The mystery of the wooden leg: vitamin C deficiency in East African prisons.

Vitamin C deficiency (scurvy) is an uncommon disease in modern times, and therefore easily misdiagnosed when it appears. While visiting prisoners in East Africa, health delegates of the International Committee of the Red Cross (ICRC) encountered prisoners suffering from a hitherto undiagnosed 'mysterious' illness, consisting mainly of swollen and hard legs, that had not responded to various treatments given by the local health centre or hospital. The ICRC set out to investigate the nature of this disease and examined 133 prisoners with the suspected clinical symptoms described as 'wooden leg' syndrome in 10 different prisons. Serum ascorbic acid levels were measured and a food basket analysis done. The diagnosis of scurvy was confirmed. All patients responded to standard treatment with oral ascorbic acid. The clinical presentation of scurvy in these East African prisons seems to be somewhat different from the classic descriptions, but is in line with historic records of the disease. Treatment is easy and cheap, and response to treatment is quick. Scurvy remains a problem in prisons in Africa and clinicians working in prisons need to be aware of its presence and its presentations.

First-line tuberculosis therapy and drug-resistant Mycobacterium tuberculosis in prisons.

BACKGROUND: We assessed a programme of tuberculosis control in a prison setting in Baku, Azerbaijan. The programme used first-line therapy and DOTS (directly observed treatment, short course). METHODS: 467 patients had sputum-positive tuberculosis. Their treatment regimens followed WHO guidelines, and they had regular clinical examinations and dietary supplements. Isolates were tested by standard methods for resistance to isoniazid, rifampicin, ethambutol, and streptomycin in three laboratories. Treatment success was defined as three consecutive negative sputum smears at end of treatment. Factors independently associated with treatment failure were estimated by logistic regression. FINDINGS: Drug-resistance data on admission were available for 131 patients. 55% of patients had strains of Mycobacterium tuberculosis resistant to two or more antibiotics. Mortality during treatment was 11%, and 13% of patients defaulted. Overall, treatment was successful in 54% of patients, and in 71% of those completing treatment. 104 patients completed a full treatment regimen and remained sputum-positive. Resistance to two or more antibiotics, a positive sputum result at the end of initial treatment, cavitary disease, and poor compliance were independently associated with treatment failure. INTERPRETATION: The effectiveness of a DOTS programme with first-line therapy fell short of the 85% target set by WHO. First-line therapy may not be sufficient in settings with a high degree of resistance to antibiotics.

Overwhelming consumption in prisons: human rights and tuberculosis control.

Tuberculosis is thought to be the single biggest cause of death among the world's prisoners, but a human rights approach to tuberculosis control has not yet been applied. We propose that existing guidelines for the control of HIV be adapted and applied to tuberculosis. Tuberculosis control in prisons provides a platform to develop these concepts.

Vaccination of the civilian population in a country at war: it can be done; it can also be evaluated. The ICRC experience in Mozambique.

The medical division of the International Committee of the Red Cross undertook an expanded programme of immunization in rural areas of Mozambique controlled by the resistance. This programme was evaluated by a 30 cluster survey which showed that 82 per cent of children between 1 and 5 years and 81.7 per cent of mothers of children of less than 1 year had had contact with the vaccination service. Full vaccination was achieved in 40.6 and 35.2 per cent respectively. The reasons for immunization failure were established. The study shows that vaccination of the civilian population of a developing country at war is possible and, importantly, the outcome of the programme can be assessed.

Drug resistant tuberculosis in prisons in Azerbaijan: case study.

OBJECTIVES: To document the existence of drug resistance in a tuberculosis treatment programme that adheres strictly to the DOTS principles (directly observed treatment, short course) and to determine the extent of drug resistance in a prison setting in one of the republics of the former Soviet Union. DESIGN: Case study. SETTING: Central Penitentiary Hospital in Baku, the referral centre for tuberculosis patients from all prisons in Azerbaijan. SUBJECTS: Prisoners with tuberculosis: 28 selected patients not responding clinically or bacteriologically to the standard treatment (group 1) and 38 consecutive patients at admission to the programme (group 2). MAIN OUTCOME MEASURES: Drug resistance of Mycobacterium tuberculosis strains grown from sputum. RESULTS: All the non-responding patients (group 1) had strains resistant to at least one drug. 25 (89%) of the non-responding patients and nine (24%) of the consecutive patients had M tuberculosis strains resistant to both rifampicin and isoniazid. A further 17 patients in group 2 had strains resistant to one or more first line drugs. CONCLUSIONS: Drug resistant M tuberculosis strains are common in prisons in Azerbaijan. Tuberculosis problems tend to be worse in prisons, but prisoners and former prisoners may have an important role in the transmission of tuberculosis, particularly of drug resistant forms, in the community. National programmes to control tuberculosis will have to take into account and address the problems in prisons to ensure their success.

PIP: Tuberculosis is a significant health problem in Azerbaijan. In prisons, this problem is compounded by overcrowding, poor general health, a high representation of risk groups, late case finding, and incomplete treatments. The present study investigated the extent of drug resistance at the Central Penitentiary Hospital in Baku--the country's only treatment center for prisoners with tuberculosis. This International Committee of the Red Cross program, established in 1995, uses the directly observed treatment, short course (DOTS) strategy. Sputum samples were collected from two groups of prisoners: 1) 28 patients who failed to respond, clinically or bacteriologically, after a minimum of 8 weeks to the treatment regimen recommended by the World Health Organization and 2) 38 patients consecutively enrolled over a 4-week period from whom sputum was taken before the start of treatment. Mycobacterium tuberculosis was isolated from all 66 sputum specimens. In the first group, 25 strains (98%) were multidrug resistant (to rifampicin and isoniazid). Such resistance occurred in all new cases and 14 (82%) of the 17 failure or relapse cases. In the second group, 9 strains (24%) were multidrug resistant and only 12 (32%) were fully susceptible. This resistance was found in 3 strains (15%) among the 20 new cases and in 6 strains (33%) among the 18 cases of treatment failure or relapse. These findings suggest that prisoners may have an important future role in the transmission of tuberculosis, especially multidrug resistant forms, in the former Soviet Union.

