Public health requirements for rapid progress in global health.

Effective public health interventions can save hundreds of millions of lives in developing countries, as well as create broad social and economic benefits. Unfortunately, public health approaches and solutions applied in developed countries are often assumed to be inappropriate or unattainable in developing countries. This has sometimes forestalled effective interventions in parts of the world where they are most needed, despite conditions that now facilitate lasting solutions to both long-standing and emerging global public health problems. Core public health functions are similar regardless of a country's income level. Although some resource-intensive approaches from industrialised nations are inappropriate in less developed countries, many basic public health measures achieved decades ago in developed countries are urgently needed, highly appropriate, extremely cost-effective and eminently attainable in developing countries today. About half of the disease burden in low and middle-income countries is now from non-communicable diseases, but non-communicable disease epidemics that will otherwise increase rapidly in the developing world can be avoided or reversed. Progress of public health in developing countries is possible, but will require sufficient funding and human resources; improved physical plant and information systems; effective programme implementation and regulatory capacity; and, most importantly, political will at the highest levels of government.

[Vitamins for the eyes? Risks and opportunities for physician and patient]. / Vitamine für das Auge? Risiken und Chancen für Arzt und Patienten.

This article discusses the effects of dietetic measures and specialized food supplements on age-related macular degeneration (AMD) and diabetic retinopathy. The sale of products in doctors' offices is already prohibited by laws governing the medical profession. The results of the Age-Related Eye Disease Study (AREDS) concerning high doses of vitamins and zinc cannot simply be transferred to other doses and substances. Furthermore, there are health risks that have to be examined. Opportunities could arise for both doctor and patient if the AREDS formulation were granted authorization to be marketed as a medicinal product; however, a certain protective effect can be expected only for specific forms of AMD after a careful risk-benefit analysis and assessment within the statutory marketing authorization procedure for medicinal products.

Invasive group B streptococcal disease in Maryland nursing home residents.

Between 1991 and 1995, among 999 nonpregnant adult Maryland residents with group B Streptococcus (GBS) isolated from a normally sterile site, 84 resided in nursing homes (NHs). The age-adjusted annual incidence of GBS infection (per 100,000 population) among those > or = 65 years old was 72.3 for NH residents and 17.5 for community residents (relative risk, 4.1; P < 0.001). Thirty-four case patients resided in 11 NHs with > or = 2 cases; 1 NH had 8 case patients within 22 months. Six of 8 case patients from 3 NHs had serotype V GBS. Molecular subtyping of several isolates identified 2 case patients in 1 NH with identical subtype patterns. NH residents have a markedly higher incidence of invasive GBS than do community residents > or = 65 years old and may serve as a target group for immunization when GBS vaccines become available. Further evaluation of intra-NH transmission of GBS is warranted.

Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS).

Transjugular intrahepatic portosystemic shunt (TIPS) has become a routine procedure in patients with portal hypertension, yet there are few data concerning the incidence of bacteremia associated with this shunt. All patients who underwent TIPS placement at a university hospital from January 1992 through January 1999 were studied. Ninety-nine TIPS were placed, and 10 patients subsequently developed sustained bacteremia; 5 patients had no identifiable source of bacteremia despite rigorous evaluation and were presumed to represent TIPS infections, for an estimated annual incidence of 7 cases/1000 TIPS procedures. Case patients developed bacteremia a median of 100 days after TIPS placement (range, 6-732 days). Bacteremia resolved in all patients after treatment with appropriate intravenous antibiotics (median, 2 weeks of therapy). Although the incidence of TIPS-associated bacteremia appears low, the increasing frequency of this procedure suggests that more information is needed to define this entity and to develop appropriate treatment recommendations.

Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis.

For reasons not yet determined, chronic liver disease (CLD) has been a leading cause of excess morbidity and mortality in central Harlem. We conducted a case series and case-control analysis of demographic, clinical, epidemiological, and alcohol-intake-related information from patients with CLD and age- and sex-matched hospitalized control patients. Patients' sera were tested for markers of viral hepatitis. The presumed etiology of CLD among case-patients was as follows: both alcohol abuse and hepatitis C virus (HCV) infection, 24 persons (46% of case-patients); alcohol abuse alone, 15 (29%); HCV infection alone, 6 (12%); both alcohol abuse and chronic hepatitis B virus (HBV) infection, 3 (6%); and 1 each (2%) from: 1) schistosomiasis, 2) sarcoidosis, 3) unknown causes, and 4) alcohol abuse, chronic HBV, and HCV combined. In the case-control analysis, patients who had both alcoholism and either HBV (odds ratio [OR]: 6.3; 95% CI: 0. 5-334) or HCV (OR: 2.9; 95% CI: 1.3-6.2) were at increased risk for CLD, whereas patients who had only one of these three factors were not at increased risk for CLD. Patients who tested positive for the hepatitis G virus (HGV) did not have a significantly increased risk of CLD, and neither severity of CLD nor mortality was greater among these patients. Most patients in central Harlem who had CLD had liver damage from a combination of alcohol abuse and chronic viral hepatitis. Alcohol and hepatitis viruses appear to be synergistically hepatotoxic; this synergy appears to explain both the high rate of CLD in central Harlem and the recent reductions in this rate. Persons at risk for chronic HBV and HCV infection should be counseled about their increased risk of CLD if they consume excessive alcohol. Morbidity and mortality from liver disease could be decreased further by a reduction in alcohol consumption among persons who have chronic HBV and HCV infection, avoidance of needle sharing, and hepatitis B vaccination.

