Six years after the original 2000 target date for the global eradication of polio, public health workers are encountering several stumbling blocks. Poliovirus circulation persists in countries where the virus is endemic; new outbreaks are occurring in previously polio-free areas, including, most recently, Kenya's first documented wild-type poliovirus infection in 22 years; and complex social challenges stand in the way of public health efforts in some countries.

berculosis is the most common HIV-related opportunistic infection in India, and caring for patients with both diseases is a major public health challenge. India has about 1.8 million new cases of tuberculosis annually, accounting for a fifth of new cases in the world — a greater number than in any other country (see pie chart).1 Patients with latent Mycobacterium tuberculosis infection are at higher risk for progression if they are coinfected with HIV. Patients with HIV infection have a similar bacteriologic response to tuberculosis treatment as those who are not infected but have higher risks of recurrence and death. The influence of tuberculosis coinfection on the progression of HIV disease is controversial.2

On April 1, 2007, India will launch a new phase of its National AIDS Control Program (NACP). Its goals include reducing the number of new human immunodeficiency virus (HIV) infections — currently, an estimated 98.5 to 99.5% of India's 1.1 billion people remain uninfected — improving treatment, and providing therapy to more people. The 5-year program, known as NACP-III, has a budget of about $2.6 billion, two thirds of which is earmarked for prevention and one sixth for treatment (with the remainder primarily for management), and represents a substantial increase in the attention to and spending on HIV–AIDS. More than 80% of the funds will come from outside India — from the World Bank and other international organizations, governments, and philanthropies. Most of the funding has already been committed.

Kala-azar Medical Research Center, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. The Indian Government aspires to eliminate Kala-azar by 2010. Success of any disease control program depends on community participation, and there is no published data about the knowledge, attitude, and practices of the community about Kala-azar in endemic regions of India. For this knowledge, attitude, and practices (KAP) study, the heads of 3,968 households in a rural area, consisting of 26,444 populations, were interviewed using a pre-tested, semi-structured schedule. Most of the study subjects (97.4%) were aware of Kala-azar. Fever (71.3%) and weight loss (30.5%) were the most commonly known symptoms. The infectious nature of the disease was known to 39.9%. The majority believed that the disease spreads by mosquito bites (72.8%). For 63.6%, the breeding site of the vector was garbage collection. Only 23.6% preferred the public health sector for treatment, and 55.9% believed that facilities at primary health centers are not adequate. Poor knowledge of the study subjects about the disease and breeding sites of the vector underscores the need for health educational campaigns if the elimination program is to succeed. PMID: 16968930 [PubMed - indexed for MEDLINE]

Department of Pediatrics, Chang Gung Children's Hospital, Kweishan, Taoyuan, Taiwan. BACKGROUND AND PURPOSE: Kawasaki disease (KD) is rare in infants < or =3 months of age. This study analyzed the features of KD in 25 infants < or =3 months of age treated from February 1994 to December 2004. METHODS: Basic characteristics, clinical, laboratory, echocardiographic, therapeutic, and follow-up data of the infants were obtained from chart records. RESULTS: There were 19 male and 6 female infants in this cohort. The frequency of the 5 principal clinical features was as follows: changes in lips and oral cavity, 84%; bilateral bulbar conjunctival injection without exudates, 80%; polymorphous exanthem, 68%; cervical lymphadenopathy, 28%; and changes in extremities, 24%. Six infants (24%) fulfilled criteria for KD including fever which persists for 5 or more days with at least 4 of the principal clinical criteria, and the remaining infants were classified as having incomplete KD (all of whom showed coronary involvement). Coronary artery dilatation was found in 20 infants (80%). One infant developed a medium-size aneurysm (5.2 mm), while the others had only coronary arterial ectasia or small aneurysms. Coronary artery aneurysms regressed within 1-year follow-up in all but one infant. No fatal or recurrent case was observed during the study period. CONCLUSIONS: Infants < or =3 months of age with KD usually presented with incomplete clinical features. A high proportion of coronary artery involvement was observed in this series. Echocardiography should be considered in very young infants with unexplained prolonged fever who do not present all of the principal clinical features of KD. PMID: 17066200 [PubMed - indexed for MEDLINE]

Adherence to highly active antiretroviral therapy (HAART) medication is the greatest patient-enabled predictor of treatment success and mortality for those who have access to drugs. We systematically reviewed the literature to determine patient-reported barriers and facilitators to adhering to antiretroviral therapy.

