The changing pattern of imported malaria in British visitors to Kenya 1987-1990

Following a sudden increase of imported malaria from Kenya in December 1989-January 1990, an investigation was set up to identify risk factors for travellers' malaria. A questionnaire asking for details of travel patterns and compliance with prophylaxis was sent to cases reported over the 6-month Kenyan winter period. Quarterly malaria attack rates between January 1987 and June 1991 were calculated and linked to meteorological conditions in Mombasa. The number of travellers to Kenya has doubled in the 4 years studied and the quarterly rates varied 4-fold over this period. There was no clear seasonal pattern of malaria in travellers, nor was there any clear relation of malaria to coastal rainfall. Compliance with chemoprophylaxis was poor, with only 16% of cases using currently advised regimens. While the annual malaria attack rate per 10,000 travellers decreased by 37% over the study period, the total numbers of malaria cases imported from Kenya rose by 61%, reflecting the increase in the numbers of travellers to the region. As the popularity of East Africa as a tourist destination continues to increase, Kenya will remain an important and significant source of malaria imported into the UK.     

The diagnosis and treatment of malaria in Australia

The number of reported malaria cases is increasing each year with several deaths reported recently. This article reviews the types of malarias, including their incidence, prevention, presentation and the standard treatment protocols.     

South American camelids in the United Kingdom: population statistics, mortality rates and causes of death

A survey of the health of South American camelids in the United Kingdom was carried out between December 1992 and June 1993; 123 members of the British Camelid Owners and Breeders Association and 19 non-members were sent questionnaires and usable responses were received from 84 (59 per cent). In total 689 camelids were included, and in 1992, 66 per cent were Ilama, 21 per cent alpaca and 13 per cent guanaco. Their ages ranged from less than six months to over 10 years, with animals aged two to five years constituting the largest proportion. The mortality rates between 1990 and 1992 were 2.7 to 3.3 per cent for Ilama, 3.5 to 6.9 per cent for alpaca and 0 to 11.4 per cent for guanaco. The highest mortality was in animals less than six months and more than 10 years old; 4 to 11 per cent of Ilama deaths and 17 to 33 per cent of alpaca deaths were in animals aged less than six months and a high proportion of these occurred during the first week of life. In the cases for which a cause was reported, accidents and injury accounted for 20 per cent of Ilama deaths, and perinatal deaths accounted for 22 per cent of alpaca deaths. A third of the deaths were reported as being of unknown cause, and a veterinary diagnosis was reported in less than half of the cases. These data suggest that attention to the environment and housing conditions of Ilama, the neonatal care of alpaca and improvements in diagnosis are priorities for reducing the mortality and improving the health of South American camelids in the UK.     

Mathematical modeling of platelet survival with implications for optimal transfusion practice in the chronically platelet transfusion-dependent patient

Even now 50% of the world population are still living in malaria endemic areas and every year 200 million new cases with 2 million deaths are reported. Most of the malaria deaths are children under 5 years old. Although malaria endemicity currently exists mainly in tropics, before the human started its efforts to eradicate malaria in large scale in 1950s, malaria was more widely distributed in the world. At this time Japan and malaria together with North America and European countries. However some areas were precluded from malaria endemicity: i.e., high mountains and deserts. Also Polynesian islands in the Pacific have never been malarious, even though Melanesian Papua New Guinea, Solomon, and Vanuatu are highly malarious even now. Human disease malaria is caused by Plasmodium parasites and transmitted by Anopheles mosquitoes. Human is classified into the malaria donor and recipient. The environment is supporting this system: for example, temperature and rainfall are important factors together with vegetation, or housing, health infrastructure, war situation, and poverty status. In 1950s, the WHO malaria eradication program focused its efforts on vector control, using DDT-residual spraying. But the program completely failed with mainly operational reasons and we already learned it is almost impossible to control malaria only killing mosquitoes. In 1992 the new Global Malaria Control Strategy adopted by Malaria Summit at Amsterdam says the primary objective is early diagnosis and treatment to prevent malaria death. In this context malaria chemotherapy is a key issue. Also we understand more and more the environmental management is very important. Malaria vaccine may be a conceptually important tool, but may be available soon.     