Universal radiographic screening for tuberculosis among inmates upon admission to jail.

OBJECTIVES: This study evaluated the efficacy of radiographic screening for tuberculosis in correctional facilities. METHODS: Inmates at an admission facility in New York, NY, were screened for tuberculosis by registry cross-match, symptom interviews, tuberculin testing, and chest radiography. RESULTS: Thirty-two cases of tuberculosis were detected among 4172 inmate admissions (767 cases per 100,000). Twenty-five inmates (78%) were previously diagnosed but incompletely treated; all were identified by registry cross-match. Seven inmates (22%) were newly diagnosed, of whom four (57%) were asymptomatic, had negative skin tests, and were detected only by their abnormal radiographs. CONCLUSIONS: Screening strategies that limit radiographic testing to inmates with either positive skin tests or symptoms may result in missed opportunities for diagnosing active tuberculosis.

A national survey of immunization practices following allogeneic bone marrow transplantation.

OBJECTIVES: To describe the frequency and patterns of use of routine childhood and hepatitis B, pneumococcal, influenza, and meningococcal vaccines following allogeneic bone marrow transplantation (BMT). DESIGN, SETTING, AND PARTICIPANTS: Survey of all US transplantation centers participating in the National Marrow Donor Program (NMDP) during 1994. MAIN OUTCOME MEASURES: Use, timing, and total doses of selected vaccines given to patients younger than 7 years and patients aged 7 years or older following allogeneic BMT. RESULTS: Of 66 centers associated with the NMDP, 45 (68%) responded. A total of 97% of centers performing transplants on patients younger than 7 years and 88% of centers performing transplants on patients aged 7 years or older gave either the diphtheria-tetanus vaccine or the diphtheria-tetanus-pertussis vaccine compared with 77% and 58% usage, respectively, of Haemophilus influenza type b conjugate vaccine (P=.03 and .003, respectively). Centers were more likely to administer inactivated poliovirus and measles-mumps-rubella vaccines to patients younger than 7 years than to the older age group (94% vs 73% for poliovirus, P=.02; and 94% vs 70% for measles-mumps-rubella, P=.01). About one half of centers routinely administer hepatitis B vaccine and approximately three quarters immunize with pneumococcal and influenza vaccines. Few programs, regardless of age of bone marrow recipient, use multiple vaccine (> or =2) doses. The number of schedules reported for specific vaccines varied widely (3-11 schedules per vaccine). CONCLUSIONS: Despite convincing evidence that patients lose protective antibodies to vaccine-preventable diseases following allogeneic BMT and accumulating data showing the safety and efficacy of many vaccines after BMT, vaccines are underutilized and schedules vary widely at US transplant centers. National guidelines for optimal doses and timing of vaccines after BMT are warranted.

Vancomycin-resistant Enterococcus faecium on a pediatric oncology ward: duration of stool shedding and incidence of clinical infection.

OBJECTIVE: To determine the duration of stool shedding and incidence of clinical infection among pediatric oncology patients colonized with vancomycin-resistant Enterococcus faecium (VRE) in our institution. METHODS: Stool cultures were obtained from all patients admitted from May 15 to August 2, 1994. Patients were followed for evidence of clinical VRE infection and surveillance stool results through August 15, 1995. Genetic relatedness of stool-clinical isolate pairs and serial stool samples was evaluated using pulsed field gel electrophoresis. RESULTS: Twenty-three (32%) of 73 screened patients were colonized with VRE. Eight (35%) of the colonized patients cleared VRE from stool; 10 (43%) were persistent carriers, excreting organisms for 19 to 331 days (median, 112 days); and 5 patients had an insufficient number of stools to determine length of carriage. Persistent carriers had a median of 6 hospital readmissions; 8 of 10 were positive at first or second readmission Clinical VRE infection developed in 6 of 73 patients (annual incidence, 8.2%). Clinical cases had more days of neutropenia between colonization and infection than colonized patients during a comparable follow-up (49 vs. 16 days, P = 0.04). Five of 6 stool-clinical isolate pairs were identical by pulsed field gel electrophoresis. Serial stools from 6 of 7 patients (collected 20 to 343 days apart) were identical by pulsed field gel electrophoresis. CONCLUSION: Persistent gastrointestinal colonization with VRE is common among pediatric oncology patients. Carriage of the same VRE clone for up to 1 year was demonstrated. In the majority of cases invasive and colonizing isolates were identical by DNA fingerprinting techniques, suggesting that the colonizing VRE was the source of infection. Intermittent excretion of organisms in stool makes vigilant tracking and immediate isolation of such patients crucial to control efforts. Prolonged neutropenia may increase the risk of developing clinical infection among VRE-colonized patients.

