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              <MEDNEWS@ASUACAD.BITNET>
From:         David Dodell <david@STAT.COM>
Subject:      HICN506 Newsletter Part 1/4

Volume  5, Number  6                                         December 20, 1992

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                         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
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joining the automated distribution system, please contact the editor.

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::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

                       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






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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

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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

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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

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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.













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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

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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.















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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

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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

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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.

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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).




























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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.

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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
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