Epidemiology and Health

Systematic Review

Effectiveness of community-based interventions for older adults living alone: a systematic review and meta-analysis: Inhye Kim, Hyunseo An, Sohyeon Yun, Hae Yean Park; Epidemiol Health. 2024;46:e2024013. Published online January 3, 2024; DOI: https://doi.org/10.4178/epih.e2024013

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Abstract

OBJECTIVES
This study examined the effectiveness of community-based interventions designed for older adults living alone through a systematic review and meta-analysis.

METHODS

The study incorporated 4 randomized controlled trials (RCTs) and 5 non-RCTs to evaluate various interventions. The methodological quality of these studies was assessed using the Downs and Black checklist, while Q-statistic and I-square tests were performed to examine statistical heterogeneity. Additionally, visual inspection of funnel plots and the trim-and-fill method were employed to investigate potential publication bias. Of the 2,729 identified studies, 9 met the criteria for inclusion in this review. Independent variables were categorized into 5 groups (physical activity, nutrition, social relationships, social participation, and combined intervention) to examine their effects. Dependent variables were similarly classified into 5 subgroups to identify the specific effects of the interventions.

RESULTS

Interventions focusing on nutrition and combined approaches were the most effective, yielding effect sizes of 0.96 (95% confidence interval [CI], 0.66 to 1.25) and 0.43 (95% CI, 0.26 to 0.60), respectively. The interventions had the greatest impacts on the health behavior and mental health of the participants, with effect sizes of 0.98 (95% CI, 0.73 to 1.22) for health behavior and 0.67 (95% CI, 0.19 to 1.16) for mental health.

CONCLUSIONS

This study suggests a direction for the development of community-based interventions tailored to the needs of older adults living alone. Additionally, it provides evidence to inform policy decisions concerning this demographic.

Summary

Korean summary
본 연구는 독거 노인들 대상으로 한 지역사회 기반 중재의 효과에 대하여 탐색하고 그 효과 크기를 확인하기 위하여 체계적고찰 및 메타분석을 실시하였다. 영양 및 복합 중재가 특히 효과적이었으며, 이는 건강 행동과 정신건강에 있어 중요한 긍정적 효과를 나타내어 추후 개별적 맞춤 중재의 잠재적 효과성을 나타낸다. 이러한 발견은 독거노인 집단의 웰빙 향상을 위한 프로그램과 정책 입안에 근거로 활용될 수 있다.

Key Message
This systematic review and meta-analysis evaluated the impact of community-based interventions for older adults living alone, incorporating 9 studies to assess effectiveness in areas like nutrition and combined strategies. Results indicated significant benefits, particularly in health behavior and mental health, demonstrating the potential of tailored interventions. These findings support the development of targeted programs and policy decisions aimed at improving the well-being of this demographic.

Citations

Citations to this article as recorded by

Effectiveness of a resilience-building nursing intervention on psychological well-being in Arab community-dwelling older adults
Walaa Badawy Mohamed Badawy, Amal Hashem Mohamed, Mostafa Shaban
Geriatric Nursing.2024; 60: 338. CrossRef

Special Article

Limiting the spillover of zoonotic pathogens from traditional food markets in developing countries and a new market design for risk-proofing: Sandeep Ghatak, Kandhan Srinivas, Arockiasamy Arun Prince Milton, Govindarajan Bhuvana Priya, Samir Das, Johanna F. Lindahl; Epidemiol Health. 2023;45:e2023097. Published online October 30, 2023; DOI: https://doi.org/10.4178/epih.e2023097

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Abstract Summary PDF: Abstract
Traditional food markets are age-old systems that primarily serve the food supply needs of society’s less affluent sectors, often operating with minimal infrastructure. These markets are prevalent in low and middle-income countries. However, their hygienic conditions are frequently suboptimal, potentially fostering the emergence and spread of presumptive zoonotic diseases. The recent emergence of zoonotic or potentially zoonotic diseases and their possible links to traditional food markets underscore the need for focused attention on this overlooked issue. The socioeconomic characteristics of traditional food markets reveal that despite the risk of zoonotic pathogen spread, these markets play a crucial role for large segments of the population. These individuals rely on such markets for their livelihood, food, and nutrition. Therefore, a comprehensive set of measures addressing various aspects of traditional food markets is necessary to manage and mitigate the risks of potential zoonotic disease emergence. In this article, we explore various facets of traditional food markets, paying special attention to the risks of zoonotic diseases that urgently require stakeholder attention. We also propose a new market design to prevent the risk of zoonotic spillover and advocate for the development of a Market Hygiene Index for these markets.; Summary

