Syphilis and HIV prevalence among commercial sex workers in Central Java, Indonesia: risk-taking behavior and attitudes that may potentiate a wider epidemic.

A cross-sectional study was conducted on 200 commercial sex workers (CSWs) from two brothel communities in Central Java, Indonesia, to determine the seroprevalence of syphilis and HIV and characterize associated knowledge, beliefs, and risk-taking behaviors. A questionnaire was administered and blood drawn for HIV and syphilis serologies. Focus groups with a total of 20 women were also conducted at both communities to supplement survey data. The mean CSW age was 27.3 years; mean number of clients seen per day was 2.27. The prevalence of syphilis and HIV were 7.5% and 0.5%, respectively. Thirty percent said they and their partners never used condoms during sex, and only 3.0% said they always used condoms. The most common client groups were truck drivers and sailors. While Central Java appears to remain in a pre-epidemic state, there is enormous potential for a significant increase in HIV and STD transmission.

Lactation and the risk of breast cancer.

Some factors are suggested to have an association with an increased risk of breast cancer, which are called risk factors. Lactation is one of the risk factors that still needs to be studied because of conflicting findings in epidemiological studies and also uncertainty regarding biologic plausibility. Our objective was to study the relationship between lactation and the risk of breast cancer. A pair of unmatched case control studies was held among parous women at Dr. Soetomo Hospital (general hospital) and some private hospitals in the Surabaya municipality. There are 219 (51.9%) cases and 203 (48.1%) controls analyzed in this study. Age, age at menarche, regular menstruation and number of parity between both groups are not statistical different. When we divided the age at menarche (below 13), it was statistically different. The cases consisted of more women with menarche below 13 (p = 0.00038). Other factors showing statistical differences in the risk of breast cancer between case and control are age at first delivery, family history of breast cancer and age at menopause. Women who have lactated (more than 4-month duration of breast feeding) show a "protective effect" against breast cancer, OR 0.57 (95% CI 0.33-0.99). However, there was no clear duration of lactation and the risk of breast cancer. Logistic regression analysis showed that lactation was not any independent factor. Lactation exerts a "protective effect" against breast cancer. However, the duration of lactation did not show an influence in reducing the risk of breast cancer, and logistic regression analysis did not show that lactation was an independent factor in the risk of breast cancer.

Vitamin A supplementation selectively improves the linear growth of indonesian preschool children: results from a randomized controlled trial.

BACKGROUND: Vitamin A deficiency is associated with stunting and wasting in preschool children, but vitamin A supplementation trials have not shown a consistent effect on growth. OBJECTIVE: We examined the effect of vitamin A supplementation on height and weight increments among Indonesian preschool children. DESIGN: Data were obtained from a randomized, double-masked, placebo-controlled trial of rural Javanese children aged 6-48 mo. Children received 206000 IU vitamin A (103000 IU if aged <12 mo) or placebo every 4 mo. RESULTS: High-dose vitamin A supplementation modestly improved the linear growth of the children by 0.16 cm/4 mo. The effect was modified by age, initial vitamin A status, and breast-feeding status. Vitamin A supplementation improved height by 0.10 cm/4 mo in children aged <24 mo and by 0.22 cm/4 mo in children aged >/=24 mo. The vitamin A-supplemented children with an initial serum retinol concentration <0.35 micromol/L gained 0.39 cm/4 mo more in height and 152 g/4 mo more in weight than did the placebo group. No growth response to vitamin A was found among children with an initial serum retinol concentration >/=0.35 micromol/L. In non-breast-fed children, vitamin A supplementation improved height by 0.21 cm/4 mo regardless of age. In breast-fed children, vitamin A supplementation improved linear growth by approximately 0.21 cm/4 mo among children aged >/=24 mo, but had no significant effect on the growth of children aged <24 mo. CONCLUSION: High-dose vitamin A supplementation improves the linear growth of children with very low serum retinol and the effect is modified by age and breast-feeding.

Enterotoxigenic Escherichia coli diarrhea in children less than five years of age in central Java.

