WHO target product profiles for TB preventive treatment

BACKGROUND: The WHO has developed target product profiles (TPPs) describing the most appropriate qualities for future TPT regimens to assist developers in aligning the characteristics of new treatments with programmatic requirements.METHODS: A technical consultation group was convened by the WHO to determine regimen attributes with greatest potential impact for patients (i.e., improved risk/benefit profile) and populations (i.e., reduction in transmission and TB prevalence). The group categorised regimen attributes as 'priority´ or 'desirable´; and defined for each attribute the minimum requirements and optimal targets.RESULTS: Nine priority attributes were defined, including efficacy, treatment duration, safety, drug-drug interactions, barrier to emergence of drug resistance, target population, formulation, dosage, frequency and route of administration, stability and shelf life. Regimens meeting optimal targets were characterised, for example, as having superior efficacy, treatment duration of ≤2 weeks, and improved tolerability and safety profile compared with current regimens. The four desirable attributes included regimen cost, safety in special populations, treatment adherence and need for drug susceptibility testing in the index patient.DISCUSSION: It may be difficult for a single regimen to satisfy all characteristics so regimen developers may have to consider trade-offs. Additional operational aspects may be relevant to the feasibility and public health impact of new TPT regimens.

Interventions to reduce losses in the cascade of care for latent tuberculosis: a systematic review and meta-analysis

BACKGROUND: Losses can occur throughout the latent tuberculosis infection (LTBI) cascade of care. This can result in suboptimal rates of effective treatment for LTBI. We conducted a systematic review and meta-analysis to estimate the effect of different interventions to reduce losses in the LTBI cascade before treatment completion.METHODS: We searched several databases for articles reporting outcomes for interventions designed to strengthen the LTBI cascade. We included papers published in English from January 1990 until February 2018. Where possible, estimates were pooled using random-effects meta-analysis.RESULTS: We identified 30 studies that evaluated 32 different interventions aimed at reducing losses in the LTBI cascade. In pooled analysis, interventions that improved completion of cascade steps included patient incentives (respectively 42 [95% CI 34-51] and 48 [95% CI 15-81] additional patients completing initial assessment and medical evaluation per 100 starting); health care worker education (28 [95% CI 4-52] additional patients initiating initial assessment per 100 identified; home visits (additional 13 [95% CI 4-21] patients completing initial assessment per 100 starting); digital solutions (additional 11 [95% CI 4-21] patients initiating initial assessment per 100 identified); and patient reminders (additional 7 [95% CI 0.3-13] patients completing initial assessment per 100 starting). Several other interventions reduced losses at specific cascade steps, but evidence for these interventions came from single studies and could not be pooled.CONCLUSIONS: Although there is limited evidence that any single intervention significantly improves the LTBI cascade, many studies provide information about effective ways to strengthen it.

Latent tuberculosis diagnostic tests to predict longitudinal tuberculosis during dialysis: a meta-analysis

SETTING

Tuberculosis (TB) rates in dialysis patients are more than 10 times greater than in the general population. Recent recommendations advise the use of interferon-gamma release assays (IGRAs) over the tuberculin skin test (TST) to aid in the diagnosis of latent tuberculous infection (LTBI); however, their longitudinal predictive ability for TB development has not been assessed.

OBJECTIVE

To determine whether the TST or IGRA are able to predict longitudinal TB development in dialysis patients.

DESIGN

We performed a systematic review to determine the longitudinal risk of TB in dialysis patients. Random-effects meta-analysis was used to determine the incidence rate ratio (IRR) of longitudinal TB development and the predictive value of such tests.

RESULTS

Eight studies were included. An IRR of 2.59 (95%CI 1.20-5.57) for longitudinal TB was seen in patients with a TST ⩾ 10 mm compared to patients with a TST < 10 mm. The positive predictive value (PPV) of a TST ⩾ 10 mm was 11.93% and the negative predictive value was 94.03%. We were unable to analyse the studies that used IGRAs, as only one study had TB events.

CONCLUSION

A TST with a 10 mm cut-off point appears to offer the capability to distinguish long-term risk of TB, with a modest PPV. The predictive value of IGRAs could not be quantified.

Management practices associated with pain in cattle on western Canadian cow-calf operations: A mixed methods study

The implementation of on-farm pain mitigation strategies is dependent on feasibility and importance to producers. Currently, there is a lack of information regarding adoption of management practices associated with pain in cattle within the Canadian beef industry. The objective of this mixed methods study was to describe pain-associated practices implemented on farm and producer perceptions toward pain mitigation strategies. A questionnaire about calving management and calf processing was delivered to 109 cow-calf producers in western Canada. In addition, 15 respondents were purposively selected based on questionnaire responses to participate in individual semistructured, on-farm interviews. The prevalence of pain mitigation strategies used for dystocia and cesarean section by respondents were 46 and 100%, respectively. The majority of operations reported castrating and dehorning calves before 3 mo of age (95 and 89%, respectively). The majority of operations did not use pain mitigation strategies for castration and dehorning (90 and 85%, respectively). Branding was practiced by 57% of respondents, 4% of which used pain mitigation. Thematic content analysis revealed that producers' perception of pain were influenced by what they referred to as "common sense," relatability to cattle, visual evidence of pain, and age of the animal. Factors that influenced participant rationale for the implementation of pain mitigation practices included access to information and resources, age of the animal, benefit to the operation, cost and logistics, market demands, and personal conscience. Overall, management practices were generally in compliance with published Canadian guidelines. Results of this study may provide direction for future policy making, research, and extension efforts to encourage the adoption of pain mitigation strategies.

