Knowledge of human papillomavirus and anal cancer among men who have sex with men attending a New York City sexually transmitted diseases clinic.

Men who have sex with men (MSM) are at risk for human papillomavirus (HPV) infection and anal cancer (AC) yet little is known regarding MSM knowledge and risk perception for these outcomes. We surveyed 116 MSM attending a sexually transmitted disease clinic and found that over a quarter (27%) did not know HPV is transmitted via anal sex and most (77%) were unaware of the link with AC. Many MSM (60%) perceived risk for HPV; far fewer (35%) perceived risk for AC. In adjusted logistic regression analyses, having friends or acquaintances with HPV or genital warts was associated with knowledge of anal HPV transmission (odds ratio [OR] = 4.3; 95% confidence interval [CI] = 1.4, 13.4) and AC risk-perception (OR = 6.2; 95% CI = 2.3, 16.7); reporting a regular source of care was associated with awareness of a link between HPV and AC (OR = 3.1; 95% CI = 1.1, 9.1); and MSM and women versus MSM, had less perceived risk for HPV (OR = 0.05; CI = 0.01, 0.29). Nearly all expressed hypothetical acceptance of HPV vaccine. In our sample, many MSM were unaware of a link between MSM sexual practices and HPV-related outcomes.

An outbreak of syphilis in Alabama prisons: correctional health policy and communicable disease control.

OBJECTIVES: After syphilis outbreaks were reported at 3 Alabama State men's prisons in early 1999, we conducted an investigation to evaluate risk factors for syphilis infection and describe patterns of syphilis transmission. METHODS: We reviewed medical, patient interview, and prison transfer records and documented sexual networks. Presumptive source cases were identified. Odds of exposure to unscreened jail populations and transfer from other prisons were calculated for case patients at 1 prison. RESULTS: Thirty-nine case patients with early syphilis were identified from 3 prisons. Recent jail exposure (odds ratio [OR] = 8.0, 95% confidence interval [CI] = 0.3, 158.7, P = .14) and prison transfer (OR = 32.0, 95% CI = 1.6, 1668.1, P < .01) were associated with being a source case patient. CONCLUSIONS: Probable sources of syphilis introduction into and transmission within prisons included mixing of prisoners with unscreened jail populations, transfer of infected inmates between prisons, and multiple concurrent sexual partnerships. Reducing sexual transmission of disease in correctional settings is a public health priority and will require innovative prevention strategies.

Sexually transmitted diseases of older persons in Washington State.

BACKGROUND: Sexually transmitted diseases (STDs) in persons older than 50 years are rarely studied because STDs are more common in young people. Understanding the epidemiology of STDs in older persons is important for reducing STD morbidity and for improving STD care. GOAL: To understand the epidemiology of STDs in older persons. METHODS: Washington State's STD surveillance data from 1992 to 1998 were analyzed to describe the burden of STDs and source of care for these diseases in older persons. RESULTS: From 1992 to 1998, 1535 episodes of STDs were reported for 50- to 80-year-olds in Washington State, accounting for 1.3% of all reported STDs. The most common STDs were nongonococcal urethritis in men and genital herpes in women. As compared with younger persons, older individuals more frequently sought care at private clinics and had symptoms at the time of the clinic visit. CONCLUSIONS: Sexually transmitted diseases are reported among older persons, although at lower rates than among younger persons. Services for STD and counseling regarding safe sex should be available to persons of all ages.

Diagnosis and management of febrile children using the WHO/UNICEF guidelines for IMCI in Dhaka, Bangladesh.

OBJECTIVE: To determine whether the fever module in the WHO/UNICEF guidelines for the integrated management of childhood illness (IMCI) identifies children with bacterial infections in an area of low malaria prevalence. METHODS: Physicians assessed a systematic sample of 669 sick children aged 2-59 months who presented to the outpatient department of Dhaka Shishu Hospital, Bangladesh. FINDINGS: Had IMCI guidelines been used to evaluate the children, 78% of those with bacterial infections would have received antibiotics: the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%) and urinary tract infection (83%); and 50% or less of children with bacteraemia (50%), dysentery (48%), and skin infections (30%). The current fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot, and have a history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current IMCI module. CONCLUSIONS: In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.

