Geographic predictors of primary multidrug-resistant tuberculosis cases in an endemic area of Lima, Peru

SETTING

Peru reports among the highest multidrug-resistant tuberculosis (MDR-TB) rates in the Americas, with a growing proportion in previously untreated tuberculosis (TB) cases. The identification of clusters of primary MDR-TB compared with drug-susceptible TB (DS-TB) could help prioritize interventions.

OBJECTIVE

To examine the clustering of primary MDR-TB case residences and their proximity to high-risk locations in San Juan de Lurigancho District, Lima, Peru.

DESIGN

Enrolled primary MDR-TB and primary DS-TB cases were interviewed and their primary residence was recorded using handheld Global Positioning System devices. Kuldorff's spatial scan statistic was used for cluster detection (SaTScan(TM), v. 9.1.1). Identified clusters were visualized in Quantum Geographic Information Systems software (v1.8.0). The following cluster centers were tested: a health centre with the highest TB and MDR-TB rates (Clinic X), a hospital and two prisons. Using regression analyses, we examined predictors of primary MDR-TB cases.

RESULTS

A statistically significant cluster of primary MDR-TB cases was identified within a 2.29 km radius around Clinic X. Proximity to Clinic X remained a significant predictor of primary MDR-TB in adjusted regression analyses.

CONCLUSION

We identified a hotspot of primary MDR-TB cases around Clinic X in a TB-endemic area. Causes of this clustering require investigation; targeted interventions for this high-risk area should be considered.

Strategies to decrease tuberculosis in us homeless populations: a computer simulation model

CONTEXT

The rate of tuberculosis (TB) among US homeless persons may be 20 times that of the general adult population. Studies suggest that the majority of urban homeless TB cases are attributable to ongoing transmission of TB. Optimal TB-control strategies in both chronically and transiently homeless populations are not known.

OBJECTIVE

To examine the effects of TB-control strategies on projected TB cases and deaths in US homeless populations using a computer-based simulation model.

DESIGN, SETTING, AND POPULATION

The US general population and a theoretical population of 2 million homeless individuals in 1995 were divided into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus (HIV) infection in a semi-Markov model.

MAIN OUTCOME MEASURES

Prevalence of transiently and chronically homeless individuals with active TB and deaths from TB as a function of public health measures taken to control and eliminate TB, including improvement of treatment effectiveness, improvement in access to treatment, and vaccination with BCG.

RESULTS

A 10% increase in access to treatment among homeless persons with active TB produced larger declines in predicted TB cases and deaths after 10 years (cases and deaths among chronically homeless persons decreased 12.5% and 19.8% and among transiently homeless persons dropped 35.9% and 32.4%, respectively) than improvements in the effectiveness of treatment programs (cases and deaths among chronically homeless persons declined 7.2% and 3.1% and among transiently homeless persons dropped 10.9% and 4.1%, respectively). A 10% increase in access to treatment among homeless persons with latent TB infection led to a 6.7% decline in TB among chronically homeless persons and a 5.7% decline among transiently homeless persons, while a 10% improvement in effectiveness of treatment for latent TB infection was associated with declines of 3.0% and 3.3%, respectively. When treatment for latent TB infection was modeled to be the same in vaccinated and nonvaccinated populations, BCG vaccination led to TB case declines of 15.4% and 21.5% in chronically and transiently homeless populations, respectively.

CONCLUSIONS

Overcoming barriers faced by homeless individuals in accessing TB treatment programs will be crucial to reducing the burden of TB in this high-risk group. Increased treatment access, improvement in the effectiveness of treatment programs, and BCG vaccination of HIV-negative homeless individuals have the best chance to markedly decrease TB morbidity and mortality.

Preventing tuberculosis with bacillus Calmette-Guérin vaccine: a meta-analysis of the literature

This article reviews a previously published meta-analysis of 1264 titles or abstracts and 70 selected studies for evaluation of the efficacy of bacillus Calmette-Guérin (BCG) vaccine in preventing tuberculosis. Following review, data from 26 studies were included in the analysis. These 26 studies reveal that vaccination with BCG significantly reduces the risk of tuberculosis by an average of 50%. This level of protection persists across a number of subgroups defined by age at vaccination and study design. Vaccination with BCG was significantly associated with a reduction in the incidence of pulmonary tuberculosis and extrapulmonary disease. In general, the results of this meta-analysis lend weight and confidence to arguments favoring the use of BCG vaccine.

