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The only practical way to make an impact on the appalling maternal mortality and morbidity is to offer a choice of contraceptives throughout the country. A pioneer social marketing programme, supported by Population Services International, has already sold 4 million condoms at a subsidised price (see Lancet May 30, p 1348) and similar programmes in other countries have successfully marketed oral contraceptives. Ethnic diversity sometimes makes family planning controversial. Fortunately there is no sign of such resistance in the current election.
Malcolm Potts
Medicine and the Law Meningitis, schools, and public alarm At an inquest at Southwark Coroner’s Court on June 1, 1992, on the death of a 10-year-old boy from meningitis, Sir
Montague Levine discussed guidelines on the notification of parents and schools when specified infectious diseases are reported in an area. The boy had been perfectly well until he awoke on March 11, 1992, feeling "out of sorts" with a headache and vomiting but no temperature. His stepmother felt that he was not fit to go to school and decided to take him to the child minder’s until she could collect him at about 3.30 that day; had she thought there was anything serious brewing she would have taken time off work and called in a doctor. The boy’s condition gradually deteriorated. He seemed listless and by the end of the morning was drowsy and febrile. The child minder did not call the doctor because she knew the mother would be arriving in the early afternoon. The mother found the child drowsy and incoherent and she called a doctor, who arrived within 10 minutes. He noted the first signs of a rash and arranged for immediate admission to hospital. Meningitis with septicaemia was diagnosed and within hours kidney (and ultimately multiorgan) failure ensued. He was transferred to Guy’s Hospital, London, where he died the next day. In February two other cases of meningitis in children living in the same area of Milton Keynes had been diagnosed. Both had been admitted to hospital; neither had septicaemia and they recovered. The first case, diagnosed on Feb 14, was in a 10-year-old boy at the same school as the third and fatal case. The second case (Feb 18) was in a 5-year-old who went to a different school and did not know the two boys. There was anxiety about whether the cases might be connected and about whether all potential contacts had been investigated and whether procedures for notification of parents were adequate. Had the boy’s parents been warned of the possibility of meningitis they might have called in a doctor sooner, though it will never be known whether this would have affected the outcome. The coroner said that everybody had acted properly within the guidance they were given. However, perhaps the advice given to the headteacher by the department of health, aimed at not causing alarm among parents in response to an apparently isolated instance of meningitis in the school, should be reviewed. On notification of the second case the head-teacher had immediately (March 12) sent a letter to all parents. Current guidance on the epidemiology and control of meningococcal diseases is dated Feb 24,1989 (Commun Dis
Rep 1989, no 8), and states that "Transmission from case to case is rare and most cases acquire infection from healthy carriers by droplet spread or direct contact... the risk of symptomatic infection in household contacts following the diagnosis of meningococcal meningitis in the index case, though small, is significantly greater than in the general population". The period of increased risk for household contacts is not known "but most studies of secondary attack rates ... have used an arbitrary period of 30 days after last In Gloucestershire the risk of subsequent cases occurring in household contacts was increased for much longer than 28 days". The guidance
exposure to the index case
...
refers to chemoprophylaxis with rifampicin but states that "Contacts at school are not usually considered to require chemoprophylaxis unless more than one related case occurs". When meningitis in a schoolchild is notified the head-teacher and family doctors in the area should be informed but "Public concern persisting despite reassurance from the public health doctor should not be an indication for mass chemoprophylaxis". A case in a nursery school of day-care centre should prompt an offer of chemoprophylaxis for close contacts among children and staff. The Southwark inquest resulted from a request by the family’s solicitor, who felt that there might be lessons to be learned and argued that close classroom contact could provide as much or greater opportunity for the spread of meningitis as a household setting. The coroner recommended a review of guidelines issued to public health departments on the notification of schools when more than one case of specified infectious diseases has occurred in an area, and head-teachers should be given more specific advice on the handling of information from the public health
department. Diana Brahams
Conference Endometriosis Developments in cell biology and immunology dominated the proceedings of the Third World Congress on Endometriosis that was held in Brussels early this month. Several groups have used cell cultures derived from uterine endometrial preparations to investigate the control of endometriotic tissue growth. Stromal cell proliferation is inhibited by interleukin-1and stimulated by epidermal
growth factor, platelet-derived growth factor, transforming growth factor &bgr;, and b fibroblast growth factor, for example. The source of these growth factors may be cells resident in endometriotic tissue itself or in peritoneal fluid. Peripheral blood monocytes from women with endometriosis but not those from fertile women also stimulate endometrial cell proliferation. Whether these fmdings can be taken to indicate how the growth of endometriotic implants is controlled remains to be proven. In the past decade, there has been accumulating evidence linking endometriosis with alterations in both cell-mediated and humoral immunity. For example, natural killer cell activity in peripheral blood and peritoneal fluid is reduced in women with endometriosis. Thus failure of the mechanisms designed to clear menstrual debris might account for implantation of endometrial cells that are transported to the peritoneal cavity by retrograde menstruation. Women with
The only practical way to make an impact on the appalling maternal mortality and morbidity is to offer a choice of contraceptives throughout the country. A pioneer social marketing programme, supported by Population Services International, has already sold 4 million condoms at a subsidised price (see Lancet May 30, p 1348) and similar programmes in other countries have successfully marketed oral contraceptives. Ethnic diversity sometimes makes family planning controversial. Fortunately there is no sign of such resistance in the current election.
