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have an advantage over those who were allegedly denied treatment at the rapid treatment centre. Unless re-infected, men who received treatment before public exposure of the Tuskegee study might not have required treatment for syphilis after public exposure in 1972. This treatment and non-treatment issue has not been considered by conventional information sources. The editorial’s call for a re-analysis of the Tuskegee study1 was appropriate given that discussions have been limited, in part, to the men who were allegedly untreated, not treated, and denied treatment—but not the men who were treated.
4 5 6 7 8 9 10
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Robert M White
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12054 Eaglewood Court, Silver Spring, MD 20902, USA.
[email protected]
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The Lancet Infectious Diseases. Clearing the myths of time: Tuskegee revisited. Lancet Infect Dis 2005; 5: 127. Taylor MB. Tuskegee revisited. Lancet Infect Dis 2005; 5: 467–68. White RM. Unraveling the Tuskegee study of untreated syphilis. Arch Intern Med 2000; 160: 585–98.
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Crissey JT. Treatment of syphilis: a 1932 advertisement. Ann Intern Med 1977; 87: 30. Angell M. Tuskegee revisited. Wall Street Journal October 28, 1997: A22. Thomas SB, Curran JW. Tuskegee: from science to conspiracy metaphor. Am J Med Sci 1999; 317: 1–4. Branche GC. Therapeutic quartan malaria in the treatment of neurosyphilis among Negroes. J Nerv Ment Dis 1936; 83: 177–88. Branche GC. Therapeutic quartan malaria in the treatment of neurosyphilis among Negroes. Am J Psychiatry 1940; 96: 967–78. Robinson HM. Syphilis. Treatment of neurosyphilis. In: Practical dermatology and syphilis. Baltimore: Chelsea Pub Co, 1947: 110. Becker FT. Induced malaria as a therapeutic agent. In: Boyd MF, ed. Malariology. A comprehensive survey of all aspects of this group of diseases from a global standpoint. Volume II. Philadelphia: WB Saunders Co, 1949: 1145–57. Miller LH, Mason SJ, Clyde DF, McGinniss MH. The resistance factor to Plasmodium vivax in blacks. The Duffy-blood-group genotype, FyFy. N Engl J Med 1976; 295: 302–04. Jones JH. Bad blood: the Tuskegee syphilis experiment. New York, NY, USA: Free Press, 1993. Gray FD. The Tuskegee syphilis study: the real story and beyond. Montgomery, AL, USA: Black Belt Press, 1998. Reverby SM. Tuskegee’s truths: rethinking the Tuskegee syphilis study. Chapel Hill, NC, USA: University of North Carolina Press, 2000. Burns SB. A morning’s work: medical photographs from the Burns Archive & Collection. Santa Fe, NM, USA: Twin Palms, 1998. Schuman SH, Olansky S, Rivers E, Smith CA, Rambo DS. Untreated syphilis in the male negro. Background and current status of patients in the Tuskegee study. J Chron Dis 1955; 2: 543–58.
Polio eradication and measles immunisation in Nigeria Almost 11 million children under the age of 5 years die annually worldwide, with 80% of these deaths occurring in Africa. These daunting figures are from the World Health Report 2005, which shows the current status of progress towards the Millennium Development Goals.1 One of the main goals is a reduction of childhood (under 5) mortality by twothirds by 2015 compared with 1990 levels. Measles is responsible for 5% of deaths in children under 5 years in the African region.2 A recent study by Otten and colleagues3 shows that measles deaths have dropped substantially in several African countries, while the Measles Initiative has publicised a decrease of 60% since 1999 for the whole of Africa.4 However, measles remains a major cause of childhood mortality, estimated to have claimed 282 000 lives in 2003;5,6 half of these occurred in Nigeria.7 In 2003, the under-5 mortality rate in Nigeria was estimated at 198 per 1000 live births.1 Current predictions show that the goal of reducing this mortality rate by two-thirds is unlikely to be met8 without a more integrated approach. Nigeria is one of only ten countries in the world with vaccine coverage of less than 50% and one of nine countries in which children do not have a chance of a http://infection.thelancet.com Vol 6 February 2006
second measles vaccination.7 With vaccine coverage remaining persistently below 40% since 1997,9 measles has remained hyperendemic. At the beginning of 2005, a large epidemic was reported in Adamawa state in northeastern Nigeria.10 Large-scale outbreaks of measles were also reported in other northern Nigerian states.10 Nigeria has the highest prevalence of circulating wild poliovirus in the world.11 It is under immense pressure from the international community to get its polio vaccination back on track after a 1-year suspension in Kano, northern Nigeria, following concerns about
Figure: Billboard of the National Programme on Immunization, near Yola, Adamawa state, Nigeria
