The first generation to control family size: a microstudy of the causes of fertility decline in a rural area of Bangladesh

In Bangladesh, the total fertility rate declined from more than six children per woman of reproductive age in 1980 to 3.3 children per woman in 1996. Much discussion has ensued about the circumstances responsible for this decline and, in particular, about the contribution made by the national family planning program. For this study, qualitative interviews were conducted with 67 women concerning the factors influencing their reproductive behavior. The participants, residents of a rural area in southwestern Bangladesh, consisted of two groups: women who were currently practicing family planning and women who had never practiced or had not done so for at least four years. The findings suggest that the family planning program has played an important role in reducing family size, but also indicate that economic and social changes, and especially growing aspirations (particularly for a life outside agriculture) have combined with changes in the nature of family decision making to make couples more receptive to the idea of family planning.

Summary of research issues in personal, interpersonal, and group dynamics

People working on space missions, whether they are crewmembers or Mission Control personnel, must interact in groups. Consequently, it is important to consider interpersonal and group dynamic issues to assure that mission goals are accomplished. Simulation studies on Earth and anecdotal reports from space have described a number of such issues that include crew heterogeneity, culture and language variations, leadership roles, and personality differences. Problems that can result include increased group tension, decreased cohesion, subgrouping, scapegoating, miscommunication, role confusion, and displacement of tension and dysphoria from one group to another. The three papers by Drs. Caldwell, Kanas, and Stuster that are presented in this session address some of these issues at the group level. They suggest three critical questions related to: 1) improving communication between space crews and Mission Control personnel; 2) dealing with emotional and interpersonal decrements during the second half of space missions; and 3) minimizing the effects of culture and language differences. These questions in turn lead to six research strategies related to: 1) developing and testing new technologies to enhance crew-ground communication; 2) developing tools to recognize important communication themes and the factors that affect them over time; 3) studying the ability of voice analysis technology to detect on-board interpersonal stress; 4) developing and testing countermeasures to deal with second half emotional and interpersonal decrements; 5) studying the effects of cultural and language differences on crew tension, cohesion, and performance; and 6) studying the effects of crew heterogeneity and size on crew tension, cohesion, and performance.

Detection of hepatitis C core antigen in the antibody negative 'window' phase of hepatitis C infection

BACKGROUND AND OBJECTIVES

Despite improvements in assays for anti-HCV, there remains a significant delay before the appearance of antibodies following infection, during which, circulating viral RNA is present. We have evaluated a prototype assay for the serological detection of hepatitis C virus (HCV) core antigen with specimens derived from the early phase of HCV infection.

MATERIALS AND METHODS

Serial specimens from 24 individuals undergoing HCV seroconversion were tested for the presence of anti-HCV, HCV RNA and HCV core antigen.

RESULTS

HCV antigen was detected at the same time as HCV RNA in 83% (20/24) cases. The mean time to the first detection of HCV antigen was approximately 1 day later than HCV RNA. Overall, 87% of HCV-RNA-positive specimens contained detectable HCV core antigen.

CONCLUSION

These results indicate that HCV core antigen can be identified by routine serological ELISA in specimens from the early antibody-negative phase of HCV infection. A test for HCV core antigen may be a useful test for identifying window phase blood donations from antibody negative donors infected with HCV.

Detection of hepatitis C core antigen in the antibody negative 'window' phase of hepatitis C infection

BACKGROUND AND OBJECTIVES

Despite improvements in assays for anti-HCV, there remains a significant delay before the appearance of antibodies following infection, during which, circulating viral RNA is present. We have evaluated a prototype assay for the serological detection of hepatitis C virus (HCV) core antigen with specimens derived from the early phase of HCV infection.

MATERIALS AND METHODS

Serial specimens from 24 individuals undergoing HCV seroconversion were tested for the presence of anti-HCV, HCV RNA and HCV core antigen.

RESULTS

HCV antigen was detected at the same time as HCV RNA in 83% (20/24) cases. The mean time to the first detection of HCV antigen was approximately 1 day later than HCV RNA. Overall, 87% of HCV-RNA-positive specimens contained detectable HCV core antigen.

CONCLUSION

These results indicate that HCV core antigen can be identified by routine serological ELISA in specimens from the early antibody-negative phase of HCV infection. A test for HCV core antigen may be a useful test for identifying window phase blood donations from antibody negative donors infected with HCV.

Trends in perinatal transmission of HIV/AIDS in the United States

CONTEXT

Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission.

OBJECTIVE

To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998.

