Robert E. Black

Epidemic Yersinia enterocolitica Infection Due to Contaminated Chocolate Milk

In September and October, 1976, an outbreak of illness due to chocolate milk contaminated with Yersinia enterocolitica resulted in hospitalization of 36 children, 16 of whom had appendectomies. Infection with Y. enterocolitica serotype 0:8 was demonstrated in 38 ill persons. Sixty-one per cent of the persons who were infected had a titer greater than 1:160 OH agglutinins to serotype 8 yersinia, whereas 48 per cent of the hospitalized children had a fourfold change in agglutinin titer. An epidemiologic investigation demonstrated that illness was associated with drinking of chocolate milk purchased in school cafeterias, and Y. enterocolitica 0:8 was subsequently isolated from the milk. The investigation suggested that the bacterium was introduced at the dairy during the mixing by hand of chocolate syrup with previously pasteurized milk.

Hypersensitivity reactions associated with botulinal antitoxin

During an 11-year period (1967 through 1977) CDC monitored reactions of hypersensitivity to botulinal antitoxin of equine origin. Of 268 persons given botulinal antitoxin, 24 (9.0 percent) had nonfatal acute (5.3 percent) or delayed (3.7 percent) hypersensitivity reactions to a skin test or therapeutic dose. The over-all rate of reaction did not differ with the age or sex of the recipient or with the type (AB or ABE) of antitoxin administered. Serum sickness occurred significantly more frequently in persons who received more than 40 ml of serum antitoxin (p < 0.02). The over-all reaction, rate was higher than that associated with other equine serum products and probably cannot be substantially reduced. This risk, however, would be substantially reduced if not eliminated by using botulinal immune globulin obtained from hyperimmunized human donors.

Comparative efficacy and toxicity of amikacin/carbenicillin versus gentamicin/carbenicillin in leukopenic patients: A randomized prospective trail

Abstract Between July 1974 and August 1976, 157 leukopenic patients who had a neoplastic disease or bone marrow failure syndrome were assigned at random to receive either amikacin (7.5 mg/kg every 8 hours)/carbenicillin (100 mg/kg every 4 hours) or gentamicin (2 mg/kg loading, 1.5 mg/kg every 8 hours)/ carbenicillin on admission to the hospital or on completion of a previous course of antibiotic therapy. Fever and evidence suggesting gram-negative rod infection prompted initiation of therapy, and its duration was determined by the patients clinical course and culture data. A total of 155 courses of amikacin therapy and 140 courses of gentamicin therapy were given. The over-all clinical response rate was 75 per cent for both antibiotic regimens. Cure of urinary tract or soft tissue infections was observed in over 90 per cent of the cases. In gram-negative bacillemias only 15 of 23 patients (65 per cent) treated with amikacin and 10 of 17 patients (59 per cent) given gentamicin survived. Two bacteremic patients with gentamicin-resistant (but amikacin-sensitive) rods were assigned at random to receive gentamicin; they died. Improved survival in both treatment groups was associated with the use of combinations of drugs that interacted synergistically in vitro. There was no significant difference in the incidence of ototoxicity and nephrotoxicity. For patients with infections due to an organism susceptible to both amikacin and gentamicin, a regimen which incorporates carbenicillin and either drug is equally effective, but empiric use of amikacin is indicated when there is a reasonable possibility of infection due to gentamicin-resistant organisms.

The Epidemiology of Cholera

Since the first pandemic of cholera in 1817 spread through the Middle East to Europe, cholera has been among the most feared of the classic epidemic diseases.1 Cholera was highly virulent, decimating entire communities within weeks of its introduction. The disease had a high case-fatality ratio that approached 50% in some areas and spread relentlessly in worldwide pandemics from endemic foci in Asia to the Middle East, Europe, East Africa, and the Americas. While cholera epidemics have been extensively described and studied, epidemiologic understanding of the transmission of V. cholerae 01 is still too inadequate to permit effective control measures that would contain the disease and prevent its emergence and spread.2 Proper and timely rehydration therapy can reduce mortality to less than 1%, and antibiotic treatment can decrease shedding of vibrios, but neither of these treatment measures has significantly altered the spread of disease.

Epidemiological and clinical characteristics of acute and persistent diarrhoea in rural Bangladeshi children.

