Tracheal intubation of healthy pediatric patients without muscle relaxant: a survey of technique utilization and perceptions of safety.

UNLABELLED: We conducted a survey of Society for Pediatric Anesthesia anesthesiologists practicing within the United States to determine the frequency of tracheal intubation of healthy infants and children using an inhaled anesthetic without muscle relaxation (IAWMR). We also examined reasons for the use of this technique. Of all responders who listed their most often used technique for tracheal intubation of healthy infants and children, IAWMR was chosen over intubation with a muscle relaxant by 38.1% and 43.6%, respectively. Anesthesiologists who most often used IAWMR for tracheal intubation of healthy infants and children had over twice the odds (odds ratio [OR] 2.30 for infants, 95% confidence interval [CI] 1.18-4.50; P = 0.015) of classifying their own practice as nonacademic, and one-third the odds (OR 0.34 for infants, 95% CI 0.17-0.68; P = 0.002) of conducting more than half of their cases in a supervisory role. Anesthesiologists who use IAWMR to tracheally intubate healthy pediatric patients most commonly selected as their reasons the lack of need for a muscle relaxant and the desire to avoid both succinylcholine and the excessive duration of nondepolarizing muscle relaxants. IMPLICATIONS: Inhaled anesthetic without muscle relaxation is the most often used method of intubation for more than one third of Society for Pediatric Anesthesia anesthesiologists when tracheally intubating healthy, fasted pediatric patients undergoing elective procedures. The frequency of this practice seems to be highest in nonacademic practices.

Patterns of health seeking behavior during episodes of childhood diarrhea: a study of Tzotzil-speaking Mayans in the highlands of Chiapas, Mexico.

In Chiapas, Mexico, diarrheal disease causes the majority of all deaths in children under the age of five. Treatment of childhood diarrhea may be influenced by local beliefs and cultural practices. Few studies have attempted to quantitatively evaluate health seeking behavior (HSB) for diarrheal diseases in indigenous communities, while controlling for potential confounding factors such as parental education or socioeconomic status. A rapid ethnographic survey was conducted in Nabenchauc, Chiapas, to determine hypothetical HSB patterns for each of four major types of childhood diarrhea. Additionally, we examined the actual HSB for the last episode of childhood diarrheal illness within the household. One hundred households participated in the survey; 94 households with children < 5 years old reported a mean of 1.9 diarrheal episodes during the preceding month. Households reported using a mean of 1.3 types of in-home remedies. Oral rehydration therapy (ORT) was used in <2% of the 368 HSB patterns elicited for the four types of diarrhea. HSB patterns utilized an eclectic combination of traditional, allopathic, local and distant health care options. A mean of 2.5 outside-the-home health care options were reported for each diarrheal type; the local grocery store was reported in 245 (67%) of the hypothetical HSB patterns and as a first option in 199 (54%). Maternal and/or paternal education had little impact on hypothetical HSB. Households with lower SES were more likely to report using local grocery stores as a first option and were less likely to use options outside the village. The rapid ethnographic survey approach allows for assessment of changes in the approach to health care option utilization in cultures incorporating new health care paradigms. Public health interventions targeting local stores may lead to increased use of ORT, thereby potentially reducing early morbidity and mortality due to childhood diarrhea.

Public health interventions to encourage TB class A/B1/B2 immigrants to present for TB screening.

