- Email: [email protected]
COCONUT WATER
281 associated with stunting though not with wasting. parallel association with intensity of infection per g faeces) by Trichuris. In contrast, Ascaris eggs Mminth lumbricoides intensity did not correlate with colitis or with stunting. Both parasitic infections were similar in prevalence and intensity in the village, but the intensity of infection with one parasite was not correlated with that of the other in individuals. We suggest that the essential special feature of Trichuris infection, in contrast to Ascaris, is one long appreciated by clinicians who have done endoscopies in severe cases with heavy worm burdens—namely, inflammation of the colonic and rectal mucosa-and that this accounts for the children’s stunting. We calculate that the morbidity rate from trichuriasis in St Lucia may be as high as 100 per 1000 infected children, yet the morbidity rate as assessed by self-presentation to medical services is only 10 or so per 1000. An often cited worldwide estimate? of morbidity rate hitherto has been 0-2 per 1000. In the village studied,’ 3-5% of children aged 6 months to 6 years had recurrent rectal prolapse associated with intense Trichuris infection. The gross underestimation of morbidity rate has given a falsely benign impression of the whipworm’s importance in world public health and the association of dysentery itself with stunting implies that whipworm infestation may be a major determinant of chronic malnutrition in children.
significantly
There
was a
We acknowledge assistance from the Commonwealth Caribbean Medical Research Council, World Health Organisation, the Wellcome Trust, the Rockefeller Foundation, the International Development Research Centre (Canada), and the St Lucia Ministry of Health. Parasite Epidemiology Research Group, Department of Pure and Applied Biology,
Imperial College, London SW7 2AZ
E. S. COOPER D. A. P. BUNDY
International Centre for Diarrhoeal Disease Research, Bangladesh,
F. J. HENRY
Dhaka-2, Bangladesh
1 Bundy DAP. Epidemiological aspects of Tnchuns and trichuriasis in Caribbean communities. In. Symposium on gastrointestinal helminth infections. Trans R Soc Trop Med Hyg (m press). 2 Bell DR. Lecture notes on tropical medicine, 2nd ed. Oxford: Blackwell, 1985: 181. 3. Henry FJ, Alam N, Aziz KMS, Rahaman MM. Dysentery, not watery diarrhoea is associated with stunting in Bangladeshi children. In: Proceedings of the second annual conference of Indian Society for Medical Statistics, 1984: abstr. 4 Cooper ES, Bundy DAP Trichuriasis in St Lucia. In: Walker-Smith J, McNeish AS, eds. Diarrhoea and malnutrition in childhood. London: Butterworths, 1986: 91-96. 5 Jung RC, Beaver RM. Clinical observations on Trichocephalus trichiurus (whipworm) infestation in children. Pediatrics 1952; 8: 548-57. 6 Sandler M. Whipworm infestation in the colon simulating Crohn’s colitis. Lancet 1981, ii: 210. 7 Walsh JA, Warren KS. Selective primary health care. an interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-74.
COCONUT WATER
SIR,-For about ten years, from the mid 1970s, I encouraged the use of coconut water for the home treatment of diarrhoea in children
in the island of St Lucia. The encouragement was a success, to the point where it has become a part of folklore, so I must feel some concern when Dr Msengi (July 5, p 50) says that "the electrolyte composition of this fluid makes it potentially dangerous for children with acute diarrhoea". This almost sodium-free solution will do nothing to re-expand a contracted extracellular fluid volume in a cnld who is becoming acutely dehydrated. However, this makes coconut water useless rather than dangerous-as useless as, say, boiled water. A child in this state will drink WHO formulation oral rehydration solution (ORS) avidly. My approach was to encourage mothers to take young infants who looked ill to a health centre immediatety, and there ORS would be administered. However, mfants who are not dehydrated are not eager to drink ORS; a thirst :s needed. Coconut water tastes better, while, as Msengi shows in his table, it is in its ionic composition closer to intracellular than actnceMar fluid. Malnourished children have raised intracellular and therefore whole-body) sodium, and whole-body deficits of potassium and magnesium,l in which the unripe coconut is so rich. The mfants who die from diarrhoea, in my experience, are those m shock for whom resuscitation comes too late, and those
with malnutrition, who often die after an initially successful resuscitation. Potassium and magnesium are much more difficult to put back than sodium. Best to start at home. I shall continue to support breast milk and/or coconut water as the best fluids for the child with diarrhoea at home or on the way to the health centre. Gloucestershire Royal Hospital, Gloucester GL1 3NN
1.
E. S. COOPER
Jackson AA, Golden MHN. Protein energy malnutrition. In: Weatherall DJ, Ledingham JGG, Warrell DA. Oxford textbook of medicine. Oxford. Oxford University Press, 1983.
