Effectiveness of Coronavirus Disease 2019 (COVID-19) Vaccines Among Incarcerated People in California State Prisons: Retrospective Cohort Study

BACKGROUND

Prisons and jails are high-risk settings for coronavirus disease 2019 (COVID-19). Vaccines may substantially reduce these risks, but evidence is needed on COVID-19 vaccine effectiveness for incarcerated people, who are confined in large, risky congregate settings.

METHODS

We conducted a retrospective cohort study to estimate effectiveness of messenger RNA (mRNA) vaccines, BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna), against confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections among incarcerated people in California prisons from 22 December 2020 through 1 March 2021. The California Department of Corrections and Rehabilitation provided daily data for all prison residents including demographic, clinical, and carceral characteristics, as well as COVID-19 testing, vaccination, and outcomes. We estimated vaccine effectiveness using multivariable Cox models with time-varying covariates, adjusted for resident characteristics and infection rates across prisons.

RESULTS

Among 60 707 cohort members, 49% received at least 1 BNT162b2 or mRNA-1273 dose during the study period. Estimated vaccine effectiveness was 74% (95% confidence interval [CI], 64%-82%) from day 14 after first dose until receipt of second dose and 97% (95% CI, 88%-99%) from day 14 after second dose. Effectiveness was similar among the subset of residents who were medically vulnerable: 74% (95% CI, 62%-82%) and 92% (95% CI, 74%-98%) from 14 days after first and second doses, respectively.

CONCLUSIONS

Consistent with results from randomized trials and observational studies in other populations, mRNA vaccines were highly effective in preventing SARS-CoV-2 infections among incarcerated people. Prioritizing incarcerated people for vaccination, redoubling efforts to boost vaccination, and continuing other ongoing mitigation practices are essential in preventing COVID-19 in this disproportionately affected population.

Suicide Deaths Among Women in California Living With Handgun Owners vs Those Living With Other Adults in Handgun-Free Homes, 2004-2016

IMPORTANCE

Little is known about the extent to which secondhand exposure to household firearms is associated with risk of suicide in adults who do not own guns, most of whom are women.

OBJECTIVE

To evaluate changes in risk of suicide among women living in gun-free households after one of their cohabitants became a handgun owner.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study observed participants for up to 12 years and 2 months from October 18, 2004, to December 31, 2016. Data were analyzed from April to November 2021. The study population included 9.5 million adult women in California who did not own guns and who entered the study while living with 1 or more adults in a handgun-free home.

EXPOSURES

Secondhand exposure to household handguns.

MAIN OUTCOMES AND MEASURES

Suicide, firearm suicide, nonfirearm suicide.

RESULTS

Of 9.5 million women living in handgun-free homes, 331 968 women (3.5% of the study population; mean [SD] age, 41.6 [18.0] years) became exposed to household handguns during the study period. In the entire study population, 294 959 women died: 2197 (1%) of these were by suicide, 337 (15%) of which were suicides by firearm. Rates of suicide by any method during follow-up were higher among cohort members residing with handgun owners compared with those residing in handgun-free homes (hazard ratio, 1.43; 95% CI, 1.11-1.84). The excess suicide rate was accounted for by higher rates of suicide by firearm (hazard ratio, 4.32; 95% CI, 2.89-6.46). Women in households with and without handguns had similar rates of suicide by nonfirearm methods (hazard ratio, 0.90; 95% CI, 0.63-1.27).

CONCLUSIONS AND RELEVANCE

In this study, the rate of suicide among women was significantly higher after a cohabitant of theirs became a handgun owner compared with the rate observed while they lived in handgun-free homes.

Homicide Deaths Among Adult Cohabitants of Handgun Owners in California, 2004 to 2016 : A Cohort Study

BACKGROUND

Although personal protection is a major motivation for purchasing firearms, existing studies suggest that people living in homes with firearms have higher risks for dying by homicide. Distribution of those risks among household members is poorly understood.

