Asthma-related mortality after release from prison: a retrospective data linkage study.

BACKGROUND: People who experience incarceration are at increased risk of asthma and have a higher prevalence of risk factors associated with asthma-related mortality. However, there has been little research on the relationship between asthma and mortality in people released from prison. OBJECTIVES: This study examined the association between asthma and all-cause and cause-specific mortality, and estimated the increased risk of asthma-related mortality among adults released from prison compared to the age- and sex-matched general population. DESIGN: We used data from a nested case-control sample (N = 1658) within a retrospective cohort study of all adults released from prisons in Queensland, Australia, from 1994 to 2007 (N = 42015). Deaths were identified using linkage to national mortality records. Nested study cases were sampled from deaths, with a matched control from the cohort. We examined medical and case management records to identify risk factors potentially associated with mortality. Asthma-related mortality in the cohort was compared to that of the matched general population of Queensland. RESULTS: People released from prison were more likely than their age and sex matched general population counterparts to have an asthma-related death (HR = 3.32 95%CI:2.14-5.16). Those who had been identified as having asthma in prison had increased odds of mortality from all-cause (OR = 1.86 95%CI:1.40-2.47), drug-related (OR = 2.5 95%CI:1.40-4.46), cardiovascular-related (OR = 3.2 95%CI:1.57-6.51), and respiratory-related (OR = 3.30 95%CI:1.63-6.70). CONCLUSION: Among people exposed to incarceration, those with asthma are at elevated risk of death after release from custody. Improved management of respiratory disease in this population may contribute to reducing their high rate of preventable mortality.

Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis.

BACKGROUND: The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis. METHODS: We analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression. RESULTS: Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28 days, VFD were 16 (IQR 0-25) and 25 (IQR 7-26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0-87) and 87 (IQR 0-88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p = 0.177). CONCLUSIONS: In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.

Schistosomiasis in the People's Republic of China - down but not out.

Schistosomiasis has been subjected to extensive control efforts in the People's Republic of China (China) which aims to eliminate the disease by 2030. We describe baseline results of a longitudinal cohort study undertaken in the Dongting and Poyang lakes areas of central China designed to determine the prevalence of Schistosoma japonicum in humans, animals (goats and bovines) and Oncomelania snails utilizing molecular diagnostics procedures. Data from the Chinese National Schistosomiasis Control Programme (CNSCP) were compared with the molecular results obtained.Sixteen villages from Hunan and Jiangxi provinces were surveyed; animals were only found in Hunan. The prevalence of schistosomiasis in humans was 1.8% in Jiangxi and 8.0% in Hunan determined by real-time polymerase chain reaction (PCR), while 18.3% of animals were positive by digital droplet PCR. The CNSCP data indicated that all villages harboured S. japonicum-infected individuals, detected serologically by indirect haemagglutination assay (IHA), but very few, if any, of these were subsequently positive by Kato-Katz (KK).Based on the outcome of the IHA and KK results, the CNSCP incorporates targeted human praziquantel chemotherapy but this approach can miss some infections as evidenced by the results reported here. Sensitive molecular diagnostics can play a key role in the elimination of schistosomiasis in China and inform control measures allowing for a more systematic approach to treatment.

An appraisal of respiratory system compliance in mechanically ventilated covid-19 patients.

