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Comments: Gated by NETNEWS@AUVM.AMERICAN.EDU Path: sparky!uunet!paladin.american.edu!auvm!STAT.COM!DAVID X-Delivery-Notice: SMTP MAIL FROM does not correspond to sender. Organization: Stat Gateway Service, WB7TPY Message-ID: <4003VB2w165w@stat.com> Newsgroups: bit.listserv.mednews Approved: NETNEWS@AUVM.AMERICAN.EDU Date: Sun, 20 Dec 1992 09:28:26 MST Sender: MEDNEWS - Health Info-Com Network Newsletter <MEDNEWS@ASUACAD.BITNET> From: David Dodell <david@STAT.COM> Subject: HICN506 Newsletter Part 1/4 Lines: 706 Volume 5, Number 6 December 20, 1992 +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Compilation Copyright 1992 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed bimonthly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. E-Mail Address: Editor: Internet: david@stat.com FidoNet = 1:114/15 Bitnet = ATW1H@ASUACAD LISTSERV = MEDNEWS@ASUACAD.BITNET (or internet: mednews@asuvm.inre.asu.edu) anonymous ftp = vm1.nodak.edu Notification List/ftp = hicn-notify-request@stat.com FAX Delivery = Contact Editor :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: T A B L E O F C O N T E N T S 1. Centers for Disease Control - MMWR [10 Dec 92] Population-Based Mortality Assessment, Somalia, 1992 ..... 1 Poliomyelitis Outbreak -- Netherlands, 1992 .......................... 5 Knowledge of the Purpose of Community Water Fluoridation ............. 7 Tuberculosis Transmission in State Correctional Institution .......... 11 Availability of Parenteral Isoniazid -- United States ................ 15 2. Food & Drug Administration News FDA Approves Depo Provera ............................................ 16 FDA Warns Against Hismanal Interaction ............................... 18 New Food Safety Education Program for Nursing Homes .................. 19 Sotalol Hydrochloride Approved For Ventricular Arrhythmia ............ 21 FDA Advisory Committee Recommends Taxol For Ovarian Cancer ........... 23 FDA Bans 415 Over-The-Counter Drug Ingredients ....................... 24 PHS Advisory On Persistent Vaginal Fungal Infection .................. 29 3. Columns Chronic Fatigue Syndrome Newsletter .................................. 31 AIDS Daily Summary ................................................... 35 4. Articles X-Ray Crystallography used to Track Down Viruses ..................... 43 Sperm Homing Signal Discovered ....................................... 46 Health InfoCom Network News Page i Volume 5, Number 6 December 20, 1992 :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Centers for Disease Control - MMWR :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Morbidity and Mortality Weekly Report December 10, 1992 Courtesy of Karen S. Fleming, Epidemiologist Infectious Disease Epidemiology Section Arizona Department of Health Services International Notes Population-Based Mortality Assessment -- Baidoa and Afgoi, Somalia, 1992 Since 1990, Somalia has been the site of an intense civil war that has disrupted health-care services and food delivery to a substantial part of the country. A regional drought, in combination with the ongoing civil disturbances, has further resulted in widespread famine. Multiple international government- and nongovernment-aid agencies are involved in the relief effort for Somalia. However, security problems in most areas of Somalia have prevented recent, systematic population-based assessments of the health and nutritional status of local Somali populations for use in directing relief efforts. To characterize the mortality of various Somali populations and to provide data on major population centers outside of the capital (Mogadishu), CDC, in collaboration with the United Nations Children's Fund (UNICEF) and the U.S. Agency for International Development, conducted a survey (1) of urban populations in a central region of Somalia (Figure 1). This report describes two pilot assessments performed during November 20-25 and December 5-6, 1992, in the towns of Baidoa and Afgoi. Baidoa Baidoa is a regional center of the Bay Region of Somalia. Formal census data on this city were not available, and population estimates were provided by nongovernment-aid agencies. In early August 1992, the estimated population of Baidoa was 37,000 persons; by November 20, the town population had decreased to an estimated 21,000. On November 20, based on hut counts, the displaced population at two major camps for displaced persons (DPs) in Baidoa was approximately 5200 persons. An additional unknown number of DPs resided in the town itself. For this mortality assessment, the DP-camp population was divided into seven areas of approximately equal populations (i.e., clusters), and survey starting points were randomly chosen in each of the seven areas. From the random starting point, residents in approximately seven consecutive huts in each cluster were selected to be interviewed. Interviewees were asked questions regarding deaths that occurred in the family (i.e., parents, spouse, or children) from the first day