Malaria surveillance -- United States, 1994

PROBLEM/CONDITION: Malaria is caused by infection with one of four species of Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, and P. malariae ), which are transmitted by the bite of an infective female Anopheles sp. mosquito. Most malarial infections in the United States occur in persons who have traveled to areas (i.e., other countries) in which disease transmission is ongoing. However, cases are transmitted occasionally through exposure to infected blood products, by congenital transmission, or by local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to adapt prevention recommendations. REPORTING PERIOD COVERED: Cases with onset of symptoms during 1994. DESCRIPTION OF SYSTEM: Malaria cases confirmed by blood smear are reported to local and/or state health departments by health-care providers and/or laboratories. Case investigations are conducted by local and/or state health departments, and the reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), which was the source of data for this report. Numbers of cases reported through NMSS may differ from those reported through other passive surveillance systems because of differences in the collection and transmission of data. RESULTS: CDC received reports of 1,014 cases of malaria with onset of symptoms during 1994 among persons in the United States or one of its territories. This number represented a 20% decrease from the 1,275 cases reported for 1993. P. vivax, P. falciparum, P. malariae, and P. ovale accounted for 44%, 44%, 4%, and 3% of cases, respectively. More than one species was present in five persons (<1% of the total number of patients). The infecting species was not determined in 50 (5%) cases. The number of reported malaria cases in U.S. military personnel decreased by 86% (i.e., from 278 cases in 1993 to 38 cases in 1994). Of the U.S. civilians who acquired malaria during travel to foreign countries, 18% had followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Five persons became infected while in the United States; the infection was transmitted to two of these persons through transfusion of infected blood products. The remaining three cases, which occurred in Houston, Texas, were probably locally acquired mosquitoborne infections. Four deaths were attributed to malaria. INTERPRETATION: The 20% decrease in the number of malaria cases from 1993 to 1994 resulted primarily from an 86% decrease in cases among U.S. military personnel after withdrawal from Somalia. Because most malaria cases acquired in Somalia during 1993 resulted from infection with P. vivax, there was a proportionately greater decrease during 1994 in the number of cases caused by P. vivax relative to those caused by P. falciparum. ACTIONS TAKEN: Additional information was obtained concerning the four fatal cases and the five cases acquired in the United States. Malaria prevention guidelines were updated and distributed to health-care providers. Persons traveling to a geographic area in which malaria is endemic should take the recommended chemoprophylactic regimen and should use protective measures to prevent mosquito bites. Persons who have a fever or influenza-like illness after returning from a malarious area should seek medical care; medical evaluation should include a blood smear examination for malaria. Malarial infections can be fatal if not promptly diagnosed and treated. Recommendations concerning prevention and treatment of malaria can be obtained from CDC.     

Epidemiological trends for malaria in the cities of the upper Paraguay River basin, Mato Grosso do Sul, Brazil 1990-1996

Through the Regional Office of the Brazilian National Health Foundation in the State of Mato Grosso do Sul, we obtained numerical data on malaria for the upper Paraguay basin (UPB): 159 cases in 1990, 126 in 1991, 135 in 1992, 61 in 1993, 143 in 1994, 41 in 1995, and 20 in 1996, the majority of which were imported cases. There were no autochthonous cases in 1990, and since 1991 the rates of over 15% dropped to around 1.60%. Imported cases, corresponding to 0. 63% in 1990, increased in 1991 and 1992 to some 1.50%, and to 3.28% in 1993. Induced cases were recorded only in 1991 and 1992 (less than 1%). Most cases were between 16 and 45 years of age. There was a predominance of Plasmodium vivax in the thick blood smears. Although autochthonous cases of malaria are not the majority, the disease is still an important public health problem in the UPB in the presence of the Anopheles (N.) darlingi vector and human migration into the region.     

Characterization of mutant Bordetella pertussis adenylate cyclase toxins with reduced affinity for calmodulin. Implications for the mechanism of toxin entry into target cells

BACKGROUND: Data and statistics are presented on cancer death certification for 1993 in Italy, updating previous publications covering the period 1955-1992. METHODS: Data for 1993 subdivided into 30 cancer sites are presented in 8 tables, including age- and sex-specific absolute and percentage frequencies of cancer deaths, and crude, age-specific and age-standardized rates, at all ages and truncated for the 35-64 year age group. RESULTS: Age-adjusted death certification rates (on the world standard population) for all neoplasms declined from 189.8 in 1992 (and a peak of 199.2 in 1986) to 187.8/100,000 males in 1993, and remained stable around 100,000 females. The favorable trends were even larger in middle and younger age males, but not in children below age 15, whose overall age-standardized cancer mortality rates increased for the fourth subsequent year. Lung cancer was the leading site of cancer mortality, with over 30,900 deaths. For the fifth subsequent year, its rates in males declined, to reach 56.0/100,000. The decline in lung cancer rates is now established in Italian males and is substantial in middle age, whereas the rise in female lung cancer rates seems to have leveled off over the last few years. Rates for other major cancer sites (intestines, stomach, female breast, prostate, pancreas, leukemias and lymphomas) were stable, but some decrease was apparent also in 1993 for Hodgkin's disease. CONCLUSIONS: Italian cancer mortality rates in 1993 were moderately favorable in males, due to the leveling of the tobacco-related epidemic, whereas no appreciable change was registered in females. The persisting unfavorable trends in childhood cancer mortality should be investigated.     

