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Thanin Asawavichienjinda a
Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, b National Health
Security Office, and c Medical Service Department, Bangkok Metropolitan Administration, Bangkok , and d Bureau of
Health Administration, Ministry of Public Health, Nonthaburi, Thailand; e Department of Neurology, Geffen School
Key Words (CRM) to assess reporting biases. Methods: The three main
Parkinson’s disease ⴢ Parkinson’s disease registry ⴢ sources of data input to the Registry, i.e. (1) public hospitals,
Prevalence ⴢ Capture-recapture method (2) private hospitals and (3) self-registration, require check-
ing for duplicates and also allow estimation of completeness
of recording (the degree of underreporting) in this disease
Abstract registry. There is underreporting because of poor record
Background: Parkinson’s disease (PD) occurs worldwide but keeping and administrative procedures in some facilities,
prior to this review of data from the Thailand Parkinson’s Dis- and there is an unknown number of persons with PD who are
ease Registry there had been no nationwide PD registry re- not properly diagnosed because of inadequate facilities and
ported globally. Objective: To determine the distribution staffing in some areas. Since our data sources should be
and prevalence of PD in Thailand and related risk factors in overlapping in some way, and assuming that the likelihood
order to more adequately develop and allocate prevention of being detected in one system is independent of the oth-
and treatment resources where they are most needed and ers, we estimated these data sources’ actual coverage and
to ascertain risk factors that are specific to the Thai popula- the expected total number of patients utilizing the ‘capture-
tion. Design: The Thailand Parkinson’s Disease Registry is a recapture’ statistical technique. Results: As of March 2011,
new resource, and data collection began in March 2008. Data the Thailand PD Registry had identified 40,049 PD patients.
is collected by the Registry from physicians, and a mecha- Employing log-linear modeling, the CRM analysis based on
nism is also provided for patients to self-report. This data was the three data sets estimated underreporting of 20,516 cas-
further analyzed by the capture-recapture methodology es. The revised estimated total is thus 60,565 cases, resulting
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# PD prevalence >200/100,000
X PD prevalence 100–200/100,000
PD prevalence <100/100,000
Pesticide use 230–730 USD/farm
Pesticide use 130–230 USD/farm
Pesticide use 30–130 USD/farm
Pesticide use <30 USD/farm
es in our study (33.8%), supporting the assertion that the areas than in rural areas in London [44], Italy [45] and
CRM is a reliable method of including the undercount in Estonia [46]. Indeed, very few studies have specifically
the prevalence rate. compared the difference between rural and urban areas.
Although rural living has long been recognized as a One recent population-based study in Taiwan indicated
risk factor for PD [12, 41–43], some of the literature did that the prevalence of PD in the urban areas was twice as
not support this similarly to our own data, i.e. a higher high as in the rural areas (p ! 0.001) [47]. By applying the
prevalence of PD was reported for persons living in urban US Census 2000 urban and rural classification [1], our
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Strickland and Bertoni [14], Nebraska, USA passive PD registry 5,179 crude prevalence = 329.3
2004
Our study Thailand passive PD registry 60,565 crude prevalence = 95.34
age-adjusted = 424.57
Zhang et al. [30], 2005 Beijing, Xian, door-to-door survey with 277 crude prevalence = 1,070 (≥55 years)
Shanghai, China reexamination age-adjusted = 1,340 (≥55 years)
Wang et al. [31], 1996 Kinmen, Taiwan door-to-door survey 23 crude prevalence = 587 (≥50 years)
age-adjusted = 119
Tan et al. [32], 2004 Singapore door-to-door 46 crude prevalence = 290 (≥50 years)
age-adjusted = 250 (≥50 years)
Bharucha et al. [33], 1988 Bombay, India door-to-door 46 crude prevalence = 328.3
age-adjusted = 192
Moriwaka et al. [35], 1996 Hokkaido, Japan record-based survey 5,342 crude prevalence = 94.7
age-adjusted = 71.2
Kimura et al. [34], 2002 Japan record-based survey 963 crude prevalence = 118.7
age-adjusted = 76.6
results also indicated that the prevalence of PD in urban ual provinces in Thailand with reference to the amount
cities in Thailand is 1.4 times higher than those in rural of pesticide use in each province as shown in figure 2.
