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MEDITERRANEAN SPOTTED FEVER PRESENTING AS ACUTE LEUCOCYTOCLASTIC VASCULITIS
1393 SPECIFIC IgE ANTIBODIES TO BORDETELLA PERTUSSIS AFTER IMMUNISATION IN INFANCY
SIR,-Dr Wamer (May 7, p 1058) comments on our earlier letter in which we described the development of specific IgE antibodies to the Bordetella pertussis vaccine (BPV) after routine immunisation in infancy. Our main intention was to report the formation of specific IgE antibodies in infants with an atopic family history after routine immunisation with diphtheria/pertussis-tetanus (DPT) vaccine. This inappropriate immunological response to the pertussis antigen, which is known to be a powerful adjuvant for the reaginic response, has not previously been described in man. We accept that work was not controlled or designed to lead to recommendations about the administration of the DPT vaccine. We would, however, emphasise that none of our infants with a negative atopic family history acquired specific IgE antibodies to BPV, which suggests that this response is facilitated in those infants with a strong genetic predisposition for atopy. In Wamer’s study, respiratory symptoms were more commonly found in atopic children or those having a positive family history of atopy after whooping cough. This supports our suspicion that the increasing respiratory complaints may be due to the development of an inappropriate allergic response to the pertussis antigen. Warner does not present sufficient data to suggest the corollary that natural infection with pertussis is more effective in stimulating the allergic response than DPT immunisation. The critical immunological factors in the genesis of atopic sensitisation 2-3 together with our confirmation that specific IgE antibodies may develop in infants with an atopic family history after routine immunisation, are cause enough for our concern about the routine immunisation of the infant at high risk of an allergic response with the pertussis antigen. Furthermore, Warner’s view that the full pertussis syndrome occurs preferentially in children with an atopic family history supports our concern on the role of the pertussis antigen in the pathogenesis of atopic sensitisation. Trials designed to provide unequivocal guidelines on the administration of the pertussis vaccine in these infants should become a priority. our
Maternal haematocrit at delivery, blood transfusion, and maternal mortality in unbooked women in Zaria, Nigeria.
(Reproduced by permission Gyrtaecology.z
of the British
Journal of Obstetrics and
the operative deliveries were caesarean sections, laparotomies for uterine rupture, or embryotomies for the relief of advanced obstructed labour. Haematocrits, on admission, ranged from 0-05 to 0.60, 301 women having values below 0.20 and 205 having readings above 0-40. Anaemia (haematocrit below 0-30) was from the combined effects of malaria and nutritional deficiencies of iron and folic acid, chronic blood loss playing a part in a few cases; high haematocrits were thought to be due to plasma depletion, as in eclampsia, or to haemoconcentration consequent on dehydration, as in neglected obstructed labour. Blood transfusion, to correct anaemia or to replace blood loss at delivery, was given to 50% of the survivors and 55% of the women who died. Blood transfusion, which was life-saving when the haematocrit was below 020, turned out to be risky when used to replace blood loss in women with haematocrits above 0-40 (figure), especially in the presence of eclampsia, neglected obstructed labour, uterine rupture, and genital sepsis. We do not know why the outlook was so poor in women with high haematocrits who had their operative losses replaced by transfusion, but there are several possibilities. Transfusion in these cases may have been inappropriate; the patients could have been overtransfused; coexisting biochemical disturbances were probably present, but they were neither sought nor corrected for; or the high haematocrit values may simply have reflected the severity of the underlying disease so that the deaths were due not so much to the transfusion itself but to the severity of the underlying disease. All these propositions and others call for further research. Meanwhile these results indicate that in the circumstances prevailing in the most deprived areas in developing countries-where women rarely receive professional antenatal care and where those in whom major obstetric complications develop are often seen for the first time in labour-an important step towards reducing maternal mortality is the installation of a microhaematocrit centrifuge in the labour ward. Emergency admissions can then be screened on the spot for anaemia or volume depletion, and disasters can be avoided. Department of Obstetrics and Gynaecology, University of Port Harcourt, Port Harcourt, Nigeria *Present address
Gynaecologists, 1. Harrison
Office of the Vice President, Royal London NW1 4RG c o
K. A. HARRISON* College of Obstetricians
and
KA, Rossiter CE. Maternal mortality. In: Harrison, KA, ed. Child-bearing, health and social priorities. Br J Obstet Gynaecol 1985; suppl 5: 100-15.
