclerosis and coronary heart disease is well known from animal, clinical and epidemiological studies; the influence of dietary factors is realized through their impact on body mass, lipids and blood pressure. The aim of this investigation was to study the levels of some biological risk factors: blood pressure, total cholesterol, triglycerides and body mass, as well as nutrition, in the male population of Tallinn, the capital of Estonia, in 1984/1985 and 1992/1993 (the transition period). METHODS: Two independent random samples of the male population of Tallinn, aged 30 to 54, were examined in 1984/1985 (1,890 men) and in 1992/1993 (752 men). Standard epidemiological investigation methods were used; the diet was studied by the 24 h recall method. RESULTS: By the time of the second survey the age-adjusted mean values of systolic and diastolic blood pressure, body mass index and triglycerides, as well as the prevalence of arterial hypertension, hypercholesterolaemia and hypertriglyceridaemia were lower than at the first survey. These data were in accordance with the dietary pattern: lower energy, animal protein, fat, saturated fatty acids, cholesterol intake and higher consumption of vegetable protein and P/S ratio at the second survey. Taking into account close relationships between many nutrients and biological risk factors found previously, changes in the diet of the population, which occurred in postsocialist Estonia in the early 1990s, could be regarded as one of the reasons for the differences in the levels of these risk factors.

Adult↗

PubMed2006

Major improvements, but persisting inequalities in infant survival in Estonia 1992-2002.

BACKGROUND: Inequality in adult health increased in Estonia during the transition period after 1991. We examined inequality in infant survival from 1992 to 2002. METHODS: All 132 854 singleton live births reported to the Estonian Medical Birth Registry in 1992-2001 were linked to the Estonian Mortality Database. The effect of mother's education, nationality, marital status, and place of residence on neonatal (0-27 days) and post-neonatal (28-364 days) death was evaluated in logistic regression with adjustments for maternal age, parity, smoking, sex of the infant, birth weight, and gestational age. RESULTS: Infant mortality decreased substantially. Risk of death in neonatal period was lowest in Tartu, with a decline from 4.9/1000 in infants born in 1992-1996 to 2.1/1000 in those born in 1997-2001. Decline in neonatal mortality in other regions was from 9.2/1000 to 5.1/1000. Persisting regional differences were unexplained by mothers' nationality, education, or marital status, or the infants' length of gestation. Decline in post-neonatal mortality was less marked and although risk differences between different socio-economic groups decreased, mothers' marital status and education in particular remained strongly associated with risk of post-neonatal death [odds ratio for infants born to mothers with basic or lower education compared to university education 3.70 (95% confidence interval 2.34-5.85) in 1992-1996 and 3.56 (2.06-6.14) in 1997-2001]. CONCLUSIONS: Infant survival improved appreciably in Estonia after 1991 and risk differences between social groups decreased. The improvements were not accompanied by reduction in the strength of the effects of social characteristics on infant death measured as risk ratios.

Adult↗

PubMed2006

Detecting changes in financial protection: creating evidence for policy in Estonia.

Ninety-four per cent of the Estonian population is covered by public health insurance, but private expenditure has been increasing quickly both in real terms and as a percentage of total health expenditure. To date, little attention has been given to the impact this could have on the population's financial protection. Out-of-pocket payments, which account for the bulk of the private expenditure in many low- and middle-income countries, can push people into poverty and more generally represent too high a burden for some households. It is therefore very important that governments monitor the impact of out-of-pocket payments on health. Using an example from Estonia, this paper aims to illustrate that, if household budget survey data are available, monitoring a population's financial protection is not a complex undertaking. Further, by combining simple statistical analyses of these data with a good knowledge of a country's health system, it is possible to give a fairly detailed diagnostic of the nature of the population's coverage limitation. This allows for the presentation of easily interpretable results that can raise awareness among policy-makers and help to target adequate policy responses. Using Estonian household budget surveys from 1995, 2001 and 2002, we show that the proportion of households who spend more than 20% of their capacity to pay on health increased from 3.4% in 1995 to 7.4% in 2002 and that in 2002, 1.3% of the population fell into poverty because of health payments. Logistic regression helps in identifying the population most at risk: elderly patients who belong to poor households and spend high amounts on medicines. This study, which can be replicated, did raise awareness among policy-makers about the changes in financial protection over the years in Estonia.

