HICNet Medical News Digest Thu, 09 Jun 1994 Volume 07 : Issue 25 Today's Topics: [MMWR 3 Jun 94] Arbovirus Disease [MMWR] Progress Toward Poliomyelitis Eradicaton [MMWR] Rubella and Congenital Rubella Syndrome [MMWR] Invasive Group A Streptococcal Infections [MMWR] Reported Cases of Diseases Preventable by Vaccine Course: DNA Databanks and Repositories Course: Radiologic Pathology New Drug Treatments for Parkinson's Disease Award Prize for Best Article on Chronic Fatique Syndrome AIDS Daily News Summaries +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Compilation Copyright 1994 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine Martin I. Herman, M.D., LeBonheur Children's Medical Center, Memphis TN Stephen Cristol, M.D., Dept of Ophthalmology, Emory Univ, Atlanta, GA Subscription Requests = mednews@stat.com anonymous ftp = vm1.nodak.edu; directory HICNEWS FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Thu, 09 Jun 94 05:00:48 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 3 Jun 94] Arbovirus Disease Message-ID: <28iNNc1w165w@stat.com> Arbovirus Disease -- United States, 1993 During 1993, health departments from 20 states reported 78 cases of arboviral encephalitis to CDC. Of these, 55 (71%) were California encephalitis (CE). This report summarizes information about arboviral encephalitis in the United States during 1993. California Encephalitis During 1993, a total of 55 human CE cases were reported from 11 states, including Florida (one), Illinois (two), Indiana (two), Iowa (six), Minnesota (three), Mississippi (one fatal), Missouri (one fatal), North Carolina (three), Ohio (six), West Virginia (13), and Wisconsin (17). Patients ranged in age from 5 months to 22 years (mean: 7 years). The Mississippi case occurred in a 5-year-old child from George County. Immunoglobulin M (IgM) antibody to several California (CAL) serogroup viruses was detected in serum and cerebrospinal fluid (CSF); neutralizing antibody against the same CAL serogroup viruses was detected in the serum but not in the CSF. The Mississippi State Health Department obtained blood samples from three family members and four neighbors of the child. Neutralizing antibody was detected in serum from four persons; in three persons, antibody titers to Jamestown Canyon virus were at least fourfold higher than other CAL serogroup viruses. The Missouri case occurred in a 4-year-old resident of Stone County; La Crosse virus was recovered from brain tissue. The case in Florida was diagnosed by detection of IgM antibody titers to several CAL serogroup antigens in serum obtained 2 days after onset of illness and by positive IgM titers to multiple CAL group antigens in a convalescent-stage serum sample. Cases from other states were diagnosed as La Crosse virus infections. St. Louis Encephalitis During 1993, a total of 18 human cases of St. Louis encephalitis (SLE) were reported from five states. Five cases were reported in the Texas gulf coast area in two foci: two cases occurred in contiguous Galveston and Brazoria counties, and three occurred in Nueces County. North of the coastal area, single cases were reported from Harris County (Houston) and Denton County, north of Dallas-Fort Worth. Patients ranged in age from 19 to 84 years (mean: 40 years). In Florida, two cases were reported from Lee County and three from contiguous Collier County. Patients ranged in age from 21 to 54 years. Three cases were reported in California, including two from San Bernardino County and one from Imperial County. Patients ranged in age from 19 to 64 years. In Colorado, one case was reported in an 11-year-old child in Arapahoe County. In Illinois, one case (in a person aged 33 years) was reported from Whiteside County and one from Cook County (in a person aged 69 years). Eastern Equine Encephalomyelitis During 1993, a total of five human cases of eastern equine encephalomyelitis (EEE) were reported from four states. Two cases-- including one fatal--occurred in Michigan in persons aged 73 and 60 years. One case each was reported in George County, Mississippi (in a person aged 14 years), and Holmes County, Florida (in a person aged 23 years). A fatal case in Rhode Island occurred in a 14-year-old exposed during a recreational outing. Blood samples were obtained from 16 other participants in the outing; EEE IgM antibody was detected in one person who reported no recent illness. Western Equine Encephalomyelitis and EEE in Domestic Animals During 1993, 13 western equine encephalomyelitis (WEE) cases among horses were reported from 10 states: Arizona (three), Nebraska (two), and one each in California, Colorado, Idaho, North Dakota, Oklahoma, Oregon, Utah, and Wisconsin. WEE virus was isolated from a turkey in Merced County and from emus in Placer and Yuba counties, California, and from an emu in Arkansas. A total of 88 EEE cases among horses were reported from 10 states: Florida (67 cases); South Carolina (four cases); three cases each from Georgia, Maryland, Michigan, and Virginia; Mississippi (two cases); and one case each from Indiana, Louisiana, and North Carolina. EEE was isolated from other species in Georgia (dog, chukar, quail, and emu), Maryland (pheasant), Mississippi (emu), North Carolina (emu), and South Carolina (emu). Enzootic Arbovirus Activity During 1993, enzootic arbovirus activity was reported from 15 states, including CE in Arizona, New York, and Texas; SLE in Arizona, California, Texas, Illinois, and Ohio; EEE in Alabama, Delaware, Massachusetts, Maryland, New Jersey, New York, and Rhode Island; and WEE in Arizona, California, Colorado, South Dakota, and Utah. Documented arbovirus activity was high in the Sacramento Valley in California based on isolates of WEE virus from Culex tarsalis mosquitoes and serologic conversions in sentinel chicken flocks; however, no cases were reported in humans or domestic animals. Reported by: K Reilly, DVM, Veterinary Public Health, R Emmons, MD, Viral and Rickettsial Laboratory; GW Rutherford III, MD, State Epidemiologist, California Dept of Health Svcs. M Currier, MD, J Goddard, PhD, E White, FE Thompson, MD, State Epidemiologist, Mississippi State Dept of Health. HD Donnell, Jr, MD, State Epidemiologist, Missouri Dept of Health. A Gettman, PhD, Rhode Island Dept of Environmental Management; M Rittman, U Bandy, MD, BT Matyas, MD, State Epidemiologist, Rhode Island Dept of Health. D Alstad, DVM, National Veterinary Svcs Laboratory, Animal Plant Health Inspection Svc, US Dept of Agriculture, Ames, Iowa. Participating state epidemiologists, veterinarians, and vector-control coordinators. Arbovirus Diseases Br and Medical Entomology/Ecology Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC. Editorial Note: In 1993, 19 states conducted arbovirus surveillance using virus isolation or antigen