[Health care organization and health in a region of Zaire]

Kampene is a roughly 10,000 inhabitants village in Kivu, eastern region of Republic of Zaire. The equatorial rainforest in river Zaire basin surrounds it, far from the main and most crowded roads. Climate is warm and wet, rainfalls constant throughout ten months a years. Eighty seven per cent of the population of Kampene and of its administrative district (around 100,000 inhabitants) work in agriculture. Most of the remainder gets by on mineral search and mining (tin, cassiterite, gold). Health facilities and their organisation should be set up as according to Zaire Health Planning, worked out of 1977 Alma Ata Conference's guidelines on Primary Health Care, but actually they are hard to be implemented because of the wide territory, of the scattered settlements to be served, because of infrastructure and funds shortages. High children death ratio (roughly from 104 to 200/1000 altogether, short mean lifetimes and generally morbidity are caused by: parasitoses (malaria, filariasis, gut worms, bilharziosis, amebiasis), bacterial infections (breast feeding babies' toxic enteritis, tuberculosis, salmonellosis, shigellosis, gonococcosis, tetanus, epidemic meningitis), viral diseases (measles, poliomyelitis, virus B hepatitis, AIDS), protein-energy malnutrition, obstetric pathology (uterus fractures, ectopic pregnancy, obstructed labour). The management of Kampene Hospital is taken over by a Zaire-Italian team, according to the "Progetto Socio-Sanitario a Kampene", project carried out by Centro Volontari Marchigiani, a not-governmental organisation recognized and financed by Italian Foreign Office. The utilization of Kampene hospital wards has been investigated throughout 20 months (since 1/1/1986 to 31/8/1987) by working some parameters out: numbers of admissions, numbers of hospital days, man length of stay, bed occupancy rate, turnover index for bed. The utilisation of outpatient clinic has been investigated by means of the number of outpatients and outpatients per health operator ratio. Moreover the death rate for each ward has been appraised. These data show that wards and outpatient clinics are largely utilized; but a better redistribution of beds from Gynecology to Medicine and Pediatrics wards is suggested. The importance of a steady health team on the run stands out. Moreover the data stress the high death rates both of measles epidemics and protein-energy malnutrition (21.4% so far). In conclusion mother-child clinic is not yet satisfactory and should be better developed; protein-energy malnutrition urges food supply and deeper food consumption education projects to be supported.

Pneumocystis carinii is not a major cause of pneumonia in HIV infected patients in Lusaka, Zambia

The clinical occurrence of Pneumocystis carinii and Mycobacterium tuberculosis was investigated in patients infected with human immunodeficiency virus (HIV) who had clinical pneumonia of unknown aetiology in Lusaka, Zambia. The results were compared with a similar group of patients in Stockholm, Sweden. Induced sputum samples were stained for Pneumocystis by indirect immunofluorescence using monoclonal antibody 3F6 and toluidine blue O. Mycobacterial culture and acid fast stain were performed on the specimens from Lusaka. P. carinii cysts were detected in none of 27 Lusaka patients, compared to 10 of 33 Stockholm patients. M. tuberculosis was identified in 11 of 22 Lusaka patients tested. In conclusion, P. carinii could not be incriminated as the aetiological agent of HIV-associated pneumonia in Zambia in contrast to the situation in Sweden, where Pneumocystis is the dominating aetiological agent.

HIV and HTLV-I infections in the Americas: a regional perspective

With over 143,000 cases of AIDS reported to the World Health Organization from 145 countries and with an estimated 5 to 10 million people worldwide infected with HIV, AIDS has become firmly established as a global pandemic. In the region of the Americas over 100,862 cases of AIDS have been reported with indigenous transmission documented in 45 to 46 countries. While North America has the highest annual number of AIDS cases per population, with 72 cases/million, the Caribbean subregion has a disproportionately high number of cases, with annual rates as high as 200 to 300 cases/million population for some countries. Despite differences in absolute number of cases, there has been a remarkable similarity in the temporal rate of increase of AIDS in the countries of the Americas, reflecting delayed introduction of the virus to some areas with an early exponential increase similar to that observed initially in the United States. Although the modes of transmission of HIV are the same throughout the region, evidence of increasing bisexual and heterosexual transmission, particularly in the Caribbean subregion, has resulted in a lower male-to-female ratio of AIDS cases and increased perinatal transmission. Clinically, a resurgence of diarrheal diseases, respiratory infections, and tuberculosis has been documented in association with HIV infection in many tropical countries of the Americas. With relatively high rates of HTLV-I infection already established in the Caribbean subregion, the overall public health problems of the Americas will be markedly potentiated by further spread of these 2 human retroviruses. If HIV infection continues to penetrate the poor and less advantaged populations in Latin America and the Caribbean, the potential exists for a massive epidemic in the Americas that may rapidly parallel the situation in Africa.

