HICNet Medical News Digest Thu, 19 Jan 1995 Volume 08 : Issue 04 Today's Topics: [MMWR 6 Jan 95] Hemorrhage/Shock with Invasive Pneumococcal Infections [MMWR] Asthma -- United States, 1982-1992 [MMWR] Changes in Notifiable Diseases Data Presentation [MMWR] Lack of Evidence for Wild Poliovirus Circulation [MMWR] Recommended Childhood Immunization Schedule New Listserv: Addiction-Medicine AIDS Daily Summary +------------------------------------------------+ ! ! ! 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 Mosaic WWW *Asia/Pacific: http://biomed.nus.sg/MEDNEWS/welcome.html *Americas: http://cancer.med.upenn.edu:3000/ *Europe: http:/www.dmu.ac.uk/0/departments/pharmacy/archive/www/MEDNEWS/welcome .html 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. MPH, 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, 19 Jan 95 07:33:38 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR 6 Jan 95] Hemorrhage/Shock with Invasive Pneumococcal Infections Message-ID: Hemorrhage and Shock Associated with Invasive Pneumococcal Infection in Healthy Infants and Children -- New Mexico, 1993-1994 From December 1993 through May 1994, four previously healthy children (including two infants) in New Mexico developed a severe illness characterized by septic shock and hemorrhage into the skin or internal organs. An investigation subsequently implicated Streptococcus pneumoniae as the cause of illness. The two infants attended the same child care center (CCC) and died 6 weeks apart. This report describes the syndrome, an investigation of potential transmission in the CCC, and prevention measures. Case Investigations On December 10, 1993, the New Mexico Department of Health (NMDH) received a report of a previously healthy 4-month-old girl (patient 1) who died from septic shock with petechiae and hemorrhage into the adrenal glands, heart, and diaphragm. Blood and tissue cultures were negative. However, because her clinical presentation suggested meningococcemia, a prophylactic regimen of rifampin was prescribed for infants, toddlers, and staff at the CCC she attended. On February 9, 1994, a 7-month-old infant (patient 2) who attended the same CCC died from septic shock, purpura, and Waterhouse-Friderichsen syndrome. Gram-positive cocci were detected on a smear of the patient's blood buffy coat, and a latex agglutination test on cerebrospinal fluid (CSF) indicated infection with S. pneumoniae as the cause of death; pneumococcal infection was confirmed by polymerase chain reaction (PCR), using primers for the pneumococcal autolysin gene on autopsy tissue, and by counterimmunoelectrophoresis (CIE) of CSF (serogroup 19). Analysis of autopsy tissue from patient 1, using the same PCR assay, suggested that she also had died from pneumococcal infection. On February 17 and May 13, 1994, NMDH received reports of two other previously healthy children in whom septic shock and purpura fulminans had been diagnosed but who resided in different communities and who did not attend the CCC. Both children (aged 22 months and 4 years) were critically ill but fully recovered. Routine cultures were negative for both patients, but S. pneumoniae (serogroups 14 and 12, respectively) was detected by CIE of CSF from each child. CCC Investigation After determining the specific cause of death for the two infants, NMDH evaluated potential transmission of pneumococcal disease in the CCC. At the time of the investigation (February 9-March 25), 75 children aged 6 weeks-10 years were enrolled in the CCC, and 17 persons were employees there. CCC attendees were divided into classrooms by age: the infant group (age less than 1 year) had infrequent contact with the toddler group (age 1-2 years) and no contact with the older children. Staff rotated between the classrooms. The CCC staff routinely adhered to infection-control procedures that were consistent with state and federal guidelines, including handwashing after diaper changes and exclusion of infants and children with potentially infectious illnesses (1). To characterize the number and type of illnesses occurring among attendees aged less than or equal to 2 years during the 2-week periods preceding the two infants' deaths, NMDH conducted a self-administered survey of CCC staff and parents of CCC attendees. Parents were asked if their children had symptoms including cough, fever, and conjunctivitis or if a physician had told them their child had otitis media, pneumonia, or sinusitis--illnesses suggestive of pneumococcal infection. Six of the nine members of the infant group (excluding patients 1 and 2) and four of eight in the toddler group had had illnesses suggestive of pneumococcal infection during November 26-December 10, 1993. Otitis media was diagnosed by a physician for the six ill infants and three of the four ill toddlers; one of the ill toddlers had had purulent conjunctivitis. During January 25- February 8, 1994, illnesses suggestive of pneumococcal infection were diagnosed in five of the nine infants (four with otitis media and one with otitis media and pneumonia) and two of the eight toddlers (one with otitis media and one with otitis media and purulent conjunctivitis). To assess the prevalence of pneumococcal carriage, on February 11, nasopharyngeal samples were obtained from CCC staff and from children in the infant and toddler groups. Of the 38 persons from whom swabs were obtained, pneumococci were isolated from six children and two staff (serogroup 19 in two infants and one toddler). To prevent additional cases among children and staff at the CCC, NMDH and CDC, in consultation with University of New Mexico clinicians, recommended pneumococcal polysaccharide vaccine for all children aged greater than or equal to 2 years and for all staff. Because the vaccine is poorly immunogenic in children aged less than 2 years, health officials recommended those children receive one dose of benzathene penicillin administered intramuscularly with a repeat dose 1 month later. Reported by: L Nims, MS, K Hatch, M Gallaher, MD, R Voorhees, MD, M Tanuz, I Vold, MPH, M Goldstein, MD, C Powers, J Knott, N Kalishman, MD, G Simpson, MD, CM Sewell, DrPH, State Epidemiologist, New Mexico Dept of Health; A Paul, MD, L Shandler, MD, Santa Fe, New Mexico; KB Nolte, MD, New Mexico Office of the Medical Investigator; G Overturf, MD, Univ of New Mexico Hospital, Albuquerque. J Groover, D Musher, MD, Veteran's Administration Medical Center, Houston. Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: S. pneumoniae is the most common cause of invasive bacterial disease in the United States (2). The findings in New Mexico indicate that systemic pneumococcal infection in previously healthy children may be complicated by the rapid onset of septic shock accompanied by hemorrhage into the skin or other organs. Overwhelming sepsis with hemorrhagic complications has been well documented in persons who are asplenic and in adults with underlying medical conditions (3,4). However, reports of hemorrhage and shock associated with pneumococcal septicemia in previously healthy children have been limited and have included cases in a previously healthy 13-month-old who developed fatal Waterhouse-Friderichsen syndrome (5); two children with purpura fulminans (6); and two children with pneumococcal septicemia, shock, and hemorrhagic complications (7). Because CSF, blood, and tissue cultures were negative, determining the etiology of the four cases in New Mexico required use of alternative diagnostic methods. Latex agglutination testing is performed on CSF specimens of some patients with suspected bacterial meningitis. CIE, a technique not commonly used, is highly specific for most pneumococcal serogroups when used on CSF specimens, but its sensitivity may be lower than that of other methods (8). The validity of PCR using primers for the pneumococcal autolysin gene on autopsy tissue has not been evaluated (9). Although the most common pneumococcal diseases in persons in CCCs include otitis media and sinusitis, transmission of invasive pneumococcal disease in this setting has been reported previously (10). The report of the two deaths among children who attended the New Mexico CCC underscores the need to improve prevention of pneumococcal disease transmission in CCCs. However, until a vaccine effective in children aged less than 2 years is