Management practices associated with stress in cattle on western Canadian cow-calf operations: A mixed methods study

Handling, weaning, and euthanasia are some of the most stressful practices performed on cow-calf operations. Although strategies to minimize stress exist, their use on western Canadian cow-calf operations is unknown. The objectives were to describe current stress-associated practices on western Canadian cow-calf operations, describe producer and operation demographics associated with the use of nonabrupt weaning methods, and explore producer perceptions toward these practices. A questionnaire focusing on stressful management practices was delivered to 109 cow-calf producers in western Canada. Fifteen respondents were purposively selected for individual interviews. The majority of producers reported calves less than 1 wk of age were handled by manual restraint (87%) and those older than 1 wk of age were handled using a cattle squeeze or table. Most producers performed abrupt weaning (70%). Interviewees often mentioned that cost and logistics were major factors in deciding on a weaning strategy. Pasture availability and facilities were viewed as constraints toward the adoption of a nonabrupt weaning method. Animal stress was considered, as producers expressed concern that nonabrupt weaning methods may cause increased stress because of the additional handling required. Producers conveyed that animal age was a major factor that impacted weaning stress and that improved animal performance might motivate them to adopt a nonabrupt weaning strategy. Producers also expressed reluctance to change previously successful traditional approaches. Of respondents, 13% did not euthanize cattle on farm and 8% did not confirm death. Producers interviewed reported that the decision to euthanize cattle on farm was difficult and that veterinary advice was often considered. Factors that influenced their decision to euthanize included the animal's likelihood of recovery and degree of pain and distress. Finally, producers explained that they considered whether the animal was salvageable and able to be transported. Identification of common methods of handling provides focus for future research to determine optimal handling strategies. Identified barriers to nonabrupt weaning may be addressed through research, extension, or policy to encourage the adoption of weaning methods that could improve animal welfare. Confirmation of death after euthanasia was identified as an area that needs to be addressed by producer education to minimize animal stress during on-farm euthanasia.

Agreement between Three Serological Tests for Neospora Caninum in Beef Cattle

During 1999, serum samples were collected from beef cows on pastures in western Canada. Some of the herds had a history of confirmed abortions associated with Neospora caninum infection. All these samples were initially analyzed using a single application of 1 common commercial enzyme-linked immunosorbent assay (ELISA) for antibodies to N. caninum. From these initial results, 239 positive and 250 negative samples were randomly selected for further testing. This group of samples was retested using the 3 commercially available ELISA tests for N. caninum as per the manufacturer's recommendations. The agreement between 2 of the ELISAs was good (k = 0.76); agreement of these 2 tests with the third test was much lower (k = 0.46 and 0.60). Quantitative agreement between tests measured by intraclass correlation coefficients was also acceptable between the first 2 tests but was almost zero when the first 2 tests were compared with the third. This information is necessary to understand the differences in seroprevalence reported in different regions from laboratories using different methods.

Prevalence of enterotoxigenic Escherichia coli (ETEC) in hospitalized acute diarrhea patients in Denpasar, Bali, Indonesia

The relationship between enterotoxigenic Escherichia coli (ETEC) and hospitalized patients with acute diarrhea was examined in a study conducted in two hospitals from June 2000 to May 2001 in Denpasar, Bali, Indonesia. A total of 489 hospitalized patients with acute diarrhea were enrolled, and their rectal swabs were screened for enteric bacterial pathogens. Toxins, colonization factor antigens (CFAs), in vitro antimicrobial susceptibility and seasonal distribution patterns associated with ETEC were ascertained. The diagnosis of ETEC infection and CFAs association were performed with GM-1 ELISA and Dot blot immunoassays. Enterotoxigenic Escherichia coli was isolated from the rectal swabs of 14.9% of the patients. The distribution of toxins among the ETEC strains found was ST in 51 (69.9%), while LT and ST/LT were found in 28.8% and 1.3% respectively. The highest isolation rate for ETEC was found among children between the ages of 1 and 15 years. Colonization factor antigens were identified in 28.8% of the ETEC strains. A high prevalence of CFA was found among the rectal swabs of patients with ST isolates. High frequency of resistance to ampicillin, trimethoprim/sulfamethoxazole, chloramphenicol, tetracycline and cephalothin was displayed among the ETEC strains. All ETEC strains were susceptible to norfloxacin, ciprofloxacin and nalidixic acid. The results of this study document the prevalence of ETEC in hospitalized patients with acute diarrhea in Denpasar, Bali, Indonesia. Data generated in this study depicts the prevalence of ETEC diarrhea and CFA types among diarrhea patients in the tourist city of Denpasar, Bali, Indonesia.

First documented outbreak of hepatitis E virus transmission in Java, Indonesia

A suspected hepatitis outbreak occurred in Bondowoso District, East Java Province, Indonesia, in March-May 1998. An investigation was initiated in April 1998, involving a retrospective review of hospital records, a community-based cross-sectional study, and a health service-based case detection and household follow-up. Sera and epidemiological information were collected from 962 individuals: 235 from 3 outbreak-affected communities along the same rural stretch of river, 101 from community controls living distant from the river, 151 cases detected in health centres, 141 family members of the cases, and 334 subjects from neighbouring families. The prevalence of acute hepatitis E virus (HEV), based on anti-HEV IgM, total antibody (Ig) to HEV and polymerase chain reaction (PCR), was significantly (P < 0.00001) higher (52.4%) among the outbreak communities than among the community controls (3%). The background prevalence of HEV, based on anti-HEV IgG, was also significantly (P < 0.00001) higher (47%) among the outbreak communities than among the community controls (3%). None of the 476 sera screened for anti-HAV (hepatitis A virus) IgM was positive. These results indicate that HEV was the aetiological agent responsible for the outbreak. The overall attack rate (AR) for the 3 outbreak-affected communities surveyed was 19%, with AR determined on the basis of clinically recognized, acute jaundice illness. The usage of river water as primary source for bathing, human-waste disposal, and drinking purposes differed significantly (P < 0.00001) between the communities in outbreak areas and those in non-outbreak areas. There is no significant influence attributed to 'boiling water' on acute HEV. No climatic influences (flooding or drought) predisposed this instance of epidemic HEV transmission. This outbreak represents the first documented evidence of epidemic HEV transmission in Java, Indonesia.