Staphylococcal food poisoning caused by imported canned mushrooms.

From February through April 1989, four outbreaks of staphylococcal food poisoning in the United States were associated with eating mushrooms canned in the People's Republic of China (PRC). In the four outbreaks, 99 persons who ate at a suspect facility developed gastrointestinal symptoms within 24 h, including 18 who were hospitalized. Illness was associated with eating mushrooms at a university cafeteria (relative risk [RR] = 53.0), a hospital cafeteria (RR = 13.8), a pizzeria (odds ratio [OR] = infinity), and a restaurant (OR = infinity) (all P < .0001). Staphylococcal enterotoxin A was found by ELISA in mushrooms at the sites of two outbreaks and in unopened cans from the three plants thought to have produced mushrooms implicated in outbreaks. These investigations led to multistate recalls and a US Food and Drug Administration order to restrict entry into the United States of all mushrooms produced in the PRC; until this action, the United States imported approximately 50 million pounds yearly.

A citywide survey of vancomycin-resistant Enterococcus--New York City, 1993.

Vancomycin-resistant Enterococcus (VRE) has become an increasingly important nosocomial pathogen. Questionnaires were sent to all New York City (NYC)-licensed laboratories to ask about testing procedures used, number of isolates identified, species identified, and vancomycin susceptibility for enterococcal isolates in 1993. Of 127 laboratories, 118 (93%) responded. Fifty-three (45%) of the 118 laboratories reported both the number of enterococcal isolates tested and the number of VRE isolates identified during 1993; 15 (28%) of the 53 laboratories did not isolate VRE, and the remaining 38 laboratories identified 3,822 (8.1%) VRE isolates. VRE was first identified by a NYC-licensed (commercial) laboratory in 1988. Among NYC hospital laboratories, 65 (97%) of 67 identified at least one VRE isolate during 1989-1993. This survey demonstrates that there has been a marked increase in the number of VRE isolates identified in NYC laboratories.

A community-wide outbreak of hepatitis A: risk factors for infection among homosexual and bisexual men.

PURPOSE: To assess risk factors for hepatitis A infection among homosexual and bisexual men during a community-wide outbreak of hepatitis A in New York City. PATIENTS AND METHODS: Twenty-five homosexual and bisexual men, 20 to 49 years of age with hepatitis A identified from health department surveillance data (cases) were compared with 42 homosexual and bisexual men of similar age distribution who were seronegative for hepatitis A virus and identified from private physician offices (controls). Odds ratio (OR) were determined for acute hepatitis A infection according to demographics, numbers of sexual partners, frequency of specific sexual behaviors, and self-reported human immunodeficiency virus status. RESULTS: Cases had more anonymous sex partners (0 to 1 partner versus > 1 partner) than controls during the 6 weeks before illness onset (OR = 4.4, 95% confidence interval [CI] 1.4 to 14.4). Cases were more likely than controls to have engaged in group sex (OR = 3.8, 95% CI 1.1 to 12.6). Among specific sexual behaviors examined, oral-anal intercourse (oral role) and digital-rectal intercourse (digital role) with anonymous sex partners were more commonly reported by cases than controls (OR = 9.7, 95% CI 1.2 to 78.7 and OR = 2.6, 95% CI 1.0 to 7.4, respectively). Multivariate analysis showed that > 1 anonymous sex partner, group sex, oral-anal intercourse, and digital-rectal intercourse were associated with illness in models controlling for duration of sexual activity. Because these variables were highly correlated, independent risk could not be evaluated in a single model. CONCLUSIONS: Hepatitis A infection among homosexual and bisexual men is associated with oral-anal and digital-rectal intercourse, as well as with increasing numbers of anonymous sex partners and group sex. These findings reinforce the importance of developing educational activities for homosexual and bisexual men that focus on risk reduction for hepatitis A as well as other sexually transmitted disease spread via the fecal-oral route.

Typhoid fever in New York City, 1980 through 1990.