developed and licensed, substantial morbidity from pneumococcal infections among children in CCCs will probably continue to occur. The incidence of hemorrhage and shock as a complication of pneumococcal infection in healthy children is unknown. Identification of S. pneumoniae as the etiology of infection in a child with this presentation is difficult when cultures are negative and other diagnostic tests are not performed. CDC recommends the following case definition to facilitate further study and reporting of this illness: septic shock, hemorrhage into the skin (petechiae or purpura) or Waterhouse- Friderichsen syndrome, and evidence of pneumococcal infection in an otherwise healthy person. Evidence of pneumococcal infection may include isolation of pneumococci from sterile body fluids or detection of pneumococci by nonculture methods. If CSF or autopsy tissues are available and routine diagnostic tests are negative, CDC can assist with detection or characterization of pneumococci. Physicians and other health-care providers are encouraged to report patients with this clinical presentation to CDC through their state health departments. References 1. American Public Health Association/American Academy of Pediatrics. Caring for our children--national health and safety performance standards: guidelines for out-of-home child care programs. Washington, DC: American Public Health Association/American Academy of Pediatrics, 1992. 2. Wenger JD, Hightower AW, Facklam RR, Gaventa S, Broome CV, and the Bacterial Meningitis Study Group. Bacterial meningitis in the United States, 1986: report of a multistate surveillance study. J Infect Dis 1990;162:1316-23. 3. Hautekeete ML, Berneman ZN, Bieger R, et al. Purpura fulminans in pneumococcal sepsis. Arch Intern Med 1986;146:497-9. 4. Johansen K, Hansen ST. Symmetrical peripheral gangrene (purpura fulminans) complicating pneumococcal sepsis. Am J Surg 1993;165:642-5. 5. Ryan CA, Wenman W, Henningsen C, Tse S. Fatal childhood pneumococcal Waterhouse-Friderichsen syndrome. Pediatr Infect Dis J 1993;12:250-1. 6. Cohen JR, Lackner R, Keller A, Douglas B. The surgical implications of purpura fulminans. Ann Vasc Surg 1990;4:276-9. 7. Floret D, Andre S. Fulminating pneumococcal septicemia in children. Pediatrie 1985;40:475-80. 8. Ballard TL, Roe MH, Wheeler RC, Todd JK, Glode MP. Comparison of three latex agglutination kits and counterimmunoelectrophoresis for the detection of bacterial antigens in a pediatric population. Pediatr Infect Dis J 1987;6:630-4. 9. Rudolph KM, Parkinson AJ, Black CM, Mayer LW. Evaluation of polymerase chain reaction for diagnosis of pneumococcal pneumonia. J Clin Microbiol 1993;31:2661-6. 10. Cherian T, Steinhoff MC, Harrison LH, Rohn D, McDougal LK, Dick J. A cluster of invasive pneumococcal disease in young children in child care. JAMA 1994;271:695-7. ------------------------------ Date: Thu, 19 Jan 95 07:34:25 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Asthma -- United States, 1982-1992 Message-ID: <3NJ7yc2w165w@stat.com> Asthma -- United States, 1982-1992 Asthma is characterized by variable airflow obstruction with airway hyperresponsiveness; prominent clinical manifestations include wheezing and shortness of breath. During the 1980s, the prevalence of and mortality associated with asthma increased in the United States and other countries (1,2). To describe national trends in disease burden for asthma in the United States, CDC analyzed data for 1982-1992 (the most recent year for which data are available) for deaths, hospital discharges, and self-reported morbidity. This report summarizes the findings of the analysis. This analysis used data maintained by CDC, including the multiple-cause-of-death file, the National Hospital Discharge Survey, and the National Health Interview Survey. For asthma deaths, the underlying cause was listed as International Classification of Diseases, Ninth Revision, Clinical Modification, code 493. Because of the limited accuracy of diagnosing asthma in persons aged greater than 35 years (3), this analysis presents overall age-adjusted rates and rates for persons aged 5- 34 years. Race-specific analyses were restricted to blacks and whites because numbers for other races were too small to enable calculation of stable estimates. From 1982 through 1991*, the overall annual age-adjusted death rate** for asthma increased 40% and steadily, from 13.4 per 1 million population (3154 deaths) to 18.8 per 1 million (5106 deaths). During this period, the rate increased 59% for females (from 15.4 to 24.6) and 34% for males (from 11.7 to 15.7). For persons aged 5-34 years, the rate increased 42%, from 3.4 (401 deaths) to 4.9 (569 deaths) (Figure 1). The annual death rate was consistently higher for blacks than for whites. During this period, the rate increased 41% for females (from 3.6 to 4.6) and 43% for males (from 3.7 to 5.3). The overall annual age-adjusted hospital discharge rate for asthma as the primary diagnosis decreased slightly from 18.4 per 10,000 in 1982 to 17.9 per 10,000 in 1992. For persons aged 5-34 years, the rate was constant in both years (12.8 per 10,000); rates for females were consistently higher than for males, and rates for blacks were consistently higher than for whites. From 1982 through 1992, the overall annual age-adjusted prevalence rate of self-reported asthma increased 42%, from 34.7 per 1000 to 49.4 per 1000. For persons aged 5-34 years, the rate increased 52%, from 34.6 to 52.6 (Figure 2). The rate for males increased by 29% (from 39.7 to 51.4) and for females increased 82% (from 29.4 to 53.6). Reported by: Air Pollution and Respiratory Health Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC. Editorial Note: Three national health objectives for the year 2000 include decreasing disability and hospitalizations for asthma and increasing education about asthma (objectives 11.1, 17.4, and 17.14) (4). Although hospitalization rates for asthma were stable during 1982-1992, both prevalence and death rates increased during this period. Potential explanations for the stable hospitalization rates for asthma, despite the increased prevalence of self-reported disease, include improved outpatient treatment and, because of billing practices, classification of cases of asthma under other diagnostic categories. Prominent racial differences in asthma death rates and hospitalization rates indicate the need for further investigation of potential explanations (e.g., access to appropriate health care and socioeconomic factors). Although the specific etiology of asthma is unknown, this problem may be associated with familial, infectious, allergenic, environmental, socioeconomic, and psychosocial factors. For example, in 1991, an estimated 6.4 million (63%) of the 10.3 million persons with asthma in the United States resided in areas where at least one National Ambient Air Quality Standard was exceeded (5). Factors associated with risk for death among persons with asthma include medication overuse (6), substance abuse (7), and cigarette smoking (8). Morbidity and mortality associated with asthma may be affected by patient compliance, patient education, and medical management. In particular, a high proportion of asthma morbidity and mortality may be preventable through patient recognition and aggressive medical management. In 1989, the National Asthma Education Project was implemented to increase awareness about asthma and to improve effective control of asthma by providing physicians and patients with updated treatment information. This program has developed educational materials for patients and physicians about the treatment of asthma during pregnancy, for physicians about educating patients about asthma, and for educators about adding or improving awareness about asthma in schools. Additional information about these or other asthma materials are available from the National Heart, Lung, and Blood Institute Information Center, telephone (301) 251- 1222. References 1. Weiss KB, Wagener DK. Changing patterns of asthma mortality: identifying target populations at high risk. JAMA 1990;264:1683-7. 2. Woolcock AJ. Worldwide differences in asthma prevalence and mortality: úÿ why is asthma mortality so low in the USA? Chest 1986;90(suppl):40S- 45S. 3. Sears MR, Rea HH, de Boer G, et al. Accuracy of certification of deaths due to asthma: a national study. Am J Epidemiol 1986;124:1004-11. 