Characteristics and outcomes of a hospitalized cohort with reduced mortality from COVID-19, White Mountain apache tribal lands, April 1 - July 31, 2020

BACKGROUND

Widespread transmission of COVID-19 continues to threaten public health, particularly of rural, American Indian communities. Although COVID-19 risk factors for severe disease and clinical characteristics are well described in the general population, there has been little shared on hospitalized American Indian populations.

METHODS

In this observational study, we performed chart extractions on all persons hospitalized with COVID-19 from April 1 through July 31, 2020 among an exclusively American Indian population living on or near Tribal lands in eastern Arizona. We provide descriptive statistics for the cohort stratified by presentation, comparing those who self-presented or were referred by an outreach program. Exploratory analyses were performed to identify risk factors for morbidity and mortality.

RESULTS

During the observation period, 2262 persons were diagnosed with COVID-19 and 490 (22%) were hospitalized. Hospitalized persons had a median age of 54 years; 92% had at least one comorbidity, 72% had greater than one comorbidity, and 60% had a BMI of > 30. Most persons required supplemental oxygen (83%), but the majority (62%) only required nasal cannula and only 11% were intubated. The case fatality rates were 1.7% for the population, 7.1% among hospitalizations, and 9.3% among hospitalized patients 50 years and older. All rates that are significantly lower than those reported nationally during the same period.

CONCLUSIONS

We observed a cohort of American Indian patients hospitalized secondary to COVID-19 with greater number of comorbidities compared to the general population but with lower mortality rates. We posit that the primary driver of mortality reduction for this population and the hospitalized cohort was a community-based referral program that led to disproportionately lower fatality rates among the oldest persons.

494. Characteristics and Outcomes of COVID-19 in Hospitalized Native American Patients: A Single-Site Retrospective Analysis

Background

COVID-19 continues to threaten public health, particularly in Native American (NA) communities, which experienced some of the highest rates of COVID-19 infection and mortality in the US. Although the risk factors and clinical characteristics of COVID-19 are well documented in the general population, there has been little research on NA patients.

Methods

We present descriptive data based on chart reviews of COVID-19 patients hospitalized between April 1 and July 31, 2020 at the Whiteriver Service Unit (WRSU), an Indian Health Service site on the Fort Apache Reservation.

Results

Of the 2,262 COVID-19 cases during the observation period, 490 (22%) were hospitalized and 35 (1.6%) died within 28 days. Compared to previous reports, hospitalized patients at WRSU were younger (median age 54), more likely to be female (55% female), and more likely to have comorbidities (92% at least 1, median 2). Patients under 50 (n=200) often had a history of alcohol abuse (51%) or polysubstance abuse (20%). One third of hospitalized patients (34%) were monitored at home and referred for treatment through a high-risk outreach program. Patients were admitted much earlier at WRSU than in other locations, with a median interval of 4 days from symptom onset to hospitalization compared to 7 days reported elsewhere, but over half were still transferred to higher care. Although WRSU patients had higher rates of comorbidities, the 28-day hospital mortality rate from COVID-19 was nearly half of what has been previously reported (35/490, 7% vs 15-20% reported elsewhere, p < 0.001). This trend persisted after controlling for age. Multivariate logistic regression showed that increasing age, male sex, and high BMI were significantly associated with higher risk of death from COVID-19 (overall model p < 0.001).

Characteristics and outcomes of hospitalized COVID-19 patients at WRSU

Conclusion

Hospitalized patients at WRSU tended to be younger but with more comorbidities than previous studies. This may reflect the fact that NAs tend to acquire comorbidities at younger ages than the general population. This may also reflect the high rates of substance abuse in younger patients, which could be an additional risk factor for severe COVID-19. We believe that the low mortality rates at WRSU are a result of our outreach program, which likely decreased the interval between symptom onset and medical treatment.

Disclosures

All Authors: No reported disclosures

Outcome Comparison of High-Risk Native American Patients Who Did or Did Not Receive Monoclonal Antibody Treatment for COVID-19

This quality improvement study compares outcomes among high-risk Native American patients who did or did not receive monoclonal antibody treatment for COVID-19.

Two-dimensional core-shell donor-acceptor assemblies at metal-organic interfaces promoted by surface-mediated charge transfer

Organic charge transfer (CT) complexes obtained by combining molecular electron donors and acceptors have attracted much interest due to their potential applications in organic opto-electronic devices. In order to work, these systems must have an electronic matching - the highest occupied molecular orbital (HOMO) of the donor must couple with the lowest unoccupied molecular orbital (LUMO) of the acceptor - and a structural matching, so as to allow direct intermolecular CT. Here it is shown that, when molecules are adsorbed on a metal surface, novel molecular organizations driven by surface-mediated CT can appear that have no counterpart in condensed phase non-covalent assemblies of donor and acceptor molecules. By means of scanning tunneling microscopy and spectroscopy it is demonstrated that the electronic and self-assembly properties of an electron acceptor molecule can change dramatically in the presence of an additional molecular species with marked electron donor character, leading to the formation of unprecedented core-shell assemblies. DFT and classical force-field simulations reveal that this is a consequence of charge transfer from the donor to the acceptor molecules mediated by the metallic substrate.