BACKGROUND: Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous small-case series or studies conducted at a national level. METHODS: We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe CRS-calculated as: tidal volume/[airway plateau pressure-positive end-expiratory pressure (PEEP)]-and its association with ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide. RESULTS: We studied 745 patients from 22 countries, who required admission to the ICU and MV from January 14 to December 31, 2020, and presented at least one value of CRS within the first seven days of MV. Median (IQR) age was 62 (52-71), patients were predominantly males (68%) and from Europe/North and South America (88%). CRS, within 48 h from endotracheal intubation, was available in 649 patients and was neither associated with the duration from onset of symptoms to commencement of MV (p = 0.417) nor with PaO2/FiO2 (p = 0.100). Females presented lower CRS than males (95% CI of CRS difference between females-males: - 11.8 to - 7.4 mL/cmH2O p < 0.001), and although females presented higher body mass index (BMI), association of BMI with CRS was marginal (p = 0.139). Ventilatory management varied across CRS range, resulting in a significant association between CRS and driving pressure (estimated decrease - 0.31 cmH2O/L per mL/cmH20 of CRS, 95% CI - 0.48 to - 0.14, p < 0.001). Overall, 28-day ICU mortality, accounting for the competing risk of being discharged within the period, was 35.6% (SE 1.7). Cox proportional hazard analysis demonstrated that CRS (+ 10 mL/cm H2O) was only associated with being discharge from the ICU within 28 days (HR 1.14, 95% CI 1.02-1.28, p = 0.018). CONCLUSIONS: This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV. CRS measured within 48 h from commencement of MV has marginal predictive value for 28-day mortality, but was associated with being discharged from ICU within the same period. Trial documentation: Available at https://www.covid-critical.com/study . TRIAL REGISTRATION: ACTRN12620000421932.

Why do psychiatric patients have higher cancer mortality rates when cancer incidence is the same or lower?

OBJECTIVE: Studies of overall cancer incidence and mortality in psychiatric patients have had mixed results. Some have reported lower than expected cancer incidence or mortality, while others have found no association or an increased risk depending on sample, psychiatric diagnosis, cancer site and methodology. Few studies have compared cancer incidence and mortality using the same population and methodology. METHOD: A population-based record-linkage analysis to compare cancer incidence and mortality in psychiatric patients with that for the general Queensland population, using an historical cohort to calculate age- and sex-standardised rate ratios and hazard ratios. Mental health records were linked with cancer registrations and death records from 2002 to 2007. RESULTS: There were 89,992 new cancer cases, of which 3349 occurred in people with mental illness. Cancer incidence was the same as the general population for most psychiatric disorders. Rates were actually lower for dementia (hazard ratio = 0.77; 95% confidence interval = [0.67, 0.88]) and schizophrenia (hazard ratio = 0.84; 95% confidence interval = [0.72, 0.98]). By contrast, mortality was increased in psychiatric patients (hazard ratio = 2.27; 95% confidence interval = [2.15, 2.39]) with elevated hazard ratios for all the main psychiatric diagnoses. CONCLUSIONS: Lifestyle, such as alcohol or tobacco use, would not explain our findings that people with mental illness are no more likely than the general population to develop cancer but more likely to die of it. Other factors may be the difficulty in differentiating medically explained and unexplained symptoms, greater case fatality or inequity in access to specialist procedures. The study highlights the need for improved cancer screening, detection and intervention in this population.

Spatial Analysis of Schistosomiasis in Hunan and Jiangxi Provinces in the People's Republic of China.

Understanding the spatial distribution of schistosome infection is critical for tailoring preventive measures to control and eliminate schistosomiasis. This study used spatial analysis to determine risk factors that may impact Schistosoma japonicum infection and predict risk in Hunan and Jiangxi Provinces in the People's Republic of China. The study employed survey data collected in Hunan and Jiangxi in 2016. Independent variable data were obtained from publicly available sources. Bayesian-based geostatistics was used to build models with covariate fixed effects and spatial random effects to identify factors associated with the spatial distribution of infection. Prevalence of schistosomiasis was higher in Hunan (12.8%) than Jiangxi (2.6%). Spatial distribution of schistosomiasis varied at pixel level (0.1 × 0.1 km), and was significantly associated with distance to nearest waterbody (km, ß = -1.158; 95% credible interval [CrI]: -2.104, -0.116) in Hunan and temperature (°C, ß = -4.359; 95% CrI: -9.641, -0.055) in Jiangxi. The spatial distribution of schistosomiasis in Hunan and Jiangxi varied substantially and was significantly associated with distance to nearest waterbody. Prevalence of schistosomiasis decreased with increasing distance to nearest waterbody in Hunan, indicating that schistosomiasis control should target individuals in close proximity to open water sources as they are at highest risk of infection.