4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 5. CDC. Populations at risk from air pollution--United States, 1991. MMWR 1993;42:301-4. 6. Ernst P, Habbick B, Suissa S, et al. Is the association between inhaled beta-agonist use and life-threatening asthma because of confounding by severity? Am Rev Respir Dis 1993;148:75-9. 7. Greenberger PA, Miller TP, Lifschultz B. Circumstances surrounding deaths from asthma in Cook County (Chicago) Illinois. Allergy Proc 1993;14:321-6. 8. Marquette CH, Saulnier F, Leroy O, et al. Long-term prognosis of near-fatal asthma: a 6-year follow-up study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma. Am Rev Respir Dis 1992;146:76-81. * Mortality data were not available for 1992. ** Intercensal population estimates were used to calculate age- adjusted rates standardized to the 1980 U.S. population. ------------------------------ Date: Thu, 19 Jan 95 07:35:05 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Changes in Notifiable Diseases Data Presentation Message-ID: <7oJ7yc3w165w@stat.com> Changes in Notifiable Diseases Data Presentation The next issue of MMWR (dated January 13, 1995 [volume 44, number 1]), will incorporate modifications to Tables I and II, Cases of Notifiable Diseases, United States. The purposes of these modifications are to improve the usefulness of notifiable diseases data (1,2) and to respond to changing priorities in notifiable disease surveillance. This report describes the rationale for data dissemination in Table I and Table II. Table I Table I will present the cumulative number of cases of low- frequency diseases (in general, less than or equal to 500 cases per year) reported for the current year. In addition, Table I will present the reported number of cases of congenital syphilis, which currently is updated quarterly, and Haemophilus influenzae, for which serotype-specific information about the vaccine-preventable subgroup (serotype b) often is not reported. Data that will be deleted from Table I, but that will continue to be published in Table II, include the number of reported cases of acquired immunodeficiency syndrome (AIDS), gonorrhea, Lyme disease, measles, syphilis (primary and secondary), and tuberculosis. Publication of reports of cases of botulism will be discontinued in MMWR (weekly) but will be included in the Annual Summary of Notifiable Diseases. Diseases proposed for deletion from the national notifiable diseases list by the Council of State and Territorial Epidemiologists (CSTE) at its National Surveillance Conference (November 30-December 2, 1994) include aseptic meningitis, primary encephalitis (except for arboviral encephalitis), postinfectious encephalitis, unspecified hepatitis, leptospirosis, and tularemia. These diseases had been published weekly; they will continue to be published in Table I until deletion is formally approved by CSTE. Table II Table II will present high-frequency diseases (in general, greater than 500 cases per year) or selected diseases targeted by the national Childhood Immunization Initiative for elimination of indigenous transmission in the United States (3). Cumulative totals for both the current and immediately preceding years will be presented by state or territory. Table II also will present the number of cases of measles, pertussis, and rubella reported during the previous week. Reports of cases of imported measles previously included out-of-state cases but now will include only the number of cases believed to have resulted from importation from other countries. The category indigenous measles cases will include all other measles cases reported by the state or territory. Publication of reports of cases of three diseases--tickborne typhus fever (Rocky Mountain spotted fever), toxic shock syndrome, and typhoid fever--will be discontinued in Table II but will be included in Table I. Reported by: Council of State and Territorial Epidemiologists. Div of Surveillance and Epidemiology, Epidemiology Program Office, CDC. Editorial Note: National notifiable diseases data presented weekly in MMWR generally are transmitted through the National Electronic Telecommunications System for Surveillance (NETSS) (4); the exception is data on AIDS cases, which are transmitted through the human immunodeficiency virus/AIDS reporting system. A key determinant for the changes in the table formats was the importance of listing the distribution of cases by state or region for high-frequency diseases and diseases targeted for national elimination. As a basis for comparison, cumulative totals for both current and past year (when available) will be presented for the diseases listed in Table II. The decision to change the classification of imported measles cases will facilitate tracking of cases imported from other countries. Weekly publication of NETSS data on botulism cases was not believed to be either timely or useful because an emergency botulism antitoxin surveillance system is already in place. Although deletions and additions to the national notifiable diseases list generally are made during CSTE's annual meeting in the spring, the recent national surveillance conference focused on changes to the list. During that meeting, proposals also were tentatively approved for adding diseases to national public health surveillance, including genital chlamydia infections, coccidioidomycosis (recommended for regional surveillance), cryptosporidiosis, hantavirus infection, hemolytic uremic syndrome, invasive group A streptococcal infections, and drug- resistant Streptococcus pneumoniae. These additions have not yet been formally approved by CSTE. References 1. CDC. Update: changes in notifiable disease surveillance data-- United States, 1992-1993. MMWR 1993;42:824-6 2. CDC. National notifiable diseases reporting--United States, 1994. MMWR 1994;43:800-1. 3. CDC. Reported vaccine-preventable diseases--United States, 1993, and the Childhood Immunization Initiative. MMWR 1994;43:57-60. 4. CDC. National Electronic Telecommunications System for Surveillance- - United States, 1990-1991. MMWR 1991;40;502-3. ------------------------------ Date: Thu, 19 Jan 95 07:36:20 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Lack of Evidence for Wild Poliovirus Circulation Message-ID: <0qJ7yc5w165w@stat.com> Lack of Evidence for Wild Poliovirus Circulation -- United States, 1993 Following the isolation of wild poliovirus type 3 during January- February 1993 among members of a religious community objecting to vaccination in Alberta, Canada, surveillance for poliomyelitis was enhanced among related communities in the United States (1). In addition, during May-July 1993, a series of surveys was conducted in seven states (Iowa, Missouri, New York, Ohio, Pennsylvania, Washington, and Wisconsin) to determine whether wild poliovirus was circulating or had circulated recently among members of these religious communities residing in the states. This report summarizes the results of these surveys. The isolation of wild poliovirus in Canada and the efforts to enhance surveillance in the United States followed a polio outbreak in the Netherlands during September 1992-February 1993 (2-4). The outbreak was attributed to wild poliovirus type 3 and resulted in 71 cases of polio among members of a religious community objecting to vaccination. A virtually identical genotype of wild poliovirus type 3 was subsequently isolated from stool samples collected from members of related religious groups in Alberta during January-February 1993 (3) and again from samples collected in April 1993; however, this genotype was not isolated from samples collected in June 1993 (P. Duclos, Laboratory Center for Disease Control, Ottawa, Canada, personal communication, November 1994). Based on nucleotide sequence studies, the poliovirus detected in the Netherlands and Canada most likely originated in India (4). In response to the importation of poliovirus type 3 into the Western Hemisphere, measures taken by state health departments in the United States during April 1993 included 1) intensified efforts to vaccinate persons in religious communities that usually object to vaccination; 2) enhanced surveillance to identify medical conditions possibly caused by poliovirus (i.e., aseptic meningitis and acute paralysis); and 