Does access to healthy food vary according to socioeconomic status and to food store type? an ecologic study.

BACKGROUND: The food environment can influence opportunities and barriers to food access. This study aimed to investigate whether access to healthy foods varies according to store types and the socioeconomic status of the users of the public health promotion program in Brazil, known as the Health Academy Program. METHODS: A total of 18 Health Academy Program centers were selected via simple conglomerate sampling. Health Academy Program users living up to 1 km from the food stores were evaluated (n = 2831). Their socioeconomic status was investigated via face-to-face interviews. The food stores were audited through direct observation. Variables included the community nutrition environment (type and location) and consumer nutrition environment (healthy food store index, involving variables such as availability, variety, and advertising of healthy and unhealthy products). Multiple linear regression analysis was performed to examine the association between access to healthy foods, socioeconomic status, and food store type. RESULTS: A total of 336 stores were investigated. The majority were specialty fruit and vegetable markets/stores or open-air food markets. Access to healthy food was only associated with the food store type. An increase of 1% in the availability of specialized fruits and vegetable markets or open-air food markets and supermarket raised healthy food store index values by 0.12 and 0.07, respectively. CONCLUSIONS: Public food supply policies aimed at improving the diet quality of the population and reducing inequality in access should prioritize the implementation of stores of better quality, such as specialty fruit and vegetable markets and open-air food markets.

Congenital toxoplasmosis in the state of Minas Gerais, Brazil: a neglected infectious disease?

This study aimed to investigate the distribution of congenital toxoplasmosis in the state of Minas Gerais, Southeastern Brazil and describe the demographic and socioeconomic profile of the municipalities associated with the disease. An ecological study was conducted using socioeconomic indicators of a database (MGSSRI) created by Fundação João Pinheiro (a government technical support agency of Minas Gerais), in order to show the development of the municipalities in the state. The prevalence of toxoplasmosis was the outcome and the items of the MGSSRI were the explanatory variables. Of 146,307 newborns screened (November 2006 to May 2007), 190 had congenital toxoplasmosis, yielding a prevalence of 1·3/1000, ranging from 0 to 76·9/1000 in the municipalities. The multivariate model indicated a higher occurrence of toxoplasmosis in municipalities with smaller populations and worse indexes of tax performance. Congenital toxoplasmosis appears to be a neglected disease in the state of Minas Gerais, given the high prevalence found and its concentration in municipalities with worse socioeconomic indexes.

Developing a conceptual framework of urban health observatories toward integrating research and evidence into urban policy for health and health equity.

Detailed information on health linked to geographic, sociodemographic, and environmental data are required by city governments to monitor health and the determinants of health. These data are critical for guiding local interventions, resource allocation, and planning decisions, yet they are too often non-existent or scattered. This study aimed to develop a conceptual framework of Urban Health Observatories (UHOs) as an institutional mechanism which can help synthesize evidence and incorporate it into urban policy-making for health and health equity. A survey of a select group of existent UHOs was conducted using an instrument based on an a priori conceptual framework of key structural and functional characteristics of UHOs. A purposive sample of seven UHOs was surveyed, including four governmental, two non-governmental, and one university-based observatory, each from a different country. Descriptive and framework analysis methods were used to analyze the data and to refine the conceptual framework in light of the empirical data. The UHOs were often a product of unique historical circumstances. They were relatively autonomous and capable of developing their own locally sensitive agenda. They often had strong networks for accessing data and were able to synthesize them at the urban level as well as disaggregate them into smaller units. Some UHOs were identified as not only assessing but also responding to local needs. The findings from this study were integrated into a conceptual framework which illustrates how UHOs can play a vital role in monitoring trends in health determinants, outcomes, and equity; optimizing an intersectoral urban information system; incorporating research on health into urban policies and systems; and providing technical guidance on research and evidence-based policy making. In order to be most effective, UHOs should be an integral part of the urban governance system, where multiple sectors of government, the civil society, and businesses can participate in taking the right actions to promote health equity.

Factors associated with the calibration of a food frequency questionnaire for the Bambuí Project, Brazil.

