Amebiasis in institutions for the mentally retarded in Kanagawa Prefecture, Japan

A parasitologic survey of 620 mentally retarded patients, institutionalized in five different facilities in Kanagawa Prefecture, revealed a high incidence (12.6%) of infection with Entamoeba histolytica. A concomitant serologic survey, by the indirect fluorescent antibody test, gave a much higher incidence (26.5%). Moreover, most zymodeme patterns of the amebae isolated from infected individuals were of a pathogenic type (Zymodeme II). Our findings demonstrate that the mentally retarded in Japan, as in the United States, still are plagued by a high rate of amebic infection.     

潍坊市坊子区2012年产前HBsAg筛检及新生儿首针乙肝疫苗接种情况分析

目的：了解住院分娩产妇乙肝病毒表面抗原（ HBsAg）检测及其所生新生儿首针乙肝疫苗及时接种情况,为进一步完善新生儿乙型肝炎的免疫预防策略提供依据。方法对2012年坊子区设有产科的医院每月上报的产妇HBsAg 检测和新生儿首针乙肝疫苗接种资料进行分析。结果坊子区2012年设有产科的医疗机构共报告住院分娩产妇2975名,产前HBsAg筛检2881名,筛检率为96．84％,各医疗机构筛检率在96．55％和97．50％之间;检出HBsAg阳性者66例,阳性率为2．29％,各医疗机构阳性率在0．00％和5．52％之间。新生儿共2975名,其中常住者所生新生儿2612名,流动者所生新生儿363名,常住和流动的新生儿乙肝疫苗接种率分别为96．13％和94．21％,及时接种率分别为93．87％和90．36％,差异均无统计学意义（χ2＝2．98、3．67,P＞0．05）。122名未及时接种首针乙肝疫苗的新生儿系患各种疾病所致。结论坊子区2012年设有产科的医院对住院的孕产妇产前HBsAg筛查率较高,其所生的新生儿24 h内乙肝疫苗及时接种率较高。     

Knowledge of genetics among residents in obstetrics and gynecology.

A supervised genetics examination was administered to 76 obstetrics and gynecology (ob/gyn) residents from 15 different institutions in the Philadelphia area. The questions were specifically designed to be applicable to obstetrical practice. Overall, the mean score was 69% (range 32%-88%). Using the nonparametric Mann-Whitney rank sum test, we found that the 25 residents from institutions with an obstetrics-gynecology-genetics (OGG) program, coordinated by an obstetrician/gynecologist board certified in clinical genetics, had statistically significant higher scores than the remaining 51 residents from institutions without an OGG program (77% vs. 65%, respectively; P < .001). This study demonstrates that knowledge of genetics among residents in ob/gyn is deficient, especially among residents at institutions without OGG programs. Special efforts should be made to provide genetics education to these individuals. We propose that more obstetricians be encouraged to pursue postgraduate training in genetics in light of the rapid development of medical genetics; its application to prenatal screening, diagnosis, and counseling; the anticipated utilization of genetics services; and the need for educational initiatives geared toward ob/gyn patients.     

Investigation of Hepatitis B Virus and Human Immunodeficiency Virus Transmission among Severely Mentally Ill Residents at a Long Term Care Facility

Background

A high prevalence of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections have been reported among persons with severe mental illness. In October, 2009, the Cook County Department of Public Health (CCDPH) initiated an investigation following notification of a cluster of HBV infections among mentally ill residents at a long term care facility (LTCF).

Methods

LTCF staff were interviewed and resident medical records were reviewed. Residents were offered testing for HBV, HCV, and HIV. Serum specimens from residents diagnosed with HBV or HIV infection were sent to the Centers for Disease Control and Prevention (CDC) for analysis.

Results

Eleven newly diagnosed HBV infections were identified among mentally ill residents at the LTCF. Of these 11 infections, 4 serum specimens were available for complete HBV genome sequencing; all 4 genomes were found to be closely related. Four newly diagnosed HIV infections were identified within this same population. Upon molecular analysis, 2 of 4 HIV sequences from these new infections were found to be nearly identical and formed a tight phylogenetic cluster.

Conclusions

HBV and HIV transmission was identified among mentally ill residents of this LTCF. Continued efforts are needed to prevent bloodborne pathogen transmission among mentally ill residents in LTCFs.     

