Influence of inflammation as measured by alpha-1-acid glycoprotein on iron status indicators among HIV-positive postpartum Zimbabwean women.

OBJECTIVES: The acute phase response (APR) influences indicators of iron status. A recent WHO/CDC consultation recommended concurrent measurement of alpha-1-acid-glycoprotein (AGP) in surveys to control for the APR, and aid in interpreting iron status. They proposed further exploratory analyses using AGP. We examined whether the APR (measured by AGP) influences the expected relationships between iron status indicators in an HIV-infected population. SUBJECTS: We measured hemoglobin (Hb), serum ferritin (SF), transferrin receptor (TfR), erythropoietin (EPO) and AGP in a cross-sectional survey of 643 HIV-positive Zimbabwean women. RESULTS: SF was significantly higher in APR-positive (AGP>1 g/l) women (P<0.001), in whom there was no association between SF and Hb. TfR was inversely associated with Hb, in both APR-positive and APR-negative women (P<0.001). However, among anemic women (Hb<110 g/l), APR-positive women had marginally lower TfR concentrations (P=0.053). There was no difference in EPO response to decreasing Hb among APR-positive and APR-negative women. CONCLUSIONS: AGP captured the influence of the APR on iron indicators and their relationships with each other. The APR influenced SF and its relationship with Hb as expected. TfR behaved unexpectedly. Although TfR has been promoted as an iron indicator that is uninfluenced by the APR, TfR concentrations were depressed among anemic APR-positive women. Because TfR reflects iron deficiency and erythropoietic activity, pro-inflammatory cytokines associated with the APR may be inhibiting erythropoiesis, which is reflected by lower TfR concentrations. We support the WHO/CDC recommendation that AGP is a useful indicator to assess the influence of the APR on iron status indicators.

Elevated iron stores are associated with HIV disease severity and mortality among postpartum women in Zimbabwe.

OBJECTIVES: The relationship between Fe status and HIV infection is complex and poorly understood. While anaemia is a major complication of HIV infection, higher Fe stores may be associated with disease progression. There is limited and conflicting data available from Africa. DESIGN: Cross-sectional and prospective cohort study. SETTING, SUBJECTS AND METHODS: We examined the association between postpartum Fe status (Hb, serum ferritin (SF) and transferrin receptor (TfR)) and viral load (VL) and HIV-related mortality in 643 HIV-positive Zimbabwean women over a period of 12 months. RESULTS: In non-anaemic women a log10 increase in SF was associated with a 2.3-fold increase in VL (P = 0.019); this association was absent in anaemic women. In prospective analyses, a log10 increase in SF was associated with a 4-fold increase in mortality by 12 months (P = 0.002). Hb was negatively associated with VL (P = 0.001) and mortality (P = 0.047). The adverse associations between SF and both VL and mortality were found at SF concentrations > 45 microg/l (P < 0.05). Controlling for alpha1 acid glycoprotein, a marker of inflammation, attenuated the association between both SF and VL and mortality, but these remained significant. CONCLUSIONS: These results are consistent with the hypothesis that high Fe stores have adverse consequences in HIV infection. If adverse consequences are real, our data suggest that they occur at SF concentrations exceeding those consistent with adequate Fe nutriture.

Adoption of safer infant feeding and postpartum sexual practices and their relationship to maternal HIV status and risk of acquiring HIV in Zimbabwe.

OBJECTIVE: To examine the relationships between maternal knowledge and concern about HIV status, adoption of preventive practices and risk of acquiring HIV in Zimbabwe. METHODS: Knowledge and behavioural data were collected via interview from 2595 mothers enrolled in ZVITAMBO, a randomized trial of postpartum vitamin A supplementation that also offered education on safer infant feeding and sexual practices. Mothers were tested for HIV at delivery; those uninfected at baseline were retested during study follow-up. Logistic regression methods were used to identify variables associated with adoption of preventive behaviours and, for HIV-negative mothers, their relationship to risk of acquiring HIV post-delivery. RESULTS: A total of 518 mothers (20%) reported practicing safer sex and 289 mothers (11%) reported modifying their feeding behaviour because of HIV. Fear of transmitting HIV (50.4%) and protecting the baby's health (30.9%) were the most frequently cited reasons for behaviour change. Forty-nine HIV-negative mothers acquired HIV during the first postpartum year. After taking into account other significant covariates, mothers who were concerned about their own HIV status were 1.9 times more likely (95% CI: 1.05-3.52; P = 0.03), and those reporting safer sex practices were 58% less likely to become infected (adjusted odds ratio: 0.42; 95% CI: 0.17-1.04; P = 0.06). Married women who reported practicing abstinence to prevent HIV were 3.2 times more likely to become infected than non-abstaining mothers (P = 0.01), while there were no new HIV infections among abstaining single mothers. CONCLUSIONS: Greater emphasis should be given to safer sex practices among women who test negative in mother-to-child HIV prevention programmes.

