57 Dec 2012

Public Health &EpidemiologyBulletin

Volume 21 Number 3 Dec 2012Homepage : http://www.dh.gov.hk/

Department of HealthHong Kong, China

A SURVEY OF INFANT AND YOUNGCHILD FEEDING IN HONG KONG

Dr W Y LUK 1 Dr Shirley LEUNG 2

1 Senior Medical & Health Officer 2 Assistant Director of Health

Contents

A Survey of Infant and Young ChildFeeding in Hong Kong .................

An Overview of Injury in Hong KongBreast Ca ncer Prevent ion and

Screening in Hong Kong .................News in Brief .................................Announcement ................................HIV/AIDS Surveillance................Conta ct N u mbe r s for Prompt

Notification ..................................N u mb e r of N o t i f i c a t i o n s o f

Infectious Diseases .........................

8 67 6

5 76 8

87

Page

8 7

8 8

8 7

Advisory Board

Dr Joseph ChanMr K M ChengDr K L HauDr Catherine LamDr T S LamDr Raymond LeungDr W L LimDr K K LoDr C M TamDr Luke TsangDr K H Wong

Editorial Board

Editor-in-ChiefDr T H Leung

MembersDr Winnie AuDr Jacqueline ChoiDr S K ChuangDr Ronald Lam

Mr Y H LeeDr Y C Lo

Dr Tina MokDr Monica Wong

Ms Keziah Yip

The publication is produced bythe Department of Health,

21/F, Wu Chung House,213 Queen’s Road East,

Hong Kong, China.All rights reserved

Background

A healthy diet with an optimal nutrient intake in earlychildhood lays the foundation for future eating habitsand is of great importance to long-term health.Evidences showed that infants and children have theability to se lf-regula te food intake.1-3 Foodpreferences have been shown to take shape early inlife and track through adulthood.4-6 Through makingavailable a variety of nutritious foods, providing asuitable context within which feeding occurs andappropriate feeding interactions, parents andcaregivers can exert a strong influence on the foodacceptance and eating habits of young children.

To examine the perceptions and feeding practices ofparents with young children as well as their children’sfood consumption and nutrient intake, the FamilyHealth Service of the Department of Health (DH)collaborated with the Department of Applied SocialSciences, Hong Kong Polytechnic University and theDepartment of Medicine & Therapeutics, Centre forNutritional Studies, the Chinese University of HongKong to conduct a survey between January andSeptember 2010.

58Dec 2012

The Survey

A total of 2 849 children of six age groupsranged from 6 to 48-month-old wererandomly selected from the child healthregistry of 29 Maternal and Child HealthCentres (MCHCs). The sample includedthose who were born at a gestational ageof 37 weeks or more, and whose bothparents were Hong Kong residents andChinese. Children born with congenitala b n o r m a l i t i e s , d e v e l o p m e n t a labnormalities or those suffering fromchronic illnesses were excluded.

Of these, 1 588 children and their parentswere successfully contacted by phoneinterview. Weight and height of thechildren were measured by nurses at

MCHCs. Among the participants, 1 474parents completed a quest ionnaireconcerning their perception and practiceof child feeding and a questionnaire onthe child’s milk consumption for thosewith children 12 months or older; while1 272 parents completed a 3-day dietaryrecord for their children. A total of 1 158parents participated in both parts of thesurvey. Table 1 showed the distribution ofparticipants of the six age groups.

Results

Detailed results are shown in the fullreports which can be accessed at thewebsite of the Family Health Service[http://www.fhs.gov.hk].7-9 Importantfindings are highlighted below.

Table 1 Age and Sex Distribution of Participants in the Survey

Number ofparticipants

Boys(%)

Girls(%)

Number ofparticipants

Boys(%)

Girls(%)

194 50.5 49.5 177 52.0 48.0

213 50.2 49.8 164 53.7 46.3

194 51.0 49.0 171 50.9 49.1

277 40.4 59.6 233 38.2 61.8

378 59.0 41.0 314 56.7 43.3

218 51.8 48.2 213 52.6 47.4

1 474 51.0 49.0 1 272 50.8 49.2

Number of participants who completed

Questionnaire onparental perceptions and practices 3-day dietary recordAge

24-month

48-month

Total

6-month

9-month

12-month

18-month

Source : Survey of Infant and Young Child Feeding in Hong Kong.

59 Dec 2012

Nutritional Status of Children

Among the 1 272 participants of the dietand nutrient intake survey, 17 (1.3%) wereunderweight and 20 (1.6%) were wasted.Thirty-four (2.7%) were overweight orobese with respect to the WHO ChildGrowth Standard. One hundred and sixty-two (12.7%) were at possible risk ofoverweight. The prevalence of overweightor obesity was higher in the 24- and 48-month-old groups, with 3.8% (20/527)compared to 1.9% (14/745) in children ofthe other age groups.

Energy and Protein Intake

As far as energy is concerned, 56.1% (713/1 272) had intake per kilogramme bodyweight above the estimated averager e q u i r e m e n t f o r e n e r g y i n t a k erecommended by the WHO10, which is thelevel of energy intake meet ing therequirement of 50% of a particular age-sex population.

Regarding protein intake, 99.0% (1 258/1 272) had intake above the safe individualintake level recommended by the WHO.11

Protein accounted for 9.8%, 13.0%,14.5%, 15.2%, 15.3% and 16.2% of thetotal energy intake in the 6-, 9-, 12-, 18-,24- and 48-month-old groups respectively.

Food Consumption Pattern of Children12 Months and Older

The food consumption pattern of childrenaged 12 months or above is compared withthe food serving size specified in thehealthy eating food pyramid for 1 to 3-year-old and 3 to 6-year-old children.12

Vegetables Intake

The mean intake of vegetables of childrenin the 12-, 18-, 24- and 48-month-oldgroups were 63.6g, 69.4g, 68.9g and86.0g respectively. These were lowerthan the daily recommended intake for theage. Compared to the recommended intakeof at least 80g (or two taels) per day forone to three years and at least 160g (orfour taels) per day for three to six years,70.8% (112/171), 63.9% (149/233),65.0% (204/314) and 91.1% (194/213)in the 12-, 18-, 24- and 48-month-oldgroups respectively had inadequatevegetable intake.

Consumption of Fruits

The mean intake of fruits of children inthe 12-, 18-, 24- and 48-month-old groupswere 48.6g, 60.1g, 66.3g and 88.4grespectively. Of the children in the 12-,18-, 24-month-old groups, 45.6% (78/171), 38.2% (89/233) and 32.5% (102/314) respectively had intake of less than40g of fruit a day. There was 50.2% (107/213) of the children in the 48-month-oldgroup consumed less than 80g of fruit a day.

Consumption of Meat, Poultry, Fish, Eggsand Legumes

The mean daily consumption of this foodgroup was 44.4g, 57.6g, 65.1g and 99.0grespectively in the 12-, 18-, 24- and 48-month-old groups.

It was more common for older children tohave a high intake of this food group.Compared to the recommended intakerange of this food group, namely 40 to

60Dec 2012

80g for 1 to 3-year-old and 80 to 120g for3 to 6-year-old, 12.9% (22/171), 24.0%(56/233), 34.7% (109/314) and 34.3%(73/213) children in the 12-, 18-, 24- and48-month-old groups respectively wereconsidered having a high intake.

Consumption of Milk

Of the children in 12- to 24-month-oldgroups , 3 .8% (27 /718) were s t i l lbreastfed. Consumption of formula milkwas reported in 94.2% (161/171), 98.3%(229/233), 98.7% (310/314) and 77.0%(164/213) in children of the 12-, 18-, 24-and 48-month-old groups. The mean dailyconsumption was 563ml, 483ml, 434mland 247ml respectively in the 12-, 18-,24- and 48-month-old groups. Seventeenchildren (8.0%) in the 48-month-old groupdid not consume milk in the three recordeddays. High milk consumption was verycommon in the toddler group, and 69.9%(119/171) in the 12-month-old group,47.6% (111/233) in the 18-month-oldgroup, 35.7% (112/314) in the 24-month-old group and 9.9% (21/213) in the 48-month-old group drank more than 480ml aday.

Food Consumption Pattern and Milk Intake

Analysis of covariance was carried out toexamine the effect of higher intake of milkon intake of other foods in the diet withthe adjustment of daily total energy intake.There was a general trend of lowerconsumption of the other food groups withincrease in milk consumption. Childrenwho drank more milk than 480ml a dayconsumed significantly less grain andcereals, and fruit in the 12-, 18-, 24-month-old groups, and less from the food groupsof meats and fish in the 24- and 48-month-old groups.

Parent’s Beliefs about Milk

Parental perception of the nutritional valueof milk, formula milk in particular, mighthave influence on their food choices andfeeding practices. Overall, 84.6% ofparents with children 12 months or olderwere of opinion that “Milk is indispensablefor growth and development of children”.Concerning the relat ive benefits offormula and cow milk, 78.5% were of theopinion that “Follow-up Formulae aremore suitable for 1- to 4-year-old childrenthan cow milk” . Moreover, 53.4%believed that “Follow-up Formula is addedwith nutrients that promote children’s braindevelopment, which cannot be found inother foods” and 25.4% believed that it“can replace other food to providenutrients”.

Mi lk Dr in k in g U ten s i l and Mi lkConsumption

Use of feeding bottle for milk drinkingwas prevalent among children aged 12months or older. Figure 1 showed theutensils that the children drank milk from.Although the recommended age ofstopping milk bottle use was 14 months13,95.2% (258/271) and 89.4% (329/368)of children in the 18- and 24-month groupswere st ill using the bott le for milkdrinking. Even in the 48-month group,55.2% (106/192) still drank from bottle.

Per s i s t en t bo t t le u se rs consumedsignificantly more milk than those drinkingfrom cups. The median milk intake perday of bottle users and non-bottle users inthe 24-month-old group was 480mlcompared to 360ml respectively (Mann-Whitney U test, p<0.001). Bottle users inthe 48-month-old group had a medianintake of 360ml/day compared to 240ml/

61 Dec 2012

day among the non-bottle users (Mann-Whitney U test, p<0.001).

