Plasmid patterns and antimicrobial susceptibilities of Neisseria gonorrhoeae in Bandung, Indonesia.

Antimicrobial susceptibilities of Neisseria gonorrhoeae isolates from female sex workers and from men with urethritis in Bandung, Indonesia, were determined by an agar dilution technique. Typing of the Tet M plasmid in tetracycline-resistant isolates (TRNG) was performed using a polymerase chain reaction (PCR) technique and plasmid profiles of penicillinase-producing isolates (PPNG) were determined. All PPNG possessed the 4.4 MDa beta-lactamase plasmid and all TRNG showed a PCR fragment characteristic of the 'Dutch' type Tet M plasmid. Of the 50 gonococci isolates tested, all were resistant to tetracycline; 47 were TRNG, 26 were PPNG, and 6 were resistant to thiamphenicol. Chromosomal resistance to penicillin was not detected. All isolates were susceptible to ceftriaxone, ciprofloxacin, norfloxacin, ofloxacin, kanamycin, spectinomycin, and trimethoprim/sulfamethoxazole. Spectinomycin and fluoroquinolones are useful primary drugs for treatment of gonococcal infection in Bandung. Continued surveillance of antimicrobial resistance should be part of gonorrhoea control in Indonesia.

Evolution of the Viral Hepatitis Prevention Board--VHPB.

The Viral Hepatitis Prevention Board (VHPB) was formed in 1992 to provide authoritative information and advice on hepatitis B as an occupational hazard and to act as a scientific lobby group to promote hepatitis B vaccination as part of an overall risk reduction strategy. The VHPB published Viral Hepatitis, a newsletter whose format and content was designed to appeal to both professional and lay readers seeking information on hepatitis. The VHPB was successful in lobbying the European Parliament to add the Code of Practice on Vaccination to legislation protecting workers from occupationally acquired infections. The first initiative on occupational hepatitis B culminated in an international congress in March 1993 and the publication of 'Hepatitis B as an Occupational Hazard' in the WHO occupational health series. Since 1993 the Board has discussed HBV as a community acquired infection; control of hepatitis A (HAV) and eligibility for hepatitis A vaccine and combined hepatitis A and B vaccines; hepatitis C; and reviewed progress towards the control of HBV and the adoption of universal vaccination programmes in countries of low endemicity. A major international congress in Cannes in November 1993 took stock of actions taken to control hepatitis B as a community health risk in industrialised countries. The constitution and membership of the Board underwent significant change at the end of 1994. A Secretarial was located within the Centre for the Evaluation of Vaccination at the University of Antwerp to deal with all administrative matters and publications in peer reviewed journals. The format of Viral Hepatitis was re-focused to increase the scientific content. The Board extended its actions geographically in 1996 to include the countries of Central and Eastern Europe (CEE) and the Newly Independent States (NIS) of the former Soviet Union. The success of the VHPB has exceeded all the expectations of the founding members. The major focus of the annual programme of meetings and of publications remains on hepatitis B and its prevention through vaccination. But more and more the broad range of prevention and control strategies for all forms of hepatitis is dealt with.

Control of hepatitis B in central and eastern Europe (CEE) and the Newly Independent States (NIS): recommendations of the October 1996 meeting in Siófok, Hungary.

The prevention and control of hepatitis B virus (HBV) infection constitutes a major health policy priority especially in countries belonging to the CEE and the NIS (the former Soviet Union). Many of these countries report high prevalence rates of HBV infection, clinical disease and even high mortality. The Viral Hepatitis Prevention Board (VHPB) jointly organized with the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) a meeting to bring together managers of national immunization programs, hepatitis experts and senior officials from ministries of health. The meeting was held in Siófok, Hungary from 6 to 9 October 1996. The aim of the meeting was to put the prevention of hepatitis B on the political agenda and to speed up the progress of the countries in central and eastern Europe and the Newly Independent States towards the implementation of universal childhood vaccination against hepatitis B. The epidemiology of hepatitis B in the countries concerned was discussed, the different strategies for prevention of hepatitis B reviewed, major elements in priority setting elaborated, with emphasis on health economics and strategies for resource mobilization outlined: national and international experts exchanged views during six workshops (resource mobilization: monitoring and surveillance; vaccines and immunization; vaccine production, quality control and regulation issues; nosocomial transmission and diagnostics). A major outcome of the meeting was a consensus statement and recommendations for action. These recommendations concerned the countries of the region but also 'partners in development' and the WHO, insisting that the international agencies should support technically and financially the hepatitis B prevention efforts of the countries.

Evaluation of syndromic patient management algorithm for urethral discharge.