Assessment of pseudarthrosis in pedicle screw fusion: a prospective study comparing plain radiographs, flexion/extension radiographs, CT scanning, and bone scintigraphy with operative findings

Tribal warfare is a way of life in the highlands of Papua New Guinea. In earlier times direct confrontation with bushknives and axes, and shooting with bows and arrows were common. In recent years there have not been as many instances of direct confrontation with bushknives and axes, but the use of bows and arrows is on the rise. Since 1993, guns have been increasingly used, with devastating results. In 1993, 18 deaths were reported from tribal warfare in one area of the Southern Highlands Province, especially from gunshots, while in 1994, 24 deaths were reported from another area. A five-year review of tribal fight admissions to Mendi Hospital, from 1990 to 1994, showed an increase in the number and proportion of gunshot wounds; there were none in 1990-1992 but they constituted 18% of tribal fight injuries in 1993 and 33% in 1994.     

Malaria at Christmas: risks of prophylaxis versus risks of malaria

A large increase in the number of falciparum malaria cases imported into the UK was reported to the malaria reference laboratory in the first quarter of 1998. Contributory factors were unusually heavy rains in east Africa and a reduction in the use of the most effective antimalarial drug, mefloquine. There was also an increase in the number of cases of severe malaria in the UK. During December 1997 and January 1998, the Hospital for Tropical Diseases, London, treated 5 patients for severe malaria and gave advice on 20 more patients with malaria who had been admitted to intensive care units throughout England. 4 of the severe cases treated at the hospital are reported. In 3 of those 4 cases, incorrect, misleading, or inadequate advice was given by health care professionals. Media coverage of the adverse effects of antimalarial drugs has contributed to confusion about prophylactic regimens among both health care professionals and the public. The incidence of falciparum malaria among travellers who do not take prophylactic drugs is about 0.6% in east Africa and 3.5% in west Africa over a 2-week travel period. Travellers need to take measures to avoid being bitten by mosquitoes and should be taught to promptly seek medical help if they develop a fever while abroad or after they return. Moreover, using any one of the recommended prophylactic regimens is better than not using a potent regimen or no prophylaxis at all. Mefloquine is 90% protective against malaria in sub-Saharan Africa. While the efficacy of proguanil and chloroquine in 1987 was about 70% in west Africa and 50% in east Africa, those levels are now probably lower. The side effects of antimalarial drugs are discussed.     

Epidemiology of homicide in Allegheny County, Pennsylvania, between 1966-1974 and 1984-1993

BACKGROUND: We compared homicide death rates and characteristics of homicide victims and perpetrators in 1966-1974, 1984-1990, 1992-1993, and 1996 in Allegheny County, Pennsylvania, in an attempt to detect possible differences in the pattern of homicides. METHODS: Data were obtained from death certificates, coroner's records, police reports and newspapers. RESULTS: In the 1990s the homicide death rate increased for 15- to 24-year-old black men. The rate was 69 per 100,000/year for black men ages 15-24 years from 1966 to 1974 and rose to 275 per 100,000 from 1992 to 1993. Currently, the rates appear to be declining again. Preliminary data from 1996 showed the number of homicide deaths excluding vehicular homicides between 1993 and 1996 to decline from 19 to 8 for white men, from 70 to 42 for black men, from 9 to 3 for white women, and from 13 to 6 for black women with little change in the population (denominator). The dramatic drop from 111 to 61 deaths over a short time is similar to changes across the United State and is characteristic of epidemic rise and fall of homicides in the community. CONCLUSIONS: Between 1966 and 1993 Allegheny County experienced two separate homicide epidemics, one between 1966 and 1976 and the other between 1990 and 1993. Epidemics of homicide occur frequently and have different characteristics. New characteristics of the most recent epidemic of homicide include more homicides out of home, among strangers; less association with alcohol; and multiple perpetrators. Drug-use-associated homicides have also increased. Guns are the primary agents of homicide epidemics.     

Primaquine and travelers from the Arab world. A report and recommendations

This paper reports on 2 hemolytic serious reactions in 2 Arabian patients because of the use of primaquine as presumptive antimalarial treatment given in Cuba to all travellers from countries where malaria is endemic. Taking into account the non-existence of imported malaria cases in travellers from the Arab-world since more then 15 years and the frequency of individuals presenting with glucose-6-phosphate dehydrogenase deficiency it is recommended not to use this therapeutic procedure, and to maintain the rest of surveillance measures to all travellers from such region.     

