Death following puncture of the aorta during laparoscopic sterilization.

Lacerations of major vessels have been associated with use of the Veress needle and sharp trocar for laparoscopy. A death caused by puncture of the aorta during insertion of a Veress needle is reported. Deaths from major vessel laceration can be prevented by using proper technique for inserting the needle and trocar or choosing alternative methods of sterilization that do not require these instruments. Should major vessel laceration occur, prompt recognition and treatment may prevent death.

Complications of interval laparoscopic tubal sterilization.

In 1978, the Centers for Disease Control initiated a multicenter prospective study to assess the safety of the various female sterilizing operations and the ways in which they could be made safer. During the first 31 months, 3500 women who underwent interval laparoscopic tubal sterilization by electrocoagulation or Silastic banding without other concurrent operations were enrolled in the study. When a standard definition of complications was used, the overall rate of an intraoperative or postoperative complication was 1.7 per 100 women. Several patients factors increased the risk of complications twofold or more: diabetes mellitus, previous abdominal or pelvic surgery, lung disease, a history of pelvic inflammatory disease, and obesity. There was a fivefold difference in complication rates between procedures performed under general anesthesia and those done under local anesthesia.

Candida pericarditis: clinical profile and treatment.

BACKGROUND: Candida pericarditis is a rare medical and surgical emergency which, unless treated, leads to impaired cardiac function and death. To facilitate early diagnosis, the clinical features of this condition should be identified. METHODS: Twenty-five cases of Candida pericarditis reported in the last 30 years along with 1 new case were reviewed with regard to demographics, precipitating factors, diagnosis, treatment, and outcome. RESULTS: The syndrome occurred in immunocompromised (73%), antibiotic-treated (62%), or postpericardiotomy (54%) patients. The clinical presentation was frequently subtle and nonspecific. Nevertheless, unexplained fever, an increasing cardiac shadow on chest roentgenogram, or the development of cardiac tamponade may be suggestive. Positive culture for Candida in pericardial fluid or histologic evidence of yeast forms in pericardial tissue establishes the diagnosis. A combination of pericardiocentesis followed by operative drainage and antifungal agents is the usual treatment. Untreated, Candida pericarditis is 100% lethal, whereas prompt diagnosis and treatment lead to cure (mean follow-up, 19 months). CONCLUSIONS: Fever and evolving cardiac tamponade in immunocompromised or postpericardiotomy patients may be suggestive of Candida pericarditis; the presence of organisms in pericardial fluid is diagnostic. Pericardiocentesis followed by operative drainage and antifungal agents appears to be the treatment that is most likely to be curative.

Sexually transmitted diseases and native Americans: trends in reported gonorrhea and syphilis morbidity, 1984-88.

Native Americans experienced higher reported gonorrhea and syphilis morbidity than did non-Native Americans from 1984 through 1988 in 13 States with large Native American populations. Gonorrhea rates among American Indians and Alaska Natives were approximately twice the rates for non-Indians. The highest gonorrhea rate was reported among Alaska Natives, with a 5-year average of 1,470 cases per 100,000, more than five times the average non-Native rate in Alaska. The average primary and secondary (P&S) syphilis rate from 1984 through 1988 was more than two times higher among Native Americans, largely due to high syphilis morbidity in Arizona and New Mexico. In Arizona the average American Indian P&S syphilis case rate was seven times higher than the non-Indian rate. True rates for sexually transmitted diseases (STD) among Native Americans may be higher than those reported due to racial misclassification of Native American cases, particularly in nonreservation areas. Improved recognition and reporting of STD cases among Native Americans are needed to target STD prevention and education more effectively.

The association between oral contraception and hepatocellular adenoma--a preliminary report.

Women with long-term use of oral contraception (OC) are at increased risk of developing a serious, though nonmalignant, liver tumor--hepatocellular ademona (HCA)--according to a case-control study conducted by the Center for Disease Control (CDC) in collaboration with the Armed Forces Institute of Pathology (AFIP). The tumor is sometimes fatal, deaths usually being due to sudden rupture and hemorrhage. This study suggests that, in addition to long-term OC use, a women's age and the hormonal potency of the OC she uses affect her changes of developing HCA. Women 27 years old and older who have used OC with high hormonal potency for 7 or more years are at the greatest risk.

Deaths associated with laparoscopic sterilization in the United States, 1977-79.

In 1979, the Centers for Disease Control began epidemiologic surveillance of deaths associated with tubal sterilization as part of an effort to assess the mortality risks associated with different methods of fertility control. The surveillance system identified nine deaths following laparoscopic sterilization in the United States from 1977 through 1979. The causes of these deaths and how some of them might have been averted are discussed.

PIP: This report is concerned only with those deaths in the U.S. identified to date that were attributable to laparoscopic sterilization. In 1979 the Centers for Disease Control (CDC) asked state health departments and state maternal mortality review committees for assistance in identifying deaths attributable to tubal sterilization. A sterilization attributable death was considered to be a death resulting from complications of the operation itself, the chain of events that lead to death and were initiated by the operation, or aggravation of an unrelated condition by the physiologic or pharmacologic effects of the operation. 9 deaths attributable to laparoscopic sterilization that occurred after January 1, 1977 were identified. 5 of these deaths were reported to have been caused by cardiorespiratory arrests that occurred during the use of general anesthesia. 5 deaths were reviewed in detail. 1 patient died from an irreversible heart block that occurred intraoperatively. Of the other 4 deaths, 1 was related to the method of entry into the abdominal cavity; 3 were related to a single method of tubal occlusion. This series of 9 deaths represents an unknown fraction of the deaths that occurred following laparoscopic sterilization from 1977 through 1979. As many as 750,000 laparoscopic sterilizations were performed during that period. Thus far, the most frequently reported cause of death from laparoscopic sterilization was cardiorespiratory arrest occurring during general anesthesia.

Characteristics of vasectomies performed in selected outpatient facilities in the United States, 1980.

In 1981 the American Association of Gynecologic Laparoscopists and the Division of Reproductive Health, Centers for Disease Control, jointly conducted a study of vasectomies performed in outpatient facilities in 1980 in the United States. One hundred twenty-nine facilities that responded to either a mailed questionnaire or a telephone interview stated that vasectomies were performed there in 1980. The average cost was $273, with a range of $50-1,000. Facilities differed markedly in the use of anesthesia. Freestanding surgical centers reported the use of general anesthesia for 29% of the vasectomies. Other types of facilities were more likely to use local or regional anesthesia. Our data suggest areas for further research to improve the availability and safety of vasectomy.

PIP: In 1981 the American Association of Gynecologic Laparoscopists and the Centers for Disease Control conducted a survey of US clinics providing female and males sterilization procedures. This analysis provides new information on the numbers of vasectomies performed in 1980 in outpatient facilities, types of anesthesia used, cost, and lenght of postoperative stay. Results reveal that in 1980: 1) 10,394 vasectomies were performed in respondent facilities of all types; 70 freestanding surgical centers performed 4347 vasectomiew, and 32 family planning clinics performed 4163 vasectomies; 2) the average reported charge for a vasectomy in respondent facilities was $273, which included the physician's and anesthesia fees; 3) throughout the US, the average cost of a vasectomy was higher in freestanding surgical centers than in other facilities; 4) in all regions, 96% of the facilities other than freestanding surgical centers, reported only the use of local or regional anesthesia; 5) of the 11 facilities reporting that vasectomies cost more than $500, 82% reported that more than 75% of the vasectomies were done using general anesthesia; and 6) the mean postoperative stay for all reported vasectomies was 1.3 hours--facilities reporting higher percentages of general anesthesia use tended to have longer postoperative stays. This data address only 2% of the 520,000 vasectomies estimated to have been performed in the US in 1980. Although vasectomy is often considered a cheap, simple, safe, and effective outpatient procedure, in this study an unexpectedly high use of general anesthesia is found. In addition, vasectomy may be fairly expensive, sometimes costing as much of $1000, and the postoperative observation may not be as long as recommended.

Tubal sterilizations performed in freestanding, ambulatory-care surgical facilities in the United States in 1980.

In 1981 the American Association of Gynecologic Laparoscopists and the Division of Reproductive Health, Centers for Disease Control, jointly conducted a study of tubal sterilizations performed in 141 freestanding, ambulatory-care surgical facilities in 1980 in the United States. Information was collected through mailed questionnaires and telephone interviews. Of 330 potential responding facilities, 141 we identified as freestanding, ambulatory-care surgical facilities. About 16,500 tubal sterilizations were performed in these facilities in 1980. The mean number of tubal sterilizations per freestanding, ambulatory-care surgical facility was 212. Sixty-seven percent of tubal sterilizations were performed in the south and west. General anesthesia was the anesthetic method used in 97% of the procedures. Nearly 91% of tubal sterilizations were done via laparoscopy, with bipolar electrocoagulation the tubal-occlusion method used most frequently. After tubal sterilization the patients were observed for an average of 2.4 hours before discharge. The average cost of laparoscopic tubal sterilization was $801; for nonlaparoscopic tubal sterilization it was $850.

Surveillance for gonorrhea and primary and secondary syphilis among adolescents, United States--1981-1991.

PROBLEM/CONDITION: During the 1980s, an increasing proportion of adolescent women reported having had premarital sexual intercourse, thus potentially placing an increasing number of young persons at higher risk of acquiring a sexually transmitted infection. REPORTING PERIOD COVERED: To determine rates and examine trends of sexually transmitted infections among adolescents, we analyzed data for reported cases of gonorrhea and primary and secondary syphilis among 10- to 19-year-olds for 1981 through 1991. DESCRIPTION OF SYSTEM: Summary data for cases of gonorrhea and primary and secondary syphilis that were identified and reported to state health departments were sent annually to CDC. These data included total number of cases by disease (gonorrhea, primary and secondary syphilis), sex, racial/ethnic group (white, not of Hispanic origin; black, not of Hispanic origin; Hispanic; Asian/Pacific Islander; or American Indian/Alaskan Native), 5-year age group, and source of report (public, private). RESULTS: From 1981 through 1991, 24%-30% of the reported morbidity from gonorrhea and 10%-12% of the reported morbidity from primary and secondary syphilis in the United States affected the adolescent age groups. Some of the highest rates of gonorrhea during that time period were among 15- to 19-year-olds. Gonorrhea rates among adolescents increased or remained unchanged from 1981 through 1991, while the rates among older age groups decreased. Although primary and secondary syphilis rates were lower among adolescents than older age groups, adolescents contributed to the epidemic of syphilis that occurred from 1987 through 1990. Differences in reported rates of both syphilis and gonorrhea among white, black, and Hispanic adolescents increased during the latter half of the 1980s. INTERPRETATION: Reporting biases could account for some the differences among rates for white, black, and Hispanic adolescents. However, if gonorrhea has been underreported for any racial group, the high rates of gonorrhea among 15- to 19-year-olds represented an underestimate of the true infection rate. Increases in sexual activity among adolescents and a lack of clinical services in settings convenient to adolescents could have contributed to the increasing rates of gonorrhea and syphilis among these young persons during this time period. ACTIONS TAKEN: If gonorrhea and other sexually transmitted infections are cofactors for facilitating the transmission of human immunodeficiency virus (HIV), the high incidence of gonorrhea in some locales among some populations of adolescents could result in dramatic increases in HIV acquisition, a situation that demands attention from public health organizations.

Regional and temporal trends in the surveillance of syphilis, United States, 1986-1990.

During the latter half of the 1980s, an epidemic of syphilis occurred throughout the United States. A comparison of regional rates of primary and secondary syphilis in 1990 indicated that the rates were highest in the South, followed by the Northeast, the West, and the Midwest. Primary and secondary syphilis rates from 1986 through 1990 exhibited different regional patterns. Rates of primary and secondary syphilis in the West peaked in 1987 and declined from 1987 to 1990. Rates increased in the Northeast and the South from 1986 to 1990, but the increase reached a plateau in the Northeast in 1990. Rates did not begin to increase in the Midwest until 1988. More detailed analyses of the syphilis epidemics in specific communities in each region are needed to better understand the regional patterns. A comparison of these findings across regions could be helpful in evaluating which sexually transmitted disease intervention and control programs are most effective during epidemic periods.

An evaluation of surveillance for Chlamydia trachomatis infections in the United States, 1987-1991.

PROBLEM/CONDITION: Chlamydia is the most common sexually transmitted bacterial pathogen in the United States; however, no precise data on the prevalence and incidence of chlamydia infection are available because currently no comprehensive national surveillance system exists for chlamydia. Despite the absence of such a system, states do report numbers of male and female chlamydia cases to CDC on a quarterly basis. REPORTING PERIOD COVERED: This report summarizes and reviews the chlamydia surveillance data received by CDC from 1987 through 1991. DESCRIPTION OF SYSTEM: Summary data on cases of chlamydia reported to state health departments were sent quarterly to CDC in Atlanta, Georgia. The quarterly data from each state included total number of chlamydia cases by sex and by source of report (public, private). RESULTS: From 1987 through 1991, the number of states with legislation mandating reporting of chlamydia increased twofold. The reported chlamydia rate from those states also doubled during the same time period, from 91.4 cases per 100,000 population in 1987 to 197.5 cases per 100,000 population in 1991. INTERPRETATION: This twofold increase in the rate of chlamydia reported to CDC did not represent a doubling in chlamydia prevalence or incidence during this time period. Instead, the increase resulted from the increase in the number of states with reporting laws and from the initial attempts of those states to identify and report diagnosed chlamydia infections. ACTIONS TAKEN: More accurate measures of the number of chlamydia infections and of trends in the chlamydia infection rate are needed to justify, develop, and evaluate public health programs to control chlamydia infections. An outline of possible surveillance activities for local communities is presented.

Epidemiology of syphilis in the United States, 1941--1993.

BACKGROUND AND OBJECTIVES: The distribution and trends of syphilis are influenced by biologic factors, sexual behaviors, biomedical technology, availability of and access to health care, public health efforts, changes in population dynamics, and sociocultural factors. The objective of this article is to review the epidemiology of syphilis in the United States during the period 1941-1993 in the context of some of these factors. STUDY DESIGN: Surveillance data on cases of syphilis and congenital syphilis reported by state and city health departments to the Centers for Disease Control and Prevention were analyzed to show distribution and trends by geographic location, racial and ethnic groups, gender, and age. RESULTS: Historically, syphilis was distributed widely throughout the country and declined rapidly after the introduction of penicillin therapy and broad-based public health programs, attaining its lowest levels in the 1950s. However, in recent years, the disease has returned and become focused in the southern region and in urban areas outside that region. Rates of syphilis have remained highest in black Americans, and the most recent national epidemic of syphilis primarily involved them. Rates in white men were at intermediate levels during the early 1980s but have declined to low rates in the 1990s, possibly because of changes in behavior in response to the AIDS epidemic. Rates in white women and other racial and ethnic groups have remained low throughout the 1980s and 1990s. CONCLUSIONS: Syphilis remains a significant problem in the United States, and its epidemiology is influenced by a complex combination of factors. To prevent and control syphilis effectively, public health practitioners must understand these factors and design programs and interventions that address the disease in the context of these factors.

Chlamydia trachomatis infection among Hispanic women in the California-Mexico border area, 1993: establishing screening criteria in a primary care setting.

BACKGROUND: Chlamydia prevalence and transmission patterns in California-Mexico border communities are unknown, and selective screening strategies for Hispanic populations have not been evaluated. GOAL OF THIS STUDY: To determine chlamydia prevalence among Hispanic women in the California-Mexico border area and established screening criteria. STUDY DESIGN: This was a cross-sectional prevalence survey of family planning/prenatal Hispanic clients (n = 2378) in San Diego and Imperial Counties, California, and Tijuana, Mexico. RESULTS: Overall, chlamydia prevalence was 3.2% (3.3% in California; 2.1% in Mexico). Women born in Mexico or those who visited Mexico for at least 1 week in the recent past had a prevalence rate similar to women without those characteristics. Multivariate analysis showed that young age (less than 25 years old), unmarried status, or having clinical signs of a chlamydia syndrome (primarily cervicitis) or vaginosis independently predicted chlamydia infection. Applying minimum screening criteria recommended by the Centers for Disease Control would require screening less than half of the clients. However, only 69% of infections would be identified. Using survey-based criteria (less than 25 years old, unmarried, and clinical signs of a chlamydia syndrome) would require screening 64% of clients, but would identify 92% of those infected. CONCLUSION: Chlamydia prevalence among Hispanic women seeking reproductive healthcare was similar (< 5%) on both sides of the California-Mexico border. Among Hispanic women, using easily obtained demographic data (age and marital status) and clinical signs (primarily cervicitis), an effective selective screening strategy can be implemented.

PIP: During January 1-October 15, 1993, three clinics in Imperial County, California, located east of the coastal mountain range which borders Baja California; a large community health center in San Diego County, California; and a public health/family planning clinic in Tijuana in Baja California, Mexico, successfully screened 2378 Hispanic women for Chlamydia trachomatis. The overall chlamydia prevalence was 3.2% (2.1% in Tijuana; 3.3% in California). Chlamydia was more common among the prenatal clients than family planning clients (4.7% vs. 2.6%; p 0.02). Adolescents had the highest chlamydia infection rate (7.5%). Women born in Mexico or those who visited Mexico for at least one week during the last three months had a similar chlamydia prevalence rate as those born in the US or those who had not visited Mexico recently. The multivariate analysis revealed that significant independent predictors of chlamydia infection included young age (25 years) (prevalence ratio [PR] = 4.5 for 20 years and 2.5 for 20-24 years), unmarried status (PR = 2), high risk sex behavior (PR = 1.1), exposure to a sexually transmitted disease (PR = 2.6), discharge/bleeding (PR = 1.4), vaginosis (PR = 3.6), and cervicitis (i.e., chlamydia syndrome) (PR = 6). If the clinics had applied the minimum screening criteria recommended by the US Centers for Disease Control, less than 50% of the clients would have been screened. Yet it would have identified only 69% of chlamydia infections. If clinics would apply the criteria identified in this survey, they would need to screen 64% of their clients, which would identify 92% of clients infected with chlamydia. These findings indicate that, in the California-Mexico border region, chlamydia prevalence among Hispanic women seeking reproductive health care was comparable. They also show that clinics can implement an effective selective screening strategy.

Mortality risk associated with tubal sterilization in United States hospitals.

Despite the millions of women who have undergone tubal sterilization in United States hospitals, little has been published about the risk of death from these procedures. To estimate a case-fatality rate of tubal sterilization, we combined data from the Commission on Professional and Hospital Activities and the National Center for Health Statistics with a review of the clinical circumstances for each woman whose death was identified as being potentially sterilization attributable. Considering all deaths temporally associated with tubal sterilization, we estimate that the case-fatality rate is nearly 8/100,000 procedures. When only deaths determined to be attributable to the sterilization operation per se are considered, the case-fatality rate is approximately 4/100,000 procedures, making death attributable to tubal sterilization a rear event.

PIP: To obtain an accurate estimate of the risk of dying from tubal sterlization, the Centers for Disease Control (CDC) combined an analysis of national data on numbers and characteristics of sterilization procedures with a review of individual medical records for women whose deaths were identified as being associated with sterilization. This estimate was refined to include just those deaths actually attributable to the sterilization operation. Data for calculating case factality rates in this study are based on information for the years 1977 and 1978, obtained from the Commission on Professional and Hospital Activities (CPHA) and the National Center for Health Statistics in their National Hospital Discharge Survey. To identify deaths that were potentially sterilization attributable, the CPHA performed a computer-file search to identify patients who died during hospitalization and who also underwent a procedure coded 66.2 (bilateral salpingectomy), 66.3 (endoscopic bilateral salpingectomy), or 66.4 (other bilateral destruction, ligation, and division of fallopian tubes). To make estimates of the denominator, the total number of tubal sterilizations performed in Professional Activity Study (PAS) hospitals in 1977 and 1978 were determined. The CPHA computer-file search identified 63 deaths as potentially sterilization attributable. Of these 63, 38 deaths were reviewed after permission was given by hospital administrators. For the other 25 deaths, hospital administrators refused to cooperate. Of the 38 deaths reviewed, 25 were sterilization associated. The remaining 13 involved miscoding, i.e., either the woman did not die, did not have a sterilization procedure, or had PAS numbers which hospitals could not identify. The 25 sterilization-associated deaths occurred in connection with 521,400 tubal sterilization procedures peformed in PAS hospitals in 1977 and 1978. Of the 25 sterilization-associated deaths, only 9 were determined to be sterilization attributable. Since 9 of 38 of the deaths reviewed were sterilization attributable, it can be assumed that 23.7% or 6 of the 25 deaths that were not reviewed were also sterilization attributable. If this assumption is correct, a total of 15 sterilization-attributable deaths occurred, resulting in a case-fatality rate of 3.6/100,000 tubal sterilization. If none of the 25 deaths was sterilization attributable, the case-fatality rate would be 2.2/100,000 tubal sterilizations. Death attributable to tubal sterilization is rare, occurring at the rate of approximately 4/100,000 procedures.

Deaths associated with laparoscopic sterilization by unipolar electrocoagulating devices, 1978 and 1979.

In 1978 and 1979, two women in the United States were reported to have died from electrical complications following sterilization with unipolar coagulating devices. Both deaths followed apparent bowel injuries occurring at the time of sterilization. Numerous reports have documented the electrical accidents associated with unipolar electrocoagulation. Because unipolar electrocoagulation has greater risk for these complications than alternative sterilization techniques, without proved greater benefits, we question the need for continuing its use in female sterilization.

PIP: Most of the laparoscopy procedures performed in the U. S. use electric current to coagulate the fallopian tubes. Most of the coagulations are done with unipolar devices, with its attendant risks of accidental burns to the patient and the operator. In the years 1978 and 1979, 2 sterilization-related deaths were recorded by the Center for Disease Control, apparently resulting form inadvertent burns to the bowel sustained during sterilization with unipolar devices. The 1st case involved a 41-year old woman, gravida 6, para 5, abortus 1 who underwent a laparoscopic tubal sterilization via electrocoagulation with a unipolar device. 23 days after the operation, she returned to the hospital complaining of abdominal pain and evidence of peritonitis. Laparotomy was performed, but her condition deteriorated. She died 41 days after the laparotomy. Autopsy revealed bowel perforation with subcutaneous abscess. The 2nd case involved a healthy 22-year old woman, gravida 4, para 4 who underwent a similar sterilization procedure. She presented to the hospital 7 days after the operation complaining of abdominal pain. Laparotomy was also performed but she died two days later of septic shock. Bowel perforation was strongly suspected, although the perforation site was never located. Bipolar coagulation may reduce the risk of electric accidents. The need for continuing the use of unipolar electrocoagulation, in the light of risk of death, is questioned.

The impact of laparoscopy on tubal sterilization in United States hospitals, 1970 and 1975 to 1978.

During the 1970s, tubal sterilization became an important method of fertility control in the United States. Over the same period laparoscopy emerged as an important innovation, one that has been associated with both a shift from postpartum to interval sterilization and a dramatic decrease in length of hospital stay required for sterilization. The use of laparoscopy has also been associated with an increase in hospital-based outpatient sterilization, particularly in the West. The number of sterilizations performed in hospitals and the use of laparoscopy for interval sterilization in hospitals both appear to have peaked. The laparoscope is an example of a technologic advance that has reduced medical care costs.

PIP: The number and characteristics of women having laparoscopic sterilizations in hospitals in the United States over the 1975 through 1978 period are reported along with some of the important influences that the introduction of laparoscopy had on tubal sterilization trends in the 1970s. The data are derived from data collected by the National Center for Health Statistics in their National Hospital Discharge Survey for the years 1970 and 1975 to 1978. 4.2 million women in the age range of 15 to 44 had tubal sterilizations performed in the United States in the 1970 to 1978 period. In 1970, fewer than 1% of sterilizations were done with a laparoscope. In the 1975-1978 period, approximately 815,000, or 1/3 of all tubal sterilizations during that period, were performed via laparoscopy. Only 29% of women underwent interval sterilization in 1970, but by 1976 the proportion of interval sterilization had increased annually to a high of 58%. Over the same period that interval sterilization increased in popularity, the use of laparoscopy for interval sterilization also increased. With respect to geographic region, the South had the lowest and the Northeast had the highest percentage of interval sterilizations performed via laparoscopy. Older women were more likely to have interval sterilization performed via laparoscopy. The average length of hospital stay for tubal sterilization declined from 6.5 nights in 1970 to 4.0 nights in the period 1975 to 1978. Much of this change is attributable to the shortened length of stay for laparoscopic sterilization.

Demographic trends of tubal sterilization in the United States 1970-75.

An estimated 2,300,000 women in the United States underwent tubal sterilizations in 1970-1975. During this period the rate of tubal sterilizations per 1,000 women 15-44 years of age rose from 4.7 to 11.7. We studied the influence on sterilization trends of four demographic variables: age, region of residence, race, and marital status. Women 25-34 years of age were twice as likely to be sterilized as older or younger women. Rates were about 40 per cent lower in the West than in the rest of the country. In 1970 rates for non-white women were double those for Whites. Rates for Whites rose faster than those for non-Whites, however, and by 1975 the rates were similar for the 2 races. Non-Whites still tended to be sterilized about one year younger than Whites, and marked regional differences existed in the race-specific rate trends. Rates rose more sharply for previously married women than for currently married women; by 1975 rates for these two groups were similar. Never married women had rates about 1/7 of those of currently married and previously married women. Among the never married, tubal sterilization rates for non-Whites were nine times higher than those for Whites.

Control of epidemic early syphilis: the results of an intervention campaign using social networks.

BACKGROUND: During an epidemic of early syphilis, social networks were used for an intervention campaign. GOAL OF THIS STUDY: To characterize the epidemic and describe the yield of new cases from index-case interviews. METHODS: Analyses of morbidity data collected by the Montgomery County, Alabama, sexually transmitted disease program determined the course of the epidemic and characterized the new case yields from social networks identified via index-case interviews (partner notification investigations) and interviews with sex partners and their associates (cluster investigations). Results and costs were compared to a noncampaign period. RESULTS: The number of reported syphilis cases nearly doubled from 1990 to 1991 (201 to 348 per 100,000 residents). During the 21-week campaign, 373 case-patients had partner notification/cluster investigations; 113 (11%) of 984 sex partners and 41 (3%) of 1,146 high-risk associates (persons identified during cluster investigations) had syphilis. No subgroup of case-patients for which the partner notification/cluster investigation yielded more infected persons than other subgroups was identified. The cost per case detected was more than twice that during a noncampaign period ($1,627 vs. $771). CONCLUSION: Partner notification investigations yielded more infected persons than cluster investigations. Further evaluation is needed to determine the role of intense partner notification/cluster investigators' efforts in the control of epidemic syphilis.

The changing paradigm of sexually transmitted disease control in the era of managed health care.

Several trends in sexually transmitted diseases (STDs) have laid the foundation for a new paradigm for STD treatment and prevention that encompasses a community-wide, population-oriented approach. Public health STD programs, in partnership with a wide variety of community collaborators, will need to carry out the essential functions of public health-assessment, policy development, and assurance-by developing resources for community organizing and planning, enhanced information systems, and comprehensive training programs for professional staff and community partners. Community providers (particularly practicing clinicians and community and hospital clinics) will need to deliver primary prevention (community health promotion and clinical preventive services) and secondary prevention (screening and treatment) services while categorical STD clinics focus on providing care for high-risk, high-frequency STD transmitters who serve as the reservoir for much of a community's bacterial STDs. Managed care organizations and public health STD programs will need to formalize collaborative arrangements and capitalize on the strengths of each organization in order to have a population-level impact on STD transmission.

Deaths attributable to tubal sterilization in the United States, 1977 to 1981.

In 1979, the Centers for Disease Control began surveillance of deaths attributable to tubal sterilization in order to determine why they occur and what may be done to prevent them. Since that time, 29 such deaths have been identified as occurring in the United States from 1977 through 1981. Of these 29 deaths, 11 followed complications of general anesthesia, seven were due to sepsis, four were due to hemorrhage, three were due to myocardial infarction, and four deaths were related to other causes. Some of these deaths might have been prevented by use of endotracheal intubation for general anesthesia, particularly for laparoscopic sterilization, safer use of unipolar coagulation or use of alternative techniques, careful insertion of the needle and trocar for laparoscopy, and discontinuation of oral contraceptives before sterilization. Further surveillance may help to make tubal sterilization even safer.

PIP: 29 tubal sterilization deaths occurring in the US between 1977-1981 were identified. 11 followed complications of general anesthesia, 7 were due to sepsis, 4 to hemorrhage, 3 to myocardial infarction, and 4 to other causes. Sterilization was performed by laparoscopy in 17 cases, laparotomy in 11, of which 8 were pregnancy-related, and colpotomy in 1. The mean age was 31, ranging from 19-43. 10 women had underlying medical conditions that may have contributed to their deaths. 6 of the deaths due to complications of anesthesia were probably due to hyperventilation in women who were not intubated, 4 to intraoperative cardiorespiratory arrests with unknown precipitating events, and 1 to hyperkalemia probably caused by an idiosyncratic reaction to succinylcholine. 3 deaths attributed to sepsis followed apparent bowel injury during unipolar coagulation. 3 deaths from hemorrhage followed major vessel lacerations during laparoscopic sterilization. 2 women dying of myocardial infarction were heavy smokers and 1 was also 35 and used oral contraceptives (OCs) to the day of the operation. The 3rd woman was obese and had a strong family history of cardiac disease. 1 other death may have been associated with use of OCs. The 29 deaths may not include all sterilization-attributable deaths from 1977-81, resulting in possible biases in distribution of causes. Use of endotracheal intubation when general anesthesia is used, particularly for laparoscopic sterilization; safer use of unipolar coagulation or use of alternative techniques; careful insertion of the needle and trocar for laparoscopy; and discontinuation of OC use prior to sterilization may help prevent steriliztaion-attributable deaths.