Transmission of HIV in Belle Glade, Florida: lessons for other communities in the United States.

The high cumulative incidence of AIDS and the large percentage of AIDS patients with no identified risks in Belle Glade, Florida, were evaluated through case interviews and neighborhood-based seroepidemiologic studies. It was found that of 93 AIDS patients reported between July 1982 and 1 August 1987, 34 could be directly linked to at least one other AIDS patient or to a person with AIDS-related complex by sexual contact, sharing of needles during intravenous drug abuse (or both), or perinatal exposure; of 877 randomly selected adults, 28 had antibodies to HIV; no person over age 60 and none of 138 children aged 2 to 10 years had antibodies to HIV; no clustering of infected persons within households occurred, except in sex partners; and HIV-seropositive adults were more likely than HIV-seronegative adults to be from Haiti, have a lower income, report sex with intravenous drug abusers, and have a history of previous treatment for sexually transmitted diseases. The presence of antibodies to five arboviruses prevalent in South Florida or the Caribbean did not correlate significantly with HIV infection. The high cumulative rate of AIDS in Belle Glade appears to be the result of HIV transmission through sexual contact and intravenous drug abuse; the evidence does not suggest transmission of HIV through insects.

Tuberculosis and acquired immunodeficiency syndrome--Florida.

Florida reported 1858 cases of the acquired immunodeficiency syndrome (AIDS) and 8455 cases of tuberculosis from January 1, 1981, through October 31, 1986. Of the patients with AIDS, 159 (8.6%) also had tuberculosis, and 154 (1.8%) of the patients with tuberculosis also had AIDS. Among patients with both diagnoses, tuberculosis was diagnosed before AIDS by more than 1 month in 50%, was diagnosed within 1 month before or 1 month after the diagnosis of AIDS in 30%, and was diagnosed more than 1 month after the AIDS diagnosis in 20%. Compared with patients with AIDS only, patients with both diagnoses were also more likely to be Haitian, black (other than Haitian), or Hispanic. Compared with patients with tuberculosis only, patients with both diagnoses were more likely to be younger, male, Haitian, black (other than Haitian), and Hispanic, have extrapulmonary tuberculosis and negative tuberculin skin tests, and have noncavitary chest roentgenograms. These data suggest that patients with AIDS may have an increased risk of tuberculosis and that patients with both diagnoses differ in important demographic and clinical characteristics from patients with AIDS only or tuberculosis only.

High rate of HIV seroconversion among patients attending urban sexually transmitted disease clinics.

OBJECTIVE: To study rates of documented HIV seroconversion and syphilis as a cofactor for seroconversion in sexually transmitted disease (STD) clinics. In the main clinic the HIV seroprevalence rate was 12% and most infections had been shown to be acquired by heterosexual contact. METHODS: We analyzed computer records of patients who had at least two HIV-antibody tests between 1 December 1987 and 31 December 1990, at STD clinics in Dade County (Miami), Florida. RESULTS: Of 5164 individuals with two HIV tests, 208 (4.0%) seroconverted. The overall seroconversion rate was 3.1 per 100 person-years. Among blacks, who accounted for 77% of seroconversions, the rate was higher for women (4.8) than for men (2.7). The highest rate was in 15-19-year-old black women (7.1 per 100 person-years). The HIV seroconversion rate was 12.8 for patients with primary or secondary syphilis diagnosed between two HIV tests, 3.1 for patients who acquired syphilis before their first HIV test, and 2.3 for patients who had never had syphilis. Eighteen per cent of all HIV seroconversions were attributable to syphilis acquired in the interval between two HIV tests. CONCLUSIONS: We found high HIV seroconversion rates, especially among black teenagers and black women, in an STD clinic population in which the majority of HIV infections were shown previously to have been acquired heterosexually. Syphilis was a marker for HIV seroconversion and syphilitic ulcers may facilitate HIV transmission. Innovative prevention programs directed towards women and adolescents should be developed and evaluated.

Epidemiologic studies of measles, measles vaccine, and subacute sclerosing panencephalitis.

Histories obtained in 350 of 375 clinically cofirmed cases of subacute sclerosing panencephalitis (SSPE) reported to a national registry showed that 292 patients had measles and 58 had no history of measles. Forty of the latter patients received live, attenuated measles virus vaccine. In patients with a history of measles, measles illness occurred before age 2 years in 46%, and a mean of 7.0 years before onset of SSPE. In contrast, there was no relationship of SSPE with age at vaccination in 35 of the 40 patients historically associated with measles vaccine, and SSPE occurred a mean of 3.3 years after vaccination. Based on estimated national measles morbidity data and national measles vaccine distribution data, the risk of SSPE following measles vaccination (0.5 to 1.1 cases/106) appears to be less than the risk following measles (5.2 to 9.7 cases/106). Because live measles vaccine is highly effective in preventing measles illness and a high proportion of children in the United States have received measles vaccine, these data are consistent with the observed downward trend in SSPE incidence since 1969.

A review of five years' experience with rubella vaccine in the United States.

National morbidity figures show a decline in reported rubella and congenital rubella syndrome since 1969, concurrent with widespread use of rubella vaccine. In addition, no nationwide outbreak, such as the 1963-1964 epidemic, has occurred, though on the basis of long-term secular trends, one would be expected between 1970 and 1974. Recent rubella outbreaks have occurred in unimmunized students in high schools and universities, and there appears to have been a slight upward shift in the age-specific incidence of rubella in the United States since the beginning of widespread immunization. Currently available vaccines have provided durable protection to date, and, although reinfection is known to occur following vaccination, it has not proven a risk to the pregnant woman. There is a small but significant incidence of adverse reactions and a potential risk to the woman who is vaccinated during pregnancy. These data indicate that rubella vaccines are safe and effective. They also imply that rubella vaccines, as they are currently applied, have been successful in reducing the morbidity of congenital rubella syndrome, although continued surveillance will be necessary to confirm this trend.