3) the initiation of a series of serologic, stool, and/or environmental surveys in Iowa, Missouri, New York, Ohio, Pennsylvania, Washington, and Wisconsin. The purpose of these surveys was to determine whether poliovirus type 3 was circulating currently or had circulated at any time since 1980 among unvaccinated members of these religious communities. No cases of aseptic meningitis or acute paralysis have been detected among members of the religious communities since April 1993. Members of these religious communities were enrolled for the serologic, stool, and environmental surveys; poliovirus was not isolated (or detected) in the 122 stool specimens collected from members of 73 families in five states (Iowa, Missouri, Ohio, Pennsylvania, and Washington). A total of 123 serum specimens from persons in four states (Missouri, Ohio, Pennsylvania, and Washington) were tested for neutralizing poliovirus antibody; antibody to poliovirus types 1, 2, or 3 were detected in 40%, 92%, and 26% of specimens, respectively. However, poliovirus type 3 was not detected in any of the 40 children from Ohio and Pennsylvania who were unvaccinated and born after 1979. Based on the serologic surveys, poliovirus type 3 had not circulated in these communities since 1980. A total of 12 sewage and latrine waste specimens was collected during June and July 1993 from Iowa, Missouri, New York, Pennsylvania, and Wisconsin and was examined by polymerase chain reaction; wild poliovirus was not detected in these samples. Reported by: AM Shemo, MD, S Miller, R Longenecker, A Gray, F Zitnik, R Berman, Pennsylvania Dept of Health. J Bronowski, T Payton, R Genieve, TJ Halpin, MD, State Epidemiologist, Ohio Dept of Health. F James, MD, J Hensley, Whatcom County Health Dept, Bellingham; S LaCroix, State Public Health Laboratory, Washington State Dept of Health. C Friedman, DO, J Hinkle, H Marx, HD Donnell, Jr, MD, State Epidemiologist, Missouri Dept of Health. J Berg, Div of Health, Wisconsin Dept of Health and Social Svcs. J Warming, D Miller, Iowa Dept of Public Health. S Thompson, G Birkhead, MD, D Krohn, New York State Dept of Health. R Berke, MD, M Clark, Chautauqua County Health Dept, Jamestown, New York. M Sobsey, PhD, Environmental Virology Laboratory, Univ of North Carolina, Chapel Hill. Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; National Immunization Program, CDC. Editorial Note: Wild poliovirus infection has not been documented among persons in the United States since 1986, when wild poliovirus type 1 was isolated from a person with imported paralytic polio. The last indigenous cases of polio in the United States occurred in 1979 (5), and the last imported case in which wild poliovirus was not isolated was reported in 1993*. Polio can be prevented by vaccination. All children and all previously unvaccinated adults should receive a primary series of at least three doses of oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine. For children, the standard recommended 4-dose series of OPV comprises doses at ages 2, 4, and 6 months and 4-6 years (6). The findings in this report suggest that poliovirus type 3, which caused both the outbreak in the Netherlands during 1992-93 (4) and the "silent" transmission in Canada during 1993 (3), was not imported into the United States. Despite these findings, members of religious groups that object to vaccination and suboptimally vaccinated preschool-aged children who reside in urban areas may be susceptible to polio. If poliovirus is introduced into these unvaccinated groups, the number of persons who are susceptible may support virus circulation. Some members of groups usually opposed to vaccination will accept vaccination if offered. On September 29, 1994, the International Commission for the Certification of Polio Eradication concluded that wild poliovirus transmission had been interrupted in the Western Hemisphere (7). However, the commission recognized that the region will remain at risk for poliovirus importation until polio is eradicated globally (8). The importations into the Netherlands and Canada underscore the efficiency by which poliovirus can be transported across borders and continents (3,9,10). Unvaccinated persons in groups objecting to vaccination is the primary group in the United States in which transient circulation of imported poliovirus may occur. To ensure that poliovirus transmission cannot be sustained in the United States, poliovirus vaccination coverage should be increased to 90% in all areas. References 1. CDC. Poliomyelitis--Netherlands, 1992. MMWR 1992;41:775-8. 2. CDC. Update: poliomyelitis outbreak--Netherlands, 1992. MMWR 1992;41:917-9. 3. CDC. Isolation of wild poliovirus type 3 among members of a religious community objecting to vaccination--Alberta, Canada, 1993. MMWR 1993;42:337-9. 4. Oostvogel PM, van Wijngaarden JK, van der Avoort HG, et al. Poliomyelitis outbreak in an unvaccinated community in The Netherlands, 1992-93. Lancet 1994;344:665-70. 5. Strebel PM, Sutter RW, Cochi SL, et al. Epidemiology of poliomyelitis in the United States one decade after the last reported case of indigenous wild virus-associated disease. Clin Infect Dis 1992;14:568-79. 6. CDC. General recommendations on immunizations: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994;43(no. RR-1). 7. CDC. Certification of poliomyelitis eradication--the Americas, 1994. MMWR 1994;43:720-2. 8. Pan American Health Organization. Americas certified polio free. EPI Newsletter 1994;16:2-3. 9. Rico-Hesse R, Pallansch MA, Nottay BK, Kew OM. Geographic distribution of wild poliovirus type 1 genotypes. Virology 1987;160:311-22. 10. Kew OM, Pallansch MA, Nottay BK, Rico-Hesse R, De L, Yang CF. Genotypic relationship among wild polioviruses from different regions of the world. In: Brinton MA, Heinz FX, eds. New aspects of positive-strand RNA viruses. Washington, DC: American Society for Microbiology 1990;52:357-65. * This imported case occurred in a 2-year-old child who had onset of paralysis on December 15, 1993, in Nigeria and was brought for tertiary hospital care to New York 2 weeks later; no poliovirus was isolated from this child. ------------------------------ Date: Thu, 19 Jan 95 07:37:14 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: [MMWR] Recommended Childhood Immunization Schedule Message-ID: Recommended Childhood Immunization Schedule -- United States, January 1995 Since the 1960s, the two groups that historically have developed vaccine guidelines for the United States have been the Advisory Committee on Immunization Practices (ACIP) and the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP). During 1994, these organizations participated in a working group that included representatives from the American Academy of Family Physicians to develop one vaccination schedule that would accommodate the current ACIP and AAP recommendations and ensure the earliest administration of vaccines. The recommended childhood immunization schedule (Table 1) has been endorsed by these groups and becomes effective January 1995. In the first year of life, three doses each of diphtheria and tetanus toxoids and pertussis vaccine (DTP), Haemophilus influenzae type b (Hib) vaccine, and oral poliovirus vaccine (OPV) are recommended to be administered at ages 2, 4, and 6 months; however, the third dose of OPV may be administered through age 18 months, and for children who receive Haemophilus b conjugate vaccine (Meningococcal Protein Conjugate) (PRP- OMP) at ages 2 and 4 months, a dose at age 6 months is not required. For hepatitis B vaccine, the first dose is recommended at birth (but can be given up to age 2 months), the second at age 2 months (age 1-4 months is acceptable, provided at least 1 month has elapsed since receipt of the first dose), and the third at age 6- 18 months. Vaccines recommended at age 12-15 months can be administered simultaneously during one visit or during two separate visits. The second dose of measles, mumps, and rubella vaccine (MMR) may be given at entry to kindergarten or middle school. Diphtheria and tetanus toxoids (Td) is recommended at age 11-12 years but may be given through age 14-16 years. When this vaccine is given at age 11-12 years, health-care providers can ensure that the child has received a second dose of MMR. Reported by: Advisory Committee on Immunization