Effect of HIV infection on leprosy: a three-year survey in Bamako, Mali

From February 1992 until June 1994, all patients with histologically proven leprosy examined at the Leprology Unit of the Institut Marchoux in Bamako, Mali, were screened for HIV serology. In total, 740 leprosy patients have been tested; 553 known, previously treated leprosy cases and 187 new cases, mainly self-reporting and referred cases. The global seroprevalence in the sample was 1.5% (11/740), and increased from 1.3% in 1992 to 3.1% in 1994. HIV seroprevalence was higher in paucibacillary (PB) than in multibacillary (MB) cases (3.8% versus 0.8%, p < 0.05), and was slightly higher in new cases than in known, already treated cases (2.1% versus 1.3%), although not significantly. Among the 553 known, already treated leprosy patients, 1 out of 7 HIV-seropositive patients relapsed, as opposed to 34 out of 546 HIV-seronegative cases (14.2% versus 6.2%, p = 0.36). Among the new cases, none of the 37 patients with reaction and/or neuritis was HIV positive. In known, treated leprosy cases, there was no difference in the frequency of reactions and/or neuritis between HIV-positive and HIV-negative cases. Migration in a neighboring country appeared to be a risk factor for HIV seropositivity in our sample (chi 2 = 4.5, p = 0.04). In order to estimate the association of HIV with leprosy as compared to the general population, a control group of blood donors was set up, matched for age and sex. There was, however, no difference in HIV seroprevalence between the control group (9/735, 1.2%) and the leprosy group (1.5%). Although leprosy patients recruited for this study constitute a highly selected sample, it appears that HIV infection has little effect on leprosy, particularly on the PB/MB ratio, leprosy reactions and neuritis, but there is a suggestion the HIV infection might be associated with increased frequency of relapse.

Randomised controlled trial of treatment of chronic suppurative otitis media in Kenyan schoolchildren

BACKGROUND

The outcomes of treatment of chronic suppurative otitis media (CSOM) are disappointing and uncertain, especially in developing countries. Because CSOM is the commonest cause of hearing impairment in children in these countries, an effective method of management that can be implemented on a wide scale is needed. We report a randomised, controlled trial of treatment of CSOM among children in Kenya; unaffected schoolchildren were taught to administer the interventions.

METHODS

We enrolled 524 children with CSOM, aged 5-15 years, from 145 primary schools in Kiambu district of Kenya. The schools were randomly assigned treatments in clusters of five in a ratio of two to dry mopping alone (201 children), two to dry mopping with topical and systemic antibiotics and topical steroids (221 children), and one to no specific treatment (102 children). Schools were matched on factors thought to be related to their socioeconomic status. The primary outcome measures were resolution of otorrhoea and healing of tympanic membranes on otoscopy by 8, 12, and 16 weeks after induction. Absence of perforation was confirmed by tympanometry, and hearing levels were assessed by audiometry. 29 children were withdrawn from the trial because they took non-trial antibiotics. There was no evidence of differences in timing of withdrawals between the groups.

FINDINGS

By the 16-week follow-up visit, otorrhoea had resolved in a weighted mean proportion of 51% (95% CI 42-59) of children who received dry mopping with antibiotics, compared with 22% (14-31) of those who received dry mopping alone and 22% (9-35) of controls. Similar differences were recorded by the 8-week and 12-week visits. The weighted mean proportions of children with healing of the tympanic membranes by 16 weeks were 15% (10-21) in the dry-mopping plus antibiotics group, 13% (5-20) in the dry-mopping alone group, and 13% (3-23) in the control group. The proportion with resolution in the dry-mopping alone group did not differ significantly from that in the control group at any time. Hearing thresholds were significantly better for children with no otorrhoea at 16 weeks than for those who had otorrhoea, and were also significantly better for those whose ears had healed than for those with otorrhoea at all times.

INTERPRETATION

Our finding that dry mopping plus topical and systemic antibiotics is superior to dry mopping alone contrasts with that of the only previous community-based trial in a developing country, though it accords with findings of most other trials in developed countries. The potential role of antibiotics needs further investigation. Further, similar trials are needed to identify the most cost-effective and appropriate treatment regimen for CSOM in children in developing countries.

Fetal Candida infection associated with an intrauterine contraceptive device

Fetal Candida infection is rarely described but is often associated with a retained intrauterine contraceptive device (IUCD). A case of abortion due to Candida infection in a patient wearing an IUCD is reported.

[A rare case of primary abdominal actinomycosis]

The authors describe a case of primary abdominal actinomycosis operated on because of peritonitis sustained by a tubo-ovarian abscess. They discuss the pathogenesis of the case: the patient had been on intrauterine device contraception till two months earlier and had been operated on for breast cancer. Preoperative diagnosis is quite impossible and only the microscopic observation of the specimen can show the causative agent. Surgical options are reported, stressing the need for an adequate period of antimicrobial therapy.

