The relationship between maternal and child bone density in Nigerian children with and without nutritional rickets

We found a positive relationship between bone density in Nigerian children with and without rickets and that of their mothers. After treatment, children with rickets had greater bone density than children without rickets, indicating that children genetically programmed to have greater bone density may have a higher risk of rickets.

INTRODUCTION

To determine the relationship between bone density in children with and without rickets and that of their mothers METHODS: Using an unmatched case-control design, forearm areal bone mineral density (aBMD) was measured in 52 and 135 Nigerian children with and without rickets and their mothers, respectively. We performed multivariate linear regression analyses to assess the relationship between maternal and child aBMD Z-scores.

RESULTS

Forearm aBMD Z-scores in children were associated with maternal aBMD Z-scores at metaphyseal (effect estimate 0.23; 95% CI 0.08 to 0.37) and diaphyseal (effect estimate 0.16; 0.01 to 0.30) sites, after adjustment for rickets in the child, child's age and sex, height-for-age Z-score, and weight-for-age Z-score. In the adjusted model, rickets was inversely associated with child's aBMD Z-score at the diaphyseal site only (- 0.45, - 0.65 to - 0.24). The positive relationship between maternal and child aBMD Z-scores was marginally greater in children with rickets (slope 0.56, r = 0.47) than without rickets (slope 0.19, r = 0.20) at the diaphyseal site only (P = 0.06 for interaction) but not at the metaphyseal site (slopes 0.35 and 0.30, respectively, P = 0.48). After treatment with calcium for 6 months, metaphyseal aBMD Z-scores were greater in children with treated rickets (effect estimate 0.26; 95% CI 0.02 to 0.49) than in those without rickets.

CONCLUSION

In Nigerian children with and without rickets, forearm aBMD Z-scores were positively associated with maternal aBMD Z-scores. Active rickets in the child marginally modified the relationship at the diaphyseal site only. After treatment, children with rickets had greater metaphyseal aBMD Z-scores than children without rickets.

Sex differences in fitness and cardiac function during exercise in adolescents with chronic fatigue

Females demonstrate less robust Frank-Starling mechanism with respect to cardiac preload than males at rest. We asked whether this phenomenon would also affect cardiac performance during exercise. We hypothesized that stroke volume (SV) response to exercise would be more limited in deconditioned females such that cardiac output would be mainly rate dependent, compared with males. We conducted a chart audit of clinical exercise tests performed by adolescents with chronic fatigue. Oxygen uptake (V˙O2) was measured breath-by-breath at rest and during cycle ergometry, while cardiac output was measured by acetylene rebreathing at rest plus 2-3 subthreshold workloads. SV response was analyzed in two ways: after normalization for body surface area (SV index, SVI) and as percentage change from resting values. Among 304 adolescents (78% females) with chronic fatigue, 189 (80%) of 236 females and 52 (76%) of 68 males were deconditioned (peakV˙O₂ <90% predicted). Heart rate trajectory during exercise was steeper for unfit than fit females, 70 vs 61 beat·min^-1 per L·min^-1 V˙O2, (P=.003); but not for males, 47 vs 42 beat·min^-1 per L·min^-1 V˙O2 (P=.23). The highest measured SVI did not differ between unfit vs fit females (42.8 vs 41.5 mL·m^-2 , P=.39) while fit males showed larger SV during exercise than their unfit peers (highest SVI 55.9 vs 48.0 mL·m^-2 , P=.014). Both qualitative and quantitative sex differences exist in SV responses to exercise among chronically fatigued adolescents, suggesting volume loading may be more efficacious in girls.

Pharmacokinetics of daily versus monthly vitamin D3 supplementation in non-lactating women

This study compared serum cholecalciferol and 25-hydroxyvitamin D (25(OH)D) concentrations over four weeks in healthy, non-pregnant, non-lactating females aged 18-40 years, who were randomized to oral cholecalciferol 5000 international units (IU) daily for 28 days or a single dose of 150 000 IU. The study was conducted in Rochester, MN in March and April of 2010. We found no difference in mean 25(OH)D between treatment groups on study day 0 or day 28 (P=0.14 and 0.28, respectively). The daily group had 11 more days of detectable serum cholecalciferol than the single-dose group (P<0.001). There was no difference observed in cholecalciferol area under the curve (AUC28) between groups (P=0.49). However, the single-dose group had a significantly greater mean 25(OH)D AUC28 compared with the daily group (P<0.001).

