Subacute sclerosing panencephalitis in papua new guinean children: the cost of continuing inadequate measles vaccine coverage

Introduction

Subacute sclerosing panencephalitis (SSPE) is a late, rare and usually fatal complication of measles infection. Although a very high incidence of SSPE in Papua New Guinea (PNG) was first recognized 20 years ago, estimated measles vaccine coverage has remained at ≤70% since and a large measles epidemic occurred in 2002. We report a series of 22 SSPE cases presenting between November 2007 and July 2009 in Madang Province, PNG, including localized clusters with the highest ever reported annual incidence.

Methodology/Principal Findings

As part of a prospective observational study of severe childhood illness at Modilon Hospital, the provincial referral center, children presenting with evidence of meningo-encephalitis were assessed in detail including lumbar puncture in most cases. A diagnosis of SSPE was based on clinical features and presence of measles-specific IgG in cerebrospinal fluid and/or plasma. The estimated annual SSPE incidence in Madang province was 54/million population aged <20 years, but four sub-districts had an incidence >100/million/year. The distribution of year of birth of the 22 children with SSPE closely matched the reported annual measles incidence in PNG, including a peak in 2002.

Conclusions/Significance

SSPE follows measles infections in very young PNG children. Because PNG children have known low seroconversion rates to the first measles vaccine given at 6 months of age, efforts such as supplementary measles immunisation programs should continue in order to reduce the pool of non-immune people surrounding the youngest and most vulnerable members of PNG communities.     

Study of children not immunised for measles.

The results of a survey of the 165 children born in 1980 in a population served by a health centre showed that 42 were not immunised against measles. The reasons for non-immunisation included 18 refusals (usually on the grounds of incorrect contraindications) and 19 defaulters (where the children were not brought for immunisation). Twenty of the children had contracted measles by March 1984. Among the 19 defaulters 12 had been registered with the health centre since age six months or under. Their average number of consultations a year was four. None of the 42 children had Department of Health and Social Security recommended contraindications to measles immunisation.     

The present prophylactic trends of rubella and measles

Starting from the epidemiological investigation on a sample of 22.560 subjects of different chronological age classes in the Latium region with the research of hemoagglutinoinhibiting antibodies of the Rubella virus, and of 9.800 subjects with the research of hemoagglutinoinhibiting antibodies of the Measles virus, the authors observe that the diffusion of the seroprotection presents on an average 82.5% for Rubella and 79.8% for Measles. On the strength of the results, referred also according to the established chronological age classes, any obligatory treatment against Rubella is excluded in prepuberal age. In order to prevent the risk of congenital malformation in cases of pregnant and not seroprotected subjects who, during the first three months of gestation might come into contact with sick affected by Rosolia or with healthy carriers, the authors suggest the vaccination three months before the conception. Evidently, this involves a screening of the adult female population before their marriage. On the contrary as concerns Measles, the vaccination within the second year of life is being hypothesized exactly on the basis of the consideration that this is a matter of a serious illness and not always free from grave complications. In these cases, after shortly referring on the results of the experiments of different authors, the mixed anti-Measles and anti-Rubella vaccination might be taken into consideration, though with all the precautions that are suggested.     

A meta-analysis of prophylactic antibiotics in head and neck surgery.

Although it is generally agreed that prophylactic antibiotics are necessary for the prevention of postoperative wound infection, the choice of antibiotic regimen is controversial. In an attempt to determine the most effective antibiotic regimen, a meta-analysis of published clinical trials of prophylactic antibiotics for head and neck surgery was undertaken. The meta-analysis revealed a relative difference in infection rates of 43.7 percent in favor of the use of antibiotics versus placebo, of 8.3 percent in favor of multiple antibiotics versus a single antibiotic, of 13.7 percent in favor of multiple antibiotics versus cefazolin, and of 4.1 percent in favor of multiple-day prophylaxis versus single-day prophylaxis. This meta-analysis suggests that a 1-day course of clindamycin may be the most effective prophylactic antibiotic regimen for head and neck surgery.     

The prophylactic use of antibiotics in cell culture

This article describes the historical development of the prophylactic use of antibiotics in cell culture as well as their effects on cells. The influence of antibiotics on cell morphology, cellular degeneration and cell death and cellular function is summarized. Cellular DNA as well as protein synthesis are affected which can lead to interference with, or even changes in, metabolic processes. Such effects must be considered in cell culture research. As antibiotics are used in multifold ways, the otherwise standardized conditions in cell culture are no longer comparable. The prophylactic use of antibiotics is rejected for scientific reasons.     

