University of Zambia Medical Library


ZAMBIA HEALTH INFORMATION DIGEST

Volume 4 Number 4 Oct-Dec 1997

PUBLISHED BY:
THE UNIVERSITY OF ZAMBIA MEDICAL LIBRARY

IN ASSOCIATION WITH:
THE MINISTRY OF HEALTH, ZAMBIA
THE DREYFUS HEALTH FOUNDATION OF NEW YORK
A GRANT FROM THE IBM CORPORATION

[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Andrew L.Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Ms. Regina Shakakata, Health Information & Promotions Officer: World Health Organisation-Zambia
Mr. Edgar Chani, Health Information Officer: Ministry of Health, Zambia
Dr. Katele Kalumba: Minister of Health, Zambia
Dr. Mannasseh Phiri, Chief Medical Officer: Company Clinic, Kitwe
Mrs. Norah Mumba, Medical Librarian (Ag): University of Zambia Medical Library

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Zambia Health Information Digest
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Ketiwe Shani
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Jane M. Phiri

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COMMUNICATIONS FOR BETTER HEALTH -DREYFUS HEALTH FOUNDATION &
COMMONWEALTH REGIONAL HEALTH COMMUNITY SECRETARIAT FOR EAST, CENTRAL AND SOUTHERN AFRICA HEALTH INFORMATION DISSEMINATION(CRHCS- ECSA)

The Zambia Health Information Digest is produced to provide current information to health workers who have little access to current health related publications and information.

SOURCE:
The abstracts of journal articles published in this quarterly Digest are obtained from the MEDLINE databases provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.
Computer equipment has been supplied through a grant from the IBM Corporation. Subjects that are prominently reflected on the Medical Library's MEDLINE search requests and information on prevalent health conditions seen in Zambia are published. Other health related subjects are also included.
The Health Sciences Centre Library of the University of Florida, our cooperating partners, will supply photocopies of the full text articles to the University Medical Library on request, which in turn will be supplied to readers on request. When available in the library, articles will be photocopied at a nominal cost.
Production costs are supported by The Dreyfus Health Foundation of New York. Full articles on unsafe abortion are provided by courtesy of Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa (CRHCS), who have also contributed generously to the expansion of the Digest. We encourage readers to submit requests for articles highlighted in the Digest.

CUSTOM SEARCHES:
Using the MEDLINE compact disc databases, custom searches can be done on any health issue to obtain the most up-to-date information available. Readers are encouraged to submit requests for searches on relevant health problems which they face. Requests should be sent to the Medical Library, attention Norah Mumba.

TABLE OF CONTENTS:

Editorial:

Seventy years ago corneal ulceration causing blindness from Vitamin A deficiency was first recognised in an orphanage in Denmark. It was called xerophthalmia. Since that time much has been learnt about this tragic and entirely preventable disease which kills and blinds so many young children. Unfortunately this knowledge is still not being put into practice and xerophthalmia is still common in many developing countries. It would seem that at least half of child blindness in Africa is caused by xerophthalmia and its complications. Its prevention is quite simple although its causes are complex. The first cause is a dietary deficiency of vitamin A. However, isolated vitamin deficiencies are not common and most of these children have some degree of protein-energy malnutrition as well. Also the severe corneal ulceration that causes blindness nearly always follows an acute ill ness, especially measles. Other factors may contribute to the corneal ulceration. These are severe herpes infection, exposure ulceration of the cornea, and damage from toxic traditional eye medicines. Occasionally, secondary bacterial infection may occur. John Sandford-Smith, Consultant Ophthalmologist at the Leicester Royal Infirmary in an article on Xerophthalmia and blinding corneal ulceration in children.

Several abstracts of papers presented at a Seminar for Eyes Diseases which took place in Lusaka in 1988 give a localised picture of the dimensions of the problem of eye diseases in Zambia. Also in this issue is a feature article on eye complications associated with diabetes.

Eye Diseases (Current Abstracts of Journal Articles -- MEDLINE)

Low vision and blindness

A survey to determine the prevalence and causes of blindness and visual impairment in the Extreme North Province of Cameroon was conducted in the Spring of 1992. A total of 10,647 people age 6 years and older was selected from a multi-stage, clustered sample stratified by ecological zone. The subjects were examined by ophthalmologist-led teams for visual acuity and ocular diseases. Approximately 1.2% of the sample was bilaterally blind by the World Health Organization classification (Category 3) of vision less than the ability to count fingers at 3 meters. Similarly to results found in other developing countries, senile cataract was the most common diagnosis encountered and the most frequent principal cause of low vision and blindness.
Wilson MR. Mansour M. Ross-Degnan D. Moukouri E. Fobi G. Alemayehu W. Martone JF. Casey R. Bazargan M. Prevalence and causes of low vision and blindness in the Extreme North Province of Cameroon, West Africa.
Ophthalmic Epidemiology. 3(1):23-33, 1996 Mar.

Graft survival and visual outcome

Yorston D. Wood M. Foster A. Penetrating keratoplasty in Africa: graft survival and visual outcome.
British Journal of Ophthalmology. 80(10):890-4, 1996 Oct.

Socioeconomic consequences of blindness in West Africa

Onchocerciasis or river blindness, a major cause of irreversible blindness among adults, has been the focus of international disease control efforts for over 20 years in West Africa. This paper employs the international classification of impairment, disability and handicap (ICIDH) to interpret results from a field study to assess the socioeconomic consequences of onchocerciasis in Guinea in 1987. In a sample of 136 blind, 94 visually impaired and 89 well-sighted persons, decreasing visual acuity is strongly associated with mobility, occupational and marital handicaps. Individual, household and disease correlates were explored. The implications of these findings for the ICIDH concept of handicap are discussed with particular emphasis on the need to extend analysis beyond the individual when assessing the socioeconomic consequences of disabling disease.
Evans TG. Socioeconomic consequences of blinding onchocerciasis in west Africa.
Bulletin of the World Health Organization. 73(4):495-506, 1995.

Hereditary disease as a cause of childhood blindness

There is evidence from developed countries that genetic disease is the major cause of childhood blindness. Little data are available from most developing and newly industrialised countries concerning the relative importance of hereditary diseases as a cause of childhood blindness. Children in schools for the blind in 13 countries of Africa, Latin America and Asia were examined between 1990 and 1994 using a standardised method The anatomical site of abnormality and underlying aetiology were analysed for children with a corrected acuity in the better eye of less than 6/60 (severe visual impairment and blindness, svi/BL). In these countries II-39% of svi/BL was attributed to genetic disease. Genetic diseases were responsible for a higher proportion of childhood visual loss in countries with higher levels of socio-economic development. An autosomal recessive mode of inheritance was reported in 22-52% of children with genetic disease. Retinal dystrophies were the commonest form of genetic eye disease (49-80%) in all countries apart from Thailand and the Philippines where cataract was the commonest (43.9%). The role of consanguinity, and opportunities for further research are discussed.
Gilbert C. Rahi J. Eckstein M. Foster A. Hereditary disease as a cause of childhood blindness: regional variation. Results of blind school studies undertaken in countries of Latin America, Asia and Africa.
Ophthalmic Genetics. 16(1):1-10, 1995 Mar.

