798
will have no abnormalities. Compression reduces the thickness of breast tissue in the X-ray beam over the automatic exposure control detector. Thus a shorter exposure time is needed to produce the same density on the processed film. Compression increases the distance of the skin surface and some breast tissue from the source of X-rays, also reducing radiation dose. Compression is essential to the production of high-quality, low-dose mammograms. Fitment of motorised compression devices is recommended for all mammographic X-ray units used in the National Health Service (NHS) breast screening programme. 1.2 The maximum compression force recommended by the Department of Health is 200 N. The importance of checking breast compression devices has been recognised for some time3.4 and is routinely monitored in the NHS northern region. Our measurements in seventeen mammography units indicate the mean maximum force to be 166 N (SD 22). The simple relation between force and pressure does not apply to a complex compressible object, such as the breast in mammography. The pressure within the breast will vary with position, especially when close to the chest wall. The pressure distribution will depend on breast size and composition as well as the design of the compression plate. The degree of compression applied in practice will depend on the woman’s tolerance of pressure. Pressure measurements on the surface of the breast indicate that a specific compression force can result in a factor of 5 variation in pressure between subjects.s Others should examine the assertion made by Watmough and Quan about the dissemination of cells, especially since the difference between the Health Insurance Plan and Malmo studies, cited by them, could be attributable to factors other than breast
immediate development of the lesion but increases the intervals between episodes to 3 months. We do not have any pathophysiological explanation for this clinical observation.
ICI-Pharma,
Cergy,
M. AZAB
France
Ultrasonography of benign adrenal tumours SIR,-Real-time ultrasonography is a safe and inexpensive diagnostic procedure that requires no more than an electric socket and an experienced examiner. To the benefit of patients and the health-care system, it has begun to replace more expensive and less readily available imaging techniques, such as computed tomography (CT),1 in establishing the definite diagnosis of intra-abdominal masses. Improvements in image resolution now allow for accurate identification of the adrenal gland in more than 90% of subjects2 and safe needle biopsy of adrenal tumours under ultrasonic guidance.3 We have studied the diagnostic accuracy of real-time ultrasonography and CT in patients with benign adrenal tumours that were surgically removed and therefore available for pathological validation. Over the past seven years we have seen ten such tumours (table); all patients were initially admitted with symptoms that pointed to a possible adrenal involvement (no incidentally discovered masses).
compression. Regional Medical Physics Department, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
PH. VENNIN E. GOUGEON
Centre Oscar Lambret, Lille 59020, France
ADRENAL TUMOUR DIAMETERS (mm)
K. FAULKNER K. J. ROBSON C. J. KOTRE
Department of Health and Social Security. Guidance notes for health authorities on mammographic equipment required for breast cancer screening (STD/87/34). London: DHSS, 1987 2 Department of Health. Revised guidance notes for health authorities on mammographic equipment required for breast cancer screening (STD/90/46). London: DHSS, 1990 3. Faulkner K, Chambers IR, Hedley P, Thompson SR An instrument for monitoring the force applied by breast compression devices on mammography X-ray units. Clin Phys Physiol Meas 1989; 10: 177-80 4. Institute of Physical Sciences in Medicine. The commissioning and routine testing of mammographic X-ray systems (TGR 59 1989) York IPSM, 1989 5 Clark DJ, Chambers IR, Faulkner K, Rayson J, Hacking PM, Milton J. Pressure measurements during automatic breast compression in mammography J Biomed Engin 1990; 12: 444-46 1.
