Diphtheria epidemic in the Republic of Uzbekistan, 1993-1996

The Republic of Uzbekistan, like the other Newly Independent States in the 1990s, experienced epidemic diphtheria during the 1990s. The outbreak in Uzbekistan began in 1993 in southern regions that bordered areas of Tajikistan that were experiencing a very intense diphtheria epidemic. However, the Uzbek epidemic rapidly spread and threatened to involve the entire country. From 1993-1996, 1169 cases of diphtheria were reported, compared with 58 in 1990-1992. Unvaccinated or only partially vaccinated cases were more likely to have clinically severe forms of diphtheria than those who were fully vaccinated. Strong epidemiologic links with the Tajik diphtheria epidemic and the predominance of mitis biotype strains of Corynebacterium diphtheriae in Uzbekistan make it likely that the Uzbek outbreak arose independently of the predominantly biotype gravis epidemic that began in Russia. The epidemic appeared to be due to low population immunity and the large-scale reintroduction of toxigenic strains of C. diphtheriae. Several mass vaccination campaigns and general enhancement of routine immunization procedures led to control of the epidemic in 1996.     

Universal immunization: the diphtheria control strategy of choice in the Republic of Tajikistan, 1993-1997

During the 1993-1997 diphtheria epidemic in Tajikistan, the incidence rate was the highest observed throughout the Newly Independent States of the former Soviet Union (76.2 cases/100,000 population in 1995). Factors that contributed to this situation included an increase in the number of persons who were not fully immunized, a breakdown of health care services and disease surveillance, civil war, an increase in migration, shortages of qualified medical personnel, and shortages of products, resources, and services. The Ministry of Health and numerous international organizations have worked to address the needs of the republic, and in the fourth quarter of 1995, the number of reported cases began to decrease. It is believed that this decrease was largely the result of routine immunization, implementation of national immunization days, and use of a World Health Organization-recommended system for working with patients and contacts, and it underscores the importance of universal diphtheria immunization with special booster doses in such an epidemic setting.     

Epidemic diphtheria in the Republic of Georgia, 1993-1996: risk factors for fatal outcome among hospitalized patients

Epidemic diphtheria reemerged in the republic of Georgia in November 1993. To identify risk factors for fatal outcomes, clinical and epidemiologic data on all hospitalized diphtheria patients were examined. Medical charts of patients from 1993-1995 were reviewed. A total of 659 cases and 68 deaths were identified (case fatality rate [CFR] = 10.3%). Fifty-two percent of all cases and 68% of deaths were in children 3 days) between onset of symptoms to antitoxin treatment were significantly associated with fatal outcomes. Immunization of children and 40- to 49-year-old adults was required to rapidly control the epidemic.     

Taeniosis in the lower Silesia province in the 1993 - 1997 years

This paper is the result of investigations of taeniosis in inhabitants of four former provinces of the Lower Silesia area in the 1993 - 1997 years. Analysis of frequency taneniosis (according to place of living and sex) confirmed clearly the decrease of tendency of thisparasitosis.     

Outbreak of amebiasis in Tbilisi,Republic of Georgia, 1998

In 1998, we investigated a suspected outbreak of amebic liver abscesses caused by Entamoeba histolytica in the Republic of Georgia, using a case-control study. A questionnaire was administered and blood samples were obtained from cases and controls for serologic diagnosis. Medical records showed that E. histolytica infections were rarely diagnosed before 1998. However, from July through September 1998, 177 cases of suspected amebiasis were identified. Of 52 persons who had diagnosed liver abscesses, 37 (71%) were confirmed serologically to have antibodies against E. histolytica, compared with 11 of 53 persons (20.8%) diagnosed with intestinal amebiasis. In addition, 9-14% of asymptomatic controls were seropositive. Logistic regression identified the fact that interruptions in the water supply, decreases in water pressure, and increased water consumption were significantly associated with infection. The data support the hypothesis that drinking water was the source of infection, either because of inadequate municipal water treatment or contamination of municipal water in the distribution system.     

