Mortality among internal and international migrants in the 100 Million Brazilian Cohort

Background

There is limited evidence on the health of migrant populations in low and middle-income countries (LMICs). Here, we investigated the patterns of mortality risk in migrants and non-migrants in women and men over the life course.

Methods

We linked socioeconomic and mortality data from 1st Jan 2011 to 31st Dec 2018 in the 100 Million Brazilian Cohort. We calculated all-cause and cause-specific age-standardised mortality rates according to individuals’ migration status. Using Cox regression models, we estimated the age- and sex-adjusted mortality hazard ratios (HR) for internal migrants (i.e., people born in Brazil but living in a different Brazilian state to their state of birth) compared to Brazilian-born non-migrants; and for international migrants (i.e., people born in another country) compared to Brazilian-born individuals.

Results

We followed 45,051,476 individuals, of whom 6,057,814 were internal migrants and 277,230 were international migrants. Internal migrants had a similar overall risk of all-cause mortality compared to Brazilian non-migrants (aHR=0.99, 95%CI=0.98-0.99), with lower mortality from some causes but higher mortality for some non-communicable diseases (NCDs). Compared to Brazilian-born individuals, international migrants had a lower risk of all-cause mortality (aHR=0.82, 95%CI=0.80-0.84), with up to 50% lower risk of death attributed to interpersonal violence among international migrant men (aHR=0.50, 95%CI=0.40-0.64), but a markedly higher risk of death by avoidable causes related to maternal health among young migrant women (aHR=2.17, 95%CI=1.17-4.05).

Conclusions

Overall, internal migration was not associated with excess all-cause mortality, while international migration into Brazil was associated with lower all-cause mortality. Mortality patterns among migrant populations in Brazil show marked variation for specific causes of death, and risks varied by age and sex.

Key messages

• Non-communicable diseases and maternal mortality are disproportionally higher among internal and international migrants, respectively.

• Further investigation of the underlying factors associated with higher maternal mortality among international migrant women is key to informing the targeting of social and health interventions.

Detection of Reactive Oxygen Species in Human Neutrophils Under Various Conditions of Exposure to Galectin

Reactive oxygen species (ROS) have been extensively studied in biology in the past years. This class of molecules can be derived from endogenous sources (e.g., phagocytic cells as neutrophils, eosinophils, monocytes, macrophages, and organelles as mitochondria and peroxisomes) and participate in physiological and pathological conditions. The beneficial and harmful effects of ROS depend on redox regulation, which establishes the balance between their production and the activity of antioxidant systems to prevent oxidative stress in vivo. Neutrophils are the immune effectors most well depicted with an intense oxidative burst in response to tissue inflammation. Several proteins and members of the galectin family are involved in this fine modulation of ROS production by neutrophils. Interestingly, studies have indicated that Galectin-1 (Gal-1) can up- or downregulate ROS production by neutrophils even when exposed to N-formyl-Met-Leu-Phe (fMLP) or Phorbol Myristate Acetate (PMA), both of which are potent neutrophil stimulants that trigger high levels of ROS production. Similarly, Galectin-3 (Gal-3) induces ROS in neutrophils from a sterile or nonsterile inflammatory environment, possibly creating a negative loop that could control ROS production. Besides, superoxide production is also induced by Galectin-8 (Gal-8) and Galectin-9 (Gal-9) in neutrophils but in a different manner. We describe herein the luminol and lucigenin-dependent chemiluminescence technique by using a luminometer as a method of assessment to measure ROS production by human neutrophils isolated and exposed to purified human recombinant Gal-1. The protocol described herein could be applied for the investigation of the role of other galectins in the modulation of ROS production by neutrophils.

Investigation of Galectins in Frozen Tissue and Mammalian Cell Culture Using Confocal Miccroscopy

Galectins are multifunctional glycan-binding proteins present in various tissues that participate in multiple physiological and pathological processes and are considered as not only biomarkers of human diseases but also molecular targets for treating cancer and inflammatory illnesses in many organs. In the glycobiology field, it is crucial to determine the pattern of galectin expression and location in cells and tissues. Confocal microscopy is a powerful imaging technology that represents a unique approach to investigate the expression and location of biomolecules in various tissues and cells. The confocal microscope acquires images of the specimen through the reflected or fluorescent light from the objective's focal plane, using laser light focused on a small spot inside the tissue or cell. This technique provides high-resolution and high-contrast images without artifacts generated by conventional microscopy and enables reconstruction of virtual tridimensional images by acquiring multiple sections from several focal planes, which makes it possible to obtain the precise spatial location of any cellular structure or molecule. Furthermore, confocal microscopy is a non-invasive tissue imaging strategy used in clinical practices. We describe herein the immunofluorescence confocal method for examining galectins in frozen tissue sections and mammalian cell culture.

Endogenous Galectin-3 is required for skeletal muscle repair

Skeletal muscle has the intrinsic ability to self-repair through a multifactorial process, but many aspects of its cellular and molecular mechanisms are not fully understood. There is increasing evidence that some members of the mammalian β-galactoside-binding protein family (galectins) are involved in the muscular repair process (MRP), including galectin-3 (Gal-3). However, there are many questions about the role of this protein on muscle self-repair. Here, we demonstrate that endogenous Gal-3 is required for: i) muscle repair in vivo using a chloride-barium myolesion mouse model, and ii) mouse primary myoblasts myogenic programming. Injured muscle from Gal-3 knockout mice (GAL3KO) showed persistent inflammation associated with compromised muscle repair and the formation of fibrotic tissue on the lesion site. In GAL3KO mice, osteopontin expression remained high even after 7 and 14 days of the myolesion, while MyoD and myogenin had decreased their expression. In GAL3KO mouse primary myoblast cell culture, Pax7 detection seems to sustain even when cells are stimulated to differentiation and MyoD expression is drastically reduced. The detection and temporal expression levels of these transcriptional factors appear to be altered in Gal-3-deficient myoblast. Gal-3 expression in WT states, both in vivo and in vitro, in sarcoplasm/cytoplasm and myonuclei; as differentiation proceeds, Gal-3 expression is drastically reduced, and its location is confined to the sarcolemma/plasma cell membrane. We also observed a change in the temporal-spatial profile of Gal-3 expression and muscle transcription factors levels during the myolesion. Overall, these results demonstrate that endogenous Gal-3 is required for the skeletal muscle repair process.

The Centre for Data and Knowledge Integration for Health (CIDACS): Linking Health and Social Data in Brazil

The Centre for Data and Knowledge Integration for Health (CIDACS) was created in 2016 in Salvador, Bahia-Brazil with the objective of integrating data and knowledge aiming to answer scientific questions related to the health of the Brazilian population. This article details our experiences in the establishment and operations of CIDACS, as well as efforts made to obtain high-quality linked data while adhering to security, ethical use and privacy issues. Every effort has been made to conduct operations while implementing appropriate structures, procedures, processes and controls over the original and integrated databases in order to provide adequate datasets to answer relevant research questions. Looking forward, CIDACS is expected to be an important resource for researchers and policymakers interested in enhancing the evidence base pertaining to different aspects of health, in particular when investigating, from a nation-wide perspective, the role of social determinants of health and the effects of social and environmental policies on different health outcomes.

Marginal Zone B Cells Induce Alloantibody Formation Following RBC Transfusion

Red blood cell (RBC) alloimmunization represents a significant immunological challenge for some patients. While a variety of immune constituents likely contribute to the initiation and orchestration of alloantibodies to RBC antigens, identification of key immune factors that initiate alloantibody formation may aid in the development of a therapeutic modality to minimize or prevent this process. To define the immune factors that may be important in driving alloimmunization to an RBC antigen, we determined the specific immune compartment and distinct cells that may initially engage transfused RBCs and facilitate subsequent alloimmunization. Our findings demonstrate that the splenic compartment is essential for formation of anti-KEL antibodies following KEL RBC transfusion. Within the spleen, transfused KEL RBCs are found within the marginal sinus, where they appear to specifically co-localize with marginal zone (MZ) B cells. Consistent with this, removal of MZ B cells completely prevented alloantibody formation following KEL RBC transfusion. While MZ B cells can mediate a variety of key downstream immune pathways, depletion of follicular B cells or CD4 T cells failed to similarly impact the anti-KEL antibody response, suggesting that MZ B cells may play a key role in the development of anti-KEL IgM and IgG following KEL RBC transfusion. These findings highlight a key contributor to KEL RBC-induced antibody formation, wherein MZ B cells facilitate antibody formation following RBC transfusion.