Practices. American Academy of Pediatrics. American Academy of Family Physicians. National Immunization Program, CDC. ------------------------------ Date: Thu, 19 Jan 95 07:38:37 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: New Listserv: Addiction-Medicine Message-ID: <3uJ7yc7w165w@stat.com> ====================================================================== New InterPsych Forum: Addiction-Medicine ====================================================================== To join send the message: subscribe addiction-medicine to: MAJORDOMO@AVOCADO.PC.HELSINKI.FI ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ This conference has been set up to encourage an exchange of ideas, opinions, and information among health care professionals working in the field of addiction to alcohol and/or other psychoactive substances. A broad working definition of addiction follows: "Addiction is a disease characterized by continuous or periodic; impaired control over the use of drugs or alcohol, preoccupation with drugs or alcohol, continued use of these chemicals despite adverse consequences related to their use, and distortions in thinking, most notably denial." (Adapted from the American Society of Addiction Medicine). We recognize that there is a spectrum of use of alcohol and some psychoactive drugs, from intermittent use that does not interfere with health, to malignant destructive use. For the purposes of this list we would in general encourage open discussion about all aspects of addiction as defined above. Please note that this list is intended for those working in the field and is not to be used as a recovery list to work on individual issues. Such work is supported by many lists on Internet. Strong opinions are welcomed, but flaming will NOT be tolerated! ====================================================================== Peter E Mezciems, MD, CCFP. Director of Undergraduate Education Homewood Alcohol and Drug Services Homewood Health Centre 150 Delhi St. Guelph, Ontario Canada N1E 6K9 Voice: 519-824-1762, ext. 159 Fax: 519-824-1827 ====================================================================== Mr Ian Pitchford Department of Biomedical Science University of Sheffield Western Bank SHEFFIELD, S10 2TN United Kingdom Tel: +44 742 780319 ------------------------------ Date: Thu, 19 Jan 95 07:49:41 MST From: mednews@stat.com (HICNet Medical News) To: hicnews Subject: AIDS Daily Summary Message-ID: AIDS Daily Summary úÿ 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 In this issue: ********************************************************************* "Human Tests Near on Oral AIDS Vaccine" "Intersecting Epidemics--Crack Cocaine Use and HIV Infection among Inner-City Young Adults" "CDC Links Rifabutin Use to Uveitis in Some Patients" "Medical Briefs: Cell-Based Therapy on Trial" "Randomised Trial of Thiacetazone and Rifampicin-Containing Regimens for Pulmonary Tuberculosis in HIV-Infected Ugandans" "HIV-1 in Blister Fluid of a Patient with Toxic Epidermal Necrolysis and AIDS" "Immune Reconstitution for AIDS" "Postnatal Transmission of HIV-1 through Pooled Breast Milk" "Association Between Hepatitis E Virus and HIV Infection in Homosexual Men" "The Response of Symptomatic Neurosyphilis to High-Dose Intravenous Penicillin G in Patients with Human Immunodeficiency Virus Infection" "Approaches to AIDS Vaccines" "Hypopyon Uveitis in Patients with Acquired Immunodeficiency Syndrome Treated for Systemic Mycobacterium Avium Complex Infection with Rifabutin" "Learning about HIV-2" "Use of Living Wills in HIV Infection and AIDS" "Cellular Immune Response to Common Mycobacterial Antigens in Subjects Seropositive for Trypanosoma Cruzi" "The WHO and Why of HIV Vaccine Trials" "HIV Testing in Prison: What's the Controversy?" "Non-Cytolytic CD8 T-Cell Anti-HIV Responses in Primary HIV-1 Infection" "Patient-to-Patient HIV Transmission Trial" "The Cost-Effectiveness of Voluntary Counseling and Testing of Hospital Inpatients for HIV Infection" "Management of Suicidal Patients with HIV Disease" "The Next Step Toward a Global AIDS Vaccine" "Survival and Disease Progression According to Gender of Patients with HIV Infection" "Mother to Child Transmission of Zidovudine-Resistant HIV-1" ********************************************************************* "Human Tests Near on Oral AIDS Vaccine" New York Times (12/01/94) P. A18 Patients were enrolled at San Francisco General Hospital this week for the first human test of an oral AIDS vaccine. An oral vaccine, said Dr. James Kahn, was easier to administer than an injected medicine and stimulated the body to fight HIV at it first line of defense--the fluids of the membranes that line the digestive and respiratory systems. Kahn reported in November that his study of the injected version of the drug found it to be safe. The virus was fought off by antibodies from approximately 80 percent of the patients in test-tube studies. Kahn said he would evaluate the safety of the oral vaccine for potential use in producing antibodies in sperm, vaginal fluid, and saliva. "Intersecting Epidemics--Crack Cocaine Use and HIV Infection among Inner-City Young Adults" N.E.J.M. (11/24/94) Vol. 331, No. 21, P. 1422 Edlin, Brian R.; Irwin, Kathleen L.; Faruque, Sairus et al Edlin et al studied 1967 people between the ages of 18 and 29 from inner-city communities in Miami, New York City, and San Francisco who had never smoked crack to determine the relationship between smoking crack cocaine and HIV infection. Smoking crack is thought to be associated with high-risk sexual practices that accelerate the spread of HIV. The prevalence of HIV infection was 2.4 times higher among crack smokers that among the nonsmokers. Crack-smoking women in New York City and Miami had the highest prevalence of HIV positivity at 29.6 percent and 23 percent, respectively. A total of 30.4 percent of the 283 women in the two cities who had sex in exchange for drugs or money were infected with HIV, compared to 9.1 percent of the 286 other women. Almost 43 percent of the 91 men who had anal sex with other men were HIV-infected, but only 9.3 of the 582 men who did not have anal sex were infected with HIV. The higher prevalence of HIV infection among crack smokers seems to be because of the high-risk sexual practices of this group. The researchers concluded that in inner-city communities, young smokers of crack cocaine-- especially women who exchange sex for money or drugs--are at high risk for infection with HIV. If effective measures are not taken, they reasoned, crack use is likely to result in continued heterosexual HIV transmission. "CDC Links Rifabutin Use to Uveitis in Some Patients" AIDS Alert (11/94) Vol. 9, No. 11, P. 159 The Centers for Disease Control and Prevention reports that the use of rifabutin for prophylaxis for Mycobacterium avium complex (MAC) has caused uveitis in some patients. Uveitis is an inflammatory eye condition characterized by pain, redness, and temporary or permanent loss of vision. The condition has occurred in participants of studies for treatment and prophylaxis of MAC using doses of 300-900 mg of rifabutin per day in conjunction with other drugs, such as clarithromycin and fluconazole. The CDC says that while uveitis was rare in patients who only used rifabutin, the higher doses administered in combination with other drugs may create a higher risk. "Medical Briefs: Cell-Based Therapy on Trial" Advocate (11/15/94) No. 668, P. 44 Researchers from Activated Cell Therapy Inc. and the Stanford University School of Medicine will study a cell-based therapy created to boost the immune systems of people with HIV. The National Institute of Allergy and Infectious Diseases' Strategic Program for Innovative Research on AIDS Treatment has provided a grant for this research. The scientists will infuse extremely strong antigen-presenting cells from uninfected siblings--treated with HIV antigens--into the patients. By conducting this study, the researchers hope to prime the patient's T cells against HIV and increase their immunity to the virus. "Randomised Trial of Thiacetazone and Rifampicin-Containing Regimens for Pulmonary Tuberculosis in HIV-Infected Ugandans" Lancet (11/12/94) Vol. 344, No. 8933, P. 1323 Okwera, A.; Whalen, C.; Byekwaso, F. et al In a randomized clinical trial of HIV-infected patients with