Association between use of spermicide-coated condoms and Escherichia coli urinary tract infection in young women

Diaphragm/spermicide use increases the risk of urinary tract infection (UTI). To determine whether spermicide-coated condoms are also associated with an increased risk of UTI, the authors conducted a case-control study at a large health maintenance organization in Seattle, Washington. Cases were sexually active young women with acute UTI caused by Escherichia coli, identified from computerized laboratory files during 1990-1993. Age-matched controls were randomly selected from the enrollment files of the plan. Of 1,904 eligible women, 604 cases and 629 controls (65%) were interviewed. During the previous year, 40% of the cases and 31% of the controls had been exposed to any type of condom. The unadjusted odds ratio for UTI increased with frequency of condom exposure from 0.91 (95% confidence interval (CI) 0.65-1.28) for weekly or less during the previous month to 2.11 (95% CI 1.37-3.26) for more than once weekly. Exposure to spermicide-coated condoms conferred a higher risk of UTI, with odds ratios ranging from 1.09 (95% CI 0.58-2.05) for use weekly or less to 3.05 (95% CI 1.47-6.35) for use more than once weekly. In multivariate analyses, intercourse frequency (odds ratio (OR) = 1.14 per weekly episode), history of UTI (OR = 2.64), and frequency of spermicide-coated condom exposure (OR = 3.34 for more than once weekly and 5.65 for use more than twice weekly) were independent predictors of UTI. Spermicide-coated condoms were responsible for 42% of the UTIs among women who were exposed to these products.

A study of risk factors for pneumococcal disease among children in a rural area of west Africa

BACKGROUND

Pneumoccal infection is one of the leading causes of pneumonia, meningitis and septicaemia in developing countries. We have investigated possible risk factors for pneumococcal disease among children living in a rural area of The Gambia.

METHODS

A prospective case-control study was conducted in which children with pneumococcal infection were identified from among children attending out-patient and under-fives clinics and matched according to age with healthy children selected randomly from the local community. A questionnaire was used to investigate possible nutritional, medical, socioeconomic and environmental risk factors for pneumococcal disease.

RESULTS

An increased risk of pneumococcal disease was associated with poor weight gain, a history of serious illness in the previous 6 months, exposure to cigarette smoke or being carried on mother's back while cooking. The risk of pneumococcal disease was reduced among children whose mothers had a personal source of income.

CONCLUSIONS

The incidence of pneumococcal disease could be reduced by improving nutrition and taking steps to identify and rehabilitate those children whose weight is faltering or falling. Encouraging mothers to develop greater financial independence may also be beneficial. Reduced exposure to smoke should be promoted by improving ventilation in kitchens, introducing more efficient and less polluting stoves, keeping children away from smoky environments and discouraging parental smoking.

Helicobacter pylori infection in the young in Bangladesh: prevalence, socioeconomic and nutritional aspects

BACKGROUND

The gastric acid barrier, an important host defence against small bowel infection, may be compromised by infection with Helicobacter pylori. In developing countries, H. pylori infection occurs early in life and prevalence of hypochlorhydria is high particularly in the malnourished, which may predispose a child to repeated gastrointestinal infection and diarrhoea. Diarrhoea being a leading cause of childhood mortality and morbidity in developing countries, we investigated the prevalence of H. pylori infection in children in a poor Bangladeshi community and explored its association with socioeconomic and nutritional status.

METHODS

The study was conducted in a poor periurban community among 469 children aged 1-99 months. Parents were interviewed using a questionnaire. To detect active infection with H. pylori a 13C-urea breath test was performed and weight was recorded on a beam balance with a sensitivity of 20 g.

RESULTS

In all, 61% of 36 infants aged 1-3 months were positive for H. pylori; this rate dropped steadily with increasing age and was 33% in 10-15 month old children and then rose to 84% in 6-9 year olds. Overall H. pylori infection had no association with nutritional state of the child, or family income but the infection rate was 2.5 times higher in children of mothers with no schooling.

CONCLUSIONS

The H. pylori infection rate is very high in early infancy in a poor periurban community of Bangladesh. The reason for a drop in the infection rate in late infancy is unclear but could be due to initial clearance of the infection by the body's defence mechanisms but with possible alteration of the gastric mucosa which sustains infection. Maternal education may be protective and may operate through some unidentified proximate behavioural determinants. The rate of H. pylori infection in infants and young children may predispose them to repeated gastrointestinal infection and diarrhoea.