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vaccine safety. This suspension led to the re-emergence of poliomyelitis in many neighbouring states and countries, setting back the entire global eradication programme.12 The Nigerian National Programme on Immunization is investing huge efforts in the polio eradication programme to get it back on track (figure). Three rounds of national immunisation days took place within the first 5 months of 2005. During the national immunisation days, vaccination teams move from house to house to immunise children below 5 years of age with oral polio vaccine. Thousands of primary health-care workers have been trained across the country. Substantial investments have been made in infrastructure such as computers, refrigerators, ice packs, and uniforms. These national immunisation days, which follow each other in short intervals, demand the full-time commitment of the personnel involved, extensive preparation and evaluation periods, and put continuous stress on the public-health system, consuming a lot of human and financial resources.13 However, they also come with substantial financial incentives to health-care workers in addition to their normal income so there is always guaranteed participation and prioritisation above all other activities. One of the stated objectives of the polio eradication programme is to support health systems development by strengthening routine immunisation and surveillance for communicable diseases.14 Questions are already being asked whether this is being achieved. Field observations in sub-Saharan Africa show polio vaccination campaigns can be temporarily disruptive and divert attention from the development of routine services.15 While all national and international efforts are primarily focused on winning the race against polio, Nigeria seems to be losing an important battle against measles, despite the availability of a safe and effective vaccine for the past 40 years. Insufficient capacity and resources remain to respond appropriately when confronted with a public-health emergency such as a large measles outbreak. While three confirmed cases of poliomyelitis registered in Adamawa state in 200514 triggered massive resource mobilisation and action, hundreds of children dying due to measles during the same time frame did not elicit anything close to an appropriate outbreak response. 64
Improving routine immunisation can prevent many deaths, yet we do not seem to be able to muster the required resolve to pursue this goal without diseasespecific targets. A window of opportunity exists to broaden the benefits of these vertical programmes beyond the specific disease, in this case poliomyelitis. Active efforts should be made to plan for the diversification of these skills. This can only be achieved if the donor that supports these programmes actively demands integration. If these integrated programmes are adequately resourced, the results in terms of public health will be evident, even if there is no outcome like “eradication” or “elimination” to boast of. Sustained vaccine coverage for measles of below 40%, as in Nigeria, in an era of regular national immunisation days for polio eradication is highly disconcerting. Barbara Schimmer, Chikwe Ihekweazu BS and CI are fellows of the European Programme for Intervention Epidemiology Training, Solna, Sweden. BS is also at the Norwegian Institute of Public Health, Oslo, Norway. CI is also at the Health Protection Agency South West, Stroud, UK. Correspondence to: Dr Barbara Schimmer, Department of Infectious Diseases Epidemiology, Norwegian Institute of Public Health, Geitmyrsveien 75, PO box 4404, Nydalen NO-0403 Oslo, Norway. Tel +47 (0) 22042392; fax +47 (0) 22042513;
[email protected] The views expressed in this article are entirely those of the authors and do not necessarily reflect the views of the European Programme for Intervention Epidemiology Training. 1 2
WHO. World health report 2005. Geneva: WHO, 2005. Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet 2005; 365: 1147–52. 3 Otten M, Kezaala R, Fall A, et al. Public health impact of accelerated measles control in the WHO African Region 2000–03. Lancet 2005; 366: 832–39. 4 WHO. Measles cases and deaths fall by 60% in Africa since 1999. http://www.who.int/mediacentre/news/releases/2005/pr55/en/index.ht ml (accessed Dec 13, 2005). 5 Stein CE, Birmingham M, Kurian M, Duclos P, Strebel P. The global burden of measles in the year 2000—a model that uses country-specific indicators. J Infect Dis 2003; 187 (suppl 1): S8–14. 6 WHO. Progress in reducing global measles deaths: 1999-2003. Wkly Epidemiol Rec 2005; 80: 78–81. 7 Hersh B. Beyond 2005: next steps in measles control. 5th Annual Measles Partners for Measles Advocacy Meeting; Geneva, Switzerland; Feb 8–9, 2005. 8 United Nations Development Programme. National Millennium Development Goals report 2004–Nigeria. Nigeria’s profile. http://www.undg.org/documents/5430-Nigeria_MDG_Report__Nigeria_Profile.pdf (accessed Jan 5, 2006). 9 WHO. WHO vaccine preventable diseases monitoring system: 2004 global summary. http://www.who.int/vaccines-documents/ GlobalSummary/GlobalSummary.pdf (accessed Dec 23, 2005). 10 WHO. Acute fever and rash syndrome, Nigeria. Wkly Epidemiol Rec 2005; 80: 101. 11 WHO. Global Polio Eradication Initiative 2004 annual report. Geneva: WHO. 12 Samba E, Nkrumah F, Leke R. Getting polio eradication back on track in Nigeria. N Engl J Med 2004; 350: 645–46.
