The role of epidemiology in informing United States childhood immunization policy and practice.

One of the ten greatest public health achievements is childhood vaccination because of its impact on controlling and eliminating vaccine-preventable diseases (VPDs). Evidence-based immunization policies and practices are responsible for this success and are supported by epidemiology that has generated scientific evidence for informing policy and practice. The purpose of this report is to highlight the role of epidemiology in the development of immunization policy and successful intervention in public health practice that has resulted in a measurable public health impact: the control and elimination of VPDs in the United States. Examples in which epidemiology informed immunization policy were collected from a literature review and consultation with experts who have been working in this field for the past 30 years. Epidemiologic examples (e.g., thimerosal-containing vaccines and the alleged association between the measles, mumps, and rubella (MMR) vaccine and autism) are presented to describe challenges that epidemiologists have addressed. Finally, we describe ongoing challenges to the nation's ability to sustain high vaccination coverage, particularly with concerns about vaccine safety and effectiveness, increasing use of religious and philosophical belief exemptions to vaccination, and vaccine hesitancy. Learning from past and current experiences may help epidemiologists anticipate and address current and future challenges to respond to emerging infectious diseases, such as COVID-19, with new vaccines and enhance the public health impact of immunization programs for years to come.

Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank.

PIP: This paper explores the socioeconomic obstacles to HIV prevention and treatment in developing countries. The opening sections explain the historical origins of structural adjustment programs and their characteristics. Structural adjustment programs undermine the social fabric of many developing countries, and potentially promote behaviors which place people at increased risk of HIV infection. The authors discuss the declining sustainability of the rural subsistence economy, development of a transportation infrastructure, migration and urbanization, and reductions in spending on health and social services. Social and economic interventions are needed to stem the spread of HIV and care for those who are already infected. While a substantial amount of biomedical research has been conducted, socioeconomic aspects of the AIDS epidemic have often been ignored. For HIV transmission in developing countries to be substantially reduced, economic policies which may have promoted the spread of disease must be modified. An alternative development strategy consists of satisfying people's basic human needs, shifting from an export-driven economy to diversified agricultural production in the interest of securing regional self-sufficiency, supporting marginal producers and subsistence farmers, and placing greater emphasis upon human resource development in developing countries. Moreover, the IMF and World Bank need to change their policy to one which is truly about cooperative development, while the charters of the IMF and World Bank need to be altered to permit the cancellation or rescheduling of debt. These institutions should also play a leading role in the restructuring of debt owed to private lenders.^ieng

'Dry sex' and HIV infection among women attending a sexually transmitted diseases clinic in Lusaka, Zambia.

OBJECTIVES: To describe 'dry sex' practices intended to decrease vaginal secretions and to determine whether these practices are related to HIV infection. SUBJECTS AND METHODS: A cross-sectional study was conducted in a sexually transmitted diseases clinic in a teaching hospital in Lusaka, Zambia. The subjects comprised 329 women aged 15-50 years presenting consecutively for an initial evaluation of sexually transmitted disease symptoms. Dry sex practices were assessed by questionnaire, and serological testing for HIV antibodies was performed. RESULTS: Fifty percent of women had engaged in at least one dry sex practice. The most common practices were drinking 'porridge' (a liquid or suspension believed to cause drying of the vagina; 28%), removing vaginal secretions with a cloth (22%) and placing leaves in the vagina (11%). The most frequent reasons given for drinking porridge were to increase the partner's sexual enjoyment and to tighten the vagina, while cleaning the vagina was mentioned often by those using cloth or leaves. Swelling or peeling of the vagina was reported by approximately 10% of women using cloth or leaves. Overall, the HIV seroprevalence in the sample was 58%. In bivariate analysis, no practice was statistically significantly associated with HIV infection. Multiple logistic regression had little impact on these findings. CONCLUSIONS: Although a variety of practices with potential relevance to HIV transmission were reported, there was no evidence in this study population of a strong relationship between these practices and HIV infection. Women should be counseled about the potential risks of these practices, but prevention efforts should continue to emphasize measures of known effectiveness, particularly limiting the numbers of sexual partners, consistently using condoms and obtaining appropriate treatment for sexually transmitted diseases.

Adolescent sexual behavior along the Trans-Africa Highway in Kenya.