HIV-1 and HIV-2 prevalence and associated risk factors among postnatal women in Harare, Zimbabwe.

Studies of antenatal women form the predominant source of data on HIV-1 prevalence in Africa. Identifying factors associated with prevalent HIV is important in targeting diagnostic services and care. Between November 1997 and January 2000, 14,110 postnatal women from Harare, Zimbabwe were tested by ELISAs reactive to both HIV-1 and HIV-2; a subset of positive samples was confirmed with assays specific for HIV-1 and HIV-2. Baseline characteristics were elicited and modelled to identify risk factors for prevalent HIV infection. HIV-1 and HIV-2 prevalences were 32.0% (95% CI 31.2-32.8) and 1.3% (95% CI 1.1-1.5), respectively; 4% of HIV-1-positive and 99% of HIV-2-positive women were co-infected. HIV-1 prevalence increased from 0% among 14-year-olds to >45% among women aged 29-31 years, then fell to <20% among those aged>40 years. In multivariate analyses, prevalence increased with parity, was lower in married women than in single women, divorcees and widows, and higher in women with the lowest incomes and those professing no religion. Adjusted HIV-1 prevalence increased during 1998 and decreased during 1999. Age modified the effects of parity, home ownership and parental education. Among older women, prevalence was greater for women who were not homeowners. Among younger women, prevalence increased with parity and low parental education. None of these factors distinguished women co-infected with HIV-2 from those infected with HIV-1 alone. Prevalent HIV-1 infection is associated with financial insecurity and weak psychosocial support. The ZVITAMBO study apparently spanned the peak of the HIV-1 epidemic among reproductive women in Harare.

Macroscopic characteristics of hacking trauma.

Hacking trauma is often encountered in forensic cases, but little experimental research has been conducted that would allow for the recognition of wounds caused by specific weapon types. In this paper, we report the results of a hacking trauma caused by machete, cleaver, and axe weapons and the characteristics of each weapon type on bone. Each weapon type was employed in multiple trials on pig (Sus scrofa) bones and then the wounds were examined macroscopically for several characteristics that serve to differentiate the weapons.

Vitamin A supplementation of young infants.

PIP: A meta-analysis of several large trials established that vitamin A supplementation of 6-month-old to 5-year-old children living in areas where vitamin A is deficient can reduce their risk of dying by an average of 23%. However, published studies are less conclusive about the necessity, safety, or the benefits of such supplementation. In this article, the authors argue that infant vitamin A supplementation should be increased rather than abandoned. According to studies from Bangladesh, Brazil, and Indonesia, 25% to over 90% of the 6-month-old infants studied had inadequate liver stores. These breast-fed infants of undernourished mothers will need additional vitamin A to attain normal physiological stores at 6 months of age. In terms of safety, it is noted that the only common acute side effect of the intervention is bulging of the fontanelle, and there are no long-term developmental consequences. Moreover, an Indonesian study highlighted that the intervention reduces infant mortality by 64% when vitamin A supplements are given on the first day of life and during the first 4 months of life. Furthermore, the minimum requirement of vitamin A given to infants is 237 mcmol.^ieng

Retinol analysis in dried blood spots by HPLC.

There are many advantages to measuring vitamin A in dried blood spots (DBS) from a finger prick as compared to plasma collected by venipuncture. The advantages include easier collection, transport and storage; accessibility to younger and more remote populations; and decreased risk of disease transmission. We describe a method for the extraction of retinol from DBS for analysis by HPLC and initial comparison to plasma retinol. The effects of various buffers, detergents, antioxidants and chelators were evaluated to establish the most effective approach to elute the retinol: retinol binding protein (holo-RBP) complex from the blood collection cards. The process involves ultrasonic agitation to elute holo-RBP into a phosphate buffer containing an antioxidant and metal chelator. The holo-RBP complex was denatured by the addition of ethanol containing additional antioxidants permitting the extraction of free retinol into hexane. Following solvent evaporation, the extract was dissolved in methanol for HPLC analysis. The initial measured retinol levels in freshly collected DBS declined for 6-10 d whether stored at 25, 4 or -20 degrees C, but remained consistent thereafter (homeostatic). By incorporating a "recovery/volume adjustment" factor, measured retinol values in homeostatic DBS were adjusted to the equivalent of plasma retinol. For 17 normal adults, the correlation coefficient was 0.90 between plasma retinol and adjusted DBS retinol in samples that had been stored at -70 degrees C for < 9 mo. The use of this new sample matrix for vitamin A assessment will allow access to previously unavailable populations.

