HIV wasting syndrome in the United States.

OBJECTIVE: To describe the characteristics of individuals > or = 13 years of age with HIV wasting syndrome in the United States and US territories. DESIGN: Retrospective review of national AIDS case surveillance data. METHODS: Data for the 147,225 individuals with AIDS reported to the Centers for Disease Control from 1 September 1987 to 31 August 1991 were reviewed. The frequency of HIV wasting syndrome and its association with demographic and exposure category variables and with other AIDS-indicator diseases were assessed. RESULTS: A total of 10,525 (7.1%) had wasting syndrome as the only AIDS-indicator condition, and 15,726 (10.7%) had wasting syndrome plus at least one other AIDS-indicator condition. Patients with wasting syndrome as the only AIDS diagnosis were more likely to be female, to be black or Hispanic, and to have a mode of HIV exposure reported as injecting drug use, heterosexual contact, or transfusion/hemophilia. The proportion of AIDS patients reported with wasting syndrome varied by geographic distribution, ranging from 11% in the northeastern United States to 47% in Puerto Rico. The association between HIV wasting syndrome and Hispanic ethnicity was due to the much higher prevalence of wasting syndrome reported in Puerto Rican AIDS patients. The other AIDS-indicator conditions most strongly associated with wasting syndrome were isosporiasis, pulmonary candidiasis, esophageal candidiasis, HIV encephalopathy, chronic mucocutaneous herpes simplex, and coccidioidomycosis. CONCLUSIONS: The association between HIV wasting syndrome and injecting drug use, and the significant racial/ethnic and geographic differences in prevalence of this AIDS diagnosis may reflect differences in diagnostic and reporting practices and/or access to medical care.

Changes in AIDS incidence trends in the United States.

Estimating the current prevalence of human immunodeficiency virus (HIV) and projecting the future incidence of AIDS require that trends in incidence be analyzed and interpreted. We analyzed AIDS incidence trends in the United States by exposure category and selected demographic factors. In 1987, the trend in United States AIDS incidence changed as growth in the number of cases diagnosed per quarter began to decline. The slowing in growth is due in large part to a plateau in quarterly incidence in men who have sex with men in the New York City, San Francisco, and Los Angeles metropolitan statistical areas (MSAs), and in injecting drug users in the New York City MSA and New Jersey. Incidence has also reached a plateau in both adult/adolescent and pediatric blood and blood product recipients. Quarterly U.S. AIDS incidence was roughly constant during 1990, but appears to have increased to a higher level during the first half of 1991. The variation in incidence trends among subgroups suggests that several factors have affected the trend in total incidence and that the burden of severe symptomatic HIV disease may be shifting.

Epidemiology of human immunodeficiency virus encephalopathy in the United States.

To investigate the epidemiology of human immunodeficiency virus (HIV) encephalopathy, we analyzed cases of acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control (CDC) from September 1, 1987, through August 31, 1991. Of 144,184 persons with AIDS (PWAs), 10,553 (7.3%) were reported to have HIV encephalopathy. The proportion of PWAs with HIV encephalopathy was highest at the extremes of age: in PWAs less than 15 years old the proportion was 13%, and in PWAs greater than or equal to 15 years old the proportion progressively increased with age, from 6% in PWAs 15 to 34 years old to 19% in PWAs greater than or equal to 75 years old (p = 0.00001, chi 2 test for linear trend in proportions). The reported annual incidence of HIV encephalopathy per 100,000 population aged 20 to 59 years was 1.4 in 1988, 1.5 in 1989, and 1.9 in 1990. This analysis best provides estimates for HIV encephalopathy as the initial manifestation of AIDS because the CDC AIDS reporting system often does not ascertain diagnoses after the initial AIDS report. These data suggest that age (very young or old) is associated with the development of HIV encephalopathy and that HIV encephalopathy is a common cause of dementia in adults less than 60 years old in the United States.

Exposure to and precautions for blood and body fluids among workers in the funeral home franchises of Fort Worth, Texas.

