Developing WHO guidelines with pragmatic, structured, evidence-based processes: A case study.

Many guidelines, including those produced by the World Health Organisation (WHO), have failed to adhere to rigorous methodological standards. Operational examples of guideline development processes may provide important lessons learned to improve the rigour and quality of future guidelines. To this end, this paper describes the process of developing WHO guidelines on prevention and care interventions for adults and adolescents living with HIV. Using a pragmatic, structured, evidence-based approach, we created an organising committee, identified topics, conducted systematic reviews, identified experts and distributed evidence summaries. Subsequently, 55 global HIV experts drafted and anonymously submitted guideline statements at the beginning of a conference. During the conference, participants voted on statements using scales evaluating appropriateness of the statements, strength of recommendation and level of evidence. After review of voting results, open discussion, re-voting and refinement of statements, a draft version of the guidelines was completed. A post-conference writing team refined the guidelines based on pre-determined guideline writing principles and incorporated external comments into a final document. Successes and challenges of the guideline development process were identified and are used to highlight current issues and debates in developing guidelines with a focus on implications for future guideline development at WHO.

Trends in HIV testing among pregnant women: United States, 1994-1999.

OBJECTIVES: This study evaluated 1995 guidelines for HIV testing of pregnant women. METHODS: Analysis focused on Behavioral Risk Factor Surveillance System data for the years 1994 through 1999. Data were aggregated across states. RESULTS: Percentages of pregnant women tested for HIV increased from 1995 to 1996 (from 41% to 53%) and again from 1997 (52%) to 1998 (60%). CONCLUSIONS: After implementation of the guidelines, the percentage of pregnant women tested for HIV increased, although nearly half had not been tested. More efforts are needed to encourage women to undergo testing for HIV during pregnancy, thus maximizing opportunities for offering antiretroviral therapy.

Successful implementation of perinatal HIV prevention guidelines. A multistate surveillance evaluation.

In 1994, zidovudine (ZDV) was demonstrated to substantially reduce perinatal transmission of the human immunodeficiency virus (HIV). Guidelines regarding the use of ZDV to reduce transmission and regarding counseling and voluntary testing of pregnant women were issued in 1994 and 1995, respectively. Surveillance methods were used to evaluate the implementation of these guidelines and to understand reasons for continued perinatal transmission of HIV. Population-based enhanced perinatal surveillance was used in seven states to collect information regarding mother-infant pairs in 1993, 1995, and 1996. Birth registries and HIV/Acquired immunodeficiency virus (AIDS) registries were matched to determine the number of HIV-infected women with diagnosis before delivery. Supplemental epidemiologic information was collected for 1,321 pairs. The estimated total number of HIV-infected women giving birth each year was derived from the Survey of Childbearing Women, an anonymous serologic survey of the prevalence of HIV infection among women giving birth. From 1993 through 1996, the proportion of HIV-infected women with diagnosis before delivery increased from 70% to 80%. The proportion of women with a diagnosis who received ZDV prenatally increased from 27% to 83% and intrapartum, 6% to 75%; for neonates, the increase was from 8% to 77%. Overall, 14% of women received no or only one prenatal care visit. A total of 36% of women who used illicit drugs during pregnancy had not had prenatal care. Of the children who received any ZDV, 8% were infected compared with 16% of those who received no ZDV. ZDV, used for treating pregnant HIV-infected women, has been rapidly adopted in clinical practice and has reduced the transmission of HIV. To achieve continued declines in perinatal transmission of HIV infection, continued progress is needed in the following areas: a) increases in the proportion of women who receive prenatal care and an HIV diagnosis; and b) implementation of rapid testing methods (when licensed rapid tests are available) or rapid turnaround of standard tests (expedited EIA tests).

Drug safety during pregnancy and in infants. Lack of mortality related to mitochondrial dysfunction among perinatally HIV-exposed children in pediatric HIV surveillance.