Age related cataract

Cook CD. Stulting AA. Prevalence and incidence of blindness due to age-related cataract in the rural areas of South Africa.
South African Medical Journal. 85(1):26-7, 1995 Jan.

Corneal ulcers & use of traditional eye medicines

The most common cause of monocular blindness in Africa is cornealopacification. Traditional eye medicines (TEM) are widely used in Africaand their use has been associated with corneal ulceration, however, nocontrolled studies of the effects of TEM on the cornea have been published. We conducted a case-control study of 39 patients with corneal ulcers matched to controls with severe conjunctivitis. Microbiological investigations were conducted on 20 cases. There was a significant association between corneal ulceration and TEM use and, in particular, peripheral corneal ulcerations were significantly associated with TEM use.
Lewallen S. Courtright P. Peripheral corneal ulcers associated with use of African traditional eye medicines.
British Journal of Ophthalmology. 79(4):343-6, 1995 Apr.

Eye care delivery in developing countries

Only 5% of the world's population is found in the United States, yet we as a nation consume 40% of the world's resources. In stark contrast, two thirds of the world's population live in developing countries where 90% of all blindness occurs and where even the most basic resources for eye care delivery are scarce or absent. Using U.S. criteria defining blindness (less than 20/200 [6/60]), the World Health Organization estimated in 1984 that 42-52 million people were blind from all causes, an increase of more than 10% since 1978. High population growth rates in most developing countries coupled with the failure of governments to develop health services commensurate with needs are responsible for this trend. On economic grounds alone, the U.S. eye care delivery paradigm cannot be broadly replicated in the developing world. Instead, cost-effective creative strategies, many already in place, such as mass surgery camps in Asia and delivery of eye care by non-ophthalmologists in Africa, can be expanded and streamlined. The upgrading of sight restoration and preservation care depends upon mobilization of political will within the international health community; governments must prioritize eye care as a public health problem; health planners must mobilize financial resources and work closely with technical assistance organizations, and ministries of health must cease to emulate expensive high-technology eye care models.
Schwab L. Eye care delivery in developing nations: paradigms, paradoxes, and progress.
Ophthalmic Epidemiology. 1(3):149-54, 1994 Dec.

Blindness from uveitis

A retrospective study was conducted to assess the causes of blindness and visual impairment in patients who visited an eye hospital in Sierra Leone, West Africa, in 1989 and 1992. These data were compared with figures from 1981. Throughout the years, senile cataract was the major cause of blindness, followed by uveitis (including onchocerciasis). Uveitis remained the second most important cause of blindness in this population, despite the significant decrease in blindness from onchocerciasis (from 30% in 1981 to 15% in 1992). An increasing number of patients with uveitis from non-onchocercal origin was observed: almost 10% of the blindness found in 1992 was due to uveitis of non-onchocercal origin. A reduction in visual handicap in patients with non-onchocercal uveitis could be achieved if local hospitals could obtain more accurate diagnoses in these patients.
Ronday MJ. Stilma JS. Barbe RF. Kijlstra A. Rothova A. Blindness from uveitis in a hospital population in Sierra Leone.
British Journal of Ophthalmology. 78(9):690-3, 1994 Sep.

Vitamin A deficiency

Of 207 children (aged 4-7 years) in western Mali examined clinically and by conjunctival impression cytology (CIC), 2% had night blindness, no child had Bitot spots and 78% were found to have abnormal CIC suggesting deficiency in vitamin A. In a cohort of 53 children examined by CIC pre and post-harvest (June and December), abnormal CIC were seen in 77.4% and 54.7%, respectively (P = 0.04). Subclinical vitamin A deficiency is a problem in this area. A seasonal variation is demonstrated. CIC is a useful method for identifying communities with subclinical vitamin A deficiency. A variety of strategies for dealing with vitamin A deficiency are discussed.
Perkins AL. Evaluation of vitamin A deficiency in the Yelimane Circle of Mali, west Africa.
Tropical Doctor. 24(2):70-2, 1994 Apr.

Retinitis pigmentosa in southern Africa

Retinitis pigmentosa (RP) is a heterogeneous group of inherited retinaldisorders which are a common cause of genetic blindness. The relative frequencies of the different forms of RP in South Africa, as determined from the register at the DNA banking centre for RP at the Department of Human Genetics, University of Cape Town, are presented and discussed. Of the 125 families analysed, 29 (23%) showed autosomal dominant, 33 (27%) autosomal recessive and 3 (3%) X-linked inheritance. In 10 families the pedigree data were insufficient to allow accurate genetic subtyping and a further 50 patients were sporadic without a family history of RP or other syndromic features which would allow categorization.
Greenberg J. Bartmann L. Ramesar R. Beighton P. Retinitis pigmentosa in southern Africa.
Clinical Genetics. 44(5):232-5, 1993 Nov.

Eye problems in developing countries

Berger IB. Nnadozie J. Onchocerciasis and other eye problems in developing countries: a challenge for optometrists. [Review] [14 refs]
Journal of the American Optometric Association. 64(10):699-702, 1993 Oct.

Blindness in Africa

An ophthalmic assessment survey of 430 students in Zimbabwe's two schools for the blind was conducted in 1988. Bilateral corneal opacity was found to be responsible for 75% of all blindness among institutionalised blind students. Thirteen per cent of the study patients could gain improved vivision through either ocular surgical intervention or spectacle correction. Findings in this survey are similar to those from other schools for the blind elsewhere in Africa.
Schwab L. Kagame K. Blindness in Africa: Zimbabwe schools for the blind survey.
British Journal of Ophthalmology. 77(7):410-2, 1993 Jul.


Causes of childhood blindness

Using World Health Organization definitions of visual loss and a standardised methodology, 905 children were examined in Chile, West Africa and South India. Of these 806 (89%) suffered from blindness (BL) or severe visual impairment (SVI). Causes of SVI and BL were classified anatomically and aetiologically, and avoidable causes identified. In W. Africa (n = 284) the major anatomical cause of SVI/BL was corneal scar/phthisis bulbi (35.9%). Retinal disease accounted for 20.4%, cataract 15.5% and glaucoma 13.0%. Aetiologically 33.8% of SVI/BL was due to childhood factors and 21.1% to hereditary disease. In S. India (n = 305) the major anatomical cause of SVI/BL was corneal scar/phthisis bulbi (38.4%). Retinal disease accounted for 22.6%, cataract 7.4% and glaucoma 3%. Aetiologically 37.0% of SVI/BL was due to childhood factors and 29.8% to hereditary disease. In Chile (n = 217) the major anatomical cause of SVI/BL was retinal disease (47.0%). Cataract accounted for 9.2%, glaucoma 8.3% and 6.9% was due to corneal pathology. Aetiologically 30.4% of SVI/BL was due to hereditary factors, and 20.8% to perinatal factors of which four-fifths (16.6%) was due to retinopathy of prematurity. Avoidable conditions accounted for 70%, 47% and 54% of cases in W. Africa, S. India and Chile respectively.
Gilbert CE. Canovas R. Hagan M. Rao S. Foster A. Causes of childhood blindness: results from west Africa, south India and Chile.
Eye. 7 ( Pt 1):184-8, 1993.


