Anthropometric assessment of nutritional status in adolescent populations in humanitarian emergencies.

OBJECTIVE: To outline the difficulties and suggest potential solutions in anthropometric assessment of adolescents during humanitarian emergencies. DESIGN: Literature review. SETTING: Multiple settings in which the nutritional status of adolescents has been assessed using anthropometric measurements. SUBJECTS: Adolescents in multiple populations. INTERVENTIONS: None. RESULTS: The use of anthropometry may be more difficult in adolescents than in other age groups because anthropometric indices in normally nourished adolescents change with age and sexual development. Moreover, survey and reference populations may differ in the age at which certain pubertal landmarks are attained, requiring adjustment for differences between survey and reference populations. Adolescent populations may also differ by ethnicity in various body proportions that affect anthropometric indices. Adjustment may be required when the body proportions of adolescents in the reference population differ from those in the population assessed. CONCLUSIONS: Although no definitive recommendation can be made regarding which anthropometric indices are the most appropriate for adolescents, some revisions may improve current practices. Weight-for-height could be used for prepubertal adolescents and body mass index could be used for postpubertal adolescents. Because cut-off points are age-specific, age should be collected as accurately as possible for all adolescents measured during screening or survey activities. The WHO-recommended reference population of US adolescents is inappropriate in most populations of adolescents. Adolescents should never undergo nutritional assessment in isolation; other population subgroups should be included, and other health, nutrition and food data should be collected at the same time. SPONSORSHIP: The United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition.

Safety of neonatal hepatitis B vaccine administration.

OBJECTIVE: To determine whether hepatitis B vaccination of newborns increases the incidence of fever and/or suspected sepsis. METHODS: A prospective clinical study was undertaken at the Kaiser Permanente San Francisco Medical Center involving normal full term newborns born between November 1, 1991, and April 30, 1994. During this time 3302 infants were vaccinated within 21 days of birth with hepatitis B vaccine, and 2353 were not. Clinical and demographic data were collected from Kaiser Permanente's existing clinical information systems, and laboratory data for blood and cerebrospinal fluid (CSF) cultures were obtained from the comprehensive automated regional laboratory reporting system. RESULTS: There were no significant differences between vaccinated and unvaccinated newborns in the proportion of infants who received care for fever (0.8% vaccinated and 1.1% unvaccinated, P = 0.28), allergic reactions, seizures or other neurologic events in the first 21 days of life. Vaccinated newborns were significantly less likely to undergo microbiologic evaluation for possible sepsis. Among vaccinated newborns 4.0% had blood cultures and 1.6% had CSF cultures. Among infants who were not vaccinated 8.3% had blood cultures and 1.6% had CSF cultures (P <0.001 for both tests). CONCLUSION: This study found no evidence that newborn hepatitis B vaccination is associated with an increase in the number of febrile episodes, sepsis evaluations or allergic or neurologic events. In addition our data did not support any increase in medical procedures attributed to receipt of hepatitis B vaccine.

The accuracy of mortality reporting in displaced persons camps during the post-emergency phase.

For humanitarian organisations, accurate data are essential to identify emerging health problems and determine programme needs. We visited 45 post-emergency phase displaced persons camps and collected three months' mortality data which we compared with organisations' routine mortality reports. Organisations reported 612 deaths and we identified 741 deaths, for a mortality-reporting ratio, defined as the number of organisation-reported deaths divided by the number of investigator-identified deaths, of 83 per cent. For the majority of camps which under-reported deaths, mortality reporting ratios were significantly higher for women than men, and for camps with central mortality registers rather than those without. In the few camps which over-reported deaths, these occurred primarily among children younger than five years of age, probably due to the inclusion of abortions and stillbirths. Despite the overall under-reporting of deaths by humanitarian organisations, the existing health information systems appear to estimate mortality rates adequately in these post-emergency camps. However, organisations should improve the precision and completeness with which they report the characteristics of deaths in order to provide valuable data to target their programmes at the most vulnerable people.

Randomized intervention study comparing several regimens for the treatment of moderate anemia among refugee children in Kigoma Region, Tanzania.