Pattern of preventable diseases in Afghanistan: suggestions to reduce the morbidity and mortality at IGICH

Over nine years period (1354-1362), 1,39,436 children were admitted in Indira Gandhi Institute of Child Health (IGICH), Kabul. Of these 51,212 (46.8%) children were hospitalised with preventable diseases. Seventy four per cent of patients were under five years of age. Among the infectious diseases, gastroenteritis accounted for nearly 70% of admissions. Tuberculosis, measles, diphtheria and typhoid fever were other common infectious diseases. Malnutrition of varying degree was the core problem among the hospitalised children and was seen in nearly two thirds of admissions. Twenty per cent of them had severe protein energy malnutrition which contributed for higher mortality. Gastroenteritis contributed for half (51.5%) of the mortality. Septicemia, tetanus neonatorum and central nervous system infections were associated with high mortality especially among the neonates. Deaths following 6-target preventable diseases accounted for nearly 1/4th of deaths (20.4-24.6%) over these years.

HIV infection in patients with tuberculosis in Kinshasa, Zaire

To better define the interrelationship of infection with human immunodeficiency virus (HIV) and tuberculosis (TB), we conducted three HIV serosurveys of inpatients and outpatients with confirmed or suspected TB in Kinshasa, Zaire. HIV seroprevalence in hospitalized sanatorium patients did not change significantly in serosurveys conducted in 1985 and 1987 (92/231 [40%] versus 85/234 [36%]). These proportions were significantly higher than the 17% HIV seroprevalence observed in a 1987 serosurvey of 509 consecutive patients with an initial diagnosis of pulmonary TB seen at an outpatient TB diagnostic center in Kinshasa (p less than 0.001). HIV seroprevalence was higher in sanatorium patients with extrapulmonary TB (22/46 [48%]) and suspected pulmonary TB (60/132 [45%]) than in patients with bacteriologically confirmed pulmonary TB (94/287 [33%]) (p less than 0.02). Mycobacterium sputum isolation rates were similar in HIV-seropositive (28/34 [82%]) and HIV-seronegative patients (135/159 [85%]). All isolates were Mycobacterium tuberculosis. Eighteen (21%) of 84 HIV-seropositive sanatorium patients in 1987, who were followed for two months after admission, had died, compared with 11 (9%) of 128 HIV-seronegative patients (p less than 0.01). However, clearance rates of acid-fast bacilli from sputum after standard therapy were equally good in HIV-seropositive and HIV-seronegative survivors. With the growing AIDS problem, the serious TB burden in sub-Saharan Africa may become even more onerous and may critically overload the stressed African health care systems.

The association of tuberculosis and HIV infection in Burundi

AIDS and tuberculosis (TB) are both endemic in Bujumbura, Burundi. An 11% failure rate to standard antituberculosis treatment (n = 173) was observed at the Tuberculosis Treatment Center of Bujumbura (CATB) in 1985-1986. All resistant cases (n = 19) were HIV seropositive. Among 328 consecutive cases with tuberculosis at the CATB during a 3 month period in 1986, 54.5% were HIV seropositive, which is five times higher than the prevalence in the general population in Bujumbura. More female patients than male cases were HIV antibody positive (62 versus 49%, respectively; p less than 0.02). Persistent weight loss, cough, and an anergic tuberculin test were more common in the HIV-seropositive group. Among 48 household members of HIV-seropositive patients with tuberculosis, 6 (12.5%) new cases of tuberculosis were identified, compared with none among 28 household members of HIV-seronegative patients with tuberculosis (odds ratio, 3.8; 95% confidence interval, 0.43-33.2). HIV infection is a new risk factor for tuberculosis in Africa, and HIV-infected cases of tuberculosis may be more infectious than HIV-negative patients. The AIDS epidemic may drastically complicate the diagnosis, management, and control of tuberculosis in populations in which both infections are endemic.

The expanded programme on immunization: a decade of progress in India

The Expanded Programme on Immunization (EPI) was initiated in India in 1978 with the objective to reduce morbidity and mortality from diphtheria, pertussis, tetanus, poliomyelitis and childhood tuberculosis by providing immunization services to all eligible children and pregnant women by 1990. Measles vaccine was included when the EPI was accelerated by launching the Universal Immunization Programme (UIP) in 1985-6. Approximately half of all infants now receive complete primary immunization with diphtheria, polio and tetanus (DPT), oral polio vaccine (OPV) and BCG vaccine. Forty-six per cent of pregnant women currently receive a second or booster dose of tetanus toxoid (TT). Surveillance reports from selected areas have documented impact through reduction of disease incidence. Although vaccination coverage levels are increasing, continued acceleration is needed to achieve the universal levels targeted for 1990.