following the Moslem holiday Ramadan (April 3, 1992) to the day of the interview and deaths that occurred during the 30 Health InfoCom Network News Page 1 Volume 5, Number 6 December 20, 1992 days preceding the interview. Mortality data were collected for 349 DPs who were alive on April 3 (Table 1). From April 3 through November 21, 137 (39%) persons were reported to have died, resulting in an average daily crude mortality rate (CMR) of 16.9 deaths per 10,000 population. Among 63 displaced children aged less than 5 years, 44 (70%) died from April 3 through November 21 (aged less than 5 years mortality rate [less than 5MR]=30.1 deaths daily per 10,000 population aged less than 5 years). For all age groups, the most common reported causes of death based on a structured verbal autopsy were diarrhea (56% [9.4 deaths daily per 10,000]) and measles (23% [3.8 deaths daily per 10,000]). During the 30 days preceding the survey, 16 (7%) of 228 persons died (average CMR=23.4 deaths daily per 10,000), and among children aged less than 5 years, five (21%) of 24 died (less than 5MR=69.4 deaths daily per 10,000). Of the sample population alive on November 20, 9% were children aged less than 5 years. To measure mortality for the entire town of Baidoa, mortality surveillance data collected by the International Committee of the Red Cross and the Somali Red Crescent Society were used. Each morning, dead persons found in the city were counted after they were transported by truck for burial. From August 9 through November 14, 12,255 dead persons were transported for burial (37% of the estimated August 9 Baidoa population). During this period, an additional 3700 (10%) persons may have emigrated or have died and been buried without being counted. Deaths peaked in early September during concurrent epidemics of measles and multidrug-resistant Shigella dysenteriae (Figure 2). Afgoi Afgoi is a town of approximately 35,000 persons that straddles the Shabelle River 19 miles (30 km) west of Mogadishu. To characterize health and mortality patterns in this town, 19 cluster survey starting points were randomly chosen. On November 24-25 and December 5-6, eight consecutive huts or houses were visited in each cluster. However, this survey was curtailed before the target number of clusters were visited because of security concerns. Mortality data were collected from 152 households for 1004 persons who were alive on April 3. Of the 767 long-term residents of Afgoi and 237 persons displaced from other areas who were included in the sample, 94 (9%) persons died from April 3 through December 6 (average CMR=4.0 deaths daily per 10,000). The most commonly reported causes of death based on a structured verbal autopsy were measles (28% [1.1 deaths daily per 10,000]) and diarrhea (22% [0.9 deaths daily per 10,000]). DPs were more than 1.5 times as likely to die than were residents during this period (DP average CMR=5.5 deaths daily per 10,000; resident average CMR=3.5 deaths daily per 10,000). As in Baidoa, children aged less than 5 years were at highest risk for death (less than 5MR=9.4 deaths daily per 10,000); moreover, during this period, mortality rates for displaced children aged less than 5 years reached 12.8 deaths daily per 10,000. CMRs during the 30 days preceding the survey remained elevated (DPs=6.3 Health InfoCom Network News Page 2 Volume 5, Number 6 December 20, 1992 deaths daily per 10,000; residents=3.7 deaths daily per 10,000) compared with the average daily CMRs for the preceding 7 months (DPs=5.6 deaths daily per 10,000; residents=3.5 deaths daily per 10,000) (Table 1). Reported by: United Nations Children's Fund, Mogadishu, Somalia. Disaster Assistance Response Team, US Agency for International Development, Nairobi, Kenya. Div of Field Epidemiology, Epidemiology Program Office; Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases; Div of Environmental Hazards and Health Effects, National Center for Environmental Health; International Health Program Office, CDC. Editorial Note: Extreme mortality rates commonly occur in famine-affected, internally displaced, and refugee populations (1). During the 1984-85 famine in the Horn of Africa, average CMRs exceeded 20 deaths daily per 10,000 persons (1). By comparison, the reported annual CMRs in the Horn of Africa during nonfamine times ranged from 20 to 24 deaths per 1000, which is equivalent to daily CMRs of 0.55-0.65 deaths per 10,000 persons (2). The findings in these investigations of mortality among DPs in Baidoa and both displaced and resident populations in Afgoi suggest that health conditions are considerably worse in Somalia than they were during peak mortality periods of the 1984-85 famine in Ethiopia and Sudan. The CMRs reported in these villages in Somalia are among the highest ever documented by a population survey among famine- affected civilians. Because of two important limitations in these studies, the findings cannot be generalized to the entire population of Somalia. First, although these studies were designed as cluster sample-population