Epitaxial Templating of C60 with a Molecular Monolayer

Commensurate epitaxial monolayers of truxenone on Cu (111) were employed to template the growth of monolayer and bilayer C60. Through the combination of STM imaging and LEED analysis we have demonstrated that C60 forms a commensurate 8 × 8 overlayer on truxenone/Cu (111). Bilayers of C60 retain the 8 × 8 periodicity of templated monolayers and although Kagome lattice arrangements are observed these are explained with combinations of 8 × 8 symmetry.

Determination of the individual atomic site contribution to the electronic structure of 3,4,9,10-perylene-tetracarboxylic-dianhydride (PTCDA)

We have studied the element and orbital-specific electronic structure of thin films of 3,4,9,10-perylene-tetracarboxylic-dianhydride (PTCDA) using a combination of synchrotron radiation-exited resonant x-ray emission spectroscopy, x-ray absorption spectroscopy, x-ray photoelectron spectroscopy, as well as density functional theory calculations. Resonant and non-resonant x-ray emission spectroscopies were used to measure the C and O 2p partial densities of state in PTCDA. Furthermore, resonant x-ray emission at the C and O K-edges is shown to be able to measure the partial densities of states associated with individual atomic sites. The flat molecular orientation of PTCDA on various substrates is explained in terms of the carbonyl O atom acting as a hydrogen-bond acceptor leading to multiple in-plane intermolecular C=O···H-C hydrogen bonding between carbonyl groups and the perylene core of the neighboring PTCDA molecules. We support this conclusion by comparison of our calculations to measurements of the electronic structure using element-, site-, and orbital-selective C and O K-edge resonant x-ray emission spectroscopy, and photoemission spectroscopy.

Using HapMap Tools in Pharmacogenomic Discovery: The Thiopurine Methyltransferase Polymorphism

One purpose of the International HapMap Project is to provide a genome-wide resource to discover pharmacogenetic determinants of drug response. The thiopurine methyltransferase (TPMT) 719A>G single-nucleotide polymorphism (SNP) causes decreased TPMT activity, increased intracellular thiopurines, and drug toxicities. Using HapMap cell lines and 3.3 million SNPs, we tested whether the TPMT 719A>G SNP could be identified as predicting TPMT phenotype. Assuming TPMT was a candidate gene, five SNPs and four haplotypes predicted TPMT phenotype, two of which were in complete linkage disequilibrium with the functional 719A>G SNP. We also used a genome-wide approach to rank all 17,542 genes as predictors of TPMT activity. A TPMT haplotype, HAP1, significantly predicted TPMT phenotype; however, haplotypes of 96 genes ranked higher than TPMT. Our findings show that HapMap resources are useful for pharmacogenetic discovery when the candidate gene is known, but challenges remain for definitive gene identification when a genome-wide agnostic approach is employed.

Photophysics of PTCDA and Me-PTCDI Thin Films: Effects of Growth Temperature

The effect of deposition temperature on the photophysical properties of 3,4,9,10-perylenetetracarboxylic dianhydride (PTCDA) and N,N'-dimethylperylene-3,4,9,10-bis(dicarboximide) (Me-PTCDI) films is investigated with steady-state and time-resolved spectroscopy. Atomic force microscopy (AFM) images of the film surfaces show an increase in the dimensions of crystallites with substrate temperature, culminating in the formation of elongated crystallites on substrates held close to the sublimation temperature. In contrast, despite an improvement in the crystal quality, X-ray diffraction (XRD) studies indicate that the substrate temperature has a negligible effect on the molecular orientation; the PTCDA and Me-PTCDI molecules align parallel and tilted to the substrate surface, respectively. Both materials exhibit characteristic absorption, due to mixing between charge-transfer and Frenkel species, and broad structureless photoluminescence. Growth at elevated temperatures gives rise to increased low-energy absorption, attributed to the formation of charge-transfer species, and enhanced blue-shifted emission, although the effects are less pronounced for Me-PTCDI. Time-correlated single-photon counting data indicate that the enhancement coincides with a lengthening of the fluorescence decays, over the whole emission spectrum.

Charge Recombination in CuPc/PTCDA Thin Films

The recombination kinetics of photogenerated charge carriers in perylene-3, 4, 9, 10-tetracarboxylic dianhydride (PTCDA) and copper phthalocyanine (CuPc) thin films grown by organic molecular beam deposition have been studied using transient absorption spectroscopy. Optical excitation is observed to generate long-lived polaron states, which exhibit power law recombination dynamics on time scales from microseconds to milliseconds. Studies as a function of excitation density and temperature, and comparison between heterostructures and PTCDA single layers, all indicate that this power law behavior results from trapping of PTCDA- polarons in localized states, with an estimated trap state density of approximately 6 x 10(17) polarons cm(-3). This recombination behavior is found to be remarkably similar to that previously observed for polymer/fullerene blends, suggesting that it may be generic to a range of semiconducting materials.

First report of human immunodeficiency virus transmission via an RNA-screened blood donation

BACKGROUND AND OBJECTIVES

Blood banks in the USA have recently introduced minipool nucleic acid amplification testing (MP-NAT) of blood products to reduce the transmission of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) by transfusions. However, MP-NAT is limited in its ability to detect preseroconversion samples with very low viral RNA loads.

MATERIALS AND METHODS

To determine whether a red blood cell unit, from an MP-NAT-negative donation, transmitted HIV when transfused to a patient, we compared the viral sequences from the blood donor and recipient. The implicated donation was also tested by commercially available NAT assays at a range of dilution factors to determine whether the infectious unit could have been detected using individual-donation NAT (ID-NAT).