OBJECTIVE: To describe the demographic characteristics and HIV-related risk behaviors of adolescents frequenting truck stops along the Trans-Africa Highway in Kenya. METHODS: A cross-sectional study of 200 adolescents (52% female) aged 15-19 years was conducted at the Malaba, Sachangwan and Mashinari truck stops in Kenya. A standardized questionnaire assessing the adolescents' demographic characteristics and sexual behavior was administered. RESULTS: Most (89%) of the adolescents interviewed were out of school. Their median monthly family income was Ksh1000 (US$25). Most felt that their families provided inadequate access to food (72%), clothing (70%) and pocket money (87%). Ninety-three per cent of girls and 87% of boys had ever had sexual intercourse and of these 54% of girls and 38% of boys had ever used a condom. Fifty-two per cent of the girls and 30% of the boys reported ever having had a sexually transmitted disease. Forty-six percent of girls reported usually having sex with truck drivers, 78% of girls reported usually exchanging sex for gifts or money and 59% of boys reported usually giving gifts or money for sex. Subjects engaging in these three risk behaviors were generally less likely to be in school, less likely to live with relatives and less likely to report getting along well with their parents. CONCLUSION: Adolescents at truck stops along the Trans-African Highway in Kenya appear to be at significant risk for HIV infection. In the absence of an immediate and wide-ranging intervention, these conditions are likely to facilitate the spread of HIV from truck drivers and sex workers to adolescents.

Socioeconomic status and risk of HIV-1, syphilis and hepatitis B infection among sex workers in São Paulo State, Brazil. Instituto Adolfo Lutz Study Group.

OBJECTIVES: To determine how HIV risk behavior and the prevalences of sexually transmitted diseases vary according to socioeconomic status and city among sex workers in São Paulo State, Brazil. SUBJECTS AND METHODS: A cross-sectional study of 600 female sex workers (100 of a higher socioeconomic status and 100 of a lower socioeconomic status in each city) was conducted in the cities of São Paulo, Campinas and Santos. HIV risk behavior was assessed by questionnaire; serological tests were administered to assess prior exposure to HIV-1, syphilis and hepatitis B. RESULTS: Only statistically significant (P < 0.05) findings are reported here. Compared to those with a higher socioeconomic status, sex workers with a lower socioeconomic status worked longer hours each day (9.6 versus 7.9), had more clients per day (5.4 versus 2.6) and had fewer episodes of intercourse per client per encounter (1.1 versus 1.4). Levels of condom use for vaginal, anal and oral sex were significantly higher in Santos than in São Paulo or Campinas. Twenty-three per cent of the women said they feared violence if they insisted that their clients wear condoms; 74% voiced similar fears regarding their non-client sexual partners. Overall, 11% of sex workers were positive for exposure to HIV-1, 45% for syphilis and 39% for hepatitis B. Those with a lower socioeconomic status were more likely than those with a higher socioeconomic status to be infected with HIV-1 (17 versus 4%), syphilis (66 versus 24%) and hepatitis B (52 versus 26%), but there were no differences in prevalence rates by city. CONCLUSIONS: These data demonstrate substantial heterogeneity in HIV risk behavior and the prevalence of HIV-1 and other sexually transmitted diseases among sex workers in São Paulo State, many of which were related to differences in socioeconomic status. Interventions to prevent HIV transmission among sex workers must be tailored to the local environment and, in particular, to the socioeconomic status of these workers.

Rising HIV infection rates in Ho Chi Minh City herald emerging AIDS epidemic in Vietnam.

OBJECTIVE: To describe the epidemiology of HIV in Ho Chi Minh City in the context of current surveillance data from Vietnam. METHODS: Since the late 1980s, HIV surveillance data have been collected in Ho Chi Minh City from centers for the treatment of venereal disease and tuberculosis, centers for the rehabilitation of injecting drug users and sex workers, prenatal clinics, blood banks and other sites. RESULTS: The first case of HIV infection in Vietnam was identified in 1990 in Ho Chi Minh City. The cumulative number of reported HIV infections in this city at the end of 1996 was 2774, about half of the number of cases in the country; 86% of infections were among men, 86% among injecting drug users, 2.5% among patients with sexually transmitted diseases and 2.5% among sex workers. The first HIV infection among antenatal women was detected in 1994. The prevalence of HIV among injecting drug users rose dramatically from 1% in 1992 to 39% in 1996, compared with 1.2% among sex workers, 0.3% among blood donors and 1.3% among tuberculosis patients in 1996. The populations of injecting drug users and sex workers in Ho Chi Minh City are estimated to be 30000 and 80000, respectively, and rates of sexually transmitted diseases are 2-3 per 1000 persons per year. By the end of December 1996, 42 out of 53 provinces had reported HIV infections, and border areas near China and Cambodia began identifying large numbers of HIV-seropositive people. CONCLUSIONS: Ho Chi Minh City is at the forefront of a new HIV epidemic in Vietnam. This epidemic shows similarities to that in Thailand nearly a decade ago, with rapidly rising HIV rates among injecting drug users and infection already established among sex workers. Prevention efforts should include the targeting of injecting drug users and sex workers outside rehabilitation centers, the availability of sterile needles and condoms, the establishment of anonymous testing sites, the control of sexually transmitted diseases and the coordination of programs within southeast Asia.