surveys to assess nutritional status and vaccination coverage among children aged 6-59 months, too few children were present in the sampled households to permit precise estimates of the prevalence of malnutrition in these populations. Second, the Baidoa survey characterized the mortality history only of displaced persons, and the Afgoi survey results may not have characterized all sections of the town because the survey was interrupted. Despite these limitations, these findings are a measure of the magnitude of the famine-related disaster in Somalia. These findings are also consistent with assessments of previous emergencies that have documented that children aged less than 5 years and DPs are at highest risk for dying. One indicator of the intensity of this disaster is that only 9% of the sample population in the Baidoa study were aged less than 5 years compared with 20%-25% for most developing-nation populations. Although the surveillance data based on body counts in Baidoa suggest a gradual improvement in mortality rates, the mortality rates derived from Health InfoCom Network News Page 3 Volume 5, Number 6 December 20, 1992 surveys of Afgoi and DPs in Baidoa may not have decreased during the 30 days preceding the survey, despite the massive relief efforts. The CMR in Afgoi is more than two times higher than the rate recorded for the nearby towns of Merca and Qorioley from April 1991 through April 1992 (3). Anecdotal reports from other regions of Somalia (e.g., Bardera and Saco Uen) suggest that local mortality rates may be higher than in Baidoa or Afgoi. Measles, diarrhea, dysentery, acute respiratory infections, and malaria are common but preventable causes of mortality among famine-affected populations. Feeding programs are critical for reducing protein-energy malnutrition; however, community health programs that focus on the prevention of these infections can also have a major impact on mortality. Community- based measles vaccination and oral rehydration programs should be given high priority during famine-related emergencies. In addition, routine vitamin A supplementation for all children aged less than 5 years (and older children if malnutrition rates are high in older age groups) may also reduce child mortality, especially measles-related mortality (4). Surveillance efforts should include monitoring of trends in morbidity and mortality and evaluation of relief efforts. References 1. CDC. Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR 1992;41(no. RR-13). 2. United Nations Children's Fund. State of the World's Children, 1991. New York: United Nations Children's Fund, 1992. 3. Manoncourt S, Doppler P, Enten F, et al. Public health consequences of the civil war in Somalia, April 1992. Lancet 1992;340:176-7. 4. Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO 1988;66:689-97. Health InfoCom Network News Page 4 Volume 5, Number 6 December 20, 1992 Update: Poliomyelitis Outbreak -- Netherlands, 1992 The outbreak in the Netherlands of poliomyelitis among unvaccinated persons who are members of religious groups that generally do not accept vaccination is continuing (1). From September 17 through December 5, 1992, 54 cases of poliomyelitis were reported to the Netherlands' Office of the Chief Medical Officer of Health (Figure 1). Of the 54 patients, 41 (76%) had paralytic manifestations of this illness; one neonate died, and 12 patients had aseptic meningitis. Fifty-one (94%) of the cases have been laboratory confirmed: 40 patients had wild poliovirus type 3 isolated from stool, and 11 had IgM-specific antibody to poliovirus type 3 suggestive of recent infection. All of the reported cases have occurred among unvaccinated (n=53) or inadequately vaccinated (n=1) persons belonging to a religious denomination that routinely does not accept vaccination. Patients ranged in age from less than 1 month to 56 years (mean age: 18.9 years). Of the 12 provinces in the Netherlands, seven have reported cases of poliomyelitis; the most severely affected provinces are South Holland and Gelderland. Reported by: JK van Wijngaarden, MD, Div of Infectious Diseases, Office of the Chief Medical Officer of Health; AM van Loon, PhD, P Oostvogel, MD, MN Mulders, MSc, Laboratory of Virology, National Institute for Public Health and Environmental Protection; J Buitenwerf, PhD, Laboratory of Virology, CF Engelhard, MD, Dept of Infectious Diseases, Municipal Health Svcs, Rotterdam, the Netherlands. World Health Organization, Geneva. Div of Immunization, National Center for Prevention Svcs; Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The poliomyelitis epidemic in the Netherlands continues despite control measures initiated by the Dutch health authorities, including offering oral poliovirus vaccine to all previously unvaccinated persons belonging to affected religious groups and to other previously unvaccinated persons aged less than 41 years and offering one dose of enhanced-potency inactivated poliovirus vaccine to persons who are incompletely vaccinated. Based on the ratio