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Diphtheria immunity in adults
THE LANCET
change in proportions for blacks from 1992 to 1993 are 10·7% for ages 50–59, 0·4% for ages 60–69, and –27·4% for ages 70–79. While the magnitude of the proportions is related to age group among both whites and blacks, there is a fairly consistent disparity between the proportion of white and black men receiving a radical prostatectomy. It is unclear why a decline in the proportion of prostate cancer patients treated with a radical prostatectomy exists in all age groups among whites but only in the oldest two age groups among blacks. Because the decline in proportions among whites appears to have begun in the age group 70–79, then in earlier age groups, a similar but delayed pattern may emerge among blacks. In any case, population-based surveillance of the proportion of men receiving a radical prostatectomy is needed to determine whether decreasing proportions reflect the beginning of more conservative management of prostate cancer.
an EIA such as ours, and possibly inappropriate interpretative criteria, will result in the levels of immunity detected being artificially raised. The consequence may be failure to boost immunity in individuals who require it. *P A C Maple, R C George, E Miller, P Morgan-Capner, P Hayward *Special Projects Group, and Respiratory and Systemic Infection Laboratory, Central Public Health Laboratory, 61 Colindale Avenue, London NW9 5HT, UK; Immunisation Division, Communicable Disease Surveillance Centre, London; and Public Health Laboratory, Royal Preston Hospital, Preston, UK
1 2 3
4
Ray M Merrill Cancer Control Research Program of the National Cancer Institute, Applied Research Branch, Bethesda, MD 20892-7368, USA
1
2 3 4
5
Harlan L, Brawley O, Pommerenke F, Wali P, Kramer B. Geographic, age, and racial variation in the treatment of local/regional carcinoma of the prostate. J Clin Oncol 1995; 13: 93–100. Lu-Yao GL, Greenberg ER. Changes in prostate cancer incidence and treatment in USA. Lancet 1994; 343: 251–54. Hinman F Jr. Screening for prostatic carcinoma. J Urol 1991; 145: 126–30. Kramer BS, Brown ML, Prorok PC, Potosky AL, Gohagan JK. Prostate cancer screening: what we know and what we need to know. Ann Int Med 1993; 119: 914–23. Wasson JH, Cushman CC, Bruskewitz RC, Littenberg B, Mulley AG Jr, Wennberg JE. A structured literature review of treatment for localized prostate cancer. Arch Fam Med 1993; 2: 487–93.
Diphtheria immunity in adults SIR—Both John et al1 and Hanlon et al2 have alerted readers to the lack of diphtheria immunity in healthcare workers. They both have used enzyme immunoassay (EIA), although detailed methodology was not given, and interpreted the results using criteria recommended in a previous study by ourselves.3 Unfortunately, the criteria recommended only apply to in-vivo or in-vitro neutralisation assays; antitoxin levels obtained by EIA tend to be artificially elevated by the binding of non-neutralising antibodies. The figure shows the importance of this effect in a study that we have recently undertaken. In this study, 137 sera with antitoxin levels 0·1 IU/mL or more by EIA4 were retested by Vero-cell assay and only 70 (51%) were fully protected (0·1 IU/mL or more), 31 (23%) had basic protection (0·01–0·09 IU/mL), and 36 (26%) were susceptible (less than 0·01 IU/mL). The use of
Number of sera
40
30
20
10
0
Angiostrongylus eosinophilic meningitis in Egypt SIR—Although in 1978 Yousif and colleagues described Angiostrongylus cantonensis in Egypt, both in a definitive host, Rattus norvegicus, and in an intermediate snail host, Lanistes carinatus,1 to our knowledge human infection has not been described in Egypt. We report three cases admitted to the Abbassia Fever Hospital in Cairo, Egypt, during July and August, 1994. Case 1—a 12-year-old boy from the Lower Nile Delta was referred with a 2-week history of low-grade fever, headache, photophobia, vomiting, and low backache, and a 4–5 day history of cough, drowsiness, and possible seizures. He was afebrile, drowsy, with no focal neurological or fundoscopic abnormalities. Laboratory data are shown in the table. Case 2—the 12-year-old girl cousin of case 1 was admitted 1 week after him with a 20-day history of low-grade fever, headache, photophobia, confusion, cough, and vomiting. On examination she was alert and afebrile, with meningism, mild bilateral