Anemia-specific mortality was markedly elevated among refugee children < 5 years of age in Tanzania. In a randomized, double-blind study, 215 anemic children were initially treated for malaria and helminth infection and then received 12 weeks of thrice-weekly oral iron and folic acid. Group I received placebo and chloroquine treatment for symptomatic malaria infection (i.e., no presumptive anti-malarial treatment given). Group II received placebo and monthly presumptive treatment with sulfamethoxazole-pyrimethamine (SP). Group III also received monthly SP and thrice-weekly vitamins A and C (VAC). Mean hemoglobin concentration increased from 6.6 to 10.2 g/dL, with no significant differences among groups. Group II had lower mean serum transferrin receptor levels (TfR) than group I [P = 0.023]. A greater proportion of participants in group III had normal iron stores (TfR < 8.5 microg/ mL) than in group II [P = 0.012]. Initial helminth and malaria treatment, followed by thrice-weekly iron and folic acid supplements resulted in increased hemoglobin levels. Monthly SP and thrice-weekly VAC contributed to improve iron stores. Monthly SP may have a role in situations where asymptomatic disease is prevalent or where access to care is limited. Because administration of VAC also hastened recovery of iron stores over administration of monthly SP alone, health care personnel could add VAC to the treatment for moderate anemia if maximum recovery of iron stores is desired.

Injections given in healthcare settings as a major source of acute hepatitis B in Moldova.

BACKGROUND: Reported rates of acute hepatitis B are high in many former Soviet Union republics and modes of transmission are not well defined. METHODS: Two case-control studies were undertaken in Moldova to identify risk factors for acute hepatitis B in people aged 2-15 years (children) and > or =15 years (adults). Serologically confirmed acute hepatitis B cases occurring between 1 January 1994 and 30 August 30 1995, were matched on age, sex, and district of residence to three potential controls who were tested for hepatitis B markers to exclude the immune. Stratified odds ratios (SOR) were calculated using bivariate and multivariate methods. RESULTS: In multivariate analysis, compared with the 175 controls, the 70 adult cases (mean age 25 years, 66% male) were more likely to report receiving injections in the 6 months before illness during a dental visit (SOR = 21; 95% CI: 3.7-120), a hospital visit (SOR = 35; 95% CI: 7.2-170), or a visit to the polyclinic (SOR = 13; 95% CI: 2.4-74). Among children, receiving injections during a hospital visit (SOR = 5.2; 95% CI: 1.2-23) was the only exposure reported significantly more often by the 19 cases (mean age 8 years, 68% male) compared with the 81 controls. CONCLUSION: These results, along with reported unsafe injection practices in Moldova, suggest that injections are a major source of hepatitis B virus transmission and highlight the importance of proper infection-control procedures in preventing transmission of blood-borne infections.

PIP: Two case-control studies were conducted between January 1994 and August 1995 to determine the relative importance of injections and other exposures as a source of acute hepatitis B in Moldova among adults (aged 15 years) and children (aged 2-15 years). Results showed that injections in various health care settings were associated with acute hepatitis B and showed a higher proportion among adults compared with children. Contact with an HBsAg-positive person was also associated with illnesses; however, there was no statistically significant association between acute hepatitis B and other exposures. The risk of HBV transmission following percutaneous exposure is high (at least 30%). Calculation of the population attributable to risk suggests that injections associated with acute hepatitis B cases occurred in adults (52%) and children (21%). Adverse effects of injections may not be apparent in causing chronic infections. Transmission of blood-borne pathogens through unsafe injection practices is a problem increasingly identified worldwide.

Prevalence of hepatitis B, D and C virus infections among children and pregnant women in Moldova: additional evidence supporting the need for routine hepatitis B vaccination of infants.