Characterization of Norwalk-like virus associated with gastroenteritis in Indonesia

Norwalk Virus and Norwalk-like viruses (NLVs) are reportedly responsible for 2.5-4.0% of nonbacterial acute gastroenteritis (NBAG) worldwide. To help clarify the impact of NLVs on NBAG in Indonesia, stool specimens from 102 patients, 74 with NBAG and 28 with BAG, were screened for the presence of NLVs, using a reverse transcription-polymerase chain reaction (RT-PCR) assay. The specimens were subtyped using prototype-specific oligonucleotide probes and were sequenced and compared with published NLV sequences. Of the 102 specimens examined, 31 (30%) were found to be positive for NLVs. Type-specific probe analysis of the RT-PCR products indicated that 31 isolates hybridized to UK1 (Taunton agent) and UK3/4 (Hawaii agent/Snow Mountain agent) prototype strains. The results of this study indicate that prototype strains of NV or NLVs co-circulate in Indonesia and contribute to the overall level of acute gastroenteritis throughout the region.

Incidence of Norwalk-like viruses, rotavirus and adenovirus infection in patients with acute gastroenteritis in Jakarta, Indonesia

Norwalk-like viruses (NLVs), rotavirus and adenovirus are reportedly responsible from 4 to 42% of non-bacterial acute sporadic gastroenteritis. The incidence of NLVs, adenovirus and rotavirus infections in Indonesia is unclear. A total of 402 symptomatic cases from Indonesian patients with acute gastroenteritis and 102 asymptomatic controls that tested negative for bacteria and parasites were screened for the presence of NLVs, rotavirus and adenovirus using the reverse transcriptase-polymerase chain reaction (RT-PCR), Rotaclone kits and Adenoclone kits. Specific prototype probes were used to ascertain which NLV prototypes were present in the area. NLVs were detected in 45/218 (21%), rotavirus was detected in 170/402 (42%) and adenovirus was detected in 11/273 (4%) samples examined. Genetic analysis of the RT-PCR products using specific prototype probes for NLVs indicated that the prototypes were 42% Taunton agent and 58% Hawaii/Snow Mountain agent. Comparative data on patients showed that the incidence of rotavirus infections was two times greater than the NLVs infections, and that adenovirus infections were the least prevalent. All of the control samples tested were negative for NLVs and adenoviruses, however 8/70 (11%) of the samples were positive for rotaviruses. The high incidence of enteric viral-related infections is a threat among acute diarrheic patients in Jakarta, Indonesia.

Experimental infection of Macaca nemestrina with a Toronto Norwalk-like virus of epidemic viral gastroenteritis

Norwalk virus (NV) and Norwalk-like viruses (NLVs) are common etiologic agents of viral gastroenteritis. Viral gastroenteritis is a common disease that is highly transmissible, spreading rapidly through families, institutions, and communities. Because methods for in vitro cultivation of Norwalk etiologic agents are not available, information regarding this syndrome has come largely from studies in human volunteers. Sequential passaging of an NLV through an immunoincompetent newborn pigtail macaque (Macaca nemestrina) may allow for the adaptation of a human NLV to a primate host, thus providing an animal model for investigating this disease. A fecal filtrate of human origin containing NLV, Toronto virus P2-A, was obtained from a patient during an epidemic of viral gastroenteritis. The filtrate was administered via nasogastric tube to three newborn pigtailed macaques. Clinical illness, which was characterized by diarrhea, dehydration, and vomiting, occurred in three monkeys. Reverse transcription-polymerase chain reaction (RT-PCR) and oligonucleotide probe analysis of RNA extracted from the stool samples following infection revealed viral RNA in all inoculated monkeys. Infection was also transmitted experimentally by feeding two additional newborn macaques a fecal filtrate prepared from the three previously infected animals. Detection of viral RNA in the stools of animals that received the fecal filtrate indicates that viral replication occurred in association with clinical illness. The susceptibility of Macaca nemestrina to infection with a Norwalk-like agent will facilitate the study of the mechanisms of the pathogenesis of NLV. This system may also have the potential to serve as a vaccine test model for human epidemic viral gastroenteritis.

Semantic features of an enterprise interface terminology for SNOMED RT

OBJECTIVE

To evaluate the utility of SNOMED RT in support of a natural language interface for encoding of clinical assessments.

METHOD

Using a random sample of clinical terms from the UNMC Lexicon, I mapped the terminology into canonical data entries using SNOMED RT. Working from the source term language, I evaluated lexical mapping to the SNOMED term set, and the function of the SNOMED RT semantic network in support of a language-based clinical coding interface.

RESULTS

Ambiguity in the source terms was low at 0.3%. Lexical (language-based) mapping could account for only 48.8% of meaning from the source terms. The RT semantic network accounted for 39.5% of meaning, and supplementing the lexical map this led to 80.2% capture of source content. Error rates in the segment of RT which I reviewed were low at 0.6%. 97.6% of source content could be accurately captured in SNOMED RT.

CONCLUSION

SNOMED RT supported an accurate and reliable representation of clinical assessment data in this sample. The semantic network of RT substantially enhanced the encoding of concepts relative to lexical mapping. However these data suggest that natural language encoding with SNOMED RT in an enterprise environment is unlikely at this time.

Parity violation in proton-proton scattering at 221 MeV

The parity-violating longitudinal analyzing power, A(z), has been measured in pvectorp elastic scattering at an incident proton energy of 221 MeV. The result obtained is A(z) = [0.84+/-0.29(stat)+/-0.17(syst)]x10(-7). This experiment is unique in that it selects a single parity violating transition amplitude (3P2 - 1D2) and consequently directly constrains the weak meson-nucleon coupling constant h(pp)(rho). When this result is taken together with the existing pvectorp parity violation data, the weak meson-nucleon coupling constants h(pp)(rho) and h(pp)(omega) can, for the first time, both be determined.