Glutathione peroxidase and glutathione S-transferase in blood and liver from a hypoxia-tolerant fish under oxygen deprivation

Liver enzyme activities can be employed as biomarkers, but liver can only be obtained with death of the specimen. On the other hand, blood withdrawal is a non-lethal procedure. Accordingly, the hypothesis of this study is to verify if glutathione peroxidase (GPX) and glutathione S-transferase (GST) activities in blood parallel those in the liver of the hypoxia-tolerant fish, Piaractus mesopotamicus (pacu), submitted to hypoxia conditions. GPX was assayed with H₂O₂ in cytosols from both liver and erythrocytes and exhibited no significant variation, either in erythrocytes or in liver, when comparing pacus under normoxia with those under hypoxia (42 h). GST activity with chloro-dinitrobenzene (CDNB), an artificial substrate suitable for almost all GST isoenzymes, was compared to activity with 4-hydroxy-nonenal (4-HNE), a physiological endogenous substrate. GST activity with CDNB did not change in liver or in erythrocyte cytosols in pacus under hypoxia compared to those under normoxia. On the other hand, a significant decrease in erythrocyte activity with 4-HNE was observed after 42 h of hypoxia in both erythrocytes and liver, which may be a response to increased lipid oxidation in erythrocytes. Erythrocyte GST activity was 3-fold higher with 4-HNE than with CDNB, indicating that 4-HNE is a more appropriate substrate to determine GST activity in pacu erythrocytes.

Effect of Brazil's conditional cash transfer programme on tuberculosis incidence

OBJECTIVE

To evaluate the impact of the Brazilian cash transfer programme (Bolsa Família Programme, BFP) on tuberculosis (TB) incidence in Brazil from 2004 to 2012.

DESIGN

We studied tuberculosis surveillance data using a combination of an ecological multiple-group and time-trend design covering 2458 Brazilian municipalities. The main independent variable was BFP coverage and the outcome was the TB incidence rate. All study variables were obtained from national databases. We used fixed-effects negative binomial models for panel data adjusted for selected covariates and a variable representing time.

RESULTS

After controlling for covariates, TB incidence rates were significantly reduced in municipalities with high BFP coverage compared with those with low and intermediate coverage (in a model with a time variable incidence rate ratio = 0.96, 95%CI 0.93-0.99).

CONCLUSION

This was the first evidence of a statistically significant association between the increase in cash transfer programme coverage and a reduction in TB incidence rate. Our findings provide support for social protection interventions for tackling TB worldwide.

A soluble recombinant form of human leucocyte antigen-G 6 (srHLA-G6)

Human Leucocyte Antigen-G (HLA-G) is a non classical major histocompatibility complex (MHC) molecule that through RNA splicing can encode seven isoforms which are membrane bound (-G1, -G2, -G3 and -G4) and soluble (-G5, -G6 and -G7). HLA-G is described as important immune suppressor endogenous molecule to favor maternal-fetal tolerance, transplant survival and tumor immune scape. HLA-G shows low protein variability and a unique structural complexity that is related with the expression of different isoforms followed by biochemical processes, such as, proteolytic cleavage, molecular interactions, and protein ubiquitination. Studies with HLA-G have shown difficult to assess the role of the individual isoforms. Thus, the aim of this work was to obtain a HLA-G6 recombinant form. The results indicated the production of high homogeneous preparations of soluble recombinant HLA-G6 (srHLA-G6) with molecular mass 23,603.76 Da, determined by MALD-TOF/TOF. In addition, native and denatured srHLA-G6 were detected by ELISA, using commercial monoclonal antibodies. Finally, we developed a suitable methodology to express srHLA-G6 that could contribute in structural and functional studies involving specific isoforms.

Response of phytoplankton to an experimental fish culture in net cages in a subtropical reservoir

This study aimed to evaluate nutrients concentration and spatial-temporal changes in phytoplankton biovolume during an experimental fish culture in net cages in a lateral arm of Salto Caxias reservoir, Brazil. Two sampling stations were placed in the affected lateral arm and other two in a cageless lateral arm. Neither abiotic variables nor phytoplankton biovolume presented significant differences between the treatments. Only temporal changes were confirmed by the analysis performed. Both lateral arms were classified as oligotrophic, reflecting low influence of the net cages. Phytoplankton growth seems to be limited by nitrogen. Biovolume values were, in general, low and five major functional groups were recognized (E, F, G, K and P). In summer higher biovolume values were observed and representatives of Chlorophyceae and Cyanobacteria belonging to the functional groups F and K, respectively, were the most important. In winter phytoplankton was mainly composed by Bacillariophyceae taxa from P group. G group was also restricted to winter and E group occurred in winter and summer. The variations recorded in phytoplankton structure appear to have been mainly influenced by seasonal changes in temperature, precipitation and nutrients availability. The effects of net cages on the abiotic variables and phytoplankton biovolume appear to have been small, probably due to the small number of net cages employed and the system dilution capacity. However, a permanent monitoring of phytoplankton is recommended, since this environment has a carrying capacity, from which the trophic state may increase.

Immunoexpression of HPV 16/18 E6 and E7 oncoproteins in high-grade cervical squamous intraepithelial lesions in HIV-positive women

The aim of this study was to assess the immunoexpression of human papillomavirus genotypes 16 and 18 (E6 and E7) oncoproteins in cervical high-grade squamous intraepithelial lesions (HSIL) of human immunodeficiency virus (HIV)-positive women. These results were also compared to the persistence and/or recurrence of lesions after loop electrosurgical excision procedure. Cervical samples from 158 patients were divided into three groups according to the presence or absence of HSIL in women who were or were not HIV-positive. By using the tissue microarray technique, immunohistochemistry was performed to analyze the expression of HPV 16/18 E6 and E7 oncoproteins. Cervical samples from 95 HIV-positive women and 63 HIV-negative women were studied. A statistically significant difference was found in the immunoexpression of E6 and E7 oncoproteins in samples from HIV-positive women with HSIL and that of women with non-neoplastic tissue (P < 0.001). There was also a statistically significant correlation between the immunoexpression of E6 (P = 0.012) and E7 (P < 0.001) oncoproteins in lesion persistence among HIV-positive women. Within the limitations of this study, the immunoexpression of HPV 16/18 E6 and E7 oncoproteins may have prognostic value regarding lesion persistence in HIV-positive women.

Floral resources and habitat affect the composition of hummingbirds at the local scale in tropical mountaintops

Hummingbird communities tend to respond to variation in resources, having a positive relationship between abundance and diversity of food resources and the abundance and/or diversity of hummingbirds. Here we examined the influence of floral resource availability, as well as seasonality and type of habitat on the composition of hummingbird species. The study was carried out in two habitats of eastern Brazilian mountaintops. A gradient representative of the structure of hummingbird community, based on species composition, was obtained by the ordination of samples using the method of non-metric multidimensional scaling. The composition of hummingbird species was influenced by the type of habitat and floral resource availability, but not by seasonality. Hummingbird communities differ between habitats mainly due to the relative abundance of hummingbird species. The variation in composition of hummingbird species with the variation in floral resource availability may be related to differences in feeding habits of hummingbirds. Hummingbird species with the longest bills visited higher proportions of ornithophilous species, while hummingbirds with shorter bills visited higher proportions of non-ornithophilous species. The results demonstrate that at local-scale the composition of hummingbird species is affected by the type of habitat and floral resources availability, but not by seasonality.