Department of Family and Community Medicine, University of Missouri-Columbia, Columbia, Missouri, USA. editor@dynamicmedical.com Up to 7 percent of girls and 2 percent of boys will have a symptomatic, culture-confirmed urinary tract infection by six years of age. Urinary tract infection may be suspected because of urinary symptoms in older children or because of fever, nonspecific symptoms, or failure to thrive in infants. Urine dipstick analysis is useful for ruling out urinary tract infections in cases with low clinical suspicion. However, urine culture is necessary for diagnosis of urinary tract infections in children if there is high clinical suspicion, cloudy urine, or if urine dipstick testing shows positive leukocyte esterase or nitrite activity. Despite current recommendations, routine imaging studies (e.g., renal ultrasonography, voiding cystourethrography, renal scans) do not appear to improve clinical outcomes in uncomplicated urinary tract infections. Oral antibiotics are as effective as parenteral therapy in randomized trials. The optimal duration of antibiotic therapy has not been established, but one-day therapies have been shown to be inferior to longer treatment courses. PMID: 16370404 [PubMed - indexed for MEDLINE]

Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi - 110 029, India. Leishmaniasis is caused by the infection of haemoparasite Leishmania . The disease is a major public health problem in at least 88 countries, including India. Various species of Leishmania are involved in causing this disease. In India, Leishmania donovani species causes visceral leishmaniasis or kala-azar. The parasite is mainly transmitted from infected to uninfected person through the bites of female sandfly. Rarely the parasite can transmit through placenta from mother to child, through sexual intercourse, as laboratory acquired and through blood transfusion. This paper reports a unique case of transfusion-transmitted fatal kala-azar in an Indian infant who acquired this infection within few days of his birth after receiving blood from his maternal uncle, who was asymptomatic at the time of blood donation but died due to severe kala-azar within three months. The baby started having fever and developed hepatosplenomegaly within one month of blood transfusion and in spite of repeated anti-leishmanial treatment with sodium antimony gluconate the child died at the age of 7 months. This paper details the clinico-pathological findings of this child and also reviews the literature on this aspect and its impact on transfusion medicine. PMID: 16912434 [PubMed - indexed for MEDLINE]

Kalazar Research Centre, Muzaffarpur, Bihar, India. dr_tkjha@hotmail.com Pentavalent antimonials (SbV) have been successfully used for treatment of kala-azar since last six decades. Since 1970s its conventional dosages have failed to achieve with 60 per cent unresponsiveness reported with WHO regimen in Bihar (India). Pentamidine initially used as a second line of drug, acquired resistance (25%) even with prolonged dosage. Newer oral drug miltefosine is a potent antileishmanial drug with longer half-life, a property likely to acquire resistance. Paromomycin has undergone extensive clinical trials in Indian kala-azar patients. Being an aminoglycoside, acquired resistance is likely to occur when used as a monotherapy. To encounter the problem of treatment failure in kala-azar and to reduce length of therapy, combination of at least two effective antileishmanial agents is a desirable option. In India sodium stibogluconate (SSG) in standard dose has been combined with other antileishmanial agents including paromomycin without encouraging result. Infection with Leishmania donovani depresses cell-mediated immunity. Immunological balance is tilted in favour of Th2 suppressive cytokines over Th1 producing protective cytokines. Interferon gamma (IFN-gamma) has been used in combination with SbV in Indian kala-azar patients with unexpectedly discouraging results. Combination of two most potent leishmanicidal drugs amphotericin B and miltefosine which are not dependent on host immune system, may shorten the course of therapy besides encountering unresponsiveness. A combination therapy should be preferred when treating kala-azar associated with HIV/AIDS. Immunotherapy with exogenous Th1 stimulating cytokines or use of antileishmanial vaccine in combination with a potent chemotherapeutic agent is a future option. PMID: 16778318 [PubMed - indexed for MEDLINE]