active pulmonary tuberculosis, researchers studied the safety and short-term efficacy of thiacetazone and rifampicin-containing regimens. Thiacetazone has been associated with cutaneous hypersensitivity and recurrent tuberculosis among HIV-positive patients receiving treatment for active tuberculosis. A total of 191 HIV-positive adult Ugandan participants with acid-fast bacilli sputum smear-positive pulmonary tuberculosis received isoniazid, rifampicin, and pyrazinamide for two months followed by isoniazid and rifampicin for seven months (a regimen known as RHZ) or streptomycin, thiacetazone, and isoniazid for two months followed by thiacetazone and isoniazid for 10 months (a regimen called STH). The overall one-year rate of survival for the two regimens was similar but the relative risk of death for STH compared to RHZ--when controlled for baseline differences in Mantoux reaction size and absolute lymphocyte count--was 1.57. A greater percentage of RHZ patients compared to STH patients had sterilized their sputum within two months. The researchers recommend that rifampicin-containing regimens be given to HIV-infected patients in developing countries to reduce drug toxicity and to extend survival. "HIV-1 in Blister Fluid of a Patient with Toxic Epidermal Necrolysis and AIDS" Lancet (11/19/94) Vol. 344, No. 8934, P. 1432 Correia, Osvaldo; Delgado, Luis; Santos, Cristina et al The existence of markers for HIV infection in the blister fluid of a patient with toxic epidermal necrolysis (TEN) and full-blown AIDS is described in a letter to the editor by Correia et al appearing in the Lancet. A series of tests for HIV-1 and HIV-2 were performed on blood and blister fluid samples from a 34-year-old woman. Definitive evidence of HIV-1 infection in the patient was proven by HIV-1 antibodies, positivity to different viral antigen bands, HIV core antigen p24 positivity, and a positive viral culture in the skin blister fluid. The results emphasize the need for safety precautions for blood and body fluids. While the antigen specificity of epidermal CD8 T lymphocytes in TEN--in which significant numbers of CD8 T cells are found--has not been determined, numerous AIDS studies propose that both the increase in non-specific cytotoxic responses and CD8 HIV-specific cytotoxic T lymphocytes play a part in pathological syndromes associated with HIV infection. Correia et al suggest that the findings could also be related to the increased risk of severe cutaneous adverse reactions, such as TEN, in AIDS patients. "Immune Reconstitution for AIDS" Science (11/18/94) Vol. 266, No. 5188, P. 1150 Rachel Nowak The theory that it is possible to cure late-stage AIDS by reconstructing the patient's immune system with a that of a baboon may soon be tested, if the proposal is approved by the ethics review board at the University of California, San Francisco (UCSF). Transplant surgeon and immunologist Suzanne Ildstad conceived the plan to transplant baboon bone marrow into four late-stage AIDS patients. Ildstad, UCSF AIDS researcher Paul Volberding, and others have created a baboon whose immune cells are 15 percent human, although it is not yet clear whether the cells are functional. The clinical trial plans a cautious approach designed to minimize the risk to patients. The first patient will receive very low doses of irradiation and immunosuppressive drugs--both of which can be toxic to HIV-infected patients--and only if the levels are tolerated will the second patient undergo the procedure. Some AIDS researchers, however, claim that human trial are premature. Two of the many questions they would like answered before trials begin are will the baboon immune cells be able to effectively attack agents that infect AIDS patients, and is the damaged human immune system capable of "educating" the baboon stem cells to tolerate human tissue. "Postnatal Transmission of HIV-1 through Pooled Breast Milk" Lancet (11/19/94) Vol. 344, No. 8934, P. 1432 Nduati, R. W.; John, G. C.; Kreiss, J. In a letter to the editor appearing in the Lancet medical journal, Nduati et al report a case of HIV-1 infection in Kenya that is likely due to pooled breast milk. Because of a decrease in his mother's milk production, a male infant's milk intake was supplemented for four weeks with freshly unpasteurized pooled milk from the mothers of other infants admitted to the same unit. During an evaluation for failure to thrive, he was noted to have generalized lymphadenopathy. HIV-1 infection was confirmed when an HIV ELISA test came back positive, as did repeat ELISA and western blot tests. The boy received all his primary immunizations at the mission hospital in which he was born and his mother was assured that both the needles and syringes were sterile. It is probable that the boy became infected from pooled breast milk, although his prematurity and oral thrush might have made him more susceptible to acquisition of infection. While recommendations to pasteurize donor breast milk and screen donors for HIV-1 antibodies have been made, it is not likely that the recommendations have been widely accepted in developing countries. This case highlights the need for attention to the potential of HIV transmission through breast milk--especially in areas of high seroprevalence, conclude Nduati et al. "Association Between Hepatitis E Virus and HIV Infection in Homosexual Men" Lancet (11/19/94) Vol. 344, No. 8934, P. 1433 Montella, F.; Rezza, G.; Di Sora, F. et al Although little is known about the risk factors for hepatitis E (HEV), in industrialized countries, higher prevalence rates have been found in injection drug users (IDUs) and in travelers to endemic areas, write Montella et al in a letter to the editor appearing in the Lancet. A total of 162 homosexual men and 66 IDUs attending an outpatient facility in Rome whose sera had been collected for HIV serology were tested for HEV antibodies. The researchers found a higher prevalence of HEV among homosexual men, which indirectly confirms the role of transmission through fecal-oral activity facilitated by sexual practices. Thirty-seven percent of the HEV-positive homosexual men were also HIV-positive, while none of the HEV-positive IDUs were HIV-positive. The reasons for the relationship between HIV and HEV are not clear, but Montella et al suggest that HIV-induced immunosuppression could facilitate HEV transmission. The findings may be explained by the high frequency of sexual practices at risk for HEV infection in people with HIV risk behavior. "The Response of Symptomatic Neurosyphilis to High-Dose Intravenous Penicillin G in Patients with Human Immunodeficiency Virus Infection" N.E.J.M. (12/01/94) Vol. 331, No. 22, P. 1469 Gordon, Steven M.; Eaton, Molly E.; George, Rob et al To determine whether HIV infection affects the course of syphilis and the response to treatment, researchers studied the response to treatment with high-dose penicillin G benzathine in 11 HIV-positive participants with symptomatic neurosyphilis. The patients were intravenously administered 18 million to 24 million units of penicillin G benzathine daily. The researchers found that after 24 weeks, four of the seven patients studied had decreased serum titers on rapid plasma reagin (RPR) testing by at least two doubling dilutions, and four patients had reductions in the cerebrospinal fluid titers on Venereal Disease Research Laboratory (VDRL) testing or reverted to nonreactive results. There was no normalization or improvement in serum titers on RPR testing or cerebrospinal fluid titers on VDRL testing, cell counts, or protein concentrations in two patients. Six months after treatment, one patient relapsed with meningovascular syphilis. Although T. pallidum was detected in three of 10 patients before treatment, it was not found in any of the 10 post-treatment specimens. Gordon et al concluded that therapy may fail and neurosyphilis may develop in HIV-infected patients with early syphilis. The high-dose penicillin recommended for neurosyphilis is not consistently effective in HIV-positive patients. "Approaches to AIDS Vaccines" Lancet (11/19/94) Vol. 344, No. 8934, P. 1425 Rowe, Paul M. Several approaches to AIDS vaccines were presented at the seventh annual meeting of the National Cooperative Vaccine Development Groups for AIDS. Patricia N. Fultz of Alabama presented