OBJECTIVE

To estimate the association between living with a lawful handgun owner and risk for homicide victimization.

DESIGN

This retrospective cohort study followed 17.6 million adult residents of California for up to 12 years 2 months (18 October 2004 through 31 December 2016). Cohort members did not own handguns, but some started residing with lawful handgun owners during follow-up.

SETTING

California.

PARTICIPANTS

17 569 096 voter registrants aged 21 years or older.

MEASUREMENTS

Homicide (overall, by firearm, and by other methods) and homicide occurring in the victim's home.

RESULTS

Of 595 448 cohort members who commenced residing with handgun owners, two thirds were women. A total of 737 012 cohort members died; 2293 died by homicide. Overall rates of homicide were more than twice as high among cohabitants of handgun owners than among cohabitants of nonowners (adjusted hazard ratio, 2.33 [95% CI, 1.78 to 3.05]). These elevated rates were driven largely by higher rates of homicide by firearm (adjusted hazard ratio, 2.83 [CI, 2.05 to 3.91]). Among homicides occurring at home, cohabitants of owners had sevenfold higher rates of being fatally shot by a spouse or intimate partner (adjusted hazard ratio, 7.16 [CI, 4.04 to 12.69]); 84% of these victims were female.

LIMITATIONS

Some cohort members classified as unexposed may have lived in homes with handguns. Residents of homes with and without handguns may have differed on unobserved traits associated with homicide risk.

CONCLUSION

Living with a handgun owner is associated with substantially elevated risk for dying by homicide. Women are disproportionately affected.

PRIMARY FUNDING SOURCE

The National Collaborative on Gun Violence Research, the Fund for a Safer Future, the Joyce Foundation, Stanford Law School, and the Stanford University School of Medicine.

Uptake of COVID-19 Vaccination Among Frontline Workers in California State Prisons

Question

In California prisons, what proportion of prison staff who have direct contact with residents are unvaccinated, and what are their characteristics?

Findings

In this cohort study of 23 472 custody staff and 7617 health care staff in California state prisons, 14 317 custody staff (61%) and 2819 (36%) health care staff remained unvaccinated through June 30, 2021, despite widespread vaccine availability. Unvaccinated staff were younger and more likely to have had COVID-19; they were also more likely to work alongside other unvaccinated staff and live in communities with relatively low rates of vaccination.

Meaning

The study results suggest that low vaccination rates among prison staff pose continuing risks.

Importance

Prisons and jails are high-risk environments for COVID-19. Vaccination levels among workers in many such settings remain markedly lower than those of residents and members of surrounding communities. The situation is troubling because prison staff are a key vector for COVID-19 transmission.

Objective

To assess patterns and timing of staff vaccination in California state prisons and identify individual-level and community-level factors associated with remaining unvaccinated.

Design, Setting, and Participants

This cohort study used data from December 22, 2020, through June 30, 2021, to quantify the fractions of staff and incarcerated residents who remained unvaccinated among 23 472 custody and 7617 health care staff who worked in roles requiring direct contact with residents at 33 of the 35 prisons operated by the California Department of Corrections and Rehabilitation. Multivariable probit regressions assessed demographic, community, and peer factors associated with staff vaccination uptake.

Main Outcomes and Measures

Remaining unvaccinated throughout the study period.

