1322
As the populace ages, a huge elderly population becomes a reality and the issue of withholding and withdrawing expensive forms of care will gain even more prominence. Advance directives are but one step in this process. J, Orentlicher D, Moss RJ. Advance directives on admission. JAMA 1991; 266: 402-05. 2. White ML, Fletcher JC. The patient self determination act: on balance, more help than hindrance. JAMA 1991; 266: 410-12. 3. Emanuel EJ, Emanuel LL. Living wills: past present and future. J Clin 1. LaPuma
Ethics 1990; 1: 9-19. 4. Menikoff JA, Sachs GA, Siegler M. Beyond advance directives: health care surrogate laws. N Engl J Med 1992; 327: 1165-69. 5. Kubler-Ross E. On death and dying. London: Tavistock, 1970. 6. Becker E. The denial of death. New York: Free Press, 1973. 7. Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA 1991; 266: 825-28. 8. O’Boyle CA, McGee HM, Hickey A, et al. Individual quality of life in patients undergoing hip replacement. Lancet 1992; 339: 1088-91. 9. Cohen SR, Mount BM. Quality of life in terminal illness: defining and measuring subjective well-being in the dying. J Palliat Care 1992; 8: 40-45. 10. Schneiderman LJ, Kronick R, Kaplan RM, et al. Effects of offering advance directives on medical treatments and costs. Ann Intern Med 1992; 117: 599-606. 11. Epstein A. Using proxies to evaluate quality of life: can they provide valid information about patients’ health status and satisfaction with medical care? Med Care 1989; 27 (3S): S91-98.
Guinea
worm:
good
news
from
Ghana In
Ghana’s president, Flight Lieutenant Jerry Rawlings, first espoused the cause of
guinea
1988,
when
worm
(dracunculiasis) eradication, making
flying visits to endemic villages and persuading traditional chiefs to look at the vector cyclopoids swimming about in a glass of murky water, no doubt some of the country’s public health officials had wry smiles on their faces. Politicians’ enthusiasm for such issues tends not to last, and still less to have a significant and beneficial impact on disease control. Even the persuasion of US ex-president Jimmy Carter, another convert to the cause,l flanked on his visit by eminent advisers with distinguished service in the smallpox eradication campaign, left many observers sceptical-and the target of eradicating guinea worm by 1993 must have had them laughing up their sleeves. Guinea worm, however painful and debilitating,2 is not the killer that smallpox was, and is hardly the first priority of most African health workers. Moreover, its eradication will require a far higher degree of compliance and public participation than the singledose immunisation that defeated smallpox. Villagers will have to be persuaded to change their behaviour, filtering their water or changing their water source, and preventing their infected neighbours from contaminating surface sources. With a one-year incubation period and a tendency for many people exposed to infection to escape the disease,3there are many in West Africa who will not be easily convinced of the parasite’s transmission cycle and the need to interrupt it.
