Updates: Antiretroviral Therapy and Pregnancy; Cryptococcosis on Vancouver Island; Foodborne Outbreaks
June 15, 2002 4 minutes read
Source: Tuomala RE, et al. N Engl J Med. 2002;346:1863-1870.
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Preliminary reports suggested that protease inhibitor therapy in pregnant HIV-infected women may increase the risk of premature delivery, although confirmation was lacking. Tuomala and colleagues assessed the pregnancy outcomes of 2,123 HIV-infected women who delivered between 1990 and 1998. Women enrolled in 2 completed clinical trials (PACTG studies 076 and 185) and 5 ongoing studies were included in the analysis. A total of 1590 women received monotherapy, 396 received combination therapy without a protease inhibitor (PI), 137 received combination therapy with a protease inhibitor, and 1143 women did not receive antiretroviral therapy. In those receiving antiretroviral therapy, there did not appear to be a difference in the week of gestation that treatment was initiated.
Unadjusted rates for premature delivery were significantly lower among treated women, although no apparent difference was found between the treated and untreated groups for other adverse outcomes, such as low APGAR scores, low birth weights, and stillbirths. The risk of low birth weights was higher in women receiving monotherapy or combination therapy with a PI than among those born to women who received combination therapy without a PI. However, women who received a PI-combination were significantly more likely to be older and have lower CD4 cell counts than those women who received antiretroviral therapy without PIs. This suggests that women receiving PIs may have had more advanced HIV disease.
After adjustment for multiple risk factors, the use of combination therapy did not appear to increase the risk of low birth weight or premature delivery compared with infants born to mothers receiving monotherapy. Any apparent risk appeared to be small, and did not outweigh the benefit of combination therapy in these women. The goal of antiretroviral therapy in a pregnant woman should be the optimal suppression of viral load with the most appropriate therapy, although efavirenz should be avoided because of its potential teratogenicity. However, any of the protease inhibitors appear to be safe during pregnancy, although the greatest experience has been with the use of nelfinavir, and no specific data exist for amprenavir or lopinavir. Preliminary data suggest that the 750 mg t.i.d. dose of nelfinavir may not provide adequate blood levels, and studies to evaluate nelfinavir 1250 mg twice daily in pregnant women are in process.
Cryptococcosis on Vancouver Island
Source: ProMED-mail post, June 7-8, 2002. www.promedmail.org.
Authorities have issued an advisory alert regarding an outbreak of cryptococcosis on Vancouver Island, which is affecting both humans and animals. Since 1999, a total of 52 human cases of cryptococcosis have been identified, most of which resulted in either respiratory or central nervous system disease. One individual has died. None of the cases were known to be HIV-infected, although details regarding the presence of other underlying disease is lacking. The organism has been identified as serotype B, var. gattii, which has been previously associated with infection in Australia and Eucalyptic trees. About 40 animal cases have also been detected, including cases involving domestic cats and dogs, and several porpoises.
Surveillance studies on the island have found evidence of the organism in several rotting fir and alders in both Tathtrevor Provincial Park and Cathedral Grove Park. This sudden increase in disease incidence remains unexplained, but some experts are blaming global warming and an adverse affect on trees in the area. Despite the apparent increase in cases, the overall incidence of disease remains low (2.5 per 100 000 cases), and travelers should not be discouraged from visiting the island.
Foodborne Outbreaks: An Ongoing Problem
Source: ProMED-mail post, May 22, 2002; www.promedmail.org.
Another outbreak of foodborne Hepatitis A infection—this time associated with blueberries imported to the United States from New Zealand—has been reported. Berry pickers are, not surprisingly, paid by the pound picked. Eager to increase their "yield," it is apparently not uncommon for berry pickers to urinate in their baskets.
Another similar outbreak, this time related to the importation of Susie brand cantaloupe from Mexico, resulted in dozens of cases of salmonellosis in the United States and Canada in May. The causative agent was Salmonella poona, which is generally associated with reptiles, and has been previously linked to outbreaks from cantaloupe in the past.
Post these cases in your offices for patients to read! The increased globalization of food production is bringing fancier and more plentiful foods to our tables—along with all kinds of foreign (and not so foreign) pathogens. Who knew that berry pickers in New Zealand peed on those blueberries you generously sprinkled on your breakfast cereal? These cases make good reminders for patients that careful washing of all fruits and vegetables is increasingly important. Even fruits and vegetables with a skin or a rind need to be washed—peeling and slicing doesn’t cut it anymore.
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