Environmental determinants of diarrheal morbidity in under-five children, Keffa-Sheka zone, south west Ethiopia.

A population-based cross-sectional study on diarrheal morbidity was carried out in thirty two rural and urban areas of Keffa-Sheka zone, to determine the prevalence of diarrhea in under-5 children and identify environmental risk factors. A total of 952 children between the ages of 0 and 59 months living in the sampled households formed the study population. Data collected include demographic characteristics of the child, and information on environmental and housing variables. The overall diarrheal prevalence was 15%. Acute watery diarrhea, dysentery, and persistent diarrhea were responsible for 66%, 20%, and 14% of the episodes, respectively. Overall a third of the diarrheal episodes were bloody and/or persistent. Young age, male gender, living in a house with fewer number of rooms, and obtaining water from storage containers by dipping showed statistically significant association with diarrheal morbidity (p < 0.05). Type of water source, amount of water consumed, and latrine availability were not found to be significant risk factors (p > 0.05). Diarrhea, particularly dysentery and/or persistent diarrhea, affect a large proportion of children. Water is scarce and the environmental status of the area is generally poor. Efforts to educate the community about correct water handling behavior, personal and domestic hygiene should also be important components of the diarrhea control strategy. Further study on other environmental determinants, socio-demographic factors, feeding patterns and immunization status of children, and ORS accessibility is also recommended.

The utility of pallor detecting anemia in under five years old children.

The diagnosis and management of anemia, which affects a significant proportion of young children in developing countries, largely depends on the clinical assessment for pallor. This study was conducted with the aim of evaluating the utility of pallor in detecting anemia. Children aged 2 to 60 months who visited the pediatric outpatient department of Jimma Hospital over 3 months period were assessed for the presence and degree of pallor in 4 anatomic sites (conjunctivae, tongue and buccal mucosa, nailbeds, palm) by trained nurses. Hemoglobin was then determined using the HemoCue method. Individuals involved in clinical examination did not have access to the laboratory results before documenting their findings. The mean hemoglobin in the 574 children examined was 11.03 gm/dl, and about 46% had anemia. Children younger than 2 years were found to have a higher prevalence of anemia as compared to older children (p < 0.001). Palmar pallor, with a sensitivity of 58%, had the highest sensitivity to detect moderate anemia as compared to other anatomic sites. The presence of either palmar or conjunctival pallor increased the sensitivity to 73%. The inter-observer agreement was highest for conjunctival pallor (kappa value = 0.81). The findings of the study suggest that pallor of a single anatomic site does not have adequate sensitivity to detect moderate anemia. We recommend further studies to look at the performance of severe pallor in correctly identifying severe anemia. Furthermore, the magnitude and causes of anemia need to be studied in a community setting.

Aminosidine and its combination with sodium stibogluconate in the treatment of diffuse cutaneous leishmaniasis caused by Leishmania aethiopica.

Treatment of diffuse cutaneous leishmaniasis (DCL) caused by Leishmania aethiopica remains unsatisfactory as the parasite is relatively insensitive to antimonial compounds. Reports of the clinical effectiveness of aminosidine sulphate, especially in combination with sodium stibogluconate, in visceral leishmaniasis and the finding that this antibiotic is potent against L. aethiopica in vitro, prompted us to evaluate its usefulness in DCL. Two patients with long-standing, active DCL were treated for 60 d with aminosidine sulphate, 14 mg/kg/d parenterally. The skin lesions resolved completely in both patients although they relapsed subsequently. Synergism between aminosidine and stibogluconate was demonstrated in vitro against parasites isolated from the patients. This led us to administer combined therapy, aminosidine sulphate 14 mg/kg/d and sodium stibogluconate 10 mg/kg/d, to the 2 patients in relapse and to another, third patient. Treatment was continued for 2 months beyond parasitological cure. Side effects were minimal. Following treatment, a return of specific cell-mediated immunity occurred, as expressed by a moderate infiltration of lymphocytes into the lesions and by lymphocyte proliferation in vitro in the presence of live Leishmania antigen, with synthesis of interleukin-2 and interferon gamma with one patient and interleukin 4 with the other. During follow-up periods of 2 to 21 months after treatment, no sign of relapse was seen.

