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Volume  6, Number 11                                           April 25, 1993

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                         Editor: David Dodell, D.M.D.
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Compilation Copyright 1993 by David Dodell,  D.M.D.  All  rights  Reserved.  
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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





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Volume  6, Number 11                                           April 25, 1993



::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
               Centers for Disease Control and Prevention - MMWR
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

               Rates of Cesarean Delivery -- United States, 1991
               =================================================
                   SOURCE: MMWR 42(15)   DATE: Apr 23, 1993

     Cesarean deliveries have accounted for nearly 1 million of the 
approximately 4 million annual deliveries in the United States since 1986 
(Table 1). The cesarean rate in the United States is the third highest among 
21 reporting countries, exceeded only by Brazil and Puerto Rico (1). This 
report presents data on cesarean deliveries from CDC's National Hospital 
Discharge Survey (NHDS) for 1991 and compares these data with previous years. 
     Data on discharges from short-stay, nonfederal hospitals have been 
collected annually since 1965 in the NHDS, conducted by CDC's National Center 
for Health Statistics. For 1991, medical and demographic information were 
abstracted from a sample of 274,000 inpatients discharged from 484 
participating hospitals. The 1991 cesareans and vaginal births after a prior 
cesarean (VBAC) presented in this report are based on weighted national 
estimates from the NHDS sample of approximately 31,000 (11%) women discharged 
after delivery. The estimated numbers of live births by type of delivery were 
calculated by applying cesarean rates from the NHDS to live births from 
national vital registration data. Therefore, estimates of the number of 
cesareans in this report will not agree with previously published data based 
solely on the NHDS (2). Stated differences in this analysis are significant at 
the 95% confidence level, based on the two-tailed t-test with a critical value 
of 1.96. 
     In 1991, there were 23.5 cesareans per 100 deliveries, the same rate as 
in 1990 and similar to rates during 1986-1989 (Table 1). The primary cesarean 
rate (i.e., number of first cesareans per 100 deliveries to women who had no 
previous cesareans) for 1986-1991 also was stable, ranging from 16.8 to 17.5. 
In 1991, the cesarean rate in the South was 27.6, significantly (p<0.05) 
higher than the rates for the West (19.8), Midwest (21.8), and Northeast 
(22.6). Rates were higher for mothers aged greater than or equal to 30 years 
than for younger women; in proprietary hospitals than in nonprofit or 
government hospitals; in hospitals with fewer than 300 beds than in larger 
hospitals; and for deliveries for which Blue Cross/Blue Shield * and other 
private insurance is the expected source of payment than for other sources of 
payment (Table 2). The same pattern characterized primary cesarean deliveries. 
     Since the early 1970s, the number and percentage of births to older women 
increased; however, if the age distribution of mothers in 1991 had remained 
the same as in 1986, the overall cesarean rate in 1991 would have been 23.3, 
essentially the same as the 23.5 observed. 
     Based on the NHDS, of the approximately 4,111,000 live births in 1991, an 

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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 

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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. 


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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 

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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 

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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.


















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Volume  6, Number 11                                           April 25, 1993



::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
                                  Dental News
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

            International Workshop Explores Oral Manifestations of
                                 HIV Infection

                             NIDR Research Digest
                             written by Jody Dove
                                  March 1993
                     National Institute of Dental Research

     At the Second International Workshop on the Oral Manifestations of HIV 
Infection, held January 31-February 3 in San Francisco, participants explored 
issues related to the epidemiology, basic molecular virology, mucosal 
immunology, and oral clinical presentations of HIV infection. 
     The workshop was organized by Dr. John Greenspan and Dr. Deborah 
Greenspan of the Department of Stomatology, School of Dentistry, University of 
California, San Francisco.  An international steering committee and scientific 
program committee provided guidance. 
     The conference drew more than 260 scientists from 39 countries, including 
Asia, Africa, Europe, Central America, South America, as well as the United 
States and Canada.  Support tor the workshop was provided by the National 
Institute of Dental Research, the National Cancer Institute, the National 
Institute of Allergy and Infectious Diseases, the NIH Office of AIDS Research, 
and the Procter and Gamble Company. 
     Among the topics discussed were: the epidemiology of HIV lesions; ethics, 
professional responsibility, and public policy; occupational issues; provision 
of oral care to the HIV-positive population; salivary HIV transmission and 
mucosal immunity; opportunistic infections; pediatric HIV infection; and 
women's issues. 