The impact of maternal malaria on newborns

BACKGROUND

Each year, malaria threatens 125 million pregnancies, and gestational malaria is responsible for up to 200,000 infant deaths in sub-Saharan Africa. With advancing knowledge of malaria in pregnancy and its impact on newborns, improved preventive and therapeutic interventions are possible.

METHODS

We reviewed and, by consensus, evaluated published literature relevant to malaria and newborns. Important findings are summarised.

RESULTS

Pregnant women are more likely than others to be inoculated with and infected by malaria parasites. Poor outcomes are particularly common in primigravid women and their offspring. The placenta is affected through cellular adhesion, cytokine production and mononuclear cell infiltrates. As a result, newborns may have low birthweight owing to intrauterine growth retardation or prematurity. Recent evidence suggests that a subset of these infants is also at higher risk of malaria infections later in life. Preventive strategies to improve maternal and fetal outcomes include intermittent preventive treatment and insecticide-treated bed nets. Asymptomatic malaria infection is not uncommon in newborns, and symptomatic disease occurs. Fever and death are possible during the early days of life, and presentation with a sepsis-like illness can occur during the 1st 2 months of life. Malaria-affected infants face higher than usual risks of infantile anaemia, subsequent malaria infection and death during the 1st year of life.

CONCLUSIONS

Malaria is common during pregnancy and can have serious consequences for neonatal health. Neonatal morbidity and mortality can be significantly reduced by proper implementation of insecticide-treated nets and intermittent preventive treatment.

Big hopes for the children of the world: a review of the Millennium Development Goals

The Millennium Development Goals are a set of eight goals drafted by the United Nations in 2000 with the aim of improving the health and welfare of people worldwide. The goals provide specific targets to be met by 2015, using the 1990 basis as a standard. This review presents these goals as they relate to children, discussing progress and future aims. Although not all eight goals specifically address children, each has its own impact on global child health. Thus far, much progress has been made, but increased rates of improvement must be achieved in order to meet the goals by 2015 and improve the health of children worldwide.

Clinical and radiographic improvement of rickets in Bangladeshi children as a result of nutritional advice

BACKGROUND

Calcium-deficiency rickets is common in south-east Bangladesh and responds to calcium supplementation.

AIM

To evaluate the healing effect on active rickets of a five-component nutritional advice programme aimed at doubling dietary calcium intakes.

METHODS

Forty-nine children aged <10 years with mild lower limb deformities and active rickets were followed over a period of 12 months. All were provided with a five-component nutritional advice programme advocating (i) the routine addition of 1 g limestone/kg rice, (ii) consuming small fish (including bones) instead of large ones, and (iii) daily consumption of 5 g ground sesame seeds, (iv) 100 g leafy vegetables and, if possible, (v) 100 ml of milk.

RESULTS

Radiographic scores improved in 90% of children. The response was positively associated with age (r=0.34, n=48, p=0.01) and severity of radiographic score at baseline (r=0.85, n=49, p<0.0001).

CONCLUSIONS

Despite the lack of a statistically significant association between radiographic improvement and compliance with nutritional advice, in mild calcium-deficiency active rickets, nutritional advice may be a cost-effective treatment and possibly a valuable long-term solution to the problem.

Causes of lead toxicity in a Nigerian city

BACKGROUND

Up to 70% of young Nigerian children have been reported to have blood lead concentrations > or =10 microg/dl.

AIMS

To better elucidate risk factors for lead toxicity among Nigerian families with children at risk for lead toxicity.

METHODS

Two geographic wards in Jos, Nigeria were selected for study, one previously reported to have a high mean blood lead level (37 (SD 13) microg/dl) and one with a lower mean blood lead level (17 (SD 10) microg/dl) in young children. Data pertaining to potential risk factors for lead exposure were collected from children and adults in 34 households.