Rates of acute hepatitis B are high in Moldova, but the prevalence of chronic infection is unknown. In 1994, we surveyed children and pregnant women, collected demographic information, and drew blood for laboratory testing. Among the 439 children (mean age, 5 years), the prevalence of antibody to hepatitis B core antigen (anti-HBc) and hepatitis B surface antigen (HBsAg) were 17.1 and 6.8%, respectively. Among the 1098 pregnant women (mean age, 26 years), 52.4% were anti-HBc-positive and 9.7% were HBsAg-positive. Of the HBsAg-positive pregnant women, 35.6% were hepatitis B e antigen (HBeAg) positive and 18.3% had antibodies to hepatitis D virus. The prevalence of antibody to hepatitis C virus was 1.4% in children and 2.3% in pregnant women. The high HBeAg prevalence among HBsAg-positive pregnant women and the high anti-HBc prevalence among children indicate that both perinatal and early childhood transmission contribute to the high hepatitis B virus endemicity in Moldova.

Factors associated with anemia in refugee children.

A nutrition survey was performed in 1990 among children 6 through 35 mo of age living in Palestinian refugee camps in Syria, Jordan, the West Bank, Gaza Strip and Lebanon. Overall, 67% [95% confidence interval (CI): 66, 68] were anemic (hemoglobin <110 g/L), ranging from 54% in the West Bank to 75% in Syria. The following factors were significantly associated with anemia in one or more of three age groups (6-11.9, 12-23.9 and 24-35.9 mo) by logistic regression: living in Syria, Lebanon, or Gaza [with prevalence odds ratios (POR) in the range of 1.4-2.6 depending on the age group and area, relative to children living in Jordan]; never having been breast-fed (POR = 1.7); male sex (POR = 1.2); maternal illiteracy (POR = 1.4 relative to those with >/=6 y of education); having a recent (within 2 wk) or current episode of fever or diarrhea; and stunting. Recent or current illness and stunting interacted in two age groups with the general trend of stunted children with recent or current illness having high POR. Early childhood anemia is associated with factors reflecting poor socioeconomic status and recent diarrheal and febrile illnesses in Palestinian refugee camps.

Incentives and motivators in school-based hepatitis B vaccination programs.

During a school-based vaccination program, incentives and education were offered to help motivate students to participate. Each student at all schools in the program received scholastic credit for returning a signed form, material rewards for receiving each vaccine dose, and free attendance at a social event after completing the vaccine series. In two of four schools, classes received a reward if every student in the classroom returned a signed form within five days: in these schools, 91% and 98% of students returned signed forms within five days, compared to 82% and 85%, respectively, in the two schools without this peer incentive. Approximately half the students receiving the peer incentive reported that it played a motivating role, whereas 60% cited wanting to be protected. Few students named individual rewards as motivators. Although peer incentives appeared effective in encouraging some students to return parent consent or refusal forms, the desire to be protected may have been a stronger motivator.

Immunizations from ground zero: lessons learned in urban middle schools.

The Centers for Disease Control and Prevention funded a three-year demonstration project in San Francisco to assess the feasibility of a large-scale school-based vaccination effort. The project overcame a number of barriers, including lack of pre-existing health services, diversity of home languages, and an every-50-minute-bell schedule. The project targeted seventh graders and all special education students for hepatitis B vaccine (HBVac). Of 4,928 students targeted, 3,509 (71%) consented to vaccination and received the first dose. Of these 3,509 students, 3,256 (93%) completed the three-dose series at school. Key lessons learned include emphasizing a collaborative process in the planning stage, offering an educational component for students, providing an incentive to get timely parental consent, planning distribution and collection of parent materials, and planning vaccination clinics to minimize interrupting the school day. The project clearly demonstrated that, with sufficient attention to political and logistical dimensions, school-based vaccination programs are possible in large urban schools.

Attitudes and educational practices of obstetric providers regarding infant hepatitis B vaccination.

OBJECTIVE: To survey the current knowledge, attitudes, and practices of obstetric providers regarding the education of pregnant women about infant hepatitis B vaccination. METHODS: A questionnaire was mailed to 264 physicians providing obstetric services in San Francisco. Of these, 113 were confirmed to be providing prenatal care. RESULTS: Seventy-six obstetric providers returned completed questionnaires. Among eligible respondents, 79% believed that hepatitis B vaccine should be administered to all infants at birth, and 92% believed that it is feasible to educate all expectant mothers about infant hepatitis B vaccination. However, only 53% of respondents provided such education to all their pregnant patients. Only 23% provided education about other routine childhood immunizations. CONCLUSIONS: Obstetric providers in San Francisco are willing to educate pregnant patients about hepatitis B vaccination but are not always doing so. Providing education in a consistent manner may improve infant hepatitis B vaccination rates and may increase coverage with other childhood vaccines.

