What is common becomes normal: the effect of obesity prevalence on maternal perception.

BACKGROUND AND AIMS: This analysis investigates the poorly-known effect of local prevalence of childhood obesity on mothers' perception of their children's weight status. METHODS AND RESULTS: In 2008, a national nutritional survey of children attending the third grade of elementary school was conducted in Italy. Children were measured and classified as underweight, normal weight, overweight and obese, using the International Obesity Task Force cut-offs for body mass index (BMI). A parental questionnaire included parental perception of their child's weight status (underweight, normal, a little overweight and a lot overweight). Regions were classified by childhood obesity prevalence (<8%, 8-12%, ≥13%). The association between incorrect maternal perception and regional obesity prevalence, and maternal and child characteristics were examined using bivariate and logistic regression analyses. Complete data were available for 37 590 children, of whom 24% were overweight and 12% obese. Mothers correctly identified the status of 84% of normal weight, 52% of overweight and 14% of obese children. Among overweight children, factors associated with underestimation of the child's weight included lower maternal education (adjusted odds ratio, aOR, 1.9; 95% confidence interval (CI) 1.6-2.4), residence in a high-obesity region (aOR 2.2; 95% CI 1.9-2.6), male gender (aOR 1.4; 95% CI 1.2-1.6) and child's BMI. CONCLUSION: Higher regional obesity prevalence is associated with lower maternal perception, suggesting that what is common has a greater likelihood of being perceived as normal. As perception is a first step to change, it may be harder to intervene in areas with high-obesity prevalence where intervention is most urgent.

Validation of the line-probe assay for rapid detection of rifampicin-resistant Mycobacterium tuberculosis in Vietnam.

BACKGROUND: Delays in identifying multidrug-resistant tuberculosis (MDR-TB) contribute to higher TB morbidity and mortality, and ongoing transmission. The line-probe assay (LiPA) is a rapid, commercially available polymerase chain reaction based assay that detects most mutations in the rpoB gene for rifampicin (RMP) resistance. We validated and compared this assay with conventional drug susceptibility testing (DST). METHODS: We re-cultured a random sample of stored isolates known to be either RMP-resistant or RMP-susceptible according to DST (proportion method). We performed a blinded comparison between LiPA and conventional DST. Genetic sequencing of the rpoB gene was performed on RMP-resistant isolates and discordant results. RESULTS: We tested 79 RMP-resistant and 64 RMP-susceptible strains. Concordance of LiPA with DST was 94%. For detecting RMP resistance, LiPA sensitivity was 90% and specificity was 100%. Molecular analysis of possible false-negative isolates by LiPA revealed an absence of mutations in the rpoB gene. RMP resistance was a good proxy for MDR-TB, as 66 (93%) of 71 RMP-resistant isolates were also isoniazid-resistant. CONCLUSION: The LiPA provided rapid results that were highly predictive of RMP resistance and MDR-TB. False-negatives occurred, but only among isolates with mutations in regions not assessed by LiPA. Performance and cost-effectiveness should be evaluated in patients during routine program conditions.

Reduction incidence of myocardial infarction associated with a national legislative ban on smoking.

AIM: The aim of the present study was to assess change in admissions for acute myocardial infarction (AMI) in the period immediately subsequent to the coming into force of law no. 3/2003 ''Protection of the health of non-smokers''. METHODS: Four Italian regions (Piedmont, Friuli Venezia Giulia, Lazio and Campania) took part in the study. Data regarding admissions for AMI were taken from the daily discharge papers of patients aged between 40 and 64 (cod. ICD9-CM 410.), in the period 10 January-10 March 2001-2005. Repeated admissions were excluded. Admission rates standardised by age and overall total, and specifically by region, age and gender were calculated. The hypothesis of a significant reduction between 2005 and 2004 was also checked. RESULTS: The results showed a decrease in the number of cases and in the standardised rates between 2004 and 2005. The number of admissions estimated with a linear regression model for 2005 was significantly higher than that really observed (+13%). The decrease between the 2005 and 2004 rates was noteworthy for all four regions. Analysis by gender shows that the effect is observed only in male patients and in the age classes 45-49 and 50-54. CONCLUSION: This study shows that there has been an appreciable reduction in the incidence of heart attacks in the period immediately subsequent to the coming into force of the non-smoking Law in the populations surveyed, and that this reduction mainly regards men of working age. The reduction reverses a trend that has been evident for a number of years, namely that of a decidedly upward trend in the number of admissions for AMI.

