Letters to the Editor Letters to the Editor are welcomed and will be published, iffound suitable, as space permits. Submission of a Letter to the Editor constitutes permission for its publication in the Journal. Letters should not duplicate similar material being submitted or published elsewhere. Letters referring to a recent Journal article should be received within three months of the article's publication. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and should not exceed 400 words.
Incorporation of Pyrazinamide into Community-Wide Treatment of Tuberculosis In 1986, the American Thoracic Society and the Centers for Disease Control (ATS/CDC) revised their joint recommendation for treatment of tuberculosis to include the option of using pyrazinamide in the initial drug regime. ' This recommendation was based on the 100
information that pyrazinamide, when added for the first two months of a regime ofisoniazid and rifampin, allows a reduction in length of therapy from nine to six months for most patients.2-4 In comparison with the standard ninemonth isoniazid/rifampin regime, the six-month pyrazinamide containing regime is equivalent in efficacy, costs no more, and has no more side effects.5 Since this recommendation was made, there has been no information on the acceptance of pyrazinamide by the medical profession in the United States. Consequently, the tuberculosis case registries of the Seattle-King County Department of Public Health for the month of September of the years 1986 through 1989 were reviewed. Cases that were receiving drug therapy for current tuberculosis were classified as to whether pyrazinamide was included in the initial regime. Cases that appeared in more than one registry were counted only the first time they appeared. Sixty-five patients were registered in September 1986, 86 in September 1987, 81 in September 1988, and 75 in
pevin:
HeaHuM Dewmnonly:
X4 Heed De
Prvate prctiti
otdpW practitonzer e r only
IL.75 I a
aj50 w' CL
g25
19% .0%
S90 FIGURE 1-Proportion of patients being treated for current tuberculosis who received pyrazhnaide (PZA) In the initial drug regimen (Patents evaluated were those induded in the Seatie-King Coumty tuberculosis registies for the stipulated months and years. The triplet bar graphs stratify patents acding to origin of medical superviion.)
AJPH December 1990, Vol. 80, No. 12
September 1989. The proportion of patients receiving care only at the Department of Public Health ranged between 52 percent and 68 percent; those receivingjoint public and private supervision, 15 to 22 percent; and those receiving only private care, 19 to 24 percent. Figure 1 shows utilization of pyrazinamide in the initial drug regime for patients under management by the Department of Public Health, private medical practitioners, and the two in partnership. Among patients receiving Department of Public Health care either exclusively or in partnership with a private practitioner, the proportion receiving pyrazinamide increased steadily and in September 1989 included a majority of all patients. By contrast, pyrazinamide did not appear in the initial regime ofpatients receiving private care exclusively until September 1988, and in September 1989, only one quarter of patients under private medical management were treated initially with pyrazinamide. This study indicates that the use of pyrazinamide is evolving slowly among private medical practitioners. A likely reason is that pyrazinamide has little familiarity among medical practitioners in the U.S. because the research that led to the ATS/CDC recommendation was done abroad;2-4 evaluations of the pyrazinamide containing regime in patients from this country have just begun to appear.6,7 This sluggish evolution in the treatment of tuberculosis should be viewed as a problem in technology transfer; the adoption of new procedures into clinical practice.8 Technology assessment and transfer has been identified as one of the three major steps in implementation of a strategic plan to eliminate tuberculosis from the US.9 On the basis of the present report, this agency and other interested and responsible parties such as the University of Washington, the Washington State Department of Health, and the American Lung Association of Washington have initiated joint efforts to introduce pyrazinamide more widely to the medical profession in this region. Presentations are currently being given at hospital grand rounds and continuing 1 525
LETTERS TO THE EDITOR