papilloedema, and an incomplete right cranial nerve VI deficit with nystagmus on right-lateral gaze. Case 3—the 10-year-old brother of case 2 was admitted 1 week later with a 10-day history of intermittent low-grade fever, headache, photophobia, seizures, drowsiness, cough, and low-back pain. On examination he was afebrile but lethargic, with delayed pupillary light reflexes, no papilloedema or focal neurologic deficits, basilar crepitations on chest ausculation, and a palpable liver edge. Computed tomography of the head for cases 1 and 2 showed no focal abnormalities. Stool and cerebrospinal fluid (CSF) examinations for parasites were repeatedly negative in all three cases. ELISA serologies of serum and CSF for parasitic infections, including hydatid, fascioliasis, trichinosis, and schistosomiasis, were negative in cases 1 and 3. Sera and CSF from case 2 were positive for hydatid by a non-specific ELISA with a crude hydatid-cyst fluid extract. Ultrasound examination of the right upper quadrant done Case
>=4·096 0·016 0·064 0·256 1·024 <0·016 0·032 0·128 0·512 2·048
Diptheria antitox in level (IU/mL) Figure: Diphtheria antitoxin levels monitored by Vero-cell assay for sera with antitoxin levels 0·1 IU/mL or more by ELISA
964
John C, Selzer G, Preiser W, Zielen S. Diphtheria immunity in health staff. Lancet 1996; 347: 969. Hanlon M, Isaacs D, Kakakios A. Diphtheria immunity in health staff. Lancet 1996; 347: 1839–40. Maple PA, Efstratiou A, George RC, Andrews NH, Sesardic D. Diphtheria immunity in UK blood donors. Lancet 1995; 345: 963–65. Melville-Smith M. Diphtheria and tetanus antitoxins. In: ELISA in the clinical microbiology laboratory. Wreghitt TG, Morgan-Capner P, eds. London: Public Health Laboratory Service, 1990: 136–47.
1 2 3
Peripheral WBCs
CSF
⫻109/L
% eosinophils
WBCs (5µL)
Peak % eosinophils
Glucose (mg/dL)
Protein (mg/dL)
13 700 10 500 10 400
20 8 15
480 630 850
20 19 18
45 59 72
49 60 380
WBC=white blood cell, CSF=cerebrospinal fluid.
Table: Laboratory data
Vol 348 • October 5, 1996
change in proportions for blacks from 1992 to 1993 are 10·7% for ages 50–59, 0·4% for ages 60–69, and –27·4% for ages 70–79. While the magnitude of the proportions is related to age group among both whites and blacks, there is a fairly consistent disparity between the proportion of white and black men receiving a radical prostatectomy. It is unclear why a decline in the proportion of prostate cancer patients treated with a radical prostatectomy exists in all age groups among whites but only in the oldest two age groups among blacks. Because the decline in proportions among whites appears to have begun in the age group 70–79, then in earlier age groups, a similar but delayed pattern may emerge among blacks. In any case, population-based surveillance of the proportion of men receiving a radical prostatectomy is needed to determine whether decreasing proportions reflect the beginning of more conservative management of prostate cancer.
an EIA such as ours, and possibly inappropriate interpretative criteria, will result in the levels of immunity detected being artificially raised. The consequence may be failure to boost immunity in individuals who require it. *P A C Maple, R C George, E Miller, P Morgan-Capner, P Hayward *Special Projects Group, and Respiratory and Systemic Infection Laboratory, Central Public Health Laboratory, 61 Colindale Avenue, London NW9 5HT, UK; Immunisation Division, Communicable Disease Surveillance Centre, London; and Public Health Laboratory, Royal Preston Hospital, Preston, UK
1 2 3
4
Ray M Merrill Cancer Control Research Program of the National Cancer Institute, Applied Research Branch, Bethesda, MD 20892-7368, USA
1
2 3 4
5
Harlan L, Brawley O, Pommerenke F, Wali P, Kramer B. Geographic, age, and racial variation in the treatment of local/regional carcinoma of the prostate. J Clin Oncol 1995; 13: 93–100. Lu-Yao GL, Greenberg ER. Changes in prostate cancer incidence and treatment in USA. Lancet 1994; 343: 251–54. Hinman F Jr. Screening for prostatic carcinoma. J Urol 1991; 145: 126–30. Kramer BS, Brown ML, Prorok PC, Potosky AL, Gohagan JK. Prostate cancer screening: what we know and what we need to know. Ann Int Med 1993; 119: 914–23. Wasson JH, Cushman CC, Bruskewitz RC, Littenberg B, Mulley AG Jr, Wennberg JE. A structured literature review of treatment for localized prostate cancer. Arch Fam Med 1993; 2: 487–93.
