[Child health in a developing population with changing patterns of belief (Gaza 1973-1983)].

The Gaza strip is an area in transition. 13 years ago it had a very high infant mortality of between 100-150 per 1000 live births, largely due to a combination of poverty and ignorance. As in most developing countries, this was compounded by the deep-set belief of both the general population and even medical staff, that this situation was an integral part of their destiny and could not be changed. Lack of confidence of the local population in modern medicine aggravated the situation. This resulted in a seemingly vicious cycle with no solution in sight. The apparently impossible task of improving child health was achieved by integration of pediatric services and their expansion into the community, involvement of the community, and implementation of legal procedures. With these measures the confidence of the population was gained. This resulted in a vaccination coverage of over 90% of the infant population, in a successful program of diarrhea control by oral rehydration, and in the establishment of neighborhood birth centers. The participation of lay and religious leaders in the program caused vaccination to become a kind of religious precept with noncompliance considered almost a sin. As a result of these activities, infectious diseases such as poliomyelitis, measles, and neonatal tetanus have virtually disappeared. Infant mortality in 1987 was down to only 29 per 1000 live births. We believe that a major reason for our success is that we did not antagonize the traditional leaders but succeeded in convincing them of the validity and importance of what we were doing. The moment their belief systems changed with regard to health, the battle was as good as won.

Rotavirus infection and rotavirus serum antibody in a cohort of children from Gaza observed from birth to the age of one year.

Rotaviruses were studied in a cohort of children from Gaza, during their first year of life. Surveillance was effected through visits to the local health clinic by parents and infants, and to a lesser extent, field workers' home visits. The observed rate of diarrhoea (all causes), and of rotavirus-associated diarrhoea was 1.25 and 0.1 episode per child-year, respectively. Of the 130 diarrhoea episodes in the cohort, only 6.9% were rotavirus-associated. Only nine (37.5%) of 24 children in whom rotavirus antigen was detected experienced a bout of diarrhoeal illness. However, 59.2% of cohort children had rotavirus serum antibodies by one year of age. The data indicate that rotavirus excretion in Gazan children tends to be asymptomatic during the first year of life.

How to predict the immune status of poliovirus vaccinees? A comparison of virus neutralization at a very low serum dilution versus ELISA in a cohort of infants.

A cohort of children from Gaza was observed from birth to the age of one year. Blood specimens were collected at birth, before and after poliovirus vaccination and at one year of age. Poliovirus immunity before and after vaccination was assessed by ELISA and virus neutralization (NT). Positive predictive values for ELISA were between 81.5% and 90.8%. However, ELISA revealed a high frequency of false negatives, and unacceptably low negative predictive values between 28.6% and 55.4%. The history of poliovirus immunity in the cohort was further investigated by NT. A high level of seropositivity to poliovirus type 1 (PV-1) was found. In cord blood, 83.3% had a NT titre greater than or equal to 4 and 99.0% had a titre greater than or equal to 2. Similarly, by one year of age, 85.7% had a titre greater than or equal to 4 and 90.5% had a titre greater than or equal to 2. Seropositivity to PV-2 and PV-3 were slightly lower, ie 80.8% of children had a PV-2 titre greater than or equal to 4 and 75.4% had a PV-3 titre greater than or equal to 4. As for other developing areas, poliomyelitis eradication in Gaza will come about when universal vaccination fills all 'immunity gaps' and improved sanitation and housing reduces the endemicity of wild polioviruses.

Male pseudohermaphroditism due to 17 beta-hydroxysteroid dehydrogenase deficiency: gender reassignment in early infancy.

Male pseudohermaphroditism due to 17 beta-hydroxysteroid dehydrogenase (17 beta-HSD) deficiency has a high prevalence within the Arab population of the Gaza strip and is characterised by marked virilization at puberty, leading in many cases to the spontaneous adoption of a male gender role. As a result of this, parents of 7 affected male infants (aged 1-10 months) born with female phenotype requested early gender reassignment. Diagnosis was suspected in 5 on the basis of a positive family history, but confirmed in all cases by the finding of low to normal testosterone levels (30-184 ng/dl) with high delta 4-androstenedione levels (188-808 ng/dl), after hCG. Treatment with im testosterone oenanthate (25-50 mg/dose) was given in one to three 3-months courses and penile size was increased into the normal range without evoking a significant increase in height velocity or skeletal maturation. Five patients underwent the first stage of male genitoplasty between 2 and 3 years of age. This consisted of bilateral orchidopexy, chordee release and penile lengthening - yielding finally an anatomically normal-sized and shaped penis. Androgen responsive male pseudohermaphroditism due to 17 beta-HSD deficiency or a similar defect and diagnosed in infancy should be treated as soon as possible with systemic testosterone before considering any sex change, and in preparation for male genitoplasty. Early gender reassignment according to genetic and gonadal sex is probably the management of choice for these cases since this may result in a normal adjustment to the male gender role, particularly after puberty.