Effect of urban vs. rural residence on the association between atopy and wheeze in Latin America: findings from a case-control analysis

Background

The association between atopy and asthma is attenuated in non-affluent populations, an effect that may be explained by childhood infections such as geohelminths.

Objective

To investigate the association between atopy and wheeze in schoolchildren living in urban and rural areas of Ecuador and examine the effects of geohelminths on this association.

Methods

We performed nested case–control studies among comparable populations of schoolchildren living in rural communities and urban neighbourhoods in the Province of Esmeraldas, Ecuador. We detected geohelminths in stool samples, measured recent wheeze and environmental exposures by parental questionnaire, and atopy by specific IgE (sIgE) and skin prick test (SPT) reactivity to aeroallergens.

Results

Atopy, particularly sIgE to house dust mite (HDM), was more strongly associated with recent wheeze in urban than rural schoolchildren: (urban, adj. OR 5.19, 95% CI 3.37–8.00, P < 0.0001; rural, adj. OR 1.81, 95%CI 1.09–2.99, P = 0.02; interaction, P < 0.001). The population fractions of wheeze attributable to atopy were approximately two-fold greater in urban schoolchildren: SPT to any allergen (urban 23.5% vs. rural 10.1%), SPT to HDM (urban 18.5% vs. rural 9.6%), and anti-HDM IgE (urban 26.5% vs. rural 10.5%), while anti-Ascaris IgE was related to wheeze in a high proportion of rural (49.7%) and urban (35.4%) children. The association between atopy and recent wheeze was attenuated by markers of geohelminth infections.

Conclusions

Our data suggest that urban residence modifies the association between HDM atopy and recent wheeze, and this effect is explained partly by geohelminth infections.

Schistosome infection is negatively associated with mite atopy, but not wheeze and asthma in Ghanaian schoolchildren

BACKGROUND

Epidemiological evidence suggests that helminth infection and rural living are inversely associated with allergic disorders.

OBJECTIVE

The aim of the study was to investigate the effect of helminth infections and urban versus rural residence on allergy in schoolchildren from Ghana.

METHODS

In a cross-sectional study of 1385 children from urban-high socio-economic status (SES), urban-low SES and rural schools, associations between body mass index (BMI), allergen-specific IgE (sIgE), parasitic infections and allergy outcomes were analysed. Allergy outcomes were skin prick test (SPT) reactivity, reported current wheeze and asthma.

RESULTS

Helminth infections were found predominantly among rural subjects, and the most common were hookworm (9.9%) and Schistosoma spp (9.5%). Being overweight was highest among urban-high SES (14.6%) compared to urban-low SES (5.5%) and rural children (8.6%). The prevalence of SPT reactivity to any allergen was 18.3%, and this was highest among rural children (21.4%) followed by urban-high SES (20.2%) and urban-low SES (10.5%) children. Overall, SPT reactivity to mite (12%) was most common. Wheeze and asthma were reported by 7.9% and 8.3%, respectively. In multivariate analyses, factors associated with mite SPT were BMI (aOR 2.43, 95% CI 1.28-4.60, P = 0.007), schistosome infection (aOR 0.15, 95% CI 0.05-0.41) and mite sIgE (aOR 7.40, 95% CI 5.62-9.73, P < 0.001) but not area. However, the association between mite IgE and SPT differed by area and was strongest among urban-high SES children (aOR = 15.58, 95% CI 7.05-34.43, P < 0.001). Compared to rural, urban-low SES area was negatively associated with current wheeze (aOR 0.41, 95% CI 0.20-0.83, P = 0.013). Both mite sIgE and mite SPT were significantly associated with current wheeze and asthma.

CONCLUSION AND CLINICAL RELEVANCE

Infection with schistosomes appeared to protect against mite SPT reactivity. This needs to be confirmed in future studies, preferably in a longitudinal design where schistosome infections are treated and allergic reactions reassessed.

Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systematic review and meta-analysis

OBJECTIVES

To determine whether BCG vaccination protects against Mycobacterium tuberculosis infection as assessed by interferon γ release assays (IGRA) in children.

DESIGN

Systematic review and meta-analysis. Searches of electronic databases 1950 to November 2013, checking of reference lists, hand searching of journals, and contact with experts.

SETTING

Community congregate settings and households.

INCLUSION CRITERIA

Vaccinated and unvaccinated children aged under 16 with known recent exposure to patients with pulmonary tuberculosis. Children were screened for infection with M tuberculosis with interferon γ release assays.

DATA EXTRACTION

Study results relating to diagnostic accuracy were extracted and risk estimates were combined with random effects meta-analysis.

RESULTS

The primary analysis included 14 studies and 3855 participants. The estimated overall risk ratio was 0.81 (95% confidence interval 0.71 to 0.92), indicating a protective efficacy of 19% against infection among vaccinated children after exposure compared with unvaccinated children. The observed protection was similar when estimated with the two types of interferon γ release assays (ELISpot or QuantiFERON). Restriction of the analysis to the six studies (n=1745) with information on progression to active tuberculosis at the time of screening showed protection against infection of 27% (risk ratio 0.73, 0.61 to 0.87) compared with 71% (0.29, 0.15 to 0.58) against active tuberculosis. Among those infected, protection against progression to disease was 58% (0.42, 0.23 to 0.77).

CONCLUSIONS

BCG protects against M tuberculosis infection as well as progression from infection to disease.Trial registration PROSPERO registration No CRD42011001698 (www.crd.york.ac.uk/prospero/).

Flowers visited by hummingbirds in the open habitats of the southeastern brazilian mountaintops: species composition and seasonality

The hummingbird-visited plant community located on the open-habitat mountaintop of the Espinhaço Range was studied for two years (from August 2007 to July 2009) in Serra do Cipó National Park, Southeastern Brazil (19° 15′ S and 43° 31′ W). The floral characteristics and flowering period of the hummingbird-visited plants was monthly recorded along trails located in three vegetation types: (1) typical campos rupestres (TCR), (2) open fields (OPF), and (3) capões de mata(CAM). Hummingbird visitation was observed in 51 plant species, 22 ornithophilous and 29 non-ornithophilous species. The TCR showed the greatest number of species visited (N = 38), followed by the OPF (N = 18) and CAM (N = 17). Six species of hummingbirds were recorded visiting flowers: Augastes scutatus, Campylopterus largipennis, Colibri serrirostris, Chlorostilbon lucidus, Eupetomena macroura and Phaethornis pretrei. This study demonstrates that the species richness and the number of ornithophilous species visited by the hummingbirds at the study site are more similar to hummingbird-plant communities of the Atlantic Forest than to those of the Cerrado communities and other Brazilian highland open-habitat communities. The plant families most visited by hummingbirds were Bromeliaceae and Asteraceae. Although the Asteraceae family is rarely used as a food resource for hummingbirds in other high and lowland communities, in the study site this family is used mainly by the endemic hummingbird Augastes scutatus. We found a large overlap of flowering throughout the year among the species visited by the hummingbirds. Thus, the nectar availability supports these resident hummingbirds. The present study also showed that the studied hummingbird-plant community is composed of many species endemic to the campos rupestres of the Espinhaço Range, some of which are considered to be in danger of extinction, thus constituting a unique and threatened community. Thus, understanding hummingbird-plant pollination dynamics becomes fundamental to the conservation of the campos rupestres.

Systematic review and meta-analysis of the current evidence on the duration of protection by bacillus Calmette-Guérin vaccination against tuberculosis

BACKGROUND

Recent evidence suggests that the duration of protection by bacillus Calmette-Guérin (BCG) may exceed previous estimates with potential implications for estimating clinical and cost-efficacy.

OBJECTIVES

To estimate the protection and duration of protection provided by BCG vaccination against tuberculosis, explore how this protection changes with time since vaccination, and examine the reasons behind the variation in protection and the rate of waning of protection.