detection in mosquitoes and/or serologic assays in wild or sentinel birds. In collaboration with CDC, in 1993, six additional states initiated surveillance in response to the potential for increased mosquitoborne disease associated with flooding in the midwestern United States. These surveillance programs provide current information on arbovirus transmission and assist in characterizing levels of enzootic/epizootic activity associated with the risk of human disease. The CE case in southeastern Mississippi in 1993 was the first reported from the state since 1967. In Missouri, where the other fatal CE case occurred, 12 CE cases have been reported since data collection began in 1963. The CE case in Florida was the first reported from that state since 1963 (1). Previous serosurveys have documented widespread infection with CAL serogroup viruses in the United States. However, because of the limited availability of serologic testing for infection with multiple CAL serogroup viruses, illness associated with CAL serogroup viruses may be underdiagnosed. Although the pathogenic arboviruses in the continental United States usually cause sporadic disease in humans and/or domestic animals, they can cause severe epidemics and epizootics. Surveillance and identification of early seasonal enzootic transmission is important in detecting and controlling arbovirus outbreaks and reducing the risk for human disease through vector control and modification of human activity patterns. Health-care providers should consider arboviruses in the differential diagnosis of all cases of aseptic meningitis and viral encephalitis, obtain appropriate specimens for serologic testing, and promptly report cases to state health departments. New rapid diagnostic assays that detect both virus-infected mosquitoes and human antiviral IgM antibodies have facilitated confirmation of virus activity. Reference 1. Quick DT, Smith AG, Lewis AG, Sather GE, Hammon WM. California encephalitis virus infection: a case report. Am J Trop Med Hyg 1965;14:456. ------------------------------ Date: Thu, 09 Jun 94 05:01:38 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Progress Toward Poliomyelitis Eradicaton Message-ID: Progress Toward Poliomyelitis Eradication -- Socialist Republic of Vietnam, 1991-1993 In 1988, the World Health Organization (WHO) established the goal of global eradication of poliomyelitis by the year 2000 (1), and the Western Pacific Region (WPR) of WHO established the goal of regional eradication by 1995 (2). In 1990, the Socialist Republic of Vietnam (1993 population: 70.9 million; approximately 2 million births annually) endorsed this regional goal and enacted a National Plan of Action for eradication. This plan comprises three main strategies: 1) maintenance of high coverage with three doses of oral poliovirus vaccine (OPV) through routine vaccination; 2) supplemental vaccination with OPV, including National Immunization Days (NIDs) and outbreak-response vaccination; and 3) surveillance of acute flaccid paralysis (AFP) cases. This report summarizes the polio eradication effort in Vietnam during 1991-1993. Vaccination coverage of children aged less than 1 year who received three doses of OPV was 88.6% in 1992 and 90.1% in 1993, based on routine monthly reports of doses administered. These monthly reports may have overestimated true coverage because vaccination coverage surveys in April 1992 in six of 53 provinces (Dac Lac, Hanoi, Kien Giang, Nghe An, Quang Binh, and Song Be) estimated that coverage with three doses of OPV was 0- 16% lower than reported by the doses-administered method. During October-November 1991, supplemental OPV activities in selected areas of Vietnam resulted in the vaccination of 375,000 children aged less than 3 years in Hanoi and Ho Chi Minh City with two doses each of OPV. During October-November 1992, 1.25 million children aged less than 3 years received one dose of OPV in each of two separate vaccination rounds during Provincial Immunization Days in Hanoi, Ho Chi Minh City, and six provinces (Binh Dinh, Can Tho, Dong Nai, Hai Hung, Nam Ha, and Tien Giang). The first NIDs were conducted during November-December 1993 and enabled administration of two doses of OPV to 9.7 million children (85%-90% of vaccinated children were aged less than 5 years) (Figure 1); estimated coverage of children aged less than 5 years was 83%-88%. Vaccines were delivered from fixed sites or by outreach teams. In addition to OPV, all children aged 6-59 months received one dose of vitamin A; 202,000 children aged 9-23 months in selected areas received measles vaccine; and 1.1 million women of childbearing age each received two doses of tetanus toxoid. The NIDs involved participation of 200,000 volunteers in 10,000 communes, 30,000 health workers, national political leaders, local governments, community organizations, religious leaders, medical staff, police officers, military personnel, and teachers. In the 1-2 weeks before the NIDs, lists of eligible children were compiled in most provinces and letters of appointment issued to parents during house-to-house visits by health workers. The NIDs were preceded by intensive mass media publicity, including daily national and local television and radio broadcasts, newspaper reports, posters, and loudspeaker announcements. The central and provincial governments contributed approximately $1.2 million for campaign activities. Vaccines were supplied by Rotary International, the United Nations Children's Fund, the Australian International Development Assistance Bureau, the Japan International Cooperation Agency, the Canadian International Development Agency, SmithKline Beecham Biologicals* (Rixensart, Belgium), and Pasteur-Merieux Serums and Vaccines (Lyon, France). In 1992, 677 cases of AFP were reported in 42 (79%) of 53 provinces and in 184 (33%) of 552 districts; 557 cases were confirmed as polio based on standard WHO criteria. In 1993, the number of reported cases of AFP decreased to 641; of these, 425 were confirmed as polio (including 75 by type 1 wild poliovirus isolation) (provisional data). During 1993, there was no characteristic summertime seasonal increase in confirmed polio cases in the six provinces where 1992 Provincial Immunization Days were conducted (Figure 2). Reported by: Le D Hong, MD, Nguyen V Bien, MD, Trinh Q Huan, MD, Cao V Hoa, MD, Dang X Khoat, MD, Tran V Hung, MD, Tran V Hieu, Expanded Program on Immunization, Ministry of Health, Hanoi; Hoang T Nguyen, MD, Nguyen V Man, MD, Tran V Tien, MD, Nguyen T Yen, MD, Thanh K Dung, MD, Doan N Anh, PhD, Pham TN Oanh, National Institute of Hygiene and Epidemiology, Hanoi; Le D Hinh, MD, Bach Mai Hospital, Hanoi; Doan T Tam, MD, National Center for Vaccine Quality Control, Hanoi; Ha B Khiem, MD, Pham K Sac, MD, Nguyen TT Thuy, MD, Van TT Binh, MD, Nguyen M Phuong, MD, Phan V Tu, MD, Nguyen T Long, MD, Pasteur Institute, Ho Chi Minh City; Vo C Khanh, MD, Center for Tropical Diseases, Ho Chi Minh City; Nguyen TT Tram, MD, Pasteur Institute, Nha Trang; Nguyen A Phuong, MD, Institute of Hygiene and Epidemiology, Tay Nguyen, Socialist Republic of Vietnam. Expanded Program on Immunization Unit, Western Pacific Regional Office, World Health Organization, Manila, Philippines. Expanded Program on Immunization, Global Program for Vaccines, World Health Organization Headquarters, Geneva. Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Polio Eradication Activity, National Immunization Program, CDC. Editorial Note: Among member countries of the WPR, Vietnam had the second highest reported incidence of polio in 1992 and 1993 (after Cambodia), resulting in 557 (29%) of the 1912 confirmed cases reported in the WPR in 1992 and 425 (35%) of the 1228 confirmed cases reported in 1993 (provisional data). Although the increased OPV coverage through routine vaccination has resulted in a substantial decrease in the incidence of polio in Vietnam, supplemental vaccination activities are warranted for three reasons: 1) routine vaccination with three OPV doses has not been successful in interrupting wild poliovirus transmission in most countries with endemic polio; 2) outbreaks of polio in Vietnam could occur following the accumulation of susceptible persons during years of reduced incidence; and 3) NIDs that deliver two OPV doses at 1-2-month intervals to all children aged less than 5 years have been successful in interrupting wild poliovirus transmission in the Western Hemisphere (3). The decrease in the number of reported AFP cases in Vietnam in 1993 primarily reflects a decrease in reported cases in the six provinces in which immunization days were conducted for children aged less than 3 years in 1992. This pattern is consistent with findings in China that, under certain circumstances, supplemental OPV vaccination targeting children aged less than 3 or less than 4 years, rather than less than 5 years, may be sufficient to reduce or interrupt wild poliovirus transmission. The incidence of polio in Vietnam has been highest in the southern provinces of the Mekong Delta region, which border provinces in Cambodia where the incidence is also high. Preliminary genotype studies indicate that type 1 polioviruses circulating in the Mekong Delta region of southern Vietnam and Cambodia are closely related and represent a common virus reservoir; isolates from northern Vietnam constitute a separate reservoir (CDC, unpublished data, 1993). Because population movement across the border is extensive, supplemental vaccination activities in Cambodia will be critical to reduce the risk of cross-border importations and to interrupt wild poliovirus circulation in the WPR. The apparent elimination of wild poliovirus infections in the Americas and the substantial progress in the WPR demonstrate the feasibility of achieving eradication in WPR and other regions of the world (4). Each of the five countries with endemic polio in the WPR have adopted the 1995 eradication goal and are conducting or planning to conduct NIDs in 1994 and 1995 (5,6). The success of the first NIDs in Vietnam resulted from the combination of strong political and financial commitment from the highest levels of government, a successful social mobilization and information campaign, and coordination among donor agencies to supply adequate quantities of vaccine. References 1. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva: World Health Organization, 1988. (Resolution WHA41.28). 2. World Health Organization, Regional Committee for the Western Pacific. Eradication of poliomyelitis by 1995. Manila, Philippines: World Health Organization, Regional Committee for the Western Pacific, 1988. (Resolution WPR/RC39.R15). 3. CDC. Update: polio eradication--the Americas, 1993. MMWR 1993;42:685-6. 4. Foege WH. A world without polio. JAMA 1993;270:1859-60. 5. CDC. Poliomyelitis National Immunization Days--People's Republic of China, 1993. MMWR 1993;42:837-9. 6. CDC. National Immunization Days and status of poliomyelitis eradication- -Philippines, 1993. MMWR 1994;43:6-7,13. * Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. ------------------------------ Date: Thu, 09 Jun 94 05:02:27 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Rubella and Congenital Rubella Syndrome Message-ID: Rubella and Congenital Rubella Syndrome -- United States, January 1, 1991-May 7, 1994 Following a resurgence of rubella and congenital rubella syndrome (CRS) during 1989-1991, the reported number of rubella cases during 1992 and 1993 was the lowest ever recorded. However, outbreaks of rubella have continued to occur, indicating the need for intensified and sustained efforts to reach the goal of eliminating indigenous rubella and CRS in the United States by 1996. This report summarizes surveillance for rubella and CRS from January 1, 1991, through May 7, 1994. Information is based on cases reported to the National Notifiable Disease Surveillance System (NNDSS) and a telephone survey of 28 areas reporting rubella to obtain verification and information on age, laboratory confirmation, and vaccination status of persons with rubella reported in 1993. Rubella Following an all-time low of 225 cases reported in 1988, the incidence of rubella increased in 1989 and peaked in 1991 with 1401 reported cases (Figure 1, page 397) (1). In 1992, a new low of 160 cases was reported, followed by an increase to 190 reported cases (provisional total) in 1993. In 1991, 33 states, New York City, and the District of Columbia reported rubella cases; six states, each reporting 25 or more cases, together accounted for 91% of all cases reported (Figure 2, page 398). California accounted for 267 (19%) reported cases. Outbreaks among members of religious communities that traditionally refuse vaccination resulted in large increases in cases reported from Michigan, New York, Ohio, Pennsylvania, and Tennessee and accounted for at least 900 (89%) of the 1007 cases reported in these states during 1991. Cases were reported from 27 states and three territories in 1992 and from 24 states and New York City in 1993. As of May 7, 1994, a provisional total of 134 rubella cases has been reported from 11 states and Guam. Age-specific data were available from NNDSS for 1991 and 1992 for all states except California and, in 1993, for all states (Table 1). In 1991, 52% of cases were reported among persons aged 5-19 years and 28% among adults aged greater than or equal to 20 years. The distribution in 1991 reflected outbreaks that occurred in religious communities in which unvaccinated children and young adults congregated in schools and other settings where they were in