Parents' attitudes toward school-based hepatitis B vaccination of their children.

OBJECTIVE: As part of a larger hepatitis B vaccination program in San Francisco, hepatitis B vaccine is offered to seventh-grade students in selected middle schools. We investigated attitudes and beliefs about hepatitis B, hepatitis B vaccine, and school-based vaccination among parents of eligible students. METHODS: A survey was conducted of random samples of parents who consented, refused, or did not respond to a request for vaccination consent. RESULTS: A larger proportion of persons who signed a vaccination consent or refusal form were biological parents and were Asian or white than parents who did not return a signed form. The most common reason for refusing vaccination, given by 84% of refusing parents, was that their children had already been vaccinated against hepatitis B. These parents recognized the severity and duration of hepatitis B virus infection as much as parents consenting to vaccination. About one third of parents who refused vaccination did not agree that schools were good places to vaccinate children. Overall, 116 parents (40%) consulted someone before deciding to consent or refuse; 95 (33%) spoke with a health professional. Most parents not returning signed consent or refusal forms reported that they never received forms from their children or that they returned signed forms to their children, who never delivered them to school. CONCLUSIONS: Most parents accepted school-based vaccination, and obtaining parental consent for school-based vaccination was possible. Nonetheless, new approaches may be needed for those students and parents who do not comply with the consent process.

Progress toward integrating hepatitis B vaccine into routine infant immunization schedules in the United States, 1991 through 1994. Connecticut Hepatitis B Project Group.

OBJECTIVE: We assessed progress toward universal infant immunization against hepatitis B, which was first recommended in November 1991. METHODS: Multiple data sources were used to describe vaccination policies and trends in infant hepatitis B vaccine coverage. RESULTS: As of June 1993, 51% of the 63 local, state, and territorial immunization programs recommended hepatitis B vaccination of all newborns shortly after birth. The number of first dosages of hepatitis B vaccine administered to infants in public sector clinics increased rapidly from late 1992 to 1993, and at the end of 1993 was approximately two thirds the number of first dosages of other infant antigens. In a nationwide survey of hospital nurseries 47% offered hepatitis B vaccine to all newborns. Of 3982 sampled newborns in these hospitals, 36.2% had been vaccinated before discharge. In San Francisco and Connecticut, where public health officials encouraged hospitals to offer hepatitis B vaccination, first-dose coverage at discharge was 82.3% in 1994 and 69.1% in 1993, respectively. Coverage was higher in healthier infants and lower in infants of older or better-educated mothers. Results from the National Health Interview Survey demonstrate that three-dose completion at 12 months of age increased form less than 1% of children born in 1989 to 40% of children born in the fourth quarter of 1992. Vaccination at birth increased from less than 1% of infants born in 1989 to 32% of infants born in the second half of 1993. CONCLUSIONS: Infant hepatitis B vaccination has expanded rapidly since national recommendations were made; however, universal coverage has not been achieved.

Nosocomial transmission of hepatitis A in a pediatric hospital traced to an anti-hepatitis A virus-negative patient with immunodeficiency.

From July through October 1991, an outbreak of hepatitis A virus (HAV) infection involving 26 hospital staff, inpatients and household contacts occurred in a pediatric hospital. All ill staff members had cared for one inpatient who had profuse diarrhea with gross fecal contamination of the environment, negative HAV serology and idiopathic immunodeficiency. HAV infection in this patient was later confirmed by polymerase chain reaction. Among hospital staff HAV attack rates were highest in nursing personnel (15%). A retrospective cohort study of nurses found that the risk of infection was greatest in those who handled the source patient's soiled bed pad (relative risk, 6.7; 95% confidence intervals, 1.6, 27.8), diaper (relative risk, 5.4; 95% confidence intervals, 0.8, 39.2) or gown (relative risk, 2.9; 95% confidence intervals, 1.1, 7.8). Glove use during these activities was not associated with a lower risk of infection, possibly because of gross environmental contamination or less use than reported. This situation was unusual because the patient was HAV-infected but had negative serology, probably because of immunodeficiency. In situations of potentially extensive environmental contamination, such as with a diapered or incontinent patient with suspected or confirmed hepatitis A, careful attention to frequent handwashing is an essential protective measure; in addition strict glove use whenever entering the patient's room should be followed to provide additional protection.