BACKGROUND: The present study aimed to calibrate a food frequency questionnaire (FFQ) using one 24-h recall (R24) associated with foodstuff replicas. METHODS: Calibration was performed by linear regression. Of a probability sample of 150 individuals (>18 years) of the town of Bambui, 98 completed the study. RESULTS: The mean age of the participants was 43.8 years and 63.3% were women. The calibration of the FFQ included sex for the estimation of iron, protein and zinc; and an interaction between sex and R24 was significant for vitamin A and cholesterol models. Age contributed to the vitamin C, polyunsaturated fatty acids, proteins and zinc models, and an interaction between age and R24 was significant for protein and zinc. CONCLUSIONS: Calibration coefficients and many interactions in linear regression models revealed important differences between dietary methods, indicating the complexity encountered when combining two methodologies for estimating food intake.

Implementation of a cardiology care program in remote areas in Brazil: influence of governability.

INTRODUCTION: A telecardiology remote cardiology medical care system was implemented in 82 municipalities of Minas Gerais State, Brazil to support basic network services in the early diagnosis and management of cardiovascular diseases. OBJECTIVE: To investigate the factors associated with the implementation of this program in the municipalities. METHOD: This 2006 ecological study involved 393 candidate municipalities to implement the system. The municipalities were divided into two groups: non-random intervention (n = 82) and comparative (n = 311). The social, structure, healthcare needs, and governability indexes of the two groups of municipalities were compared by descriptive and multiple regression analysis using the generalized estimation equation model. RESULTS: After fitting for other characteristics, participation of the municipalities in the intervention was associated with a higher social responsibility index (OR: 2.44, CI: 1.50-3.96) and lower healthcare needs (OR: 2.29, CI: 1.24-4.22). CONCLUSION: Greater efforts by municipality management was the key to attracting and implementing the remote cardiology intervention, even when fitted for lower healthcare needs, which suggests greater municipal political and social engagement. This translated to improved access to cardiovascular health care for Brazilian rural and remote populations in the intervention municipalities.

[The seroprevalence of HCV in patients submitted to hemodialysis and health professionals in the State of Minas Gerais, southwest of Brazil]. / Seroprevalencia del virus de la hepatitis C en pacientes en hemodiálisis y en profesionales de la salud en el Estado de Minas Gerais, región Sudeste de Brasil.

UNLABELLED: Patients with chronic renal failure(CRF) in hemodialysis(HD) programs comprise a risk group for acquisition of hepatitis C virus(HCV) infection. The objectives were to evaluate the seroprevalence of HCV in patients submitted to HD in State of Minas Gerais(MG), southwest of Brazil; to correlate this seroprevalence with the time of treatment on HD; to investigate the anti-HCV seropositivity in health professionals, to investigate the existence of a correlation between mean HCV seroprevalence and the human development index (HDI). Patients from 66 healthcare units(HU) were studied using a validated questionnaire and considering the positive values of anti-HCV(Elisa III) tests performed in these units between january and december 2003. RESULTS: the majority of patients were male (56.2%), between 41 and 60 years old. The mean seroprevalence of HCV in the 66 healthcare units was 13+/-9.5%; the three-monthly seroprevalence was below 20%, 15% and 10% in 75%, 50% and 40% of healthcare units, respectively. When the HU were grouped according to HCV seroprevalence into low(<5%), medium(5-15%) and high seroprevalence(>15%), 20% of the units have low, 42% medium and 37.5% were found to have high seroprevalence. No correlation was found between HDI and HCV seroprevalence (r=0.42; p=0.174) but in the regions in which the HDI was higher, HCV seroprevalence was also higher. There was a positive correlation between HCV seroprevalence and time on HD in 884 patients in the 4 HU (p<0.001). The seroprevalence of HCV was investigated in 387 healthcare professionals(29%) working in 14 HU. They were divided into two groups according to their time of professional activity: <10 y (G1) and >10 y (G2). In G1, there were no cases of anti-HCV seropositivity. In G2, 3 members of the staff were anti-HCV seropositive. The mean time of work of the seropositive staff in the HU was 15.6 years. The seroprevalence of HCV was 0.8% when all the healthcare professionals were taken into consideration. There was no statistically significant difference with respect to HCV seroprevalence between G1 and G2 with respect to the time of occupational exposure (p=0.27). CONCLUSION: the seroprevalence of HCV in patients on HD in MG is 13+/-9.5% and was <10% in 40% of the HU; there was no statistically significant correlation between HDI and seroprevalence of HCV in the healthcare units evaluated; there was a statistically significant correlation between HCV seroprevalence and time of treatment on HD; HCV seroprevalence in the health professionals studied was 0.8% and similar to the literature.