The persistent bottle users also had ahigher BMI-z-score than the non-bottleusers. Among the persistent bottle usersin the 24- and 48-month old groups, 5.6%(22/394) were overweight or obesecompared to 1.7% (2/117) in the childrenwho used cups for milk drinking (P=0.08).Besides, drinking milk while falling asleepwas more commonly reported amongbottle users. (Table 2)

Paren ta l Fe ed in g Pr ac t i ce s an dPerceptions

Meal Time Environment

Table 3 showed the meal time environmentreported by the parents. A significantproportion of children never ate withfamily members during dinner. It was alsocommon for children to eat their mealswhile watching television or playingtoys.

Figure 1 Utensils for Milk Drinking Used by the Child in the Past Seven days

12-month18-month

24-month48-month

Regular cup

Training cup

Cup with a strawMilk bottle

95.2%89.4%

55.2%

3.8% 9.2% 16.3%14.6%0.5% 4.1% 6.3%

3.6%0.5%3.0% 12.0% 53.1%

0%

20%

40%

60%

80%

100%

99.5%

Age group

Prop

ortio

n of

chi

ldre

n (%

)

Source : Survey of Infant and Young Child Feeding in Hong Kong.

62Dec 2012

Table 2 BMI-z-scores and the Prevalence of Falling Asleep while Drinking Milk among Bottle Users and Non-bottle Users

in the 24- and 48-month-old Groups

Fell asleep while drinking milk n (%)24-month 329 75 (22.8%) 39 3 (7.7%)48-month 106 20 (18.9%) 86 1 (1.1%)

Total 435 95 (21.8%) 125 4 (3.2%) p < 0.001

BMI-z-score Mean (s.d.) Mean (s.d.)24-month 297 0.23 (0.97) 36 -0.07 (0.92)48-month 97 0.26 (1.00) 81 0.02 (0.87)

Total 394 0.24 (0.96) 117 -0.01 (0.88) p = 0.02

Bottle users Non-bottle users

N n (%)

N

N

N

Source : Survey of Infant and Young Child Feeding in Hong Kong.

Note : “N” refers to the total number of bottle/non-bottle users. “n” refers to the number of children fell asleepwhile drinking milk.

Table 3 Meal Time Environment of the Children

9-month(n=213)n (%)

12-month(n=194)

n (%)

18-month(n=277)

n (%)

24-month(n=378)n (%)

48-month(n=218)n (%)

144(67.6%)

95(49.2%)

65(23.5%)

104(27.5%)

25(11.5%)

51(23.9%)

66(34.2%)

106(38.3%)

180(47.6%)

80(36.7%)

43(20.2%)

75(38.7%)

71(25.6%)

100(26.5%)

34(15.6%)

I always let my child play toyswhile having meals

I always let my child watchtelevision while having meals

My child almost never eats dinnerwith most of the family members

Source : Survey of Infant and Young Child Feeding in Hong Kong.

Parents Did Not Trust Children’s Self-regulation in Food Intake

Among the 6 to 18-month-old groups,38.1% (333/874) of the parents wereconcerned that their children might not

eat enough if they were allowed to decidehow much to eat. About half (54.9%, 480/874) were of the opinion that parentsshould decide how much a child shouldeat.

63 Dec 2012

During meal time or feeding, 27.2% (396/1 454) of parents reported that they almostnever let their children decide how muchto eat, and 39.7% (577/1 454) reportedthat they always demanded their childrento finish their meals. It was also observedthat parents were less likely to grantchildren autonomy in deciding the amountof food to eat as they grew older.

Instrumental Feeding Practices

Using food as a means to manage children’sbehaviour was common among the 24- and48-month old groups (Table 4) and 9.4%(56/596) of the parents reported theyalways offered junk food to encouragetheir children to eat healthy food. Thesepractices might reinforce the desire for

junk food and make the healthy food moreundesirable to the child.

Table 4 Using Child’s Favourite Food to Manage Child Behaviour

24-month(n = 378)

n (%)

48-month(n = 218)

n (%)

Always 66 (17.5%) 35 (16.1%)

Sometimes 139 (36.8%) 102 (46.8%)

Always 81 (21.4%) 53 (24.3%)

Sometimes 147 (38.9%) 117 (53.7%)

Always 73 (19.3%) 28 (12.8%)

Sometimes 182 (48.1%) 105 (48.2%)

Managing child emotion orbehaviour problem

Making child behave

Rewarding good behaviour

Source : Survey of Infant and Young Child Feeding in Hong Kong.

Parental Perception on Children’s WeightStatus

There was a tendency for parents to under-estimate their children’s weight status(Figure 2). They also tended to worrya b o u t t h e i r c h i ld r e n b e c o m i n gunderweight. Overall, 34.6% (463/1 340)were worr ied about their chi ldrenbecoming underweight whereas 18.5%(248/1 340) were worried about their

children becoming overweight. There were30.7% (412/1 340) parents who wereworried about under-eating, while only9.7% (130/1 340) parents were worriedabout over-eating.

Parental perception of the child beingunderweight was significantly associatedwith both the worry about childrenbecoming underweight and about children’sunder-eating when examined by logisticregression. Child’s actual weight statuswas only associated with parental concernof over-eating.

64Dec 2012

Figure 2 Parent’s Perceived Weight Status of the Child in Relation to the Child’s Actual Weight Status

Child’s actual weight status with respect to WHO child growth standard

Prop

ortio

n of

par

ents

(%)

2.5%

67.7%

0.0%

8.9%

47.5%

23.4%

75.0%

50.0%

25.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Underweight Normal Overweight

Underweight Normal Overweight / obese

Source : Survey of Infant and Young Child Feeding in Hong Kong.

Coe r c ive f eed ing p rac t i ce s w ereassociated with parental worry aboutunder-eating by multiple regression.These included pushing food into thechild’s mouth or urging the child to eatwhen he slows down, repeatedly urgingthe child to eat more, letting the child playwith toys while eating, supplementing withfood if the child does not eat enough atmain meals, and chasing after the child tofeed to finish meals.

Discussion

The survey showed that the energy andprotein intake of the participating children

was adequate. The food consumptionp a t t e r n o f yo u n g c h i ld r e n w a scharacterised by inadequate intake ofvegetables and fruits, over-dependence onformula milk among children between oneand two years of age for nutrients and highintake of prote in-r ich foods. Theanthropometric data indicated that theoverweight and obesity prevalence wasincreased in children of the 24- and 48-month-old groups.

High milk intake was related to continualuse o f feeding bo t t le beyond therecommended age for weaning off the milkbottle. The findings of a higher milk intake

65 Dec 2012

and higher BMI in persistent bottle userswere consistent with the observation inother countries.14,15

On the other hand, parent’s beliefs aboutthe nutritional benefits of formula milkover natural foods may have contributedto the high milk intake, through influencingtheir food choices and feeding practices.The findings probably re flect t hepermeation of aggressive marketing offormula milk for infant and young childrenand the lack of knowledge of the nutritivevalue of family meals prepared fromnatural ingredients.

Although formula milk provides adequatemacro and micronutrients for children,high intake of milk displaces appetite andinterest from eating other foods. Fortoddlers and preschool children to acceptvegetables and fruits, repeated exposureto the taste of a variety of vegetables andfruits is essential.16,17 The predominanceof formula milk in the diet becomes abarrier for the development of a diet ofvariety.

The survey revealed that the feedingpractices of parents tended to be non-responsive. Coercive feeding practice wasa s s o c i a t e d w i t h t h e p a r e n t s ’underestimating children’s weight andworry about children not eating enough orbecoming underweight. A systematicreview indicated that non-responsivefeeding pract ices (e.g. controlling,restrictive, indulgent, uninvolved) wereassociated with children’s under- or over-weight.18 The demand for children to finishup meals may prompt them to eataccording to external cues rather than theirself-regulation.19 Moreover, it may leadto more avoidant eating behaviours or mealtime problems.20

It was also common for parents to offerchildren their favourite foods, which areusually snacks high in fat and sugar, asrewards or as a means to manage children’sbehaviour. This not only promotes theconsumption of these foods but alsoinfluences food habits by promoting itsdesirability in children.21,22

Provision of a family meal and eating withthe family is an important strategy inpromoting healthy eating habits inchildren.23 However , a significantproportion of children did not dine withparents or family. The practice of eatingwhile playing or watching television wascommon. This disrupts communicationsduring meal time. Moreover, in olderchildren eating while watching televisionwas found to be associated with a lowerintake of vegetables and fruits.24

Limitations of the survey

This is a cross-sectional survey. Thedirection of causation between foodconsumptions, feeding practices andperception cannot be established. Thefinding may not be representative of non-participants and non-users of the MCHCs.

Conclusion

The present survey indicated that the dietaryp a t t e r n i n yo u n g c h i l d r e n w a spredominated by formula milk, which maybe related to the persistent use of thefeeding bottle and parent’s misconceptionsabout the benefits of formula milk.Parents’ over-concern about their childrenbeing under-weight and not eating enoughwas associated with various controllingfeeding practices which might result in anegative eating atmosphere and avoidanteating behaviours. In turn, these behaviours

66Dec 2012

migh t d r ive pa ren t s to u se morecontrolling strategies, thus creating avicious spiral. On the other hand, thesefeeding pract ices may cause somechildren to overeat and become obese.

Recommendations

A posit ive and responsive feedingenvironment facilitates food acceptance.Parents are primarily responsible forproviding scheduled meals, a distraction-free and comfortable environment foreating, a variety of nutritious foods inappropriate textures, and being sensitiveto children’s hunger and fullness cue whilechildren desire how much to eat a particularfood. Parents should facilitate children

to acquire age-appropriate feeding skillsand achieve the developmental milestoneof weaning from the feeding bottle before18 months.