DATA SOURCES

Electronic databases including MEDLINE, Excerpta Medica Database (EMBASE), Cochrane Databases, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE), Web of Knowledge, Biosciences Information Service (BIOSIS), Latin American and Caribbean Health Sciences Literature (LILACs), MEDCARIB Database, Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from inception to May 2009. Index to Theses, System for Information on Grey Literature in Europe (SIGLE), Centre for Agricultural Bioscience International (CABI) Abstracts, Scopus, Article First, Academic Complete, Africa-Wide Information, Google Scholar, Global Health, British National Bibliography for Report Literature, and clinical trial registration websites were searched from inception to October 2009.

REVIEW METHODS

Electronic databases searches, screening of identified studies, data extraction and analysis were undertaken. Meta-analysis was used to present numerical and graphical summaries of clinical efficacy and efficacy by time since vaccination. Evidence of heterogeneity was assessed using the tau-squared statistic. Meta-regression allowed the investigation of observed heterogeneity. Factors investigated included BCG strain, latitude, stringency of pre-BCG vaccination tuberculin testing, age at vaccination, site of disease, study design and vulnerability to biases. Rate of waning of protection was estimated using the ratio of the measure of efficacy after 10 years compared with the efficacy in the first 10 years of a study.

RESULTS

Study selection. A total of 21,030 references were identified, providing data on 132 studies after abstract and full-text review. Efficacy. Protection against pulmonary tuberculosis in adults is variable, ranging from substantial protection in the UK MRC trial {rate ratio 0.22 [95% confidence interval (CI) 0.16 to 0.31]}, to absence of clinically important benefit, as in the large Chingleput trial [rate ratio 1.05 (95% CI 0.88 to 1.25)] and greater in latitudes further away from the equator. BCG vaccination efficacy was usually high, and varied little by form of disease (with higher protection against meningeal and miliary tuberculosis) or study design when BCG vaccination was given only to infants or to children after strict screening for tuberculin sensitivity. High levels of protection against death were observed from both trials and observational studies. The observed protective effect of BCG vaccination did not differ by the strain of BCG vaccine used in trials.

DURATION

Reviewed studies showed that BCG vaccination protects against pulmonary and extrapulmonary tuberculosis for up to 10 years. Most studies either did not follow up participants for long enough or had very few cases after 15 years. This should not be taken to indicate an absence of effect: five studies (one trial and four observational studies) provided evidence of measurable protection at least 15 years after vaccination. Efficacy declined with time. The rate of decline was variable, with faster decline in latitudes further from the equator and in situations where BCG vaccination was given to tuberculin-sensitive participants after stringent tuberculin testing.

LIMITATIONS

The main limitation of this review relates to quality of included trials, most of which were conducted before current standards for reporting were formulated. In addition, data were lacking in some areas and the review had to rely on evidence from observational studies.

CONCLUSIONS

BCG vaccination protection against tuberculosis varies between populations, to an extent that cannot be attributed to chance alone. Failure to exclude those already sensitised to mycobacteria and study latitude closer to the equator were associated with lower efficacy. These factors explained most of the observed variation. There is good evidence that BCG vaccination protection declines with time and that protection can last for up to 10 years. Data on protection beyond 15 years are limited; however, a small number of trials and observational studies suggest that BCG vaccination may protect for longer. Further studies are required to investigate the duration of protection by BCG vaccination.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Influence of fish farming in net cages on phytoplankton structure: a case study in a subtropical Brazilian reservoir

This study investigated the enrichment influence due to fish farming in net cages on the phytoplankton composition, density and diversity in two arms of a subtropical reservoir (Salto Caxias, Paraná). There were no statistically significant differences in the phytoplankton composition and diversity, as well as for concentrations of nutrients among the handled treatment. The density values were higher during the summer. Richness and Shannon diversity values were low during the study period. The equitability values were high during the winter and low in the summer. Variations of phytoplankton community and nutrients were mainly influenced by seasonality. The absence of significant differences between the treatments was probably due to the small number of net cages and fish used, as well as to the hydrodynamics of the studied environments, which are influenced by upstream rivers inflows.

Validation of a food frequency questionnaire for children and adolescents aged 4 to 11 years living in Salvador, Bahia

OBJECTIVE

To assess the validity of a food frequency questionnaire (FFQ) by applying it to children and adolescents living in Salvador, Bahia.

METHODS

The validity of this FFQ with 98 food items was investigated among 108 children and adolescents who were selected from a sample of 1445 that had been planned for a study on the risk factors for asthma and other allergic diseases. The adults responsible for these children and adolescents gave responses for a 24-hour recall (R24h) and an FFQ. The average energy and nutrient values from the FFQ were compared with those from the R24h by means of the paired t test and Pearson correlation coefficients. The concordance was evaluated using the Bland-Altman method and kappa statistics.

RESULTS

The energy and nutrient intake estimated using the FFQ was significantly higher than what was obtained using the R24h. The correlation coefficients adjusted for energy were statistically significant for protein, fat, vitamin C and zinc. The weighted kappa values ranged from 0.06 for vitamin A (p = 0.24) to 0.34 for energy (p < 0.00). The results from the Bland-Altman plots for lipid, protein and zinc showed the most significant validity parameters, and zinc was found to show the best concordance.

CONCLUSION

The results suggest that the FFQ showed satisfactory validity for use in studies involving children and adolescents.

Effects of geohelminth infection and age on the associations between allergen-specific IgE, skin test reactivity and wheeze: a case-control study

Background

Most childhood asthma in poor populations in Latin America is not associated with aeroallergen sensitization, an observation that could be explained by the attenuation of atopy by chronic helminth infections or effects of age.

Objective

To explore the effects of geohelminth infections and age on atopy, wheeze, and the association between atopy and wheeze.

Methods

A case-control study was done in 376 subjects (149 cases and 227 controls) aged 7–19 years living in rural communities in Ecuador. Wheeze cases, identified from a large cross-sectional survey, had recent wheeze and controls were a random sample of those without wheeze. Atopy was measured by the presence of allergen-specific IgE (asIgE) and skin prick test (SPT) responses to house dust mite and cockroach. Geohelminth infections were measured in stools and anti-Ascaris IgE in plasma.

Results

The fraction of recent wheeze attributable to anti-Ascaris IgE was 45.9%, while those for SPT and asIgE were 10.0% and 10.5% respectively. The association between atopy and wheeze was greater in adolescents than children. Although Anti-Ascaris IgE was strongly associated with wheeze (adj. OR 2.24 (95% CI 1.33–3.78, P = 0.003) and with asIgE (adj. OR 5.34, 95% CI 2.49–11.45, P < 0.001), the association with wheeze was independent of asIgE. There was some evidence that the association between atopy and wheeze was greater in uninfected subjects compared with those with active geohelminth infections.

Conclusions and clinical relevance

Atopy to house dust mite and cockroach explained few wheeze cases in our study population, while the presence of anti-Ascaris IgE was an important risk factor. Our data provided only limited evidence that active geohelminth infections attenuated the association between atopy and wheeze in endemic areas or that age modified this association. The role of allergic sensitization to Ascaris in the development of wheeze, independent of atopy, requires further investigation.

Spatial and temporal variation of the phytoplankton community in a section of the Iguaçu River, Paraná, Brazil

The work aimed to show variations in the composition and structure of the phytoplankton community at high water and low water in Iguaçu Falls, Iguaçu River and to examine the influence of these waterfalls and environmental variables on the community. Phytoplankton samples were taken monthly during a year from two sampling stations in the Iguaçu River. A total of 408 taxa were identified, with Bacillariophyceae being the most strongly represented group. A large differentiation in the composition of the phytoplankton was observed between the sampling stations. The total richness and density of the phytoplankton groups was very low in both sample locations, as well as the Shannon diversity index, but the evenness value was generally high. No significant seasonal and spatial difference in the studied features of the phytoplankton community was seen. But, significant seasonal differences were observed when the density and richness of the algae classes were assessed separately. The heterogeneity of the Iguaçu River's characteristics between the sampling sites caused no significant spatial differentiation in the features of the phytoplankton community. However, the seasonal variation of the climatic conditions has significantly influenced the composition and structure of the community in the Iguaçu River.