Epidemic typhus in a prison in Burundi.

The International Committee of the Red Cross investigated an outbreak of fever of unknown origin in Ngozi prison, Burundi, which resulted in a crude mortality rate of 2.61% in January 1996. A definite diagnosis of epidemic typhus caused by Rickettsia prowazekii was established by enzyme-linked immunosorbent assay using specific antigens. Control measures included complete cleansing of the prison with cyfluthrine, shaving and dusting all prisoners with permethrin 0.5% dusting powder, and replacement of all mattresses and clothes. All prisoners and guards received a single dose of doxycyline (100 mg) simultaneously. The crude mortality rate dropped abruptly to 1.27% in February 1996 and remained at or below 0.5% from March onwards. Health authorities and medical agencies working in Burundi need to consider epidemic typhus in the differential diagnosis of fever of unknown origin in order to be able to take appropriate control measures in time.

Effects of the civil war in central Mozambique and evaluation of the intervention of the International Committee of the Red Cross.

In October 1994, a retrospective study of mortality of children was conducted in Maringué, a district of central Mozambique. Estimates based on maternity histories of 1503 women aged 15-60 years revealed complex changes in the under-5 death rate. During the colonial period (1955-1974), mortality declined from 373 to 270 per 1000. During the civil war period (1975-1991), mortality increased rapidly to reach a peak of 473 per 1000 in 1986. It declined again thereafter and reached a plateau of 380 in 1991. A health intervention conducted by the International Red Cross Committee since 1992 further reduced mortality to 269 per 1000 in 1994. Most of the 1992-1994 decline was attributable to vaccinations, in particular measles and tetanus immunizations, and to Vitamin A supplementation.

Frequency of a positive modified Allen's test in 1,000 consecutive patients undergoing cardiac catheterization.

The modified Allen's test (A.T.) is used to prove the adequacy of the blood supply through the ulnar artery to the hand. The test is considered normal if, after compression of both the ulnar and radial arteries followed by repeated clenching of the fingers to squeeze out the blood, the normal or a slightly more pronounced red color of the palm of the hands returns within < 10 sec after release of only the ulnar artery. It is important to perform the test whenever intravascular access to the radial artery is planned. The objective of this study was to determine the percentage of patients presenting a clearly positive (< 5 sec), a moderately positive (between 5-9 sec), or a negative A.T. (10 sec and more), We performed an A.T. on 1,000 consecutive and different patients undergoing cardiac catheterization, on the right wrist, two times, each time by a different examinator trained in this test. An A.T. was performed on 1,000 patients:640 men, 360 women, mean age 62.3 yr (range 28-90 yr). In our population of patients, the relative percentages of a clearly positive (< 5 sec), moderately positive (between 5-9 sec), or negative modified Allen's test (10 sec and more) is 49%, 24%, and 27%, respectively.

The management of tuberculosis in refugees along the Thai-Kampuchean border.

The treatment of tuberculosis in refugees living in campus along the Thai-Kampuchean border has remained a controversial issue since the beginning of the Khmer relief operation in 1979. During the 1984-85 dry season, war-related disruptions forced the evacuation of the 240,000 residents of 21 camps into evacuation sites in Thailand. Seven tuberculosis treatment programmes, using a fully supervised, daily protocol of isoniazid(H), rifampicin(R), pyrazinamide(Z) and streptomycin(S) 3 HRZS/HR, (6 months for pulmonary and 9 months for extrapulmonary tuberculosis), were able to continue operation, with acceptably low rates of default from therapy. During the 18 month period beginning in July 1984, 984 patients were started on treatment: 755 completed a full course while 86 defaulted. The programme design and organisation are described.

Enteritis necroticans among Khmer children at an evacuation site in Thailand.

A severe illness characterised by bloody diarrhoea and intestinal dysfunction was recognised at an evacuation site on the Thai-Kampuchean border. From June, 1985, to July, 1986, the illness occurred in 62 Khmer children aged 10 months to 10 years (mean 4 years); it was characterised by bloody diarrhoea (94%), fever (90%), and abdominal pain (78%). The overall mortality rate was 58%. Among 16 children who died and underwent necropsy, small-intestinal necrosis of varying severity was found; in 5 of these children small-intestinal lesions with areas of full-thickness necrosis were seen that histologically resembled those in cases of enteritis necroticans (pigbel) in Papua New Guinea. Beta-toxin-producing Clostridium perfringens type C was isolated from 2 of 23 children from whom specimens for anaerobic cultures were collected, and antibodies to beta toxin were detected in 5 of 9 survivors but not in 10 healthy, age-matched control children. These cases show that enteritis necroticans can cause substantial morbidity and mortality outside Papua New Guinea.

Deaths following ingestion of a cardiotoxic plant in Kampuchean children in Thailand.

Twenty-seven Khmer children at a refugee camp in Thailand developed vomiting and diarrhea after ingestion of the seeds of the plant Erythrophleum succirubrum Gagnep. Two children died of cardiac arrest. Ingestion of seed of Erythrophleum species that contain digitalis-like alkaloids causes fatal epidemics of poisoning in children as well as livestock.