Increased mortality associated with vitamin A deficiency during human immunodeficiency virus type 1 infection.

OBJECTIVE: To determine whether plasma vitamin A levels are associated with immunologic status and clinical outcome during human immunodeficiency virus type 1 (HIV-1) infection. PATIENTS AND METHODS: Analysis of vitamin A levels, CD4 T cells, complete blood cell count, and serologic markers for liver disease in a random subsample of 179 subjects from a cohort of more than 2000 intravenous drug users with longitudinal follow-up to determine survival. RESULTS: Mean (+/- SE) follow-up time was 22.8 +/- 1.1 months, and 15 subjects died during follow-up. More than 15% of the HIV-1-seropositive individuals had plasma vitamin A levels less than 1.05 mumol/L, a level consistent with vitamin A deficiency. The HIV-1-seropositive individuals had lower mean plasma vitamin A levels than HIV-1-seronegative individuals (P < .001). Vitamin A deficiency was associated with lower CD4 levels among both seronegative individuals (P < .05) and seropositive individuals (P < .05). In the HIV-seropositive participants, vitamin A deficiency was associated with increased mortality (relative risk = 6.3; 95% confidence interval, 2.1 to 18.6). CONCLUSION: Vitamin A deficiency may be common during HIV-1 infection, and vitamin A deficiency is associated with decreased circulating CD4 T cells and increased mortality. Vitamin A is an essential micronutrient for normal immune function, and vitamin A deficiency seems to be an important risk factor for disease progression during HIV-1 infection.

Instability of delayed-type hypersensitivity skin test anergy in human immunodeficiency virus infection.

OBJECTIVE: To evaluate stability of delayed-type hypersensitivity (DTH) skin test over time in human immunodeficiency virus (HIV)-seropositive and HIV-seronegative injecting drug users. METHOD: A community-based cohort of injecting drug users who had serial skin testing with purified protein derivative tuberculin, mumps, and Candida albicans antigen. Delayed-type hypersensitivity anergy was defined as a skin test result of less than 3 mm for all three antigens; DTH positivity was a skin test result of 3 mm or greater for at least one antigen (Centers for Disease Control and Prevention, Atlanta, Ga, 1993). RESULTS: At baseline, 36% of HIV-seropositive subjects (n = 401) were anergic as compared with 14% of HIV-seronegative subjects (n = 552; P < .001). During follow-up, fewer HIV-seropositive subjects remained DTH positive (42%) and more remained anergic (19%) than of HIV-seronegative subjects (67% and 7%, respectively). Twenty-four percent of HIV-seropositive subjects who were initially DTH positive became anergic as compared with 15.3% of the HIV-seronegative subjects. However, the proportion changing from anergy to DTH positivity was greater among HIV-seropositive subjects (15%) than HIV-seronegative subjects (12%). In comparison to those who remained DTH positive, HIV-seropositive subjects with CD4 cell counts of less than 0.50 x 10(9)/L (odds ratio = 6.4) and less than 0.35 x 10(9)/L (odds ratio = 11.2) were more likely to remain anergic than those who had CD4 cell counts above 0.50 x 10(9)/L or were HIV seronegative. CONCLUSIONS: Although the prevalence and incidence of DTH anergy were higher in HIV-seropositive subjects, high rates of change in DTH status occurred in both directions. This suggests that instability of DTH skin testing is substantial and only partially dependent on HIV status. Although a single test may be an unreliable indicator of HIV-induced immunosuppression, two consecutive anergic readings were strongly associated with a CD4 cell count below 0.50 x 10(9)/L and particularly below 0.35 x 10(9)/L. For determining false negativity of tuberculin tests, persistent DTH anergy is more reliable than a single test among HIV-seropositive injecting drug users. Anergy testing appears to be unnecessary with CD4 cell counts greater than 0.5 x 10(9)/L.

