Northward expansion of the tick Ixodes scapularis is driving Lyme disease (LD) emergence in Canada. Information on mechanisms involved is needed to enhance surveillance and identify where LD risk is emerging.
We used passive and active surveillance and phylogeographic analysis of Borrelia burgdorferi to investigate LD risk emergence in Quebec.
In active surveillance, we collected ticks from the environment and from captured rodents. B. burgdorferi transmission was detected by serological analysis of rodents and by polymerase chain reaction assays of ticks. Spatiotemporal trends in passive surveillance data assisted interpretation of active surveillance. Multilocus sequence typing (MLST) of B. burgdorferi in ticks identified likely source locations of B. burgdorferi.
In active surveillance, we found I. scapularis at 55% of sites, and we were more likely to find them at sites with a warmer climate. B. burgdorferi was identified at 13 I. scapularis-positive sites, but infection prevalence in ticks and animal hosts was low. Low infection prevalence in ticks submitted in passive surveillance after 2004-from the tick-positive regions identified in active surveillance-coincided with an exponential increase in tick submissions during this time. MLST analysis suggested recent introduction of B. burgdorferi from the northeastern United States.
These data are consistent with I. scapularis ticks dispersed from the United States by migratory birds, founding populations where the climate is warmest, and then establishment of B. burgdorferi from the United States several years after I. scapularis have established. These observations provide vital information for public health to minimize the impact of LD in Canada.
Cites: Am J Trop Med Hyg. 1988 Jul;39(1):105-93400797
OBJECTIVE: Exposure to environmental organochlorines has been examined as a potential risk factor for human breast cancer with mixed results. Our purpose was to examine associations between organochlorines and the development of breast cancer in a large prospective study using stored adipose tissue. METHODS: We conducted a nested case-control study of 409 postmenopausal women who developed breast cancer and 409 controls selected from the 29,875 women enrolled in the Danish Diet, Cancer, and Health cohort between 1993 and 1997. We measured concentrations of 14 pesticides and 18 polychlorinated biphenyls in adipose tissue, collected upon enrollment, and estimated relative risk (RR) of breast cancer using conditional logistic regression. RESULTS: The results showed no higher risk of breast cancer among women with higher levels of any pesticides or polychlorinated biphenyls; the RR associated with the upper quartile of 1,1-dichloro-2, 2-bis(p-chlorophenyl)ethylene concentration was 0.7 [95% confidence interval (95% CI), 0.5-1.2] contrasting the lower quartile, and for the sum of polychlorinated biphenyls the similar risk was 1.1 (95% CI, 0.7-1.7). We observed a pattern of substantially lower risk of estrogen receptor-negative breast cancer in association with higher levels of most of the pesticides and polychlorinated biphenyls; the RR for the higher quartile of 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene was 0.1 (95% CI, 0.0-0.5) and for the sum of polychlorinated biphenyls it was 0.3 (95% CI, 0.1-0.9). CONCLUSION: The results do not support that higher organochlorine body levels increase the risk of breast cancer in postmenopausal women. The interpretation of the inverse association for estrogen receptor-negative breast cancer is currently unclear.
The association between advancing paternal age and increased risk of schizophrenia in the off-spring is well established. The underlying mechanisms are unknown. In order to investigate whether the psychosocial environment associated with growing up with an aged father explains the increased risk we conducted a study of all adoptive children in Sweden from 1955-1985 (n =31 188). Their risk of developing schizophrenia or non-affective psychosis in relation to advancing age of their adoptive fathers' was examined. We found no association between risk of psychoses and advancing adoptive paternal age. There was no support of psychosocial environmental factors explaining the "paternal age effect".