From 1985 to 1995 the proportion of all Santa Clara County, California (SCC), tuberculosis (TB) cases among recent immigrants climbed 73% (137 to 237). In SCC the efficient and cost-effective means encouraging TB Class A/B1/B2 immigrants (TBIMs) to present for TB screening and the prevalence of active TB among them were never investigated. We studied all TBIMs entering SCC from October 1, 1995 to June 30, 1996, notified to SCC by the CDC's Division of Quarantine (DQ). Encouraging TBIMs to seek TB screening, we sent letters to them promptly on the DQ notification, followed sequentially by phone calls and home visits. We determined the outcome of screening and its cost. We screened 314 of 323 (97.2%) TBIMs including 79 of 323 TBIMs who presented prior to interventions, 213 of 314 (87.3%) who responded to letters, 17 (7%) to phone calls, and 5 (2%) to home visits. Of 283 TBIMs screened 16 (5.7%) had active TB. To locate one TBIM cost $9.90 by letter, $43.25 by phone, and $129.88 by home visit. Locating one TB case cost $175.88 by letter, $696.26 by phone call. The prevalence of active TB in TBIMs is high. Our interventions resulted in low-cost TB screening and high-yield identification of active TB cases. We recommended that health departments develop a system for encouraging TBIMs to present for prompt TB screening.

Tuberculosis and race/ethnicity in the United States: impact of socioeconomic status.

Despite the long-standing observation that tuberculosis (TB) case rates are higher among racial and ethnic minorities than whites in the United States (U.S.), the proportion of this increased risk attributable to socioeconomic status (SES) has not been determined. Values for six SES indicators (crowding, income, poverty, public assistance, unemployment, and education) were assigned to U.S. TB cases reported from 1987-1993 by ZIP code- and demographic-specific matching to 1990 U.S. Census data. TB risk between racial/ethnic groups was then evaluated by quartile for each SES indicator utilizing univariate and Poisson multivariate analyses. Relative risk (RR) of TB increased with lower SES quartile for all six SES indicators on univariate analysis (RRs 2.6-5.6 in the lowest versus highest quartiles). The same trend was observed in multivariate models containing individual SES indicators (RRs 1.8-2.5) and for three SES indicators (crowding, poverty, and education) in the model containing all six indicators. Tuberculosis risk increased uniformly between SES quartile for each indicator except crowding, where risk was concentrated in the lowest quartile. Adjusting for SES accounted for approximately half of the increased risk of TB associated with race/ethnicity among U.S.-born blacks, Hispanics, and Native Americans. Even more of this increased risk was accounted for in the final model, which also adjusted for interaction between crowding and race/ethnicity. SES impacts TB incidence via both a strong direct effect of crowding, manifested predominantly in overcrowded settings, and a TB-SES health gradient, manifested at all SES levels. SES accounts for much of the increased risk of TB previously associated with race/ethnicity.

Impact of HIV on tuberculosis in sub-Saharan Africa: a regional perspective.

SETTING: The relative magnitude of the recent rise in tuberculosis (TB) in sub-Saharan Africa and the proportion of excess TB cases attributable to the human immunodeficiency virus (HIV) have not been evaluated from a regional perspective. METHODS: For each of 10 countries in mainland sub-Saharan Africa, we used reported TB case data from 1975-1993 to calculate annual excess TB cases after 1985, by subtracting the number of TB cases that would have been expected had pre-1985 trends continued from the number of reported cases for each year from 1985-1993. Using HIV seroprevalence rates from the literature for TB patients and the general population, we estimated the number of HIV-attributable TB cases in each country from 1985-1994. RESULTS: Excess TB cases accounted for a mean of 34% (range, 0-72%) of reported cases post-1985. HIV seropositivity in TB patients was a mean of 3.5 times (range, 1.8-6.1 times) higher than in the general population. The percentage of excess TB cases attributable to HIV increased as the HIV seroprevalence among TB patients increased, with HIV-attributable cases equalling or exceeding the number of excess TB cases in four of the six countries where > or = 50% of TB patients were estimated to be seropositive in 1992. CONCLUSION: Approximately one-third of TB cases in sub-Saharan Africa after 1985 would not have occurred had pre-1985 trends continued. The dramatic interaction of HIV and TB in the region was underscored by the high rates of HIV infection among TB patients and the high proportion of excess TB morbidity attributable to HIV.

Host and viral factors affecting the decreased immunogenicity of Sabin type 3 vaccine after administration of trivalent oral polio vaccine to rural Mayan children.

