From: <Saved by Windows Internet Explorer 7>
Subject: Updates from BOTUSA Early infant diagnosis of HIV and the diarrhea outbreak
Date: Mon, 2 Jun 2008 00:15:22 +0100
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	PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
	if( IsFramesMode() ) {
		UpdNavPane(); UpdOtlPane(); UpdNtsPane()
	}
}
function GoToSld( href )
{
	if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
	GetHrefObj( GetSldNum(href) ).mVis=3D1
	PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
	if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
	gPrevSld=3DgCurSld
	gCurSld=3DGetSldNum(id)
	if( IsFramesMode() ) {
		UpdNavPane(); UpdOtlPane(); UpdNtsPane()
	}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && =
GetHrefObj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
	if( HideMenu() ) return;
	var event =3D PPTSld.event;
	if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || =
event.keyCode=3D=3D32 || event.type=3D=3D"click" ) )
		window.close( self );
	CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
	gIsEndShow=3D1;
	PPTSld.document.body.scroll=3D"no";
	PPTSld.document.onkeypress=3DCloseWindow;
	PPTSld.document.onclick=3DCloseWindow;
	PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
	if( IsFramesMode() ) return
	if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
	doc=3DPPTSld.document
	doc.open()
	doc.writeln('<html><body bgcolor=3Dblack onload=3Dparent.SetupEndShow() =
onunload=3Dparent.Unload()><center><p><font face=3DTahoma color=3Dwhite =
size=3D2><br><b>' + ENDSHOW_MESG + =
'</b></font></p></center></body></html>')
	doc.close()
}
function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue =
}
function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited }
function hrefList( sldHref, visible, advDelay, advClk )
{
	this.mSldHref=3D this.mNtsHref =3D sldHref
	this.mOrigVis=3D this.mVis =3D visible
	this.mVisited=3D false
	this.mAdvDelay=3D advDelay
	this.mAdvOnClk=3D advClk
}
function SldList(arr,curSld,fEnd)
{
	this.mCurSld =3D curSld;
	this.mList =3D new Array();
	var idx =3D 1;
	for(ii=3D0;ii<arr.length;ii++) {
		this.mList[ii] =3D new hrefList( arr[ii].mSldHref, arr[ii].mOrigVis, =
arr[ii].mAdvDelay, arr[ii].mAdvOnClk );
		if( arr[ii].mOrigVis )
			this.mList[ii].mSldIdx =3D idx++;
	}
	this.mNumVisSlds =3D idx-1;
	this.fEndShow =3D fEnd;
}
function GetSldList() {	return gSldStack[gSldStack.length-1] }
function GetCurSld() { return parent.GetSldList().mList[parent.gCurSld - =
1] }
gSldStack =3D new Array();
gSldStack[0] =3D new SldList(gMainDoc,gCurSld,1)
function ViewCustomShow(idx,fEnd)
{
	if( !IsFullScrMode() ) return;
	var sldList =3D new Array();
	var custShow =3D custShowList[idx-1];
	var jj =3D 0;
	for( ii=3D0;ii<custShow.length;ii++ ) {
		if( custShow[ii] <=3D gMainDoc.length )
			sldList[jj++] =3D gMainDoc[custShow[ii]-1];
	}
	if (sldList.length > 0) {
	PushSldList(sldList,fEnd);
	gCurSld =3D 1;
	}
	else
		if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
	var ii =3D gSldStack.length;
	gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
	GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
	if (gSldStack[gSldStack.length-1].fEndShow)
		EndShow()
	else {
	gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
	gSldStack[gSldStack.length-1] =3D null;
	gSldStack.length--;
	var sldList =3D gSldStack[gSldStack.length-1];
	GoToSld( sldList.mList[gCurSld - 1].mSldHref );
	}
}
var custShowList=3Dnew Array();
function ImgBtn( oId,bId,w,action )
{
	var t=3Dthis
	t.Perform    =3D _IBP
	t.SetActive  =3D _IBSetA
	t.SetInactive=3D _IBSetI
	t.SetPressed =3D _IBSetP
	t.SetDisabled=3D _IBSetD
	t.Enabled    =3D _IBSetE
	t.ChangeIcon =3D null
	t.UserAction =3D action
	t.ChgState   =3D _IBUI
	t.mObjId   =3D oId
	t.mBorderId=3D bId
	t.mWidth   =3D w
	t.mIsOn    =3D t.mCurState =3D 0
}
function _IBSetA()
{
	if( this.mIsOn ) {
		obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
		obj.style.posTop=3D0
	}
}
function _IBSetI()
{
	if( this.mIsOn ) {
		obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
		obj.style.posTop=3D0
	}
}
function _IBSetP()
{
	if( this.mIsOn ) {
		obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
		obj.style.posLeft+=3D1; obj.style.posTop+=3D1
	}
}
function _IBSetD()
{
	obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
	obj.style.posTop=3D0
}
function _IBSetE( state )
{
	var t=3Dthis
	GetObj( t.mBorderId ).style.visibility=3D"visible"
	if( state !=3D t.mIsOn ) {
		t.mIsOn=3Dstate
		if( state )
			t.SetInactive()
		else
			t.SetDisabled()
	}
}
function _IBP()
{
	var t=3Dthis
	if( t.mIsOn ) {
		if( t.UserAction !=3D null )
			t.UserAction()
		if( t.ChangeIcon ) {
			obj=3DGetObj(t.mObjId)
			if( t.ChangeIcon() )
				obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
			else
				obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
		}
		t.SetActive()
	}
}
function _IBUI( clr1,clr2,nextState )
{
	var t=3Dthis
	SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
	obj=3DGetObj( t.mObjId )
	=
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-ob=
j.style.posTop
	t.mCurState=3DnextState
	return obj
}
function TxtBtn( oId,oeId,action,chkState )
{
	var t=3Dthis
	t.Perform    =3D _TBP
	t.SetActive  =3D _TBSetA
	t.SetInactive=3D _TBSetI
	t.SetPressed =3D _TBSetP
	t.SetDisabled=3D _TBSetD
	t.SetEnabled =3D _TBSetE
	t.GetState   =3D chkState
	t.UserAction =3D action
	t.ChgState   =3D _TBUI
	t.mObjId      =3D oId
	t.m_elementsId=3D oeId
	t.mIsOn       =3D 1
}
function _TBSetA()
{
	var t=3Dthis
	if( t.mIsOn && !t.GetState() )
		t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
	var t=3Dthis
	if( t.mIsOn && !t.GetState() )
		t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
	if( this.mIsOn )
		this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{
	this.ChgState( gFaceClr,gFaceClr,0,0 )
	this.mIsOn =3D 0
}
function _TBSetE()
{
	var t=3Dthis
	if( !t.GetState() )
		t.ChgState( gFaceClr,gFaceClr,0,0 )
	else
		t.ChgState( gShadowClr,gHiliteClr,1,1 )
	t.mIsOn =3D 1
}
function _TBP()
{
	var t=3Dthis
	if( t.mIsOn ) {
		if( t.UserAction !=3D null )
			t.UserAction()
        if( !t.GetState )
            return
		if( t.GetState() )
			t.SetPressed()
		else
			t.SetActive()
	}
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
	SetBorder( GetObj( this.mObjId ),clr1,clr2 )
	Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; =
obj.style.left=3Dleft }
function SetBorder( obj, upperLeft, lowerRight )
{
	s=3Dobj.style;
	s.borderStyle      =3D "solid"
	s.borderWidth      =3D 1
	s.borderLeftColor  =3D s.borderTopColor =3D upperLeft
	s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() =
}
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() =
}
function BtnOnUp()
{
	b=3DGetBtnObj()
	if( b !=3D null )
		b.Perform()
	else
		Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
	s=3Ddocument.all.item( this.m_flagId ).style
	s.display=3D"none"
	if( fVal )
		s.display=3D""
	else
		s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) =
b.SetActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) =
b.SetInactive() }
var =
gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"TH=
REEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( =
"nb_otl","nb_otlElem",parent.ToggleOtlPane,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( =
"nb_otl","nb_otlElem",parent.ToggleOtlPane,GetOtlState )
gBtnArr["nb_nts"] =3D new TxtBtn( =
"nb_nts","nb_ntsElem",parent.ToggleNtsPane,GetNtsState )
gBtnArr["nb_prev"]=3D new ImgBtn( =
"nb_prev","nb_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_next"]=3D new ImgBtn( =
"nb_next","nb_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( =
"nb_sldshw","nb_sldshwBorder",18,parent.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( =
"nb_sldshw","nb_sldshwBorder",parent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( =
"nb_sldshw","nb_sldshwText",parent.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"]  =3D new ImgBtn( =
"nb_voice","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxt"]=3D new ImgBtn( =
"nb_otlTxt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_nts"].m_flagId=3D "notes_flag"
gBtnArr["nb_nts"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End =
Show",sFont=3D"Arial",sArrow=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Re=
ctangle",sOval=3D"Oval"
function ShowMenu()
{
	BuildMenu();
	var =
doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=3DPP=
TSld.event.clientY+doc.scrollTop
	m =3D PPTSld.document.all.item("ctxtmenu")
	m.style.pixelLeft=3Dx
	if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
		m.style.pixelLeft=3Dx-m.scrollWidth
	m.style.pixelTop=3Dy
	if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
		m.style.pixelTop=3Dy-m.scrollHeight
	m.style.display=3D""
}
function _CM()
{
	if( !parent.IsFullScrMode() ) return;
	if(!PPTSld.event.ctrlKey) {
		ShowMenu()
		return false
	} else
		HideMenu()
}
function BuildMenu()
{
	if( PPTSld.document.all.item("ctxtmenu") ) return
	var mObj=3DCreateItem( PPTSld.document.body )
	mObj.id=3D"ctxtmenu"
	mObj.style.visibility=3D"hidden"
	var s=3DmObj.style
	s.position=3D"absolute"
	s.cursor=3D"default"
	s.width=3D"120px"
	SetCMBorder(mObj,"menu","black")
	var iObj=3DCreateItem( mObj )
	SetCMBorder( iObj, "threedhighlight","threedshadow" )
	iObj.style.padding=3D2
	CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
	CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