A community-based prospective study was performed from December 1993 through March 31, 1994 in Indonesia in children less than five years of age. Enterotoxigenic Escherichia coli (ETEC) was identified in diarrheic stool by colony hybridization assay, using toxin probes, and this bacterium was isolated from 19% of 340 episodes of diarrhea. Sixty-one percent of ETEC produced heat-labile toxin (LT) only, 325 LT and heat-stable toxin (ST), and 75 ST only. The age-specific incidence rates of diarrhea among children 0-1 and 2-3 years of age were 77% and 61%, respectively, during the study period; ETEC was isolated from 26% of children 0-1 years of age versus 53% for children 2-3 years of age. As many as seven episodes of diarrhea were repeatedly experienced by a single child during the four-month study period; however, only two children had more than one episode of known ETEC-associated diarrheal disease during the period of observation.

Vitamin A supplementation fails to reduce incidence of acute respiratory illness and diarrhea in preschool-age Indonesian children.

Vitamin A supplementation of populations of vitamin A-deficient preschool-age children has been shown to reduce childhood mortality, but the primary preventive effects of such supplements on childhood infectious diseases have not been carefully evaluated. We conducted an individually randomized, placebo-controlled, double-masked trial among 1,407 Indonesian preschool-age children, to measure the effects of high dose vitamin A on acute respiratory and diarrheal illnesses. Signs and symptoms of morbidity were monitored using every other day home surveillance by trained interviewers. High dose vitamin A supplements increased the incidence of acute respiratory illnesses (ARI) by 8%, and acute lower respiratory illnesses (ALRI) by 39%. These detrimental effects on acute lower respiratory illnesses were most marked in children with adequate nutritional status (rate ratio 1.83, 95% confidence interval 1.257-2.669). In contrast, vitamin A tended to be protective of ALRI in chronically malnourished children (rate ratio 0.71, 95% confidence interval 0.375-1.331). There was no overall effect of high-dose vitamin A supplements on the incidence of diarrheal disease (rate ratio 1.06, 95% confidence interval 0.920-1.225). However, we found a significant interaction between supplementation and age: vitamin A increased the incidence of diarrhea in children < 30 mo of age, but tended to reduce the incidence in older children. The finding of a significant adverse effect of vitamin A supplements in adequately nourished children highlights the need to review the criteria for selecting populations of preschool-age children for vitamin A supplementation.

Serum retinol levels among preschool children in Central Java: demographic and socioeconomic determinants.

BACKGROUND: Vitamin A deficiency is a significant problem in many countries in the developing world. Reports have noted demographic and socioeconomic risk factors for vitamin A deficiency. 'Deficiency' has usually been defined by clinical signs and symptoms which represent only a small proportion of those children at increased risk for vitamin A preventable morbidity and mortality. METHODS: As part of a population-based trial of vitamin A to prevent childhood morbidity, we collected census data (n = 666), baseline socioeconomic data (n = 636) and sera (n = 666) from children aged 6-48 months in 25 adjacent villages in a rural area in Central Java, Indonesia; there was more than 95% participation. We used t tests, ANOVA, and a multiple variable linear regression model in our analyses. RESULTS: Differences in mean retinol level were detected for the following variables: village (P < 0.001), child's age (P = 0.03), size of sibship (P < 0.001), mother's occupation (P < 0.01), mother's education (P = 0.05), father's education (P = 0.03), monthly household earnings (P = 0.02), land ownership (P = 0.03), possession of ducks (P = 0.06), radio or tape player (P = 0.02), or a watch or clock (P = 0.07), and presence of a natural well (P = 0.09). Our regression model verified the predictive value of village, age, sibship, land ownership and earnings. CONCLUSIONS: We found that owning land and that the highest and lowest categories of reported household income were associated with higher serum retinol levels. We also noted clustering of serum retinol levels by village and discovered that children from larger sibships and infants had significantly lower serum retinol levels. Vitamin A supplementation of lactating mothers, particularly of high parity, and/or their infants should be considered.