of cases of asymptomatic infection to paralytic disease for persons infected with poliovirus type 3 (at least 1000:1) (2), an estimated 54,000 persons in the Netherlands may have been infected with wild poliovirus type 3 during this outbreak. Therefore, the risk for infection may be greater than previously assumed for unvaccinated or inadequately vaccinated travelers to the Netherlands. In addition, the potential for spread of this poliovirus to other areas (including the North American continent) by asymptomatically infected travelers from the Netherlands--even if not directly linked to a Health InfoCom Network News Page 5 Volume 5, Number 6 December 20, 1992 clinical case--also may be higher than previously assumed. To prevent transmission of imported polioviruses and cases of paralytic disease in the United States, increased efforts are necessary to vaccinate all unvaccinated or inadequately vaccinated persons in the United States in accordance with recommendations of the Advisory Committee on Immunization Practices (3,4). Public health agencies and health-care providers should intensify outreach, especially to unvaccinated persons in these religious communities who do not routinely accept vaccination. The risk for acquiring poliomyelitis while in the Netherlands is considered small because of the excellent sanitation in the country and because transmission of the poliovirus has been limited primarily to unvaccinated religious groups. Nonetheless, the polio immunity of travelers to the Netherlands should be evaluated, and persons with inadequate protection should complete a primary vaccination series with three doses of poliovirus vaccine before departure. For travelers with a completed primary series of poliovirus vaccine, it may be prudent to obtain one dose of poliovirus vaccine before departure, especially if extensive travel in the Netherlands or contact with persons in the affected religious groups is anticipated. References 1. CDC. Poliomyelitis--Netherlands, 1992. MMWR 1992;41:775-8. 2. Salk JE. Requirements for persistent immunity to poliovirus. Tr Ass Am Physicians 1956; 69:105-14 3. CDC. Poliomyelitis prevention. MMWR 1982;31:22-6,31-4. 4. CDC. Poliomyelitis prevention: enhanced-potency inactivated poliomyelitis vaccine--supplementary statement. MMWR 1987;36:795-8. Health InfoCom Network News Page 6 Volume 5, Number 6 December 20, 1992 Effectiveness in Disease and Injury Prevention Knowledge of the Purpose of Community Water Fluoridation -- United States, 1990 Expansion of water-fluoridation programs in the United States has been based on the clear documentation of the caries-preventive benefits of fluoride (1), as well as resources made available since the 1970s through the Fluoridation and Preventive Services Block grants administered by CDC. An estimated 135 million persons in the United States--approximately 61% of the population served by public water supplies--have access to drinking water with clinically important levels of fluoride (0.7 ppm or higher) for the prevention of dental caries (2). Efforts to expand the implementation of community water fluoridation require dissemination and understanding of information about health benefits and purported health risks. This report summarizes results from the 1990 National Health Interview Survey (NHIS) regarding public knowledge of the purpose and value of fluoridation of community drinking water. Data for the NHIS were collected by CDC's National Center for Health Statistics through personal interviews with a representative sample of the civilian, noninstitutionalized, U.S. population aged greater than or equal to 18 years. The NHIS is conducted throughout the year and has two parts: a basic health and demographic questionnaire (core) that is constant, and several specific health-topic questions directed to adults in sample households. The 1990 NHIS included 41,104 respondents. Respondents were asked: "As you understand it, what is the purpose of adding fluoride to the public drinking water?" Interviewers coded responses as one of the following: "prevent tooth decay, protect teeth, or related response"; "purify the water or related response"; "other"; or "don't know." Analysis reflects adjustment for unequal probabilities of selection and for clustering introduced during sampling. Almost two thirds (62%) of respondents correctly identified the purpose of fluoridation. Correct knowledge of the purpose of fluoridation was highest for persons aged 35-54 years (68%-70%), than for persons aged 18-24 years (49%) and aged greater than or equal to 75 years (40%) (Table 1). Persons with more than a high school education were more than twice as likely than those with less than a high school education (76% versus 36%) to correctly identify the purpose of fluoridation. Among persons with a high school education, 61% answered correctly. Among persons with less than a high school education, 30% believed the purpose of fluoridation was to purify water, compared with 36% who knew it was for preventing tooth decay. Persons