A series of parent education resources onfeeding children during the transitionalfeeding period from 6 to 24 month of agehave been produced to empower parentsto adopt a responsive feeding practice andto provide information about food choicesand preparation. These are distributed toparents through the MCHCs when childrenare between 4 and 12 months. They arealso accessible through the website of theFamily Health Service [http://www.fhs.gov.hk].

67 Dec 2012

References

1. Davis. Results of the self-selection of diets by youngchildren. The Canadian Medical Association Journal. 1939Sep; 41(3): 257-61.

2. Fomon SJ, Filer LJ Jr, Thomas LN, Rogers RR, ProkschAM. Relationship between formula concentration and rateof growth of normal infants. Journal of Nutrition. 1969Jun; 98(2): 241-54.

3. Fox MK, Devaney B, Reidy K, Razafindrakoto C, ZieglerP. Relationship between portion size and energy intakeamong infants and toddlers: evidence of self-regulation.Journal of the American Dietetic Association. 2006 Jan;106(1 Suppl 1): S77-83.

4. Skinner JD, Carruth BR, Bnounds W, Ziegleer P, ReidyK. Do food related experiences in the first 2 year of lifepredict dietary variety in school age children. Journal ofNutrition Education and behaviour 2002, 34: 310-15.

5. Skinner JD, Carruth BR, Wendy B, Ziegler PJ. Children'sfood preferences: a longitudinal analysis. J Am Diet Assoc.2002 Nov; 102(11): 1638-47.

6. Nicklaus S, Boggio V, Chabanet C, Issanchou S. Aprospective study of food variety seeking in childhood,adolescence and early adult life. Appetite. 2005 Jun; 44(3): 289-97.

7. Leung S, Leung C, Luk WY. A Survey of Infant and YoungChild Feeding in Hong Kong: Parental Perceptions andPractices. http://www.fhs.gov.hk/english/reports/files/Survey_IYCF_parents%20perception.pdf .

8. Chan R, Woo J, Li L, Luk WY. A Survey of Infant andYoung Child Feeding in Hong Kong: Diet and NutrientIntake. http://www.fhs.gov.hk/english/reports/files/Survey_IYCF_Dietnutrient%20intake.pdf .

9. Luk WY, Leung S, Leung C. A Survey of Infant and YoungChild Feeding in Hong Kong: Milk Consumption. http:// w w w . f h s . g o v . h k / e n g l i s h / r e p o r t s / f i l e s /Survey_IYCF_milkconsumption_1904.pdf.

10. World Health Organization, Food and AgriculturalOrganization of the United Nations (2004). Human energyrequirements. Report of a Joint FAO/WHO/UNU ExpertConsultation, Rome, Italy, 17-24 October 2011. Geneva:World Health Organization, Food and AgriculturalOrganization of the United Nations, and United NationsUniversity.

11. World Health Organization, Food and AgriculturalOrganization of the United Nations, United NationsUniversity (2007). Protein and amino acid requirementsin human nutrition. Report of a joint FAO/WHO/UNUexpert consultation (WHO Technical Report Series 935).Geneva: World Health Organization.

12. http://2plus3.cheu.gov.hk/html/b5/sec1_content.asp?fname=sec1_q6.aspx#2.

13. Oral Health Education Unit, Department of Health,HKSARG. Oral Health Care for Your Children.

14. Gooze RA, Anderson SE, Whitaker RC. Prolonged bottleuse and obesity at 5.5y of age in US children. J Pediatr.2011 Sep; 159(3): 431-6.

15. Bonuck KA, Huang V, Fletcher J. Inappropriate bottleuse: an early risk for overweight? Literature review andpilot data for a bottle weaning trial. Maternal and ChildNutrition 2010. 6; 38-52.

16. Cooke L. The importance of exposure for healthy eatingin childhood: a review. J Hum Nutr Diet. 2007 Aug; 20(4):294-301.

17. Benton D. Role of parents in the determination of thefood preferences of children and the development ofobesity. Int J Obes Relat Metab Disord. 2004 Jul; 28(7):858-69.

18. Hurley KM, Cross MB, Hughes SO. A systematic reviewof responsive feeding and child obesity in high-incomecountries. The Journal of Nutrition. 2011; 141: 495-501.

19. Johnson SL. Improving Preschoolers' self-regulation ofenergy intake. Pediatrics. 2000 Dec; 106(6): 1429-35.

20. Wright C, Parkinson KN, Drewett RF. How doesmaternal and child feeding behavior relate to weight gainand failure to thrive? Data from a prospective birth cohort.Pediatrics 2006; 117(4): 1262-9.

21. Birch LL, Zimmerman SI, Hing H. The influence of Social- affective context on the formation of Children’s foodpreference. Child Development. 1980; 51: 856-61.

22. Newman J, Taylor A. Effect of a Means-End Contingencyon Young Children’s Food Preference. Journal ofExperimental Child Psychology 1992; 64: 200-16.

23. Gidding SS, Lichtenstein AH, Faith MS, Karpyn A,Mennella JA, Popkin B, Rowe J, Van Horn L, Whitsel L.Implementing American Heart Association pediatric andadult nutrition guidelines: a scientific statement from theAmerican Heart Association Nutrition Committee of theCouncil on Nutrition, Physical Activity and Metabolism,Council on Cardiovascular Disease in the Young, Councilon Arteriosclerosis, Thrombosis and Vascular Biology,Council on Cardiovascular Nursing, Council onEpidemiology and Prevention, and Council for High BloodPressure Research. Circulation. 2009 Mar 3; 119(8): 1161-75.

24. Fitzpatrick E, Edmkunds LS, Dennison BA. Positiveeffects of family dinner are undone by television viewing.J Am Diet Assoc. 2007; 107: 666-71.

68Dec 2012

AN OVERVIEW OF INJURY IN HONG KONGDr Albert YUNG 1 Dr Gladys YEUNG 2 Dr P H CHUNG 3

1 Scientific Officer 2 Medical & Health Officer 3 Senior Medical & Health Officer

Introduction

Injury is an important public health issuein Hong Kong. Since the 1960s, injurieshave remained as one of the ten leadingcauses of death in Hong Kong. Injuriesaccounted for 1 500 to 2 200 registereddeaths annually between 1981 and 2011.In terms of potential years of life lost atthe age of 75, injuries ranked the secondamong the ten leading causes of death inHong Kong from 2001 to 2011.

Epidemiology

Between 1981 and 2011, the number ofregistered deaths due to injuries rangedfrom 1 500 to 2 200 per year (Figure 1).The average injury-related death rate inHong Kong from 2007 to 2011 was 25.7per 100 000 population. This accountedfor 4.3% of total deaths.

Figure 1 Number of Registered Deaths Due to Injuries#, 1981-2011

0

500

1 000

1 500

2 000

2 500

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011Year

Num

ber o

f reg

iste

red

deat

hs

Sources : Census and Statistics Department, Department of Health.

Note : # Injuries correspond to codes E800-E999 in International Statistical Classification of Diseases andRelated Health Problems (ICD) 9th Revision (before 2001) and codes V01-Y98 in ICD 10th Revision(from 2001 onwards).

In 2011, 1 567 registered deaths wererelated to injuries. This accounted for

69 Dec 2012

3.7% of total deaths. Injuries were thesixth leading cause of death in 2011. Thedeath rates for males and females were30.0 and 15.3 per 100 000 populationre spect ive ly. Among these 1  567registered deaths related to injuries in2011, the main causes of death indescending order were intentional self-harm (821 or 52.4%), falls (183 or 11.7%),accidental poisoning by and exposure tonoxious substances (149 or 9.5%),t ransport accidents (102 or 6 .5%),accidental drowning and submersion (30or 1.9%), assault (23 or 1.5%), exposure

to smoke, fire and flames (5 or 0.3%) andother external causes (254 or 16.2%).

In general, among all deaths due to injuries,the proportion caused by intentionalinjuries (i.e. injuries that are purposelyinflic ted ei ther by in jured personsthemselves or other persons) remainedrelatively stable during the past decade. In2011, 53.9% of the total number ofregistered deaths caused by injuries wasintentional in nature, compared with46.1% which was unintentional^ in nature.(Figure 2)

Figure 2 Number and Proportion of Intentional and Unintentional Injury Deaths, 2002 to 2011

53.4% 56.9%58.9%

55.1% 54.9%51.0% 51.0%

54.9% 56.1%53.9%

46.6% 43.1%

41.1%44.9%

45.1%49.0%

49.0%

45.1% 43.9%

46.1%

0

500

1 000

1 500

2 000

2 500

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Intentional Unintentional

Num

ber o

f reg

iste

red

deat

hs

YearSources : Census and Statistics Department, Department of Health.

^ Unintentional injuries include injuries of undetermined intent.

70Dec 2012

Apart from collecting mortality andhospitalisation statistics, the Departmentof Health had also conducted a territory-wide household survey, the Injury Survey,in 2008 to collect pertinent informationon the characteristics and burden ofunintentional injuries in Hong Kong. Atota l of 9  022 persons, from 3 025households, were interviewed in theSurvey. The response rate was 74.1%. Inthis survey, an injury episode was definedas an unintentional injury that was seriousenough to limit the normal activities of aperson. It was estimated that at least460 000 injury episodes were recordedduring the 12 months before enumerationby the Survey. Based on the results of theSurvey, it was estimated that 415 200persons (or 6.2% (95% CI: 5.6%-6.7%)of the Hong Kong land-based non-institutional population of 6.74 million)had sustained at least one injury episode

in the 12 months before enumeration bythe Survey. The rate was similar in bothgender groups and was found to be highestfor elders aged 75 and above (8.9%). Thethree commonest main causes of injuryepisodes were falls (32.2%), sprain(25.8%) and sports (14.1%). Falls werefound to occur more commonly in femalesand at the extremes of age (aged 0-14 and55 and above). Over 80% of the injuryepisodes affected the extremities.