RESULTS

The mean (SD) blood lead concentration of 275 subjects, aged 3 weeks to 90 years, was 8.7 (5.7) microg/dl (range 1-34 microg/dl); 92 (34%) had concentrations > or =10 microg/dl. In multivariate analysis, an age of 5 years and under, flaking house paint, residence near a gasoline seller, male gender, increasing maternal and paternal education, and use of a lead ore eye cosmetic were independently associated with greater blood lead concentration. Vehicle ownership was associated with reduced lead concentration. Compared with the low-lead ward, residence in the high-lead ward remained significantly associated with greater lead values, indicating that additional factors likely contribute to lead exposure.

CONCLUSION

Although the cause of increased lead levels in Jos appears to be multi-factorial, several remediable sources contribute to lead exposure in Nigeria.

The sick placenta-the role of malaria

The human placenta is an ideal site for the accumulation of Plasmodium falciparum malaria parasites, and as a consequence serious health problems arise for the mother and her baby. The pathogenesis of placental malaria is only partially understood, but it is clear that it leads to a distinct epidemiological pattern of malaria during pregnancy. The objectives of this review are: (1) To review recent data on the epidemiology of malaria in pregnancy, with emphasis on placental malaria; (2) to describe the pathological changes and immunological factors related to placental malaria; and (3) to discuss briefly the functional consequences of this infection for the mother and her baby. The review attempts to bring together local events at the maternal-fetal interface which encompass immunological and pathological processes which relate to the epidemiological pattern of malaria in pregnancy in areas of both high and low malaria transmission. An integrated understanding of the epidemiological, immunological and pathological processes must be achieved in order to understand how to control malaria in pregnancy. The yearly exposure of at least 50 million pregnancies to malaria infection makes it the commonest and most recurrent parasitic infection directly affecting the placenta. These statistics and our limited understanding of its pathogenesis suggest the research priorities on this subject.

Vitamin D receptor polymorphisms and nutritional rickets in Nigerian children

Nutritional rickets is common in Nigeria where vitamin D deficiency is rare and dietary insufficiency of calcium is common. It occurs more commonly in siblings of affected children than of unaffected children. Postulating that vitamin D receptor (VDR) polymorphisms might relate to the susceptibility of some Nigerian children to develop rickets in the setting of low calcium intake, we compared the VDR genotypes, as determined by the presence or absence of Bsm I, Apa I, Taq I, and Fok I restriction enzyme cleavage sites, between 105 children with active nutritional rickets and 94 subjects representative of the community from which the rachitic children came. In the rickets group, the ff genotype was less common than in the community group, and the FF genotype was relatively increased (f allele frequency, 17% in rachitic children and 26% in the community group, p = 0.03). Neither individual allele frequencies for the other polymorphisms nor combinations of genotypes at different sites were different between the rachitic and community groups. Although it is not clear why a presumed better-functioning VDR variant (F allele) is associated with an increased risk of developing rickets, this study raises the possibility that VDR alleles might be important in determining an individual's susceptibility to developing rickets when faced with dietary calcium deficiency.

Case-control study of factors associated with nutritional rickets in Nigerian children

OBJECTIVE

Because the causes of nutritional rickets in tropical countries are poorly understood, we conducted a case-control study to determine factors associated with rickets in Nigerian children.

STUDY DESIGN

We compared 123 Nigerian children who had rickets with matched control subjects. Dietary, demographic, anthropometric, and biochemical data were collected to assess factors related to calcium and vitamin D status, which might predispose children to rickets.

RESULTS

Mean (+/- SD) daily dietary calcium intake was low in both children with rickets and control children (217 +/- 88 mg and 214 +/- 77 mg, respectively; P =.64). Children with rickets had a greater proportion of first-degree relatives with a history of rickets (14.6% vs 3.1%; P <.001), a shorter mean duration of breast-feeding (16.0 vs 17.3 months; P =.041), and a delayed age of walking (14 vs 12 months; P <.001). Among children with rickets, biochemical features suggestive of calcium deficiency included hypocalcemia, extremely low calcium excretion, and elevated 1, 25-dihydroxyvitamin D and parathyroid hormone values. Median 25-hydroxyvitamin D concentrations were 32 and 50 nmol/L (13 and 20 ng/mL) in children with rickets and control children, respectively (P <.0001). Only 46 subjects with rickets (37%) had 25-hydroxyvitamin D values <30 nmol/L (12 ng/mL).

