Alcohol in combination with illicit drugs among fatal injuries in Sao Paulo, Brazil: An epidemiological study on the association between acute substance use and injury.

Injury deaths have a major impact on public health systems, particularly in the Latin American region; however, little is known about how different drugs, in combination or not with alcohol, interact with each injury type. We tested an epidemiological protocol for investigating alcohol and other drug acute use among fatally injured victims taking into account the injury context for all injury causes in Sao Paulo, Brazil. Blood alcohol and drug content were fully screened and confirmed following a probability sample selection of decedents (n = 365) during 19 consecutive months (2014-2015). Drug concentrations, including benzodiazepines, cannabis, cocaine, and opioids were determined by gas chromatography-mass spectrometry (GC-MS) or liquid chromatography tandem mass spectrometry (LC-MS/MS). Toxicology data were interpreted in combination with injury context retrieved from police records regarding cause, place of injury, and victims' criminal history. More than half of all fatally injured victims studied were under the influence of at least one substance (55.3%). Alcohol was the leading substance consumed before a fatal injury event (30.1%), followed by cocaine (21.9%) and cannabis (14%). Illicit drug use (cocaine and cannabis) comprised more than two thirds of all drug-related deaths. Alcohol-positive deaths are over-represented among road traffic injuries, while drug-positive deaths are more prevalent among intentional injuries. Victims who had previous criminal convictions were significantly more likely to have used illicit drugs compared to those who did not have a criminal background. We estimated that one in every two fatal injuries in the city of Sao Paulo is associated with acute substance use by the victim. The health burden attributed to alcohol- and drug-related fatal injury events has reached significant higher levels in Latin American cities such as Sao Paulo compared globally.

Measles and Rubella Global Strategic Plan 2012-2020 midterm review.

KEY HIGHLIGHTS: 1. Measles eradication is the ultimate goal but it is premature to set a date for its accomplishment. Existing regional elimination goals should be vigorously pursued to enable setting a global target by 2020. 2. The basic strategic approaches articulated in the Global Measles and Rubella Strategic Plan 2012-2020 are valid to achieve the goals but have not been fully implemented (or not appropriately adapted to local situations). 3. The report recommends a shift from primary reliance on supplementary immunization activities (SIAs) to assure two doses of measles-containing vaccine (MCV) are delivered to the target population to primary reliance on ongoing services to assure administration of two doses of MCV. Regular high quality SIAs will still be necessary while ongoing services are being strengthened. 4. The report recommends a shift from primary reliance on coverage to measure progress to incorporating disease incidence as a major indicator. 5. The report recommends that the measles/rubella vaccination program be considered an indicator for the quality of the overall immunization program and that measles/rubella incidence and measles and rubella vaccination coverage be considered as primary indicators of immunization program performance. 6. Polio transition presents both risks and opportunities: risks should be minimized and opportunities maximized. 7. A school entry immunization check could contribute significantly to strengthening overall immunization services with assurance that recommended doses of measles and rubella vaccines as well as other vaccines have been delivered and providing those vaccines at that time if the child is un- or under-vaccinated. 8. Program decisions should increasingly be based on good quality data and appropriate analysis. 9. The incorporation of rubella vaccination into the immunization program needs to be accelerated - it should be accorded equivalent emphasis as measles. 10. Outbreak investigation and response are critical but the most important thing is to prevent outbreaks.

Group B streptococcus infections of soft tissue and bone in California adults, 1995-2012.

Group B streptococcus (GBS) is an increasing cause of disease in adults. We present long-term trends in incidence of overall infections and identify characteristics of patients with GBS cellulitis, bone and joint infections. Active, population-based surveillance was conducted from 1995-2012 in three California counties and the data were analysed retrospectively. All cases had isolation of GBS from a normally sterile site. Cases of cellulitis were classified based on clinical diagnosis. GBS bone or joint infection was defined as isolation of GBS from a bone or joint or a diagnosis of osteomyelitis or septic arthritis. Medical charts were reviewed for demographic and clinical information. There were 3917 cases of GBS; the incidence of disease increased from 5·8 to 8·3 cases/100 000 persons (P < 0·001) from 1995 to 2012. In adults aged ⩾40 years, the overall incidence of GBS increased from 8·5 to 14·2 cases/100 000 (P < 0·001) persons during the study period. The incidence of cellulitis increased from 1·6 to 3·8 cases/100 000 (P < 0·001), bone infection increased from 0·7 to 2·6 cases/100 000 (P < 0·001), and the incidence of joint infection remained approximately constant at an average rate of 1·0 case/100 000. The highest incidence rates were observed in men, persons aged ⩾80 years, non-Hispanic blacks and Hispanics. Diabetes was the most common underlying condition (51·2% cellulitis cases, 76·3% bone infections, 29·8% joint infections).