Key Message
Embracing Tradition, Ensuring Safety! Traditional food markets are vital for many communities, supplying food and livelihoods. Yet, their suboptimal hygiene poses potential risks for zoonotic diseases. Our article sheds light on the importance of addressing this issue and offers a new market design for risk-proofing in developing countries. Join the conversation on safeguarding these markets and support the vulnerable for a safer, healthier future!

Original Articles

Evaluation of an air quality warning system for vulnerable and susceptible individuals in Korea: an interrupted time series analysis: YouHyun Park, Jun Hyuk Koo, Hoyeon Jeong, Ji Ye Jung, Changsoo Kim, Dae Ryong Kang; Epidemiol Health. 2023;45:e2023020. Published online February 14, 2023; DOI: https://doi.org/10.4178/epih.e2023020

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Abstract

OBJECTIVES
This study was conducted to elucidate the effects of an air quality warning system (AQWS) implemented in January 2015 in Korea by analyzing changes in the incidence and exacerbation rates of environmental diseases.

METHODS

Data from patients with environmental diseases were extracted from the National Health Insurance Service-National Sample Cohort database from 2010 to 2019, and data on environmental risk factors were acquired from the AirKorea database. Patient and meteorological data were linked based on residential area. An interrupted time series analysis with Poisson segmented regression was used to compare the rates before and after AQWS introduction. Adjustment variables included seasonality, air pollutants (carbon monoxide, nitrogen dioxide, sulfur dioxide, particulate matter less than 10 μm in diameter, and ozone), temperature, and humidity.

RESULTS

After AQWS implementation, the incidence of asthma gradually decreased by 20.5%. Cardiovascular disease and stroke incidence also significantly decreased (by 34.3 and 43.0%, respectively). However, no immediate or gradual decrease was identified in the exacerbation rate of any environmental disease after AQWS implementation. Sensitivity analyses were performed according to age, disability, and health insurance coverage type. Overall, the AQWS effectively mitigated the occurrence of most environmental diseases in Korea. However, the relationships between alarm system implementation and reduced incidence differed among diseases based on the characteristics of vulnerable and sensitive individuals.

CONCLUSIONS

Our results suggest that by tailoring the AQWS to demographic and sociological characteristics and providing enhanced education about the warning system, interventions can become an efficient policy tool to decrease air pollution-related health risks.

Summary

Korean summary
한국에서 미세먼지경보제의 시행은 환경성질환의 발생률을 점진적으로 감소시켰으나, 민감·취약계층 특징에 따라 정책 시행에 영향을 받은 환경성질환 종류는 상이하였다. 한편, 기존 환경성질환 환자의 악화(입원 또는 응급실 방문)의 경우 미세먼지경보제 시행으로 인한 영향은 파악되지 않았다.

Key Message
Air Quality Warning System (AQWS) effectively mitigated the occurrence of most environmental diseases in Korea. The relationships between alarm system implementation and reduced incidence differed among diseases based on the characteristics of vulnerable and sensitive individuals.

Citations

Citations to this article as recorded by

Trends in the Use of Air Quality Indexes in Asthma Studies
Angie Daniela Barrera-Heredia, Carlos Alfonso Zafra-Mejía, Alejandra Cañas Arboleda, María José Fernández Sánchez, Liliana López-Kleine, Adriana Rojas Moreno
Atmosphere.2024; 15(7): 847. CrossRef
Personal Strategies to Reduce the Cardiovascular Impacts of Environmental Exposures
Luke J. Bonanni, Jonathan D. Newman
Circulation Research.2024; 134(9): 1197. CrossRef

Deprived areas and community water fluoridation in Brazil: a multilevel approach for refocusing public policy: Franklin Barbosa da Silva, José Leopoldo Ferreira Antunes, Paulo Frazão; Epidemiol Health. 2021;43:e2021031. Published online May 1, 2021; DOI: https://doi.org/10.4178/epih.e2021031