Antibody persistence after primary immunization with trivalent oral poliovirus vaccine.

Five years after primary infant immunization with trivalent oral poliovirus vaccine, employing either a three-dose primary series as recommended by the U.S. Public Health Service Advisory Committee on Immunization Practices (ACIP) or a four-dose series as recommended by the Committee on Infectious Diseases of the American Academy of Pediatrics. 115 children were serologically tested for persistence of neutralizing antibodies by the microneutralization test. Of the 57 individuals immunized according to the ACIP recommendation, antibody persistence was demonstrated in 92% for type 1 poliovirus, 98% for type 2, and 84% for type 3. Of those 58 individuals originally receiving a four-dose primary infant immunization series, the persistence of antibody was 98% to type 1, 98% to type 2, and 87% to type 3. Twenty-one of 24 negative sera showed neutralizing ability when tested by a more sensitive plaque reduction test. Thus, individuals completing either immunization schedule demonstrated satisfactory persistence of neutralizing antibody to all three poliovirus types over a five-year period.

Risk of human immunodeficiency virus infection among pregnant crack cocaine users in a rural community.

OBJECTIVE: To investigate why women who use crack cocaine are at increased risk of human immunodeficiency virus (HIV) infection. METHODS: One thousand one hundred fifty-two (99.7%) of 1155 consecutive prenatal patients attending a rural public health clinic were interviewed about drug use and sexual practices and tested for HIV infection and other sexually transmitted diseases. RESULTS: Fifty-one (4.7%) of 1096 pregnant women reported ever using crack cocaine, but only five (10%) of the crack cocaine users had ever injected drugs. Eighteen (35%) of the crack users were HIV infected compared with 22 (2%) of the 1045 women who reported never using crack (odds ratio 25, 95% confidence interval 12-52; P < .001). Crack users were more likely to have had a known HIV-infected sex partner, exchanged sex for money or drugs, and tested positive for syphilis than were non-crack users (for each comparison, P < .001). Before using crack, 18% of crack users had exchanged sex for money or drugs and 8% had averaged three or more sex partners per month; in contrast, after beginning to use crack, 76% of crack users exchanged sex for money or drugs and 63% averaged three or more sex partners per month (for both comparisons, P < .001). Crack users who were not HIV infected were more likely to have almost always used condoms and/or had fewer than three sex partners per month than were HIV-infected crack users (P < .01). CONCLUSION: Women who reported using crack cocaine were at an increased risk of HIV infection because crack use was associated with a significant increase in unprotected sexual contact.

AIDS: the HIV epidemic. A time of transition.

The surveillance of clinical cases of acquired immune deficiency syndrome (AIDS) in the United States began in June 1981 when the first case was reported. Since then, state and federal public health officials have continuously monitored progression of the epidemic by the number of persons reported with diagnosed clinical AIDS. The human immunodeficiency virus (HIV) that causes AIDS was identified in 1983 and an antibody test was licensed by the Food and Drug Administration in 1985. Recent studies have shown that the time from HIV infection to development of clinical AIDS is an average of seven or more years. Consequently, the reported cases of clinical AIDS reflect the severity of the epidemic an average of seven years ago or more, not now, and certainly not in the future. The AIDS epidemic is in reality an HIV epidemic. The number of persons with HIV infections is a better measure of the present status and future course of the disease. This paper discusses the development of HIV prevalence and incidence studies and illustrates the use of these data to predict the future number of persons with clinical AIDS and the economic impact of the epidemic.

Epidemiology of AIDS in Florida.

Florida is third in the nation in the cumulative number of AIDS cases. The epidemic in the state has grown steadily since 1981, clustering initially in metropolitan South Florida but dispersing to other urban and nonurban areas. Heterosexually transmitted AIDS is fast increasing and is more than twice as common in Florida than the United States; however, homosexual/bisexual men and intravenous drug-using men and women continue to represent the majority of new cases. Special serologic studies of the prevalence of HIV infection provide a timely view of the dynamics and characteristics of the epidemic in various segments of the state's population. Data from a large, ongoing serosurvey suggest that about one in every 220 childbearing women is HIV-infected, a finding consistent with Florida's rank of second nationally in the number of pediatric AIDS cases.

Florida's tuberculosis epidemic. Public health response.

Florida ranked fourth in the nation with 1,707 tuberculosis cases reported in 1992 for a rate of 12.7 per 100,000 population. Thirteen percent of these patients had AIDS. Recent cases in prisons, shelters, hospitals and schools have stimulated interest and media coverage. Resurgence of strains of multiple-drug resistant tuberculosis is a serious concern. The Florida Department of Health and Rehabilitative Services, in collaboration with allied agencies, has utilized several initiatives in response. The most significant, Tuberculosis Epidemic Containment Plan, details intervention strategies needed to eliminate TB in the state by the year 2010. Successful implementation depends upon local TB prevention and control coalitions that include private and public sector providers.

Current status of rubella in the United States, 1969-1975.

Implementation of the rubella immunization policy in the United States has resulted in marked decreases in the number of reported cases of both rubella and CRS. Emphasis on immunization of one- to 12-year-old children has resulted in a dramatic reduction in reported rubella in this age group. Accordingly, the proportion of reported cases occurring in adolescents and young adults has increased. Therefore, it seems appropriate to place more emphasis on immunizing susceptible adolescent and adult females as an adjunct to routine immunization in early childhood. This joint strategy should result in a further decrease in the incidence of rubella and CRS.