OBJECTIVE: To determine feasibility, validity, and cost effectiveness of the syndromic approach to male patients with urethral discharge in Bandung, Indonesia. METHODS: The WHO algorithm on urethral discharge with no microscopy available was evaluated. Patients presented with a complaint of urethral discharge and if discharge was confirmed the algorithm was applied. Treatment covered gonococcal and chlamydial infection (ciprofloxacin 500 mg single oral dose plus doxycycline 100 mg, twice daily orally for 7 days). The gold standard for validation was gonococcal culture and chlamydia antigen detection. RESULTS: 140 male patients with a complaint of urethral discharge were enrolled; 119 had confirmed discharge and entered the decision tree: 107 were followed and 104 (97%) were clinically cured. Of the three patients with persistent discharge, one had a purulent urethral discharge, diagnosed as gonococcal urethritis and he was probably reinfected; two patients had a serous discharge and microbiological tests were negative. Overall, 106 out of 107 patients (99%) were microbiologically cured. Sensitivity of the algorithm is 100% and its positive predictive value (PPV) is 75% or 97% if validated against gold standard microbiological tests or Gram stain, respectively. Cost per patient is rupiah (Rp)5.894 ($US2.56) for the algorithm compared with Rp43.024 ($18.70) for full microbiological diagnosis. The cost estimate for an algorithm of urethral discharge with microscopy available is Rp6.432 ($2.80) CONCLUSION: The "symptom and sign" algorithm is fully adapted to the prevailing situation in primary healthcare settings, is acceptable to healthcare workers and patients (who are effectively treated at their first visit), is highly cost effective, is 100% sensitive (no false negatives, which is not the case with microbiological diagnosis), and has a high PPV, between 75% and 97%. It is an excellent patient management tool and a sound basis for partner notification so that it should have a major impact on STD/HIV control and prevention in both men and women.

Integration of hepatitis B vaccination into national immunisation programmes. Viral Hepatitis Prevention Board.

Hepatitis B is a major public health problem even though safe and effective vaccines have been available for over 10 years. Because hepatitis B infection is largely asymptomatic with long term complications occurring after many years it has not received the attention it deserves. Strategies to immunise those at high risk have failed to control the disease. Delegates to the World Health Assembly of the World Health Organisation recommended in May 1992 that all countries should integrate hepatitis B vaccination into their national immunisation programmes by 1997. Some western European countries remain unconvinced that the burden of disease warrants the expense of universal vaccination. However, epidemiological data and economic evaluation show that universal hepatitis B vaccination is cost effective in countries with low endemicity and that it will control hepatitis B, reinforcing the necessity for action.

Perinatal mortality and morbidity in rural West-Java, Indonesia. Part II: The results of a longitudinal survey on pregnant women.

The main objective of this prospective survey is to obtain more information on the natural history of pregnancy and its outcome, including low birth weights, and of the factors closely associated with it. During the survey period the birth rate was 40 per thousand and the perinatal death rate 48 per thousand. The main causes of neonatal deaths are infections (predominantly tetanus) and hypoxia/birth asphyxia. Perinatal mortality is significantly associated with the following risk factors: age of mother less than 20 years; birth interval shorter than 18 months, twins, and breech presentation. The incidence of low birth weight is 14.7%. Statistically significant associations have been found between low birth weight and several risk factors.

PIP: Traditional birth attendants made 5 home visits to each pregnant woman in Ujung-Berung area of rural West Java in Indonesia between September 1978-February 1980 to determine the natural history of pregnancy and its outcome and the factors associated with the different outcomes. They performed 87% of the deliveries. 4 mothers died (1.7% of all live births). The birth rate was 40% and 2335 infants were born. The perinatal mortality rate stood at 44.5. The percentage of fetal deaths was 13.7% (32) and of early neonatal deaths was 31.2% (72). The leading cause of early neonatal death was infection (50.2%) and tetanus neonatorum contributed to mortality in 79% of these cases (case fatality rate 100%). In the early neonatal period, the tetanus specific perinatal mortality was 17%. Further it stood at a high of 9.5/1000 live births due to low tetanus immunization coverage. Intrauterine hypoxia and birth asphyxia contributed the most to perinatal deaths (57.8%) followed by infections (23.6%). Twin births posed 4.14 times the risk of perinatal mortality than did singleton births (p.05). The single most significant risk factor for perinatal mortality, however, was breech delivery (relative risk [RR] 5.7; p.05). Mother's age 20 years (RR 1.28) and birth interval between 6-17 months (2.76) comprised the only other 2 significant risk factors (p.05). 14.7% of the infants weighed 2500 g. For low birth weight (LBW) infants, twin births posed the greatest risk to mortality (RR 5.65) followed by complications before delivery (RR 3.7), breech birth (RR 2.3), and 1st birth (RR 2.06) [all significant at p.05]. LBW infants had a high percentage of illnesses during the neonatal period (30.2%). Overall morbidity during this time stood at 16.9%.

Antimicrobial activity of seven metallic compounds against penicillinase producing and non-penicillinase producing strains of Neisseria gonorrhoeae.

The in vitro activity of seven metallic compounds was tested against penicillinase (beta lactamase) producing strains of Neisseria gonorrhoeae (PPNG) and non-PPNG strains. On a weight basis, the mercurials showed the greatest in vitro activity. Phenylmercuric borate, thiomersal, and mercuric chloride inhibited 90% of all strains at concentrations of 5 mg/l, 5 mg/l, and 20 mg/l respectively. Silver nitrate inhibited 90% of the strains at 80 mg/l and the MIC90 for mild silver protein was 200 mg/l. Copper and selenium salts had lower in vitro activities, inhibiting 90% of all the strains at 320 mg/l and 640 mg/l respectively. Silver nitrate and the six other compounds tested showed equal activities against PPNG and non-PPNG strains. This finding supports the recommendation for prophylaxis of gonococcal conjunctivitis of the newborn with 1% silver nitrate eye drops.