Impact of maternal HIV infection on obstetrical and early neonatal outcome.

In a case-control study of 177 HIV-seropositive and 326 seronegative women and their newborns in Nairobi, Kenya, maternal HIV infection at term was independently associated with travel to other African countries [odds ratio (OR) 4.9, P less than 0.0001], history of a blood transfusion since 1980 (OR 3.5, P = 0.01), history of more than one sexual partner in the previous 5 years (OR 1.8, P = 0.02) and unmarried status (OR 1.8, P = 0.02). Neonates of HIV-positive and HIV-negative women differed little with respect to occurrence of congenital malformations, stillbirths, in-hospital mortality, sex, APGAR score, or gestational age. However, the mean birth weight of singleton neonates of HIV-positive women was significantly lower than that of controls (3090 versus 3220 g, P = 0.005), and birth weight was less than 2500 g in 9% of cases and 3% of controls (OR 3.0, P = 0.007). Among neonates of HIV-seropositive women, birth weight was less than 2500 g in 17% if mothers were symptomatic and 6% if mothers were asymptomatic (OR 3.4, P = 0.08).

Audit of a breast cancer screening programme using clinical examination and lightscanning.

To ascertain the accuracy of a breast cancer screening programme which relied on clinical examination and lightscanning, women attending between 1984 and 1989 were retrospectively followed-up. Three thousand, seven hundred and twenty women, median age 40 years, made 5,150 visits for screening. Two hundred and sixteen women (4.2%) were positive on screening but only six were found to have breast cancer. The sensitivity of clinical examination was 46%. The likelihood that a lesion found on clinical examination was a breast cancer rose with age, from 1.1% in women under 45 years to 33% in women over 54 years of age. Lightscanning had a sensitivity of 8%, but did not make an independent contribution to diagnosis. Sixty-five asymptomatic women without clinical abnormalities had false positive lightscans requiring subsequent investigation. This screening programme has demonstrated a demand for breast cancer screening from women of all ages. However the yield of clinical examination was low, and lightscanning proved to be an unsatisfactory screening test. Routine audit must be an integral part of all screening programmes.

Enteric fever in Scotland 1975-1990.

In the 16-year period 1975-90, there were 267 cases of acute infection with typhoidal salmonellae reported in Scotland, in addition to which 32 chronic carriers were identified. The overall incidence of disease changed little over this period, but there was a fall in indigenously acquired paratyphoid B and typhoid, and a rise in imported paratyphoid A. The majority, 215 (81%), had a history of recent travel and were considered to have acquired infection overseas. Only six of the indigenously acquired infections were traced to acutely infected persons, illustrating the low risk of transmission associated with acute enteric fever in the UK. Only one death was definitely ascribed to enteric fever, and one person with S. paratyphi B became a chronic carrier. Significant illness was observed in five chronically infected individuals, including one with carcinoma of the gallbladder. UK residents of 'Asian' ethnicity returning from the Indian subcontinent accounted for 63 (46%) of the 137 cases of typhoid, and 34 (64%) of the 53 cases of paratyphoid A. People of 'Asian' ethnicity were more likely to have acquired infection overseas than 'non-Asians': 110 (89%) of 123 persons compared with 105 (73%) of 144 (odds ratio 3.1, 95% confidence interval 1.5-6.6, P = 0.001). Although there seems to be limited scope for preventing indigenously acquired infection, immunisation of travellers could contribute significantly to reducing the incidence of typhoid.

Human hydatid disease leading to hospital admission in Scotland 1968-1989.

An attempt to estimate the impact of hydatid disease upon human health in Scotland between 1968-89 was made by examining Scottish hospital discharge statistics, and death statistics. Because hydatid disease may be asymptomatic, and coding errors are more likely to occur with rare diseases, an assessment was made as to the likelihood of hydatid disease having been responsible for hospital admission. Over the 22 year period a total of 110 hospitalised individuals with a diagnosis of hydatid disease were identified; no deaths were recorded. Inspection of the other diagnoses and operations recorded for each case suggested that hydatid disease was responsible for hospital admission in only 65 individuals (59%). One further individual, who had been admitted to a hospital outside Scotland, was identified from a Western Isles register of cases receiving surgery for hydatid disease. This register was used to assess the completeness of the Scottish hospital statistics; 10/11 Western Isles cases were identified using hospital statistics. Local case registers seem essential for accurate estimates of incidence and prevalence, and to evaluate the need for control programmes. The median age of the 66 individuals considered to have been admitted to hospital because of hydatid disease was 49 years (range 4-85); 38 (58%) were male. A total of 36 cases were managed surgically (55%), and there was a tendency for the use of surgery to increase over the 22 year period. The Health Boards with the highest incidence of clinically apparent infection leading to hospital admission were: Western Isles, Shetland and Highland; with 2.53, 1.23, and 0.21 cases per 100,000 population per year respectively.

Public health medicine advice to local authorities: does it happen?