Heavy alcohol use as a risk factor for severe outcomes among adults hospitalized with laboratory-confirmed influenza, 2005-2012.

We examined heavy alcohol use as a risk factor for severe influenza (intensive care admission or death) among hospitalized adults. In <65- and ≥65-year-olds, heavy alcohol use increased disease severity [relative risk (RR) 1.34; 95 % confidence interval (CI): 1.04-1.74, and RR 2.47; 95 % CI: 1.69-3.60, respectively]. Influenza vaccination and early, empiric antiviral treatment should be emphasized in this population.

Developing evidence-based immunization recommendations and GRADE.

The Strategic Group of Advisory Experts (SAGE) on immunization is an independent advisory committee with a mandate to advise the World Health Organization (WHO) on the development of vaccine and immunization related policies. SAGE working groups are established on a time-limited basis to review and provide evidence-based recommendations, together with their implications, for open deliberation and decision-making by SAGE. In making its recommendations, SAGE takes into consideration: the epidemiologic and clinical characteristics of the disease; vaccine and immunization characteristics; economic analysis; health system considerations; the existence of and interaction with other intervention and control strategies; costing and social impacts; and legal and ethical concerns. Since 1998, WHO has produced evidence-based vaccine position papers for use primarily by national public health officials and immunization programme managers. Since April 2006 all new or updated position papers have been based on SAGE recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been adopted by WHO and, since 2008, GRADE tables that rate the quality of evidence have been produced in support of key recommendations. SAGE previously expressed concern that GRADE was not ideally suited to many immunization-specific issues such as the vaccine population level effect and the inclusion of surveillance system data, particularly for vaccine safety. Extensive productive interactions with various advisory groups including the US Advisory Committee on Immunization Practices, the European Centres for Disease Control, the German Standing Committee on Vaccination (STIKO), WHO's Global Advisory Committee on Vaccine Safety and the GRADE working group resulted in key enhancements to accommodate vaccine-relevant evidence. This facilitated integration and acceptability of the GRADE approach in the development of immunization related SAGE and WHO recommendations. Ongoing utilisation should result in further fine-tuning of the approach to ensure that recommendations are based on the full range of appropriate evidence.

Prevalence and correlates of bacterial vaginosis among young women of reproductive age in Mysore, India.

PURPOSE: Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge among women of childbearing age and is associated with STI/HIV and adverse birth outcomes. The objective of this study was to determine the prevalence and correlates of BV among young women of reproductive age in Mysore, India. METHODS: Between October 2005 and December 2006, 898 sexually active women of 15-30 years of age were enrolled from two reproductive health clinics in Mysore. The women underwent an interview followed by physical examination, HSV-2 serologic testing, endocervical culture for Neisseria gonorrhoeae , and vaginal swabs for diagnosis of BV, Trichomonas vaginalis infection and candidiasis. Statistical analyses included conventional descriptive statistics and multivariable analysis using logistic regression. RESULTS: Of the 898 women, 391 (43.5%) were diagnosed with >or=1 endogenous reproductive tract infection and 157 (17.4%) with >or=1 sexually transmitted infection. Only 863 women had Gram-stained vaginal smears available, out of which 165 (19.1, 95% confidence interval [CI]: 16.3%-22.2%) were found to have BV and 133 (15.4, 95% CI: 12.9%-18.3%) were in the 'intermediate' stage. BV was related to concurrent infections with T. vaginalis (odds ratio [OR]=4.07, 95% CI: 2.45-6.72) and HSV-2 seropositivity (OR=2.22, 95% CI: 1.39-3.53). CONCLUSIONS: In this population, the prevalence of BV at 19% was relatively low. Coinfection with T. vaginalis , however, was common. BV was independently associated with concurrent T. vaginalis infection and partner's alcohol use. Muslim women had reduced odds of BV as compared to non-Muslim women. Further research is needed to understand the role of T. vaginalis infection in the pathogenesis of BV and the sociocultural context surrounding the condition in India.