Assessment of 28-Day In-Hospital Mortality in Mechanically Ventilated Patients With Coronavirus Disease 2019: An International Cohort Study.

Factors associated with mortality in coronavirus disease 2019 patients on invasive mechanical ventilation are still not fully elucidated. OBJECTIVES: To identify patient-level parameters, readily available at the bedside, associated with the risk of in-hospital mortality within 28 days from commencement of invasive mechanical ventilation or coronavirus disease 2019. DESIGN SETTING AND PARTICIPANTS: Prospective observational cohort study by the global Coronavirus Disease 2019 Critical Care Consortium. Patients with laboratory-confirmed coronavirus disease 2019 requiring invasive mechanical ventilation from February 2, 2020, to May 15, 2021. MAIN OUTCOMES AND MEASURES: Patient characteristics and clinical data were assessed upon ICU admission, the commencement of invasive mechanical ventilation and for 28 days thereafter. We primarily aimed to identify time-independent and time-dependent risk factors for 28-day invasive mechanical ventilation mortality. RESULTS: One-thousand five-hundred eighty-seven patients were included in the survival analysis; 588 patients died in hospital within 28 days of commencing invasive mechanical ventilation (37%). Cox-regression analysis identified associations between the hazard of 28-day invasive mechanical ventilation mortality with age (hazard ratio, 1.26 per 10-yr increase in age; 95% CI, 1.16-1.37; p < 0.001), positive end-expiratory pressure upon commencement of invasive mechanical ventilation (hazard ratio, 0.81 per 5 cm H2O increase; 95% CI, 0.67-0.97; p = 0.02). Time-dependent parameters associated with 28-day invasive mechanical ventilation mortality were serum creatinine (hazard ratio, 1.28 per doubling; 95% CI, 1.15-1.41; p < 0.001), lactate (hazard ratio, 1.22 per doubling; 95% CI, 1.11-1.34; p < 0.001), Paco2 (hazard ratio, 1.63 per doubling; 95% CI, 1.19-2.25; p < 0.001), pH (hazard ratio, 0.89 per 0.1 increase; 95% CI, 0.8-14; p = 0.041), Pao2/Fio2 (hazard ratio, 0.58 per doubling; 95% CI, 0.52-0.66; p < 0.001), and mean arterial pressure (hazard ratio, 0.92 per 10 mm Hg increase; 95% CI, 0.88-0.97; p = 0.003). CONCLUSIONS AND RELEVANCE: This international study suggests that in patients with coronavirus disease 2019 on invasive mechanical ventilation, older age and clinically relevant variables monitored at baseline or sequentially during the course of invasive mechanical ventilation are associated with 28-day invasive mechanical ventilation mortality hazard. Further investigation is warranted to validate any causative roles these parameters might play in influencing clinical outcomes.