who were edentulous (i.e., had lost all of their natural teeth) were less likely to know the correct purpose of fluoridation than were persons who still had their natural teeth (44% versus 64%). In addition, persons who visited the dentist 1-3 times during the preceding 12 months (66%-69%) were more likely to know the correct purpose of fluoridation than those who had not Health InfoCom Network News Page 7 Volume 5, Number 6 December 20, 1992 visited the dentist (50%). Reported by: Disease Prevention and Health Promotion Br, Epidemiology and Oral Disease Prevention Program, National Institute of Dental Research; Musculoskeletal Disease Br, Extramural Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Div of Oral Health and Office of the Director, National Center for Prevention Svcs, CDC. Editorial Note: Dramatic declines in dental caries in the United States during the past half century that have been attributed largely to water fluoridation and other fluoride therapies reflect the public importance of fluoride exposure to human health (1). At the same time, continuing concerns have been raised about possible adverse health effects of fluoride. Because more than one third of the U.S. adult population cannot correctly identify the purpose of fluoridation, these persons may be less likely to make an informed decision when presented with conflicting information about the benefits and risks of fluoridation during local efforts to fluoridate. The findings of the NHIS suggest that misunderstanding of or resistance to fluoridation may be associated with the age and educational composition of a community. For example, because older populations have higher rates of edentulousness and are less likely to visit dentists, opportunities for reinforcement of the benefits of fluoridation are reduced (3). Efforts to fluoridate water may be subjected to greater levels of scrutiny than other public health interventions because fluoridation is a purposeful process to benefit individuals that must be instituted at the community level. For example, issues involving the relation between fluoridation and bone health and osteoporosis are representative of the range of concerns raised about potentially serious health effects of fluoridation. In the United States, approximately 250,000 hip fractures occur each year; osteo-porosis is an important underlying risk factor for this problem (4). However, based on reports from public health agencies, the importance of results from some recent studies examining the relation of fluoride in drinking water to bone health and bone fracture susceptibility (5-10) appears to have been overinterpreted. To address concerns about the possible relation of bone health to fluoride exposure, the National Institutes of Health (NIH) convened a conference of experts to evaluate current public health practices regarding fluoride (11). The conference participants concluded that there was not an "adequate basis for making firm conclusions relating fluoride levels in drinking water to hip fracture and bone health" (11), and there were no recommended changes in the Public Health Service policy regarding fluoride. Since the NIH conference, two additional studies have been reported regarding the relation of fluoride exposure to bone health (9,10,12). An ecologic study involving three communities in Utah reported weak statistical Health InfoCom Network News Page 8 Volume 5, Number 6 December 20, 1992 evidence of increased risk for hip fracture in the exposed community (9); however, this study was constrained by a variety of methodologic limitations (10). The second study, conducted in Rochester, Minnesota, used a historical baseline incidence of hip fracture in a highly stable population; in this study, there was no increased risk for hip fracture following institution of fluoridation (12). The findings of these additional studies do not alter the conclusions and recommendations of the NIH conference. The findings of the NHIS indicate a continuing modest level of knowledge of the purpose of fluoridation in the United States-- especially among young adults, the oldest adults, and the least educated. These findings, coupled with conflicting information and possible misinterpretation about safety, may hinder efforts to expand fluoridation. Accordingly, health-care providers, public health agencies, and schools should intensify efforts to educate the public, especially children and young adults, about the benefits of fluoridation and maintaining oral health. References 1. Public Health Service. Review of fluoride benefits and risks: report of the ad hoc subcommittee of fluoride of the Committee to Coordinate Environmental and Health Related Programs. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991. 2. CDC. Public health focus: fluoridation of community water systems. MMWR 1992;41:372-5,381. 3. National Institutes of Health. Oral health of United States adults, national findings. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1987; publication no. 87-2868. 