A randomized, placebo-controlled, double-blind clinical trial of curcuminoids in oral lichen planus.

We studied the efficacy of curcuminoids in the treatment of oral lichen planus (OLP), a chronic, mucocutaneous, immunological disease. Curcuminoids are components of turmeric (Curcuma longa) that have anti-inflammatory activity. Turmeric has been used in Ayurveda (Indian traditional medicine) for centuries. A randomized, double-blind, placebo-controlled trial was conducted. In all, 100 consecutive, eligible patients with OLP presenting to the oral medicine clinic at the University of California, San Francisco, were to be selected. Two interim analyses were to be conducted during the trial. The trial was conducted between February 2003 and September 2004. The first interim analysis was conducted in October 2004 using data from the first 33 subjects. Study subjects were randomized to receive either placebo or curcuminoids at 2000 mg/day for 7 weeks. In addition, all subjects received prednisone at 60 mg/day for the first 1 week. The primary outcome was a change in symptoms from baseline. Secondary outcomes were changes in clinical signs and occurrence of side effects. The first interim analysis did not show a significant difference between the placebo and curcuminoids groups. Conditional power calculations suggested a less than 2% chance that the curcuminoids group would have a significantly better outcome as compared with the placebo group if the trial were continued to completion. Therefore, the study was ended early for futility. Reaching a conclusion regarding the efficacy of curcuminoids based on the results of this study is not possible as it was ended early for futility. Curcuminoids at this dose were well tolerated and the results suggest that for future studies a larger sample size, a higher dose and/or longer duration of curcuminoids administration should be considered; however, for the next step, an RCT of a shorter duration, using a higher dose of curcuminoids, and without an initial course of prednisone, should be considered.

Novel recruitment strategies to increase participation of women in reproductive health research in India.

In India, care seeking for reproductive health among women is inadequate. This poses a unique challenge to researchers recruiting cohorts for studies in clinic-based settings. The purpose of this paper is to describe the recruitment process used in a prospective cohort study investigating the relationship between bacterial vaginosis and acquisition of HSV-2 among sexually active women in Mysore, India. Participants were initially recruited from an obstetrics/gynaecology outpatient clinic. Results were compared with a 'community supported' enrolment process, which included community preparation and reproductive health education followed by screening of potential participants. During November 2005, 1,054 women were screened in the clinic. Of the total screened, 246 (23%) were eligible and only 78 (7%) enrolled. Between December 2005 and April 2006, investigators adopted a community supported enrolment process. During that period, 1,077 potential participants were screened, 947 were eligible, and 918 (85%) enrolled. Fifty-six (72%) participants recruited from the clinic returned for their first follow-up visit, compared with 795 (97%) participants recruited using the community supported enrolment process. Since obstetrics/gynaecology departments in India are poor places to recruit non-pregnant women of reproductive age, a community supported process yields more eligible potential participants to screen, and results in significantly better study retention.

Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults.