[Survey of the nutritional status and related risk factors in primary school children in two Italian health units]. / Stato nutrizionale dei bambini delle scuole primarie nelle ASL 4 di Terni e 5 di Bari e fattori DI rischio correlati.

During the months of May and June 2007 two prevalence studies were conducted in two local health units in Italy (Terni and Bari). The objectives of the studies were to test methods and procedures to be used in the nutritional surveillance in primary schools; to measure the prevalence of obesity and overweight in children from those schools; and to determine the prevalence of physical activity and sedentary behaviour A total of 1026 children were measured and interviewed. The refusal rate was 17% in Terni and 16% in Bari. In Terni 8% of children were obese, 24% overweight, while in Bari the corresponding values were 11% and 24%. A high prevalence of behavioural risk factors for obesity was registered such as: not eating breakfast, reduced physical activity and sedentary behaviour It was also demonstrated that parents are often unaware that their children were overweight. The results of these surveys were consistent with the high prevalence that has been registered in other studies on Italian children in the third grade. The results showed also the feasibility of surveys in schools on the nutritional situation of children in primary schools, that can be adopted as a tool for a national surveillance.

Effects of a generalised ban on smoking in bars and restaurants, Italy.

CONTEXT: Italy implemented a law in January 2005 banning smoking in all enclosed public spaces. OBJECTIVES: To document perceived obstacles and effects of the law and observed client smoking behaviours in bars and restaurants. DESIGN: Four surveys were conducted between December 2004 and February 2006. Protocols and questionnaires were posted on a public health website to solicit participation among local health units (LHUs). Participating LHUs randomly selected 50 bars and restaurants using the electronic Yellow Pages. Self-administered questionnaires were delivered to owners or managers of selected locales; all of them were revisited during peak hours to collect questionnaires and observe client smoking. RESULTS: Before the ban, smokers were observed in 31% of locales; 24% of owners predicted major financial losses. One year later, no smokers were observed and only 7% reported major financial losses. Only 30% had received law enforcement visits. Most owners/managers (88%) reported positive attitudes about the law and 79% reported such attitudes among clients. CONCLUSIONS: The Italian smoking law has drastically reduced smoking in bars and restaurants despite minimal enforcement visits. Perceived negative effects on profits appear limited, and the owners and managers and their clients are satisfied.

A multicenter evaluation of tuberculin skin test positivity and conversion among health care workers in Brazilian hospitals.

SETTING: Four general Brazilian hospitals. OBJECTIVE: To assess the occupational risk of Mycobacterium tuberculosis (TB) in participating hospitals. DESIGN: In phase one of this longitudinal study, a cross-sectional survey documented baseline tuberculin skin test (TST) positivity rates. In phase two, TST conversion rates were evaluated in participants with an initial negative two-step TST. TST conversion data were analyzed to determine risk factors for TB infection using an increase of > or = 10 mm compared to baseline TST. RESULTS: The initial TST positivity rate was 63.1%; the follow-up TST conversion rate was 10.7 per 1000 person-months (p-m). Hospital of employment, recent bacille Calmette-Guerin (BCG) vaccination, nosocomial TB exposure, and employment as a nurse were independent risk factors for TST conversion. Hospitals without TB infection control measures had higher conversion rates than those with control measures (16.0 vs. 7.8/ 1000 p-m, P < 0.001). CONCLUSIONS: This study indicates an important occupational risk of infection in health care settings with a high TB incidence. Longitudinal TST studies are a valuable tool to assess the occupational risk of TB, even in BCG-vaccinated populations, and should be used to direct limited resources for infection control.