RESULTS

Phylogenetic linkage of HIV sequences in the blood donor and recipient confirmed the transmission of HIV by blood transfusion, the first such case identified since introduction of MP-NAT screening in 1999. Viral RNA was reliably detected by ID-NAT, but only inconsistently detected by MP-NAT.

CONCLUSIONS

Even following the introduction of MP-NAT, a preseroconversion donation with a viral load of <or= 150 copies of RNA/ml went undetected and resulted in an HIV transmission. Implementation of ID-NAT will further reduce such rare transmissions, but at a considerable cost per infectious unit interdicted.

Syringe laws and pharmacy regulations are structural constraints on HIV prevention in the US

OBJECTIVE

To review the legal and regulatory barriers that restrict pharmacy sales of syringes to injection drug users (IDUs) and to discuss how reducing these barriers can facilitate access to sterile syringes for IDUs and improve HIV prevention.

BACKGROUND

IDUs' access to sterile syringes from community pharmacies in the United States is limited by state laws and regulations governing syringe sales. Restricted availability of sterile syringes from pharmacies is a structural barrier that greatly impedes HIV prevention for IDUs, who often share and reuse syringes because they cannot obtain and possess sterile syringes. These high-risk behaviors contribute to the transmission of HIV and other blood-borne pathogens among IDUs, their sexual partners, and their children. STATE EXPERIENCES: In Connecticut, because of high HIV prevalence among IDUs, restrictive syringe laws were changed. After the legal changes in Connecticut, both pharmacy sales of syringes in areas of high drug use and purchases of syringes in pharmacies (reported by IDUs) increased, while syringe sharing (reported by IDUs) decreased. Maine and Minnesota have made similar changes in laws.

CONCLUSIONS

Increasing access to sterile syringes through pharmacies requires the repeal or modification of legal barriers. Pharmacy sale of syringes to IDUs is an inexpensive HIV prevention intervention with the potential to substantially reduce HIV transmission. Further studies are needed to document how changes to legal barriers can influence HIV prevention for IDUs.

Syringe disposal options for injection drug users: a community-based perspective

This study was a qualitative exploration of syringe disposal interventions for injection drug users (IDUs). Data were collected through in-depth interviews with 26 community members who injected drugs and 32 noninjecting community members in Atlanta, Georgia. Both groups supported syringe exchange programs as syringe disposal interventions, while noninjecting community members favored a one-way drop box. IDUs identified fear of arrest for possession of syringes as the most salient barrier to safe syringe disposal, revealing the negative consequences of drug paraphernalia laws.

Prevalence of sexual and drug-related HIV risk behaviors in the U.S. adult population: results of the 1996 National Household Survey on Drug Abuse

CONTEXT

Data on the prevalence of HIV risk behavior that are representative of the general population are needed to help evaluate the effectiveness of prevention programs.

OBJECTIVE

To use data from a large national interview survey to make estimates of the prevalence of sexual and drug-related HIV risk behaviors in the adult population of the United States.

DESIGN

Nationally representative cross-sectional survey with in-person interviews collecting information on drug use and sexual behavior.

SETTING AND PARTICIPANTS

12,381 U.S. adults aged between 18 and 59 who were respondents to the 1996 National Household Survey on Drug Abuse, as part of sample of the noninstitutionalized population. Interviews took place in respondents homes using face-to-face interviewer-administered and self-administered questionnaires.

RESULTS

In total, 2.8% of respondents were classified as having increased risk for HIV through sexual behavior; this represents 3.9 million persons. 1.7% reported some degree of risk through drug-related behaviors, representing 1.2 million persons. 3.5% of adults (5 million persons) were found to have some degree of HIV risk from sexual or drug-related behavior. Persons who were at risk through drug behavior were much more likely than others to be at risk through sexual behavior. Condom use was not related to HIV risk, although having a recent HIV test was found to be. Among those who reported some behaviors that placed them at increased risk for HIV infection, only 22% used a condom the last time they had sex with a regular partner.

CONCLUSIONS

The high rate of sexual risk behavior on the part of drug users suggests increasing condom use for this group should be a priority goal for programs, especially condom use with main partners. Survey work needs to be continued and improved to make it possible to assess the impact of successful local prevention efforts on national rates of HIV risk behavior.

Condom use and HIV risk behaviors among U.S. adults: data from a national survey

CONTEXT

How much condom use among U.S. adults varies by type of partner or by risk behavior is unclear. Knowledge of such differentials would aid in evaluating the progress being made toward goals for levels of condom use as part of the Healthy People 2000 initiative.

METHODS

Data were analyzed from the 1996 National Household Survey of Drug Abuse, an annual household-based probability sample of the noninstitutionalized population aged 12 and older that measures the use of illicit drugs, alcohol and tobacco. The personal behaviors module included 25 questions covering sexual activity in the past year, frequency of condom use in the past year, circumstances of the last sexual encounter and HIV testing.