Intradermal recombinant interleukin 2 enhances peripheral blood T-cell responses to mitogen and antigens in patients with lepromatous leprosy.

Thirty-one patients with lepromatous leprosy received recombinant interleukin 2 (IL-2) intradermally in doses ranging from 10 to 30 micrograms. Before injection and at time intervals of 2-21 days thereafter, samples of peripheral blood mononuclear cells (PBMC) were obtained. Single or multiple injections (1-3) of IL-2 did not modify the total number of circulating lymphocytes or the number of T cells and the CD4/CD8 T-cell ratio. However, IL-2 had a pronounced influence on the [3H]thymidine incorporation in response to various stimuli 4-8 days after intradermal IL-2. Stimulation indices of three- to sevenfold above pre-IL-2 levels were observed with the polyclonal activator phytohaemagglutinin (PHA) and enhanced thymidine incorporation occurred in the presence of antigens to which the patients were already sensitized, such as purified protein derivative and BCG. IL-2 had no effect on the unresponsive state of lepromatous leprosy patient T cells to the antigens of Mycobacterium leprae.

Administration of recombinant interleukin-2 reduces the local parasite load of patients with disseminated cutaneous leishmaniasis.

Three patients with disseminated cutaneous leishmaniasis received three intranodular injections of 10 micrograms of recombinant interleukin 2 (rIL-2) at 48-h intervals. After 7 and 14 days, 4-mm punch biopsies were taken of control and injected nodules and processed for histology, electron microscopy, immunocytochemistry, and parasite culture. Control sites exhibited loose infiltrates of parasitized macrophages and T cells predominantly of the CD8+ phenotype. Amastigotes were present in large numbers and were found distributed within tightly apposed endosomes and larger vacuoles. After the administration of rIL-2, there was a prominent influx of T cells, predominantly of the CD4+ phenotype, and an increased number of plasma cells. At 7 days, leishmanial amastigotes were present in either the same or somewhat reduced numbers but predominantly within large, lucent vacuoles. By 14 days the number of amastigotes was strikingly lower. Lymphokine-treated skin sites became sterile in two patients, as evaluated by parasite culture after rIL-2 injection. The results suggest that the local administration of rIL-2 induces a beneficial enhancement of the cellular immunity with a consequent disposal of parasites in the cutaneous site.

The reconstitution of cell-mediated immunity in the cutaneous lesions of lepromatous leprosy by recombinant interleukin 2.

Human rIL-2 (10-30 micrograms) was injected intradermally into the skin of patients with lepromatous leprosy with high bacillary loads. All patients responded to the lymphokine with local areas of induration that peaked at 24 h and persisted for 4-7 d irrespective of whether the site was "normal skin" or a nodular lesion. Within 24 h there was an extensive emigration of T cells and monocytes into the site. The percentage of the dermis infiltrated by mononuclear cells increased by more than sevenfold, peaking at 4 d and persisting for greater than 15 d. Both CD4+ and CD8+ T cells entered the site. T cells of CD4+ phenotype predominated at 2-7 d but by 11 d, CD8+ cells were predominant. Considerable numbers of T6+ Langerhans' cells appeared in the dermis by 72 h and persisted for 3 wk. By 4 d the thickness of the overlying epidermis had increased twofold, and keratinocytes were expressing MHC class II antigen and the IFN-gamma-induced peptide IP-10. Starting at 48 h, there was an extensive destruction of mononuclear phagocytes that contained structurally intact or fragmented M. leprae observed at the electron microscope level. The organisms, either free or contained within endocytic vacuoles, were discharged into the extracellular space and then reingested by blood-borne monocytes. This was followed by marked reductions in the number of acid-fast organisms in the injected site, evident as early as 4-7 d and more marked at 2-3 wk after injection. 13 of 15 patients exhibited a disposal of acid-fast bacilli ranging from 5- to 1,000-fold with a mean value of approximately 100-fold. The administration of IL-2 leads to the generation of an effective cell-mediated immune response, recapitulating an antigen-driven event and leading to striking local reductions in M. leprae. In comparison with the purified protein derivative of tuberculin reaction, bacilli are cleared more promptly, although emigratory cells persist for a shorter time.