Institute of Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa
M. HAUS* E. G. WEINBERG
*Present address: Janssen Pharmaceutica, PO Box 785939, Sandton 2146, South Africa. 1. Mota
I, Perini A, Trindade VS. The mechanism of the adjuvant effect of Bordetella
pertussis; the substance responsible for the selective enhancement of IgE anti-body production. Int Arch Allergy 1974; 47: 425. 2. Bjorkstén B, Juto P. Immunoglobulin E and T-cells m infants, In Kerr JW, Ganderton MA, eds. Proc IX Int Cong Allergol Clin Immunol. London: MacMillan 1983; 139. 3. Soothill JF. Some intrinsic and extrinsic factors Med 1976; 69: 439.
predisposing to allergy.
Proc R Soc
MEDITERRANEAN SPOTTED FEVER PRESENTING AS ACUTE LEUCOCYTOCLASTIC VASCULITIS
SIR,-A 69-year-old woman was admitted, 1 week after returning from a 10-day holiday on a farm in Portugal, with fever, rash, dysphagia, dysphonia, arthralgia, dyspnoea, cough, chest pain, and proximal muscle weakness. Her only medication was amoxycillin/clavulanate, prescribed in Portugal for the cough. She was toxic. Her temperature was 38’5OC, and she was covered with a florid papular purpuric rash. Her blood pressure was 80/50 mm Hg with a pulse of 104/min in sinus rhythm. The joints were painful to passive movement and a proximal myopathy was present. A cotton wool spot and a single haemorrhage was seen in the right fundus, both ankle jerks were absent, and there was mild meningisim. Laboratory findings included: Hb 129 g/dl, white cell count 84 x 109/1 (92% neutrophils, showing toxic granulation), platelets 88 x 109/1, ESR 59 mm/h, haematuria (with 1 ’3 g/1 proteinuria), and raised transaminases. CSF cell count normal, pressure normal, and glucose not depressed; CSF protein was increased (0-7 mg/ml). Bone marrow aspiration demonstrated generalised hypocellularity with numerous haemophagocytic histiocytes. A skin biopsy showed
1394 ANONYMOUS HIV ANTIBODY TESTING OF WOMEN ATTENDING
leucocytoclastic vasculitis with linear basement deposition of C3 and perivascular fibrin. Serum protein electrophoresis showed a sharp band in the gamma region with an IgM level of 11 -7 g/l (normal 0-5-2-0). C3 was low at 0-3 g/l
severe
acute
membrane
CITY AND HACKNEY HEALTH DISTRICT ANTENATAL CLINICS
zone
(normal 09-1 92). The cause of the severe leucocytoclastic vasculitis was unclear. Since she had had contact with mangy dogs at the farm rickettsial disease was considered despite the absence of tâche noir. In view of the possibility of allergy to amoxycillin, a penicillin was not used; she was given tetracycline, prednisolone, and broad-spectrum antibiotics (cefotaxime, clindamycin, metronidazole). She remained seriously ill with fast atrial fibrillation, loss of anterior R waves, and worsening proximal myopathy. She then improved slowly over 10 days. Serology for typhus, brucellosis, toxoplasmosis, and virus infections was negative and blood cultures were sterile. Mediterranean spotted fever was diagnosed when acute and convalescent sera showed a rise in Rickettsia coronii antibody titre from below 16 to 320. Recovery took several weeks and was complicated by pneumonia, gastrointestinal Clostridium difficile infection, total alopecia, and
A further 1000
seropositive.
