Overlooked opportunities for investing in health research and development.

In 1996, an Ad Hoc Committee on Health Research Relating to Future Intervention Options (formed under the auspices of the World Health Organization) described a model for setting priorities in research funding. This model, however, as presented in the Ad Hoc Committee's report entitled Investing in health research and development, fails in the following important situations: (i) when there is a health problem about which little is known; (ii) when current control measures are unsustainable; (iii) when there are complex risk factors, like "social factors", which affect many different diseases; and (iv) when the disease burden and resources for control vary greatly from one place to another. In situations of uncertainty or complexity, a method of priority-setting that emphasizes certainty and simplicity may actually mislead. A transparent, matrix-based process--illustrated with an example of priority-setting for malaria--may permit such uncertainty and complexity to be better taken into account in setting health research priorities.

Utilization of health services among rural women in Gujarat, India.

This study examined the effects of four sets of factors on use of curative health services among rural women living in Gujarat, India. The sets of factors analyzed were as follows: (1) the demographic characteristics of the women; (2) the characteristics of the household in which they lived; (3) the characteristics of the environment in which they lived; and (4) the price and convenience of care. The study focused on rural married women aged 17-45 who had at least one child. Nested multiple logistic regressions were computed on cross-sectional data to assess the simultaneous influences of the independent variables on (1) reports of episodes of illness (2) use of curative services among rural women who reported an illness and (3) use of a specific service. Four types of service were examined as outcomes of interest, namely, private doctors, Aga Khan Health Services centres, government health centres, and traditional healers. Other things being equal, women's education, income, family structure and kinship affiliation were significant predictors of use of service. Women seemed to be more sensitive to travel time to the health service and its associated costs (purdah restrictions, transportation and time costs) than to the direct costs of service. Factors such as women's occupation and sanitation facilities, while associated with use of service in the expected direction, were not significant predictors of use of service. Implications for health planning are offered, including initiatives to implement health promotion and disease prevention programs in addition to increasing access to the existing health services. Avenues for future studies are suggested, particularly in regard to decision-making processes affecting the health-seeking behavior of rural women. It is recommended that such policies and studies should consider the cultural environment in addition to the existing pluralistic health system.

Unmet needs and unused skills: physicians' reflections on their liberal arts education.

Physicians who graduated from 1955 to 1982 from three liberal arts colleges in southeastern Pennsylvania were asked about the ways that their undergraduate education had prepared or failed to prepare them for careers in medicine and about changes that they would, in retrospect, have made in their courses of undergraduate study. For many, college had failed to meet their perceived need, as physicians, for skill in dealing with people, but had provided skills in the form of basic science knowledge and willingness to be different that exceeded the demands of their careers. They wished that in college they had taken more courses in the humanities--especially art, history, music, and English literature--and less chemistry, mathematics, physics, and biology. Would-be physicians should be encouraged to take full advantage of the humanizing opportunities of a liberal arts education with confidence that it will contribute to their future professional and personal lives.

Epidemiology as a liberal art.

Epidemiology has features that resemble those of the traditional liberal arts. This makes it fit both for inclusion in an undergraduate curriculum and as an example in medical school of the continuing value of a liberal education. As a "low-technology" science, epidemiology is readily accessible to nonspecialists. Because it is useful for taking a first look at a new problem, it is applicable to a broad range of interesting phenomena. Furthermore, it emphasizes method rather than arcane knowledge and illustrates the approaches to problems and the kinds of thinking that a liberal education should cultivate: the scientific method, analogic thinking, deductive reasoning, problem solving within constraints, and concern for aesthetic values.

An outbreak of type 4b Listeria monocytogenes infection involving patients from eight Boston hospitals.