PIP: Vitamin A deficiency is a significant problem in many countries in the developing world. Reports have noted demographic and socioeconomic risk factors for vitamin A deficiency. As part of a population-based trial of vitamin A to prevent childhood morbidity, census data (n = 666), baseline socioeconomic data (n = 636) and sera (n = 666) were collected from children 6-48 months old in 25 adjacent villages in a rural area in Central Java, Indonesia. Participation amounted to more than 95%. The analyses used t tests, ANOVA, and a multiple variable linear regression model. The distribution of serum retinol levels (in mcmol/l) in males shifted to the left relative to females, resulting in a higher proportion of males with a level 0.70 mcmol/l (20 mcg/dl); 216/346 males versus 173/320 females (p = 0.03). However, there was no significant difference in the means by gender. Differences in mean retinol level were detected for the following variables: village (p 0.001); child's age (p = 0.03); size of sibship (p 0.001); mother's occupation (p 0.01); mother's education (p = 0.05); father's education (p = 0.03); monthly household earnings (p = 0.02); land ownership (p = 0.03); possession of ducks (p = 0.06), radio or tape player (p = 0.02), or a watch or clock (p = 0.07); and presence of a natural well (p = 0.09). There was no significant difference in mean serum retinol level for mother's marital status; father's occupation; monthly household expenditures; house ownership; composition of floors, walls, or roofs; or possession of buffaloes, cattle, goats, kerosene light fixtures, televisions, or motorcycles. The regression model verified the predictive value of village, age, sibship, land ownership, and earnings. Owning land and the highest and lowest categories of reported household income were associated with higher serum retinol levels. Also clustering of serum retinol levels was noted by village, and children from larger sibships and infants had significantly lower serum retinol levels. Vitamin A supplementation of lactating mothers, particularly of high parity, and/or their infants should be considered.

HIV and AIDS in Indonesia.

PIP: Indonesia is the fourth most populous nation in the world, with a population of 184 million in 1993. By the end of December 1993, the Ministry of Health had reported 193 confirmed HIV infections. There have been 34 deaths from AIDS and HIV infections have been reported from 11 of the 27 provinces in the country. Where nationality is known, native Indonesians comprise 51% of HIV infections and non-Indonesians the remaining 49%. Sexual transmission accounts for 96% of cases where the route of transmission is known; route is unknown in 54 cases. Male:female sex ratio is 23:1 for reported AIDS cases and 4:1 for HIV infections for which sex is known. There have been no pediatric cases reported and 96% of those infected for whom age is known are 15-49 years. The present reporting system definitely underestimates the actual number of HIV infections. The window of prevention in the linear growth phase of the epidemic closed in 1992, when Indonesia began to experience exponential epidemic growth. Although the epidemiologic situation is worsening rapidly, a chance remains that HIV can be kept from becoming a major development problem. The government is now addressing the epidemic as a developmental issue, calling for action across sectors and in partnership with nongovernmental organizations and the private sector much earlier than elsewhere. The successful family planning program instituted in response to the population crisis will serve as a model for HIV prevention strategies and programs in Indonesia.^ieng

Comparison of the efficacy between flunarizine and nifedipine in the prophylaxis of migraine.

BACKGROUND: Several calcium channel blockers have been evaluated in controlled clinical studies and some hold considerable promise for future. Efficacy in migraine prophylaxis has been claimed for drugs belonging to all three classes of calcium channel blockers (nifedipine-like, verapamil-like, and flunarizine-like), but the extent and quality of the evidence varies, and a comparison of efficacy between different calcium channel blockers has not been reported. OBJECTIVE: The objective of the study is to assess the comparison of efficacy and safety of flunarizine and nifedipine in migraine prophylaxis. PATIENTS AND METHODS: The study was conducted in a prospective, double-blind, randomized controlled trial, parallel group design. 78 patients were studied for a 1-month period during which all patients received placebo followed by a 3-month experimental period. Headache response to medication was measured monthly by compilation of migraine-scores derived from quantitative data recorded by patients in a daily diary. Student's t-test was used to compare results from the flunarizine (10 mg) and nifedipine (20 mg) group for each month. RESULTS: Both groups showed a significant reduction in the migraine-scores after 3-months. No significant differences were detected between groups, but there was a clinical significantly different reduction of migraine-scores between the groups in the first month after the run-in period (58% vs 38%). It shows that the beneficial effect of flunarizine was more rapidly manifest than that of flunarizine. Tachycardia more frequently occurred in the nifedipine group than in the flunarizine treatment group. CONCLUSION: It concluded that flunarizine is a potentially more useful agent in the prophylaxis of migraine headache.