Data Collection↗

PubMed2000

Social determinants of birthweight and length of gestation in Estonia during the transition to democracy.

BACKGROUND: To investigate social variation in birthweight and length of gestation in Estonia in the period of transition to a democracy and market economy. METHODS: All live births resulting from singleton pregnancies reported to the Estonian Medical Birth Registry in 1992-1997 (n = 84, 629) were studied with respect to social variation in birthweight and preterm delivery (<37 weeks gestation). The results were adjusted for maternal age, parity, education, nationality, marital status, smoking in pregnancy, sex of the infant (and gestational age). RESULTS: Between 1992 and 1997, mean birthweight increased from 3,465g to 3,497g (P < 0.001) and the preterm rate fell from 5.8% to 5.1% (P = 0.001). Maternal education, marital status and nationality were all independently related to the mean birthweight and the risk of preterm birth. The mean difference in birthweight between children of mothers with basic and university education was 87 g (95% CI : 74-100). Children born to mothers of non-Estonian compared to Estonian nationality were on average 77 g lighter (95% CI: 70-84). While the effect of nationality and marital status on birthweight was relatively stable during the study period, differences in birth outcome by maternal education became stronger. CONCLUSIONS: The mean birthweight increased and the preterm rate decreased in Estonia as a whole during the transition. However, the improvements were not shared equally by all social groups. An increase in variation in birthweight by maternal education was particularly notable.

Adolescent↗

PubMed2003

Estonia 1989-2000: enormous increase in mortality differences by education.

BACKGROUND: Having regained its political autonomy in 1991, Estonia experienced major changes in political, economic, and social realities. We aimed to analyse mortality changes by education from 1989 to 2000 in order to assess the impact of recent changes in Estonia, as well as the delayed effects of pre-transitional developments. METHODS: Two census-based analyses were compared. Individual cause-specific death data for those aged 20+ for 1987-1990 (72 003 deaths) and 1999-2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Mortality for all causes combined and for selected causes of death were analysed for high, mid, and low educational groups. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates. To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. RESULTS: Educational differences in mortality increased tremendously from 1989 to 2000: over the 10-year period life expectancy improved considerably for graduates, and worsened for those with the lowest education. In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Large differences were observed in all selected causes of death in 1989 and in 2000 and the trends were invariably much more favourable for the higher educated. Educational differences in total mortality increased in all age groups. CONCLUSIONS: Social disruption and increasing inequalities in wealth can be considered main recent determinants; however, causal processes, shaped decades before recent reforms, also contribute to this widening gap.

Adult↗

PubMed2000

Seropositivity to Helicobacter pylori and CagA protein in schoolchildren of different ages living in urban and rural areas in southern Estonia.

OBJECTIVE: To evaluate Helicobacter pylori and CagA seropositivity in a non-selected group of schoolchildren in southern Estonia, with reference to previous studies where high seroprevalence to H. pylori (87%) and anti-CagA positivity (63%) in an adult population from the same region were found. STUDY POPULATION: A total of 421 schoolchildren selected haphazardly from a random population (n = 1018, ages 9, 12 or 15 years) and living in urban or rural areas. METHODS: H. pylori status was determined by evaluation of IgG antibodies against cell surface proteins of H. pylori, strain CCUG 17874, using standard ELISA. Anti-CagA IgGs were determined by ELISA using a recombinant fragment of CagA (CCUG 17874) as solid-phase antigen. Absorbance values > 0.3 (405 nm) were taken as a CagA-positive result based on a study of 25 sera from H. pylori-negative children. RESULTS: Of the 421 subjects, 235 (56%) were H. pylori-ELISA positive, and 109 out of the 235 (46%) were anti-CagA positive. Neither H. pylori nor CagA positivity were significantly different in girls and boys, or in children aged 9, 12 or 15 years. The H. pylori prevalence rate (118/181, 65%) as well as CagA positivity (64/181, 35%) in rural areas were higher compared with those in towns (117/240, 49% and 54/240, 22%, respectively; P = 0.001 and P = 0.005). CONCLUSION: Of schoolchildren living in southern Estonia, 56% were seropositive to H. pylori. Half of them had anti-CagA antibodies. Schoolchildren living in rural areas were infected significantly more often with CagA-seropositive strains compared with those living in towns.