The
Antiviral response to tamoxifen up a 58-year old woman who, in 1983, right breast cancer treated by mastectomy, radiotherapy, and chemotherapy. In July, 1988, shortly after breast reconstruction, she had a metastatic bone lesion of D9 treated by radiotherapy and tamoxifen 30 mg per day for a year followed by 20 mg daily. Her only other treatment is calcium 100 mg per day since June, 1988. While on tamoxifen, the patient noticed complete disappearance of an old and cyclic herpetic skin eruption. Since the age of 40 she has had monthly herpetic eruptions, usually on the right buttock and sometimes labially. The association between these eruptions and the menstrual cycle is difficult to evaluate retrospectively. Each episode of herpes was preceded by pruritus for 4 days and lasted 7-8 days. The patient had a natural menopause at age of 40 and the herpetic episodes continued till the start of tamoxifen. On 30 mg daily, the patient did not have any herpetic manifestations. Small eruptions recurred
SIR,-We have followed
had
when the dose was reduced to 20 mg. In June, 1990, after 2 years, tamoxifen was stopped because there was no further tumour progression and because of hot flushes. The skin eruptions recurred monthly during the 4 months in which tamoxifen was stopped. The patient restarted tamoxifen by herself at 20 mg per day for 5 days once the skin manifestations start. She says that intake of tamoxifen in this way does not modify the
investigators doing
the
ultrasonography (real-time, Picker
7000, curved linear array 3-5 MHz) and the CT (Siemens, Somatom 2), the surgeon, and the surgical pathologist, were asked the widest diameter of the tumour. As expected, the smallest masses were found to be hormone-producing tumours while the larger ones were either inactive adenomas or phaeochromocytomas. Ultrasonography failed to identify three benign adrenal masses, all of which were less than 25 mm in diameter; this corresponds to the critical diameter below which needle biopsy of intra-abdominal masses under ultrasonic guidance frequently yields false-negative results.’ CT missed one aldosterone-producing adenoma (13 mm diameter), which was later found angiographically. All other tumours were correctly localised and identified by both ultrasonography and CT. With the surgical pathologist arbitrarily considered as the most reliable source of our measurements, ultrasonography predicted the exact size of tumours smaller than 60 mm within 72 (SD 32) mm and CT within 10’ 1 (2.4) mm (within 14-3 [5] mm and 15.77 [6] mm, respectively, for tumours > 60 mm). The operating surgeon generally reported larger diameters than the pathologist; in the absence of obvious technical explanations, we attributed this discrepancy to surgical enthusiasm. Ultrasonography and CT tended to underestimate the exact tumour diameter. We conclude that ultrasonography of benign adrenal tumours is similar in diagnostic accuracy to CT. Ultrasonography failed to recognise adenomas of less than 2-5 cm in diameter in our patients. to measure
799
Ultrasonography probably cannot replace CT in patients in whom small aldosterone-producing or cortisol-producing adenomas are suspected or where needle biopsy of such small tumours is to be attempted. Department of Surgery,
Hospital
of the Medical
Faculty,
Aachen
KARL-HEINZ TREUTNER
Department of Medicine I, Ulm University, 7900 Ulm, Germany
MARKUS M. LERCH
1. Mindel S. The full potential of ultrasound. Lancet 1988; i: 244 2 Zappasodi F, Derchi LE, Rizatto G. Ultrasonography of the normal adrenal glands: a study using linear-array real-time equipment. Br J Radiol 1986; 59: 759-64. 3 Jaeger HJ, MacFie J, Mitchell CJ, Couse N, Wai D. Diagnosis of abdominal masses with percutaneous biopsy guided by ultrasound. BMJ 1990; 301: 1188-91. 4. Jennings PE, Donald JJ, Coral A, Rode J, Lees WR. Ultrasound-guided core biopsy.
Lancet 1989; i: 1369-71.