The objectives were to assess whether any deaths reported among perinatally exposed, uninfected, or indeterminate children were consistent with mitochondrial dysfunction, and to characterize perinatal exposure to antiretrovirals among children born in the last five years and reported to perinatal HIV surveillance. Population-based HIV/AIDS surveillance data on perinatally exposed children born in 1993 through 1998 from 32 states with HIV reporting and from a special HIV surveillance project in Los Angeles County and in 22 hospitals in New York City were used. The classifications of exposure and deaths were consistent with the investigation of deaths across all US cohorts. Deaths were ascertained from recent matches with death registries in each state. Causes of death were ascertained from death certificates, autopsy records when available, and medical records. None of the 98 deaths (1.1%) among 9067 perinatally exposed uninfected or indeterminate children born from 1993 through 1998 and reported through pediatric HIV surveillance died of conditions that were consistent with mitochondrial dysfunction. This included 679 children exposed to zidovudine (ZDV) and 3TC, 277 exposed to other antiretroviral combinations, 4512 exposed to ZDV alone, 927 with no antiretroviral exposure, and 2672 with unknown exposure--1128 of whom were born before March 1994 and were unlikely to have been exposed to ZDV. No deaths attributable to mitochondrial dysfunction were found through this evaluation of population-based HIV surveillance data. Long-term follow-up of antiretroviral-exposed children has been recommended by the Public Health Service. This evaluation highlights the contribution of population-based surveillance to the evaluation of potential toxicities associated with maternal antiretroviral use.

Epidemiology of human immunodeficiency virus-associated opportunistic infections in the United States in the era of highly active antiretroviral therapy.

The incidence of nearly all AIDS-defining opportunistic infections (OIs) decreased significantly in the United States during 1992-1998; decreases in the most common OIs (Pneumocystis carinii pneumonia ¿PCP, esophageal candidiasis, and disseminated Mycobacterium avium complex ¿MAC disease) were more pronounced in 1996-1998, during which time highly active antiretroviral therapy (HAART) was introduced into medical care. Those OIs that continue to occur do so at low CD4+ T lymphocyte counts, and persons whose CD4+ counts have increased in response to HAART are at low risk for OIs, a circumstance that suggests a high degree of immune reconstitution associated with HAART. PCP, the most common serious OI, continues to occur primarily in persons not previously receiving medical care. The most profound effect on survival of patients with AIDS is conferred by HAART, but specific OI prevention measures (prophylaxis against PCP and MAC and vaccination against Streptococcus pneumoniae) are associated with a survival benefit, even when they coincide with the administration of HAART. Continued monitoring of incidence trends and detection of new syndromes associated with HAART are important priorities in the HAART era.

Epidemiology of HIV/AIDS in children.

HIV infection has been a major cause of morbidity and mortality since the first cases of AIDS among children were reported in 1982 in the United States. Considerable advances, especially in the past 5 years, in the understanding of the pathogenesis, diagnosis, treatment, monitoring, and prevention of HIV infection in children have changed the rate of pediatric HIV infection in the United States. Efforts to maximally decrease perinatal HIV transmission in the United States are ongoing. Physicians must try to prevent HIV infection among women, especially adolescents.

Trends in perinatal transmission of HIV/AIDS in the United States.

CONTEXT: Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission. OBJECTIVE: To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998. MAIN OUTCOME MEASURES: Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states. RESULTS: Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n = 6990) to 1995 (n = 5797). Among infants, PCP rates per 100000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%. CONCLUSIONS: According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.

Sexual abuse of children: intersection with the HIV epidemic.

