自從民國七十一年起惡性腫瘤（俗稱癌症）開始躍昇為國人十大死因之第一位，而且癌症死亡率有逐年攀升的趨勢。另外，根據衛生署公佈的「民國八十五年癌症登記報告」中，發現國人罹患癌症的情況不僅有集中特定癌症而且亦有逐年遞增的現象，由此可知癌症一直威脅著國人的健康。 由於政府在民國八十四年開辦全民健康保險，提供大部份國民基本的醫療保障，然而健保的給付項目以及金額仍然有限，因此壽險業者為了補足全民健保的缺口，陸續推出終身癌症保險以提供國人更完整的保障。然而國內終身癌症保險仍屬初期階段，缺乏完整的統計經驗資料，大部份採用國外再保險公司所提供的癌症經驗資料，並未參酌國內醫院所作的癌症統計；壽險業最近因損失率過高，也將終身癌症保險的給付內容重新修訂，以作為調整保費的依據，因此其終身癌症保險之保費適足性值得探討。 本研究限定在定額型個人終身癌症保險，主要探討在國人癌症發生率逐年上升情況下，如何去建立一套終身癌症保險費率釐定模型，並且參考國內醫院的癌症統計資料，在合理的精算假設下，使用S-Plus統計軟體計算出終身癌症保險之保費，進一步探討壽險業之費率適足性。 在本文實證分析中，列舉國內三家壽險公司，就其給付內容比較保費，並探討其保費適足性，發現其相同處在於國內三家壽險公司的年繳保費明顯不足，而且其年繳保費差額隨著年齡呈直線遞增。其兩者年繳保費之比率方面，本實證分析的年繳保費皆高出三家壽險公司二至四倍左右，因此在長期之下保費的不足會導致壽險公司虧損，進而可能影響到壽險公司的清償能力，此結果可提供壽險業者及監理機關參考。 / With the increasing of cancer incidence rate, the insurers provide completely and thoughtfully designed planning in order to meet the requirements of the public, supplemental to the national health insurance program enforced by the government of R.O.C. in 1995. However, many domestic insurers have faced the problem of the experience loss ratio beyond the expected. Since the whole life cancer insurance policies have been issued on the market a few years ago, the empirical data from the insurance are insufficient for the pricing. In addition, only a fewer researches have focused on the actuarial model of this type of insurance. In this paper, we will investigate the premium calculation of the whole life cancer insurance under the influence of specified factors, and outline the appropriate model construction procedures. The data we use are not only from Department of Health of the Executive Yuan but also from domestic hospital, such as National Taiwan University Hospital and Veterans General Hospital. Moreover, we make reference to medical studies and make use of rational actuarial assumptions, i.e., the trend of cancer incidence rate, cancer survival rate, cancer outpatient rate, average cancer outpatient treatment days, cancer inpatient rate, cancer surgical rates, cancer radiotherapy or chemotherapy rates, average cancer radiotherapy or chemotherapy treatment days, cancer bone marrow transplantation rates, cancer mortality rates, and other cancer rates, available to the premium calculation in empirical analysis. Finally, we examine the premiums of three whole life insurance policies to compare to our results in empirical analysis and discuss whether premiums are adequate. We hope that this paper could be beneficial to the actuaries and also provide suggestions for the government surveillance.