Cholera in Indonesia in 1993-1999

Cholera-specific surveillance in Indonesia was initiated to identify the introduction of the newly recognized Vibrio cholerae non-O1, O139 serotype. Findings from seven years (1993-1999) of surveillance efforts also yielded regional profiles of the importance of cholera in both epidemic and sporadic diarrheal disease occurrence throughout the archipelago. A two-fold surveillance strategy was pursued involving 1) outbreak investigations, and 2) hospital-based case recognition. Rectal swabs were transported to Jakarta for culture and isolates were characterized by serotypic identification. Outbreak findings showed that V. cholerae O1, Ogawa serotype, was the predominant etiology in all 17 instances of investigated epidemic transmission. Monitoring of eight hospitals representing seven provinces provided 6,882 specimens, of which 9% were culture positive for V. cholerae: 589 (9%) for O1 and 20 (< 1%) for non-O1 strains. Proportional representation of V. cholerae O1 among cases of sporadic diarrheal illness was variable, ranging from 13% in Jakarta to < 1% in Batam. Overall, 98% of V. cholerae O1 cases were the Ogawa serotype. There was no instance of non-O1, O139 serotype introduction in either epidemic or sporadic disease form. Anti-microbial drug susceptibility was consistently demonstrated, both temporally and spatially, except against colistin. Evidence is provided that epidemic and sporadic cholera occurrence in western Indonesia is associated with periods of low rainfall. Conversely, in the more eastern portion of the country, heavy rainfall may have contributed to epidemic cholera transmission.

Toxins and colonization factor antigens of enterotoxigenic Escherichia coli among residents of Jakarta, Indonesia

Infection caused by enterotoxigenic Escherichia coli (ETEC) poses a serious health problem among children and adults in developing countries. Colonization of the small intestinal mucosa by ETEC strains is mediated by antigenically specific fimbriae, also known as colonization factor antigens (CFA). The significance of this study arises from reports that active and passive immunization with ETEC strains harboring CFAs has previously been shown to induce protective immunity against diarrhea in animal models. The aim of this study was to determine toxin-associated CFAs of ETEC isolated from a diarrheal disease case-control study in Jakarta, Indonesia. Thirteen hundred and twenty-three diarrheic and control patients with lactose-fermenting colonies were screened by ganglioside GM1-enzyme-linked immunosorbent assay (GM1-ELISA) for heat-labile (LT) and heat-stable (ST) toxins. Two hundred and forty-six (19%) ETEC isolates identified by GM1-ELISA for the LT/ST toxins were screened for CFAs by Dot blot assay using monoclonal antibodies against CFA/I, II, and IV and against the putative colonization antigens (PCF) PCFO159, PCFO166, CS7, and CS17. Of the 246 ETEC isolates, 177 (72%) elaborated ST, 56 (23%) produced LT, while 13 (5%) elicited both the ST and LT toxins. CFA testing of the 246 ETEC isolates showed that 21 (8%) expressed CFA/I, 3 (1%) exhibited CFA/II, 14 (6%) elaborated CFA/IV, while 7 (3%) expressed PCFO159 and PCFO159 plus CS5. No CFAs or PCFs could be associated with 201 (82%) of the ETEC strains. This report documents the types of CFAs associated with ETEC strains in Jakarta, Indonesia. These data may help current research efforts on the development of CFA-based vaccines for humans against ETEC and provide additional information for future ETEC vaccine trials in Southeast Asia.

Associations between total sulfation, hydrogen sulfide deposition, and beef-cattle breeding outcomes in western Canada

Beef cows sometimes are pastured close to oil- and gas-production and processing facilities. We measured the health and productivity of cow-calf herds with differing exposure to sour-natural-gas processing facilities in western Canada. In seven cow-calf herds, the numbers of eligible mature females included in the study for the breeding seasons beginning in 1993, 1994, and 1995 were 1177, 1251, and 1236, respectively. Outcomes included pregnancy status, calving interval, and the occurrence of twins, abortions, stillbirths, and neonatal mortality. Information also was collected on other risk factors known to influence beef-herd health and productivity. Monthly measurements from a network of passive air-monitoring devices were used to estimate exposure. Total sulfation and H2S deposition were used as markers for the complex mixture of compounds found in emissions from sour-gas processing plants and sour flares. Most herds were managed in multiple pasture groups. Cumulative exposure assessments were made from records of individual-animal movements between pastures. Generalized estimating equations were used to evaluate the association between exposure and outcome and to adjust for potential confounders and clustering of binomial outcomes within herd. No consistent associations were found between either total sulfation or H2S deposition and productivity parameters across the cow-calf production cycles. There were, however, five examples of significant associations between increasing cumulative exposure to total sulfation and decreased productivity in the 18 models examined.

Associations between oil- and gas-well sites, processing facilities, flaring, and beef cattle reproduction and calf mortality in western Canada

From the fall of 1992 through calving 1996, detailed cow breeding outcome records were maintained actively for seven large cow-calf herds in western Canada. The numbers of mature females in the study for the breeding seasons beginning in 1992, 1993, 1994, and 1995 were 1122, 1177, 1251, and 1236, respectively. Outcomes included pregnancy status, calving interval, and the occurrence of twins, abortions, stillbirths, and neonatal mortality. Information also was collected on other risk factors known to influence beef-herd health and productivity. Detailed maps of active and inactive oil and natural-gas sites, batteries, compressor stations and processing plants were verified. Records of flaring activity at each facility were obtained from the government regulatory agency. Each flaring site then was classified as sour or sweet based on the presence or absence of hydrogen sulfide in the flared gas. A detailed inventory was prepared itemizing the type and number of facilities within 1.6 km (1 mile) of the center of each quarter section used for pasture. The total volume of gas flared within 1.6 km of the center of each pasture was determined for each month of the study. Appropriate risk periods where specified for each outcome and a cumulative exposure calculated for each breeding female (using detailed individual-animal records of cow movements between pastures and herd-management groups). Generalized estimating equations were used to evaluate the association between exposure and outcome and to adjust for potential confounders and clustering of binomial outcomes within herd. Increased risk of non-pregnancy was sometimes associated with exposure to one or more of the following facility types: sour-gas flaring battery facilities, all battery-flaring sites, active gas wells, and larger field facilities. The associations were not, however, consistent among years or even among risk periods for the same year. Facility proximity and flaring were not associated with increased abortion risk. Volume of flared sour gas from battery sites was associated with increased risk of stillbirth. Finally, sour-gas flaring was associated with increased calf-mortality risk for the 1992-1993 calf crop. Several examples of associations between exposure and increased productivity also were found (most of which involved either oil wells or all well sites).