competitive EIA (’Enzygnost’; Behring) and by gel particle agglutination (’Serodia-HIV’; Fujirebio). 8 (0-7%) of the 1200 sera gave positive results with all three tests. 1 other serum gave weak positive results in the indirect EIA and gel particle agglutination tests but was negative by competitive EIA. This retested by
further tested for antibodies to HIV-2 by indirect EIA (’Elavia-HIV2’; Pasteur) and gave a strong positive result: it was also tested by western blotting against the antigens of an HIV-2 isolate (’WB LAV2-Blot’; Pasteur) and the reaction pattern obtained was identical to that given by the positive control serum of this test. The serum had been donated by a woman whose country of origin was in sub-Saharan Africa and the results strongly suggest serum was
widespread desquamation. R coronii, the causative agent of Mediterranean spotted fever, is usually transmitted by the dog tick Rhipicephalus sanguineus. The disease is usually mild and is characterised by a tâche noir, a small indurated black lesion with a necrotic centre that develops at the site of the tick bite. To our knowledge an association between R coronii infection and leuocytoclastic vasculitis has been described only twice before,t.2 and in both cases a tâche noir was present, but no such lesion was present in our case. It would be prudent therefore to measure R coronii antibody titres in cases of unexplained leucocytoclastic vasculitis if there is a history of travel in an area affected by Mediterranean spotted fever, even if a tâche nair is
that she was infected with HIV-2 or a similar virus. Because of the unexpected high incidence of the positive results obtained, a further 1000 unselected sera from women who had sequentially booked at antenatal clinics from November, 1987, to February, 1988, were also tested in a similar manner. 3 sera (0-3%) were positive on screening and by competitive EIA and gel particle agglutination. This investigation was undertaken because it was known that a significant number of women booking at our clinics give their country of origin as being in Africa and because of the serious drug abuse problem in the area. We failed to obtain adequate data on the incidence of HIV infection in these women on a voluntary named basis and we doubt whether meaningful results can be obtained by this method. In contrast, anonymous or involuntary unnamed testing has shown that it is likely that at least 0-3% of our antenatal patients are infected and that the probability is much greater in certain groups such as those who were born or have lived in areas of the world where there is a high prevalence of AIDS. In our opinion anonymous testing is the only method whereby health authorities can rapidly assess the gravity of the AIDS problem in particular patient groups and so plan local strategies.
absent. St Thomas’ Hospital, London SE1 7EH St Peter’s Hospital, Chertsey, Surrey
D. J. PENNELL H. C. GRUNDY
M. D. JOY
Simony J, Dumont D, Fixy P, et al. Vasculante cutanee au cours d’une fievre boutonneuse mediterraneenne. Presse Med 1985; 14: 1248. 2. De Micco C, Raoult D, Benderitter T, Gallais H, Toga M. Immune complex vasculitis associated with Mediterranean spotted fever. J Infect 1987; 14: 163-65. 1.
