------------- cut here ----------------- Volume  6, Number 11                                           April 25, 1993                +------------------------------------------------+               !                                                !               !              Health Info-Com Network           !               !                Medical 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 1993 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  biweekly.  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 = hicn-notify-request@stat.com                  FAX Delivery = Contact Editor for information   ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                         T A B L E   O F   C O N T E N T S   1.  Centers for Disease Control and Prevention - MMWR      [23 April 1993] Rates of Cesarean Delivery ...........................  1      Malaria Among U.S. Embassy Personnel .................................  5      FDA Approval of Hib Vaccine for Children/Infants .....................  8  2.  Dental News      Workshop Explores Oral Manifestations of HIV Infection ............... 11  3.  Food & Drug Administration News      FDA Approves Depo Provera, injectable contraceptive .................. 14      New Rules Speed Approval of Drugs for Life-Threatening Illnesses ..... 16  4.  Articles      Research Promises Preventing/Slowing Blindness from Retinal Disease .. 18      Affluent Diet Increases Risk Of Heart Disease ........................ 20  5.  General Announcments      Publications for Health Professionals from National Cancer Institute . 23      Publications for Patients Available from National Cancer Institute ... 30  6.  AIDS News Summaries      AIDS Daily Summary for April 19 to April 23, 1993 .................... 38  7.  AIDS Statistics      Worldwide AIDS Statistics ............................................ 48      HICNet Medical Newsletter                                            Page    i Volume  6, Number 11                                           April 25, 1993    ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                Centers for Disease Control and Prevention - MMWR ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                 Rates of Cesarean Delivery -- United States, 1991                =================================================                    SOURCE: MMWR 42(15)   DATE: Apr 23, 1993       Cesarean deliveries have accounted for nearly 1 million of the  approximately 4 million annual deliveries in the United States since 1986  (Table 1). The cesarean rate in the United States is the third highest among  21 reporting countries, exceeded only by Brazil and Puerto Rico (1). This  report presents data on cesarean deliveries from CDC's National Hospital  Discharge Survey (NHDS) for 1991 and compares these data with previous years.       Data on discharges from short-stay, nonfederal hospitals have been  collected annually since 1965 in the NHDS, conducted by CDC's National Center  for Health Statistics. For 1991, medical and demographic information were  abstracted from a sample of 274,000 inpatients discharged from 484  participating hospitals. The 1991 cesareans and vaginal births after a prior  cesarean (VBAC) presented in this report are based on weighted national  estimates from the NHDS sample of approximately 31,000 (11%) women discharged  after delivery. The estimated numbers of live births by type of delivery were  calculated by applying cesarean rates from the NHDS to live births from  national vital registration data. Therefore, estimates of the number of  cesareans in this report will not agree with previously published data based  solely on the NHDS (2). Stated differences in this analysis are significant at  the 95% confidence level, based on the two-tailed t-test with a critical value  of 1.96.       In 1991, there were 23.5 cesareans per 100 deliveries, the same rate as  in 1990 and similar to rates during 1986-1989 (Table 1). The primary cesarean  rate (i.e., number of first cesareans per 100 deliveries to women who had no  previous cesareans) for 1986-1991 also was stable, ranging from 16.8 to 17.5.  In 1991, the cesarean rate in the South was 27.6, significantly (p<0.05)  higher than the rates for the West (19.8), Midwest (21.8), and Northeast  (22.6). Rates were higher for mothers aged greater than or equal to 30 years  than for younger women; in proprietary hospitals than in nonprofit or  government hospitals; in hospitals with fewer than 300 beds than in larger  hospitals; and for deliveries for which Blue Cross/Blue Shield * and other  private insurance is the expected source of payment than for other sources of  payment (Table 2). The same pattern characterized primary cesarean deliveries.       