American cutaneous leishmaniasis in Southeast Brazil: space-time clustering.

BACKGROUND: American cutaneous leishmaniasis (ACL) is endemic in many rural areas of Brazil where different transmission patterns of the disease have been described. This ecological study was carried out in a municipality located in Southeast Brazil and aimed to investigate the space-temporal patterns of the disease and environmental risk factors from 1966 to 1996. METHODS: Incident ACL cases were defined by clinical diagnosis, confirmed by a positive skin test and/or parasitological examination. Age-adjusted morbidity rate of ACL was calculated by year for this municipality and their different census enumeration districts. The homogeneity chi2 test, Moran and empirical Bayes index and Knox procedure were employed for testing the significance of clusters in time, space and in time-space, respectively. A Poisson regression model was used to identify environmental factors related to rate variability. RESULTS: A total of 1712 new ACL cases were reported with a yearly incidence rate of 48/100000 inhabitants. Higher incidence rates were detected in 1968, 1974, and 1988 (100, 160, and 190 cases/100000, respectively) with evidence of spatial clustering from 1986 to 1993. Significant space-time clustering with epidemic peaks followed by low incidence in subsequent periods was observed. The incidence rates of ACL were independently associated with rural areas; areas lacking sanitary installations and with higher proportion of exposed garbage (P < 0.01). CONCLUSIONS: This study suggests that ACL rates vary across space and time. Rural areas and some environmental factors could explain part of this variation. Environmental modifications in the vicinity of households over time and accumulation of susceptible individuals are discussed as possible factors responsible for variability.

PIP: This paper presents the results of an ecological study on American cutaneous leishmaniasis (ACL) cases carried out in Caratinga municipality, Southeast Brazil. The study aimed to estimate the incidence rates of ACL from 1966 to 1996, to test for space and temporal patterns in the rates and to correlate them to sociogeographic factors. Findings of the study showed an increase in the incidence rates of reported ACL cases. A total of 1712 ACL cases were reported in Caratinga during 1966-96, with a yearly incidence rate of 48/100,000 inhabitants. Evidence of spatial clustering was noted during 1986-93. Higher incidence rates were detected in 1968 (100 cases/100,000 inhabitants), 1974 (160/100,000), and 1988 (190/100,000). In addition, an observation noted that explosive outbreaks of ACL are followed with very low incident rate cases in the subsequent period. This observation indicates a lifelong resistance for treated individuals following clinically apparent infection. Moreover, prevalence of ACL infection was associated with rural areas, lack of sanitary disposal, and exposed garbage.

Snake bite and antivenom complications in Belo Horizonte, Brazil.

Factors associated with clinical complications of snake bite and antivenom therapy were studied in 310 hospital patients admitted with snake bite over 6 years to a tertiary referral hospital in Belo Horizonte, southeast Brazil. Overall, 17.4% had early clinical complications including tissue loss associated with abscess and necrosis, acute renal failure, shock, acute lung oedema and intracranial haemorrhage. 3% had permanent sequelae, caused by muscle contractures and amputations, chronic renal failure, or death. Early complications were associated with the following: age under 9 years (P = 0.04), residence in a rural area (P = 0.04), and a delay of more than 8 h in seeking clinical care (P < 0.01). Antivenom was administered to 98.1% of patients; 13.8% presented with anaphylaxis and 11.8% with pyrexia. Individuals from a rural area had a higher occurrence of anaphylactic reactions (P = 0.03). Neither anaphylaxis nor pyrexia was linked with antivenom type and dosage. This study suggested that antivenom might be associated with a reduced risk of serious injuries related to snake bite, especially when administered within the first 8 h. Complications appeared to be a far greater risk than adverse reactions to the antivenom.

Hospital malnutrition: the Brazilian national survey (IBRANUTRI): a study of 4000 patients.

