Drug use among the urban poor in Kolkata: behaviour and environment correlates of low HIV infection.

BACKGROUND: HIV infection in injecting drug users (IDUs) has worked as a driving force for further spread of the virus in other population groups. Major metropolitan cities such as Mumbai, Kolkota, Chennai and Delhi have seen a diffusion of injecting drug use within the last decade. The prevalence of HIV infection among injectors ranges from 2% to 30%. Identifying effective interventional elements that have kept the prevalence of HIV low for the past 7 years among IDUs of Kolkata is thus of public health importance. METHODS: A purposive sample of opioid/opiate users was studied. Primary and secondary data on drug users, law-enforcement environment, records at drug treatment centres, jail admission data related to the 'Narcotic Drug and Psychotropic Substance Act' and interventions in other risk groups were collected. Laboratory tests for HIV, hepatitis B surface antigen and syphilis were done on consenting IDUs (n=129) and non-IDUs (n=120). For univariate and multivariate analysis, IDUs were taken as cases and non-IDUs as controls. RESULT: Of the IDUs, 2% were positive for HIV. No non-IDU was HIV-positive. Significantly more non-IDUs (10% v. 4%, p=0.05) were positive for syphilis. Sharing injection equipment within the past 6 months was reported by 71% of IDUs; sharing partners were stable and ranged from 1 to 3. More IDUs compared to non-IDUs reported being in touch with intervention programmes. The police has been tolerant to needle-syringe exchange and oral sublingual buprenorphine substitution conducted in Kolkata. Unlike in the early 1990s, non-IDUs did not switch to injecting during non-availability of brown sugar in the latter half of the 1990s and instead sought tratment. The availability of high quality heroin (>20%-50%) was low and the proportion of moderate quality heroin (>10%-20%) went up during these times due to increased police seizures. No intervention exists in jails despite the fact that a large number of drug users spend time in jail. CONCLUSION: Stable and few injection equipment-sharing partners of IDUs, launching of early targeted interventions among IDUs and sex workers in the city, police tolerance to harm reduction activities and preference of non-IDUs for detoxification during heroin draught periods have kept HIV prevalence at a low level among drug users of Kolkata for the past 7 years. immediate launching of interventions for drug users in jails seems necessary. Similar multi-pronged strategies with targeted and environmental intervention could work in other settings as well.

Tetracycline in the treatment of severe cholera due to Vibrio cholerae O139 Bengal.

Vibrio cholerae O139 synonym Bengal, recognized in 1993, is the second member in the list of about 200 serogroups of V. cholerae with epidemic and pandemic potential. Although replacement of fluids and electrolytes remains the cornerstone in the management of cholera, antimicrobial therapy can significantly shorten the duration of diarrhoea, and reduce stool volume and requirements ofrehydration fluids. The role of antimicrobial therapy on the natural course of the disease caused by this relatively new pathogen has not been systematically assessed. A randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the efficacy of tetracycline in the treatment of adults with severe cholera due to V. cholerae O139 Bengal. Forty-three adult males with severe cholera were randomly allocated to receive either 500 mg of tetracycline (n=21) or placebo (n=22) for three consecutive days. Demographic and clinical characteristics of these patients on admission were comparable. Tetracycline therapy was associated with significantly reduced total median (inter-quartile range) stool volume [216.48 (90.18-325.22) mL/kg vs 334.25 (215.12-537.64) mL/kg; p=0.001], higher rates of clinical cure (81% vs 27%; p<0.001), and shorter median (inter-quartile range) duration of diarrhoea [32 (24-48) hours vs 80 (48-104) hours; p<0.001]. The mean +/- (SD) requirement of intravenous fluid was not significantly different between the two groups [146.42 +/- 42.12 mL/kg vs 150.44 +/- 27.21 mL/kg; p=0.70]. The median (inter-quartile range) duration of faecal excretion of V. cholerae O139 was significantly shorter in the tetracycline group than the placebo group [1(1-2) day vs 5 (3-6) days; p<0.001]. The results of the study indicate that tetracycline therapy is clinically useful in the treatment of severe cholera due to V. cholerae O139 Bengal.

Vibrio cholerae O139 Bengal: a descriptive study.

