Death rates for acquired hypothyroidism and thyrotoxicosis in English populations (1979-2010): comparison of underlying cause and all certified causes.

BACKGROUND: Overt hypothyroidism and thyrotoxicosis have widespread systemic effects and are associated with increased mortality. Most death certificates that include them do not have the thyroid disease coded as the underlying cause of death. AIM: To describe regional (1979-2010) and national (1995-2010) trends in mortality rates for acquired hypothyroidism and thyrotoxicosis, analysing all certified causes of death (termed 'mentions') and not just the underlying cause. DESIGN: Analysis of death registration data. METHODS: Analysis of data for the Oxford region (mentions available from 1979) and English national data (mentions available from 1995). The data were grouped in periods defined by different national rules for selecting the underlying cause of death (1979-83, 1984-92, 1993-2000 and 2001-10) and were also analysed as single calendar years. RESULTS: Mentions mortality for acquired hypothyroidism in the Oxford region declined significantly from 1979 to 2010: the average annual percentage change (AAPC) was -2.6% (95% confidence intervals -3.5, -1.8). Most of the decrease occurred during the 1980s. The AAPC in rates for later years in England (1995-2010) was non-significant at 0.2% (-0.7, 1.0). Mortality rates for thyrotoxicosis decreased significantly: the AAPC was -2.8% (-4.1, -1.5) in the Oxford region and -3.8% (-4.7, -3.0) in England. In England, between 2001 and 2010, hypothyroidism or thyrotoxicosis was coded as the underlying cause of death on, respectively, 17 and 24% of death certificates that included them. CONCLUSION: Mortality rates for hypothyroidism and thyrotoxicosis have fallen substantially. The fall is probably wholly or mainly a result of improved care.

Death rates for asthma in English populations 1979-2007: comparison of underlying cause and all certified causes.

OBJECTIVE: To report on trends in mortality for asthma using all certified causes of death mentioned on death certificates (conventionally termed 'mentions'), not just the underlying cause. STUDY DESIGN: Retrospective analysis using death certificate information and population data. METHOD: Analysis of mortality records in the Oxford region (mentions available from 1979 to 2007) and English national data (mentions available from 1995 to 2007). The data were considered in periods defined by different national rules for selecting underlying cause of death (1979-1983, 1984-1992, 1993-2000, 2001-2007), and were also analysed as single calendar years. RESULTS: In Oxford, underlying cause mortality rates per million population in the four periods were 25, 32, 22 and 15, respectively. Rates for mentions were 44, 47, 41 and 29, respectively. Rule changes exaggerated the increase in underlying cause mortality in 1984-1992 (when 67% of asthma deaths were coded as underlying cause). Conversely, the decrease in underlying cause mortality for asthma by 2001-2007 is less than it seems (because just under 50% of asthma deaths in 2001-2007 were coded as underlying cause). Comparisons of trends in asthma and chronic obstructive airways disease (COPD) for individuals aged ≥ 55 years showed a decrease for both asthma and COPD in men; in women, a decrease in asthma and an increase in COPD was seen from the early 1990s. CONCLUSIONS: Approximately half of all deaths certified for asthma are missed when asthma mortality is analysed using underlying cause alone. The long-term decreasing trend in asthma mortality is real, and is not attributable to a trend in transferring certification from underlying to contributing cause. Nonetheless, caution is needed when comparing asthma deaths using underlying cause alone across periods that include changes to rules for the selection of underlying cause.

Mortality trends for tuberculosis and sarcoidosis in English populations, 1979-2008.