Surveillance, a prerequisite in any eradication effort,would also be far from easy. With no effective chemotherapy, there is little that a conventional health
facility can offer to patients which can mitigate their suffering, so they have little incentive to present themselves for treatment. Consequently, only a small proportion of cases can be detected without an active search. In the circumstances, the campaign launched by Fit Lt Rawlings was very successful, achieving a 31% drop in case numbers in the first year, with little more than a mass media campaign. By 1991, a volunteer had been chosen and trained in every endemic village in the country, to seek out cases, file a monthly surveillance report, offer health education, and distribute filter cloth. They reported not much more ..than half the numbers of cases found in the previous year’s case-search. One might have supposed this drop was due to less efficient case detection, were it not for the fact that the spot checks to validate the monthly surveillance system have been more numerous, more thorough, and with more positive results than those of the national case-searchers. The latest results from the Ghana Ministry of Health are especially exciting. The historical peak transmission season finished in July, so the total for 1992 should be less than 30 000 cases compared with nearly 180 000 cases in 1989. With annual reductions in the monthly incidence figures reaching 80%, guinea worm disease in Ghana seems to be well on the way to extinction. What is the secret of this success? External support (from several donors, led by USAID) has certainly helped, and an important element is a well-trained and dedicated cadre of health workers at district and regional level. A key factor is probably that the national coordinator of the programme is himself a regional medical officer and not an official in the Ministry of Health in Accra. This enables him to speak to his colleagues in other regions as one who understands the difficulties they face, and to develop strategies with them that are rooted in practical
experience. A recent example of the Ghanaians’ pragmatism their willingness to take on board a new and unorthodox surgical technique for extracting the worms before they emerge. It was developed by Dr B. L. Sharma, an Ayurvedic practitioner in Rajasthan, India, who had added minor surgery (learned in the vasectomy campaign) to his herbalist repertoire.5 Extraction prevents the suffering and the disease transmission that occur while the worm (60 cm long) gradually emerges from beneath the skin. It soon became clear that this approach also improved surveillance; people would come from miles around to have their worms extracted. After a study visit to India by two Ghanaians, UNICEF agreed to fly Dr Sharma to Ghana, where he trained 25 doctors and medical assistants in the method. They have since trained another 235, so worm extraction can now be offered at health facilities throughout the country’s endemic was
1323
the case-containment phase of the eradication effort gets under way. Ghana is not alone in controlling dracunculiasis successfully: India, Pakistan, Nigeria, and Cameroun have achieved substantial reductions in the numbers of cases in recent years, typically about 35 % each year.bIndia, for instance, which had over 44 000 cases when its eradication programme began in 1983, should have less than 1000 this year. But if Ghana’s remarkable rate of advance in the past few months is sustained, it could even beat India to the eradication finishing post. And then what? Such an effective network of village health workers must not be allowed to fall apart after the guinea worm has gone. The question of their future role is already urgent, because the resources of the eradication programme are not sufficient to maintain links with the volunteers in villages from which the disease has already been eliminated. The Ghana Ministry of Health is reviewing its policy on village health workers, and is unwilling to take any initiative until this is completed. By then, it may be too late. It should grasp the opportunity which these volunteers represent to establish village-based public health surveillance, and eventually village-based primary health care, at least in the villages that have successfully driven out dracunculiasis. After guinea worm, polio eradication areas as
beckons. 1. Carter J. Guinea worm: no-one should suffer. In: Medical and health annual. Chicago: Encyclopedia Britannica Inc., 1992. 2. Hopkins DR, Ruiz-Tiben E. Dracunculiasis eradication: target 1995. Am J Trop Med Hyg 1990; 43: 296-300. 3.Muller R. Dracunculus and dracunculiasis. Adv Parasitol 1971; 9:
73-151. 4. Richards FO, Hopkins DR. Surveillance: the foundation for control and elimination of dracunculiasis in Africa. Int J Epidemiol 1989; 18: 934-43. 5. Anon. SWACH-Dungarpur/Banswara. Fifth progress report. New Delhi: UNICEF, 1991. 6. Centers for Disease Control. Guinea worm wrap-up #35. Atlanta: WHO Collaborating Center for Research, Training and Eradication of
Dracunculiasis,
1992.
Endotoxaemia
or
endotoxinaemia?