Short-term effects of large-dose vitamin A supplementation on viral load and immune response in HIV-infected women.

Vitamin A supplementation has been suggested for treatment and prevention of HIV infection. However, some in vitro data indicate that vitamin A may activate HIV. Randomly, 40 HIV-seropositive women of reproductive age were allocated to receive a single oral dose of 9900 micromol (300,000 IU) vitamin A or placebo. Plasma HIV-1 RNA concentration, total lymphocytes, selected lymphocyte subsets and activation markers, and in vitro lymphocyte proliferation to phytohemagglutinin (PHA) and Candida were measured before dosing and at various time points over an 8-week follow-up period. No differences were found between treatment groups in the frequency of signs or symptoms of acute vitamin A toxicity, nor were differences evident in any lymphocyte subset or activation marker at any time during follow-up. Mean and median viral load concentration at each time point and change in viral load from baseline to each follow-up point did not differ between treatment groups. No difference was measured between treatment groups in the proportion of women who responded to PHA or Candida. This study provides no evidence that high dose vitamin A supplementation of HIV-infected women is associated with significant clinical or immunologic adverse effects.

Neonatal vitamin A supplementation: effect on development and growth at 3 y of age.

We reported recently that neonatal supplementation with 52 micromol vitamin A reduced infant mortality by 64%; acute side effects were limited to a 3% excess rate of a bulging fontanelle. The current study was conducted to identify developmental changes at 3 y of age associated with neonatal vitamin A supplementation or a bulging fontanelle. Children who had a bulging fontanelle (n = 91) and 432 children who had normal fontanelles after receiving vitamin A or placebo were evaluated with the Bayley Scales of Infant Development. Mean scores for the mental, psychomotor, and behavioral rating scale (BRS) plus 3 subscales of the BRS were not significantly different for treatment-fontanelle-specific groups. In regression models predicting each score, a bulging fontanelle had a small negative effect in all models; when 1 child who was injured from birth was removed from the analysis the effect of a bulging fontanelle was not significant in any model (P > or = 0.35). Vitamin A supplementation had a small beneficial effect on all developmental scores, which was significant for one of the BRS subscales (orientation-engagement) and also for a second (motor quality) when the outlier child was removed. Compared with children with normal fontanelles in the placebo group, children with a bulging fontanelle in the vitamin A group tended to grow less (-0.5 cm, P = 0.33), whereas those with normal fontanelles in the vitamin A group grew significantly more (0.68 cm, P < 0.05), over the first 3 y of life. This study provides no evidence that neonatal vitamin A supplementation is associated with biologically significant adverse growth or developmental sequelae.

Impact of neonatal vitamin A supplementation on infant morbidity and mortality.

OBJECTIVE: To determine whether vitamin A supplementation at birth could reduce infant morbidity and mortality. STUDY DESIGN: We conducted a placebo-controlled trial among 2067 Indonesian neonates who received either 52 micromol (50,000 IU) orally administered vitamin A or placebo on the first day of life. Infants were followed up at 1 year to determine the impact of this intervention on infant mortality. A subgroup (n = 470) was also examined at 4 and 6 months of age to examine the impact on morbidity. RESULTS: Vital status was confirmed in 89% of infants in both groups at 1 year. There were 19 deaths in the control group and 7 in the vitamin A group (relative risk = 0.36; 95% confidence interval = 0.16, 0.87). The impact was stronger among boys, infants of normal compared with low birth weight, and those of greater ponderal index. Among infants examined at 4 months of age, the 1-week period prevalence of common morbidities was similar for vitamin A and control infants. However, during this same 4-month period, 73% and 51% more control infants were brought for medical treatment for cough (p = 0.008) and fever (p = 0.063), respectively. CONCLUSIONS: Neonatal vitamin A supplementation may reduce the infant mortality rate and the prevalence of severe respiratory infection among young infants.

Night blindness is prevalent during pregnancy and lactation in rural Nepal.