Repeat Chlamydia trachomatis infection in women: analysis through a surveillance case registry in Washington State, 1993-1998.

Repeat infections with Chlamydia trachomatis are associated with increased risk for long-term sequelae. The authors analyzed the frequency and predictors of repeat chlamydial infection by using a population-based chlamydia registry in Washington State and evaluated whether women would seek care at the same clinic for repeat infections. Among 32,698 women with an appropriately treated initial chlamydial infection during 1993-1998, 15% developed one or more repeat infections during a mean follow-up time of 3.4 years. Among women less than age 20 years at the time of initial infection, 6% were reinfected by 6 months, 11% by 1 year, and 17% by 2 years. Young age was the strongest predictor for one and two or more repeat infections after controlling for the length of follow-up and other variables. Only 36% of the repeat infections were diagnosed at the same clinical setting as the initial infection, and 50% were diagnosed at the same type of clinic. Adolescent girls had the least consistency in the source of care for chlamydia. This study suggests that efforts to prevent repeat chlamydial infection in young women remain an urgent public health priority and that the burden of repeat infection may be substantially higher than estimates from clinic-based studies.

Duration of untreated genital infections with chlamydia trachomatis: a review of the literature.

BACKGROUND: Estimates of the duration of untreated genital infections with Chlamydia trachomatis vary. Accurately estimating the distribution of the duration of infection would be useful in the counseling patients, and is essential when modeling the burden of chlamydial disease and the potential impact of prevention programs. GOAL: The authors review the scientific literature to summarize what is known about the duration of genital chlamydial infection and the factors that affect it. STUDY DESIGN: Literature review of animal and human studies. RESULTS: Animal studies document a longer duration of infection in primates than in mice or guinea pigs. Although animals spontaneously become culture negative over time, numerous studies document persistent nonculture evidence of chlamydiae in the upper genital tract. Studies in which women have been serially cultured suggest that most untreated infections remain culture positive for more than 60 days. Small series report that some infections may persist for years. Most infections eventually become culture negative; however, non-culture evidence of chlamydiae often persist in women with negative cultures. The duration of chlamydial infection is reduced in animals previously exposed to chlamydiae and in older humans, suggesting that partial immunity may result from exposure. Data are inadequate to define the median duration of untreated infection or to derive a curve that describes the natural history of untreated genital chlamydial infections. CONCLUSION: Current data do not allow one to reliably estimate the duration of genital infections with C trachomatis. Systematic retesting could help to better define the duration of infection in patients who, against medical advice, delay treatment for genital chlamydial infections.

Health care reform in Oregon: the impact of the Oregon Health Plan on utilization of mammography.

BACKGROUND: In 1994, Oregon implemented the Oregon Health Plan (OHP), extending health care coverage under a system of capitated managed care to uninsured citizens living below the Federal Poverty Level (FPL). We conducted a study to measure receipt of clinical preventive services among women newly enrolled in the OHP. METHODS: Six hundred and sixty six women aged 52-64, and living below the FPL in Oregon were randomly selected from OHP enrollment rosters and interviewed by telephone. A follow-up survey was conducted 1 year later. The main outcome of interest was receipt of a screening mammogram during the first year in the OHP. RESULTS: At enrollment 17% (65/383) of participants had never had health care coverage. Sixty-six percent of the women (220/333) were overdue for a mammogram. Fifty-five percent (121/220) reported cost as the main reason they had not had this procedure. Mammography rates doubled under the OHP (21% to 52%, 95% CI = 0.25-0.38, p < 0.001). Among women who were overdue for a mammogram at the time they enrolled, an expressed plan to get a mammogram (OR3.0, 95% CI = 1.1-8.7, p = 0.04), citing cost as the main reason for being overdue (OR3.0, 95% CI = 1.3-7.2, p = 0.014), receipt of a routine checkup (OR9.5, 95%CI = 3.7-24.9, p < 0.001), and health care provider's (HCP's) recommendation for mammography (OR8.1,95% CI = 2.9-23.0, p < 0.001) were independently associated with receipt of a mammogram. CONCLUSION: The OHP enrolled and successfully delivered clinical preventive services to a medically under served population. Even after removing the financial barrier, obstacles to mammography remain. These may be overcome by health systems changes to insure receipt of routine checkups and appropriate provider recommendations.