Results

Of 23 472 custody staff, 3751 (16%) were women, and 1454 (6%) were Asian/Pacific Islander individuals, 1571 (7%) Black individuals, 9008 (38%) Hispanic individuals, and 6666 (28%) White individuals. Of 7617 health care staff, 5434 (71%) were women, and 2148 (28%) were Asian/Pacific Islander individuals, 1201 (16%) Black individuals, 1409 (18%) Hispanic individuals, and 1771 (23%) White individuals. A total of 6103 custody staff (26%) and 3961 health care staff (52%) received 1 or more doses of a COVID-19 vaccine during the first 2 months vaccines were offered, but vaccination rates stagnated thereafter. By June 30, 2021, 14 317 custody staff (61%) and 2819 health care staff (37%) remained unvaccinated. In adjusted analyses, remaining unvaccinated was positively associated with younger age (custody staff: age, 18-29 years vs ≥60 years, 75% [95% CI, 73%-76%] vs 45% [95% CI, 42%-48%]; health care staff: 52% [95% CI, 48%-56%] vs 29% [95% CI, 27%-32%]), prior COVID-19 infection (custody staff: 67% [95% CI, 66%-68%] vs 59% [95% CI, 59%-60%]; health care staff: 44% [95% CI, 42%-47%] vs 36% [95% CI, 36%-36%]), residing in a community with relatively low rates of vaccination (custody staff: 75th vs 25th percentile:, 63% [95% CI, 62%-63%] vs 60% [95% CI, 59%-60%]; health care staff: 40% [95% CI, 39%-41%] vs 34% [95% CI, 33%-35%]), and sharing shifts with coworkers who had relatively low rates of vaccination (custody staff: 75th vs 25th percentile, 64% [95% CI, 62%-66%] vs 59% [95% CI, 57%-61%]; health care staff: 38% [95% CI, 36%-41%] vs 35% [95% CI, 31%-39%]).

Conclusions and Relevance

This cohort study of California state prison custody and health care staff found that vaccination uptake plateaued at levels that posed ongoing risks of further outbreaks in the prisons and continuing transmission from prisons to surrounding communities. Prison staff decisions to forgo vaccination appear to be multifactorial, and vaccine mandates may be necessary to achieve adequate levels of immunity in this high-risk setting.

Patterns of handgun divestment among handgun owners in California

Background

Little is known about voluntary divestment of firearms among US firearm owners. Here, we aim to estimate the proportion of handgun owners who divest their handguns in the years following their initial acquisition; examine the timing, duration, and dynamics of those divestments; and describe characteristics of those who divest.

Methods

We use data from the Longitudinal Study of Handgun Ownership and Transfer, a cohort of registered voters in California with detailed information on 626,756 adults who became handgun owners during the 12-year study period, 2004–2016. For the current study, persons were followed from the time of their initial handgun acquisition until divestment, loss to follow-up, death, or the end of the study period. We describe the cumulative proportion who divest overall and by personal and area-level characteristics. We also estimate the proportion who reacquired handguns among persons who divested.

Results

Overall, 4.5% (95% CI 4.5–4.6) of handgun owners divested within 5 years of their first acquisition, with divestment relatively more common among women and among younger adults. Among those who divested, 36.6% (95% CI 35.8–37.5) reacquired a handgun within 5 years.

Conclusions

Handgun divestment is rare, with the vast majority of new handgun owners retaining them for years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00362-6.

Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies

BACKGROUND

Residents of prisons have experienced disproportionate COVID-19-related health harms. To control outbreaks, many prisons in the USA restricted in-person activities, which are now resuming even as viral variants proliferate. This study aims to use mathematical modelling to assess the risks and harms of COVID-19 outbreaks in prisons under a range of policies, including resumption of activities.

METHODS

We obtained daily resident-level data for all California state prisons from Jan 1, 2020, to May 15, 2021, describing prison layouts, housing status, sociodemographic and health characteristics, participation in activities, and COVID-19 testing, infection, and vaccination status. We developed a transmission-dynamic stochastic microsimulation parameterised by the California data and published literature. After an initial infection is introduced to a prison, the model evaluates the effect of various policy scenarios on infections and hospitalisations over 200 days. Scenarios vary by vaccine coverage, baseline immunity (0%, 25%, or 50%), resumption of activities, and use of non-pharmaceutical interventions (NPIs) that reduce transmission by 75%. We simulated five prison types that differ by residential layout and demographics, and estimated outcomes with and without repeated infection introductions over the 200 days.