	CreateSeparator( iObj )
	CreateMenuItem( iObj,sEnd,M_End,M_True )
	mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; =
window.event.returnValue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
	e=3DPPTSld.event.srcElement
	if( e.type=3D=3D"menuitem" && e.IsActive() )
		e.Action()
	else
		PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
	e=3DPPTSld.event.srcElement
	if( e.type=3D=3D"menuitem" && e.IsActive() ) {
		e.style.backgroundColor=3Dbg
		e.style.color=3Dclr
	}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { history.back(); =
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
	var e=3DCreateItem( node )
	e.type=3D"menuitem"
	e.Action=3Daction
	e.IsActive=3Deval
	e.innerHTML=3Dtext
	if( !e.IsActive() )
		e.style.color=3D"threedshadow"
	e.onclick=3DPerform
	e.onmouseover=3DHighlight
	e.onmouseout=3DDeselect
	s=3De.style;
	s.fontFamily=3DsFont
	s.fontSize=3D"9pt"
	s.paddingLeft=3D2
}
function CreateSeparator( node )
{
	var sObj=3DCreateItem( node )
	SetCMBorder(sObj,"menu","menu")
	var s=3DsObj.style
	s.borderTopColor=3D"threedshadow"
	s.borderBottomColor=3D"threedhighlight"
	s.height=3D1
	s.fontSize=3D"0px"
}
function CreateItem( node )
{
	var elem=3DPPTSld.document.createElement("DIV")
	node.insertBefore( elem )
	return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
	var s=3Do.style
	s.backgroundColor=3D"menu"
	s.borderStyle=3D"solid"
	s.borderWidth=3D1
	s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}

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Content-Type: multipart/alternative;
	boundary="----=_NextPart_001_0007_01C8C445.BF492AD0"


------=_NextPart_001_0007_01C8C445.BF492AD0
Content-Type: text/html;
	charset="Windows-1252"
Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/frame.htm

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Frameset//EN">
<HTML><HEAD><TITLE>Updates from BOTUSA Early infant diagnosis of HIV and =
the diarrhea outbreak</TITLE>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Dwindows-1252">
<META content=3DPowerPoint.Slide name=3DProgId>
<META content=3D"MSHTML 6.00.6000.16640" name=3DGENERATOR><LINK =
id=3DMain-File=20
href=3D"../TracyCreek.htm" rel=3DMain-File><LINK href=3D"preview.wmf" =
rel=3DPreview><![if !ppt]>
<SCRIPT=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/scrip=
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<SCRIPT>
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var gNavLoaded =3D gOtlNavLoaded =3D gOtlLoaded =3D false;
function Load()
{
	str=3Ddocument.location.hash,idx=3Dstr.indexOf('#')
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	if(str) PPTSld.location.replace(str);
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//-->
</SCRIPT>
<![endif]></HEAD><FRAMESET border=3D0 frameSpacing=3D0 rows=3D*,25 =
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onload=3DLoad()=20
cols=3D25%,*><FRAMESET rows=3D100%,* onload=3DLoad()><FRAME =
title=3DOutline name=3DPPTOtl=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/outli=
ne.htm"></FRAMESET><FRAMESET=20
id=3DPPTVertAdjust frameSpacing=3D2 rows=3D*,40 frameBorder=3D1 =
onload=3DLoad()><FRAME=20
title=3DSlide name=3DPPTSld=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/slide=
0123.htm"><FRAME=20
title=3DNotes name=3DPPTNts=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/slide=
0123.htm"></FRAMESET></FRAMESET><FRAMESET=20
frameSpacing=3D1 onload=3DLoad() cols=3D25%,*><FRAME=20
title=3D"Outline&#13;&#10;Navigation Bar" name=3DPPTOtlNav=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/outli=
ne.htm"=20
noResize scrolling=3Dno><FRAME title=3D"Slide&#13;&#10;Navigation Bar" =
name=3DPPTNav=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/outli=
ne.htm"=20
noResize scrolling=3Dno></FRAMESET></FRAMESET></HTML>

------=_NextPart_001_0007_01C8C445.BF492AD0
Content-Type: text/html;
	charset="Windows-1252"
Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/outline.htm

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Dwindows-1252">
<META content=3DPowerPoint.Slide name=3DProgId>
<META content=3D"MSHTML 6.00.6000.16640" name=3DGENERATOR><LINK =
id=3DMain-File=20
href=3D"../TracyCreek.htm" rel=3DMain-File><LINK href=3D"preview.wmf" =
rel=3DPreview>
<META content=3DNoIndex name=3DRobots>
<SCRIPT=20
src=3D"http://www.blsmeetings.net/implementhiv2006/TracyCreek_files/scrip=
t.js"></SCRIPT>

<SCRIPT><!--
if( !(IsWin("PPTOtl")||IsWin("PPTNav")||IsWin("PPTOtlNav")) )
{
	obj =3D GetObj("Main-File")
	parent.location.href=3Dobj.href
}
var =
gOtlHiliteClr=3D"#ffffff",gOtlNormalClr=3D"#000000",gOtlActiveClr=3D"#fff=
f00",gSelected=3D"",gTxtState=3Dfalse,gChildEntryTable=3Dnew Array()
function Load()
{
	if( IsWin("PPTOtl" ) ){ LoadOtl(); parent.gOtlLoaded=3Dtrue; return }
	if( g_supportsPPTHTML ) {
		if( IsWin("PPTNav" ) ){ LoadNav("NavObj",UpdNav); =
parent.gNavLoaded=3Dtrue; return }
		if( IsWin("PPTOtlNav" ) ){ LoadNav("OtlNavObj",UpdOtlNav); =
parent.gOtlNavLoaded=3Dtrue; return }
	}
}
function Upd(){ if( IsWin("PPTNav") ) LoadNav("NavObj",UpdNav) }
function LoadNav( oId,UpdFunc )
{
	document.ondragstart=3DCancelDrag
	document.onselectstart=3DCancelDrag
	document.body.style.margin=3D2
	UpdFunc()
	obj=3Ddocument.all.item(oId)
	obj.style.display=3D"block"
	obj.style.visibility=3D"visible"
	document.bgColor=3D"threedface"
	if( parent.frames["PPTNts"] )
		notesBtn.style.display =3D ""
	if( parent.gHasNarration )
		nb_voiceBorder.style.display =3D ""
}
function LoadOtl()
{
	var otl=3DGetObj("OtlObj")
	otl.style.display=3D"block"
	otl.style.visibility=3D"visible"
	if( gOtlActiveClr =3D=3D "" ) gOtlActiveClr=3Ddocument.linkColor
	if( gOtlHiliteClr =3D=3D "" ) gOtlHiliteClr=3Ddocument.fgColor
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<TABLE style=3D"POSITION: relative" cellSpacing=3D0 cellPadding=3D0 =
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  <TBODY>
  <TR>
    <TD>
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      style=3D"BORDER-RIGHT: buttonface 1px solid; BORDER-TOP: =
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<DIV id=3DOtlObj style=3D"DISPLAY: none; VISIBILITY: hidden">
<TABLE style=3D"FONT-SIZE: 9pt; FONT-FAMILY: Arial" width=3D"100%">
  <TBODY>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>1</FONT></DIV></TD>
    <TD width=3D"100%">
      <DIV class=3DPTxt id=3DPPTP1><FONT size=3D2><A id=3DPPTL1=20
      href=3D"javascript:GoToSld('slide0001.htm');">Role of infant =
feeding and HIV=20
      in a severe outbreak of diarrhea and malnutrition among young =
children -=20
      Botswana, 2006 <BR><BR>Tracy Creek, MD<BR>Centers for Disease =
Control and=20
      Prevention<BR>For the Botswana infant diarrhea outbreak =
team<BR>June 13,=20
      2006</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>2</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP2><FONT size=3D2><A id=3DPPTL2=20
      href=3D"javascript:GoToSld('slide0123.htm');">PMTCT in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC2 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>HIV prevalence in pregnant women 33.4% 2005=20
        <LI>National PMTCT program started 1999=20
        <LI>Program provides=20
        <UL>
          <LI>ARV therapy for women with CD4&lt;200=20
          <LI>AZT 12 weeks to mothers, 4 weeks to infants=20
          <LI>SD NVP for mothers and infants=20
          <LI>Free infant formula for 12 months </LI></UL>
        <LI>High uptake since 2004, 80% receive AZT=20
        <LI>HIV transmission to infants ~7% in recent data, an 80% =
reduction=20
        </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>3</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP3><FONT size=3D2><A id=3DPPTL3=20
      href=3D"javascript:GoToSld('slide0124.htm');">Infant formula in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC3 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>All HIV-positive women advised to formula feed=20
        <LI>63% of HIV-positive women used formula in 2005=20
        <LI>Difficulty maintaining and distributing formula supply=20
        <LI>Efforts to strengthen logistics, counseling, and application =
of WHO=20
        criteria for replacement feeding (acceptable, feasible, =
affordable,=20
        sustainable, safe) </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>4</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP4><FONT size=3D2><A id=3DPPTL4=20
      href=3D"javascript:GoToSld('slide0125.htm');">Mashi study showed =
high=20
      mortality among formula fed infants</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC4 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Harvard study in Botswana, results 2005=20
        <LI>1200 infants of HIV-positive mothers=20
        <UL>
          <LI>Half formula fed from birth=20
          <LI>Half breastfed for 6 months </LI></UL>
        <LI>At 18 months, 15% in both groups had either acquired HIV or =
died=20
        <UL>
          <LI>Formula fed group more likely to die=20
          <LI>Breastfed group more likely to acquire HIV=20
          <LI>No net advantage of formula =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>5</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP5><FONT size=3D2><A id=3DPPTL5=20
      href=3D"javascript:GoToSld('slide0128.htm');">Overall infant =