CONCLUSIONS

Vitamin D deficiency appears unlikely to be the primary etiologic factor of rickets in African children. Moreover, low dietary calcium intake alone does not account for rickets. Insufficient dietary calcium probably interacts with genetic, hormonal, and other nutritional factors to cause rickets in susceptible children.

Radiographic scoring method for the assessment of the severity of nutritional rickets

Radiographic changes of rickets are well characterized, but no method of grading the severity of these changes has been in general use. Consequently, it is difficult to compare objectively or follow radiographic improvement. We prospectively evaluated the utility and reproducibility of a scoring method for measuring the severity of rickets. A 10-point score for radiographs of wrists and knees was devised to assess the degree of metaphyseal fraying and cupping and the proportion of the growth plate affected. The score progresses in half point increments from zero (normal) to 10 points (severe). Four trained physicians independently scored radiographs on two separate occasions from 67 children with active rickets. A broad representation of mean radiographic scores was moderately correlated with alkaline phosphatase (r = 0.58). Interobserver correlation of radiographic scores was 0.84 or greater for all observer pairs and intraobserver correlation was 0.89 or greater for each observer. Researchers and clinicians should find the score useful to assess objectively the severity of rickets.

Nutritional rickets without vitamin D deficiency in Bangladesh

To understand nutritional rickets in Bangladesh better, 14 rachitic and 13 'unaffected' children were evaluated. Seventy per cent of children with active rickets had no evidence of either vitamin D deficiency or familial rickets. Rickets in Bangladesh is probably related to calcium deficiency. Abnormalities in 'unaffected' children suggest that subclinical calcium insufficiency is common.

A comparison of calcium, vitamin D, or both for nutritional rickets in Nigerian children

BACKGROUND

Nutritional rickets remains prevalent in many tropical countries despite the fact that such countries have ample sunlight. Some postulate that a deficiency of dietary calcium, rather than vitamin D, is often responsible for rickets after infancy.

METHODS

We enrolled 123 Nigerian children (median age, 46 months) with rickets in a randomized, double-blind, controlled trial of 24 weeks of treatment with vitamin D (600,000 U intramuscularly at enrollment and at 12 weeks), calcium (1000 mg daily), or a combination of vitamin D and calcium. We compared the calcium intake of the children at enrollment with that of control children without rickets who were matched for sex, age, and weight. We measured serum calcium and alkaline phosphatase and used a 10-point radiographic score to assess the response to treatment at 24 weeks.

RESULTS

The daily dietary calcium intake was low in the children with rickets and the control children (median, 203 mg and 196 mg, respectively; P=0.64). Treatment produced a smaller increase in the mean (+/-SD) serum calcium concentration in the vitamin D group (from 7.8+/-0.8 mg per deciliter [2.0+/-0.2 mmol per liter] at base line to 8.3+/-0.7 mg per deciliter [2.1+/-0.2 mmol per liter] at 24 weeks) than in the calcium group (from 7.5+/-0.8 [1.9+/-0.2 mmol per liter] to 9.0+/-0.6 mg per deciliter [2.2+/-0.2 mmol per liter], P<0.001) or the combination-therapy group (from 7.7+/-1.0 [1.9+/-0.25 mmol per liter] to 9.1+/-0.6 mg per deciliter [2.3+/-0.2 mmol per liter], P<0.001). A greater proportion of children in the calcium and combination-therapy groups than in the vitamin D group reached the combined end point of a serum alkaline phosphatase concentration of 350 U per liter or less and radiographic evidence of nearly complete healing of rickets (61 percent, 58 percent, and 19 percent, respectively; P<0.001).

CONCLUSIONS

Nigerian children with rickets have a low intake of calcium and have a better response to treatment with calcium alone or in combination with vitamin D than to treatment with vitamin D alone.

Pseudoephedrine and air travel-associated ear pain in children

BACKGROUND

Young children often appear bothered by ear pain during ascent and descent while traveling on commercial airplanes. While pseudoephedrine hydrochloride is effective in decreasing the risk for earache in adults with recurrent air travel-associated ear pain, such use in children has not been studied.