OBJECTIVE: Sexual transmission of human immunodeficiency virus (HIV) is the predominant risk exposure among adolescents and adults reported with HIV infection and acquired immunodeficiency syndrome (AIDS). Although perinatal transmission accounts for the majority of HIV infection in children, there have been reports of HIV transmission through sexual abuse of children. We characterized children <13 years of age who may have acquired HIV infection through sexual abuse. METHODS: All reports by state and local health departments to the national HIV/AIDS surveillance system of children with HIV infection not AIDS (n = 1507) and AIDS (n = 7629) through December 1996 were reviewed for history of sexual abuse. Information was ascertained from data recorded on the case report form as well as investigations of children with no risk for HIV infection reported or identified on initial investigation. For children with a possible history of sexual abuse, additional data were collected, including how sexual abuse was diagnosed; characteristics of the perpetrator(s) (ie, HIV status and HIV risks); and other possible risk factors for the child's HIV infection. RESULTS: Of 9136 children reported with HIV or AIDS, 26 were sexually abused with confirmed (n = 17) or suspected (n = 9) exposure to HIV infection; mean age of these children at diagnosis of HIV infection was 8.8 years (range, 3 to 12 years). There were 14 females and 3 males who had confirmed sexual exposure to an adult male perpetrator at risk for or infected with HIV; of these, 14 had no other risk for HIV infection, and 3 had multiple risks for HIV infection (ie, through sexual abuse, perinatal exposure, and physical abuse through drug injection). The other 9 children (8 females, 1 male) had no other risk factors for HIV infection and were suspected to have been infected through sexual abuse, but the identity, HIV risk, or HIV status of all the perpetrator(s) was not known. All cases of sexual abuse had been reported to local children's protective agencies. Sexual abuse was established on the basis of physician diagnosis or physical examination (n = 20), child disclosure (n = 15), previous or concurrent noncongenital sexually transmitted disease (n = 9), and for confirmed cases, criminal prosecution of the HIV-infected or at-risk perpetrator (n = 8). For the 17 children with confirmed sexual exposure to HIV infection, 19 male perpetrators were identified who were either known to be HIV infected (n = 18) or had risk factors for HIV infection (n = 17), most of whom were a parent or relative. CONCLUSIONS: These 26 cases highlight the tragic intersection of child sexual abuse and the HIV epidemic. Although the number of reported cases of sexual transmission of HIV infection among children is small, it is a minimum estimate based on population-based surveillance and is an important and likely underrecognized public health problem. Health care providers should consider sexual abuse as a possible means of HIV transmission, particularly among children whose mothers are HIV-antibody negative and also among older HIV-infected children. The intersection of child abuse with the HIV epidemic highlights the critical need for clinicians and public health professionals to be aware of the risk for HIV transmission among children who have been sexually abused, and of guidelines for HIV testing among sexually abused children, and to evaluate and report such cases.

Trends in zidovudine prescription for pregnant women infected with HIV.

OBJECTIVE: The purpose of this analysis was to describe trends in zidovudine prescription during pregnancy among women infected with HIV. METHODS: We used data from the Adult and Adolescent Spectrum of Disease Surveillance Project, which collects information on HIV-related conditions through medical record review. Women who were reported pregnant from 1990 through 1996 were included in the analysis. RESULTS: From 1990 through 1996, of 7047 women in the project, 714 (10%) were pregnant for a total of 782 pregnancies. We found a high proportion (82%) of pregnancies during which zidovudine was prescribed for women with CD4+ T-lymphocyte count of 0 to 199 cells/microl (n = 125), but no trend over time. In contrast, from 1990 through 1996 zidovudine was prescribed for an increasing proportion of pregnancies in which the woman's CD4+ count was 200 to 499 cells/microl (62%-78%; p = .01; n = 337) and > or = 500 cells/microl (22%-55%; p = .001; n = 250). CONCLUSIONS: Our study demonstrated differences in zidovudine prescription over time by CD4+ count; these differences may be based on the woman's health and guidelines for perinatal prevention.

Projection of AIDS and HIV incidence among children born infected with HIV.

By 31 December 1995, 6285 children with perinatally acquired immunodeficiency syndrome (AIDS) had been reported to the Centers for Disease Control and Prevention (CDC) by the state and local health departments of all 50 states, the District of Columbia, Puerto Rico, and the U.S. territories. We present here the statistical methods used to estimate the number of infants born with HIV and to predict the number of diagnoses of perinatally acquired AIDS among children to 1997. We estimate that there were 13,900 children who had perinatally acquired HIV infection by the end of 1995 and who will eventually be reported with AIDS. If 85 per cent of all diagnoses are reported, this represents a total of more than 16,300 diagnoses. Of these, 6600 had developed AIDS by the end of 1995 and will eventually be reported to CDC. We project that, during 1996 and 1997, another 1500 HIV-infected children will be born.