RESULTS

Sixty-two percent of adults reported using a condom at last intercourse outside of an ongoing relationship, while only 19% reported using condoms when the most recent intercourse occurred within a steady relationship. Within ongoing relationships, condom use was highest among respondents who were younger, black, of lower income and from large metropolitan areas. Forty percent of unmarried adults used a condom at last sex, compared with the health objective of 50% for the year 2000. Forty percent of injecting drug users used condoms at last intercourse, compared with the 60% condom use objective for high-risk individuals. Significantly, persons at increased risk for HIV because of their sexual behavior or drug use were not more likely to use condoms than were persons not at increased risk; only 22% used condoms during last intercourse within an ongoing relationship.

CONCLUSIONS

Substantial progress has been made toward national goals for increasing condom use. The rates of condom use by individuals at high risk of HIV need to be increased, however, particularly condom use with a steady partner.

HIV risk behaviors associated with the injection process: multiperson use of drug injection equipment and paraphernalia in injection drug user networks

This study examines drug acquisition and multiperson use of paraphernalia, drugs, and needles/syringes. Ethnographers observed 54 injection episodes in which IDUs were linked by HIV risk behaviors, and developed a typology of higher-risk, lower-risk, and nonsharing-risk networks. Multiperson use of injection paraphernalia or drug solution occurred in most injection events (94%). Serial use of syringes/needles occurred infrequently (14%) relative to "backloading" (37%) and reuse of paraphernalia (cookers 84%, cotton 77%, water 77%). Higher-risk injection networks were characterized by larger size and pooling of resources for drugs. Prevention messages must include avoiding reuse of injection paraphernalia and transfer of drug solution.

Community-based programs for safe disposal of used needles and syringes

OBJECTIVES

To review issues related to discarded syringes in the community and to describe community-based programs for the safe disposal of used needles and syringes.

METHODS

We used the medical literature and chain referral to identify community-based syringe disposal programs other than syringe exchange programs (SEPs). We held a workshop in June 1996 involving staff from disposal programs; manufacturers of syringes, sharps containers, and other disposal devices; solid waste companies; public health staff; and researchers.

RESULTS

Fifteen programs for the safe disposal of syringes were identified in the United States, Canada, and Australia. Of these, 12 primarily served persons with diabetes who use insulin, and 3 primarily served injection drug users (IDUs). The programs used three major strategies: puncture-resistant containers discarded in trash, community drop boxes, and sharps containers turned in for biohazard disposal at community sites, hospitals, or pharmacies. Participants in the workshop described key points in developing syringe disposal programs. Programs should involve pharmacists, physicians, waste disposal companies, public health departments, hospitals, diabetes educators, persons with diabetes who use insulin, and IDUs. For IDUs, criminal penalties for possession of syringes are a substantial deterrent to participation in community efforts to safely dispose of used syringes. The multiple and sometimes conflicting local, state, and federal laws and regulations concerning medical waste hinder development of multistate or national approaches to the safe disposal of syringes. More information is needed on community-based syringe disposal programs.

CONCLUSION

Communities in the United States, Canada, and Australia have developed different approaches to achieve safe disposal of used syringes.

Arrests and incarceration of injection drug users for syringe possession in Massachusetts: implications for HIV prevention

Multiperson use of syringes is a major risk behavior responsible for the spread of HIV-1 among injection drug users (IDUs). In Massachusetts, two laws regulate syringes: one is a prescription law prohibiting possession or purchase of syringes without a prescription, and the other makes it illegal to possess drug paraphernalia, including syringes. In 1993, Massachusetts amended the prescription law to permit the establishment of syringe exchange programs in two cities. Enrolled participants are allowed to possess syringes anywhere in the state, and about 5% of the estimated 40,000 IDUs in Massachusetts are program participants. To understand how HIV prevention efforts with active IDUs may be constrained by the enforcement of laws criminalizing possession of syringes after the amendment in the law, we reviewed data from multiple sources to assess the number of arrests for syringe possession in 10 large cities in Massachusetts to evaluate incarceration rates and lengths of sentences for those convicted of syringe possession and to estimate costs of incarceration for those convicted of syringe possession. At least 824 persons were arrested for syringe possession in 1995. In examining the data on convictions, we found that 417 persons were convicted in 1994 of syringe possession in the absence of other serious charges, and of these, 41.0% were sentenced to incarceration. The average sentence imposed was 5 months (range, 3 days-2 years). Assuming that those convicted serve about two thirds of their sentences, the cost of incarceration was estimated at $1,140,183 excluding costs for arrest, pretrial detention, prosecution, or other costs of enforcement. Costs for incarcerating persons convicted of both syringe and drug possession were not included; the total cost of incarceration of persons convicted of possession of a syringe, with or without other major charges, is probably considerably higher. Had these funds been allocated to pay for drug treatment, 1629 admissions to drug detoxification programs could have been purchased. Retaining drug paraphernalia and syringe prescription laws in Massachusetts may contribute to HIV transmission. These findings support the recommendation of the American Medical Association to modify drug paraphernalia laws so that IDUs can purchase and possess syringes without a prescription.

A sterile syringe for every drug user injection: how many injections take place annually, and how might pharmacists contribute to syringe distribution?