OBJECTIVE: We assessed nutrition status and prevalence of malnutrition in hospital patients as determined by the Subjective Global Assessment Form, awareness of patients' nutrition status by health teams, and the use of nutrition therapy. METHODS: We enrolled 4000 hospital patients at least 18 y old who were covered by the Brazilian public health care system in a cross-sectional, multicenter epidemiologic study. We used Student's t and chi-square tests for univariate and multiple logistic regression analyses. RESULTS: Malnutrition was present in 48.1% of patients and severe malnutrition was present in 12.5% of patients. The prevalence of malnutrition was higher in the northern and northeastern regions of Brazil, where per-capita income is lower. Malnutrition correlated with primary diagnosis at admission, age (60 y), presence of cancer or infection, and longer hospital stay (P < 0.05). Fewer than 18.8% of patients' records contained information on nutrition-related issues. Nutrition therapy was used in 7.3% of patients (6.1% enteral nutrition and 1.2% parenteral nutrition). CONCLUSIONS: The prevalence of malnutrition in hospitalized patients in Brazil is high, physician awareness of malnutrition is low, and nutrition therapy is underprescribed.

The Bambui health and aging study: is calibration of dietary intake necessary among older adults?

Accurate measurements of food intake in surveys are difficult to be obtained especially in the older adults. Calibration, using two instruments, has been adopted in order to improve the information. This study was carried out in a random sample of older adults (> or =60) living in a Brazilian town. Food intake was obtained by the semi-quantitative food frequency questionnaire associated with photos (SFFQ-P) and the 24 hours recall (R24) with or without food models. Statistical analysis included tests to compare averages, Pearson's correlation coefficient and multiple linear regression. For all nutrients, the average intake obtained through SFFQ-P was significantly higher compared to the obtained by the R24 (p < or =0.05). SFFQ-P correlated better with R24 with food models, which was chosen as the reference method. In the multiple linear regression, vitamin C, fatty acid, protein and zinc intakes were influenced by age, especially when such nutrients were more concentrated in food not frequently reported. For protein and zinc, the significantly interaction between age with the 24 hours recall may have happened because of a differential selection of food sources as a function of age. This fact is probable related to chewing difficulties, reduction in the income and, a diet simplification associated with less complicated preparations, such as meat. This study reinforces the need for calibration of SFFQ in nutritional surveys among older adults, especially in etiological studies where the exposure assessment has to be accurate. In this case, R24 with food models should be used as a reference method to best estimate the true intake.

Effect of breastfeeding support from different sources on mothers' decisions to breastfeed.

A cross-sectional study compared 100 breastfeeding and 100 non-breastfeeding new mothers in order to investigate the relationship between mothers' choice of breastfeeding and support from health professionals and lay people, taking into account potentially confounding sociodemographic influences. The importance of the male partners' opinion about breastfeeding was also examined. A favorable attitude of partners towards breastfeeding was the most important factor associated with breastfeeding (odds ratio = 32.8). Prenatal class attendance and breastfeeding support from lay people increased the odds of breastfeeding 2.7 and 3.3 times, respectively. Breastfeeding orientation provided by doctors, nurses, and nutritionists was not associated with the maternal decision to breastfeed. The results point toward the need for reevaluation of prenatal care interventions, inclusion of fathers in breastfeeding educational programs, and emphasis on community-based programs.

Epidemiological and clinical aspects of snakebite in Belo Horizonte, southeast Brazil.

Epidemiologic and clinical aspects of 310 hospitalized snakebite patients and 310 matched controls were described, over a seven years period, from an emergency hospital in Belo Horizontal, Southeast Brazil. The diagnosis was based upon clinical picture or actual snake identification. Fifty six percent of victims were bitten by the snakes of genus Bothrops, 32.0% by Crotalus, 1.0% by Lachesis and 10.0% undetermined. During the study period, stable number of cases and marked seasonal variation were noted. In comparing cases of snakebite and controls, those from a rural area or who were involved in agricultural labor activity were identified as a high risk group, with an odds ratio (OR) of 14.7 and 6.7, respectively, in favor of being bitten. Upon treatment, snakebite patients were 13.5 times more likely to have had early anaphylactic reactions than their controls, with a higher association in the age group > or = 20 years (OR = 30.3). Increased risks were also detected for pyrexia (OR = 11.7), with a marked association in the group under 19 years old (OR = 16.6). Severe cases of snakebite are an important treatable cause of morbidity in Brazil but therapy may be potentially life threatening. The higher case-fatality ratio encountered, compared to national statistics may be due the representativeness of the more severe cases who sought hospitalization. Preventing snakebite and early referral of those who are bitten is proposed.