feeding in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC5 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>HIV negative or unknown mothers=20
        <UL>
          <LI>20% weaned from breast before 6 months in 2006 CDC survey =
</LI></UL>
        <LI>HIV positive mothers=20
        <UL>
          <LI>63% formula fed from birth </LI></UL>
        <LI>Total 35% of infants under 6 months old not breastfeeding=20
      </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>6</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP6><FONT size=3D2><A id=3DPPTL6=20
      href=3D"javascript:GoToSld('slide0068.htm');">2006 diarrhea =
outbreak,=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC6 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Nov 2005 =96 Feb 2006: Unusually heavy rains, flooding =
<BR><BR>
        <LI>Jan 2006: Increase in pediatric diarrhea cases and deaths =
reported=20
        to MOH <BR><BR>
        <LI>Feb 2006: Large number of pediatric diarrhea admissions and =
deaths=20
        overwhelmed hospitals around the country <BR><BR>
        <LI>Facilities reported anecdotally that most affected infants =
were=20
        bottle fed =96 CDC assistance requested=20
        <UL>
          <LI></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>7</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP7><FONT size=3D2><A id=3DPPTL7=20
      href=3D"javascript:GoToSld('slide0005.htm');">Botswana under-5=20
      diarrhea</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>8</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP8><FONT size=3D2><A id=3DPPTL8=20
      =
href=3D"javascript:GoToSld('slide0106.htm');">Botswana</A></FONT></DIV></=
TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>9</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP9><FONT size=3D2><A id=3DPPTL9=20
      href=3D"javascript:GoToSld('slide0134.htm');"><SPAN=20
      style=3D"mso-spacerun: yes"></SPAN></A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>10</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP10><FONT size=3D2><A id=3DPPTL10=20
      href=3D"javascript:GoToSld('slide0136.htm');">CDC=20
      investigations</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC10 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Assisted MOH with outbreak investigation and management=20
        <LI>Tested water for fecal contamination=20
        <LI>Collected stool, CDC-Atlanta laboratories identified =
outbreak=20
        pathogens=20
        <LI>Case-control study to identify risk factors for diarrhea=20
        <LI>Followed hospitalized patient cohort and described impact of =
HIV,=20
        nutrition on course of diarrheal illness and mortality=20
        <LI>Household cluster survey to assess malnutrition and diarrhea =
in=20
        surrounding community </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>11</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP11><FONT size=3D2><A id=3DPPTL11=20
      href=3D"javascript:GoToSld('slide0122.htm');">CDC =
findings</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC11 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Water contamination widespread in 4 northern districts=20
        <UL>
          <LI>Public water supply contaminated in 26 villages we tested=20
          <LI>Water in Francistown not contaminated=20
          <LI>Water in Botswana usually regarded as clean, multiple =
sources and=20
          treatment strategies </LI></UL>
        <LI>Diarrhea patients had multiple pathogens=20
        <UL>
          <LI>Cryptosporidium<SPAN style=3D"mso-spacerun: yes">&nbsp;=20
          </SPAN>(protozoal parasite)=20
          <LI>Enteropathogenic e. coli (EPEC, classic =93bottle =
diarrhea=94)=20
          <LI>Salmonella=20
          <LI>Other pathogens =
</LI></UL><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>12</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP12><FONT size=3D2><A id=3DPPTL12=20
      href=3D"javascript:GoToSld('slide0112.htm');">CDC findings: risk =
factors for=20
      diarrhea</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC12 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>We compared children visiting emergency room with diarrhea =
to those=20
        visiting for other reasons=20
        <LI>Interviewed parents about health, feeding, environment to =
determine=20
        what factors increased diarrhea risk =
</LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>13</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP13><FONT size=3D2><A id=3DPPTL13=20
      href=3D"javascript:GoToSld('slide0003.htm');">CDC findings: =
diarrhea=20
      inpatients</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC13 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>154 inpatients followed in hospital <BR><BR>
        <LI>Demographics &amp; illness=20
        <UL>
          <LI>96% &lt;2 years old (median 9 mos)=20
          <LI>93% not breastfeeding=20
          <LI>51% had poor growth before illness=20
          <LI>35% had had diarrhea for &gt;2 weeks <BR><BR></LI></UL>
        <LI>HIV=20
        <UL>
          <LI>65% of mothers HIV positive (94% tested)=20
          <LI>18% of infants HIV infected=20
          <UL>
            <LI>Among infants of positive mothers, 27% HIV infected (85% =
tested)=20
            </LI></UL></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>14</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP14><FONT size=3D2><A id=3DPPTL14=20
      href=3D"javascript:GoToSld('slide0032.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Feeding of infants &lt;12 =
months</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>15</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP15><FONT size=3D2><A id=3DPPTL15=20
      href=3D"javascript:GoToSld('slide0082.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Course of illness (n=3D154)</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC15 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Diarrhea prolonged: 43% discharged and readmitted at least =
once=20
        during study=20
        <LI>Many developed severe acute malnutrition during or after =
diarrhea=20
        <UL>
          <LI>42% developed marasmus=20
          <LI>20% developed kwashiorkor=20
          <LI>Most growing poorly before diarrhea, not adequately =
managed=20
          despite monthly weighing at clinics </LI></UL>
        <LI>High mortality: 21% (32/154) died=20
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>16</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP16><FONT size=3D2><A id=3DPPTL16=20
      href=3D"javascript:GoToSld('slide0051.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Mortality</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC16 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Risk factors for death=20
        <UL>
          <LI>Not breastfed OR 8.5, p=3D0.04=20
          <LI>Kwashiorkor<SPAN style=3D"mso-spacerun: yes">&nbsp;&nbsp; =
</SPAN>OR=20
          2.6, p=3D0.03 </LI></UL>
        <LI>Not associated with death=20
        <UL>
          <LI>Maternal HIV status=20
          <LI>Infant HIV status=20
          <LI>Socioeconomic status=20
          <LI>Water source=20
          <LI>Urban vs. rural residence=20
          <LI>Specific pathogen =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>17</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP17><FONT size=3D2><A id=3DPPTL17=20
      href=3D"javascript:GoToSld('slide0037.htm');">CDC findings: =
formula=20
      supply</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC17 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Some mothers told us their children stopped growing because =
clinics=20
        would not give them enough formula=20
        <LI>Reviewed records of 20 infant formula recipients who died=20
        <LI>Most given appropriate amount of formula at birth (6 tins)=20
        <LI>After birth, infants received only 51% of the formula they =
should=20
        have received before their illness=20
        <LI>In many cases, mothers returned to clinics multiple times =
per month=20
        but still not given adequate formula =
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>18</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP18><FONT size=3D2><A id=3DPPTL18=20
      href=3D"javascript:GoToSld('slide0130.htm');">Total outbreak =
mortality=20
      unknown</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC18 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Household survey indicated that many infants died outside of =
health=20
        facilities=20
        <LI>Mortality described in several settings=20
        <UL>
          <LI>CDC household survey estimated 547 excess deaths in 3 =
districts=20
          during outbreak, 4x historical &lt;5 mortality rate=20
          <LI>Among formula-fed newborns CDC started following in =
January before=20
          outbreak, preliminary data indicate 10% dead when re-visited =
at age=20
          3-4 months=20
          <LI>One village we visited lost 30% of their formula-fed =
babies (and=20
          no other babies) during outbreak =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>19</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP19><FONT size=3D2><A id=3DPPTL19=20
      href=3D"javascript:GoToSld('slide0131.htm');">Summary of=20