Maternal
serum
screening policy for Down’s syndrome
SIR,-Professor Wald and colleagues (Aug 22, p 494) regard as inappropriate the restriction of maternal serum screening for Down’s syndrome to above a specified age, rather than offering such screening to women of any age. Although detection of affected pregnancies is maximised for a given rate of amniocentesis by screening all women, restricted screening can achieve similar results lower cost. This finding is illustrated in the table for screening with maternal serum a-fetoprotein, unconjugated oestriol, and human chorionic gonadotropin in 100 000 pregnant women who, without antenatal diagnosis, would deliver 130 Down’s syndrome infants. Screening all women irrespective of age (policy 1) would lead to 5000 amniocenteses, and 75 affected pregnancies would be detected. at
Restricting screening to women aged 27 or more but lowering the cut-off risk (policy 2), so that the same number of women had amniocentesis, would detect 66 affected pregnancies. The detection rate with policy 2 is not drastically lower than that for policy 1 and is achieved at much reduced costs since less than half the tests need be done. Lowering the cut-off further (policy 3), so that 9000 women had amniocentesis, would yield the same detection rate as policy 1, but would be 10% cheaper. ESTIMATED EFFECT OF THREE MATERNAL SERUM SCREENING POLICIES APPLIED TO 100000 WOMEN*
BCG vaccination in children born to
HIV-positive mothers SIR,-Dr Athale and colleagues from Lusaka (Aug 15, p 434) suggested that in countries of high HIV prevalence BCG (bacillus Calinette-Guerin) vaccination should be given only to
have
children over twelve months of age because of the risk of disseminated BCG infection. By that age it should be clear which children are infected. In a prospective study in Zaire of children born to HIV positive and negative mothers (seroprevalence 3’8%/ vertical transmission rate 23%2)all received BCG at birth. During follow-up of two years, 9 of 21 HIV-infected children developed tuberculosis which was disseminated in only 1, and 7 had a family contact. None had BCG adenitis. All responded well to shortcourse chemotherapy (avoiding thiacetazone). In the two matched control groups uninfected by HIV, 12 developed tuberculosis-4 born to 21 HIV-positive mothers and 8 born to 21 HIV-negative mothers. None of these had disseminated infection and 1 had BCG adenitis (mother seronegative). The HIV-infected and noninfected groups did not differ significantly. In the past ten years we have had only 1 case of probable disseminated BCG infection in a child of five months. He was vaccinated at three months and developed suppurating axillary BCG adenitis. His weight curve was static and he had persistent fever. Radiography showed typical miliary lesions and he responded well to short-course therapy. His mother was seropositive for HIV and he had no family tuberculosis contacts. We agree that many cases of tuberculosis in children infected with HIV simulate the adult form with cavitation and extensive pneumonias but only in children over two years old. We suggest that this finding is probably due to progression of the primary focus rather than reactivation or progression of BCG vaccination. Such children respond well to short-course therapy but tend to relapse and have persisting problems because of lung damage (bronchiectasis). HIV infection in infants has a bimodal presentation.3 The early presenters will have symptoms by twelve months, but only a few late presenters will have them. We would not expect nursing staff at a busy clinic or vaccination centre to have time to pick out those with mildly symptomatic HIV infection. Although there is some evidence that BCG at three months produces a larger induration, more frequent scar formation, and less lymphadenopathy than if it is given at birth," we suggest that in African countries this is not the time to change the policy of giving BCG near birth. Attendance at vaccination clinics falls off strikingly after the measles vaccine at nine months and therefore many healthy children would not receive BCG. However, a good case could be made for chemoprophylaxis for children of HIV-positive mothers who have had active tuberculosis in the orevious two vears. S. D. R. GREEN Department of Child Life and Health, A. NGANGA University of Edinburgh, W. A. M. CUTTING Edinburgh EH9 1UW, UK, and
A. G. DAVIES
IME, Kimpese, Zaire
1. Green
*Denved from ’ndices in ref 1 for maternal serum oc-fetoprotein, unconjugated oestnol, and human chorionic gonadotropin with gestational age based on "dates", and assuming 100% uptake tlnwomen with risk of Down’s syndrome term pregnancy based on maternal age and serum levels that exceed cut-off nsk, assuming 100% uptake of amniocentesis tAssummg E15for screening and E150 for amniocentesis
Resources are scarce, so purchasers have to make difficult choices when considering the introduction of the new screening tests for Down’s syndrome. In this context it is not inappropriate to restrict screening to older women, which might be the only affordable
option. Institute of
Epidemiology and Health Department of Clinical Medicine, University of Leeds, Leeds LS2 9LN, UK
SDR, Cutting WAM, Mokili JLK, et al. Seroprevalence and determinants of HIV-1 infection in pregnancy in rural Zaire. (Presented at VIIIth International Conference on AIDS, Amsterdam, July 1992; abstract POC 4016.) 2 Cutting WAM, Davies AG, Green SDR, Mokili JKL, Bopopi J, Maude G Vertical transmission of HIV-1 in rural Zaire (Presented at VIIIth International Conference on AIDS, Amsterdam, July 1992; abstract POC 4234.) 3. Blanche S, Tardieu M, Duliege A, et al. Longitudinal study of 94 symptomatic infants with permatally acquired immunodeficiency virus infection: evidence for a bimodal expression of clinical and biological symptoms. Am J Dis Child 1990; 144: 1210-15. 4. Ildirim I, Sapan N, Cavusoglu B. Companson of BCG vaccination at birth and at third month of life Arch Dis Child 1992; 67: 80-82.