BACKGROUND: Although typhoid fever incidence decreased in the 1960s and 1970s in New York City and elsewhere, it did not disappear. In this article, trends associated with various modes of transmission of Salmonella typhi in New York City patients are described. METHODS: Typhoid fever surveillance reports from 1980 to 1990 were reviewed for clinical, demographic, and epidemiologic characteristics. Cases of typhoid fever were classified as travel related or domestically acquired. RESULTS: In all, 479 typhoid cases were identified, of which 67% were travel related. The age groups most frequently affected were children and adolescents. Cases more than doubled in the decade, and the ratio of travel-related cases to domestically acquired cases increased steadily from 63% to 80%. Travelers to Southeast Asia were at three times higher risk than those visiting South America and eight times higher than those visiting the Caribbean. The case-fatality proportion was 1.5%. CONCLUSION: The trends of S typhi infection in New York City followed the trends observed in the United States since 1978, which demonstrates the importance of international travel. Although food and water precautions may be effective for short-term travelers, selective use of oral antityphoid vaccines for New York City travelers to high-risk endemic countries should be encouraged.

Risk factors for developing eosinophilia myalgia syndrome among L-tryptophan users in New York.

Using a case-control study design, patients with eosinophilia myalgia syndrome (EMS) who had used L-tryptophan (LT) were compared with LT users who did not develop EMS. Of the 113 case patients and 95 controls who had used a retail brand that could be traced to a bulk LT producer, all (100%) case-patients and 69 (73%) controls used LT brands that were traced to Showa Denko K.K. (lower 95% CL = 10.0). Among the users of LT produced by Showa Denko K.K., the risk of EMS was greater for persons who used LT produced after December 1, 1988 (OR = 25.8, [95% CL = 7.1, 101.4]). The risk of developing EMS increased with increased dosage of LT, increased age, and use of LT as a sleeping aid. These epidemiologic data support the hypothesis that the etiologic agent in EMS is a contaminant introduced into LT products during production.

Eosinophilia-myalgia syndrome in patients ingesting a single source of L-tryptophan.

OBJECTIVE: To estimate the attack rate for eosinophilia-myalgia syndrome and to identify potential risk factors for illness among patients attending a New York City medical clinic, who purchased L-tryptophan containing products produced exclusively by Showa Denko K.K. METHODS: A case-control design was used. Cases and controls purchased L-tryptophan containing products at the medical clinic from July 1, 1989--December 1, 1989. All case-patients identified with illness onset during the study period were included. Controls were selected by a systematic sample of the 683 purchasers of L-tryptophan attending the same clinic. RESULTS: Twelve (2.2%) of an estimated 553 L-tryptophan users were case-patients. Multivariate analysis suggested that lot 2 use (adjusted odds ratio [OR] = 35.9), concomitant use of chromium (adjusted OR = 12.3), and concomitant use of pyridoxine (adjusted OR = 5.8) were associated with the development of illness. Chemical analysis of tablets corresponding to the 3 Showa Denko K.K. lots ingested by study participants showed that lot 2 had the highest concentration of ethylidenebis (L-tryptophan), a proposed causative agent or marker for a causative agent in the eosinophilia-myalgia syndrome. CONCLUSIONS: Information from our study of persons exposed to implicated L-tryptophan supports the role for a contaminant as the causative agent in the eosinophilia-myalgia syndrome and identifies possible cofactors that deserve further study.

A neonatal hepatitis B surveillance and vaccination program: New York City, 1987 to 1988.

From July 1987 to June 1988, 1030 pregnant women with hepatitis B were reported to a New York City surveillance program. Among 832 infants under follow-up, the coverage rates for combined hepatitis B immune globulin and vaccine doses 1, 2, and 3 were 84%, 77%, and 59%, respectively. Infants covered by Medicaid and uninsured Black and Hispanic infants were significantly less likely to be completely vaccinated. An estimated 160 cases of chronic hepatitis B infection were prevented among infants enrolled in the program. Strategies are needed to improve vaccine coverage among hard-to-reach groups.

Vitamin A levels and severity of measles. New York City.

Recent studies show that vitamin A levels decrease during measles and that vitamin A therapy can improve measles outcome in children in the developing world. Vitamin A levels of children with measles have not been studied in developed countries. We therefore measured vitamin A levels in 89 children with measles younger than 2 years and in a reference group in New York City, NY. Vitamin A levels in children with measles ranged from 0.42 to 3.0 mumol/L; 20 (22%) were low. Children with low levels were more likely to have fever at a temperature of 40 degrees C or higher (68% vs 44%), to have fever for 7 days or more (54% vs 23%), and to be hospitalized (55% vs 30%). Children with low vitamin A levels had lower measles-specific antibody levels. No child in the reference group had a low vitamin A level. Our data show that many children younger than 2 years in New York City have low vitamin A levels when ill with measles, and that such children seem to have lower measles-specific antibody levels and increased morbidity. Clinicians may wish to consider vitamin A therapy for children younger than 2 years with severe measles. Additional studies of vitamin A in measles and other infectious diseases, and in vaccine efficacy trials, should be done.