TST reversion in a BCG-revaccinated population of nursing and medical students, São Paulo, Brazil, 1997-2000.

SETTING: A major university in São Paulo, Brazil, where vaccination against tuberculosis (TB) with bacille Calmette-Guerin (BCG) was routinely offered to first-year medical and nursing students. OBJECTIVES: To estimate the probability of negative tuberculin skin test (TST) results over a 4-year period following BCG revaccination, and to evaluate the effect of factors associated with reversion. DESIGN: Students were enrolled in 1997, initially given a two-step TST, and were retested annually or biannually for the duration of the study. Data on TB exposures and potential risk factors for TST negativity and reversion were collected through annual surveys. A linear mixture survival model was used to estimate the probability of negative TST results over time. RESULTS: Of 159 students, an estimated 20% had a negative TST result despite revaccination, and a further 31% reverted to negative over 4 years of follow-up. No cofactors significantly affected the probability of reversion. CONCLUSION: Overall, in the absence of reported exposure to Mycobacterium tuberculosis, 51% of students revaccinated upon entering nursing or medical school would have a negative TST result by the time they begin their internships. In this recently vaccinated population, reversion was common, suggesting that annual TST screening may remain a useful tool.

Capacity building for international tuberculosis control through operations research training.

SETTING: In resource-poor countries, few tuberculosis (TB) program staff at the national, provincial, and even district levels have the basic analytical and epidemiological skills necessary for collecting and analyzing quality data pertaining to national TB control program (NTP) improvements. This includes setting program priorities, operations planning, and implementing and evaluating program activities. OBJECTIVES: To present a model course for building capacity in basic epidemiology and operations research (OR). DESIGN: A combination of didactic lectures and applied field exercises were used to achieve the main objectives of the 6-day OR course. These were to increase the understanding of quantitative and qualitative research concepts, study design, and analytic methods, and to increase awareness of how these methods apply to the epidemiology and control of TB; and to demonstrate the potential uses of OR in answering practical questions on NTP effectiveness. As a final outcome, course participants develop OR proposals that are funded and later implemented. RESULTS: Since 1997, this OR course has been conducted nine times in five countries; 149 key NTP and laboratory staff have been trained in OR methods, and 44 OR protocols have been completed or are underway. CONCLUSION: This low-cost model course can be adapted to a wide range of public health issues.

Survey of drug resistance of Mycobacterium tuberculosis in 3 Mexican states, 1997.

BACKGROUND: Drug resistance threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Mexico. OBJECTIVE: To obtain population-based data on Mycobacterium tuberculosis drug resistance in Mexico. METHODS: To obtain drug resistance data, we conducted a population-based study of TB cases in the states of Baja California, Sinaloa, and Oaxaca, Mexico. We performed cultures and drug susceptibility testing on M tuberculosis isolates from patients with newly diagnosed, smear-positive TB from April 1 to October 31, 1997. RESULTS: Mycobacterium tuberculosis was isolated from 460 (75%) of the 614 patients. Levels of resistance in new and retreatment TB cases to 1 or more of the 3 current first-line drugs used in Mexico (isoniazid, rifampin, and pyrazinamide) were 12.9% and 50.5%, respectively; the corresponding levels of multi-drug-resistant TB were 2.4% and 22.4%. Retreatment cases were significantly more likely than new cases to have isolates resistant to 1 or more of the 3 first-line drugs (relative risk [RR], 3.9; 95% confidence interval [CI], 2.8-5.5), to have isoniazid resistance (RR, 3.6; 95% CI, 2.5-5.2), and to have multi-drug-resistant TB (RR, 9.4; 95% CI, 4.3-20.2). CONCLUSIONS: This population-based study of M tuberculosis demonstrates moderately high levels of drug resistance. Important issues to consider in the national strategy to prevent M tuberculosis resistance in Mexico include consideration of the most appropriate initial therapy in patients with TB, the treatment of patients with multiple drug resistance, and surveillance or periodic surveys of resistance among new TB patients to monitor drug resistance trends.