Efficacy of an 11-valent pneumococcal conjugate vaccine against radiologically confirmed pneumonia among children less than 2 years of age in the Philippines: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Pneumococcus is a leading cause of childhood pneumonia worldwide. Pneumococcal conjugate vaccines (PCV) have demonstrated efficacy against childhood invasive pneumococcal disease (IPD) and pneumonia in the United States and Africa. No information is available from Asia on the impact of PCV on childhood pneumonia. METHODS: We conducted a randomized, placebo-controlled, double-blind trial in Bohol, the Philippines (ISRCTN 62323832). Children 6 weeks to <6 months of age were randomly allocated to receive 3 doses of either an 11-valent PCV (11PCV, sanofi pasteur, Lyon, France) or a saline placebo, with a minimum interval of 4 weeks between doses to determine vaccine efficacy (VE) against the primary outcome of a child experiencing first episode of community-acquired radiologically defined pneumonia in the first 2 years of life. Secondary end points were clinical pneumonia, IPD, safety, and immunogenicity. RESULTS: Twelve thousand one hundred ninety-one children were enrolled. By per protocol (PP) analysis, 93 of 6013 fully vaccinated 11PCV recipient children had a first episode of radiologic pneumonia compared with 120 of 6018 placebo recipients. VE against radiologically defined pneumonia for the PP cohort of children 3 to 23 months old was 22.9% (95% CI: -1.1, 41.2; P = 0.06), for the prespecified subgroups of children 3 to 11 months of age, 34.0% (95% CI: 4.8, 54.3; P = 0.02), and of those 12 to 23 months old, 2.7% (95% CI: -43.5, 34.0; P = 0.88). By intent-to-treat (ITT) analysis, 119 of 6097 11PCV recipient children had an episode of radiologic pneumonia compared with 141 of 6094 placebo recipients. VE against radiologic pneumonia for the ITT cohort of children <2 years old was 16.0% (95% CI -7.3, 34.2; P = 0.16), for a subgroup of children <12 months of age, 19.8% (95% CI: -8.8, 40.8; P = 0.15). VE against clinical pneumonia by PP was not significant (VE 0.1%; 95% CI -9.4, 8.7; P = 0.99). IPD was rare: only 3 cases of IPD due to vaccine serotypes were observed during the study. 11PCV was immunogenic and well tolerated. Among 11PCV recipients, a small excess of serious adverse respiratory events was observed in the first 28 days after the first and second dose of vaccine, and of nonrespiratory events after the first dose. An excess of pneumonia episodes in 11PCV recipients in the month following the second dose of vaccination was the principal reason for lower VE by ITT analysis than by PP analysis. CONCLUSIONS: In PP analysis, a 22.9% reduction of community-acquired radiologically confirmed pneumonia in children younger than 2 years of age in the 11-valent tetanus-diphtheria toxoid-conjugated PCV vaccinated group was observed; a reduction similar as observed in other PCV trials. We could not demonstrate any VE against clinical pneumonia. Our finding confirms for the first time that in a low-income, low-mortality developing country in Asia, at least one-fifth of radiologically confirmed pneumonia is caused by pneumococcus, and thus preventable by PCV. Whether PCV should be included in national program in such settings, however, depends on careful country specific disease burden measurement and cost-effectiveness calculation.

A cluster randomized controlled cross-over bed net acceptability and preference trial in Solomon Islands: community participation in shaping policy for malaria elimination.

BACKGROUND: A key component of the malaria elimination strategy in Solomon Islands (SI) is widespread coverage of long-lasting insecticidal nets (LLINs). The success of this strategy is dependent on LLIN acceptability and compliance. There has been unresolved debate among policy makers and donors as to which type of LLIN would be most appropriate for large-scale distribution in SI, and anecdotal reports of a lack of acceptability of certain brands of LLINs. A cluster randomized controlled crossover bed net acceptability and preference trial was therefore carried out from July to September, 2008 to inform policy and to facilitate community engagement and participation in the selection of the most appropriate LLIN for use in SI. METHOD: A three-stage sampling method was used to randomly select the study population from Malaita Province, SI. Three brands of LLINs were assessed in this study: Olyset, PermaNet and DuraNet. Bed net acceptability and preference were evaluated through surveys at three defined time points after short and longer-term trial of each LLIN. RESULTS: The acceptability of PermaNet after short-term use (96.5%) was significantly greater than Olyset (67.3%, p < 0.001) and DuraNet (69.8%, p < 0.001). The acceptability of DuraNet and Olyset after short-term use was not significantly different at the 5% level. LLINs that were perceived not to prevent mosquito bites were significantly less acceptable than LLINs that were perceived to prevent mosquito bites (OR 0.15; 95%CI 0.03 to 0.6). LLINs that allow a pleasant night's sleep (OR 6.3; 95%CI:3.3-12.3) and have a soft texture (OR 5.7; 95%CI:1.9-20.5) were considered more acceptable than those that did not. Olyset's acceptability decreased over time and this was due to net wrinkling/shrinkage after washing resulting in reduced efficiency in preventing mosquito bites. The increase in DuraNet acceptability was a result of a reduction in minor adverse events following longer-term use. CONCLUSION: This research was conducted to inform LLIN procurement as part of the national malaria control and elimination programme in SI. The success of malaria elimination in the Pacific and elsewhere relies on provision of acceptable interventions, consideration of local-level realities and engagement of communities in strategy development. TRIAL REGISTRATIONS: Clinical trials ACTRN12608000322336.