medical education seminars, and articles have been prepared for publication in appropriate bulletins and other local and regional medical literature. Results of this process to implement an important advance in the treatment of tuberculosis will be monitored on an ongoing basis. REFERENCES 1. American Thoracic Society/Centers for Disease Control. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986; 134:355-63. 2. Hong Kong Chest Service/British Medical Research Council. Controlled trial of four thriceweekly regimens and a daily regimen all given for 6 months for pulmonary tuberculosis. Lancet 1981; 1:171-4. 3. East and Central AfricanlBritish Medical Research Council. Fifth collaborative study, controlled clinical trial of r short-course regimens of chemotherapy (three 6-month and one 8-month) for pulmonary tuberculosis. Tubercle 1983; 64:153-6. 4. Singapore Tuberculosis Service/British Medical Research Council. Clinical trial of six-month and four-month regimens of chemotherapy in the treatment of pulmonary tuberculosis. Tubercle 1981; 62:95. 5. Judd K, Miller R, Luft H, Hopewell P. (abstract) Outcomes and costs of tuberculosis treatment strategies in the United States. Am Rev Respir Dis 1989; 139:A314. 6. Combs DL, O'Brien RJ, Geiter U. USPHS Tuberculosis short course chemotherapy study 21 :effectiveness, toxicity, and acceptability. The report offinal results. Ann Intern Med 1990; 112:397-406. 7. Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbara JA. A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed and cost effective regimen. Ann Intern Med 1990; 112:407-415. 8. Reichman LB. The national tuberculosis training initiative. Am Intern Med 1989; 197-8. 9. Centers for Disease Control. A Strategic Plan for the Elimination of Tuberculosis in the United States. MMWR 1989; 38 (Suppl. No. S-3): 1-25. Charles M. Nolan, MD Seattle-King County Department of Public Health, 610 Third Avenue, Seattle, WA 98104.
Dietary Vitamin C Intake and Cigarette Smoking In two recent articles in this Journal using the NHANES II 24-hour dietary
recall data, Schechtman and colleagues' and Subar and colleagues2 found decreased intake ofvitamin C in the diets of cigarette smokers compared with nonsmokers. To pursue this finding in a different setting, we analyzed smoking and food frequency-based dietary data from two large epidemiologic studiesone a prospective cohort study of 17,818 White males mostly from the upper midwest area ofthe US,3 and the other a large study of 855 White oral cancer cases and 975 population-based controls conducted in four areas of the US.4 We utilized the food frequency data (37 questions for the cohort study, 61 for the case-control study), together with information on usual portion size derived from the Second National Health and Nutritional Examination Survey (NHANES II) and information on food, vitamin C and calorie content from the US Department of Agriculture, to estimate each person's usual dietary vitamin C intake.5 Imputed median values were used for missing data items. Table 1 shows dietary vitamin C intake according to cigarette smoking level. Mean vitamin C intake shows a clear downward trend (p < .001) with increasing levels of cigarette smoking among the men of the cohort. In the case-control study, all current smokers combined consumed significantly (p < .001) less vitamin C than nonsmokers, with a significant overall downward trend (p = .002). When examined by sex and case-control status, the trends were not significant. Vitamin C intake among ex-smokers tended to be intermediate between those of nonsmokers and current smokers. In both studies, users of tobacco other than cigarettes did not consume less vitamin C than the nonsmokers (not shown). Vitamin C values were also adjusted (not shown) for total calorie consumption from the reported
food frequency data (vitamin C per 1,000 calories), body mass, age, education, alcohol consumption, and surrogate interviews, with no effect on the patterns reported in Table 1. The data from these two studies support previous reports from 24-hour recall data in USI,2 and Canadian6 surveys that found smokers to have lower dietary intake of vitamin C. While the absolute levels of vitamin C intake reported here are somewhat higher than those of the surveys in the US or Canada, the relative relationships were the same. Hence research into the etiologic role of vitamin C in cancer or other diseases should consider potential confounding by cigarette smoking, while prevention strategies involving vitamin C might include smokers among target groups for intervention. REFERENCES 1. Schectman G, Byrd JC, Gruchow HW: The influence of smoking on vitamin C status in adults. Am J Public Health 1989;79:158-162. 2. Subar AF, Harlan LC, Mattson ME: Food and nutrient intake differences between smokers and non-smokers in the US. Am J Public Health 1990;80:(in press November). 3. Bjelke E: Epidemiologic studies of cancer of the stomach, colon, and rectum with special emphasis on the role of diet. Vols. I-IV. PhD Thesis: University of Minnesota. Ann Arbor, Michigan: University Microfilms, 1973. 4. McLaughlin JK, Gridley G, Block G, et al: Dietary factors in oral and pharyngeal cancer.