Recent epidemiological status of malaria in Calcutta Municipal Corporation area, West Bengal

In Calcutta, Plasmodium falciparum cases and death due to malaria show remarkably increasing trend since 1990. The incidence of P. falciparum malaria has increased more than eleven folds in 1996 in comparison to 1990, with 0, 0, 0, 3, 7, 52 and 17 deaths in 1990, 1991, 1992, 1993, 1994, 1995 and 1996 respectively. Situation is more serious than what it is projected in official records as annual blood examination rate (ABER) in Calcutta Municipal area is poor, varying from 1.5 to 3.9 in 1993 and 1996 respectively. This is further evident from the fact that in a study area in 19 months (January 1995 to July 1996) the slide positivity rate (SPR) was 47.94% on an average 28.72% suffer from P. falciparum infection (as low as 0.5% in June 1996 and as high as 71.5% in November 1996). For the first time resistance of P. falciparum to chloroquine has been noted at RII and RIII level. The response of the same parasite strain to sulfa-pyrimethamine combination drug is very much promising. Fresh infection is occurring in all the months of the year and the favourable period is from July to November 1995 that is corroborating with Container index and Breteau index related to the vector mosquito Anopheles. Susceptibility status of An. stephensi indicates that the mosquito species has acquired resistance to DDT, BHC, propoxure and malathion but is still susceptible to fenthion and deltamethrin.     

Long term relative survival after surgery for abdominal aortic aneurysm in western Australia: population based study

OBJECTIVE: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. DESIGN: Population based study. SETTING: Western Australia. SUBJECTS: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. MAIN OUTCOME MEASURES: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. RESULTS: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. CONCLUSION: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.     

Fluoridated etching on orthodontic bonding

To evaluate the impact of the 1993 expansion of the acquired immunodeficiency syndrome (AIDS) surveillance definition on reporting of persons with no HIV risk exposure information, we compared persons reported with and without risk in 1992 and 1993. The expanded case definition resulted in a large increase in both the number of persons reported with risk (121% increase) and without risk (167% increase). The changes in demographic characteristics for each group were similar from 1992 to 1993. Persons reported based on immunologic criteria were more likely and persons with pulmonary tuberculosis (PTB) less likely than those meeting the pre-1993 definition criteria to be reported with risk. Many persons with PTB were retrospectively identified from tuberculosis registries that do not systematically include HIV risk information. Ascertainment of risk information continues to be an essential part of AIDS surveillance with >90% of reports including risk exposure.     

Mortality and morbidity from malaria after stopping malaria chemoprophylaxis

Gambian children who had received malaria chemoprophylaxis for a variable period of time during their first 5 years of life were followed to determine whether they experienced a rebound in mortality or in morbidity from malaria during the period after chemoprophylaxis was stopped. The risk of dying between the ages of 5 years, when chemoprophylaxis was stopped, and 10 years was no higher among children who had received chemoprophylaxis with Maloprim (pyrimethamine plus dapsone) for some period during their first 5 years of life than among children who had received placebo (21 vs. 24 deaths) and the beneficial effect of chemoprophylaxis on mortality observed during the first 5 years of life was sustained. The incidence of clinical attacks of malaria during the year after medication was stopped was significantly higher among children who had previously received Maloprim for several years than among children who had previously received placebo. However, at the end of this year, there was no significant difference in spleen rate, parasite rate or packed cell volume between the 2 groups of children. Thus, stopping chemoprophylaxis after a period of several years increased the risk of clinical malaria but did not result in a rebound in mortality in Gambian children. However, the number of deaths recorded was small, so a modest effect on mortality cannot be excluded.     

A survey of mortality in slaughter pigs during transport and lairage

Of 2.9 million pigs transported to seven slaughter plants in 1991 and 1992, 1781 (0.061 per cent) died in transit and 314 (0.011 per cent) died subsequently in the lairage. Overall mortality for both years was 0.072 per cent and mortality in 1992 was 0.066 per cent. There was little seasonal variation in the number of pigs dying in lairage, but more pigs died in transit in months when the weather was hotter. The relationship with temperature was curvilinear; above about 15 to 17 degrees C the detrimental effect of high temperatures was far more serious. In 1992, the year for which complete data were available, average mortality in the seven plants ranged from 0.045 to 0.093 per cent, but this variation was not related to the size of the plant. The number of pigs which died in lairage, rather than in transit, ranged from 4 to 21 per cent of all deaths in the different plants, and the average was 15 per cent. The variation might be related to differences in average lairage times or to the policies of individual plants with regard to moribund pigs. The survey provided no evidence that the mortality among transported pigs has increased over the last 20 years.     