Immunisation of adults during an outbreak of diphtheria.

In an outbreak of infection due to Corynebacterium diphtheriae in a hospital for mentally subnormal adults sera from 211 members of staff were screened for diphtheria antitoxin titres. Of these, 79 (37%) required immunisation, and a low dose preparation (1 LfU of diphtheria and 10 LfU tetanus toxoids) was offered. Of the 64 subjects who accepted a single immunisation and were subsequently retested, seroconversion to diphtheria toxoid occurred in 45 (70%), the rate being highest in younger adults. Seroconversion to tetanus toxoid occurred in 59% of subjects. Local reactions to the single dose were reported by 29 (43%) subjects, and nine (13%) experienced moderately severe local reactions and systemic symptoms. We conclude that adults should not be vaccinated without previous screening for susceptibility to diphtheria; that neither previous immunisation nor age is reliable in predicting the need for vaccination; and that though a single booster dose of diphtheria toxoid is probably effective in adults under 45, two doses should be given to those in the older age group.     

Human cases of infection with canine whipworms, Trichuris vulpis (Froelich, 1789), in Japan

The eggs of Trichuris, detected in the feces of 19 persons who had stayed in institutions for mentally retarded and/or multi-handicapped patients, were identified as those of T. vulpis (Froelich, 1789) on the basis of morphological features. This is the first record of human infection with the canine whipworm in Japan.     

应用多聚酶链式反应快速分析FMR-1基因突变

为了建立一种在先天性智力低下患儿中快速分析脆性X综合征智力低下基因1(Fragile X mental retardation gene 1.FMR-1)突变的方法,对先天性智力低下儿童进行脆性X综合征的大面积筛查和诊断,应用复式多聚酶链式反应一次性扩增FMR-1基因的(CGG)n的重复区,分析CGG重复序列的大小,判断FMR-1基因状态(正常、突变前、突变后),对脆性X综合征可疑患儿快速筛查,在113倒不明原因的先天性智力低下患儿中,分析有脆性X综合征携带者(FMR-1基因前突变者)7例(2男5女),脆性X综合征患者(FMR-1基因突变者)5例,应用多聚酶链式反应可以对脆性X综合征可疑患儿进行大面积初筛,确定携带者和患者。     

Outbreak of Hepatitis B Virus Infections Associated with Assisted Monitoring of Blood Glucose in an Assisted Living Facility–Virginia, 2010

Introduction

In January 2010, the Virginia Department of Health received reports of 2 hepatitis B virus (HBV) infections (1 acute, 1 chronic) among residents of a single assisted living facility (ALF). Both infected residents had diabetes and received assisted monitoring of blood glucose (AMBG) at the facility. An investigation was initiated in response.

Objective

To determine the extent and mechanism of HBV transmission among ALF residents.

Design

Retrospective cohort study.

Setting

An ALF that primarily housed residents with neuropsychiatric disorders in 2 adjacent buildings in Virginia.

Participants

Residents of the facility as of March 2010.

Measurements

HBV serologic testing, relevant medical history, and HBV genome sequences. Risk ratios (RR) and 95% confidence intervals (CIs) were used to identify risk factors for HBV infection.

Results

HBV serologic status was determined for 126 (91%) of 139 residents. Among 88 susceptible residents, 14 became acutely infected (attack rate, 16%), and 74 remained uninfected. Acute HBV infection developed among 12 (92%) of 13 residents who received AMBG, compared with 2 (3%) of 75 residents who did not (RR  = 35; 95% CI, 8.7, 137). Identified infection control breaches during AMBG included shared use of fingerstick devices for multiple residents. HBV genome sequencing demonstrated 2 building-specific phylogenetic infection clusters, each having 99.8–100% sequence identity.

Limitations

Transfer of residents out of the facility prior to our investigation might have contributed to an underestimate of cases. Resident interviews provided insufficient information to fully assess behavioral risk factors for HBV infection.

Conclusions

Failure to adhere to safe practices during AMBG resulted in a large HBV outbreak. Protection of a growing and vulnerable ALF population requires improved training of staff and routine facility licensing inspections that scrutinize infection control practices.     