Immune response to intramuscular revaccination after primary intradermal vaccination against hepatitis B.

We studied the immune response to (re)vaccination with three 1-mL doses of recombinant hepatitis B vaccine administered intramuscularly on days 0, 30, and 180 to 75 public safety workers (PSWs) who had not developed antibody to hepatitis B surface antigen (anti-HBs) after three intradermal doses of hepatitis B vaccine; to 45 PSWs who had initially developed antibody but did not have detectable levels 11 months after intradermal vaccination; and to 16 hepatitis B-susceptible PSWs. Levels of anti-HBs were measured on days 14 and 210 after the first intramuscular dose. Overall, 46 (61%) of 75 PSWs in the initial-nonresponse group, 43 (96%) of 45 PSWs in the lost-response group, and 5 (31%) of 16 PSWs in the new-vaccinee group had anti-HBs titers of > or = 10 mIU/mL on day 14. On day 210 (after three doses), the figures were 62 (89%) of 70 PSWs in the initial-nonresponse group, 43 (98%) of 44 PSWs in the lost-response group, and 15 (94%) of 16 PSWs in the new-vaccine group. We conclude that persons who do not seroconvert after intradermal vaccination should receive three doses of hepatitis B vaccine by the intramuscular route.

Prevalence of hepatitis B, hepatitis C, and human immunodeficiency virus infection among women attending prenatal clinics in San Juan, Puerto Rico, from 1989-1990.

OBJECTIVE: To evaluate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) among pregnant women in Puerto Rico. METHODS: An anonymous serosurvey was conducted in four prenatal clinics in San Juan, Puerto Rico, involving women presenting consecutively for their first prenatal visit. RESULTS: Nineteen of 997 pregnant women (1.9%, 95% confidence interval [CI] 1.2-3.0) tested positive for HCV antibody (anti-HCV), and eight (0.8%, 95% CI 0.4-1.6) were HIV seropositive. Of the 992 women for whom serum samples were tested for HBV markers, 91 (9.2%, 95% CI 7.5-11.2) had evidence of past or current HBV infection, and four (0.4%, 95% CI 0.1-1.1) were HBV carriers. The age-specific HBV prevalence ranged from 4.1% among women 15-19 years old to 18.5% among those at least 30 years old (P < .001, chi 2 test for trend). Anti-HCV prevalence was also higher among women at least 30 years old compared to younger women (3.1 versus 1.9%; prevalence ratio 1.6, 95% CI 0.6-4.9), although the difference was not statistically significant. Anti-HCV prevalence was higher among women with past or current HBV infection than among women who were not infected (7.7 versus 1.3%; prevalence ratio 5.8, 95% CI 2.3-14.3). CONCLUSIONS: The prevalence of chronic HBV and HCV infection among pregnant women tested in San Juan, Puerto Rico, is comparable to that among pregnant women in the United States. The prevalence of HIV infection among pregnant women in San Juan is higher than among childbearing women in the United States.

A description of nonfatal spinal cord injury using a hospital-based registry.

To formulate an epidemiologic description of West Virginia spinal cord injury (SCI) resulting in hospitalization, we used data collected during the West Virginia Spinal Cord Injury Registry's first three years of operation, July 1985 through June 1988, supplemented by data from registries in neighboring states. The West Virginia registry was established to detect newly injured persons potentially in need of rehabilitation services. Because reporting is hospital based, the registry records only injured patients surviving until hospitalization. The overall incidence of hospitalized SCI patients was 25 per million per year; the sex-specific rate among men was 4.6 times the rate among women. Age-specific rates peaked in the 15-24 years age group and declined with increasing age. Motor vehicle crashes accounted for 69% of all hospitalized SCI; falls, for 21%; and sports, falling objects, and violence, for less than 10% each. Most cause-specific incidence rates were highest for young males; however, falls were more common for the elderly. At least 25% of victims used drugs or alcohol shortly before injury, and none injured in auto or truck crashes reported wearing seat belts. Quadriplegia resulted for 56% of recorded SCI patients, whereas paraplegia resulted for the remaining 44%. SCI was more common in the summer months, on weekends, and during late afternoon hours. Both neurologic deficit and time of occurrence varied by cause. Although limitations exist, registry data has proved useful in describing spinal cord injury in West Virginia and has potential public health use in guiding prevention programs.