Familial insulin resistance and acanthosis nigricans.

Insulin resistance exists in 0.1% of diabetics having insulin treatment. In addition to diabetics, insulin resistance can also be seen in association with acanthosis nigricans. Both conditions become a syndrome that may happen in a family. This is a report of two siblings, a brother and a sister, 14 and 10 years of age, whose parents are cousins, who suffered from diabetes mellitus, acanthosis nigricans, and growth retardation. The insulin therapy until 54 units per day given to the boy and 174 units per day to the girl, did not give response to the plasma glucose level. Plasma C-peptide and prolactin values of the girl were normal. The plasma fasting insulin level of both was high. Measurement of insulin binding to erythrocytes and monocytes was not performed. The GTT observations of their parents did not represent glucose intolerance.

Polio and lameness in Yogyakarta, Indonesia.

This survey for residual paralysis among rural and urban children in Central Java shows an overall rate for polio lameness of 9/10 000 children. A recent rise in reported cases of acute poliomyelitis is reflected in paralysis rate among preschool children of 22/10 000. Three quarters of cases occur before the third birthday. A majority of children below age 3 are lacking antibody titres to one or more types of polio virus, demonstrating the need for mass immunisation. A simple questionnaire detected polio cases with a sensitivity of 84%.

Teaching epidemiology in developing countries: a field exercise.

A field exercise demonstrating the principles of a sample survey is described which, in 9 steps carried out over 3-4 days, provides reliable data on selected infectious diseases, vital rates, causes of mortality and other health indicators. Survey design, implementation, analysis and interpretation are applied in a practical and visible way during the exercise. Frequent outbreaks of common childhood infectious diseases in developing countries makes an epidemic tracing and characterisation exercise usually possible during the course of this exercise as well. The resulting data appear to be quite reliable, in contrast to existing data gathered passively through the health services system, and provide a useful indicator of present priorities and needed action in the control of infectious diseases.

Elementary-school pupils as health educators: role of school health programmes in primary health-care.

The high proportion of children attending primary schools in rural parts of Indonesia and the low health-care cover in these areas prompted a plan to involve schoolchildren in a health-education programme. Action-oriented health lessons aimed at modifying community-health-related behaviour were designed to suit the teaching format familiar to rural teachers. The lessons involved pupils in health activities in their own homes and neighbourhoods. Evaluation of the teaching module on diarrhoea showed a substantial improvement in knowledge, skills, and attitudes of rural families regarding this illness, and indicated how a vastly increased outreach of primary health-care activities is possible through a well-designed school-health programme.

PIP: The high proportion of children attending primary schools in rural parts of Indonesia and the low health-care coverage in these areas prompted a plan to involve school children in a health-education program. Designed to suit the teaching format familiar to rural teachers, the action-oriented health lessons aimed at modifying community-health-related behavior. The lessons involved pupils in health activities in their own homes and neighborhoods. Evaluation of the teaching module on diarrhea found a substantial improvement in knowledge, skills, and attitudes of rural families regarding this illness. The evaluation indicates how a vastly increased outreach of primary health-care activities is possible through a well designed school-health program. Children and teachers alike are enthusiastic about action-oriented lessons which have clear goals and observable results. In a semiliterate society, the primary school child may well be the first in the family to be educated. The information he carries home may be seen as modern, reliable, and believable. Of 20 million children attending Indonesian primary schools, 7 million are in classes 4-6, for whom the lessons were planned.

Training course for village nutrition programs.