Since the early 1970s, the number and percentage of births to older women  increased; however, if the age distribution of mothers in 1991 had remained  the same as in 1986, the overall cesarean rate in 1991 would have been 23.3,  essentially the same as the 23.5 observed.       Based on the NHDS, of the approximately 4,111,000 live births in 1991, an   HICNet Medical Newsletter                                              Page  1 Volume  6, Number 11                                           April 25, 1993  estimated 966,000 (23.5%) were by cesarean delivery. Of these, an estimated  338,000 (35.0%) births were repeat cesareans, and 628,000 (65.0%) were primary  cesareans. Since 1986, approximately 600,000 primary cesareans have been  performed annually. In 1986, 8.5% of women who had a previous cesarean  delivered vaginally, compared with 24.2% in 1991. Of all cesareans in 1991,  35.0% were associated with a previous cesarean, 30.4% with dystocia (i.e.,  failure of labor to progress), 11.7% with breech presentation, 9.2% with fetal  distress, and 13.7% with all other specified complications.       The average hospital stay for all deliveries in 1991 was 2.8 days. In  comparison, the hospital stay for a primary cesarean delivery was 4.5 days,  and for a repeat cesarean, 4.2 days -- nearly twice the duration for VBAC  deliveries (2.2 days) or for vaginal deliveries that were not VBACs (2.3  days). In 1986, the average hospital stay for all deliveries was 3.2 days, for  primary cesareans 5.2 days, for repeat cesareans 4.7 days, and for VBAC and  non-VBAC vaginal deliveries 2.7 and 2.6 days, respectively.   Reported by: Office of Vital and Health Statistics Systems, National Center  for Health Statistics, CDC.   Editorial Note: The cesarean rate in the United States steadily increased from  1965 through 1986; however, the findings in this report indicate that rates  have been stable since 1986 (3). Because there is little evidence that  maternal and child health status has improved during this time and because  cesareans are associated with an increased risk for complications of  childbirth, a national health objective for the year 2000 (4) is to reduce the  overall cesarean rate to 15 or fewer per 100 deliveries and the primary  cesarean rate to 12 or fewer per 100 deliveries (objective 14.8).       Postpartum complications -- including urinary tract and wound infections  -- may account in part for the longer hospital stays for cesarean deliveries  than for vaginal births (5). Moreover, the prolonged hospital stays for  cesarean deliveries substantially increase health-care costs. For example, in  1991, the average costs for cesarean and vaginal deliveries were $7826 and  $4720, respectively. The additional cost for each cesarean delivery includes  $611 for physician fees and $2495 for hospital charges (6). If the cesarean  rate in 1991 had been 15 (the year 2000 objective) instead of 23.5, the number  of cesarean births would have decreased by 349,000 (617,000 versus 966,000),  resulting in a savings of more than $1 billion in physician fees and hospital  charges.       Despite the steady increase in VBAC rates since 1986, several factors may  impede progress toward the year 2000 national health objectives for cesarean  delivery. For example, VBAC rates substantially reflect the number of women  offered trial of labor, which has been increasingly encouraged since 1982 (7).  Of women who are offered a trial of labor, 50%-70% could deliver vaginally (7)  --a level already achieved by many hospitals (8). Trial of labor was routinely  offered in 46% of hospitals surveyed in 1984 (the most recent year for which   HICNet Medical Newsletter                                              Page  2 Volume  6, Number 11                                           April 25, 1993  national data are available) (9) when the VBAC rate (according to NHDS data)  was 5.7%. The year 2000 objective specifies a VBAC rate of 35%, based on all  women who had a prior cesarean, regardless of whether a trial of labor was  attempted. To reach the overall cesarean rate goal, however, increases in the  VBAC rate will need to be combined with a substantial reduction in the primary  rate.       One hospital succeeded in reducing the rate of cesarean delivery by  applying objective criteria for the four most common indications for cesarean  delivery, by requiring a second opinion, and by instituting a peer-review  process (10). Other recommendations for decreasing cesarean delivery rates  include eliminating incentives for physicians and hospitals by equalizing  reimbursement for vaginal and cesarean deliveries; public dissemination of  physician- and hospital-specific cesarean delivery rates to increase public  awareness of differences in practices; and addressing malpractice concerns,  which may be an important factor in maintaining the high rates of cesarean  delivery (4).   