MAIN OUTCOME MEASURES

Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states.

RESULTS

Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n = 6990) to 1995 (n = 5797). Among infants, PCP rates per 100000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%.

CONCLUSIONS

According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.

Effect of price and access on contraceptive use

The Family Planning Program in Bangladesh has been very successful. The contraceptive prevalence rate (CPR) has increased from 13% in 1979 to 49% in 1996. Now that the program has matured and demand for family planning has been created, the Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh is concerned with increasing its financial sustainability. Options to increase financial sustainability include cost sharing and a gradual transition from doorstep to static clinic delivery of contraceptives. Many of these alternatives would involve additional travel time or charges for consumers, and it is important to estimate the effect that these additional prices would have on the use of contraception. The effect of economic constraints, such as cash price and access to services on contraceptive method use, the choice of contraceptive method and provider choice, has been analyzed, taking into account the socioeconomic factors that influence decision-making for individual family members. Two data sources have been used for this analysis: (1) a survey on use of contraception and (2) two baseline surveys of 1993 and 1994 in the two field sites of the MCH-FP Extension Project (Rural) of International Center for Diarrhoeal Disease Research, Bangladesh. No effect of cash prices was found on the probability of use of any contraceptive method, but clients were to a limited extent responsive to price in making choices about contraceptive methods and providers. In addition, couples were less likely to use contraception or choose methods if the travel time to fixed clinics was greater than 30 min.

The role of resource allocation models in selecting clinical preventive services

OBJECTIVE

To demonstrate the potential value and current limitations of using resource allocation models for selecting health services.

DESIGN

To identify the most efficient mix of preventive services that could be offered by a managed care organization (MCO) for a fixed budget, an optimization model (greatest number of life years saved) and a cost-effectiveness model (rank order of most to least cost effective) were developed. Because of the lack of cost-effectiveness analyses that met the study criteria, only 9 preventive services were selected to demonstrate each model.

PATIENTS AND METHODS

The 2 models were applied to a hypothetical managed care population of 100,000 enrollees with age, sex, and risk distribution similar to that of the US population. Data for the input variables were obtained from cost-effectiveness studies of 9 preventive services. Model variables included the target population, percent of enrollees who received the preventive service, the cost of the preventive service, life years saved, and cost-effectiveness ratios.

RESULTS

The models demonstrated that efficient allocation of finite resources can be achieved. When budgets are limited, different premises between the 2 models may yield different health consequences. However, as the budgets were increased, results from the 2 models were more closely aligned.

CONCLUSIONS

Resource allocation models have the potential for assisting MCOs in selecting a set of preventive services that will maximize population health. Before this potential can be fully realized, additional methodological development and cost-effectiveness studies are needed. The use of resource allocation should be examined for selecting all healthcare services.

Sexual regimes and sexual networking: the risk of an HIV/AIDS epidemic in Bangladesh

Bangladesh adjoins the Asian region with the severest AIDS epidemic and has common borders with two of the most affected areas, the Indian Hill States and northern Burma. There has been disagreement about the danger to Bangladesh, one view citing the likelihood of transmission from neighbouring infected populations and the other claiming that the country's predominantly Muslim culture protects it. This paper reports on a 1995-1997 research project. Preliminary research was carried out in Dhaka in 1995-1996 which suggested that the poor squatter areas might well sustain an epidemic. The experience also showed that more accurate measures of sexual networking could be obtained from males than females. The 1997 field research reported here investigated 983 males, 52% single and 48% married in Chittagong city and two more rural areas of Chittagong Division in southeast Bangladesh. It was found that around half of all males and probably a somewhat lower proportion of females, experience premarital sexual relations, with males having a lower level of extramarital than premarital relations. The factor heightening Bangladesh's risk of an epidemic is that one-quarter of single males and a significant but lower level of married males have had relations with prostitutes. This is one explanation for quite high levels of STDs in Bangladesh. The factors restricting the chances of a major national epidemic are the small number of premarital sexual episodes per person and the low level of intravenous drug use.

Coitus-dependent family planning methods: observations from Bangladesh

Some coitus-dependent methods of family planning, such as withdrawal, periodic abstinence, and the condom, require male involvement for their use, and using these methods in combination has proved to be sensible. An investigation of why male and female respondents in a survey conducted in Bangladesh often gave conflicting answers about which methods they were currently using, particularly about "traditional" methods and condoms, showed that inconsistency in their reports arose because these methods are used in combination to such an extent that they are difficult to distinguish. In order to obtain reliable responses about these methods, a survey approach different from the long-established one is required.