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Abstract Summary PDF: Abstract
OBJECTIVES
The aim of this study was to determine whether geographic location, socioeconomic status, infant mortality, and mortality from diarrheal disease in health regions are associated with the provision of community water fluoridation (CWF) in Brazilian municipalities.
METHODS
A multilevel ecological study was conducted based on data from the National Survey of Basic Sanitation and Human Development Atlas. A multilevel analysis was carried out considering Brazilian municipalities as the first level and health regions as the second level, comprising sanitation, demographic, socioeconomic, and health characteristics.
RESULTS
The observation units comprised 5,565 municipalities clustered in 438 health regions in Brazil. The lack of CWF provision was positively associated with the following municipal characteristics: a below-median proportion of inhabitants covered by the sewage network, medium to very low human development index, below-median per capita gross domestic product, and an above-median percentage of expenditures on sanitation. In relation to the health regions, the likelihood of a lack of CWF provision was greater in the municipalities belonging to the health regions located in the Northern and Northeastern areas of Brazil and in those where child mortality due to acute diarrheal disease and the proportion of people with low income were higher when adjusted by municipal indicators.
CONCLUSIONS
Information on the characteristics associated with CWF provision constitutes important input for refocusing public policy to reduce inequalities among Brazilian municipalities and health regions. These findings may help policy-makers to understand the challenges facing CWF expansion in low-, middle-, and high-income countries.; Summary

Key Message
Just as the challenges for CWF's expansion in Brazil's most vulnerable areas require firm leadership for refocusing public policy, expansion in low- and middle-income countries demands a continued global collaborative effort.

Factors associated with indoor smoking at home by adults across Korea: a focus on socioeconomic status: Bomgyeol Kim, Yejin Lee, Young Dae Kwon, Tae Hyun Kim, Jin Won Noh; Epidemiol Health. 2020;42:e2020067. Published online October 28, 2020; DOI: https://doi.org/10.4178/epih.e2020067

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
Secondhand smoke is an issue that cannot be ignored due to its various negative effects. Especially, secondhand smoke inside the household is an area where health policy must pay attention as it can affect all age groups. This study aims to identify the factors associated with smoking inside the household focusing on socioeconomic status in Korea.

METHODS

We used data from the Community Health Survey of 2017 and a total of 33,462 participated in the study. Data were analyzed through IBM SPSS version 25.0 to conduct binary logistic regression analysis.

RESULTS

Results indicated that indoor smoking had a significant association with socioeconomic status. This association was more marked in those participants who had low household income or those with elementary school education level or less. Furthermore, the study indicates that when the smoker is a woman, older, has higher stress, and is a heavier smoker, the probability of her smoking inside the house is higher.

CONCLUSIONS

Based on the results, it is meaningful that this study has found the factors of smoking inside household. The result identify the factors associated with indoor smoking at home, and it can be used as baseline data for developing new smoking cessation policies.

Summary

Korean summary
이 연구는 가정 실내 흡연과 관련된 다양한 요인들을 파악하였으며, 소득, 교육수준과 같은 사회경제적 요인과 가정 실내 흡연의 연관성을 확인하였다. 이를 통해 가정 실내 흡연 감소를 위한 금연 정책의 근거자료로 활용될 수 있을 것으로 기대된다.

Citations

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Tobacco usage in the home: a cross-sectional analysis of heated tobacco product (HTP) use and combustible tobacco smoking in Japan, 2023
Satomi Odani, Takahiro Tabuchi
Environmental Health and Preventive Medicine.2024; 29: 11. CrossRef
Impacts of smoking ban policies on billiard halls sales in South Korea using objective sales information of a credit card company: A quasi-experimental study (Preprint)
Jin-Won Noh, Jooyoung Cheon, Hohyun Seong,, Young Dae Kwon, Ki-Bong Yoo
JMIR Public Health and Surveillance.2023;[Epub] CrossRef

Effects of living in the same region as one’s workplace on the total fertility rate of working women in Korea: Yeon-Yong Kim, Hee-Jin Kang, Seongjun Ha, Jong Heon Park; Epidemiol Health. 2019;41:e2019043. Published online October 9, 2019; DOI: https://doi.org/10.4178/epih.e2019043

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Abstract Summary PDF

Abstract

OBJECTIVES
The lowest-low fertility status of Korea has continued for the past 17 years despite governmental efforts to encourage childbirth. As the number of working women has increased, their residence patterns have changed; however, the impact of this factor has yet to be explored. Therefore, this study was conducted to investigate the effects of residence patterns relative to the workplace on the total fertility rate of working women.