Prevalence and incidence of vertically acquired HIV infection in the United States.

OBJECTIVE: To estimate human immunodeficiency virus (HIV) type I prevalence among childbearing women, HIV incidence in infants, and the number of children living with HIV infection and acquired immunodeficiency syndrome as a result of transmission from mother to infant (vertical transmission). DESIGN: The national HIV serosurvey of childbearing women was used to estimate the incidence of vertically acquired HIV infection in children born between 1988 and 1993. Data from the national acquired immunodeficiency syndrome case surveillance system and a multicenter pediatric HIV surveillance project were modeled to estimate incidence in children born between 1978 and 1987. SETTING: Surveillance conducted by the Centers for Disease Control and Prevention, Atlanta, Ga, in collaboration with state and local health departments. RESULTS: Approximately 14,920 HIV-infected infants were born in the United States between 1978 and 1993. Of these, an estimated 12,240 children were living at the beginning of 1994; 26% were younger than 2 years, 35% were aged 2 to 4 years, and 39% were aged 5 years or older. Approximately 6530 HIV-infected women gave birth in the United States in 1993, and, based on a 25% vertical transmission rate, an estimated 1630 of their infants were HIV infected. CONCLUSIONS: These results provide a basis for estimating medical and other resource needs for HIV-infected women and their children and for measuring the impact of interventions to reduce vertical transmission of HIV.

Mumps surveillance--United States, 1988-1993.

PROBLEM/CONDITION: CDC monitors the incidence of mumps in the United States through the passive reporting of cases to its National Notifiable Disease Surveillance System (NNDSS). REPORTING PERIOD COVERED: 1988-1993. DESCRIPTION OF SYSTEM: Weekly reports to the NNDSS from 48 states and the District of Columbia were used to calculate incidence rates for mumps. State immunization requirements were obtained from the U.S. Department of Health and Human Services. RESULTS: After the licensure of mumps vaccine in the United States in December 1967 and the subsequent introduction of state immunization laws in an increasing number of states, the reported incidence of mumps decreased substantially. The 1,692 cases of mumps reported for 1993 represent the lowest number of cases ever reported to NNDSS and a 99% decrease from the 152,209 cases reported for 1968. During 1988-1993, most cases occurred in children 5-14 years of age (52%) and in persons > or = 15 years of age (36%). Although the incidence decreased in all age groups, the largest decreases (> 50% reduction in incidence rate per 100,000 population) occurred in persons > or = 10 years of age. Overall, the incidence of mumps was lowest in states that had comprehensive school immunization laws requiring mumps vaccination and highest in states that did not have such requirements. INTERPRETATION: Because of the extensive use of mumps vaccine and the increased number of states that had enacted mumps immunization laws, the number of reported mumps cases decreased further since the marked decline that began during the early 1970s. The earlier shift in incidence from children of school ages to older persons that was noted during 1985-1988 continued until 1992, when the proportion of cases occurring in children of school ages increased and exceeded the proportions occurring in other age groups. ACTIONS TAKEN: All health-care providers are encouraged to a) report mumps cases to their local and state health departments for transmission to NNDSS and b) enact school immunization laws requiring mumps vaccination.

Teenagers at risk of human immunodeficiency virus type 1 infection. Results from seroprevalence surveys in the United States.