Post traumatic stress disorder and coping in a sample of adult survivors of the Italian earthquake.

The aim was to investigate the prevalence of post traumatic stress disorder (PTSD) in people who had left their damaged homes and were still living in temporary housing more than a year after the April 2009 L'Aquila (Italy) earthquake. In addition, we evaluated the differences in coping strategies implemented by persons who had and who did not have PTSD. A cross-sectional prevalence study was carried out on a sample of 281 people aged >18 years and living in temporary housing after the earthquake. The questionnaires used include the Davidson Trauma Scale and the Brief Cope. The prevalence of PTSD was 43%. Women and the non-employed were more vulnerable to PTSD, while, age and level of education were not associated with PTSD. Those with PTSD symptoms often employed maladaptive coping strategies for dealing with earthquake and had the highest scores in the domains of denial, venting, behavioral disengagement, self-blame. By contrast, those without PTSD generally had more adaptive coping mechanisms. Adults who were living in temporary housing after the earthquake experienced high rates of PTSD. The difference in coping mechanisms between those who have PTSD and those who do not also suggests that they influence the likeliness of developing PTSD.

HTLV-II/HIV-1 coinfection and risk for progression to AIDS among intravenous drug users.

To determine whether coinfection with HTLV-II influences the course of HIV-1 infection, we evaluated the progression from asymptomatic HIV infection (CDC group II) to persistent generalized lymphadenopathy (CDC group III) to AIDS-related complex (CDC group IVA) to full-blown AIDS (CDC group IVC) to death from AIDS in two groups of HIV-seropositive intravenous drug users (IVDUs). The first group consisted of 123 patients infected with HIV-1 only, and the second comprised 22 patients with serological and molecular evidence of HTLV-II/HIV-1 coinfection. Results of the immunological and clinical follow-up indicated a greater likelihood of developing persistent generalized lymphadenopathy among individuals infected with HIV-1 alone than among those coinfected with HTLV-II. However, no statistical difference was detected between the two groups in the depletion of CD4+ cells, the temporal decrease of the CD4/CD8 ratio, or the progression to ARC or AIDS or to death from AIDS. These findings suggest that HTLV-II may have no effect on the clinical evolution of HIV infection in IVDUs, which may be explained by the lack of pathogenicity of the HTLV-II coinfecting strain(s) and/or other still unclear biological or immunological cofactors or mechanisms.

Declining prevalence of anemia in childhood in a middle-class setting: a pediatric success story?

To study trends of anemia among middle-class children, we collected 6,162 hematocrit measurements from the medical records of 2,432 children, ages 9 months through 6 years, as seen at a private pediatric clinic during the past 18 years. A decline in prevalence of anemia was observed during that period. The overall age-adjusted rate of anemia decreased from 6.2% in 1969 to 1973, 5.8% in 1974 to 1977, 3.8% in 1978 to 1981, and 2.7% in 1982 to 1986. The decline was also observed when trends were determined for three age groups using a single hematocrit measurement per child. The 1982 to 1986 prevalences of anemia for various age groups among this middle-class pediatric population were relatively low: 2.8% among 9- to 23-month-old children, 2.4% among 24- to 47-month-old children, and 2.7% among 48- to 83-month-old children. Most of these recent cases of anemia were mild--most were only slightly less than the hematocrit values used to define anemia--and most did not show strong evidence of iron deficiency based on elevated levels of erythrocyte protoporphyrin. We conclude that iron deficiency is now mild and uncommon in these middle-class children. This improved nutritional status with regard to iron is probably related to increased intake of iron among infants and young children during the past two decades. These findings suggest that the recommended screening schedule for iron deficiency with hemoglobin or hematocrit measurements may need to be reassessed for well-defined populations of low-risk children.

