A multicentre, randomised controlled trial to compare the clinical and cost-effectiveness of Lee Silverman Voice Treatment versus standard NHS Speech and Language Therapy versus control in Parkinson's disease: a study protocol for a randomised controlled trial.

BACKGROUND: Parkinson's disease (PD) affects approximately 145,519 people in the UK. Speech impairments are common with a reported prevalence of 68%, which increase physical and mental demands during conversation, reliance on family and/or carers, and the likelihood of social withdrawal reducing quality of life. In the UK, two approaches to Speech and Language Therapy (SLT) intervention are commonly available: National Health Service (NHS) SLT or Lee Silverman Voice Treatment (LSVT LOUD®). NHS SLT is tailored to the individuals' needs per local practice typically consisting of six to eight weekly sessions; LSVT LOUD® comprises 16 sessions of individual treatment with home-based practice over 4 weeks. The evidence-base for their effectiveness is inconclusive. METHODS/DESIGN: PD COMM is a phase III, multicentre, three-arm, unblinded, randomised controlled trial. Five hundred and forty-six people with idiopathic PD, reporting speech or voice problems will be enrolled. We will exclude those with a diagnosis of dementia, laryngeal pathology or those who have received SLT for speech problems in the previous 2 years. Following informed consent and completion of baseline assessments, participants will be randomised in a 1:1:1 ratio to no-intervention control, NHS SLT or LSVT LOUD® via a central computer-generated programme, using a minimisation procedure with a random element, to ensure allocation concealment. Participants randomised to the intervention groups will start treatment within 4 (NHS SLT) or 7 (LSVT LOUD®) weeks of randomisation. PRIMARY OUTCOME: Voice Handicap Index (VHI) total score at 3 months. Secondary outcomes include: VHI subscales, Parkinson's Disease Questionnaire-39; Questionnaire on Acquired Speech Disorders; EuroQol-5D-5 L; ICECAP-O; resource utilisation; adverse events and carer quality of life. Mixed-methods process and health economic evaluations will take place alongside the trial. Assessments will be completed before randomisation and at 3, 6 and 12 months after randomisation. The trial started in December 2015 and will run for 77 months. Recruitment will take place in approximately 42 sites around the UK. DISCUSSION: The trial will test the hypothesis that SLT is effective for the treatment of speech or voice problems in people with PD compared to no SLT. It will further test whether NHS SLT or LSVT LOUD® provide greater benefit and determine the cost-effectiveness of both interventions. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ID: 12421382. Registered on 18 April 2016.

Influenza A(H1N1)pdm09 vaccination policies and coverage in Europe.

In August 2010 the Vaccine European New Integrated Collaboration Effort (VENICE) project conducted a survey to collect information on influenza A(H1N1)pdm09 vaccination policies and vaccination coverage in the European Union (EU), Norway and Iceland. Of 29 responding countries, 26 organised national pandemic influenza vaccination and one country had recommendations for vaccination but did not have a specific programme. Of the 27 countries with vaccine recommendations, all recommended it for healthcare workers and pregnant women. Twelve countries recommended vaccine for all ages. Six and three countries had recommendations for specific age groups in children and in adults, countries for specific adult age groups. Most countries recommended vaccine for those in new risk groups identified early in the pandemic such as morbid obese and people with neurologic diseases. Two thirds of countries started their vaccination campaigns within a four week period after week 40/2009. The reported vaccination coverage varied between countries from 0.4% to 59% for the entire population (22 countries); 3% to 68% for healthcare workers (13 countries); 0% to 58% for pregnant women (12 countries); 0.2% to 74% for children (12 countries). Most countries identified similar target groups for pandemic vaccine, but substantial variability in vaccination coverage was seen. The recommendations were in accordance with policy advice from the EU Health Security Committee and the World Health Organization.

Pandemic risk prevention in European countries: role of the ECDC in preparing for pandemics. Development and experience with a national self-assessment procedure, 2005-2008.