An analog of MSH/ACTH 4–9 enhances interpersonal and environmental awareness in mentally retarded adults

In a double blind procedure, four doses (0, 5, 10 and 20 mg) of an orally active analog of ACTH/MSH 4–9 was administered to mentally retarded adults. Changes in behavior and in productivity were evaluated as subjects performed their job in a sheltered workshop. During the first week productivity suffered while behavior related to communication and sociability increased in clients receiving the peptide analog. During the second week, clients given the peptide were more productive and attentive to environmental events while differences in sociability stabilized. Five and 10 mg enhanced productivity of tasks requiring precision and concentration whereas 20 mg depressed performance of all tasks. Regression equations indicated that different doses of the peptide generated unique relationships between behavior and productivity with self-stimulation characterizing the clients given the peptide. The use of the peptide analog of ACTH/MSH as a potential treatment with the mentally retarded is encouraged by these findings.     

Epidemiology of human toxocariasis in northern Italy

Sera from both clinically healthy adults (2112) and adult patients (471) were tested to assess the main risk factors for Toxocara infection in humans in Northern Italy. The patient group included 257 adult epileptics, 76 Strongyloides stercoralis-infected adult patients and 142 institutionalized mentally retarded adult patients. The overall seroprevalence in healthy population was 3.98%. No significant differences in seroprevalence were observed for sex, residence (urban or rural) or dog ownership, while seroprevalence significantly increased with age (18- greater than 51 years). Highest seroprevalence values were found in outdoor or soil-related workers. The seroprevalence was 4.35% in adult epileptics, 9.21% in Strongyloides stercoralis-infected patients and 14.47%-10.61% among institutionalized mentally retarded patients. These findings suggest that the prevalent source of human toxocariasis is the environmental contamination by infectious eggs of the parasite.     

Investigation of outbreaks of salmonella in hospitals.

In a two year prospective survey of outbreaks of salmonella infection in hospitals in England and Wales 55 outbreaks were identified. Reports of investigation of these outbreaks were reviewed for evidence of food borne infection and cross infection. Food borne infection probably accounted for only six outbreaks, but these made up 40% of the 15 outbreaks in which there were more than five patients and staff with symptoms. Person to person transmission was the probable mode of spread in most outbreaks. It is recommended that in addition to bacteriological investigations clinical and epidemiological data should be collected to implicate food or other possible common vehicles of infection. Bacteriological screening of patients and staff who do not have symptoms may be unrewarding in the absence of epidemiological data to define groups at risk of infection.     

Is Universal HBV Vaccination of Healthcare Workers a Relevant Strategy in Developing Endemic Countries? The Case of a University Hospital in Niger

Background

Exposure to hepatitis B virus (HBV) remains a serious risk to healthcare workers (HCWs) in endemic developing countries owing to the strong prevalence of HBV in the general and hospital populations, and to the high rate of occupational blood exposure. Routine HBV vaccination programs targeted to high-risk groups and especially to HCWs are generally considered as a key element of prevention strategies. However, the high rate of natural immunization among adults in such countries where most infections occur perinatally or during early childhood must be taken into account.

Methodology/Principal Findings

We conducted a cross sectional study in 207 personnel of 4 occupational groups (medical, paramedical, cleaning staff, and administrative) in Niamey’s National Hospital, Niger, in order to assess the prevalence of HBV markers, to evaluate susceptibility to HBV infection, and to identify personnel who might benefit from vaccination. The proportion of those who declared a history of occupational blood exposure ranged from 18.9% in the administrative staff to 46.9% in paramedical staff. Only 7.2% had a history of vaccination against HBV with at least 3 injections. Ninety two percent were anti-HBc positive. When we focused on170 HCWs, only 12 (7.1%) showed no biological HBV contact. Twenty six were HBsAg positive (15,3%; 95% confidence interval: 9.9%–20.7%) of whom 8 (32%) had a viral load >2000 IU/ml.

Conclusions/Significance

The very small proportion of HCWs susceptible to HBV infection in our study and other studies suggests that in a global approach to prevent occupational infection by bloodborne pathogens, a universal hepatitis B vaccination of HCWs is not priority in these settings. The greatest impact on the risk will most likely be achieved by focusing efforts on primary prevention strategies to reduce occupational blood exposure. HBV screening in HCWs and treatment of those with chronic HBV infection should be however considered.     

