Paolo Guglielmetti (MD, PhD, DTM) works as Administrator in the "Health Threats Unit" of the "Health and Consumer (SANCO)" Directorate General of the European Commission. He arrived in the European Commission in 2002 after a career spent in the field of communicable diseases, tropical medicine and management of public health emergencies during natural disasters and conflict situations. In the "Health Threats Unit" Mr Guglielmetti is currently Head of the Team leading for prevention, early warning and co-ordination of the public health response to health threats caused by biological, chemical, and radio-nuclear events.
Abstract:
Since the start of 2009 H1N1 influenza pandemic, a notablesurge in messages communicated through the Early Warning and Response System (EWRS) for the prevention and control of communicable diseases in the European Union has been recorded. In order to measure the impact of this increase on the reporting of other events, we compared the messages posted in the EWRS since April 2009 with those posted in the previous years (2004-2008). The analysis revealed that a ten-fold increase in messages was recorded during the pandemic period, from April to September 2009, and that the reporting of other threats dropped to a significantly low rate. These results suggest an important impact on the notification process of events in case of a situation requiring extensive mobilisation of public health resources. It emphasises the importance keeping an appropriate balancing of resources during sustained emergencies, in particular in view of a possible second wave of pandemic influenza cases, to ensure prompt detection and reporting of potential concomitant emerging threats.
Abstract: G Rezza and colleagues (Dec 1, p 1840)(1) report the first documented autochthonous vector-borne transmission of Chikungunya virus on the European continent. This Italian outbreak occurred 3 years after Chikungunya virus caused a series of outbreaks, starting in Kenya and reaching the Indian Ocean islands, including La Reunion (EU French territory), and subsequently India. Considering the frequency of travel between these areas and the European mainland, the European Centre for Disease Prevention and Control (ECDC) consulted experts to assess the risk for the EU in March, 2006 (2). We concluded that the risk of Chikungunya virus transmission in Europe was real, although not quantifiable. Consequently, the ECDC and the European Commission assisted member states to share information, strengthen preparedness, enhance early warning and surveillance, extend Chikungunya diagnostic capacity, implement targeted blood-safety measures, and intensify control of imported goods such as lucky bamboos and used tyres (likely vehicles for vector importation). Therefore, the possibility of Chikungunya virus transmission on the European continent was not unexpected, since it had been recognised 16 months before the occurrence of the Italian outbreak. EU member states implemented appropriate measures to detect and control the event, but we agree with Rezza and colleagues that further strengthening of preparedness for reoccurrences is needed. ECDC updated the risk assessment for the EU in September, 2007, (3) and further preparedness activities have taken place since, including risk mapping for vector establishment in the EU, developing health communication material, and interacting with experts to ensure the rapid mobilisation of expertise when needed.
Bibliography
(1) Rezza G, Nicoletti L, Angelini R, et al. Infection with Chikungunya virus in Italy: an outbreak in a temperate region. Lancet 2007; 370: 1840â46.
(2) European Centre for Disease Prevention and Control. Meeting report: consultation on Chikungunya risk assessment for Europe. Stockholm: ECDC, 2006. http://ecdc.europa.eu/documents/pdf/Final_chik_meeting_report.pdf 1(accessed Jan 30, 2008).
(3) European Centre for Disease Prevention and Control. Mission report: Chikungunya in Italy. Stockholm: ECDC, 2007.
http://ecdc.europa.eu/pdf/071030CHK_mission_ITA.pdf (accessed Jan 30, 2008).
Abstract: Under Decision 2119/98/EC of the European Parliament and of the Council, a network for epidemiological surveillance and control of communicable diseases in the Community was set up in 1998. One pillar of Decision 2119/98/EC is the early warning and response system (EWRS). The main objective of the network is to establish permanent communication between European Union (EU) Member States' public health authorities, which are responsible for determining the measures required to control communicable disease-related events. Since 1998, a web based informatics tool has been developed in order to allow information to be shared between the relevant public health authorities. Between 1998 and December 2005, a total of 583 messages were circulated through the EWRS, notifying 396 events. The information shared through the system helped to coordinate public health measures in the EU. However, only few events prompted specific measures at Community level and most of them were controlled with public health measures applied at national level. Major events (such as the Severe Acute Respiratory Syndrome) and the results of simulation exercises prompted the Commission to upgrade the informatics system on the basis of user needs. Since 1 May 2004 the 10 newest Member States have provided information under the current legislation and since April 2005 the European Centre for Disease Prevention and Control (ECDC) is part of the system. Future developments will include a link between the existing EWRS and the communication platform currently developed by the ECDC.
Abstract: Risk factors for acquiring Helicobacter pylori infection include hygienic, social, and environmental conditions. Some of these conditions usually change over time. We therefore investigated the existence of risk factors in a group of teenagers living in a place with the same environmental characteristics, in which hygienic and crowding conditions have not changed significantly in the last 20 years. A group of 164 students, mostly borne in 1977, attending four different schools, were examined serologically for H. pylori infection and CagA status. The importance of the risk factors for the transmission of the infection were evaluated by the chi2 test. P values <0.05 were considered significant. Twenty-two students (13.4%) were H. pylori seropositive. Students attending teachers' college and high school of arts were infected significantly more often than those attending high school (P = 0.011 and P = 0.012, respectively). Students who smoked and students whose parents had a manual job had an increased risk of acquiring the infection (P = 0.002, and P = 0.036, respectively). Crowding conditions and the presence of domestic animals were close to being statistically significant. Other factors, such as gender, number of bathrooms and bedrooms, sharing the bed with adults as a child, presence of a sexual partner, and a family history of peptic ulcer and gastric cancer, did not increase the risk of infection. The prevalence of seropositivity for CagA was similar in the various risk groups. Manual job of parents and smoking were the most important factors for acquiring H. pylori infection.