Pediatric tuberculosis: what needs to be done to decrease morbidity and mortality

OBJECTIVE

Tuberculosis (TB) control programs have been less successful among children than among adults in the United States. Between 1992 and 1997, the rate of decline of TB cases among 0- to 14-year-old children was less than the rate of decline among any other age group of US-born persons. Because of the higher prevalence of active TB among adults and their higher infectivity, most programs for TB in the United States have targeted adults. The inherent assumption has been that by targeting adults, from whom children may become infected, TB morbidity and mortality among children also will be reduced effectively.

METHODS

Using a semi-Markov model that divided the US population into age groups <15 years old and >/=15 years old and into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus infection, we developed a computer-based simulation model to examine the effect of a range of potential TB control strategies on projected TB cases and deaths in children. We compare the impact of interventions targeted at children with the impact of interventions targeted at adults on pediatric morbidity and mortality.

RESULTS

After 10 years, a 5% increase in the number of adults with TB who enter treatment would only lead to a.05% decline in TB cases among children, compared with predicted cases without this intervention. Improving treatment efficacy among those adults who are already receiving treatment for their TB leads to a smaller decline in cases among children of only.003%. In contrast, a 5% increase in the number of children who enter treatment leads to a 25% decline, after 10 years, in the number of TB cases among children and a 16% decline in the number of TB deaths. In the presence of immigration of tuberculin-positive children, the benefit of targeting programs directly at children is magnified.

CONCLUSIONS

Marginal changes in programs targeted directly at children are significantly more effective at further reducing pediatric TB morbidity and mortality than the same changes in programs targeted at adults with the indirect goal of reducing spread to children. Marginal increases in the number of children who enter treatment are far more effective at decreasing morbidity and mortality than equivalent marginal increases in treatment effectiveness. Unfortunately, declining insurance coverage and increasing restrictions on services to immigrants have made it harder for those who are at greatest risk of TB to get medical care. Marginal increases in preventive therapy rates substantially reduce future pediatric TB cases and deaths among children with TB infection and human immunodeficiency virus.

An effectiveness and cost analysis of presumptive treatment for Mycobacterium tuberculosis

BACKGROUND

Delay in treatment of tuberculosis has contributed to both the spread of tuberculosis and its case fatality rate.

METHODS

Decision analysis was used to examine the effectiveness and cost of presumptive treatment in patients evaluated for tuberculosis.

RESULTS

Over a range of assumptions, empiric antituberculous therapy for acid-fast bacillus smear-positive persons lowers mortality and cost per person evaluated when available rapid diagnostic laboratory methods for tuberculosis are used. In contrast, the average cost per life saved by giving presumptive treatment to all acid-fast bacillus smear- and HIV-negative patients exceeds. $1 million. Empiric treatment for HIV-infected patients with acid-fast bacillus-negative smears decreases average mortality by 2% at an additional cost of $8000 per life saved. When the prevalence of multiple-drug resistance exceeds 9.6%, presumptive drug-resistant therapy for acid-fast bacillus smear-positive patients, rather than the initial four-drug regimen recommended for much of the United States, minimizes both mortality and costs.

CONCLUSIONS

Empiric antituberculous therapy often minimizes average mortality and cost for patients evaluated for tuberculosis when rapid diagnostic methods are used.

The influence of program acceptability on the effectiveness of public health policy: a study of directly observed therapy for tuberculosis

OBJECTIVES

This study examined how patient acceptability influences the effectiveness of directly observed therapy for tuberculosis.

METHODS

Decision and sensitivity analyses were used in assessing influences.

RESULTS

If mandatory directly observed therapy discourages 6% of initial tuberculosis patients (range: 4% to 10%) from seeking care, then such therapy will be less effective than self-administered therapy. Directly observed therapy is more effective than repeated self-administered therapy for patients failing to complete initial treatment unless 32% (range: 27% to 38%) of patients avoid seeking care.