5-Lipoxygenase deficiency impairs innate and adaptive immune responses during fungal infection

5-lipoxygenase-derived products have been implicated in both the inhibition and promotion of chronic infection. Here, we sought to investigate the roles of endogenous 5-lipoxygenase products and exogenous leukotrienes during Histoplasma capsulatum infection in vivo and in vitro. 5-LO deficiency led to increased lung CFU, decreased nitric oxide production and a deficient primary immune response during active fungal infection. Moreover, H. capsulatum-infected 5-LO^−/− mice showed an intense influx of neutrophils and an impaired ability to generate and recruit effector T cells to the lung. The fungal susceptibility of 5-LO^−/− mice correlated with a lower rate of macrophage ingestion of IgG-H. capsulatum relative to WT macrophages. Conversely, exogenous LTB4 and LTC4 restored macrophage phagocytosis in 5-LO deficient mice. Our results demonstrate that leukotrienes are required to control chronic fungal infection by amplifying both the innate and adaptive immune response during histoplasmosis.

Delays in seeking treatment for symptomatic tuberculosis in Sabah, East Malaysia: factors for patient delay

SETTING

The state of Sabah contributes one third of the tuberculosis (TB) cases in Malaysia.

OBJECTIVE

To collect information on factors that affect the time period from the onset of symptoms to first contact with health care providers, whether private or government.

DESIGN

A cross-sectional study using a pre-tested questionnaire was conducted among 296 newly registered smear-positive TB patients in 10 districts in Sabah. Univariable and multivariable analyses were used to determine which risk factors were associated with patient delay (>30 days) and 'extreme' patient delay (>90 days).

RESULTS

The percentage of patients who sought treatment after 30 and 90 days was respectively 51.8% (95%CI 45.7-57.9) and 23.5% (95%CI 18.6-29.0). The strongest factors associated with patient delay and 'extreme' patient delay was when the first choice for treatment was a non-government health facility and in 30-39-year-olds. 'Extreme' patient delay was also weakly associated, among other factors, with comorbidity and livestock ownership.

CONCLUSION

Delay and extreme delay in seeking treatment were more common when the usual first treatment choice was a non-government health facility. Continuous health education on TB aimed at raising awareness and correcting misconceptions is needed, particularly among those who use non-government facilities.

Li(+)- and Eu(³+)-doped poly(ε-caprolactone)/siloxane biohybrid electrolytes for electrochromic devices

The sol-gel process has been successfully combined with the "mixed cation" effect to produce novel luminescent and ion conducting biohybrids composed of a diurethane cross-linked poly(ε-caprolactone) (PCL530)/siloxane hybrid network (PCL stands for the poly(ε-caprolactone) biopolymer and 530 is the average molecular weight in gmol(-1)) doped with a wide range of concentrations of lithium and europium triflates (LiCF(3)SO(3) and Eu(CF(3)SO(3))(3), respectively) (molar ratio of ca. 50:50). The hybrid samples are all semicrystalline: whereas at n = 52.6 and 27.0 (n, composition, corresponds to the number of (C(═O)(CH(2))(5)O) repeat units of PCL(530) per mixture of Li(+) and Eu(3+) ions) a minor proportion of crystalline PCL(530) chains is present, at n = 6.1, a new crystalline phase emerges. The latter electrolyte is thermally stable up to 220 °C and exhibits the highest conductivity over the entire range of temperatures studied (3.7 × 10(-7) and 1.71 × 10(-4) S cm(-1) at 20 and 102 °C, respectively). According to infrared spectroscopic data, major modifications occur in terms of hydrogen bonding interactions at this composition. The electrochemical stability domain of the biohybrid sample with n = 27 spans more than 7 V versus Li/Li(+). This sample is a room temperature white light emitter. Its emission color can be easily tuned across the Commission Internationale d'Éclairage (CIE) chromaticity diagram upon simply changing the excitation wavelength. Preliminary tests performed with a prototype electrochromic device (ECD) comprising the sample with n = 6.1 as electrolyte and WO(3) as cathodically coloring layer are extremely encouraging. The device exhibits switching time around 50 s, an optical density change of 0.15, good open circuit memory under atmospheric conditions (ca. 1 month) and high coloration efficiency (577 cm(2) C(-1) in the second cycle).

Long-term periodic anthelmintic treatments are associated with increased allergen skin reactivity

Background

The low prevalence of allergic disease in the rural tropics has been attributed to the protective effects of chronic helminth infections. There is concern that treatment-based control programmes for these parasites may lead to an increase in the prevalence of allergic diseases.

Objective

We measured the impact of 15–17 years of anthelmintic treatment with ivermectin on the prevalence of allergen skin test reactivity and allergic symptoms in school-age children.

Methods

The prevalence of allergen skin test reactivity, exercise-induced bronchospasm and allergic symptoms was compared between school-age children living in communities that had received community-based treatments with ivermectin (for onchocerciasis control) for a period of 15–17 years with those living in geographically adjacent communities that had received no ivermectin.

Results

The prevalence of allergen skin test reactivity was double in children living in treated communities compared with those in untreated communities (16.7% vs. 8.7%, adjusted OR 2.10, 95% CI 1.50–2.94, P<0.0001), and the effect was mediated partly by a reduced prevalence of Trichuris trichiura among treated children. Ivermectin treatments were associated with an increased prevalence of recent eczema symptoms (adjusted OR 2.24, 95% CI 1.05–4.78, P=0.04) but not symptoms of asthma or rhino-conjunctivitis. The effect on eczema symptoms was not associated with reductions in geohelminth infections.

Conclusion

Long-term periodic treatments with ivermectin were associated with an increased prevalence of allergen skin test reactivity. There was some evidence that treatment was associated with an increased prevalence of recent eczema symptoms but not those of asthma or rhino-conjunctivitis.

Cite this as: P. Endara, M. Vaca, M. E. Chico, S. Erazo, G. Oviedo, I. Quinzo, A. Rodriguez R. Lovato, A.-L. Moncayo, M. L. Barreto, L. C. Rodrigues and P. J. Cooper, Clinical & Experimental Allergy, 2010 (40) 1669–1677.

Interannual variability of phytoplankton in the main rivers of the Upper Paraná River floodplain, Brazil: influence of upstream reservoirs

The interannual variation of phytoplankton communities in the three main rivers of the Upper Paraná River floodplain is evaluated in relation to changes in the hydrosedimentological regime. These changes are a result of climatic variability and the formation of Porto Primavera Reservoir, located at the upper Paraná River. Phytoplankton species richness and density were investigated in rivers during a prior period (1993-1994) and eight years after reservoir impoundment (2000-2007). Multiple analyses were conducted to test the differences between these time periods in order to find predictor variables for phytoplankton attributes. A total of 454 phytoplanktonic taxa were found. The regression analysis revealed significant differences between periods. In the years following construction of the Porto Primavera dam, species richness was lower in the Paraná River and density was higher in the three rivers. In general, the algal density decreased from 2005 to 2007. Diatoms and cyanobacteria contributed significantly to the total density during the period from March 1993 to February 1994. The years 2000-2007 presented the lowest diatom contribution to species richness and the highest cyanobacteria contribution. From 2000 on, cryptomonads and cyanobacteria dominated. The interannual variability of phytoplankton was probably influenced by changes in hydrosedimentological regime due to climatic variations (La Niña and El Niño-Southern Oscillation events--ENSO) and the operational procedures associated with an upstream reservoirs. Studies on climatic variability and its effects on hydrosedimentological regimes of the Paraná, Baía and Ivinhema rivers and the biota therein are necessary to obtain subsidies for management, including decisions related to the operation of dams upstream and downstream of the study area, with the purpose of minimizing risks to the Environmental Protection Area.

