In this month's Bulletin

Tuberculosis in health workers in Malawi (pp. 526–531)

Guidelines that can help to control the nosocomial transmission of TB are readily adopted but not necessarily followed. Rapid diagnosis of infectious TB is one of the most important ways of reducing transmission where resources are scarce, and most of the hospitals studied stated that they had set up systems for doing this. However, this was not followed by any reduction in the interval between admission and diagnosis or between admission and treatment. Staff shortages and low motivation are thought to be the main obstacle to improvement.

Treating epilepsy in Mali (pp. 532–537)

Low daily doses of phenobarbital produced a reduction or cessation of seizures in 96% of patients. Improvements in patients' physical and mental health and social status were also noted. The cost of treating all epileptic patients in Mali with a protocol such as the one described is estimated to be US$ 1 million a year, and the social cost of not treating them at US$ 6 million.

Treating malaria in young children in Cameroon (pp. 538–545)

Of three treatments tested, the sulfadoxine–pyrimethamine–amodiaquine combination was found to be the most effective. It is recommended as a temporary means of slowing the spread of multidrug resistance in Plasmodium falciparum malaria in Africa while the introduction of other combinations, including artemisinin derivatives, is awaited. Chloroquine is no longer effective in Cameroon except in the northern provinces.

Street food in Accra (pp. 546–554)

In developing countries a large proportion of ready-to-eat food is sold on the streets. Street foods sold in Accra, Ghana, include fermented maize dough, pounded cassava, boiled rice, okra soup, tomato stew, fried peppers, beans, fish, and rice. People who depend on foods available on the street are often more interested in convenience than quality, safety or hygiene. The health hazards include lack of running water and toilet facilities, washing-up done in buckets and bowls without disinfectant, lack of refrigeration, and exposure of food to flies and rodents. The street food traders in Accra were found to be mainly women. Though practices were in many cases hygienic, the need was seen for several improvements, especially serving food with a spoon or fork instead of bare hands, and washing dishes and utensils in soapy water.

Death certification in Beirut (pp. 555–561)

Death certificates over the last 25 years in Beirut were examined. The information on demographic variables such as sex, marital status and date of death was in most cases complete, but occupation and month of birth were usually missing. Though the proportion of certificates that gave a cause of death increased with time, there were still 43% that lacked this in the most recent registration cohorts. Possible reasons for these deficiencies and ways of rectifying them are discussed. Without reliable data on causes of death, the choice of public health priorities can be mistaken.

Respiratory syncytial virus in the Gambia (pp. 562–568)

RSV is an important cause of acute lower respiratory infection leading to hospital admission in the Gambia. Of 4799 under- two-year-olds with ALRI admitted to the three study hospitals, 421 had severe RSV-associated respiratory illness, and of these 55 were hypoxaemic. It was not possible to estimate the mortality due to RSV in this study, but morbidity was clearly considerable, and efforts at prevention are likely to be worthwhile.

Hepatitis B vaccination in prisons (pp. 569–574)

Infection with hepatitis B virus is common among prison inmates. Many come from marginal sections of the population such as intravenous drug users, with high rates of exposure to the virus. The options for vaccination programmes in prison settings are discussed, with particular reference to the advantages of modelling and active case finding. Good case-holding, a short vaccination schedule, a 20 µg per dose vaccine, and a higher reference level for determining seroprotection are recommended.

Skill mix for health workers (pp. 575–580)

Increased use of less qualified nursing staff will not be effective in all situations, though in some the increased use of care assistants has led to greater organizational effectiveness. Evidence of the doctor–nurse overlap indicates that there is unrealized scope in many systems for extending the use of nursing staff. The effectiveness of different skill mixes in other groups, and that of developing new roles in health care, remains relatively unexplored.

How underpaid health staff survive (pp. 581–584)

Under-the-counter fees, pressure on patients to attend private consultations, sale of drugs that are supposed to be free, and other such practices are known to be rampant in many countries. In addition, many underpaid public sector clinicians switch between public and private practice to top up their incomes, whether the regulations allow this or not. Health system managers have fewer opportunities for predation than clinicians, so they may resort to corruption, teaching, consulting for development agencies, or non-medical work. What should be done about it?

Mass immunization campaign against measles (pp. 585–591)

A measles epidemic seemed imminent in mid-1997 in Hong Kong Special Administrative Region of China. A mass immunization campaign was therefore organized, targeting all those between one and 19 years of age who could not produce written proof of having previously received two doses of measles/mumps/rubella or measles vaccine. Coverage was 77%, the rate of adverse events was low, and measles notifications fell to 0.9 per 100 000 in 1998. A two-dose strategy and supplementary campaigns are expected to keep measles susceptibility low enough to make elimination feasible.

Sorting out medical education in North America in 1910 (pp. 594–602)

"Overproduction of ill-trained men is due in the main to the existence of a very large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out of industrial occupations into the study of medicine."

The Flexner report.&nbsp