Abstract: The end of the conflict in the Federal Republic of Yugoslavia (FRY) and Kosovo in June 1999, brought with it a number of major health and health system challenges. The effects of the war in FRY added to more than a decade of violent political conflict in Kosovo, during which the Albanian community devised and implemented an alternative structure - which was not formally recognised - in the civil society. This included a health system with a network of >90 primary health-care centres, as well as a university course in medicine and surgery. In the context of such a setting, the special administration of the United Nations Mission in Kosovo (UNMIK) and the International Community were faced with the major challenge of addressing the effects of the conflict on people's health and the rehabilitation of the health system itself.
The Italian Co-operation (IC) was present in Kosovo from mid-1998, and was in the municipality of Pec/Peja from the end of June 1999. The UNMIK, together with the World Health Organization, requested the Italian Government to manage the General Hospital in the municipality of Pec/Peja (a referral hospital with more than 500 beds). This paper examines the context and process of the approach of the IC during the first nine months of work, managing and supervising the related activities and initiatives. The presentation focuses on the following key points:
1) Pre- and post-conflict setting;
2) Terms of reference for the new hospital Director;
3) The IC approach to negotiations with UNMIK and its Albanian counterpart;
4) Logistical and practical issues in the context of both the structural aspects and the clinical routine activities related to in- and out-patients services;
5) Co-ordination of the aid for the hospital;
6) Evaluation indicators; and
7) Short- and mid-term future perspectives.
The main points highlight the following results:
1) After June 1999, the hospital did not interrupt its activities, despite the serious situation that had arisen;
2) Top priority was given to the re-integration process of the Albanian medical and paramedical personnel following the departure of the Serbian medical personnel. Clinical activities were guaranteed to the highest levels possible in the given situation, with positive indicators for efficacy and a very good impact on the perception by the local and international community. Although the lack of an official staff training/retraining programme restricted the impact of interventions on the most urgent needs, it stimulated discussions to devise a clear and common strategy to achieve the objectives of an appropriate education programme for health personnel;
3) The difficulties encountered in allocating resources and the number of international agencies involved in the rehabilitation plan contributed to the emergence of a pattern of investment, which on the one hand, was highly fragmented, but on the other, when properly oriented, was highly flexible and adapted to a situation of rapid change; and
4) A rehabilitation plan for the next two years is proposed, which also addresses educational issues and takes into account the lessons learned during the first nine months of activities.
Abstract: On 29 October 1998, Hurricane Mitch first struck Central America and devastated Honduras and Nicaragua. It also hit Guatemala, El Salvador, Belize, and to a lesser extent, Costa Rica. At its peak, Mitch was the fourth-strongest hurricane recorded in the Atlantic. It affected an estimated 6.5 million people region-wide, of whom at least 2.5 million were left homeless. Estimates indicate that at least 11,000 people died and 10,000 still are missing. As an immediate response to this emergency situation, the Emergency Office of the Italian Co-operation provided a first-aid "package" consisting of food parcels, emergency relief items, and medical support, followed up by a second intervention that provided support to the victims in the following areas:
1) Health;
2) Water and sanitation;
3) Rehabilitation; and
4) Prevention of natural disasters.
The second aid package amounted to a total of US$6.4 million (approximately 12 billion Italian lire) for the entire region.
The interventions were driven by the principal strategic and methodological approach of the Emergency Office of the Italian Co-operation during natural disasters. Considering the limited amount of the contribution, one of the major challenges was to ensure a balanced sheet of budgeted priorities, taking into consideration the emergency requirements of all of the countries affected. Under such a methodological approach, interventions were implemented in Honduras and Nicaragua (31% and 27% of the total budget, respectively), followed by Guatemala (24%), El Salvador (15%), and Belize (3%). Both the magnitude of the event's impact on the population and the main needs of each country affected were the criteria used when allocating the available resources. The evaluation of the strategy to balance the contribution and the projects implemented through the emergency programme, demonstrated that simple criteria are useful to select the appropriate allocation strategy. Considering that in situations in which several countries are involved in the same disaster, economic realities make some emergencies more deserving than others. This suggests that some countries automatically will be favoured as being a recipient for humanitarian assistance and disaster relief.
Abstract: Orthopaedic and reconstructive surgery for war wounds is different from the type of surgery performed for civilian injuries. Furthermore, in developing countries, additional problems often arise from the lack of an integrated approach (which includes pre- and post-operative treatment and pre- and post-operative rehabilitation) to the war wounds and related complications.
From the outbreak of the Ethiopian-Eritrean conflict, the Italian Co-operation supported this complex emergency situation by sending to the site, a surgical team consisting of an orthopaedic surgeon, a maxillo-facial and plastic surgeon, an anaesthesist specialist, a ward nurse, a scrub nurse, and a physiotherapist. The emergency surgical team, in collaboration with the local Eritrean staff, was based at the Asmara Halibet Hospital (Eritrea) from April to December 1999.
The presentation reports the results obtained during this period, and focuses on the methodological approach selected to improve the quality of the treatment of patients, and to best manage the situation in an emergency setting. 650 patients were treated according to the ICRC guidelines. The safest and cheapest peripheral anaesthesia procedures were performed in 60% of cases. On-the-job training on the integrated treatment of persons with war injuries with the resident staff was carried out daily. The integrated approach towards war wounds and the prevention of complications using the existing resources were the main objectives of the rapid response, and confirmed the efficacy of the intervention.
Abstract: During the last three years, major epidemics as well as a cluster of cases of dengue virus infections and leptospirosis have been recorded by the Cuban Ministry of Public Health. The most serious episode was the 1997 epidemic of dengue in Santiago de Cuba, where there were over 3,000 clinical cases in addition to 205 cases of haemorrhagic diseases (5.6% mortality rate). Leptospirosis also has been identified as having an increasing incidence during the last four years (25.6 cases per 100,000 inhabitants in 1994) throughout the island.