PIP: An analysis of annual sentinel surveillance data from Viet Nam indicates that Ho Chi Minh City is at the forefront of a new HIV epidemic. Since 1990, data on HIV cases have been collected from prenatal clinics, blood banks, centers for the treatment of sexually transmitted diseases (STDs) and tuberculosis, and rehabilitation centers for injecting drug users and commercial sex workers. The first HIV case in Viet Nam was reported in 1990 in Ho Chi Minh City. By the end of 1996, a cumulative total of 4961 HIV cases had been documented in Viet Nam, 2774 of which were in Ho Chi Minh City. In Ho Chi Minh City, 86.5% of cumulative HIV infections involved men. The distribution of total HIV cases by group has been: injecting drug users, 86.0%; tuberculosis patients, 3.3%; sex workers, 2.5%; STD patients, 2.5%; and pregnant women, 0.6%. By 1996, 42 of Viet Nam's 53 provinces had reported HIV cases and infection rates are rising dramatically in border areas near China and Cambodia. The pattern documented in this analysis resembles that observed in Thailand a decade ago: rapidly rising HIV rates among injecting drug users and infection already established among sex workers, without dissemination to the general population. The necessary infrastructure and resources for control of the epidemic are far more limited in Viet Nam than Thailand, however. Recommended, to prevent the further spread of HIV in Viet Nam, are educational activities targeted at injecting drug users and sex workers outside of rehabilitation centers, the availability of condoms and sterile needles, establishment of anonymous testing sites, control of STDs, and the coordination of programs within southeast Asia.

Prolonged prostaglandin E1 infusion in an infant with cyanotic congenital heart disease.

A small-for-gestational-age premature infant with severe tetralogy of Fallot was treated with prostaglandin E1 to dialate the ductus arteriosus and increase pulmonary blood flow. The infusion was continued for 29 days without complication at which time surgery was performed.

An X-linked recessive cardiomyopathy with abnormal mitochondria.

A transvascular endomyocardial biopsy from an infant with cardiomyopathy and chronic congestive heart failure showed abnormal mitochondria when examined by electron microscopy. At necropsy, similar abnormal mitochondria were seen in skeletal muscles, liver, and kidney. The patient's family pedigree revealed several male babies who had cardiac disease and died in infancy. Myocardium obtained at necropsy from three cousins contained mitochondria with abnormalities similar to those from the proband. An X-linked recessive cardiomyopathy seems likely in this family.

Transvascular endomyocardial biopsy in infants and small children: description of a new technique.

A miniaturized technique for transcatheter endomyocardial biopsy has been developed in the belief that myocardial biopsy performed in infancy, when the disease process in cardiomyopathy may be most active, should yield important etiologic and nosologic information. To obtain six biopsy specimens, three from each ventricle, adds about 1 hour to a diagnostic right and left heart catheterization. A no. 4 or 5 French forceps with a modified soft shaft is guided to the site in theapical septum of the right and left ventricles through a previously molded to measure guide tube of ultrathin radiopaque Teflon. With biplane fluoroscopy the guide tube of ultrathin radiopaque Telflon. With biplane fluorsocopy the guide tube is introduced as a sheath over a matching catheter and the catheter is removed. Contrast medium in injected to verify position, the forceps is introduced and the biopsy specimen is taken. If the forceps is sharp and pressure on the endocardium in light, evidence of biopsy is not discrenible on examination of the heart 1 week later. The method was developed in small dogs and proved safe and effective in rabbits weighing 3 kg. Biopsy has been performed safely in children aged 4 1/2 months to 5 1/2 years and weighing 4.5 to to 19.6 kg.

Findings on endomyocardial biopsy in infants and children with dilated cardiomyopathy.