SIR,-We disagree with Dr
Athale and
colleagues’ conclusions
that, in countries with high prevalence of HIV-1 infection Services Research,
HOWARD CUCKLE
1 Wald NJ, Cuckle HS, Densem JW, Kennard A, Smith D. Maternal serum screening for Down’s syndrome the effect of routine ultrasound scan determination of gestational age and adjustment for maternal weight. Br J Obstet Gynaecol 1992; 99: 144-49.
such as those of central and east Africa, BCG vaccination should be discouraged at birth and postponed until 1 year of life, when clinical disease due to HIV infection will be evident. First, the cited HIV-1 seroprevalence of 15-25% in pregnant women from east and central Africa is an overestimate of the current national prevalence in most of these countries. It refers to women living in urban areas,’ who usually represent a minority of the total population. Second, the rate of mother-to-child transmission
will have no abnormalities. Compression reduces the thickness of breast tissue in the X-ray beam over the automatic exposure control detector. Thus a shorter exposure time is needed to produce the same density on the processed film. Compression increases the distance of the skin surface and some breast tissue from the source of X-rays, also reducing radiation dose. Compression is essential to the production of high-quality, low-dose mammograms. Fitment of motorised compression devices is recommended for all mammographic X-ray units used in the National Health Service (NHS) breast screening programme. 1.2 The maximum compression force recommended by the Department of Health is 200 N. The importance of checking breast compression devices has been recognised for some time3.4 and is routinely monitored in the NHS northern region. Our measurements in seventeen mammography units indicate the mean maximum force to be 166 N (SD 22). The simple relation between force and pressure does not apply to a complex compressible object, such as the breast in mammography. The pressure within the breast will vary with position, especially when close to the chest wall. The pressure distribution will depend on breast size and composition as well as the design of the compression plate. The degree of compression applied in practice will depend on the woman’s tolerance of pressure. Pressure measurements on the surface of the breast indicate that a specific compression force can result in a factor of 5 variation in pressure between subjects.s Others should examine the assertion made by Watmough and Quan about the dissemination of cells, especially since the difference between the Health Insurance Plan and Malmo studies, cited by them, could be attributable to factors other than breast
immediate development of the lesion but increases the intervals between episodes to 3 months. We do not have any pathophysiological explanation for this clinical observation.