Risk factors for diphtheria: a prospective case-control study in the Republic of Georgia, 1995-1996

The large-scale resurgence of diphtheria in the former Soviet Union offered a unique opportunity to evaluate risk factors for the transmission of respiratory diphtheria; therefore, a prospective case-control study was done in the republic of Georgia. In total, 218 diphtheria cases (hospitalized between October 1995 and March 1996) and 408 matched controls participated. One hundred cases (45%) were /=15 years of age (range: <1 to 75 years). In the multivariate analyses, the following risk factors were found to be significant: lack of vaccination (matched odds ratio [mOR]=19.2), household exposure to diphtheria (mOR=7.4), exposure to skin lesions (mOR=5.8), history of eczema (mOR=3.4), fever with myalgia prior to illness (mOR=2.6), having tonsils (mOR=4.4), sharing a bed (mOR=1.9), sharing cups and glasses (mOR=2.7), and taking a bath less than once a week (mOR=2.6). These findings emphasize primary prevention through immunizations, secondary prevention following exposure to diphtheria (and to suspicious skin lesions), and adherence to strict standards of personal hygiene.     

Diphtheria in Lithuania, 1986-1996

Diphtheria reappeared in Lithuania in 1986 and rose to epidemic levels by 1992. Between 1991 and 1996, 110 cases of diphtheria were registered, with an incidence of 0.03-1.15/100,000 population. Most cases (84%) and all 17 deaths occurred among persons >/=15 years, most of whom had never been vaccinated. Persons 40-49 years old had the highest average annual age-specific morbidity (1.70/100,000) and mortality (0.53/100,000) rates. Low levels of immunity among individuals 40-49 years old and migration to epidemic areas in Russia and Belarus contributed to the epidemic's occurrence. Between 1991 and 1995, toxigenic Corynebacterium diphtheriae strains were isolated from 84 of all registered patients (76%), and nontoxigenic strains were isolated from 13 (12%). By 1996, two mass vaccination campaigns, which provided one dose of vaccine to individuals 25-30 years old and three doses of vaccine to persons 31-60 years old, helped reduce the number of cases. The first campaign achieved 69% coverage; the second achieved 48% coverage.     

Diphtheria in Estonia, 1991-1996

Clinical diphtheria reappeared in Estonia in 1991. Between 1991 and 1996, 61 cases and 5 deaths occurred; 19 cases were among children 5-9 years of age, and 11 were among persons 40-49 years of age. From 1993-1995, vaccine supplies donated by Finland were used in vaccination programs. In 1995, the International Federation of Red Cross and Red Crescent Societies and the Estonian Red Cross launched a mass vaccination campaign targeting the adult population. By the end of 1997, it was estimated that 46% of adults had received at least one dose of vaccine. Although the vaccination campaigns did not target the pediatric population, vaccination coverage in school-aged children remained high due to continuing routine vaccination programs. The reappearance and epidemic of clinical diphtheria cases and the mass vaccination campaign efforts demonstrated that preventive measures are important and must be maintained in order to keep diphtheria under control.     

Diphtheria in Latvia, 1986-1996

After nearly two decades without a diphtheria case in Latvia, the disease reappeared in 1986. From 1990 to 1996, case counts were highest among adults 40-49 years of age, school-aged children, and adolescents. Nonetheless, the average annualized incidence of disease was highest among infants and preschoolers. In August 1995, mass vaccination efforts began to provide adults 25-60 years of age with at least one dose of vaccine. By the end of the year, a 77% coverage rate was achieved, resulting in a decrease of reported diphtheria cases by 1996. From February to September 1997, special outreach efforts were focused on hard-to-reach populations; as a result, by June 1997, 55% of adults had received three doses of vaccine. While decreases in the incidence of and morbidity from diphtheria have occurred, additional efforts still need to be concentrated on improving vaccination coverage in adults and children <2 years of age and in reducing mortality from diphtheria.     