      outbreak</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC19 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Unusually heavy rains caused water contamination=20
        <LI>Outbreak of diarrhea &amp; malnutrition with high mortality =
among=20
        children &lt; 2 years=20
        <LI>Diarrhea not associated with HIV, many HIV-negative infants=20
        hospitalized and died=20
        <LI>Seriously ill children nearly all non-breastfed=20
        <LI>Poor nutritional status contributed to deaths=20
        <LI>Not breastfeeding was most significant risk factor for =
diarrhea and=20
        death <BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>20</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP20><FONT size=3D2><A id=3DPPTL20=20
      href=3D"javascript:GoToSld('slide0132.htm');">Lessons=20
      learned</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC20 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Early weaning among HIV-negative women common, BF promotion =
needs=20
        strengthening=20
        <LI>Formula program for HIV-positive women expensive, complex, =
data from=20
        Mashi study and outbreak indicate it is not saving lives=20
        <LI>Infant formula program needs review=20
        <UL>
          <LI>Other feeding strategies may promote higher child survival =

          <LI>Infants who are formula fed need clean water, more support =
and=20
          monitoring </LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>21</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP21><FONT size=3D2><A id=3DPPTL21=20
      href=3D"javascript:GoToSld('slide0133.htm');">Immediate way=20
      forward</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC21 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Botswana=20
        <UL>
          <LI>CDC recommends formula policy review and external =
consultation=20
          <UL>
            <LI>Women who are exclusively breastfeeding, have high CD4, =
or take=20
            ARV therapy have low risk of HIV transmission </LI></UL>
          <LI>Ensure formula-fed infants have enough formula and safe =
water=20
          <LI>Improve training for health staff and mothers in nutrition =
and=20
          management of diarrhea=20
          <LI>Study impact of point-of-use water treatment, safe water =
vessels,=20
          soap and handwashing promotion=20
          <UL>
            <LI>PEPFAR can fund for HIV-infected and -exposed children =
under=20
            preventive care &amp; OVC guidance=20
      </LI></UL></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>22</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP22><FONT size=3D2><A id=3DPPTL22=20
      href=3D"javascript:GoToSld('slide0135.htm');">Implications for =
other=20
      programs</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC22 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL><BR>
        <LI>Programs offering formula should ensure clean water, =
uninterrupted=20
        supply of formula, growth monitoring, nutrition counseling=20
        <LI>Health staff should be taught that formula fed infants are =
at risk,=20
        what to look for, and how to intervene=20
        <LI>Outbreak reinforces use of WHO criteria for replacement =
feeding=20
        (acceptable, feasible, affordable, sustainable, and safe)=20
        <LI>=93Safe=94 cannot be assumed: new programs should verify =
that formula=20
        saves lives in their context before widespread implementation=20
        <BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>23</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP23><FONT size=3D2><A id=3DPPTL23=20
      =
href=3D"javascript:GoToSld('slide0071.htm');">Acknowledgements</A></FONT>=
</DIV>
      <DIV class=3DCTxt id=3DPPTC23 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Centers for Disease Control=20
        <LI>CDC-Botswana (BOTUSA)=20
        <LI>Margarett Davis, MD, MPH=20
        <LI>BOTUSA-Francistown staff=20
        <LI>Global AIDS Program=20
        <LI>Thomas Finkbeiner, MD=20
        <LI>Andrea Kim, PhD=20
        <LI>Lydia Lu, MPH=20
        <LI>Foodborne &amp; Diarrheal Diseases Branch=20
        <LI>Wences Arvelo, MD, MSc=20
        <LI>Anna Bowen, MD, MPH=20
        <LI>International Emergency &amp; Refugee Health Branch=20
        <LI>Ondrej Mach, MD, MPH=20
        <LI>Coordinating Office for Global Health=20
        <LI>Laurel Zaks, RD, MPH=20
        <LI>Laboratory staff in Divisions of Parasitic Disease, Viral=20
        Gastroenteritis, Bacterial Enteric Pathogens <BR><BR><BR><BR>
        <LI>Nyangabgwe Hospital=20
        <LI>Japhter Masunge, MD=20
        <LI>Department of Pediatrics <BR><BR>
        <LI>Botswana Ministry of Health=20
        <LI>Loeto Mazhani, MD=20
        <LI>Julius Mboya, MD <BR><BR>
        <LI>Francistown, Tutume, North East District Health Teams =
<BR><BR>
        <LI>UNICEF=20
        <LI>Medicines Sans Frontieres=20
        <LI>USAID/Office of Foreign Disaster Assistance=20
        <LI>Wisconsin State Laboratory of Hygiene=20
        <LI>American Association of Public Health Laboratories=20
        <LI>World Health Organization =
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>24</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP24><FONT size=3D2><A id=3DPPTL24=20
      href=3D"javascript:GoToSld('slide0126.htm');">Percent of infants =
who died in=20
      MASHI study</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>25</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP25><FONT size=3D2><A id=3DPPTL25=20
      href=3D"javascript:GoToSld('slide0127.htm');">Percent of infants =
who died or=20
      acquired HIV infection in Mashi=20
study</A></FONT></DIV></TD></TR></TBODY></TABLE></DIV>
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style=3D"FONT-SIZE: 88%">HIV prevalence in pregnant women 33.4% 2005=20
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style=3D"LEFT: 3.6%; WIDTH: 96.17%; POSITION: absolute; TOP: 0%; HEIGHT: =
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style=3D"FONT-SIZE: 86%">ARV therapy for women with CD4&lt;200=20
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style=3D"LEFT: 5.99%; WIDTH: 88.2%; POSITION: absolute; TOP: 8%; HEIGHT: =
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v:shape=3D"_x0000_s189442">PMTCT in Botswana</DIV>
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style=3D"LEFT: 5.99%; WIDTH: 103.18%; POSITION: absolute; TOP: 23.75%; =
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style=3D"LEFT: 3.62%; WIDTH: 96.37%; POSITION: absolute; TOP: 0%; =
HEIGHT: 100%"><SPAN=20
style=3D"FONT-SIZE: 88%"><SPAN=20
style=3D"LEFT: -3.76%; POSITION: absolute; mso-special-format: =
bullet">=95</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 88%">HIV prevalence in pregnant women 33.4% 2005=20
</SPAN></SPAN></DIV>
<DIV class=3DB=20
style=3D"LEFT: 5.99%; WIDTH: 88.2%; POSITION: absolute; TOP: 30.75%; =
HEIGHT: 6%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 4.24%; WIDTH: 95.75%; POSITION: absolute; TOP: 0%; =
HEIGHT: 100%"><SPAN=20
style=3D"FONT-SIZE: 88%"><SPAN=20
style=3D"LEFT: -4.43%; POSITION: absolute; mso-special-format: =
bullet">=95</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 88%">National PMTCT program started 1999 =
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style=3D"LEFT: 5.99%; WIDTH: 88.2%; POSITION: absolute; TOP: 37.5%; =
HEIGHT: 6%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 4.24%; WIDTH: 95.75%; POSITION: absolute; TOP: 0%; =
HEIGHT: 100%"><SPAN=20
style=3D"FONT-SIZE: 88%"><SPAN=20
style=3D"LEFT: -4.43%; POSITION: absolute; mso-special-format: =
bullet">=95</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 88%">Program provides </SPAN></SPAN></DIV>
<DIV class=3DB1=20
style=3D"LEFT: 11.04%; WIDTH: 83.14%; POSITION: absolute; TOP: 44.25%; =
HEIGHT: 5.25%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 3.6%; WIDTH: 96.17%; POSITION: absolute; TOP: 0%; HEIGHT: =
100%"><SPAN=20
style=3D"FONT-SIZE: 86%"><SPAN=20
style=3D"LEFT: -3.74%; POSITION: absolute; mso-special-format: =
bullet">=96</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 86%">ARV therapy for women with CD4&lt;200=20
</SPAN></SPAN></DIV>
<DIV class=3DB1=20
style=3D"LEFT: 11.04%; WIDTH: 83.14%; POSITION: absolute; TOP: 50%; =
HEIGHT: 5.25%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 3.6%; WIDTH: 96.17%; POSITION: absolute; TOP: 0%; HEIGHT: =
100%"><SPAN=20
style=3D"FONT-SIZE: 86%"><SPAN=20
style=3D"LEFT: -3.74%; POSITION: absolute; mso-special-format: =
bullet">=96</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 86%">AZT 12 weeks to mothers, 4 weeks to infants=20
</SPAN></SPAN></DIV>
<DIV class=3DB1=20
style=3D"LEFT: 11.04%; WIDTH: 83.14%; POSITION: absolute; TOP: 56%; =
HEIGHT: 5.25%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 3.6%; WIDTH: 96.17%; POSITION: absolute; TOP: 0%; HEIGHT: =
100%"><SPAN=20
style=3D"FONT-SIZE: 86%"><SPAN=20
style=3D"LEFT: -3.74%; POSITION: absolute; mso-special-format: =
bullet">=96</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 86%">SD NVP for mothers and infants =
</SPAN></SPAN></DIV>
<DIV class=3DB1=20
style=3D"LEFT: 11.04%; WIDTH: 83.14%; POSITION: absolute; TOP: 61.75%; =
HEIGHT: 5.25%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 3.6%; WIDTH: 96.17%; POSITION: absolute; TOP: 0%; HEIGHT: =