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13 Aylward RB, Linkins J. Polio eradication: mobilizing and managing the human resources. Bull World Health Organ 2005; 83: 268–73. 14 WHO. Poliomyelitis. http://www.who.int/mediacentre/factsheets/fs114/ en/ (accessed Dec 23, 2005).
15 Bonu S, Rani M, Razum O. Global public health mandates in a diverse world: the polio eradication initiative and the expanded programme on immunization in sub-Saharan Africa and South Asia. Health Policy 2004; 70: 327–45.
Rapidly progressive soft tissue infections We disagree with Donald Vinh and John Embil’s statement1 that non-limb infections may be treated on an outpatient basis, especially facial soft tissue infections, which can be rapidly progressive and life threatening. Such infections often need proper and careful clinical attention. For example, furuncles of the nose (figure 1),2 facial dog bite lesions, common skin and soft tissue infections of dental origin, and acute noma3 can cause serious general morbidity and involvement of deeper soft tissue structures. In immunocompromised individuals, fulminate aspergillus and mucormycosis infections prompt consideration of combining antifungal and surgical therapy at an early stage in a clinical setting.4 Apart from that, there can be very disfiguring defects after medical therapy and surgical intervention by exploration and radical debridement that coincide with inadequate respiration, drinking, and feeding (figure 2).
Figure 2: A Malinese woman with acute noma, general malaise, and difficulties with swallowing, drinking, and feeding
The microorganisms involved in these progressive facial soft tissue infections are diverse and they have been adequately pointed out by Vinh and Embil,1 except for the oral periodontal bacterial flora and fungi. Anticipating medical and surgical therapy, empirically but preferably evidence-based using clinical symptomatology and literature data, is essential. Philip A Van Damme, Ed H M Hartman
Rights were not granted to include this image in electronic media. Please refer to the printed journal
PAVD is a surgeon in the Department of Oral and CranioMaxillofacial Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands. EHMH is a surgeon in the Department of Plastic Surgery, Radboud University Nijmegen Medical Centre. Correspondence to: Dr Philip A Van Damme, Department of Oral and Cranio-Maxillofacial Surgery (590), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, Netherlands. Tel +31 24 3614561/3617314; fax +31 24 3541165;
[email protected] 1 2
3 4 Figure 1: A carbuncle of the upper lip, nose, and left cheek area, with a fulminate course Reproduced with permission from reference 2.
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Vinh DC, Embil JM. Rapidly progressive soft tissue infections. Lancet Infect Dis 2005; 5: 501–13. Van Damme PA. Diagnostic image (185). A man with a pimple on the upper lip. Carbuncle of the upper lip. Ned Tijdschr Geneeskd 2004; 148: 777 (in Dutch). Van Damme PA, Sokoto noma-team 19, September 2002. Noma. Lancet Infect Dis 2004; 4: 73. Van Damme PA, Ingels KJAO, Boetes C, De Graaf SSN, Verweij PE, Hartman EHM. Mucormycosis opposite to aspergillosis of the cheek and/or maxillary sinus. Potential clinical consequences and the value of quick analysis. Ned Tijdschr Med Microbiol 2005; 13: 48–50 (in Dutch).
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