FOOD ALLERGY

160 RATES OF INFECTION WITH N GONORRHOEAE IN HOMOSEXUAL

MEN,

HETEROSEXUAL MEN, AND HETEROSEXUAL WOMEN ATTENDING DENVER METRO HEALTH CLINIC,]ANVARY-MARCH, 1982 AND

AIDS, it appears that many homosexual

men may be opting for conservative sexual life styles. This is reflected in declining rates of infection with Ngonorrhoeae. It is likely that rates of other sexually transmitted diseases are being similarly affected and that lower steady-state rates will be reached. more

Department of Medicine (Infectious Diseases), University of Colorado Health Sciences Center; and Denver Disease Control

Denver, Colorado 80204, USA

Service,

FRANKLYN N. JUDSON

PASSIVE ANAL INTERCOURSE AS A RISK FACTOR FOR AIDS IN HOMOSEXUAL MEN

SIR,-Recent reports have indicated that passive (receptive) anal a significant risk factor for acquired immunodeficiency syndrome (AIDS). 1,2 In our study of 50 homosexual men

AIDS. Variables that separated AIDS patients from other homosexual men included a history of syphilis, large numbers (>1000) of lifetime partners, inserting a fist into the rectum of a sexual partner, and meeting sexual partners in bath-houses. After one or more of these variables had been entered into logistic regression equations, the number of male partners who had inserted penises into the rectums of respondents was not significantly associated with AIDS at the 95% level of confidence. In our study, passive anal intercourse did not appear to put some homosexual men at increased risk for developing AIDS. However, if AIDS is caused by a transmissible agent, the agent may be spread from an infected host to a susceptible partner during certain sexual activities. As is the case with syphilis, hepatitis B, and other sexually transmitted diseases,having a large number of different partners seems to increase the chances of acquiring AIDS. Intimate sexual contact with partners who might have AIDS should be avoided.6 Furthermore, homosexual men should be aware that the risk of acquiring AIDS increases with an increasing number of different sexual partners. AIDS Activity, Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333, USA

intercourse may be

with AIDS and 145 age, race, and city-of-residence matched homosexual men without AIDS,3 we asked many questions about sexual partners and specific sexual activities. Included was the question, "Considering all the episodes of sexual contact with male partners during the past year, about what percent of these episodes have involved ... [your] partner put[ting] his penis in your rectum?" Responses to this question about anal intercourse ranged from 0 (3 patients and 13 controls) to 100% (3 patients and 6

controls). When responses from the 50 patients were compared with the responses of all 145 controls (including 23 personal friends who were not sexual partners of patients, 44 patients of private physicians who were not chronically ill, and 78 patients of public health clinics who had sought medical service for sexually transmitted diseases), no significant differences were found. Similarly, differences of means in passive anal intercourse tested by Student’s t-test were not significant when AIDS patients (mean 42%) were compared with their friends (45%) or with private practice (40%) or public clinic (34%) controls. When analysed by the method of Mantel,4no differences were detected in the amount of passive anal intercourse (some, >10%, >40%, and >70%) reported by the four categories of respondent. Although no differences were discovered for the proportion of passive anal exposures reported by patients and matched controls, the interaction of proportion of passive anal exposures and number of different male partners in the year before onset of symptoms in patients may have been an important risk factor for AIDS. According to the t-test results, patients had significantly more partners insert penises into their rectums (mean = 92 partners) than their friends (57), private practice controls (28), or public clinic controls (62). However, cross-tabulation analyses indicated that the relation between the interactive variable and AIDS was not significant at the 95% level of confidence. Finally, a series of stepwise logistic regression analyses was done to assess the relative importance of the interactive variable (passive anal intercourse times number of male partners) as a risk factor for R, Fahey JL, Schwartz K, Greene RS, Visscher BR, Gottlieb MS Relation between sexual practices and T-cell subsets in homosexually active men. Lancet

1. Detels

1983, 1: 609-11 2. Zimmerman D The passive gay sexual partner may court AIDS. Med Tribune April 13,

1983: 7, 18. 3.

4.

Jaffe HW, Choi K, Thomas PA, Haverkos H, et al. National case-control study of Kaposi’s sarcoma and Pneumocystis carinii pneumonia in homosexual men: Epidemiologic results. Ann Intern Med (in press). Mantel N. Chi-square tests with one degree of freedom: extensions of the MantelHaenszel procedure. J Am Stat Assoc 1963; 58: 690-700.