ANONYMOUS TESTING OF WOMEN ATTENDING ANTENATAL CLINICS FOR EVIDENCE OF INFECTION WITH HIV
SiR,—To obtain more accurate information on the epidemiology of AIDS in the UK, a working group reporting to the Department of Health and Social Security’ has recommended that a large cohort of pregnant women should be tested for evidence of HIV infection. They advise that such testing should be on a voluntary named basis but state that the use of involuntary unnamed testing must not be ruled out for the future. The antenatal clinics of the City and Hackney Health Authority introduced a voluntary named HIV testing scheme in August, 1987, for women in the DHSS high-risks groups, as specified by a Royal College of Obstetricians and Gynaecologists working party.2 This has proved to be a dismal failure: during the 5 months September, 1987, to January, 1988, only 9 out of an estimated 1500 women booking at the clinics agreed to be tested (all 9 were seronegative). With the approval of the local ethical committee and our obstetricians we therefore set up an involuntary unnamed investigation in which sera from 1200 antenatal clinic patients were tested anonymously in a way which made it impossible to identify any patient whose serum gave a positive (or negative) result. The sera were selected on the basis of ethnic designation and country of origin (table). This information is routinely obtained from the patients booking at our clinics. The sera had been routinely donated for assessment of rubella immune status and carriage of hepatitis B virus during the 16 month period between August, 1986, and November, 1987. The sera were screened by indirect enzyme immunoassay (EIA) (’Vironostica’; Organon) and those giving positive results were
sequential antenatal clime booking sera obtamed between November, were subsequently tested anonymously and 3 were HIV
1987, and February, 1988,
Department of Virology, St Bartholomew’s Hospital, London EC1A 7BE
R. B. HEATH P. C. A. GRINT A. E. HARDIMAN
Report of a working group on the monitoring and surveillance of HIV infection and AIDS. London: Department of Health and Social Security, 1988. 2. Report of the RCOG sub-committee on problems associated with AIDS in relation to obstetrics and gynaecology. London: Royal College of Obstetricians and Gynaecologists, 1987. 1.
BREAST FEEDING AND HIV INFECTION
’’
SIR,-At this year’s World Health Assembly in Geneva, the UK delegate cited a Department of Health and Social Security circular on breastfeeding and AIDS as a model for member countries. Having now secured the circular, we are shocked to find that the policy deprives babies of the advantages of breast feeding without anti-HIV testing of the mother. Although the document is said to be applicable to the UK only, such policies if pursued in the majority of WHO member countries will almost certainly lead to greatly increased infant mortality. The ethics of arbitrarily depriving babies of breast milk without the most careful consideration and testing must be questioned. The International Baby Food Action Network (IBFAN) has issued a statement, entitled Breast Feeding Endorsed: IBFAN Africa Statement on AIDS, which contains the following paragraph. "It is unprofessional to base any recommendations for artificial feeding on guesswork as to a mother’s probable HIV status.
SIR,-Dr Wamer (May 7, p 1058) comments on our earlier letter in which we described the development of specific IgE antibodies to the Bordetella pertussis vaccine (BPV) after routine immunisation in infancy. Our main intention was to report the formation of specific IgE antibodies in infants with an atopic family history after routine immunisation with diphtheria/pertussis-tetanus (DPT) vaccine. This inappropriate immunological response to the pertussis antigen, which is known to be a powerful adjuvant for the reaginic response, has not previously been described in man. We accept that work was not controlled or designed to lead to recommendations about the administration of the DPT vaccine. We would, however, emphasise that none of our infants with a negative atopic family history acquired specific IgE antibodies to BPV, which suggests that this response is facilitated in those infants with a strong genetic predisposition for atopy. In Wamer’s study, respiratory symptoms were more commonly found in atopic children or those having a positive family history of atopy after whooping cough. This supports our suspicion that the increasing respiratory complaints may be due to the development of an inappropriate allergic response to the pertussis antigen. Warner does not present sufficient data to suggest the corollary that natural infection with pertussis is more effective in stimulating the allergic response than DPT immunisation. The critical immunological factors in the genesis of atopic sensitisation 2-3 together with our confirmation that specific IgE antibodies may develop in infants with an atopic family history after routine immunisation, are cause enough for our concern about the routine immunisation of the infant at high risk of an allergic response with the pertussis antigen. Furthermore, Warner’s view that the full pertussis syndrome occurs preferentially in children with an atopic family history supports our concern on the role of the pertussis antigen in the pathogenesis of atopic sensitisation. Trials designed to provide unequivocal guidelines on the administration of the pertussis vaccine in these infants should become a priority. our
Maternal haematocrit at delivery, blood transfusion, and maternal mortality in unbooked women in Zaria, Nigeria.