In 1982 the Centers for Disease Control published a set of recommendations and measures to protect persons working in health care settings or performing mortician services from possible exposure to the human immunodeficiency virus. This study of a number of funeral homes in the Fort Worth area was designed to determine the level of exposure of funeral home workers to blood and other body fluids and also to assess existing protective measures and practices in the industry. Workers in 22 funeral home franchises were surveyed with a predesigned questionnaire. Eighty-five responses from 20 of the 22 establishments were received. All 85 respondents admitted exposure of varying degrees to blood and body fluids. Sixty persons (70%) admitted heavy exposure, that is, frequent splashes. Analysis of the responses showed that 81 of 85 (95.3%) persons consistently wore gloves while performing tasks that might expose them to blood or other body fluids. Of the 60 persons who were heavily exposed, 43 wore long-sleeved gowns, 27 wore waterproof aprons, 17 surgical masks, and 15 goggles. The study further revealed that 52.9% (45/85) of the respondents had sustained accidental cuts or puncture wounds on the job. In light of these findings it is important to target educational efforts to persons in this industry to help them minimize their risks of infection with blood and body fluid borne infections.

Malaria and human immunodeficiency virus infection among male employees of a sugar estate in Malawi.

In sub-saharan Africa, where malaria is endemic and diagnostic and laboratory services are limited, fever is generally presumed to be due to malaria; however, the proportion of fevers actually related to malaria is unknown in most places. This study was conducted to determine the relationship between fever, malaria parasitaemia and human immunodeficiency virus (HIV) infection. Between February and April 1994, 643 consenting adult male workers of the Sugar Corporation of Malawi (SUCOMA) in Nchalo, Chikwawa District, Malawi were enrolled in a cross-sectional study. Participants underwent routine physical examinations and data were collected on age, axillary temperature, and history of fever or other illness in the 2 weeks before enrollment. Patients with axillary temperature > or = 37.5 degrees C were considered to be febrile. Blood was collected and thick blood films were prepared and examined for the presence of malaria parasites. HIV testing was done using the Wellcozyme enzyme-linked immunosorbent assay. Complete information was obtained from 605 subjects (94%), of whom 248 (41%) reported a history of fever (only 15% of the fever reporters were parasitaemic), 139 (23%) were HIV positive, and 131 (22%) received an antimalarial drug. HIV infection was significantly associated with fever but not with parasitaemia. Fever reporters and non-fever reporters were of similar age (means 32.8 and 33.1 years, respectively). These data suggest that in this population there was both high HIV seroprevalence and gross overestimation of fever as malaria. High HIV prevalence makes it necessary to re-examine the common practice in Malawi of treating all fever among adults as malaria.

PIP: 643 adult male employees of the Sugar Corporation of Malawi in Nchalo, Chikwawa District, participated in a cross-sectional study during February-April 1994 to determine the relationship between fever, malaria parasitemia, and HIV infection. Participants underwent routine physical examinations and data were collected on their ages, axillary temperatures, and histories of fever or other illnesses in the 2 weeks before enrollment in the study. Blood was collected and thick blood films prepared and examined for the presence of malaria parasites. Complete information was obtained from 605 subjects, of whom 248 (41%) reported a history of fever, 139 (23%) were HIV positive, and 131 (22%) received an antimalarial drug. Only 15% of fever reporters were parasitemic. HIV infection was significantly associated with fever, but not with parasitemia. Fever reporters and non-fever reporters were of mean ages 32.8 and 33.1 years, respectively. These data suggest that there was both high HIV seroprevalence and considerable overestimation of fever as malaria in this population. This high prevalence of HIV demands the reconsideration of the common practice in Malawi of treating all fever among adults as malaria.

Validity of mother's history regarding antimalarial drug use in Malawian children under five years old.

History obtained from parents and carers is an important, and often the only, source of information for health workers treating children for malaria, but its validity has not been well evaluated. At 2 hospitals in Malawi, we obtained malaria treatment histories from mothers of 973 ill children reported to have had fever as part of the illness. Urine samples were collected from 755 of the 973 children (78%). Of the 755, 457 (61%) were reported to have received some kind of treatment. Among those who reportedly received treatment, 79 (17%) were said to have received chloroquine and 23 (5%) a sulphonamide-containing medicine; however, when urine specimens were tested for antimalarial drugs, chloroquine was found in 182 specimens (40%) and a sulphonamide in 148 (32%). Among urine specimens collected from 291 children who were reported to have received no treatment (no report was recorded for 7 children), chloroquine was detected in 56 (19%) and a sulphonamide in 44 (15%). Although not statistically significant, mothers often reported a child as not having received an antimalarial drug if the child was younger than 12 months or had been sick for more than 3 d. The mothers' information regarding home treatment of fever in children was highly inaccurate. Malaria treatment histories, whether collected at health facilities or in surveys of knowledge, attitudes, and practices, must be interpreted with caution.