Age and Gender

The rate of injury episodes was similar inmales (6.1%, 95% CI: 5.4%-6.9%) andfemales (6.2%, 95% CI: 5.4%-6.9%).Analysed by age group, the rate was thelowest for children aged 0 to 4 years(2.6%) and the highest for older personsaged 65 and above (7.0%). (Table 1)

Table 1 Estimated Number and Rate* of the Population Sustaining Injury Episode(s) in the 12 Months before Enumeration

by Age Group and Gender

Rate(%)

Rate(%)

Rate(%)

0-4 2.3 2.0 3.4 3.2 5.7 2.6

5-14 18.0 5.2 20.4 6.3 38.3 5.7

15-24 31.2 7.4 22.0 5.0 53.2 6.2

25-64 126.9 6.6 134.7 5.9 261.5 6.2

65+ 16.2 4.3 40.2 9.4 56.4 7.0

Total 194.6 6.1 220.6 6.2 415.2 6.2

TotalMale FemaleAge group(years) No. of persons

(’000)No. of persons

(’000)No. of persons

(’000)

Note : * As a percentage of all persons in the respective age groups.Base : Respondents who sustained injury episode(s) in the 12 months before enumeration.Source : Injury survey 2008.

71 Dec 2012

Recurrent Episodes of Injury

Among those who had sustained injuryepisode(s) in the 12 months beforeenumeration, a higher proportion of

children aged 0 to 4 years had three ormore injury episodes (12.4%) during thestudy period as compared to the other agegroups (0.8% - 6.1%). (Table 2)

Table 2 Number of Times Injured in the 12 Months before Enumeration in Injured Persons by Age Group

Once 3.3 58.3 35.2 91.8 46.6 87.7 242.5 92.7 52.3 92.8 380.0 91.5

Twice 1.7 29.4 2.4 6.2 3.3 6.2 14.6 5.6 3.6 6.4 25.6 6.2

Three times or more

0.7 12.4 0.8 2.0 3.2 6.1 4.4 1.7 0.5 0.8 9.6 2.3

Total 5.7 100.0 38.3 100.0 53.2 100.0 261.5 100.0 56.4 100.0 415.2 100.0

No. ofpersons(’000)

No. ofpersons(’000)

No. ofpersons(’000)

No. ofpersons(’000)% % %

0 - 4 5 - 14 15 - 24 25 - 64

No. ofpersons(’000)

No. ofpersons(’000)% %

Number oftimes injuredin the 12months beforeenumeration %

65 and above Total

Base : Respondents who sustained injury episode(s) in the 12 months before enumeration.Source : Injury survey 2008.

Nature of Injury

The proportion of injury episodes mainlydue to falls in females was higher than thatin males (40.8% vs 23.0%), whereas maleinjury episodes were more likely due tosports (19.5% vs 9.3%) and hit / struck(11.5% vs 6.0%). The proportions of otherinjury causes were similar across gender

except that of traffic (4.7% vs 2.6%).

In terms of age, falls were the commonestcause of injuries sustained by childrenaged 0 to 4, 5 to 14, as well as personsaged 65 and above. Sports and spraininjuries were the commonest in personsaged 15 to 24 and 25 to 64, respectively.(Table 3)

72Dec 2012

Table 3 Main Cause of Injury Episodes Sustained in the 12 Monthsbefore Enumeration by Age Group

Notes : † ‘Others’ did not include drowning/near-drowning, poisoning and electric shock.* denotes magnitude less than 0.05.

Base : Injury episodes (up to three most serious ones) sustained by the respondents in the 12 months beforeenumeration.

Source : Injury survey 2008.

Socio-demographic Factors

Among those aged 15 and above (Table 4),the injury rate was higher in people withlower educational attainment (6.5% insecondary or lower education vs 5.8% inpost-secondary education, 95% CI: 4.5%-7.0%). The injury rate was also higher inpeople who were divorced / separated(9.3%, 95% CI: 5.7%-13.0%), comparedto people who were married or cohabiting(6.5%, 95% CI: 5.7%-7.2%) and peoplewho were never married (5.7%, 95%CI: 4.7%-6.6%). The proportion ofpopulation aged 15 and above whos us ta i ne d i n j u r y e p i s od e ( s ) wa ssignificantly higher for persons living

alone (10.6%, 95% CI: 7.8%-13.3%), ascompared to those who were not livingalone (6.1%, 95% CI: 5.5%-6.7%). Theproportion of population aged 15 and abovewho sustained injury episode(s) in the 12months before enumeration was higher forpersons residing in smaller quarters of 250square feet or less (10.7%, 95% CI:8.1%-13.3%) when compared to thoseliving in larger quarters of more than1 000 square feet (5.4%, 95% CI: 1.7%-9.1%).

Analysed by occupation, the proportion ofemployed persons aged 15 and above whosustained injury episode(s) was the highestamong service workers, shop and market

Falls 5.6Sprain 1.5Sports *Hit / struck

0.9

Cutting / piercing

*

Traffic *Burns *Crush *Animal bite

0.8

Others†*

Total 8.8 100.0 460.0 100.0

%

* 5.4 1.2

3.9 9.2 2.0

100.0 285.0 100.0 60.9100.0 42.3 100.0 63.0

* * 10.3 2.2* 2.9 6.8 * * 7.5 2.6

* 3.9 1.4 *8.7 0.7 1.7 *1.2 2.0 7.2 1.6* 3.4 8.1 * * 2.6 0.9

1.4 6.0 2.1 2.4* * * 0.90.5 0.8 16.5 3.6

1.6 39.2 8.5

* * * 2.1 3.3 14.0 4.9

7.1 32.2 11.3 1.0* 1.5 3.6 4.4

1.6 2.6 39.9 8.73.3 65.1 14.1

9.9 4.3 10.3 6.5 10.3 26.6 9.337.0 29.2 10.3 2.0* 10.6 25.1 23.3

7.8 12.8 118.8 25.873.0 148.3 32.2

17.5 3.1 7.2 13.6 21.6 92.8 32.619.3 70.2 24.6 44.563.9 15.8 37.3 12.2

%

No. ofepisodes

(’000)

Total

%

No. ofepisodes

(’000)

25 – 64 65 and above

No. ofepisodes

(’000) %

No. ofepisodes

(’000) %

No. ofepisodes

(’000)

No. ofepisodes

(’000)

Main causeof injuryepisodes

0 – 4 5 – 14 15 – 24

%

73 Dec 2012

Table 4 Proportion of Population Aged 15 and above Who Sustained Injury Episode(s) in the 12 Months before Enumeration

by Socio-demographic and Risk Factor

Note : † The base is employed respondents.Source : Injury survey 2008.

Proportion of population aged 15Socio-demographic / risk factor 95% CIand above who sustained injury

Educational attainment No schooling/pre-primary /primary 6.5% 5.4% − 7.7%Secondary/sixth form 6.5% 5.6% − 7.3%Post-secondary 5.8% 4.5% − 7.0%

Marital statusNever married 5.7% 4.7% − 6.6%Married or cohabiting 6.5% 5.7% − 7.2%Widowed 7.5% 5.2% − 9.7%Divorced/separated 9.3% 5.7% − 13.0%

Living alone Living alone 10.6% 7.8% − 13.3%Not living alone 6.1% 5.5% − 6.7%

Size of quarters ≤ 250 sq ft 10.7% 8.1% − 13.3%251- 500 sq ft 5.5% 4.7% − 6.2%501- 1 000 sq ft 6.8% 5.8% − 7.9%> 1 000 sq ft 5.4% 1.7% − 9.1%

Occupation†

Service workers, shop and market sales workers 8.9% 6.5% − 11.3%Legislators, senior officials and managers 7.2% 4.7% − 9.6%Plant / machine operators and assemblers 6.7% 3.8% − 9.5%Professionals 6.4% 3.6% − 9.1%Technicians and associate professionals 6.1% 3.7% − 8.4%Clerks and secretaries 5.7% 4.1% − 7.3%Craft and related trades workers 5.6% 3.0% − 8.2%Elementary occupations 5.3% 3.7% − 6.9%

Personal incomeHK$0 5.5% 4.4% − 6.6%HK$1 - HK$9,999 5.8% 5.0% − 6.6%HK$10,000 - HK$19,999 7.7% 6.3% − 9.1%HK$20,000 and above 7.6% 5.7% − 9.4%

Binge drinkingDid not engage in binge drinking 6.1% 5.5% − 6.7%Engaged in binge drinking 11.9% 8.1% − 15.7%

Chronic health condition Nil 5.5% 4.9% − 6.2%One 8.9% 7.1% − 10.7%Two 10.9% 7.8% − 13.9%Three or more 10.5% 6.2% − 14.8%

74Dec 2012

sales workers (8.9%). It was followed bylegislators, senior officials and managers(7.2%) and plant / machine operators andassemblers (6.7%). The proportion wasthe lowest among those engaging inelementary occupations (5.3%). Theproportion of population aged 15 and abovewho sustained injury episode(s) generallyincreased with their average monthlypersonal income. It increased generallyfrom 5.5% for persons with no income to7.6% for persons with average monthlypersonal income of HK$20,000 and above.

Among the population aged 15 and above,those who had engaged in binge drinkinghad a significant higher proportion(11.9%, 95% CI: 8 .1%-15.7%) ofsustaining injury episodes in the 12 monthsbefore enumeration when compared tothose who had not engaged in bingedrinking (6.1%, 95% CI: 5.5%-6.7%). Theproportion of population aged 15 and abovewho sustained injury episode(s) increasedfrom 5.5% (95% CI: 4.9%-6.2%) forpersons without any chronic healthcondition to 10.5% (95% CI: 6.2%-14.8%)for persons with three or more chronichealth conditions.

Results showed that people with lowereducat ional a t ta inment , d ivorced /separated, living alone, living in quartersof small size, with binge drinking habitand with increased number of chronichealth conditions, may be at higher risk ofunintentional injuries.

Burden of Disease

Despite the fact that injuries ranked onlythe sixth among the leading causes of deathin 2011, potential years of life lostattributable to injuries ranked the second(13.2% of the total) among all causes ofdeath. This implied that injuries impose aheavy load on premature mortality. This

ranking was second to cancer (44.7% ofthe total), and was followed by heartdiseases (10.0%), cerebrovasculardiseases (5.0%), etc.