Adolescent↗

PubMed2004

Treatment of sexually transmitted diseases in Estonia: consistency with the evidence-based medicine principles.

BACKGROUND: Estonia is among those Eastern European countries that have witnessed an explosive intravenous drug use-driven HIV epidemic. Early sexually transmitted disease (STD) diagnosis and appropriate treatment is essential to prevent an STD-driven HIV epidemic. OBJECTIVES: The objectives of this study were to define the schedule of antibiotic treatment doctors in Estonia used to treat STDs, and to determine if the treatments used correspond to evidence-based medicine treatment principles. STUDY DESIGN: Using an administrative database of the Estonian Health Insurance Fund on pharmaceuticals reimbursement, we obtained information on: drug (ATC 1998) prescribed with an STD diagnosis (International Classification of Diseases and Related Health Problems, syphilis, gonorrhea, genital Chlamydia trachomatis and Trichomonas vaginalis infections, and genital herpes), prescribing physician specialty, and patient demographics (date of birth, gender). To evaluate the correspondence of STD treatment to evidence-based medicine principles, the therapeutic regimens used were compared with recommendations from the European Sexually Transmitted Infections Management Guidelines. RESULTS: In 2001 and 2002, physicians ordered 17,077 prescriptions for systemic antibacterial medications to treat STDs in 12,823 different individuals: 2942 men (mean age, 31.8 years) and 9880 women (mean age, 29.5 years). The majority of STD treatments were prescribed by gynecologists (60%) or dermatovenerologists (29%); general practitioners treated 8% of STDs. In 11% of treatment episodes, the drug prescribed was inconsistent with guideline recommendations; additionally, in 9% of episodes, the recommended drug was chosen but the prescribed dose was too low. At least 20% of treatment episodes could therefore be considered inappropriate. CONCLUSIONS: Educational efforts are needed to increase physician awareness of evidence-based approaches for STD management and treatment to assure effective STD care.

Adult↗

PubMed2004

Helicobacter pylori infection in children in Estonia: decreasing seroprevalence during the 11-year period of profound socioeconomic changes.

BACKGROUND: The prevalence of Helicobacter pylori infection is inversely associated with socioeconomic conditions in childhood. In Estonia, a high prevalence of H. pylori infection has been observed among children born in 1987 and earlier. Since 1991, after the dissolution of the USSR, profound social and economic changes have taken place in the country. The aim of the study was to evaluate changes in the seroprevalence of H. pylori infection among children in the period 1991-2002. MATERIALS AND METHODS: The hospital-based study population consisted of two groups of children enrolled in 1991 (n = 425) and 2002 (n = 296) according to the same inclusion criteria. The immunoglobulin G antibodies to the cell surface proteins of H. pylori were determined by enzyme-linked immunosorbent assay, and the sera with the borderline results were analyzed by immunoblot analysis. Multiple regression analysis was used to determine the associations between H. pylori seropositivity and different variables such as demographic characteristics, diagnoses and year of enrollment. RESULTS: The only two variables linked independently to H. pylori serostatus were age and year of enrollment: the adjusted odds of being H. pylori seropositive were 1.92 [95% confidence interval (CI) 1.33-2.76] times higher for the children enrolled in 1991 compared with the children enrolled in 2002. The age-standardized seroprevalence rate was 42.2% (95% CI 37.4-47.0%) for the group of 1991 and 28.1% (95% CI 23.1-33.6%) for the group of 2002. CONCLUSION: The prevalence of H. pylori infection among children has significantly decreased during the 11-year period of profound socioeconomic changes in Estonia.

Adolescent↗

PubMed1999

Prevalence of childhood epilepsy in Estonia.