The Italian Co-operation (IC) has been present in Cuba since 1998. One of the first initiatives was focused on supporting the Cuban Ministry of Health in its attempts to control the spread of dengue and leptospirosis. The approach of the IC was based on a multi-disciplinary approach that focused on the following key points:
1) Education and training of populations at greater risk of exposure to the principal domestic vector, Aedes aegypti, as well as to rodents;
2) Support to the surveillance system for dengue and leptospirosis;
3) Strengthen the capacity of early clinical recognition (suspected cases) and laboratory confirmation of new cases of leptospirosis;
4) Support to the Aedes aegypti and rodent control programmes;
5) Structural/infrastructural interventions with impact on urban and rural environments, in order to limit the risk of an increase in vectors and the rodent population; and
6) Select a strict system of evaluation indicators to monitor the efficacy of the intervention.
One year following the implementation of the programme in selected areas of the island (Pinar del Rio, Ciudad Habana, Cienfuegos, and Granma), the main results are:
1) Decrease in the larval breeding index of Aedes aegypti (p <0.01, 1999 vs. 1998);
2) Decrease in the incidence of dengue cases, with no recordings of epidemics or clusters of cases;
3) Decrease in the incidence of leptospirosis (p <0.0l, 1999 vs. 1998);
4) Reduction in rodent population, with a special impact on the urban area; and
5) Increase in chemoprophylaxis and early treatment of new cases of leptospirosis.
Conclusions: The results obtained highlight the short-term efficacy of the IC approach in controlling the spread of dengue and leptospirosis in this setting. The discussion will focus on the advantages and drawbacks of this integrated strategy in order to control two diseases that traditionally have been controlled by vertical programmes. The impact of the support to the entomological, epidemiological, clinical, environmental, and educational sectors will be compared to each other and then discussed. This should allow the strong points of each component to be identified, considering that such an approach is not only a method for preventing and treating infectious diseases, but also is a path towards the creation of healthy communities.
Abstract: Random amplification of polymorphic DNA (RAPD) using an arbitrary oligonucleotide primer (5'-CGGTGCGACG) and analysis of restriction fragment length polymorphism of ribosomal DNA (rDNA-RFLP) after digestion of genomic DNA with restriction endonuclease EcoRI were investigated as tools for genotypic delineation beyond the species level of 91 Candida clinical isolates and four reference strains including 33 Candida albicans, 19 Candida tropicalis, 22 Candida krusei and 21 Candida (Torulopsis) glabrata. Results indicated that both techniques can be useful for typing isolates of the above species, although showing a variable discriminative potential with different species. As compared to RAPD fingerprinting, the discriminative potential of rDNA-RFLP appeared to be highest for C. albicans and lowest for C. glabrata, being overall similar for C. krusei and identical for C. tropicalis. A comparative analysis of the results obtained with the two typing techniques showed that, except for C. tropicalis, they were able to provide non-redundant information, and that their use in combination could enhance the discriminative potential for delineation among C. glabrata and C. krusei isolates.
Abstract: A survey on toxocara canis-IgG seroprevalence was carried out in two Bolivian communities (Mora and Zanja Honda) living in the Cordillera Province, Department of Santa Cruz. Two hundred and sixteen people, both males and females, 2 to 85 years old were sampled. Altogether, 73 people were positive (34%). The seroprevalence was 27% in Mora and 42% in Zanja Honda (p = 0.022). No statistical correlations were found with sex and age. High prevalences were also found for intestinal helminths (hookworms, Trichuris trichiura, Ascaris lumbricoides, Hymenolepis nana and Strongyloides stercoralis). Positive association between T. canis seropositivity and presence of T. trichiura and between T. trichiura and hookworms were found. T. canis egg prevalence in dog population was found consistently higher in Zanja Honda than in Mora (40% vs 27%).
Abstract: A five month old male infant was referred with watery diarrhea, vomiting and fever, to the paediatric ward of the provincial Pediatric Hospital of Las Tunas, Cuba. Abdominal examination revealed tenderness; liver and spleen were normal.
Chest, cardiovascular and other systems were normal. The patient was rehydratated with oral rehydratation with solution according to the World Health Organization formula and breast-feeding was continued. The clinical picture improved gradually and the patient was discharged after six days without diarrhea and in good condition. On admission stool sample was taken and cultured on Salmonella-Shigella and MacConkey agar for isolation of Salmonella, Shigella spp., enterotoxigenic and enteropathogenic Escherichia coli, Vibrio spp., Aeromonas spp., and Plesiomonas shigelloides (JF McFaddin 1980, p. 19-34. Biochemical Test for Identification of Medical Bacteria, 2nd ed., The Williams and Wilkins Co, Baltimore).
Blood agar suplemented with Butzler's antimicrobials was employed for the isolation of Campylobacter spp. The presence of Rotavirus was ruled out by latex agglutination assay. Three different samples of feaces were analyzed by conventional microscopic examination for the presence of ova, cyst or vegetative forms of parasites (Organizacion Mundial de la Salud 1992, p. 10-20, Metodos Basicos de Laboratorio en Parasitologia Medica, OMS, Geneva).
The stool specimen plated on MacConkey agar yielded a pure culture of lactose non-fermenting Gram-negative rods, moved by polar flagella, identified at genus level as Vibrio. The national strategy for cholera control in Cuba shows that the country is still free from cholera. A slide agglutination with polyvalent O1 group antiserum for presumptive identification of V. cholerae O1 strain was performed; the test was negative.