Parasitic infections in Asian refugees in Fort Worth.

This report describes parasitic infections recorded from April 1984 to December 1987 in refugees using services of the Fort Worth-Tarrant County Public Health Department. Infections with 1,601 parasitic infections were documented in 824 laboratory specimens obtained from refugees. Ascariasis and giardiasis were more prevalent than other parasitic infections. The highest attack rates occurred in refugees from Cambodia (70.0%), Laos (69.7%), and Vietnam (54.3%). Information from this study supports published data on high attack rates and endemicity of infections in refugees from Southeast Asia. Continued surveillance and treatment of these refugees should improve their health conditions and prevent the development of endemic foci in the United States.

Cryptosporidiosis in a day-care center.

Cryptosporidiosis has typically been considered a disease of animals, and the occasional human case has been considered a rare zoonosis or evidence of immunoincompetence. In this report, person-to-person transmission is postulated for illness documented in two of five rooms of a day-care center. Of 46 persons (34 children and 12 staff members), 29 (63%) became ill, and 27 (58.7%) had Cryptosporidium in their stools. Symptoms in children included diarrhea (55%), weight loss (25%), flatulence (15%), and fever (10%). Symptoms of cryptosporidiosis ceased without treatment, and three months later all previously infested children had negative stool specimens. Questionnaires administered to parents revealed no association with water, travel, or ill pets. Cultures for Salmonella, Shigella, and Campylobacter were negative; no viral cultures were done. All affected children and their parents were immunocompetent. It is presumed that this outbreak occurred as a result of person-to-person transmission of the protozoa in the day-care centers, primarily by staff with inadequate hygiene practices. Physicians should look for this organism in children or adults who present with diarrhea and gastroenteritis in which the pathogenic agent is not readily identifiable by the usual bacterial cultures.

Efficacy of sulphadoxine-pyrimethamine for acute uncomplicated malaria due to Plasmodium falciparum in Malawian children under five years old.

In 1993, Malawi replaced chloroquine (CQ) with sulphadoxine-pyrimethamine (SP) as its first-line treatment for uncomplicated malaria in children < 5 years of age. To assess the efficacy of SP after 5 years of widespread use, we undertook this study at 7 sites in 6 districts of Malawi. Febrile children < 5 years attending the outpatient clinics of selected hospitals whose parents consented were enrolled in the study if they had an axillary temperature of > or = 37.5 degrees C and pure Plasmodium falciparum parasitaemia of >or =2000 asexual parasites/mm3. They were then followed for 14 days or until clinical failure. Parasitological resistance rates (RII and RIII) ranged from 7% to 19%. Resistance was higher in the north than in the central and southern regions, although this difference was not statistically significant. Resistance rates were a mean 19% during the rainy season vs. 12% in the dry season (P > 0.05). 80% of parasitological resistance was at the RII level. Of all children who failed parasitologically (90/641), 84 (93%) had no fever on day 7 and their mothers did not report them as being ill; only 6 of 641 (0.9%) patients met the WHO criteria for clinical treatment failure. Regardless of study site, 75% of mothers reported their children as having improved by day 3; 90% reported improvement by day 7, and all reported improvement by day 14. None of the children experienced any serious adverse reactions and none died. We found that after more than 5 years of widespread use of SP in Malawi, its efficacy remains acceptable for treatment of uncomplicated malaria, and it should therefore be retained as first-line treatment.

Palpation as a method of fever determination in Malawian children who are less than 5 years old: how reliable is it?