Survival after acute lymphocytic leukaemia: effects of socioeconomic status and geographic region.

National cancer registry data, linked to an areal measure of material deprivation, were used to explore possible socioeconomic and regional variation in the survival of children (0-14 years) diagnosed with acute lymphocytic leukaemia (ALL) in England and Wales from 1971 to 1990. Survival analysis and Poisson regression were used to estimate observed (crude) survival probabilities and the adjusted hazard of death. There was little evidence of a socioeconomic gradient in survival. Regional differences in survival were observed over time. These differences were most pronounced in the first six months after diagnosis, and may be attributable to differential access to centralised paediatric oncology services or treatment protocols, or to the artefact of variations in regional cancer registry practice. Similar analyses should be repeated for other, less treatable childhood cancers. The results of this study can be used to help identify ways of reducing regional variation in survival.

Identifying sick children requiring referral to hospital in Bangladesh.

The object of this study was to evaluate and improve the guidelines for the Integrated Management of Childhood Illness (IMCI) with respect to identifying young infants and children requiring referral to hospital in an area of low malaria prevalence. A total of 234 young infants (aged 1 week to 2 months) and 668 children (aged 2 months to 5 years) were prospectively sampled from patients presenting at a children's hospital in Dhaka, Bangladesh. The study paediatricians obtained a standardized history and carried out a physical examination, including items in the IMCI guidelines developed by WHO and UNICEF. The paediatricians made a provisional diagnosis and judged whether each patient needed hospital admission. Using the paediatrician's assessment of a need for admission as the standard, the sensitivity and specificity of the current and modified IMCI guidelines for correctly referring patients to hospital were examined. The IMCI's sensitivity for a paediatrician's assessment in favour of hospital admission was 84% (95% confidence interval (CI): 75-90) for young infants and 86% (95% CI: 81-90) for children, and the specificity was, respectively, 54% (95% CI: 45-63) and 64% (95% CI: 59-69). One fourth or more in each group had a provisional diagnosis of pneumonia, and the IMCI's specificity was increased without lowering sensitivity by modifying the respiratory signs calling for referral. These results show that the IMCI has good sensitivity for correctly referring young infants and children requiring hospital admission in a developing country setting with a low prevalence of malaria. The guidelines' moderate specificity will result in considerable over-referral of patients not needing admission, thereby decreasing opportunities for successful treatment of patients at first-level health facilities. The impact of the IMCI guidelines on children's health and the health care system must be judged in the light of current treatment practices, health outcomes and referral patterns.

PIP: Findings are presented from a study conducted to evaluate and improve the integrated management of childhood illness (IMCI) training program guidelines on identifying young infants and children who need to be referred to hospitals in an area of low malaria prevalence. 234 infants aged 1 week to 2 months and 668 children aged 2 months to 5 years were prospectively sampled from patients who presented at a children's hospital in Dhaka, Bangladesh. Pediatricians obtained standardized histories from the patients and conducted a physical examination. The IMCI's sensitivity relative to a pediatrician's assessment in favor of hospital admission was 84% for young infants and 86% for children, while specificities were 54% and 64%, respectively. 25% or more of both young infants and children were provisionally diagnosed with pneumonia. The IMCI's specificity increased without reducing sensitivity by changing the respiratory signs demanding referral. Study findings indicate that the IMCI is sensitive enough to result in the proper referral of young infants and children in need of hospital admission in a developing country setting with a low prevalence of malaria.

Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria.