OBJECTIVE

To assess the efficacy and side effects of prophylactic pseudoephedrine in children traveling by air.

DESIGN

A placebo-controlled, double-blind clinical trial.

SUBJECTS AND METHODS

Children aged 6 months to 6 years were included in this study. Pseudoephedrine hydrochloride (1 mg/kg body weight) or placebo was administered 30 to 60 minutes prior to departure on commercial air flights. Caregivers noted historical details and the degree of apparent ear pain, drowsiness, and excitability with ascent and descent.

RESULTS

Ninety-one flights involving 50 children were studied, with ear pain being reported in 13 (14%) of flights. Ear pain was not associated with a history of air travel-associated ear pain, recent ear infection, or recent upper airway symptoms. Pseudoephedrine use was not associated with a decrease in ear pain during either ascent (4% with pseudoephedrine vs 5% with placebo; P approximately 1.00) or descent (12% with pseudoephedrine vs. 13% with placebo; P approximately 1.00). Pseudoephedrine use was, however, linked to drowsiness at takeoff (60% with pseudoephedrine vs. 27% with placebo; P = .003) but not at landing (P = .39). Treatment was not associated with excitability at takeoff (P = .09) or landing (P approximately 1.00).

CONCLUSIONS

Ear pain is not uncommon in children traveling by commercial aircraft. The predeparture use of pseudoephedrine does not decrease the risk for in-flight ear pain in children but is associated with drowsiness.

Absence of vitamin D deficiency in young Nigerian children

OBJECTIVE

To determine the prevalence of vitamin D deficiency in young Nigerian children residing in an area where nutritional rickets is common.

STUDY DESIGN

A randomized cluster sample of children aged 6 to 35 months in Jos, Nigeria.

RESULTS

Of 218 children evaluated, no child in the study had a 25-hydroxyvitamin D (25-OHD) concentration <10 ng/mL (the generally held definition of vitamin D deficiency). Children spent an average of 8.3 hours per day outside of the home. Twenty children (9.2%) had clinical findings of rickets. Children with clinical signs of rickets were more likely to be not currently breast fed and have significantly lower serum calcium concentrations than those without signs of rickets (9.1 vs 9.4 mg/dL, respectively, P =.01). Yet, 25-OHD levels were not significantly different between those children with clinical signs of rickets and those without such clinical signs.

CONCLUSION

Vitamin D deficiency was not found in this population of young children in whom clinical rickets is common. This is consistent with the hypothesis that dietary calcium insufficiency, without preexisting vitamin D deficiency, accounts for the development of clinical rickets in Nigerian children.

Travel with infants and children

The risks faced by children traveling internationally may be minimized by providing and applying advice about comfort, safety, skin protection, and food and water hygiene. Prior to travel, children should be current on standard immunizations and may receive several specialized vaccines. Antibiotics for the presumptive treatment of travelers' diarrhea are usually indicated, and malaria chemoprophylaxis may be safely administered even to young children. Evaluation and care following prolonged stays in foreign countries can decrease the burden of imported disease.

Short report: severe malaria associated with blood group

The ABO blood groups are not linked to the incidence of simple malaria infection but have been associated with rosette formation. In an effort to see if clinically severe malaria is associated with blood group, 489 patients were studied in Zimbabwe. Patients with malaria and group A blood had lower hemoglobin levels and more risk of coma than did infected patients with other blood groups. In this population, severe malaria is associated with blood group.

Congenital malaria: an African survey

Even in malaria-endemic areas, congenital malaria has been considered to be rare. Some recent reports suggest, however, that up to one fourth of newborns in some areas may be parasitemic. In an effort to determine current prevalence rates of congenital malaria, malaria smears were done on peripheral blood from 100 peripartum mothers and on cord blood from their offspring at each of seven sites spanning sub-Saharan Africa. The prevalence rate of maternal parasitemia was 15% overall and varied from 4% to 30% at the different sites. Congenital malarial infection was found in 7% of newborns, the prevalence rate varying from 0% to 23% at the different sites. There was no apparent relationship between the season of sampling and either the prevalence rates of parasitemia or the penetrance of malaria from mother to offspring. In summary, congenital malarial infection is not rare in sub-Saharan Africa, but the prevalence rate of neonatal parasitemia varies from site to site.