FINDINGS

If a viral variant is introduced into a prison that has resumed pre-2020 contact levels, has moderate vaccine coverage (ranging from 36% to 76% among residents, dependent on age, with 40% coverage for staff), and has no baseline immunity, 23-74% of residents are expected to be infected over 200 days. High vaccination coverage (90%) coupled with NPIs reduces cumulative infections to 2-54%. Even in prisons with low room occupancies (ie, no more than two occupants) and low levels of cumulative infections (ie, <10%), hospitalisation risks are substantial when these prisons house medically vulnerable populations. Risks of large outbreaks (>20% of residents infected) are substantially higher if infections are repeatedly introduced.

INTERPRETATION

Balancing benefits of resuming activities against risks of outbreaks presents challenging trade-offs. After achieving high vaccine coverage, prisons with mostly one-to-two-person cells that have higher baseline immunity from previous outbreaks can resume in-person activities with low risk of a widespread new outbreak, provided they maintain widespread NPIs, continue testing, and take measures to protect the medically vulnerable.

FUNDING

Horowitz Family Foundation, National Institute on Drug Abuse, Centers for Disease Control and Prevention, National Science Foundation, Open Society Foundation, Advanced Micro Devices.

COVID-19 in the California State Prison System: an Observational Study of Decarceration, Ongoing Risks, and Risk Factors

BACKGROUND

Correctional institutions nationwide are seeking to mitigate COVID-19-related risks.

OBJECTIVE

To quantify changes to California's prison population since the pandemic began and identify risk factors for COVID-19 infection.

DESIGN

For California state prisons (March 1-October 10, 2020), we described residents' demographic characteristics, health status, COVID-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of COVID-19 infection and room occupancy and out-of-room labor, respectively.

PARTICIPANTS

Residents of California state prisons.

MAIN MEASURES

Changes in the incarcerated population's size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs. dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident COVID-19 case rates.

KEY RESULTS

The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≥60, 18.3% had high COVID-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≥10 occupants. Nearly 40% of residents with high COVID-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95% CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95% CI, 1.39-1.74).

CONCLUSION

Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.

Effectiveness of COVID-19 Vaccines among Incarcerated People in California State Prisons: A Retrospective Cohort Study

Background

Prisons and jails are high-risk settings for COVID-19 transmission, morbidity, and mortality. COVID-19 vaccines may substantially reduce these risks, but evidence is needed of their effectiveness for incarcerated people, who are confined in large, risky congregate settings.

Methods

We conducted a retrospective cohort study to estimate effectiveness of mRNA vaccines, BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna), against confirmed SARS-CoV-2 infections among incarcerated people in California prisons from December 22, 2020 through March 1, 2021. The California Department of Corrections and Rehabilitation provided daily data for all prison residents including demographic, clinical, and carceral characteristics, as well as COVID-19 testing, vaccination status, and outcomes. We estimated vaccine effectiveness using multivariable Cox models with time-varying covariates that adjusted for resident characteristics and infection rates across prisons.

Findings

Among 60,707 residents in the cohort, 49% received at least one BNT162b2 or mRNA-1273 dose during the study period. Estimated vaccine effectiveness was 74% (95% confidence interval [CI], 64-82%) from day 14 after first dose until receipt of second dose and 97% (95% CI, 88-99%) from day 14 after second dose. Effectiveness was similar among the subset of residents who were medically vulnerable (74% [95% CI, 62-82%] and 92% [95% CI, 74-98%] from 14 days after first and second doses, respectively), as well as among the subset of residents who received the mRNA-1273 vaccine (71% [95% CI, 58-80%] and 96% [95% CI, 67-99%]).

Conclusions

Consistent with results from randomized trials and observational studies in other populations, mRNA vaccines were highly effective in preventing SARS-CoV-2 infections among incarcerated people. Prioritizing incarcerated people for vaccination, redoubling efforts to boost vaccination and continuing other ongoing mitigation practices are essential in preventing COVID-19 in this disproportionately affected population.