A community‐based longitudinal study of acute and persistent diarrhoea in 705 children less than five years old was carried out for a year in a rural area of Bangladesh. Diarrhoea morbidity data were collected from each study child every fourth day by home visit. Clinical features of diarrhoeal episodes and diarrhoeal management information were documented. The overall diarrhoeal incidence rate in the study children was 4.6 episodes per child per year. The incidence of persistent diarrhoea was 34/100 child‐years. Persistent diarrhoea was positively associated with young age and more severe illness, characterized by the presence of clinical dehydration or blood in the stool in the first week. Use of ORT in the first week was positively associated and use of an antibiotic was negatively associated with the occurrence of persistent diarrhoea. Reduced breast‐feeding and consumption of cows milk at some time during the episode were also positively associated with persistence. This would suggest that appropriate fluid and dietary management for all episodes should be the goal. Children with more severe initial illness characterized by the presence of blood in the stool or clinical dehydration should have more careful follow‐up to identify persistent episodes and adverse nutritional effects. Breastfeeding should be continued during acute diarrhoea, but the role of ORT, antibiotics and cows milk deserves further investigation.

Bacteroides fragilis resistant to the administration of clindamycin

The susceptibility of Bacteroides fragilis to the administration of clindamycin, and the efficacy of this agent in Bacteroides infections are well documented. Clindamycin-resistant strains of B. fragilis were isolated from two patients with bacteremia at two institutions. Clinically significant resistance to clindamycin therapy has not been noted previously in B. fragilis infections.

Safety and immunogenicity of tetravalent rhesus-based rotavirus vaccine in Bangladesh.

Background. Rotavirus is the most common cause of severe gastroenteritis among children worldwide. Objectives. To compare the safety, immunogenicity and shedding patterns of rhesus rotavirus (RRV)-tetravalent vaccine vs. placebo among infants in rural Bangladesh. Methods. A double blinded, placebo-controlled trial was conducted in which infants (n = 120) were randomly assigned to receive three doses of either vaccine or placebo administered at ∼6, 10 and 14 weeks of age together with routine immunizations. Data on possible adverse effects of vaccinations were collected daily for 7 days after each dose. Stool samples were collected after each dose, and serum samples were obtained before the first and after the third vaccination. Results. Fever (≥38°C), as measured by study assistants, was noted more frequently among vaccinees (15%) than among placebo recipients (2%) during the 7 days after vaccination but was not reported more frequently by parents of vaccinees vs. placebo recipients. Overall 87% of vaccinees had an antibody response (measured by IgA or anti-RRV-neutralizing antibodies) after vaccination compared with 32% of placebo recipients. Rates of seroconversion were higher among subjects with lower levels of prevaccination antibodies and those who shed rotavirus after vaccination. Vaccine strain viruses were detected in stools from placebo vaccine recipients who had evidence of IgA seroconversion. Conclusions. In this population RRV-tetravalent vaccine was comparably immunogenic and safe as in trials conducted in developed countries, where this vaccine has been proved effective in preventing severe rotavirus diarrhea. These data support continued evaluation of rotavirus vaccines in developing countries.

Diagnosis and management of febrile children using the WHO/UNICEF guidelines for IMCI in Dhaka, Bangladesh

OBJECTIVE To determine whether the fever module in the WHO/UNICEF guidelines for the integrated management of childhood illness (IMCI) identifies children with bacterial infections in an area of low malaria prevalence. METHODS Physicians assessed a systematic sample of 669 sick children aged 2-59 months who presented to the outpatient department of Dhaka Shishu Hospital, Bangladesh. FINDINGS Had IMCI guidelines been used to evaluate the children, 78% of those with bacterial infections would have received antibiotics: the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%) and urinary tract infection (83%); and 50% or less of children with bacteraemia (50%), dysentery (48%), and skin infections (30%). The current fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot, and have a history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current IMCI module. CONCLUSIONS In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.

Relations between socio‐economic status and morbidity, food intake and growth in young children in two villages in Bangladesh

The relations between socio‐economic status (SES) and food‐intake, morbidity and anthropometric status of children under five years old were analyzed from longitudinal data collected in two Bangladeshi villages. Illness surveillance every other day and monthly anthropometric measurements were done during one year for 197 children, and weighed food intake studies were done monthly for 65 of these children. Socio‐economic variables included wealth (ownership of land, livestock and dwelling size), income (total income and amounts of foodstocks in two seasons) and education (of the head of household, mother and highest in the household). The types of foods taken by study children were associated most with the education of the household head, while the quantity of specific foods eaten, after controlling for the childs age, was more related to the income of the household. Considering diarrheal illnesses, the duration of diarrhea due to Shigella or rotavirus and the incidence of shigellosis were negatively asso...

Rationale for the Development of a Rotavirus Vaccine for Infants and Young Children

Vaccinology is a relatively new term, but its very existence reflects the progress in vaccine development. The field of vaccinology embraces the breadth of biology ranging from molecular biologic initiatives to conven-tional, well-established techniques.