HIV seroprevalence amongst pregnant women in northeastern Zaire

To assess the seroprevalence of HIV in pregnant women in northeastern Zaire and factors that correlate with seropositivity, sequential blood sampling and interviews were performed on 700 women at antenatal clinics in northeastern Zaire. The seroprevalence of the 3 clinics surveyed varied from 0.3%-5.5%, rates being higher in more urban areas. Seropositivity was associated with greater education (P<0.001) and having a partner whose job involved travelling (P<0.001). No correlation was found with marital status, age, or gravidity. Women in northeastern Zaire are at a greater risk of being infected with HIV if they are well educated or have a husband who travels due to his work. Health education on HIV should be particularly directed at women who are well educated and at men who have 'mobile' jobs.

Wistar rat-Plasmodium berghei model does not approximate human congenital malaria

Until recently, congenital malaria was thought to be rare. Now, several reports suggest that more than 10% of newborns in some settings are parasitemic. The pathophysiology of transplacental transmission of Plasmodium is not well understood, and no animal model of congenital malaria exists. A rodent model of malaria in pregnant females, however, has been developed. In an effort to test the usefulness of this model in the study of congenital malaria, Wistar rats were injected intraperitoneally with approximately 10(6) NYU-2 strain Plasmodium berghei-infected erythrocytes at various times relative to conception. Perinatal maternal and neonatal blood was tested for the presence of parasites. Two rats infected preconceptually, 1 at 29 and the other at 11 days prior to mating, delivered aparasitemic pups. Fourteen rats were inoculated during gestation. Five of 5 rats infected on the fifth gestational day succumbed prior to delivery; 1 fetus was parasitemic. Offspring of females infected on the 9th, 10th, 12th, and 14th days of gestation were aparasitemic at birth. Four rats conceived after an initial Plasmodium infection had waned and were reinfected during pregnancy; none of their pups showed evidence of parasitemia. Thus, though rare, transplacental passage of malaria parasites can occur in rats. The Wistar rat-P. berghei model of gestational malaria, however, does not seem to be useful for the study of congenital malaria.

Nosocomial mumps: report of an outbreak and its control

BACKGROUND

Mumps is a relatively uncommon disease in the United States, and nosocomial transmission of mumps is rare.

METHODS

When a recently arrived Mexican immigrant became ill with mumps in a pediatric hospital in the United States, control measures and careful secondary case surveillance were instituted. Outbreak control included isolation of the patient with symptoms, seclusion of patients potentially incubating mumps virus, and immunization of susceptible patients and health care workers.

RESULTS

A 3-year-old patient showed symptoms of mumps 18 days after onset of illness in the index patient. Two employees, a physical therapist and a nurse, became ill with mumps 20 and 28 days after the onset of illness in the index patient. No other hospital or community cases of mumps were identified.

CONCLUSIONS

Outbreak control measures were incompletely successful in stopping the spread of mumps. Preadmission immunization of all patients and mumps-specific screening and vaccination of hospital employees might be indicated in such a situation, but such measures are neither easy nor inexpensive.

HIV seroprevalence in healthy blood donors in northeastern Zaire

Despite high seroprevalence rates in some parts of Africa, there is notable variation in prevalence between population subgroups. To document changes and trends in HIV seroprevalence in northeastern Zaire, 1989 to 1992 blood donor data were reviewed. Overall, 2453 donors were tested with seropositivity varying from 2.8% in 1989 to 6.9% in 1992. The increase in seropositivity was significant for men (2.5 to 5.8%, P = 0.017) and for people residing in rural areas (2.0 to 6.1%, P = 0.0008) but not for women (5.4 to 8.6%, P = 0.15) nor for urban individuals (10.5 to 8.6%, P = 0.55). These findings suggest that: 1) HIV infection is spreading in previously less-affected population subgroups rather than increasing widely in the entire population, 2) the HIV epidemic could be reaching a plateau or endemic phase in northeastern Zaire, and, 3) continued blood donor screening and wise transfusion practices are needed.