Our objectives were to estimate the annual number of injections by injection drug users (IDUs) in the United States of America, and to describe the potential role of pharmacists in providing IDUs with a sterile syringe for every injection. We estimated the number of annual injections by IDUs for the United States, selected U.S. states, and selected U.S. cities according to the following formula: number of injections per year = (number of IDUs) x (average number of injections per IDU per day) x 365. Data were obtained from published articles, personal communications with local experts, and selected national databases. We also reviewed published and unpublished studies of pharmacy kits, pharmacist attitudes, and pharmacist practices in the United States and abroad. Between 920 million and 1.7 billion injections by IDUs take place each year in the United States. We estimated 12 million injections per year in San Francisco and >80 million in New York City. A similar number of syringes would be needed to satisfy the goal of a sterile syringe for every injection. Pharmacy-based strategies, including the sale of kits for injection drug use, have provided sterile syringes to IDUs in Europe, Australia, and New Zealand. Modification of laws restricting syringe purchase and possession has led to marked increases in purchase of syringes from pharmacies and reductions in needle-sharing. In conclusion, large numbers of syringes would be required to provide a sterile syringe for every injection, but significant numbers of pharmacists seem to be willing to play a central role in syringe sale and distribution. Outreach programs should emphasize that using a sterile syringe for every injection is the optimal HIV prevention practice for IDUs who cannot or will not stop injecting. Pharmacy-based syringe sale or distribution has the potential to augment current efforts to prevent HIV infection in IDUs, their sex partners, and their children.

Injection and syringe sharing among HIV-infected injection drug users: implications for prevention of HIV transmission. Supplement to HIV/AIDS Surveillance Group

Because HIV-infected injection drug users (IDUs) can transmit HIV infection, we investigated factors associated with sharing of syringes in the past year among IDUs infected with HIV. We analyzed data from an interview survey of 11,757 persons > or = 18 years of age with HIV or AIDS between June 1990 and August 1995 who were reported to 12 state or city health departments in the United States. Of the 1527 persons who had ever shared syringes and reported injecting in the 5 years before the interview, 786 (51%) had injected in the year before interview, and of these, 391 (50%) had shared during that year. IDUs who were aware of their HIV infection for >1 year were less likely to share (43%) than those who were aware of their infection for 1 year or less (65%, adjusted odds ratio=2.15, 95% confidence interval, 1.52-3.03). The only statistically significant time trend was that the proportion of IDUs from Connecticut who shared decreased from 71% in 1992 to 29% in 1995. This trend appears to be related to the 1992 changes in Connecticut laws that allowed purchase and possession of syringes without a prescription. Because many HIV-infected IDUs continue to inject and share, prevention efforts should be aimed at HIV-infected IDUs to prevent transmission of HIV. Early HIV diagnosis and access to sterile syringes may be important methods for reducing syringe sharing by HIV-infected IDUs.

Access to sterile syringes in Maine: pharmacy practice after the 1993 repeal of the syringe prescription law

In October 1993, the Maine legislature repealed the prescription law regulating the sale of syringes. The new law allowed but did not require licensed pharmacists to dispense syringes without a prescription to anyone 18 years of age or older. From November 1995 to January 1996, we conducted a telephone survey of 208 Maine pharmacists to evaluate the sale of syringes with and without a prescription and to assess pharmacists' willingness to sell syringes without a prescription. We found that 94% of pharmacists were willing, in all cases or at the discretion of the pharmacist, to sell syringes without a prescription. However, when asked specifically about willingness to sell syringes without a prescription to suspected injection drug users (IDUs) > or =18 years of age, 47% were willing, 40% were not willing, and 13% did not know or declined to answer. Pharmacists reported other requirements for the purchase of syringes without a prescription, such as the requirement for the customer to provide a reasonable justification for the purchase. In all, there were 31 (15%) pharmacists in the sample willing to sell syringes to without a prescription with no additional requirements for purchase to suspected IDUs as permitted by law. There were few negative incidents reported involving IDUs and the sale of syringes without a prescription since amendment of the law. Although sales of syringes without a prescription were reported, the numbers sold fell short of the estimated number of syringes required for IDUs in Maine to use a new syringe for every injection. Despite the change in the prescription law intended to increase access to syringes, the data suggest barriers such as drug paraphernalia laws and pharmacy policies may prevent IDUs from purchasing syringes and contribute to ongoing transmission of HIV. Amendment of the drug paraphernalia and syringe possession laws, clarification of the legitimate medical purpose of access to sterile syringes for IDUs, and offering pharmacists continuing education on the prevention of blood-borne disease appear to be necessary steps in the effort to decrease the transmission of HIV among IDUs in Maine.

Impact of the change in Connecticut syringe prescription laws on pharmacy sales and pharmacy managers' practices

We assessed the impact of the 1992 change in Connecticut syringe prescription laws on pharmacy sales and pharmacy managers' sales practices. A mail survey was conducted in 1994 of all current pharmacy managers in the five largest cities in Connecticut (Hartford, New Haven, Waterbury, Bridgeport, and Stamford) and a random sample of those practicing in all other areas. Of these, 89.3% of the pharmacies in the five largest cities and 85.1% in the other areas had ever sold syringes without a prescription since the July 1992 law went into effect. Most pharmacists identified safety issues as very important in their personal decision about the sale of syringes without a prescription. Although the purpose of the change in the prescription law was to provide expanded access to sterile syringes by injection drug users (IDUs), only 31.4% of the managers who were allowed to sell in all instances and 18.1% of those who sold at their discretion were very willing to sell syringes to IDUs. In the logistic regression model of pharmacies with a sell-in-all-instances policy, the perceived benefit of the sale of syringes on health and community well-being was the only influence independently associated with managers support for nonprescription sales. Overall, managers reported they did not know what other pharmacists thought (40.4%) or did (42.9%) regarding the sale of syringes. When pharmacists had discretion over syringe sales, managers' beliefs about what other Connecticut pharmacists thought and did about the nonprescription sale of syringes remained a significant influence on the degree of support for sales. Most pharmacies implemented and maintained policies permitting the sale of syringes without a prescription. Several issues, including risk of discarded contaminated syringes around pharmacies and in the community and reluctance to sell to IDUs, reduced pharmacists willingness to sell syringes. Efforts to incorporate pharmacists as active partners in HIV prevention in IDUs should promote the sale of syringes without a prescription to IDUs as acceptable public health practice.