                                Recommendations

     Recommendations emerged from the workshop to define the association 
between the appearance of oral lesions and rate of progression of HIV, to 
establish a universal terminology for HIV-associated oral lesions, to look for 
more effective treatments for oral manifestations, to expand molecular biology 
studies to understand the relationship between HIV infection and common oral 
lesions, and to study the effects of HIV therapy on oral lesions. 

                                 Epidemiology

     Since the First International Workshop on Oral Manifestations of HIV 
Infection was convened five years ago, the epidemiology of HIV infection has 

HICNet Medical Newsletter                                              Page 11
Volume  6, Number 11                                           April 25, 1993

radically changed.  In 1988, HIV infection was detected and reported largely 
in homosexual and bisexual males, intravenous drug users, and hemophiliacs.  
Today, more HIV infection is seen in heterosexual males and females and in 
children and adolescents. 
     While the predominant impact of HIV infection has been felt in Africa, a 
major increase in infection rate is being seen in Southeast Asia as well.  
Five hundred thousand cases have been reported to date in this region and more 
are appearing all the time. 
     Researchers are continuing to document the epidemiology of oral lesions 
such as hairy leukoplakia and candidiasis.  They also are beginning to explore 
the relationships between specific oral lesions and HIV disease progression 
and prognosis. 

                            Social/political Issues

     Discussion on the social and political implications of HIV infection 
focused on changing the public's attitude that AIDS is retribution for 
indiscriminate sexual behavior and drug use.  Speakers also addressed health 
care delivery for HIV-infected patients, and the need to educate the public 
about what AIDS is, and how it is acquired. 

                          Saliva and Salivary Glands

     Conference speakers described transmission issues and the HIV-inhibitory 
activity of saliva, the strength of which varies among the different salivary 
secretions.  Whole saliva has a greater inhibitory effect than submandibular 
secretions, which in turn have a greater inhibitory effect than parotid 
secretions.  Research has shown that at least two mechanisms are responsible 
for salivary inhibitory activity.  They attributed the HIV-inhibitory effect 
of saliva to the 1) aggregation/agglutination of HIV by saliva, which may both 
promote clearance of virus and prevent it reaching a target cell, and 2) 
direct effects on the virus or target cells. 
     Other topics discussed were the manifestation of salivary gland disease 
in HIV-infected persons and current research on oral mucosal immunity. 

                               Pediatric Issues

     Pediatric AIDS recently has emerged as an area of intense interest.  With 
early and accurate diagnosis and proper treatment, the life expectancy of HIV-
infected children has tripled.  The prevention of transmission of HIV from 
mother to child may be possible in many cases, particularly if the mother's 
sero-status is known prior to giving birth. 

                    Periodontal and Gingival Tissue Disease


HICNet Medical Newsletter                                              Page 12
Volume  6, Number 11                                           April 25, 1993

     Oral health researchers continue to explore periodontal diseases and 
gingivitis found in individuals with HIV infection.  Recommendations made at 
the workshop include the standardization of terminology, refinement of 
diagnostic markers, standardization of study design, and proper consideration 
of confounding variables resulting from periodontal therapy. 

                       Occupational and Treatment Issues

     Occupational issues surrounding the treatment of HIV-infected individuals 
and treatment rendered by HIV-infected health care professionals still command 
considerable attention.  Factors under consideration include the cost/benefit 
of HIV testing, patient-to-health care provider transmission of HIV infection 
and the reverse, and the use of mainstream versus dedicated facilities for the 
treatment of HIV-infected patients. 
     Conference participants anticipate that a third International Workshop on 
the Oral Manifestations of HIV Infection will be held in five years or less.  
Proceedings from the second workshop will be published by the Quintessence 
Company in late 1993.






















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