CONCLUSIONS

Patient acceptability must be taken into consideration before selecting public health strategies.

Tuberculosis control in Asia and the western Pacific: a role for computer modelling

Despite the availability of effective treatment, tuberculosis (TB) causes more deaths than any other infection. Most of the world's TB cases and deaths occur in Asia and the Western Pacific, and the growing prevalence of multiple drug-resistant TB and the spread of human immunodeficiency virus (HIV) present ever greater obstacles to effective TB control. The management of TB remains difficult, and epidemiologic studies to assess control programmes require significant time and expense and may not be generalizable to other regions. Computer models are powerful and relatively inexpensive tools for rapidly planning and evaluating TB control strategies. Models have demonstrated the value of targeted chemoprophylaxis strategies for the prevention of TB among HIV-infected individuals, and programmes to ensure that all HIV-infected individuals receive TB chemoprophylaxis should be considered in Asia and the Western Pacific. Though directly observed therapy (DOT) is effective when designed to be attractive to patients, modelling has shown that DOT, if poorly accepted by patients, may lead to fewer patients seeking care and thus to paradoxical rises in TB case rates. Models may be used to make accurate predictions of TB morbidity and programme costs using local epidemiologic and demographic inputs. The use of models in Asia and the Western Pacific offers a low-cost way to compare programmes, to improve the evaluation of programmes, to project future cases, and to examine programme needs while providing insights into TB control helpful to countries in and out of the region.

Effectiveness and cost of rapid and conventional laboratory methods for Mycobacterium tuberculosis screening

OBJECTIVE

Because delay in the diagnosis of tuberculosis (TB) contributes to the spread of disease and the associated mortality risk, the authors examined the effectiveness and cost of recent advances in methods of diagnosing TB and testing for drug susceptibility, comparing these rapid methods to traditional approaches.

METHODS

Decision analysis was used to compare newer rapid and older nonrapid methods for diagnosing TB and testing for drug susceptibility. The average time to diagnosis, average time to treatment, average mortality, and cost of caring for patients evaluated for TB were compared.

RESULTS

Using a combination of solid medium and broth cultures, nucleic acid probes for identification, and radiometric broth drug susceptibility testing would lead to diagnosis on average 15 days faster and to appropriate therapy on average five days sooner than methods currently employed by many U.S. laboratories. The average mortality would drop by five patients per 1000 patients evaluated (31%) and the average cost per patient would drop by $272 (18%).

CONCLUSIONS

In this era of cost containment, it is important to incorporate test sensitivity and specificity when evaluating technologies. Tests with higher unit costs may lead to lower medical expenditures when diagnostic accuracy and speed are improved. U.S. laboratories should employ available rapid techniques for the diagnosis of TB.

Evaluation of tuberculosis control policies using computer simulation

OBJECTIVE

To develop more effective methods to assess tuberculosis (TB) control strategies so we can meet national goals for the elimination of TB in the United States.

DESIGN

Using a semi-Markov model that divided the US population into 3 age groups and 18 clinical states based on disease status and risk for TB and human immunodeficiency virus (HIV) infection, we measured the effects of 5 changes in TB policy, introduced singly and in combination: (1) increased coverage and (2) improved efficacy of preventive therapy, (3) increased coverage and (4) improved efficacy of treatment, and (5) introduction of BCG vaccination.

RESULTS

A BCG vaccination program that reached 10% of eligible children and 1% of eligible adults each year would produce a 17% reduction in cases and an 11% decline in deaths over 10 years. Preventive therapy programs among the general population would have little effect on the number of TB cases, but a program targeting HIV-infected patients would reduce HIV-associated TB cases and deaths 14% to 20%. A 10% improvement in the coverage and efficacy of both preventive therapy and treatment, coupled with the BCG vaccination program, would lead to a 47% decline in TB cases and a 50% decline in TB deaths relative to baseline over 10 years.

CONCLUSIONS

Improvements in treatment coverage or effectiveness alone are unlikely to reach established national goals for the elimination of TB. These goals can be achieved through a combination of improvements in current programs with targeted preventive therapy and BCG vaccination programs.