Obituaries

Although tetanus is now rare, vaccination is currently recommended for the entire population. Most elderly North Americans have never received tetanus vaccination. We evaluated the expected cost-effectiveness of using mailed reminders from family physicians to increase primary tetanus vaccination coverage among elderly Canadians. We estimated that over 10 years the program would prevent five cases of tetanus and one death from tetanus, resulting in a gain of 13 life-years. There would be 16,700 adverse reactions to tetanus toxoid, 17% in people already immune to tetanus. The net cost of the program (in 1984 Canadian dollars) would be $1.9 million per case of tetanus prevented, $7.1 million per death prevented and $810,000 per life-year gained. These high cost-effectiveness ratios are largely attributable to the very low risk of tetanus, even among nonimmune elderly people. Tetanus toxoid and physicians'' services for vaccination would account for 86% of the program costs. Because the mailed reminders would be responsible for only 13% of the program costs, other possible programs to increase primary tetanus vaccination coverage could not be expected to have substantially lower cost-effectiveness ratios. We conclude that efforts to increase primary tetanus vaccination coverage among elderly Canadians would be a questionable use of health care resources.     

Risk of hepatitis B infection among young injection drug users in San Francisco: opportunities for intervention

Objective To compare the demographic characteristics and risk behaviors for hepatitis B infection among injection drug users younger than 30 years with those aged 30 or older and to evaluate participants'' knowledge, attitudes, and experiences of infection, screening, and vaccination against hepatitis B virus. Design A systematic sample of injection drug users not currently in a treatment program were recruited and interviewed at needle exchange programs and community sites. Participants 135 injection drug users younger than 30 years and 96 injection drug users aged 30 or older. Results Injection drug users younger than 30 were twice as likely as drug users aged 30 or older to report having shared needles in the past 30 days (36/135 [27%] vs 12/96 [13%]). Injection drug users younger than 30 were also twice as likely to report having had more than two sexual partners in the past 6 months (80/135 [59%] vs 29/96 [30%]). Although 88 of 135 (68%) young injection drug users reported having had contact with medical providers within the past 6 months only 13 of 135 (10%) had completed the hepatitis B vaccine series and only 16 of (13%) perceived themselves as being at high risk of becoming infected with the virus. Conclusion Few young injection drug users have been immunized even though they have more frequent contact with medical providers and are at a higher risk for new hepatitis B infection than older drug users. Clinicians caring for young injection drug users and others at high risk of infection should provide education, screening, and vaccination to reduce an important source of hepatitis B infection.     

Determinants of Acceptance and Subsequent Uptake of the HPV Vaccine in a Cohort in Eldoret,Kenya

The development of Human Papillomavirus (HPV) vaccines provides new opportunities in the fight against cervical cancer. Many acceptability studies have revealed high interest in these vaccines, but acceptance is only a precursor of behavior, and many factors, at personal, community and provider level, may inhibit the translation of willingness to vaccinate into actual uptake. Through a longitudinal study in Eldoret, Kenya, HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256). In between baseline and follow-up, a pilot HPV vaccination program was implemented via the GARDASIL Access Program, in which parents could have their daughter vaccinated for free at the referral hospital. The program was promoted at schools: Health staff informed teachers who were then asked to inform students and parents. Even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughter had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers. Being well-informed about the program and baseline awareness of cervical cancer were independently associated with vaccine uptake, while baseline acceptance was correlated in bivariate analysis. Side effects were of great concern, even among those whose daughter was vaccinated. Possible partner disapproval lowered acceptance at baseline, and women indeed reported at follow-up that they had encountered his opposition. In Kenya, women prove to be very willing to have their daughter vaccinated against cervical cancer. However, in this study, uptake was more determined by program awareness than by HPV vaccine acceptance. School-based vaccination might improve coverage since it reduces operational problems for parents. In addition, future HPV vaccination campaigns should address concerns about side effects, targeting men and women, given both their involvement in HPV vaccination decision-making.     