Relatedness and HLA-DRB1 typing may discriminate the magnitude of the genetic susceptibility to tuberculosis using a household contact model

BACKGROUND

Tuberculosis clusters in families may be due to increased household exposure, shared genetic factors, or both. Household contact studies are useful to control exposure because socioeconomic and environmental conditions are similar to all subjects, allowing the evaluation of the contribution of relatedness to disease development.

METHODS

In this study, the familial aggregation of tuberculosis using relatedness and a specific inherited marker (HLA-DRB1) was evaluated. Fifty families, which had at least two cases of tuberculosis diagnosed within the past 5 years, were selected from a cohort of tuberculosis carried out in Recife, Brazil. The first case diagnosed was considered to be a primary case. The secondary attack rate of tuberculosis in household contacts was estimated according to the degree of relatedness. The relative risk of having tuberculosis based on the degree of relatedness household and the population attributable fraction to relatedness were also estimated. HLA-DRB1 typing and attributable etiologic/preventive fractions were calculated among sick and healthy household contacts.

RESULTS

Compared to unrelated contacts, the relative risk for tuberculosis adjusted for age was 1.38 (95% CI 0.86 to 2.21). Relatedness contributed 23% to the development of tuberculosis at the population levels. The HLA-DRB1*04 allele group (OR=2.44; p=0.0324; etiologic fraction=0.15) was overrepresented and the DRB1*15 allele group (OR=0.48; p=0.0488; protective fraction=0.19) was underrepresented among household contacts exhibiting tuberculosis. The presence of DRB1 shared alleles between primary cases and their contacts was a risk factor for tuberculosis (p=0.0281).

CONCLUSION

This household contact model together with the utilisation of two genetic variables permitted the evaluation of genetic factors contributing towards tuberculosis development.

Rapid reduction in hospitalisations after an intervention to manage severe asthma

Asthma is the third cause of hospitalisations due to clinical illnesses in Brazil. The Programme for Control of Asthma in Bahia (ProAR) leads an initiative in Salvador City (Brazil) to manage severe asthma for free. The aim of this study was to identify trends in asthma hospitalisation in the entire city and to evaluate the impact of ProAR. Information on asthma hospitalisations from 1998 to 2006 was collected. We analysed trends in Salvador (2.8 million inhabitants) before and after ProAR, taking pneumonia and myocardial infarction into account for local comparison. As an external control we obtained information on asthma from Recife, which is the most comparable Brazilian city. In Salvador, asthma hospital admissions declined by 82.3% (1998-2006). A greater proportion of this reduction (74%) occurred after 2003, in parallel with the implementation of ProAR. The reduction in asthma admissions in Recife was smaller. The rates of hospitalisation in 2006 were 2.25 per 10,000 inhabitants in Salvador and 17.06 in Recife. In Salvador, we found an inverse correlation between the provision of medication for asthma and hospitalisation (-0.801; p<0.0001). A rapid reduction in asthma admissions in the entire city of Salvador was associated with ProAR, a public health intervention targeting severe asthma.

The economic impact of severe asthma to low-income families

BACKGROUND

To estimate the direct and indirect costs of severe asthma and the economic impact of its management to low-income families in Salvador, Brazil.

METHODS

One hundred and ninety-seven patients with severe asthma and referred to a state-funded asthma center providing free treatment were evaluated. At registration, they were asked about family cost-events in the previous year and had a baseline assessment of lung function, symptoms and quality of life. During the subsequent year, they were reassessed prospectively.

RESULTS

One hundred-eighty patients concluded a 12-month follow-up. Eighty-four percent were female patients, and the median family income was US$ 2955/year. Forty-seven percent of family members had lost their jobs because of asthma. Total cost of asthma management took 29% of family income. After proper treatment, asthma control scores improved by 50% and quality of life by 74%. The income of the families increased by US$ 711/year, as their members went back to work. The total cost of asthma to the families was reduced by a median US$ 789/family/year. Consequently, an annual surplus of US$ 1500/family became available.

CONCLUSIONS

Family costs of severe asthma consumed over one-fourth of the family income of the underprivileged population in a middle-income country. Adequate management brings major economic benefit to individuals and families.

Contact with armadillos increases the risk of leprosy in Brazil: a case control study

BACKGROUND

Mycobacterium leprae infection has recently been detected in wild armadillos in Brazil. Leprosy is still endemic in Brazil and although its transmission is mostly by person-to-person contact, many cases report no history of previously known leprosy contact. It has been suggested that other sources of M. leprae may contribute to the transmission of leprosy in some areas.

AIM

Our objective was to investigate whether contact with armadillos is associated with leprosy.

METHODS

A case-control study was carried out in Brazil. Data was collected from 506 leprosy patients and 594 controls on exposure to armadillos and age, sex, place of birth and living conditions. Univariate analysis and unconditional logistic regression were conducted to investigate whether leprosy was associated with exposure to armadillos.

RESULTS

Direct armadillo exposure was reported by 68% of leprosy cases and by 48% of controls (P < 0.001) roughly doubling the risk of leprosy, with odds ratio (OR) 2.0, 95% confidence interval (CI) [1.36-2.99].

CONCLUSION

The results of this study suggest that direct exposure to armadillos is a risk factor for leprosy in Brazil.

Asthma in Latin America: a public heath challenge and research opportunity

Asthma has emerged as an important public health problem in many Latin American countries over the past decade. In Brazil and Costa Rica, the prevalence of asthma and associated morbidity is as great or greater as reported in traditional high prevalence countries such as the US, but remains neglected as a public health priority. Asthma in Latin America is associated particularly with underprivileged populations living in cities but remains relatively rare in many rural populations. The causes of asthma in Latin America are likely to be associated with urbanization, migration, and the adoption of a modern 'Westernized' lifestyle and environmental changes that follow these processes that include changes in diet, physical activity, hygiene, and exposures to allergens, irritants, and outdoor and indoor pollutants. Because of the enormous social, genetic, and environmental contrasts within and between Latin American countries, and the large differences in prevalence associated with these differences, the investigation of asthma in Latin America provides important research opportunities to identify the social and biological mechanisms that underlie asthma development. Asthma in Latin America poses enormous challenges for health policy makers, health services, and researchers to respond to and alleviate the growing burden of asthma disability, particularly among marginalized urban populations.

Modelling heterogeneity and the impact of chemotherapy and vaccination against human hookworm

There is a growing emphasis on the development of vaccines against helminths (worms), and mathematical models provide a useful tool to assess the impact of new vaccines under a range of scenarios. The present study describes a stochastic individual-based model to assess the relative impact of chemotherapy and vaccination against human hookworm infection and investigates the implications of potential correlations between risk of infection and vaccine efficacy. Vaccination is simulated as a reduction in susceptibility to infection and the model includes population heterogeneities and dynamical waning of protection. To help identify appropriate measures of vaccine impact, we present a novel framework to quantify the vaccine impact on the infection-associated morbidity and introduce a measure of symmetry to study the correspondence between reduction in intensity and reduction in morbidity. Our modelling shows that, in high-transmission settings, the greatest impact of vaccination will be attained when vaccine efficacy is the greatest among individuals harbouring the heaviest worm burdens, and that the decline of morbidity primarily depends on the level of protection attained in the most at risk 8-12% of the population. We also demonstrate that if risk of infection and vaccine protection are correlated, there is not always a direct correspondence between the reduction in worm burden and in morbidity, with the precise relationship varying according to transmission setting.

Sexual behaviour and HIV/sexually transmitted infection risk behaviours in the general population of Slovenia, a low HIV prevalence country in central Europe

Objectives:

To describe sexual and HIV/sexually transmitted infection (STI) risk behaviours in Slovenia.

Methods:

A nationally representative cross-sectional survey of the general population aged 18–49 years in 1999–2001 was conducted. The data were collected by face-to-face interviews and anonymous self-administered questionnaires. Statistical methods for complex survey data were used.