Risk factors for malnutrition in patients undergoing gastroenterological and hernia surgery: an analysis of 374 patients.

OBJECTIVE: The aim of this study was to assess the nutritional status of 374 surgical patients with gastrointestinal disease and hernias of the abdominal wall; to identify risk factors associated with a poorer nutritional status in this group of patients and to assess awareness of the patient's nutritional status by medical teams. SUMMARY BACKGROUND DATA: Malnutrition is prevalent among surgical patients and is associated with higher surgical complication rates and mortality. The major causes of poor nutritional status are related to the underlying disease, socio-economic factors, age, and length of hospitalization. Despite its high prevalence, medical teams often overlook malnutrition, and screening of these patients is not routine. It is of utmost importance to identify patients at risk for malnutrition in order to prevent related complications. METHODS: The 374 patients evaluated in this study were a subgroup of a larger multicenter, cross-sectional, randomized study that was carried out in 1996. Nutritional status was assessed by using Subjective Global Assessment. RESULTS: Malnutrition was present in 55% of the patients, with 19% of the patients severely malnourished. The presence of cancer, infection, age over 60 years, upper gastrointestinal disease, and longer length of hospital stay all negatively influenced nutritional status. Despite the high prevalence of malnutrition, the medical teams only assessed the nutritional status of a few patients. CONCLUSION: Malnutrition was highly prevalent in this setting of patients. Therefore, patients with the risk factors above presented should routinely undergo nutritional screening and/or assessment in order to be able to early diagnose or prevent malnutrition and its correlated morbidity and mortality.

[Resurgence of the measles epidemic: situation in Minas Gerais, Brazil]. / Resurgimiento de la epidemia de sarampión: situación de Minas Gerais, Brasil.

This study aims to describe the measles vaccination campaigns that have been carried out in the state of Minas Gerais, Brazil, since 1988; to highlight their importance in the control of the disease, and to pinpoint the age groups at risk during the recent epidemic, which began in 1996, spread all over the country, and declined in 1998. However, the analysis includes only data up to September 1997. The methodology used was based on the birth cohort analysis design. Data compared by cohorts included target population and vaccination coverage for each campaign, and measles incidence rates during the present epidemic. Results show that the more opportunities for exposure to vaccination campaigns, the lesser the risk for having measles in any birth cohort. In 1997, the relative risk for getting measles was 15.38 (IC 95%: 9.89 to 23.93) for the cohort under 2 years of age, which had not had the opportunity to be exposed to any vaccination campaigns, as compared to cohorts between 3 and 19 years of age with two or more opportunities of exposure to vaccination campaigns. On the basis of the experiences analyzed, catch-up measles vaccination campaigns as well as follow-up campaigns--particularly when routine vaccination did not achieve sufficient coverage--have had an outstanding role in controlling the measles epidemic in the state of Minas Gerais. We therefore suggest making the measles vaccine immediately available to all birth cohorts that did not have the opportunity for exposure to past vaccination campaigns and intensifying epidemiological surveillance. Moreover, it is necessary to find ways to improve routine vaccination coverage in order to achieve the 95% goal set by the National Plan to Eliminate Measles by the Year 2000.

Bacterial pneumonia in adult populations with human immunodeficiency virus (HIV) infection.

Recurrent bacterial pneumonia was recently added to the definition of the acquired immunodeficiency syndrome (AIDS), based on the observation that bacterial pneumonia rates have been increased in human immunodeficiency virus (HIV)-infected persons and are indicative of immunosuppression in this population. Nonetheless, risk factors for bacterial pneumonia among HIV-infected persons remain largely uninvestigated. Identification of risk factors that may be associated with bacterial pneumonia can guide development of future interventions and further clarify target groups for such interventions. From a methodological viewpoint, diagnostic algorithms need to be further standardized to provide comparable estimates of disease incidence. Epidemiologic studies will also need to address the effectiveness of chemoprophylaxis and vaccine interventions in HIV-infected populations. Since clinical trials will not be feasible for testing efficacy of interventions that are already recommended, observational data will be critically important in guiding clinical practice.