data suggesting that attenuated virus can induce strain-specific immunity and that vaccines must incorporate whatever strain is present in the population in order to be protected. Michael S. Wyand of Massachusetts informed the group that an attenuated SIV construct with three genes deleted generated protective immunity in adult macaques. He also found that the number of monkeys protected from an SIV challenge expanded with time after vaccination. Ruth M. Ruprecht, also of Massachusetts, however, injected three newborn macaques with the attenuated SIV construct with three genes deleted and all have developed persistent high levels of replicating virus and AIDS--one has died. Raymond A Daynes of Utah presented a report showing that mucosal immunity can be induced through vaccination using 1.25 dihydroxy vitamin D(3) as an adjuvant. The findings suggest that lymphocytes adjust their pattern of cytokine secretion and choose the tissue to which they will return after circulation through the lymph system. "Hypopyon Uveitis in Patients with Acquired Immunodeficiency Syndrome Treated for Systemic Mycobacterium Avium Complex Infection with Rifabutin" J.A.M.A. (12/07/94) Vol. 272, No. 21, P. 1636p Iridocyclitis is a dosage-dependent side effect in AIDS patients being treated for Mycobacterium avium complex (MAC) infection with systemic rifabutin. In a retrospective study, researchers reviewed seven cases of acute hypopyon uveitis imitating infectious endophthalmitis in AIDS patients to determine whether there was an association. Each of the patients was receiving treatment for MAC infection with rifabutin and clarithromycin. Microbiological investigations showed negative results in five patients. While hypopyon developed in the contralateral eye in five patients, iridocyclitis became bilateral in all seven. The hypopyon cleared up quickly with intensive topical corticosteroid therapy. The researchers concluded that the use of rifabutin, clarithromycin, and fluconazole concomitantly may precipitate hypopyon uveitis in AIDS patients being treated for MAC infection. "Learning about HIV-2" Lancet (11/19/94) Vol. 344, No. 8934, P. 1380 O'Shaughnessy, Michael V.; Schechter, Martin T. Although HIV-1 and HIV-2 are related, the molecular organizations of the two viruses are different and their genetic homology is modest, write O'Shaughnessy et al in a letter to the editor. In comparison to HIV-1, HIV-2 has lower rates of sexual and perinatal transmission, lower cell killing, lower viral burdens, more gradual CD4 cell loss, slower rates of progression to AIDS and death, and relative geographical confinement. Although relatively little is known about why the two viruses act differently, HIV-2 may provide a useful model in the efforts to control HIV-1. Greater understanding of the structure and function relationships of the viral genes that are critical to the disease process may be derived from studies focusing on the two viruses' genetic differences. Because there are no perfect models with which to study HIV, one must exercise caution in extrapolating results to HIV-1. The use of transgenic mice and in-vitro studies of genetically altered HIV-1 variants should also be pursued because they may provide insight into tranmissability and pathogenicity. "Use of Living Wills in HIV Infection and AIDS" Lancet (11/26/94) Vol. 344, No. 8935, P. 1509 Meadows, Paul In October 1992, The Terrence Higgins Trust, in cooperation with the Centre of Medical Law and Ethics at King's College, London, published a form of living will and healthcare proxy specifically designed for use by people with HIV and AIDS, writes Paul Meadows in a letter to the editor of the Lancet medical journal. Thus far, 20,000 copies of the living will form have been distributed. A questionnaire to test the document's acceptability showed that it is mainly being used by men between the ages of 30 and 40 with a diagnosis of HIV or AIDS. Very few of the living will users discussed their advanced directive with anyone and Meadows notes that the form should emphasize the importance of discussing a living will with someone--especially a doctor--to guarantee that the patient's wishes are carried out. A revised living will form that has been simplified to reflect the concerns of the users identified during research and to clarify the accompanying notes is now available. The revision also reflects changes in recent case law, which shows that under certain condition, the advance refusal of medical treatment will be legally binding. "Cellular Immune Response to Common Mycobacterial Antigens in Subjects Seropositive for Trypanosoma Cruzi" Lancet (12/03/94) Vol. 344, No. 8936, P. 1540 úÿ Bottasso, O.A.; Ingledew, N.; Keni, M. et al Researchers studied the impairment of immune responses in patients in the silent stage of Chagas' disease, which is caused by Trypanosoma cruzi and affects about 20 million people in Latin America. Bottasso et al used quadruple skin-testing with new tuberculins in 37 adults who were symptom-free but seropositive for T. cruzi, and in 37 matched seronegative controls. While none of the seropositive group responded to them, nearly one-fifth of the control group responded, with variable specificity, to common mycobacterial antigens. The researchers suggest that the loss of response to mycobacterial antigens may influence the course of Chagas' disease. Individuals who are infected with T. cruzi may be more susceptible to tuberculosis, leprosy, and HIV infection--all of which are associated with immune unresponsiveness. "The WHO and Why of HIV Vaccine Trials" Nature (11/24/94) Vol. 372, No. 6504, P. 313 Moore, John; Anderson, Roy John Moore of the Aaron Diamond AIDS Research Center and Roy Anderson of the Centre for the Epidemiology of Infectious Diseases discuss the reasoning behind the World Health Organization (WHO) advisory committee's decision to approve Phase III HIV vaccine trials in developing countries. Ninety percent of the 16 million people estimated by the WHO to be HIV-infected live in poor communities in the developing world. While the main concern of the committee members was that the products would not work, clinicians and epidemiologists argued that the only way to determine efficacy is to run an efficacy trial. The WHO committee concluded that, ultimately, any decision to go ahead with a trial of any product must be made by the host country for the trial. Phase I/II safety trials should precede a Phase III trial. The panel also stated that the specific HIV-1 subtypes among the proposed trial population should be a significant consideration, as should counseling of the trial populations about the potential risks of vaccination and the necessity of following safe sex practices. The WHO committee emphasized a long-term commitment to AIDS vaccine development and testing worldwide. "HIV Testing in Prison: What's the Controversy?" Lancet (12/17/94) Vol. 344, No. 8938, P. 1650 Diamond, Jan In a Lancet commentary, Jan Diamond of Merrithew Memorial Hospital in Martinez, Calif., wonders whether HIV testing in prisons remains controversial. While the debate during the 1980s focused on mandatory testing for inmates and segregation of those who tested positive, the latest emphasis is on ways to increase voluntary testing and to improve the medical care of infected prisoners. Prison officials contend that protection--of the infected and uninfected inmates and of the correctional staff--is their main concern. The Centers for Disease Control and Prevention (CDC), however, has not found any instances of HIV infection or AIDS in correctional staff due to work-related transmission. Fifteen of the 16 U.S. prisons that conduct mandatory HIV testing do not segregate the HIV-infected inmates, which does not justify claims for any protective efforts. To maximize the effectiveness of voluntary testing and maintain the trust between staff and inmates, HIV testing should be performed by non-correctional staff. Anonymous testing should be considered. Testing must be followed by counseling, education, and good medical care, and interventions known to reduce transmission--such as condom distribution--should be adopted. "Non-Cytolytic CD8 T-Cell Anti-HIV Responses in Primary HIV-1 Infection" Lancet (12/17/94) Vol. 344, No. 8938, P. 1671 Mackewicz, Carl E.; Yang, Limei C.; Lifson, Jeffrey