ICI-Pharma,
Cergy,
M. AZAB
France
Ultrasonography of benign adrenal tumours SIR,-Real-time ultrasonography is a safe and inexpensive diagnostic procedure that requires no more than an electric socket and an experienced examiner. To the benefit of patients and the health-care system, it has begun to replace more expensive and less readily available imaging techniques, such as computed tomography (CT),1 in establishing the definite diagnosis of intra-abdominal masses. Improvements in image resolution now allow for accurate identification of the adrenal gland in more than 90% of subjects2 and safe needle biopsy of adrenal tumours under ultrasonic guidance.3 We have studied the diagnostic accuracy of real-time ultrasonography and CT in patients with benign adrenal tumours that were surgically removed and therefore available for pathological validation. Over the past seven years we have seen ten such tumours (table); all patients were initially admitted with symptoms that pointed to a possible adrenal involvement (no incidentally discovered masses).
compression. Regional Medical Physics Department, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
PH. VENNIN E. GOUGEON
Centre Oscar Lambret, Lille 59020, France
ADRENAL TUMOUR DIAMETERS (mm)
K. FAULKNER K. J. ROBSON C. J. KOTRE
Department of Health and Social Security. Guidance notes for health authorities on mammographic equipment required for breast cancer screening (STD/87/34). London: DHSS, 1987 2 Department of Health. Revised guidance notes for health authorities on mammographic equipment required for breast cancer screening (STD/90/46). London: DHSS, 1990 3. Faulkner K, Chambers IR, Hedley P, Thompson SR An instrument for monitoring the force applied by breast compression devices on mammography X-ray units. Clin Phys Physiol Meas 1989; 10: 177-80 4. Institute of Physical Sciences in Medicine. The commissioning and routine testing of mammographic X-ray systems (TGR 59 1989) York IPSM, 1989 5 Clark DJ, Chambers IR, Faulkner K, Rayson J, Hacking PM, Milton J. Pressure measurements during automatic breast compression in mammography J Biomed Engin 1990; 12: 444-46 1.
The
Antiviral response to tamoxifen up a 58-year old woman who, in 1983, right breast cancer treated by mastectomy, radiotherapy, and chemotherapy. In July, 1988, shortly after breast reconstruction, she had a metastatic bone lesion of D9 treated by radiotherapy and tamoxifen 30 mg per day for a year followed by 20 mg daily. Her only other treatment is calcium 100 mg per day since June, 1988. While on tamoxifen, the patient noticed complete disappearance of an old and cyclic herpetic skin eruption. Since the age of 40 she has had monthly herpetic eruptions, usually on the right buttock and sometimes labially. The association between these eruptions and the menstrual cycle is difficult to evaluate retrospectively. Each episode of herpes was preceded by pruritus for 4 days and lasted 7-8 days. The patient had a natural menopause at age of 40 and the herpetic episodes continued till the start of tamoxifen. On 30 mg daily, the patient did not have any herpetic manifestations. Small eruptions recurred
SIR,-We have followed
had
when the dose was reduced to 20 mg. In June, 1990, after 2 years, tamoxifen was stopped because there was no further tumour progression and because of hot flushes. The skin eruptions recurred monthly during the 4 months in which tamoxifen was stopped. The patient restarted tamoxifen by herself at 20 mg per day for 5 days once the skin manifestations start. She says that intake of tamoxifen in this way does not modify the
investigators doing
the
ultrasonography (real-time, Picker
7000, curved linear array 3-5 MHz) and the CT (Siemens, Somatom 2), the surgeon, and the surgical pathologist, were asked the widest diameter of the tumour. As expected, the smallest masses were found to be hormone-producing tumours while the larger ones were either inactive adenomas or phaeochromocytomas. Ultrasonography failed to identify three benign adrenal masses, all of which were less than 25 mm in diameter; this corresponds to the critical diameter below which needle biopsy of intra-abdominal masses under ultrasonic guidance frequently yields false-negative results.’ CT missed one aldosterone-producing adenoma (13 mm diameter), which was later found angiographically. All other tumours were correctly localised and identified by both ultrasonography and CT. With the surgical pathologist arbitrarily considered as the most reliable source of our measurements, ultrasonography predicted the exact size of tumours smaller than 60 mm within 72 (SD 32) mm and CT within 10’ 1 (2.4) mm (within 14-3 [5] mm and 15.77 [6] mm, respectively, for tumours > 60 mm). The operating surgeon generally reported larger diameters than the pathologist; in the absence of obvious technical explanations, we attributed this discrepancy to surgical enthusiasm. Ultrasonography and CT tended to underestimate the exact tumour diameter. We conclude that ultrasonography of benign adrenal tumours is similar in diagnostic accuracy to CT. Ultrasonography failed to recognise adenomas of less than 2-5 cm in diameter in our patients. to measure
799
Ultrasonography probably cannot replace CT in patients in whom small aldosterone-producing or cortisol-producing adenomas are suspected or where needle biopsy of such small tumours is to be attempted. Department of Surgery,
Hospital
of the Medical
Faculty,
Aachen
KARL-HEINZ TREUTNER
Department of Medicine I, Ulm University, 7900 Ulm, Germany
MARKUS M. LERCH
1. Mindel S. The full potential of ultrasound. Lancet 1988; i: 244 2 Zappasodi F, Derchi LE, Rizatto G. Ultrasonography of the normal adrenal glands: a study using linear-array real-time equipment. Br J Radiol 1986; 59: 759-64. 3 Jaeger HJ, MacFie J, Mitchell CJ, Couse N, Wai D. Diagnosis of abdominal masses with percutaneous biopsy guided by ultrasound. BMJ 1990; 301: 1188-91. 4. Jennings PE, Donald JJ, Coral A, Rode J, Lees WR. Ultrasound-guided core biopsy.
Lancet 1989; i: 1369-71.
Maternal
serum
screening policy for Down’s syndrome
SIR,-Professor Wald and colleagues (Aug 22, p 494) regard as inappropriate the restriction of maternal serum screening for Down’s syndrome to above a specified age, rather than offering such screening to women of any age. Although detection of affected pregnancies is maximised for a given rate of amniocentesis by screening all women, restricted screening can achieve similar results lower cost. This finding is illustrated in the table for screening with maternal serum a-fetoprotein, unconjugated oestriol, and human chorionic gonadotropin in 100 000 pregnant women who, without antenatal diagnosis, would deliver 130 Down’s syndrome infants. Screening all women irrespective of age (policy 1) would lead to 5000 amniocenteses, and 75 affected pregnancies would be detected. at
Restricting screening to women aged 27 or more but lowering the cut-off risk (policy 2), so that the same number of women had amniocentesis, would detect 66 affected pregnancies. The detection rate with policy 2 is not drastically lower than that for policy 1 and is achieved at much reduced costs since less than half the tests need be done. Lowering the cut-off further (policy 3), so that 9000 women had amniocentesis, would yield the same detection rate as policy 1, but would be 10% cheaper. ESTIMATED EFFECT OF THREE MATERNAL SERUM SCREENING POLICIES APPLIED TO 100000 WOMEN*
BCG vaccination in children born to
HIV-positive mothers SIR,-Dr Athale and colleagues from Lusaka (Aug 15, p 434) suggested that in countries of high HIV prevalence BCG (bacillus Calinette-Guerin) vaccination should be given only to
have
children over twelve months of age because of the risk of disseminated BCG infection. By that age it should be clear which children are infected. In a prospective study in Zaire of children born to HIV positive and negative mothers (seroprevalence 3’8%/ vertical transmission rate 23%2)all received BCG at birth. During follow-up of two years, 9 of 21 HIV-infected children developed tuberculosis which was disseminated in only 1, and 7 had a family contact. None had BCG adenitis. All responded well to shortcourse chemotherapy (avoiding thiacetazone). In the two matched control groups uninfected by HIV, 12 developed tuberculosis-4 born to 21 HIV-positive mothers and 8 born to 21 HIV-negative mothers. None of these had disseminated infection and 1 had BCG adenitis (mother seronegative). The HIV-infected and noninfected groups did not differ significantly. In the past ten years we have had only 1 case of probable disseminated BCG infection in a child