Factors affecting immunogenicity of the first 2 doses of oral poliovirus vaccine (OPV) among unimmunized Mayan infants were prospectively evaluated. The relative impact of multiple variables, including mass or routine vaccination, concurrent enteric bacterial (salmonella, shigella, and campylobacter) and viral (adenovirus 40/41, astrovirus, nonpolio enteroviruses, and rotavirus) infections, interference among Sabin vaccine viruses, and preexisting poliovirus antibodies were studied. Sera were available from 181 infants after 2 OPV doses. Seroresponses were 86% to Sabin type 1, 97% to Sabin type 2, and 61% to Sabin type 3 vaccines. Mass versus routine vaccination and preexisting poliovirus antibodies did not affect immunogenicity. By multiple logistic regression analysis, fecal shedding of homologous Sabin strains was associated with increased seroresponses to all Sabin types, especially to Sabin type 3. Decreased OPV immunogenicity was primarily attributable to interference of Sabin type 3 by Sabin type 2. OPV formulations with higher doses of Sabin type 3 could improve immunogenicity among infants in developing countries.

Tuberculin skin test screening in schoolchildren in the United States.

OBJECTIVE: To determine the current practices and results of tuberculin skin test (TST) screening of schoolchildren in the United States. METHODS: Tuberculosis program staff in all states and the District of Columbia were asked about current requirements, practices, and results of school-based TST screening. RESULTS: Thirty-four states and the District of Columbia (69%) reported no current statewide statutes or policies for tuberculin screening of schoolchildren, and 10 (19%) reported having statewide requirements. In 6 states (12%), requirements were instituted at the local level, and 24 localities in these states were known to require screening. Of the 34 areas requiring screening, 18 (53%) screened all new entrants, 7 (21%) screened children in specific grades, and 9 (26%) used other criteria for screening. TST results were collected for 26 (76%) of 34 areas, and 6 areas collected results of follow-up evaluation of tuberculin-positive children. Additionally, 8 localities in 7 states with no screening requirements conducted tuberculin surveys. Sixteen areas provided results. In 7 of the 8 areas that collected information about birthplace, less than 2% of US-born children were tuberculin positive; foreign-born children had rates 6 to 24 times higher than US-born children. TST screening identified new cases of tuberculosis, less than 0.02% of the children screened. CONCLUSIONS: School-based tuberculin screening identified low rates of positive TST results in US-born children. Resources should be directed toward screening children at high risk for tuberculous infection, as recommended by the American Academy of Pediatrics and the Advisory Committee for Elimination of Tuberculosis.

Tuberculosis in sub-Saharan Africa: a regional assessment of the impact of the human immunodeficiency virus and National Tuberculosis Control Program quality.

BACKGROUND: The effect of the human immunodeficiency virus (HIV) epidemic on tuberculosis (TB) has been evaluated for certain countries in sub-Saharan Africa. However, no multi-country comparisons have been performed of the magnitude of the changes in TB case rates and the roles of the HIV epidemic and national TB control program (NTP) quality in these changes. METHODS: We examined trends in TB case rates after 1985 for 20 sub-Saharan African countries, and also from 1975-1984 for 10 of these countries (core countries). Average annual changes in TB case rates after 1985 were stratified by 1992 urban low-risk HIV seroprevalence and by NTP quality, as determined by a survey of international TB experts. RESULTS: Case rates in the core countries decreased by an average of -1.6% per year prior to 1985, but increased by an average of +7.0% per year after 1985 (+7.7% per year after 1985 in all 20 countries). Average annual case rates after 1985 increased approximately twice as fast in countries with high vs low or intermediate HIV seroprevalence ratings. In both the core countries and all 20 countries, the average annual rate of rise in case rates after 1985 decreased as NTP quality rating increased. This relationship persisted even after stratification by HIV seroprevalence rating. CONCLUSIONS: TB case rates have increased in sub-Saharan Africa since 1985. These increases were relatively greater as HIV seroprevalence increased, and relatively lower as NTP quality increased. Improving NTP quality is essential to mitigate the resurgence of TB in the HIV era.