To be effective risk prevention work takes place well before pandemics through the three Ps: Planning, Preparedness and Practise. Between 2005 and 2008 the European Centre for Disease Prevention and Control (ECDC) worked with the European Commission (EC) and the WHO Regional Office for Europe (WHO-Euro) to assist European countries in preparing themselves for a future influenza pandemic. All eligible countries in the European Union and European Economic Area participated with energy and commitment. Indicators of preparedness were developed based on WHO planning guidance and these were set within a simple assessment which included a formal country visit. The procedure evolved considerably with field experience. As the complexity of pandemic preparedness was appreciated it changed from being a classical short external assessment to longer national self-assessments with demonstrable impact, especially when self-assessments were published. There were essential supporting activities undertaken including a series of pan-European pandemic preparedness workshops organised by EC, WHO-Euro, ECDC and countries holding the European Union Presidency. The self-assessments highlighted additional work and documentation that was needed by national authorities from the ECDC. This work was undertaken and the document produced. The benefits of the self-assessments were seen in the 2009 pandemic in that EU/EEA countries performed better than some others. A number of the guidance documents were updated to fit the specific features of the pandemic. However the pandemic revealed many weaknesses and brought new challenges for European countries, notably over communication and vaccines, the need to prepare for a variety of scenarios and to factor severity estimates into preparedness, to improve surveillance for severe disease and to deliver seroepidemiology. Any revised self-assessment procedure will need to respond to these challenges.

[First exchange of experiences concerning the H1N1 pandemic in Germany 2009/2010: report on a workshop held March 22-23, 2010, in Berlin]. / Erster Erfahrungsaustausch zur H1N1-Pandemie in Deutschland 2009/2010: Bericht über einen Workshop am 22. und 23. März 2010 in Berlin.

In April 2009 the first pandemic of the 21st century developed within a few weeks starting from Mexico. Its first wave reached Germany in autumn 2009 and was responsible for 1.8-3.5 million additional medical consultations. For the public health sector, this pandemic was one of the largest challenges of the last few decades. As a contribution to broader evaluations on national and international level, the Robert Koch Institute invited representatives from different professions involved in the pandemic response to participate in a workshop on 22-23 March 2010. This workshop was structured in short presentations, group work, and plenary discussions. Main experiences were that (a) pandemic preparedness was helpful, (b) the early warning systems were reliable, (c) vaccines were available within a few months, however, in limited amounts. Need for improvement was discussed for (a) effectiveness of vaccination logistics, (b) mechanisms for the reimbursement of the cost of vaccination, (c) availability of surveillance and monitoring systems, (d) integration of physicians in decision-making processes and health education, and (e) proactive communication strategies. Investments in the above mentioned areas can help to improve public health protection in the future.

The scientific basis for offering seasonal influenza immunisation to risk groups in Europe.

This paper summarises the scientific evidence supporting selection of risk groups that would benefit from annual seasonal influenza immunisation in European Union (EU) countries. Risk groups are defined restrictively as persons in Europe at higher than average risk of adverse outcomes should they be infected with seasonal influenza and for whom use of vaccine is demonstrated to be effective in reducing the risk of those outcomes. Existing evidence indicate that older people and those with chronic disease are at higher risk of severe adverse outcome and that immunisation reduces this risk. There is thus good scientific evidence for routinely offering annual immunisation to all older people (at least those aged 65 years and older), and people with certain groups of chronic medical conditions. We estimated that these two groups account for between 19% and 28% of the population of EU countries. Thus in 2006, an estimated 84 million older people aged 65 years and over and 41 million people younger than 65 years of age with chronic conditions were living in these countries. There is also strong evidence for immunising staff caring for patients belonging to these two risk groups in residential (care home) settings in order to protect the patients. There are as yet no strong data on whether or not immunising other healthcare workers and carers protect patients though immunisation of healthcare workers can be justified on occupational health grounds. At present the scientific evidence for immunising other suggested risk groups, notably children and pregnant women is not strong for Europe though equally there is no evidence against immunising these groups.

National seasonal influenza vaccination survey in Europe, 2008.

A cross-sectional survey was undertaken with the European Union (EU) Member States and Norway and Iceland to describe seasonal influenza immunisation in the 2006-7 season, in particular to identify country-specific recommendations for risk groups, obtain vaccine uptake information and allow comparison with global recommendations. A standardised questionnaire was completed electronically by each country's project gatekeeper. Of the 29 countries surveyed, 28 recommended seasonal influenza vaccination for older age groups (22 for those aged > 65 years), and in one country vaccine was recommended for all age groups. All countries recommended vaccinating patients with chronic pulmonary and cardiovascular diseases and most countries advised to immunise patients with haematologic or metabolic disorders (n=28), immunologic disorders (n=27) and renal disease (n=27), as well as residents of long-term care facilities (n=24). Most countries recommended vaccination for staff in hospitals (n=25), long-term care facilities (n=25) and outpatient clinics (n=23), and one-third had such recommendations for workers in essential (n=10), military (n=10) and veterinary services (n=10) and poultry industry (n=13). Eight countries recommended vaccine for pregnant women; and five advised to vaccinate children (with age limits ranging from 6 months to 5 years). Twenty countries measured influenza vaccine uptake among those aged > 65 years (range 1.8%-82.1%), seven reported uptake in healthcare workers (range 14%-48%) and seven assessed coverage in persons with underlying medical conditions (range 27.6%-75.2%). The data provided by this study can assist EU states to assess and compare their influenza vaccination programme performance with other countries. The information provides a comprehensive overview of policies and programmes and their outcomes and can be used to inform joint discussions on how the national policies in the EU might be standardised in the future to achieve optimal coverage. Annual surveys could be used to monitor changes in these national policies.

Impact of infections on primary care--greater than expected.

Though infection has declined as a cause of death it consumes a major proportion of primary care resources, and because of antibiotic resistance is increasingly important. We examined the burden of illness attributable to infection in primary care by analysing data from the fourth practice-based national morbidity survey which monitored all consultations by diagnosis in 470,000 persons over a 12 month period from September 1991 to August 1992. Rates of persons consulting, new episodes of illness and consultations were calculated according to the list of infections published by Wilson and Bhopal (W&B list), and as amended by the Communicable Disease Surveillance Centre (CDSC list); selected comparisons were made with national data on hospital derived finished consultant episodes and deaths. Forty-one percent of all registered persons consulted on at least one occasion during the year for infection (estimated by either list). Infections accounted for 40% of all new episodes of illness and 29% of all consultations; respiratory infections accounted for approximately half the infection total. New episode rates were highest in children aged less than 1 year and lowest in males 25-54 years and females 55-64 years. Except in infancy, rates were higher in females. There were 734 episodes of infection annually per 1,000 population reported in general practice compared with 20 per 1,000 finished consultant episodes. The average episode of infection prompted 1.2 general practice consultations. Improved management through more precise diagnosis by near patient tests is desirable, but is unlikely to be obtained cost effectively if consultation numbers or the time spent is substantially increased. These results emphasise the importance of adequate training for general practitioners in the natural history, epidemiology, diagnosis and treatment (pharmacology) of infection.

Health protection--a strategy and a national agency.

The Chief Medical Officer for England has published a strategy for health protection and announced the formation of a new body, the Health Protection Agency, to deal with the threats to health from infectious disease, chemicals, toxins and radiation hazards. This reflects international recognition of the need to combat threats to health from the likes of tuberculosis, HIV, influenza, anti-microbial resistance, chemical accidents and bio-terrorism, and the risks to health associated with increased movements of people, animals and goods, climate change and industrialisation. The strategy will strengthen surveillance and response linking contributions from clinical specialities with public health, microbiology, toxicology and radiation science within the health protection family. The Agency will be formed by combining a number of national and specialist public bodies and personnel delivering local protection services. The strategy represents a unique opportunity to strengthen local and national structures and develop a world-class health protection service. Detailed plans are being developed by the Department of Health with a variety of stakeholders for the launch of the Agency in 2003. A number of challenges will have to be met including developing and training the workforce in health protection, providing career structures for public health scientists and nurses, strengthening electronic communications and developing health protection networks within broader public health structures. Health protection should now be recognised as a sub-speciality of public health.

Simplified antiviral prophylaxis with or and without artificial feeding to reduce mother-to-child transmission of HIV in low and middle income countries: modelling positive and negative impact on child survival.