SETTING: Analysis of data sets that included both underlying and all contributing causes of death (together termed 'mentions'): the Oxford Record Linkage Study, 1979-2008, and England national data, 1995-2008. OBJECTIVE: To determine mortality trends for the granulomatous lung conditions tuberculosis (TB) and sarcoidosis in the Oxford region (1979-2008) and England (1995-2008). RESULTS: Mortality for mentions of TB in the Oxford region declined from 39.7 deaths per million population in 1979 to 9.0 in 2008. The corresponding rates for underlying cause were 17.1, falling to 4.5. In England, mortality rates from TB fell from 18.5/million in 1995 to 12.2 in 2008 (mentions), and from 9.3 in 1995 to 6.5 in 2008 (underlying cause). Numbers of deaths from sarcoidosis in Oxford were very small, and showed no significant trend. For the much larger England population, mortality rates based on mentions were 3.6/million in 1995 and 4.2 in 2008; the corresponding rates for sarcoidosis as underlying cause were 2.1 and 2.3. CONCLUSION: TB mortality is still declining in England, despite a recent resurgence in the prevalence of the disease. Mortality from sarcoidosis has been largely stable. The conventional statistic of underlying cause of death missed almost half of all certified TB and sarcoidosis deaths.

Cancer of the body of the uterus: trends in mortality and incidence in England, 1985-2008.

OBJECTIVE: To report on trends in mortality and incidence for uterine cancer in England, 1985-2008. DESIGN: Database analysis. SETTING: England. POPULATION: Data sets of English national mortality and cancer registration statistics. METHODS: Analysis of data from death certificates with a mention of malignant neoplasm of corpus uteri or malignant neoplasm of uterus without specification of part, and analysis of incidence data from cancer registries in England. MAIN OUTCOME MEASURES: Age-adjusted and age-specific trends in rates. RESULTS: Mortality rates in the UK declined from 41.3 per million women in 1985 until about 1999 (30.0 per million), and then increased to 35.9 per million in 2008. Incidence rates for those aged 55 years and over showed little or no change from 1985 to the early 1990s, but then increased: for example, for women aged 60-64 years, the rates per million women in 1985, 1993, 2001 and 2008 were, respectively, 448, 461, 647 and 728. Rates for younger women showed a decline, followed by an increase: for example, for women aged 50-54 years the corresponding rates were 290, 254, 267 and 294. Over the period 2001-2008, the age-adjusted average annual percentage increase was 2.55% per annum (95% CI 2.13-2.98%). The increase in incidence rates, observed from the 1990s, preceded the increase in mortality by about 10 years. CONCLUSIONS: After many years of declining rates, uterine cancer has become more common in the first decade of this century. One possible contributor to this increase may be an association with the increase in body mass index in women, but other causes are possible and are discussed.

Trends in mortality and hospital admission rates for abdominal aortic aneurysm in England and Wales, 1979-1999.

BACKGROUND: The aim of this study was to investigate trends in population-based mortality, hospital admission and case fatality rates for abdominal aortic aneurysm (AAA) from 1979 to 1999. METHODS: This was an analysis of routine statistics from 79 495 death certificates in England and Wales and 3217 hospital inpatient admissions in the Oxford Region. RESULTS: Mortality rates for all AAAs increased between 1979 and 1999 from 13 to 25 per million in women and from 80 to 115 per million in men. Admission rates increased in the same time interval from three to 22 admissions per million per year in women, and from 52 to 149 per million per year in men. Case fatality rates for all non-ruptured AAAs that were operated on decreased from 25.8 to 9.0 per cent and for all ruptured AAAs from 69.9 to 54.4 per cent. CONCLUSION: Mortality rates and hospital admission rates for AAA rose in men and even more so in women between 1979 and 1999. Perioperative mortality for ruptured AAA declined a little during the study but nonetheless was still very high at the end. This reinforces the importance of detecting and treating AAA before rupture occurs.

Trends in mortality rates for death-certificate-coded diabetes mellitus in an English population 1979-99.