Funding

Horowitz Family Foundation, National Institute on Drug Abuse, Centers for Disease Control and Prevention, National Science Foundation, Open Society Foundation, Advanced Micro Devices.

Covid-19 in the California State Prison System: An Observational Study of Decarceration, Ongoing Risks, and Risk Factors

Background:

Correctional institutions nationwide are seeking to mitigate Covid-19-related risks.

Objective:

To quantify changes to California’s prison population since the pandemic began and identify risk factors for Covid-19 infection.

Design:

We described residents’ demographic characteristics, health status, Covid-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of Covid-19 infection and room occupancy and out-of-room labor, respectively.

Setting:

California state prisons (March 1-October 10, 2020).

Participants:

Residents of California state prisons.

Measurements:

Changes in the incarcerated population’s size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident Covid-19 case rates.

Results:

The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≤60, 18.3% had high Covid-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≤10 occupants. Nearly 40% of residents with high Covid-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95%CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95%CI, 1.39-1.74).

Limitations:

Inability to measure density of residents’ living conditions or contact networks among residents and staff.

Conclusion:

Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.

Funding Sources:

Horowitz Family Foundation; National Institute on Drug Abuse; National Science Foundation Graduate Research Fellowship; Open Society Foundations.

Handgun Ownership and Suicide in California

BACKGROUND

Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership.

METHODS

We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns).

RESULTS

A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition.

CONCLUSIONS

Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.).

First-Year Economic and Quality of Life Effects of the RAINBOW Intervention to Treat Comorbid Obesity and Depression

OBJECTIVE

Obesity and depression are prevalent and often co-occurring conditions in the United States. The Research Aimed at Improving Both Mood and Weight (RAINBOW) randomized trial demonstrated the effectiveness of an integrated intervention for adults with both conditions. Characterizing the intervention's economic effects is important for broader dissemination and implementation.

METHODS

This study evaluated the cost (2018 US dollars) and health-related quality of life (HRQoL) impacts during RAINBOW's first year, comparing intervention (n = 204) and usual-care groups (n = 205). Outcomes included intervention delivery costs, differential changes in antidepressant medication spending compared with the pretrial year, differential changes in medical services spending compared with the pretrial year, and HRQoL changes from baseline using Euroqol-5D US utility weights.

RESULTS

RAINBOW's 1-year delivery cost per person was $2,251. Compared with usual care, annual antidepressant medication days increased more (38 days [95% CI: 4 to 72]; P = 0.027). Annual antidepressant medication spending had a larger, nonsignificant increase ($89 [95% CI: -$20 to $197]; P = 0.109). Annual spending on medical care services had a smaller, nonsignificant decrease (-$54 [95% CI: -$832 to $941]; P = 0.905). HRQoL had a nonsignificant increase (0.011 [95% CI: -0.025 to 0.047]; P = 0.546).

CONCLUSIONS

The RAINBOW intervention's economic value will depend on how its 1-year improvements in obesity and depression translate into long-term reduced morbidity, delayed mortality, or averted costs.

Assembly of the LongSHOT cohort: public record linkage on a grand scale

BACKGROUND

Virtually all existing evidence linking access to firearms to elevated risks of mortality and morbidity comes from ecological and case-control studies. To improve understanding of the health risks and benefits of firearm ownership, we launched a cohort study: the Longitudinal Study of Handgun Ownership and Transfer (LongSHOT).

METHODS

Using probabilistic matching techniques we linked three sources of individual-level, state-wide data in California: official voter registration records, an archive of lawful handgun transactions and all-cause mortality data. There were nearly 28.8 million unique voter registrants, 5.5 million handgun transfers and 3.1 million deaths during the study period (18 October 2004 to 31 December 2016). The linkage relied on several identifying variables (first, middle and last names; date of birth; sex; residential address) that were available in all three data sets, deploying them in a series of bespoke algorithms.

