Geographic variation of HIV infection in childbearing women with syphilis in the United States.

OBJECTIVES: Substantial biologic and epidemiologic data indicate the importance of syphilis as a potential cofactor for sexual transmission of HIV infection, but few detailed data exist on the geographic covariation of these two important sexually transmitted infections. DESIGN: HIV prevalence in childbearing women and primary and secondary (P&S) syphilis data from 29 states were examined to explore the importance of the epidemiology of syphilis as a factor in facilitating HIV transmission. METHOD: The spatial relationship between P&S syphilis and HIV infection in the health districts of 29 states was analyzed and adjusted for demographic and socioeconomic factors such as racial composition, income, housing, education levels, and access to medical services using the 1990 US census, and geographic location. RESULTS: In 29 states and the District of Colombia, 448 health districts, representing more than 75% of the US population, reported HIV prevalence rates for mothers' district of residence. The HIV seroprevalence ranged from 0 to 1258/10 000 in these health districts. The incidence of P&S syphilis from 1984-1994 in these districts ranged from 0 to 87/100 000. The P&S syphilis incidence was positively associated with the prevalence of HIV infection among childbearing women (P < 0.0001). CONCLUSIONS: Syphilis that persists in communities in the United States appears to represent a 'sentinel public health event' reflecting risk for sexual HIV transmission. These findings, along with other biologic and epidemiologic information, reinforce the importance of syphilis as an indicator for targeting HIV prevention efforts generally, as well as syphilis control as a specific HIV-prevention strategy.

An outbreak of cyclosporiasis in Florida in 1995: a harbinger of multistate outbreaks in 1996 and 1997.

Before 1995, only one outbreak of cyclosporiasis had been reported in the United States. To identify risk factors for Cyclospora infection acquired in Florida in 1995, we conducted a matched case-control study (24 sporadic cases and 69 controls) and retrospective cohort studies of clusters of cases associated with two May social events (attack rates = 15.4% [8 of 52] and 54.5% [6 of 11]). In univariate analysis of data from the case-control study, consumption of fresh raspberries (odds ratio [OR] = 6.0, 95% confidence interval [CI] = 1.1-31.7) and bare-handed contact with soil (OR = 5.4, 95% CI = 1.4-20.7) were associated with infection; soil contact was also implicated in multivariate analysis. For the events, mixed-fruit items that had only fresh raspberries and strawberries in common had elevated relative risks (3.7 and 4.2), but the confidence intervals overlapped 1.0. The raspberries eaten at the events and by sporadic case-patients were imported. Given the cumulative evidence of the three studies and the occurrence in 1996 and 1997 of outbreaks in North America associated with consumption of Guatemalan raspberries, food-borne transmission of Cyclospora was likely in 1995 in Florida as well.

Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic.

In Bambari and Bria, 2 towns in the Central African Republic (CAR), we analysed a patient-led partner referral programme within enhanced sexually transmitted disease (STD) services. New (index) patients received syndromic management, counselling about notifying and treating contacts, and vouchers for distribution. From October 1993 to February 1996, 5232 and 4320 patient visits, of which 1814 (35%) and 4320 (30%) were contact referral visits, were logged in Bambari and Bria, respectively. Vouchers were distributed for at least 90% of contacts. Index and contact patients had similar age and sex distributions. In both towns, having a spouse (Bambari: odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4-1.7; Bria: OR 1.9, 95% CI 1.5-2.3) was a factor associated with successful referral of a partner. Successful referral was accomplished by both male and female patients. Appropriate counselling techniques and vouchers facilitated partner referral. Further research on how to reach casual partners would enhance STD control efforts using patient-led partner referral.

Cyclosporiasis associated with imported raspberries, Florida, 1996.