Bacille Calmette-Guérin vaccination for the prevention of tuberculosis in health care workers

For 60 years vaccination with bacille Calmette-Guérin (BCG) has been used for the prevention of tuberculosis in health care workers. In 1988 the U.S. Advisory Committee on Immunization Practices removed the category of health care worker from the list of persons for whom vaccination with BCG should be considered. Nosocomial epidemics of tuberculosis, especially those caused by multidrug-resistant strains, have led to the reconsideration of vaccination with BCG for this population. We review the available studies of the efficacy of BCG vaccine in health care workers. Although the studies had too many methodological flaws to be combined in a quantitative meta-analysis, they suggest that vaccination with BCG is effective in reducing the incidence of tuberculosis among health care workers.

Relationship between bacille Calmette-Guérin (BCG) strains and the efficacy of BCG vaccine in the prevention of tuberculosis

Bacille Calmette-Guérin (BCG) vaccination for the prevention of tuberculosis has been used in humans since 1921. Furthermore, for > 60 years it has been possible to separate BCG strains (defined here as a BCG vaccine maintained in a particular laboratory and used in a particular trial or set of trials) on the basis of in vitro and in vivo tests. Investigators have concluded that differences in the BCG strains used in efficacy trials on humans may be responsible for the wide range in levels of protection from tuberculosis reported in those trials. We review the development of the separate strains used in the trials included in a recent meta-analysis and examine data for and against the protective efficacy of different BCG strains. The difficulties in correlating results of in vitro and in vivo tests with protective efficacy in humans are discussed. The limited data available from human studies suggest that the BCG strain used for vaccination is not a significant determinant of the overall efficacy in the prevention of tuberculosis.

Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature

OBJECTIVE

To quantify the efficacy of BCG vaccine against tuberculosis (TB).

DATA SOURCES

MEDLINE with index terms BCG vaccine, tuberculosis, and human. Experts from the Centers for Disease Control and Prevention and the World Health Organization, among others, provided lists of all known studies.

STUDY SELECTION

A total of 1264 articles or abstracts were reviewed for details on BCG vaccination, concurrent vaccinated and unvaccinated groups, and TB outcome; 70 articles were reviewed in depth for method of vaccine allocation used to create comparable groups, equal surveillance and follow-up for recipient and concurrent control groups, and outcome measures of TB cases and/or deaths. Fourteen prospective trials and 12 case-control studies were included in the analysis.

DATA EXTRACTION

We recorded study design, age range of study population, number of patients enrolled, efficacy of vaccine, and items to assess the potential for bias in study design and diagnosis. At least two readers independently extracted data and evaluated validity.

DATA SYNTHESIS

The relative risk (RR) or odds ratio (OR) of TB provided the measure of vaccine efficacy that we analyzed. The protective effect was then computed by 1-RR or 1-OR. A random-effects model estimated a weighted average RR or OR from those provided by the trials or case-control studies. In the trials, the RR of TB was 0.49 (95% confidence interval [CI], 0.34 to 0.70) for vaccine recipients compared with nonrecipients (protective effect of 51%). In the case-control studies, the OR for TB was 0.50 (95% CI, 0.39 to 0.64), or a 50% protective effect. Seven trials reporting tuberculous deaths showed a protective effect from BCG vaccine of 71% (RR, 0.29; 95% CI, 0.16 to 0.53), and five studies reporting on meningitis showed a protective effect from BCG vaccine of 64% (OR, 0.36; 95% CI, 0.18 to 0.70). Geographic latitude of the study site and study validity score explained 66% of the heterogeneity among trials in a random-effects regression model.

CONCLUSION

On average, BCG vaccine significantly reduces the risk of TB by 50%. Protection is observed across many populations, study designs, and forms of TB. Age at vaccination did not enhance predictiveness of BCG efficacy. Protection against tuberculous death, meningitis, and disseminated disease is higher than for total TB cases, although this result may reflect reduced error in disease classification rather than greater BCG efficacy.

Bacon therapy and furuncular myiasis

OBJECTIVE

To evaluate a simple, noninvasive method for removing fly larvae from patients with furuncular myiasis.

DESIGN

Case series.

SETTING

Ambulatory office of a tertiary care center.