JNCI 1988;80:1237-1243. 5. Dresser CM: From nutrient data to a data base for a Health and Nutrition Examination Survey. Organization, coding and values-real or imputed. In: Tobelmann R (ed): Proceedings of the Eighth National Nutrient Data Base Conference, Minneapolis, MN, July 1983. Available from the US Dept of Commerce, NTIS, Springfield, VA. 6. Pelletier 0: Vitamin C and tobacco. Int J Vit Nutr Res 1977;16(suppl): 147-169. Gloria Gridley, MS Joseph K. McLaughlin, PhD William J. Blot, PhD Epidemiology and Biostatistics Program, Division of Cancer Etiology, National Cancer Institute, Rockville, MD 20892.
TABLE 1-Mean Dietary Vitamin C intakea (and number of sublects) by Level of Cigarette Use in a Cohort Study and a Case-Control Study Case-Control Men
Women
Cigarette Use
Cohorth mean (n)
cases mean (n)
controls mean (n)
cases mean (n)
controls mean (n)
Non-smokers Ex-smokers Current smokers 1-19 cig/day 20-29 cig/day 30+ cig/day
113(3878) 108 (5301) 104 (5035) 109 (1817) 103 (2243) 98 (975)
163 (37) 157 (101) 140 (386) 135 (30) 129 (112) 145 (244)
185(139) 184 (232) 158 (222) 168 (36) 153 (87) 159 (99)
154 (39) 126 (18) 126 (227) 137 (31) 130 (80) 121 (116)
167(150) 162 (68) 151 (116) 175 (34) 126 (53) 168 (29)
aMean vitamin C expressed in units of mg/day. b3975 men who used tobacco other than cigarettes or had unknown tobacco status were excluded.
1526
AJPH December 1990, Vol. 81, No. 12
Incorporation of Pyrazinamide into Community-Wide Treatment of Tuberculosis In 1986, the American Thoracic Society and the Centers for Disease Control (ATS/CDC) revised their joint recommendation for treatment of tuberculosis to include the option of using pyrazinamide in the initial drug regime. ' This recommendation was based on the 100
information that pyrazinamide, when added for the first two months of a regime ofisoniazid and rifampin, allows a reduction in length of therapy from nine to six months for most patients.2-4 In comparison with the standard ninemonth isoniazid/rifampin regime, the six-month pyrazinamide containing regime is equivalent in efficacy, costs no more, and has no more side effects.5 Since this recommendation was made, there has been no information on the acceptance of pyrazinamide by the medical profession in the United States. Consequently, the tuberculosis case registries of the Seattle-King County Department of Public Health for the month of September of the years 1986 through 1989 were reviewed. Cases that were receiving drug therapy for current tuberculosis were classified as to whether pyrazinamide was included in the initial regime. Cases that appeared in more than one registry were counted only the first time they appeared. Sixty-five patients were registered in September 1986, 86 in September 1987, 81 in September 1988, and 75 in
pevin:
HeaHuM Dewmnonly:
X4 Heed De
Prvate prctiti
otdpW practitonzer e r only
IL.75 I a
aj50 w' CL
g25
19% .0%
S90 FIGURE 1-Proportion of patients being treated for current tuberculosis who received pyrazhnaide (PZA) In the initial drug regimen (Patents evaluated were those induded in the Seatie-King Coumty tuberculosis registies for the stipulated months and years. The triplet bar graphs stratify patents acding to origin of medical superviion.)