Background: Dilated Cardiomyopathy (DCM) is the most common functional type of cardiomyopathy in children with significant morbidity and the leading indication for cardiac transplant over 5 years of age. Identification of baseline risk factors for failing medical management by etiologic grouping remain to be elucidated in a large populationbased study. The competing risk for heart death between all-cause mortality and heart transplantation is often overestimated in the literature and may obscure additional novel risk factors associated with poor clinical outcomes. Methods: The National Heart Lung and Blood Institute Pediatric Cardiomyopathy Registry collected longitudinal data from 1731 children with DCM in North America from 1990 to 2007. Composite endpoint (CEP) was the earlier occurrence of death or heart transplant. Univariate and multivariate predictors were identified from demographic and echocardiographic data (expressed as z-scores) collected within 30 days of diagnosis. A competing risk analysis was performed calculating cumulative incidence and identifying novel prognostic factors. All analyses were performed by etiologic group. Results: Multivariate Cox regression identified the highest mortality risk among children with idiopathic disease (N=1192, CEP: 41%) when diagnosed over age 6 years, and with congestive heart failure (CHF) and decreased left ventricular fractional shortening (FS). Risk factors for those with myocarditis (N=272, CEP: 26%) were older age, CHF, and increased left ventricular (LV) end-diastolic dimension (EDD); while for neuromuscular disease (N=139, CEP: 40%), it was a decreased FS and increased EDD. Only univariate predictors were identified for children with familial isolated cardiomyopathy (N=79, CEP: 44%) including: CHF, increased EDD, end-systolic dimension, or LV mass, and decreased FS or ejection fraction), while for children with inborn errors of metabolism (N=43, CEP: 33%) risk factors included: a positive family history of cardiomyopathy or genetic syndromes. The group of children with malformation syndromes (N=6, CEP: 50%) was not large enough to model. Comparison of cause-specific event rates between Kaplan-Meier and cumulative incidence demonstrated an overestimation with the former method. Competing risk multivariate regression showed similar models to those for CEP, with the following exceptions: for neuromuscular disease, an increased EDD had a larger hazard ratio for transplant than for death; for idiopathic disease, an increased EDD was associated with transplant, but not with death, and growth retardation (height-for-age zscore) was associated with death but not transplant. Conclusions: Within etiologic grouping, demographics and echocardiographic values at diagnosis have varying predictive value. Generally, the presence of symptomatic disease in the form of CHF, echocardiographic evidence of more severe DCM, and increased age were indicative of worse outcomes. These results help to validate those from conflicting studies; however, they suggest that etiology modifies the importance of particular factors. Analysis of competing risk provides an alternate interpretation of studies with composite endpoints and assists in the transfer of clinically relevant information. For children with idiopathic and neuromuscular disease, the degree of dilation had a differential effect that has gone unrecognized. The novel finding of reduced stature and its effect on mortality suggests a potential for treatment and mitigation of poor outcomes in idiopathic DCM. Both increased dilation and reduced stature could be used to improve the triage process and refer children to cardiac transplantation who otherwise might die prematurely and unnecessarily. Subsequent studies on the utility of these factors and their effect on improving survival are warranted.

The bacterium Listeria monocytogenes can cause the disease listeriosis in both humans and animals. For the epidemiological investigation of listeriosis detection and characterisation of the organism are important steps. Paper I. There are few reports on the incidence of L. monocytogenes in clinical samples from humans in India. Therefore, we investigated 144 samples from immunocompromised patients. L. monocytogenes was isolated from two placental bits from women with poor obstetric history, one patient with renal failure and three other patients. Five isolates were positive for the virulence genes hlyA, actA and iap. The sixth isolate was positive for hlyA and actA genes. Paper II. Characterisation of 601 human L. monocytogenes isolates causing invasive listeriosis during the period 1986 to 2007 in Sweden reveals a decrease in serovar 4b strains. Since 1996, serovar 1/2a has become the predominant serovar causing human listeriosis: PFGE analysis revealed two clusters including different serotypes suggesting that we need more studies on genetic relatedness among clinical isolates. Paper III. The incidence of Listeria species in seafood from markets in Goa was studied. One hundred and fifteen raw/fresh seafoods bought at the fish markets were sampled and tested for presence of Listeria spp. L. monocytogenes was detected in 10 samples. L. monocytogenes in raw seafood may pose a health risk in kitchen if contaminating ready-to-eat food. Paper IV. Gravad and cold-smoked salmon are associated with human listeriosis in Sweden. L. monocytogenes was isolated from 11 of 56 products. Serovar 1/2a was predominant, followed by 4b. REA/PFGE typing of the isolates identified five types of L. monocytogenes. One type was identical to a human type, two other were closely related.These findings suggest that gravad and cold-smoked salmon are still possible sources of listeriosis in Sweden. Paper V. Many outbreaks of listeriosis have been related to consumption of dairy-associated products. Therefore, 123 farm bulk milk samples in India and 20 cervico-vaginal samples from dairy cows with reproductive disorders were investigated for L. monocytogenes. L. monocytogenes was isolated from 17.9% of bulk milk samples and from 10% of cervico-vaginal swabs. The virulence gene hlyA was detected in all isolates. These findings represent a public health risk where unpasteurised milk and milk products are largely consumed. Paper VI. Isolates of L. monocytogenes (n=177) from 22 animal species were characterized and compared with human strains isolated between 1986-2006 in Sweden. Although many animals and humans shared pulsovars, they did not appear at the same time or with the same proportion of strains. The pulsovars shared by both animals and humans may indicate that there is an exchange of L. monocytogenes strains between these two groups due to either direct or indirect transmission. / <p>The work is done in cooperation with the School of Hospitality, Culinary Arts &amp; Meal Science, Örebro UniversityVishal Singh Parihar, Örebro University, Department of Restaurant and Culinary Arts, Sörälgsvägen 2, SE-712 60 Grythyttan, Sweden or ICAR Research Complex for Goa, Ela, Old Goa – 403402, Goa, India. Phone 0832-2284678/79; Fa:0832-2285649. E-mail: drvishu@yahoo.co.in</p>