The coproparasitological examination was negative and no Rotavirus or other bacterial enterophatogen were found or isolated from stool samples. The Vibrio strain isolated was sent to the National Reference Laboratory for Diarrhoeal Diseases and Cholera Control at the "Pedro Kouri" Institute of Tropical Medicine, Havana City, and confirmed to be a non-O1 and non-O139 V. cholerae by standard methods (JJ Farmer & FW Hickman Brenner 1992, p. 2552-3011. Innbsp;A Ballows, HG Truper, M Dworkin, W Harder, KH Schleifer (eds), The Prokaryotes: a Handbook on the Biology of Bacteria, Vol. 3, Springer, Verlag, New York). The strain was susceptible to 10- and 150 ug disks of the vibriostatic agent O/129; the antimicrobial susceptibility test, performed with the Kirby-Bauer method, showed that the strain was susceptible to tetracycline, ampicillin, cloram-phenicol, trimethoprim, sulphametoxazol, nalidixic acid, ciprofloxacin, streptomycin, erytromycin, gentamicin, cefuroxime and furazolidone (CW Stratton & RC Cooksey 1991, p. 1153-1165. In A Balows, WJ Hausler Jr, KL Herrmann, HD Isenberg, HJ Shadomy (eds), Manual of Clinical Microbiology, 5th ed., ASM, Washington, DC). The strain was analyzed for the presence of genomic sequences related to the V. cholerae O1 ctx genetic element, that includes the cep, orFU, ace, zot, and ctxAB genes, by using a colony-blot hybridization procedure (T Karasawa et al. 1993 FEMS Microbiol Letters 106: 143-146). The hybridization probe used was a 4.4 kbp cloned DNA fragment containing the entire ctx element of V. cholerae, and was labeled with (a 32P) dCTP by the random priming technique.The presence of a heat-stable enterotoxin gene was investigated by PCR amplification as previously described (P Guglielmetti et al. 1994 Mol Cell Probes 8: 39-44). The biological activity of the strain was tested by the conventional suckling mouse assay (Y Takeda et al. 1979 Infec Immun 25: 978-985). The results of the molecular characterization of the strain demonstrated the absence of any ctx genetic element related-sequences (data not shown) and the presence of the stn gene (Fig.): the suckling mouse assay confirmed the production and the activity of the heat-stable enterotoxin (ST).
The role of non-O1 V. cholerae strain as intestinal pathogens is well established (JG Morris 1994 p. 103-115. In IK Wachsmuth, PA Blake, O Olsvik (eds), Vibrio cholerae and Cholerae: Molecular to Global Perspectives, ASM, Washington DC); some strains isolated from patients with diarrhea may produce toxins related to those encoded by the V. cholerae ctx genetic or an ST, similar to those expressed by E. coli (S Amito et al. 1992 Eur J Biochem 129: 257-263), Yersinia enterocolitica (JG Morris 1990 J Clin Invest 85: 697-705) and V. mimicus (M Arita 1991 FEMS Microbiol Letters 79: 105-110). The role for ST as virulence factor has been demonstrated in experimental assays and some studies have established the importance of non-O1 V. cholerae strain which produce only the ST in acute gastroenteritis (K Bagchi et al. 1993 J Clin Microbiol 31: 1315-1317). The strain isolated in this patient was positive for the stn gene by PCR assay and the ST production was confirmed by the conventional suckling mouse test; the same strain was negative for all elements of the V. cholerae O1 ctx genetic element. The absence of other viral, bacterial and protozoal pathogens indicates the likelihood that the strain isolated in the diarrhea of this child, the ST, is an important virulence determinant. This case is the first reported in Cuba and, to the best of our knowledge, in the Caribbean and Central America. From an epidemiological point of view the case is also interesting due to the age of the infant, the absence of sea food comsumption from his dietary history and the geographical origin of the patient, coming from an area of the island, far away from the sea coast.
Other studies have already been planned to better understand the epidemiology and clinical relevance of V. cholerae non-O1 strains in this still cholera-free geographical location.
Copyright 1998 Fundacao Oswaldo Cruz - Fiocruz
Abstract: From January 1989 to December 1990, stool samples from 288 children with enteritis were examined for the presence of unusual campylobacters which represented about 20% of all campylobacteria isolated when the filtration technique was used. The isolation percentage was the following: C. jejuni ss. jejuni 6.9%; C. coli 2%; C. jejuni ss. doylei, C. upsaliensis and C. concisus each 0.7%. The atypical Campylobacter isolates were examined for their virulence characteristics. Toxin profiles based on cytotonic, cytotoxic and cytolethal distending factors were determined after analysis responses in Vero, CHO and HeLa cells. Adhesivity and invasivity tests were performed on Intestine 407 cells. No strain was cytotoxic. C. jejuni ss. doylei and C. concisus induced an elongation of CHO cells (a cytotonic-like effect). C. upsaliensis strains provoked a cytolethal distending effect. No strain adhered to cells in vitro. Our results suggest that the filtration technique is excellent for the isolation of atypical campylobacters and indicate that the unusual Campylobacter isolates could be potentially virulent.
Abstract: OBJECTIVE: To determine the incidence of antimicrobial-resistant, nonpathogenic Escherichia coli among healthy children aged 6-72 months in Camiri town and a rural village, Javillo, in south-eastern Bolivia. METHOD: A community-based survey: stool samples were obtained from 296 healthy children selected by modified cluster sampling in Camiri and all 25 eligible children in Javillo. E. coli isolates were tested for antimicrobial susceptibility according to the standard disc diffusion method. By a questionnaire survey of 12 pharmacies and by using simulated patients, we investigated the antimicrobial availability and the usage patterns in Camiri town. RESULTS: In Camiri, over 90%, and in Javillo over 70% of children carried E. coli resistant to ampicillin, trimethoprim-sulphamethoxazole (TMP/SMX) or tetracycline. Overall, 63% of children carried E. coli with multiple resistance to ampicillin, TMP/SMX, tetracycline and chloramphenicol. In the simulated patients study, antimicrobials were dispensed inappropriately for 92% of adults and 40% of children with watery diarrhoea, and were under-prescribed for males with urethral discharge (67%) or females with fever and dysuria (58%). The dose and/or duration of antimicrobials dispensed was almost always too low. CONCLUSION: Our study showed a disturbingly high prevalence of carriage of nonpathogenic E. coli resistant to antimicrobials. The prevalence of resistance to ampicillin and TMP/SMX was higher than that previously reported in developing countries. The existence of a large reservoir of resistance genes in healthy individuals in developing countries represents a threat to the success of antimicrobial therapy throughout the world. Programmes to improve rational and effective drug use in developing countries are urgently needed.