National haemophilia programme development in the Republic of Georgia

After the dissolution of Soviet Union in 1991, haemophilia care in the Republic of Georgia was negatively affected because of the expense of treatment products, lack of clinical and diagnostic facilities, and the need for trained personnel throughout the country. In 2001, the Georgian Government, working through the Ministry of Health, in collaboration with Georgian Association of Haemophilia and Donors, the Institute of Haematology and Transfusion, and the World Federation of Haemophilia, initiated a National Haemophilia Programme. As part of this programme the first Georgian Haemophilia Treatment Centre (HTC) was established. In this paper, we will describe (i) our outreach efforts to identify patients with haemophilia (PWH), (ii) the diagnostic and clinical services provided to patients by the HTC, and (iii) the results of a patient survey designed to assess patient satisfaction with the care provided. Total of 216 PWH were diagnosed, mean age was 25 years (range 4 months to 75 years); 43% had severe, 33% had moderate and 24% had mild haemophilia A or B. Overall, 183 (85%) had haemophilia A and 33 (15%) had haemophilia B, giving a ratio of 5.6. During the 2-year period, 77% of the expected number of PWH was identified by our outreach programme. Vast majority had comprehensive evaluation including joint assessment and over 60% were tested for blood-borne infections within a year and half period. Our findings showed that haemophilia care was considerably improved since the beginning of the National Haemophilia Programme and the survey of PWH showed a high degree of satisfaction with services provided in the HTC. In conclusion, close collaboration of the government, non-government entities and medical professionals in a Georgian national haemophilia care model; resulted in the successful delivery of the much needed services and care to the people living in Georgia with haemophilia.     

Diphtheria and infections caused by Corynebacterium diphtheriae in 1997

INTRODUCTION: Diphtheria is a reemerging disease. Two epidemics recently occurred in Algeria and Independent States Community, not so far from Europe. Imported cases were diagnosed in contiguous European countries. This review focuses on the data obtained from these epidemics, with particular emphasis on new clinical forms of Corynebacterium diphtheriae infections. CURRENTS KNOWLEDGE AND KEY POINTS: Sore throat with membranes is no longer the only clinical feature of diphtheria. However, patients' management is identical, with combination of antibiotics, injection of specific antisera, and immunization of patients' close contacts and relatives. French and American sero-epidemiological studies showed that antibody levels does not provide protection, particularly in the elderly. Adult populations would therefore be at risk every 10 years. Recent advances in molecular biology led to the development of gene amplification with polymerase chain reaction, that may be used for the detection of the toxin gene. They also promoted epidemiological surveys of circulating strains via ribotyping. Although this technic evidenced predominant strains in the various countries, genotypes encountered during an epidemics may differ. Besides diphtheria which has apparently been eradicated in France, systemic infections with non-toxigenic strains of C diphtheriae, such as endocarditis, septicemia and arthritis, are evenly diagnosed. FUTURE PROSPECTS AND PROJECTS: A French national reference center for C diphtheriae has been recently created. This center collects most of the strains isolated in France, clinical data and assesses the toxigenicity of bacteria, allowing strict epidemiological survey.     

Recent trends in the HIV epidemic among injecting drug users in Northern Italy, 1993-1999.

OBJECTIVE: To monitor and describe the time trends of the HIV epidemic among intravenous drug users (IDU) attending drug dependence treatment centres (DDTC) in Northern Italy. DESIGN: A cohort of all seronegative IDU attending DDTC in Lombardy between 1993 and 1999; all had been tested for HIV at least twice. Periodic sample interview surveys were done to assess risk behaviours. METHODS: The incidence rates of HIV infection were calculated using the person-year (PY) method and expressed as the number of cases per 1000 PY at risk. Background HIV prevalence was calculated by dividing the number of positive cases by the total number of IDU tested at all DDTC in Lombardy. RESULTS: Between 1993 and 1999, 135 seroconversions occurred in 7945 subjects followed for 19 671 PY, yielding an incidence rate of 6.9/1000 PY. Ninety seroconversions occurred among the 6563 males and 45 seroconversions among 1382 females (incidence rates 5.5 and 14.0, respectively). Among the males, the incidence of HIV was 4.5 in those aged less than 25 years and 5.8 in those aged 25 years or more. Among the females, the corresponding figures were 21.1 and 10.3. HIV prevalence decreased over time, and it was higher among females. Sexual behaviours at risk were more common among females. CONCLUSIONS: The incidence of HIV infection among IDU in Northern Italy was stable between 1993 and 1999. The higher incidence and prevalence among females and the different prevalence of risk behaviours between genders suggest an increasing role of heterosexual transmission.     