Fever is a common occurrence in children who are < 5 years old and palpation of the forehead may or may not be a reliable method for determining fever in such children. In a study of 1120 Malawian children of this age attending outpatient's clinics, each child's mother and a clinical officer (CO) were asked to palpate the child's forehead and decide whether the child was febrile (felt warm or very warm) or afebrile (felt normal). The rectal temperature of each child was then taken using a thermometer and the child considered febrile if this temperature was > or = 38 degrees C. Using palpation, mothers judged 973 (86.9%) of 1120 children to be febrile and CO judged 565 (50.4%) of 1118 to be febrile, whereas thermometer readings indicated 410 (36.7%) to be truly febrile. False-positives (i.e. afebrile children judged to be febrile by palpation) accounted for 574 (59.0%) of the 973 children who were considered febrile by their mothers and 228 (40.4%) of the 565 children so considered by CO; mothers reported significantly more false-positives than CO (P < 0.05). False-negatives (i.e. febrile children judged to be afebrile by palpation) accounted for 11 (7.5%) of the 147 children who were considered afebrile by their mothers and 73 (13.2%) of the 553 children so considered by CO; CO reported significantly more false-negatives than mothers (P < 0.05). Overall, mothers were as likely as CO to misjudge a child (721/1120 v. 781/1118; P > 0.05). Although the sensitivity of mothers and CO in determining fever was similar (97.3% v. 82.2%; P > 0.05), CO gave a higher degree of specificity than the mothers (67.8% v. 19.2%; P < 0.000001). Although the present results indicate that palpation is not a reliable method of determining fever in children who are < 5 years old, caregivers should continue to use palpation as a useful first step in deciding when a child needs to be referred.

The public health significance of trypanosomiasis (sleeping sickness) in Nigeria.

Although trypanosomiasis is no longer a major public health problem in the Federal Republic of Nigeria, it nevertheless remains a significant economic bane to farmers whose livestock suffer high morbidity and mortality and a significant loss of weight. This disease probably leaves many Nigerians, without adequate protein intake either from lost beef or from the inability of the cattle to produce milk. Ford (1970) stated that trypanosomiasis may be what is holding back the development of large areas of Africa--a statement which has credence especially when viewed in terms of the thousands of square miles of Nigeria which remain under the infestation of tsetse--land which could be employed in food production. It is therefore important that the history, epidemiology and control methods for this disease be reviewed from time to time in an attempt to ensure that the surveillance mechanisms in place are functional.

A nation-wide malaria knowledge, attitudes and practices survey in Malawi: objectives and methodology.

A malaria knowledge, attitudes and practices survey was conducted in Malawi during April and May, 1992, to provide policy makers and program managers with information needed to design or improve malaria control programs, to establish epidemiologic and behavioral baselines, and to identify indicators for monitoring program effectiveness. Using cluster-sample survey methodology, 1531 households, in 30 clusters of 51-52 households each, were identified and members interviewed. Interviews were conducted by trained survey teams composed of young Malawian women with secondary level education. Heads of households were asked about malaria prevention methods used and about household economics; caretakers of children were asked about treatment and health seeking behavior in a recent malaria episode in a child; and women who had been pregnant in the past 5 years were asked about their antenatal clinic utilization and malaria during pregnancy. Survey results will be used to make programmatic decisions, including developing health education messages and establishing monitoring and evaluation of malaria control activities and outcomes in Malawi.

PIP: A malaria knowledge, attitudes and practices survey was conducted in Malawi in the late rainy season, April 1-May 16, 1992, corresponding to the season of peak malaria transmission to provide policy makers and program managers with information needed to design or improve malaria control programs, to establish epidemiologic and behavioral baselines, and to identify indicators for monitoring program effectiveness. A cluster-sample survey methodology, modified from the Expanded Program for Immunization cluster-sampling methodology was used to identify and interview members of a total sample of 1531 households, in 30 clusters of 51 to 52 households each. Heads of households were asked about malaria prevention methods used and about household economic; caretakers of children were asked about treatment and health seeking behavior in a recent malaria episode in a child; and women who had been pregnant in the past 5 years were asked about their antenatal clinic utilization and malaria during pregnancy. A total of 7025 persons in 1531 households were included in the survey: 1178 adults with recent fever illness and caretakers of 724 children with recent fever illness were interviewed; 1395 households included at least one woman who had ever been pregnant, with 809 women having completed a pregnancy within the last 5 years. Preventive measures used in the households and household income were ascertained for 1531 households. In several articles, detailed results will be described for each part of the survey. These results will be used to be guide policy makers and program managers in making decisions based on current data in designing and improving malaria control programs and health education messages. Baseline epidemiologic and behavioral indicators will be identified for monitoring program impact to help focus intervention efforts on high risk groups, through channels that will most effectively reach the greatest number of people.

Acquired immunodeficiency syndrome in the United States associated with injecting drug use, 1981-1991.