The distribution and implications of BCG scars in northern Malawi

Reported are data on the BCG scar status of more than 112,000 individuals who were surveyed in Karonga District, northern Malawi, between 1979 and 1984. The age and sex patterns of apparent BCG scars reflect the history of BCG vaccination activities in the district. Repeated independent examinations of large numbers of people revealed that the proportions remaining with the same observed scar status among those initially classified as being scar "positive" or scar "negative" were each approximately 90%. The repeatability of positive scar reading was lower among children and older adults than among young adults aged 15-24 years, and blind follow-up of children known to have been vaccinated as infants in child health clinics indicated that less than 60% had a detectable scar 3 years after receiving the vaccine. "Negative" repeatability increased consistently with age. The implications of these findings for estimating BCG vaccine uptake and for assessing its efficacy in case-control and cohort studies are discussed. The finding that BCG scars may be difficult to read suggests there is a danger of observer bias that could lead to distortion--in particular, to overestimates of vaccine efficacy.

[Tuberculosis and human immunodeficiency virus infection in the Central African Republic]

In order to determine the proportion of tuberculosis (TB) patients in Bangui (Central African Republic) infected with human immunodeficiency virus (HIV), we collected prospectively serum samples from all new TB patients seen at the University Hospital in Bangui during a three-month period (nov. 87-Jan. 88). 220 serum samples were tested for antibodies to HIV, by an Elisa assay and confirmed by Western-Blot. The general HIV seropositivity rate among TB patients was 27.7% (31.2% in adults (N = 183), and 10.8% in children (N = 37)). Within the adult population, there was non association between HIV infection and sex or previous history of TB. Seropositivity was more common in patients with extrapulmonary TB, especially lymphadenitis, and in patients with mediastinal adenopathy, or extensive pulmonary involvement without cavitation. Seropositivity was also strongly associated with negative tuberculin skin tests, chronic diarrhoea, generalized lymphadenopathy, and thrush. It is concluded that HIV infection is responsible for the increasing incidence of tuberculosis in Central African Republic, and that investigations for TB should be carried out in every symptomatic African patient infected with HIV.

Infant mortality and childhood nutritional status among Afghan refugees in Pakistan

In 1984 and again in 1985, systematic surveys were undertaken to evaluate infant mortality and childhood nutritional status among the Afghan refugee population in Pakistan. The entire Afghan refugee population under the administration of the United Nations High Commissioner for Refugees was sampled. Infant mortality rates were estimated to be 156 per 1000 for 1984 and 119 per 1000 for 1985. A decline was also suggested in neonatal mortality rates from 61 per 1000 for 1984 to 46 per 1000 for 1985. For neither infant nor neonatal mortality was the difference statistically significant. Improvements were seen in the percentage of children who died before their fifth birthday (22.5% in 1984 and 18.8% in 1985), in the percentage of children who were malnourished (3.5% in 1984 and 2.3% in 1985), and an increase in the percentage of children above the WHO/NCHS/CDC weight-for-height reference median (26% in 1984 and 35% in 1985). Diarrhoea was the most frequently reported cause of death for both years and was a particularly important cause of death among one-year-old children. In 1985, measles was related to 24% of the deaths and neonatal tetanus to 9% of the deaths, an increase from 8% for measles and 6% for tetanus in 1984.

Cause-specific mortality among Koreans, Chinese and Americans in Japan, 1973-1982

Mortalities from selected causes from 1973 to 1982 among Koreans, Chinese, and Americans residing in Japan were compared with those of Japanese. In the Korean population, besides the well-documented excess in mortalities from liver cancer, lung cancer, liver cirrhosis and male tuberculosis, a rather prominent elevation was observed for mortalities from female tuberculosis and diabetes mellitus in both sexes. Distinctive features in the Chinese population were increased mortalities from liver cancer and female lung cancer and lowered mortality from stomach cancer, and these findings are consistent with the observations among Chinese in other areas. Mortalities from diabetes mellitus and liver cirrhosis was moderately increased in this population as well. Americans in Japan by and large showed a mortality pattern similar to that in the US although mortality from stroke among female Americans was rather elevated during the period 1973-1977. Epidemiological studies on Koreans and Chinese in Japan with reference to their lifestyle are strongly required.