Serum cholesterol changes from 1983-1984 to 1993-1994 in the People's Republic of China

BACKGROUND AND AIM: Increasing cardiovascular disease (CVD) mortality in the People's Republic of China (PRC) led to the 1981 establishment of the PRC-USA Study of Cardiovascular and Cardiopulmonary Epidemiology which, among other objectives, is concerned with the correlates of CVD morbidity and mortality in Chinese populations among other objectives. This report describes changes in total cholesterol (TC) levels in four PRC populations from 1983 to 1993 and identifies factors related to the changes. METHODS AND RESULTS: Population screenings carried out in 1983-1984, 1987-1988 and 1993-1994 involved the collection of demographic data, specimens (including blood), medical history and physical examination data. The data from cohort and independent samples were used to assess TC changes in urban and rural men and women over the decade, with and without adjustment for age and body mass index (BMI) changes. For Guangzhou men and women, the cohort analyses (aged 35-54 at baseline) showed increases in TC of 10-20 mg/dL after adjustment for age and changes in BMI; the independent sample analyses (aged 35-44) also showed higher average TC levels in 1993-1994 than in 1983-1984. For the Beijing cohorts, the results showed decreases in TC during the decade in men, an increase in TC in urban women and no change in rural women; the independent sample analyses indicated declines in TC for Beijing men and women. Possible reasons for the Guangzhou TC increases are economic growth, and dietary and BMI changes. The mean age-adjusted BMI significantly increased (5-10%) over the 10-year period in all of the studied groups. CONCLUSIONS: TC increased 10-20 mg/dL in Guangzhou men and women, probably as a result of socioeconomic development during the decade. The inconsistent patterns of TC changes in Beijing require further study.     

The community-directed, ivermectin-treatment programme for onchocerciasis control in Uganda--an evaluative study (1993-1997)

The first 5 years of a community-directed, ivermectin-treatment programme, to control onchocerciasis in 1805 endemic communities in 10 districts in Uganda, are evaluated. Each year, the desired treatment coverage of the population eligible to take invermectin (90%) was achieved in 42.6%-51% of the 1713 communities for which complete data were available; 67%-74.8% achieved 80% coverage. The annual cost per person treated with ivermectin (ACPTI) was much higher in the districts with small populations to be treated (< 15,000) than in those with large populations (> 40,000) (U.S.$0.40 v. U.S.$0.10 or less). The community members' acceptance of the programme was related to their attendance at health-education sessions (P = 0.009), and their participation in the mobilisation of other community members increased greatly when they were allowed to take part in the selection of the community-based distributors (CBD) and the choice of treatment sites. The overall target ratio of one CBD/71 families was attained by 1997. However, the failure of some trained CBD to participate in the treatment exercise prevented some communities achieving 90% treatment coverage. Providing CBD with cash incentives or externally derived incentives 'in kind' proved counter-productive whereas locally generated incentives 'in kind' were simply regarded as the normal obligations of the community. District health staff successfully integrated the programme with their other health commitments, but the involvement of CBD in other programmes proved detrimental to their performance. Other constraints identified were rebel insurgency in some areas, and abnormally heavy rains in hilly areas with poor roads.     

The emerging HIV/AIDS epidemic in Georgia

The first case of HIV in Georgia was diagnosed in 1989. Through December 2002, a total of 375 cases of HIV infection were reported. However, the World Health Organization estimates that the true number of infections may be closer to 1700. In all, 70% of reported cases are among injection drug users. Based on the UNAIDS classification, Georgia is a 'low-level HIV country' with an HIV prevalence of less than 1% in all groups, including drug users. However, there is a high prevalence of hepatitis B and C, suggesting a significant risk for the spread of HIV. Georgia, a newly independent republic, is experiencing an increase in injection drug use, a rise in sexually transmitted infections and commercial sex trade that create a fertile soil for the potential rapid spread of HIV. However, it is also a country with a unique window of opportunity for limiting the spread of HIV.     

Irritable bowel syndrome: patterns of ambulatory health care and resource use in the United States, 1993-1997

In the mid-1980s irritable bowel syndrome was estimated to result in 2.5 million office-based physician visits per year in the United States. This study investigates more recent patterns of ambulatory care in the United States using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey for the years 1993–1997. We estimate that there are 11.3 ambulatory physician visits per 1000 US population per year with a diagnosis of irritable bowel syndrome: 92% (2.7 million visits per year) are to office-based physicians, 7% to outpatient departments and 1% to emergency departments. Women account for 74% of visits. Drugs, most commonly gastrointestinal agents and anxiolytics, are prescribed at more than three quarters of all visits; prescribing of multiple drugs is common. Office-based physician visit rates and patterns of drug treatment have not changed markedly since the 1980s. Visit rates increase more steeply with age than previously reported.