PURPOSE: To establish the prevalence rate (PR) and main characteristics of childhood epilepsy in Estonia. METHODS: We performed a population-based case ascertainment of all the possible sources of medical care in seven counties of Estonia from January 1995 to December 1997. Only cases of patients from 1 month to 19 years of age with active epilepsy (i.e., at least one seizure during the last 5 years, regardless of treatment) were included. All patients were examined by a pediatric neurologist. RESULTS: Five hundred sixty cases met the study criteria on the prevalence day, December 31, 1997. The total PR was 3.6 per 1,000 population (boy/girl ratio, 1.2:1.0). The PR was the highest-4.3 per 1,000-in the 5-to-9-year-old age group. The prevalence declined markedly in children age 14 years and on. The correlation between age and PR was negative (-0.542, p < 0.0001) by regression analyses. The most frequent seizure types in the total group were primarily generalized seizures-PR 2. 1/1,000 [rate ratio (RR) 1.4, 95% confidence interval (CI) 1.2, 1.6]. The predominance of generalized seizures was significant in those younger than 10 years. In 14.8% of cases, there was a history of epilepsy among first- and second-degree relatives. Benign rolandic epilepsy-PR 0.2/1,000-was the most frequent among idiopathic syndromes, and Lennox-Gastaut syndrome-PR 0.08/1,000-was the most frequent among cryptogenic ones. Perinatal factors-PR 0.8/1,000 were the most frequently found cause of epilepsy. In 304 cases (54.2%), additional medical problems existed. CONCLUSIONS: The prevalence of childhood epilepsy was comparable with that found in developed countries. Generalized seizures predominated, and the main cause was perinatal factors.

Adolescent↗

PubMed2001

Diversity of Helicobacter pylori genotypes among Estonian and Russian patients with perforated peptic ulcer, living in Southern Estonia.

To compare the genomic variation of Helicobacter pylori in samples obtained from patients with perforated peptic ulcer, living in the same area of Estonia but belonging to different nationalities, 50 non-consecutive patients (32 Estonians and 18 Russians) admitted in the Tartu University Hospital in 1997-1999 were studied. Gastric samples of antral mucosa were obtained during operation and analysed histologically and with PCR for detection of different genotypes of H. pylori (cagA and vacA s and m subtypes). Among the 50 perforated peptic ulcer patients with histologically proven H. pylori colonisation no sample of gastric mucosa showed the s1b subtype of the vacA gene. The perforated peptic ulcer patients were mainly infected with cagA (82%) and s1 (98%) genotypes of H. pylori. The distribution of s1a/m1, s1a/m2 and s2/m2 subtypes of vacA genes was statistically different in Estonian and Russian patients (P<0.05). In conclusion differences in the distribution of vacA s and m subtypes of H. pylori were revealed between Estonian and Russian patients with perforated peptic ulcer from Southern Estonia.

Antigens, Bacterial↗

PubMed1999

Registry of first-ever stroke in Tartu, Estonia, 1991 through 1993: outcome of stroke.

OBJECTIVES: To provide information about the functional ability of the survivors of first-ever stroke in Estonia. PATIENTS AND METHODS: A population based epidemiological study 1991 through 1993 in Tartu. Herewith the data for 1991 and 1993 are presented. A total of 519 persons were registered; 82% of them were admitted (mean length 14 days), 66% were discharged home. RESULTS: During 6 months 41% of the patients died, the remaining 305 patients were interviewed about their living conditions, and functional ability using the Barthel ADL Index. Although 58% of patients responded to the questionnaire, no significant differences in several factors between the respondents and non-respondents were found. Thirty-eight percent of the patients were totally independent in ADL. CONCLUSION: The case-fatality rate at 6 months was high in Estonia and the proportion of totally independent patients 6 months after stroke is slightly lower compared to other studies. The short length of hospital treatment was possibly compensated by sufficient support by relatives after discharge.

Activities of Daily Living↗

PubMed1996

Results of coeliac disease screening in Estonia in 1990-1994.