Toxoplasmosis and mental retardation--report of a case-control study.

A case-control study evaluating the association between mental retardation and toxoplasmosis was conducted among 845 school children in Belo Horizonte, MG, Brazil. Cases (450) were mentally retarded children attending a public school for special education. Controls (395) were children from the regular public school system. Clinical and anthropometric examinations and interviews were carried out to determine risk factors for toxoplasmosis and mental retardation. Diagnosis of Toxoplasma gondii infection was based upon an indirect immunofluorescent test (IFA); 55% of cases and 29% of controls were positive. The Relative Odds of mental retardation in children with positive serology was 3.0 (95% CI 2.2-4.0). Maternal exposure to cats and contact with soil were associated with an increased risk of mental retardation. Retinochoroiditis was fourfold more prevalent among cases than controls and was only diagnosed in T. gondii IFA positive participants. Congenital toxoplasmosis, in its subclinical form, appears to be an important component in the etiology of mental retardation, especially in high risk (lower socio-economic) groups. The population attributable risk was estimated as 6.0-9.0%, suggesting the amount of mental retardation associated with this infection.

Vitamin A deficiency and wasting as predictors of mortality in human immunodeficiency virus-infected injection drug users.

A nested case-control study of vitamin A deficiency and wasting as risk factors for mortality from AIDS and infections was done within a large prospective cohort of human immunodeficiency virus (HIV)-infected injection drug users (IDUs). Fifty adult subjects who died from AIDS and infections were matched with 235 controls who survived. Plasma vitamin A, weight, and body mass index were measured. Mean length of follow-up was 2.4 +/- 1.1 years. Vitamin A deficiency occurred in 50% and wasting occurred in 38% of patients in the last visit before death. CD4 cells count < 200/microL, wasting, and vitamin A deficiency were associated with mortality. There was a higher risk of death in HIV-infected subjects with vitamin A deficiency (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.8-11.3) and wasting (OR, 8.8; 95% CI, 2.7-28.2). Vitamin A deficiency and wasting are common during HIV infection and are independent predictors of mortality in HIV-infected IDUs.

Drug smoking, Pneumocystis carinii pneumonia, and immunosuppression increase risk of bacterial pneumonia in human immunodeficiency virus-seropositive injection drug users.

To examine the risk factors for the first episode of bacterial pneumonia among human immunodeficiency virus (HIV)-seropositive injection drug users (IDUs), medical record review was performed on IDUs participating in a cohort study from January 1988 to June 30, 1992. HIV-seropositive IDUs with a first episode of bacterial pneumonia (n = 40) were matched with up to five HIV-seropositive control subjects without bacterial pneumonia (n = 197) by date of entry (+/- 3 mo) and length of follow-up. Odds ratios (OR) were estimated using conditional logistic regression. The incidence of bacterial pneumonia was 1.93 in 100 person-years in HIV seropositive and 0.45 in 100 person-years in HIV seronegative subjects (relative incidence = 4.3; 95% CI 2.4 to 7.5). In univariate analyses, CD4 lymphocyte count < 200 cells/microliters previous episode of Pneumocystis carinii pneumonia (PCP), age between 30 and 40 yr and smoking illicit drugs (marijuana, cocaine, or crack) were associated with bacterial pneumonia. Cigarette smoking was associated with an increased odds of bacterial pneumonia (OR = 2.0), but this was not statistically significant because it was nearly universal in this cohort. In multivariate analysis, CD4 < 200 cells/microliters (OR = 6.75, 95% CI 2.13 to 21.42) and smoking illicit drugs (OR = 2.24, 95% CI 1.03 to 4.89) remained significantly associated with bacterial pneumonia. The odds ratio for cigarette smoking in the final model remained at 2.08 but was still not significant (95% CI 0.49 to 8.70). Smoking illicit drugs had the strongest effect on risk of bacterial pneumonia among HIV-seropositive IDUs with a previous history of PCP (OR = 22.94; 95% CI 2.18 to 241.10).