BACKGROUND: Antiviral prophylaxis is recommended for HIV positive mothers to prevent mother-to-child transmission of HIV. To date UNAIDS and WHO policy has been based on a study in Thailand which showed a reduction in transmission by half with short course AZT (Zidovudine) treatment together with artificial feeding. We modelled the possible positive and negative effects on child deaths in low and middle resource developing country settings of two interventions to reduce mother to child transmission (MTCT) of HIV: antenatal testing, short-course antivirals (zidovudine or nevirapine), firstly with and then without artificial feeding. MATERIAL AND METHODS: Estimates are made of child lives likely to be saved by the programme by age ten years, balanced against increases in deaths due to more uninfected mothers choosing to use artificial feeds where these are part of the intervention. Mid-point values for variables affecting the balance of mortality gains and losses are taken from recent published data for low and middle income developing countries and a sensitivity analysis is undertaken. RESULTS: In low income settings the use of antivirals alone would result in an estimated gain in child survival of around 0.36%, representing 360 deaths avoided from a birth cohort of 100,000 by age 10 years. Adding artificial feeding could reduce the gain to 0.03% (30 deaths avoided). In middle income settings the gain from antivirals alone would be 0.26% but as 'spill-over' of artificial feeding to uninfected women was more likely it could result in a net increase of child deaths of up to 1.08% (1,080 additional deaths). A sensitivity analysis emphasised this potential for regimens using artificial feeding if progamme participation was low, and under most circumstances in middle income settings. CONCLUSIONS: HIV testing and use of antivirals by infected mothers, if well implemented, will be effective at a population level in reducing MTCT. However the addition of artificial feeding is potentially be a high risk strategy, especially in middle income countries.

National assessment of PID diagnosis, treatment and management in general practice: England and Wales.

A questionnaire based audit was used to evaluate the diagnosis and management of suspected pelvic inflammatory disease (PID) cases by general practitioners (GPs) in England and Wales. Responses were compared against a clinical management 'gold standard' devised by an independent group of GPs and specialists. Two hundred and ninety-seven (38%) of the 781 questionnaires were returned. Only 21 (7%) had all 'gold standard' sections correct. Diagnostic quality was significantly higher when the clinician was female compared with male (odds ratio [OR]=2.34; 95% confidence limits [CL]=1.19-4.63) and diagnostic quality increased with increasing socioeconomic deprivation. This is the first evaluation of the diagnosis and management of PID by GPs in England and Wales. The unusually poor response rate to a Medical Research Council General Practice Research Framework (MRC GPRF) study may reflect low disease awareness and sub-optimal management. This represents a fundamental obstacle to effective intervention and surveillance. Effective intervention will only be possible if diagnostic practice and management are improved substantially.

Strategic options for antenatal screening for syphilis in the United Kingdom: a cost effectiveness analysis.

OBJECTIVE: Antenatal screening for syphilis is well established in the United Kingdom. The prevalence of syphilis is now very low, prompting the question as to whether this screening programme is still necessary. This paper aims at identifying possible screening strategy options for the programme and comparing their effectiveness and cost effectiveness. METHODS: The cost of the screening programme in the United Kingdom was estimated. This was based on the cost of screening tests, treatment, and follow up of infected women and their infants. This information was obtained from laboratories, antenatal clinics, and genitourinary medicine clinics. Epidemiological data from a survey of women treated for syphilis in pregnancy were analysed to identify groups at increased risk of syphilis. Strategic options for the screening programme were then identified. The effectiveness, number needed to treat, and cost effectiveness of these options were compared. RESULTS: Antenatal screening in the United Kingdom detected at least 40 pregnant women who need treatment for syphilis every year. This means that 18602 women are screened for every woman detected who needs treatment for syphilis. The marginal annual cost of this screening programme in the United Kingdom is 672366 pounds sterling. This is equivalent to 90p per woman screened, or 16670 pounds sterling to detect one woman who needs treatment for syphilis. The screening programme could be targeted geographically at pregnant women in the Thames regions. This option has the potential to save 482185 pounds sterling. Other strategic options are to target pregnant women in non-white ethnic groups, or those born outside the United Kingdom. These targeted options would each detect between 70% and 77% of women needing treatment for syphilis. These options could potentially save 592938 pounds sterling and 562691 pounds sterling respectively. CONCLUSIONS: Targeting or stopping the screening programme would save relatively little money. Although selectively screening groups by country of birth or by ethnic group could detect at least 70% of cases, this would be politically and practically difficult. Targeting by region would facts and the changing international epidemiology of syphilis lead us to recommend that the current universal antenatal screening for syphilis should continue.