In the period of 1990-94, 2895 individuals (629 children with suspicion of coeliac disease selected throughout Estonia; 700 consecutively hospitalized children; 105 children with atopic dermatitis; 1461 inhabitants of a small Estonian town) were serologically screened for coeliac disease. The enzyme-linked immunosorbent assay was used for antigliadin antibody determinations and R1-type antireticulin antibodies were detected using an indirect immunofluorescence method. Coeliac disease was diagnosed according to recent criteria recommended by the European Society for Paediatric Gastroenterology and Nutrition. Antigliadin antibody testing was positive in 44 (3.1%) of 1434 children studied, and in 33 of whom coeliac disease was confirmed. In all the coeliac patients R1-type antireticulin antibody test was positive. However, 52 (3.5%) of 1461 adults studied who did not have coeliac disease had positive antigliadin antibody test but negative antireticulin antibody test. Thus, in Estonia, the antigliadin antibody test can be used in screening for coeliac disease in children but not in adults.

Adolescent↗

PubMed2001

Spread of drug-resistant pulmonary tuberculosis in Estonia.

Restriction fragment length polymorphism (RFLP) analysis of 209 Mycobacterium tuberculosis clinical isolates obtained from newly detected pulmonary tuberculosis patients (151 male and 58 female; mean age, 41 years) in Estonia during 1994 showed that 61 isolates (29%) belonged to a genetically closely related group of isolates, family A, with a predominant IS6110 banding pattern. These strains shared the majority of their IS6110 DNA-containing restriction fragments, representing a predominant banding pattern (similarity, >65%). This family A comprised 12 clusters of identical isolates, and the largest cluster comprised 10 strains. The majority (87.5%) of all multidrug-resistant (MDR) isolates, 67.2% of all isolates with any drug resistance, but only 12% of the fully susceptible isolates of M. tuberculosis belonged to family A. These strains were confirmed by spoligotyping as members of the Beijing genotype family. The spread of Beijing genotype MDR M. tuberculosis strains was also frequently seen in 1997 to 1999. The members of this homogenous group of drug-resistant M. tuberculosis strains have contributed substantially to the continual emergence of drug-resistant tuberculosis all over Estonia.

Adult↗

PubMed2002

Association of cagA and vacA genotypes of Helicobacter pylori with gastric diseases in Estonia.

Gastric biopsy specimens from 156 adult patients from southern Estonia suffering from chronic gastritis, peptic ulcer disease, and perforated peptic ulcer were analyzed by PCR. The cagA gene was evenly distributed throughout 87% of the specimens from the patients with the different gastric diseases. The presence of the cagA gene correlated with that of vacA signal sequence type s1a (99%). However, no clear differences were found in the distribution of cagA and vacA genotypes among patients in Estonia with severe perforated peptic ulcer, uncomplicated peptic ulcer, or chronic gastritis.

Antigens, Bacterial↗

PubMed2004

Characterization of a highly evolved vaccine-derived poliovirus type 3 isolated from sewage in Estonia.

Two types of vaccine-derived polioviruses have been recently designated to emphasize the different origins of the evolved viruses: circulating vaccine-derived polioviruses (cVDPV) associated with outbreaks of paralytic disease and strains isolated from chronically infected immunodeficient individuals (iVDPV). We describe here a type 3 VDPV (PV3/EST/02/E252; later E252) isolated from sewage collected in Tallinn, Estonia, in October 2002. Due to aberrant properties in subtyping, the virus was subjected to detailed characterization. Partial genomic sequencing suggested that the closest relative was the oral vaccine strain PV3/Sabin, but the two virus strains shared only 86.7% of the 900 nucleotides (nt) coding for the capsid protein VP1. Phylogenetic analysis of the nearly complete genome [nt 19 to poly(A)] revealed multiple nucleotide substitutions throughout the genome and a possible Sabin 3/Sabin 1-recombination junction site in the 2C coding region. A calculation based on the estimated mutation frequency of the P1 region of polioviruses suggested that the E252 virus might have replicated in one or more individuals for approximately 10 years. No persons chronically excreting poliovirus are known in Estonia. Amino acid substitutions were seen in all known antigenic sites, which was consistent with the observed aberrant antigenic properties of the virus demonstrated by both monoclonal antibodies and human sera from vaccinated children. In spite of the apparent transmission potential, no evidence was obtained for circulation of the virus in the Estonian population.