AIMS: Mortality statistics have customarily been coded and analysed using only one underlying cause of death. Rules for selecting the underlying cause, when more than one cause is certified on a death certificate, have changed twice in England over the past 20 years. We used data from death certificates for 1979-99 to compare mortality rates for diabetes mellitus certified anywhere on death certificates with those certified as the underlying cause. METHODS: Analysis of data from 18,917 death certificates that included diabetes mellitus in the former Oxford health region. RESULTS: Based on the underlying cause of death, mortality rates for diabetes varied substantially between the periods defined by rule changes. Based on mentions of diabetes anywhere on the death record, mortality rates were almost unchanged over time: they showed a non-significant rise of 0.1% per year (95% confidence interval -0.3, 0.6). Circulatory diseases were certified causes of death in 71% of all deaths in people with diabetes. Although mortality rates from circulatory diseases in the general population fell by 2.5% per year, rates for circulatory diseases in combination with diabetes did not fall. CONCLUSIONS: Two explanations are possible for the lack of change in mortality rates for diabetes based on all certified mentions between 1979 and 1999. Increasing prevalence and improved survival may have resulted in no net change; and/or there may have been no improvement in survival for people whose diabetes is associated with life-threatening pathology and in particular with circulatory diseases.

Trends in mortality for cancers, comparing multiple- and underlying-cause rates, in an English population 1979-1999.

In compiling official mortality statistics, rules for selecting the underlying cause of death have changed twice in the last 20 years in England. Mortality statistics for most types of cancer were not greatly affected, but there were significant effects on coding for cancers of colon, liver, breast, prostate, testis and bladder, and for lymphoma and leukaemia.

Estrogen stimulation of ovarian surface epithelial cell proliferation.

Ovarian cancer is the leading cause of gynecological cancer mortality, and 85-90% of this malignancy originates from the ovarian surface epithelium (OSE). The etiology of ovarian epithelial cancer is unknown, but a role for estrogens has been suspected. However, the effect of estrogens on OSE cell proliferation remains to be determined. Using the rabbit model, our studies have demonstrated that 17beta-estradiol stimulates OSE cell proliferation and the formation of a papillary ovarian surface morphology similar to that seen in human ovarian serous neoplasms of low malignant potential. Immunohistochemical staining of ovarian tissue sections with an antibody to the estrogen receptor alpha demonstrates its expression in both OSE cells and stromal interstitial cells. In primary ovarian cell cultures, the proliferative response of the epithelial cells to 17beta-estradiol depends on the expression of the estrogen receptor alpha in the epithelial cells. However, when the epithelial cells are grown together with ovarian stromal cells, their proliferative response to this hormone is greatly enhanced, suggesting the involvement of stromal-epithelial interactions. These studies suggest a role for estrogens and the estrogen receptor alpha in OSE growth.

Human matrix metalloproteinase-9: activation by limited trypsin treatment and generation of monoclonal antibodies specific for the activated form.

For many studies on matrix metalloproteinases in immunohistochemistry it is important to be able to distinguish between the zymogen and activated forms of the enzymes. Activated human matrix metalloproteinase-9 (MMP-9, gelatinase B) was produced from the proenzyme by limited digestion with trypsin. The products of cleavage were characterised by SDS/PAGE and N-terminal sequencing. Trypsin treatment led to a stepwise removal of the propeptide domain and also caused cleavage within the C-terminal domain. Monoclonal antibodies specific for the activated form of human MMP-9 were raised by using a peptide corresponding to the N-terminus of the activated enzyme as immunogen. The antibodies do not recognise the MMP-9 proenzyme or the active or proenzyme forms of matrix metalloproteinase-2 (MMP-2, gelatinase A) and do not react with unrelated proteins in an unfractionated tissue extract. The antibodies were used to detect, by immunohistochemistry, activated MMP-9 in formalin-fixed, wax-embedded sections from a series of oesophageal cancer cases previously shown to contain MMP-9. All of the tumours contained activated MMP-9 localised to tumour cells and macrophages. As the antibodies are effective in immunohistochemistry on formalin-fixed, wax-embedded sections, they should prove useful for the detection of activated MMP-9 in various disease processes.

Matrix metalloproteinases and their inhibitors in gastric cancer.