Incidence and risk factors for mortality after release from prison in Australia: a prospective cohort study.

AIMS: To estimate the incidence and identify risk factors for mortality in adults released from prisons in the state of Queensland, Australia. DESIGN: Prospective cohort study, linking baseline survey data with a national death register. SETTING: Selected prisons within Queensland, Australia. PARTICIPANTS: Adults (n = 1320) recruited in Queensland prisons within 6 weeks of expected release, between August 2008 and July 2010, followed for up to 4.7 years in the community. MEASUREMENTS: Participants completed a comprehensive baseline survey covering psychosocial circumstances, physical and mental health, substance use and health risk behaviours. Clinical data were abstracted from prison medical records and obtained through probabilistic linkage with state-based, community health records. Dates of prison release and reincarceration were obtained from correctional records. Deaths were identified through probabilistic linkage with the National Death Index. Adjusted hazard ratios (AHR) were calculated using proportional hazards regression models. Standardized mortality ratios (SMR) were calculated using the population of Queensland as the reference. General population data were obtained from the Australian Bureau of Statistics. FINDINGS: The rate of mortality in the cohort was higher than in the age- and sex-matched general population of Queensland for all causes [SMR = 4.0, 95% confidence interval (CI) = 2.9-5.4] and drug-related causes (SMR = 32, 95% CI = 19-55). In a multivariable model, adjusting for age, sex and Indigenous status, factors associated with increased mortality risk included expecting to have average or better funds available on release (AHR = 2.9, 99% CI = 1.2-7.1), poor mental health (AHR = 2.6, 99% CI = 1.1-6.1) and self-reported life-time history of overdose (AHR = 2.5, 99% CI = 1.04-6.2). CONCLUSIONS: People released from prison in Queensland, Australia are at increased risk of death, due particularly to drug-related causes. Those at greatest risk of death are characterized by poor physical and mental health and a history of risky substance use.

Development and Validation of a National System for Routine Monitoring of Mortality in People Recently Released from Prison.

BACKGROUND: People released from prison are at increased risk of death. However, no country has established a system for routine monitoring of mortality in this population. The aims of this study were to (a) evaluate a system for routine monitoring of deaths after release from prison in Australia and (b) estimate the number of deaths annually within 28 and 365 days of prison release from 2000 to 2013. METHODS: Persons released from prison and deaths were identified in records held by Centrelink, Australia's national provider of unemployment benefits. Estimates generated in this manner were compared with those from a study that probabilistically linked correctional records with the National Death Index (NDI), for each calendar year 2000 to 2007. Using Centrelink data, national estimates of mortality within 28 and 365 days of release were produced for each calendar year 2000 to 2013. FINDINGS: Compared with estimates based on linkage with the NDI, the estimated crude mortality rate based on Centrelink records was on average 52% lower for deaths within 28 days of release and 24% lower for deaths within 365 days of release. Nationally, over the period 2000 to 2013, we identified an average of 32 deaths per year within 28 days of release and 188 deaths per year within 365 days of release. The crude mortality rate for deaths within both 28 and 365 days of release increased over this time. CONCLUSIONS: Using routinely collected unemployment benefits data we detected the majority of deaths in people recently released from prison in Australia. These data may be sufficient for routine monitoring purposes and it may be possible to adopt a similar approach in other countries. Routine surveillance of mortality in ex-prisoners serves to highlight their extreme vulnerability and provides a basis for evaluating policy reforms designed to reduce preventable deaths.