of five months. He was vaccinated at three months and developed suppurating axillary BCG adenitis. His weight curve was static and he had persistent fever. Radiography showed typical miliary lesions and he responded well to short-course therapy. His mother was seropositive for HIV and he had no family tuberculosis contacts. We agree that many cases of tuberculosis in children infected with HIV simulate the adult form with cavitation and extensive pneumonias but only in children over two years old. We suggest that this finding is probably due to progression of the primary focus rather than reactivation or progression of BCG vaccination. Such children respond well to short-course therapy but tend to relapse and have persisting problems because of lung damage (bronchiectasis). HIV infection in infants has a bimodal presentation.3 The early presenters will have symptoms by twelve months, but only a few late presenters will have them. We would not expect nursing staff at a busy clinic or vaccination centre to have time to pick out those with mildly symptomatic HIV infection. Although there is some evidence that BCG at three months produces a larger induration, more frequent scar formation, and less lymphadenopathy than if it is given at birth," we suggest that in African countries this is not the time to change the policy of giving BCG near birth. Attendance at vaccination clinics falls off strikingly after the measles vaccine at nine months and therefore many healthy children would not receive BCG. However, a good case could be made for chemoprophylaxis for children of HIV-positive mothers who have had active tuberculosis in the orevious two vears. S. D. R. GREEN Department of Child Life and Health, A. NGANGA University of Edinburgh, W. A. M. CUTTING Edinburgh EH9 1UW, UK, and
A. G. DAVIES
IME, Kimpese, Zaire
1. Green
*Denved from ’ndices in ref 1 for maternal serum oc-fetoprotein, unconjugated oestnol, and human chorionic gonadotropin with gestational age based on "dates", and assuming 100% uptake tlnwomen with risk of Down’s syndrome term pregnancy based on maternal age and serum levels that exceed cut-off nsk, assuming 100% uptake of amniocentesis tAssummg E15for screening and E150 for amniocentesis
Resources are scarce, so purchasers have to make difficult choices when considering the introduction of the new screening tests for Down’s syndrome. In this context it is not inappropriate to restrict screening to older women, which might be the only affordable
option. Institute of
Epidemiology and Health Department of Clinical Medicine, University of Leeds, Leeds LS2 9LN, UK
SDR, Cutting WAM, Mokili JLK, et al. Seroprevalence and determinants of HIV-1 infection in pregnancy in rural Zaire. (Presented at VIIIth International Conference on AIDS, Amsterdam, July 1992; abstract POC 4016.) 2 Cutting WAM, Davies AG, Green SDR, Mokili JKL, Bopopi J, Maude G Vertical transmission of HIV-1 in rural Zaire (Presented at VIIIth International Conference on AIDS, Amsterdam, July 1992; abstract POC 4234.) 3. Blanche S, Tardieu M, Duliege A, et al. Longitudinal study of 94 symptomatic infants with permatally acquired immunodeficiency virus infection: evidence for a bimodal expression of clinical and biological symptoms. Am J Dis Child 1990; 144: 1210-15. 4. Ildirim I, Sapan N, Cavusoglu B. Companson of BCG vaccination at birth and at third month of life Arch Dis Child 1992; 67: 80-82.
SIR,-We disagree with Dr
Athale and
colleagues’ conclusions
that, in countries with high prevalence of HIV-1 infection Services Research,
HOWARD CUCKLE
1 Wald NJ, Cuckle HS, Densem JW, Kennard A, Smith D. Maternal serum screening for Down’s syndrome the effect of routine ultrasound scan determination of gestational age and adjustment for maternal weight. Br J Obstet Gynaecol 1992; 99: 144-49.
such as those of central and east Africa, BCG vaccination should be discouraged at birth and postponed until 1 year of life, when clinical disease due to HIV infection will be evident. First, the cited HIV-1 seroprevalence of 15-25% in pregnant women from east and central Africa is an overestimate of the current national prevalence in most of these countries. It refers to women living in urban areas,’ who usually represent a minority of the total population. Second, the rate of mother-to-child transmission