Persistent measles infection in malnourished children.

Thirty malnourished and 25 well-nourished children were studied six to 31 days after the onset of a measles rash. Evidence of the virus was found in 40% of the malnourished children but in none of the well-nourished controls. Giant cells were found in the nasal secretions of five out of 17 malnourished children and measles antigen was detected in the lymphocytes of eight out of 28. The malnourished children showed depressed cell-mediated immunity to measles and candida antigens and a low response to meningococcal vaccine. Fifteen died from intercurrent infections. Malnutrition was thought to have depressed the immune response in these children, resulting in a severe and prolonged attack of measles. This, in turn, led to further damage to the immune system and more severe malnutrition. Thus these children were made susceptible to intercurrent infection.     

Aggressive lipid management for cardiovascular prevention: evidence from clinical trials

Epidemiologic evidence shows that elevated serum cholesterol, specifically low-density lipoprotein cholesterol (LDL-C), increases the risk of coronary heart disease (CHD). Moreover, large-scale intervention trials demonstrate that treatment with HMG-CoA reductase inhibitors (statins), the most effective drug class for lowering LDL-C, significantly reduces the risk of CHD events. Unfortunately, only a moderate percentage of hypercholesterolemic patients are achieving LDL-C targets specified by the National Cholesterol Education Program (NCEP), in part because clinicians are not effectively titrating medications as needed to achieve LDL-C goals. Recent evidence suggests that more aggressive LDL-C lowering may provide greater clinical benefit, even in individuals with moderately elevated serum cholesterol levels. Furthermore, recent studies suggest that statins have cardioprotective effects in many high-risk individuals, including those with baseline LDL-C <100 mg/dl. High-density lipoprotein cholesterol (HDL-C) was recognized by the NCEP-Adult Treatment Panel II (ATP II) as a negative risk factor for CHD. The NCEP-ATP III guidelines have also reaffirmed the importance of HDL-C by increasing the low HDL-C designation from <35 to <40 mg/dl as a major risk factor for CHD. Similarly, triglyceride control will play a larger role in dyslipidemia management. As more clinicians effectively treat adverse lipid and lipoprotein cardiovascular risk factors, patients will likely benefit from reductions in cardiovascular events.     

Meta-analysis of cancer risk in folic acid supplementation trials

Several reports suggest that folate has a procarcinogenic effect. Folate has a unique role because its coenzymes are needed for de novo purine and thymine nucleotide biosynthesis. Antifolates, such as methotrexate, are used in cancer treatment. Using a meta-analysis weighted for the duration of folic acid (pteroylglutamic acid) supplementation, we analyzed the cancer incidence of six previously published large prospective folic acid-supplementation trials in men and women. These articles were carefully selected from over 1100 identified using PubMed search. Our analyses suggest that cancer incidences were higher in the folic acid-supplemented groups than the non-folic acid-supplemented groups (relative risk=1.21 [95% confidence interval: 1.05-1.39]). Folic acid-supplementation trials should be performed with careful monitoring of cancer incidence. Solid monitoring systems to detect side effects, including increase in cancer risk, should be established before the initiation of folic acid supplementation trials.     

Heavy use of prophylactic antibiotics in aquaculture: a growing problem for human and animal health and for the environment

The accelerated growth of finfish aquaculture has resulted in a series of developments detrimental to the environment and human health. The latter is illustrated by the widespread and unrestricted use of prophylactic antibiotics in this industry, especially in developing countries, to forestall bacterial infections resulting from sanitary shortcomings in fish rearing. The use of a wide variety of antibiotics in large amounts, including non-biodegradable antibiotics useful in human medicine, ensures that they remain in the aquatic environment, exerting their selective pressure for long periods of time. This process has resulted in the emergence of antibiotic-resistant bacteria in aquaculture environments, in the increase of antibiotic resistance in fish pathogens, in the transfer of these resistance determinants to bacteria of land animals and to human pathogens, and in alterations of the bacterial flora both in sediments and in the water column. The use of large amounts of antibiotics that have to be mixed with fish food also creates problems for industrial health and increases the opportunities for the presence of residual antibiotics in fish meat and fish products. Thus, it appears that global efforts are needed to promote more judicious use of prophylactic antibiotics in aquaculture as accumulating evidence indicates that unrestricted use is detrimental to fish, terrestrial animals, and human health and the environment.