Results:

849 men and 903 women were interviewed. In the past 5 years, both men and women reported a median of one heterosexual partner (means 3.2, 1.5, respectively), concurrent heterosexual partnerships were reported by 24.4% of men and 8.2% of women, heterosexual sex with non-Slovenian partners by 12.6% of men and 12.2% of women, forced sex by 4.8% of women, paid heterosexual sex by 2.6% of men, sex with another man by 0.6% of men and heterosexual sex with an injecting drug user by 1.2% of men and 1.3% of women. In the past year, 22.7% of men and 9.5% of women reported forming at least one new heterosexual partnership. The mean numbers of episodes of heterosexual sex in the previous 4 weeks were 6.1 for men and 6.0 for women. Consistent and inconsistent condom use was reported more frequently among men reporting multiple female partners and those not married or cohabiting.

Conclusions:

Recent patterns of reported sexual behaviour are consistent with a low risk of HIV and STI transmission in Slovenia. The results will inform Slovenian sexual health policies including HIV/STI prevention, and are particularly valuable because population-based data on HIV/STI risk behaviour have not previously been available in low HIV prevalence countries of central Europe.

Early infection with Trichuris trichiura and allergen skin test reactivity in later childhood

BACKGROUND

Allergic diseases cause a large and increasing burden in developed countries and in urban centres in middle-income countries. The causes of this increase are unknown and, currently, there are no interventions to prevent the development of allergic diseases. The 'hygiene hypothesis' has tried to explain the increase through a reduction in the frequency of childhood infections causing a failure to program the immune system for adequate immune regulation. Intestinal helminth parasites are prevalent in childhood in developing countries and are associated with a lower prevalence of allergen skin test reactivity and asthma.

OBJECTIVES

To investigate whether children who had intestinal helminth infections during early childhood have a lower prevalence of allergen skin test reactivity later in childhood.

METHODS

We re-visited a population of 1055 children from whom stool samples had been collected for detection of intestinal helminth infections for another study, and collected new stool samples and performed allergen skin prick testing. Information on potential confounding variables was collected.

RESULTS

Children with heavy infections with Trichuris trichiura in early childhood had a significantly reduced prevalence of allergen skin test reactivity in later childhood, even in the absence of T. trichiura infection at the time of skin testing in later childhood.

CONCLUSION

Early heavy infections with T. trichiura may protect against the development of allergen skin test reactivity in later childhood. Novel treatments to program immune-regulation in early childhood in a way that mimics the effects of early infections with T. trichiura may offer new strategies for the prevention of allergic disease.

Antiretroviral agents and acid-base balance at delivery of the neonate

Limited evidence is available regarding antiretroviral (ARV) safety for uninfected infants exposed to these drugs in utero. Our objective was to determine if ARV administered to pregnant women is associated with decreasing umbilical arterial pH and base excess in uninfected infants. A prospective study was conducted on 57 neonates divided into three groups: ZDV group, born to mothers taking zidovudine (N = 20), triple therapy (TT) group, born to mothers taking zidovudine + lamivudine + nelfinavir (N = 25), and control group (N = 12), born to uninfected mothers. Umbilical cord blood was used to determine umbilical artery gases. A test was performed to calculate the sample by comparing means by the unpaired one-tailed t-test, with alpha = 0.05 and beta = 20%, indicating the need for a sample of 18 newborn infants for the study groups to detect differences higher than 20%. The control and ARV groups were similar in gestational age, birth weight, and Apgar scores. Values of pH, pCO2, bicarbonate, and base excess in cord arterial blood obtained at delivery from the newborns exposed to TT were 7.23, 43.2 mmHg, 19.5 mEq/L, and -8.5 nmol/L, respectively, with no significant difference compared to the control and ZDV groups. We conclude that intrauterine exposure to ARV is not associated with a pathological decrease in umbilical arterial pH or base excess. While our data are reassuring, follow-up is still limited and needs to be continued into adulthood because of the possible potential for adverse effects of triple antiretroviral agents.

Factors associated with early sexual debut in Slovenia: results of a general population survey

OBJECTIVES

To investigate time trends in age at first heterosexual intercourse (FHI) and associated factors.

METHODS

Data were collected from a national probability sample of the general population aged 18-49 years.

RESULTS

Median age at FHI was 17 years for men and 18 years for women, but declined from 18 years to 17 years in men born after the early 1960s and in women born after the early 1970s. Early FHI (before age 16) was reported by 15.2% of men and 7.4% of women, but in recent cohorts (born 1975-82), proportions were similar in both sexes (16.9% and 14.4%, respectively). In women, higher educational level and acquiring most knowledge about sex from parents or in school were associated with later age at FHI. Half the women with early FHI judged the event to have occurred too soon. 4.2% of women with early FHI reported coercion at FHI, compared to 0.9% overall. The main factor associated with early FHI in men was not living with both parents up to the age of 15. Individuals with early FHI were more likely to report higher risk sexual behaviour as well as teenage motherhood and, for men, not having used a condom at FHI and bacterial sexually transmitted infections. Three in four individuals with early FHI thought they had inadequate sexual knowledge at FHI. Many would have liked to have learned more from parents and in school.

CONCLUSIONS

Improved sexual education among young Slovenians should aim to delay FHI until a more mature age and to be better prepared for safer sex.

A case-control study of protection against tuberculosis by BCG revaccination in Recife, Brazil

SETTING

Metropolitan region of Recife, Brazil.

OBJECTIVE

To estimate the additional protection against tuberculosis (TB) provided by a second dose of bacille Calmette-Guérin (BCG) vaccine.

DESIGN

Case-control study. Cases were cases of TB newly diagnosed by the TB control programme, independent of clinical form. Three matched neighbourhood controls were selected using a systematic routine, starting from the case's address. The matching was within the age groups 7-9, 10-14 and 15-19 years.

RESULTS

Analysis was conducted among 169 cases and 477 controls. For the efficacy of BCG revaccination against TB overall, matched (crude) vaccine effectiveness (VE) was -3 (95% CI -50-29) and matched (adjusted) VE was 8 (95% CI -77-52).

CONCLUSIONS

This study suggests that a second dose of BCG does not offer additional protection. Revaccination should not be offered. As large numbers of subjects are already vaccinated and vaccine appears to offer some protection in older subjects, further studies with larger sample sizes could investigate the potential efficacy of revaccination with BCG in the age group > or = 15 years.

How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study

AIMS

To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation.

METHODS

Case-control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls).

RESULTS

After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged > or = 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped.

CONCLUSIONS

Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households.

Temperature dependence of reported Campylobacter infection in England, 1989-1999

Campylobacter is the most common bacterial cause of gastroenteritis in England and Wales, with 45000 cases reported annually. Campylobacter incidence is highly seasonal; the consistent peak in late spring suggests a role for meteorological factors in the epidemiology of this organism. We investigated the relationship between ambient temperature and Campylobacter enteritis using time-series analysis to study short-term associations between temperature and number of Campylobacter reports adjusted for longer-term trend and seasonal patterns. We found a linear relationship between mean weekly temperature and reported Campylobacter enteritis, with a 1 degrees C rise corresponding to a 5% increase in the number of reports up to a threshold of 14 degrees C. There was no relationship outside this temperature range. Our findings provide evidence that ambient temperature influences Campylobacter incidence, and suggest that its effect is likely to be indirect, acting through other intermediate pathways.

Human allergy and geohelminth infections: a review of the literature and a proposed conceptual model to guide the investigation of possible causal associations

Geohelminth infections and allergic disease are major public health problems and there is evidence in developing countries that they are associated. Although there is an extensive literature of the relationship between geohelminth infections and allergy, there is little consensus on whether the association is causal and if so, whether geohelminth infections may increase or decrease the risk of allergy. An explanation for the conflicting findings of epidemiological studies is that geohelminths decrease the risk of allergy in areas of high infection prevalence and increase the risk of allergy in areas of low prevalence. Chronic geohelminth infections are inversely associated with allergy and anthelmintic treatment may increase the prevalence of allergy. In this paper, we review studies that have investigated the relationship between geohelminths and allergy; discuss the relevance of prevalence and timing of geohelminth infections and propose a conceptual model to define relevant scientific questions in future human and animal studies.