close contact. In comparison, in 1992 and 1993, 49%-63% of cases occurred among persons aged greater than or equal to 20 years; in addition, the proportion of cases among persons aged greater than or equal to 30 years increased by more than threefold over that in 1991. In each year, 16%-23% of cases occurred among children aged less than 5 years. In 1991, Hispanics and Asians/Pacific Islanders together accounted for 33 (3%) of 1028 cases in persons with known race/ethnicity. In comparison, in 1992, Asians/Pacific Islanders accounted for 27 (39%) of 70 cases with known race, and Hispanics accounted for 14 (19%) of 73 cases with known ethnicity. In 1993, Asians/Pacific Islanders accounted for 31 (29%) of 108 cases with known race, and Hispanics accounted for 39 (22%) of 176 cases with known ethnicity. Outbreaks identified during 1993-1994 primarily have involved persons in prisons, colleges, and work settings. During 1993, outbreaks were identified in six areas: California (an adult class and a prison); New Jersey, New York City, and New York State (work settings); Texas (a college); and Massachusetts (community and a prison). The outbreak that began in Massachusetts in 1993 is ongoing; through May 7, 1994, a total of 99 cases had been reported in prisons, homeless shelters, a psychiatric facility, and a community including persons who immigrated from areas that do not routinely vaccinate against rubella (e.g., most central and south American countries). An outbreak in 1994 in a college in Oklahoma has involved four international students who were unvaccinated. Data on vaccination status of persons with rubella are not routinely collected in NNDSS and were not available for 1991 and 1992. Vaccination status of persons with rubella reported in 1993 was determined by the telephone survey. Of the 190 persons with reported rubella, 13 were not eligible for vaccination (aged less than 1 year). Vaccination status was known for 97 (55%) of the remaining 177 persons; of these, 52 (54%) were unvaccinated, 39 (40%) reported vaccination or specified receipt of one dose, and six (6%) reported receipt of two doses of vaccine. Among persons with reported rubella in 1993, 127 (67%) had clinical diagnosis confirmed by a laboratory, eight (4%) had a clinical diagnosis and were epidemiologically linked to another person with rubella, and 27 (14%) had a clinical diagnosis only; method of ascertainment was unknown for 28 (15%). Congenital Rubella Syndrome Information about CRS was based on data from the National CRS Registry maintained by CDC's National Immunization Program (1,2). The incidence of CRS paralleled the rise and decline of rubella from 1989 to 1993 (Figure 1). During 1991, 31 indigenous cases of confirmed and compatible CRS were reported in the United States (Table 2); 20 (65%) of these occurred in Pennsylvania. A survey to determine the risk for CRS among infants born to Amish mothers residing in one county in Pennsylvania in 1991 indicated the rate of CRS was 14 per 1000 live births, compared with 0.006 for the U.S. total population (3). During 1992, five cases of CRS were reported in the United States, including two in Pennsylvania and three in California. No indigenous CRS was reported among infants born in 1993; three cases reported in 1994 are pending confirmation. Eight imported cases of CRS were reported among infants born during 1991-1993 (with exposure in Mexico [five cases], Germany [two], and Poland [one]). Reported by: State and territorial epidemiologists. Div of Surveillance and Epidemiology, Epidemiology Program Office; Epidemiology and Surveillance Div, National Immunization Program, CDC. Editorial Note: The incidence of rubella among persons aged greater than or equal to 20 years has declined dramatically since licensure of rubella vaccine and since the 1980s, when increased emphasis was placed on vaccinating adolescents and adults, particularly women of childbearing age (4). However, many persons in this age group--particularly women of childbearing age--remain susceptible (5). The outbreaks that have occurred since 1991 indicate the ongoing transmission of rubella and underscore the potential risk for CRS. The outbreaks in 1991 occurred primarily among religious groups that remain unvaccinated (3,6). Since 1992, outbreaks have occurred in settings where young adults congregate, particularly among persons in specific racial/ethnic groups (e.g., Asians/Pacific Islanders and Hispanics) who often are unvaccinated. Some of these outbreaks also have been associated with transmission of cases acquired outside the United States. Limited or absent efforts in some countries to vaccinate against rubella also poses a risk for rubella exposure and transmission and of CRS in the United States. For example, in 1993, 27 of 28 reported cases in Hawaii were imported. In the outbreak in Massachusetts that started in 1993, two of the early cases were in persons who had immigrated from Brazil. The outbreak later spread to a community in Boston including immigrants from areas that do not routinely vaccinate against rubella. Since 1989, 14 infants were born in the United States to mothers infected in other countries, including 10 of the 14 whose mothers were from Mexico, where persons are not routinely vaccinated against rubella. The findings in this report indicate that achieving the goal of eliminating indigenous rubella and CRS in the United States by 1996 will require improving control strategies that target young adults (7). Strategies include 1) increasing vaccination coverage in children; 2) implementing laws requiring all students receive two doses of measles-mumps-rubella vaccine; 3) encouraging health-care providers to take advantage of every opportunity to vaccinate susceptible adolescents and adults; 4) adopting prematriculation vaccination requirements in colleges; 5) initiating prevention and control programs in correctional institutions; 6) encouraging persons in religious groups who do not seek health care to accept vaccination; and 7) targeting special vaccination programs toward young adults who are likely to be unvaccinated and to have contact with persons infected with rubella from countries that do not routinely vaccinate against rubella. CDC, in collaboration with state and local health departments, is planning enhanced surveillance to better define the epidemiology of rubella and CRS. Additional information that will be collected for each rubella case includes serologic confirmation, vaccination status, location of exposure (i.e., indigenous or imported), and transmission setting. This information will be used to design more effective prevention strategies for rubella and CRS. References 1. CDC. Increase in rubella and congenital rubella syndrome--United States, 1988-1990. MMWR 1991;40:93-9. 2. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):32. 3. CDC. Congenital rubella syndrome among the Amish--Pennsylvania, 1991- 1992. MMWR 1992;41:468-9,475-6. 4. CDC. Rubella and congenital rubella syndrome--United States, 1985-1988. MMWR 1989;38:173-8. 5. Stehr-Green PA, Cochi SL, Preblud SR, Orenstein WA. Evidence against increasing rubella seronegativity among adolescent girls. Am J Public Health 1990;80:88. 6. CDC. Outbreaks of rubella among the Amish--United States, 1991. MMWR 1991;40:264-5. 7. CDC. Rubella prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-15). ------------------------------ Date: Thu, 09 Jun 94 05:03:16 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Invasive Group A Streptococcal Infections Message-ID: <6BJNNc4w165w@stat.com> Invasive Group A Streptococcal Infections -- United Kingdom, 1994 On May 27, 1994, the Communicable Disease Surveillance Center in England reported that six persons in Gloucestershire had disease characteristic of invasive group A streptococcal infection (GAS) with necrotizing fasciitis. Three patients died. Patients ranged in age from 46 to 68 years. Group A streptococcal isolates from blood or joint fluid from five patients were typed by the Public Health Laboratory Service Streptococcus Reference Laboratory. Four different types were identified (M1 [2], M3, M5, and M-nontypable). Since 1992, the total number of laboratory reports of systemic GAS in England and Wales has remained stable; during the first 16 weeks of 1994, a total of 200 blood isolates were reported, compared with 212 and 200 during the first 16 weeks of 1993 and 1992, respectively. Adapted from: Communicable Disease Report 1994;4(21). Reported by: Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The report from the United Kingdom underscores the potential for severe disease associated with GAS. GAS is associated with a broad spectrum of complications in humans, the most common being streptococcal pharyngitis. Serious invasive disease, which occurs less commonly, is defined by isolation of the bacteria from usually sterile sites and is associated with case-fatality rates of 10%-20%. One form of invasive GAS, necrotizing fasciitis, is characterized by destruction of muscle and fat tissue. Based on extrapolation of incidence rates determined by active surveillance in four states during 1989-1991, 10,000-15,000 cases of invasive GAS occurred annually in the United States; necrotizing fasciitis occurred in 5%-10% of patients (case-fatality rate: 28%) (CDC, unpublished data, 1992). These findings were consistent with a retrospective review of all invasive GAS in Pima County, Arizona, during 1986-1990; in this review, necrotizing fasciitis was identified in 6.5% of infections (1). Interest in necrotizing fasciitis as a serious manifestation of invasive GAS increased in 1989 following a report of 20 patients with group A streptococcal toxic-shock syndrome, of whom 11 had necrotizing fasciitis (2); a subsequent case definition for this syndrome included necrotizing fasciitis as one component (3). Since 1991, there has been no active surveillance for invasive GAS in the United States; although passive surveillance exists, this disease is not reportable in most states. Development of invasive GAS appears to be facilitated by the presence of specific virulent strains and predisposing host factors. To evaluate the role of strain characteristics, CDC examined group A streptococcal isolates from surveillance for postulated virulence factors including M-type, protease activity, and pyrogenic exotoxin production (4). Protease activity was significantly associated with necrotizing fasciitis; M-type 1 infection also was associated with protease activity. These findings suggest that certain group A streptococcal strains are more likely to cause necrotizing fasciitis when infection occurs. Other reports suggest that the risk for invasive GAS is associated with the presence of surgical or nonsurgical wounds, diabetes mellitus, and other underlying medical problems. Rapid treatment is necessary to reduce the risk for death, and penicillin remains the treatment of choice for GAS. Although penicillin resistance has never been identified in group A Streptococcus, some strains are resistant to erythromycin (which is recommended as therapy in penicillin-allergic patients). In addition to antibiotics, surgical intervention is usually needed in cases of necrotizing fasciitis. The occurrence of the cluster of necrotizing fasciitis in England and the recent recognition of a streptococcal toxic-shock syndrome underscore the potential for group A streptococci to cause severe illness and new clinical syndromes and the need to monitor clinical manifestations and changes in the epidemiology of these infections (5). References 1. Hoge CW, Schwartz B, Talkington DF, Breiman RF, MacNeill EM, Englender SJ. The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic-shock like syndrome. JAMA 1993;269:384-9. 2. Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infection associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989;321:1-7. 3. Working Group on Severe Streptococcal Infections. Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA 1993;269:390-1. 4. Talkington DF, Schwartz B, Black CM, et al. Association of phenotypic and genotypic characteristics of invasive Streptococcus pyogenes isolates with clinical components of streptococcal toxic shock syndrome. Infect Immun 1993;61:3369-74. 5. CDC. Addressing emerging infectious disease threats: a prevention strategy for the United States. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994. ------------------------------ Date: Thu, 09 Jun 94 05:04:08 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Reported Cases of Diseases Preventable by Vaccine Message-ID: Number of reported cases of diseases preventable by routine childhood vaccination -- United States, April 1994 and January-April 1993 and January-April 1994 * ================================================================================= ===================== No. cases among Total cases children aged <5 years + No. cases, -------------- ------------------------ Disease April 1994 1993 1994 1993 1994 --------------------------------------------------------------------------------- ------ Congenital rubella syndrome (CRS) 0 5 3 3 3 Diphtheria 0 0 0 0 0 Haemophilus influenzae & 106 474 374 161 110 Hepatitis B @ 1103 3935 3682 39 51 Measles 173 103 272 48 66 Mumps 146 580 439 99 52 Pertussis 212 960 991 548 541 Poliomyelitis, paralytic ** -- -- -- -- -- Rubella 48 65 132 12 11 Tetanus 3 8 12 0 1 --------------------------------------------------------------------------------- ------ * Data for 1993 are final and for 1994, provisional. + For 1993 and 1994, age data were available for 