Birth weight and childhood growth.

Most previous studies of the relationship between birth weight and childhood growth have concentrated on the growth of low birth weight infants. To examine this relationship throughout the full range of birth weights, growth data for children less than 5 years of age from the Tennessee Special Supplemental Food Program for Women, Infants, and Children linked to birth certificate records for 1975 to 1985 were used. Growth status was compared for 500-g birth weight categories from 1,000 g to 4,999 g using mean Z scores and the percentage of children more than 2 SD above or less than 2 SD below the median for height for age, weight for age, and weight for height. Infants with lower birth weights were likely to remain shorter and lighter throughout childhood, especially those who were intrauterine growth retarded rather than premature. Conversely, those infants with higher birth weights were likely to remain taller and heavier and to have a higher risk of obesity. Birth weight is a strong predictor of weight and height in early childhood, not only for low birth weight children but also for those of normal and high birth weight.

Epidemiology of hemophilia and of HIV infection in Italy. GICC. Gruppo Italiano Coagulopatie Congenite.

To evaluate the incidence and prevalence of hemophilia in Italy and the impact of HIV infection on the Italian hemophiliac population, data from a computerized national registry of patients from 95% of the hemophilia care centers in Italy were analyzed. A total of 4643 patients were included in the registry. The prevalence of hemophilia A was 8.2 per 100,000 males, with no significant regional differences; for hemophilia B the corresponding figure was 1.5 per 100,000. Temporal trends in hemophilia incidence suggest that the diagnosis of mild and moderate hemophilia has improved. The overall HIV prevalence was 26% and was significantly (p < 0.001) higher in patients with hemophilia B (47.1%) compared to those with hemophilia A (26.8%) or other diseases (16.5%). The highest rate of HIV seropositivity was among patients 20-29 years of age. The annual amount of clotting factor concentrates received was significantly (p < 0.001) higher in HIV seropositive patients than in those who were seronegative. Antibody testing was never performed on 10.1% of severely affected patients. The number of patients in the Italian registry was similar to the number that would have been expected based on prevalence estimates from other countries. In comparison with other countries, the prevalence of HIV infection recorded in Italy was lower in persons with hemophilia A, but higher in those with hemophilia B. Our study demonstrates the usefulness of a registry in delineating the epidemiology of hemophilia and in studying risk factors for HIV infection. It also underlines the need for continuing surveillance of this population.

Epidemiology of pertussis in a developed country with low vaccination coverage: the Italian experience.

In Italy pertussis vaccination is optional. Fewer than 40% of children younger than 5 years of age are vaccinated, and pertussis remains a common childhood disease. We use data from a variety of sources to examine trends and characteristics of Italian children with pertussis and reasons behind the low vaccine coverage. Approximately 25% of Italian children have experienced clinical pertussis by their fifth birthday. The disease is most severe in those less than 1 year of age; in this group an estimated 1 in 14 cases are hospitalized and 1 in 850 die. The incidence appears to be increasing in the 1- to 4-year age group despite increased vaccination coverage. The low vaccine coverage appears to be caused by the ambivalence of the Italian pediatric community about the vaccine rather than parental concerns about vaccine safety. Legislation is being considered to make pertussis vaccination mandatory.

Assessing sex differences in neonatal survival: a study of discordant twins.

We identified 1699 liveborn twin pairs, discordant for sex. In this study, which essentially controls for gestational age, race, and maternal risk factors among males and females, there was no significant sex difference (108 male deaths and 103 female deaths) in neonatal mortality (p greater than 0.50). However, there was a sex difference in intrauterine growth, since 53% of the males, but only 42% of the females had birthweights greater than 2499 grams (p = 0.0002). A differential growth pattern can bias birthweight-specific assessments of survival. Such a bias may have been responsible for our finding that low-birthweight white females had better survival than did males in that category, since there was no such sex difference found among white twins born prematurely (greater than 36 weeks gestation). Therefore, we recommend that accurate assessments of sex differences in neonatal survival should be on the basis of gestational age, controlling for race and maternal risk factors.