Regarding morbidity, among all in-patientdischarges and deaths in all hospitals in2011, 89 304 episodes were due toinjuries. Injuries accounted for 4.7% oftotal in-patient discharges and deaths forthat year. Among these 89 304 episodesof injury-related in-patient discharges anddeaths, falls had the largest share (36 435episodes or 40.8%), followed by accidentalexposure to other and unspecified factors(21 997 episodes or 24.6%) and exposureto inanimate mechanical forces (7 083episodes or 7.9%).

According to Injury Survey 2008, theaverage medical expenses incurred bypatient as a result of each injury episodewas HK$1,929 (median HK$300). Thetotal cost incurred as a result of injuries(excluding refusals and unknown / missingcases) in Hong Kong in 2008 wasestimated at HK$838.6 million (95% CI:HK$473.9 mil lion to HK$1,203.4million). The cost increased with age andwas the highest in persons aged 65 andabove. In employed persons, more thanhalf of the injury episodes (51.3%)sustained caused the injured persons to beabsent from work temporarily. The averageduration of absence was 19.8 days (median7.0 days). The mean and median numbersof days of paid sick leaves taken were13.5 and 5.0, respectively. The mean andmedian numbers of days of unpaid sickleaves t aken wer e 29 .6 and 7 .0 ,respectively. Among all injury episodes,36.2% caused the injured persons tochange their normal daily activities and1.4% caused them to develop residualdisabilities for six months or longer.Among students, 17.1% of the injuryepisodes sustained caused the injured

75 Dec 2012

Reference

1. Department of Health. Promoting Health in Hong Kong: A Strategic Framework for Prevention and Control of Non -communicable Diseases, 2008.

persons to take days off from schooltemporarily for an average of 11.5 days(median 3.0 days).

Limitations

Since the Survey covered the land-basednon-institutional population in Hong Kong,it was subject to limitations. Injuryepisodes susta ined by res idents ininstitutions such as elderly homes, andpersons living on boats or vessels werenot included. Injury episodes sustainedby elderly persons who used to live incommunity dwellings but now residing inelderly homes after the occurrence of theinjury episodes were also not captured inthe Survey. These groups formed the tipof the injury pyramid.

Moreover, an injury episode was definedas unintentional that was “serious enoughto limit the normal activities of a person”in this Survey. That means even for thesame level of physical harm, pain andinconvenience caused by an injury episode,one might regard it as limiting his / hernormal activity but another one might not.

Initiative on Injury Prevention

The fact that injury causes significantmorbidity and mortality worldwide

warrants our attention. Injury occurrenceva r i es among d iffe ren t sub -grouppopulations. Interventions with regard toEducation, Engineering and Enforcement- the building blocks of injury preventionshould thus be tailor-made to meet theneeds of specific target groups and addressthe special patterns of injury.

A Working Group on Injuries, comprisingthe Hong Kong Government and differenthealth advocates, was established inFebruary 2012. It has taken the initiativeto implement a variety of interventionsstriving for providing a safe environmentfor the general public to play, study, workand live. The Working Group consists ofr ep r e s e n t a t i ve s f r om co mmu n i t yorganisat ions, academia, healthcareprofessions, social services sector, publicsector and government departments.Strategic directions will be identified forfocusing the attention, resources andactions at areas where investments in non-communicable disease prevention andcontrol can bring the greatest return interms of health outcomes.1 The WorkingGroup will advise on the priority actionsfor health improvement in the area ofi n j u r y p r e v e n t i o n , a n d m a k erecommendations on the development,implementation and evaluation of actionplans for prevention of injuries.

76Dec 2012

BREAST CANCER PREVENTION ANDSCREENING IN HONG KONG

Ms Ella HO 1 Ms May AU YEUNG 1 Dr Carrie WONG 2 Dr Duncan TUNG 3

Worldwide, breast cancer is the mostcommon cancer among females in 2008,with an estimated 1.38 million new cancercases (23% of all cancer cases). The age-standardised incidence and mortality ratesof breast cancer were 38.9 and 12.4 per100 000 female population respectivelyin the world.1 Currently, organised andpopulation-based breast cancer screeningprogramme using mammography asscreening tool has been introduced in over20 countries, including Asian countriessuch as Singapore. However, there areconsiderable controversies over theefficacy and effectiveness and increasingc o n c e r n s a b o u t t h e h a r m s o fmammographic screening. While manyWestern countries are revisiting the wholeissue of breast cancer screening in termsof benefits and harms, there are calls forsimilar screening programme in HongKong in view of rising breast cancerincidence rate and increasing publicconcern.

This article will cover the latest localburden of breast cancer, the Government’srecommendat ions on breast cancerscreening for general female populationand their rationale; discuss the updatedevidence and controversies on screening;and look out to the future of breast cancerprevention in Hong Kong.

Local Burden of Female Breast Cancer

Epidemiology

In Hong Kong, breast cancer has been the

1 Scientific Officer 2 Medical & Health Officer 3 Senior Medical & Health Officer

commonest cancer among females sincethe early 1990’s. There were 3 014 newlyregistered female breast cancer cases in2010, accounting for 24.1% of all newcancer cases in females. The median ageof diagnosis was 53 years. The cumulativelifetime risk of developing breast cancerwas one in 19. The crude incidence rateand age-standardised incidence rate ofbreast cancer were 80.8 and 54.8re spe c t i ve ly pe r 100 000 f ema lepopulation.2

In 2011, being the third leading cause ofcancer deaths, breast cancer caused 552deaths among women, representing 10.4%of all female cancer deaths. The crudemorta lity rate and age-standardisedmortality rate of female breast cancer were14.6 and 9.1 respectively per 100 000female population.3

International Comparison

Over the past two decades, the absolutenumber and the crude rate of female breastcancer new cases and cancer deaths wereon a rising trend in Hong Kong. Afteradjusting for population ageing, the age-standardised morta lity rate becamerelatively stable, while the incidence ratemaintained an increasing trend (Figure 1).Even though the age-s tandard isedincidence rate of breast cancer wasincreasing in Hong Kong, it was much lessthan those reported in Western countries(e.g. UK, Australia, Canada) in 2008.1

(Figure 2)

77 Dec 2012

Figure 2 International Comparison of Age-standardised Incidence andMortality Rates of Female Breast Cancer, 2008

Notes : 1. For comparison purpose, the age-standardised rates for Hong Kong are calculated using the sameage-standardisation method adopted by GLOBOCAN 2008, in which the age-standardised rates arecalculated based on the World Standard population modified by Doll et al. (1966) from thatproposed by Segi (1960), and are calculated using ten age-groups.

2. USA = United States of America; UK = United Kingdom.Source : GLOBOCAN 2008, International Agency for Research on Cancer (IARC), WHO.

17.6

15.6

14.7

14.7

14.2

13.7

13.6

10.8

8.5

5.3

9.1

18.6

0 10 20 30

UK

France

Canada

Australia

USA

Sweden

Finland

ingapore

Thailand

Japan

Korea

Rate (per 100 000 standard population)

Hong Kong

Age-standardised Mortality Rate

S

99.7

79.4

76.0

59.9

42.7

38.9

30.7

89.1

86.3

84.8

83.2

47.7

0 30 60 90 120

France

UK

Finland

Australia

Canada

Sweden

USA

Singapore

Japan

Korea

Thailand

Rate (per 100 000 standard population)

Hong Kong

Age-standardised Incidence Rate

0

5

1015

20

25

30

35

40

4550

55

60

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Incidence rate

Mortality rate

Age

-sta

ndar

dise

d ra

te(p

er 1

00 0

00 st

anda

rd p

opul

atio

n)

Year

Age-standardised Incidence and Mortality Rates* ofFemale Breast Cancer in Hong Kong, 1990 to 2010†

Figure 1

Notes : * According to a new world standard population specified in GPE Discussion Paper Series: No.31, EIP/GPE/EBD, World Health Organization, 2001.

† Figures from 2001 onwards are classified according to ICD-10 and thus may not be comparable withfigures for previous years classified according to ICD-9. Breast cancer corresponds to codes 174 inICD-9 and C50 in ICD-10.

78Dec 2012

Risk Factors for Breast Cancer

Many factors determine a woman’s risk ofdeveloping breast cancer. Epidemiologicalstudies have found that women with familyhistory of breast cancer or carryingBRCA 1 or BRCA 2 deleterious mutationsare associated with increased risk ofdeveloping breast cancer .4,5 Otherestablished personal risk factors include:6-9

l advancing age;l history of atypical hyperplasia or

lobular carcinoma in situ;l previous breast cancer;l previous ovarian or endometrial

cancer;l previous radiation therapy to the chest

when younger than 30 years of age;l i n c r e a s e d b r e a s t d e n s i t y o n

mammogram;l early menarche (<12 years of age) or

late menopause (>55 years of age);

l nulliparity, late first live birth (>30years of age);

l no breastfeeding;l obesity after menopause;l hormone replacement therapy;l alcohol consumption; andl physical inactivity.

Screening Tests of Breast Cancer

Screening tests aim to detect breast cancerin women who have no symptom of thed i sease . The common sc reen ingmodalities for breast cancer include breastself-examination (BSE), clinical breastexamination (CBE), and mammography.When initiating a population-basedscreening programme, some factors shouldbe considered according to the screeningcriteria in World Health Organization(WHO)’s Principles and Practice ofScreening for Disease written by Wilsonand Jungner.10 (Table 1)

Table 1 Basic Principles of Screening by Wilson and Jungner, WHO10

1. The condition sought should be an important health problem. 2. There should be an accepted treatment for patients with recognised disease. 3. Facilities for diagnosis and treatment should be available. 4. There should be a recognisable latent or early symptomatic stage. 5. There should be a suitable test or examination. 6. The test should be acceptable to the population. 7. The natural history of the condition, including development from latent to

declared disease, should be adequately understood. 8. There should be an agreed policy on whom to treat as patients. 9. The cost of case-finding (including diagnosis and treatment of patients diagnosed)

should be economically balanced in relation to possible expenditure on medical care as a whole.