A prospective study was conducted to determine the clinical and laboratory characteristics and the clinical course of cholera due to Vibrio cholerae O139 Bengal. The study subjects included 22 adult males with stool culture-proven V. cholerae O139. On enrollment, mean +/- SD concentrations (mmol/L) of serum sodium, potassium, chloride, and bicarbonate were 134 +/- 3, 4 +/- 1, 102 +/- 4, and 13 +/- 4 respectively, and stool sodium, potassium, chloride, and bicarbonate concentrations were 120 +/- 24, 18 +/- 6, 93 +/- 16, and 37 +/- 9 respectively. Seventeen patients (7.8%) had faecal leukocytes ranging from 11 to 50 per high-power field. All V. cholerae O139 isolates (100%) were susceptible to tetracycline, erythromycin, and ciprofloxacin, 92% to furazolidine, and only 5% to trimethoprim-sulphamethaxazole. The median (interquartile) volume of liquid stool during the first 24 hours was 9 (5-12) litre. The median (interquartile) volume of liquid stool and the amounts of intravenous and oral rehydration fluids required during the entire study period were 16 (9-24) litre, 9 (6-18) litre, and 14 (9-20) litre respectively. The median (interquartile) duration of diarrhoea was 80 (48-104) hours. The median (interquartile) duration of excretion of V. cholerae O139 in stool was 5 (3-6) days. Clinical and laboratory features, and case management of cholera due to V. cholerae O139 are very similar to conventional cholera due to V. cholerae O1.

Shelf-life of pre-cooked rice oral rehydration salt packets.

The shelf-life of pre-cooked rice oral rehydration salts (ORS) at the household level was studied in urban Dhaka. To prepare the packets, cooked rice was dried and ground to fine powder and the salt ingredients were mixed according to the World Health Organization formulation. For each half liter packet, 10 g glucose was replaced by 25 g of instant cooked rice powder. The packets were kept in different environments for three months among 30 households of varying socioeconomic status. At monthly intervals, two packets from each family were collected for laboratory tests. Physical characteristics of ORS such as color and dispersibility remained the same throughout the three month study period. However, in the third month flavor changed slightly. The electrolyte concentration of the prepared solution remained the same at the end of the first, second and third months. However, progressive but minimal increase in moisture content of the packets was noted over the allotted time period. This increase in moisture was less when the mixture was packed in double thin layer polythene bags as opposed to the single layer bags. In conclusion, the shelf-life of pre-cooked rice ORS remains stable at least up to three months when stored at the household level. Therefore, pre-cooked rice ORS can be kept at households for future use in the event of diarrheal episodes.

Orientación sobre la lactancia materna en un hospital para enfermedades diarréicas / Breast-feeding counseling in a diarrhoeal disease hospital

Se adiestró a consejeras en materia de lactancia materna para que dieran asesoramiento a las madres de lactantes parcialmente amamantados y hospitalizados por diarrea, con el fin de lograr que las madres iniciaran la lactancia materna exclusiva durante su permanencia en el hospital. Se asignó de forma aleatoria a lactantes (n = 250) de 12 meses de edad o menos a un grupo de intervención y a un grupo testigo. Las madres del grupo de intervención fueron asesoradas individualmente por las consejeras, mientras que las madres del grupo testigo recibieron solo la educación sanitaria impartida en grupo rutinariamente. Durante el seguimiento que hicieron las consejeras en el hogar una semana más tarde, solo las madres del grupo de intervención fueron asesoradas. A las 2 semanas de su egreso, todas las madres fueron evaluadas en términos de sus prácticas de amamantamiento en el hogar. En cuanto a los 125 pares de madres e hijos que había en cada grupo, 60% de las madres del grupo de intervención alimentaban a sus hijos al pecho exclusivamente en el momento del egreso, en comparación con solo 6% de las madres del grupo testigo (P < 0,001); 2 semanas más tarde, estos porcentajes subieron a 75 y 8 en el grupo de intervención y en el grupo testigo, respectivamente (P < 0,001). Sin embargo, 49% de las madres del grupo testigo volvieron a alimentar a sus hijos con biberón, en comparación con 12% de las madres del grupo de intervención (P < 0,001). Por consiguiente, la orientación individual tuvo un efecto favorable en las madres, ya que hizo que iniciaran la lactancia materna exclusiva durante la hospitalización y que la siguieran practicando en el hogar. Los centros de salud maternoinfantil deben incluir la orientación sobre lactancia materna como parte integral de sus programas para mejorar las prácticas de alimentación de los lactantes.

Lactation counsellors were trained to advise mothers of partially breast-fed infants who were admitted to hospital because of diarrhoea, so that they could start exclusive breast-feeding during their hospital stay. Infants (n = 250) up to 12 weeks of age were randomized to intervention and control groups. Mothers in the intervention group were individually advised by the counsellors while mothers in the control group received only routine group health education. During follow-up at home by the counsellors a week later, only the mothers in the intervention group were counselled. All the mothers were evaluated for infant feeding practices at home two weeks after discharge. Among the 125 mother­infant pairs in each group, 60% of mothers in the intervention group were breast-feeding exclusively at discharge compared with only 6% in the control group (P < 0.001); two weeks later, these rates rose to 75% and 8% in the intervention and control groups, respectively (P < 0.001). However, 49% of mothers in the control group reverted back to bottle-feeding compared with 12% in the intervention group (P < 0.001). Thus, individual counselling had a positive impact on mothers to start exclusive breast-feeding during hospitalization and to continue the practice at home. Maternal and child health facilities should include lactation counselling as an integral part of their programmes to improve infant feeding practices.