A hundred years ago Pfeiffer1,2 coined the term "endotoxin" to emphasise the fact that this substance was not, like exotoxins, excreted by bacterial cells but released only after bacteriolysis. Ingress and presence of endotoxin in human blood are, almost without exception, called endotoxaemia rather than endotoxinaemia. The distinction between these two terms is at first glance too trivial to be worthy of any special comment. Nevertheless, the abbreviated form may change the sense, leading to a distorted clinical view that the condition is primarily harmful: clinicians unfamiliar with the origin of the term endotoxin tend to split the word incorrectly into misleading etymological roots "endo" and "toxaemia". Thus endotoxaemia has come to imply a serious morbid state associated with a hazardous and acute course, much like the related septicaemia and bacteraemia. It is true that circulating endotoxin plays
fatal part in the terminal scene of adult respiratory distress syndrome; it is likewise true that endotoxin in blood is evidence of the gastrointestinal disorders that are the leading cause of death in horses of all ages;3 but it is equally true that the sole presence of endotoxin in the blood may be innocuous. This last category warrants the proper term---endotoxinaemia. The expression "physiological endotoxaemia"4 is confusing and unnecessary. As the constituents of gram-negative bacteria, endotoxins are found virtually everywhere-in tap water, in sterile distilled waterand on sterile surgical gloves.6Experimentally it has hitherto been ahnost impossible to produce endotoxin-free life.’ Small amounts of endotoxin regularly enter the portal circulation from the gut but they are removed efficiently by Kupffer cells in the liver.Endotoxins can enter the pulmonary circulation in herbivores by inhalation: owing to heavy contamination of fodder, endotoxin is always present in the ruminal fluid of forestomachs of ruminants.9 The acute effects of inhaled endotoxin are likewise well known in human beings10-organic dust toxic syndrome and perhaps even sick building syndrome." Injections of endotoxin (eg, Pyrexal in Europe, Lipexal and Piromen in the USA) were widely used in clinical medicine12 both for pyrogenic therapy and for therapeutic or diagnostic bone marrow stimulation;13 patients so treated were never regarded as having endotoxaemia. Endotoxaemia and endotoxinaemia are but omission of the former would be no synonymous, loss to clinical semantics. At its baptismal centenary, endotoxin has the right to retain its identity after entering the bloodstream. a
1. Pfeiffer R. Untersuchungen über das Choleragift. Z Hyg 1892; 11: 393-412. 2. Wolff A. Ueber antitoxische und antiendotoxische Immunität und über die Eigenschaften der Endotoxine. Clbr Bakteriol 1904; 37: 390-97. 3. Morris DD, Henry MM, Moore JN, Fischer JK. Effects of dietary linolenic acid on endotoxin-induced production of tumor necrosis factor by peritoneal macrophages in horses. Am J Vet Res 1991; 52: 528-32. 4. Roth RI, Levin FC, Levin J. Optimization of detection of bacterial endotoxin in plasma with the Limulus test. J Lab Clin Med 1990; 116: 153-61. 5. Kluger MJ. Fever: role of pyrogens and cryogens. Physiol Rev 1991; 71: 93-127.
6. Peiró SA, Kulander L, Erikson Ö. Quantitative determination of endotoxins on surgical gloves. J Hosp Infect 1990; 16: 167-72. 7. Westphal O, Westphal U, Sommer T. The history of pyrogen research. In: Schlessinger D, ed. Microbiology: 1977. Washington: American
Society for Microbiology, 1977: 232. Gallery MP, Kamei T, Mangino MJ, Flye W. Organ interactions in sepsis. Host defense and hepatic-pulmonary macrophage axis (Condon RE. Clinical relevance statement). Arch Surg 1991; 126: 28-32. 9. Cort N, Fredriksson G, Kindahl H, Edqvist L-E, Rylander RA. Clinical and endocrine study on the effects of orally administered bacterial endotoxin in adult pigs and goats. J Vet Med 1990; A37: 130-37. 10. Rylander R, Snella M-C. Endotoxin and the lung: cellular reactions and risk for diseases. Prog Allergy 1983; 33: 332-44. 11. Rylander R. Epilogue. Am J Ind Med 1990; 17: 147-48. 12. Wolff SM. Biological effects of bacterial endotoxins in man. J Infect Dis 1973; 128 (suppl): 259-64. 13. Westphal O, Jann K, Kimmelspach K. Chemistry and immunochemistry of bacterial lipopolysaccharides as cell wall antigens and endotoxins. Prog Allergy 1983; 33: 9-39. 8.