84% or more cases, except for 1993 age data for congenital rubella syndrome (CRS), which were available for 60% of cases. & Invasive disease; H. influenzae serotype is not routinely reported to the National Notifiable Diseases Surveillance System. @ Because most hepatitis B virus infections among infants and children aged <5 years are asymptomatic (although likely to become chronic), acute disease surveillance does not reflect the incidence of this problem in this age group or the effectiveness of hepatitis B vac- cination in infants. ** No cases of suspected poliomyelitis have been reported in 1994; three cases of suspected poliomyelitis have been reported in 1993. Four of the five suspected cases with onset in 1992 were confirmed; the confirmed cases were vaccine associated. ================================================================================= ===================== ------------------------------ Date: Thu, 09 Jun 94 05:06:29 MST From: mednews (HICNet Medical News) To: hicnews Subject: Course: DNA Databanks and Repositories Message-ID: DNA DATABANKS & REPOSITORIES will be presented 4-5 November 1994 at the Sheraton Inn Midway, St Paul Minnesota, USA. SPONSORS: Armed Forces Institute of Pathology and the American Registry of Pathology. GENERAL INFORMATION: AFIP Education Dept. (INT), 14th & Alaska Avenue, NW, Washington, DC, 20306-6000 USA; (301)427-5231; FAX (301)427-5001; or INTERNET: LOWTHER@email.afip.osd.mil CONTENT: DNA typing of biologic tissues and fluids has revolutionized criminalistics. This technology is so powerful that over one half of all states have legislatively mandated the creation of DNA databanks and repositories for law enforcement purposes with other states considerating the same. The passage of the federal DNA Identification Act will bolster the growth of these databanks. DNA repositories also have been established for military remains identification, for scientific human geneic diversity studies, and for numerous public health reasons. This is the third national conference devoted strictly to the establishment of DNA databanks and repositories. This conference is designed to be a practical discussion on the creation and the set-up of DNA databanks/repositories, focusing on forensic identification. It is intended for DNA repository directors, policy makers, and administrators considerating establishment of a DNA collections program, and other interested persons. Lectures will be presented on current state sex offender databanks, the FBI's National DNA Index, the DNA Identification Act, practical aspects of databank setup and administration, and the associated legal and ethical issues. Convictions based on the Minnesota State DNA Database will be featured and a tour of the Minnesota Bureau of Criminal Apprehension's facility will be conducted. (English) COURSE DIRECTOR: Victor W. Weedn, LTC, MC, USC TUITION: $220. ------------------------------ Date: Thu, 09 Jun 94 05:08:39 MST From: mednews (HICNet Medical News) To: hicnews Subject: Course: Radiologic Pathology Message-ID: <5kJNNc8w165w@stat.com> RADIOLOGIC will be presented 10-14 October 1994 at Disney's Contemporary Resort, Lake Buena Vista, Florida, USA. SPONSOR: The Armed Forces Institute of Pathology, the American Registry of Pathology, and the Department of Radiologic Pathology. GEN INFO: Department of Radiologic Pathology, ARP/AFIP, P.O. Box 59648, Washington, DC 20012, USA; 202/576-0413 or FAX 202/576-0768; INTERNET: LOWTHER@email.afip.osd.mil CONTENT: This week-long course in radiologic pathologic correlation is designed for practicing radiologist. The curriculum has the two-fold purpose of refreshing basic principles and presenting new developments in radiologic pathologic correlation. Each day will be devoted to one of the major organ systems and will include a display and discussion of unknown cases to illustrate contemporary concepts. The course objective is to refresh basic principles of the present contemporary approaches to radiologic pathologic correlation in each of the major organ systems. (English) TUITION: $525. Active Duty military, DoD civilians, full-time permanent Dept. of Veterans Affairs employees (not residents or fellows), and commissioned officers of the Public Health Services with authorized approval have a registration fee of $225. ------------------------------ Date: Thu, 09 Jun 94 05:09:46 MST From: mednews (HICNet Medical News) To: hicnews Subject: New Drug Treatments for Parkinson's Disease Message-ID: New Drug Treatments on Parkinson's Disease APDA Newsletter, Winter 1993-1994 Copyright 1993, Reproduced with Permission Abraham Lieberman, M.D. Chief Movement Disorders Barrow Neurological Institute Phoenix, AZ Chairman, APDA Medical Advisory Board Levodopa combined with carbidopa (Sinemet, Atamet) remains the mainstay of Parkinson's disease (PD) treatment. Initially, most patients respond well. Indeed, failure to respond to levodopa indicates a condition other than PD. After an initial good response, most patients develop daily response fluctuations, the "on- off" effect, after 2 to 5 years of treatment. These fluctuations are related in part to progression of PD and in part to levodopa metabolism. Several drugs are used to reduce fluctuations. These include a long acting levodopa preparation (Sinemet CR) and drugs that block one of the enzymes that break down dopamine, like deprenyl (Eldepryl), and dopamine agonists like (bromocriptine (Parlodel) and pergolide (Permax)) that supplement the actions of levodopa. While these treatments are helpful, response fluctuation remains a major problem. Several new treatments are being developed and tested at selected research centers. The following treatments are being tested at the Barrow Neurological Institute in Phoenix, Arizona: Dopamine Agonists: Three new dopamine agonists which may have advantages over bromocriptine and pergolide. Cabergoline, like bromocriptine and pergolide, is an ergot compound. It is longer acting than bromocriptine and pergolide and is administered on a once a day basis. Cabergoline is especially useful in patients with response fluctuations. Ropinerole, a non-ergot agonist with properties different from Cabergoline, is also useful in patients with response fluctuations. Pramipexole is an agonist with properties different from Cabergoline and Ropinerole. In one study Pramipexole is given to patients with advanced PD who have the "on-off" effect, while in another study it is administered to patients with early PD. Pramipexole delays the need for levodopa and is especially useful in relieving tremor. Because of differences in the way PD patients respond to drugs it is important that several agonists be available. MAO Blockers: Lazebemide, like deprenyl, blocks the enzyme monoamine oxidase (MAO). And, like