100%"><SPAN=20
style=3D"FONT-SIZE: 86%; COLOR: #ff3300"><SPAN=20
style=3D"LEFT: -3.74%; POSITION: absolute; mso-special-format: =
bullet">=96</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 86%; COLOR: #ff3300">Free infant formula for 12 =
months=20
</SPAN></SPAN></DIV>
<DIV class=3DB=20
style=3D"LEFT: 5.99%; WIDTH: 91.19%; POSITION: absolute; TOP: 67.75%; =
HEIGHT: 6%; mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 4.1%; WIDTH: 95.89%; POSITION: absolute; TOP: 0%; HEIGHT: =
100%"><SPAN=20
style=3D"FONT-SIZE: 88%"><SPAN=20
style=3D"LEFT: -4.28%; POSITION: absolute; mso-special-format: =
bullet">=95</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 88%">High uptake since 2004, 80% receive AZT=20
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<DIV class=3DB style=3D"mso-line-spacing: '90 20 0'"><SPAN=20
style=3D"LEFT: 9.73%; WIDTH: 97.37%; POSITION: absolute; TOP: 74.75%; =
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style=3D"FONT-SIZE: 88%"><SPAN=20
style=3D"LEFT: -3.84%; POSITION: absolute; mso-special-format: =
bullet">=95</SPAN></SPAN><SPAN=20
style=3D"FONT-SIZE: 88%">HIV transmission to infants ~7% in recent data, =

</SPAN></SPAN><SPAN=20
style=3D"LEFT: 9.73%; WIDTH: 84.45%; POSITION: absolute; TOP: 80.25%; =
HEIGHT: 6%"><SPAN=20
style=3D"FONT-SIZE: 88%">an 80%=20
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      <DIV class=3DPTxt id=3DPPTP1><FONT size=3D2><A id=3DPPTL1=20
      href=3D"javascript:GoToSld('slide0001.htm');">Role of infant =
feeding and HIV=20
      in a severe outbreak of diarrhea and malnutrition among young =
children -=20
      Botswana, 2006 <BR><BR>Tracy Creek, MD<BR>Centers for Disease =
Control and=20
      Prevention<BR>For the Botswana infant diarrhea outbreak =
team<BR>June 13,=20
      2006</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>2</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP2><FONT size=3D2><A id=3DPPTL2=20
      href=3D"javascript:GoToSld('slide0123.htm');">PMTCT in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC2 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>HIV prevalence in pregnant women 33.4% 2005=20
        <LI>National PMTCT program started 1999=20
        <LI>Program provides=20
        <UL>
          <LI>ARV therapy for women with CD4&lt;200=20
          <LI>AZT 12 weeks to mothers, 4 weeks to infants=20
          <LI>SD NVP for mothers and infants=20
          <LI>Free infant formula for 12 months </LI></UL>
        <LI>High uptake since 2004, 80% receive AZT=20
        <LI>HIV transmission to infants ~7% in recent data, an 80% =
reduction=20
        </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>3</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP3><FONT size=3D2><A id=3DPPTL3=20
      href=3D"javascript:GoToSld('slide0124.htm');">Infant formula in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC3 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>All HIV-positive women advised to formula feed=20
        <LI>63% of HIV-positive women used formula in 2005=20
        <LI>Difficulty maintaining and distributing formula supply=20
        <LI>Efforts to strengthen logistics, counseling, and application =
of WHO=20
        criteria for replacement feeding (acceptable, feasible, =
affordable,=20
        sustainable, safe) </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>4</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP4><FONT size=3D2><A id=3DPPTL4=20
      href=3D"javascript:GoToSld('slide0125.htm');">Mashi study showed =
high=20
      mortality among formula fed infants</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC4 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Harvard study in Botswana, results 2005=20
        <LI>1200 infants of HIV-positive mothers=20
        <UL>
          <LI>Half formula fed from birth=20
          <LI>Half breastfed for 6 months </LI></UL>
        <LI>At 18 months, 15% in both groups had either acquired HIV or =
died=20
        <UL>
          <LI>Formula fed group more likely to die=20
          <LI>Breastfed group more likely to acquire HIV=20
          <LI>No net advantage of formula =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>5</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP5><FONT size=3D2><A id=3DPPTL5=20
      href=3D"javascript:GoToSld('slide0128.htm');">Overall infant =
feeding in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC5 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>HIV negative or unknown mothers=20
        <UL>
          <LI>20% weaned from breast before 6 months in 2006 CDC survey =
</LI></UL>
        <LI>HIV positive mothers=20
        <UL>
          <LI>63% formula fed from birth </LI></UL>
        <LI>Total 35% of infants under 6 months old not breastfeeding=20
      </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>6</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP6><FONT size=3D2><A id=3DPPTL6=20
      href=3D"javascript:GoToSld('slide0068.htm');">2006 diarrhea =
outbreak,=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC6 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Nov 2005 =96 Feb 2006: Unusually heavy rains, flooding =
<BR><BR>
        <LI>Jan 2006: Increase in pediatric diarrhea cases and deaths =
reported=20
        to MOH <BR><BR>
        <LI>Feb 2006: Large number of pediatric diarrhea admissions and =
deaths=20
        overwhelmed hospitals around the country <BR><BR>
        <LI>Facilities reported anecdotally that most affected infants =
were=20
        bottle fed =96 CDC assistance requested=20
        <UL>
          <LI></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>7</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP7><FONT size=3D2><A id=3DPPTL7=20
      href=3D"javascript:GoToSld('slide0005.htm');">Botswana under-5=20
      diarrhea</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>8</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP8><FONT size=3D2><A id=3DPPTL8=20
      =
href=3D"javascript:GoToSld('slide0106.htm');">Botswana</A></FONT></DIV></=
TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>9</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP9><FONT size=3D2><A id=3DPPTL9=20
      href=3D"javascript:GoToSld('slide0134.htm');"><SPAN=20
      style=3D"mso-spacerun: yes"></SPAN></A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>10</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP10><FONT size=3D2><A id=3DPPTL10=20
      href=3D"javascript:GoToSld('slide0136.htm');">CDC=20
      investigations</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC10 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Assisted MOH with outbreak investigation and management=20
        <LI>Tested water for fecal contamination=20
        <LI>Collected stool, CDC-Atlanta laboratories identified =
outbreak=20
        pathogens=20
        <LI>Case-control study to identify risk factors for diarrhea=20
        <LI>Followed hospitalized patient cohort and described impact of =
HIV,=20
        nutrition on course of diarrheal illness and mortality=20
        <LI>Household cluster survey to assess malnutrition and diarrhea =
in=20
        surrounding community </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>11</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP11><FONT size=3D2><A id=3DPPTL11=20
      href=3D"javascript:GoToSld('slide0122.htm');">CDC =
findings</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC11 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Water contamination widespread in 4 northern districts=20
        <UL>
          <LI>Public water supply contaminated in 26 villages we tested=20
          <LI>Water in Francistown not contaminated=20
          <LI>Water in Botswana usually regarded as clean, multiple =
sources and=20
          treatment strategies </LI></UL>
        <LI>Diarrhea patients had multiple pathogens=20
        <UL>
          <LI>Cryptosporidium<SPAN style=3D"mso-spacerun: yes">&nbsp;=20
          </SPAN>(protozoal parasite)=20
          <LI>Enteropathogenic e. coli (EPEC, classic =93bottle =
diarrhea=94)=20
          <LI>Salmonella=20
          <LI>Other pathogens =
</LI></UL><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>12</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP12><FONT size=3D2><A id=3DPPTL12=20
      href=3D"javascript:GoToSld('slide0112.htm');">CDC findings: risk =
factors for=20
      diarrhea</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC12 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>We compared children visiting emergency room with diarrhea =
to those=20
        visiting for other reasons=20
        <LI>Interviewed parents about health, feeding, environment to =
determine=20
        what factors increased diarrhea risk =
</LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>13</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP13><FONT size=3D2><A id=3DPPTL13=20
      href=3D"javascript:GoToSld('slide0003.htm');">CDC findings: =
diarrhea=20
      inpatients</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC13 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>154 inpatients followed in hospital <BR><BR>
        <LI>Demographics &amp; illness=20
        <UL>
          <LI>96% &lt;2 years old (median 9 mos)=20
          <LI>93% not breastfeeding=20
          <LI>51% had poor growth before illness=20