RESULTS

Assembly of the LongSHOT cohort commenced in January 2016 and was completed in March 2019. Approximately three-quarters of matches identified were exact matches on all link variables. The cohort consists of 28.8 million adult residents of California followed for up to 12.2 years. A total of 1.2 million cohort members purchased at least one handgun during the study period, and 1.6 million died.

CONCLUSIONS

Three steps taken early may be particularly useful in enhancing the efficiency of large-scale data linkage: thorough data cleaning; assessment of the suitability of off-the-shelf data linkage packages relative to bespoke coding; and careful consideration of the minimum sample size and matching precision needed to support rigorous investigation of the study questions.

Comparison of Preventive and Therapeutic Zinc Supplementation in Young Children in Burkina Faso: A Cluster-Randomized, Community-Based Trial

BACKGROUND

The WHO and UNICEF recommend therapeutic zinc supplementation (TZS) for the treatment of diarrhea. In zinc-deficient populations, preventive zinc supplementation might provide greater benefits for reducing diarrhea and malaria incidence and increasing growth and plasma zinc (pZn) concentration. If effective, intermittent preventive zinc supplementation (IPZS) would cost less than daily preventive zinc supplementation (DPZS).

OBJECTIVE

We assessed the effects of IPZS, DPZS, and TZS in children on the primary outcomes of diarrhea incidence, malaria incidence, growth, and pZn concentration compared with nonsupplemented control groups.

METHODS

Rural Burkinabe children (n = 7641; 6-30 mo old) in 36 clusters were randomly assigned to 1 of 5 treatment groups for 16, 32, or 48 wk: 1) IPZS (10 mg Zn/d for 10 d every 16 wk); 2) DPZS (7 mg Zn/d); 3) TZS (20 mg Zn/d for 10 d for diarrhea); 4) morbidity surveillance control (MSC); or 5) nonintervention control (NIC). Supplemented groups remained masked until completion of primary analyses with mixed models.

RESULTS

At baseline, stunting (28.6%) and low pZn concentration (<65 μg/dL; 43.5%) were common. After 48 wk, mean ± SE pZn increased more (P = 0.008) in the DPZS group (3.9 ± 1.3 μg/dL) than in the TZS (-0.5 ± 1.2 μg/dL) and NIC (-1.2 ± 0.9 μg/dL) groups. All supplemented groups had a moderately lower incidence of reported diarrhea (0.48-0.49 compared with 0.57 episodes/100 d, P = 0.001) and reported fever (1.1-1.2 compared with 1.5 episodes/100d, P < 0.001) and gained slightly less length (3.15-3.20 compared with 3.36 cm/16 wk, P < 0.001) than the MSC group, but did not differ from each other. Prevalence of diarrhea and incidences of confirmed fever and malaria were not different across study groups.

CONCLUSIONS

The preventive and TZS groups had reduced diarrhea incidence, but it is uncertain whether this resulted from a functional response to zinc or reporting bias. The comparison should be re-examined in populations known to respond to zinc supplementation. This trial was registered at www.clinicaltrials.gov as NCT00944359.

Factors Affecting the Validity of Coverage Survey Reports of Receipt of Vitamin A Supplements During Child Health Days in Southwestern Burkina Faso

BACKGROUND

Assessment of high-dose vitamin A supplementation (VAS) coverage often relies on postevent coverage (PEC) surveys, but the validity of these methods has rarely been evaluated.

OBJECTIVES

To assess reported VAS coverage and factors associated with missed coverage and to investigate the reliability of the results.

METHODS

During a cross-sectional survey, 10 454 caregivers of children <27 months old were asked whether their child had received VAS in the past 6 months. During a 48-week longitudinal study of 6232 children 6 to 30 months old, caregivers were asked every 4 weeks if their child had received VAS in the past 4 weeks.