References  1. Notzon FC. International differences in the use of obstetric interventions.  JAMA 1990; 263:3286-91.   2. Graves EJ, NCHS. 1991 Summary: National Hospital Discharge Survey.  Hyattsville, Maryland: US Department of Health and Human Services, Public  Health Service, CDC, 1993. (Advance data no. 227).   3. Taffel SM, Placek PJ, Kosary CL. U.S. cesarean section rates, 1990: an  update. Birth 1992;19:21-2.   4. Public Health Service. Healthy people 2000: national health promotion and  disease prevention objectives -- full report, with commentary. Washington, DC:  US Department of Health and Human Services, Public Health Service, 1991; DHHS  publication no. (PHS)91-50212.   5. Danforth DN. Cesarean section. JAMA 1985;253:811-8.   6. Hospital Insurance Association of America. Table 4.15: cost of maternity  care, physicians' fees, and hospital charges, by census region, based on  Consumer Price Index (1991). In: 1992 Source book of health insurance data.  Washington, DC: Hospital Insurance Association of America, 1992.   7. Committee on Obstetrics. ACOG committee opinion no. 64: guidelines for  vaginal delivery after a previous cesarean birth. Washington, DC: American  College of Obstetricians and Gynecologists, 1988.    HICNet Medical Newsletter                                              Page  3 Volume  6, Number 11                                           April 25, 1993  8. Rosen MG, Dickinson JC. Vaginal birth after cesarean: a meta-analysis of  indicators for success. Obstet Gynecol 1990;76:865-9.   9. Shiono PH, Fielden JG, McNellis D, Rhoads GG, Pearse WH. Recent trends in  cesarean birth and trial of labor rates in the United States. JAMA  1987;257:494-7.   10. Myers SA, Gleicher N. A successful program to lower cesarean-section  rates. N Engl J Med 1988;319:1511-6.   * Use of trade names and commercial sources is for identification only and  does not imply endorsement by the Public Health Service or the U.S. Department  of Health and Human Services.                                 HICNet Medical Newsletter                                              Page  4 Volume  6, Number 11                                           April 25, 1993           Malaria Among U.S. Embassy Personnel -- Kampala, Uganda, 1992          =============================================================                    SOURCE: MMWR 42(15)   DATE: Apr 23, 1993       The treatment and prevention of malaria in Africa has become a  challenging and complex problem because of increasing drug resistance.  Although the risk of acquiring malaria for U.S. citizens and their dependents  stationed overseas generally has been low, this risk varies substantially and  unpredictably. During May 1992, the Office of Medical Services, Department of  State (OMS/DOS), and CDC were notified of an increased number of malaria cases  among official U.S. personnel stationed in Kampala, Uganda. A review of the  health records from the Embassy Health Unit (EHU) in Kampala indicated that 27  cases of malaria were diagnosed in official personnel from March through June  1992 compared with two cases during the same period in 1991. EHU, OMS/DOS, and  CDC conducted an investigation to confirm all reported malaria cases and  identify potential risk factors for malaria among U.S. Embassy personnel. This  report summarizes the results of the investigation.       Malaria blood smears from 25 of the 27 reported case-patients were  available for review by OMS/DOS and CDC. A case of malaria was confirmed if  the slide was positive for Plasmodium sp. Of the 25 persons, 17 were slide- confirmed as having malaria.       A questionnaire was distributed to all persons served by the EHU to  obtain information about residence, activities, use of malaria  chemoprophylaxis, and use of personal protection measures (i.e., using bednets  and insect repellents, having window and door screens, and wearing long  sleeves and pants in the evening). Of the 157 persons eligible for the survey,  128 (82%) responded.       Risk for malaria was not associated with sex or location of residence in  Kampala. Although the risk for malaria was higher among children aged less  than or equal to 15 years (6/32 19%) than among persons greater than 15  years (11/94 12%), this difference was not significant (relative risk  RR=1.6; 95% confidence interval CI=0.6-4.0). Eighty-two percent of the  cases occurred among persons who had been living in Kampala for 1-5 years,  compared with those living there less than 1 year. Travel outside of the  Kampala area to more rural settings was not associated with increased risk for  malaria.       