WILLIAM W. DARROW HAROLD W. JAFFE JAMES W. CURRAN

FOOD ALLERGY

SIR,-We appreciate the

comments of Dr Rippere (July 2, p 45) article Food Allergy: How Much in the Mind? (June 4, p 1259). However, some of her criticisms are based on erroneous assumptions about how we did the study, which was designed to seek, but failed to find, evidence that psychological symptoms are the direct result of food hypersensitivity. We agree that many organic adverse reactions to food are not immunologically mediated. This is why we did not use the absence of skin reactions or response to cromoglycate to "prove" that patients did not react clinically, as Rippere suggests. We only used these features as positive evidence of food hypersensitivity, and as suggesting the probable presence of IgE-mediated allergy. If both were not positive, we tested for hypersensitivity (of unknown mechanism) by double-blind provocation with the same food incriminated by open testing. Rippere suggests that the double-blind tests we did could have been falsely classified as negative because of incorrect dosages of food, or improper spacing of individual provocations: we gave amounts of food in double-blind tests, similar to those which had produced positive responses on open testing in the same patient; and at similar time intervals. We accept that provocation tests could be obscured by sensitivity to "placebo" substances, but doubt that this explains our results. None of our patients reacted consistently to any particular placebo substance during double-blind tests, and the same patients tolerated the same substances on open testing. We doubt that testing could remain double-blind if distilled water was the only vehicle for several grams of solid material. Rippere seems to imply that psychological symptoms following food can never be psychogenic, while accepting that somatic symptoms may be. The evidence for psychogenic reactions seems very strong in some of our patients, who "reacted" every time they knew they were getting a particular substance, but who did not respond to an identical preparation when they did not know what it contained. Subsequently, the "allergies" of some of the same patients were cured by direct treatment of their psychiatric disturbance. However one interprets our other results, there seems little doubt that dietary changes resulting from the diagnosis of food allergy (whether correct or not), are often potentially more harmful than the disease they are designed to treat. We are disturbed by the frequency with which we now see patients on dangerous diets, sometimes on

about

our

5. Darrow WW, Barrett D, Jay K, Young A. The gay report on sexually transmitted diseases. Am J Publ Health 1981; 71: 1004-11. 6. Centers for Disease Control. Prevention of acquired immune deficiency syndrome (AIDS): Report of inter-agency recommendations. MMWR 1983; 32: 101-3

161 medical advice. A recent example was a 3-year-old boy with moderate eczema, whose diet was grossly deficient in first-class protein, calcium, and vitamin D. We believe strongly that exclusion diets should only be prescribed when of proven necessity; and then only with supervision from a qualified dietician.

DURATION OF BREASTFEEDING, CROWDING, AND CHILD MORTALITY (BALANTAS, MANDINGAS, AND FULAS) IN

FOR THREE ETHNIC GROUPS

A RURAL SETTING. GUINEA-BISSAU

1979-82

Department of Medicine, University Hospital of South Manchester, Manchester M20 8LR

DAVID

Department of Psychiatry, University of Leeds Warrington & District General Hospital

J. PEARSON

KEITH J. B. RIX STEPHEN J. BENTLEY

SPACING, CROWDING, AND CHILD MORTALITY IN GUINEA-BISSAU

SIR,-Prolonged breast feeding and a long birth interval have been associated with better health and survival of children. 1,2 One risk factor for child health seems to be overcrowding: the severity of infections increases when two or more children are sick