Epidemiology of Infectious Disease-Related Death After Release from Prison, Washington State, United States, and Queensland, Australia: A Cohort Study.

OBJECTIVES: People in prison may be at high risk for infectious diseases and have an elevated risk of death immediately after release compared with later; their risk of death is elevated for at least a decade after release. We compared rates, characteristics, and prison-related risk factors for infectious disease-related mortality among people released from prisons in Queensland, Australia, and Washington State, United States, regions with analogous available data. METHODS: We analyzed data from retrospective cohort studies of people released from prison in Queensland (1997-2007, n=37,180) and Washington State (1999-2009, n=76,208) and linked identifiers from each cohort to its respective national death index. We estimated infectious disease-related mortality rates (deaths per person-years in community) and examined associations using Cox proportional hazard models. RESULTS: The most frequent infectious disease-related underlying cause of death after release from prison was pneumonia (43%, 23/54 deaths) in the Australian cohort and viral hepatitis (40%, 69/171 deaths) in the U.S. cohort. The infectious disease-related mortality rate was significantly higher in the U.S. cohort than in the Australian cohort (51.2 vs. 26.5 deaths per 100,000 person-years; incidence rate ratio = 1.93, 95% confidence interval 1.42, 2.62). In both cohorts, increasing age was strongly associated with mortality from infectious diseases. CONCLUSION: Differences in the epidemiology of infectious disease-related mortality among people released from prison may reflect differences in patterns of community health service delivery in each region. These findings highlight the importance of preventing and treating hepatitis C and other infectious diseases during the transition from prison to the community.

Suicide in adults released from prison in Queensland, Australia: a cohort study.

BACKGROUND: Previous research has demonstrated elevated mortality following release from prison. We contrasted the risk of opioid overdose death with the risk of suicide in a cohort of adults released from prison in Queensland, Australia over a 14-year-period. We examine risk factors for suicide in the cohort, and make comparisons with the general population. METHOD: We constructed a retrospective cohort of all adults released from prison between 1994 and 2007 and linked this to the National Death Index for deaths up to 31 December 2007. RESULTS: We identified 41 970 individuals released from prison. Of the 2158 deaths in the community, 371 were suicides (crude mortality rate (CMR) 13.7/10 000 person-years) and 396 were due to drug-related causes (CMR 14.6/10 000 person-years). We observed a spike in drug-related deaths in the first 2 weeks after release from prison but no such pattern was observed for suicide. Being married (HR 0.40) and number of prior imprisonments (HR 3.1 for ≥5 prior incarcerations compared with none) independently predicted suicide. Age, sex, Indigenous status, length of incarceration and offence history were not associated with suicide. The standardised mortality ratios indicated that released women were 14.2 times and released men 4.8 times more likely to die from suicide than would be expected in the population. CONCLUSIONS: This study demonstrates that the rate of suicide in adults released from prison is similar to the rate of drug-related deaths. Strategies that provide support to vulnerable people after release may reduce suicide in this population.

Striking subgroup differences in substance-related mortality after release from prison.