OBJECTIVES: Until 1995, infection with Cyclospora cayetanenis, a parasite that causes gastroenteritis, was diagnosed in the US primarily in overseas travelers; its modes of transmission were largely unknown. In 1995, 45 cases of cyclosporiasis were diagnosed in Florida residents who had no history of recent foreign travel, but an investigation could not pinpoint a source for the parasite. In 1996, a North American outbreak of cyclosporiasis resulted in more than 1400 cases, 180 of them in Florida. The authors investigated the 1996 Florida outbreak to identify the vehicle of transmission. METHODS: The authors conducted a matched case-control study in which each of 86 laboratory-confirmed sporadic cases was matched with up to four controls. They also investigated nine clusters of cases associated with common meals and attempted to trace implicated foods to their countries of origin. RESULTS: In the case control study, eating raspberries was strongly associated with cyclosporiasis (matched odds ratio = 31.9; 95% confidence interval [CI] 7.4, 138.2). In the cluster investigation, raspberries were the only food common to all nine clusters of cases; a summary analysis showed a strong association between consumption of raspberries and confirmed or probable cyclosporiasis (risk ratio = 17.6; 95% CI 1.9, 188.8). Guatemala was the sole country of origin for raspberries served at six of nine events. CONCLUSIONS: Guatemalan raspberries were the vehicle for the 1996 Florida cyclosporiasis outbreak. Cyclospora is a foodborne pathogen that may play a growing role in the etiology of enteric disease in this country as food markets become increasingly international.

Examining self and partners for syphilis among men who have sex with men: five US cities, 2009-2011.

To increase self-examination for syphilis among men who have sex with men (MSM), we developed educational materials to increase knowledge of primary and secondary syphilis manifestations. Materials were piloted in five cities' infectious disease or MSM clinics. Self- and partner-examination behaviour was assessed with an anonymous questionnaire. Of 1459 participants, 914 men had had sex with a man in the previous three months; the 171 MSM who reported having read the materials were significantly more likely to examine themselves (anus, adjusted prevalence ratio [aPR] 1.3, 95% confidence interval [CI] 1.15-1.52), mouth, penis and skin, and their partners' anus (aPR 1.3, 95% CI 1.03-1.73) and mouth (aPR 1.6, 95% CI 1.1-2.26). Further research is needed to determine whether educational materials affect early detection and treatment of primary and secondary syphilis and reduce transmission.

Infant and child mortality in the Elim District, northern Transvaal, 1976-1986, and a comparison of trends.

Childhood mortality rates among rural blacks in South Africa are currently not based on a reliable registration system. National childhood mortality statistics rely on mortality extrapolations and population estimates. This study attempts to provide further information on infant and child mortality among rural blacks in the northern Transvaal, using a direct method. Currently available obstetric histories from hospital and clinic records of the Elim Hospital Health Ward were reviewed, covering the years 1976-1988 and approximately 28,000 pregnancies. The mean infant mortality rate was 88/1,000 live births, and did not change significantly over 10 years, in contrast to other populations in South Africa with documented decreases. Components of the infant mortality rate were also calculated. There was a 1 in 10 risk of death among children less than 5 years of age over this period, although the risk had declined slightly over 10 years. Mortality among boys was higher than that among girls in all age groups studied. Conclusions include that small but measurable changes have occurred in rural South African black childhood mortality rates, although there has been no discernible change in infant mortality, and that a simple direct method can illustrate levels as well as trends in mortality. This has implications for health policy.

Preventing adverse sequelae of bacterial vaginosis: a public health program and research agenda.