Using a knowledge, attitudes and practices survey to supplement findings of an outbreak investigation: cholera prevention measures during the 1991 epidemic in Peru

BACKGROUND

To assess the effectiveness of the cholera prevention activities of the Peruvian Ministry of Health, we conducted a knowledge, attitudes, and practices (KAP) survey in urban and rural Amazon communities during the cholera epidemic in 1991.

METHODS

We surveyed heads of 67 urban and 61 rural households to determine diarrhoea rates, sources of cholera prevention information, and knowledge, attitudes, and practices regarding ten cholera prevention measures.

RESULTS

Twenty-five per cent of 482 urban and 11% of 454 rural household members had diarrhoea during the first 3-4 months of the epidemic. Exposure to mass media education was greater in urban areas, and education through interpersonal communication was more prevalent in rural villages. Ninety-three per cent of rural and 67% of urban respondents believed they could prevent cholera. The mean numbers of correct responses to ten knowledge questions were 7.8 for urban and 8.2 for rural respondents. Practices lagged behind knowledge and attitudes (mean correct response to ten possible: urban 4.9, rural 4.6). Seventy-five per cent of respondents drank untreated water and 91% ate unwashed produce, both of which were identified as cholera risk factors in a concurrently conducted case-control study.

CONCLUSIONS

The cholera prevention campaign successfully educated respondents, but did not cause many to adopt preventive behaviours. Direct interpersonal education by community-based personnel may enhance the likelihood of translating education into changes in health behaviours. Knowledge, attitudes, and practices surveys conducted with case-control studies during an epidemic can be an effective method of refining education/control programmes.

Colitis and lower abdominal mass by Actinomyces israelii in a patient with an IUD

Abdominal actinomycosis is a rare disorder. The diagnosis is frequently missed preoperatively. We describe a patient who had had an intrauterine contraceptive device in situ for 5 years. She presented with a painful pelvicoabdominal mass, located between the uterus and rectum, and a colitis-like disease of the distal colon. Culture of the removed IUD demonstrated Actinomyces. She was intensively treated with intravenously penicillin for six weeks. Following this conservative treatment the abdominal tumor and the colitis-like symptoms totally disappeared. During two years follow-up she is free of symptoms and no signs of recurrence of the disease have been noticed. The case described here strongly underlines that Actinomyces infection should be born in mind in the differential diagnosis of a young female with an IUD, presenting with colitis, fever and an abdominal mass. Prolonged intravenously administered penicillin is warranted before surgery should be considered.

Preventing opportunistic infections in human immunodeficiency virus-infected persons: implications for the developing world

More than 18 million persons in the world are estimated to have been infected with human immunodeficiency virus (HIV), the cause of the acquired immunodeficiency syndrome (AIDS). As immunodeficiency progresses, these persons become susceptible to a wide variety of opportunistic infections (OIs) The spectrum of OIs varies among regions of the world. Tuberculosis is the most common serious OI in sub-Saharan Africa and is also more common in Latin America and in Asia than in the United States. Bacterial and parasitic infections are prevalent in Africa; protozoal infections such as toxoplasmosis, cryptosporidiosis, and isosporiasis are also common in Latin America. Fungal infections, including cryptococcosis and Penicillium marneffei infection, appear to be prevalent in Southeast Asia. Despite limited health resources in these regions, some measures that are recommended to prevent OIs in the United States may be useful for prolonging and improving the quality of life of HIV-infected persons. These include trimethoprim-sulfamethoxazole to prevent Pneumocystis carinii pneumonia, toxoplasmosis, and bacterial infections; isoniazid to prevent tuberculosis; and 23-valent pneumococcal vaccine to prevent disease due to Streptococcus pneumoniae. Research is needed to determine the spectrum of OIs and the efficacy of various prevention measures in resource-poor nations, and health officials need to determine a minimum standard of care for HIV-infected persons. An increasing problem in the developing world, HIV/AIDS should receive attention comparable to other tropical diseases.

Clinical profile and risk factors for oral candidosis in sick newborns

OBJECTIVES

To provide the clinical profile and assess the significance of various risk factors contributing to the occurrence of oral candidosis in newborns.

DESIGN

Case-control study.

SETTING

Neonatal Intensive Care Unit (NICU).

SUBJECTS

Twenty newborns with oral candidosis and an equal number of age and weight matched controls.

INTERVENTIONS

All cases of oral candidosis were treated with local application of 1% Clotrimazole.