10.Case-finding should be a continuing process and not a “once and for all” project.

S ource : World Health Organization.

79 Dec 2012

The Government’s Recommendations onBreast Cancer Screening

The Government set up a high-level CancerCoordinating Committee (CCC) in 2001,which is chaired by the Secretary for Foodand Health, to steer the direction of workon prevention and control of cancer inHong Kong. In 2002, the Cancer ExpertWorking Group on Cancer Prevention andScreening (CEWG) was formed under the

CCC to review scientific evidence, assesslo c a l p r e ve n t i o n a n d s c r e e n i n ginterventions on cancers, and formulatelocal guidelines on cancer prevention andscreening.

In 2010, the CEWG has reviewed newscientific evidence, and defined increasedrisk of breast cancer according to a set ofqualitative risk stratification criteria(Table 2). Based on systemic review of

Table 2 Increased Risk of Female Breast Cancer Defined by the CEWG11

N ote 1: Women with any one of the risk factors are at high risk of developing breast cancer.Note 2: Women with any one of the risk factors are at moderately increased risk of developing breast cancer.* First-degree female relatives include mother, daughter and sister.** Second-degree female relatives include grandmother, granddaughter, aunt, niece and half-sister.

Women at Increased Risk Groups High risk (Note 1) 1. A carrier of BRCA 1 / BRCA 2 deleterious mutations confirmed by genetic testing. 2. Family history of

(a) Any first-degree female relative* being a confirmed carrier of BRCA 1 / BRCA 2 deleterious mutations;

(b) Any first-degree or second-degree female relative** with both breast and ovarian cancer (in the same person) regardless of age at diagnosis;

(c) Any first-degree female relative with bilateral breast cancer; (d) Any male relative with a history of breast cancer; (e) Two first-degree female relatives diagnosed to have breast cancer AND one of them

being diagnosed at or below 50 years of age; (f) Two or more first-degree or second-degree female relatives with ovarian cancer

regardless of age at diagnosis; (g) Three or more first-degree or second-degree female relatives with breast cancer OR a

combination of breast cancer and ovarian cancer, regardless of age at diagnosis.

3. Personal risk factors (a) History of radiation to chest for treatment (not Chest X-ray) between age 10 and 30

years, e.g. for Hodgkin’s disease; (b) History of breast cancer, including ductal carcinoma in situ (DCIS); (c) History of lobular carcinoma in situ (LCIS); (d) History of atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH).

Moderately increased risk (Note 2) Family history of (a) Only one first-degree female relative with breast cancer diagnosed at or below 50 years of age;

or (b) Two first-degree female relatives diagnosed to have breast cancer after the age of 50 years.

80Dec 2012

e v i d e n c e , t h e C EW G m a d e t h erecommendat ions on breast cancerscreen ing fo r the gene ral womenpopulation (i.e. women at average risk ofbreast cancer) and women at increased riskof breast cancer respectively.

Recommendations for General FemalePopulation

The CEWG’s recommendations on breastcancer screening for general femalepopulation11 are summarised as follows:

(1) Routine breast cancer screening byBSE is not recommended;

(2) There is so far insufficient evidenceto recommend CBE; and

(3) There is insufficient evidence tor e c o m m e n d f o r o r a g a i n s tmammography screening for thegeneral female population in HongKong.

Rec o mm en d a t i on s f o r Wo me n a tIncreased Risk of Breast Cancer

Local women with any one of the riskfactors listed in Table 2 are at increasedrisk of developing breast cancer. Forwomen at high risk of breast cancer(Table 2), the CEWG recommends thatthey should see a doctor and have breastcancer screening by mammography everyyear and should begin screening at age 35or ten years prior to the age at diagnosisof the youngest affected relative (for thosewith a family history), whichever is earlier,but not earlier than 30 years of age.11

For women at moderately increased risk(Table 2), the CEWG recommends thatthey should discuss with their doctorsabout the pros and cons of breast cancer

screening before deciding whether to startscreening by mammography every two tothree years.11

The above recommendations have beenuploaded onto the websites of the Centrefor Health Protection and the Departmentof Health for public information (http://w w w . c h p . g o v . h k / f i l e s / p d f /recommendations_on_breast_cancer_screening_2010.pdf).

In the last CEWG meeting in 2012, havingconsidered the latest local epidemiology,overseas and local development ofscreening for breast cancer, the CEWGconcluded that the above recommendationswere still valid.

Rational for CEWG’s Recommendationson Breast Cancer Screening for GeneralWomen Population

Breast Self-examination

BSE had low sensitivity (17% - 26%) indetecting breast cancer. The Cochranereview in 2008 concluded that the reviewof data from two large population-basedtrials in Shanghai and Russia did not find abeneficial effect of screening by BSE, butdid suggest increased harm in terms ofincreased numbers of benign lesionsidentified and an increased number ofbiopsies performed.12 Thus, routinescreening by BSE is not recommended.

Clinical Breast Examination

The only large population-based trial onCBE conducting in the Philippines in 2006showed that the test sensitivity andspecificity for annual CBE was 53.2% and100% respectively, and the sensitivitydecreased to 39.8% for biennial screeningby CBE. However , th is t r i a l was

81 Dec 2012

discontinued due to poor compliance withfollow up and no conclusion on theeffectiveness of CBE in reducing breastcancer can be drawn from this study.13

Therefore, there is inadequate evidence torecommend CBE as a screening test forbreast cancer.

Mammography

Mammography is widely used in countrieswith population-based breast cancerscreening programme. Experiences fromWestern countries (e.g. UK and Australia)suggested that organised and nationwidescreening programmes are effective interms of detection of tumors at an earlierstage and reduction in mortality in thefemale population aged over 50. Theevidence o f the e ffec t iveness o fpopula t ion-based breast screeningprogrammes had been documented inWestern countries; nevertheless, there wasno randomised controlled trial that showeddecreased breast cancer mortality frommammography sc reening in Asianpopulation. Moreover, before we decidewhether the findings from studies onCaucasians can be generalised to HongKong women who are mostly Chinese, itis necessary to consider the potentialharms done to women due to population-based screening, including false-positivescreening results, unnecessary follow-upi n v e s t i g a t i o n s , o v e r d i a g n o s i s ,overtreatment and psychological harms.

Poten t ia l Harms of Sc reen ing byMammography

a . Fa lse -pos i t i ve and Assoc ia t ed Complications

The accuracy4 of mammography is one ofthe important aspects to consider. Localstudies have found that the sensitivity5

(69.2% - 84.3%) and the specificity6

(94.9%) of mammography in the HongKong female population were comparableto those overseas. Nevertheless, despitethe comparable accuracy, the positivepredictive value (PPV)7 of mammographyin Hong Kong women is lower (only 4.9%- 7 .7%) as compared with 9.1% inCaucasians. The low PPV in Hong Kong,due to the relatively low prevalence ofbreas t cancer in the local fema lepopulation, means that there will be ahigher proportion of false-positive8 casesthan that in Western populations, leadingto more harm related to unnecessaryinterventions for follow-up or eventreatment for false-positive screeningresults.

The potential impacts of breast cancerscreening in Hong Kong had beenestimated by modelling studies. One localstudy conducted in 2002 estimated thatfor every 100,000 Hong Kong Chinesewomen aged 50 years or above screenedannually for ten years, 77 lives would besaved, but at the same time, there would

4 Accuracy of a screening test is the ability of the test to correctly classify the presence or absence of the target disease,usually expressed by sensitivity and specificity.

5 Sensitivity of a screening test is the probability that a person with the disease will be correctly identified as diseasedby the test.

6 Specificity of a screening test is the probability that a person without the disease will be correctly identified as non-diseased by the test.

7 Positive Predictive Value (PPV) is the probability that a person with a positive test result is a true positive (i.e. doeshave the disease). PPV is determined by both the accuracy of the screening test and the prevalence of the disease.When the prevalence of the disease in the screening population is low, the PPV will be low.

8 False-positive refers to a positive test result in a person who does not have the disease.

82Dec 2012

be 8 980 fa lse posi t i ve s and 134complications.14 Another study in 2008estimated that a biennial mammographicscreening programme for local women of50-74 age group would result in 33 700false-positives per year and this would leadto 29 900 repeated mammograms orultrasound scans, 6 800 biopsies and 620biopsy-related complications.15 Overseasstudies showed that the complicationscomprised events at different levels ofseverity, including vasovagal reactions,bleeding, pain, hematoma and woundi n fe c t i on , a l th o ugh mo s t o f th ecomplications would be relatively minorand ea s i ly r e so lvab le . 1 4 ,1 5 Mo reimportantly, the false-positive screeningresults not only lead to repeated follow-up visits and biopsies, but also fear, anxietyand breast cancer worry among screenedwomen.

b. Overdiagnosis and Overtreatment

Mammography may lead to the harmsassociated with overdiagnosis of breastcancer that would never be identifiedclinically in a woman’s life, as well asunnecessary treatment of this diagnosis.Apart from invasive ductal cancer,mammography screening often detectsDCIS, the majority of which may notprogress to invasive disease i f leftuntreated.16 Although there is a 30%chance that it will develop into invasivedisease , the natural h is tory of th isprogression is uncertain. Once DCIS isdetected through mammography screening,women will be likely treated as invasivedisease with lumpectomy and radiationtherapy, because doctors do not knowwhich one will or will not progress. Thus,a proportion of women diagnosed withDCIS detected through mammagraphyscreening will be treated unnecessarily.Based on these considerations and the bestavailable evidence, the CEWG concludedthere is inadequate evidence to recommend

for or against mammography screening forthe general female population.

Recent Evidence and Controversies overRoutine Mammography Screening inWestern Countries

Population-based breast cancer screeningprogramme has been implemented inWestern countries for years, which allowa sufficiently long period to evaluate theeffectiveness of screening programmes onthe reduction in breast cancer mortalityof their population. Nevertheless, thereare considerable doubts about theeffectiveness of mammography screeningin reducing the breast cancer mortality. Inaddition, the uncertainties of its effects inwomen of various ages are debated, due tolack of proven efficacy in mammographicscreening for women younger than 50years as well as limited data about its effectin those who aged 70 or older. Below aresome of the latest studies and reviews thathave been published.