cities (p ! 0.001). While a disparity can be due to the dif- The results from this ecologic comparison indicated that
ferences in studied populations, the effect of age cohorts, two provinces (Chainat and Singburi) in the central plain
environmental factors and types of urbanization, the region of Thailand that have the highest prevalence of
risks associated with rural living observed in the univar- PD were also reported to use the largest amount of pesti-
iate analysis may be confounded by exposure to pesti- cides – more than 230 USD per farm per crop year. Fur-
cides, used in rural homes and farming [12]. The latter thermore, a recent study also demonstrated the high in-
possibility was supported by a case-cohort study in Tai- door air concentration of organochlorine pesticides in
wan indicating that the increased risk of PD associated urban homes in the Bangkok Metropolitan Region [3].
with rural residence was no longer statistically significant This may play a role in the higher prevalence of PD in ur-
when applying multiple conditional logistic regression ban areas in Thailand. The finding of high pesticide use
analysis to adjust for previous occupational pesticide use in the areas of high prevalence of PD in Thailand is con-
[48]. sistent with a growing body of information linking pesti-
Pesticides have been consistently implicated as one of cide exposures and PD and should be followed up in a
the most likely major environmental risk factors for PD population-based case-control study with individual lev-
[12, 49–51]. This potential link has been particularly el exposure data.
strong for organophosphates, organochlorines, rotenone Our results provide additional interesting findings
and paraquat, partly due to a structural similarity be- implicating urbanization and pesticide use as risk factors
tween the neurotoxin 1-methyl-4-phenylpyridinium and of PD in Thailand. Nevertheless, the CRM is not without
these pesticides [52]. Pesticide imports to Thailand have limitations, and additional methodological and concep-
increased rapidly over the past decade, and total tonnage tual research needs to be devoted in its refinement. What
has more than doubled between 2010 and 1996 [4, 5]. Pes- is critical in our PD Registry is that the CRM will not
ticide residues, especially organophosphate compounds, count cases that have never been diagnosed due to lim-
have been found in soil, water and agricultural products ited access to health care; rather it provides relatively ac-
throughout the country [6] and there are mounting con- curate estimates of PD cases that have been diagnosed but
cerns that increased pesticide use in Thailand may partly were not captured by our systems [18]. Therefore, since
be responsible for the increased numbers of patients with our technique counts only diagnosed cases of PD and
neurodegenerative disorders such as PD [13, 53]. There- does not count undiagnosed PD, we may still underesti-
fore, we have estimated the prevalence of PD in individ- mate the prevalence of PD in Thailand. Another limita-
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Appendix
References 1 United States Census Bureau: Census 2000
urban and rural classification. United States
List of the Committee Members of the Thailand PD Census, 2000.
Registry Collaborative Network 2 2010 Thailand statistical yearbook, Special
Edition. Bangkok, Statistical Forecasting
Thailand PD Registry Working Committee Bureau, National Statistical Office, 2010.
(1) The TRC Society 3 Pentamwa P, Oanh NT: Levels of pesticides
Mr. Phan Wannamethee; Assoc. Prof. Roongroj Bhidayasiri; and polychlorinated biphenyls in selected
Prof. Adisorn Phatharadul; Ms. Nonthiya Kaewket; Dr. Priya Ja- homes in the Bangkok Metropolitan Region,
Thailand. Ann NY Acad Sci 2008; 1140: 91–
gota; Dr. Surat Singmaneesakulchai; Ms. Nutthaporn Simsiriwat; 112.
Ms. Surasa Kongprasert; Ms. Lalita Kaewwilai; Ms. Kamolwan 4 IPM DANIDA Project: Strengthening farm-
Boonpeng; Mr. Neil Brenden; Ms. Sudaluk Inpom; Prof. Kam- ers’ IPM in pesticide-intensive areas: did you
mant Phanthumjinda; Ms. Krongthong Petwong; Ms. Suwaree take your poison today? Bangkok, Depart-
Leelasethakul; Dr. Natlada Limotai; Dr. Suthida Boonyawairoj; ment of Agriculture, 2003.
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