Tropical pediatrics

Tropical pediatrics often is more a study of the consequences of poverty than of exotic infections. Pediatricians involved with the care of children in or from the tropics must deal with poverty, place an appropriate emphasis on preventive medicine, and seek to bridge their own cultural and linguistic barriers. Malaria, diarrheal disease, and malnutrition account for a large part of pediatric morbidity and mortality in tropical countries. P falciparum can cause severe malarial disease. Treatment must be initiated promptly; resistance to antimalarial drugs is possible. Hygienic and nutritional prevention of diarrhea must be coupled with widespread use of oral rehydration therapy for acute cases of diarrhea. Identification and early treatment of mildly malnourished children can prevent some of the mortality of overt marasmus and kwashiorkor.

Malaria during pregnancy: neonatal morbidity and mortality and the efficacy of chloroquine chemoprophylaxis

In malaria-endemic regions, the impact of malaria upon pregnancy and the value of chemoprophylaxis for malaria for pregnant women remain controversial. We prospectively studied 302 pregnant women who presented in labor to Centre Médical Evangélique, Nyankunde, Zaire. We evaluated the incidence of malarial infection in mothers, placentas, and neonates and examined the effect of infection on birth weight and perinatal mortality. We analyzed the outcome of pregnancy in relation to prophylaxis with chloroquine, controlling for parity and prenatal clinic attendance. Peripartum smears of maternal blood (21%), placentas (33%), cord blood (9%), and neonatal blood (7%) were positive for Plasmodium falciparum. Maternal malaria increased the risk of perinatal death (relative risk [RR] = 12.4) and low birth weight (RR = 3.7). Neonatal malaria increased the risk of perinatal death (RR = 7.2). Chloroquine prophylaxis protected against maternal (RR = 0.4) and fetal malaria (RR = 0.2), low birth weight (RR = 0.39), and perinatal death (RR = 0.38). Peripartum malaria increases the risk of perinatal death and low birth weight. Chemoprophylaxis with chloroquine during pregnancy may have a protective effect, even in certain areas where chloroquine-resistant P. falciparum is endemic.

How many bloods will a 'HIVCHEK' check? Multiple tests for HIV antibody for a single screening kit

Detection of HIV infection in blood donors or populations is usually by testing sera for antibodies to HIV-1 and HIV-2. Screening tests are now highly sensitive and specific, but still expensive and scarce in Africa. We tested the commercially available kits 'HIVCHEK 1 + 2' in two field laboratories, on specimens from blood donors and antenatal women in rural Zaire. We describe a method of using one test kit for up to five serum samples, saving money and time. In 491 antenatal mothers in Eastern Zaire, among whom the HIV seroprevalence was 3.3%, we compared 'HIVCHEK' results with results obtained by ELISA and Western blot. The 'HIVCHEK' multiple-sample method had a sensitivity of 82% and a specificity of 99.6%. In an area with an HIV seroprevalence of < 4%, using 'HIVCHEK' by the multiple sample method would lead to a saving of about 2,400 pounds for every 1000 individuals tested.

Co-sleeping and neonatal weight loss

The degree of neonatal weight loss and the time required for a newborn to regain birth-weight vary between different populations. It has been suggested that co-sleeping, the sharing of a single bed by mother and baby, might be an important factor in determining the neonatal weight change. In a rural setting in central Africa, 203 mother-baby pairs were studied. For 101 babies cared for in cribs and for 102 babies who shared their mothers' beds, sleeping location was associated with no significant difference either in the weight loss (6.3% for each group) or the time taken to regain birthweight (5.3 days for crib-cared babies and 5.4 days for co-sleepers). It is concluded that co-sleeping does not play a major role in determining the neonatal weight change.

