Rosén KG, Amer-Wåhlin L, Bretones S, Luzietti R, Norén K, Pöllanen P, for the STAN study group and the EU Innovation project FECG. Detection of intrapartum hypoxia. In: Perinatal medicine of the new millennium. Proceedings 5th World Congress of Perinatal Medicine. In: Carrera JM, Cabero L, Baraibar R, eds. Bologna, Italy: Monduzzi Editore, 2001: 774–79.
Pseudomonas aeruginosa infection and cystic fibrosis Sir—Shona McCallum and colleagues (Aug 18, p 558)1 propose that analysis by pulsed-field gel electrophoresis (PFGE) is important to classify infection of the respiratory tracts by epidemic Pseudomonas aeruginosa strains in adults with cystic fibrosis (CF). They show that cross infection with P aeruginosa can arise. Therefore, this method is proved useful for surveillance. Patients admitted to hospital after surgery might have a lower risk of P aeruginosa infection than patients with CF, but they might also acquire respiratory infections from such epidemic strains. We have isolated epidemic strains from the sputa of patients with the same genetic fingerprint (analysis by PFGE), and noted three patterns of antibiotic susceptibility (the strains showed resistance to antibiotics that the patients had never received). Different patterns of antibiotic susceptibility were also found in a nosocomial outbreak of multiresistant P aeruginosa strains in a cancer centre.2 We tried to develop a simple in-vitro method to assess the patterns and the degrees of cross resistance in the P aeruginosa strains by use of exposure to imipenem, ceftazidime, ciprofloxacin, or other antibiotics. The strains showed an increase in minimum inhibitory concentration for any antibiotic after five exposures, and also showed strong cross resistance between carbapenems, between cephalosporins, and between quinolones (p<0·05), and little or no cross resistance with structurally unrelated antibiotics (p<0·05). We calculated the degree of cross resistance as an index. Therefore, the isolates could be classified by analysis (with the index) of antibiotic susceptibility. The multiresistance in our epidemic strains suggests that development of resistance to one antibiotic results in resistance to another antibiotic, that there is stepwise selection of resistance (which was shown in our in-vitro study and in patients3), and that individual strains
will show different susceptibility to various antibiotics. Therefore, classification of epidemic P aeruginosa strains on the basis of antibiotic resistance is necessary in addition to genotypic classification based on PFGE. *Komei Kato, Tadatoshi Takayama Third Department of Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan (e-mail: [email protected]
McCallum SJ, Corkill J, Gallagher M, Ledson MJ, Hart CA, Walshaw MJ. Superinfection with transmissible strain of Pseudomonas aeruginosa in adults with cystic fibrosis chronically colonised by P aeruginosa. Lancet 2001; 358: 558–60. Kr cméry ˇ V, Trupl J. Nosocomial outbreak of meropenem resistant Pseudomonas aeruginosa infections in a cancer centre. J Hosp Infect 1994; 26: 69–71. Harris A, Torres-Viera C, Venkataraman L, et al. Epidemiology and clinical outcomes of patients with multiresistant Pseudomonas aeruginosa. Clin Infect Dis 1999; 28: 1128–33.
Culturally-based health promotion programmes
outcome. In Peru there is a high maternal mortality rate (around 215 per 100 000 by 2000). More than 80% of mothers die at home despite an adequate number of antenatal care visits.2 Women in the Andes generally delivered their babies at home because of fear and shame from using modern delivery methods that do not accord with local cultural beliefs.3 We took into account the requirements of rural people and negotiated with local Ministry of Health staff. So far, after 9 months of implementation, the number of institutional deliveries is rising, and is contributing to lower maternal mortality. *J Jaime Miranda, Rosa Malca, Eduardo Bedriñana, Efraín Loayza Health Unlimited, Peruvian Programme, Apartado Postal 9, Ayacucho, Peru (e-mail: [email protected]
Sir—Michael Elmore Meegan and colleagues (Aug 25, p 640)1 report a decrease in mortality rates due to neonatal tetanus in five Massai areas (sub-Saharan Africa) after introduction of a culturally-based health promotion approach. Promotion activities were done by local community actors in the intervention areas, whereas in control areas, such activities were done by local Ministry of Health staff. Although the study period was almost 20 years, the death rates in children younger than 6 weeks fell sharply after the first year of intervention and has not risen again in the past 11 years. In view of such spectacular change, we wonder whether Meegan and colleagues promoted this approach to other communities, rather than just continuing with the analysis for such a long time. Moreover, we would like to know if they transferred this knowledge to local sustainable actors such as Ministry of Health bodies. We disagree with the long observation period because the study control areas could have benefited from this culturally based approach for at least 11, if not 18, years. Culturally-adequate approaches result in wider local acceptance and higher compromise with local actors, thereby providing greater chances of sustainability. Our experience with culturally adequate delivery services implemented on rural health facilities from the Peruvian Andes reflects this
Meegan ME, Conroy RM, Lengeny SO, Renhault K, Nyangole J. Effect on neonatal tetanus mortality after a culturally-based health promotion programme. Lancet 2001; 358: 640–41. Guerra V. Lucha contra la muerte materna, Ayacucho. Salud Para Todos 2001; 1: 6. Investigation report: provision of culturally adequate sexual and reproductive health services in rural communities affected by violence. Ayacucho, Peru: Health Unlimited, Peruvian Programme, 2000.
Authors’ reply Sir—Our research was not run as a prospective study. Mortality data for the control areas were extracted from records by the Kenyan Ministry of Health at our request in 1999, when we were collating and analysing the records of the ICROSS traditional birth attendant programme. The control areas were not left without a traditional birth attendant programme as part of a controlled experiment. Rather, they had no programme because the Ministry of Health had neither the resources nor the expertise to launch and maintain such programmes. The ICROSS programme, which is run in partnership with the Kenyan Ministry of Health, is supported by the Irish and Danish Governments. ICROSS has made several attempts to secure funding to extend the traditional birth attendant programme to other areas in Kenya, but to date these have been unsuccessful. Many bilateral donors have shifted funds away from supporting primary healthcare, perhaps partly because of lack of evidence that such support really improves community health. We hope that our results will help to highlight the untapped potential that is represented by the traditional healers and birth attendants in communities in lessdeveloped countries. Rather than
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