Vitamin A

Vitamin A was first discovered in 1913. Its deficiency was soon associated in animal models and case reports with stunting, infection, and ocular changes (xerophthalmia) resulting in blindness. The ocular consequences dominated clinical interest through the early 1980s. A longitudinal prospective study of risk factors contributing to vitamin A deficiency and xerophthalmia revealed a close, dose-response relationship between the severity of mild preexisting vitamin A deficiency and the subsequent incidence of respiratory and diarrheal infection (relative risk [RR], 2.0-3.0) and, most dramatically, death (RR, 3.0-10.0). Subsequent community-based prophylaxis trials of varying design confirmed that vitamin A supplementation of deficient populations could reduce childhood (1-5 years old) mortality by an average of 35%. Concurrent hospital-based treatment trials with vitamin A in children with measles revealed a consistent reduction in measles-associated mortality in Africa of at least 50%. It is now estimated that improving the vitamin A status of all deficient children worldwide would prevent 1-3 million childhood deaths annually. [References: 63]
Sommer A. Vitamin A, infectious disease, and childhood mortality: a 2 solution?.
Journal of Infectious Diseases. 167(5):1003-7, 1993 May.


"Stones in the eye"

A retrospective study of 1214 outpatients in Sierra Leone, West Africa was done to answer the question, "What is the visual acuity following extracapsular cataract extraction (ECCE) with an intraocular lens (IOL) for patients in a developing country?" Only 24% achieved uncorrected pseudophakic visual acuity of 20/20 to 20/50. Additionally, postoperative complications and patient complaints were tracked. Results showed suture irritation was less prevalent in those patients when 10-0 nylon suture was used, cut close, and the knot rotated and buried.
Winter JD. "Stones in the eye": post cataract suture irritation--a transcultural study from Sierra Leone, West Africa.
Insight. 19(4):8-10, 1994 Dec.


Traditional treatment of cataract

Empiric treatment of cataracts by couching is still commonly performed by traditional healers in West Africa. In the ophthalmology department in the regional hospital of Zinder, in Niger, 22 cases have been identified and their complications treated medically and surgically. The semiotic analysis demonstrated the diversity of methods used, sometimes successfully by the traditional healers. Apart from the classical technics of luxation in the vitreous, we have observed a number of cases with integrity of the posterior capsule and disappearance of the nucleus. These last observations have lead us to believe that certain traditional healers may use local plants with phakolytic effects in their pharmacopia.
Mariotti JM. Amza A. [Traditional treatment of cataract in Niger. Apropos of 22 cases]. [French]
Journal Francais d Ophtalmologie. 16(3):170-7, 1993.


Methods for detection of glaucoma

Quigley HA. West SK. Munoz B. Mmbaga BB. Glovinsky Y. Examination methods for glaucoma prevalence surveys.
Archives of Ophthalmology. 111(10):1409-15, 1993 Oct.

SELECT ABSTRACTS FROM: SEMINAR ON EYE DISEASES IN AFRICA.

Lusaka 25 - 26 February 1988. Organised by Tropical Diseases Research Centre (TDRC); National Food & Nutrition Commission; Zambia Flying Doctor Service; Ministry of Health.


PREVALENCE AND DISTRIBUTION OF XEROPHTHALMIA AND TRACHOMA IN THE LUAPULA VALLEY OF ZAMBIA
 D.J. Kwendakwema : Zambia Flying Doctor Services

Luapula Valley is found in the Northern part of Luapula Province. It has a population of 300,000 people(1980 Pop estimate). The Luapula river which runs in the valley from the national boundary with Zaire. The valley is between ten and twenty five kilometres in width, covering a surface area of approximately 2,5000 km. The valley runs through three districts namely, Nchelenge, Kawambwa and Mwense. For close to four decades now, the Luapula valley has been traditionally known as the "Valley of the blind" because of the high prevalence of blindness. Between 1955 and 1966 , studies were conducted by various researchers to determine the rate and major causes of blindness in the valley among the children under the age 15 years. John Wilson (1955) estimated that the rate of blindness in Mununga was 2,640 per 100,000 population and that for the children under the age 15, it was 3,000 per 100,000 children. This was the highest figure ever recorded in Zambia. A survey conducted by the Government Ophthalmologist Mr Philips (1959) obtained a blindness rate 2,369 per 100,000 for children aged under 18 months. These figures were suspected to be erroneously high because total population figures used were an underestimate.

There was conflicting information regarding the causes of blindness in the valley where as Mr Philips felt that "Muti" (traditional medicine) was the major causes of blindness. Ridley (1961) , Cobb,(1962), Awdry(1963) were of the opinion that malnutrition (due to vitamin A deficiency) was responsible. M. C. Glashan (1964-66) analysed the distribution of blindness in Luapula using information from Registry of Blind Persons and the population statistics of 1963 census and he attributed the cause of blindness to measles.

Fris Hansen and M.C. Gullough (1961, 1962) who carried out parasitological, nutrition and medical survey - selected areas of Luapula concluded that vitamin A deficiency was the major causes of blindness. However, Blackhast (1967), a WHO consultant found no clinical evidence of Vitamin a deficiency in hundred of children many of whom were malnourished.

It is against this background that a survey was carried out between August and December, 1985 to determine the rate and the major causes of blindness among children aged under 6 years. A total of 4,275 children in three districts in the Luapula Valley received ocular examination for xerophthalmia and trachoma. Ocular examination for xerophthalmia looked for Butot's spots (xib), corneal xerosis (x2), severe corneal lesions (x3A, x3B) and corneal scars (xs) and mothers were also asked whether or not the child currently had night blindness (XN). The prevalence of xerophthalmia in all the districts was 1.89%(1.48, 2.30). The prevalence of XN, XIB, X3A and X3B, and XS were 1.26%, 0.44%, 0.02% and 0.68% respectively.
Three gradings were used for trachomatous infection:- (I) Follicular trachomatous inflammation (TF) (ii) Severe trachomatous inflammation(TS) (iii) Trachomatous cicatrisation (TC) *95% confidence interval (CS)

The cross sectional study showed a trachoma prevalence of 16.56% among the children aged under 6 years . The youngest child found with TF was three months old. These survey findings in the Luapula Valley province some of the first reliable information of the prevalence of Xerophthalmia and Trachoma in the pre-school age children. Other findings indicate that Xerophthalmia is a Public Health problem in the Luapula Valley whereas trachoma is not.