HIV seroprevalence among healthy blood donors in northeastern Zaire

Human immunodeficiency virus (HIV)-antibody screening of blood donors in northeastern Zaire was reviewed to determine overall seroprevalence in the population and to identify particular subgroups of the population who are at relatively high risk. Six hundred and seventy-five healthy blood donors were tested from March 1989 to May 1990 using either the HIV-CHEK or Karpas cell tests. A total of 25 donors (3.7%) were seropositive, and seropositivity was more common in female donors (5.4%) than in male donors (2.5%, P less than 0.05). Donors who came from major population centres had a higher rate of seropositivity than did individuals coming from rural villages (10.5% vs 2.0%, P less than 0.001). There was a tendency toward increasing seroprevalence during the 13 months of the study with 2.8% of donors positive in 1989 and 5.8% positive in 1990 (P less than 0.1). It is concluded that in healthy blood donors in northeastern Zaire: (1) HIV seropositivity is more frequent in women and in individuals coming from major population centres, and, (2) HIV seropositivity seems to be increasing rapidly.

Malignant tumors in children of northeastern Zaire. A comparison of distribution patterns

In an effort to better understand the epidemiology of cancer in Zaire, a retrospective review of biopsy-proven malignant tumors was undertaken. Of 188 biopsies taken from children aged 0-15 years over a 4.5 year period, 73 (39%) revealed malignancy. Fifty-six percent of patients with malignant tumors were boys. Lymphoma was the most common tumor (28 patients, 15 with Burkitt's Lymphoma). Sarcoma (15 patients), carcinoma (8 patients), Wilms' Tumor (6 patients), and retinoblastoma (5 patients) were also seen. Lymphomas were most heavily represented in the first 5 years of life, while sarcoma and carcinoma accounted for most of the malignancies in children after 10 years of age. Lymphomas and sarcomas are relatively more common in Zaire than in North America and Europe, while leukemia and central nervous system tumors are notably less common in Zaire. In view of current limitations on health care in rural Zaire, cancer care should be directed toward early diagnosis, quick referral for appropriate surgical care, and use of the limited arsenal of chemotherapy.

Neonatal weight loss in rural Zaire

It has been reported that some African babies lose less weight during the neonatal period than their Caucasian counterparts. A prospective study of 330 newborns in rural Zaire was done to evaluate the degree of newborn weight loss and to determine what factors might be causally associated with the weight loss. Overall, the mean weight loss was 7%. Factors correlated with weight loss were asphyxia, birthweight and age at the initiation of breast feeding. The weight loss in the population studied was similar to that reported in Caucasian babies. Early initiation of breast feeding might decrease the degree of weight loss. Further studies are needed to assess the significance of weight changes in the neonatal period.

Prevention of neonatal conjunctivitis in Zaire

With the emergence of chlamydia as a major cause of neonatal conjunctivitis, silver nitrate is no longer the prophylactic agent of choice in many parts of the world. We studied 450 consecutive newborns in north-eastern Zaire in an effort to determine which of two agents provided the most effective prophylaxis. None of 236 newborns treated at birth with 1% silver nitrate and none of 123 treated with 1% tetracycline was found to develop conjunctivitis. Three of 91 "forgotten" babies developed gonococcal conjunctivitis. Nurses, thinking tetracycline was "messy", tended to "forget" to treat babies for whom tetracycline was prescribed. The use of silver nitrate still provides adequate prophylaxis in Zaire. Potential changes in the prophylactic regimen would need to take the perceptions of health care workers into account.

Measles in Zaire: 1987

Despite widespread efforts to prevent measles, a measles epidemic raged in Zaire during 1986 and early 1987. Hospitalized patients were studied with the goals of better understanding the weakness of the current efforts and of suggesting improvements in the local practice of primary health care. One hundred seventy five patients were hospitalized with measles or measles complications between October 1986 and February 1987 at the Evangelical Medical Center in northeastern Zaire. Ten percent died. Most patients were young (but older than 15 months) and poorly nourished. All patients were incompletely vaccinated. A changed vaccine schedule is proposed, and more thorough application of primary health care measures is encouraged.

Bactericidal activities of five antibiotics during short-term exposure to coagulase-negative staphylococci

After a 1-h exposure to concentrations used for topical prophylaxis in neurosurgical procedures, bacitracin, vancomycin, and oxacillin were bactericidal against more than 90% of 48 body fluid isolates of coagulase-negative staphylococci. More than 10% of isolates survived despite exposure for 4 h to concentrations of gentamicin and streptomycin greater than those employed for topical prophylaxis.