Cites: Arch Gen Psychiatry. 2001 Apr;58(4):361-711296097
Cites: Nature. 2012 Aug 23;488(7412):471-522914163
Cites: Am J Psychiatry. 2002 Sep;159(9):1528-3312202273
Cites: Am J Psychiatry. 2002 Sep;159(9):1591-212202282
OBJECTIVES: This study examined certain occupational exposures and the risk for adult-onset asthma. METHODS: A nested case-referent study of adult-onset asthma was performed on a random population sample (N=15813), aged 21 to 51 years. Cases for the study included 2 groups: subjects reporting "physician-diagnosed" asthma (N=251) and a broader "asthma" group (N=362). The "asthma" group consisted of subjects with "physician-diagnosed" asthma (N=251) and subjects reporting asthma-like symptoms without having "physician-diagnosed" asthma (N=111). The referents (N=2044) were randomly selected from the whole population sample. The case-referent sample was investigated with a comprehensive questionnaire about occupational exposures, asthma, respiratory symptoms, smoking, and atopy. Odds ratios were calculated with stratification for gender, year of diagnosis, and birth year. RESULTS: The highest odds ratio for "physician-diagnosed" asthma was associated with exposure to flour dust [odds ratio (OR) 2.8, 95% confidence interval (95% CI) 1.5-5.2] and the occupational handling of resin-based paints (isocyanates) (OR 3.0, 95% CI 1.6-5.9). Exposure to welding fumes, textile dust, and work with glues containing acrylates was also associated with an increased odds ratio for "physician-diagnosed" asthma. Including persons with asthma-like symptoms (ie, the asthma group) showed similar results. CONCLUSION: This population-based case-referent study from Sweden indicates that occupational exposure to acrylate-based compounds and welding fumes is associated with increased risk for adult-onset asthma.
This retrospective cohort study evaluated adverse birth outcomes in infants whose birth records indicated maternal residence in villages containing dumpsites potentially hazardous to health and environment. Birth records from 1997 to 2001 identified 10,073 eligible infants born to mothers in 197 Alaska Native villages. Outcomes included low or very low birth weight, preterm birth, and intrauterine growth retardation. Infants from mothers in villages with intermediate (odds ratio (OR) = 1.73, 95% confidence interval (CI): 1.06, 2.84) and high (OR = 2.06, 95% CI: 1.28, 3.32) hazard dumpsites had a higher proportion of low birth weight infants than did infants from mothers in the referent category. More infants born to mothers from intermediate (OR = 4.38, 95% CI: 2.20, 8.77) and high (OR = 3.98, 95% CI: 1.93, 8.21) hazard villages suffered from intrauterine growth retardation. On average, infants weighed 36 g less (95% CI: -71.2, -0.8) and 55.4 g less (95% CI: -95.3, -15.6) when born to highly exposed mothers than did infants in the intermediate and low exposure groups, respectively, an effect even larger in births to Alaska Native mothers only. No differences in incidence were detected across exposure levels for other outcomes. This is the first study to evaluate adverse pregnancy outcomes associated with open dumpsites in Alaska Native villages.
Exposure to microorganisms resistant to antimicrobials may constitute a health risk to human populations. It is believed that one route of exposure occurs when people engage in recreational activities in water contaminated with these microorganisms. The main objective of this study was to explore population-level and environmental determinants specifically associated with the presence of antimicrobial resistant (AMR) generic Escherichia coli isolated from recreational waters sampled from beaches located in southern Quebec, Canada. Water samples originated from the Quebec provincial beach surveillance program for the summers of 2004 and 2005. This study focused on three classes of determinants, namely: agricultural, population-level and beach characteristics for a total of 19 specific factors. The study was designed as a retrospective observational analysis and factors were assessed using logistic regression methods. From the multivariable analysis, the data suggested that the percentage of land used for spreading liquid manure was a significant factor associated with the presence of AMR E. coli (OR=27.73). Conceptually, broad factors potentially influencing the presence of AMR bacteria in water must be assessed specifically in addition to factors associated with general microbial contamination. Presence of AMR E. coli in recreational waters from beaches in southern Quebec may represent a risk for people engaging in water activities and this study provides preliminary evidence that agricultural practices, specifically spreading liquid manure in agricultural lands nearby beaches, may be linked to the contamination of these waters by AMR E. coli.
It has been suggested that children that are exposed to a stressful environment at home have an increased susceptibility for air pollution-related asthma. The aim here was to investigate the association between air pollution exposure and asthma, and effect modification by mental health and by socio-economic status (as markers of a stressful environment). All individuals under 18 years of age in four Swedish counties during 2007 to 2010 (1.2 million people) were included. The outcome was defined as dispensing at least two asthma medications during follow up. We linked data on NO2 from an empirical land use regression to data from national registers on outcome and potential confounders. Data was analyzed with logistic regression. There was an odds ratio (OR) of 1.02 (95% Confidence Interval (CI: 1.01-1.03) for asthma associated with a 10 µg·m-3 increase in NO2. The association only seemed to be present in areas where NO2 was higher than 15 µg·m-3 with an OR of 1.09 (95% CI: 1.07-1.12), and the association seemed stronger in children with parents with a high education, OR = 1.05 (95% CI: 1.02-1.09) and OR = 1.04 (95% CI: 1.01-1.07) in children to mothers and father with a high education, respectively. The association did not seem to depend on medication history of psychiatric disorders. There was weak evidence for the association between air pollution and asthma to be stronger in neighborhoods with higher education levels. In conclusion, air pollution was associated with dispensed asthma medications, especially in areas with comparatively higher levels of air pollution, and in children to parents with high education. We did not observe support for our hypothesis that stressors linked to socio-economy or mental health problems would increase susceptibility to the effects of air pollution on the development of asthma.