BACKGROUND: Structured treatment interruptions (STI) of antiretroviral therapy (ART) have been investigated as part of novel treatment strategies, with different aims and objectives depending on the populations involved. These populations include: 1) patients who initiate ART during acute HIV infection; 2) patients with chronic HIV infection, on ART, with successfully suppressed viremia; and 3) patients with chronic HIV infection and treatment failure, with persistent viremia due to multi-drug resistant HIV (Hirschel 2001; Deeks 2002; Miller 2003). In an earlier Cochrane review (Pai 2005), we had summarized the evidence about the effects of STI in chronic suppressed HIV infection. In this review, we summarize the evidence on STI in patients with chronic unsuppressed HIV infection due to drug-resistant HIV. Unsuppressed HIV infection describes those patients who cannot suppress viremia, due to the presence of multi-drug-resistant virus. It is also referred to as treatment failure. Drug resistance is identified by the presence of resistant mutations at baseline.STI as a treatment strategy in HIV-infected patients with chronic unsuppressed viremia involves interrupting ART in controlled clinical settings, for a pre-specified duration of time. These interruptions have various aims, including the following: 1) to allow wild virus to re-emerge and replace the resistant mutant virus, with the hope of improving the efficacy of a subsequent ART regimen; 2) to halt development of drug resistance and to preserve subsequent treatment options; 3) to alleviate treatment fatigue and reduce drug-related adverse effects; and 4) to improve quality of life (Miller 2003; Montaner 2001; Vella 2000;). OBJECTIVES: The objective of our systematic review was to synthesize the evidence on the effect of structured treatment interruptions in adult patients with chronic unsuppressed HIV infection. SEARCH STRATEGY: We included all available intervention studies (randomized controlled trials and non-randomized trials) conducted in HIV-infected patients worldwide. We searched nine databases, covering the period from January 1996 to February 2006. We also scanned bibliographies of relevant studies and contacted experts in the field to identify unpublished research, abstracts and ongoing trials. In the first screen, a total of 3186 potentially eligible citations from nine databases and sources were identified, of which 2047 duplicate citations were excluded. The remaining 1139 citations were examined in detail, and we further excluded 951 citations that were modeling studies, animal studies, case reports, and opinion pieces. As shown in Figure 01, 188 citations were identified in the second screen as relevant for full-text screening. Of these, 60 basic science studies, editorials and abstracts were excluded and 128 full-text articles were retrieved. In the third screen, all full-text articles were examined for eligibility in our review. These were subclassified into three categories: 1) chronic suppressed HIV infection; 2) chronic unsuppressed HIV infection; and 3) acute HIV infection. Studies were further excluded if their abstracts did not contain enough information for inclusion in our reviews. A total of 62 studies were finally classified into chronic suppressed, acute, and chronic unsuppressed categories. Of these, 17 trials met the eligibility criteria for this review. SELECTION CRITERIA: Inclusion criteriaAll available randomized or non-randomized controlled trials investigating planned treatment interruptions among patients with chronic unsuppressed HIV infection. Early pilot non-randomized prospective studies on treatment interruptions of fixed and variable durations were also included. Relevant abstracts on randomized controlled trials were also included if they contained sufficient information. Exclusion criteriaEditorials, reviews, modeling studies, and basic science studies were excluded. Studies on STI among patients with chronic suppressed HIV infection were summarized in a separate review. Studies on STI in primary HIV infection were beyond the scope of this review. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, evaluated study eligibility and quality. Disagreements were resolved in consultation with a third reviewer.A total of seventeen studies on STI were included in our review. However, due to significant heterogeneity across studies (i.e. in study design, populations, baseline characteristics, and reported outcomes; and in reporting of measures of effect, hazard ratios, and risk ratios), we considered it inappropriate to perform a meta-analysis. MAIN RESULTS: In early pilot non-randomized trials, a pattern was evident across studies. During treatment interruption, a decline in CD4 cell counts, increase in viral load, and a shift in the level of genotypic drug resistance towards more of a wild-type HIV virus was reported. This suggests that STI may be used to increase drug susceptibility to an optimized salvage regimen upon treatment re-initiation. These studies generated useful data and hypotheses that were later tested in randomized controlled trials. Randomized controlled trials rated high on quality. Of the eight randomized controlled trials reviewed, seven had been completed while one was ongoing and remains blinded. Of the seven completed randomized controlled trials, six have reported consistent virologic and immunologic patterns, and found no significant benefit in virologic response to subsequent ART in the STI arm, compared to the control arm. In addition, the largest completed randomized trial reported greater numbers of clinical disease progression events and evidence of prolonged negative impact on CD4 cell counts in the STI arm (Beatty 2005; Benson 2004; Deeks 2001; Lawrence 2003; Walmsley 2005; Ruiz 2003). The single RCT with divergent findings from the others (GigHAART), reporting a significant virologic and immunologic benefit due to STI, was different in prescribing a shorter STI duration and a salvage ART regimen of 8-9 drugs. There were also differences in the patient population characteristics with this study, targeting those with very advanced HIV disease (Katlama 2004). Although we await the unblinded results of the eighth RCT (OPTIMA), the evidence so far does not support STI in the setting of chronic unsuppressed HIV infection with antiretroviral treatment failure (Brown 2004; Holodniy 2004; Kyriakides 2002; Singer 2006). AUTHORS' CONCLUSIONS: The current available evidence primarily supports a lack of benefit of STI before switching therapy in patients with unsuppressed HIV viremia despite ART. There is evidence of harm in attempting STI in patients with relatively advanced HIV disease, due to the associated CD4 cell decline and the increased risk of clinical disease progression. At this time, there is no evidence to recommend the use of STI in this clinical category of patients with treatment failure.