CHLAMYDIA TRACHOMATIS AND INFERTILITY
SiR,—We write to support the concern expressed by Dr Bradbeer and her colleagues (June 21, p 1442), about the identification and management of genital chlamydia infection. We have studied 100 unselected patients attending the Danum Lodge Nursing Home for artificial insemination by donor (AID), comparing pregnancy rates in women who had serological evidence of Chlamydia trachomatis infection with those who did not. Before treatment, an endocervical swab was taken for C trachomatis culture.1,2 Blood was tested for type-specific antibodies to chlamydia by a modified microimmunofluorescence test (Institute of Ophthalmology, London). For comparison we used published data on London blood donors3 and on patients undergoing sterilisation for family planning. All our patients were cervical negative for C - irachamatis. However, significant upper-tract disease may be present without recoverable chlamydiae in the endocervical canal,s and 26 of our 100 AID patients were seropositive, indicating exposure to C trachomatis at some time. 12 of these women had IgG titres of 646 or more. 8 seropositive women had IgM antibody, suggesting active or recent chlamydial infection. The prevalence of chlamydial seropositivity (26%) was greater than the 3% found in London blood donors (p < 0-001) and the 11%found in family planning sterilisation patients (p < O’OOl) 11of our 100 women who had had AID elsewhere. 5 (45%) were seropositive for C trachomatis and 3 were IgM positive. Our numbers are small but it is of interest that of the 89 women attending and AID clinic for the first time, 21 (24%) were seropositive for C trachomatis of whom 5 were IgM positive. Chalamydia may be a contributory factor to infertility in either partner and since chalmydiae attach to the sperm membrane in vitro7 the use of semen donors with chlamydial disease may have led to infection in women with prior AID. We now screen all potential semen donors for chlamydia infection. Once a donor has been accepted repeat screening will be done. Another explanation of our findings could be infection via a third party, the seropositivity simply reflecting earlier disease. It is too soon for us to tell if the success rate of AID is reduced in women who are seropositive for C trachomatis. Of the first AID 18 pregnancies achieved in these 100 women 3 were in the seropositive group; and 15 were
seronegative women. If a trend to increased failure of AID in seropositives does emerge this would be compatible with the increased failure rate reported in seropositive women undergoing in-vitro fertilisation and embryo
replacement.8 Department of Genitourinary Medicine, Doncaster Royal Infirmary, Doncaster DN2 5LT British Pregnancy Advisory Service, Danum Lodge Nursing Home, Doncaster
Department of Genitourinary Medicine, Doncaster Royal Infirmary
T. R. Moss A. NICHOLLS P. VIERCANT
S. GREGSON
J. HAWKSWELL
The growth of Chlamydia trachomatis m McCoy cells treated with cycloheximide B. Appl Microbiol 1974, 28: 912. 2. Oriel JD, Ridgeway GL Genital infection by Chlamydia trachomatis. London Arnold, 1982. 1.
Sompolinsky D, Richmond S.
significantly
There
was a
We acknowledge assistance from the Commonwealth Caribbean Medical Research Council, World Health Organisation, the Wellcome Trust, the Rockefeller Foundation, the International Development Research Centre (Canada), and the St Lucia Ministry of Health. Parasite Epidemiology Research Group, Department of Pure and Applied Biology,
Imperial College, London SW7 2AZ
E. S. COOPER D. A. P. BUNDY
International Centre for Diarrhoeal Disease Research, Bangladesh,
F. J. HENRY
Dhaka-2, Bangladesh
1 Bundy DAP. Epidemiological aspects of Tnchuns and trichuriasis in Caribbean communities. In. Symposium on gastrointestinal helminth infections. Trans R Soc Trop Med Hyg (m press). 2 Bell DR. Lecture notes on tropical medicine, 2nd ed. Oxford: Blackwell, 1985: 181. 3. Henry FJ, Alam N, Aziz KMS, Rahaman MM. Dysentery, not watery diarrhoea is associated with stunting in Bangladeshi children. In: Proceedings of the second annual conference of Indian Society for Medical Statistics, 1984: abstr. 4 Cooper ES, Bundy DAP Trichuriasis in St Lucia. In: Walker-Smith J, McNeish AS, eds. Diarrhoea and malnutrition in childhood. London: Butterworths, 1986: 91-96. 5 Jung RC, Beaver RM. Clinical observations on Trichocephalus trichiurus (whipworm) infestation in children. Pediatrics 1952; 8: 548-57. 6 Sandler M. Whipworm infestation in the colon simulating Crohn’s colitis. Lancet 1981, ii: 210. 7 Walsh JA, Warren KS. Selective primary health care. an interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-74.