          <LI>35% had had diarrhea for &gt;2 weeks <BR><BR></LI></UL>
        <LI>HIV=20
        <UL>
          <LI>65% of mothers HIV positive (94% tested)=20
          <LI>18% of infants HIV infected=20
          <UL>
            <LI>Among infants of positive mothers, 27% HIV infected (85% =
tested)=20
            </LI></UL></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>14</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP14><FONT size=3D2><A id=3DPPTL14=20
      href=3D"javascript:GoToSld('slide0032.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Feeding of infants &lt;12 =
months</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>15</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP15><FONT size=3D2><A id=3DPPTL15=20
      href=3D"javascript:GoToSld('slide0082.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Course of illness (n=3D154)</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC15 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Diarrhea prolonged: 43% discharged and readmitted at least =
once=20
        during study=20
        <LI>Many developed severe acute malnutrition during or after =
diarrhea=20
        <UL>
          <LI>42% developed marasmus=20
          <LI>20% developed kwashiorkor=20
          <LI>Most growing poorly before diarrhea, not adequately =
managed=20
          despite monthly weighing at clinics </LI></UL>
        <LI>High mortality: 21% (32/154) died=20
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>16</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP16><FONT size=3D2><A id=3DPPTL16=20
      href=3D"javascript:GoToSld('slide0051.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Mortality</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC16 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Risk factors for death=20
        <UL>
          <LI>Not breastfed OR 8.5, p=3D0.04=20
          <LI>Kwashiorkor<SPAN style=3D"mso-spacerun: yes">&nbsp;&nbsp; =
</SPAN>OR=20
          2.6, p=3D0.03 </LI></UL>
        <LI>Not associated with death=20
        <UL>
          <LI>Maternal HIV status=20
          <LI>Infant HIV status=20
          <LI>Socioeconomic status=20
          <LI>Water source=20
          <LI>Urban vs. rural residence=20
          <LI>Specific pathogen =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>17</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP17><FONT size=3D2><A id=3DPPTL17=20
      href=3D"javascript:GoToSld('slide0037.htm');">CDC findings: =
formula=20
      supply</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC17 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Some mothers told us their children stopped growing because =
clinics=20
        would not give them enough formula=20
        <LI>Reviewed records of 20 infant formula recipients who died=20
        <LI>Most given appropriate amount of formula at birth (6 tins)=20
        <LI>After birth, infants received only 51% of the formula they =
should=20
        have received before their illness=20
        <LI>In many cases, mothers returned to clinics multiple times =
per month=20
        but still not given adequate formula =
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>18</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP18><FONT size=3D2><A id=3DPPTL18=20
      href=3D"javascript:GoToSld('slide0130.htm');">Total outbreak =
mortality=20
      unknown</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC18 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Household survey indicated that many infants died outside of =
health=20
        facilities=20
        <LI>Mortality described in several settings=20
        <UL>
          <LI>CDC household survey estimated 547 excess deaths in 3 =
districts=20
          during outbreak, 4x historical &lt;5 mortality rate=20
          <LI>Among formula-fed newborns CDC started following in =
January before=20
          outbreak, preliminary data indicate 10% dead when re-visited =
at age=20
          3-4 months=20
          <LI>One village we visited lost 30% of their formula-fed =
babies (and=20
          no other babies) during outbreak =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>19</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP19><FONT size=3D2><A id=3DPPTL19=20
      href=3D"javascript:GoToSld('slide0131.htm');">Summary of=20
      outbreak</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC19 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Unusually heavy rains caused water contamination=20
        <LI>Outbreak of diarrhea &amp; malnutrition with high mortality =
among=20
        children &lt; 2 years=20
        <LI>Diarrhea not associated with HIV, many HIV-negative infants=20
        hospitalized and died=20
        <LI>Seriously ill children nearly all non-breastfed=20
        <LI>Poor nutritional status contributed to deaths=20
        <LI>Not breastfeeding was most significant risk factor for =
diarrhea and=20
        death <BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>20</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP20><FONT size=3D2><A id=3DPPTL20=20
      href=3D"javascript:GoToSld('slide0132.htm');">Lessons=20
      learned</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC20 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Early weaning among HIV-negative women common, BF promotion =
needs=20
        strengthening=20
        <LI>Formula program for HIV-positive women expensive, complex, =
data from=20
        Mashi study and outbreak indicate it is not saving lives=20
        <LI>Infant formula program needs review=20
        <UL>
          <LI>Other feeding strategies may promote higher child survival =

          <LI>Infants who are formula fed need clean water, more support =
and=20
          monitoring </LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>21</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP21><FONT size=3D2><A id=3DPPTL21=20
      href=3D"javascript:GoToSld('slide0133.htm');">Immediate way=20
      forward</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC21 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Botswana=20
        <UL>
          <LI>CDC recommends formula policy review and external =
consultation=20
          <UL>
            <LI>Women who are exclusively breastfeeding, have high CD4, =
or take=20
            ARV therapy have low risk of HIV transmission </LI></UL>
          <LI>Ensure formula-fed infants have enough formula and safe =
water=20
          <LI>Improve training for health staff and mothers in nutrition =
and=20
          management of diarrhea=20
          <LI>Study impact of point-of-use water treatment, safe water =
vessels,=20
          soap and handwashing promotion=20
          <UL>
            <LI>PEPFAR can fund for HIV-infected and -exposed children =
under=20
            preventive care &amp; OVC guidance=20
      </LI></UL></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>22</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP22><FONT size=3D2><A id=3DPPTL22=20
      href=3D"javascript:GoToSld('slide0135.htm');">Implications for =
other=20
      programs</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC22 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL><BR>
        <LI>Programs offering formula should ensure clean water, =
uninterrupted=20
        supply of formula, growth monitoring, nutrition counseling=20
        <LI>Health staff should be taught that formula fed infants are =
at risk,=20
        what to look for, and how to intervene=20
        <LI>Outbreak reinforces use of WHO criteria for replacement =
feeding=20
        (acceptable, feasible, affordable, sustainable, and safe)=20
        <LI>=93Safe=94 cannot be assumed: new programs should verify =
that formula=20
        saves lives in their context before widespread implementation=20
        <BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>23</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP23><FONT size=3D2><A id=3DPPTL23=20
      =
href=3D"javascript:GoToSld('slide0071.htm');">Acknowledgements</A></FONT>=
</DIV>
      <DIV class=3DCTxt id=3DPPTC23 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Centers for Disease Control=20
        <LI>CDC-Botswana (BOTUSA)=20
        <LI>Margarett Davis, MD, MPH=20
        <LI>BOTUSA-Francistown staff=20
        <LI>Global AIDS Program=20
        <LI>Thomas Finkbeiner, MD=20
        <LI>Andrea Kim, PhD=20
        <LI>Lydia Lu, MPH=20
        <LI>Foodborne &amp; Diarrheal Diseases Branch=20
        <LI>Wences Arvelo, MD, MSc=20
        <LI>Anna Bowen, MD, MPH=20
        <LI>International Emergency &amp; Refugee Health Branch=20
        <LI>Ondrej Mach, MD, MPH=20
        <LI>Coordinating Office for Global Health=20
        <LI>Laurel Zaks, RD, MPH=20
        <LI>Laboratory staff in Divisions of Parasitic Disease, Viral=20
        Gastroenteritis, Bacterial Enteric Pathogens <BR><BR><BR><BR>
        <LI>Nyangabgwe Hospital=20
        <LI>Japhter Masunge, MD=20
        <LI>Department of Pediatrics <BR><BR>
        <LI>Botswana Ministry of Health=20
        <LI>Loeto Mazhani, MD=20
        <LI>Julius Mboya, MD <BR><BR>
        <LI>Francistown, Tutume, North East District Health Teams =
<BR><BR>
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        <LI>Medicines Sans Frontieres=20