Structured treatment interruptions (STI) in chronic suppressed HIV infection in adults.

BACKGROUND: Although antiretroviral treatment (ART) has led to a decline in morbidity and mortality of HIV-infected patients in developed countries, it has also presented challenges. These challenges include increases in pill burden; adherence to treatment; development of resistance and treatment failure; development of drug toxicities; and increase in cost of HIV treatment and care. These issues stimulated interest in investigating the short-term and long-term consequences of discontinuing ART, thus providing support for research in structured treatment interruptions (STI). Structured treatment interruptions of antiretroviral treatment involve taking supervised breaks from ART. STI are defined as one or more planned, timing pre-specified, cyclical interruptions in ART. STI are attempted in monitored clinical settings in eligible participants. STI have generated hopes of reducing drug toxicities, decreasing costs and total time on treatment in HIV-positive patients. The first STI was attempted in the case of a patient in Germany, who later permanently discontinued treatment. This successful anecdotal case report led to several trials on STI worldwide. OBJECTIVES: The objective of this systematic review was to assess the effects of structured treatment interruptions (STI) of antiretroviral therapy (ART) in the management of chronic suppressed HIV infection, using all available high-quality studies. SEARCH STRATEGY: Nine databases covering the time period from January 1996 to March 2005 were searched. Bibliographies were scanned and experts contacted in the field to identify unpublished research and ongoing trials. Two reviewers independently extracted data, and evaluated study eligibility and quality. Disagreements were resolved in consultation with a third reviewer. Data from 33 studies were included in the review. SELECTION CRITERIA: STI is a planned, timing pre-specified experimental intervention. In our review, we decided to include all available intervention trials in HIV-infected patients, with or without control groups. We reviewed evidence from 18 randomized and non-randomized controlled trials, and 15 single arm trials. Single arm trials were included because these pilot studies made significant contribution to the early development and refutation of hypotheses in STI. DATA COLLECTION AND ANALYSIS: Trials included in this review varied in study participants, methodology and reported inconsistent measures of effect. Due to this heterogeneity, we did not attempt to meta-analyse them. Results were tabulated and a qualitative systematic review was done MAIN RESULTS: For the purpose of this review, STI strategies were classified either as a timed-cycle STI strategy or a CD4-guided STI strategy. In timed-cycle STI strategy, a predetermined period of fixed duration (e.g. one week, one month) off ART was attempted followed by resumption of ART, while closely monitoring changes in CD4 levels and viral load levels. Predetermined criteria for interruption and resumption were laid out in this strategy. Timed-cycle STI fell out of favor due to reports of development of resistance in many studies. Moreover, there were no significant immunological and virological benefits, and no reduction in toxicities, reported in these studies. In CD4-guided STI strategy, ART was interrupted for variable durations guided by CD4 levels. Participants with high nadir CD4 levels qualified for this approach. A reduction in costs of ART, a reduction in mutation, and a better tolerability of this CD4-guided STI strategy was reported. However, concerns about long-term safety of this strategy on immunological, virological, and clinical outcomes were also raised. AUTHORS' CONCLUSIONS: Timed-cycle STI have not been proven to be safe in the short term. Although CD4-guided STI strategy has reported favorable outcomes in the short term, the long-term safety, efficacy and tolerability of this strategy has not been fully investigated. Based on the studies we reviewed, the evidence to support the use of timed-cycle STI and CD4-guided STI cycles as a standard of care in the management of chronic suppressed HIV infection is inconclusive.

Invasive group A streptococcal infections in the San Francisco Bay area, 1989-99.

To describe the epidemiology of invasive group A streptococcal (iGAS) infections in the San Francisco Bay Area, population-based active surveillance for laboratory-confirmed iGAS was conducted by the California Emerging Infections Program in three California counties. From January 1989 to December 1999, 1415 cases of iGAS were identified. Mean iGAS incidence was 4.06/100,000 person-years and case fatality ratio was 13%, with no linear trends over time. Incidence was lowest in adolescents, was higher in men than women (4.4 vs. 3.2/100,000 person-years), and was higher in African-Americans (6.7) than in non-Hispanic (4.1) or Hispanic (3.4) Whites, Asians (2.2) or Native Americans (17/100,000 person-years). Injecting drug use was the riskiest underlying condition and was associated with the highest attributable risk. Cases were associated with several underlying conditions, but 23% occurred in previously healthy persons. From 1989-1999, iGAS infections in the San Francisco Bay Area became neither more common nor more deadly.