LUAPULA EYE DISEASES SURVEY PROJECT
 A.B. Vermoer : National Food and Nutrition Commission, Lusaka, Zambia.

Zambia has a high incidence and prevalence of blindness with the Luapula Valley contributing significantly to the total number of blind persons. Based on sporadic past surveys, the causes of blindness in the Luapula Valley have been conflicting and has resulted in the delay of implementation of preventive and curative measures. Among suspected causes of high prevalence of blindness in the Luapula Valley are: To unify past conflicting findings and to quantify the extent and distribution of blinding eye disorders to serve as a baseline against which the effectiveness of intervention programmes would be evaluated in the Luapula Valley, a cross-sectional prevalence survey of approximately 5,000 children under 6 years of age and 2,5000 persons six years and older was conducted in 1985 with financial assistance from the International Development Research Centre(IDRC), Canada, and the Government of the Republic of Zambia. Causes and risk factors of blinding disorder in the Luapula Valley will be presented and corrective intervention strategies recommended.

THE ROLE LEAF CONCENTRATE (THE RICHEST FOOD SOURCE OF BETA-CAROTENE) IN THE PREVENTION OF NUTRITIONAL BLINDNESS
 Michael Norman Gly Davis : Find Your Feet Limited, United Kingdom

Over the intervening years Tony Pirie has emphasized the importance of leaf concentrate particularly its rich B-carotene content. Leaf concentrate contains at least 1.5 mg betacarotene/gram dry matter. The initial observations suggest that the simplicity of its production from widely available raw material make it useful in the prevention and treatment of both vitamin A and Iron deficiency. For several years now, in 7 countries, children have been eating leaf concentrate regularly. The ease with which this is accomplished once the simple technique is learnt lead us to suggest that leaf concentrate is a better, simpler and more acceptable way for children to eat greens. In addition, the leaf concentrate tastes better then greens. Much of the bitter leafy taste is removed in the simple, inexpensive processing. Even more interesting may be the fact that leaf concentrate is frequently a less expensive source of B-carotene than leafy vegetables themselves for the entire above ground plant in processed and used - if not for food then for animal feed - whereas with vegetable only "edible" leaves are used.

Introducing the simple technology of leaf concentrate production and use as well as providing the inexpensive production equipment to needy villages in developing countries is the special mission to find Your Feet. Find Your Feet thinks that introducing leaf concentrate may often be the most effective as well as the least expensive way for people in developing countries to their own resources to minimize the prevalence of vitamin A deficiency. Find Your Feet is thus very willing to work with other groups and to assist them to utilize the nutrient potential of green vegetation .


DIAGNOSTIC POTENTIAL OF NIGHT BLINDNESS FOR EARLY DETECTION OF VITAMIN A DEFICIENCY AND XEROPHTHALMIA
 David Mwandu, Chilunga Puta: Tropical Diseases Research Centre, Ndola Zambia.

As part of the Luapula Eye Diseases Survey, an inquiry was made to biochemically validate the assessment of NIGHT BLINDNESS for the diagnosis and surveillance of vitamin A deficiency and xerophthalmia. A total of 25 children with a history of NIGHT BLINDNESS with age, sex and village controls had their blood analysed to vitamin A levels. Twenty (20) cases had vitamin A levels less than 20ug/dI and 5 cases over 20 ug/dI. Likewise, 10 controls had their Vitamin A levels below 20ug/dI while 15 controls had vitamin A levels above 20ug/dI The overall prevalence of NIGHT BLINDNESS by questionnaire was 1.26%. The sensitivity of NIGHT BLINDNESS to select vitamin A deficiency and xerophthalmia was 66.6% and the specificity was 3.33%. The positive predictive value was 80% and the negative predictive value was 58%.

With a relative predictive value of 80%, this suggests that using a history of NIGHT BLINDNESS one could give vitamin A to people with NIGHT BLINDNESS without doing a confirmatory biochemical vitamin A test. However, all this depends on the prevalence of vitamin a deficiency in the area. It is suggested that since the detection of NIGHT BLINDNESS was done by questionnaire, there is need to confirm these findings with other supportive tests such as physical examination (dark-adaptation test), impression cytology technique, biochemical vitamin A and dietary information in order to validate its diagnostic potential. In addition, a bigger sample size is required to put the minds of the statistician at ease.

World Health Organization Emerging and other Communicable Diseases (EMC)

Disease outbreaks reported:
News on disease outbreaks during the period 24 December 1997 to 5 January 1998: Updated information will be accessible from WHO's automatic fax service (number 41-22-791 46 66).

23 December 1997:
Influenza A(H5N1) in Hong Kong Special Administrative Region of China (From a WHO press release to be issued today):

In the absence of any sign of human-to-human transmission of the H5N1 influenza virus, no new measures, such as travel restrictions or quarantine, are warranted, the World Health Organization (WHO) stressed today.

The H5N1 virus, formerly found only in fowl, has been identified as the cause of nine confirmed cases of influenza in Hong Kong, Special Administrative Region of China, since May. Three of these cases have been fatal. There are an additional three suspected cases currently under investigation. This number is likely to increase slowly in coming weeks due to the enhanced surveillance activities now in progress.

Detection of new cases is probably the result of very comprehensive surveillance rather than an indication of increased transmission. The Department of Health in Hong Kong has stepped up its monitoring and surveillance activities. In addition to all hospitals and clinics in Hong Kong, a selected number of general practitioners are also now part of the surveillance system.

"The cases so far isolated come from all parts of Hong Kong and there is still no definite sign of human-to-human transmission. The cluster of cases which has been observed within a family does appear to have a common source and we are working to identify that," said Dr Daniel Lavanchy of WHO's Division of Emerging and other Communicable Diseases Control and Surveillance (EMC).

It is evident that the virus transmits poorly. WHO will continue to assist to the authorities of Hong Kong in the surveillance and the search for any evidence of the infection in live chickens, and other animals such as rats, mice, dogs, cats and other domestic and wild birds, in Hong Kong and the vicinity.

There is still no indication that a vaccine is needed but laboratory work is in progress in the WHO Collaborating Centres to produce a seed virus which would be suitable for vaccine production should this become necessary.

19 December 1997:
Cholera in the Horn of Africa: WHO meeting in Nairobi, 18/19 December 1997

The cholera situation in the Horn of Africa was discussed this week at a meeting in Nairobi, Kenya organized by WHO. The meeting was called because of an increase in cholera outbreaks in the countries concerned and to ensure that national and international health officials make a pro-active response to the worsening situation.