Malcolm Potts
Medicine and the Law Meningitis, schools, and public alarm At an inquest at Southwark Coroner’s Court on June 1, 1992, on the death of a 10-year-old boy from meningitis, Sir
Montague Levine discussed guidelines on the notification of parents and schools when specified infectious diseases are reported in an area. The boy had been perfectly well until he awoke on March 11, 1992, feeling "out of sorts" with a headache and vomiting but no temperature. His stepmother felt that he was not fit to go to school and decided to take him to the child minder’s until she could collect him at about 3.30 that day; had she thought there was anything serious brewing she would have taken time off work and called in a doctor. The boy’s condition gradually deteriorated. He seemed listless and by the end of the morning was drowsy and febrile. The child minder did not call the doctor because she knew the mother would be arriving in the early afternoon. The mother found the child drowsy and incoherent and she called a doctor, who arrived within 10 minutes. He noted the first signs of a rash and arranged for immediate admission to hospital. Meningitis with septicaemia was diagnosed and within hours kidney (and ultimately multiorgan) failure ensued. He was transferred to Guy’s Hospital, London, where he died the next day. In February two other cases of meningitis in children living in the same area of Milton Keynes had been diagnosed. Both had been admitted to hospital; neither had septicaemia and they recovered. The first case, diagnosed on Feb 14, was in a 10-year-old boy at the same school as the third and fatal case. The second case (Feb 18) was in a 5-year-old who went to a different school and did not know the two boys. There was anxiety about whether the cases might be connected and about whether all potential contacts had been investigated and whether procedures for notification of parents were adequate. Had the boy’s parents been warned of the possibility of meningitis they might have called in a doctor sooner, though it will never be known whether this would have affected the outcome. The coroner said that everybody had acted properly within the guidance they were given. However, perhaps the advice given to the headteacher by the department of health, aimed at not causing alarm among parents in response to an apparently isolated instance of meningitis in the school, should be reviewed. On notification of the second case the head-teacher had immediately (March 12) sent a letter to all parents. Current guidance on the epidemiology and control of meningococcal diseases is dated Feb 24,1989 (Commun Dis
Rep 1989, no 8), and states that "Transmission from case to case is rare and most cases acquire infection from healthy carriers by droplet spread or direct contact... the risk of symptomatic infection in household contacts following the diagnosis of meningococcal meningitis in the index case, though small, is significantly greater than in the general population". The period of increased risk for household contacts is not known "but most studies of secondary attack rates ... have used an arbitrary period of 30 days after last In Gloucestershire the risk of subsequent cases occurring in household contacts was increased for much longer than 28 days". The guidance
exposure to the index case
...
refers to chemoprophylaxis with rifampicin but states that "Contacts at school are not usually considered to require chemoprophylaxis unless more than one related case occurs". When meningitis in a schoolchild is notified the head-teacher and family doctors in the area should be informed but "Public concern persisting despite reassurance from the public health doctor should not be an indication for mass chemoprophylaxis". A case in a nursery school of day-care centre should prompt an offer of chemoprophylaxis for close contacts among children and staff. The Southwark inquest resulted from a request by the family’s solicitor, who felt that there might be lessons to be learned and argued that close classroom contact could provide as much or greater opportunity for the spread of meningitis as a household setting. The coroner recommended a review of guidelines issued to public health departments on the notification of schools when more than one case of specified infectious diseases has occurred in an area, and head-teachers should be given more specific advice on the handling of information from the public health
department. Diana Brahams
Conference Endometriosis Developments in cell biology and immunology dominated the proceedings of the Third World Congress on Endometriosis that was held in Brussels early this month. Several groups have used cell cultures derived from uterine endometrial preparations to investigate the control of endometriotic tissue growth. Stromal cell proliferation is inhibited by interleukin-1and stimulated by epidermal
growth factor, platelet-derived growth factor, transforming growth factor &bgr;, and b fibroblast growth factor, for example. The source of these growth factors may be cells resident in endometriotic tissue itself or in peritoneal fluid. Peripheral blood monocytes from women with endometriosis but not those from fertile women also stimulate endometrial cell proliferation. Whether these fmdings can be taken to indicate how the growth of endometriotic implants is controlled remains to be proven. In the past decade, there has been accumulating evidence linking endometriosis with alterations in both cell-mediated and humoral immunity. For example, natural killer cell activity in peripheral blood and peritoneal fluid is reduced in women with endometriosis. Thus failure of the mechanisms designed to clear menstrual debris might account for implantation of endometrial cells that are transported to the peritoneal cavity by retrograde menstruation. Women with