BACKGROUND: The cause of bacterial vaginosis remains poorly understood. Recent evidence strengthens the association between bacterial vaginosis and serious medical complications. GOAL: To review the evidence linking bacterial vaginosis with adverse pregnancy outcomes, complications after gynecologic procedures, and HIV infection, and to identify prevention strategies. METHODS: In March 1999, the Centers for Disease Control and Prevention organized a conference to accomplish this goal. RESULTS: Better understanding is needed concerning the etiology, epidemiology, and natural history of bacterial vaginosis. More efficacious treatment of bacterial vaginosis and strategies to reduce maternal complications associated with bacterial vaginosis, such as premature rupture of the fetal membranes, chorioamnionitis, premature labor and delivery, postdelivery endometritis, and postpartum infant complications should be developed. Recent evidence shows that screening and treatment of bacterial vaginosis before abortion reduces postabortion pelvic inflammatory disease, and that anaerobic coverage during hysterectomy reduces postoperative complications. Better understanding concerning the relation of bacterial vaginosis to acquisition of sexually transmitted diseases and HIV infection are needed as well as possible prevention strategies. CONCLUSIONS: A national prevention effort should be guided by the results of research that addresses current knowledge gaps.

Laboratory testing for Neisseria gonorrhoeae by recently introduced nonculture tests: a performance review with clinical and public health considerations.

Since 1992 two new nucleic acid-based tests (Gen-Probe Pace 2 and Abbott LCR) for the diagnosis of Neisseria gonorrhoeae infection have been approved by the U.S. Food and Drug Administration. We systematically assessed the quality of 21 studies that evaluated these tests' performance compared with that of culture for diagnosis of gonorrhea, on the basis of established criteria. We estimated overall test sensitivity and specificity by the testing method, sex, and anatomic site. None of the studies optimally fulfilled all quality criteria; few studies adequately used reference tests or described blinding. The sensitivity and specificity of nucleic acid hybridization (approximately 85%, approximately 98%) and amplification tests (approximately 95%, approximately 99%) were high and did not appear to differ substantially by sex or anatomic site. When proficiency in the performance of culture is high, the new tests are comparable to culture and may not offer a substantial advantage; in settings where optimization of culture is difficult, nucleic acid amplification may detect more infections than nucleic acid probe or culture.

Sexually transmitted diseases during pregnancy: screening, diagnostic, and treatment practices among prenatal care providers in Georgia.

BACKGROUND: Sexually transmitted diseases (STD) during pregnancy are associated with adverse outcomes. We conducted a prenatal care provider survey to determine STD screening, diagnosis, and treatment practices. METHODS: Standard questionnaires were mailed to Georgia-licensed obstetrician/ gynecologists, family practitioners, and nurse-midwives (N = 3,082) in 1998. RESULTS: Of the 1,300 care providers who returned the survey, 565 (44%) provided prenatal care, 390 (57%) were male, and 396 (70%) were obstetrician/ gynecologists. Overall, 553 prenatal care providers (98%) reported screening all pregnant patients for syphilis, 551 (98%) for hepatitis B, 501 (89%) for trichomonas, 474 (84%) for human immunodeficiency virus (HIV), 401 (71%) for gonorrhea, 403 (71%) for chlamydia, 475 (84%) for group B streptococci, and 130 (23%) for bacterial vaginosis (BV) (high risk). Less than 10% used amplification tests for chlamydia or gonorrhea. Most providers used appropriate regimens to treat STD in pregnant women. A written office policy on testing for BV or HIV was associated with increased screening. CONCLUSIONS: Provider education is needed about diagnosis and treatment of STD during pregnancy.

Providing low-cost sexually transmitted diseases services in two semi-urban health centers in Central African Republic (CAR): characteristics of patients and patterns of health care-seeking behavior.

BACKGROUND: While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa. GOAL: To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure. DESIGN: STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds. RESULTS: Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD. CONCLUSIONS: Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.

PIP: This study examines the feasibility of providing comprehensive, low-cost sexually transmitted disease (STD) services through the existing primary care infrastructure in two semi-urban health centers in the Central African Republic. The results showed that out of the 9552 visits made by index patients and partners over a 28-month period, 60% were made by women. Among these women, 90% were symptomatic, 77% had vaginal discharge, 70% had lower abdominal pain, and 7% had genital ulcer. In addition, 44% of men, as compared to 18% of women, had looked for treatment elsewhere prior to the clinic visit. The average cost per STD treated with the recommended drugs was $3.90. Furthermore, condom use was low in both areas and etiologic data suggest that a large proportion of patients was infected with an STD. The findings suggest that a comprehensive and affordable model for STD control can be implemented in primary care systems to prevent the spread of STDs in Africa.