D. et al While acute HIV infection is accompanied by a significant increase in virus titres that soon fall, the role of humoral and cellular immunity is not clear in the control of virus replication. Researchers studying seven HIV-infected patients found that a non-cytolytic CD8 T-cell response preceded seroconversion. The response was inversely related to the level of plasma viremia in some of the subjects. During follow-up, only two patients developed neutralizing antibodies. The results suggest that cellular immune responses, reflected by non-cytolytic CD8 cell anti-HIV activity, may control viral replication soon after replication. "Patient-to-Patient HIV Transmission Trial" Lancet (12/17/94) Vol. 344, No. 8938, P. 1695 Ragg, Mark A surgeon in Sydney, Australia, was recently found guilty of unsatisfactory professional conduct after the apparent HIV infection of four people who attended his surgery in November 1989. The New South Wales Medical Tribunal said that Dr. Todd Davis was responsible for the infection of four women who had minor procedures performed in his surgery on the same day as a man who later died of AIDS. The man was not known to be HIV-infected at the time. Despite its finding, the tribunal--which has the power to deregister doctors--took no action against the doctor. "The very fact that these proceedings were taken constitute severe punishment. We would propose that [Dr. Davis] be reprimanded," said Judge Hubert Bell, chairman of the tribunal. Another unusual feature of the case is that the nature of Davis' violation of professional conduct was not determined. While the prosecution favored the theory that he had used multiple-dose vials of local anesthetic, they found no evidence that Davis had used anything but single-dose vials. Davis faces civil proceedings from at least one of the infected women. "The Cost-Effectiveness of Voluntary Counseling and Testing of Hospital Inpatients for HIV Infection" J.A.M.A. (12/21/94) Vol. 272, No. 23, P. 1832 Lurie, Peter; Avins, Andrew L.; Phillips, Kathryn A. The Centers for Disease Control and Prevention say that HIV testing in acute care hospitals should be instituted to assist in clinical diagnosis, to permit early medical management of HIV infection, and to counsel HIV-positive patients or those at risk about methods to prevent secondary transmission to their sex partners. A study was conducted to determine the cost-effectiveness of voluntary counseling and testing of U.S. hospital inpatients for HIV. The two outcomes evaluated were: the cost per health care worker (HCW) HIV-infection prevented per year, if HCWs adopt precautions to prevent exposure from HIV-infected patients; and the cost per inpatient HIV infection detected per year. The researchers found that testing to avoid HCW infection may prevent close to four infections with HIV per year. The total program cost would be $2.7 billion, or $753 million per infection avoided. Testing to detect inpatient HIV infection would cost $16,104 per year per infection found. The researchers concluded that there was no justification for testing inpatients to prevent HIV infection of HCWs. The analysis illustrates the importance of carefully considering the purpose of HIV testing before beginning large-scale programs. "Management of Suicidal Patients with HIV Disease" J. of Nurses in AIDS Care (11/94-12/94) Vol. 5, No. 6, P. 19 Valente, Sharon M.; Saunders, Judith M. There are higher numbers of suicidal acts among patients with HIV than among the general population. Stress related to HIV diagnosis, treatment, and medications can lead to depression--which increases suicide risk. "A lot of AIDS patients don't want to hang around 'til the end--they don't see a cure on the horizon and have no hope for recovery...Quality of life becomes the issue. People define it themselves," said one AIDS patient. Depressed people require a high quality of care based on sound scientific knowledge of evaluation of suicide. Early detection and evaluation are critical for a depressed person. Safety precautions include hospitalization and removal of the method of suicide. A nurse's responsibility is to help patients consider options that improve the quality of life, reduce patients' distress and suffering, and help patients thoroughly consider alternatives to suicide. "The Next Step Toward a Global AIDS Vaccine" Science (11/25/94) Vol. 266, No. 5189, P. 1335 Koff, Wayne C. There are four important areas where increased public sector efforts to facilitate private sector product development initiatives could significantly advance the timetable for the development of a safe and globally effective AIDS vaccine. First, incentives must be provided for expanded biopharmaceutical investment in AIDS vaccine development. Second, an international regulatory consensus of criteria for licensure of an effective AIDS vaccine must be established. Third, international capabilities of evaluating the efficacy of the best potential AIDS vaccines need to be expanded. Finally, mechanisms to facilitate information flow to vaccine manufacturers should be improved. These efforts, as well as an effective financing plan to maximize worldwide vaccine delivery and minimize lag periods between vaccine development and widespread distribution, would significantly accelerate the potential for development of a successful AIDS vaccine. "Survival and Disease Progression According to Gender of Patients with HIV Infection" J.A.M.A (12/28/94) Vol. 272, No. 24, P. 1915 Melnick, Sandra L.; Sherer, Renslow; Louis, Thomas A. et al To compare disease progression and mortality between HIV-infected men and women, Melnick et al studied 768 women and 3779 men at 17 community-based centers participating in the Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). The women studied were more likely to be younger, African-American or Hispanic, and more likely to have a history of injection drug use than men. The relative risk for death among women compared with men was 1.33 and for disease progression was 0.97. While women were at increased risk of bacterial pneumonia, they were at a reduced risk for Kaposi's sarcoma and oral hairy leukoplakia. The increased risk of death and bacterial pneumonia for women compared to men was primarily found among women with a history of intravenous drug use. Women are at an increased risk of death but not disease progression, the study concluded. Both men and women had were similarly at risk for opportunistic infections, but women were at an increased risk for bacterial pneumonia. The researchers suggest that the findings may reflect differences in access to health care and standard treatments or different socioeconomic status and social support for women compared to men. "Mother to Child Transmission of Zidovudine-Resistant HIV-1" Lancet (12/24/94-12/31/94) Vol. 344, No. 8939/8940, P. 1771 Siegrist, Claire-Anne; Yerly, Sabine; Kaiser Laurent et al Siegrist et al report the first case of neonatal infection by zidovudine-resistant HIV-1. An HIV-1-infected woman with a CD4 cell count of 176, recurrent herpes simplex, and severe cervical dysplasia received zidovudine for 15 months. Treatment was stopped shortly before pregnancy, but re-introduced two weeks before delivery in hopes of reducing the risk of transmission. Zidovudine was administered during labor and to the infant for the first six weeks of its life. At one week, the infant showed a weakly positive p24 antigenaemia. When the baby was three months old, early and severe HIV-1 infection was confirmed. Tests of frozen samples from the mother revealed a viral genotype of reverse transcriptase codon 215, and measures of the infant's serum showed a 215 mutant HIV-1 genotype. The 215 mutant codon was present in the mother's system before pregnancy, which suggests the long persistence of the mutant strains even in the absence of drug pressure. The detection of p24 antigen at seven days supports in utero rather than late perinatal transmission. The authors recommend that until previously treated mothers and infants can be safely offered combined therapies, that zidovudine alone should not be prescribed without first showing the absence of drug-resistant variants. ------------------------------ End of HICNet Medical News Digest V08 Issue #04 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD