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From: [email protected] (David Dodell)
Subject: HICN611 Medical News Part 1/4
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Volume 6, Number 11 April 25, 1993
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Editor: David Dodell, D.M.D.
10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA
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Compilation Copyright 1993 by David Dodell, D.M.D. All rights Reserved.
License is hereby granted to republish on electronic media for which no
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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
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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
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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.
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