Characteristics of persons with syphilis in areas of persisting syphilis in the United States: sustained transmission associated with concurrent partnerships.

BACKGROUND AND GOAL: In areas with persistent syphilis, to characterize persons at higher risk for transmitting syphilis. STUDY DESIGN: Cohort study. Structured interviews of persons with early syphilis from four research centers were linked to outcomes of partner tracing. RESULTS: Of 743 persons with syphilis, 229 (31%) reported two or more partners in the previous month, and 57 (8%) received money or drugs for sex in the previous three months. Persons with at least one partner at an earlier stage of syphilis than themselves were defined as transmitters; 63 (8.5%) of persons with early syphilis met this definition. Having concurrent partners (two or more in one week in the last month) was independently associated with being a transmitter. CONCLUSION: Sexual network/behavioral characteristics of syphilis patients and their partners, such as concurrency, can help identify persons at higher risk for transmitting syphilis who should receive emphasis in disease prevention activities.

Malaria surveillance -- United States, 1994.

PROBLEM/CONDITION: Malaria is caused by infection with one of four species of Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, and P. malariae ), which are transmitted by the bite of an infective female Anopheles sp. mosquito. Most malarial infections in the United States occur in persons who have traveled to areas (i.e., other countries) in which disease transmission is ongoing. However, cases are transmitted occasionally through exposure to infected blood products, by congenital transmission, or by local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to adapt prevention recommendations. REPORTING PERIOD COVERED: Cases with onset of symptoms during 1994. DESCRIPTION OF SYSTEM: Malaria cases confirmed by blood smear are reported to local and/or state health departments by health-care providers and/or laboratories. Case investigations are conducted by local and/or state health departments, and the reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), which was the source of data for this report. Numbers of cases reported through NMSS may differ from those reported through other passive surveillance systems because of differences in the collection and transmission of data. RESULTS: CDC received reports of 1,014 cases of malaria with onset of symptoms during 1994 among persons in the United States or one of its territories. This number represented a 20% decrease from the 1,275 cases reported for 1993. P. vivax, P. falciparum, P. malariae, and P. ovale accounted for 44%, 44%, 4%, and 3% of cases, respectively. More than one species was present in five persons (<1% of the total number of patients). The infecting species was not determined in 50 (5%) cases. The number of reported malaria cases in U.S. military personnel decreased by 86% (i.e., from 278 cases in 1993 to 38 cases in 1994). Of the U.S. civilians who acquired malaria during travel to foreign countries, 18% had followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Five persons became infected while in the United States; the infection was transmitted to two of these persons through transfusion of infected blood products. The remaining three cases, which occurred in Houston, Texas, were probably locally acquired mosquitoborne infections. Four deaths were attributed to malaria. INTERPRETATION: The 20% decrease in the number of malaria cases from 1993 to 1994 resulted primarily from an 86% decrease in cases among U.S. military personnel after withdrawal from Somalia. Because most malaria cases acquired in Somalia during 1993 resulted from infection with P. vivax, there was a proportionately greater decrease during 1994 in the number of cases caused by P. vivax relative to those caused by P. falciparum. ACTIONS TAKEN: Additional information was obtained concerning the four fatal cases and the five cases acquired in the United States. Malaria prevention guidelines were updated and distributed to health-care providers. Persons traveling to a geographic area in which malaria is endemic should take the recommended chemoprophylactic regimen and should use protective measures to prevent mosquito bites. Persons who have a fever or influenza-like illness after returning from a malarious area should seek medical care; medical evaluation should include a blood smear examination for malaria. Malarial infections can be fatal if not promptly diagnosed and treated. Recommendations concerning prevention and treatment of malaria can be obtained from CDC.