AIMS: To compare the incidence, timing and risk factors for substance-related death between Indigenous and non-Indigenous ex-prisoners in Queensland, Australia. DESIGN: Retrospective cohort study. SETTING: All adult prisons in the state of Queensland, Australia, linked to deaths registered in Australia. PARTICIPANTS/CASES: We obtained records for all adults released from prison in Queensland, Australia from 1 January 1994 to 31 December 2007. Among this cohort of 42 015 individuals we observed 82 315 releases from prison and 2158 deaths in the community by the end of 2007, of which 661 were substance-related deaths. MEASUREMENTS: Incarceration data were obtained from Queensland Corrective Services and linked probabilistically with deaths recorded in the Australian National Death Index. FINDINGS: In the first year after release, Indigenous ex-prisoners were more likely to die from alcohol-related causes [hazard ratio (HR) = 1.9, 95% confidence interval (CI) = 1.1-3.1)] but less likely to die of drug-related causes (HR = 0.34, 95%CI = 0.21-0.53) than were non-Indigenous ex-prisoners. Among non-Indigenous prisoners only, the risk of substance-related death was significantly higher in the first 4 weeks [relative risk (RR) = 5.1, 95% CI = 3.7-6.9] when compared with the risk after 1 year post-release. Most evaluated risk factors for substance-related death were similar for Indigenous and non-Indigenous ex-prisoners; however, the hazard of death increased with age more for Indigenous ex-prisoners (HR = 1.7 per decade of age, 95% CI = 1.4-2.1) than for non-Indigenous ex-prisoners (HR = 1.3, 95% CI = 1.2-1.4). CONCLUSIONS: In Australia, patterns of substance-related death in ex-prisoners differ markedly according to Indigenous status. Efforts to prevent substance-related deaths in ex-prisoners should consider heterogeneity in the target population and tailor responses accordingly.

Systematic review of record linkage studies of mortality in ex-prisoners: why (good) methods matter.

AIMS: World-wide, more than 30 million people move through prisons annually. Record linkage studies have identified an increased risk of death in ex-prisoners. In order to inform preventive interventions it is necessary to understand who is most at risk, when and why. Limitations of existing studies have rendered synthesis and interpretation of this literature difficult. The aim of this study was to describe methodological characteristics of existing studies and make recommendations for the design, analysis and reporting of future studies. METHODS: Systematic review of studies using record linkage to explore mortality in ex-prisoners. Based on analysis of these studies we illustrate how methodological limitations and heterogeneity of design, analysis and reporting both hamper data synthesis and create potential for misinterpretation of findings. Using data from a recent Australian study involving 42,015 ex-prisoners and 2329 observed deaths, we quantify the variation in findings associated with various approaches. RESULTS: We identified 29 publications based on 25 separate studies published 1998-2011, mainly from the United Kingdom, United States and Australia. Mortality estimates varied systematically according to features of study design and data analysis. A number of common, avoidable and significant methodological limitations were identified. Substantial heterogeneity in study design, methods of data analysis and reporting of findings was observed. CONCLUSIONS: Record linkage studies examining mortality in ex-prisoners show widely varying estimates that are influenced substantially by avoidable methodological limitations and reducible heterogeneity. Future studies should adopt best practice methods and more consistent methods of analysis and reporting, to maximize policy relevance and impact.

Risk of death for young ex-prisoners in the year following release from adult prison.

BACKGROUND: In the community, all-cause mortality rates among those younger than 25 years are considerably lower than those of older adults and are largely attributable to risk-taking behaviours. However, given the unique health profiles of prisoners, this pattern may not be replicated among those leaving prison. We compared rates and patterns of mortality among young and older ex-prisoners in Queensland, Australia. METHODS: We linked the identities of 42,015 persons (n=14,920 aged <25 years) released from adult prisons in Queensland, Australia with the Australian National Death Index. Observations were censored at death or 365 days from release. We used Cox proportional hazards regression to explore associations between mortality and demographic and criminographic characteristics. We used indirect standardisation to compare rates of all-cause mortality for both age groups with those for the general population. We calculated proportion of deaths across specific causes for each age group and relative risks for each cause for young versus older ex-prisoners. RESULTS: Being young was protective against death from all causes (AHR=0.7, 95% CI 0.5-0.8); however, the elevation in risk of all-cause death relative to the general population was greater for those aged less than 25 years (SMR=6.5, 95% CI 5.3-8.1) than for older ex-prisoners (SMR=4.0, 95% CI 3.5-4.5). Almost all deaths in young ex-prisoners and the majority of those in older ex-prisoners were caused by injury or poisoning. CONCLUSIONS: Young people are at markedly increased risk of death after release from prison and the majority of deaths are preventable.