Fifteen infants and children with dilated cardiomyopathy underwent transvascular endomyocardial biopsy. The light and electron microscopic findings were reviewed to evaluate the presence of lymphocytes as an indicator of active myocarditis. Both ventricles were biopsied in 13 patients, and the right ventricle only was biopsied in 2. None of the endomyocardial specimens obtained by biopsy revealed an inflammatory process. Interstitial fibrosis, myofiber hypertrophy, degeneration and necrosis were found. Ultrastructural abnormalities of the mitochondria, T tubules or Z bands were noted in approximately one-third of patients. Persistent, active myocarditis is an uncommon cause of dilated cardiomyopathy in children. Immunosuppressive therapy, which may be harmful, should be considered only after myocardial inflammation has been documented by endomyocardial biopsy.

Transvascular endomyocardial biopsy in infants and small children. Myocardial findings in 10 cases of cardiomyopathy.

Transvascular endomyocardial biopsy specimens from nine children with congestive cardiomyopathy and one with hypertrophic cardiomyopathy were studied by light microscopy using sections 1 mu thick cut from Epon embedded tissue and by electron microscopy. There was a disparity between the severity of the physiologic impairment and the morphologic abnormalities. Interstitial fibrosis was present only in the one case in which significant viral antibody titers were obtained. The sizes of the cardiac muscle cells varied abnormally in all specimens. Cardiac muscle cells in two patients contained abnormal mitochondria, and a leptomeric fibril was found in one patient. Virologic cultures of the tissues were negative and no viral particles were identified by electron microscopy. An attempt was made to correlate the clinical and pathologic findings.

Drug promotion and labeling in developing countries: an update.

Recent studies of drug promotion and labeling in Third World countries since 1972 have observed important changes in the policies of multinational corporations. Earlier studies found that multinational and national drug companies often grossly exaggerated the indications for the drugs and minimized or ignored the hazards. In the latest study, initiated in 1987, considerable improvement in promotional practices of the multinational corporations has been found, but little or no improvement on the part of the national companies. As a result, physicians are still provided with grossly exaggerated claims and the hazards of prescription drugs are covered up or glossed over. A very serious problem--the marketing of fraudulent drug products--has been identified in a number of Third World countries. Drug products are shaped and colored to resemble the original multinational company product, but contain only a small percentage of the active ingredient stated on the label, or perhaps none at all. In Indonesia fraudulent drug products may represent 20-30% of all drug products in the market. Similar fraudulent products have been reported in Brazil, Thailand, Bangladesh and Malaysia.

Immunocompetence, immunodeficiency and prognosis in cancer.

Immunocompetence and prognosis are related in solid tumors, malignant lymphomas, and acute leukemia. Among the parameters of immunocompetence vigorous delayed-type hypersensitivity responses to recall antigens or to primary immunization with Keyhole limpet hemocyanin, vigorous in vitro lymphocyte blastogenic responses to mitogens such as PHA, and relatively high B-lymphocyte levels, all correlate with a good prognosis. The spectrum of immune reactivity as measured by established delayed-type hypersensitivity to recall antigens and in vitro blastogenic responses to mitogens and antigens is similar in melanoma patients and their nontumor-bearing spouses. In melanoma, only patients with widespread inoperable metastatic disease show severe immunological deficiency and this is selective for certain antigens. There are highly significant differences in response to specific antigens when patients with melanoma and lung cancer are compared. Immunotherapy with BCG and C. parvum can boost immunocompetence as measured by recall DTH skin testing. However, the relationship between the initial immunocompetence and prognosis still holds in patients receiving BCG immunotherapy to prevent recurrence of melanoma. These data indicate that a broader survey of immunological reactivity in cancer patients is needed, that immunological testing is useful in cancer prognosis clinically, and that the results of immunological testing can be used to evaluate therapy and to indicate new pathways for improved treatment.

Low birth weight and Latino ethnicity. Examining the epidemiologic paradox.

OBJECTIVE: To assess the relation between Latino ethnicity, Latino subgroup, and low birth weight (LBW). DATA SOURCES: From the MEDLINE computer data-base, we used the key words birth weight; infant, LBW; Latinos; Hispanic Americans; Cuban Americans; Mexican Americans; and Puerto Ricans to identify studies that analyzed LBW in Latinos. STUDY SELECTION: Thirty-two studies, published from 1982 to 1996, that analyzed US Latinos and whites or multiple Latino subgroups, that used the revised definition of LBW (< 2500 g), and had a large sample size (> 10,000) were selected. DATA EXTRACTION: Two reviewers extracted LBW rates and data on the relation between Institute of Medicine risk factors and LBW by maternal ethnicity and Latino subgroup. DATA SYNTHESIS: Low-birth-weight rates were similar for Latino (median, 6.2%) and white infants (median, 5.8%). By Latino subgroup, LBW rates were similar for Central/South American, Cuban, Mexican, and white infants. Puerto Rican infants had consistently higher LBW rates (median, 9.1%). Two risk factors-maternal birth-place and gestational weight gain-were identified as confounders of the relation between Latino ethnicity, Latino subgroup, and LBW. CONCLUSIONS: Low-birth-weight rates of Latinos and whites are similar, consistent with the "epidemiologic paradox" of unexpectedly favorable perinatal outcomes for Latinos. However, this paradoxical relation for all Latinos masks the notably elevated LBW risk among Puerto Ricans. Further study of LBW among Latinos, including cultural factors, is needed.