Epidemic dengue transmission in southern Sumatra, Indonesia

An outbreak of dengue fever (DF), dengue haemorrhagic fever (DHF), and dengue shock syndrome (DSS) in the city of Palembang, south Sumatra, Indonesia was investigated to (i) validate epidemic occurrence, (ii) confirm dengue virus aetiology and associated serotype(s), (iii) provide a demonstrable measure of community impact, and (iv) identify causative relationship (if any) with climatic El Niño Southern Oscillation (ENSO) influences. Trend analysis based on a 6-year retrospective review of hospital records demonstrates a 3-fold increase in clinical cases for the outbreak period (January-April 1998), relative to historical records. In the 2 hospitals surveyed, the monthly mean number of outbreak-related dengue cases over 4 months was 833 (range 650-995 cases/month); the mean monthly value for the previous 72 months was 107 (range 14-779 cases/month). An apparent trend in epidemic transmission was observed, evolving from a 5-year cyclic phenomenon to an annual occurrence, often indistinguishable from one year to the next. The proportional distribution of clinical outbreak cases into DF, DHF and DSS diagnostic categories was 24%, 66%, and 10%, respectively. The population aged 10-19 years accounted for the largest (35%) proportion of hospitalized DHF cases, followed by children aged 5-9 years (25%) and children aged 4 years (16%). Serum samples obtained during acute illness from 221 hospitalized patients were examined using serology, RT-PCR, and virus isolation in cell culture: 59% of samples had laboratory evidence of a dengue infection. All 4 dengue virus serotypes (DEN 1-4) were identified in epidemic circulation, with DEN 3 predominating (43%). DEN 1 was the principal serotype associated with less severe dengue illness, suggesting that virulence may be, in part, a function of infecting serotype. The climatic influence of ENSO on rainfall and temperature in the months leading up to and during the outbreak was dramatic, and is likely to contribute to favourable outbreak conditions.

Vibrio parahaemolyticus associated with cholera-like diarrhea among patients in North Jakarta, Indonesia

A diarrhea study was conducted in North Jakarta, Indonesia from December 1996 through December 1997. Vibrio parahaemolyticus was isolated from 333 (6.1%) of 5442 rectal swab samples collected from patients with cholera-like diarrhea. Vibrio cholerae O1 was isolated from 545 (10.0%) and V. cholerae non-O1 from 183 samples (3.4%), respectively. Patients positive for V. parahaemolyticus were mostly adults between 20 and 40 years of age, with males constituting 62%. A majority (65%) of these patients demonstrated watery diarrhea with a frequency of fewer than 10 episodes per 24 hour. A large number of the patients had abdominal pain (83%) and vomiting (76%) and were non-febrile (90%). The highest isolation rate (9.6%) of V. parahaemolyticus was found during the dry season (June, July) and the lowest (4.5%) in the rainy season (December, January, February). All of the V. parahaemolyticus isolates were hemolytic on human blood agar (positive Kanagawa) but none was urease positive. Disk diffusion antibiotic susceptibility tests performed on the isolates demonstrated resistance to ampicillin (98%), cephalothin (24%), kanamycin (15%), colistin (97%), neomycin (2%) and ceftriaxone (0.3%). All isolates (100%) were sensitive to chloramphenicol, tetracycline, trimethoprim-sulfamethoxazole, gentamicin, and ciprofloxacin.

Allergic response to metabisulfite in lidocaine anesthetic solution

True allergies to local anesthetics are rare. It is common for practitioners to misdiagnose a serious adverse event to local anesthetics as an allergic reaction. The most likely causes for an allergic response are the preservative, antioxidant, or metabolites and not the anesthetic itself. This case report illustrates the need for practitioners to understand the many potential allergens in local anesthetics and to correctly diagnose patients that are truly allergic to the local anesthetic.

Pneumothorax with soft tissue emphysema following abrupt wake-up and self-extubation

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Shigella spp. surveillance in Indonesia: the emergence or reemergence of S. dysenteriae

From June 1998 through November 1999, Shigella spp. were isolated in 5% of samples from 3,848 children and adults with severe diarrheal illness in hospitals throughout Indonesia. S. dysenteriae has reemerged in Bali, Kalimantan, and Batam and was detected in Jakarta after a hiatus of 15 years.

In vitro antibiotic susceptibility of Neisseria gonorrhoeae in Jakarta, Indonesia

Antibiotic susceptibilities were determined for 122 Neisseria gonorrheae isolates obtained from 400 sex workers in Jakarta, Indonesia, and susceptibilities to ciprofloxacin, cefuroxime, cefoxitin, cefotaxime, ceftriaxone, chloramphenicol, and spectinomycin were found. All isolates were resistant to tetracycline. A number of the isolates demonstrated decreased susceptibilities to erythromycin (MIC >/= 1.0 microg/ml), thiamphenicol (MIC >/= 1.0 microg/ml), kanamycin (MIC >/= 16.0 microg/ml), penicillin (MIC >/= 2.0 microg/ml), gentamicin (MIC >/= 16.0 microg/ml), and norfloxacin (MIC = 0.5 microg/ml). These data showed that certain antibiotics previously used in the treatment of gonorrhea are no longer effective.

The association between caries and childhood lead exposure

Epidemiologic studies suggest an association between lead exposure and caries. Our objective was to establish whether children with a higher lead exposure as toddlers had more caries at school age than children with a lower lead exposure. We used a retrospective cohort design. A sample of children who attended second and fifth grades in the Rochester, New York, public schools during the 1995-1996 and 1996-1997 school years were examined for caries through a dental screening program. For each child we assessed the number of decayed, missing, or filled surfaces on permanent teeth (DMFS), and the number of decayed or filled surfaces on deciduous teeth (dfs); the number of surfaces at risk (SAR) was also recorded. Lead exposure was defined as the mean of all blood lead levels collected between 18 and 37 months of age by fingerstick [provided the blood lead level was [less than/equal to] 10 microg/dL)] or venipuncture. A total of 248 children (197 second graders and 51 fifth graders) were examined for caries and had a record of blood lead levels to define lead exposure. The mean dfs was 3.4 (range 0-29); the mean DMFS was 0.5 (range 0-8). Logistic regression was used to examine the association between the proportion of children with DMFS [Greater/equal to] 1, and the proportion with dfs [Greater/equal to] 1, and lead exposure [< 0.48 micromol/L vs. [Greater/equal to] 0.48 micromol/L (< 10 microg/dL vs. [Greater/equal to] 10 microg/dL)] while controlling for SAR, age at examination, and grade in school. For DMFS, the adjusted odds ratio was 0.95 [95% confidence interval (CI), 0.43-2.09; p = 0.89); for dfs, the odds ratio was 1.77 (95% CI, 0.97-3.24; p = 0.07). This study did not demonstrate that lead exposure > 10 microg/dL as a toddler was a strong predictor of caries among school-age children. However, the results should be interpreted cautiously because of limitations in the assessment of lead exposure and limited statistical power.