Abstract: A serosurvey for antibodies to Borrelia burgdorferi using an enzyme-linked immunosorbent assay (ELISA) was conducted on sheep, goat and dog serum samples collected in Cordillera Province, Bolivia, in 1992 Sera from 98 sheep, 218 goats and 43 dogs were tested. The observed seroprevalence in sheep and dogs was 0.0%, whereas the seropositivity rate for goat serum samples was 5.0%. Upon analysing 10 positive sera by Western immunoblotting, five reacted against the specific protein antigens and all of them met the criteria for positivity on the basis of immunoglobulin G (IgG) bands, indicating that goats in Cordillera Province were exposed to B. burgdorferi. These findings, which are further proof of the existence of B. burgdorferi infection in Bolivia, indicate the serologic analysis of goats as a suitable tool for Lyme borreliosis surveillance.
Abstract: The response to measles revaccination was evaluated in 1994 among 202 Bolivian school-aged children whose antibody levels were below 200 miu (milli-international units) by haemagglutination inhibition (HI) in a large-scale serosurvey conducted in Santa Cruz one year earlier. Of the 202 revaccinated children, 164 (82%) had seroconverted between the 1993 serosurvey and the pre-revaccination blood sample. A measles outbreak occurred in Santa Cruz 6 months before the revaccination. Among the seroconvertors, only 6% gave a history of measles, and 15% a history of contact with a case of measles. All 20 children with undetectable HI antibody pre-revaccination, and all 6 children with levels below 100 miu, seroconverted after revaccination. The geometric mean titres by HI at 4 weeks after revaccination were 2018 miu (95% confidence limits [95% CL] 1143, 3564) and 398 miu (95% CL 254, 625) in the 2 groups, respectively. Six of 9 children with pre-revaccination antibody titres of 100-199 miu also seroconverted. No child demonstrated a measles-specific immunoglobulin M response. Among the 29 children who seroconverted and were followed up at one year after revaccination, 15(52%) showed a fourfold or greater decline in antibody levels, which in 8 fell to levels below 200 miu. This study confirmed the observation that revaccination is successful in producing an antibody response in children with low or undetectable pre-revaccination titres, but it also confirmed that vaccine-induced immunity wanes rapidly.
Abstract: From 1981 to 1990, stool samples from 6403 gastroenteritis cases were examined for the presence of campylobacters as well as Salmonella, Shigella, Aeromonas species and Yersinia enterocolitica. The percentages of isolation were the following: campylobacters 10.8 (86.1% of isolates were C. jejuni and 13.9% were C. coli), Salmonella spp. 8.4, Aeromonas spp 1.4, Yersinia enterocolitica 0.3. Shigella spp. were isolated only occasionally. Predominant biotypes of campylobacters were C. jejuni I (69.5%), C. jejuni II (29.5%) and C. coli I (92.7%). The six most common LIO serogroups-36; 4; 1; 28.53; 11; 2-accounted for 50% ca. of typable strains. Campylobacters are the most common etiological agent of bacterial enteritis in children living in this area of Tuscany. The species and serogroup determination can be useful from an epidemiological point of view.
Abstract: A serological survey for antibodies to Leptospira spp. was conducted on sheep, goat and dog serum samples collected in three localities in Cordillera province in the southern part of the Santa Cruz Department (Bolivia) in 1992. A total of 98 sheep, 218 goats and 43 dogs were tested against 29 leptospiral serovars using the microscopic agglutination test. At the time of blood collection all of the examined animals appeared healthy and presented no clinical sign suggestive of leptospirosis. Antibody prevalences, as determined by positive results at a 1:100 dilution or higher, was 14.3% in sheep, 19.7% in goats, and 14.0% in dogs. Agglutinins against six serovars (poi. shermani, pomona, canicola, javanica, djasiman) were found in positive animals. The highest serological prevalence in sheep and goats was recorded for serovar poi, followed by pomona in sheep and shermani in goats. Titres to shermani were the commonest in dogs. The results of this survey indicate that leptospiral infection is common in south-east Bolivia and that serovars of several serogroups concur in the etiology.
Abstract: BACKGROUND: Infectious diarrheal diseases remain an important cause of childhood morbidity in industrialized countries. The knowledge of the etiology and epidemiology of childhood diarrhea in a given area is needed to plan any measure designed to prevent or ameliorate diarrheal illness and to develop practice guidelines for the most appropriate stool examination procedures. METHODS: We evaluated 618 children with diarrhea and 135 controls prospectively for viral, bacterial and parasitic enteric pathogens. Diarrheagenic Escherichia coli was identified by gene probes specific to different virulence factors. Stool filtrates were examined for the presence of free bacterial toxins by a cell culture cytotoxicity assay. Clinical and epidemiologic data were recorded and analyzed in relation to microbiologic findings. RESULTS: Enteropathogens were identified in 59% of children with diarrhea and in 10.4% of asymptomatic controls. The agents mainly associated with disease were rotavirus (23.6%), Salmonella (19.2%) and Campylobacter (7.9%). Rotavirus was significantly more frequent among children observed as inpatients whereas Campylobacter was significantly more common in outpatients. Infections with diarrheagenic E. coli, Shigella flexneri, yersinia enterocolitica, Cryptosporidium and Giardia were observed in a limited number of patients. The clinical presentation of children was not sufficiently characteristic to permit presumptive diagnosis of a specific pathogen. conversely the presence of blood and/or leukocytes in stools had a high positive predictive value for Salmonella or Campylobacter infection. CONCLUSION: The results of this study will be useful for planning strategies to prevent and control diarrheal diseases in our country.