Effect of Mammographic Screening onBreast Cancer Mortality

In Norway, the breast cancer screeningprogramme offering mammography wasstarted in 1996. According to a Norwegianstudy in 2010, the introduction of a breastcancer s creen ing programme wasassociated with a reduction in the rate ofdeath from breast cancer, but the screeningitself accounted for only about a third oftotal reduction, which implies the magnitudeof this benefit is modest in such a nationaland high-attendance screening program.17

Another study in 2011 compared the trendsin breast cancer mortality within threepairs of neighbouring European countriesin relation to implementation of nationalorganised mammography screeningprogramme. The trends in mortality ratesof breast cancer varied little between

83 Dec 2012

countries where women were screened fora considerable time compared with thosewhere women were largely unscreenedduring that same period. For example, inNorthern Ireland the overall reduction inbreast cancer mortality from 1989 to 2006was slightly greater than in Republic ofIreland (29.6% vs 26.7%), but organisedscreening programme was introduced inNorthern Ireland since 1990 and thecoverage was more than 70%, whileorganised screening started in the Republicof Ireland in 2000 and coverage was around50%. Thi s s tudy conc luded tha tmammography screening did not play adirect part in the reductions of breastcancer mortality and that improvements intreatment and in the effic iency ofhealthcare systems seem to be moreplausible explanations.18

The latest Cochrane review in 2011included seven randomised controlledtrials involving 600 000 women withmammography screening every 12 to 33months. Among seven trials reviewed,three trials with adequate randomisationdid not show a significant reduction inbreast cancer mortality, with a relative risk(RR) of 0.90 (95% confidence interval(CI): 0.79-1.02) at 13 years, while anotherfour trials with suboptimal randomisationshowed a significant reduction in breastcancer mortality with the RR of 0.75 (95%CI: 0.67-0.83). Therefore, as the effectof screening on breast cancer mortalitywas the lowes t in the adequa te lyrandomised trials, a reasonable estimateis a 15% reduction which corresponds toan absolute risk reduction of 0.05%.19

Harms of Screening by Mammography

The 2011 Cochrane review (as mentionedin last paragraph) estimated mammographyscreening also leads to 30% overdiagnosisand overtreatment of breast cancer, or anabsolute risk increase of 0.5%. In other

words, for every 2 000 women invited forscreening throughout ten years, one wouldhave her life prolonged, but ten healthywomen who would not have been diagnosedif they had not been screened would betreated unnecessarily. More than 200women would experience importantpsychological distress for many monthsbecause of fa lse-pos i t ive r esul ts .Therefore , i t was unclear whethersc reen ing fo r b reast cance r wi thmammography does more good than harm,so women should be fully informed ofboth the benefits and harms before theydecide whether or not to receive screening.19

Similarly, a US modelling study in 2011estimated that the probability of a 50-year-old woman with screen-detected breastcancer could avoid breast cancer death dueto mammography screening was only 13%.Most women were unlikely to havebenefited from screening, and they wereeither merely diagnosed earlier but withn o e f fe c t o n t he i r mo r t a l i t y, o roverdiagnosed.20 Another UK modellingstudy in 2011 also supported the claim inCochrane review that the introduction ofmammographic breast cancer screeningmight be causing net harm for up to tenyears after the start of screening.21

Recently, a study in 2012 estimated thepercentage of overdiagnosis of breastcancer attributable to mammographyscreening program in Norway, involving39,888 female patients with invasive breastcancer. The results indicated 15% to 25%of cancer cases are overdiagnosed,t r ans la t ing to s i x t o t en womenoverdiagnosed for every 2 500 womeninvited. These findings are in line with2011 Cochrane review that mammographyscreening leads to a substantial amount ofoverdiagnosis, and women eligible forscreening need to be comprehensivelyinformed about this risk.22

84Dec 2012

Recent Updates of Overseas and LocalRecommendations of Breast CancerScreening

In view of the recent evidence on theb e n e f i t s a n d h a r ms o f r o u t i n em a mm o g r a p h y s c r e e n i n g , s o m einternational and local health organisationshave updated their breast cancer screeningrecommenda t ions fo r the genera lpopulation. For example, the United StatesPreventive Services Task Force (USPSTF)(www.uspreventiveservicestaskforce.org)and the Canadian Task Force on PreventiveH e a l t h C a r e ( C T F P H C ) ( w ww .canadiantaskforce.ca) updated theirrecommendat ions on breast cancerscreening in 2009 and 2011 respectively.I n c o n t r a s t t o t h e i r p r e v i o u srecommendations, both the USPSTF andthe CTFPHC support a reduction in theuse and frequency of mammographicscreening, and clearly states that womenaged 40-49 should not be routinelysc re ene d fo r b rea s t ca nc e r wi thmammography.23,24 The USPSTF reducesthe recommended frequency of screeningfrom every one to two years to every twoyears for those aged 50-74, while theCTFPHC reduces the recommendedfrequency of screening from every otheryear to every two to three years for thoseaged 50-69 and recommends cliniciansshould discuss with each woman the potentialbenefits and harms of screening.23,24

Moreover, UK Department of Healthannounced in 2011 that they wouldundertake an independent review of there search evidence r e la t ing to theeffectiveness of breast screening, andwould revise the breast screening leafletby presenting the information about thebenefits and harms of mammography towomen so as to promote informed choice.25

The findings have been published inNovember 2012. The Panel estimated arelative risk reduction of 20% in breastcancer mortality for women who had

routine breast screening, and also foundthat some over-diagnosis occurred. Forevery 10 000 women aged 50 years invitedto screening for the next 20 years, 43breast cancer deaths would be preventedand 129 breast cancer cases would be over-diagnosed. It is concluded that clearcommunication of harms and benefits ofscreening is essential to women so thatthey can make an informed choice.26

Locally, the Hong Kong Anti-CancerSociety (HKACS) (www.hkacs.org.hk) hasupdated the recommendations on breastcancer screening in 2011. The HKACSconcludes that there is insufficiente v i de n c e t o r e c o mme n d r o u t i n emammography screening for the femalegeneral population in Hong Kong, and forwomen considering mammography, theyshould be fully informed of potentialbenefits, risks and limitations to make aninformed choice.27

Primary Prevention and Early Detection

As it is still unclear whether screeningwould cause more good than harm, whatcan a well woman do to prevent breastcancer? Apart from screening, there arestrategies that help women prevent breastcancer by reducing the breast cancer risk.The CEWG stated that primary preventivemeasures are important in lowering therisk of developing breast cancer. Womenare advised to have regular physicalactivity, have high intake of vegetables andfruits, maintain a healthy body weight andavoid alcohol use. Women are alsorecommended to have childbirth at anearlier age and breastfeed each child forlonger duration to reduce their risk ofbreast cancer.11

The CEWG also advised that women shouldbe aware of early symptoms of breastcancer and visit their doctors promptly ifthese symptoms appear .11 B reas tawareness is different from breast self-

85 Dec 2012

examination which is a regular, formallytaught and ritual examination of a woman’sbreasts by herself to look and feel for anyabnormal feature or lump in her breasts orarmpits. Breast awareness means beingfamiliar with the normal look, feel andcyclical changes of their breasts (e.g.change in size and shape of the breast) sothat women can spot unusual changes earlyon. Earlier diagnosis of breast cancerleads to earlier treatment and betteroutcomes for women.

Conclusion and Way Forward

Despite the potential benefits of massmammographic screening programmes inWestern countries, there are increasingco n t ro ve r s i e s ove r the e ff ec t o fmammography screening in reducing thebreast cancer mortality rate and moreevidence on ha rms of s c reening.Currently, there is insufficient evidence

to recommend for or against routinemammography screening for the generalfemale population in Hong Kong. Thereshould be more clinical research on thecost-effectiveness of mammographicscreening among Hong Kong women, aswell as their attitudes towards breast cancerscreening. Healthcare professionalsshould discuss both the potential benefitsand harms of breast cancer screening witheach woman and help her to make aninformed decision.

Breast cancer is preventable throughreduction of risk factors. All women,regardless of high risk or average risk, canlower their risk of breast cancer throughlifestyle modification (e.g. have regularphysical activity, maintain healthy bodyweight and avoid alcohol use), and shouldbe breast aware to spot irregular changesearly on and seek medical advice whennecessary.

References

1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C andParkin DM. GLOBOCAN 2008 v2.0, Cancer Incidenceand Mortality Worldwide: IARC CancerBase No. 10[Internet]. Lyon, France: International Agency forResearch on Cancer; 2010. Available from: http://globocan.iarc.fr (accessed on 15 August 2012).

2. Hospital Authority. Hong Kong Cancer Registry. FemaleBreast Cancer in 2010. Available at: http://www3.ha.org.hk/cancereg/breast_2010.pdf (accessed on 12 December2012).

3. Statistics on Breast Cancer Mortality. Hong Kong SAR:Department of Health (accessed on 20 September 2012).

4. Pharoah PD, Day NE, Duffy S, Easton DF, Ponder BA.Family history and the risk of breast cancer: a systematicreview and meta-analysis. Int J Cancer. May 29 1997; 71(5): 800-9.

5. National Cancer Institute: PDQ® Genetics of Breast andOvarian Cancer. Bethesda, MD: National Cancer Institute.Date last modified (8 August 2012) http://cancer.gov/cancertop ics/pdq /genetics/breast-and -ovarian/HealthProfessional (accessed on 21 September 2012).

6. Warner E, Heisey RE, Goel V, Carroll JC, McCready DR.Hereditary breast cancer. Risk assessment of patients witha family history of breast cancer. Can Fam Physician. Jan1999; 45: 104-12.