PIP: The aims and objectives of a training course to train the trainers for village nutrition programs in Indonesia are described along with the selection and preparation of participants, course syllabus, and the various field and classroom activities. Certain aspects of both the program and training course are unique to Indonesia, but the principles of community nutrition and education techniques are applicable to many varied situations. The training course is aimed at workers who will be training villagers and overseeing the initiation and the operation of the various program activities envisioned. The assumption is that participants will enter the course with a firm background knowledge of nutrition and some grasp of the precepts of public health. The participants are divided into groups of 6-7 persons in order to ensure a heterogeneous mix of experience, geography and professional background. The general course objective was to educate persons designated as trainer for specified districts who will be prepared to train village level volunteers to organize and operate the village nutrition programs. Course content includes the following: nutrition; anthropometry; village weighing program; supplementary feeding; nutritional first aid; simple curative health services; home gardening; and organization/management. The specific objectives for each of the course content areas are outlined. A precourse reading assignment is sent to each participant 6 weeks prior to the training. The assignment includes 4 concise pamphlets covering basic nutrition, simple anthropometry, a village weighing guide, and a supplementary feeding program guide. Accompanying these pamphlets is a detailed examination to be used as a self test by the participant to assure an adequate standard of baseline knowledge on entering the course. Emphasis during the course is on small group (5-7 members) problem solving activities in the classroom and in the field. All lectures are illustrated with slides and briefly stenciled outlines that provide all necessary information. This approach encourages participants to interact more freely with the speaker and to grasp concepts rather than trying to record facts. A set of detailed written guides to provide clear instructions for action on return home is provided to all participants. A course schedule is outlined in detail.^ieng

Salmonellosis in Indonesia: phage type distribution of Salmonella typhi.

The distribution of phage types was studied among 577 strains of Salmonella typhi from Indonesia. Chemotype, colicinogeny, and tetrathionate reductase activity were also studied for most of these strains. The current phage type formula for Java was determined to be: A, D2, D6, E1a, E2, M1, and 46, but two other large groups of strains were also found, I + IV and degraded Vi+ strains. Significant differences in S. typhi strain distributions were noted between two localities on Java with respect to phage type and tetrathionate reductase activity. Comparisons were made with past phage typing studies in Jakarta as well as with more recent studies in other parts of south-east Asia. Phage types A, D1, D2, and E1 persisted at a rather steady level in Jakarta for 28 years. Evidence was found for epidemiological links to European and Asian areas. Antibiotic resistance among these Indonesian S. typhi strains was rare.

Salmonellosis in Indonesia: phage type distribution of Salmonella paratyphi A.

The distribution of phage types among 221 human strains of Salmonella paratyphi A in Indonesia was studied. Approximately 50% were phage type 5, a rare type elsewhere in the world. Most other isolates were the cosmopolitan phage type 1. The ratio of phage type 1-5 was compared for two cities on Java, Jakarta and Yogyakarta. The ratios were significantly different, phage type 5 predominating in Jakarta. The ratio of phage types among 10 S. paratyphi A strains isolated from Jakarta river water was similar to that found in Jakarta patients.

Primary care in the village. An approach to village self-help health programmes.

PIP: The health clinic run in Kalirandu, Indonesia, by Foster Parents Plan, a private philanthropic welfare organization is described. In 1974 the Plan was serving 3000 families through 4 clinics, providing general curative services, pre- and postnatal services, family planning, dental care, and referral to the local urban hospital where needed. Each clinic treated about 100 patients per day at a cost of $1 per client family per month. However, few inocculations were given and few preventive health checks were requested. When the number of Plan families grew to 9500 while the population of the served communities grew to 400,000 with no increase in clinic budget, a different approach was tried. Instead of serving only the families helped direactly by the Plan, a total community service was developed. Plan personnel began to encourage use of the government health clinics. A rural health insurance system was developed which entitles the families to preventive health services. Plan medical staff and the local health center trained volunteers from Kalirandu in the use of a few simple medicines. The volunteers were selected by the village headmen and generally have elementary school education and a position of responsibility. This health "kader" works without payment and has 10-15 families living near him for whom he is responsible. At the time of writing there were over 500 kaders trained. Inservice courses are conducted to keep them up-to-date. An acceptors club was formed to motivate use of family planning. Seeking a more active role in village life, the acceptors club then took on child nutrition as a project, weighing children and reminding mothers of inoculations. The self-help momentum is spreading to housing and better farming practices, which is providing more vegetable gardens and better sources of Vitamin A. It is emphasized that this type of group responsibility cannot be imposed from outside. It is community leaders within that provide the motivation for self-help projects.^ieng