BACKGROUND: The matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) are strongly implicated in tumour invasion and metastasis. AIMS: To investigate the presence of individual MMPs and TIMPs in gastric cancer. METHODS: The presence of MMP-1, MMP-2, MMP-3, MMP-9, TIMP-1, and TIMP-2 was identified in a group of gastric cancers (n=74) by immunohistochemistry using monoclonal antibodies. These antibodies were effective on formalin fixed, paraffin wax embedded sections. RESULTS: A large proportion (94%) of gastric cancers contained MMP-2; MMP-1 and MMP-9 were also detected in 73% and 70% of tumours respectively. MMP-3 was only present in 27% of tumours. MMP-1 and MMP-9 were found predominantly in intestinal type tumours. TIMP-1 and TIMP-2 were identified in 41% and 57% of tumours respectively. Immunoreactivity for individual MMPs or TIMPs was not identified in normal stomach. CONCLUSIONS: This study shows the presence of matrix metalloproteinases, particularly MMP-2, and TIMPs in stomach cancer. Antibodies which are effective in formalin fixed, paraffin wax embedded sections are useful for the identification of MMPs and TIMPs in diagnostic specimens.

Matrix metalloproteinase-1 is associated with poor prognosis in oesophageal cancer.

The matrix metalloproteinases (MMPs) are a family of closely related proteolytic enzymes which are involved in the degradation of different components of the extracellular matrix. There is increasing evidence to indicate that individual MMPs have an important role in tumour invasion and tumour spread. Monoclonal antibodies specific for MMP-1, MMP-2, or MMP-9 have been produced, using as immunogens peptides selected from the amino acid sequences of individual MMPs. The presence of MMP-1, MMP-2, and MMP-9 in oesophageal cancer was investigated by immunohistochemistry on formalin-fixed, wax-embedded sections of oesophageal cancers. The relationship of individual MMPs to prognosis and survival was determined. MMP-1 was present in 24 per cent of oesophageal cancers, while MMP-2 and MMP-9 were present in 78 and 70 per cent of tumours, respectively. The presence of MMP-1 was associated with a particularly poor prognosis (log rank test 8.46, P < 0.004) and was an independent prognostic factor (P = 0.02). The identification of individual MMPs in oesophageal cancer provides a rational basis for use in the treatment of oesophageal cancer of MMP inhibitors which are currently undergoing clinical trial.

STDS in women attending family planning clinics: a case study in Addis Ababa.

For cultural reasons modern contraception has been slow to gain acceptance in Ethiopia. Knowledge about contraception and abortion is still limited in many family and community settings in which it is socially disapproved. By 1990 only 4% of Ethiopian females aged 15-49 used contraception. Little is known of sexually transmitted disease (STD) prevalence in family planning (FP) attenders in Africa in general and Ethiopia in particular, even though attenders of family planning clinics (FPCs) are appropriate target groups for epidemiological studies and control programmes. A study of 2111 women of whom 542 (25.7%) attended FPCs in Addis Ababa showed utilisation rates to be highest in women who were: Tigre (33%) or Amhara (31%), aged 20-34 years (30%), age 16 or older at first marriage/coitus (28%:38% in those first married after 25 years); who had a monthly family income of 10 Ethiopian Birr (EB) or more (33%:36% for those with income 100-500 EB), three or more children (37%), more than five lifetime husbands/sexual partners (39%); or were bargirls (73%) or prostitutes (43%). The seroprevalence rates for all STDs, higher in FPC attenders compared with other women, were syphilis (TPHA) 39%, Neisseria gonorrhoeae 66%, genital chlamydia 64%, HSV-2 41%, HBV 40% and Haemophilus ducreyi 20%. Only 4% of FPC attenders had no serological evidence of STD: 64% were seropositive for 3 or more different STD. Clinical evidence of pelvic inflammatory disease (PID) was also more common in the FPC attenders (54%), 37% having evidence of salpingitis. The FPC provides a favourable setting for screening women likely to have high seroprevalence of STD, who for lack of symptoms will not attend either an STD clinic nor a hospital for routine check up. We recommend that measures be taken to adequately screen, treat and educate FPC attenders, their partners, and as appropriate and when possible their clients, in an attempt to control STDs and ultimately HIV in the community. Social, economic and cultural factors in the occurrence of STDs, prostitution, family planning and modern contraception coverage in Ethiopia are identified and deficiencies of current programmes briefly discussed with the objective of targeting services more effectively.