As the populace ages, a huge elderly population becomes a reality and the issue of withholding and withdrawing expensive forms of care will gain even more prominence. Advance directives are but one step in this process. J, Orentlicher D, Moss RJ. Advance directives on admission. JAMA 1991; 266: 402-05. 2. White ML, Fletcher JC. The patient self determination act: on balance, more help than hindrance. JAMA 1991; 266: 410-12. 3. Emanuel EJ, Emanuel LL. Living wills: past present and future. J Clin 1. LaPuma
Ethics 1990; 1: 9-19. 4. Menikoff JA, Sachs GA, Siegler M. Beyond advance directives: health care surrogate laws. N Engl J Med 1992; 327: 1165-69. 5. Kubler-Ross E. On death and dying. London: Tavistock, 1970. 6. Becker E. The denial of death. New York: Free Press, 1973. 7. Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA 1991; 266: 825-28. 8. O’Boyle CA, McGee HM, Hickey A, et al. Individual quality of life in patients undergoing hip replacement. Lancet 1992; 339: 1088-91. 9. Cohen SR, Mount BM. Quality of life in terminal illness: defining and measuring subjective well-being in the dying. J Palliat Care 1992; 8: 40-45. 10. Schneiderman LJ, Kronick R, Kaplan RM, et al. Effects of offering advance directives on medical treatments and costs. Ann Intern Med 1992; 117: 599-606. 11. Epstein A. Using proxies to evaluate quality of life: can they provide valid information about patients’ health status and satisfaction with medical care? Med Care 1989; 27 (3S): S91-98.
Guinea
worm:
good
news
from
Ghana In
Ghana’s president, Flight Lieutenant Jerry Rawlings, first espoused the cause of
guinea
1988,
when
worm
(dracunculiasis) eradication, making
flying visits to endemic villages and persuading traditional chiefs to look at the vector cyclopoids swimming about in a glass of murky water, no doubt some of the country’s public health officials had wry smiles on their faces. Politicians’ enthusiasm for such issues tends not to last, and still less to have a significant and beneficial impact on disease control. Even the persuasion of US ex-president Jimmy Carter, another convert to the cause,l flanked on his visit by eminent advisers with distinguished service in the smallpox eradication campaign, left many observers sceptical-and the target of eradicating guinea worm by 1993 must have had them laughing up their sleeves. Guinea worm, however painful and debilitating,2 is not the killer that smallpox was, and is hardly the first priority of most African health workers. Moreover, its eradication will require a far higher degree of compliance and public participation than the singledose immunisation that defeated smallpox. Villagers will have to be persuaded to change their behaviour, filtering their water or changing their water source, and preventing their infected neighbours from contaminating surface sources. With a one-year incubation period and a tendency for many people exposed to infection to escape the disease,3there are many in West Africa who will not be easily convinced of the parasite’s transmission cycle and the need to interrupt it.