Trends of HIV infection among injection drug users in Brazil in the 1990s: the impact of changes in patterns of drug use.

BACKGROUND: Santos Metropolitan Region (SMR), State of Sao Paulo, historically is well known as being one of the areas with the largest number of AIDS cases in Brazil, especially among injection drug users (IDUs). The main objective of this study was to assess the effects of changes in drug-using patterns among IDUs on trends in HIV infection among IDUs in the 1990s. METHODS: During 1991 through 1992 (wave 1; n = 214), 1994 through 1996 (wave 2; n = 135), and 1999 (wave 3; n = 108), we conducted three cross-sectional studies of IDUs. All participants were interviewed and tested for antibodies to HIV. FINDINGS: The overall sample population was 69% male, and 87% of the sample population was under 40 years old. Eighty-four percent of the population had less than 9 years of education. HIV seroprevalence was 63% in wave 1, 65% in wave 2, and 42% in wave 3 ( p <.001). Smoking of crack cocaine increased from 11% in wave 1 to 60% in wave 2 and 67% in wave 3 ( p <.001). The prevalence of frequent injections (>5 per day) decreased from 42% in wave 1 to 30% in wave 2 and 15% in wave 3 ( p <.001). INTERPRETATION: HIV prevalence decreased as injection frequency decreased and crack cocaine use increased. In SMR, patterns of drug use have been affecting the HIV epidemic more than scant public health intervention.

Trends in antifungal drug susceptibility of Cryptococcus neoformans isolates in the United States: 1992 to 1994 and 1996 to 1998.

The antifungal drug susceptibilities of two collections of Cryptococcus neoformans isolates obtained through active laboratory-based surveillance from 1992 to 1994 (368 isolates) and 1996 to 1998 (364 isolates) were determined. The MICs of fluconazole, itraconazole, and flucytosine were determined by the National Committee for Clinical Laboratory Standards broth microdilution method; amphotericin B MICs were determined by the E-test. Our results showed that the MIC ranges, the MICs at which 50% of isolates are inhibited (MIC(50)s), and the MIC(90)s of these four antifungal agents did not change from 1992 to 1998. In addition, very small numbers of isolates showed elevated MICs suggestive of in vitro resistance. The MICs of amphotericin B were elevated (>or=2 microg/ml) for 2 isolates, and the MICs of flucytosine were elevated (>or=32 microg/ml) for 14 isolates. Among the azoles, the fluconazole MIC was elevated (>or=64 microg/ml) for 8 isolates and the itraconazole MIC (>or=1 microg/ml) was elevated for 45 isolates. Analysis of 172 serial isolates from 71 patients showed little change in the fluconazole MIC over time. For isolates from 58 patients (82% of serial cases) there was either no change or a twofold change in the fluconazole MIC. In contrast, for isolates from seven patients (12% of serial cases) the increase in the MIC was at least fourfold. For isolates from another patient there was a 32-fold decrease in the fluconazole MIC over a 1-month period. We conclude that in vitro resistance to antifungal agents remains uncommon in C. neoformans and has not significantly changed with time during the past decade.

Adenovirus type 3 viremia in an adult with toxic shock-like syndrome.

Surveillance by the Unexplained Deaths and Critical Illnesses Project (UNEX) uncovered a novel presentation of adenovirus type 3 infection that satisfied the criteria for toxic shock-like syndrome in a 28-year-old immunocompetent man. Adenovirus may be a cause of toxic shock syndrome; surveillance systems such as UNEX may uncover additional causes of this and other clinically defined infectious syndromes.

Use of recommended laboratory testing methods among patients with tuberculosis in California.

This study assessed the extent to which laboratory methods recommended by the Centers for Disease Control and Prevention were used in tuberculosis testing of patients in California in 1998. While recommended methods were used for most patients, there was room for improvement by hospital and independent non-health maintenance organization laboratories.

Active bacterial core surveillance of the emerging infections program network.