METHODS

Information on eligibility and healthcare utilization was obtained from the National Health Information Database between 2011 and 2015. The study participants were working women aged 15-49 years. We classified their residence relative to their workplace into 3 patterns: same municipality, same province, and different province. The total fertility rate was calculated and logistic regression was performed of childbirth according to residence pattern, adjusting for age, insurance contribution quartile, size of the workplace, year of birth, and province of residence.

RESULTS

The total fertility rates of working women from 2011 to 2015 were 1.091, 1.139, 1.048, 1.073, and 1.103, respectively. The total fertility rate by residence pattern was highest in women residing in the same municipality as their workplace. After adjustment, the odds of childbirth in women from the same municipality and the same province were 21.6% and 16.0% higher than those of women residing in a different province, respectively.

CONCLUSIONS

The total fertility rate was higher among women living near their workplace. Therefore, effective policy measures should be taken to promote the proximity of working women’s workplace and residence.

Summary

Korean summary
이 연구를 통하여 직장과 동일한 시군구에 거주하는 직장 여성의 출산율이 타 시군구 및 타 시도에 거주하는 경우보다 더 높게 나타나는 것을 확인하였다. 기존 인구사회학적 특성 위주의 출산 관련 연구에 비해 이 연구에서는 직장과 거주지의 차이의 영향을 확인하였다는 데 의의가 있다. 저출산 대책에 대한 다양한 정책적 접근이 요구되는 시점에 직장 여성의 출산율을 높이기 위하여 거주지 대책 등이 종합적으로 고려될 수 있음을 시사한다.

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Lecture

Shared decision making: relevant concepts and facilitating strategies: Jong-Myon Bae; Epidemiol Health. 2017;39:e2017048. Published online October 30, 2017; DOI: https://doi.org/10.4178/epih.e2017048

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Abstract

As the paradigm in healthcare nowadays is the evidence-based, patient-centered decision making, the issue of shared decision making (SDM) is highlighted. The aims of this manuscript were to look at the relevant concepts and suggest the facilitating strategies for overcoming barriers of conducting SDM. While the definitions of SDM were discordant, several concepts such as good communication, individual autonomy, patient participants, and patient-centered decision-making were involved. Further, the facilitating strategies of SDM were to educate and train physician, to apply clinical practice guidelines and patient decision aids, to develop valid measurement tools for evaluation of SDM processes, and to investigate the impact of SDM.

Summary

Korean summary
오늘날 보건의료가 지향하는 목표가 근거에 기반한 환자중심의 의사결정 (Evidence-based Patient-centered Decision Making)인 점에서, 공유된 의사결정 (Shared Decision Making, SDM)의 중요성이 강조되고 있다. 본 원고는 SDM의 관련 개념들을 정리하고, 진료에 적용하는 과정에서의 한계점들과 이를 극복하기 위한 방안들을 살펴보았다.

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Perspective

Suggestions for the promotion of evidence-based public health in South Korea: Jong-Myon Bae; Epidemiol Health. 2017;39:e2017030. Published online July 19, 2017; DOI: https://doi.org/10.4178/epih.e2017030

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Abstract

Evidence-based public health (EBPH) is defined as public health decision-making based on current best evidence. Debates about the latent tuberculosis infection control program suggested by the Korea Centers for Disease Control and Prevention in 2017 highlight the need to promote EBPH. Three strategies have been proposed, including providing necessary evidence by evaluating policy-evidence gaps; delivering high-quality, relevant, and timely evidence by conducting systematic reviews and adapting public health guidelines; and making value-driven decisions by training and educating public health policymakers.

Summary

Korean summary
근거중심 공중보건 (EBPH)는 공중보건영역에서 최신과 최선의 근거에 기반하여 의사결정을 하는 것이다. EBPH를 활성화하기 위해서는 정책-근거 간의 간극을 알아내고, 체계적 고찰을 통한 공중보건지침을 개발하며, 의사결정참여자의 역량을 높이기 위한 교육훈련을 추진하는 것이다.