As of June 30, 1991, 182,834 AIDS cases in the United States had been reported to the Centers for Disease Control, of which 58,879 (32.2%) were associated with illicit drug use. Of these, 39,904 (70.0%) were in both women and heterosexual men reported as injecting drug users (IDUs), 11,823 (20.7%) in men who have sex with men who are also IDUs, 5,305 (9.3%) in sex partners of IDUs, and 1,847 (3.1%) in children whose mothers were either IDUs or sex partners of IDUs. From 1989 to 1990, the increase in the number of United States AIDS cases associated with IDU either directly or indirectly was higher in all regions compared with the Northeast. The highest percentage increases were in the South, U.S. territories, and the North Central. From 1989 to 1990, the percentage of AIDS cases attributed directly to IDU increased in women and men (15.3 and 5.9%, respectively); however, the increase in sex partners of IDUs was much larger (34.5% in men and 29.1% in women). Increases were also higher in sex partners of IDUs than in IDUs when compared by race/ethnicity and by region of residence. Because HIV can spread rapidly among IDUs and their sex partners, there is an immediate need for targeting effective HIV prevention messages to all IDUs and their sex partners in communities with high HIV infection rates.

Efficacy of sulphadoxine/pyrimethamine for Plasmodium falciparum malaria in Malawian children under five years of age.

In March 1993, sulphadoxine/pyrimethamine (SP) replaced chloroquine as the first line drug for malaria treatment in Malawi. Since then, the Ministry of Health has been receiving anecdotal and written reports of SP treatment failures in children. To determine whether treatment failure with SP was a widespread problem, children < 5 years of age with axillary temperature > 38.0 degrees C and parasite density > 2000/mm3 attending the outpatient clinics of the Mangochi and Karonga District Hospitals were enrolled in the study with parental consent. These were then followed for 28 days or until they failed clinically. Of 159 patients enrolled, 145 (91.2%) were followed for 28 days or until clinical failure. Of these, none had RII resistance and 3 (1.9%) had RIII resistance: 2/69 (2.9%) in Mangochi and 1/76 (1.3%) in Karonga; 142/145 (97.9%) exhibited RI/sensitive patterns. Of those followed to day 28 or to clinical failure, 77.1% had parasite clearance by day 3 and 98.6% had parasite clearance by day 7. Of those with temperature readings (n = 140), 129 (92.1%) clinically improved on day 3 and 98.6% improved by day 7. Other indicators of clinical improvement (from day 0 to day 3) included, reported increased level of activity in 136 (97.1%) of the children, and mother's impression of child's improvement in 113 (80.7%). Of the 14 patients not followed to day 28 or to clinical failure, 11 were lost to follow-up by day 7. No allergic skin reactions were noted, and no deaths were observed. These data show that after one year of widespread use of SP in Malawi, Plasmodium falciparum parasite resistance remains very low, and therefore contradicts reports of widespread parasite resistance to SP.

The effect of oral iron therapy during treatment for Plasmodium falciparum malaria with sulphadoxine-pyrimethamine on Malawian children under 5 years of age.

In sub-Saharan countries, although malaria and malaria-associated anaemia are major public health problems, the usefulness of supplementary iron treatment for children with malaria-associated anaemia is unknown. In a 6-week period during the 1995 rainy season, 222 Malawian children aged < 5 years, who sought treatment for malaria, had > or = 500 parasites/microliter blood and at least 5 g haemoglobin (HB)/dl blood and whose parents gave consent, were randomized into a prospective study comparing the efficacy of sulphadoxine- pyrimethamine only (SP), SP plus daily iron (SPD) and SP plus weekly iron (SPW) as treatment for malaria-associated anaemia. The patients had their HB concentrations measured on enrollment (day 0), just before antimalarial treatment, and on days 3, 7, 14, 21 and 28; 215 (96.8%) completed the 28-day study. Among the children with 5-8 g HB/dl on enrolment, HB gain by the end of the study was significantly greater than in the children with > 8 g HB/dl initially (4.1 v. 2.2 g/dl; P < 0.05), and those in the SPD group gained significantly more HB by days 21 and 28 (3.6 and 4.9 g/dl, respectively) than those in either the SPW (2.7 and 3.7 g/dl, respectively) or the S2 groups (2.6 and 3.5 g/dl, respectively); there was no difference in HB gain between the SP and SPW groups. Type of treatment had no apparent effect, at any time during the study, on HB gains in those patients who had > 8 g HB/dl on enrolment. Thus the children with 5-8 g HB/dl on enrolment benefited from daily iron therapy whereas those with > 8 g HB/dl derived no significant benefit; improvement in HB depended most on whether enrolment HB was < or = 8.0 g/dl. As treatment with an effective antimalarial drug resulted in HB gains, irrespective of treatment group or HB concentration at enrolment, the anaemia observed may be mostly related to malaria. However, as a larger proportion of the iron-treated patients failed to clear their parasitaemias than of those given SP alone, oral iron may inhibit SP action. It is therefore recommended that, for children with both malaria and malaria-associated anaemia, the malaria should first be cleared with an effective antimalarial drug, such as SP, before the anaemia, if it still persists, is treated with iron.