RESULTS

The cross-sectional study showed that 94.4% (95% confidence interval [CI]: 93.8%, 94.9%) of eligible children 6 to 26 months of age reportedly received VAS in the previous 6 months, as did 85.8% (CI: 84.5%, 87.2%) of ineligible, 0 to 5 months old children. The longitudinal study showed that 81.6% of children surveyed within 4 weeks following a VAS campaign reportedly received VAS during the campaign and 13.4% of caregivers incorrectly reported receiving VAS when no campaign had actually occurred. False-positive reporting was more likely when oral polio vaccine (OPV) was distributed during the reporting period (20.6% vs 5.4%; P < .001). Showing a photo of OPV during the interview reduced the odds ratio (OR) of false-positive reports (OR = 0.7 [0.6-0.8]).

CONCLUSIONS

The PEC surveys should include children outside the target age to assess targeting efficiency, and pictures of both VAS and oral vaccines distributed during the same period should be shown during interviews to enhance reporting accuracy.

Risk of self-reported symptoms or diagnosis of active tuberculosis in relationship to low body mass index, diabetes and their co-occurrence

OBJECTIVE

Globally, tuberculosis prevalence has declined, but its risk factors have varied across place and time - low body mass index (BMI) has persisted while diabetes has increased. Using India's National Family Health Survey (NFHS), wave 3 and World Health Survey (WHS) data, we examined their relationships to support projection of future trends and targeted control efforts.

METHODS

Multivariate logistic regressions at the individual level with and without diabetes/BMI interactions assessed the relationship between tuberculosis, diabetes and low BMI and the importance of risk factor co-occurrence. Population-level analyses examined how tuberculosis incidence and prevalence varied with diabetes/low BMI co-occurrence.

RESULTS

In NFHS, diabetic individuals had higher predicted tuberculosis risks (diabetic vs. non-diabetic: 2.50% vs. 0.63% at low BMI; 0.81% vs. 0.20% at normal BMI; 0.37% vs. 0.09% at high BMI), which were not significantly different when modelled independently or allowing for risk modification with diabetes/low BMI co-occurrence. WHS findings were generally consistent. Population-level analysis found that diabetes/low BMI co-occurrence may be associated with elevated tuberculosis risk, although its predicted effect on tuberculosis incidence/prevalence was generally ≤0.2 percentage points and not robustly statistically significant.

CONCLUSIONS

Concerns about the additional elevation of tuberculosis risk from diabetes/low BMI co-occurrence and hence the need to coordinate tuberculosis control efforts around the nexus of co-occurring diabetes and low BMI may be premature. However, study findings robustly support the importance of individually targeting low BMI and diabetes as part of ongoing tuberculosis control efforts.

Caregiver recognition of childhood diarrhea, care seeking behaviors and home treatment practices in rural Burkina Faso: a cross-sectional survey

INTRODUCTION

To design effective national diarrhea control programs, including oral rehydration solution (ORS) and therapeutic zinc supplementation, information is needed on local perceptions of illness, external care seeking behaviors, and home treatment practices.

METHODS

A cross-sectional, community-based household survey was conducted in the Orodara Health District, Burkina Faso. Caregivers of 10,490 children <27 months were interviewed to assess child diarrhea prevalence and related care practices. Characteristics of households, caregivers, children, and reported illnesses were compared for those caregivers who did or did not recognize the presence of diarrhea, as defined according to clinical criteria (≥ 3 liquid or semi-liquid stools/day). Multiple logistic regression models were used to examine factors associated with illness recognition and treatment.