An assessment of Mustard's operation as a palliative procedure for transposition of the great vessels.

Ten patients in whom palliative Mustard operations have been performed for transposition of the great vessels with ventricular septal defect and elevated pulmonary vascular resistance are reported. There has been early or late mortality in this group of patients, and postoperative morbidity has been minimal. Five of them have been recatheterized, and the results indicate substantial improvement in postoperative arterial oxygen saturation with change in pulmonary vascular resistance. The operation is reserved for those patients in whom peripheral desaturation is the major cause of symptomatology. Clinical improvement has been gratifying, and the continued use of the operation in selected patients seen indicated.

The content and accessibility of sex education information on the Internet.

The objective of this study was to describe Web sites with sex education material and assess the accessibility of specific information on the Internet. First, the authors conducted a review of Web sites using specific sex education keywords. Second, 27 undergraduate students were asked to locate information on proper condom use and sexually transmitted disease (STD) symptoms. The time, number of search attempts, and number of clicks needed to identify each piece of information were recorded. The authors identified 41 sites with sex education material from almost 6 million pages yielded by the keywords. Sixty-three percent of the 1,556 most compatible pages were categorized as pornography. The students found the information on condom use and STD symptoms in an average of 4 minutes, using fewer then six clicks and two searches. The authors concluded that general information on sex education is difficult to locate on the Internet and often lacks essential elements, but accurate and useful information on specific topics can be more easily obtained.

Endocardial fibroelastosis found on transvascular endomyocardial biospsy in children.

Left ventricular endocardium obtained by transvascular endomyocardial biopsy from nine infants and children with various congestive cardiomyopathies showed thickening in five, with hyperplasia of endocardial cells and increase in elastic and collagen fibers (endocardial fibroelastosis). Based on the morphologic findings, we suggest a chronologic sequence of hyperplasia of smooth muscle (SM) cells followed by transformation and translocation. The sequence appears to be (1) proliferation of dark SM cells with many surface vesicles, many myofilaments, and fusiform densities; (2) possible proliferation of light SM cells containing fewer surface vesicles and fewer myofilaments than the dark SM cells; (3) transformation of SM cells to leiomyoid cells that resemble both SM cells and fibroblasts; and (4) transformation to typical fibroblasts. The cells producing the increased elastin and collagen are believed to be the SM cells and the leiomyoid cells.

Awareness and utilization of the hepatitis B vaccine among young men in the Ann Arbor area who have sex with men.

The authors conducted a preliminary assessment of hepatitis B vaccination rates among men 18- to 37-years-old who have sex with men in a college town to determine what proportion were willing to be vaccinated. Participants, who were sampled in gay bars, gay advocacy groups, a swim team, and a dance club, completed a 25-item questionnaire. Sixty-seven percent were aware of the hepatitis B vaccine, yet only 22% had received the full series of three injections; only 37% had been tested for the virus. On a scale of 1 to 10 for willingness to be vaccinated (10 being most willing), 58% indicated a 10 (M = 8.5). Thirty percent indicated they received safer sex information from university health services, and 14% reported they had received hepatitis B vaccination information there. Hepatitis B vaccination of men who have sex with men in college towns should be a high priority for university health services.

Fifteen solutions to the problems of prescription drug abuse.

In the 17 years since the publication of Pills, Profits, and Politics by Silverman and Lee, not one of that book's proposals has been fully implemented. This article begins by identifying the elements of prescription drug abuse: inappropriate physician prescribing, patient noncompliance, and poor doctor-patient communication. It then offers 15 solutions to these problems; these are divided into nonregulatory and regulatory solutions. Multiple prescription form laws are singled out for special attention and the experience with such a law in New York is discussed. Finally, the article offers some reflections on the optimal balance between nonregulatory and regulatory approaches to the problem of prescription drug abuse.