Malarone-donation programme in Africa.

PIP: Glaxo Wellcome announced in November 1996 its intent to donate up to 1 million treatment courses per year of its new antimalarial drug, Malarone, to countries in Africa, Southeast Asia, and South America, where malaria is endemic. Because the effectiveness of the small number of available antimalarial drugs is threatened by the emergence of drug resistance, the advantages of introduction of this new drug to a given area should be given careful consideration. Chloroquine, for example, is nearing the end of its effectiveness as a first-line drug for the treatment of uncomplicated falciparum malaria in many areas of East and Central Africa. The lifespan of its replacement, sulfadoxine-pyrimethamine, is likely to be even shorter given its long half-life and the ease with which resistance-conferring mutations occur. In Southeast Asia and the Amazon basin of South America, where multidrug-resistant Plasmodium falciparum malaria is a serious problem, the advantages of Malarone introduction clearly outweigh any disadvantages. In sub-Saharan Africa, the premature distribution and increasing use of artemisinins may jeopardize their long-term effectiveness, however. Another factor complicating decisions to introduce Malarone is its required 3-day course of treatment, necessitating hospitalization if compliance is to be ensured. The donation project gives patients in developing countries access to an expensive drug that would otherwise be unavailable. Time must be taken, however, to fully debate the project's pros and cons, resolve inherent logistic problems, and establish guidelines for Malarone use in sub-Saharan Africa.^ieng

Increasing frequency of heterosexually transmitted AIDS in southern Florida: artifact or reality?

Acquired immunodeficiency syndrome (AIDS) cases reported as the result of heterosexual contact have been increasing in the United States, with Florida reporting a disproportionate number. We investigated 168 such AIDS cases from southern Florida. After follow-up, 50 (30%) patients were reclassified into other transmission categories. The data suggest that the increased rate of heterosexually acquired AIDS cases reported from southern Florida was partially related to misclassification of risk.

Age-related differences in cell-specific cytokine production by acutely ill Malawian patients.

Age-related changes in human cell-specific cytokine responses to acute illness have not been well examined. We therefore evaluated age-related differences in T, B and natural killer (NK) peripheral blood lymphocyte cytokine responses of 309 acutely ill hospitalized people in Malawi, Africa, < 1 month-61 years of age. We used four-colour flow cytometry and performed Wilcoxon rank sum and Kruskal-Wallis tests, Pearson (rp) and Spearman (rs) correlations, and linear and logistic regression analyses to control for human immunodeficiency virus infection (HIV) status, the percentages of lymphocytes expressing CD4, and the nature of the acute infection. The percentages of CD8- and CD8+ T cells producing induced IL-8 decreased with age (rs = -0.44 and -0.53). The percentages of T cells producing TNF-alpha were higher, and the percentages producing IL-10 were lower, in those > or =13 than those < 13 years old (medians: 17.7 versus 10.5 and 1.4 versus 3.0, respectively). The percentages of CD8- T cells producing IFN-gamma were higher and stable in those > or =1 year old compared to infants (medians: 23.5 versus 10.4); the percentages of NK producing IFN-gamma were higher post-infancy and then declined to relatively low levels with increasing age. The percentages of T cells producing IL-2 were highest in those 5- <31 years old (median 5.6) and lowest in those > or =31 years old (median 1.9). The ratios of the percentages of T cells producing IL-4 to those producing IL-8 and to those producing IL-10 both increased with age. These data suggest that innate immunity, represented by NK IFN-gamma production, dominates in early life. A number of shifts occur after infancy and before adolescence, including a proinflammatory shift from IL-8 to TNF-gamma and a type 2 shift from IL-10 to IL-4 dominance. These findings suggest distinct age-related differences in the human response to acute illness and may be useful in directing future efforts at immunomodulatory therapies.