Matrix metalloproteinase-1 is associated with poor prognosis in colorectal cancer.

Colorectal cancer is one of the commonest malignant tumors and has a relatively poor prognosis. The outcome depends on the extent of local and particularly metastatic tumor spread. The matrix metalloproteinases (MMPs) are a family of closely related enzymes that degrade the extracellular matrix and are considered to be important in facilitating tumor invasion and spread (1-3). Using immunohistochemistry we have investigated the occurrence in colorectal cancer of MMP-1 (interstitial collagenase). Our monoclonal antibody was prepared against a synthetic peptide corresponding to an amino acid sequence specific for MMP-1 and was selected to react in formalin-fixed wax-embedded sections, thus allowing use in diagnostic histopathology and also enabling access to archival material. We found that the presence of MMP-1 in colorectal cancer is associated with a poor prognosis (P = 0.006) and has prognostic value independent of Dukes stage. One MMP inhibitor that strongly inhibits MMP-1 has already been shown to inhibit growth of human colon cancer xenografts in nude mice (4). Our results suggest that treatment of those individuals whose colon tumors produce MMP-1 with MMP inhibitors is a therapeutic strategy worth pursuing.

Chlamydial infection in a population of Ethiopian women attending obstetric, gynaecological and mother and child health clinics.

The prevalence of chlamydial infection was assessed in 1,846 Ethiopian women attending clinics in Addis Ababa. Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGVI-3), and C. pneumoniae (CPn), in a micro-immunofluorescence (micro-IF) test. Three levels of chlamydial infection were established. Sera with: 1) antibodies to CTA-C, CTD-K, LGV 1-3 and CPn singly or in combination, are considered as evidence of overall exposure to chlamydial species (OEC); 2) antibodies to CTD-K and LGV 1-3 are considered as evidence of exposure to genital chlamydial pathogens (GENCI); 3) IgM titre > or = 1/8, or Ig G titre > or = 1/64 to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn is considered as being evidence of active genital chlamydial infection (AGCI). OEC was found in 84 pc, GENCI in 60 pc and AGCI in 42 pc. Infection was highest in family planning and lowest in antenatal clinic attenders. OEC increased progressively with age while GENCI and AGCI peaked at ages 35 to 49. Chlamydial infection was highest in those married and sexually active < 13 years of age (OEC 88 pc, GENCI 69 pc, AGCI 49 pc); the lowest income groups (OEC 85 pc, GENCI 65 pc, AGCI 45 pc); those with more than five sexual partners (OEC 92 pc, GENCI 78 pc and AGCI 65 pc); with highest prevalence in bargirls (OEC 97 pc, GENCI 84 pc, AGCI 75 pc). Fifty pc had clinical evidence of past or present infection in the urethra, salpinges or bartholin glands (USB). OEC, GENCI and AGCI were associated with PID. The association of seropositivity with USB was remarkably similar for both gonorrhoea and chlamydial infection: we recommend adoption of a treatment regimen effective for both infections. The micro-IF test is a useful epidemiological tool for identifying the of antibodies to chlamydial pathogens. Use of antigen pools CTA-C, CTD-K LGVI-3 and CPn enables a distinction to be made between genital and non-genital infections. The problem of symptomatic and asymptomatic chlamydial disease needs to be addressed urgently.