During September and October 1979, 23 patients admitted to hospitals in the Boston area had systemic Listeria monocytogenes infection. Twenty (87%) of these isolates were L monocytogenes type 4b, whereas only nine (33%) of the isolates serotyped during the preceding 26 months had been 4b. Patients with type 4b Listeria infection during the epidemic period (case patients) differed from patients with sporadic Listeria infection in the preceding two years in that more of the case patients had hospital-acquired infection (15/20 vs 4/18), had received antacids or cimetidine before the onset of listeriosis (12/20 vs 3/18), and had gastrointestinal tract symptoms that began at the same time as fever (17/20 vs 4/18). In addition, more case patients took antacids or cimetidine compared with patients matched for age, sex, and date of hospitalization (12/20 vs 10/40). Three foods were preferred by case patients more frequently than by control patients: tuna fish, chicken salad, and cheese. However, the only common feature appeared to be the serving of these foods with raw celery, tomatoes, and lettuce. The raw vegetables may have been contaminated with Listeria, which was able to survive ingestion because of gastric acid neutralization and subsequently to cause enteritis, bacteremia, and meningitis in susceptible hosts. However, we cannot exclude pasteurized milk as a source of this outbreak.

Bacteremia in Charleston County, South Carolina.

To describe the epidemiology of bacteremia in a large, well defined population, the authors reviewed medical records for residents of Charleston County, South Carolina, who had bacteria isolated from blood in the period 1974 to 1976. The incidence was 80 cases per 100,000 population per year. The most common organisms were Escherichia coli, Staphylococcus aureus, Klebsiella, and Streptococcus pneumoniae. The incidence was highest for neonates, infants, and those 70 years of age and older with annualized attack rates of 1,864,250, and 446 cases per 100,000 population, respectively. The incidence was 3.2 times higher for blacks than for whites and, within races, appeared to be independent of family income. Twenty-five per cent of patients had no clinically apparent focus of infection, 26% had urinary tract infection, and 17% had pneumonia. Thirty-nine per cent of cases were nosocomial, and 30% of patients died.

Pneumococcal vaccine efficacy in selected populations in the United States.

The efficacy of pneumococcal vaccine in groups of patients in the United States at high risk for pneumococcal disease was estimated by comparing distributions of serotypes of Streptococcus pneumoniae isolated from vaccinated and unvaccinated persons. Between May 1978 and March 1984, 187 blood isolates and 62 cerebrospinal fluid isolates from vaccinated patients, and 1447 blood isolates and 191 cerebrospinal fluid isolates from unvaccinated patients were serotyped at the Centers for Disease Control. The study did not include patients who were less than 2 years old or who had Hodgkin's disease, multiple myeloma, or immunoglobulin deficiency. In patients with bacteremic disease, the overall efficacy of pneumococcal vaccine was estimated at 64% (95% confidence limits, 47% to 76%); efficacy did not differ significantly with age. In persons over 65 years of age with diabetes mellitus, chronic heart disease, pulmonary disease, or no underlying illnesses, efficacy was 61% (95% confidence limits, 1% to 85%). These findings support the use of pneumococcal vaccine in selected populations in the United States.

Potable water as a source for legionellosis.

Several lines of evidence have been examined in attempts to implicate potable water as a source for legionellosis. Success has been mixed. The strongest evidence has been the similarity of strains recovered from patients and from potable water and the cessation of outbreaks following institution of measures to eradicate Legionella from potable water systems. Epidemiologic efforts to identify the effective mode of exposure to water (e.g. ingestion) have been remarkably unsuccessful. Although L pneumophila can clearly be acquired on occasion from potable water, the proportion of cases traceable to this source is unknown, as is the role of potable water as a source of infection by other Legionellae. Hyperchlorination, raising hot water temperatures to greater than 55 degrees C, and replacing rubber gaskets are useful methods for controlling outbreaks of legionellosis traced to potable water systems but are not yet justified as routine preventative methods in the absence of such an outbreak.

Risk of group A meningococcal disease: bacterial interference and cross-reactive bacteria among mucosal flora.

