Objective: To understand associations of punitive policies to the population prevalence of injection drug users and to HIV seroprevalence among injectors. Design and methods: A lagged-cross-sectional analysis of metropolitan statistical area data. Estimates of drug injectors per capita and of HIV seroprevalence among injectors in 89 large US metropolitan areas were regressed on three measures of legal repressiveness (hard drug arrests per capita; police employees per capita; and corrections expenditures per capita) controlling for other metropolitan area characteristics. Results: No legal repressiveness measures were associated with injectors per capita; all three measures of legal repressiveness were positively associated with HIV prevalence among injectors. Conclusions: These findings suggest that legal repressiveness may have little deterrent effect on drug injection and may have a high cost in terms of HIV and perhaps other diseases among injectors and their partners – and that alternative methods of maintaining social order should be investigated.

This study examined commuting patterns among 23,141 methadone patients enrolling in 84 opioid treatment programs (OTPs) in the United States. Patients completed an anonymous one-page survey. A linear mixed model analysis was used to predict distance traveled to the OTP. More than half (60%) the patients traveled <10 miles and 6% travelled between 50 and 200 miles to attend an OTP; 8% travelled across a state border to attend an OTP. In the multivariate model (n=17,792), factors significantly (P<.05) associated with distance were, residing in the Southeast or Midwest, low urbanicity, area of the patient's ZIP code, younger age, non-Hispanic white race/ethnicity, prescription opioid abuse, and no heroin use. A significant number of OTP patients travel considerable distances to access treatment. To reduce obstacles to OTP access, policy makers and treatment providers should be alert to patients' commuting patterns and to factors associated with them.

Research from JAMA — Identification of a W Variant Outbreak of Mycobacterium tuberculosis via Population-Based Molecular Epidemiology — ContextTyping of Mycobacterium tuberculosis could provide a more sensitive means of identifying outbreaks than use of conventional surveillance techniques alone. Variants of the New York City W strain of M tuberculosis were identified in New Jersey.ObjectiveTo describe the spread of the W family of M tuberculosis strains in New Jersey identified by molecular typing and surveillance data.DesignPopulation-based cross-sectional study.Setting and SubjectsAll incident culture-positive tuberculosis cases reported in New Jersey from January 1996 to September 1998, for which the W family was defined by insertion sequence (IS) IS6110 DNA fingerprinting, polymorphic GC-rich repetitive sequence (PGRS) typing, spacer oligotyping (spoligotyping), and variable number tandem repeat (VNTR) analysis.Main Outcome MeasureIdentification and characterization of W family clones supplemented by surveillance data.ResultsIsolates from 1207 cases were analyzed, of which 68 isolates (6%) belonged to the W family based on IS6110 and spoligotype hybridization patterns. The IS6110 hybridization patterns or fingerprints revealed that 43 patients (designated group A) shared a unique banding motif not present in other W family isolates. Strains collected from the remaining 25 patients (designated group B), while related to W, displayed a variety of IS6110 patterns and did not share this motif. The PGRS and VNTR typing confirmed the division of the W family into groups A and B and again showed group A strains to be closely related and group B strains to be more diverse. The demographic characteristics of individuals from groups A and B were specific and defined. Group A patients were more likely than group B patients to be US born (91% vs 24%, P<.001), black (76% vs 16%, P<.001), human immunodeficiency virus positive (40% vs 0%, P = .007), and residents of urban northeast New Jersey counties (P<.001). Patients with group B strains were primarily non-US born, of Asian descent, and more dispersed throughout New Jersey. No outbreak had been detected using conventional surveillance alone.ConclusionsThe implementation of multiple molecular techniques in conjunction with surveillance data enabled us to identify a previously undetected outbreak in a defined geographical setting. The outbreak isolates comprise members of a distinct branch of the W family phylogenetic lineage. The use of molecular strain typing provides a proactive approach that may be used to initiate, and not just augment, traditional surveillance outbreak investigations.

Infective endocarditis is a potentially fatal consequence of illicit injection drug use. We estimate that the number of hospitalization for injection