(Reproduced by permission Gyrtaecology.z
of the British
Journal of Obstetrics and
the operative deliveries were caesarean sections, laparotomies for uterine rupture, or embryotomies for the relief of advanced obstructed labour. Haematocrits, on admission, ranged from 0-05 to 0.60, 301 women having values below 0.20 and 205 having readings above 0-40. Anaemia (haematocrit below 0-30) was from the combined effects of malaria and nutritional deficiencies of iron and folic acid, chronic blood loss playing a part in a few cases; high haematocrits were thought to be due to plasma depletion, as in eclampsia, or to haemoconcentration consequent on dehydration, as in neglected obstructed labour. Blood transfusion, to correct anaemia or to replace blood loss at delivery, was given to 50% of the survivors and 55% of the women who died. Blood transfusion, which was life-saving when the haematocrit was below 020, turned out to be risky when used to replace blood loss in women with haematocrits above 0-40 (figure), especially in the presence of eclampsia, neglected obstructed labour, uterine rupture, and genital sepsis. We do not know why the outlook was so poor in women with high haematocrits who had their operative losses replaced by transfusion, but there are several possibilities. Transfusion in these cases may have been inappropriate; the patients could have been overtransfused; coexisting biochemical disturbances were probably present, but they were neither sought nor corrected for; or the high haematocrit values may simply have reflected the severity of the underlying disease so that the deaths were due not so much to the transfusion itself but to the severity of the underlying disease. All these propositions and others call for further research. Meanwhile these results indicate that in the circumstances prevailing in the most deprived areas in developing countries-where women rarely receive professional antenatal care and where those in whom major obstetric complications develop are often seen for the first time in labour-an important step towards reducing maternal mortality is the installation of a microhaematocrit centrifuge in the labour ward. Emergency admissions can then be screened on the spot for anaemia or volume depletion, and disasters can be avoided. Department of Obstetrics and Gynaecology, University of Port Harcourt, Port Harcourt, Nigeria *Present address
Gynaecologists, 1. Harrison
Office of the Vice President, Royal London NW1 4RG c o
K. A. HARRISON* College of Obstetricians
and
KA, Rossiter CE. Maternal mortality. In: Harrison, KA, ed. Child-bearing, health and social priorities. Br J Obstet Gynaecol 1985; suppl 5: 100-15.
Institute of Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa
M. HAUS* E. G. WEINBERG
*Present address: Janssen Pharmaceutica, PO Box 785939, Sandton 2146, South Africa. 1. Mota
I, Perini A, Trindade VS. The mechanism of the adjuvant effect of Bordetella
pertussis; the substance responsible for the selective enhancement of IgE anti-body production. Int Arch Allergy 1974; 47: 425. 2. Bjorkstén B, Juto P. Immunoglobulin E and T-cells m infants, In Kerr JW, Ganderton MA, eds. Proc IX Int Cong Allergol Clin Immunol. London: MacMillan 1983; 139. 3. Soothill JF. Some intrinsic and extrinsic factors Med 1976; 69: 439.
predisposing to allergy.