PIP: Specialists in tuberculosis (TB) prevention and control examined trends in TB case rates after 1985 for 20 sub-Saharan African countries and these trends during 1975-84 for 10 of the countries (core countries). They aimed to determine the effect of the HIV epidemic on TB. The 20 countries accounted for 50% of the total population of sub-Saharan Africa and 85% of TB cases. The figures for the core countries were 19% and 27%, respectively. In the core countries, TB case rates fell on average by 1.6% (range, -12.7% to 4.6%) annually before 1985, but increased on average by 7% (range, -2.6% to 18%) thereafter. The TB case rate increased by 7.7% (range, -4.5% to 14.5%) after 1985 in the 20 countries. TB case rates after 1985 increased almost twice as fast in countries with high HIV prevalence ratings when compared to those with low or intermediate HIV prevalence ratings (12.7% vs. 4.6% and 4.5% in core countries and 7.8% and 5.1% in the 20 countries, respectively). In both the core countries and the 20 countries, the annual rate of increase in TB case rates fell as the quality of the national TB control program increased. This held true when the researchers stratified by HIV prevalence. Improving quality had the least impact on the rate of increase in TB case rates in countries with a high HIV seroprevalence. These findings suggest that sub-Saharan African countries should invest in improving the quality of the national TB control program to effect reductions in TB morbidity, even in the face of the HIV epidemic.

Tuberculosis screening among homeless persons with AIDS living in single-room-occupancy hotels.

Congregate facilities for homeless persons with the acquired immunodeficiency syndrome (AIDS) are often endemic for tuberculosis. We evaluated tuberculosis screening methods at single-room-occupancy hotels housing persons with AIDS. Residents were screened by cross matching the New York City Tuberculosis Registry, interviewing for tuberculosis history, skin testing, and chest radiography. Cases were classified as either previously or newly diagnosed. Among the 106 participants, 16 (15%) previously diagnosed tuberculosis cases were identified. Participants' tuberculosis histories were identified by the questionnaire (100%) or by registry match (69%). Eight participants (50%) were noncompliant with therapy. These findings prompted the establishment of a directly observed therapy program on site.

Epidemiology of tuberculosis in the United States, 1985 through 1992.

OBJECTIVE: To examine the distribution and sources of increased tuberculosis (TB) morbidity in the United States from 1985 through 1992. DESIGN: Review of TB surveillance data. PARTICIPANTS: All incident TB cases in the United States reported to the Centers for Disease Control and Prevention from 1980 through 1992. MAIN OUTCOME MEASURES: Changes in reported number of TB cases from 1985 through 1992 were analyzed by sex, race/ethnicity, age, county of birth (1986 through 1992), site of disease, geographic location, and socioeconomic status (through 1991). From 1985 through 1992, reported number of cases was compared with expected number of cases, extrapolated from 1980 through 1984 trends, to estimate excess cases by sex, race/ethnicity, and age. RESULTS: Increases in number of cases from 1985 through 1992 were concentrated among racial/ethnic minorities, persons 25 to 44 years of age, males, and the foreign-born. Excess cases occurred in both sexes, all racial/ethnic groups, and all age groups. Foreign-born cases accounted for 60% of the total increase in the number of US cases from 1986 through 1992 and had the greatest impact among Asians, Hispanics, females, and persons other than those 25 to 44 years of age. Human immunodeficiency virus infection had the greatest impact on TB morbidity among whites, blacks, males, and persons 25 to 44 years of age. From 1985 through 1992, the number of cases among children 4 years old or younger increased 36%, suggesting that transmission of TB increased during this period. CONCLUSIONS: Multiple factors contributed to the recent increases in the number of TB cases. The effectiveness of TB screening in immigrants needs further evaluation. Intensified efforts to determine the human immunodeficiency virus status of persons with TB are needed. Screening of subpopulations at increased risk for tuberculous infection or TB should be expanded.