<p>Oral cancer is characterised by marked geographical differences in frequency and site preference as reported by various studies. In South Africa, a few studies have been reported on the patterns and aetiology of oral cancer, and age standardised incidence rates (ASIR). Studies in several countries have shown an increase in oral cancer incidence among younger people. Title:&nbsp / Epidemiology of oral cancer in South Africa 1996-2002.&nbsp / Aim and Objective: The aim of this study was to determine the age standardised incidence rates (ASIR) of oral cancer by age, gender, race&nbsp / and site in South Africa for a consecutive period of seven years. Method: Pathology case records of oral cancer diagnosed over a seven-year period from 1996 to 2002 and reported to the National&nbsp / Cancer Registry (NCR) were analysed for age, sex, race, and date of diagnosis, basis of diagnosis, topography and tumour type. The data was tabulated and categorised using Microsoft Excel. The South African population size for each year of the study was estimated by linear extrapolation using the 1996 and 2001 census results. Age standardisation incidence rates against the world&nbsp / population were calculated by the standard direct method. Results: The total number of oral squamous cell carcinoma cases over the 7-year period was 9702. The majority of cases (34%) were&nbsp / on the tongue. The male to female ratio was 1:3. The age standardized incidence rates in this study was lower among African women / (0.640 per 100000 per year) and the highest was 13.40 new cases per 100000 per year (coloured males). Lip cancer was highest among both males and females of the white population. The cumulative rate of developing oral cancer was 1:83 and 1:32 for males and females respectively.</p>

Background In the past half-century, the prevalence of asthma among children and adolescents has risen and asthma has become an important public health challenge in Sweden as well as in many other countries, necessitating further studies on this complex disease and its risk factor pattern. The studies included in this thesis aimed to investigate the clinical expression of childhood asthma over time, to describe the determinants of new-onset and remission of asthma, and to evaluate possible environmental risk factors in northern Sweden. Methods As the result of a repeated questionnaire survey among primary school children aged 7-8 years in three municipalities in the north of Sweden, two pediatric cohorts were formed, one in 1996 (n=3430) and one in 2006 (n=2585). The cohort created in 1996 was followed annually until the age of 19 years. Skin prick testing was performed on children in both cohorts. Lung function and bronchial hyperreactivity testing were carried out in children with asthma in the first cohort. The study participation and retention rates were very high in both cohorts. Among children in the second cohort living in Luleå, the home addresses were assigned to coordinates in a geographical information system (GIS) to evaluate the impact on respiratory health of living near roads with much traffic, which was measured as the number of vehicles daily. We used a validated reported diagnosis of asthma and International Study of Asthma and Allergies in Childhood (ISAAC) questions were incorporated into the questionnaire. A cross-sectional study of children of the same age ten years apart, longitudinal studies on asthma incidence and remission as well as a cross-sectional study on vehicle traffic were performed. Results While children aged 7-8 years in 2006 more often had a physician-diagnosed asthma compared to children of the same age in 1996 (7.4% vs 5.7%, p&lt;0.001), they had less asthma symptoms, especially severe symptoms. In parallel, a more beneficial environment and a more intense treatment with inhaled corticosteroids (ICS) were observed. The explanation for this change in clinical expression probably includes also an increased awareness and diagnosing of asthma. From age 12 years to age 19 years, the cumulative incidence of physician-diagnosed asthma was 7.2% and of current wheeze 22.0%. The risk of new-onset asthma in adolescence was increased among girls, sensitized and those with heredity for asthma. Smoking and home dampness increased the risk for incident wheeze. The risk for both incident asthma and wheeze was inversely related to number of siblings. Among children with current asthma at age 7-8 years, 21% were in remission, 38% had periodic asthma and 41% had persistent asthma at a follow-up at age 19 years. Subjects in remission and with periodic asthma had significantly less airway obstruction and showed less bronchial hyperreactivity compared to subjects with persistent asthma. The probability of asthma remission from childhood to early adulthood was significantly increased by absence of allergic sensitization, male gender and a low asthma severity scoring at age 7-8 years. Sensitization to furred animals was more important as a determinant of both incidence and remission than sensitization to pollen. Living close to roads with high traffic flows, especially with heavy vehicles, was associated with an increased risk for current wheeze. Stratified analyses showed that the effect of traffic on asthma and wheeze was restricted to non-sensitized subjects. Conclusion Asthma onset in adolescence was more common among girls and remission was more common among boys. Children sensitized to furred animals and children with a more severe asthma were risk groups for persistence of asthma. Environmental factors such as smoking and dampness were associated to onset of asthma symptoms during adolescence, and vehicle traffic was associated with asthma symptoms among children also in a small city with relatively low traffic flows. Preventive measures like smoking reduction programs, improvement of damp housing conditions and separation of areas where many children live from heavily trafficked roads could prove to be beneficial. / OLIN-studierna