Ectopic pregnancy mortality, United States, 1979 to 1980: clinical aspects.

Ectopic pregnancy has recently become a major cause of maternal mortality in the United States. Despite its increasing public health impact, relatively little is known about the clinical epidemiology of this condition. Therefore, the authors investigated all reported deaths from ectopic pregnancy in the United States occurring in 1979 and 1980, to determine characteristics of, and risk factors for, fatal ectopic pregnancy. Most women (85%) died from hemorrhage. Abdominal and interstitial implantations were more likely to become symptomatic later in gestation and to be fatal than were tubal implantations. Of those deaths for which circumstances were known, more prompt diagnosis and treatment of ectopic pregnancy by health professionals might have prevented one-half of the deaths. One-third of the deaths might have been prevented if the women had notified or visited a physician more promptly after the onset of symptoms. Timelier action by women and health professionals could reduce ectopic pregnancy mortality.

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.

Drug-resistant tuberculosis in foreign-born persons from Mexico, the Philippines, and Vietnam-United States, 1993-1997.

SETTING: Foreign-born persons in the United States represent a growing proportion of the nation's tuberculosis (TB) cases. OBJECTIVE: To characterize drug resistance patterns in foreign-born TB patients from the three most common birth countries. DESIGN: A descriptive analysis of national TB surveillance data for 1993-1997. TB case reports for foreign-born persons who were at least 15 years old and born either in Mexico (6221), the Philippines (3624), or Vietnam (3351) were included. RESULTS: Among those with no prior history of TB, the proportions with isoniazid-resistant TB and MDR-TB (resistance to at least isoniazid and rifampin) were 9.2% and 1.6% for persons from Mexico, 13.7% and 1.4% for those from the Philippines, and 17.8% and 1.4% for those from Vietnam. Levels of isoniazid resistance and MDR-TB did not change during the 5-year study period. Levels of isoniazid resistance decreased with older age for persons with no prior TB from all three countries; however, rates of MDR-TB did not vary with age. Persons with <1 year of residence in the US were more likely to have MDR-TB; however, duration of residence in the US was not associated with isoniazid resistance. CONCLUSION: Increased drug resistance in younger and more recent arrivals suggests that vigorous efforts to prevent further development of MDR-TB in the three countries are essential.

Validation of the surveillance system for tuberculosis in Botswana.

SETTING: Gaborone and Francistown, Botswana, where surveillance data in the 1997 Electronic Tuberculosis (TB) Register suggest that 39% of pulmonary TB patients did not have pre-treatment sputum smear microscopy performed. OBJECTIVE: To determine the proportion of patients with reportedly missing pre-treatment sputum smear results in 1997 who had smears examined, and to identify stages in the system where results were lost. METHODS: Patients with pulmonary TB in 1997 who were missing pre-treatment sputum smear results in the Electronic TB Register were cross-matched with laboratory records; medical records were reviewed. RESULTS: Of 374 patients with pre-treatment sputum smear results missing, 224 (60%) actually had had a sputum smear examined in the laboratory. The proportion of pulmonary TB patients in Gaborone and Francistown who did not have sputum examined was therefore 16% instead of 39%. Most missing results (69%) had not been transcribed from the laboratory results onto the TB Treatment Card. Patients who had a negative smear result or who sought care at a clinic that was different from where their diagnostic evaluation had been initiated were more likely to have missing results. CONCLUSIONS: The actual performance of the Botswana National TB Programme with respect to sputum microscopy examination is much better than surveillance indicators suggest. In addition to sputum collection, proper recording of results needs reinforcement among health care workers to improve routine performance indicators.