The public health applications of unlinked anonymous seroprevalence monitoring for HIV in the United Kingdom.

BACKGROUND: In order to monitor the epidemiology of human immunodeficiency virus (HIV), integrated national programmes of unlinked anonymous (blinded) HIV sero-surveys have taken place in the UK since 1990. METHODS: The programmes comprise multi-centre surveys primarily using specimens gathered routinely for screening groups of patients. All specimens are irreversibly unlinked from patient identifiers before being tested. RESULTS: The surveys have met their prime aim of providing at low cost minimally biased estimates of current HIV prevalence and trends in sentinel populations. The surveys have remained acceptable to professionals and the public, being successfully implemented without breech of their founding principles. The findings have had major public health applications, have influenced HIV policy and funding, been used for monitoring the spread of HIV, for targeting and evaluating health promotion and improving projections of severe HIV disease. The surveys have detected substantial prevalence rises and under-diagnosis of HIV which would otherwise have been unrecognised. The programmes' value is being increased by sub-typing HIV-1 isolates, capturing additional demographic information to detect spread among minority groups. The same specimens are used for monitoring other infections (initially hepatitis A, B and C). CONCLUSIONS: Monitoring HIV and other infections through unlinked anonymous HIV surveillance has become an integral essential part of national HIV and AIDS surveillance. Although it has unique applications the value of unlinked anonymous surveillance is maximized when used in conjunction with behavioural data, information from HIV and AIDS reporting, and behavioural data and surveillance for other sexually transmitted infections.

The impact of HIV-1 infection on child health in sub-Saharan Africa: the burden on the health services.

HIV-1 infection in sub-Saharan Africa is resulting in substantial child mortality and an increase in the number of sick children presenting to health services. Many of the sick children come to health centres and hospitals, inflating numbers on paediatric wards. The presentations of childhood HIV-1 infection are many and varied so that HIV-1 infection is the new "great imitator' of other conditions. Some other infections are more severe in HIV-1 infected children (specifically bacterial infections and measles). However, there is no clear evidence of consequent rises in the incidence of other childhood infections, though this is likely to be the case of tuberculosis. HIV-1 infected children with other infections often respond to locally available anti-microbials, but may require longer courses. Treatment is problematic because of the impossibility of distinguishing infected from uninfected children and because of shortages of medicines, which are being intensified further by the child and adult HIV-1 epidemics. Severe HIV disease in adult family members is adding to child morbidity and creating substantial orphanhood. Staff fear nosocomial infection, while simultaneously experiencing falling personal incomes and lacking resources to care for their patients. Substantial numbers of trained staff are being lost because of HIV-1 caused disease and death. The reality of HIV-1 infection through breast-feeding is not yet appreciated. When this becomes generally apparent, there is a risk that a lethal increase in bottle feeding could occur in some areas. Reduction in the number of new paediatric HIV-1 infections in sub-Saharan Africa can be achieved only by ameliorating the adult HIV-1 epidemic, reducing unnecessary blood transfusions and ensuring a safe blood supply.

The impact of HIV-1 infection on mortality in children under 5 years of age in sub-Saharan Africa: a demographic and epidemiologic analysis.

OBJECTIVE: To estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eastern and central, and southern Africa. METHODS: A lifetable method that allows for the effects of competing causes (i.e., mortality due to HIV and other causes) was used to estimate mortality. Our calculations used published and unpublished data on HIV-1 infection in African adults and children (incidence and prevalence, vertical transmissions, transmission by blood transfusion and natural history), and typical baseline fertility and child mortality data. The results were applied to model rural and urban populations to explore the effects of parameters such as mortality in HIV-1-infected children, fertility in infected mothers and overall population growth. RESULTS: We estimate that child mortality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern and central, and southern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of one-third in eastern and central Africa and three-quarters in southern Africa. This will cancel or reverse existing advantages in urban over rural levels of child mortality and this effect will be more pronounced in southern Africa. The exact impact of HIV-1 will vary according to mortality among HIV-1-infected children and to fertility among infected women. However, changes in age structure and population growth have relatively little impact on mortality. CONCLUSIONS: There are likely to be substantial increases in child mortality in sub-Saharan Africa as a result of HIV-1 infection. The main determinant of childhood infection is the scale of the epidemic among adults. Increases in mortality will depend on local adult seroprevalence but are hard to predict precisely because of possible variation in death rates among HIV-1-infected children. In rural areas with low seroprevalence other diseases will remain the main cause of mortality. However, in urban areas families and health services will have to face considerably increased demands from ill and dying children.