BACKGROUND: Organ transplantation is one of the best modalities for treating fatal organ failure. Despite the success of this procedure, an increasing incidence of cancer in this population has drawn the attention of public health officials in recent years. OBJECTIVES: The overall objective of this study is to conduct a detailed examination of adverse health outcomes among Canadian organ transplant recipients, with an emphasis on cancer incidence and mortality. METHODS: This project employed a retrospective cohort follow-up study design, whereby Canadian Organ Replacement Registry records were linked to the Canadian Mortality Database and the Canadian Cancer Registry Database. The study population consisted of more than 16,000 solid organ transplant recipients registered between January 1, 1981 and December 31, 1998. This study was designed to assess the risks of developing cancer, overall and site-specific, in transplant recipients in comparison to the general Canadian population using Standardized Incidence Ratios (SIR), Standardized Mortality Ratios (SMR), and Proportionate Mortality Ratios (PMR). In addition, Cox and logistic models were used to assess the effects of various risk factors on cancer incidence and mortality in transplant sub-populations, while cumulative incidence was used to study the patient survival pattern. Lastly, Population Attributable Risk (PAR) was used to quantify the impact of organ transplantation on cancer incidence and mortality. RESULTS: Among major causes of death, the highest PMRs are due to genitourinary diseases, followed by endocrine, nutritional and metabolic diseases, and infectious diseases. SIRs indicate that cancer incidence and mortality were relatively lower than that observed for other major causes of death, and slightly higher than that observed in the general Canadian population. Lastly, logistic regression results indicate that age, year of surgery, and smoking status were significant risk factors in mortality due to all causes, while the Cox regression model shows that age, sex and year of surgery were significant risk factors for cancer incidence. Overall, the PAR in this cohort was very minimal, indicating that the risk in mortality and cancer incidence due to organ transplantation is negligible. CONCLUSION: Life threatening diseases such as those of the genitourinary system, as well as endocrine, nutritional and metabolic diseases and infectious diseases are leading causes of death. Future research should be directed at ways of reducing incidence and subsequent mortality due to these causes.

This bachelor thesis is written as a part of the geography program at Stockholm University, Sweden, and the study was conducted from April to June 2012. Tuberculosis (TB) is an airborne disease and one of the most widespread infectious diseases in the world with more than nine million new cases each year (SMI 2012, digital source). The disease is a major source of death and suffering in many places and the number of deaths remains high despite the availability of highly efficacious treatment. To control and prevent further spread of TB, the mapping of the disease spatial distribution is of essential importance. In this study, maps were produced that shows the spatial distribution of TB between the years 2002 to 2011 in the municipality of Stockholm. These maps allow an analysis of the spatial distribution at a local scale over time. The aim of this paper is to study how the spatial distribution of TB has looked like in the municipality of Stockholm the last 10 years and to analyze why the spatial distribution of the disease looked like it did. This study is based on the hypothesis “drift”. The hypothesis imply that individuals with certain conditions for a particular state of health or disease is passed (drift) to a certain location or become concentrated there through various social processes. The processes would therefore lead to fact that specific qualities or health attributes become more common in certain geographical places than others (Schæerström et al, 2011:110). The maps of the disease prevalence between the years 2002-2011 illustrates that TB was more concentrated in specific geographical areas of the municipality of Stockholm. The result of the analyzed factors in the different neighborhood areas in 2002, 2006 and 2010 reveals that there are individuals with certain socio-economic conditions which are largely concentrated in the areas mentioned above. The results provide a basis for an assumption that the cause of the spatial distribution of TB during the studied period largely depends on what the drift hypothesis implies. Drift is therefore a likely contributing factor to the fact that particular characteristics and health manifestations were more common in certain geographical places than others in the municipality of Stockholm between the years 2002-2011.