Diphtheria immunity in adults SIR—Both John et al1 and Hanlon et al2 have alerted readers to the lack of diphtheria immunity in healthcare workers. They both have used enzyme immunoassay (EIA), although detailed methodology was not given, and interpreted the results using criteria recommended in a previous study by ourselves.3 Unfortunately, the criteria recommended only apply to in-vivo or in-vitro neutralisation assays; antitoxin levels obtained by EIA tend to be artificially elevated by the binding of non-neutralising antibodies. The figure shows the importance of this effect in a study that we have recently undertaken. In this study, 137 sera with antitoxin levels 0·1 IU/mL or more by EIA4 were retested by Vero-cell assay and only 70 (51%) were fully protected (0·1 IU/mL or more), 31 (23%) had basic protection (0·01–0·09 IU/mL), and 36 (26%) were susceptible (less than 0·01 IU/mL). The use of
Number of sera
40
30
20
10
0
Angiostrongylus eosinophilic meningitis in Egypt SIR—Although in 1978 Yousif and colleagues described Angiostrongylus cantonensis in Egypt, both in a definitive host, Rattus norvegicus, and in an intermediate snail host, Lanistes carinatus,1 to our knowledge human infection has not been described in Egypt. We report three cases admitted to the Abbassia Fever Hospital in Cairo, Egypt, during July and August, 1994. Case 1—a 12-year-old boy from the Lower Nile Delta was referred with a 2-week history of low-grade fever, headache, photophobia, vomiting, and low backache, and a 4–5 day history of cough, drowsiness, and possible seizures. He was afebrile, drowsy, with no focal neurological or fundoscopic abnormalities. Laboratory data are shown in the table. Case 2—the 12-year-old girl cousin of case 1 was admitted 1 week after him with a 20-day history of low-grade fever, headache, photophobia, confusion, cough, and vomiting. On examination she was alert and afebrile, with meningism, mild bilateral papilloedema, and an incomplete right cranial nerve VI deficit with nystagmus on right-lateral gaze. Case 3—the 10-year-old brother of case 2 was admitted 1 week later with a 10-day history of intermittent low-grade fever, headache, photophobia, seizures, drowsiness, cough, and low-back pain. On examination he was afebrile but lethargic, with delayed pupillary light reflexes, no papilloedema or focal neurologic deficits, basilar crepitations on chest ausculation, and a palpable liver edge. Computed tomography of the head for cases 1 and 2 showed no focal abnormalities. Stool and cerebrospinal fluid (CSF) examinations for parasites were repeatedly negative in all three cases. ELISA serologies of serum and CSF for parasitic infections, including hydatid, fascioliasis, trichinosis, and schistosomiasis, were negative in cases 1 and 3. Sera and CSF from case 2 were positive for hydatid by a non-specific ELISA with a crude hydatid-cyst fluid extract. Ultrasound examination of the right upper quadrant done Case
>=4·096 0·016 0·064 0·256 1·024 <0·016 0·032 0·128 0·512 2·048
Diptheria antitox in level (IU/mL) Figure: Diphtheria antitoxin levels monitored by Vero-cell assay for sera with antitoxin levels 0·1 IU/mL or more by ELISA
964
John C, Selzer G, Preiser W, Zielen S. Diphtheria immunity in health staff. Lancet 1996; 347: 969. Hanlon M, Isaacs D, Kakakios A. Diphtheria immunity in health staff. Lancet 1996; 347: 1839–40. Maple PA, Efstratiou A, George RC, Andrews NH, Sesardic D. Diphtheria immunity in UK blood donors. Lancet 1995; 345: 963–65. Melville-Smith M. Diphtheria and tetanus antitoxins. In: ELISA in the clinical microbiology laboratory. Wreghitt TG, Morgan-Capner P, eds. London: Public Health Laboratory Service, 1990: 136–47.
1 2 3
Peripheral WBCs
CSF
⫻109/L
% eosinophils
WBCs (5µL)
Peak % eosinophils
Glucose (mg/dL)
Protein (mg/dL)
13 700 10 500 10 400
20 8 15
480 630 850
20 19 18
45 59 72
49 60 380
WBC=white blood cell, CSF=cerebrospinal fluid.
Table: Laboratory data
Vol 348 • October 5, 1996