Sensitivity of a national coronial database for monitoring unnatural deaths among ex-prisoners in Australia.

BACKGROUND: The period immediately after release from custody is a time of marked vulnerability and increased risk of death for ex-prisoners. Despite this, there is currently no routine, national system for monitoring ex-prisoner mortality in Australia. This study subsequently aimed to evaluate the sensitivity of Australia's National Coroners Information System (NCIS) for identifying reportable deaths among prisoners and ex-prisoners. FINDINGS: Prisoner and ex-prisoner deaths identified through an independent search of the NCIS were compared with 'gold standard' records of prisoner and ex-prisoner deaths, generated from a national monitoring system and a state-based record linkage study, respectively. Of 294 known deaths in custody from 2001-2007, an independent search of the NCIS identified 229, giving a sensitivity of 77.9% (72.8%-82.3%). Of 677 known deaths among ex-prisoners from 2001-2007, an independent search of the NCIS identified 37, giving a sensitivity of 5.5% (4.0-7.4%). Ex-prisoner deaths that were detected were disproportionately drug-related, occurring within the first four weeks post-release, among younger prisoners and among those with more than two prior prison admissions. CONCLUSIONS: Although a search of the NCIS detected the majority of reportable deaths among prisoners, it was only able to detect a small minority of reportable deaths among ex-prisoners. This suggests that the NCIS is not effective for monitoring mortality among ex-prisoners in Australia. Given the elevated rates of mortality among ex-prisoners in Australia and elsewhere, there remains an urgent need to establish a process for routine monitoring of ex-prisoner mortality, preferably through record linkage.

A cluster-randomised intervention trial against Schistosoma japonicum in the Peoples' Republic of China: bovine and human transmission.

BACKGROUND: Zoonotic schistosomiasis japonica is a major public health problem in China. Bovines, particularly water buffaloes, are thought to play a major role in the transmission of schistosomiasis to humans in China. Preliminary results (1998-2003) of a praziquantel (PZQ)-based pilot intervention study we undertook provided proof of principle that water buffaloes are major reservoir hosts for S. japonicum in the Poyang Lake region, Jiangxi Province. METHODS AND FINDINGS: Here we present the results of a cluster-randomised intervention trial (2004-2007) undertaken in Hunan and Jiangxi Provinces, with increased power and more general applicability to the lake and marshlands regions of southern China. The trial involved four matched pairs of villages with one village within each pair randomly selected as a control (human PZQ treatment only), leaving the other as the intervention (human and bovine PZQ treatment). A sentinel cohort of people to be monitored for new infections for the duration of the study was selected from each village. Results showed that combined human and bovine chemotherapy with PZQ had a greater effect on human incidence than human PZQ treatment alone. CONCLUSIONS: The results from this study, supported by previous experimental evidence, confirms that bovines are the major reservoir host of human schistosomiasis in the lake and marshland regions of southern China, and reinforce the rationale for the development and deployment of a transmission blocking anti-S. japonicum vaccine targeting bovines. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000263291.

A cluster-randomized bovine intervention trial against Schistosoma japonicum in the People's Republic of China: design and baseline results.

We describe the design and report baseline results of a cluster-randomized intervention to determine the importance of bovines for Schistosoma japonicum transmission in southern China. The study involves four matched village pairs in Hunan and Jiangxi Provinces, with a village within each pair randomly selected as intervention (human and bovine praziquantel treatment) or control (human praziquantel treatment only). Total study population prevalences at baseline were 12.4% (n = 5,390) and 15.2% (n = 1,573) for humans and bovines, respectively; village prevalences were similar within pairs. Bovine contamination index calculations showed that bovines less than 24 months of age were responsible for 74% of daily bovine environmental contamination with S. japonicum eggs. The village characteristics and baseline results underpin a rigorous study, which has major implications for deployment of a transmission-blocking bovine vaccine against S. japonicum. The combination of such a vaccine with other control strategies could potentially eliminate S. japonicum from southern China.