Proc R Soc
MEDITERRANEAN SPOTTED FEVER PRESENTING AS ACUTE LEUCOCYTOCLASTIC VASCULITIS
SIR,-A 69-year-old woman was admitted, 1 week after returning from a 10-day holiday on a farm in Portugal, with fever, rash, dysphagia, dysphonia, arthralgia, dyspnoea, cough, chest pain, and proximal muscle weakness. Her only medication was amoxycillin/clavulanate, prescribed in Portugal for the cough. She was toxic. Her temperature was 38’5OC, and she was covered with a florid papular purpuric rash. Her blood pressure was 80/50 mm Hg with a pulse of 104/min in sinus rhythm. The joints were painful to passive movement and a proximal myopathy was present. A cotton wool spot and a single haemorrhage was seen in the right fundus, both ankle jerks were absent, and there was mild meningisim. Laboratory findings included: Hb 129 g/dl, white cell count 84 x 109/1 (92% neutrophils, showing toxic granulation), platelets 88 x 109/1, ESR 59 mm/h, haematuria (with 1 ’3 g/1 proteinuria), and raised transaminases. CSF cell count normal, pressure normal, and glucose not depressed; CSF protein was increased (0-7 mg/ml). Bone marrow aspiration demonstrated generalised hypocellularity with numerous haemophagocytic histiocytes. A skin biopsy showed
1394 ANONYMOUS HIV ANTIBODY TESTING OF WOMEN ATTENDING
leucocytoclastic vasculitis with linear basement deposition of C3 and perivascular fibrin. Serum protein electrophoresis showed a sharp band in the gamma region with an IgM level of 11 -7 g/l (normal 0-5-2-0). C3 was low at 0-3 g/l
severe
acute
membrane
CITY AND HACKNEY HEALTH DISTRICT ANTENATAL CLINICS
zone
(normal 09-1 92). The cause of the severe leucocytoclastic vasculitis was unclear. Since she had had contact with mangy dogs at the farm rickettsial disease was considered despite the absence of tâche noir. In view of the possibility of allergy to amoxycillin, a penicillin was not used; she was given tetracycline, prednisolone, and broad-spectrum antibiotics (cefotaxime, clindamycin, metronidazole). She remained seriously ill with fast atrial fibrillation, loss of anterior R waves, and worsening proximal myopathy. She then improved slowly over 10 days. Serology for typhus, brucellosis, toxoplasmosis, and virus infections was negative and blood cultures were sterile. Mediterranean spotted fever was diagnosed when acute and convalescent sera showed a rise in Rickettsia coronii antibody titre from below 16 to 320. Recovery took several weeks and was complicated by pneumonia, gastrointestinal Clostridium difficile infection, total alopecia, and
A further 1000
seropositive.
competitive EIA (’Enzygnost’; Behring) and by gel particle agglutination (’Serodia-HIV’; Fujirebio). 8 (0-7%) of the 1200 sera gave positive results with all three tests. 1 other serum gave weak positive results in the indirect EIA and gel particle agglutination tests but was negative by competitive EIA. This retested by
further tested for antibodies to HIV-2 by indirect EIA (’Elavia-HIV2’; Pasteur) and gave a strong positive result: it was also tested by western blotting against the antigens of an HIV-2 isolate (’WB LAV2-Blot’; Pasteur) and the reaction pattern obtained was identical to that given by the positive control serum of this test. The serum had been donated by a woman whose country of origin was in sub-Saharan Africa and the results strongly suggest serum was
widespread desquamation. R coronii, the causative agent of Mediterranean spotted fever, is usually transmitted by the dog tick Rhipicephalus sanguineus. The disease is usually mild and is characterised by a tâche noir, a small indurated black lesion with a necrotic centre that develops at the site of the tick bite. To our knowledge an association between R coronii infection and leuocytoclastic vasculitis has been described only twice before,t.2 and in both cases a tâche noir was present, but no such lesion was present in our case. It would be prudent therefore to measure R coronii antibody titres in cases of unexplained leucocytoclastic vasculitis if there is a history of travel in an area affected by Mediterranean spotted fever, even if a tâche nair is
that she was infected with HIV-2 or a similar virus. Because of the unexpected high incidence of the positive results obtained, a further 1000 unselected sera from women who had sequentially booked at antenatal clinics from November, 1987, to February, 1988, were also tested in a similar manner. 3 sera (0-3%) were positive on screening and by competitive EIA and gel particle agglutination. This investigation was undertaken because it was known that a significant number of women booking at our clinics give their country of origin as being in Africa and because of the serious drug abuse problem in the area. We failed to obtain adequate data on the incidence of HIV infection in these women on a voluntary named basis and we doubt whether meaningful results can be obtained by this method. In contrast, anonymous or involuntary unnamed testing has shown that it is likely that at least 0-3% of our antenatal patients are infected and that the probability is much greater in certain groups such as those who were born or have lived in areas of the world where there is a high prevalence of AIDS. In our opinion anonymous testing is the only method whereby health authorities can rapidly assess the gravity of the AIDS problem in particular patient groups and so plan local strategies.
absent. St Thomas’ Hospital, London SE1 7EH St Peter’s Hospital, Chertsey, Surrey
D. J. PENNELL H. C. GRUNDY
M. D. JOY
Simony J, Dumont D, Fixy P, et al. Vasculante cutanee au cours d’une fievre boutonneuse mediterraneenne. Presse Med 1985; 14: 1248. 2. De Micco C, Raoult D, Benderitter T, Gallais H, Toga M. Immune complex vasculitis associated with Mediterranean spotted fever. J Infect 1987; 14: 163-65. 1.
ANONYMOUS TESTING OF WOMEN ATTENDING ANTENATAL CLINICS FOR EVIDENCE OF INFECTION WITH HIV
SiR,—To obtain more accurate information on the epidemiology of AIDS in the UK, a working group reporting to the Department of Health and Social Security’ has recommended that a large cohort of pregnant women should be tested for evidence of HIV infection. They advise that such testing should be on a voluntary named basis but state that the use of involuntary unnamed testing must not be ruled out for the future. The antenatal clinics of the City and Hackney Health Authority introduced a voluntary named HIV testing scheme in August, 1987, for women in the DHSS high-risks groups, as specified by a Royal College of Obstetricians and Gynaecologists working party.2 This has proved to be a dismal failure: during the 5 months September, 1987, to January, 1988, only 9 out of an estimated 1500 women booking at the clinics agreed to be tested (all 9 were seronegative). With the approval of the local ethical committee and our obstetricians we therefore set up an involuntary unnamed investigation in which sera from 1200 antenatal clinic patients were tested anonymously in a way which made it impossible to identify any patient whose serum gave a positive (or negative) result. The sera were selected on the basis of ethnic designation and country of origin (table). This information is routinely obtained from the patients booking at our clinics. The sera had been routinely donated for assessment of rubella immune status and carriage of hepatitis B virus during the 16 month period between August, 1986, and November, 1987. The sera were screened by indirect enzyme immunoassay (EIA) (’Vironostica’; Organon) and those giving positive results were
sequential antenatal clime booking sera obtamed between November, were subsequently tested anonymously and 3 were HIV
1987, and February, 1988,
Department of Virology, St Bartholomew’s Hospital, London EC1A 7BE
R. B. HEATH P. C. A. GRINT A. E. HARDIMAN
Report of a working group on the monitoring and surveillance of HIV infection and AIDS. London: Department of Health and Social Security, 1988. 2. Report of the RCOG sub-committee on problems associated with AIDS in relation to obstetrics and gynaecology. London: Royal College of Obstetricians and Gynaecologists, 1987. 1.
BREAST FEEDING AND HIV INFECTION
’’
SIR,-At this year’s World Health Assembly in Geneva, the UK delegate cited a Department of Health and Social Security circular on breastfeeding and AIDS as a model for member countries. Having now secured the circular, we are shocked to find that the policy deprives babies of the advantages of breast feeding without anti-HIV testing of the mother. Although the document is said to be applicable to the UK only, such policies if pursued in the majority of WHO member countries will almost certainly lead to greatly increased infant mortality. The ethics of arbitrarily depriving babies of breast milk without the most careful consideration and testing must be questioned. The International Baby Food Action Network (IBFAN) has issued a statement, entitled Breast Feeding Endorsed: IBFAN Africa Statement on AIDS, which contains the following paragraph. "It is unprofessional to base any recommendations for artificial feeding on guesswork as to a mother’s probable HIV status.