PATIENTS

Three patients who presented with Dermatobia hominis infestation.

INTERVENTION

The patients with D hominis infestation were treated with the application of bacon fat over the larval apertures.

MAIN OUTCOME MEASURE

Removal of intact larvae.

RESULTS

Within 3 hours of the application of bacon, the larvae had migrated sufficiently far out of the skin to be removed with tweezers. Ten larvae were removed with this method. There were no treatment failures or complications.

CONCLUSIONS

Furuncular myiasis will be seen more frequently in temperate areas as individuals travel to endemic areas. We describe the clinical characteristics of myiasis and a simple method of treatment that permits rapid diagnosis and cure.

The infectious risks of transfusions in the United States: a decision-analytic approach

INTRODUCTION

The development of AIDS as a result of HIV transmission and of cirrhosis as a result of chronic non-A, non-B hepatitis are the greatest infectious risks associated with transfusion in the United States. The goal of this study is to provide explicit quantitative guidelines to determine when the risk of death from all causes associated with transfusion exceeds the risk associated with anemia.

METHODS

This study uses a decision-analytic model.

RESULTS

On the basis of reported transfusion complication rates and an independent worst-case calculation of the risk of AIDS and non-A, non-B hepatitis, transfusion with red blood cells should be recommended as long as each unit received reduces the patient's risk of dying from anemia by at least 1/1100.

DISCUSSION

Because of the relative safety of the blood supply as a result of universal screening and donor deferral, the overestimation in practice of fatal infectious complications, and the possible underestimation of the risk of anemia, undertransfusion has the potential to be as serious a problem in the United States as is overtransfusion. Although caution should be exercised not to undertransfuse when a patient has an appreciable risk of anemia-associated death, we must be wary not to overtransfuse for temporary relief of morbidity.

The problem of transfusion-associated acquired immunodeficiency syndrome in Africa: a quantitative approach

BACKGROUND

Transfusion-associated AIDS accounts for 10% of all cases of AIDS in Africa. The risk of HIV-1 contamination in transfusions continues to exist, even in countries where blood products are screened, because of limitations in test sensitivity, human error, and the window period. Furthermore, 30 African countries do not screen all of their blood products because of resource limitations.

METHODS

This study used decision analysis to compare the survival outcomes of severely anemic patients who are transfused with those of patients who are not transfused. Sensitivity analyses were performed.

RESULTS

When 5% of the blood supply is HIV-1 contaminated, every patient with a 6.6% or greater risk of dying from anemia should be transfused. Detailed results are provided for a wide range of HIV-1 contamination rates.

CONCLUSIONS

This study provides a method for developing and evaluating locality-specific transfusion guidelines. This method can be applied to other regions, including the United States, and to other diseases transmitted by blood products.

Prevalence of antibody to HIV-1 among entrants to US correctional facilities

Prevalence of antibody to the human immunodeficiency virus type 1 (HIV-1) was assessed among 10,994 consecutive male and female entrants to 10 correctional systems in the United States. The HIV-1 seroprevalence for the 10 systems ranged from 2.1% to 7.6% for men and 2.5% to 14.7% for women; seroprevalence among women was higher than among men across nine of 10 systems. Using age 25 years to divide the population, HIV-1 prevalence among young women (5.2%) was significantly higher than among young men (2.3%), but similar to that in both older women (5.3%) and older men (5.6%). Overall, HIV-1 rates for nonwhites (4.8%) were higher than those for whites (2.5%). Although categories were identified across correctional systems, which may serve to focus prevention programs, variability in rates among correctional systems indicates that program planning must take local conditions into consideration.

Death in prison: changing mortality patterns among male prisoners in Maryland, 1979-87

The leading causes of death (rate per 100,000 prisoner-years) in Maryland state prisons for the period 1979-87 were circulatory system disease (59), suicide (40), and homicide and legal intervention (30). Acquired immunodeficiency syndrome (AIDS) became the leading cause of death in 1987. Homicides declined after 1980; drug overdose deaths peaked in 1981 and later disappeared. Male inmates have 39 percent lower all-cause death rates than the general population of Maryland after adjustment for age and race.