Hepatocellular Carcinoma in Hepatitis B Surface Antigen Carriers in Eight Institutions

We reviewed records of all persons dying between 1979 and 1986 in eight California institutions for the mentally retarded. Autopsies had been done in 71% of the 1,181 deaths. Nine deaths were due to hepatocellular carcinoma, which invariably developed in carriers of hepatitis B surface antigen (HBsAg) and was fatal within four months of diagnosis. The mean age at death was 32.7 years. The incidence of hepatocellular carcinoma in HBsAg carriers was 140 times greater than in the US population. Persistent hepatitis B infection was probably etiologically related to hepatocellular carcinoma in this population, which is relatively free of exposure to other hepatocarcinogens.     

Screening for fragile X syndrome among Brazilian mentally retarded male patients using PCR from buccal cell DNA

Fragile X syndrome is one of the most frequent causes of mental retardation. Since the phenotype in this syndrome is quite variable, clinical diagnosis is not easy and molecular laboratory diagnosis is necessary. Usually DNA from blood cells is used in molecular tests to detect the fragile X mutation which is characterized by an unstable expansion of a CGG repeat in the fragile X mental retardation gene (FMR1). In the present study, blood and buccal cells of 53 mentally retarded patients were molecularly analyzed for FMR1 mutation by PCR. Our data revealed that DNA extraction from buccal cells is a useful noninvasive alternative in the screening of the FMR1 mutation among mentally retarded males.     

The vaccinal prophylaxis of hepatitis B in Russia--the achievements, problems and outlook

Certain specific features of the present epidemic situation with hepatitis B (HB) in Russia were established: significant growth of HB morbidity, starting from 1995; the prevalence of persons aged 15-29 years among HB patients, which was linked with the sharp activation of the sexual route of the transmission of HB virus in recent years; an essential increase in the number of patients having contacted this virus in the process of the intravenous use of drugs. The results of the use of vaccine "Engerix B" among persons belonging to different risk groups were considered (a decrease in HB morbidity among them by 8-19 times was noted), the study demonstrated high immunogenicity anti-HBs antibodies on protective titers were determined in 92.3-95.7% of the vaccinees) and low reactogenicity of the vaccine, as well as stable postvaccinal immunity (5 years after the course of vaccination was completed anti-HBs antibodies were retained in 70.6-74% of the vaccinees). The study showed that only the vaccination of adolescents in combination, in the presence of opportunity, with the immunization of newborn infants and young children in the first year of their life made it possible to produce an essential effect on the activity of the epidemic process. Already in 2 years such organization of work on the prophylaxis of HB in one of the cities of the Sverdlovsk region led to a decrease in HB morbidity by 2.9 times, and among adolescents 9 times.     

High Uptake of Systematic HIV Counseling and Testing and TB Symptom Screening at a Primary Care Clinic in South Africa

Background

Timely diagnosis and treatment of tuberculosis (TB) and HIV is important to reduce morbidity and mortality, and break the cycle of ongoing transmission.

Methods

We performed an implementation research study to develop a model for systematic TB symptom screening and HIV counseling and testing (HCT) for all adult clients at a primary care clinic and prospectively evaluate the 6-month coverage and yield, and 18-month sustainability at a primary care clinic in Johannesburg, South Africa.

Results

During the first 6 months, 26,515 visits occurred among 12,078 adults. The proportion of adults aware of their HIV status was 43.7% at the start of the first visit, increased to 84.6% at the end of the first visit, and to 90% at end of any visit during the first 6 months. During these 6 months, 1042 clients were newly diagnosed with HIV. HIV prevalence was 22.9% among those newly tested, and 58.9% among all adult clinic clients. High coverage of systematic HCT was sustained across all 18 months. Coverage of systematic HIV-stratified TB symptom screening during first 6-months was also high (89.6%) but only 35.0% of those symptomatic were screened by sputum. During these 6-months, 90 clients had a positive Xpert MTB/RIF assay, corresponding to a TB prevalence of 0.4% among all 23,534 clients TB symptom-screened and 2.8% among the 3,284 clients with a positive TB symptom screen. The initial high coverage of TB symptom screening was not sustained, with coverage of TB symptom screening dropping after the first six months to 70% and assessment by sputum dropping to 15%.

Conclusion

Routine, systematic HCT and HIV-stratified TB symptom screening is feasible at primary care level. Systematic HCT doubled the proportion of clients with known HIV status. While HCT was sustainable, coverage of systematic TB screening dropped significantly after the first 6 months of implementation.