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Editorial

Monitoring targets and indicators for the prevention and control of non-communicable diseases in Korea: Soon Young Lee; Epidemiol Health. 2015;37:e2015023. Published online May 4, 2015; DOI: https://doi.org/10.4178/epih/e2015023

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Abstract PDF: Abstract
In order to respond to the increasing burden of non-communicable diseases (NCDs) worldwide, the World Health Organization developed the global action plan (GAP), which included nine targets and 25 indicators to monitor the targets. Owing to space constraints, the article reviewed the status of 17 indicators for seven targets out of nine targets in the GAP in Korea. Most of these 17 indicators required additional analysis with existing national data to evaluate the status in Korea. Based on the result from evaluating indicators, the current NCD policy strategy and resources in Korea seemed unlikely to reach the GAP goals, unless innovative policy changes was planned to reduce NCD risk factors particularly focusing on smoking, excessive drinking, and insufficient physical activity.; Summary

Perspective

Strategies for an effective tobacco harm reduction policy in Indonesia: Fariz Nurwidya, Fumiyuki Takahashi, Hario Baskoro, Moulid Hidayat, Faisal Yunus, Kazuhisa Takahashi; Epidemiol Health. 2014;36:e2014035. Published online December 10, 2014; DOI: https://doi.org/10.4178/epih/e2014035

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Abstract PDF

Abstract

Tobacco consumption is a major causative agent for various deadly diseases such as coronary artery disease and cancer. It is the largest avoidable health risk in the world, causing more problems than alcohol, drug use, high blood pressure, excess body weight or high cholesterol. As countries like Indonesia prepare to develop national policy guidelines for tobacco harm reduction, the scientific community can help by providing continuous ideas and a forum for sharing and distributing information, drafting guidelines, reviewing best practices, raising funds, and establishing partnerships. We propose several strategies for reducing tobacco consumption, including advertisement interference, cigarette pricing policy, adolescent smoking prevention policy, support for smoking cessation therapy, special informed consent for smokers, smoking prohibition in public spaces, career incentives, economic incentives, and advertisement incentives. We hope that these strategies would assist people to avoid starting smoking or in smoking cessation.

Summary

Citations

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Original Articles

Perspectives of Policies on HIV/AIDS and Tuberculosis Control in Korea.: Bo Youl Choi; Korean J Epidemiol. 2006;28(1):75-84.

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Abstract PDF: Abstract
Since the early 1990s, Korea has made efforts to strengthen its National Communicable Disease Control System. In 2005, the Korea government developed various goals for communicable diseases control as a part of Health Plan 2010. The goals include 40 objectives, for the achievement of which a variety of programs and research subjects have been developed. These efforts will contribute to raising the preparedness for and response to the global threat of emerging and reemerging infectious diseases. The author reviewed the status, management goals and future tasks of HIV/AIDS and tuberculosis in Korea. HIV/AIDS is an emerging infectious disease, and tuberculosis is an endemic disease in Korea. These two diseases are included in the UN Millennium Development Goal 6. The number of HIV/AIDS cases reported in Korea at the end of December 2005 was 3,829, of which 721 have died. The reported HIV prevalence rate among adults aged in 15-49 years is below 0.1%, and the infection level is categorized as "very low". However, the number of newly infected cases has been rising rapidly. The goal of HIV/AIDS control in Health Plan 2010 is to reduce the increasing rate of HIV/AIDS to 35% in 2010. Compared with the global Millennium Development Goal, which is to halt and reverse the spread of HIV/AIDS by 2015, we should set up long-term, high level goals, in addition to a comprehensive national plan for the prevention and control of HIV/AIDS. Korea first implemented a Nationwide Tuberculosis Control Program in the 1960s. By 2005, the prevalence of radiologically active tuberculosis had fallen to 0.35% which is one-fifteenth of the level of 1965. Nevertheless, the current prevalence of and death rate from tuberculosis continue to be much higher than those of advanced nations. Given this such a level of infection, the goals of tuberculosis control need to be specified, and an enhanced tuberculosis control program needs to be implemented to reduce the incidence of tuberculosis and associated death rates.; Summary

Implementation of Effective Policies on Emerging and Reemerging Infectious Diseases.: Duk hyoung Lee; Korean J Epidemiol. 2006;28(1):69-74.