Four malaria chemoprophylaxis regimens were used by persons who  participated in the survey: mefloquine, chloroquine and proguanil, chloroquine  alone, and proguanil alone. In addition, 23 (18%) persons who responded were  not using any malaria chemoprophylaxis. The risk for malaria was significantly  lower among persons using either mefloquine or chloroquine and proguanil (8/88  9%) than among persons using the other regimens or no prophylaxis (9/37  24%) (RR=0.4; 95% CI=0.2-0.9). Twelve persons not using prophylaxis reported  side effects or fear of possible side effects as a reason.       The risk for malaria was lower among persons who reported using bednets   HICNet Medical Newsletter                                              Page  5 Volume  6, Number 11                                           April 25, 1993  all or most of the time (2/27 7%) than among persons who sometimes or rarely  used bednets (15/99 15%) (RR=0.5; 95% CI=0.1-2.0). The risk for malaria was  also lower among persons who consistently used insect repellent in the evening  (0/16), compared with those who rarely used repellent (17/110 15%) (RR=0;  upper 95% confidence limit=1.2). Risk for malaria was not associated with  failure to have window or door screens or wear long sleeves or pants in the  evening.       As a result of this investigation, EHU staff reviewed with all personnel  the need to use and comply with the recommended malaria chemoprophylaxis  regimens. EHU staff also emphasized the need to use personal protection  measures and made plans to obtain insecticide-impregnated bednets and to  provide window and door screens for all personnel.   Reported by: U.S. Embassy Health Unit, Kampala, Uganda; Office of Medical  Svcs, Dept of State, Washington, D.C. Malaria Br, Div of Parasitic Diseases,  National Center for Infectious Diseases, CDC.   Editorial Note: In Uganda, the increase in malaria among U.S. personnel was  attributed to poor adherence to both recommended malaria chemoprophylaxis  regimens and use of personal protection measures during a period of increased  malaria transmission and intensified chloroquine resistance in sub-Saharan  Africa. The findings in this report underscore the need to provide initial and  continued counseling regarding malaria prevention for persons living abroad in  malaria-endemic areas -- preventive measures that are also important for  short-term travelers to such areas.       Mefloquine is an effective prophylaxis regimen in Africa and in most  other areas with chloroquine-resistant P. falciparum; however, in some areas  (e.g., Thailand), resistance to mefloquine may limit its effectiveness. In  Africa, the efficacy of mefloquine, compared with chloroquine alone, in  preventing infection with P. falciparum is 92% (1 ). Mefloquine is safe and  well tolerated when given at 250 mg per week over a 2-year period. The risk  for serious adverse reactions possibly associated with mefloquine prophylaxis  (e.g., psychosis and convulsions) is low (i.e., 1.3-1.9 episodes per 100,000  users 2), while the risk for less severe adverse reactions (e.g., dizziness,  gastrointestinal complaints, and sleep disturbances) is similar to that for  other antimalarial chemoprophylactics (1).       Doxycycline has similar prophylactic efficacy to mefloquine, but the need  for daily dosing may reduce compliance with and effectiveness of this regimen  (3,4). Chloroquine alone is not effective as prophylaxis in areas of intense  chloroquine resistance (e.g., Southeast Asia and Africa). In Africa, for  persons who cannot take mefloquine or doxycycline, chloroquine and proguanil  is an alternative, although less effective, regimen. Chloroquine should be  used for malaria prevention in areas only where chloroquine-resistant P.  falciparum has not been reported.       Country-specific recommendations for preventing malaria and information   HICNet Medical Newsletter                                              Page  6 Volume  6, Number 11                                           April 25, 1993  on the dosage and precautions for malaria chemoprophylaxis regimens are  available from Health Information for International Travel, 1992 (i.e.,  "yellow book") (5) or 24 hours a day by telephone or fax, (404) 332-4555.   References  1. Lobel HO, Miani M, Eng T, et al. Long-term malaria prophylaxis with weekly  mefloquine in Peace Corps volunteers: an effective and well tolerated regimen.  Lancet 1993;341:848-51.   2. World Health Organization. Review of central nervous system adverse events  related to the antimalarial drug, mefloquine (1985-1990). Geneva: World Health  Organization, 1991; publication no. WHO/MAL/91.1063.   3. Pang L, Limsomwong N, Singharaj P. Prophylactic treatment of vivax and  falciparum malaria with low-dose doxycycline. J Infect Dis 1988;158:1124-7.   4. Pang L, Limsomwong N, Boudreau EF, Singharaj P. Doxycycline prophylaxis for  falciparum malaria. Lancet 1987;1:1161-4.   