Medical School, University of Tampere and the Department of Pediatrics, Tampere University Hospital, Tampere, Finland. kltaar@uta.fi OBJECTIVES: Antimicrobial treatment may disturb the colonization resistance of gastrointestinal microflora, which may induce clinical symptoms, most commonly diarrhea. The severity of antibiotic-associated diarrhea may range from a brief, self-limiting disease to devastating diarrhea with electrolyte disturbances, dehydration, crampy abdominal pain, pseudomembranous colitis, toxic megacolon, or even death. The incidence of diarrhea in children receiving a single antimicrobial treatment is unclear. In addition to more critical use of antimicrobials, adjunctive preventive measures to antibiotic-associated diarrhea are needed. The objective of this study was to evaluate the incidence of diarrhea after antimicrobial treatment in children with no history of antimicrobial use during the previous 3 months. Another aim of this study was to assess the preventive potential of Lactobacillus rhamnosus GG (Lactobacillus GG; American Type Culture Collection 53103), a probiotic strain with a documented safety record and a therapeutic effect in viral gastroenteritis on antibiotic-associated diarrhea. METHODS: Oral antimicrobial agents were prescribed for the treatment of acute respiratory infections at the clinics of the Health Care Center of the City of Tampere or Tampere University Hospital, Finland, to 167 patients who were invited to participate in the study. Of the patients, 48 were lost to follow-up; therefore, the final study population consisted of 119 children from 2 weeks to 12. 8 years of age (mean: 4.5 years). All study subjects met the inclusion criteria: they had not received any antimicrobial medication during the previous 3 months, they did not suffer from gastrointestinal disorders, and they did not need intravenous antimicrobial treatment. The patients were randomized to receive placebo or 2 x 10(10) colony-forming units of Lactobacillus GG in capsules given twice daily during the antimicrobial treatment. Lactobacillus GG and placebo capsules were indistinguishable in appearance and taste. The parents kept a daily symptom diary and recorded stool frequency and consistency at home for 3 months. Diarrhea was defined as at least three watery or loose stools per day for a minimum of 2 consecutive days. In the case of diarrhea, viral (adenovirus, rotavirus, calicivirus and astrovirus) and bacterial (Salmonella, Shigella, Yersinia, Campylobacter, Clostridium difficile, Staphylococcus aureus, and yeasts) analyses were studied in fecal samples. The metabolic activity of the gut microflora was assessed by analysis of fecal urease, beta-glucosidase, and beta-glucuronidase activities. The primary outcome measure was diarrhea during the first 2 weeks after the beginning of the antimicrobial treatment, because this period most likely reflects the effects of antimicrobial use. Secondary outcome measures were the activities of fecal urease, beta-glucuronidase, and beta-glucosidase. RESULTS: On the entire follow-up, 80% of any gastrointestinal symptoms were reported during the first 2 weeks after the beginning of the antimicrobial treatment. The incidence of diarrhea was 5% in the Lactobacillus GG group and 16% in the placebo group within 2 weeks of antimicrobial therapy (chi(2) = 3.82). The treatment effect (95% confidence interval) of Lactobacillus GG was -11% (-21%-0%). In diarrheal episodes, the viral and bacterial analyses were positive for Clostridium difficile in 2 cases and for Norwalk-like calicivirus in 3 cases. The age of the patients with diarrhea was between 3 months and 5 years in 75% of cases in both groups. The severity of diarrhea was comparable in the study groups, as evidenced by similar stool frequency (mean: 5 per day; range: 3-6) and the duration of diarrhea (mean: 4 days; range: 2-8). The activities of fecal urease and beta-glucuronidase, but not beta-glucosidase, changed significantly after the beginning of the antimicrobial treatment in the Lactobacillus GG group and in the placebo group alike. (ABSTRACT TRUNCATED)