COCONUT WATER
SIR,-For about ten years, from the mid 1970s, I encouraged the use of coconut water for the home treatment of diarrhoea in children
in the island of St Lucia. The encouragement was a success, to the point where it has become a part of folklore, so I must feel some concern when Dr Msengi (July 5, p 50) says that "the electrolyte composition of this fluid makes it potentially dangerous for children with acute diarrhoea". This almost sodium-free solution will do nothing to re-expand a contracted extracellular fluid volume in a cnld who is becoming acutely dehydrated. However, this makes coconut water useless rather than dangerous-as useless as, say, boiled water. A child in this state will drink WHO formulation oral rehydration solution (ORS) avidly. My approach was to encourage mothers to take young infants who looked ill to a health centre immediatety, and there ORS would be administered. However, mfants who are not dehydrated are not eager to drink ORS; a thirst :s needed. Coconut water tastes better, while, as Msengi shows in his table, it is in its ionic composition closer to intracellular than actnceMar fluid. Malnourished children have raised intracellular and therefore whole-body) sodium, and whole-body deficits of potassium and magnesium,l in which the unripe coconut is so rich. The mfants who die from diarrhoea, in my experience, are those m shock for whom resuscitation comes too late, and those
with malnutrition, who often die after an initially successful resuscitation. Potassium and magnesium are much more difficult to put back than sodium. Best to start at home. I shall continue to support breast milk and/or coconut water as the best fluids for the child with diarrhoea at home or on the way to the health centre. Gloucestershire Royal Hospital, Gloucester GL1 3NN
1.
E. S. COOPER
Jackson AA, Golden MHN. Protein energy malnutrition. In: Weatherall DJ, Ledingham JGG, Warrell DA. Oxford textbook of medicine. Oxford. Oxford University Press, 1983.
CHLAMYDIA TRACHOMATIS AND INFERTILITY
SiR,—We write to support the concern expressed by Dr Bradbeer and her colleagues (June 21, p 1442), about the identification and management of genital chlamydia infection. We have studied 100 unselected patients attending the Danum Lodge Nursing Home for artificial insemination by donor (AID), comparing pregnancy rates in women who had serological evidence of Chlamydia trachomatis infection with those who did not. Before treatment, an endocervical swab was taken for C trachomatis culture.1,2 Blood was tested for type-specific antibodies to chlamydia by a modified microimmunofluorescence test (Institute of Ophthalmology, London). For comparison we used published data on London blood donors3 and on patients undergoing sterilisation for family planning. All our patients were cervical negative for C - irachamatis. However, significant upper-tract disease may be present without recoverable chlamydiae in the endocervical canal,s and 26 of our 100 AID patients were seropositive, indicating exposure to C trachomatis at some time. 12 of these women had IgG titres of 646 or more. 8 seropositive women had IgM antibody, suggesting active or recent chlamydial infection. The prevalence of chlamydial seropositivity (26%) was greater than the 3% found in London blood donors (p < 0-001) and the 11%found in family planning sterilisation patients (p < O’OOl) 11of our 100 women who had had AID elsewhere. 5 (45%) were seropositive for C trachomatis and 3 were IgM positive. Our numbers are small but it is of interest that of the 89 women attending and AID clinic for the first time, 21 (24%) were seropositive for C trachomatis of whom 5 were IgM positive. Chalamydia may be a contributory factor to infertility in either partner and since chalmydiae attach to the sperm membrane in vitro7 the use of semen donors with chlamydial disease may have led to infection in women with prior AID. We now screen all potential semen donors for chlamydia infection. Once a donor has been accepted repeat screening will be done. Another explanation of our findings could be infection via a third party, the seropositivity simply reflecting earlier disease. It is too soon for us to tell if the success rate of AID is reduced in women who are seropositive for C trachomatis. Of the first AID 18 pregnancies achieved in these 100 women 3 were in the seropositive group; and 15 were
seronegative women. If a trend to increased failure of AID in seropositives does emerge this would be compatible with the increased failure rate reported in seropositive women undergoing in-vitro fertilisation and embryo
replacement.8 Department of Genitourinary Medicine, Doncaster Royal Infirmary, Doncaster DN2 5LT British Pregnancy Advisory Service, Danum Lodge Nursing Home, Doncaster
Department of Genitourinary Medicine, Doncaster Royal Infirmary
T. R. Moss A. NICHOLLS P. VIERCANT
S. GREGSON
J. HAWKSWELL
The growth of Chlamydia trachomatis m McCoy cells treated with cycloheximide B. Appl Microbiol 1974, 28: 912. 2. Oriel JD, Ridgeway GL Genital infection by Chlamydia trachomatis. London Arnold, 1982. 1.
Sompolinsky D, Richmond S.