deprenyl, it prolongs the actions of levodopa and delays the need for levodopa. As with the dopamine agonists it is desirable to have several MAO inhibitors available. In addition to their ability to increase the effectiveness of levodopa, MAO inhibitors may protect cells from dying. Trials of all of the MAO inhibitors are now being conducted in other diseases where neurons (nerve cells) die prematurely, such as Alzheimer's disease and Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig's disease). COMT Blockers: Tolcapone blocks the enzyme COMT, prolonging the action of levodopa, and markedly reducing the "on-off" effect. Tolcapone is being studied in patients with advanced PD and will be studied in patients with early and moderate PD. Low Protein Diet: A balanced 7:1 carbohydrate/protein ratio food supplement (Hearty Balance) allows levodopa to act longer. Ninety seven PD patients with fluctuations were evaluated at 4 separate centers. The high carbohydrate and 7:1 carbohydrate protein beverage resulted in significant improvement, in all symptoms measured, over a high protein beverage. The availability of this palatable, easy to use, balanced carbohydrate/low protein diet provides a dietary means of controling response fluctuations. Growth Factors: CNTF is a trophic growth factor, that is being studied in ALS. CNTF stimulate the growth of dying cells in the spinal cord and hopefully will alow them to regenerate. CNTF is one of a class of compounds that holds promise for the treatment of degenerative diseases such as PD, ALS, and Alzheimer's disease. Prior to the advent of trophic factors, treatment of these disorders was directed at lessening symptoms or possibly, as with MAO inhibitors, at slowing the progression of PD. Although CNTF is now being used on an experimental basis only for the treatment of ALS, we hope eventually to be able to use it in the other diseases. GDNF and BDNF are trophic factors that are specific for the dopamine producing cells that are involved in PD. ------------------------------ Date: Thu, 09 Jun 94 05:11:29 MST From: mednews (HICNet Medical News) To: hicnews Subject: Award Prize for Best Article on Chronic Fatique Syndrome Message-ID: ********* ANNOUNCEMENT ******** * Dutch M.E. Award * The trustees of the Dutch M.E. Fund and its Science Board will offer an award, consisting of a sculpture and 10,000 Dutch guilders, for the best scientific article on M.E. (myalgic encephalomyelitis, also known as "chronic fatigue syndrome"), published on or after January 1, 1993. The winner is expected to accept the award in person and give the Dutch M.E. Award Lecture. Travel and accommodation expenses will be paid for. Applicants must send an offprint or photocopy of their article, together with a covering letter stating their candidacy, to the secretariat of the Dutch M.E. Fund before September 1, 1994. The winner will be notified before November 1, 1994. The award ceremony is scheduled for early December 1994. For further details, please contact the secretariat: ************************************** ** ** ** Secretariat Dutch M.E. Fund ** ** Pres. Kennedylaan 745 ** ** 1079 MR Amsterdam ** ** The Netherlands ** ** Phone: +31 20 6445566 ** ** Fax: +31 20 6445440 ** ** ** ************************************** Or send e-mail to josdb@hacktic.nl (temporary e-mail address). ------------------------------ Date: Thu, 09 Jun 94 05:12:08 MST From: mednews (HICNet Medical News) To: hicnews Subject: AIDS Daily News Summaries Message-ID: AIDS Daily Summary The Centers for Disease Control and Prevention (CDC) National AIDS Clearinghouse makes available the following information as a public service only. Providing this information does not constitute endorsement by the CDC, the CDC Clearinghouse, or any other organization. Reproduction of this text is encouraged; however, copies may not be sold, and the CDC Clearinghouse should be cited as the source of this information. Copyright 1994, Information, Inc., Bethesda, MD Topics in this issue: - "Volunteers for Vaccines Get HIV" - "Genetic Attacks Readied on AIDS" - "Epidemiology of AIDS and Suicide" - "HIV's Tricks: Hide and Deactivate" - "AIDS Vaccine Set for Wide Testing, Salk Group Says" - "Discovery ... Dietary Supplement May Boost Immune System" - "Curcumin Trial Results: Antiviral Effect Reported" - "Fighting AIDS or Responding to the Epidemic: Can Public Health Find Its Way?" - "Protecting Women From AIDS" "Volunteers for Vaccines Get HIV" USA Today (05/31/94) P. 1D Several volunteers enrolled in the federal government's study to test experimental AIDS vaccines have become infected with HIV, raising concerns about the safety of such trials. The vaccines, which are being tested in small trials at five universities, do not contain any of HIV's genetic material, and cannot cause infection. Still, seven out of about 1,400 participants--including two who were receiving only placebos--have tested positive for the virus. All seven HIV-positive volunteers had been counseled about how to reduce the risk of HIV infection, but researchers have long worried that trial participants might erroneously believe that they are protected and engage in high-risk behaviors. Scientists say some new HIV infections were to be expected, and that no potential vaccine was likely to be 100 percent effective. There is concern, however, that recipients of AIDS vaccines may become more vulnerable to infection than they would have been otherwise, as the vaccines not only stimulate the immune system, but burden it. Related Stories: New York Times (05/30) P. 24; Washington Post (05/30) P. A7; Washington Times (05/30) P. A6. "Genetic Attacks Readied on AIDS" New York Times (05/31/94) P. C1 (Kolata, Gina) In search of new ways to combat HIV/AIDS, some molecular biologists say AIDS should not be treated as if it were caused by an ordinary virus. Rather, it should be viewed as a disease of DNA. Because HIV integrates itself into the DNA of chromosomes, they argue that methods of gene therapy and molecular biology should be used to attack the virus as it subverts the cell's genetic machinery. This perspective on AIDS has spawned several new approaches--two of which are now ready to be tested on AIDS patients. Dr. Gary Nabel and colleagues at the University of Michigan Medical Center are seeking to inhibit a small but critical protein made by an HIV gene called the rev. Without the rev protein, genetic messages needed to make new viruses are not transported. And, at Thomas Jefferson University in Philadelphia, Dr. Roger A. Pomerantz is also targeting the rev gene. His method is to inactivate it with a specially designed antibody. "Epidemiology of AIDS and Suicide" Focus (04/94) Vol. 9, No. 5, P. 7 (Cole, T.R.; Biggar, R.J.; Dannenberg, A.L.) A large national study of death certificates