Otitis media (OM) is one of the most common early childhood infections, resulting in an enormous economic burden to the health care system through unscheduled doctor visits and antibiotic prescriptions.
The objective of this study was to investigate the potential association between ambient air pollution exposure and emergency department (ED) visits for OM.
Ten years of ED data were obtained from Edmonton, Alberta, Canada, and linked to levels of air pollution: carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), sulfur dioxide, and particulate matter (PM) of median aerometric diameter
Cites: An Pediatr (Barc). 2004 Feb;60(2):133-814757016
Cites: Vaccine. 2008 Dec 23;26 Suppl 7:G5-1019094935
During the winter of 1994, the association between daily changes in air pollution and in the respiratory health of children 7 to 12 yr of age were studied in Kuopio, Finland. Seventy-four children with asthmatic symptoms and 95 children with cough only, living either in urban or suburban areas, were followed for 3 mo. During the study period, the mean daily concentration of particulate air pollution (PM10) was 18 micrograms/m3 in the urban area and 13 micrograms/m3 in the suburban area. Lagged concentrations of PM10, black smoke, and NO2 were significantly associated with declines in morning peak expiratory flow (PEF) among asthmatic children. The regression coefficient (x10) for a 2-d lag of PM10 was -0.911 (SE, 0.386) in the urban and -1.05 (0.596), in the suburban area. Among children with cough only, PM10, black smoke, and NO2 were not significantly associated with PEF. In the urban area, there was a significant association between SO2 and morning and evening PEF and incidence of upper respiratory symptoms among children who cough only. No other associations between air pollution and evening PEF or respiratory symptoms were observed. This study suggests that particulate air pollution is associated with respiratory health, especially among children with asthmatic symptoms.
Adverse health effects of exposure to high levels of air pollutants from biodegradable wastes have been well-studied. However, few investigations have examined the potential effects of chronic exposure to low-to-moderate levels on non-specific health symptoms among residents. Besides, most studies have relied on distances to waste sites to assign exposure status, and have not investigated whether the exposure-symptoms associations are direct or mediated by odor annoyance. In this study, individual-level exposures to a proxy indicator of biodegradable waste pollution (ammonia, NH3) in non-urban residences (n=454) during 2005-2010 were characterized by data from emission-dispersion validated models. Logistic regression and mediating analyses were used to examine associations between exposures and questionnaire-based data on annoyance and non-specific symptoms, after adjusting by person-specific covariates. Strong dose-response associations were found between exposures and annoyance, and between annoyance and symptoms. Associations between exposures and symptoms (nausea, headache, dizziness, difficulty concentrating and unnatural fatigue) were indirect (annoyance-mediated). This study indicates that environmental exposures play an important role in the genesis of non-specific symptoms among residents exposed to low-to-moderate air pollution from biodegradable wastes, although the effects seem to be indirect, relayed through stress-related mechanisms.
A disparity in smoking behavior exists between the general and minority populations residing in Taiwan's mountainous areas. This study analyzed individual and environmental factors associated with children's smoking behavior in these areas of Taiwan.
In this school-based study, data on smoking behavior and related factors for mountain-dwelling students were obtained from the 2008 and 2009 Control of School-aged Children Smoking Study surveys. A representative sample (N = 1239) from 26 primary schools was included. The association among 3 groups (never-, former-, and current-smokers) and the potential variables were simultaneously examined using unordered polytomous logistic regression analysis.
Between 13% and 34% of ever-smokers reported that their first smoking experience was in third grade. More than 70% were found to have bought cigarettes and 87% reported that the tobacco retailers had sold them cigarettes. The significant factors for current-smokers were predisposing factors, ie, attitude toward smoking (adjusted odds ratio [AOR] = 1.21); reinforcing factors, ie, family smoked in front of me (AOR = 2.44), friends smoked in front of me (AOR = 16.24), and school staff smoked in front of me (AOR = 2.98); and enabling factors, ie, cigarette availability and accessibility (AOR = 2.16 and 2.42, respectively). A student's perceived punishment for smoking at school had a positive significant effect on the risk of being former-smokers (AOR = 1.57).
The findings provide a basis for school and community to design and implement effective anti-smoking programs for remote mountain-based students to further reduce youth smoking.
The purpose of this study was to provide information to improve the management of childhood asthma in Canada. The Student Lung Health Survey (SLHS) was conducted as a stratified and multi-staged cluster survey across Canada in 1996. It included a total of 136 public, private and separate schools in nine health units. The target study population was schoolchildren aged 5 to 19 years. Among all 5-19 years old students, the prevalence of asthma was 13.0%, with the prevalence for males being higher than for females, the adjusted Odds Ratio (OR) was 1.17, (95% CI 1.14-1.19) for males, in comparison with females. The prevalence in the 15-19 age group was higher than that in the 5-9 and 10-14 age group in females, but it was higher in the 5-9 and 10-14 age group than in the 15-19 age group in males. The mean delay from the onset of symptoms to time of first diagnosis was 1, 0.4 and 0.3 years for the 1-4, 5-9 and 10-14 age group respectively. However, there was no delay in the 15-19 group. The prevalence of asthma in Prince Edward Island (17.9%), Halifax (17.1%), and Kingston (16.1%) was higher than that in Saskatoon (10.0%). Sherbrooke (9.7%) and Kelowna (11.9%). The proportion of asthma for students who smoked more than 11 cigarettes per day (OR = 1.41), were exposed to passive smoke in home (OR = 7.29), in car (OR = 4.71), and in school (OR = 4.24) or had a family income less than CAN$40,000 (OR = 1.19), was significantly higher than groups without those factors. Risk factors and socio-economic status such as living conditions and environment, pets or plants in the home, parental education levels also affected the morbidity of asthma. The results of the SLHS study demonstrated the serious burden of childhood asthma, and asthma triggers, living and environmental conditions and lifestyle influence the prevalence and the effects of childhood asthma diagnosis, treatment, and education in Canada. Asthma is still a serious chronic condition for students and it influences their academic performance and their quality of life. The diagnostic methods and the practice guidelines for asthma control are useful for preventing and controlling asthma. These findings provide indications of interventions are being used for the control of asthma in Canada.
This study examined the association between self-reported diabetes, fish consumption and serum levels of organochlorines in a First Nation community. One quarter of the 101 participants reported diabetes. Serum PCBs, but not p,p'-DDE, were positively correlated to consumption frequency of total fish, walleye and pike, but not trout. Reported diabetes was positively associated to p,p'-DDE and some PCB congeners. Odds Ratios (OR) for reported diabetes for those in the upper 75th percentile for serum p,p'-DDE compared to the others were 3.5 (95% CI 1-13.8) and 6.1 (95% CI 1.4-27.3) (weight wet and lipid-standardized values, respectively) and for total sum of PCBs: 4.91 (95% CI 1.4-19.0) and 5.51 (95% CI 1.3-24.1). For participants who were in the upper 50th percentile for trout and white fish intake, reported diabetes was respectively 6 and 4 times lower compared to the others. These findings support the hypothesis that environmental exposure to elevated p,p'-DDE and PCBs is associated with increased risk of diabetes. Consumption of trout and white fish may be beneficial to reduce risk.
BACKGROUND: Glutathione transferases (GST) detoxify environmental and endogenous compounds and levels of two polymorphic GST proteins, GSTM3 and GSTP1, are high in the brain. Previous studies of GSTM3 and GSTP1 polymorphisms and adult brain tumor risk have produced inconsistent results, whereas the GSTM3 -63 variant is newly identified and, therefore, has not yet been studied in this context. We therefore examined associations between GSTM3 -63, GSTM3 *A/*B, GSTP1 105, and GSTP1 114 variants and adult brain tumor risk and the interaction of the effects of these same polymorphisms with cigarette smoking. In addition, the enzymes NQO1 and CYP1A1 alter susceptibility to oxidative brain damage. Because there is less previous evidence for a role of NQO1, CYP1A1, GSTM1, and GSTT1 variants, we restricted analysis of these variants to a small preliminary study. METHODS: We genotyped DNA collected for an international population-based case-control study of 725 glioma cases, 329 of which were glioblastoma cases, 546 meningioma cases and 1,612 controls. Study participants were residents of Sweden, southeast England, Denmark, and Finland. RESULTS: We found no associations between the GSTM3, GSTP1, NQO1, CYP1A1, GSTM1, or GSTT1 polymorphisms and adult brain tumor risk with the possible exception of a weak association between the G-C (Val-Ala) GSTP1 105/114 haplotype and glioma [odds ratio (OR), 0.73; 95% confidence interval (95% CI), 0.54, 0.99], nor was there an interaction between the effects of the GSTM3 or GSTP1 polymorphisms and cigarette smoking. CONCLUSIONS: Overall, we observed no strong evidence for an association between GST or related enzyme polymorphisms and adult brain tumor risk.
To describe the investigation and management of an outbreak due to multiresistant Acinetobacter baumannii and to determine risk factors for acquisition of the organism.
A 14-bed regional burn unit in a Canadian tertiary-care teaching hospital.
Case-control study with multivariate analysis of potential risk factors using logistic regression analysis. Surveillance cultures were obtained from the hospital environment, from noninfected patients, and from healthcare providers.
A total of 31 (13%) of 247 patients with acute burn injuries acquired multiresistant A. baumannii between December 1998 and March 2000; 18 (58%) of the patients were infected. The organism was recovered from the hospital environment and the hands of healthcare providers. Significant risk factors for acquisition of multiresistant A. baumannii were receipt of blood products (odds ratio [OR], 10.8; 95% confidence interval [CI95], 3.4 to 34.4; P
BACKGROUND: Pseudomonas aeruginosa is an opportunistic bacterium that can cause severe infection in susceptible patients. During the winter of 2001-2002, we investigated an outbreak of P. aeruginosa infection among patients in several hospitals across Norway. METHODS: A nationwide outbreak investigation was performed with case finding, questionnaires, and product sampling. All available clinical and environmental P. aeruginosa strains were genotyped. Detailed information was collected from patients with the outbreak strain or with any P. aeruginosa in blood or cerebrospinal fluid samples. To identify risk factors, we conducted a case-control study among patients with P. aeruginosa isolated from blood or cerebrospinal fluid samples during October 2001-December 2002. Case patients were patients infected with the outbreak genotype, and control subjects were patients infected with other genotypes. RESULTS: A total of 231 patients from 24 hospitals were identified as having the outbreak strain; 39 of these patients had positive blood culture results. Seventy-one patients (31%) died while hospitalized; all of the patients who died had severe underlying disease. Among 39 case patients and 159 control subjects, use of the moist mouth swab (adjusted odds ratio, 5.3; 95% confidence interval, 2.0-13.6) and receipt of mechanical ventilation (adjusted odds ratio, 6.4; 95% confidence interval, 2.3-17.2) were associated with infection due to the outbreak strain. Genotypically identical strains of P. aeruginosa were identified in 76 mouth swabs from 12 different batches and from the production line. CONCLUSIONS: Contamination of mouth swabs during production caused the largest-ever outbreak of P. aeruginosa infection in Norway. Susceptible patient groups should use only documented quality-controlled, high-level-disinfected products and items in the oropharynx.
No comprehensive data on sources or risk factors of cadmium exposure in Ukrainian children are available. In this we measured the blood levels of cadmium among 80 Ukrainian children and evaluated sources of exposure. A nested case-control study from a prospective cohort of Ukrainian 3-year-old children was conducted. We evaluated predictors of elevated blood cadmium using a multivariable logistic regression model. The model included socioeconomic data, parent occupation, environmental tobacco smoke, hygiene, body-mass index, and diet. Dietary habits were evaluated using the 1992 Block-NCI-HHHQ Dietary Food Frequency survey. Elevated cadmium was defined as blood levels in the upper quartile (0.25 microg/L). The mean age for all 80 children was 36.6 months. Geometric mean cadmium level was 0.21 microg/L (range = 0.11-0.42 microg/L; SD = 0.05). Blood cadmium levels were higher among children taking zinc supplements (0.25 vs 0.21 microg/L; P = 0.032), children who ate sausage more than once per week (0.23 vs 0.20; P = 0.007) and children whose fathers worked in a by-product coking industry (0.25 vs 0.21; P = 0.056). In the multivariable model, predictors of elevated blood cadmium levels included zinc supplementation (adjusted OR = 14.16; P
During the past four decades, there has been an increase in the incidence rate of male reproductive disorders in some, but not all, Western countries. The observed increase in the prevalence of male reproductive disorders is suspected to be ascribable to environmental factors as the increase has been too rapid to be explained by genetics alone. To study the association between complex chemical exposures of humans and congenital cryptorchidism, the most common malformation of the male genitalia, we measured 121 environmental chemicals with suspected or known endocrine disrupting properties in 130 breast milk samples from Danish and Finnish mothers. Half the newborns were healthy controls, whereas the other half was boys with congenital cryptorchidism. The measured chemicals included polychlorinated biphenyls (PCBs), polybrominated diphenyl-ethers, dioxins (OCDD/PCDFs), phthalates, polybrominated biphenyls and organochlorine pesticides. Computational analysis of the data was performed using logistic regression and three multivariate machine learning classifiers. Furthermore, we performed systems biology analysis to explore the chemical influence on a molecular level. After correction for multiple testing, exposure to nine chemicals was significantly different between the cases and controls in the Danish cohort, but not in the Finnish cohort. The multivariate analysis indicated that Danish samples exhibited a stronger correlation between chemical exposure patterns in breast milk and cryptorchidism than Finnish samples. Moreover, PCBs were indicated as having a protective effect within the Danish cohort, which was supported by molecular data recovered through systems biology. Our results lend further support to the hypothesis that the mixture of environmental chemicals may contribute to observed adverse trends in male reproductive health.
Given the frequency with which families change residences, the effects of childhood relocations have gained increasing research attention. Many researchers have demonstrated that childhood relocations are associated with a variety of adverse outcomes. However, drawing strong causal claims remains problematic due to uncontrolled confounding factors.
We utilized longitudinal, population-based Swedish registers to generate a nationally representative sample of offspring born 1983-1997 (n = 1 510 463). Using Cox regression and logistic regression, we examined the risk for numerous adverse outcomes after childhood relocation while controlling for measured covariates. To account for unmeasured genetic and environmental confounds, we also compared differentially exposed cousins and siblings.
In the cohort baseline model, each annual relocation was associated with risk for the adverse outcomes, including suicide attempt [hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.19-1.20]. However, when accounting for offspring and parental covariates (HR 1.08, 95% CI 1.07-1.09), as well as genetic and environmental confounds shared by cousins (HR 1.07, 95% CI 1.05-1.09) and siblings (HR 1.00, 95% CI 0.97-1.04), the risk for suicide attempt attenuated. We found a commensurate pattern of results for severe mental illness, substance abuse, criminal convictions, and low academic achievement.
Previous research may have overemphasized the independent association between relocations and later adverse outcomes. The results suggest that the association between childhood relocations and suicide attempt, psychiatric problems, and low academic achievement is partially explained by genetic and environmental confounds correlated with relocations. This study demonstrates the importance of using family-based, quasi-experimental designs to test plausible alternate hypotheses when examining causality.
Helmholtz Zentrum Muenchen - German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, PO Box 1129, 85758 Neuherberg, Germany. firstname.lastname@example.org
BACKGROUND: Studies on the association between access to health care and household income have rarely included an assessment of 'forgone care', but this indicator could add to our understanding of the inverse care law. We hypothesize that reporting forgone care is more prevalent in low income groups. METHODS: The study is based on the 'Survey of Health, Ageing and Retirement in Europe (SHARE)', focusing on the non-institutionalized population aged 50 years or older. Data are included from France, Germany, Greece, Italy and Sweden. The dependent variable is assessed by the following question: During the last twelve months, did you forgo any types of care because of the costs you would have to pay, or because this care was not available or not easily accessible? The main independent variable is household income, adjusted for household size and split into quintiles, calculating the quintile limits for each country separately. Information on age, sex, self assessed health and chronic disease is included as well. Logistic regression models were used for the multivariate analyses. RESULTS: The overall level of forgone care differs considerably between the five countries (e.g. about 10 percent in Greece and 6 percent in Sweden). Low income groups report forgone care more often than high income groups. This association can also be found in analyses restricted to the subsample of persons with chronic disease. Associations between forgone care and income are particularly strong in Germany and Greece. Taking the example of Germany, forgone care in the lowest income quintile is 1.98 times (95% CI: 1.08-3.63) as high as in the highest income quintile. CONCLUSION: Forgone care should be reduced even if it is not justified by an 'objective' need for health care, as it could be an independent stressor in its own right, and as patient satisfaction is a strong predictor of compliance. These efforts should focus on population groups with particularly high prevalence of forgone care, for example on patients with poor self assessed health, on women, and on low income groups. The inter-country differences point to the need to specify different policy recommendations for different countries.