simultaneously. 3,4 During a health and nutrition project in Guinea-Bissau we had the opportunity to study ethnic groups with marked variations in child spacing and crowding-namely, Balantas in the Tombali region and Mandingas and Fulas in the Oio region. While rural Mandingas and Fulas breast feed for 30 months on average, the rural Balantas breast feed for 38 months (see table). Since all groups abstain from sexual intercourse while the woman is breast-feeding, Balantas have fewer children than Mandingas and Fulas. A high degree of polygamy increases crowding in all groups. However, whereas adult men among the Balantas have separate households, Mandinga brothers often live together in the same household so their households and living compounds tend to be bigger. On average, there were twice as many children below five years of age in Mandinga as there were in Balanta households. Among the Balantas, each wife ideally has her own room, while wives in Mandinga households live together, with up to ten women in the same circular hut. The difference in crowding is reinforced because Balanta children are said to leave their mother’s bed and move to the bed of a father or grandmother when their mother gives birth to a new child. Mandinga and Fula mothers, on the other hand, may have several children in the bed at the same time. These cultural patterns resulted in a clear difference in mean number of persons sleeping in the same bed as a mother and child (see table). While the youngest Balanta and Mandinga-Fula children aged 0-2 months had similar states of nutrition, the fall in weight-for-age began earlier among the Mandingas and Fulas and was more farreaching (table). In the years 1980 and 1981, when no major epidemic occurred in the populations surveyed, Balanta children below six months of age had a better chance of survival during the following year than did Mandinga and Fula children. While the food production systems are very different, the divergence in the states of nutrition begins before supplementary feeding plays a major role among the three groups, and the difference in mortality occurs while all children are still breastfed. Mandingas in Gambia have a very high child mortality level, but the state of nutrition did not determine risk of death.5 However, variation in severity of infection could cause a difference in state of nutrition and in mortality. Overcrowding increases the risk of early infection and raises the chance of intensive exposure and intercurrent infections. In an urban district of Bissau, we found that Balantas had a significantly lower risk of dying in measles than did other ethnic groups.4 One of the highest case fatality rates ever reported in measles was found among Mandingas in Gambia.5 1. 2

Morley D. Paediatric priorities in the developing world. London: Butterworths, 1973. Gray RH Birth intervals, postpartum sexual abstinence and child health, In: Page HJ, Lesthaeghe R, eds Child-spacing in tropical Africa: Tradition and change. London:

Academic Press, 1981: 93-110. 3 Ross AH Modification of chicken pox

in family contacts by administration of gamma globulin N Engl J Med 1962; 267: 369-76. 4. Aaby P, Bukh J, Lisse IM, Smits AJ. Measles mortality, state of nutrition, and family structure a community study from Guinea-Bissau. J Infect Dis (In press). 5 McGregor IA, Billewicz WZ, Thomson AM. Growth and mortality in children in an African village. Br Med J 1961: 1661-66.

*Data from general child examination, 1979. tCensus, 1979. No census was made in the Fula village *Data from general child examination, 1982. Mandingas constituted 68% and Fulas 29% of the children in the nutritional survey Included are all children aged less than 5 months at time of the general child examination in villages. Children who moved within the following 12 months have been counted as followed for 6 months.

From a preventive health perspective, prolonged spacing may be important because it reduces the risk of small children passing infections to each other. For children aged 1 tla-3 years, breastfeeding did not secure a better state of nutrition (table). However, prolonged breastfeeding and postpartum sexual abstinence, as practised in many parts of the world, may be functionally efficient cultural mechanisms for diminishing overcrowding of small children. Data were collected in a study jointly organised by the Ministry of Health, Guinea-Bissau, and the Swedish Agency for Research Cooperation with Developing countries. The study was supported in part by the Danish Council for Development Research.

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_

PETER AABY

Institute of Ethnology and Anthropology,

University of Copenhagen DK-1220 Copenhagen K, Denmark

JETTE BUKH IDA MARIA LISSE

ARJON J. SMITS

BIRTH SPACING IN ZIMBABWE A GENERATION AGO

SIR,-A generation ago in Zimbabwe children were deliberately spaced both to ensure they received adequate care and to avoid illhealth. with at least one child under five were asked about for birth spacing in their parents’ generation. Interviews took place at their homes in a rural area 30 miles from Gwanda and in a semiurban area on the periphery of this town, which is 91 miles south of Bulawayo. 89% of the rural and 70% of the semiurban respondents said that spacing was done mainly for the health and care of the children, to ensure that each child was brought up properly. They said that too many children born close together "burn" each other and kill each other by passing on diseases easily and that many children in such families die (rural 67%, semiurban 45%). In wartime, families could get away much more easily if only one child had to be carried (rural 51%, semiurban 57%). More than a quarter of the families (rural 26%, semiurban 30%) said that in their parents’ generation people were ashamed of having chidren too close together because it was not accepted in the culture. It was seen as carelessness on the part of the man. A third of families in both of the groups said that birthspacing facilitated work at home and in the fields. The woman could then work for many months before she had to stop for childbirth. It 204

women

reasons