5. CDC. Health information for international travel, 1992. Atlanta: US  Department of Health and Human Services, Public Health Service, 1992:98; DHHS  publication no. (CDC)92-8280.                       HICNet Medical Newsletter                                              Page  7 Volume  6, Number 11                                           April 25, 1993        FDA Approval of Use of a New Haemophilus b Conjugate Vaccine and a        Combined Diphtheria-Tetanus-Pertussis and Haemophilus b Conjugate                        Vaccine for Infants and Children       ==================================================================                    SOURCE: MMWR 42(15)   DATE: Apr 23, 1993       Haemophilus influenzae type b (Hib) conjugate vaccines have been  recommended for use in infants since 1990, and their routine use in infant  vaccination has contributed to the substantial decline in the incidence of Hib  disease in the United States (1-3). Vaccines against diphtheria, tetanus, and  pertussis during infancy and childhood have been administered routinely in the  United States since the late 1940s and has been associated with a greater than  90% reduction in morbidity and mortality associated with infection by these  organisms. Because of the increasing number of vaccines now routinely  recommended for infants, a high priority is the development of combined  vaccines that allow simultaneous administration with fewer separate  injections.       The Food and Drug Administration (FDA) recently licensed two new products  for vaccinating children against these diseases: 1) the Haemophilus b  conjugate vaccine (tetanus toxoid conjugate, ActHIB Trademark), * for  vaccination against Hib disease only and 2) a combined diphtheria and tetanus  toxoids and whole-cell pertussis vaccine (DTP) and Hib conjugate vaccine  (TETRAMUNE Trademark), a combination of vaccines formulated for use in  vaccinating children against diphtheria, tetanus, pertussis, and Hib disease.                                  ActHIB Trademark        On March 30, 1993, the FDA approved a new Haemophilus b conjugate  vaccine, polyribosylribitol phosphate-tetanus toxoid conjugate (PRP-T),  manufactured by Pasteur Merieux Serum et Vaccins and distributed as ActHIB  Trademark by Connaught Laboratories, Inc. (Swiftwater, Pennsylvania). This  vaccine has been licensed for use in infants in a three-dose primary  vaccination series administered at ages 2, 4, and 6 months. Previously  unvaccinated infants 7-11 months of age should receive two doses 2 months  apart. Previously unvaccinated children 12-14 months of age should receive one  dose. A booster dose administered at 15 months of age is recommended for all  children. Previously unvaccinated children 15-59 months of age should receive  a single dose and do not require a booster. More than 90% of infants receiving  a primary vaccination series of ActHIB Trademark (consecutive doses at 2, 4,  and 6 months of age) develop a geometric mean titer of anti-Haemophilus b  polysaccharide antibody greater than 1 ug/mL (4). This response is similar to  that of infants who receive recommended series of previously licensed  Haemophilus b conjugate vaccines for which efficacy has been demonstrated in  prospective trials. Two U.S. efficacy trials of PRP-T were terminated early  because of the concomitant licensure of other Haemophilus b conjugate vaccines   HICNet Medical Newsletter                                              Page  8 Volume  6, Number 11                                           April 25, 1993  for use in infants (4). In these studies, no cases of invasive Hib disease  were detected in approximately 6000 infants vaccinated with PRP-T. These and  other studies suggest that the efficacy of PRP-T vaccine will be similar to  that of the other licensed Hib vaccines. TETRAMUNE Trademark       On March 30, 1993, the FDA approved a combined diphtheria and tetanus  toxoids and whole-cell pertussis vaccine (DTP) and Haemophilus b conjugate  vaccine. TETRAMUNE Trademark, available from Lederle-Praxis Biologicals (Pearl  River, New York), combines two previously licensed products, DTP (TRIIMMUNOL  Registered, manufactured by Lederle Laboratories Pearl River, New York) and  Haemophilus b conjugate vaccine (HibTITER Registered, manufactured by Praxis  Biologics, Inc. Rochester, New York).       This vaccine has been licensed for use in children aged 2 months-5 years  for protection against diphtheria, tetanus, pertussis, and Hib disease when  indications for vaccination with DTP vaccine and Haemophilus b conjugate  vaccine coincide. Based on demonstration of co mparable or higher antibody  responses to each of the components of the two vaccines, TETRAMUNE Trademark  is expected to provide protection against Hib, as well as diphtheria, tetanus,  and pertussis, equivalent to that of already licensed formulations of other  DTP and Haemophilus b vaccines.       