AJPH December 1990, Vol. 80, No. 12
September 1989. The proportion of patients receiving care only at the Department of Public Health ranged between 52 percent and 68 percent; those receivingjoint public and private supervision, 15 to 22 percent; and those receiving only private care, 19 to 24 percent. Figure 1 shows utilization of pyrazinamide in the initial drug regime for patients under management by the Department of Public Health, private medical practitioners, and the two in partnership. Among patients receiving Department of Public Health care either exclusively or in partnership with a private practitioner, the proportion receiving pyrazinamide increased steadily and in September 1989 included a majority of all patients. By contrast, pyrazinamide did not appear in the initial regime ofpatients receiving private care exclusively until September 1988, and in September 1989, only one quarter of patients under private medical management were treated initially with pyrazinamide. This study indicates that the use of pyrazinamide is evolving slowly among private medical practitioners. A likely reason is that pyrazinamide has little familiarity among medical practitioners in the U.S. because the research that led to the ATS/CDC recommendation was done abroad;2-4 evaluations of the pyrazinamide containing regime in patients from this country have just begun to appear.6,7 This sluggish evolution in the treatment of tuberculosis should be viewed as a problem in technology transfer; the adoption of new procedures into clinical practice.8 Technology assessment and transfer has been identified as one of the three major steps in implementation of a strategic plan to eliminate tuberculosis from the US.9 On the basis of the present report, this agency and other interested and responsible parties such as the University of Washington, the Washington State Department of Health, and the American Lung Association of Washington have initiated joint efforts to introduce pyrazinamide more widely to the medical profession in this region. Presentations are currently being given at hospital grand rounds and continuing 1 525
LETTERS TO THE EDITOR
medical education seminars, and articles have been prepared for publication in appropriate bulletins and other local and regional medical literature. Results of this process to implement an important advance in the treatment of tuberculosis will be monitored on an ongoing basis. REFERENCES 1. American Thoracic Society/Centers for Disease Control. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986; 134:355-63. 2. Hong Kong Chest Service/British Medical Research Council. Controlled trial of four thriceweekly regimens and a daily regimen all given for 6 months for pulmonary tuberculosis. Lancet 1981; 1:171-4. 3. East and Central AfricanlBritish Medical Research Council. Fifth collaborative study, controlled clinical trial of r short-course regimens of chemotherapy (three 6-month and one 8-month) for pulmonary tuberculosis. Tubercle 1983; 64:153-6. 4. Singapore Tuberculosis Service/British Medical Research Council. Clinical trial of six-month and four-month regimens of chemotherapy in the treatment of pulmonary tuberculosis. Tubercle 1981; 62:95. 5. Judd K, Miller R, Luft H, Hopewell P. (abstract) Outcomes and costs of tuberculosis treatment strategies in the United States. Am Rev Respir Dis 1989; 139:A314. 6. Combs DL, O'Brien RJ, Geiter U. USPHS Tuberculosis short course chemotherapy study 21 :effectiveness, toxicity, and acceptability. The report offinal results. Ann Intern Med 1990; 112:397-406. 7. Cohn DL, Catlin BJ, Peterson KL, Judson FN, Sbarbara JA. A 62-dose, 6-month therapy for pulmonary and extrapulmonary tuberculosis. A twice-weekly, directly observed and cost effective regimen. Ann Intern Med 1990; 112:407-415. 8. Reichman LB. The national tuberculosis training initiative. Am Intern Med 1989; 197-8. 9. Centers for Disease Control. A Strategic Plan for the Elimination of Tuberculosis in the United States. MMWR 1989; 38 (Suppl. No. S-3): 1-25. Charles M. Nolan, MD Seattle-King County Department of Public Health, 610 Third Avenue, Seattle, WA 98104.