4. Melton LJ III. Fluoride in the prevention of osteoporosis and fractures. J Bone Miner Res 1990;5(suppl 1):S163. 5. Riggs BL, Hodgson SF, O'Fallon WM, et al. Effects of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. N Engl J Med 1990;322:802-9. 6. Kleerekoper M, Peterson EL, Nelson DA, et al. A randomized trial of sodium fluoride as a treatment for postmenopausal osteoporosis. Osteoporosis International 1991;1:155-61. 7. Sowers MF, Clark MK, Jannausch ML, Wallace RB. A prospective study of bone mineral content and fracture in communities with different fluoride exposure. Am J Epidemiol 1991;133:649-60. Health InfoCom Network News Page 9 Volume 5, Number 6 December 20, 1992 8. Jacobsen SJ, Goldberg J, Brody JA, Stiers W, Rimm AA. Regional variation in the incidence of hip fracture. JAMA 1990;264:500-2. 9. Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah's elderly population. JAMA 1992;286:746-8. 10. Kleerekoper M. 'Please pass the roach poison again' [Editorial]. JAMA 1992;286:781-2. 11. Gordon SL, Corbin SB. Summary of workshop on drinking water fluoride influence on hip fracture [and] on bone health. Osteoporosis International 1992;286:109-17. 12. Jacobsen SJ, O'Fallon WM, Melton LJ III. Hip fracture incidence before and after fluoridation of the public water supply: Rochester, Minnesota, 1950-1969. Am J Public Health (in press). Health InfoCom Network News Page 10 Volume 5, Number 6 December 20, 1992 Epidemiologic Notes and Reports Tuberculosis Transmission in a State Correctional Institution -- California, 1990-1991 During September and October 1991, active tuberculosis (TB) was diagnosed in two inmates and one employee of a California state correctional institution (1991 average annual inmate population, 5421; employees, 1500). This report presents findings from an investigation by the California Department of Health Services (CDHS), the California Department of Corrections (CDOC), and CDC to determine whether ongoing transmission of Mycobacterium tuberculosis was occurring in the institution. Case-Finding Among Inmates A case of TB was defined by using the CDC surveillance case definition for clinically or laboratory-confirmed TB (1) in any inmate diagnosed or treated for TB in the institution during 1991. Of 18 cases identified, 15 were culture confirmed. Of the 15 M. tuberculosis isolates, 12 were susceptible to all drugs tested, and three were resistant to a single drug (one to isoniazid, one to streptomycin, and one to ethambutol). For 10 (56%) of the 18 persons, onset of illness was recognized for the first time while they were in this institution during 1991, for an annual incidence of 184 per 100,000 population in the institution. For the remaining eight, seven had TB diagnosed before imprisonment, and one inmate had TB diagnosed in 1990. Restriction fragment length polymorphism analysis performed on 12 available isolates revealed three distinct DNA patterns among eight M. tuberculosis isolates; the remaining four each had different patterns. However, inmates with similar isolates were not present at the institution at the same time and therefore could not be linked epidemiologically. Because of limited clinical evaluation and prolonged time to sputum conversion, three case-patients may have been infectious for a total of 7 person-months during 1991. Other active cases were not considered infectious: three were not culture confirmed, six were diagnosed and the patients were started on adequate treatment before they entered the correctional institution, two were in persons who had no cough and had smear-negative pulmonary TB, and four were in persons who had only extrapulmonary TB. Of the 10 inmates whose diagnoses of TB were made while in the institution in 1991, two had negative tuberculin skin tests (TSTs) documented on entry to the correctional institution 8 months before the diagnosis of TB. Neither patient had any known risk factors for anergy; one was negative for antibody to human immunodeficiency virus (HIV), and the other was not tested but did not report HIV risk behaviors. Tuberculin Reactivity Among Inmates The point prevalence of tuberculin positivity and the incidence of TST conversion among inmates were estimated from inmate skin test results in November 1991 and correctional institution medical records. A positive TST was defined as a reaction of greater than or equal to 10-mm induration in response to 5 tuberculin units of tuberculin purified protein derivative administered by the Mantoux method. Health InfoCom Network News Page 11 Volume 5, Number 6 December 20, 1992 Of 3070 inmates in the prison at the end of November 1991, TST results were available for 2944 (96%). Of these, 873 (30%) were TST positive: 549 had a history of a prior positive test and were not retested in November 1991, and 324 tested positive for the first time at the prison in November 1991. Of the 324 who tested positive at the prison, 155 had no record of an earlier TST; for 21, results had been recorded as positive but the size of their TST reaction was not