Tuberculosis status and social adaptation of Indochinese refugees

The relationship between tuberculosis and social adaptation of Indochinese refugees in Manitoba, Canada, is examined in 43 randomly selected refugees treated for active and inactive tuberculosis (cases) and their matched controls. Tuberculosis status did not significantly affect adaptation as measured by selected scales and indicators. Significant predictors of better personal well-being included a low number of family members outside the household in Manitoba, non-use of traditional medicine, female gender, and high individual income. Tuberculosis status was not a significant predictor.

Tuberculosis, atypical mycobacteriosis, and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in south Florida

To study the association between mycobacterial disease and the acquired immunodeficiency syndrome, we reviewed the records of all cases of tuberculosis and all cases of the syndrome reported in Dade County, Florida, from January 1980 through June 1983. Tuberculosis was diagnosed in 27 of 45 Haitians with the syndrome, but in only 1 of 37 non-Haitians with the syndrome (p less than 0.001). Among the 27 Haitians with the syndrome and tuberculosis, 19 had extrapulmonary tuberculosis, whereas among 286 Haitian patients with tuberculosis without the syndrome, only 56 had extrapulmonary tuberculosis (p less than 0.001). Tuberculosis preceded the syndrome by 1 to 17 months (mean, 6) in 22 patients. In 10 patients with the syndrome and positive sputum cultures who were treated with conventional antituberculosis drugs, the cultures became negative within 1 to 4 months and tuberculosis did not recur. The frequency of disseminated atypical mycobacteriosis or positive sputum cultures for atypical mycobacteria was not significantly different between Haitian (11.3%) and non-Haitian (8.3%) patients with the syndrome.

Indochinese refugee health assessment and treatment

Many Southeast Asian refugees have resettled in the United States. This report reviews data from 426 refugees who underwent comprehensive examination and treatment at the Mayo Clinic. Health problems identified were primarily selected contagious illnesses and stress syndromes with functional complaints. Counseling was necessary in 17 percent of adults for psychosomatic problems or psychiatric disorders. When family-planning issues were applicable and addressed, 80 percent of women chose some method of contraception. The prevalence rate of intestinal parasites was 82 percent, and pathogens necessitated persistent treatment and follow-up. Tuberculosis skin-sensitivity testing was positive in 54 percent; the risk of active disease warrants prophylactic treatment until age 35 years. Hepatitis antigen was positive in 13 percent; precautions should be taken for potentially exposed professionals. Hematologic genetic disorders were very common and accounted for most of the 25 percent incidence of microcytosis. Physicians should become aware of cultural attitudes and treatment acceptance among Indochinese patients and should carefully investigate for infectious diseases.

Child health in Singapore--past, present and future

The state of child health in Singapore from 1914 to the present is chronicled. In 1914, there were 225 reported cases of tetanus neonatorum out of 7,420 births and 340 deaths from gastroenteritis with an infant mortality rate (IMR) of 292.9 per 1000 livebirths. In 1936 the infant mortality rate was 167.74, and in 1962, it was still high at 31.2, a figure which exceeded the IMR of USA, UK, Australia and New Zealand. However, by 1976, the IMR had fallen to 11.8 which was lower than that of the above countries and the neonatal mortality rate (NMR) was 8.4 which was also lower than the other four developed countries. In 1981, the IMR fell further still to 10.8 and the NMR was 7.7. The causes of the improvement of child health in Singapore are discussed, and the prospects and priorities for the future are described.

A randomized, double-blind study of two combined and two progestogen-only oral contraceptives

A randomized double-blind study of two combined oral contraceptives and two progestogen-only oral contraceptives was conducted using the same protocol at WHO Collaborating Centres for Clinical Research in Human Reproduction in Bombay and Ljubljana of the 518 women admitted to the trial, 123 received mestranol 50 micrograms + norethisterone 1mg (MES 50 + NET 1); 137 received ethinyl estradiol 30 micrograms + levonorgestrel 150 micrograms (EE 30 + LNG 150); 130 received norethisterone 350 micrograms/NET 350); and 128 received levonorgestrel 30 micrograms (LNG 30). At one year, between 52.6 and 61.0 percent of those recruited had discontinued oral contraceptive use for all reasons, and by two years, between 70.5 and 76.5 percent had discontinued the treatment. These rates did not differ between the four treatment groups. However, discontinuation rates for all medical reasons at one and two years, and at two years pregnancy rates and discontinuation rates for bleeding disturbances, were significantly lower in the EE/LNG preparation. The groups receiving the MES/NET, LNG and NET had similar pregnancy rates, discontinuation rates for all medical reasons and all bleeding disturbances. There were two ectopic pregnancies among the 22 pregnancies in the progestogen-only groups. Discontinuation because of headache, dizziness and other central nervous system symptoms were significantly more common in those receiving MES/NET compared to EE/LNG. In contrast, discontinuation for gastro-intestinal disturbances were significantly higher in the EE/LNG combined preparation. Bleeding disturbances in the first few cycles tended to be higher in NET than in the LNG group. The data suggest that greater consideration be given to the benefits and risks of including progestogen-only oral contraceptives in the family planning programmes of some countries.

Drug-pyridoxal phosphate interactions

In this review it has been pointed out that vitamin B6 and its vitamers can be involved in many interactions with a number of drugs, as well as with the actions of various endocrines and neurotransmitters. Nutritional deficiencies, especially of vitamins and proteins, can affect the manner in which drugs undergo biotransformation, and thereby may also modify the therapeutic efficacy of certain drugs. The differences between nutritional vitamin B6 deficiency and the hereditary disorder producing pyridoxine dependency are discussed. In addition to a pyridoxine deficiency being able to adversely affect drug actions, the improper supplementation with vitamin B6 can in some instances also adversely affect drug efficacy. A decrease by pyridoxine in the efficacy of levodopa used in the treatment of Parkinsonism is an example. The interrelationships and enzymatic interconversions among pyridoxine vitamers, both phosphorylated and non-phosphorylated, are briefly discussed, particularly regarding their pharmacokinetic properties. The ways in which the normal biochemical functions of vitamin B6 may be interfered with by various drugs are reviewed. (1) The chronic administration of isoniazid for the prevention or treatment of tuberculosis can produce peripheral neuropathy which can be prevented by the concurrent administration of pyridoxine. An acute toxic overdose of isoniazid causes generalized convulsions, and the intravenous administration of pyridoxine hydrochloride will prevent or stop these seizures. (2) The acute ingestion of excessive monosodium glutamate will, in some individuals, cause a group of symptoms including among others headache, weakness, stiffness, and heartburn, collectively known as the 'Chinese Restaurant Syndrome.' These symptoms can be prevented by prior supplementation with vitamin B6. The beneficial effect is ascribed to the correction of a deficiency in the activity of glutamic oxaloacetic transaminase, an enzyme that is dependent on pyridoxal phosphate. Some interesting relationships are pointed out between vitamin B6, picolinic acid, and zinc. It is postulated that the intestinal absorption of zinc is facilitated by picolinic acid, a metabolite of tryptophan. The derivation of picolinic acid from tryptophan depends on the action of the enzyme kynureninase, which is dependent on pyridoxal phosphate; therefore, the adequate absorption of zinc is indirectly dependent on an adequate supply of vitamin B6. The formation of pyridoxal phosphate, on the other hand, appears to be indirectly dependent on Zn2++ which activates pyridoxal kinase.(ABSTRACT TRUNCATED AT 400 WORDS)

Analysis of 187 newly diagnosed cases from 47 Swedish hospitals during the ten-year period 1968 to 1977

A retrospective analysis of symptomatology, diagnostic procedures, and treatment of all 155 new cases of genital tuberculosis at 47 Swedish gynecology departments in the period 1968-77 was performed. The frequency of genital tuberculosis was 0.002% of all patients admitted for gynecologic disease. Genital tuberculosis occurred more frequently in the postmenopausal period. The most common symptoms were metorrhagia, pain, and infertility. Chemotherapy alone was used in 40% of the cases. Conservative surgery was attempted in 8%, and 38% had radical surgery. No intrauterine and four tubal pregnancies occurred after therapy. We conclude that primary treatment should be conservative, although the chances of having a normal pregnancy are almost nil and the risk of an ectopic pregnancy is great.

Respiratory disease mortality in New Mexico's American Indians and Hispanics

To determine the effect of ethnic group on respiratory disease occurrence, average annual sex, ethnic, and disease specific mortality rates for the period of 1969 to 1977 were calculated for New Mexico's American Indian, Hispanic, and Anglo populations. Incidence data were available for respiratory tract cancer. This study corroborates previous findings of reduced mortality from lung cancer in American Indians of both sexes and in Hispanic males. American Indian mortality from tuberculosis and from influenza and pneumonia was high. Hispanic males and American Indians of both sexes showed low mortality rates for chronic obstructive pulmonary disease (COPD). Differing cigarette usage is the most obvious explanation for the variations in COPD and lung cancer occurrence with ethnic group.