Combined live and inactivated poliovirus vaccine to control poliomyelitis in a developing country--five years after.

The Gaza Strip is an area in transition which in the 1960's had a high prevalence of malnutrition and infectious diseases. The infant mortality was approximatively 140 per 1000 live births. Pediatric Services were almost non-existant. Trivalent oral poliovaccine (TOPV) has been used since 1967. Coverage however did not exceed 70%. From 1973 a network of comprehensive Child Health Centers was spread throughout the area, a set of laws was passed which made vaccination obligatory and the community became heavily involved in health education. These measures resulted in a vaccination coverage, from fixed centers, of over 90% of the susceptible infant population. Though infant mortality decreased rapidly, poliomyelitis was less affected and the mean annual incidence of the paralytic disease until 1977 continued to be 10 per 100,000 inhabitants. Two outbreaks caused by poliovirus Type 1 were registered in 1974 and 1976 with an incidence of 18 per 100,000 inhabitants. In these outbreaks 34% and 50% of the affected children, respectively, had received 3-4 doses of (TOPV). A new vaccination schedule was implemented in 1978 combining TOPV and inactivated polio vaccine in the form of an injectable quadruple vaccine. In the first three years following this change the annual incidence of the paralytic disease dropped from 10 to 2.2 per 100,000 inhabitants. In the following 5 years (1981-1985) only 4 cases of paralytic poliomyelitis were discovered, an annual incidence of 0.16 per 100,000 inhabitants. A serosurvey was done in 1980 on 117 immunized children age 6 months to three years.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful results of a program combining live and inactivated poliovirus vaccines to control poliomyelitis in Gaza.

Trivalent oral poliovirus vaccine ( TOPV ) has been used in Gaza since 1967. After an initial decrease of 33% in the incidence of the paralytic disease, no further decrease could be noted. The mean annual incidence until 1977 was 10 per 100,000 inhabitants. Two outbreaks caused by poliovirus type 1 were registered in 1974 and 1976 with an incidence of 18 per 100,000 inhabitants. In these outbreaks, 34% and 50% of the affected children, respectively, had received three to four doses of TOPV . A new vaccination schedule was introduced in 1978, combining live and inactivated poliovirus vaccines. In the years 1978-1980, the incidence decreased to 2.6 per 100,000 inhabitants; and during 1981-1982, only three cases were recorded. These results indicate that a schedule like the one used in Gaza could serve as a model to control poliomyelitis in developing countries where TOPV alone is not successful.

Cell mediated immunity to polio antigens in the early stage of acute poliomyelitis.

Specific cell-mediated immunity to polio antigens in 22 children suffering from acute paralytic poliomyelitis was investigated by the macrophage migration inhibition factor (MIF) technique. A positive response was observed in 9 of the 11 patients tested 1-4 days after the onset of the paralysis, and in 6 of the 8 patients tested between 15-90 days. In one case, the response was positive before paralysis became evident. In the 8 patients tested 90-360 days after paralysis, only three gave positive results. No response was observed in 34 of 39 healthy children tested 1-3 months after having received oral polio vaccine, or in 30 healthy adults.

Cholera in Gaza in 1981: epidemiological characteristics of an outbreak.

An outbreak of cholera involving 161 culture-positive cases of biotype El-Tor Serotype Ogawa occurred in the Gaza Strip in the summer and autumn of 1981. The signs and symptoms of the disease were mild to moderate in two thirds of the cases. In many of them the disease was so mild that the patients did not realize they had cholera. Another outstanding feature of the disease was the high percentage of family clustering. From constant monitoring of water, sewage, and vegetables we were unable to show that they played any part in the transmission. A case control study which specifically investigated these items showed no differences between cases and controls. Epidemiological investigation indicated that the disease was probably introduced into the area by a visitor from Jordan, where an epidemic was in progress. The first spread followed a wedding party and seems to have been caused by ingestion of contaminated soft drinks. Subsequent spread was probably caused mainly by carriers who were either asymptomatic or very mild cases. The actual transmission seems to have occurred from person to person, by food contamination, or by both. The authors believe, therefore, that the transmission of El-Tor cholera has many features in common with other bacterial diseases that are transmitted by the faecal-oral route.