Amino Acid Sequence↗

PubMed2004

Increasing ethnic differences in mortality in Estonia after the collapse of the Soviet Union.

STUDY OBJECTIVE: This study examined the change in ethnic differences in mortality in Estonia 1989-2000. DESIGN: Two unlinked cross sectional census based analyses were compared. Total and cause specific mortality was analysed for ethnic Estonians and Russians. The absolute differences in mortality were evaluated through life expectancy at birth and age standardised mortality rates. Relative differences were assessed by mortality rate ratios with 95% confidence intervals, calculated using Poisson regression. SETTING: Estonia before and after the fall of the Soviet Union. PARTICIPANTS: Individual cause specific death data for 1987-1990 (69549 deaths) and for 1999-2000 (33809 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. MAIN RESULTS: In the period 1989-2000, ethnic differences in life expectancy increased from 0.4 years to 6.1 years among men and from 0.6 years to 3.5 years among women. In 2000, Russians had a higher mortality than Estonians in all age groups and for almost all selected causes of death. The largest differences were found for some alcohol related causes of death especially in 2000. CONCLUSIONS: Political and economic upheaval, increasing poverty, and alcohol consumption can be considered the main underlying causes of the widening ethnic mortality gap.

Alcohol Drinking↗

PubMed1996

The ethics of Soviet medical practice: behaviours and attitudes of physicians in Soviet Estonia.

OBJECTIVES: To study and report the attitudes and practices of physicians in a former Soviet republic regarding issues pertaining to patients' rights, physician negligence and the acceptance of gratuities from patients. DESIGN: Survey questionnaire administered to physicians in 1991 at the time of the Soviet breakup. SETTING: Estonia, formerly a Soviet republic, now an independent state. SURVEY SAMPLE: A stratified, random sample of 1,000 physicians, representing approximately 20 per cent of practicing physicians under the age of 65. RESULTS: Most physicians shared information with patients about treatment risks and alternatives, with the exception of cancer patients: only a third of physicians tell the patient when cancer is suspected. Current practice at the time of the survey left patients few options when physician negligence occurred; most physicians feel that under a reformed system physician negligence should be handled within the local facility rather than by the government. It was common practice for physicians to receive gifts, tips, or preferential access to scarce consumer goods from their patients. Responses varied somewhat by facility and physician nationality. CONCLUSION: The ethics of Soviet medical practice were different in a number of ways from generally accepted norms in Western countries. Physicians' attitudes about the need for ethical reform suggest that there will be movement in Estonia towards a system of medical ethics that more closely approximates those in the West.

Adult↗

PubMed2003

A population based epidemiological study on myasthenia gravis in Estonia.

OBJECTIVE: To describe the occurrence of myasthenia gravis in the Baltic area. METHODS: Data were obtained from hospital files recorded during the period 1942 to 1996 from neurologists and the patient organisation. Survival data were checked with the Estonian Citizenship and Migration Board. Prevalence was determined on 1 January 1997. A questionnaire on the course of myasthenia gravis was sent to all the prevalent patients. RESULTS: The size of the population surveyed was 1 462 130. The average annual incidence from 1970 to 1996 was 4.0 per million (women, 5.2; men, 2.6). The point prevalence was 99 per million (women, 133; men 59). The incidence in the younger age group (<50 years) was 3.4 per million (women, 4.8; men, 1.9) and in the older age group (>or=50 years), 5.5 (women, 5.9; men, 4.9). The prevalence ratio was twofold higher in the older age group (p<0.0001)-for men (p = 0.034) as well as for women (p<0.001). CONCLUSIONS: Prevalence and incidence values of myasthenia gravis from Estonia are similar to those reported in most studies from Europe and north America. However, there seems to be a higher frequency in the elderly (>or=50 years) in Estonia.

Adolescent↗