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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

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Date: Thu, 19 Jan 95 07:33:38 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR 6 Jan 95] Hemorrhage/Shock with Invasive Pneumococcal
Infections
Message-ID: <[e-mail]>

    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: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Asthma -- United States, 1982-1992
Message-ID: <[e-mail]>

                   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:

·
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: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Changes in Notifiable Diseases Data Presentation
Message-ID: <[e-mail]>

          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: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Lack of Evidence for Wild Poliovirus Circulation
Message-ID: <[e-mail]>

   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: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Recommended Childhood Immunization Schedule
Message-ID: <[e-mail]>

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: [e-mail] (HICNet Medical News)
To: hicnews
Subject: New Listserv: Addiction-Medicine
Message-ID: <[e-mail]>

======================================================================
               New InterPsych Forum: Addiction-Medicine
======================================================================

To join send the message: subscribe addiction-medicine

to: [e-mail]
    ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
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.
<[e-mail]>
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: [phone]
======================================================================


Mr Ian Pitchford
Department of Biomedical Science
University of Sheffield
Western Bank
SHEFFIELD, S10 2TN
United Kingdom
Tel: [phone]



------------------------------

Date: Thu, 19 Jan 95 07:49:41 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: AIDS Daily Summary
Message-ID: <[e-mail]>

                     AIDS Daily Summary

·

The Centers for Disease Control and Prevention (CDC) National AIDS
Clearinghouse makes available the following information as a public
service only. Providing this information does not constitute
endorsement
by the CDC, the CDC Clearinghouse, or any other organization.
Reproduction
of this text is encouraged; however, copies may not be sold, and the
CDC
Clearinghouse should be cited as the source of this information.
Copyright 1994, Information, Inc., Bethesda, MD

     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

·
     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.



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End of HICNet Medical News Digest V08 Issue #04
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