Abstract: A cytotoxin inducing vacuolation in HEp-2 cells was detected in 19 (3.1%) of 618 stool specimens from children with diarrhea but in none of 135 from control children. Common enteric pathogens were found in only two (10.5%) of the 19 cytotoxin-positive stool specimens. The vacuoles induced by stool filtrates resembled those induced by the vacuolating toxin (VacA) of Helicobacter pylori. The vacuolating toxin was heat-labile and protease-sensitive, and it had an apparent molecular weight of > 100,000 but was not neutralized by an antiserum to H. pylori VacA. Although proper prospective case-control studies are needed to definitely assess the etiologic association between the new vacuolating cytotoxin and diarrhea, the present study suggests that microorganisms of the gastrointestinal tract produce a Helicobacter-like vacuolating toxin and may be responsible for cases of childhood diarrhea whose etiology is currently considered unknown.
Abstract: We conducted a community-based survey in Santa Cruz city, Bolivia, to determine the age-specific prevalence of measles antibodies, determine factors associated with absence of detectable measles antibodies, and to compare results of salivary and serum measles immunoglobulin G (IgG) antibody assays. Serum samples from 1654 children were assayed for measles IgG antibody using the haemagglutination inhibition (HI) assay, and salivary samples were also obtained from 187 children and tested for measles IgG antibody using an antibody capture radioimmunoassay. Reported measles vaccine coverage in children aged 12-35 months was 77% (95% confidence interval [CI], 72-81%). Eighty-seven percent (95% CI 85-89%) had detectable HI antibody, but a high proportion had antibody levels below 200 miu (30-40% of 2-14 years old children). Measles seronegativity was associated with not being vaccinated against measles, a negative history of measles disease, living in the inner city, being a lifetime resident of Santa Cruz, and young age. Of 212 children without detectable measles antibody, 58% had a positive history of vaccination or measles disease, so that historical information was not sufficiently reliable to identify susceptibles. The salivary measles antibody assay was not sufficiently sensitive to be used for population screening; only 54% of 171 salivary samples from children who had detectable serum HI antibody were positive. A mass measles vaccination campaign of all children under 15 years of age is planned in Bolivia in 1994. Although only 7% of school-age children in Santa Cruz were seronegative, the effectiveness of a mass campaign in this age group depends in part on the response to revaccination of children with low, but detectable, antibody levels.
Abstract: The prevalence of the cphA gene or related carbapenemase-encoding genes was investigated in 114 Aeromonas strains belonging to the six species of major clinical interest. A species-related distribution of cphA-related sequences was observed. Similar sequences were found in A. hydrophila, A. veronii bv. sobria, A. veronii bv. veronii, and A. jandaei, but not in A. caviae, A. trota, or A. schubertii. However, a single A. caviae strain (of 62 tested) was found carrying cphA-related sequences, suggesting the possibility of the horizontal transfer of this gene to species which normally do not carry it. Production of carbapenemase activity was detectable in 83% of the hybridization-positive strains but in none of the hybridization-negative ones. When it was present, carbapenemase activity was always inhibitable by EDTA. Either carbapenemase-producing or not, Aeromonas strains appeared to be susceptible to imipenem when in vitro susceptibility testing was performed with inocula of conventional size (10(5) CFU), for which MICs were always < or = 1 microgram/ml. With a larger inoculum (10(8) CFU), the MICs for carbapenemase-negative strains always remained < or = 1 microgram/ml, while those for carbapenemase-producing strains were always > or = 4 micrograms/ml, being usually higher than the breakpoint for susceptibility. The present results indicate that the production of metallocarbapenemase activity, apparently encoded by cphA homologs, is widespread among some of the Aeromonas species of clinical interest (A. hydrophila, A. veronii bv. sobria, A. veronii bv. veronii, and A. jandaei) and that imipenem MICs for carbapenemase-producing strains are subjected to a relevant inoculum size effect.
Abstract: A study was carried out in the Cordillera Health District (Santa Cruz Department, Bolivia) from October 1988 to April 1989 to determine the seroprevalence of measles antibodies and the seroconversion rates among a group of previously unvaccinated children (9-36 months of age) from the urban and rural area of the province, before and after immunization with a standard dose of Schwarz measles vaccine. Among 265 previously unvaccinated children, 77 (29%) had measles IgG antibodies prior to immunization; 141 out of 147 (96%) seronegative children at the time of vaccination seroconverted. No difference in seroprevalence and in seroconversion rates was found between the urban and rural groups.
Abstract: A seroepidemiological study to determine the prevalence of human Lyme borreliosis and tick-borne relapsing fever was carried out in three communities (Camiri, Boyuibe and Gutierrez) of the Cordillera Province, Santa Cruz Department, south-eastern Bolivia. Anti-B. burgdorferi, anti-B. turicatae and anti-B. parkeri antibodies, tested by the indirect immunofluorescent assay (IFA), were detected in 10.8, 16.1 and 8.2% of the serum samples tested, and confirmed by IFA-ABS in 1.3, 1.3 and 1.0%, respectively. This is the first report of the presence of Lyme borreliosis and tick-borne relapsing fever in Bolivia. For Lyme borreliosis these findings represent a further datum to support its existence in South America.
Abstract: A polymerase chain reaction assay was developed for detection of the Vibrio cholerae heat-stable enterotoxin gene (sto). The assay is based on two oligonucleotide primers suitable for amplification of the entire sto open reading frame. Reaction conditions were defined to obtain optimal results in terms of specificity and sensitivity. Under these conditions the assay was highly sensitive and enabled good results to be obtained using, as a template, crude DNA preparations from single bacterial colonies. A rapid protocol for direct sequence analysis of the amplification product, which may be used in combination with the PCR assay to confirm the product identity and analyse sequence polymorphisms within the sto gene, was also developed. Twenty-two V. cholerae non-O1 isolates from sporadic cases of V. cholerae non-O1-associated gastroenteritis from Cuba were analysed by this PCR assay. Four strains (18.2%) were found to carry the sto gene. The prevalence of V. cholerae non-O1 strains carrying the sto gene among clinical isolates is higher than that reported for other geographical areas, except in the case of epidemics.