PIP: The objective was to estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eastern, central, and southern Africa. Epidemiologic parameters were applied to three populations with different characteristics: a rural population with an HIV-1 prevalence of 3%, an urban population (Town A) with 10% seroprevalence, and a second urban population (Town B) with 30% seroprevalence among women of childbearing age, respectively. The output measures were the absolute increases in and the level of the under-5-years' mortality rate, which represents the probability of a child dying before his or her fifth birthday per 1000 births. It was estimated that child mortality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern, central, and southern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of 1/3 in eastern and central Africa and 3/4 in southern Africa. This will cancel or reverse existing advantages in urban over rural levels of child mortality with more pronounced effect in southern Africa. The exact impact of HIV-1 will vary according to mortality among HIV-1-infected children and according to fertility among infected women. The main determinant of childhood infection is the scale of the epidemic among adults. The educated urban elite can be expected to suffer from more young adult AIDS-related mortality. In rural areas with low seroprevalence, other diseases will remain the main cause of mortality. In urban areas, health services will have to face considerably increased demands from ill and dying children.

Sentinel surveillance for HIV-1 among pregnant women in a developing country: 3 years' experience and comparison with a population serosurvey.

OBJECTIVES: To establish unlinked, anonymous sentinel surveillance for HIV-1 among pregnant women attending an antenatal clinic, to determine age-specific seroprevalences, to monitor trends and to compare seroprevalence with that detected by a population serosurvey. To establish the sustainability and costs of surveillance. DESIGN: Sentinel surveillance for HIV through serial collection of unlinked, anonymous seroprevalence data from antenatal care; comparison of sentinel data with those from a population serosurvey; financial and general audit of the sentinel surveillance. SETTING: A community antenatal clinic in a large urban centre, Mwanza Municipality, Tanzania, eastern Africa, between October 1988 and September 1991. PATIENTS: Pregnant women attending for antenatal care. MAIN OUTCOME MEASURE: Age-specific HIV-1 seroprevalences, trends over time, difference from age-specific population seroprevalences, sustainability and costs. RESULTS: Overall HIV-1 seroprevalence was 11.5% (95% confidence interval, 10.5-12.4); differences in age-specific prevalences were not significant. There was no clear evidence of change in seroprevalence over the study period in any age group, although there was some indication of a rise in some age groups in 1988-1989. Sentinel surveillance among pregnant women may have significantly underestimated population HIV-1 seroprevalence for women under the age of 35 years. HIV-1 surveillance proved feasible and sustainable. Additional recurrent costs were US$1.7 per specimen for unlinked anonymous testing and US$0.57 per woman for syphilis screening. CONCLUSIONS: HIV-1 seroprevalence did not change significantly over 3 years, probably implying a substantial incidence of HIV-1 infection. In this setting seroprevalence in pregnant women may have underestimated population seroprevalence in women aged under 35 years. With modest inputs and good organization unlinked anonymous HIV-1 sentinel surveillance of pregnant women can be introduced and sustained in an African setting. This may usefully be carried out in conjunction with syphilis screening.