Bioelectrical impedance measurements at various frequencies to estimate human body compositions.

Bioelectrical impedance analyses (BIA) operating at various frequencies were used to estimate body composition parameters and compared with the biochemically determined parameters by using isotopic dilution method in 22 healthy adult (30-50 years old) male human subjects. BIA instruments, operating at 50,100 KHz and 5 to 500 KHz range, were used to measure body compositions, namely total body water (TBW), fat free mass (FFM), and fat mass (FM). TBW of these subjects was also determined by deuterium dilution method. BIA methods measured at 100 KHz and using multifrequencies appear to be more accurate than at 50 KHz when compared with isotopic dilution method as standard. This accuracy could be attributed due to measurements made at higher frequencies that falls in the region where current passes through both extra- and intracellularly, thereby giving an appropriate measure of TBW. All the subjects participated in this study belong socioeconomically to the middle class and do not apparently look obese or fatty. However, the mean of their body fat, as estimated by the standard deuterium dilution method, was about 30% which is suggestive of an unapparent obesity prevailing in this class of people in Bangladesh.

Intestinal transport of water, sodium & glucose from an electrolyte solution with & without bicarbonate.

In this study we have evaluated the role of bicarbonate on water and sodium transport in normal and secreting ilea of rabbits as controversy exists regarding the inclusion of bicarbonate in oral rehydration solution (ORS). In anaesthetized rabbits 10 cm closed ileal loops were constructed and filled with 5 ml of an electrolyte solution with and without bicarbonate, which contained polyethylene glycol (PEG; mol wt 4,000) as a non-absorbable marker. The fluid was withdrawn after an hour and analyzed for PEG, sodium and glucose. Similar studies were carried out in loops one hour after exposure to 1 microgram/ml of purified cholera toxin. Body temperature was maintained at 37 degrees C during the experiment by using a lamp. The mean +/- SE of water and sodium absorption, with bicarbonate versus without bicarbonate, was -1.4 +/- 0.1 vs -1.1 +/- 0.3 ml/h/10 cm, and -340.8 +/- 23.0 vs -308.4 +/- 35.6 mM/h/10 cm, respectively from secreting rabbit ilea. A similar effect was observed in normal ilea. It is concluded that bicarbonate containing electrolyte solution has no additional promoting effect on water and sodium absorption in normal or secreting ilea of rabbits.

Current status of oral rehydration as a strategy for the control of diarrhoeal diseases.

For more than two decades, WHO and UNICEF have recommended a single formulation of oral rehydration salts (ORS) solution based on glucose and three salts. This product has proven safe and highly effective in treating and preventing dehydration from diarrhoea of all causes and in all age groups in worldwide use and has substantially contributed to the saving of lives in developing countries. However, oral rehydration therapy (ORT) using this formulation does not make diarrhoea any less severe or stop it sooner; which is what is required. During the last 16 yr numerous studies were undertaken to develop an improved ORS that could, in addition to being effective therapy to treat and prevent dehydration, reduce severity and duration of diarrhoea. Controlled clinical trials of ORS formulations containing aminoacids showed that, while they were substantially more absorption efficient in cholera, they were no more effective than standard ORS in infants and children with noncholera diarrhoea; none of these formulations are considered a suitable replacement for standard ORS. Rice-based ORS, in a number of studies, was found superior to standard ORS in adults and children with cholera and its use in such patients is recommended. However, the benefit of using rice-based ORS in infants and small children was either small or insignificant compared to standard ORS, when feeding during ORT was actively pursued. Rice-based ORS was also as effective as standard ORS in infants under 6 months of age and in severely malnourished children. Recently, several studies evaluated glucose-based ORS made hypoosmolar by reducing the concentration of glucose and sodium (with glucose concentration of 75-90 and sodium 60-75 mmol/l and osmolarity of 225-250 mosm/l). These hypoosmolar solutions showed clinically significant benefit in reducing the severity of diarrhoea and the need for supplemental i.v. therapy in infants and children. In limited studies, similar results were obtained in adults with cholera; however, marked hyponatraemia was noted in a small proportion of high purging cholera patients. Two multicentric trials of a hypoosmolar solution, one in adults with cholera and one in children with non-cholera diarrhoea, are ongoing; results of these trials should help us decide whether such a solution could be a practical replacement for standard ORS.