Cost and cost-effectiveness of increasing access to sterile syringes and needles as an HIV prevention intervention in the United States

We determined the cost of increasing access of injection drug users (IDUs) to sterile syringes and needles as an HIV prevention intervention in the United States and the cost per HIV infection averted by such a program. We considered a hypothetical cohort of 1 million active IDUs in the United States. Standard methods were used to estimate the cost and cost-effectiveness of policies to increase access to sterile syringes and syringe disposal at various levels of coverage (e.g., a 100% coverage level would ensure access to a sterile syringe for each injection given current levels of illicit drug injection in the United States; a 50% coverage level would ensure access to one half of the required syringes). A mathematical model of HIV transmission was employed to link programmatic coverage levels with estimates of numbers of HIV infections averted. A policy of funding syringe exchange programs, pharmacy sales, and syringe disposal to cover all illicit drug injections would cost just over $423 million U.S. for 1 year. One third of these costs would be paid for as out-of-pocket expenditures by IDUs purchasing syringes in pharmacies. Compared with the status quo, this policy would cost an estimated $34,278 U.S. per HIV infection averted, a figure well under the estimated lifetime costs of medical care for a person with HIV infection. At very high levels of coverage (>88%), the marginal cost-effectiveness of increased program coverage becomes less favorable. Although the total costs of funding large-scale IDU access to sterile syringes and disposal seem high, the economic benefits are substantial. Even at high levels of coverage, such funding would save society money. As part of a comprehensive program of HIV prevention, policies to increase IDUs access to sterile syringes urgently need further consideration by public health decision makers.

Operation Red Box: a pilot project of needle and syringe drop boxes for injection drug users in East Baltimore

We assessed the acceptability and the use of a community-based needle and syringe disposal project designed to serve injection drug users. In June 1996, three surplus U.S. mail collection boxes were painted red and used as syringe and needle drop boxes in locations with high drug use in East Baltimore. Acceptance of the drop boxes was measured by focus groups of residents, drug users, and police, held before and after project implementation. Use was measured by weekly counts of needles recovered from the red boxes. A sample of all deposited needles was randomly chosen for needle washing and subsequent HIV antibody testing. Community impact was measured by systematic surveys of needles discarded on public sidewalks, in areas with and areas without drop boxes. Before implementation, members of focus groups expressed concerns that drop boxes could convey mixed messages to youth (e.g., seeming to condone drug use), might result in increased loitering, and could further community stigmatization. After project implementation, all focus groups expressed support of project expansion. In the first 10 months, 2971 needles were collected. Of 156 needles tested, 10.9% were positive for HIV antibody. Needle counts on the street showed no significant change in red box areas compared with control areas. In this pilot project, red boxes were accepted by the community and drug users. Police officers also used the boxes to dispose of confiscated needles. Although limited in the number of drop boxes and follow-up time, this pilot project shows promise as a community-based method of safe needle disposal.

An economic analysis of needle exchange and pharmacy-based programs to increase sterile syringe availability for injection drug users

Our objectives were to estimate the cost per syringe distributed for five syringe distribution strategies (a needle exchange program [NEP], a pharmacy-based NEP, free pharmacy distribution of pharmacy kits, sale of such pharmacy kits to injection drug users [IDUs], and sale of syringes in pharmacies); to assess the total costs of these strategies; and to conduct an economic analysis of these strategies in preventing HIV infection in IDUs. We estimated the costs for NEPs by using data from previous research; costs for the four pharmacy-based strategies were resource-based. Using estimates of the number of syringes required to provide a sterile syringe for each IDU injection, we estimated the total costs of the strategies in three representative U.S. cities. The lifetime cost of treating a person for HIV infection, discounted into current value, was used to estimate the number of syringes that could be distributed for that amount by the five strategies and thus the number of IDUs who could be ensured a sterile syringe for each injection. We then conducted a threshold analysis for calculating the annual HIV seroincidence for the program to be cost-neutral. The cost per syringe distributed in U.S. dollars was $0.97 for the NEP, $0.37 for the pharmacy-based NEP, $0.64 for pharmacy kit distribution, $0.43 for pharmacy kit sale, and $0.15 for syringe sale. The total annual cost in U.S. dollars of providing 50% of the syringes needed for a single syringe for every injection ranged from $6 to $40 million for New York City, from $1 to $6 million for San Francisco, and from $30,000 to $200,000 for Dayton, Ohio. The annual HIV seroincidence for the program to be cost-neutral compared with the cost of medical treatment for HIV injections was 2.1% for the NEP, 0.8% for the pharmacy NEP, 1.4% for pharmacy kit distribution, 0.9% for pharmacy kit sale, and 0.3% for syringe sale. All five strategies could distribute syringes at relatively low unit costs; NEPs would be the most expensive and syringe sales would be the cheapest. At annual seroincidences exceeding 2.1%, all strategies are likely to be cost-saving to society.