The prevalence of night blindness during pregnancy and lactation was assessed in a sample of 426 women living in the rural terai of Nepal. These women were also examined for ocular signs of vitamin A deficiency. Among 241 lactating women, 16.2% reported experiencing night blindness at some time during the pregnancy that produced the infant they were now breast-feeding. Among 185 pregnant women, 8.1% reported being night-blind at the time of the interview. The odds of night blindness in the current pregnancy were six times greater for women who reported night blindness in their previous pregnancy. Night-blind women were more likely to come from households with lower socioeconomic status. Teenage women and those over the age of 30 were at highest risk, particularly those of higher parity within these age groups. Vitamin A deficiency, for which night blindness is a marker, seems to be a problem in this population of pregnant and lactating women, with potential health consequences for women and their infants.

Determination of vitamin A in dried human blood spots by high-performance capillary electrophoresis with laser-excited fluorescence detection.

We have developed a high-performance capillary electrophoresis (HPCE) method to analyze the retinol (vitamin A) concentration as retinol-retinol binding protein (holo-RBP) from microvolumes of serum (5-10 microliters) or one to two drops (approximately 20 microliters) of blood collected and air-dried on blood collection filter paper. A 0.64-cm diameter disk was cut from the dried whole blood specimens and the samples were dissolved in a pretreatment buffer and filtered. Filtrate was injected onto the HPCE column for analysis. The separation was carried out in a 60 cm x 50 microns I.D. fused-silica capillary and the running voltage was 20 kV. A He-Cd laser with a wavelength of 325 nm was used for excitation, and the fluorescence of the holo-RBP complex was monitored at 465 nm by a photodiode. A virtual linear relationship was obtained for the retinol concentrations between HPCE and HPLC for 28 serum samples, 19 dried venous blood samples and 9 capillary dried blood spot samples, indicating that valid measures of serum retinol can be obtained from one to two drops of capillary blood collected on filter paper. The absolute detection limit for retinol by HPCE is below 3 micrograms/l. The method is very useful for vitamin A level screening, especially for children and premature new-born babies.

Response of Bitot's spots to a single oral 100,000- or 200,000-IU dose of vitamin A.

PURPOSE: A randomized, controlled clinical trial was conducted in Indonesia to study the response of Bitot's spots to a 100,000-IU dose of vitamin A, which is known to be associated with fewer acute side effects than the currently recommended 200,000-IU dose. METHODS: A total of 114 children (ages 13 to 59 months) with Bitot's spots were given an ocular examination; serum retinol concentration was measured, and the relative dose response test carried out. After administering one 100,000- or 200,000-IU oral dose of vitamin A, ocular examinations were repeated weekly for seven weeks and then biweekly for 20 more weeks, or until lesions were healed on two consecutive examinations. RESULTS: Either dose of vitamin A was similarly effective in healing Bitot's spots. The most important factor in predicting responsiveness to treatment was baseline serum retinol concentration: children with lower pretreatment concentrations were more likely to have responsive lesions. No child had a relapse within the first three months after treatment. However, by six months, children who had received the higher dose were 82% less likely to have a relapse compared with children who had received the lower dose. CONCLUSIONS: Although either a 100,000- or 200,000-IU dose of vitamin A is similarly effective in healing Bitot's spots, a 200,000-IU dose provides longer protection. This benefit justifies the higher rates of transient mild side effects associated with the 200,000-IU dose. The current 200,000-IU dose of vitamin A recommended by the World Health Organization for prophylactic dosing should not be reduced.

A 210-mumol dose of vitamin A provides more prolonged impact on vitamin A status than 105 mumol among preschool children.

A randomized controlled clinical trial was conducted to determine the relative protection afforded by two large doses of vitamin A against subclinical vitamin A deficiency among 345 preschool children. At baseline, children either had or were at high risk of developing non-corneal xerophthalmia. Vitamin A status was assessed by the relative dose response (RDR) test, serum retinol concentration, and ocular examination before and 3 and 6 mo following one oral dose of 105 mumol or 210 mumol of vitamin A. At 3 and 6 mo, mean serum retinol concentration was significantly higher in the 210-mumol group than in the 105-mumol group. The proportion of children with a positive RDR did not differ between groups at 3 mo, but by 6 mo there were three times more children positive in the 105-mumol group. Most of the observed difference was confined to children with xerophthalmia at baseline. The relative benefit of the 210-mumol dose was related to baseline vitamin A status. The current World Health Organization recommended prophylactic dose of 210 mumol seems appropriate.

Safety of one 52-mumol (50,000 IU) oral dose of vitamin A administered to neonates.

A placebo-controlled trial was carried out among 2067 Indonesian neonates to assess the safety of administering one oral 52-mumol (50,000 IU) dose of vitamin A. Infants were assessed for potential acute side-effects before and throughout 48 hours after the dose. The first 965 infants were examined by cranial ultrasound before and at 24 hours after dosing to rule out intracranial haemorrhage and determine the resistive index (RI) of the anterior cerebral artery using duplex Doppler. Groups were comparable at the baseline. A bulging fontanelle occurred in the control and vitamin A groups, respectively, among 2.7% and 4.6% of the infants at 24 hours, and 2.4% and 4.5% of the infants at 48 hours. The groups did not differ in any other sign or symptom assessed. No infant developed intracranial haemorrhage. Mean RI values were normal and not different between groups at baseline or at 24 hours. Mean RI fell during the 24 hours, as normally occurs; the mean decrease was nearly identical in the two groups. A bulging fontanelle was not associated with increased rates of any sign or symptom or with an increase in RI. The 52-mumol dose of oral vitamin A may cause a small increase in intracranial volume in a small proportion of infants, but no increase in intracranial pressure. Acute side-effects following this intervention were rare and mild.

A priming dose of oral vitamin A given to preschool children may extend protection conferred by a subsequent large dose of vitamin A.

A randomized trial tested whether a priming dose of vitamin A would extend the protection of a subsequent 60,000-micrograms retinol equivalent (RE) oral dose. Seventy-five xerophthalmic and 74 age- and neighborhood-matched non-xerophthalmic preschool children were randomized to one of three oral regimens of vitamin A, receiving peanut oil only (Group A), 7500 micrograms RE (Group B) or 60,000 micrograms RE (Group C), followed in all instances by 60,000 micrograms RE 1 wk later. Serum retinol was measured 2, 4, 6 and 12 mo following the second dose by technicians unaware of the children's treatment status. Among xerophthalmic children, mean values differed across treatment groups at 2 mo (C > A) and tended to be different at 12 mo (C > A and B > A). Among non-xerophthalmic children mean retinol concentrations differed across treatment groups at 6 mo, but not in a consistent way (A > C > B), and at 12 mo (C > A and B > A). Xerophthalmic children reverted to biochemical deficiency faster than non-xerophthalmic children. A small or large priming dose may extend the protection conferred by a 60,000-micrograms RE dose, supporting the use of repeated, spaced doses of vitamin A for treating xerophthalmia. Similar retinol concentrations in Groups B and C at 12 mo suggest the 60,000-micrograms RE prophylactic dose currently recommended by the World Health Organization need not be increased.

Vitamin A deficiency and attributable mortality among under-5-year-olds.

Reported are estimates of the prevalence in developing countries of physiologically significant vitamin A deficiency and the number of attributable deaths. The WHO classification of countries by the severity and extent of xerophthalmia was used to categorize developing countries by likely risk of subclinical vitamin A deficiency. Using vital statistics compiled by UNICEF, we derived population figures and mortality rates for under-5-year-olds. The findings of vitamin A supplementation trials were applied to populations at-risk of endemic vitamin A deficiency to estimate the potential impact of improved vitamin A nutriture in reducing mortality during preschool years. Worldwide, over 124 million children are estimated to be vitamin A deficient. Improved vitamin A nutriture would be expected to prevent approximately 1-2 million deaths annually among children aged 1-4 years. An additional 0.25-0.5 million deaths may be averted if improved vitamin A nutriture can be achieved during the latter half of infancy. Improved vitamin A nutriture alone could prevent 1.3-2.5 million of the nearly 8 million late infancy and preschool-age child deaths that occur each year in the highest-risk developing countries.

PIP: Reported are estimates of the prevalence in developing countries of physiologically significant vitamin A deficiency and the number of attributable deaths. The WHO classification of countries by the severity and extent of xerophthalmia was used to categorize developing countries by likely risk of subclinical vitamin A deficiency. Using vital statistics compiled by UNICEF, the authors derived population figures and mortality rates for under-5 year olds. The findings of vitamin A supplementation trials were applied to populations at risk of endemic vitamin A deficiency to estimate the potential impact of improved vitamin A nutriture in reducing mortality during the preschool years. Worldwide, over 125 million children are estimated to be vitamin A deficient. Improved vitamin A nutriture would be expected to prevent approximately 1-2 million deaths annually among children ages 1-4. an additional 0.25-0.5 million deaths may be averted if improved vitamin A nutriture can be achieved during the latter 1/2 of infancy. Improved vitamin A nutriture alone could prevent 1.3-2.5 million of the nearly 8 million late infancy and preschool age child deaths that occur each year in the highest risk developing countries. (author's)