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Abstract PDF: Abstract
The history of emerging infectious diseases was recently reawakened with the SARS outbreak in 2003 that resulted in 8,098 cases and 774 deaths in 26 countries. Korea dealt with 20 suspect or probable cases. From this experience of managing SARS, the public health system has been reinforced and the system's flexibility improved. The Korea Centers for Diseases Control and Prevention (KCDC) was inaugurated in January 2004 as a technically advanced and leading national organization. Thanks to SARS, multiple related Ministries and Agencies realized the need for their involvement in the case of global and national public health threat. The joint WHO/OIE/FAO consultation that was held in May 2004 in Geneva agreed that the next candidateemerging infectious disease that would affect global public health as seriously as SARS would almost certainly originate from animal infection (zoonosis) and that the most probable disease would be avian influenza. Thanks to the pandemic influenza issue, global cooperation and national preparedness for avian and pandemic influenza has been enhanced and this will provide a template for global cooperation to address all types of public health emergencies. The main strategies to develop the preparedness against the public health threat of emerging infectious diseases are firstly maintaining basic public health scheme with capacity building, and secondly establishing disease-specific supplement. As to pandemic influenza, the government is building core capacities in its organizational and functional operation, including stockpiling of antiviral (oseltamivir) and personal protective equipment. In the plan of action on public health emergency, the additional issues to be dealt with include the development of public risk communication scenarios, measures to increase social distance, disinfection measures, especially hand washing, table top exercises, and manpower mobilization. International and regional contribution and collaboration have now become prerequisites for every country. We work to ensure transparency in reporting, immediate sharing of epidemiological data and samples, capacity building and collaboration with in-country and international partners.; Summary

Epidemiologic Transition of Communicable Diseases in Korea: Academia's Contributions to the National Communicable Disease Prevention and Control Programs.: Joung Soon Kim, Hae Kwan Cheong; Korean J Epidemiol. 2006;28(1):4-21.

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Abstract PDF: Abstract
This paper describes the transition of communicable diseases in Korea since 1970s. Some of Korean's general living background and health indicators are introduced, followed by trends in the changes during the last several decades in socioeconomic, demographic, and living environmental status, which are closely associated with the transition of communicable diseases. The current incidence of classified, notifiable disease, the incidence by year, and the transition of communicable diseases are presented. Governmental responses to prevent and control communicable diseases, including both emerging and re-emerging infectious diseases, which have become recognized as having public health importance are described. Finally, the role played by academia during the last several decades in the successful control of communicable diseases is analyzed.; Summary

Review

Development of Policy and Strategy for the Control of Creutzfeldt-Jakob Disease in Korea.: Seung Il Choi, Byung Hoon Jeong, Yong Sun Kim; Korean J Epidemiol. 2005;27(1):81-89.

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Abstract PDF: Abstract
PURPOSE
Through the understanding of the current status of transmissible spongiform encephalopathy(TSE), this study was conducted to contribute to the development of policy and strategy for the control of TSE in Korea in order to keep Korea as a bovine spongiform encephalopathy(BSE)- and variant Creutzfeldt-Jakob disease(vCJD)-free country. BSE and vCJD cases have not been found in Korea. During 2001-2004, the number of patients who have been diagnosed as a definite or probable CJD was 121, which are consisted of 62 male and 59 female(average age: 63 years old). The occurrence of the patients was 5-59 people per year until 2003 and has been gradually increasing due to the recent increase in the diagnostic rate rather than the increase of the incidence. In 2004, the annual occurrence of sporadic CJD(sCJD) in Korea was 1 people per million, which is similar to the average occurrence rate of the world. Two cases of chronic wasting disease(CWD) in deer were found in Chungcheongbuk-do, one in August 2001 and one in October 2001. After that, 4 more CWD-affected deer have been reported in Kyungsangnam-do area in November 2004. We have also examined the possibility that Korean CJD occurred as a result of dietary exposure to BSE. Fortunately, all of Korean CJD patients were not vCJD cases. However, if BSE occurs in Korea, there is a great potential for most of the Korean population to be easily infected with BSE due to their highly susceptible genotype to BSE infection as well as their traditional food habit. In 2003, the total number of people who left Korea was almost identical with the total number of people who entered Korea. However, we could not analyze the number of people who visited or stayed in the UK and Europe during 1980s~1990s, in which BSE was prevalent in Europe, because there was no statistical data available.; Summary

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