Assessment of health risk behaviors. A tool to inform consumers, providers, health care organizations, and purchasers

INTRODUCTION

Tobacco use, diet and physical activity patterns, and alcohol use are the leading causes of death in the United States. To make major improvements in the health status of the population, behavioral risk factors for disease must be addressed.

METHODS

We propose a brief survey of behavioral risk factors for enrollees of health care organizations, employer groups, or other adult populations that can be used to profile the health risk behaviors of a population, assess performance of prevention and risk reduction programs, or make comparisons with other populations. The survey contains questions about tobacco, diet, physical activity, alcohol, firearms, motor vehicle safety, sexual behavior, and drugs.

RESULTS

Recommendations for survey items, implementation, and calculation of performance measures are given.

CONCLUSIONS

Widespread adoption of this type of survey would be a major step forward in acknowledging the impact that behavior has on health and in furthering individual and organizational accountability for improving health risk behaviors.

Lack of evidence of transmission of HIV-1 to family contacts of HIV-1 infected children

Although a number of studies have documented that casual household contact does not result in the transmission of HIV, isolated cases of person-to-person transmission have been reported. We report a study of household transmission in which the families were unaware the children were infected with HIV and thus took no precautions to prevent transmission. Twenty-two family members of nine transfusion-associated HIV-infected children were studied for transmission of HIV in households. There was a total of 174 person-year of household exposure; 76 of these exposure years were before the diagnosis of HIV infection in the index child. All family members tested negative for HIV by ELISA. Sharing household facilities, and interactions with the infected child including kissing, bathing, sleeping with, and helping to bathe, dress, and eat, did not result in transmission. Interactions that could theoretically result in person-to-person transmission occurred in these households such as caring for nose bleeds, biting, and home health care procedures. The findings of this and other studies support the participation of HIV-infected infants and children in out-of-home care programs. It remains prudent, however, to observe current recommendations for prevention of HIV-1 for all individuals regardless of whether HIV status is known.

Designing HeartCare: custom computerized home care for patients recovering from CABG surgery

With the current trend toward discharge of cardiac artery bypass graft (CABG) patients from the hospital after 5 days, clinicians must make effective use of existing computer technology to provide more efficiently the services once available during the patient's lengthier hospital stay. This paper describes the design of the HeartCare initiative, a computerized cardiac recovery service designed to provide home-care support for patients in the first three months following CABG surgery. Capitalizing on the expansion in health resources on the Internet, and building on the lessons from the ComputerLink projects, HeartCare will employ the World Wide Web platform in the generation of personalized in-home computerized access to recovery resources. Key implementation decisions include selection of WebTV/ as the home-based device, and application of Metadata to organizing health-related knowledge resources on the WWW.

The complete genome sequence of the gram-positive bacterium Bacillus subtilis

Bacillus subtilis is the best-characterized member of the Gram-positive bacteria. Its genome of 4,214,810 base pairs comprises 4,100 protein-coding genes. Of these protein-coding genes, 53% are represented once, while a quarter of the genome corresponds to several gene families that have been greatly expanded by gene duplication, the largest family containing 77 putative ATP-binding transport proteins. In addition, a large proportion of the genetic capacity is devoted to the utilization of a variety of carbon sources, including many plant-derived molecules. The identification of five signal peptidase genes, as well as several genes for components of the secretion apparatus, is important given the capacity of Bacillus strains to secrete large amounts of industrially important enzymes. Many of the genes are involved in the synthesis of secondary metabolites, including antibiotics, that are more typically associated with Streptomyces species. The genome contains at least ten prophages or remnants of prophages, indicating that bacteriophage infection has played an important evolutionary role in horizontal gene transfer, in particular in the propagation of bacterial pathogenesis.

Comparison of hiking stick use on lateral stability while balancing with and without a load

To compare hiking stick use on lateral stability while balancing with or without a load (15-kg internal frame backpack) under conditions of no stick, 1 stick, and 2 sticks for six trials 15 volunteers ages 19 to 23 years (M = 21.7 yr.) were tested six separate times on a stability platform. During randomly ordered, 1-min. trials, the length of time (sec.) the subject maintained balance (+/-10 degrees of horizontal) and the number of deviations beyond 10 degrees were recorded simultaneously. Backpack and hiking sticks were individually adjusted for each subject. A 2 x 3 repeated factor analysis of variance indicated that subjects balanced significantly longer both with and without a load while using 2 hiking sticks than 1 or 0 sticks. Significantly fewer deviations beyond 10 degrees were found when subjects were without a load and using 1 or 2 sticks versus when they used none, and no significant difference in the number of deviations were found between 1 and 2 hiking sticks. When subjects were equipped with a load, significantly improved balance was found only between the 2 sticks and no sticks. Balance was significantly enhanced by using hiking sticks, and two sticks were more effective than one while carrying a load. An increase in maintenance of static balance may reduce the possibility of falling and injury while standing on loose alpine terrain.