During outbreaks of group A meningococcal disease in Seattle, Wash., and Portland, Oreg., we studied the mucosal flora of the affected population and comparison groups to identify possible determinants of susceptibility and resistance to disease. Antimeningococcal immunoglobulin A can block the bactericidal activity of specific antibodies of other classes and has been associated with susceptibility in adults. We used immunoprecipitation and fluorescent-antibody techniques to detect mucosal microorganisms cross-reactive with group A meningococci that might have stimulated such antibodies. Cross-reactive strains of Bacillus pumilus and Streptococcus faecalis were found. Bacterial interference on mucosal surfaces has been shown to reduce susceptibility to other pathogens. With an agar overlay technique, we sought nasopharyngeal microorganisms that inhibited the growth of group A meningococci. Forty-five percent of subjects carried inhibitory strains representing at least nine different species. Inhibitory strains were less common (32%) in residents from "skid row" areas (see D.J. Bogue, Skid Row in American Cities, University of Chicago Press, for a comprehensive definition of these areas) than in a comparison group that did not experience meningococcal disease (61%), suggesting that their presence may be associated with resistance to acquisition of meningococci or to meningococcal disease.

Potable water as a source of Legionnaires' disease.

A three-year epidemic of legionnaires' disease in a hospital was dramatically curtailed following hyperchlorination of the potable water supply. The hypothesis that potable water was the source for the outbreak was further supported by isolation of Legionella pneumophila (the agent of legionnaires' disease) from the hospital water supply, observation that a sudden upsurge had occurred in the number of cases following a peculiar manipulation of the hospital water system, and documentation of a 30-fold increase in concentration of organisms in the water when this manipulation was artificially recreated. Thus, potable water may be an important source of epidemic legionnaires' disease and continuous hyperchlorination a method of control.

Bacterial meningitis in the United States, 1978 through 1981. The National Bacterial Meningitis Surveillance Study.

From 1977 to 1981, 18,642 cases of bacterial meningitis were reported to the Centers for Disease Control. We analyzed data from 27 states with full participation from 1978 through 1981. Hemophilus influenzae was the most frequent cause of bacterial meningitis (48.3%), followed by Neisseria meningitidis (19.6%) and Streptococcus pneumoniae (13.3%). Overall attack rates for males were greater than for females (3.3 v 2.6 cases per 10(5) population per year). Attack rates were highest in children under 1 year of age (76.7 per 10(5) population per year). Case-fatality ratios were highest for gram-negative and miscellaneous causes of bacterial meningitis (33.7%) and lowest for meningitis caused by H influenzae (6.0%). Neisseria meningitidis and S pneumonia meningitis occurred preponderantly during the winter, while H influenzae meningitis had peak activity in the spring and fall. Ampicillin resistance among H influenzae increased from 18.7% in 1978, to 23.9% in 1981. Serogroup B Neisseria meningitidis was the most common serogroup identified during the reporting period (51.1%), followed by serogroup C (22.3%), serogroup Y (5.8%), and serogroup A (4.7%) infections.

Prevention of Hemophilus influenzae type b disease.

To determine the efficacy of rifampin prophylaxis in eradication of oropharyngeal carriage of Hemophilus influenzae type b and prevention of secondary H influenzae type b disease, we conducted a multicenter placebo-controlled trial among selected persons with invasive H influenzae type b disease. Households and day-care classrooms were randomized so that their members received either rifampin (initially at a dose of 10 mg/kg/dose for two to four days [rifampin-10], but subsequently at 20 mg/kg/dose for four days [rifampin-20]) or placebo. Pretherapy H influenzae type b colonization rates were similar in the treatment groups. Therapy with either rifampin regimen significantly reduced carriage (rifampin-20, 97%; rifampin-10, 63%; placebo, 28%). New acquisition of carriage was also significantly reduced by either rifampin regimen (rifampin-20 or rifampin-10, 2% v placebo, 6%). No rifampin-resistant H influenzae type b isolates emerged after treatment. Four of 765 placebo-treated contacts experienced secondary disease in contrast to zero of 1,112 rifampin-treated contacts. Because chemoprophylaxis of close contacts with rifampin seems to reduce significantly the risk of secondary H influenzae type b disease, we recommend the administration of prophylaxis in households or day-care classrooms where children younger than 4 years have been exposed to the disease.

Group A meningococcal disease in skid rows: epidemiology and implications for control.

Interviews conducted during outbreaks of group A meningococcal disease in skid row communities suggested that heavy alcohol use was associated with increased risk of disease. Frequent moving within skid row and from one skid row to another was characteristic of a subpopulation with increased risk of disease and may have facilitated spread within and between skid rows. The observations discussed herein have important implications for control of communicable diseases in and near skid rows.