        <LI>USAID/Office of Foreign Disaster Assistance=20
        <LI>Wisconsin State Laboratory of Hygiene=20
        <LI>American Association of Public Health Laboratories=20
        <LI>World Health Organization =
<BR><BR></LI></UL></FONT></DIV></TD></TR>
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study</A></FONT></DIV></TD></TR></TBODY></TABLE></DIV>
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      in a severe outbreak of diarrhea and malnutrition among young =
children -=20
      Botswana, 2006 <BR><BR>Tracy Creek, MD<BR>Centers for Disease =
Control and=20
      Prevention<BR>For the Botswana infant diarrhea outbreak =
team<BR>June 13,=20
      2006</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>2</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP2><FONT size=3D2><A id=3DPPTL2=20
      href=3D"javascript:GoToSld('slide0123.htm');">PMTCT in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC2 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>HIV prevalence in pregnant women 33.4% 2005=20
        <LI>National PMTCT program started 1999=20
        <LI>Program provides=20
        <UL>
          <LI>ARV therapy for women with CD4&lt;200=20
          <LI>AZT 12 weeks to mothers, 4 weeks to infants=20
          <LI>SD NVP for mothers and infants=20
          <LI>Free infant formula for 12 months </LI></UL>
        <LI>High uptake since 2004, 80% receive AZT=20
        <LI>HIV transmission to infants ~7% in recent data, an 80% =
reduction=20
        </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>3</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP3><FONT size=3D2><A id=3DPPTL3=20
      href=3D"javascript:GoToSld('slide0124.htm');">Infant formula in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC3 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>All HIV-positive women advised to formula feed=20
        <LI>63% of HIV-positive women used formula in 2005=20
        <LI>Difficulty maintaining and distributing formula supply=20
        <LI>Efforts to strengthen logistics, counseling, and application =
of WHO=20
        criteria for replacement feeding (acceptable, feasible, =
affordable,=20
        sustainable, safe) </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>4</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP4><FONT size=3D2><A id=3DPPTL4=20
      href=3D"javascript:GoToSld('slide0125.htm');">Mashi study showed =
high=20
      mortality among formula fed infants</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC4 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Harvard study in Botswana, results 2005=20
        <LI>1200 infants of HIV-positive mothers=20
        <UL>
          <LI>Half formula fed from birth=20
          <LI>Half breastfed for 6 months </LI></UL>
        <LI>At 18 months, 15% in both groups had either acquired HIV or =
died=20
        <UL>
          <LI>Formula fed group more likely to die=20
          <LI>Breastfed group more likely to acquire HIV=20
          <LI>No net advantage of formula =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>5</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP5><FONT size=3D2><A id=3DPPTL5=20
      href=3D"javascript:GoToSld('slide0128.htm');">Overall infant =
feeding in=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC5 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>HIV negative or unknown mothers=20
        <UL>
          <LI>20% weaned from breast before 6 months in 2006 CDC survey =
</LI></UL>
        <LI>HIV positive mothers=20
        <UL>
          <LI>63% formula fed from birth </LI></UL>
        <LI>Total 35% of infants under 6 months old not breastfeeding=20
      </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>6</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP6><FONT size=3D2><A id=3DPPTL6=20
      href=3D"javascript:GoToSld('slide0068.htm');">2006 diarrhea =
outbreak,=20
      Botswana</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC6 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Nov 2005 =96 Feb 2006: Unusually heavy rains, flooding =
<BR><BR>
        <LI>Jan 2006: Increase in pediatric diarrhea cases and deaths =
reported=20
        to MOH <BR><BR>
        <LI>Feb 2006: Large number of pediatric diarrhea admissions and =
deaths=20
        overwhelmed hospitals around the country <BR><BR>
        <LI>Facilities reported anecdotally that most affected infants =
were=20
        bottle fed =96 CDC assistance requested=20
        <UL>
          <LI></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>7</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP7><FONT size=3D2><A id=3DPPTL7=20
      href=3D"javascript:GoToSld('slide0005.htm');">Botswana under-5=20
      diarrhea</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>8</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP8><FONT size=3D2><A id=3DPPTL8=20
      =
href=3D"javascript:GoToSld('slide0106.htm');">Botswana</A></FONT></DIV></=
TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>9</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP9><FONT size=3D2><A id=3DPPTL9=20
      href=3D"javascript:GoToSld('slide0134.htm');"><SPAN=20
      style=3D"mso-spacerun: yes"></SPAN></A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>10</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP10><FONT size=3D2><A id=3DPPTL10=20
      href=3D"javascript:GoToSld('slide0136.htm');">CDC=20
      investigations</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC10 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Assisted MOH with outbreak investigation and management=20
        <LI>Tested water for fecal contamination=20
        <LI>Collected stool, CDC-Atlanta laboratories identified =
outbreak=20
        pathogens=20
        <LI>Case-control study to identify risk factors for diarrhea=20
        <LI>Followed hospitalized patient cohort and described impact of =
HIV,=20
        nutrition on course of diarrheal illness and mortality=20
        <LI>Household cluster survey to assess malnutrition and diarrhea =
in=20
        surrounding community </LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>11</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP11><FONT size=3D2><A id=3DPPTL11=20
      href=3D"javascript:GoToSld('slide0122.htm');">CDC =
findings</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC11 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Water contamination widespread in 4 northern districts=20
        <UL>
          <LI>Public water supply contaminated in 26 villages we tested=20
          <LI>Water in Francistown not contaminated=20
          <LI>Water in Botswana usually regarded as clean, multiple =
sources and=20
          treatment strategies </LI></UL>
        <LI>Diarrhea patients had multiple pathogens=20
        <UL>
          <LI>Cryptosporidium<SPAN style=3D"mso-spacerun: yes">&nbsp;=20
          </SPAN>(protozoal parasite)=20
          <LI>Enteropathogenic e. coli (EPEC, classic =93bottle =
diarrhea=94)=20
          <LI>Salmonella=20
          <LI>Other pathogens =
</LI></UL><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>12</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP12><FONT size=3D2><A id=3DPPTL12=20
      href=3D"javascript:GoToSld('slide0112.htm');">CDC findings: risk =
factors for=20
      diarrhea</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC12 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>We compared children visiting emergency room with diarrhea =
to those=20
        visiting for other reasons=20
        <LI>Interviewed parents about health, feeding, environment to =
determine=20
        what factors increased diarrhea risk =
</LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>13</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP13><FONT size=3D2><A id=3DPPTL13=20
      href=3D"javascript:GoToSld('slide0003.htm');">CDC findings: =
diarrhea=20
      inpatients</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC13 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>154 inpatients followed in hospital <BR><BR>
        <LI>Demographics &amp; illness=20
        <UL>
          <LI>96% &lt;2 years old (median 9 mos)=20
          <LI>93% not breastfeeding=20
          <LI>51% had poor growth before illness=20
          <LI>35% had had diarrhea for &gt;2 weeks <BR><BR></LI></UL>
        <LI>HIV=20
        <UL>
          <LI>65% of mothers HIV positive (94% tested)=20
          <LI>18% of infants HIV infected=20
          <UL>
            <LI>Among infants of positive mothers, 27% HIV infected (85% =
tested)=20
            </LI></UL></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>14</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP14><FONT size=3D2><A id=3DPPTL14=20
      href=3D"javascript:GoToSld('slide0032.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Feeding of infants &lt;12 =
months</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>15</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP15><FONT size=3D2><A id=3DPPTL15=20
      href=3D"javascript:GoToSld('slide0082.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Course of illness (n=3D154)</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC15 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Diarrhea prolonged: 43% discharged and readmitted at least =