Group B streptococcal colonization and serotype-specific immunity in pregnant women at delivery

OBJECTIVE

To describe the relationship between serum concentration of group B streptococcal capsular polysaccharide-specific immunoglobulin (Ig) G, colonization status, race or ethnicity, and age in pregnant women.

METHODS

Pregnant women (n = 3307) were enrolled from geographically and ethnically diverse populations. At the time of admission for delivery, swabs of the lower vagina and rectum were obtained for isolation of group B streptococci. In a subset of women whose sera were available, capsular polysaccharide-specific IgG concentrations were quantified by serotype-specific (Ia, Ib, II, III, and V) enzyme-linked immunosorbent assay and compared by group B streptococcal colonization status.

RESULTS

Group B streptococcal colonization was detected in 856 women (26%), and the rate was significantly higher among black women (37%) than in other racial or ethnic groups (odds ratio 1.7, 95% confidence interval 1.4, 2.1). Colonization status did not differ by study site or age. Colonization with serotypes Ia, II, III, or V was associated with significantly higher serum concentrations of IgG specific for the capsular polysaccharide of the colonizing serotype compared with noncolonization. However, 48% of colonized women had low capsular polysaccharide-specific IgG levels (less than 0.5 microg/mL) in their delivery sera. Colonized teenagers had the lowest median concentration.

CONCLUSION

Colonization with group B streptococcus can elicit a systemic immune response, with a cumulative increase in the prevalence of capsular polysaccharide-specific IgG with increasing age. Conversely, low antibody levels in colonized teenagers might account in part for the reported increased risk of group B streptococcal disease in neonates born to these patients.

The effects of dietary biotin supplementation on vertical fissures of the claw wall in beef cattle

A clinical field trial was performed on a herd of Hereford beef cows in central Saskatchewan. The herd had a history of being severely affected with vertical fissures. The objective of the study was to determine the effects of supplemental dietary biotin on the prevalence of vertical fissures in beef cows. In June 1994 and June 1995, 1- and 2-year-old heifers were randomly allocated into 2 treatment groups, each composed of 79 animals. One group received a 10 mg/head/day biotin-supplemented free-choice mineral supplement, while the other groups received an identical free-choice mineral without the biotin supplementation. The claws from these animals were evaluated in June 1994, October 1994, June 1995, October 1995, and June 1996 for the presence of vertical fissures. Supplemental dietary biotin significantly increased serum levels of biotin and significantly increased claw hardness in supplemented cows. Both groups of heifers started the trial without vertical fissures. After 18 months, 15% of the cows fed supplemental dietary biotin had vertical fissures compared with 33% in the nonsupplemented group. The difference was statistically significant (P = 0.01).

Cytokines enhance opsonophagocytosis of type III group B Streptococcus

Neutrophil (polymorphonuclear leukocyte (PMN)-mediated killing is important to host defense against type III group B Streptococcus (GBS). In neonates, a qualitative and quantitative deficiency in PMN-mediated host defense may contribute to an impaired neonatal response to this pathogen.

OBJECTIVE

The purpose of this study was to determine whether tumor necrosis factor-alpha (TNF-alpha), granulocyte colony-stimulating factor (G-CSF), or granulocyte-macrophage colony-stimulating factor (GM-CSF) would enhance neonatal PMN-mediated killing of III GBS.

STUDY DESIGN

PMNs from adults or neonates were incubated with TNF-alpha, G-CSF, or GM-CSF; next, PMN-mediated killing of III GBS was assessed in an in vitro opsonophagocytic assay.

RESULTS

Treatment of PMNs with these cytokines for an interval of 5 minutes before addition of GBS to the reaction mixture enhanced opsonophagocytosis of bacteria both by adult PMNs and neonatal PMNs. The effect was statistically significant for TNF-alpha- and GM-CSF-treated adult PMNs and for GM-CSF-treated neonatal PMNs. The enhanced killing of III GBS by GM-CSF-treated PMNs was reduced by monoclonal antibody blockade of FcRIII.

CONCLUSION

G-CSF enhances the neonatal PMN-mediated killing of III GBS in vitro. These studies suggest that use of FcRIII receptors may be one mechanism by which GM-CSF augments the PMN-mediated killing of III GBS. The addition of purified immunoglobulin G containing III GBS-specific antibody facilitated opsonophagocytosis by GM-CSF-treated PMNs. We speculate that the administration of GM-CSF alone or in combination with intravenous immunoglobulin may improve the neonatal host response to III GBS.

Systemic candidiasis in extremely low birth weight infants receiving topical petrolatum ointment for skin care: a case-control study

BACKGROUND AND OBJECTIVE

An increase in the incidence of systemic candidiasis (SC) followed a change in skin care for extremely low birth weight (ELBW) infants in our neonatal intensive care unit (NICU). We sought to determine whether the use of topical petrolatum ointment (TPO) for skin care of ELBW infants was associated with risk for SC.

STUDY DESIGN

Case-control study.

SETTING

A 48-bed NICU in a private hospital in Houston, Texas.

PATIENTS

Ten ELBW infants with and 30 without SC admitted to the NICU from December 1, 1997 through July 31, 1998.