Surveillance, a prerequisite in any eradication effort,would also be far from easy. With no effective chemotherapy, there is little that a conventional health
facility can offer to patients which can mitigate their suffering, so they have little incentive to present themselves for treatment. Consequently, only a small proportion of cases can be detected without an active search. In the circumstances, the campaign launched by Fit Lt Rawlings was very successful, achieving a 31% drop in case numbers in the first year, with little more than a mass media campaign. By 1991, a volunteer had been chosen and trained in every endemic village in the country, to seek out cases, file a monthly surveillance report, offer health education, and distribute filter cloth. They reported not much more ..than half the numbers of cases found in the previous year’s case-search. One might have supposed this drop was due to less efficient case detection, were it not for the fact that the spot checks to validate the monthly surveillance system have been more numerous, more thorough, and with more positive results than those of the national case-searchers. The latest results from the Ghana Ministry of Health are especially exciting. The historical peak transmission season finished in July, so the total for 1992 should be less than 30 000 cases compared with nearly 180 000 cases in 1989. With annual reductions in the monthly incidence figures reaching 80%, guinea worm disease in Ghana seems to be well on the way to extinction. What is the secret of this success? External support (from several donors, led by USAID) has certainly helped, and an important element is a well-trained and dedicated cadre of health workers at district and regional level. A key factor is probably that the national coordinator of the programme is himself a regional medical officer and not an official in the Ministry of Health in Accra. This enables him to speak to his colleagues in other regions as one who understands the difficulties they face, and to develop strategies with them that are rooted in practical
experience. A recent example of the Ghanaians’ pragmatism their willingness to take on board a new and unorthodox surgical technique for extracting the worms before they emerge. It was developed by Dr B. L. Sharma, an Ayurvedic practitioner in Rajasthan, India, who had added minor surgery (learned in the vasectomy campaign) to his herbalist repertoire.5 Extraction prevents the suffering and the disease transmission that occur while the worm (60 cm long) gradually emerges from beneath the skin. It soon became clear that this approach also improved surveillance; people would come from miles around to have their worms extracted. After a study visit to India by two Ghanaians, UNICEF agreed to fly Dr Sharma to Ghana, where he trained 25 doctors and medical assistants in the method. They have since trained another 235, so worm extraction can now be offered at health facilities throughout the country’s endemic was
1323
the case-containment phase of the eradication effort gets under way. Ghana is not alone in controlling dracunculiasis successfully: India, Pakistan, Nigeria, and Cameroun have achieved substantial reductions in the numbers of cases in recent years, typically about 35 % each year.bIndia, for instance, which had over 44 000 cases when its eradication programme began in 1983, should have less than 1000 this year. But if Ghana’s remarkable rate of advance in the past few months is sustained, it could even beat India to the eradication finishing post. And then what? Such an effective network of village health workers must not be allowed to fall apart after the guinea worm has gone. The question of their future role is already urgent, because the resources of the eradication programme are not sufficient to maintain links with the volunteers in villages from which the disease has already been eliminated. The Ghana Ministry of Health is reviewing its policy on village health workers, and is unwilling to take any initiative until this is completed. By then, it may be too late. It should grasp the opportunity which these volunteers represent to establish village-based public health surveillance, and eventually village-based primary health care, at least in the villages that have successfully driven out dracunculiasis. After guinea worm, polio eradication areas as
beckons. 1. Carter J. Guinea worm: no-one should suffer. In: Medical and health annual. Chicago: Encyclopedia Britannica Inc., 1992. 2. Hopkins DR, Ruiz-Tiben E. Dracunculiasis eradication: target 1995. Am J Trop Med Hyg 1990; 43: 296-300. 3.Muller R. Dracunculus and dracunculiasis. Adv Parasitol 1971; 9:
73-151. 4. Richards FO, Hopkins DR. Surveillance: the foundation for control and elimination of dracunculiasis in Africa. Int J Epidemiol 1989; 18: 934-43. 5. Anon. SWACH-Dungarpur/Banswara. Fifth progress report. New Delhi: UNICEF, 1991. 6. Centers for Disease Control. Guinea worm wrap-up #35. Atlanta: WHO Collaborating Center for Research, Training and Eradication of
Dracunculiasis,
1992.
Endotoxaemia
or
endotoxinaemia?