once=20
        during study=20
        <LI>Many developed severe acute malnutrition during or after =
diarrhea=20
        <UL>
          <LI>42% developed marasmus=20
          <LI>20% developed kwashiorkor=20
          <LI>Most growing poorly before diarrhea, not adequately =
managed=20
          despite monthly weighing at clinics </LI></UL>
        <LI>High mortality: 21% (32/154) died=20
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>16</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP16><FONT size=3D2><A id=3DPPTL16=20
      href=3D"javascript:GoToSld('slide0051.htm');">CDC findings: =
diarrhea=20
      inpatients<BR>Mortality</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC16 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Risk factors for death=20
        <UL>
          <LI>Not breastfed OR 8.5, p=3D0.04=20
          <LI>Kwashiorkor<SPAN style=3D"mso-spacerun: yes">&nbsp;&nbsp; =
</SPAN>OR=20
          2.6, p=3D0.03 </LI></UL>
        <LI>Not associated with death=20
        <UL>
          <LI>Maternal HIV status=20
          <LI>Infant HIV status=20
          <LI>Socioeconomic status=20
          <LI>Water source=20
          <LI>Urban vs. rural residence=20
          <LI>Specific pathogen =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>17</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP17><FONT size=3D2><A id=3DPPTL17=20
      href=3D"javascript:GoToSld('slide0037.htm');">CDC findings: =
formula=20
      supply</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC17 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Some mothers told us their children stopped growing because =
clinics=20
        would not give them enough formula=20
        <LI>Reviewed records of 20 infant formula recipients who died=20
        <LI>Most given appropriate amount of formula at birth (6 tins)=20
        <LI>After birth, infants received only 51% of the formula they =
should=20
        have received before their illness=20
        <LI>In many cases, mothers returned to clinics multiple times =
per month=20
        but still not given adequate formula =
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>18</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP18><FONT size=3D2><A id=3DPPTL18=20
      href=3D"javascript:GoToSld('slide0130.htm');">Total outbreak =
mortality=20
      unknown</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC18 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Household survey indicated that many infants died outside of =
health=20
        facilities=20
        <LI>Mortality described in several settings=20
        <UL>
          <LI>CDC household survey estimated 547 excess deaths in 3 =
districts=20
          during outbreak, 4x historical &lt;5 mortality rate=20
          <LI>Among formula-fed newborns CDC started following in =
January before=20
          outbreak, preliminary data indicate 10% dead when re-visited =
at age=20
          3-4 months=20
          <LI>One village we visited lost 30% of their formula-fed =
babies (and=20
          no other babies) during outbreak =
</LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>19</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP19><FONT size=3D2><A id=3DPPTL19=20
      href=3D"javascript:GoToSld('slide0131.htm');">Summary of=20
      outbreak</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC19 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Unusually heavy rains caused water contamination=20
        <LI>Outbreak of diarrhea &amp; malnutrition with high mortality =
among=20
        children &lt; 2 years=20
        <LI>Diarrhea not associated with HIV, many HIV-negative infants=20
        hospitalized and died=20
        <LI>Seriously ill children nearly all non-breastfed=20
        <LI>Poor nutritional status contributed to deaths=20
        <LI>Not breastfeeding was most significant risk factor for =
diarrhea and=20
        death <BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>20</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP20><FONT size=3D2><A id=3DPPTL20=20
      href=3D"javascript:GoToSld('slide0132.htm');">Lessons=20
      learned</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC20 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Early weaning among HIV-negative women common, BF promotion =
needs=20
        strengthening=20
        <LI>Formula program for HIV-positive women expensive, complex, =
data from=20
        Mashi study and outbreak indicate it is not saving lives=20
        <LI>Infant formula program needs review=20
        <UL>
          <LI>Other feeding strategies may promote higher child survival =

          <LI>Infants who are formula fed need clean water, more support =
and=20
          monitoring </LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>21</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP21><FONT size=3D2><A id=3DPPTL21=20
      href=3D"javascript:GoToSld('slide0133.htm');">Immediate way=20
      forward</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC21 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Botswana=20
        <UL>
          <LI>CDC recommends formula policy review and external =
consultation=20
          <UL>
            <LI>Women who are exclusively breastfeeding, have high CD4, =
or take=20
            ARV therapy have low risk of HIV transmission </LI></UL>
          <LI>Ensure formula-fed infants have enough formula and safe =
water=20
          <LI>Improve training for health staff and mothers in nutrition =
and=20
          management of diarrhea=20
          <LI>Study impact of point-of-use water treatment, safe water =
vessels,=20
          soap and handwashing promotion=20
          <UL>
            <LI>PEPFAR can fund for HIV-infected and -exposed children =
under=20
            preventive care &amp; OVC guidance=20
      </LI></UL></LI></UL></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>22</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP22><FONT size=3D2><A id=3DPPTL22=20
      href=3D"javascript:GoToSld('slide0135.htm');">Implications for =
other=20
      programs</A></FONT></DIV>
      <DIV class=3DCTxt id=3DPPTC22 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL><BR>
        <LI>Programs offering formula should ensure clean water, =
uninterrupted=20
        supply of formula, growth monitoring, nutrition counseling=20
        <LI>Health staff should be taught that formula fed infants are =
at risk,=20
        what to look for, and how to intervene=20
        <LI>Outbreak reinforces use of WHO criteria for replacement =
feeding=20
        (acceptable, feasible, affordable, sustainable, and safe)=20
        <LI>=93Safe=94 cannot be assumed: new programs should verify =
that formula=20
        saves lives in their context before widespread implementation=20
        <BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>23</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP23><FONT size=3D2><A id=3DPPTL23=20
      =
href=3D"javascript:GoToSld('slide0071.htm');">Acknowledgements</A></FONT>=
</DIV>
      <DIV class=3DCTxt id=3DPPTC23 style=3D"DISPLAY: none"><FONT =
size=3D2>
      <UL>
        <LI>Centers for Disease Control=20
        <LI>CDC-Botswana (BOTUSA)=20
        <LI>Margarett Davis, MD, MPH=20
        <LI>BOTUSA-Francistown staff=20
        <LI>Global AIDS Program=20
        <LI>Thomas Finkbeiner, MD=20
        <LI>Andrea Kim, PhD=20
        <LI>Lydia Lu, MPH=20
        <LI>Foodborne &amp; Diarrheal Diseases Branch=20
        <LI>Wences Arvelo, MD, MSc=20
        <LI>Anna Bowen, MD, MPH=20
        <LI>International Emergency &amp; Refugee Health Branch=20
        <LI>Ondrej Mach, MD, MPH=20
        <LI>Coordinating Office for Global Health=20
        <LI>Laurel Zaks, RD, MPH=20
        <LI>Laboratory staff in Divisions of Parasitic Disease, Viral=20
        Gastroenteritis, Bacterial Enteric Pathogens <BR><BR><BR><BR>
        <LI>Nyangabgwe Hospital=20
        <LI>Japhter Masunge, MD=20
        <LI>Department of Pediatrics <BR><BR>
        <LI>Botswana Ministry of Health=20
        <LI>Loeto Mazhani, MD=20
        <LI>Julius Mboya, MD <BR><BR>
        <LI>Francistown, Tutume, North East District Health Teams =
<BR><BR>
        <LI>UNICEF=20
        <LI>Medicines Sans Frontieres=20
        <LI>USAID/Office of Foreign Disaster Assistance=20
        <LI>Wisconsin State Laboratory of Hygiene=20
        <LI>American Association of Public Health Laboratories=20
        <LI>World Health Organization =
<BR><BR></LI></UL></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>24</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP24><FONT size=3D2><A id=3DPPTL24=20
      href=3D"javascript:GoToSld('slide0126.htm');">Percent of infants =
who died in=20
      MASHI study</A></FONT></DIV></TD></TR>
  <TR onmouseover=3DOver(this) style=3D"CURSOR: hand" =
onclick=3DFollow(this)=20
  onmouseout=3DOut(this)>
    <TD vAlign=3Dtop align=3Dright>
      <DIV class=3DsldNum><FONT size=3D2>25</FONT></DIV></TD>
    <TD>
      <DIV class=3DPTxt id=3DPPTP25><FONT size=3D2><A id=3DPPTL25=20
      href=3D"javascript:GoToSld('slide0127.htm');">Percent of infants =
who died or=20
      acquired HIV infection in Mashi=20
study</A></FONT></DIV></TD></TR></TBODY></TABLE></DIV>
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