At the end of the meeting national health administrations, WHO, other UN agencies and major NGO's agreed on more efficient stocking and delivery of cholera supplies before outbreaks occur, better logistics and notification mechanisms and prompter responses to outbreaks. The participants also agreed that there should be one central cholera task force in each country to manage stocks and distribution of cholera treatment supplies.

Notification of outbreaks to neighbouring countries should be improved so that measures could be taken in advance to combat any outbreak. Countries still fear the negative effects that cholera notification can have on travel and trade and the participants agreed to work to demystify the disease. Dr Maria Neira, leader of the WHO Global Task Force on Cholera, said that to curtail or restrict travel to countries where a cholera outbreak is occurring is inappropriate because the disease actually represents almost no danger to the traveller as long as simple precautions are taken (food, water, hygiene). Participants in the meeting also emphasized the fact that import restrictions on almost all goods from countries where cholera was occurring were inappropriate as past experience shows that cholera does not present a risk.

The participants emphasized that cholera treatment should be essentially based on rehydration and that chemoprophylaxis is not useful for cholera control and should be abandoned. In addition, better health education concerning cholera was urgently needed so that appropriate measures could be taken to minimize the risk of infection and to ensure that health workers did not overuse drugs which might lead to the development of resistance.

It was agreed that technical assistance to cholera-endemic countries needed to be increased including health education, training and enhancement of laboratory facilities in the short and medium term. In the longer term, however, nothing could be a substitute for the provision of proper sewage and safe drinking-water facilities.

The following are cumulative numbers of cholera cases/deaths which have occurred this year in countries in the Horn of Africa: Djibouti: 1991 cases, 41 deaths; Kenya: 17,200 cases, 555 deaths; Somalia 6,724 cases, 248 deaths; Uganda 600 cases, 1 death United Republic of Tanzania 34,449 cases , 1,720 deaths, plus Zanzibar 1-15 December: 570 cases, 122 deaths. (No cases were reported in Ethiopia and Eritrea)

Cholera in Nairobi (Kenya):
The Ministry of Health has reported that 265 cases and 16 deaths have occurred in the recent outbreak of cholera in some districts of Nairobi. The MOH in collaboration with WHO are taking measures to control this outbreak. Large numbers of cholera cases have already been reported in Nyanza Province during the period June to end October this year.

Cholera in Zanzibar (United Republic of Tanzania)
The Ministry of Health has reported an outbreak of cholera in Zanzibar (Unguja Island). 570 cases with 122 deaths have occurred during the period 1 to 15 December. No cases have been reported on Pemba Island. WHO is providing technical and advisory support to help control this outbreak. Medical supplies have also been requested. Cases of cholera already occurred in Zanzibar earlier this year.

Influenza A(H5N1) in Hong Kong Special Administrative Region of China (Update)
A new case of influenza A(H5N1) was confirmed yesterday in a 4-year old boy. The boy had no reported contact with chickens and he had no link to any of the previously reported cases. The total number of confirmed cases is now eight, while two suspect cases are being investigated. Two of these 10 confirmed or suspected cases died, two are still in a critical condition and the remaining six are in a satisfactory condition or have recovered.

Detection of new cases is probably the result of a very comprehensive surveillance programme involving all health services catering for the 6.5 million population of Hong Kong and not an indication of increased transmission. Although the source of infection remains uncertain in some of the cases, it is evident that the virus transmits poorly. Surveillance of live chicken in farms and food markets will be further intensified within the coming days to evaluate the extent of virus circulation in the chicken population. In response to the recognition of the first case, 2000 blood samples were collected from health workers, family members and other contacts to investigate the extent of influenza A(H5N1) virus infections. The results of tested samples will be available in a week's time.

There is still no indication that a vaccine is needed but intensive laboratory work is in progress in the WHO Collaborating Centres to produce a seed virus which would be suitable for vaccine production should this be needed. WHO does not recommend any restrictions of travel to Hong Kong or elsewhere. However, visitors should be aware that at least two confirmed cases had been in contact with live chickens.

16 December 1997:
Influenza A(H5N1) in Hong Kong Special Administrative Region of China (Press Release WHO/92 issued 15 December:)

INTERNATIONAL EFFORT TO COMBAT NEW INFLUENZA STRAIN STEPPED UP
Although there have been no new confirmed cases of infection in humans with the avian influenza strain H5N1 beyond the six cases already announced, international public health organizations have stepped up their joint effort to combat the further spread of this virus in humans and its possible consequences.

Two main thrusts of action by the international health community are the preparation of seed virus for the eventual development of a vaccine for the H5N1 strain and increased surveillance activities in humans and birds.

The World Health Organization (WHO) Collaborating Centres for Influenza are working with various H5 strains to prepare seed virus in case a vaccine is needed. The eventual preparation of a vaccine strain may take several months, but in the absence of human-to-human transmission and of any documented outbreak, WHO is not recommending the development of a specific H5N1 vaccine. Reagents for vaccine production could be ready, at the earliest, in January 1998.

Influenza surveillance in humans has also been intensified and now includes all hospitals and 63 public health clinics in Hong Kong, Special Administrative Region of China. A team of five epidemiologists from the WHO Collaborating Centre for Influenza Reference and Research at the Centers for Disease Control and Prevention (CDC), Atlanta, USA are on site for investigations. Blood samples are being collected from family members of the four people infected, nursing staff and other contacts.

The WHO Collaborating Centre at CDC has also prepared a kit of reagents which will be despatched shortly to 110 National Influenza Centres in 82 countries for diagnosis of H5N1.

So far no case of human-to-human transmission has been identified but further tests of blood specimens are required to ascertain the origin of infection with greater precision. An additional suspected case in a human is under investigation, in Hong Kong.

Influenza-like illness has been noted in some medical and nursing staff, now on amantadine treatment, but tests so far have not shown any evidence of H5N1 infection. The illness could be due to other viruses circulating in Hong Kong. No current outbreak has been reported among animals but surveillance is being established in wild and domestic birds. There is no reason to impose travel restrictions or quarantine in Hong Kong and elsewhere.

Prior to May 1997, the H5N1 virus was known to infect only various species of birds, including chickens and ducks. It was first discovered in terns in South Africa in 1961 and can be deadly to fowl: in spring 1997, thousands of chickens died in Hong Kong after contracting it. Human infection with H5N1 is believed to have come through direct contact with infected birds.

The WHO Collaborating Centre for Studies in the Ecology of Influenza in Animals at St Jude's Research Hospital in Memphis, USA, is establishing, in close collaboration with national authorities and the University of Hong Kong, a programme for intensive epidemiological studies of animal influenza in Hong Kong. WHO is planning to send a veterinary epidemiologist from its Division of Emerging and other Communicable Diseases Surveillance and Control (EMC) to Hong Kong to assist in the implementation of this programme, while other WHO staff will be called upon as needed.