The views of public health physicians on the extent and quality of their specialty's collaboration with local government in Scotland was ascertained by postal questionnaire. Responses were received from 84 out of 97 (85%) Consultants in Public Health Medicine (CPHMs) working in Scottish health boards. Those working in health boards were more likely than colleagues in university departments to consider their service department to be sufficiently aware of and involved in issues having a bearing on health but not directly related to provision of health services (48/70 vs 4/12, RR 2.1, 95% CI 1.1-3.8). Seventy CPHMs gave advice to local authorities. They were in contact with a median of two local authority departments (range 0-6); most commonly Social Work (38 CPHMs), Environmental Health (36), and Education (26). CPHMs participated in a median of one multi-disciplinary group (range 0-3); most commonly Health Promotion (16 CPHMs), Child Welfare (9), Emergency Planning (9). The majority, 42 of 67 (63%), valued this contact highly, only three considering it of doubtful utility. Difficulties with bringing an item to the attention of a local authority department were identified by six out of 56 (11%) CPHMs and 32/69 (46%) recorded problems in ensuring Public Health Medicine input to local authority committees. In most health boards (12/14) there were formal meetings between CPHMs and heads of local authority departments; in each these were supplemented by informal meetings. One Director of Public Health and eight other CPHMs reported neither formal nor informal contact with local authorities. Spontaneous comments from respondents indicated a desire to strengthen the links with local authority departments.(ABSTRACT TRUNCATED AT 250 WORDS)

Audit of pre-employment health assessment in the National Health Service.

Seventeen (77 per cent) of the 22 NHS occupational health departments in the West Midlands Region replied to a postal questionnaire about pre-employment health assessment. In only 5 departments (29 per cent) was the decision whether to interview and examine a prospective employee dependent on the results of a self-administered questionnaire. All departments were asked how many prospective employees had been screened and how many rejected/restricted over a 2 week period. Departments which interviewed/examined all prospective employees tended to have higher rejection/restriction rates than departments operating a selective policy: 6 (2.6 per cent) out of 232 versus 16 (1.4 per cent) out of 1140, relative risk 1.6, 95 per cent confidence interval 0.8 to 3.4, P = 0.31. In departments which did not automatically interview/examine prospective employees, the median proportion seen by nurses was 56 per cent, and by doctors was only 12 per cent. Within one NHS Region we have documented wide variation in what constitutes a pre-employment health assessment. A selective approach would release a significant amount of occupational health staff time.

How long should patients with Salmonella typhi or Salmonella paratyphi be followed-up? A comparison of published guidelines.

Records were examined for 242 individuals infected with Salmonella typhi or S. paratyphi identified in Birmingham between 1981 and 1988, with a total of 335 person years of follow-up. Of these cases 77 and 78 per cent respectively were followed beyond the point at which surveillance would have ceased under guidelines published by the American Public Health Association and by the Public Health Laboratory Service for England and Wales. Under these two sets of guidelines only seven (3.8 per cent) and eight (4.3 per cent) cases respectively had subsequent positive faecal or urine cultures over a median of 335 and 295 days of additional follow-up. After 0, 1, 2, 3, 4 and 5 prior consecutive negative sets of cultures obtained at weekly intervals the likelihood of the next set of cultures being positive was 26, 9, 5, 2.2, 2.4 and 0 per cent respectively. Only 38 (1.7 per cent) of 2184 follow-up urine cultures were positive; these results did not influence duration of follow-up. Only 26 (2.6 per cent) of 1002 contacts were infected; the yields of the first, second and third sets of cultures were 1.5, 0.6 and 0.5 per cent respectively.

Towards developing a diagnostic algorithm for Chlamydia trachomatis and Neisseria gonorrhoeae cervicitis in pregnancy.

C trachomatis and N gonorrhoeae are major causes of maternal and neonatal morbidity and mortality in developing countries. To identify characteristics predictive of cervical infection, we examined pregnant women attending an antenatal clinic in Nairobi, Kenya. C trachomatis was isolated from 14/178 (8%), and N gonorrhoeae from 17 (10%); cervical infection with either pathogen was present in 28 (16%). Two characteristics were independently predictive of cervical infection by logistic regression analysis; the presence of either endocervical mucopus or induced endocervical bleeding, relative risk 4.2 (95% confidence interval (CI) 2.2 to 8.0) and having more than one sexual partner during pregnancy, relative risk 3.3 (95% CI 1.4 to 7.6). A screening programme for cervical infection which tested women with one or both risk markers would have a sensitivity of 68% (95% CI 51 to 85%) and a positive predictive value of 0.35 (95% CI 0.22 to 0.47). In countries where resources are limited, diagnostic algorithms incorporating clinical signs and behavioural characteristics may be useful in identifying pregnant women at high risk of cervical infection.

PIP: Chlamydia trachomatis and Neisseria gonorrhoea are major causes of maternal and neonatal morbidity in developing countries. 178 pregnant women attending an antenatal clinic in Nairobi, Kenya, were therefore examined in the attempt to identify characteristics predictive of cervical infection. Chlamydia trachomatis was isolated from 14 (8%) and Neisseria gonorrhoea from 17 (10%); cervical infection with either pathogen was present in 28 (16%). Logistic regression analysis found that the presence of either endocervical mucopus or induced endocervical bleeding and having more than 1 sex partner during pregnancy were independently predictive of cervical infection. A screening program for cervical infection which tested women with 1 or both risk markers wold have a sensitivity of 68% and a positive predictive value of 0.35. The authors conclude that countries with limited resources may use diagnostic algorithms and incorporate clinical signs and behavioral characteristics to help identify pregnant women at high risk of cervical infection.