Minimizing process induced prooxidant stresses

The adverse effects of trace metals, heat, steam and other conditions encountered in food processing relate to the acceleration of development of rancidity. Measures to retard oxidation of lipids, vitamins, pigments and proteins include elimination of prooxidants, removal of oxygen and use of blends of inhibitors formulated for specific substrates.

Comparison of axillary block techniques: is there a difference in success rates?

This study compared the success rates between two accepted methods of performing axillary blocks, the peripheral nerve stimulator (PNS) and the transarterial (TA) techniques. Success was based on blocking the nerves involved in the surgery. Following institutional review board approval and informed consent, 57 patients between the ages of 18 and 86 years of age scheduled for elective upper extremity surgery were studied. Patients were randomized and all blocks were performed according to the protocol for PNS and TA techniques using the dosage of local anesthetic based on patient weight. All patients were premedicated with fentanyl hydrochloride, 1 microgram/kg, and midazolam, 1 to 5 mg. Scoring was accomplished on a standardized form by one of two physicians, unaware of the technique, for 5 of the major nerves at 20 and 30 minutes after injection. Sensory blockade was determined by pinprick. Motor blockade was assessed according to a scale ranging from complete block to no effect. Two of the patients had vascular procedures, and the remainder were orthopedic procedures. There were no differences in the effectiveness on the musculocutaneous, radial, median, or ulnar nerves. There was a significant difference (P < 0.05) in the effectiveness at the axillary nerve. The transarterial technique was 66% effective as opposed to 47% for the PNS. There was no difference in the need for local supplementation or general anesthesia between the two groups. There were no significant side effects reported by the patients postoperatively. The axillary nerve was the only nerve with an increased success rate using the TA technique. This indicates that both techniques are equally acceptable.

An investigation of medical examiner cases in which methadone was detected, Harris County, Texas, 1987-1992

In 1991, media reports of an increase in the number of deaths attributed to methadone toxicity in Harris County, Texas, raised public concern about the safety of methadone. This concern was heightened by publicity surrounding the closure of three Harris County methadone maintenance treatment programs due to their poor compliance with federal methadone regulations. In response to this concern, the Texas Department of Public Health requested that the Centers for Disease Control and Prevention (CDC) assist in an epidemiologic study to determine the extent of methadone-related mortality in Harris County during 1991 and to determine the role of methadone maintenance treatment in these deaths. We reviewed cases investigated by the Harris County Medical Examiner's Office from 1987 through 1992 in which methadone was detected by postmortem drug testing. The autopsy reports for cases occurring in 1991 were also reviewed by three independent forensic pathologists who were asked to determine the role of methadone in the death. In addition, we attempted to document Harris County methadone maintenance treatment program enrollment for each decedent. We identified 91 decedents in whom methadone was detected at the time of death, with the largest number of cases occurring in 1991 (n = 27). Other substances, including alcohol, were detected in 85% of the cases. The Harris County Medical Examiner attributed 11 of the deaths to methadone toxicity. No more than three cases per year from 1987 through 1992 were attributed to methadone toxicity. In contrast, 34 deaths were attributed to polydrug toxicity, the largest number occurring in 1991 (n = 11). There was good agreement between the results of the independent review and the opinions of the Harris County Medical Examiner. Only 20% of the decedents were found to have been enrolled in a Harris County methadone maintenance treatment program at the time of death. Four people died of drug toxicity shortly after enrolling in a methadone maintenance treatment program. We found an increase in the number deaths occurring in Harris County, Texas, in 1991 in which methadone was detected. We also found that methadone blood levels were higher among decedents identified for 1991 and 1992 than among those identified in the previous years studied. However, we did not find evidence that the cause of these deaths could be attributed solely to methadone toxicity. Instead, for all years studied, the use of multiple drugs was the leading cause of death among people in whom methadone was detected. This finding points out the difficulties involved in determining the role of methadone as a cause of death.

A novel Escherichia coli lipoprotein expression vector

A novel Escherichia coli (Ec) lipoprotein expression plasmid, pSJLP, was constructed. The plasmid contains a truncated alkaline phosphatase gene (phoA) located downstream from the Lac repressor gene lacIq and the IPTG inducible Ptac promoter. The phoA gene was truncated by deleting the native phoA signal sequence and fusing the truncated phoA gene to the lipoprotein signal sequence of the major Ec lipoprotein LPP. The recombinant LPP::PhoA fusion protein is produced and processed as a lipoprotein and can therefore be used as substrate for a novel signal peptidase II assay.

Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales--Connecticut, 1992-1993

In May 1992, the Connecticut legislature passed new laws aimed at increasing injecting drug users' (IDUs) access to sterile needles and syringes (syringes); as of July 1992, pharmacists were permitted to sell and individuals were permitted to possess up to 10 syringes without medical prescriptions (nonprescription syringes). We evaluated the impact of the new laws by conducting (1) prospective surveillance of syringe sales and policies at selected community pharmacies (pharmacies) and (2) a telephone survey of pharmacy managers' reports of syringe sales and policies at a statewide stratified random sample of pharmacies. Our data provide direct evidence that most, but not all, Connecticut pharmacies sold nonprescription syringes when permitted to do so by the new laws. For example, using the telephone survey data, we estimate that during November, 1993, 83% [95% CI: 77-89%] of all Connecticut pharmacies sold nonprescription syringes and 56,000 [95% CI: 44,000-68,000] nonprescription syringes were sold, during November 1993. Our data provide indirect evidence that IDUs were purchasing nonprescription syringes at pharmacies. For example, in five Hartford pharmacies located in neighborhoods where injection drug use was prevalent, the total number of nonprescription syringes sold per month increased significantly from 460 in July 1992 to 2,482 in June 1993 (p = 0.0001). The data suggest that the new laws increased IDUs' access to sterile syringes in Connecticut.