Results of a program successfully combining live and killed polio vaccines.

Oral polio vaccine (OPV) has been used in the Gaza Strip since 1968. Although vaccine coverage had reached 80 to 90% of the infant population, the epidemiological pattern of the paralytic disease had not changed significantly as of the beginning of this study. The mean annual incidence continued to be around 10/100,000. Two outbreaks occurred, in 1974 and 1976, involving 75 and 77 children, respectively, an incidence of 18/100,000. In these two outbreaks, 34 and 50% of the affected children, respectively, received 3 to 4 doses of OPV. A serological survey done after a vaccination campaign with monovalent Type 1 vaccine showed an unexpectedly low percentage of seropositives. A parallel was found between the prevalence of diarrheal disease and vaccine failure, and a causal effect was postulated. To overcome this problem, a program of immunization was started early in 1978 combining both live and killed polio vaccines. Although cases of polio continue to appear, the incidence has been reduced to 2.4/100,000 population. In 1981, only one case was reported, in an unvaccinated child. Thus, it would seem that the new vaccination schedule combining live and killed vaccines makes eradication of polio a possibility.

Evaluation of the impact of oral rehydration therapy on the outcome of diarrheal disease in a large community.

Diarrheal diseases are a serious public health problem in the Gaza Strip, being the most important cause of hospitalization in infants and responsible for about half of postneonatal deaths, Oral rehydration therapy using oral rehydration solution (ORS), a formula recommended by WHO, has been proven effective in the treatment of dehydration in acute childhood diarrhea. The availability of a well-organized health service in Gaza provided an excellent opportunity to institute a large-scale project to evaluate the effectiveness of early ORS therapy in reducing diarrhea-related hospital admissions, mortality and malnutrition. A 3-year program was started in 1979, encompassing all community health centers and including intensive community education in the use of ORS. Compared with the prestudy year 1977, diarrhea-related hospital admissions were reduced by 35.3% in 1980 and 42.0% in 1981; hospital deaths from diarrheal diseases were reduced 34.4 and 37.4% in 1980 and 1981, respectively. Total deaths in the 0- to 3-year age-group were reduced by 28.7% in 1980 and by 41.7% in 1981. Diarrheal mortality was reduced by 35.6% in 1980 and 53.2% in 1981. This study succeeded in establishing active community and family participation.

PIP: Diarrheal diseases are a serious public health problem in the Gaza Strip: they are the most important cause of hospitalization in infants and are responsible for about 1/2 of the postneonatal deaths. Oral rehydration therapy using oral rehydration solution (ORS), a formula recommended by the World Health Organization, has been proven effective in the treatment of dehydration in acute childhood diarrhea. The availability of a well-organized health service in Gaza provided an excellent opportunity to institute a large-scale project to evaluate the effectiveness of early ORS therapy in reducing diarrhea-related hospital admissions, mortality, and malnutrition. A 3-year program was begun in 1979, encompassing all community health centers and including intensive community education in ORS use. Compared with the prestudy year 1977, diarrhea-related hospital admissions were reduced by 35.3% in 1980 and 42.0% in 1981; hospital deaths from diarrheal diseases were reduced 34.4 and 37.4% in 1980 and 1981, respectively. Total deaths in the 0-3 year age group were reduced by 28.7% in 1980 and by 41.7% in 1981. Diarrheal mortality was reduced by 35.6% in 1980 and 53.2% in 1981. This study succeeded in establishing active community and family participation.

Study of the HLA antigen in Arab children with paralytic poliomyelitis.

In 1974 and 1976, two outbreaks of paralytic poliomyelitis occurred in a vaccine-protected infant population in the Gaza Strip. To test the possibility of an increased susceptibility to the disease, the frequency of HLA antigens was studied in 58 of the affected children and compared with 113 control subjects. HLA-AW19 and -B7 were found more frequently in the affected children. These differences were not statistically significant but are consistent with the possibility that patients with the paralytic disease may have an HLA genetic makeup different from that of the rest of the population.

HLA antigens in the Arab population of the Gaza Strip.

The HLA antigen system was studied in the Arab population of the Gaza Strip. The lymphocytes of 113 individuals were typed for 13 and 16 antigens at loci A and B, respectively. The distribution of the HLA antigens was found to be similar to that of an average Caucasoid Middle Eastern population. This was more marked when the tested population was compared with Arab populations living in northern Israel or originating from Lebanon, suggesting that they probably all share a common gene pool. The only noteworthy variation in the Gaza population was the high frequency of BW21, previously found only in Eritreans and Turks.

A new variant of mannosidosis with increased residual enzymatic activity and mild clinical manifestation.

A partial deficiency of alpha-mannosidase was found in cultured skin fibroblasts, serum, and extracts of leukoytes in two siblings with mild mental retardation, delayed speech, a suggestion of coarse or full facies, and limited mobility of the large joints. All other lysosomal enzymes tested were within the normal range. Their father demonstrated intermediate alpha-mannosidase activity. The addition of 2 mM Zn++ caused a 40% increase of the alpha-mannosidase activity in cell extracts of both patients and control subjects. pH profiles and Cellogel electrophoresis of the patients' cells indicated 20% residual activity of the acidic alpha-mannosidase isoenzyme (pH optimum at 4.0), whereas the activity of the isozyme with pH optimum of 6.0 was normal. Increasing substrate concentration (1--10 mM) demonstrated a 4 to 5-fold increase in the apparent Km of the acidic alpha-mannosidase in the patients' fibroblasts. This residual activity, however, was apparently not sufficient for the normal catabolism of mannose-containing molecules, since electron microscopic examination of the cultured fibroblasts demonstrated numerous lysosomal storage bodies.

Paralytic poliomyelitis in the Gaza Strip and West Bank during recent years.

Numerous cases of paralytic poliomyelitis occurred during epidemic years and in interepidemic periods in recent years in the Gaza Strip and the West Bank. During the epidemics of 1974 and 1976, more than 100 paralytic cases were recorded each year. The dominant poliovirus was type 1. In interepidemic years, especially in the Gaza Strip, type 3 poliovirus was the prevalent type. The age group affected were infants and children up to 3 years and 50% of cases occurred during the first 12 months of life. Since 1968, oral poliovirus vaccine has been administered extensively to infants, 2 to 13 months of age. Though vaccine coverage was far from being complete, 3 doses of trivalent oral vaccine were given to the great majority of infants of this age group. Many of the paralytic cases occurred in unvaccinated or incompletely vaccinated (1-2 doses) children. However, numerous cases were recovered in children given three and four feedings. Serologic studies carried out on many of the paralyzed children indicated that "vaccine failures" had occurred. It seems that many of the vaccine failures were due to the massive and widespread circulation of various types of interfering enteroviruses. Laboratory tests of vaccine samples returned from the field prove that the vaccines used were undoubtedly of adequate potency. For these reasons we are planning a program of combined use of oral and inactivated vaccine in order to bypass the interference phenomenon.

The cell mediated immune response in acute poliomyelitis and its use in early diagnosis.

Specific cell mediated immunity to polio antigens was investigated in 22 children suffering from acute paralytic poliomyelitis by the macrophage migration inhibition (MIF) technique. A positive response was observed in 9 out of the 11 patients tested 1-14 days after the onset of the paralysis and in 6 out of the 8 patients tested between 15-90 days. In one case, the response was positive even before paralysis became evident. Out of the 8 patients tested 90-360 days after paralysis, only 3 gave positive results. No response whatsoever could, on the other hand, be observed in the great majority of children tested 1-3 months after having received oral polio vaccine or in healthy adults. These findings demonstrate that in poliomyelitis the specific C.M.I. response can be detected before the circulating antibodies and suggest that possibility of the use of this technique in the early diagnosis of poliomyelitis as well as in the differentiation between this disease and other neurological disorders.

The Dyggve-Melchio-Clausen syndrome.

Two families with Dyggve-Melchior-Clausen syndrome are reported. In the first family, Jews from Morocco, six of 10 siblings are affected. In the second family, a consanguineous marriage of Arabs from Gaza, two of three children are affected. A description of the skeletal changes in patients ranging in age from 4 to 25 years is presented. The radiologic signs of generalized platyspondyly with double humped end plates and the lace-like appearance of thickened iliac crests are pathognomonic and distinctive of the syndrome. The diagnostic features of the disease are compared to those of Morguio's disease, spondyloepiphyseal dysplasia tarda, and spondylometaphyseal dysplasia.