The object of this study was to assess the ability of pallor and other clinical signs, including those in the Integrated Management of Childhood Illness (IMCI) guidelines developed by WHO and UNICEF, to identify severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respectively, a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized history and carried out a physical examination that included pallor, signs of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with conjunctival or palmar pallor, and in a sample of the rest. Children with a blood level measurement and assessment of pallor at both sites were included in the anaemia analysis. Using the haematocrit or haemoglobin level as the reference standard, the correctness of assessments using severe and some pallor and other clinical signs in classifying severe and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the children in Bangladesh with severe anaemia to hospital, few would have received a diagnosis of severe anaemia. Severe palmar and conjunctival pallor, individually and together, had 10-50% sensitivity and 99% specificity for severe anaemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor did not work as well as conjunctival pallor in Bangladesh for the detection for severe or some anaemia. Combining "conjunctival or palmar pallor" detected 71-87% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having "moderate or mild" anaemia. Anaemia was more easily diagnosed in Uganda in children with malaria. Our results show that simple clinical signs can correctly classify the anaemia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected.

PIP: The capability of pallor and other clinical signs to identify anemia was evaluated in developing country settings with malaria (Uganda) and without malaria (Bangladesh). Enrolled were 1226 children, 2 months to 5 years of age, who presented to a rural district hospital in Fort Portal, Uganda, and 668 children from a children's hospital in Dhaka, Bangladesh. Physicians examined the children for conjunctival pallor, respiratory distress, and other clinical signs of anemia (i.e., palmar pallor) included in the World Health Organization's Integrated Management of Childhood Illness (IMCI) guidelines. 58% of Ugandan and 47% of Bangladeshi children had pallor of at least one site. Hematocrit or hemoglobin levels were measured in all children with pallor of the conjunctiva or palms and in a sample of the remaining children. In both locations, 2% of children had severe anemia; 13% and 17%, respectively, in Uganda and Bangladesh had moderate anemia, and 42% and 62%, respectively, had mild anemia. Comparison of these findings with the clinical signs indicated that use of the full IMCI process would have referred 68-90% of children with severe anemia to the hospital. Severe palmar and conjunctival pallor, individually and together, had a sensitivity of 10-50% and a specificity of 99% for severe anemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor was not as effective as conjunctival pallor for detecting anemia in Bangladesh. Combining conjunctival and palmar pallor detected 71-87% of cases of moderate anemia and half the cases of mild anemia. Anemia was more easily diagnosed in Uganda in children with malaria. These findings confirm the usefulness of clinical signs in the detection of anemia in developing countries, but suggest the feasibility of adding conjunctival pallor, and possibly grunting, to the IMCI algorithm.

Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria

The object of this study was to assess the ability of pallor and other clinical signs, including those in the Integrated Management of Childhood Illness (IMCI) guidelines developed by WHO and UNICEF, to identify severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respectively, a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized history and carried out a physical examination that included pallor, signs of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with conjunctival or palmar pallor, and in a sample of the rest. Children with a blood level measurement and assessment of pallor at both sites were included in the anaemia analysis. Using the haematocrit or haemoglobin level as the reference standard, the correctness of assessments using severe and some pallor and other clinical signs in classifying severe and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the children in Bangladesh with severe anaemia to hospital, few would have received a diagnosis of severe anaemia. Severe palmar and conjunctival pallor, individually and together, had 10-50% sensitivity and 99% specificity for severe anaemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor did not work as well as conjunctival pallor in Bangladesh for the detection for severe or some anaemia. Combining "conjunctival or palmar pallor" detected 71-87% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having "moderate or mild" anaemia. Anaemia was more easily diagnosed in Uganda in children with malaria. Our results show that simple clinical signs can correctly classify the anaemia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected

Occurrence of aflatoxins and aflatoxin-producing strains of Aspergillus spp. in soybeans.

Above average rainfall in Maryland during August, September, and October 1971 resulted in heavy mold growth in soybeans while still in the field. Of 28 samples of soybean seed, aflatoxins were found in 14, 2 of which had been used in poultry feed. Aflatoxins were identified by thin-layer chromatography, spectrophotometry, and chicken embryo bioassay. Aspergillus spp. were isolated from 11 samples, and 5 of these isolates produced aflatoxins when grown in liquid culture.