Changing patterns of self-poisoning in a UK health district

Details of admissions to a dedicated district poisons treatment unit in South Glamorgan were analysed to assess changes in self-poisoning patterns between 1987-1988 and 1992-1993. Self-poisoning rates increased in both men and women, with male rates showing a relatively larger increase, resulting in a fall in female to male ratio for person-based rates from 1.33:1 to 1.13:1. The highest age-specific rates in both period were found in 15-19-year-old females. Paracetamol was the most commonly ingested poison in 1992-1993, with 43.4% of episodes involving its use, compared with 31.3% of episodes in 1987-88. Antidepressant involvement in self-poisoning also increased from 11.3% of episodes in 1987-1988 to 17.6% of episodes in 1992-1993. Repetition of self-poisoning was relatively common, with 18% of admissions per year in 1992-1993 representing repeats. Although hospital admission increased in this health district over the study periods, this was not reflected in an increase in in-patient all-cause mortality, which was only 0.5% in 1987-1988 and 0.1% in 1992-1993.     

Pediatric head injuries and deaths from bicycling in the United States

OBJECTIVE: To estimate the potential benefit of increasing bicycle helmet use among children and adolescents in the United States. DESIGN: All bicycle-related deaths (Multiple Cause-of-Death Public Use Data Tapes, 1989 through 1992) and bicycle-related injuries treated in sampled emergency departments (National Electronic Injury Surveillance System, 1989 through 1993) were used to calculate traumatic brain injury-associated death and head injury rates per 1,000,000 US residents. Preventable injuries and deaths were estimated by calculating the population-attributable risk of head injury due to nonuse of bicycle helmets. PATIENTS: US residents aged 0 through 19 years who were injured or who died as a result of a bicycle crash. RESULTS: An average of 247 traumatic brain injury deaths and 140,000 head injuries among children and adolescents younger than 20 years were related to bicycle crashes each year in the United States. As many as 184 deaths and 116,000 head injuries might have been prevented annually if these riders had worn helmets. An additional 19,000 mouth and chin injuries were treated each year. The youngest age groups had the highest proportions of both head and mouth injuries. CONCLUSION: There continues to be a need to advocate for greater use of bicycle helmets, particularly among young children. Helmet design changes should be considered to prevent mouth injuries.     

Epidemiological features of severe paediatric malaria in north western Ethiopia

Malaria remains a major public health challenge in sub-Saharan Africa, yet our knowledge of the epidemiology of malaria in terms of patterns of mortality and morbidity is limited. To examine the clinical and epidemiological presentation of severe life-threatening malaria in Humera, north western Ethiopia studies were conducted among the childhood population in the community, those presenting to out-patient facilities and those admitted to the district hospital. The overall P. falciparum parasite rate among children aged 0-9 years resident within the area was only 12% confirming the low level of endemicity in this area. P. vivax infections were present in 5% of children. Between July 1993 and June 1994 peak out-patient presentation with Plasmodium falciparum coincided with the rains with over 50% of cases occurring between August and October whilst P. vivax infections were predominant during the hot, dry months. Malaria was an important cause of paediatric admission to the local district hospital with an estimated 4.7% of the at-risk childhood community warranting intensive clinical management each year. Case fatality rates were high and the clinical spectrum of severe disease indicated a preponderance of cerebral malaria cases. In addition, respiratory distress was a feature in 12% of the malaria admissions. The suggestion that the coexistence of Plasmodium falciparum and Plasmodium vivax may serve to reduce the severe clinical consequences of P. falciparum malaria is not supported by these observations.     

The decline of Haemophilus influenzae type b disease in Australia

Between July 1993 and June 1996, there were 412 cases of invasive Haemophilus influenzae type b (Hib) disease reported to the Hib Case Surveillance Scheme, 71% in children under the age of five years. Meningitis was the most frequent illness reported, followed by epiglottitis, septicaemia and pneumonia. There were 18 deaths. Thirty-four cases were classified as vaccine failures. The number of vaccine failures increased over time and the total number of cases of Hib disease fell, consistent with an increase in Hib vaccine coverage. Based on an estimated vaccine coverage of 50% in April 1995, the vaccine efficacy for all vaccines in the period was estimated to be 89%. Invasive Hib is a serious illness of childhood which is being significantly reduced by the use of Hib vaccines, and has the potential to be eliminated from this country. Vaccination providers should aim to immunise all children against Hib disease on time and according to the National Health and Medical Research Council Standard Vaccination Schedule.