METHODS

ELBW infants with SC were identified using hospital microbiology and infectious disease consultation databases. A case was defined as an infant weighing </=1000 g at birth with Candida spp isolated from a normally sterile body site. Three infants without SC were matched to each case by birth weight, admission date, and survival to the age of SC onset for the case. Data were collected by retrospective medical record review. Molecular analysis of Candida isolates was performed by karyotyping and restriction fragment length polymorphism using pulsed-field gel electrophoresis.

RESULTS

Case infants had a mean (+/- standard deviation) age of onset of 21.5 +/- 24 days. Infants with SC and controls did not differ in birth weight, gestational age, or duration of therapy with steroids, antibiotics, insulin, or total parenteral nutrition. Although cases were more likely to be born vaginally and had a longer duration endotracheal intubation than controls, these differences were not significant. The odds ratio for skin care with TPO in case infants versus control infants was 11 (95% confidence interval: 1.9-63). Skin care with TPO was discontinued and the incidence of SC decreased to baseline. Several Candida spp and genetic profiles were identified, suggesting that there was not a common source outbreak.

CONCLUSIONS

We conclude that the use of TPO promoted an increase in the incidence of SC in ELBW infants. Additional investigation of potential infectious risks for ELBW infants receiving TPO skin care is warranted.

Influenza A virus outbreak in a neonatal intensive care unit

BACKGROUND

Nosocomial infections with influenza virus are rarely recognized in neonatal intensive care units (NICU). An outbreak of influenza A virus infection in the NICU of an urban county hospital during the 1997 to 1998 influenza season is reported.

METHODS

Clinical and virologic data were recorded in all symptomatic NICU patients after influenza A infection was diagnosed in one infant in October, 1997.

RESULTS

Influenza A/H3N2 was isolated from two of four symptomatic infants. The application of rapid diagnostic techniques for the characterization of influenza virus infection allowed the timely institution of basic infection control measures, limiting this outbreak. Resistance to amantadine was documented for the first time in this patient population by reverse transcription-PCR within 48 h of treatment in one case.

CONCLUSIONS

Prevention by immunization is a priority in those caring for high risk NICU patients.

Predicting the outcome of the CaNa2EDTA challenge test in children with moderately elevated blood lead levels

The Centers for Disease Control and Prevention suggests the challenge test for children whose blood lead levels are 1.21-2.12 micromol/L (25-44 microg/dL). However, the challenge test is difficult to perform. By identifying children who are likely to have a negative challenge test, a medical provider can minimize the number of children undergoing this test. The goal of this study was to identify common tests that are likely to predict the outcome of the challenge test. It was conducted as a clinical descriptive study from a series of patients who underwent a CaNa2EDTA challenge test. Results from 178 challenge tests were eligible for analysis. The mean age of children undergoing the challenge test was 38.2 months, and the mean blood lead level was 1.83 micromol/L (38 microg/dL). Blood lead level, age, erythrocyte protoporphyrin level, and RATE (a measure of the rate of change of the blood lead level) were either not sensitive or not specific in predicting the outcome of a challenge test. However, based on a logistic regression model using blood lead level, age, and RATE, we determined criteria that would have identified all children who would have had a positive challenge test while excluding most children who would have had a negative challenge test. Based on this model, we recommend that the challenge test be conducted on children >=36 months of age who have a blood lead level between 1.45 and 1.64 micromol/L (30-34 microg/dL) and on children who have a blood lead level 1.69-2.12 micromol/L (35-44 microg/dL) regardless of age. This approach would have tested all children who subsequently would have had a positive challenge test while testing only 39% of children who would have had a negative challenge test.

Effects of temperature on the survival of Tritrichomonas foetus in transport, Diamond's and InPouch TF media

The abilities of two isolates of Tritrichomonas foetus to survive and replicate in transport and Diamond's medium or in the InPouch TF system (Bio-Med Diagnostics) when exposed to different temperatures for different periods were determined in a series of experiments. Tubes containing thioglycollate transport medium or pouches were inoculated with 4000 to 5000 organisms and kept for up to seven days at 37 degrees C, 22 degrees C, 4 degrees C, or -20 degrees C. When the holding time had elapsed, the numbers of motile T foetus were counted. Samples in transport medium were transferred to Diamond's medium, and both the pouches and tubes containing Diamond's medium were incubated at 37 degrees C. The cultures were examined and counted four or five times during the 10 to 14 day culture period. The sensitivity of the test under the different conditions, expressed as the number of positive cultures/the total number of samples x 100, varied from zero to 100 per cent depending upon the combination of variables considered. In each medium, with both isolates of T foetus, all samples kept for up to four days at 22 degrees C or 37 degrees C were positive. All cultures of samples kept more than five days at 4 degrees C were negative. No positive cultures were detected when samples were kept more than three hours at -20 degrees C. The day on which the cultures reached mean peak concentration varied with the temperature at which the samples had been kept before they were cultured.

Epidemiology of enterotoxigenic Escherichia coli diarrhea in a pediatric cohort in a periurban area of lower Egypt

Enterotoxigenic Escherichia coli (ETEC) are diverse pathogens that express heat-labile (LT) and/or heat-stable (ST) enterotoxins, yet little is known about whether epidemiologic patterns of pediatric ETEC diarrhea vary by the expressed ETEC toxin phenotype. In total, 242 Egyptian children aged <3 years were prospectively followed in 1993-1995. ETEC episodes were detected during twice-weekly home visits, and asymptomatic ETEC excretion was identified from monthly cross-sectional surveys. ETEC episodes were 0.6 per child-year. ST-only ETEC was 2.6 times (P<.001) more common in warmer than cooler months, while LT-only ETEC showed no seasonal variation. Ownership of a household sanitary latrine, but not breast-feeding, was associated with a lower risk of both enterotoxin phenotypes. Coexpression of a colonization factor by LT- or ST-only ETEC strengthened the association with diarrhea. These findings indicate that the epidemiologic patterns of LT-only and ST-only ETEC are not identical and that disease interventions should include improved household sanitation.

Epidemiological analysis defining concurrent outbreaks of Serratia marcescens and methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit

OBJECTIVE

To describe the epidemiology, interventions, and molecular typing methods used during the investigation and control of concurrent outbreaks of Serratia marcescens and methicillin-resistant Staphylococcus aureus (MRSA) infections in a neonatal intensive-care unit (NICU).