recorded. The remaining 148 TST-positive inmates had documented skin test conversions. Of these, 106 (72%) entered the state prison system with a negative TST and had skin test conversions while in the state prison system; for 97 of the 106, skin test conversion occurred within the previous 2 years. The remaining 42 persons who had skin test conversions spent some time outside the prison system during the conversion intervals. Because of frequent inmate movement between correctional institutions, conversions could not be attributed specifically to the institution under investigation. The 2-year conversion incidence was estimated to be 5.9 per 100 person- years spent in the prison system. Case-Finding and Prevalence Among Employees The employee identified as one of the three index case-patients was diagnosed with culture-negative pulmonary TB in September 1991; the source of the employee's infection is undetermined. This employee worked as a counselor on the prison's HIV unit and recalled exposure to one of the three infectious inmates. The employee did not report any exposure to TB outside the prison. The employee's most recent negative multipuncture skin test for TB had been in May 1989, 1 year before employment at the prison. Records regarding employees' current or past TST status were incomplete. However, two other employees had documented skin test conversions during the previous 2 years while working at the prison; one reported exposure to an inmate with possible TB. Neither reported any known exposures to M. tuberculosis outside the prison. Reported by: F Schwartz, MD, Marin County Health Dept, San Rafael; S Singh, PM Small, MD, Howard Hughes Medical Institute, Stanford; D Cashman, MD, R Campbell, DO, N Khoury, MD, California Dept of Corrections; S Coulter, S Royce, MD, R Roberto, MD, GW Rutherford, III, MD, State Epidemiologist, California Dept of Health Svcs. Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: The incidence of active TB among inmates of this prison was more than 10 times the crude incidence of TB in California (17.4 per 100,000 population) for 1991. In addition, the number of incident cases was three times what would have been predicted for a population of this size and demographic profile. Although the incident cases apparently were not linked, two findings from Health InfoCom Network News Page 12 Volume 5, Number 6 December 20, 1992 this investigation suggest that transmission of M. tuberculosis may have occurred in the prison: first, at least two inmates with active TB may have become infected at the prison; and second, a substantial number of TST conversions were documented among asymptomatic inmates. The prolonged infectiousness of the three active cases in the prison illustrates the potential for M. tuberculosis to be propagated in the prison system. Although it cannot be proven that the 97 inmates who had TST conversions within the previous 2 years were infected while in prison, the 2-year conversion incidence of 5.9 per 100 person-years in prison probably underestimates the risk for new M. tuberculosis infection. No information was available regarding the timing of conversion and the potential for acquisition of infection in the state prison system for at least 155 inmates. The findings in this report, as well as previous findings of the potential for introducing multidrug-resistant TB into correctional systems (2), emphasize the need to improve infection-control practices in these settings. State health departments can assist correctional system officials in implementing control measures in correctional facilities (3), including 1) regular and systematic TB screening of inmates and staff, with HIV testing and TB preventive therapy (PT) for those who test positive for TB and are eligible for PT; 2) rapid identification, isolation, and treatment of suspected cases of TB; 3) directly observed therapy and PT, and rigorous follow-up and recordkeeping to ensure completion of treatment; and 4) follow- up to assure continuity of care both inside and outside the correctional facilities. Recent California legislation, supported by the CDOC, the CDHS, and state employee organizations, requires inmate and employee TB skin testing, requires reporting of results to the CDHS, and designates that treatment for TB may be required as a condition of parole for inmates with active TB. The CDHS and the CDOC are cooperating in implementing the mandates of the legislation. The CDOC is addressing infection-control issues in its facilities, and its staff members are participating on the California Tuberculosis Elimination Task Force and the Interagency Working Group on Tuberculosis. References 1. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):39-40. 2. CDC. Transmission of multidrug-resistant tuberculosis among --------- end of part 1 ------------ ------------------------------------------------------------------------- Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet: ATW1H@ASUACAD FidoNet=> 1:114/15 Amateur Packet ax25: wb7tpy@wb7tpy.az.usa.na