Neonatal BCG protection against tuberculosis lasts for 20 years in Brazil

Bacille Calmette-Guérin (BCG) efficacy against pulmonary disease is highly variable; until very recently there was no evidence of protection after 10 years. In the control arm of a trial of efficacy of revaccination of schoolchildren in Brazil we found substantial protection (39%; 95%CI 9-58) of neonatal BCG against all forms of tuberculosis (TB) 15-20 years after vaccination, much longer than previously believed. This confirms recent findings from an earlier trial, and must be considered in the design of trials of new TB vaccines and in policy decisions based on assumed lack of neonatal BCG protection with time.

Lower prevalence of reported asthma in adolescents with symptoms of rhinitis that received neonatal BCG

BACKGROUND

BCG is a vaccine used against tuberculosis and leprosy and is an immunostimulant that primes T(H)1 lymphocytes to produce cytokines that antagonize atopy both in animal models and in man. Considering that atopy is the main risk factor for asthma, one can hypothesize that vaccination inducing T(H)1 responses, such as BCG, can be protective against asthma.

METHODS

OBJECTIVE

To estimate the association between neonatal BCG vaccination and prevalence of asthma among adolescents.

STUDY DESIGN

Cross-sectional study with schoolchildren aged 12-16 years. The presence of a scar compatible with BCG was used as a surrogate of neonatal vaccination. A self administered structured questionnaire was prepared based on that used by the International Study of Asthma and Allergies in Childhood. The prevalence of asthma was categorized according to the report of lifetime wheeze, lifetime asthma, lifetime asthma among those referring allergy and among those referring allergy and sneezing.

RESULTS

Neonatal BCG vaccination was not associated with the overall prevalence of reported wheezing or asthma. However, in the subgroup reporting current allergy and sneezing, neonatal BCG was associated with a 37% reduction of prevalence of lifetime asthma.

CONCLUSIONS

In the population we surveyed, neonatal BCG scar was associated with a reduction in the risk of asthma only in individuals with a past history suggestive of allergic rhinitis.

Risk factors for atopy among school children in a rural area of Latin America

BACKGROUND

Infection with common childhood infectious diseases including geohelminth infections may provide protection against the development of atopy and allergic disease. Few studies have investigated risk factors for atopy among children living in rural areas of Latin America.

OBJECTIVE

To identify risk factors associated with atopy among school-age children in a rural area of Latin America.

METHODS

Analytic cross-sectional study of school-age children conducted in seven rural schools in Pichincha Province in Ecuador. Detailed risk factor information was obtained by questionnaire, stool samples were collected for identification of geohelminth parasites, and Mantoux testing was performed to determine tuberculin sensitization.

RESULTS

A total of 1002 children from seven rural schools were recruited. The prevalence of geohelminth infections was high (70.1% were infected with at least one geohelminth parasite) and the prevalence of allergic sensitization was high (20.0% had evidence of aeroallergen sensitization). Factors associated with significant protection against atopy in multivariate analyses were the presence of overcrowding in the child's home, low socio-economic level, and infection with geohelminth parasites, and the protective effects of the three factors were statistically independent.

CONCLUSION

Low socio-economic level, overcrowding and geohelminth infection, are independently protective against atopy among school-age children living in a rural area of Latin America.

Prevalence of genital Chlamydia trachomatis infection in the general population of Slovenia: serious gaps in control

OBJECTIVES

One of the objectives of the first national survey of sexual lifestyles, attitudes, and health in Slovenia was to estimate the prevalence of and risk factors for genital Chlamydia trachomatis infection in Slovenian adults aged 18-49 years.

METHODS

Data were collected over 1999-2001 from a probability sample of the general population by face to face interviews and anonymous self administered questionnaires. Respondents were invited to provide a first void urine (FVU) specimen for polymerase chain reaction testing for C trachomatis infection. We compared the results to the equivalent British survey.

RESULTS

1447 individuals contributed FVU specimens (82.6% of survey respondents, 55.3% of those eligible). C trachomatis infection was diagnosed in 3.0% of men and 1.6% of women. Prevalence was highest in men and women aged 18-24 years (4.1% for both). Individuals reporting first heterosexual intercourse before the age of 16, unprotected sexual intercourse with at least one heterosexual partner during the preceding year, concurrent heterosexual relationships during the preceding year, and five or more lifetime heterosexual partners had a higher prevalence. The association was statistically significant only for five or more lifetime partners (adjusted OR 3.0; 95% CI 1.3 to 6.9; p = 0.01).

CONCLUSIONS

A relatively high prevalence of genital C trachomatis infection among 18-24 year old Slovenians, in the presence of relatively low risk sexual behaviour and low reported incidence rates of chlamydia infection, suggest serious gaps in the diagnosis and treatment of the condition. The results provide support for the introduction of chlamydia screening in Slovenia.

Antibiotic use and the development of Crohn's disease

BACKGROUND

Few environmental determinants of Crohn's disease are well established. Some observational data exist to implicate antibiotic use as a risk factor but these are derived from studies using questionnaires to assess reported antibiotic use that were susceptible to recall bias. We have therefore explored this relationship in prospectively gathered data.

METHODS

We selected incident cases of Crohn's disease from the General Practice Research Database with at least five years of data prior to diagnosis. Controls with five years of complete data were randomly selected. Data were extracted on smoking, drug prescriptions, age, sex, and a variety of symptoms and diagnoses that might be indicative of occult Crohn's disease. Logistic regression was used to investigate the relationship between antibiotic use and Crohn's disease.

RESULTS

A total of 587 Crohn's disease cases and 1460 controls were available for analysis. We found that antibiotic use 2-5 years pre-diagnosis occurred in 71% of cases compared with 58% of controls (p<0.001), and the median number of courses was two in the cases and one in the controls (p<0.001). Adjusting for age, sex, smoking, and use of other drugs, antibiotic use had an odds ratio of 1.32 (1.05-1.65). We were unable to show specificity to any subgroup of antibacterials. Associations similar to that with antibiotics were also found with oral contraceptive, cardiovascular, and neurological drugs.

CONCLUSIONS

We found a statistically significant association between Crohn's disease and prior antibiotic use. This cannot be explained by recall bias, but due to lack of specificity it is unclear whether it is causal.

The infectious intestinal disease study of England: a prospective evaluation of symptoms and health care use after an acute episode

The sequelae of Infectious Intestinal Disease (IID) in a population-based sample of cases and matched controls were investigated for a period of 3 months following the initial infection. Incident cases of IID presenting to GPs or occurring in the community and controls were studied at 3 weeks and over a 3-month follow-up period. Cases were six times more likely than controls to have gastrointestinal symptoms, particularly diarrhoea, at 3 weeks. Ten per cent of cases consulted their GP in the 3 months after episode and 2.3% were referred to hospital. GP presentation rates were twice as high in cases. Gastrointestinal symptoms persist after IID, leading to an increased likelihood of GP consultation and hospital referral. Diagnosis of irritable bowel syndrome may be more likely following IID. The burden of IID is likely to be considerable given its high incidence and the frequency of such sequelae.

Rates of adverse reactions to first and second doses of BCG vaccination: results of a large community trial in Brazilian schoolchildren

OBJECTIVE

To evaluate the incidence of adverse reactions to first and second bacille Calmette-Guérin (BCG) vaccination in schoolchildren.

SETTING AND DESIGN

Enhanced surveillance in a Brazilian trial. Suspected reactions were reported to a nurse who visited cases and completed a standard form.

RESULTS

Among 71341 schoolchildren studied, 33 reactions were reported. Of these, 25 fulfilled the criteria, resulting in a rate of one per 2854 vaccinations, with no deaths or BCG-osis. Reactions to second doses were more common than to first BCG vaccinations, but this difference was not statistically significant.

CONCLUSIONS

Adverse reactions to a second dose of BCG may be more frequent than reactions to a first dose, but they are still rare events.