from 1987 through 1989 showed that AIDS patients have higher rates of suicide, although the rate may be on a decline. Suicide occurred among AIDS patients of all ages, in most regions of the United States. Ninety-nine percent of the cases took place among men--a rate that was 7.4 times higher than that of the male population at large. Whites accounted for 87 percent of AIDS suicides, blacks for 12 percent, and other races made up the remaining one percent. AIDS patients most often used firearms, drug poisoning, or suffocation to end their lives. However, the rate of suicides among people with AIDS appears to be decreasing. The rate among AIDS patients dropped from 10.5 times that of the general population to 7.4 times in 1988, and to 6.0 times in 1989. The reduced rate of AIDS suicides may reflect greater optimism in the wake of medical advances, waning social stigma, and increased availability of pyschiatric support for people with AIDS. "HIV's Tricks: Hide and Deactivate" Washington Post (06/02/94) P. A8 HIV stimulates a strong immune system response, but avoids cells sent to destroy it by disguising itself and temporarily inactivating the killer cells. British researchers report that the virus outwits the immune system by altering its surface proteins to render them unrecognizable to the T-cells, which are then deactivated by the virus. This clever strategy is the product of the virus' "variability," according to Andrew McMichael, one of the researchers. Related Story: Washington Times (06/02) P. A12 "AIDS Vaccine Set for Wide Testing, Salk Group Says" Boston Globe (06/01/94) P. 17 (Knox, Richard A.) Upon completion of a series of experiments, colleagues of Jonas Salk announced yesterday that they are ready to launch large-scale testing of his AIDS vaccine in thousands of HIV patients. Salk, who developed the polio vaccine, has strayed from other vaccine theories by arguing that the best way to deal with HIV is to kill it with chemicals so that it is no longer infectious, then to provoke an immune response to the entire virus. This week, the Salk group published the first scientific report of its studies, which indicate that the vaccine significantly slowed growth of the virus in HIV-positive volunteers who received three injections. The researchers cautioned that the study does not indicate that the vaccine can delay progression to AIDS, and said they will need to enroll at least 4,000 patients for studies in up to 40 medical centers to explore that possibility. "Discovery ... Dietary Supplement May Boost Immune System" Business Wire (05/25/94) Pharma-Search Inc., which recently formulated a dietary supplement derived from natural food sources, announced that the supplement may be promising for people with AIDS. A small group of AIDS patients who had been taking the dietary supplement, shown to be safe for ingestion, demonstrated a marked increase in fighter T-cells, white blood cells, and B-cells after six weeks. Some experienced weight gain; in general, they reported feeling more energetic and less lethargic. Based on this preliminary finding, Pharma-Search intends to seek approval to prepare applications for controlled studies. "Curcumin Trial Results: Antiviral Effect Reported" AIDS Treatment News (05/06/94) No. 198, P. 1 (James, John S.) The first human trial of curcumin, an alternative AIDS treatment, demonstrated a modest antiviral effect, according to SEARCH Alliance, a community-based research organization in Los Angeles. Curcumin is derived from turmeric, the spice which gives curry its yellow tint, and is the first of a potential new class of anti-HIV treatments that target the long terminal repeat (LTR) of HIV. It first showed up in laboratory tests at the Dana-Farber Cancer Institute and follow-up viral tests at Beth Israel Hospital in Boston. In the trial, curcumin's antiviral effect was observed in measurements of HIV RNA, using an experimental test. The only toxicity noted was upper gastrointestinal discomfort in some participants. The antiviral effect, however, appeared to be only temporary, partially fading by 20 weeks. More research is needed, such as the new curcumin trial which will be conducted in Boston by the Community Research Initiative of New England. "Fighting AIDS or Responding to the Epidemic: Can Public Health Find Its Way?" Lancet (05/07/94) Vol. 343, No. 8906, P. 1145 (Decosas, Josef) Every war has its victims, and one of the victims of the war on AIDS is the discipline of public health, says Dr. Joseph Decosas of the GTZ Regional AIDS Programme for West and Central Africa. Institutions are too desperately devoted to stopping AIDS, he says. Decosas asks is it truly that important to demonstrate condom use, to spend so much effort trying to prove that treatment of sexually transmitted diseases curb the spread of AIDS, or to commission a high-powered public health professional to coordinate the activities of prostitute collectives? Of course there is a need for public education campaigns, condom marketing, economic and demographic impact analyses, and human rights conferences. But, Decosas wonders, how can the effects of these diverse activities be measured on a single cost-effectiveness scale? They cannot, he concludes, unless "stopping AIDS" is the focus. The concept of fighting AIDS by stopping HIV, however, is seriously flawed and should be discarded, Decosas asserts. Most regions in the world already have an established HIV epidemic. What is truly needed, then, is new programs, new approaches, radical reforms, and a social response ranging from a review of legislation to rethinking of national industrial development plans. "Protecting Women From AIDS" Lancet (05/21/94) Vol. 343, No. 8908, P. 1284 (Rowe, Paul M.) Despite health education campaigns, risky sexual activities are still common among Americans, and are especially severe in the Haitian, Jamaican, and Latina communities. The National AIDS Behaviour Study found that 11 percent of American women between the ages of 18 and 49 were at some risk for HIV infection. Among Latina women, many clung to the myth that women should be submissive and less sexually knowledgeable than men. And among the poor and uneducated Haitian immigrants in Florida, extreme culture and language barriers rendered the idea of "safe sex" completely useless. Most of these women believe disease is caused by supernatural causes, and many are economically dependent on their partners--who are often promiscuous. They have very little control over their own lives. Under such conditions, women are not positioned to negotiate safe sex, and even those who are better-positioned do not consider it worthwhile. ------------------------------ End of HICNet Medical News Digest V07 Issue #25 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD