REDUCTION OF HBV INFECTIONS AND MASS IMMUNISATION

53

Although both the specificity and sensitivity ot Tg measurement lower in the presence of normal thyroid tissue than after a total thyroidectomy, its determination during T4 treatment is useful for relapse detection and tor avoiding total-body 131 scans in nearly 60% of these patients.

are

Departments of Medical

Statistics and Nuclear Medicine, Institut Gustave Roussy, 94800 Villejuif, France

FLORENT DE VATHAIRE SYLVENE BLANCHON MARTIN SCHLUMBERGER

1.Ashcraft MW, Van Herle AJ The comparative value of serum thyroglobulin measurements and iodine 131 total body scans in the follow-up study of patients with treated differentiated thyroid cancer Am J Med 1981, 71: 806-14 2. Schlumberger M, Charboid P, Fragu P, Lumbroso J, Parmentier C, Tubiana M. Circulating thyroglobulin and thyroid hormones m patients with metastases of differentiated thyroid carcinoma Relationship to serum thyrotropin levels. J Clin Endrocrinol Metab 1980, 51: 513-19. 3 Tubiana M, Schlumberger M, Rougier P, et al Long term results and prognostic factors in patients with differentiated thyroid carcinoma. Cancer 1985, 55: 794-804.

HYPERPHOSPHATAEMIA IN HAEMOLYSIS

SIR,-Acute hyperphosphataemia and hyperkalaemia can result haemolysis and release of red cell phosphate and potassium.’1 However, we did not see hyperphosphataemia in patients with acute haemolytic anaemia without renal insufficiency. In in-vitro studies, we added increasing amounts of haemolysate (0’1-0’5 ml) to decreasing volumes of serum (final volume 1 ’0 ml) and measured inorganic phosphorus levels.2 Despite very high serum haemoglobin concentrations (400-2240 mg;’dl) the inorganic phosphorus level did not increase. Because increases in plasma haemoglobin in patients with acute haemolytic anaemia did not reach these in-vitro levels, hyperphosphataemia, without renal insufficiency, should not be related to release of red cell phosphate. after

Fig I-Thyroglobulin levels. Patients had differentiated thyroid cancer and had had lobectomy and isthmusectomy. 14 cases had relapsed more than two years later; 41 matched control patients were in complete remission.

Institute of Child Health,

Hacettepe Children’s Hospital, Ankara 06100, Turkey the year of initial treatment ( ± 3 years), age at initial treatment (± 5 years), and histology. The follow-up time for each control was at least as long as the time between initial treatment and recurrence for the corresponding case. Tg was measured one year (± three months) before recurrence in cases and one year (± three months) before the end of the follow-up in controls. Only 4 cases had a Tg level lower than 10 ngiml one year before recurrence (fig 1). The risk of recurrence within one year (estimated by the matched odds ratio) was 5-5times greater (95% confidence interval [CI] x 1.2-25-5, p =001) for patients with Tg levels of 10 ng/ml or more than for patients with lower Tg levels. Sensitivity was studied as a function of specificity (fig 2). With a threshold value of 10 ng/ml, sensitivity was 75% (95% CI 54-96%) and the specificity 57% (95 % CI 43-71 %). Long-term study of these patients showed that the annual risk of recurrence appeared to be small, about 1 %.3 Thus, typically in 400 patients, 4 would be expected to relapse within a year and of these 3 will have had a Tg level above 10 ng/ml one year before relapse. In the 396 patients who will not relapse within a year, 170 would be expected to have had a Tg level above 10 ng/ml that warranted a total-body 131 scan.

...,.

Fig 2-Sensitivity specificity.

of

L. V I I I V n e

thyroglobulin

I I B -

measurement as

function of

Phosphate disorders. In: Kokko and Tannen, eds Philadelphia Saunders, 1986. 451. Goldenberg H, Fernandez A. Simplified method for the phosphorus in body fluid Clin Chem 1966, 12: 871-86

SINASI ÖZSOYLU LUTFIYE MESTCI

1 Lau K.

Fluids and

electrolytes.

2.

estimation

of inorganic

REDUCTION OF HBV INFECTIONS AND MASS IMMUNISATION

SiR,—National programmes to combat hepatitis B (HB) infection are not the same for each geographical region or country, for the needs are dictated by differing epidemiological patterns, prevailing hygienic conditions, socioeconomic factors, cultural and sexual practices, and the environment. Other factors include prevailing affluence, the proportion of wealth spent on health care, relative prevalence of other major health problems, and the biases of health authorities. Thus national programmes vary from routine mass HB vaccination of all newborn babies to screening of all pregnant women for HB surface antigen (HBsAg), and administration of HB immune globulin and vaccine to babies born of HBsAg-positive mothers to selective vaccination of certain high-risk groups after serological screening for HB virus (HBV). The Greek national programme’ was based on extensive epidemiological surveys, considering all the above factors and international experience. Special measures were taken to exclude iatrogenic and transfusion-transmitted hepatitis. Information about preventive measures in health care practice as well as in everyday life was distributed through leaflets and mass media. Vaccination after serological screening was offered free of charge to defmed risk groups (patients with haemophilia or thalassaemica or on haemodialysis, homosexuals, prostitutes, intravenous drug abusers, and all health personnel). Recently we decided to estimate the prevalence of HBV infections before further expanding the vaccination programme to newborn babies. Wehave screened a random sample of 342 army recruits from all geographical areas and population strata. The results were compared with data from our studies2,3 on similar population samples. The table shows the considerable decrease in the prevalence of HBV infections from 1973 to 1986. The decrease of the HBsAg carrier rate was greater

54 REDUCTION OF HBV INFECTION PREVALENCE IN GREEK ARMY RECRUITS (1973-86)

immune.

than the fall in the number This can be attributed to the shift of the age-incidence pattern to an older age, when the risk of becoming a chronic carrier of HBsAg is smaller than in younger children. We have shown2 that the prevalence of HBV infections in Greek army recruits depends on the socioeconomic and educational level of their parents, which defines the hygienic and living conditions during childhood. Thus the reported significant decrease of HBV infections can be attributed to the considerable improvement of financial, socioeconomic, and living conditions in Greece during the past 20 years. We have also shown4 that, in contrast to some areas of South-East Asia, vertical HBV transmission does not have a significant role in Greece, since less than 5 % of the carrier pregnant women are

HBeAg positive. In view of these data

we

decided

against expanding routine

vaccination to newborn babies, until developments in recombinant DNA techniques and synthetic polypeptide vaccines provide more effective and considerably less extensive vaccines.s Our data also highlight the importance of national seroepidemiological surveys in decision making. Thus the results that Dr McMahon and colleagues report (Nov 14,1134) cannot and should not be directly extrapolated as a basis for practice in other areas of the world. National Center for Viral Hepatitis, Athens School of Hygiene, PO Box 14085, Athens 11521, Greece 1

1984. 587-91. 2. Vissoulis H, Papaevangelou G, Hadjiyannis ST. Epidemiologic characteristics of hepatitis B virus infections in Greece. Reports of the VII Int Cong Infectious and Parasitic Diseases. Varna, Bulgaria, Oct 2-6, 1978 248-53. 3 Dandolos E, Roumeliotou-Karayannis A, Richardson SC, Papaevangelou G. Safety and immunogenicity of a recombinant hepatins B vaccine. J Med Virol 1985, 17: 57-62. 4 Papaevangelou G, Hoofnagle J. Transmission of hepatitis B virus infection by asymptomatic chronic HBsAg carrier mothers. Paediatrics 1979; 63: 602-05. 5 Zuckerman AJ. The development of novel hepatitis vaccines. Bull World Health Org 1987; 65: 265-76.

PENICILLIN-RESISTANT NEISSERIA MENINGITIDIS IN SOUTHERN AFRICA

SIR,-Between Aug 16 and Sept 12, 1987, two isolates of meningitidis were found that were resistant to penicillin (minimum inhibitory concentration [MIC] greater than 256 pg/ml)

Neisseria a

the patient was discharged in a satisfactory condition. Case C.-This child was admitted from a rural area 3 weeks later with clinical meningitis and CSF culture yielded group C N meningitidis with a penicillin MIC of 025 j.!gjmJ.2.3Treatment was I MU penicillin and 250 mg chloramphenicol intravenously every 6 h (despite the laboratory report). Temperature returned to normal by the 9th day and the child was discharged clinically well on the 11th

day. No contact between the patients or recent administration of antibiotic therapy could be established in any of the cases. Organisms were identified according to standard methods’ and MIC/minimum bactericidal concentrations were measured by replication on blood agar.Penicillinase activity was investigated by the chromogenic cephalosporin method’ in isolates from the first two cases but case C did not show p-lactamase activity. Attempts to type the p-lactamase and determine its plasmid were unsuccessful. This has been an exceptionally wet spring and N meningitidis notifications have been about five times the usual prevalence at this season. These are the first documented cases of penicillinaseproducing N meningitidis in Southern Africa. Department of Medical Microbiology, University of the Orange Free State, 339 Bloemfontein, South Africa 9300

PHYLLIS BOTHA

Reeves DS, Philips I, Williams JD, Wise R, eds Laboratory methods in antimicrobial chemotherapy. Edinburgh: Churchill Livingstone, 1978 18, 47, and 68. 2. Van Esso D, Fontanals D, Uriz S, et al Neisseria meningitidis strains with decreased susceptibility to penicillin Pediart Dis J 1987, 6: 438-39 3. Scribner RK, Wedro BC, Weber AH. Activities of eight new beta-lactam antibiotics and seven antibiotic combinations against Neisseria meningitidis Antimicrob Agents Chemother 1982; 21: 678-80. 1

4. Cowan ST. Manual for the identification of medical bacteria 2nd ed.

G. J. PAPAEVANGELOU A. ROUMELIOTOU-KARAYANNIS

Papaevangelou G Hepatitis B vaccination in Greece. In. Vyas GN, Dienstag JL, Hoofnagle JH, eds. Viral hepatitis and liver disease. Orlando: Grune & Stratton,

and

mg chloramphenicol were administered intravenously every 6 h grew group B N meyaingitadis resistant to penicillin and sensitive to chloramphenicol. Penicillin was stopped after 2 days and chloramphenicol was continued for a total of 18 days. The next day

third isolate showed diminished susceptibility (MIC 0-25

IJ.g/ml). Case A.-This 15-year-old girl presented with a history of severe headache and vomiting for 2 days. Other relatives were healthy. On examination she was confused,, had no fever, and pulse was 108/min, and she had neck stiffness with positive Kernig and Brudzinski signs. Culture of blood and cerebrospinal fluid (CSF) taken before the start of intravenous therapy for 10 days with 3 MU penicillin and 500 mg chloramphenicol both 6 hourly, yielded group C N meningitidis which was sensitive to chloramphenicol (Joan Stokes’ method)’ and resistant to penicillin. Gram-stain of centrifuged CSF demonstrated scanty unphagocytosed gramnegative diplococci. The patient improved clinically. However, her parents wished to consult a traditional doctor and the patient was discharged on oral 500 mg doses of amoxycillin every 8 hours despite the laboratory report of penicillin resistance. Case B.-This 2’-year-old boy presented 5 days later with a 1-day history of vomiting and coughing. His temperature was 39°C and he had neck stiffness and a red macular rash over the chest and both arms. Culture of CSF taken before 0 75 MU penicillin and 250

Cambridge University Press,

Cambridge

1977. 81

ENTRACAVERNOSAL PHARMACOTHERAPY WITH

INJECTION PEN SiR,—The intracavemous injection of vasoactive drugs is fast

becoming the non-prosthetic treatment of choice for organic impotence.Ihave investigated the safety and efficacy of using an injection for this purpose. The pen injector, designed for insulin administration (’Insuject-X’; Nordisk Gentofte) is needle, syringe, and vial all in one. It weighs 30 g is 14-5cm long, and the cartridge has a replaceable 27G needle. The cartridge contains 2-5 ml of a mixture of 26 mg/ml papaverine hydrochloride with 1-3 mg/ml of phentolamine mesylate. The dose is pre-set, from 0-02 ml to 0 32 ml, by turning a grooved sleeve on the pen. A scale shows how much of the mixture is left. The pen can be carried discretely in a pocket and one cartridge will supply 10-15 doses. The needle must be changed between each injection. The injection is given by inserting the full length of the 10 mm needle into one cavernous body, The papaverine/phentolamine is expelled by turning the sleeve back to zero. Before’ injection a rubber band is placed round the base of the penis to prevent the escape of drugs and to ensure sufficient time for binding; the band is released after 5 min. When the cap is replaced on the pen after use the needle is automatically pulled out of the cartridge, preventing leakage and contamination. Eighteen men with erectile dysfunction were studied, 7 with neurogenic impotence (1vascular/neurogenic), and 11with undetermined organic impotence. They were asked to monitor the duration and function status of erection at home., All patients responded well to a dose of 0 08-0-32 ml. Erections sufficient for intercourse lasted 27-75 min, and there were no complications. The patients find the injection pen easier to use and more aesthetic than the traditional syringe and vial. Department of Urology, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark 1 Krane

BJARNE KROMANN-ANDERSEN

JR, Schulman CC. Editorial. World J Urol 1987; 5: 143.