Hepatitis B virus infection among pregnant women in northeastern Romania.

We conducted a serological survey of pregnant women attending prenatal clinics in northeastern Romania to determine the prevalence of hepatitis B virus (HBV) infection in this population. Overall, 162 (28%) of 573 women had evidence of past or current HBV infection, and 48 (8.4%) were carriers. The prevalence of past or current infection rose with age, but did not differ by educational level, occupation, or rural versus urban residence. Integration of hepatitis B vaccine into routine childhood immunization schedules, with the first dose given at birth, may have a substantial impact on HBV infection in Romania by preventing both perinatal and early childhood transmission.

PIP: Blood-borne pathogens like hepatitis B virus (HBV) have been a major cause of human sickness and significant economic drain worldwide. Current vaccination programs are based on levels of infection in the population. Romanian orphanages were found to have children with high levels of HBV. This paper reports the findings of a serological survey for HBV in pregnant Romanian women. Blood was taken from 573 women surveyed. Each blood sample was tested for antibodies to the HBV core antigen by radioimmunoassay. Data were statistically assessed using the Z-test, the Chi-square, and the Chi-square for trend. 162/573 women (28%) had a current or past HBV infection. 48/573 women (8.4%) were considered HBV carriers, as they tested positive for hepatitis B surface antigen (HBsAg). In Romania, HBV infections are common in women giving birth. It is for this reason that a large-scale vaccination program should be a major public health priority. HBV vaccination could be incorporated into the existing routine childhood immunization schedules.

Blood exposure and the risk of hepatitis B virus infection in firefighters.

The risk of infection with bloodborne pathogens among public safety workers is not well defined. This survey assessed personal and occupational risk factors among uniformed fire department employees by a self-administered questionnaire and hepatitis B virus (HBV) infection status by serologic testing. Overall, 46 (7.8%) of 592 employees had past or current hepatitis B virus infection. Employees reporting blood contact with skin had been infected more often than employees without this exposure (11% vs 5.8%, prevalence ratio = 1.9, 95% confidence interval, 1.1, 3.3). Prevalence of infection did not differ by age, years on the job, or job duties. The adjusted prevalence of hepatitis B virus infection among male employees (4.5%) was not significantly different than the prevalence in American men (6.8%) (P = .17). Although the overall risk of hepatitis B virus infection is not greater among fire department employees than the general population, blood contact with skin may elevate this risk.

Effect of a hepatitis B vaccination program on the prevalence of hepatitis B virus infection.

In April 1991, surveys for serologic evidence of hepatitis B virus (HBV) infection were conducted among 3- to 4-year-old children born after a hepatitis B immunization program of newborns began and among 6- to 11-year-old children targeted for early childhood vaccination in American Samoa. Compared with 3- to 4-year-olds tested in 1991, children tested at baseline in 1985 were more likely to have been infected with HBV (5/40 vs. 2/93; prevalence ratio [PR] = 5.8, 95% confidence limits [CL] = 1.2, 28.7) and to have chronic infection with HBV (3/40 vs. 0/95; PR = undefined, lower CL = 1.2). Compared with 6- to 11-year-olds tested in 1991, children in 1985 were more likely to have been infected with HBV (32/121 vs. 53/386; PR = 1.9, CL = 1.3, 2.8) and to have chronic infection with HBV (8/121 vs. 7/386; PR = 3.6, CL = 1.3, 9.8). The incorporation of hepatitis B vaccine into routine childhood vaccination schedules can prevent acute and chronic HBV infection in areas of high endemicity.