SETTING

A 206-bed women's and infants' hospital with a 48-bed NICU.

DESIGN

A 22-week, prospective, descriptive study of all NICU infants with S marcescens or MRSA infection or colonization. Repetitive polymerase chain reaction (rep PCR) and pulsed-field gel electrophoresis (PFGE), respectively, were applied to the typing of S marcescens and MRSA isolates.

INTERVENTIONS

Infants with S marcescens or MRSA infection or colonization were placed in isolation; all other infants were cohorted. A multidisciplinary task force implemented education for all hospital and medical staff regarding policies essential for outbreak control. Changes in physical setting and patient contact procedure were required to promote adherence to existing policies.

RESULTS

Two premature infants had S marcescens infection, and five were colonized; rep PCR verified that both invasive and three of five colonizing isolates were related genotypically. Five bacteremic and 10 MRSA-colonized infants were identified; PFGE confirmed that 12 of the isolates had similar electrophoretic patterns. S marcescens infection was eliminated from the NICU 3 weeks after interventions were initiated. MRSA infections also were eliminated, and MRSA colonization fell to below pre-outbreak rates within 8 weeks. Despite a 100% increase in NICU patient days per month during the subsequent 2 years, no further clusters of S marcescens or MRSA infection have occurred.

CONCLUSIONS

Concurrent outbreaks of S marcescens and MRSA in an NICU were confirmed by genotyping of strains. Control was achieved by isolation and cohorting of patients and strict adherence to NICU policies and procedures.

The effects of Tritrichomonas foetus and nutritional status on the fertility of cows on a community pasture in Saskatchewan

A prospective observational study of a breeding season in a Saskatchewan community pasture was carried out to determine the cause or causes of a chronic infertility problem. There were 774 cows, from 27 herds, divided into 4 breeding groups (A,B,C,D) on the pasture. Cows entering the pasture in May were weighed, had their body condition scored and height measured. All bulls received breeding soundness examinations and a preputial wash, which was cultured for Tritrichomonas foetus and Campylobacter foetus subsp. venerealis. In July, cows were also weighed and had their body condition scored and again when they left the pasture. In addition, cows were pregnancy checked when they left the pasture. Bulls were tested again for Tritrichomonas foetus at the end of the grazing season. Two breeding groups had T. foetus-positive bulls and an average pregnancy of 84%, which was significantly lower than that of the two T. foetus negative groups (93.5%) (P = 0.0001). A cow was 2.97 times less likely to be pregnant if she had been exposed to T. foetus-positive bulls. Cows with average daily gains above the mean for the pasture were 2.12 times more likely to be pregnant. Body condition score upon entering and leaving the pasture, height, age, and breeding group were significant predictors of average daily gain.

The prevalence and intensity of Schistosoma mansoni infection among residents in two Egyptian villages, at two and twelve months post-treatment with 40 and 60 mg praziquantel per kg body weight at these two villages respectively

Two different regiments of praziquantel, 40 mg/kg in a single dose and 60 mg/kg in two divided doses administered 6 hr apart for the treatment of S. mansoni infection, were compared at two villages of Beheira Governorate. All residents of both sexes between 5 and 50 yrs old from two rural communities (Farshout and Om El-Laban) participated in this study. The prevalence of S. mansoni infection was 58% at Farshout and 69% at Om El-Laban. Infected subjects received 60 mg/kg of praziquantel in two divided doses 6 hr apart at Farshout and 40 mg/kg in a single dose at Om El-Laban. Two months post-treatment, better cure rates (96% vs 85%, P < 0.001) were achieved with 60 mg/kg of praziquantel. Twelve months post-treatment the prevalence of infection (45% for both villages) increased, but remained lower than before treatment. This may indicate that transmission continued from cercariae transported by water from nearby hyperendemic areas. The prevalence and intensity of infection were higher in the younger (5-19 y) than in the older (20-50 y) age group both before treatment and one year post-treatment. The same applies to the incidence and reinfection of the treated subjects. We recommend that 60 mg/kg in two divided doses six hours apart be used for school children. For logistical reasons, the single dose, 40 mg/kg regimen, should be used for mass treatment. For better control of disease, mass chemotherapy with praziquantel as suggested above is essential for the whole endemic region rather than only for a focal area.

A population genetic study of Borrelia burgdorferi sensu stricto from eastern Long Island, New York, suggested frequency-dependent selection, gene flow and host adaptation

Eastern Long Island, New York, is one of the major foci of Lyme disease in the United States. As in almost all other parts of North America, Lyme disease in this region is caused by a single genomic species of spirochete, Borrelia burgdorferi sensu stricto. For three consecutive years, natural populations of Lyme Borrelia in this region were sampled and studied for gene flow among different locations, changes in population structure over time, and selective forces. The genetic diversity of Borrelia populations was measured at the outer surface protein A (ospA) locus using Cold Single-Stranded Conformation Polymorphism (Cold SSCP) analysis. The Borrelia populations were found to be highly polymorphic within any of thirteen local populations. Ewens-Watterson tests of neutrality revealed that the high level of genetic diversity within local Borrelia populations is maintained by balancing selection. Frequency-dependent selection for the different strains distinguished by the ospA alleles is likely the mechanism of the balancing selection. Allele frequency distributions of Borrelia populations were homogeneous across the region in any particular year, although different infection rates of local tick (Ixodes scapularis) populations suggested that the Borrelia populations were at least partially isolated. Since the allele frequency distribution changed over time, while remaining homogeneous over space, the nearly uniform allele frequency distribution across the region cannot be explained by recent geographic expansion from a single population. This uniform distribution across the region thus may be maintained by selection, or by a significant amount of migration or both. The genetic structure of B. burgdorferi sensu stricto also differed between spirochetes infecting nymphal ticks and those infecting adult ticks. Since larval and nymphal ticks have distinctly different host feeding preferences, host adaptation of spirochete populations is implied. This distinction and an animal study using chipmunks suggest that ticks infected by Borrelia as larvae may have high mortality in the wild. This study represents a genetic analysis of local populations of a bacterial species.