Trends in age at the first medical evaluation of human immunodeficiency virus infection among infants born to infected mothers. New York City Pediatric Spectrum of HIV Disease Clinical Consortium

OBJECTIVE

To evaluate the trends in age at the first medical evaluation of human immunodeficiency virus (HIV) infection among infants enrolled in the Pediatric Spectrum of Disease study born to mothers infected with HIV.

DESIGN

Retrospective study based on medical chart review.

SETTING

Nine pediatric centers in New York City.

PARTICIPANTS

Infants (N = 925) born between January 1988 and December 1991 to mothers infected with HIV; the infants were examined for HIV infection by age 2 years and were receiving medical care.

RESULTS

In each successive birth cohort, an increasing proportion of infants was examined by 3 months of age (from 35% in 1988 to 76% in 1991, chi 2 = 38.1, P < .001). The median age at the first evaluation persistently declined among the cohort evaluated by 24 months. The median age decreased from 6 months in 1988 to less than 1 month in 1991. The proportion of infants who were examined because of HIV-related symptoms decreased in each successive birth cohort (1988, 65%; 1989, 59%; 1990, 42%; and 1991, 25%).

CONCLUSIONS

An increasing proportion of newborns exposed to HIV are being examined within the first 3 months of life in 9 leading pediatric HIV centers in New York City. Prenatal HIV counseling and testing of mothers are optimal procedures because they benefit mothers, they allow the use of zidovudine to reduce the chance of HIV infection in the infants, and they allow mothers with HIV to be counseled about the potential risks of breast-feeding. The family and the pediatrician must have knowledge of the infants' HIV status as early in life as possible to allow the necessary postnatal interventions, including Pneumocystis carinii pneumonia prophylaxis, which reduces morbidity and may prolong survival.

Invasive pneumococcal infections in human immunodeficiency virus-infected children

Invasive pneumococcal infection (IPI) is the most common serious bacterial infection in human immunodeficiency virus (HIV)-infected children. Data from a population-based pediatric HIV surveillance project were used to determine the incidence of IPI in HIV-infected children and to conduct a case-control study assessing potential risk factors for IPI in HIV-infected children. There were 50 episodes of IPI and a cumulative incidence of 6.1 cases/100 patient-years through age 7 years. Children with IPI were more likely to have a prior AIDS diagnosis (odds ratio, 4.2; 95% confidence interval, 1.2-15.1) and higher levels of IgG and IgM (P=.01) than were controls. In a separate case-control study, the manifestations of IPI in HIV-infected children were compared with those in HIV-negative controls. Focal complication rates in the 2 groups did not differ; however, HIV-infected children were less likely than controls to have leukocytosis (P<.001) and more likely to have isolates with penicillin resistance (P=.03).

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention

OBJECTIVE

To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections.

METHOD

The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost.

RESULTS

Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million.

CONCLUSION

Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

The family and demographic change in Sri Lanka

Sri Lanka has almost completed the demographic transition with low mortality rates and fertility rates approaching replacement levels. Sri Lanka shares these characteristics with the South Indian states of Kerala and Tamil Nadu in contrast to elsewhere in South Asia where mortality and especially fertility rates remain much higher. A key part of the explanation for these differences lies in the nature of the family. The Sri Lankan family is essentially the conjugal unit of husband, wife and dependent children whereas in northern South Asia agnatic relations between son and parents are central to family structure. Related to this family system the position of women in Sri Lankan society was relatively high in South Asian terms. Consequently women had a strong say in health and fertility behaviour. When required, for example, mothers take the initiative in seeking health care for themselves and their children. Importantly family structure has facilitated female education which is associated with both mortality and fertility decline. There are few concerns that the values imparted by secular education are contrary to the values of the family or to women's roles within it. The egalitarian family structure has also contributed to fertility decline by raising the costs of children and reducing the long-run benefits to be gained from them. Sri Lanka is particularly distinctive in the contribution of changes in female age at marriage to its fertility decline, marriage age having risen six years this century. This change has been accompanied in recent times by a shift from family-arranged to self-selected (love) marriage. The explanation lies in changes in the socio-economic system which have reduced the centrality of the family in wider social and economic relations, and placed a greater premium on an individual's own abilities and attributes.