Abstract: A study was carried out to determine the occurrence of the suicide phenomenon in Aeromonas spp strains, isolated from clinical samples, and to establish its relationship with the clinical manifestations of diarrheal diseases. 23 strains were studied: 10, of Aeromonas sobria; 7, of Aeromonas hydrophila; and 6, of Aeromonas caviae. All suicidal strains were isolated from patients with acute diarrheal disease. 3 out of 8, isolated from non-diarrheic feces, showed an intermediate phenotypic profile. Various growth patterns associated to the suicide phenomenon were reported.
Abstract: The relative efficacy of a single 400 mg dose of albendazole or mebendazole in the treatment of nematode infections was assessed in 2- to 9-year-old children living in two different Bolivian rural communities. Both agents were equally very effective (100% cure rate) in treating ascariasis. Albendazole was clearly more active than mebendazole against hookworm infections, both in terms of egg reduction rate (92.8% vs. 62.4%) and cure rate (81.8% vs. 17.2%). As far as trichuriasis is concerned, albendazole produced a higher egg reduction rate than mebendazole (45.7% vs 15%), but a lower cure rate (33.3% vs 60%). Both drugs were well tolerated.
Abstract: Two cases of Campylobacter mucosalis enteritis in children are reported. The patients recovered without antimicrobial therapy. Strains were isolated only by the feces filtration technique. In one child, bactericidal antibodies to the homologous strain were detected in a convalescent-phase serum sample. C. mucosalis should be considered a primary intestinal pathogen.
Abstract: In 1988-1989, as part of a co-operative programme with the local Unidad Sanitaria, two cross-sectional surveys were carried out to study the prevalence of malaria in eight villages in the rural areas near Camiri, Boyuibe and Gutierrez (Cordillera Province, Santa Cruz Department, Bolivia). Thick and thin blood films were collected from all available two- to nine-year-old children at the end of the dry season, in the first survey (252 samples), and after the rainy season, in the second survey (346 samples). The parasite and gametocyte indices increased between surveys from 1.59-25.72 and from 0.40-1.73, respectively. All infections were due to Plasmodium vivax. Both prevalence and parasite load were lower in children aged two to four years than in older children. Prevalences, parasite loads, and parasite densities were highest in rural areas near Camiri and Gutierrez.
Abstract: The efficacy of the Acridine-orange stain (AOS) in identifying Helicobacter pylori (HP)-like organisms in biopsy smears from adults with gastroduodenal disease was studied. The results obtained indicate that AOS can replace Gram Stain in HP organism identification in gastroduodenal mucosa specimen.
Abstract: Since the exact mechanisms of the pathogenicity of Campylobacter pylori are not known, we performed an ultrastructural study with the aim of focusing on patterns of possible physical contact between C. pylori and gastric epithelium, and of considering them in relation to the bacterial pathogenicity. Among 20 random consecutive patients referred for routine gastroscopy, we studied ultrathin sections from the 11 patients with Campylobacter-like organisms, and recognized three patterns of physical contact between bacteria and epithelial cells. These patterns seem in accord with published data of C. pylori toxicity, and they could represent different evolutive stages of the infection.
Abstract: A total of 66.6% of Campylobacter pylori strains isolated from patients with peptic ulcers produced a cytotoxin active against mammalian cells in vitro, versus 30.1% of strains isolated from patients with chronic gastritis of various degrees of severity only. This difference was statistically significant and suggests that the toxic substance could be involved in the development of peptic ulcers.
Abstract: Campylobacter pylori has been associated with gastro-duodenal inflammatory disease. Ninety-five adults with dyspepsia were examined for the presence of C. pylori in the gastric antrum and near gastric or duodenal ulcers (when present) by means of culture, Gram and acridine orange stains, and urease activity of biopsies. C. pylori was identified from 51 out of 67 patients with chronic gastritis, from 9 out of 9 patients with duodenal ulcer, and from 8 out of 10 patients with gastric ulcer. Acridine orange stain revealed the highest number of positive cases, followed by culture, Gram stain and urease test. The latter showed a 100% specificity when carried out with a selective urea broth containing colistin, trimethoprim, vancomycin and amphotericin B. It has to be considered a further diagnostic tool which enables clinicians and microbiologists to diagnose the etiology of a dyspeptic syndrome even at the patient's bedside.
Abstract: Throat swabs from 334 patients, submitted to the clinical laboratory of the Institute of Infectious Diseases (Siena University), for isolation of beta-hemolytic streptococci, were inoculated and incubated aerobically and anaerobically. Beta-hemolytic streptococci were identified in 117 (35%) cases, including 77 group A streptococci. Group A streptococci were recovered significantly more often with anaerobic incubation than with aerobic incubation (77 versus 53 cases: P less than 0.01). Non-group A beta-hemolytic streptococci also were recovered significantly more often with anaerobic incubation (40 versus 22; P less than 0.01). We conclude that anaerobic incubation for throat cultures is superior to incubation in normal air for detection of beta-hemolytic streptococci.
Abstract: Of 2,500 fecal samples collected from children with diarrhea in the province of Siena, 35 (1.4%) were found to be positive for Yersinia enterocolitica. Of the isolates, 94.2% belonged to biotype 4, serotype 0:3; 2.8% belonged to biotype 2, serotype O:9; and 2.8% belonged to biotype 1, serotype O:6. The in vitro pathogenicity tests showed that all but two isolates were calcium dependent and autoagglutinable and that all but one were also invasive in HEp-2 cell culture. As regards plasmid content, 32 of 33 biotype 4, serotype O:3 strains harbored a plasmid of 48 megadaltons and 1 strain also harbored a small plasmid of 2 megadaltons. The biotype 2, serotype O:9 strain harbored a plasmid of 42 megadaltons; one of the two strans lacking plasmids belonged to biotype 1, serotype O:6, and the other belonged to biotype 4, serotype O:3. Pyrazinamidase activity was positive only for the biotype 1, serotype O:6 strain. Esculin was hydrolyzed only by the biotype 1, serotype O:6 strain.