A hundred years ago Pfeiffer1,2 coined the term "endotoxin" to emphasise the fact that this substance was not, like exotoxins, excreted by bacterial cells but released only after bacteriolysis. Ingress and presence of endotoxin in human blood are, almost without exception, called endotoxaemia rather than endotoxinaemia. The distinction between these two terms is at first glance too trivial to be worthy of any special comment. Nevertheless, the abbreviated form may change the sense, leading to a distorted clinical view that the condition is primarily harmful: clinicians unfamiliar with the origin of the term endotoxin tend to split the word incorrectly into misleading etymological roots "endo" and "toxaemia". Thus endotoxaemia has come to imply a serious morbid state associated with a hazardous and acute course, much like the related septicaemia and bacteraemia. It is true that circulating endotoxin plays
fatal part in the terminal scene of adult respiratory distress syndrome; it is likewise true that endotoxin in blood is evidence of the gastrointestinal disorders that are the leading cause of death in horses of all ages;3 but it is equally true that the sole presence of endotoxin in the blood may be innocuous. This last category warrants the proper term---endotoxinaemia. The expression "physiological endotoxaemia"4 is confusing and unnecessary. As the constituents of gram-negative bacteria, endotoxins are found virtually everywhere-in tap water, in sterile distilled waterand on sterile surgical gloves.6Experimentally it has hitherto been ahnost impossible to produce endotoxin-free life.’ Small amounts of endotoxin regularly enter the portal circulation from the gut but they are removed efficiently by Kupffer cells in the liver.Endotoxins can enter the pulmonary circulation in herbivores by inhalation: owing to heavy contamination of fodder, endotoxin is always present in the ruminal fluid of forestomachs of ruminants.9 The acute effects of inhaled endotoxin are likewise well known in human beings10-organic dust toxic syndrome and perhaps even sick building syndrome." Injections of endotoxin (eg, Pyrexal in Europe, Lipexal and Piromen in the USA) were widely used in clinical medicine12 both for pyrogenic therapy and for therapeutic or diagnostic bone marrow stimulation;13 patients so treated were never regarded as having endotoxaemia. Endotoxaemia and endotoxinaemia are but omission of the former would be no synonymous, loss to clinical semantics. At its baptismal centenary, endotoxin has the right to retain its identity after entering the bloodstream. a
1. Pfeiffer R. Untersuchungen über das Choleragift. Z Hyg 1892; 11: 393-412. 2. Wolff A. Ueber antitoxische und antiendotoxische Immunität und über die Eigenschaften der Endotoxine. Clbr Bakteriol 1904; 37: 390-97. 3. Morris DD, Henry MM, Moore JN, Fischer JK. Effects of dietary linolenic acid on endotoxin-induced production of tumor necrosis factor by peritoneal macrophages in horses. Am J Vet Res 1991; 52: 528-32. 4. Roth RI, Levin FC, Levin J. Optimization of detection of bacterial endotoxin in plasma with the Limulus test. J Lab Clin Med 1990; 116: 153-61. 5. Kluger MJ. Fever: role of pyrogens and cryogens. Physiol Rev 1991; 71: 93-127.
6. Peiró SA, Kulander L, Erikson Ö. Quantitative determination of endotoxins on surgical gloves. J Hosp Infect 1990; 16: 167-72. 7. Westphal O, Westphal U, Sommer T. The history of pyrogen research. In: Schlessinger D, ed. Microbiology: 1977. Washington: American
Society for Microbiology, 1977: 232. Gallery MP, Kamei T, Mangino MJ, Flye W. Organ interactions in sepsis. Host defense and hepatic-pulmonary macrophage axis (Condon RE. Clinical relevance statement). Arch Surg 1991; 126: 28-32. 9. Cort N, Fredriksson G, Kindahl H, Edqvist L-E, Rylander RA. Clinical and endocrine study on the effects of orally administered bacterial endotoxin in adult pigs and goats. J Vet Med 1990; A37: 130-37. 10. Rylander R, Snella M-C. Endotoxin and the lung: cellular reactions and risk for diseases. Prog Allergy 1983; 33: 332-44. 11. Rylander R. Epilogue. Am J Ind Med 1990; 17: 147-48. 12. Wolff SM. Biological effects of bacterial endotoxins in man. J Infect Dis 1973; 128 (suppl): 259-64. 13. Westphal O, Jann K, Kimmelspach K. Chemistry and immunochemistry of bacterial lipopolysaccharides as cell wall antigens and endotoxins. Prog Allergy 1983; 33: 9-39. 8.
