For the record

Israel revamps organ donation policies

Israelis who sign an organ donation card will get priority status for transplants if they need them. Those with signed donor cards, their relatives (even if they don’t themselves sign cards) and living donors will be placed higher on the waiting list under new organ donation policies that took effect in January. But Israelis who sign organ donation cards will have to wait three years before getting bumped higher on the priority list.

Dr. Jacob Lavee, director of the Heart Transplantation Unit and the deputy director of the department of cardiac surgery at the Sheba Medical Center in Tel Hashomer, wrote in an email that the aim is to reverse Israel’s low organ donor rates.

Currently, about 10% of Israeli adults have signed organ donation cards, as compared with about 30% in many Western nations. But the rate of organ donation from Israeli patients with brain death is only 45%, as compared with 70%–90% in other Western countries, Lavee says.

“The idea was simply that a higher number of individuals with donor cards would hopefully lead to an increase in actual organ donation and in the meantime will answer the perceived social need to rectify the unfairness of ‘free riders’,” he writes.

The “free-riders” are a small percentage of the Israeli public who oppose the idea of brain death and organ donation, but who have no problem accepting a transplant when the need is their own, according to Lavee.

Patients in urgent need of a heart, liver or lung transplant will continue to top the priority list, but if two patients are on the list and one has signed an organ donation card, he or she will be given preferential status. Children under 18 and those unable to express their wishes because of physical or mental disability will retain their priority status.

The new regime, which was passed into law by the Israeli Knesset, will be evaluated in two years to determine if it is having any effect on organ donation rates. — Sabrina Doyle, Ottawa, Ont.

Dementia strategy urged

A pan-Canadian plan is needed to allay the effects of a forthcoming epidemic that will see the number of Canadians living with Alzheimer disease and other forms of dementia leap to 1.125 million in 2038 from 500 000 in 2008, according to a study commissioned by the Alzheimer Society of Canada. A projected 257 800 new cases will be diagnosed in 2038, as compared with 103 700 in 2008.

The study, commissioned from Toronto, Ontario-based risk management consultants RiskAnalytica, also estimates that the economic burden of dementia will increase to $153 billion in 2038 from $15 billion in 2008. The $153 billion would include $92.8 billion in direct costs of treating dementia (medication, staff and hospital expenses), $55.7 billion in unpaid caregiver opportunity costs (wages that could have been earned by care-givers had they been in the labour force), and roughly $4.1 billion in indirect costs (such as the loss of corporate profits as a result of lower levels of labour productivity).

A national dementia plan would “prepare for and mitigate the burden of dementia on Canadian society and direct health expenditures toward activities that have the greatest potential to maximize quality of life, support individuals and families, make best use of our scarce health human resources, and reduce institutionalization and overall health costs,” says the report, Rising Tide: The Impact of Dementia in Canada (www.alzheimer.ca/docs/RisingTide/Rising%20Tide_Full%20Report_Eng_FINAL_Secured%20version.pdf).

The report sketches four scenarios in which the projected financial burden of dementia might be alleviated, including ones that might delay the onset of dementia through educational programming that promotes physical activity and healthy lifestyles. Another would bolster training and support for family care-givers, while a fourth would assign a “system navigator” to newly diagnosed dementia patients to coordinate care and “reduce caregiving time and delay admission into a long-term care facility.”

The report also argues that a comprehensive national dementia strategy would have five essential components:

• “Accelerated investment in all areas of dementia research, including Biomedical, Clinical, Quality of Life, Health Services and Knowledge Translation;

• Clear recognition of the important role played by informal caregivers by providing information and education, supporting their roles as care partners and providing financial support;

• Increased recognition of the importance of prevention and early intervention for these diseases, for both health care professionals as well as the general public;

• Greater integration and care of increased use of accepted frameworks or ‘best practices’ in chronic disease prevention and management, community support and community care coordination;

• Strengthening Canada’s dementia workforce by: increasing the availability of specialists including geriatricians, neurologists, psychiatrists and advanced practice nurses with specialized knowledge of dementia; improving the diagnostic and treatment capabilities of all frontline professionals; making the best use of general and specialized resources through inter-professional collaboration; [and] leveraging the capabilities of the voluntary sector through investment and training.” — Wayne Kondro, CMAJ

New mumps guidelines

Health care facilities should provide the measles-mumps-rubella vaccine to all health care workers who haven’t received two doses of mumps-containing vaccine, have a laboratory-confirmed case of mumps, have a “positive measles, mumps, and rubella IgG; or have a valid contraindication” to the vaccine, according to new Public Health Agency of Canada (PHAC) guidelines.