PIP: In Addis Ababa, Ethiopia, purified chlamydial antigens were used in a micro-immunofluorescence (micro-I) test to detect type-specific antibodies against various chlamydial species in blood samples from 1846 women attending family planning, prenatal, and postnatal clinics. The antigens were for Chlamydia trachomatis A-C (CTA-C), Chlamydia trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV 1-3), and C. pneumonia (CPn). The researchers considered sera with antibodies to CTA-C, CTD-K, LGV 1-3, and CPn independently or in combination as evidence of overall exposure to chlamydial species (OEC) and those to CTD-K and LGV 1-3 as evidence of exposure to genital chlamydial pathogens (GENCI). They considered sera with IgM titre of 1/8 or more, or IgG titre of 1/64 or more to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn as evidence of active genital chlamydial infection (AGCI). 84% were categorized as OEC. 60% were categorized as GENCI. 42% were categorized as AGCI. The prevalence of chlamydial infection was greatest in family planning clients and lowest in pregnant women (OECD: 88% vs. 78%, p = 0.004; GENCI: 63% vs. 54%, p 0.02; and AGCI: 46% vs. 31%) (p 0.01). The geometric mean of the titre was also highest in family planning clients and lowest in pregnant women (85% vs. 58%). The most significant factor for chlamydial infection was being married and having first coitus before age 13 (OEC: 88% vs. 75% for first coitus at 18 years; p 0.001). Other risk factors included low income (p 0.005), more than 5 sexual partners (p 0.01), bar-girl occupation (p 0.001), and Amhara and Oromo ethnic groups (p 0.001). 50% of all women had clinical evidence of past or present infection in the urethra, fallopian tubes, and/or bartholin glands. Women with pelvic inflammatory disease (PID) were more likely to have chlamydial infection than those with no infection in the urethra, fallopian tubes, or bartholin glands (OEC: 95% vs.83%; GENCI: 86% vs. 58%; AGCI: 72% vs. 38%) (p 0.001). PID was also associated with gonorrhea.

Pregnancy and leprosy neuropathy.

Women with leprosy (even apparently cured) run a serious risk of deterioration in nerve function when they become pregnant. During pregnancy and lactation the woman with leprosy may suffer: relapse, reactivation and transient exacerbation maximally in late pregnancy; ENL in the first and third trimesters, continuing with nerve damage postpartum; RR maximally postpartum, even after MDT and RFT; neuritis affecting almost 50% of women in any pregnancy/lactation, in most cases as "silent" neuritis with new motor and sensory loss, even after MDT-RFT, and stocking-and-glove anaesthesia even in PB women and post MDT-RFT. Those incubating the infection develop overt disease frequently in reaction. This tragic cycle can only be stopped by a combination of: (i) leprologists and leprosy control personnel understanding the problems of leprosy in pregnant and lactating mothers; (ii) well-planned health education for leprosy patients, and both leprosy and maternal health care workers and (iii) the highest standard of clinical supervision during pregnancy, prolonged lactation and at regular intervals during the woman's reproductive life, even after she would normally be released from surveillance after completion of multiple drug treatment (MDT).

Teenage obstetric and gynaecological problems in an African city.

OBJECTIVE: To measure the prevalence of sexually transmitted diseases (STD), pelvic inflammatory disease (PID), cervical cancer, pregnancy and use of contraception in teenagers, and to determine socioeconomic factors associated with these conditions to aid planners of medical services and promotion of sexual health. SUBJECTS: 181 Ethiopian teenagers and 1,845 women aged 20 to 45 years for comparison. SETTING: Gynaecological outpatient department, antenatal, postnatal and family planning clinics, in two teaching hospitals and a mother and child heath centre in Addis Ababa, Ethiopia. METHODS: Results of serologic tests for STD, clinical evidence of PID, and cervical cytology were analysed against socio-economic factors. RESULTS: In teenagers early age at first marriage/coitus, more common in those of rural origin, was associated with poverty, a greater number of lifetime sexual partners, and prostitution: 40 pc were first sexually active before the menarche. Prevalence of seropositivity to specific STD pathogens was; Treponema pallidum (TPHA) 21 pc, Neisseria gonorrhoeae (gonococcal antibody test: GAT) 40 pc, genital chlamydiae 51 pc, hepatitis B virus 36 pc, herpes simplex virus (HSV-2) 32 pc, and Haemophilus ducreyi 16 pc: 92 pc of teenagers were seropositive to one or more STD's. STD seroprevalence was higher in those with more than one sexual partner, those sexually active by age 15 (very high in those sexually active by age 12), those involved in prostitution and those attending the family planning clinic. Forty three pc had clinical evidence of PID; one married at age 10 had invasive cervical cancer by age 18; 40 pc of teenagers were pregnant compared with 25 pc of those aged 20 to 45; 21 pc attended for family planning; of regular FPC attenders 81 pc were GAT seropositive. CONCLUSION: Despite legislation early age of sexual debut is common, STD and PID are widely prevalent, the pregnancy rate in adolescents is high and contributes to the national population growth rate. Action is required at family, medical and governmental level to encourage cultural acceptance that marriage and sexual activity should not occur before the age of 16 years, with education appropriate to culture to prevent STD. Similar studies are recommended in other countries to establish a baseline for informed strategy regarding prevention of STD and health education.