The Advisory Committee for Immunization Practices (ACIP) recommends that  all infants receive a primary series of one of the licensed Haemophilus b  conjugate vaccines beginning at 2 months of age and a booster dose at age 12- 15 months (5). The ACIP also recommends that all infants receive a four-dose  primary series of diphtheria and tetanus toxoids and pertussis vaccine at 2,  4, 6, and 15-18 months of age, and a booster dose at 4-6 years (6-8). A  complete statement regarding recommendations for use of ActHIB Trademark and  TETRAMUNE Trademark is being developed.   Reported by: Office of Vaccines Research and Review, Center for Biologics  Evaluation and Research, Food and Drug Administration. Div of Immunization,  National Center for Prevention Svcs; Meningitis and Special Pathogens Br, Div  of Bacterial and Mycotic Diseases, National Center for Infectious Diseases,  CDC.   References  1. Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus  influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993;269:221-6.   2. Broadhurst LE, Erickson RL, Kelley PW. Decrease in invasive Haemophilus  influenzae disease in U.S. Army children, 1984 through 1991. JAMA  1993;269:227-31.   3. Murphy TV, White KE, Pastor P, et al. Declining incidence of Haemophilus  influenzae type b disease since introduction of vaccination. JAMA   HICNet Medical Newsletter                                              Page  9 Volume  6, Number 11                                           April 25, 1993  1993;269:246-8.   4. Fritzell B, Plotkin S. Efficacy and safety of a Haemophilus influenzae type  b capsular polysaccharide-tetanus protein conjugate vaccine. J Pediatr  1992;121:355-62.   5. ACIP. Haemophilus b conjugate vaccines for prevention of Haemophilus  influenzae type b disease among infants and children two months of age and  older: recommendations of the Immunization Practices Advisory Committee  (ACIP). MMWR 1991;40(no. RR-1).   6. ACIP. Diphtheria, tetanus, and pertussis -- recommendations for vaccine use  and other preventive measures: recommendations of the Immunization Practices  Advisory Committee (ACIP). MMWR 1991;40(no. RR-10).   7. ACIP. Pertussis vaccination: acellular pertussis vaccine for reinforcing  and booster use -- supplementary ACIP statement: recommendations of the  Immunization Practices Advisory Committee (ACIP). MMWR 1992;41(no. RR-1).   8. ACIP. Pertussis vaccination: acellular pertussis vaccine for the fourth and  fifth doses of the DTP series -- update to supplementary ACIP statement:  recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR  1992;41(no. RR-15).   * Use of trade names and commercial sources is for identification only and  does not imply endorsement by the Public Health Service or the U.S. Department  of Health and Human Services.                   HICNet Medical Newsletter                                              Page 10 Volume  6, Number 11                                           April 25, 1993    ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::                                   Dental News ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::              International Workshop Explores Oral Manifestations of                                  HIV Infection                               NIDR Research Digest                              written by Jody Dove                                   March 1993                      National Institute of Dental Research       At the Second International Workshop on the Oral Manifestations of HIV  Infection, held January 31-February 3 in San Francisco, participants explored  issues related to the epidemiology, basic molecular virology, mucosal  immunology, and oral clinical presentations of HIV infection.       The workshop was organized by Dr. John Greenspan and Dr. Deborah  Greenspan of the Department of Stomatology, School of Dentistry, University of  California, San Francisco.  An international steering committee and scientific  program committee provided guidance.       The conference drew more than 260 scientists from 39 countries, including  Asia, Africa, Europe, Central America, South America, as well as the United  States and Canada.  Support tor the workshop was provided by the National  Institute of Dental Research, the National Cancer Institute, the National  Institute of Allergy and Infectious Diseases, the NIH Office of AIDS Research,  and the Procter and Gamble Company.       Among the topics discussed were: the epidemiology of HIV lesions; ethics,  professional responsibility, and public policy; occupational issues; provision  of oral care to the HIV-positive population; salivary HIV transmission and  mucosal immunity; opportunistic infections; pediatric HIV infection; and  women's issues.                                   