Dietary Vitamin C Intake and Cigarette Smoking In two recent articles in this Journal using the NHANES II 24-hour dietary
recall data, Schechtman and colleagues' and Subar and colleagues2 found decreased intake ofvitamin C in the diets of cigarette smokers compared with nonsmokers. To pursue this finding in a different setting, we analyzed smoking and food frequency-based dietary data from two large epidemiologic studiesone a prospective cohort study of 17,818 White males mostly from the upper midwest area ofthe US,3 and the other a large study of 855 White oral cancer cases and 975 population-based controls conducted in four areas of the US.4 We utilized the food frequency data (37 questions for the cohort study, 61 for the case-control study), together with information on usual portion size derived from the Second National Health and Nutritional Examination Survey (NHANES II) and information on food, vitamin C and calorie content from the US Department of Agriculture, to estimate each person's usual dietary vitamin C intake.5 Imputed median values were used for missing data items. Table 1 shows dietary vitamin C intake according to cigarette smoking level. Mean vitamin C intake shows a clear downward trend (p < .001) with increasing levels of cigarette smoking among the men of the cohort. In the case-control study, all current smokers combined consumed significantly (p < .001) less vitamin C than nonsmokers, with a significant overall downward trend (p = .002). When examined by sex and case-control status, the trends were not significant. Vitamin C intake among ex-smokers tended to be intermediate between those of nonsmokers and current smokers. In both studies, users of tobacco other than cigarettes did not consume less vitamin C than the nonsmokers (not shown). Vitamin C values were also adjusted (not shown) for total calorie consumption from the reported
food frequency data (vitamin C per 1,000 calories), body mass, age, education, alcohol consumption, and surrogate interviews, with no effect on the patterns reported in Table 1. The data from these two studies support previous reports from 24-hour recall data in USI,2 and Canadian6 surveys that found smokers to have lower dietary intake of vitamin C. While the absolute levels of vitamin C intake reported here are somewhat higher than those of the surveys in the US or Canada, the relative relationships were the same. Hence research into the etiologic role of vitamin C in cancer or other diseases should consider potential confounding by cigarette smoking, while prevention strategies involving vitamin C might include smokers among target groups for intervention. REFERENCES 1. Schectman G, Byrd JC, Gruchow HW: The influence of smoking on vitamin C status in adults. Am J Public Health 1989;79:158-162. 2. Subar AF, Harlan LC, Mattson ME: Food and nutrient intake differences between smokers and non-smokers in the US. Am J Public Health 1990;80:(in press November). 3. Bjelke E: Epidemiologic studies of cancer of the stomach, colon, and rectum with special emphasis on the role of diet. Vols. I-IV. PhD Thesis: University of Minnesota. Ann Arbor, Michigan: University Microfilms, 1973. 4. McLaughlin JK, Gridley G, Block G, et al: Dietary factors in oral and pharyngeal cancer.
JNCI 1988;80:1237-1243. 5. Dresser CM: From nutrient data to a data base for a Health and Nutrition Examination Survey. Organization, coding and values-real or imputed. In: Tobelmann R (ed): Proceedings of the Eighth National Nutrient Data Base Conference, Minneapolis, MN, July 1983. Available from the US Dept of Commerce, NTIS, Springfield, VA. 6. Pelletier 0: Vitamin C and tobacco. Int J Vit Nutr Res 1977;16(suppl): 147-169. Gloria Gridley, MS Joseph K. McLaughlin, PhD William J. Blot, PhD Epidemiology and Biostatistics Program, Division of Cancer Etiology, National Cancer Institute, Rockville, MD 20892.
TABLE 1-Mean Dietary Vitamin C intakea (and number of sublects) by Level of Cigarette Use in a Cohort Study and a Case-Control Study Case-Control Men
Women
Cigarette Use
Cohorth mean (n)
cases mean (n)
controls mean (n)
cases mean (n)
controls mean (n)
Non-smokers Ex-smokers Current smokers 1-19 cig/day 20-29 cig/day 30+ cig/day
113(3878) 108 (5301) 104 (5035) 109 (1817) 103 (2243) 98 (975)
163 (37) 157 (101) 140 (386) 135 (30) 129 (112) 145 (244)
185(139) 184 (232) 158 (222) 168 (36) 153 (87) 159 (99)
154 (39) 126 (18) 126 (227) 137 (31) 130 (80) 121 (116)
167(150) 162 (68) 151 (116) 175 (34) 126 (53) 168 (29)
aMean vitamin C expressed in units of mg/day. b3975 men who used tobacco other than cigarettes or had unknown tobacco status were excluded.
1526
AJPH December 1990, Vol. 81, No. 12