Coinfection with tuberculosis and HIV-1 in male prison inmates

An association between past exposure to tuberculosis (TB) and infection with human immunodeficiency virus type 1 (HIV-1) was investigated using a case-control design among a 6-week sample of 698 male inmates consecutively admitted to the Maryland State prison system. Based on Mantoux testing and measurement of anti-HIV-1, we found a positive but not significant association between HIV-1 and TB infection (odds ratio 2.4, 95 percent confidence interval 0.9-6.3). The power of the study to detect an association of this magnitude was 0.57. Of the entire intake sample, 1.3 percent were found to be coinfected with TB and HIV-1. Some misclassification may have been present due to anergy or latent HIV-1 infection. The elevated risk of TB in coinfected inmates, coupled with the study results, suggest that the inmate screening process on entry to the prison should be modified to improve identification of coinfected people. Specifically, anergy testing should be added to the admission screening procedure, and appropriate voluntary anonymous HIV-1 antibody testing should be more widely available to inmates.

Gonorrhea prevalence in the Maryland state prisons

During a 6-month period from July 1 through December 31, 1986, 2,598 consecutive men were screened for gonorrhea upon entry into the Maryland Division of Corrections. Twenty-eight men (1.1%) demonstrated positive cultures for gonorrhea with 27 of them (92%) asymptomatic. This prevalence is substantially lower than other rates reported from prisons and detention centers. Although the role of asymptomatic males as a reservoir for gonorrhea has been well delineated, standard recommendations for screening high-risk male populations such as prison inmates have not been established. These data suggest that screening in some correctional facilities may not be cost-effective given the low prevalence observed. In addition, contact tracing may be delayed by long holding periods in local detention facilities prior to transfer to the state prison system. These data underscore the need for additional analysis to determine the most effective program structure for screening in correctional facilities and detention centers.

Suicide mortality in the Maryland state prison system, 1979 through 1987

Prisoners are reported to have a higher suicide rate than the community. We studied suicides in the Maryland prison system to determine the level of risk and risk factors for inmate suicide. There were 37 male inmate suicide deaths between 1979 and 1987 (39.6 suicides per 100,000 male inmates), which is significantly higher than the age- and race-adjusted male suicide rate in the general population of Maryland (22.0 per 100,000). Risk of male inmate suicide was increased for the following characteristics: white race (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1 to 3.9), age 25 to 34 years (RR, 1.8; 95% CI, 1.0 to 3.4), major crime committed against person (RR, 3.4; 95% CI, 1.7 to 6.7), life sentence (RR, 4.7; 95% CI, 2.2 to 10.0), and classification to the major maximum security institution in the prison system (RR, 5.1; 95% CI, 2.7 to 9.8). The methods of suicide chosen by inmates were hanging (86%), cutting wound (5%), antidepressant overdose (5%), and fall from height (3%). We conclude that inmate suicide represents a significant correctional health and public health problem. Specific implications for prevention of inmate suicide are examined.

5-Hydroxytryptophan and carbidopa in spontaneously hypertensive rats

Serial measurements of blood pressure, body weight, food and water intake, and salt and water excretion were compared in two groups of spontaneously hypertensive rats (SHR) over a 12-day period: control SHR (n = 11) and a group (n = 9) which received supplementary 5-hydroxytryptophan (5-HTP; 2 mg/ml) in its drinking water. During the final 4 days of study, both groups received additional oral carbidopa (50 mg/kg twice a day) to inhibit peripheral, but not brain aromatic L-amino-acid decarboxylase (LAAD), an enzyme necessary to the formation of 5-hydroxytryptamine (5-HT, serotonin) from 5-HTP. 5-Hydroxytryptophan increased urinary 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) markedly; following carbidopa, urinary 5-HT, and to a lesser degree urinary 5-HIAA, decreased, whereas brain 5-HT and 5-HIAA increased. Spontaneously hypertensive rats treated with 5-HTP plus carbidopa had significantly lower blood pressure levels, lower pulse rates, reductions in food and water intake, salt and water excretion, and a loss of body weight, when compared with the control SHR. These data indicate that enhanced brain formation of 5-HT can give rise to metabolic and circulatory responses with a resultant lowering of blood pressure.