Active Bacterial Core surveillance (ABCs) is a collaboration between the Centers for Disease Control and Prevention and several state health departments and universities participating in the Emerging Infections Program Network. ABCs conducts population-based active surveillance, collects isolates, and performs studies of invasive disease caused by Streptococcus pneumoniae, group A and group B Streptococcus, Neisseria meningitidis, and Haemophilus influenzae for a population of 17 to 30 million. These pathogens caused an estimated 97,000 invasive cases, resulting in 10,000 deaths in the United States in 1998. Incidence rates of these pathogens are described. During 1998, 25% of invasive pneumococcal infections in ABCs areas were not susceptible to penicillin, and 13.3% were not susceptible to three classes of antibiotics. In 1998, early-onset group B streptococcal disease had declined by 65% over the previous 6 years. More information on ABCs is available at www.cdc.gov/ncidod/dbmd/abcs. ABCs specimens will soon be available to researchers through an archive.

Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996.

Surveillance for coccidioidomycosis (CM) and a case-control study for risk factors among adults were conducted in Kern County, California. From January 1995 through December 1996, 905 cases of CM were identified, for an annual incidence of 86 cases per 100,000 population. A total of 380 adults were enrolled in the case-control study: 77 had severe pulmonary disease, 33 had disseminated disease, and 270 control patients had mild disease. Independent risk factors for severe pulmonary disease included diabetes, recent history of cigarette smoking, income of < $15,000 per year, and older age. Oral antifungal therapy before hospitalization was associated with a reduced risk of CM pneumonia. Risk factors for disseminated disease were black race, income of < $15,000 per year, and pregnancy. Early treatment of CM with oral antifungal agents may prevent severe pulmonary disease in groups considered to be at high risk, such as elderly individuals, persons with diabetes, and smokers. Persons at risk for severe CM may benefit from vaccination once an effective CM vaccine is available.

Overdoses among cocaine users in Brazil.

AIMS: A survey of cocaine users was undertaken to study (i) the frequency of reported drug overdoses among cocaine users; and (ii) the frequency of witnessing drug overdoses in the same population. DESIGN AND SETTING: A cross-sectional study as part of the World Health Organization (WHO) Multi-city Study among injecting drug users (IDUs), phase II, was conducted in Santos Metropolitan Region, State of São Paulo, Brazil, in 1999. PARTICIPANTS: Three hundred and ninety-six exclusive users of cocaine in the Santos Metropolitan Region, São Paulo State, Brazil were surveyed concerning their past experience with drug overdoses. FINDINGS: Eighty (20%) of the cocaine users reported having experienced one or more overdoses, and 50% reported that they knew one or more other cocaine users who had died of an overdose. On multivariate analysis, being female and having spent time in jail were associated with an increased likelihood of having had one or more overdoses. CONCLUSION: Cocaine overdoses are an important and under-recognized health problem in the Santos Metropolitan Region, and possibly in other areas of Brazil.

Comparison of sputum induction with fiberoptic bronchoscopy in the diagnosis of tuberculosis: experience at an acquired immune deficiency syndrome reference center in Rio de Janeiro, Brazil.

Many patients with suspected pulmonary tuberculosis (PTB) do not produce sputum spontaneously or are smear-negative for acid-fast bacilli (AFB). We prospectively compared the yield of sputum induction (SI) and fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) for the diagnosis of PTB in a region with a high prevalence of tuberculosis and human immunodeficiency virus (HIV) infection. Fifty seven percent (143 of 251) of patients had diagnoses of PTB, of whom 17% (25 of 143) were HIV seropositive. There were no significant differences in the yields of AFB smears or cultures whether obtained via SI or BAL. Among 207 HIV-seronegative patients, the AFB smear and mycobacterial culture results from specimens obtained by SI and BAL were in agreement in 97% (202 of 207) (kappa test = 0.92) and 90% (186 of 207) (kappa test = 0.78), respectively. Among HIV-seropositive patients the agreements between AFB smear and culture results for SI and BAL specimens were 98% (43 of 44) (kappa test = 0.93) and 86% (38 of 44) (kappa test = 0.69), respectively. We conclude that SI is a safe procedure with a high diagnostic yield and high agreement with the results of fiberoptic bronchoscopy for the diagnosis of PTB in both HIV-seronegative and HIV-seropositive patients.