“A community mumps outbreak can have considerable impact on health care settings and health care capacity,” states the Guidelines for the Prevention and Control of Mumps Outbreaks in Canada, which were released by PHAC on Jan. 7 (www.phac-aspc.gc.ca/publicat/ccdr-rmtc/10pdf/36s1-eng.pdf). “Factors contributing to the potential for mumps transmission in health care settings are as follows: the long infectious and incubation periods; a high proportion of sub-clinical and misdiagnosed cases; and a sizable population of susceptible health care workers.” Testing during the 2007 mumps outbreak in Nova Scotia indicated that people born after 1970 had lower levels of immunity because they were typically offered only one dose of mumps-containing vaccine and were not exposed to a wild mumps virus that circulated in Canada during earlier decades.

The guidelines add that all patients, including health care workers, who contract mumps should be advised to “stay home (self-isolate) for 5 days from symptom onset; perform hand hygiene (wash with soap and water or use an alcohol-based hand rub) frequently; avoid sharing drinking glasses, eating utensils or any object used on the nose or mouth; and cover coughs and sneezes with a tissue or forearm.”

The guidelines, which were prepared by a federal, provincial and territorial task force in response to a request from the Council of Chief Medical Officers of Health and the Canadian Immunization Committee, also recommend several improved reporting and surveillance measures. — Wayne Kondro, CMAJ

Hold the salt — please

Voluntary salt reductions in the production of prepared foods and restaurant meals were again the preferred option over regulation as the National Salt Reduction Initiative, a United States coalition of 26 city and state agencies and 17 national health organizations spearheaded by the New York City Department of Health, unveiled guidelines aimed at curbing the average American’s salt intake by 20% within five years.

The guidelines propose specific targets to reduce salt levels in 61 categories of packaged food and 25 classes of restaurant food, including two- and four-year targets for each category of food (www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml). For example, producers of grated cheeses, who now typically add 1530mg of salt to each 100g of their product would be asked to trim that to 1450 mg by 2012 and 1300 mg by 2014.

Targets, though, could be applied variably by a manufacturer. A company that sells several lines of crackers could, for example, lower the salt levels in some of its lines of crackers, while making another line “extra salty,” and still meet the sodium reduction target within its “overall cracker portfolio.”

They could also simply ignore the guidelines, as they are entirely voluntary, an identical approach to that recently recommended by Health Canada’s Sodium Working Group to trim Canadian salt consumption, which Blood Pressure Canada projects is a staggering 3500 mg of sodium per person per day, considerably higher than the recommended 1200 mg (CMAJ 2009. DOI:10.1503/cmaj.109-3100).

Still, the Washington, DC-based Salt Institute, the industry-funded trade association, balked at the proposed voluntary guidelines, arguing in a press release that “shaky science” underlies the proposition that a reduction in salt intake results in lower blood pressure and thereby, reduces the chances of heart attack and stroke (www.saltinstitute.org/content/download/11168/70799).

Food manufacturers have long contended that requiring salt reductions for processed foods is problematic because of the impact it would have on preservation and taste of foods. But advocates argue that the proposed sodium reduction levels would not have a noticeable impact on the taste or preservability of most foods. “Consumers can always add salt to food, but they can’t take it out,” stated New York City Health Commissioner Dr. Thomas Farley in a press release.

Consultations on the proposed targets will be conducted this month and final targets adopted in the spring. —Wayne Kondro, CMAJ

Flu toll on the economy

Pandemic (H1N1) 2009 and seasonal influenza exacted a toll on the Canadian economy as 9% of Canadians took off an average 19.6 hours of work as a result of the bug in November 2009, Statistics Canada says.

But 600 000 Canadians put in extra hours — including 10.5% of health workers, who put in a combined two million extra hours — so the net loss to the economy was 20.9 million hours, rather than 29.5 million hours (http://www.statcan.gc.ca/daily-quotidien/100115/dq100115c-eng.htm).

Statistics Canada, which is tracking the economic impact of influenza for a three-month period on behalf of the Public Health Agency of Canada, said the blow to the economy was comparable to the 2003 power outage that hit Ontario and part of Quebec. During the blackouts, more than 26.4 million hours of work time were lost but, when offset by 7.5 million overtime hours, the net economic effect was a loss of 18.9 million hours.

The report says that flu-related absenteeism was highest in Newfoundland and Labrador (14.2% of workers aged 15 to 69), while the lowest was in Quebec (7.6%). Some 12.4% of employees with children lost work hours, as compared with 6.9% for employees without children. — Wayne Kondro, CMAJ