Abstract: Motile and mesophilic Aeromonas strains can presumptively be differentiated into species in 18 to 24 h by testing the isolates for the production of a CAMP-like factor. Aeromonas hydrophila strains were positive either aerobically or anaerobically, Aeromonas sobria strains were positive only aerobically, and Aeromonas caviae strains were always negative.
Abstract: Viruses were detected in 150 hospitalized subjects with gastroenteritis during the years 1983-1984. The samples were collected on admission in the day care unit and after three and seven days. The research was carried out using electron microscopy (E.M.) and isolation in cell cultures in vitro. Faecal samples were also collected from 70 control subjects. Observed and/or isolated viruses were identified by structural features at E.M. and by typical cytopathic effects in cultures. Rotavirus and not cultivable adenovirus proved the most widespread agents in the aetiology of acute viral gastroenteritis in infants.
Abstract: Air travel is now widely accessible, with a resulting increase in the numbers of international air travellers and a consequently greater risk of communicable diseases being spread by infectious travellers. The transmission of airborne infections between people in confined spaces such as aircraft cabins is of particular concern to health officials and the general public.
In the early 1990s, several reports concerning the transmission of tuberculosis (TB) infection including its then most dangerous form, multidrugresistant TB (MDR-TB), from infectious travellers to other passengers and crew during long flights, caused anxiety among travellers and serious concern among public health officials and airline companies. The World Health Organization (WHO) published guidelines in 1998 defining the extent of the problem and the potential risks, and providing recommendations for travellers, physicians, health authorities and airline companies.
The recommendations were based on the limited evidence available at the time: investigations involving seven contagious TB patients and some 2600 potentially exposed air travellers. A second edition of the guidelines was published in 2006.
The emergence of MDR-TB and extensively drug-resistant TB (XDR-TB) has raised special concerns in relation to the international spread of particularly dangerous strains of Mycobacterium tuberculosis. Since the 2006 edition was published, several incidents have occurred involving air travel and potential transmission of TB. The revision of the International Health Regulations (IHR), which entered into force in June 2007, provides for the introduction of new measures that might potentially apply to international events involving TB. The IHR provide a legal framework for a more effective and coordinated international response to public health emergencies
and risks, including those caused by outbreaks of communicable diseases.
Several IHR provisions are relevant to the detection and control of TB during air travel, strengthening the role of WHO and of national public health authorities in this domain.
Following these important recent developments, WHO has prepared this third edition to address current public health risks that may arise from the potential transmission of TB during air travel, and new approaches to international collaboration. This edition builds upon the 2006 edition and adds to it in providing: (i) greater clarity in the definition of infectious index cases; (ii) procedures for the follow-up of contacts of infectious cases; and (iii) a more detailed definition of the roles and responsibilities of the agencies involved. The recommendations recognize that the response needs
to be proportional to the risk, so that public confidence is preserved and unnecessary restrictions are avoided. The guidelines were developed with the collaboration of public health authorities and international experts in the prevention and control of TB,
travel medicine and air travel. Implementing the recommendations will help to reduce the international spread of TB and decrease the risk of infection among individual travellers. Although the role of air travel-related transmission of TB is minimal compared with the overall transmission of TB worldwide, these guidelines may nevertheless be useful for national authorities, especially in countries with a low TB burden, and for the airline industry, to facilitate procedures involving multiple actors.
Abstract: Summary
The fifth meeting of the WHO Advisory Committee on Variola Virus Research reviewed current progress in essential research requiring access to live variola virus. Significant progress has been made during the past reporting year, particularly in the further characterization of the variola virus isolates held in the two repositories, on the development of diagnostic procedures for smallpox, and on studies of the genomic DNA diversity of variola virus. Additional progress was also reported on further refinement of the non-human primate model of smallpox and its use for assessing the efficacy of new antiviral compounds and vaccines. The committee made the following recommendations:
· Chimeric viruses held in the Centers for Disease Control and Prevention (CDC) repository should be destroyed and removed from the inventory; this would not preclude the preparation of genomic DNA samples for subsequent archiving.
· Isolates shown to be non-viable using the procedures employed should be similarly destroyed and removed from the inventories, with DNA being isolated if considered useful for future studies.
· WHO should approach the responsible authorities of the collaborating centres to implement the recommendations concerning destruction of the virus isolates identified above.
· The virus inventories held by the two collaborating centres should be updated according to a standardized format set up in collaboration with the WHO secretariat. Progress on implementing this recommendation should be reviewed at the next meeting of the Advisory Committee.
· Non-variola virus orthopoxviruses held in the CDC repository should not appear on the inventory and should either be held separately within the BSL-4 facility or be destroyed, as recommended previously for isolates whose retention was not scientifically justified.
· Methodologies for all diagnostic assays for smallpox developed during this programme should be made available to Member States that request them.
· Additional research should be conducted to validate the current procedures for extraction of DNA from authentic clinical samples containing variola virus DNA and to validate the available diagnostic tests using material from variola virus-infected non-human primates or historical samples.
· Further work should be done using the primate model of human smallpox to facilitate the identification of candidate antiviral compounds and vaccines.
· Work on the characterization of potential antiviral lead compounds and on the development of new vaccines should be given a high priority.
· WHO should provide guidelines for assessing the quality, safety and efficacy of new generation smallpox vaccines for those Member States engaged in this important research.
· The recommendations of the technical sub-committee and the views of members of the Advisory Committee on the simultaneous handling of variola virus and other orthopoxviruses, on the genetic engineering of variola virus, on the expression of variola
virus genes in other orthopoxviruses and on the distribution of variola virus DNA should be referred to WHOâs Biosafety Advisory Group and, subsequently, to the Ad Hoc Committee on Orthopoxvirus Infections for final adjudication.