Outbreak of respiratory illness, Sierra Leone (Update)
The WHO-sponsored team from the Ministry of Health and the District Medical Officer identified 125 active cases during its visit to several affected towns and villages in the Chiefdoms of Sulima, Sinkunia Dembelia and Folosaba Dembelia in Koinadugu District during the period 21-25 November. According to community leaders and village elders large parts of the population had been affected during the outbreak and around 2,000-3,000 cases were estimated to have occurred, most of which were adults. Thirty-six deaths were reported to have occurred. One village had reportedly been abandoned after the disease had struck all 20 inhabitants of which 5 had died. The outbreak started in late September and spread during October through November and continued in early December. A follow-up mission is planned for collection of blood samples for laboratory investigation.

Koinadugu district, located in the northern part of the country has poor access to medical services, insufficient health staff and drugs and no disease surveillance activities. WHO's emergency programme will expand the epidemiological surveillance network to cover the affected area.

Cholera in Uganda
The Ministry of Health has reported an outbreak of cholera in Kampala City where 70 cases and 3 deaths have occurred since 9 December. An outbreak has also been reported in Bugiri District (Busoga Province) which is approximately 145 kms. from Kampala. The number of cases is not yet known although 26 deaths have been reported. A task force has been formed under the Ministry of Health to organize control measures. Two temporary treatment centres have been set up in Kampala and a mobile team has been despatched to Bugiri District.

8 December 1997:
Outbreak of respiratory illness, Sierra Leone
An outbreak of acute respiratory illness in Koinadugu District was reported by the Secretary of State for Health and Sanitation on 12 November and confirmed by the District Medical Officer on 21 November. The disease was unfamiliar to both the local health staff and the affected communities. TThe District Medical Officer who investigated the outbreak reported an influenza-like illness with high fever, intense headache, protracted sneezing and painful unproductive cough during the first three days. Some cases showed inflammation of conjunctiva, pharynx and tonsils. On the seventh day, a drop in fever was accompanied by productive cough, difficult breathing, chest, neck and generalized muscle pains. Some patients experienced transient deafness and loss of smell.

The National Epidemiologist in Freetown, with the support of WHO, made a further investigation and collected specimens for laboratory examination. The outbreak, which is thought to be of viral origin, appears to affect adults more than children. A WHO national medical officer is being recruited for posting in Koinadugu and five additional WHO medical officers will be posted in the northern provinces if security clearance can be obtained.

Cholera, Malaysia
The Ministry of Health confirmed the occurrence of cholera in the State of Selangor. As of 3 December 1997, there were 47 confirmed cases with one death. Laboratory investigations have confirmed them to be biotype El Tor, serotype Ogawa.

Plague in China
Nineteen cases of bubonic plague were reported in several villages in Yiliang County, Yunnan Province during October. Control measures were immediatedly instituted. All 19 cases had recovered by 24 November and no new cases have been reported.

WHO ZAMBIA launches ZAMPAC

[From the CDC AIDS news service; "Science & Health Bulletin: Information Package" PANA Wire Service (01/07/98); Kayaya, Musengwa]

Zambia has become the first African country to adopt a health package based upon the World Health Organization Regional Office for Africa's AFROPAC information service. The country has created an information package called ZAMPAC, which offers data on many common diseases, including tuberculosis, pneumonia, measles, tetanus, diphtheria, whooping cough, cholera, and poliomyelitis. The document contains information on the causes, symptoms, treatment, and prevention of these illnesses. ZAMPAC also discusses HIV and AIDS, which is said to account for some 30 percent of deaths among sexually active adults in Zambia.

RED EYES (Conjunctivitis)

Copyright: WHO. From the Health Information Package of the WHO African Region: Coping with common diseases.

QUOTES & MISCELLANEA

DONNY'S MEDICAL TERMS : D to G

D&C: Where Washington is
Dilate: To live long
Enema: Not a friend
Fester: Quicker
Fibula: Small lie
Genital: Non-jewish
G.I. Series: Soldier ball game
Grippe: Suit case

If I speak untruth I can survive. But if I speak the truth, it is explosive. [Bulleh Shah (Punjabi poet)]

DIABETIC EYE DISEASE

Background:
Diabetes mellitus is associated with damage to the small blood vessels in the retina, resulting in loss of vision. In economically developed societies, it is a major cause of visual disability in people aged 25 years or older. In Wisconsin, United States of America, in 1980-1982, after 15 years of diabetes, 21% of diabetic people had visual impairment and 6% were legally classified as blind(142). In Denmark, blindness or severe visual handicap develop in about 33% of a cohort of younger-onset insulin-dependent people with diabetic followed for 40 or more years (21).

More recently, the overall 4-years incidence of visual impairment (9%) and blindness (2%) was estimated in IDDM patients in Wisconsin (143). The 4-year incidence of blindness was Higher (3%) in older-onset than in younger -onset IDDM patients (1.5%). As the former are more numerous, they made up a higher proportion (89%) of those who became blind than did the younger onset group(11%). In the younger-onset group, diabetic retinopathy was the underlying cause of blindness in 86% of eyes; in the older-onset group, blindness was due to diabetic retinopathy in 35% of eyes while in the remainder the causes included cataract, glaucoma and age-related macular degeneration.

Almost everyone with younger-onset diabetes will develop diabetic retinopathy after 20 years of the disease (44). At sometime during their lives. 75% will develop the most severe stage, proliferative diabetic retinopathy; in older-onset NIDDM, almost 60% will develop diabetic proliferative retinopathy. Both younger and older-onset diabetic people are at risk of developing another sight-threatening manifestation of diabetic retinopathy, namely macular oedema, a swelling of the central part of the retina. These findings are consistent from study, whether in the isolated pacific population of Nauru, Pima Indians in Arizona or Hispanic Americans in San Antonio, Texas, or Colorado (145).

Epidemiological data also suggested that loss of vision due to open-angle glaucoma and cataract may be more common in people with diabetic than in non-diabetic. Rationale for screening and intervention Clinical trials have demonstrated the benefit of laser photo coagulation for severe proliferative retinopathy and clinically significant macular oedema. Recent findings from one study, the Early treatment Diabetic Retinopathy Study, suggest that timely treatment may prevent to 90% of severe visual loss associated with proliferative retinopathy. Guidelines for ophthalmological care have been developed to implement these findings(145). However, recent epidemiological studies in the United States of America and Europe show that a significant proportion of the population may not be receiving such care(145). The reasons for this include:

Recent studies suggest that screening and the timely treatment of vision-threatening retinopathy with photo coagulation are of economic benefit(146,147).

Screening strategies:
A number of screening strategies have been remended for the detection of diabetic retinopathy(e.g.10). Examination should include:

Although fundus photography is more expensive than ophthalmoscopy, its advantages include a more permanent objective record which can be produced by technical personnel. These images can be assessed at a later time by a specialist.