Acquisition and use of needles and syringes by injecting drug users in Baltimore, Maryland

Our objective was to determine how injection drug users (IDUs) in Baltimore, Maryland obtain and use needles and syringes (NS) for drug injection, before the opening of a needle exchange program (NEP). The method of this study was a cross-sectional structured interview survey in 1992 of active IDUs in a longitudinal study of human immunodeficiency virus (HIV) infection. For 466 IDUs (94.6% black, 83% male), usual sources of NS were "street" dealers (49.6%), pharmacies (29.8%), diabetics (16.3%), friends/neighbors (2.2%), and "shooting galleries" (1.9%). Half (53.5%) reported pharmacy purchase of NS, and 55.6% had diabetic friends/relatives. Twenty-three percent traded drugs, and 5% traded sex for NS. Eighty-eight and two-tenths percent would use a needle exchange program; 24.6% currently own no NS (median owned = 2.2). NS reuse was common (median = three times). Concern about (55.2%) or history of (33.9%) hassle/arrest for NS possession was typical; 81% kept NS at home, and 67% do not carry NS when purchasing drugs. Pharmacy purchasers (versus "street") were less likely to have been jailed, shared NS, or used shooting galleries during the preceding 6 months. In Maryland, although IDUs can legally purchase NS at pharmacist discretion, possession remains illegal; fewer than one-third of IDUs use pharmacies, and most obtain NS from illegal sources. Most IDUs reuse NS, but discard them after several uses. Current patterns of NS acquisition and use in Baltimore are likely to increase HIV transmission. Increased availability and decriminalization of NS possession could decrease the risk of injection-related HIV transmission.

Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers--Connecticut, 1992-1993

To determine whether the simultaneous, partial repeal of needle prescription and drug paraphernalia laws in Connecticut affected purchasing and usage of needles and syringes (syringes) by injecting-drug users (IDUs) and risk of needlestick injuries to police officers, we conducted two serial cross-sectional surveys with IDUs recruited in drug treatment centers, correctional facilities, and health department settings. Reports of needlestick injuries among Hartford police officers were reviewed before and after the new laws. Among IDUs who reported ever sharing a syringe, syringe-sharing decreased after the new laws (52% before vs. 31% after; p = 0.02). Fewer IDUs reported purchasing syringes on the street after the new laws (74% before vs. 28% after; p < 0.0001). More IDUs reported purchasing syringes from a pharmacy after the new laws (19% before vs. 78% after; p < 0.0001). Eight to eleven months after the new laws were enacted, over two thirds (91 of 134) of active IDUs interviewed were aware of both new laws. Needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drug-related arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws). The changes in Connecticut laws were associated with decreases in self-reported syringe-sharing and increases in purchasing by IDUs of sterile syringes from reliable sources, suggesting that the simultaneous repeal of both prescription and paraphernalia laws is an important HIV prevention strategy.

Interpersonal distance, body orientation, and touch: effects of culture, gender, and age

Video recordings of naturally occurring interactions in England, France, the Netherlands, Italy, Greece, Scotland, and Ireland were coded and analyzed to examine the effects of culture, gender, and age on interpersonal distance, body orientation, and touch. Results partially supported expected differences between contact cultures of southern Europe and noncontact cultures of northern Europe with respect to touch. More touch was observed among Italian and Greek dyads than among English, French, and Dutch dyads. In addition, an interaction effect between age and gender for body orientation suggested opposite development trends for mixed-sex dyads and male dyads. Whereas mixed dyads tended to maintain less direct orientations as they aged, male dyads maintained more direct orientations.

Inadequate bleach contact times during syringe cleaning among injection drug users

Objectives were to measure syringe cleaning strategies used by injection drug users (IDUs) and to assess syringe contact with bleach during cleaning demonstrations. IDUs were interviewed about cleaning activities during their most recent injection episode; they demonstrated these activities on videotape. Coders reviewed the videotapes, categorized activities, and used stop watches to record bleach exposure. Of 161, 146 subjects reported cleaning at last injection, 85 (58%) of 146 used full strength bleach. Of bleach users, 20% had total contact time (duration of bleach inside syringe) of > or = 30 s; combining draw (time taken to fill syringe) and contact times, 54% of bleach users had total "flush" times of > or = 30 s. Median observed time per bleach flush was 16 s. Median reported cleaning times were twice as long as observed. Recent reports indicate 30 s of exposure to undiluted bleach is necessary to inactivate HIV in the laboratory; here, 80% of IDUs using bleach had contact of < 30 s. Judgment of contact time was inaccurate. On average, instructions advocating two bleach flushes may reach 30 s; here, half the subjects had insufficient time with two flushes. The majority showed inadequate techniques, therefore, alternate cleaning strategies should be developed.