RESULTS

Clinically defined diarrhea was present in 7.6% (95% CI: 7.1-8.1%) of children during the 24 hours preceding the survey but recognized by only 55% of caregivers. Over half (55%) of the caregivers of 1,067 children with a clinically defined diarrhea episode in the past 14 days sought care outside the home; 78% of those seeking care attended a public sector clinic. Care was sought and treatment provided more frequently for children with fever, vomiting, anorexia, longer illness duration, and those living closer to the health center; and care was sought more frequently for male children. 80% of children with recent diarrhea received some form of treatment; only 24% received ORS, whereas 14% received antibiotics. Zinc was not yet available in the study area.

CONCLUSIONS

Caregivers frequently fail to recognize children's diarrhea, especially among younger infants and when illness signs are less severe. Treatment practices do not correspond with international recommendations in most cases, even when caregivers consult with formal health services. Child caregivers need additional assistance to recognize diarrhea correctly, and both caregivers and health care providers need updated training on current diarrhea treatment recommendations.

Evidence-based practice and the role of nursing leadership

A new term, evidence-based practice, is beginning to appear both in the healthcare literature and at professional, conferences. Its meaning, however, is not always clear, nor is its full implication for nurse administrators explained. This article provides a pragmatic definition of evidence-based practice developed in the nursing division at Baystate Medical Center, Springfield, Massachusetts. It outlines steps required to institutionalize evidence as a routine part of nursing practice and provide examples of its use.

Survey of cardiac rehabilitation centers in New York City

Out-patient cardiac rehabilitation centers in New York City were surveyed in order to determine current practices. All 24 centers operating as of May, 1987 were sent questionnaires; 16 responded for a return rate of 67 percent. In general, practices of the centers were in accord with guidelines of the American Heart Association (AHA) and the American College of Sports Medicine. The incidence of medical complications in the centers was quite rare, perhaps accounting for the failure of centers to follow all emergency guidelines of the AHA, such as daily testing of the defibrillator. The major aim of the centers was to enhance physiological status, rather narrowly defined as aerobic fitness and cardiovascular function. Little attention was paid to nutrition, body composition and strength, despite the fact that the value of broadening the concept of fitness to include these parameters is becoming evident. Lifestyle counseling to help in long-term rehabilitation was also rare. Third party payers should be encouraged to support such components of a rehabilitation program so that centers would be more likely to incorporate them.

Clinical zinc deficiency during long-term total enteral nutrition

Zinc deficiency during long-term total parenteral nutrition has been well reported in the literature. However, there is limited information available on zinc deficiency occurring during total enteral nutrition. Two cases of clinical zinc deficiency in patients on long-term enteral feedings are presented. Nutritional assessment of these two patients on admission revealed hypoalbuminemic malnutrition. Nutritional support in the form of nasogastric tube feedings were initiated in both patients due to altered mental status. The formula used was Ensure (Ross Labs, Columbus, OH), which provided greater than 150% of the RDA for zinc. However, four months and seven months after initiation of adequate nutritional support, both patients developed skin rashes around the groin and under the breasts and axilla. Serum zinc levels were depressed in both patients, to 42 and 54 mg/dL, respectively (normal for the authors' laboratory, 66 to 120 mg/dL). Supplementation with zinc sulfate 220 mg per day via nasogastric tube resulted in disappearance of the rash with return of serum zinc to normal levels. The authors suggest close observation of patients on long-term enteral nutrition for clinical manifestation of zinc deficiency, especially an unexplained skin rash. Further studies are needed to establish minimum daily zinc requirements in patients on long-term enteral feedings.

Fatty acids ofLindera umbellata and other Lauraceae seed oils

Seed kernel oils of seven species of Lauraceae were examined and the fatty acid composition of six of these was determined. The oil ofLindera umbellata had 4% ofcis-4-decenoic, 47% ofcis-4-dodecenoic, and 5% ofcis-4-tetradecenoic acid in the total fatty acids. Positive identification of these acids was made and new derivatives were prepared. Possible routes of biosynthesis are discussed.Oils from the other species did not contain more than a trace of unsaturated C(10)-C(14) acids. Their major acids were capric and lauric with varying amounts of unsaturated C(18) acids.