Standard protocols for retinal photograph have been developed. Photographs should be obtained on colour-free or red-colour-free transparencies because they are cheaper, provided better definition and do not fade with prolonged storage as do instant prints. If the screen is performed by an ophthalmologist, fluoresce in angiography, slit-lamp biomicroscopy and other more specialized techniques may be considered, but these are not usually standard screening methods.

Findings indicating the need for referral as soon as possible to an ophthalmologist for further assessment are:

Screening should be done by an individual adequately trained to detect retinopathy by ophthalmoscopy, such as an ophthalmologist with an interest in diabetic eye disease ; where this is not feasible and the patient is not under the care of an ophthalmologist, it is recommended that the screening be the primary responsibility of the doctor or organization responsible for the health care of diabetic patients. It should be done in close collaboration with the nearest ophthalmic facilities adequately equipped for further assessment and treatment of diabetic retinopathy, glaucoma and cataract. No-physician screeners should be properly trained and qualified.

There should be established channels for rapid referral of patients with sight-threatening retinopathy. If screening is carried out using retinal photography, the pictures should be taken by medical photographers and evaluated by experience readers who should then report back to the organization responsible for the screening and the patient. People with diabetic should be encouraged to report any significant changes in visual acuity not related to changes in blood glucose to their primary care providers or their eye doctors.

All post-pubertal children with IDDM should screened, usually 5 years after diagnosis; it is rare to observe vision-threatening diabetic retinopathy in people who have had IDDM for less than 5 years(144-145). The eyes should then be examined yearly if no retinopathy if found, or more frequently if retinopathy is found, especially in the case of very poor glycemic control, initiation of good control after periods of prolonged poor control, intercurrent illness or renal impairment. Eyes should be examined when pregnancy is being considered, at confirmation of pregnancy, and then every three months or more frequently if necessary.

Patients with NIDDM should be examined at the time of diagnosis because of the relatively high level of retinopathy (10-28%) present at diagnosis (105, 144, 145). This high level of retinopathy has been suggested as a rationale fro screening for diabetes in high-risk populations. The schedule of examinations thereafter should depend on the presence of retinopathy. Recent data suggest that, if no retinopathy is present. It may be safe to wait 4 years until further retinal examination in the people with NIDDM. If retinopathy is found, yearly or more frequent examinations are recommended.

The American Diabetic association has recently made the following recommendations for screening(148).

In people with NIDDM, measurement of intra ocular pressure, examination of the optic nerve and visual field testing may be needed to determine whether open-angle glaucoma is present. There is a need to detect glaucoma because, if left untreated, it can lead to significant visual impairment. Examination of the lens by slit-lamp will permit assessment for cataract.

Intervention strategies:
Clinic trials have demonstrated the efficacy of pan-retinal laser photo coagulation for eyes with advanced proliferative retinopathy, and focal laser photo coagulation for eyes with clinically significant vision-threatening macular oedema, and these surgical treatments can be used to prevent visual loss where indicated)149,150). There are no drugs available to prevent the development or progression of retinopathy in humans. Neither aspirin nor aldose reductase inhibitors have proved beneficial.

Animals experiments and epidemiological studies in humans strongly suggest a higher incidence and further progression of retinopathy and visual loss in diabetic people with higher blood glucose concentrations (145,151,152,). However, to date, lowering of blood glucose in clinical trials has not altered the progression of retinopathy. It is hoped that the results of the United States Diabetes Control and complications Trial(110) will provide a better understanding of this relationship.

There is less consistent evidence of an association between blood pressure and the incidence and progression of retinopathy(145,154). While there are no data to indicate that intervention with antihypertensive drugs will prevent retinopathy in people with hypertension, it is important to treat hypertension when present because of its association with cardiovascular and renal disease.

Most epidemiological evidence does not support a relation between smoking and retinopathy(145). However, smoking should be discouraged because of its association with increased morbidity and mortality.

Potential obstacles to prevention:

Setting goals:
The major goals is to reduce blindness. This can be achieved by: Evaluation and Monitoring:
There is need to collect data on the current prevalence of blindness and visual impairment and, after the initiation of any screening or intervention programme, to monitor the effectiveness of retinal photo coagulation and other interventions in reducing visual impairment. Educational programmes must be evaluated by testing the knowledge of primary care physicians, other health professionals and patients about diabetic eye disease and recommended care both before and after the programme is introduced, and by monitoring changes in behaviour(consultation of ophthalmologists, etc.) Costs should also be monitored.

Conclusions:
The highest priority at present in the education of patients, their physicians and health care decision-makers about the benefits of timely detection of vision-threatening diabetic retinopathy and prompt treatment with laser photo coagulation. The screening methods used will depend on available resources but should include assessment of the ocular fundus by appropriately trained individuals and referral to specialists when vision-threatening retinopathy is detected.

If the Diabetic Control and Complications Trial(110) demonstrates that glycemic control is beneficial in reducing blindness secondary to diabetic retinopathy, there will be a need to achieve tighter control of blood glucose in those at risk. A clinical trial may be required to determine whether reduction of arterial pressure in normotensive people with IDDM will reduce the incidence and progression of diabetic retinopathy.

The likelihood of success in preventing and reducing the consequences of diabetic eye disease will depend on the availability of resources to implement education programmes and on the continuous monitoring of these programmes.

From: Prevention of diabetes mellitus: Report of a WHO Study Group (WHO Technical Report Series no. 844)

1997 World AIDS Campaign

Secretariat of the campaign:
The Joint United Nations Programme on HIV/AIDS (UNAIDS)
Steering Committee:
UNAIDS
UNAIDS cosponsors:
United Nations Children's Fund (UNICEF)
United Nations Development Programme (UNDP)
United Nations Population Fund (UNFPA)
United Nations Educational, Scientific and Cultural Organization (UNESCO)
World Health Organization (WHO)
The World Bank
Others:
François-Xavier Bagnoud Center for Health and Human Rights of the Harvard School of Public Health
Children and AIDS International NGO Network
NGO Group for the Convention on the Rights of the Child PANOS

Vision statement:
The ultimate vision of UNAIDS and its partners is towards a world in which HIV transmission is substantially reduced, adequate treatment, care and support are provided, and where the vulnerability to the impact of HIV/AIDS on children, their families and their communities is significantly reduced.

Mission Statement:
Fewer children infected, fewer children affected, fewer children who are vulnerable to the impact of HIV/AIDS, and an increasing number of girls and boys who are protected in a world that upholds their rights.

Guiding Principles:
The guiding principles for the 1997 World AIDS Campaign are in line with those set forth in the United Nations Convention on the Rights of the Child and in the 1996-2000 UNAIDS Strategic Plan. These include the definition of a child as a human being under 18 years of age.