Recommendations       Recommendations emerged from the workshop to define the association  between the appearance of oral lesions and rate of progression of HIV, to  establish a universal terminology for HIV-associated oral lesions, to look for  more effective treatments for oral manifestations, to expand molecular biology  studies to understand the relationship between HIV infection and common oral  lesions, and to study the effects of HIV therapy on oral lesions.                                    Epidemiology       Since the First International Workshop on Oral Manifestations of HIV  Infection was convened five years ago, the epidemiology of HIV infection has   HICNet Medical Newsletter                                              Page 11 Volume  6, Number 11                                           April 25, 1993  radically changed.  In 1988, HIV infection was detected and reported largely  in homosexual and bisexual males, intravenous drug users, and hemophiliacs.   Today, more HIV infection is seen in heterosexual males and females and in  children and adolescents.       While the predominant impact of HIV infection has been felt in Africa, a  major increase in infection rate is being seen in Southeast Asia as well.   Five hundred thousand cases have been reported to date in this region and more  are appearing all the time.       Researchers are continuing to document the epidemiology of oral lesions  such as hairy leukoplakia and candidiasis.  They also are beginning to explore  the relationships between specific oral lesions and HIV disease progression  and prognosis.                               Social/political Issues       Discussion on the social and political implications of HIV infection  focused on changing the public's attitude that AIDS is retribution for  indiscriminate sexual behavior and drug use.  Speakers also addressed health  care delivery for HIV-infected patients, and the need to educate the public  about what AIDS is, and how it is acquired.                             Saliva and Salivary Glands       Conference speakers described transmission issues and the HIV-inhibitory  activity of saliva, the strength of which varies among the different salivary  secretions.  Whole saliva has a greater inhibitory effect than submandibular  secretions, which in turn have a greater inhibitory effect than parotid  secretions.  Research has shown that at least two mechanisms are responsible  for salivary inhibitory activity.  They attributed the HIV-inhibitory effect  of saliva to the 1) aggregation/agglutination of HIV by saliva, which may both  promote clearance of virus and prevent it reaching a target cell, and 2)  direct effects on the virus or target cells.       Other topics discussed were the manifestation of salivary gland disease  in HIV-infected persons and current research on oral mucosal immunity.                                  Pediatric Issues       Pediatric AIDS recently has emerged as an area of intense interest.  With  early and accurate diagnosis and proper treatment, the life expectancy of HIV- infected children has tripled.  The prevention of transmission of HIV from  mother to child may be possible in many cases, particularly if the mother's  sero-status is known prior to giving birth.                       Periodontal and Gingival Tissue Disease   HICNet Medical Newsletter                                              Page 12 Volume  6, Number 11                                           April 25, 1993       Oral health researchers continue to explore periodontal diseases and  gingivitis found in individuals with HIV infection.  Recommendations made at  the workshop include the standardization of terminology, refinement of  diagnostic markers, standardization of study design, and proper consideration  of confounding variables resulting from periodontal therapy.                          Occupational and Treatment Issues       Occupational issues surrounding the treatment of HIV-infected individuals  and treatment rendered by HIV-infected health care professionals still command  considerable attention.  Factors under consideration include the cost/benefit  of HIV testing, patient-to-health care provider transmission of HIV infection  and the reverse, and the use of mainstream versus dedicated facilities for the  treatment of HIV-infected patients.       Conference participants anticipate that a third International Workshop on  the Oral Manifestations of HIV Infection will be held in five years or less.   Proceedings from the second workshop will be published by the Quintessence  Company in late 1993.                       --------- end of part 1 ------------