PIP: A survey of 181 Ethiopian females ages 14-19 years recruited from health facilities in Addis Ababa revealed a high incidence of obstetric and gynecologic problems. All subjects completed a questionnaire administered by a female health worker and underwent a gynecologic examination and serologic tests. 49% of subjects were married and 18% were divorced; 11% were prostitutes. Age at first intercourse was under 12 years in 18%, 13-15 years in 38%, and 16 years or above in 44%; 40% were sexually active before menarche. 92% of adolescents had at least one sexually transmitted disease (STD), predominantly gonorrhea (40%), genital chlamydia (51%), hepatitis B (36%), herpes simplex virus (32%), and syphilis (21%), and 43% had clinical signs of pelvic inflammatory disease (PID). 53% had had at least one pregnancy. The earlier the age at first intercourse, the more likely it was that the adolescent would have multiple sexual partners and several STDs; adolescents in this category were also more likely to be from poor families from rural areas. Only 21% were attending a family planning clinic for annual check-ups; 14% of these females were using contraception. Although only 8% were infertile at the time of assessment, 23% had clinical evidence of salpingitis--a risk factor for future infertility. Given the long-term health risks (e.g., infertility, cervical cancer, and gonorrhea-related infant morbidity) associated with the patterns observed among these adolescents, it is recommended that STD education receive higher priority and that the Ethiopian Government consider greater enforcement of the law prohibiting sexual intercourse and marriage before the age of 16 years.

Seroepidemiological studies of Haemophilus ducreyi infection in Ethiopian women.

BACKGROUND AND OBJECTIVES: To measure prevalence of anti-Haemophilus ducreyi antibodies in sera from Ethiopian female attendees, and to determine significant socioeconomic associations. STUDY DESIGN: A modified ELISA immunoassay was used to test sera of 1,831 Ethiopian women attending gynecological, obstetric, and family planning clinics in Addis Ababa. RESULTS: Overall seropositivity was 19.4%. Prevalence rates for seropositivity for antibodies to H. ducreyi were significantly associated with ethnic group and religion, older age (> or = 50 years: 28%), early age at first coitus (< 13 years: 28%) and first coitus before the menarche (25%), being divorced (27%) or a prostitute (24%), longer duration of marriage (> 20 years: 27%) and sexual life (> 20 years: 24%), number of lifetime sexual partners (2 to 5 partners: 27%) and self-reported history of both syphilis and gonorrhea (31%). Of these factors, the two most significant were first coitus before the menarche (P < 0.0001) and not being still married to the first husband/sexual partner (P < 0.001). Differences in seropositivity according to ethnic group and religion may be explained by the number of women within each group who had only one lifetime sexual partner. Women with serological evidence of exposure to another sexually transmitted disease (STD) had a greater risk of exposure to H. ducreyi. The odds ratio for H. ducreyi seropositivity in women with syphilis or gonorrhea was 3.6, for women with genital chlamydial infection, 2.3, and for those with HBV or HSV-2, 1.4 and 1.3 respectively. CONCLUSIONS: This study illustrates the usefulness of the modified ELISA immunoassay for measuring exposure to H. ducreyi, and the usefulness of H. ducreyi as a marker for cumulative sexual exposure. Further studies on the association of HIV transmission and H. ducreyi in Ethiopia are now indicated.