Dental health of male inmates in a state prison system

This study investigated the prevalence of decayed, missing, and filled teeth (DMFT) in a state prison system, using the opening of a new institution as an opportunity to examine a cross-section of the state male inmate population routinely. A representative sample of 178 male inmates was examined by a single dentist, and the results were linked to demographic information. This study found a mean DMFT of 10.5 for inmates aged 18-29, 17.1 for inmates aged 30-44, and 22.4 for inmates over age 44. In the 18-29 age group, white inmates had more filled teeth than blacks (P less than .005) and more missing teeth (P = .06). Missing teeth increased by 0.54 teeth/year of age (P less than .001) and DMFT increased by 0.66 teeth/year of age (P less than .001). The number of decayed teeth was explained using negative reciprocal time incarcerated (-1/T), and declined by 1.30 teeth between the sixth and 12th month of incarceration (P less than .01). This may have been due to a treatment effect, or by selective loss of the population with poorer teeth. Comparison with US employed adults standardized to the study population showed that inmates had more missing teeth at every age, and a greater percent of unmet dental needs.

Medical care behind bars: Maryland prison system

The inmate population in the Maryland prison system has increased dramatically over the past 10 years due to changes in sentencing by the courts. At the same time, costs of inmate health care have increased markedly following court cases mandating adequate care, an amelioration of prior inadequate standards of care. The unique demographic and disease risk characteristics of inmates predispose them to a distinct set of health problems. The state is legally obligated to provide health care to individuals sentenced to confinement in state prisons. It is often the first care these individuals have received in many years.

Transmission of HIV-1 within a statewide prison system

To assess the incidence of infection with HIV-1 in the Maryland state prison system, inmates with excess sera stored from specified intake periods between April and June 1985 and 1986 were approached in May 1987 to volunteer for venipuncture. Of the 2286 inmates for whom intake specimens were stored, 1038 (45.4%) no longer incarcerated as of April 1987 were excluded from the study; another 319 missed the survey. Of the 929 eligible inmates approached for the study, 446 (48%) consented and 422 (94.6%) provided a specimen. Twenty-nine (6.6%) were confirmed seropositive at time of entry into prison, indicating that infection had occurred prior to incarceration. Baseline seropositives were more likely (P less than 0.05) to be non-violent offenders, committed in Baltimore City, and black. The 393 participants seronegative at baseline provided a total of 482 prison-years of potential exposure to infection. Two inmates seroconverted with baseline specimens seronegative on Western blot and follow-up sera confirmed positive; their duration of pre-incarceration detention was 69 and 146 days, respectively. No interruption of incarceration was recorded for these two inmates. The rate of infection in this prison sample, which does not include an average of 2 months of pre-incarceration detention for the study sample, was 0.41% per prison-year.

Formation of biogenic amines by isolated kidneys of spontaneously hypertensive rats

Kidneys form dopamine (DA) from L-dopa and serotonin from L-5-hydroxytryptophan (L-5-HTP) via aromatic L-amino acid decarboxylase. We compared the ability of isolated perfused kidneys from adult (20-week-old) spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto rats (WKY) to form these biogenic amines. Renal vascular resistance (RVR) was greater in perfused kidneys from SHR (n = 10) than WKY (n = 8) (p less than 0.01). Slight decreases in RVR were observed during L-dopa infusion but these were unrelated to DA formation. L-Dopa infusion was associated with greater DA output in SHR than WKY in both the renal venous and urinary effluents although the latter did not achieve statistical significance. L-5-HTP increased RVR to a greater degree in SHR than WKY kidneys. This was associated with larger quantities of serotonin in the urinary and venous effluents and greater pressor responses to exogenous serotonin in SHR than WKY kidneys; however, either parameter alone was not significantly increased. Our findings do not support a deficiency of intrarenal DA formation as a pathogenic factor for hypertension in SHR. Biogenic amine formation is as great if not greater in SHR than WKY kidneys and appears to contribute largely to the greater increases in renal resistance seen in SHR kidneys on infusion of L-5-HTP. Enhanced renal serotonin formation may elevate blood pressure, whereas enhanced renal DA formation would favor blood pressure lowering, perhaps as a compensatory mechanism.