RESULTS

Oral candidosis was documented in 3.2% (20/650) cases in the NICU. Acute pseudomembranous candidosis was the most common presentation. The mean age of onset was 10.5 days. Candida albicans was isolated in 50% cases in addition to C. tropicalis, C. paratropicalis, C. krusei, C. glabrata and C. parapsilosis. On univariate analysis, male sex, birth asphyxia and prolonged antibiotic therapy had a significant correlation with occurence of oral candidosis in neonates. Out of these, birth asphyxia was the only factor significantly associated with oral candidosis (OR 8.09, 95% CI 1.34-48.8, p = 0.0226) on multivariate analysis.

CONCLUSIONS

C. albicans was the predominant isolate in this series of oral candidosis. Clinical manifestations were evident in the second week of life and birth asphyxia was the most important associated perinatal event.

Ophthalmia neonatorum in the United Arab Emirates

Ophthalmia neonatorum in small babies is a common problem in neonatal units in Al Ain, but is infrequently associated with sexually transmitted disease agents. A study of 81 babies with ophthalmia neonatorum showed that 81.5% had bacterial or fungal infections. Staphylococcus aureus was the commonest causative organism followed by Escherichia coli and Pseudomonas aeruginosa while Chlamydia trachomatis and Neisseria gonorrhoeae were responsible for less than 5% of all cases. The disease was predominantly mild to moderately severe and easily treated with topical broad-spectrum antibiotic agents which are effective against Gram-positive and Gram-negative bacteria, including hospital-associated strains. The most effective antimicrobial agents were gentamicin topically or ceftriaxone systemically.

Bacteraemia in malnourished rural African children

During a 5-month study period, 323 of 863 (37.5%) children below 5 years of age admitted to Shongwe Mission Hospital in rural South Africa were malnourished, two-thirds severely so. The incidence of bacteraemia in malnourished children was 9.6%, 11.8% in those severely malnourished and 5.8% in nutritional dwarfs. The predominant organisms retrieved were Gram-negative enteric bacilli (48.5%). Amongst the severely malnourished, who empirically receive intravenous ampicillin and gentamicin, 95.8% of all isolates were sensitive to this antibiotic combination. The case fatality rate of severely malnourished bacteraemic children was 20.8%. In malnutrition categories overall, the case fatality rate for bacteraemic children (22.6%) was significantly greater than in those without bacteraemia (9.3%). In hospitals with limited resources, full identification of bacteria may not be necessary, provided that regular surveillance for emerging resistance is conducted.

Epidemiologic study of Vibrio cholerae O1 and O139 in Thailand: at the advancing edge of the eighth pandemic

Vibrio cholerae O139 Bengal emerged on the Indian subcontinent in late 1992 and was first recognized in Thailand in 1993. To characterize the epidemiology of this disease, a hospital-based case-control study was conducted in Samutsakorn, a port city 30 km southwest of Bangkok. Between November 15, 1993, and June 3, 1994, 366 patients were confirmed to have cholera by culture, including 165 (45%) with O139 Bengal, 191 (52%) with O1 Ogawa, and 10 (3%) with both serogroups. During the same time period the previous year, 319 culture-confirmed cholera cases occurred, all serogroup O1. Questionnaires were obtained from 105 patients with O139 Bengal and 103 with O1 infections; for each case patient, two asymptomatic age- and sex-matched control persons were selected. Of the patients with O139 Bengal infections, 93% were adults (> or = 15 years) compared with 92% of patients with O1 infections. Risk factors for cholera identified by case-control comparisons were similar for the two serogroups and included consumption of untreated water, uncooked seafood, and food served at group gatherings. V. cholerae O139 Bengal has emerged in Thailand as a cause of endemic cholera, with epidemiologic features and incidence similar to those of the preexisting O1 strain.

Aerobic bacteria, Chlamydia trachomatis, Pneumocystis carinii and Cytomegalovirus as agents of severe pneumonia in small infants

The authors studied 58 infants hospitalized for pneumonia in a semi-intensive care unit. Age ranged from 1 complete to 6 incomplete months. The infants were sent from another hospital in 20 cases and from home in a further 38. Pulmonary involvement, which was alveolar in 46 cases and interstitial in 12, was bilateral in 31 children. The investigation was carried out prospectively on the etiological agents associated with respiratory infection to look for evidence of aerobic bacteria (blood cultures), Chlamydia trachomatis and Cytomegalovirus (serology), and Pneumocystis carinii (direct microscopy of tracheal aspirated material). The following infectious agents were diagnosed in 21 children (36.2%): Aerobic bacteria (8), Chlamydia trachomatis (5), Pneumocystis carinii (3), Cytomegalovirus (3), Cytomegalovirus and Chlamydia trachomatis (1), Aerobic bacteria and Cytomegalovirus (1). Seven cases of infection by Chlamydia trachomatis and/or Cytomegalovirus were diagnosed out of the 12 cases with pulmonary interstitial involvement.