Prophylaxis against Pneumocystis carinii pneumonia among children with perinatally acquired human immunodeficiency virus infection in the United States. Pneumocystis carinii Pneumonia Prophylaxis Evaluation Working Group

BACKGROUND

Pneumocystis carinii pneumonia (PCP) remains a common and often fatal opportunistic infection among children infected with the human immunodeficiency virus (HIV). HIV-infected infants between three and six months of age are particularly vulnerable. Current guidelines recommend prophylaxis in children from birth to 11 months old who have CD4+ counts below 1500 cells per cubic millimeter.

METHODS

We used national surveillance data to estimate the annual incidence of PCP among children less than one year old. We reviewed the medical records of 300 children given a diagnosis of PCP between January 1991 and June 1993 to determine why treatment according to the 1991 guidelines for prophylaxis against PCP either was not given or failed to prevent the disease.

RESULTS

In our study the incidence of PCP in the first year of life among infants born to HIV-infected mothers changed little between 1989 and 1992. Among 7080 children born to HIV-infected mothers in 1992, PCP developed in 2.4 percent. Of 300 children with PCP diagnosed from January 1991 through June 1993, 199 (66 percent) had never received prophylaxis, and for 118 of those children (59 percent) exposure to HIV was first identified 30 days or less before the diagnosis of PCP. Among 129 children less than one year old, the CD4+ count declined by an estimated 967 cells per cubic millimeter (95 percent confidence interval, 724 to 1210 cells per cubic millimeter) during the three months before the diagnosis of PCP. Among infants in whom CD4+ counts were determined within one month of the diagnosis of PCP, 18 percent (20 of 113) had at least 1500 cells per cubic millimeter, a level higher than the currently recommended threshold for prophylaxis.

CONCLUSIONS

In the United States the incidence of PCP among HIV-infected infants has not declined. If this infection is to be prevented, infants exposed to HIV must be identified earlier, and prophylaxis must be offered to more children than the guidelines currently recommend.

Factors associated with early clinical recognition of children with perinatal human immunodeficiency virus infection. Northern California Pediatric HIV Consortium

Surveillance of children born to women with human immunodeficiency virus (HIV) infection at five pediatric regional centers assessed times and patterns of clinical recognition in these children. Regional HIV seroprevalences among childbearing women were used to assess the proportion of identified children born to HIV-infected women. In total, 415 children with perinatal HIV exposure were identified. Early age at first HIV evaluation was significantly associated with maternal intravenous drug use (3.2 vs. 7.2 months for other or unknown maternal risk, P = .01), birth county with population > 500,000 (3.5 vs. 8.2 months for population < or = 500,000, P = .003), and hospital with routine HIV screening of pregnant women (0.1 vs. 8.8 months for no screening, P = .006). Race did not correlate with age at first evaluation. Using maternal HIV seroprevalence rates for 1988-1991, 34%-50% of the expected number of infants born to HIV-infected women were in clinical care. Perception of increased maternal risk for HIV infection was associated with early clinical recognition of infants of HIV-infected women.

Perinatally acquired human immunodeficiency virus infection: extent of clinical recognition in a population-based cohort. Massachusetts Pediatric HIV Surveillance Working Group

To evaluate factors that may affect the timely diagnosis of children with human immunodeficiency virus (HIV) infection, we compared data derived from two population-based pediatric HIV studies. Data from anonymous newborn HIV serosurveys were used to estimate the number of children born to HIV-seropositive mothers. A statewide active surveillance project determined the number of HIV-exposed children who had been clinically recognized. Of 88,732 Massachusetts newborn specimens tested anonymously for HIV antibodies during a 12-month period (November, 1987, to October, 1988), 223 were positive. As of October, 1991, 78 of these children (35%) had been identified by a statewide network of infectious disease physicians. HIV-exposed children born in inner city hospitals were more likely to have come to medical attention than those born in suburban hospitals (47% vs. 17%). Among the 29 children with confirmed HIV infection (13% of 223), the initial evaluation for HIV occurred at an earlier age among children born in inner city hospitals than among children born in other areas. HIV testing practices that rely heavily on risk assessment may result in delayed diagnosis of HIV infection in children whose mothers are not perceived to be at risk.