PIP: Between October 1989 and September 1991, health workers took blood samples from pregnant women attending Makongoro Clinic in Mwanza, Tanzania, to determine age-specific HIV-1 seroprevalence in pregnant women, trends over 3 years, and the feasibility, sustainability, and costs of HIV monitoring and to compare age-specific seroprevalences in pregnant women with those of all women. Overall, HIV prevalence among pregnant women stood at 11.5%. Even though the younger and older age groups had lower seroprevalence than the other age groups (10% for those under 20 years old, 11% for 30-34 year olds, and 8.3% for = or 35 year olds vs. 12.8% for 25-29 year olds and 12.3% for 20-24 year olds), the differences were not significant. HIV seroprevalence appeared to increase in 1988-89 in most age groups, but no significant evidence of a linear trend occurred during the study period for any age group. This absence of significant change in HIV seroprevalence over 3 years likely indicated a considerable HIV incidence. The population serosurvey revealed an HIV seroprevalence of 15.1% among the general adult female population, suggesting that the sentinel surveillance among pregnant women could have greatly underestimated population HIV seroprevalence for women under 35 years old (p = .02). Sentinel surveillance improved the clinic's ability to detect anemia and reintroduced syphilis screening. Unlinked anonymous testing resulted in additional recurrent costs of S$1.7/specimen. Syphilis screening added recurrent costs of US$0.57/woman. These findings indicated that health workers in Africa can successfully introduce and maintain anonymous HIV-1 sentinel surveillance of pregnant women and this can be accomplished with concurrent syphilis screening.

Performance assessment of neonatal dried blood spot testing for HIV antibody.

A study was undertaken to assess the performance of laboratories participating in the UK unlinked anonymised neonatal screening programme for the detection of HIV antibody. A coded panel of 100 contrived dried blood spots prepared form well characterised anti-HIV-1 and anti-HIV-2 positive sera and an anti-HIV negative serum was distributed to eight testing centres. Fifty-one out of 52 anti-HIV-1 positive samples were identified by all eight laboratories: five laboratories identified all 52 specimens. Only one laboratory detected all four anti-HIV-2 positive spots. None of the laboratories reported a seronegative spot as reactive. The sensitivity of anonymised neonatal anti-HIV-1 screening was deemed satisfactory in all participating laboratories but the margin of sensitivity was insufficient to allow pooling of dried blood spot eluates before testing. Technical modifications would be necessary to increase sensitivity for anti-HIV-2 were HIV-2 infection to be reported more frequently in the UK. Performance assessment of the screening programme should be repeated at regular intervals.

Children, HIV infection and AIDS.

PIP: Virtually all pediatric acquired immunodeficiency syndrome (AIDS) cases result from either vertical infection (transmission from mother to child before or at birth) or infection through transfusion with blood products that contain the human immunodeficiency virus (HIV). The risk of passing HIV infection on to an unborn child is about 25-30% if the mother is essentially healthy and higher if the mother is already showing signs of AIDS. Since maternal antibodies can persist in the infant's blood for as long as 15 months after birth, it is difficult to tell whether a positive HIV test result in an infant under this age is valid. The clinical case definition of pediatric AIDS requires the presence of 2 major signs (weight loss or abnormally slow growth, chronic diarrhea for more than 1 months, or prolonged or intermittent fever for more than 1 month) and 2 minor signs (generalized lymph node enlargement, oropharyngeal candidiasis, recurrent infections, generalized dementia, persistent cough for more than 1 month, or confirmed infection with HIV in the mother). However, diagnosis is complicated by the fact that signs and symptoms associated with HIV infection are similar to those of other treatable diseases common among children in developing countries (e.g., malnutrition, tuberculosis, and chronic diarrhea). Mothers are advised to continue breastfeeding, even where HIV indication is indicated, since there is no evidence that nursing is a significant route of infection. In addition, there is no evidence that immunizations given by trained health workers using sterile equipment transmit HIV infection.^ieng

The epidemiology and service implications of congenital and constitutional anomalies in ethnic minorities in the United Kingdom.

The literature on the incidence in the UK of congenital and constitutional anomalies in populations deriving from Africa, the Caribbean, the Far East, the Indian subcontinent and the Mediterranean is reviewed. These groups represent an increasing proportion of the whole child population. Comparison with the white population and between groups reveals that the burden of impairment varies with country of origin. Some of the reasons implicated include different gene frequencies and mating patterns, age/parity distribution and uptake of preventive services. Comparisons with prevalence at birth in the countries of origin are made where possible. In general, populations with high rates in their country of origin retain their high rates (e.g. central nervous system anomalies among births to parents deriving from the Indian subcontinent). There is a general lack of data on the prevalence of handicapping conditions such as cerebral palsy, as well as the associated health needs and service utilisation amongst ethnic minorities.