No description available.

Essay one develops and tests a revenue-maximizing tax structure model. This model represents one of the first attempts to evaluate and compare the responsiveness of various tax instruments to tax evasion within a tax revenue maximization framework. We use data from both the OECD and East African countries and estimation is via a seemingly unrelated regression model. The GDP share of agricultural income is used as an instrument to correct for the simultaneity between tax revenue shares and tax evasion. Our findings indicate that tax evasion increases the tax authority’s reliance on consumption taxes vis-à-vis taxes on income, suggesting that diverse tax instruments respond differently to tax evasion, and as such the choice of a revenue-maximizing tax structure is influenced by the amount of revenue lost through tax evasion. Essay two analyzes the incidence of tax evasion in both the formal and informal sectors of the economy using a computable general equilibrium model. This essay incorporates the element of uncertainty in an individual’s decision to evade so as to account for the uncertainty of returns to the tax evader. We also allow for varying degrees of competi¬tion or entry across sectors in the economy to examine how much of the tax advantage is retained by the initial evaders and how much is shifted via factor and commodity price changes. Our simulation results show that the evading households’ post-evasion welfare is only 0.68-3.40 percent higher than the post-tax welfare if it had fully complied with taxes. The simulation results further reveal that the evading household keeps 77.1-83.2 percent of this initial increase in welfare, while 16.8-22.9 percent of this initial gain is competed away as a result of increased competition and entry into the informal sector. The compliant households’ welfare increases by 58.8-101.7 percent with increased competition in the informal sector. Therefore, if we construe the changes in consumer welfare as an overall indicator of the gains and/or losses from tax evasion, then the evading household only benefits marginally and this advantage diminishes with increased entry or competition in the informal sector.

BACKGROUND: Organ transplantation is one of the best modalities for treating fatal organ failure. Despite the success of this procedure, an increasing incidence of cancer in this population has drawn the attention of public health officials in recent years. OBJECTIVES: The overall objective of this study is to conduct a detailed examination of adverse health outcomes among Canadian organ transplant recipients, with an emphasis on cancer incidence and mortality. METHODS: This project employed a retrospective cohort follow-up study design, whereby Canadian Organ Replacement Registry records were linked to the Canadian Mortality Database and the Canadian Cancer Registry Database. The study population consisted of more than 16,000 solid organ transplant recipients registered between January 1, 1981 and December 31, 1998. This study was designed to assess the risks of developing cancer, overall and site-specific, in transplant recipients in comparison to the general Canadian population using Standardized Incidence Ratios (SIR), Standardized Mortality Ratios (SMR), and Proportionate Mortality Ratios (PMR). In addition, Cox and logistic models were used to assess the effects of various risk factors on cancer incidence and mortality in transplant sub-populations, while cumulative incidence was used to study the patient survival pattern. Lastly, Population Attributable Risk (PAR) was used to quantify the impact of organ transplantation on cancer incidence and mortality. RESULTS: Among major causes of death, the highest PMRs are due to genitourinary diseases, followed by endocrine, nutritional and metabolic diseases, and infectious diseases. SIRs indicate that cancer incidence and mortality were relatively lower than that observed for other major causes of death, and slightly higher than that observed in the general Canadian population. Lastly, logistic regression results indicate that age, year of surgery, and smoking status were significant risk factors in mortality due to all causes, while the Cox regression model shows that age, sex and year of surgery were significant risk factors for cancer incidence. Overall, the PAR in this cohort was very minimal, indicating that the risk in mortality and cancer incidence due to organ transplantation is negligible. CONCLUSION: Life threatening diseases such as those of the genitourinary system, as well as endocrine, nutritional and metabolic diseases and infectious diseases are leading causes of death. Future research should be directed at ways of reducing incidence and subsequent mortality due to these causes.