Overall aim of the campaign
Increased understanding of the magnitude of the HIV/AIDS epidemic and its global dimensions, with an emphasis on promoting action and sound policies to prevent HIV transmission and to minimize the epidemic's impact on children, their families and their communities.

Expected Outcome:
By the end of 1997, the following outcome is expected:
Mobilisation of governmental organizations, international organizations, NGOs, the media, the corporate sector and communities to promote the aim and objectives of the campaign, and to develop actions and responses to meet them.

Campaign Objectives

Objective 1:
Better understanding of the magnitude and diversity of the impact of HIV/AIDS on children, their families and their communities. Messages : Expected Outcomes:
By the end of 1997, the following outcomes are expected for Objective 1: Objective 2:
Stronger commitment, improved policies and increased action for preventing HIV infection and minimizing the epidemic's impact on children, their families and their communities. Messages : Expected Outcomes: By the end of 1997, the following outcomes are expected for Objective 2: Objective 3:
Increased and improved access to quality education and relevant information on the prevention and care of HIV/AIDS for children, their families, and their communities. Messages : Expected Outcomes: By the end of 1997, the following outcomes are expected for Objective 3: Objective 4:
Greater understanding of the interaction between children's rights, human rights, and HIV/AIDS. Messages : Expected Outcomes: By the end of 1997, the following outcomes are expected for Objective 4:

Message from the Executive Director of UNAIDS and the Heads of UNAIDS, cosponsoring agencies on World AIDS Day - 1 December 1997

Today World AIDS Day is commemorated for the 10th time. The global community is called upon to show their solidarity with people living with HIV infection and to remember, through reflection and active involvement, all those individuals who have already died of AIDS.

This year, World AIDS Day is the culmination of the first World AIDS Campaign which was launched in June. The theme of the campaign, 'Children Living in a World with AIDS', puts the focus on the youngest and often most vulnerable members of society. Children, defined in the United Nations Convention on the Rights of the Child as all human beings under the age of 18 years, are increasingly touched by the epidemic. Children are affected directly, by risking or acquiring HIV infection, and indirectly, by suffering from the effects of HIV/AIDS on parents, siblings and friends. It is estimated that well over 1000 children worldwide are now becoming infected with HIV every day.

In organizing this year's World AIDS Campaign, UNAIDS and its partners have aimed to increase understanding of the magnitude and global dimensions of the HIV/AIDS epidemic and its impact on children, their families and their communities, and to strengthen the international response to these concerns. In this effort, UNAIDS has been supported and advised by its six cosponsors (UNICEF, UNDP, UNFPA, UNESCO, WHO and the World Bank) and by the Francois-Xavier Bagnoud Center for Health and Human Rights of the Harvard School of Public Health, the Children and AIDS International NGO Network, the NGO Group for the Convention on the Rights of the Child, and PANOS. The campaign has been a joint collaborative effort to maximize resources and increase outreach and effectiveness.

Children Living in a World with AIDS' reminds everyone of us that although progress has been made in the fight against HIV, the epidemic increasingly affects all members of the global community. The campaign has raised the world's attention to the issue of protecting young girls and boys from the devastating effects of the epidemic on their lives. Today, all children of the world face a lifetime threat from HIV. Children are exposed to the risk of HIV infection at all different life stages, very early on through mother-to-child transmission, and later through adverse circumstances such as sexual exploitation and abuse, or the violation of their human rights to information, education and services. Children who are infected are vulnerable and often face discrimination. Children orphaned by AIDS can easily fall into a vicious circle of poverty, discrimination and HIV infection risk. Hope comes from better understanding and an increased awareness of how children and young people are both infected and affected by HIV/AIDS.

Promoting children's rights, providing information to young people on the risks of transmission and methods of prevention, educating on issues of sexual health and making reproductive health services and counseling available, have been shown to be effective ways of raising awareness, changing behaviour and triggering action.

Many activities undertaken during this year's World AIDS Campaign have concerned children that live in the shadow of HIV risk. Projects have been launched to care for children orphaned by AIDS and to support them within their communities and family networks. Outreach campaigns for street children informed and educated on HIV/AIDS issues and provided support. Mobilization and sensitization of the general public regarding the risk of HIV infection and the effects of HIV/AIDS on children and young people has also been a focus. Other efforts have concentrated on increasing the understanding of human and children's rights issues in HIV/AIDS and, in parallel, of HIV/AIDS issues in human and children's rights initiatives.

Many have included the participation of children themselves in events such as regional workshops and theatre festivals or, for example, children organizing their own radio programmes and discussing HIV/AIDS issues. People and communities around the globe have become involved in the campaign and in their respective ways have contributed significantly to raising awareness about children living in a world with AIDS.

On this day, we want to remember all those directly affected by the epidemic, especially young girls and boys. We also want to thank everybody who is supporting efforts to prevent transmission of HIV and protect all children from the devastating effects of HIV/AIDS on their lives. We invite the global community to join ranks with us and continue this work together in the years to come.

Statement signed by:
Peter Piot: Executive Director, Joint United Nations Programme on HIV/AIDS
Carol Bellamy: Executive Director, United Nations Children's Fund
James Gustave Speth: Administrator, United Nations Development Programme
Nafis Sadik: Executive Director, United Nations Population Fund Federico Mayor: Director-General, United Nations Educational, Scientific and Cultural Organization
Hiroshi Nakajima: Director-General, World Health Organization
James D. Wolfensohn: President, World Bank

AUTHOR INDEX

Alemayehu, W. 6
Amza, A. 15
Barbe, RF. 11
Bartmann, L. 12
Bazargan, M. 6
Beighton, P. 12
Berger, IB. 13
Canovas, R. 14
Casey, R. 6
Cook. CD. 9
Courtright, P. 10
Davis MNG. 20
Eckstein, M. 8
Evan, TG. 8
Fobi, G. 6
Foster, A. 7,8,14.
Gilber, C. 8
Gilbert, CE. 14
Glovinsky,Y. 16
Greenberg, J. 12
Hagan, M. 14
Kagame, K. 13
Kijlstra, A. 11
Kwendakwema, DJ. 17
Lewallen, S. 10
Mansour, M. 6
Mariotti, JM. 15
Martone, JF. 6
Mmbaga, BB. 16
Moukouri, E.6
Munoz, B. 16
Mwandu D. 21
Nnadozie, J. 13
Perkins, AL. 12
Puta C. 21
Quigley, HA.16
Rahi, J. 8
Ramesar, R. 12
Rao, S. 14
Ronday, MJ. 11
Ross-Degnan, D. 6
Rothova, A. 11
Schwab, L. 10,13
Sommer, A. 14
Stilma, JS. 11
Stulting, AA. 9
Vermoer AB. 19
West, SK. 16
Wilson, MR. 6
Winter, JD. 15
Wood, M. 7
Yorston, D. 7

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Last updated June 28, 1997