PIP: Genital ulcerated disease (GUD), which includes chancroid, has been identified as a risk factor for HIV transmission. This study reports the prevalence of anti-Hemophilus ducreyi (chancroid) antibodies in 1831 Ethiopian women and looks at the behavioral and social factors which might affect the incidence and potential spread of chancroid. Patient data regarding ethnic and socioeconomic aspects were collected from detailed questionnaires. Blood collection was performed under medical surveillance. Complete gynecological examinations were performed. Papanicolaou stained smears were used as the basis of the cytological data. Serological studies utilized an enzyme immunoassay (EIA) test for STD detection. Statistical tests used included the Chi-square test, the multivariate analysis technique, and the Cochran-Mantel-Haenszel General Association Statistic Test. Antibodies to H. ducreyi were found in 335 women (19.4%). Prevalence of H. ducreyi was significantly associated with Amhara or Tigre ethnic heritage; older age; first coitus before beginning menstruation; history of STDs; divorced status; being a prostitute; longer duration of married and sexual life; and younger age at first coitus. Logistic regression demonstrated that 3 factors were significant when associated with H. ducreyi seropositivity. First coitus before beginning menstruation was highly significant (OR 1.95; 95% CI, 1.49-2.57; P 0.0001). Not being still married to the first husband was also significant (OR 1.68; 95% CI, 1.23-2.30; P 0.001). Being of the Ethiopian Orthodox religion was significant (OR 2.11; 95% CI, 1.21-3.68; P 0.005). Prevalence in women with 2-5 lifetime husbands was higher than in women with only 1 husband.

A socioeconomic, clinical and serological study in an African city of prostitutes and women still married to their first husband.

The aim of this paper was to compare women involved in prostitution with a group of women still married to their first husband and reporting having had only one sexual partner, in order to ascertain what factors if any contributed to women going into prostitution or staying still married to their first husband, their only sexual partner, and thereafter to compare clinical and serological aspects of the gynaecological conditions of the women in these two groups. The role of prostitutes in transmission of sexually transmitted diseases (STD) is widely recognised. Socioeconomic factors determining whether a woman will drift into prostitution or have a stable first marriage are largely unknown as are prevalence rates of STD, pelvic inflammatory disease (PID) and cervical cancer in these women. A socioeconomic, clinical and serologic study is reported for 2111 Ethiopian women attending teaching hospitals and maternal and child health clinics in Addis Ababa, analysing basic demographic data of three groups of women: (i) 278 engaged in prostitution, (ii) 730 still married to their one and only sexual partner, and (iii) 1103 single, widowed, divorced or married to their second or subsequent partner. Thereafter groups (i) and (ii) were compared and contrasted with regard to further socioeconomic, clinical and serological associations. The most significant socioeconomic associations for women in prostitution were low income (95% had < 50 Ethiopian birr [< U.S. $25] per month), ethnic group, and the timing of first coitus in relation to the menarche (81% were first married by age 15), in that order. Women still married to their first sexual partner had higher income, higher age at first marriage and longer duration of marriage. Sero-prevalence rates of STD in prostitutes were high: gonorrhoea 88%, genital chlamydiae 78%, syphilis (TPHA) 62%, HSV2 and HBV 46%, and chancroid 19%: 67% had PID and 2.9% cervical cancer. In comparison, rates for women married to their first and only sexual partner were: gonorrhoea 40%, genital chlamydiae 54%, syphilis (TPHA) 19%, HSV2 33%, HBV 35%, chancroid 13%, PID 47% and cervical cancer 1%. While the very high prevalence of STD in women involved in prostitution is not so unexpected, the high rate of STD in women still married to their first and only sexual partner is indicative of male promiscuity. Control of prostitution and diseases spread by it, together with education of both men and women is a national priority.