7. Mahoney MC, Bevers T, Linos E , Willet t WC.

Opportunities and strategies for breast cancer preventionthrough risk reduction. CA Cancer J Clin. Nov-Dec 2008;58(6): 347-71.

8. McPherson K, Steel CM, Dixon JM. ABC of breastdiseases. Breast cancer-epidemiology, risk factors, andgenetics. BMJ. Sep 9 2000; 321(7261): 624-8.

9. Baan R, Straif K, Grosse Y, et al. Carcinogenicity ofalcoholic beverages. Lancet Oncol. Apr 2007; 8(4): 292-3.

10. Wilson JMG, Jungner G. Principles and Practice ofScreening for Disease. Geneva: World Health Organization,1968. Public Health Papers No. 34.

11. Department of Health. Cancer Expert Working Group onCancer Prevention and Screening - Recommendations onBreast Cancer Screening. Hong Kong SAR: Departmentof Health, 2010. Available at: http://www.chp.gov.hk/files/pdf/recommendations_on_breast_cancer_screening_2010.pdf (accessed on 10 September 2012).

12. Kösters JP, Gøtzsche PC. Regular self-examination orclinical examination for early detection of breast cancer.Cochrane Database of Systematic Reviews, 2008,Issue 3 (accessed on 18 September 2012).

13. Pisani P, Parkin DM, Ngelangel C, et al. Outcome ofscreening by clinical examination of the breast in a trial inthe Philippines. Int J Cancer. Jan 1 2006; 118(1): 149-54.

14. Leung GM, Lam TH, Thach TQ, Hedley AJ. Willscreening mammography in the East do more harm than

86Dec 2012

good? Am J Public Health. Nov 2002; 92(11): 1841-6.15. Leung GM, Woo PP, Cowling BJ, et al. Who receives,

benefits from and is harmed by cervical and breast cancerscreening among Hong Kong Chinese? J Public Health(Oxf). Sep 2008; 30(3): 282-92.

16. Welch HG, Woloshin S, Schwartz LM. The sea ofuncertainty surrounding ductal carcinoma in situ–the priceof screening mammography. J Natl Cancer Inst. Feb 202008; 100(4): 228-9.

17. Kalager M, Zelen M, Langmark F, Adami HO. Effect ofscreening mammography on breast-cancer mortality inNorway. N Engl J Med. Sep 23 2010; 363(13): 1203-10.

18. Autier P, Boniol M, Gavin A, Vatten LJ. Breast cancermortality in neighbouring European countries withdifferent levels of screening but similar access to treatment:trend analysis of WHO mortality database. BMJ. 2011;343: d4411.

19. Gotzsche PC, Nielsen M. Screening for breast cancer withmammography. Cochrane Database Syst Rev. 2011(1):CD001877.

20. Welch HG, Frankel BA. Likelihood that a woman withscreen-detected breast cancer has had her "life saved" bythat screening. Arch Intern Med. Dec 12 2011; 171(22):

2043-6.21. Raftery J, Chorozoglou M. Possible net harms of breast

cancer screening: updated modelling of Forrest report. BMJ.2011; 343: d7627.

22. Kalager M, Adami HO, Bretthauer M, Tamimi RM.Overdiagnosis of invasive breast cancer due tomammography screening: results from the Norwegianscreening program. Ann Intern Med. Apr 3 2012; 156(7):491-9.

23. Screening for breast cancer: U.S. Preventive Services TaskForce recommendation statement. Ann Intern Med. Nov17 2009; 151(10): 716-26, W-236.

24. Tonelli M, Gorber SC, Joffres M, et al. Recommendationson screening for breast cancer in average-risk women aged40-74 years. CMAJ. Nov 22 2011; 183(17): 1991-2001.

25. Richards M. An independent review is under way. BMJ.2011; 343: d6843.

26. The benefits and harms of breast cancer screening: anindependent review. Lancet. Nov 17 2012; 380(9855):1778-86. 2011; 343: d6843.

27. Cancer Screening, Early Detection and PreventionGuidelines for Health Professionals. 2nd Edition. HongKong: The Hong Kong Anti-Cancer Society; 2011.

2012 Health Manpower Survey

The Department of Health is conducting the 2012 Health Manpower Survey (HMS) onregistered doctors, dentists, pharmacists, chiropractors and enrolled nurses with an aimto collect information on their characteristics and employment status. Survey results willfacilitate the development and planning of health workforce in Hong Kong.

In September, questionnaires together with the letters for renewal of practising certificatewere sent to all registered doctors and dentists in Hong Kong. The information collectedwill be handled in strict confidence and presented in aggregate form to protect theirprivacy.

Active participation from doctors and dentists is extremely important. Please kindlysupport the survey by returning your completed questionnaire to the Health ManpowerUnit of the Department of Health at 21/F, Wu Chung House, 213 Queen’s Road East,Wan Chai, Hong Kong, or through an encrypted email to hmu@dh.gov.hk by31 January 2013 (Thursday).

More information on the survey such as the background, coverage, questionnaires of the2012 HMS and the survey findings of previous rounds of the survey can be found on thehomepage of the Department of Health at http://www.dh.gov.hk/english/statistics/statistics_hms/statistics_hms.html. For further enquiries, please contact the HealthManpower Unit of the Department of Health at 2961 8566.

NEWS IN BRIEF

87 Dec 2012

Contact Numbers for Prompt Notification

Infectious Diseases otherthan Tuberculosis

2477 2770

Tel. No.

Central Notification Office

Duty Medical Officer(for urgent notification during weekends,public holidays or after office hours)

7116 3300 call 9179

-

Fax No.(Form DH1(s))

Fax No.(Form DH1A(s))

2834 6627 2574 2439

Tuberculosis andChest Service

Tuberculosis2477 2772

HIV/AIDS Surveillance

2012Quarter 3

2012Quarter 2

2011Quarter 3

2012Quarter 1-3

2011Whole Year

Cumulative totalsince 1984

HIV 140 131 113 393 438 5 663

AIDS 17 30 20 61 82 1 328

Announcement

This issue (December 2012) is our last issue. The Public Health & EpidemiologyBulletin (PHEB) was first published in 1992 to provide public health informationfor local health professionals. Throughout the years, the Department of Health(DH) as well as other local public and non-government organisations hasestablished various channels to communicate with health professionals, as wellas members of the public on important public health issues regularly. We arepleased to see these channels function well throughout the years.

The PHEB has fulfilled its role in the past 20 years. Thank you for your supportof the PHEB over the years.

The DH continues to disseminate important public health information via theDH’s website: http://www.dh.gov.hk as well as other websites of individualservice units to provide relevant information to our readers.

Editorial BoardPublic Health & Epidemiology Bulletin

88Dec 2012

Notes : * Notifiable since 17 August 2012† Notifiable since 28 September 2012‡ The figures of Shiga toxin-producing Escherichia coli infection represent Escherichia coli O157:H7 infection before

10 June 2011.

Number of Notifications of Infectious Diseases

1) Acute poliomyelitis - - - - - -2) Amoebic dysentery 1 1 - 1 5 43) Anthrax - - - - - -4) Bacillary dysentery 12 5 3 4 43 505) Botulism - - - - - -6) Chickenpox 602 451 390 743 11 025 6 2777) Chikungunya fever - - - - - -8) Cholera 1 1 - - 1 29) Community-associated methicillin-resistant 89 79 80 67 509 680

Staphylococcus aureus infection10) Creutzfeldt-Jakob disease - 1 1 1 5 611) Dengue fever 6 6 6 3 22 4712) Diphtheria - - - - - -13) Enterovirus 71 infection 8 6 5 - 61 5814) Food poisoning:

- Outbreaks 44 38 39 21 284 300 - Persons affected 129 143 173 63 1 035 1 151

15) Haemophilus influenzae type b infection (invasive) - - - - 1 116) Hantavirus infection - - - - 1 -17) Influenza A (H2), Variant Influenza A (H3N2)*, - - - - - 1

Influenza A (H5), Influenza A (H7), Influenza A (H9)18) Japanese encephalitis 1 1 - 1 1 319) Legionnaires' disease 3 4 2 - 12 2220) Leprosy - 1 - 1 6 421) Leptospirosis - 3 1 1 2 622) Listeriosis 3 2 - 1 9 2223) Malaria 4 3 1 1 37 2224) Measles 1 - - - 12 625) Meningococcal infection (invasive) - 1 - - 6 426) Mumps 13 17 12 10 133 12827) Paratyphoid fever 1 1 2 - 16 1628) Plague - - - - - -29) Psittacosis - - - - 2 130) Q fever - - - - 4 131) Rabies - - - - - -32) Relapsing fever - - - - - -33) Rubella and congenital rubella syndrome: 1 1 7 1 77 45

- Rubella 1 1 7 1 77 42 - Congenital rubella syndrome - - - - - 3

34) Scarlet fever 102 45 36 70 1 226 1 26235) Severe Acute Respiratory Syndrome - - - - - -36) Severe Respiratory Disease associated with - - - - - -

Novel Coronavirus37) Shiga toxin-producing Escherichia coli infection 1 - - - 2 838) Smallpox - - - - - -39) Streptococcus suis infection - 1 - 2 8 640) Tetanus - 1 1 - - 341) Tuberculosis 552 496 430 431 4 041 4 49242) Typhoid fever 1 - 3 - 25 2443) Typhus and other rickettsial diseases: 5 7 3 3 25 36

- Scrub typhus 3 4 1 2 4 21 - Urban typhus - - 1 - 2 1 - Spotted fever 1 2 1 - 16 7 - Unclassified 1 1 - 1 3 7

44) Viral haemorrhagic fever - - - - - -45) Viral hepatitis: 15 16 11 13 211 212

- A 1 6 5 1 43 34 - B 5 5 5 5 59 43 - C - 1 - 1 5 5 - E 9 4 1 6 104 130

46) West Nile Virus Infection - - - - - -47) Whooping cough 4 2 3 - 20 1948) Yellow fever - - - - - -

Jul2012Disease

Jan-Oct2011

Jan-Oct2012

Oct2012

Sep2012

Aug2012

†

‡