OBJECTIVE: To describe the seroprevalence of human immunodeficiency virus type 1 (HIV-1) and risk factors for HIV-1 infection among teenagers attending selected clinics. DESIGN: Anonymous, cross-sectional serosurveys conducted in 130 clinics in 24 cities. SETTINGS: Adolescent medicine clinics, sexually transmitted disease clinics, clinics in juvenile detention and correctional facilities, and homeless and runaway youth centers. PATIENTS: Teenagers in whom serum samples were drawn as part of routine medical services. MAIN OUTCOME MEASURES: Prevalence of HIV-1 infection and reported HIV risk behaviors. RESULTS: From January 1, 1990 through December 31, 1992, serum specimens were collected from 79,802 teenagers; 591 of these specimens were positive for HIV-1 antibody. Seropositive test results were found in all 24 cities surveyed, and in 95 (73%) of the 130 clinics surveyed. The median clinic-specific prevalence was 0.2% (range, 0% to 1.4%) in 22 adolescent medicine clinics, 0.3% (range, 0% to 6.8%) in 33 correctional facilities, 0.5% (range, 0% to 3.5%) in 70 sexually transmitted disease clinics, and 1.1% (range, 0% to 4.1%) in five homeless youth centers. Rates exceeded 1% in 37 sites (28%). Excluding sites with many men reporting sex with men, rates in women were similar or somewhat higher than rates in men. Rates were highest among young men reporting sex with men, with clinic rates ranging from 16% to 17% in two homeless youth sites and 13% to 17% in two sexually transmitted disease clinics. Most teenagers with risk information reported heterosexual activity as their only potential risk exposure to HIV-1. CONCLUSIONS: Seroprevalence of HIV was generally low but varied by type of clinic and geographic area. The highest rates were observed among young women and gay men in some settings, suggesting that targeted prevention messages are needed.

Prophylaxis against Pneumocystis carinii pneumonia among children with perinatally acquired human immunodeficiency virus infection in the United States. Pneumocystis carinii Pneumonia Prophylaxis Evaluation Working Group.

BACKGROUND: Pneumocystis carinii pneumonia (PCP) remains a common and often fatal opportunistic infection among children infected with the human immunodeficiency virus (HIV). HIV-infected infants between three and six months of age are particularly vulnerable. Current guidelines recommend prophylaxis in children from birth to 11 months old who have CD4+ counts below 1500 cells per cubic millimeter. METHODS: We used national surveillance data to estimate the annual incidence of PCP among children less than one year old. We reviewed the medical records of 300 children given a diagnosis of PCP between January 1991 and June 1993 to determine why treatment according to the 1991 guidelines for prophylaxis against PCP either was not given or failed to prevent the disease. RESULTS: In our study the incidence of PCP in the first year of life among infants born to HIV-infected mothers changed little between 1989 and 1992. Among 7080 children born to HIV-infected mothers in 1992, PCP developed in 2.4 percent. Of 300 children with PCP diagnosed from January 1991 through June 1993, 199 (66 percent) had never received prophylaxis, and for 118 of those children (59 percent) exposure to HIV was first identified 30 days or less before the diagnosis of PCP. Among 129 children less than one year old, the CD4+ count declined by an estimated 967 cells per cubic millimeter (95 percent confidence interval, 724 to 1210 cells per cubic millimeter) during the three months before the diagnosis of PCP. Among infants in whom CD4+ counts were determined within one month of the diagnosis of PCP, 18 percent (20 of 113) had at least 1500 cells per cubic millimeter, a level higher than the currently recommended threshold for prophylaxis. CONCLUSIONS: In the United States the incidence of PCP among HIV-infected infants has not declined. If this infection is to be prevented, infants exposed to HIV must be identified earlier, and prophylaxis must be offered to more children than the guidelines currently recommend.

Prevalence of hepatitis B, hepatitis C, and human immunodeficiency virus infection among women attending prenatal clinics in San Juan, Puerto Rico, from 1989-1990.

OBJECTIVE: To evaluate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) among pregnant women in Puerto Rico. METHODS: An anonymous serosurvey was conducted in four prenatal clinics in San Juan, Puerto Rico, involving women presenting consecutively for their first prenatal visit. RESULTS: Nineteen of 997 pregnant women (1.9%, 95% confidence interval [CI] 1.2-3.0) tested positive for HCV antibody (anti-HCV), and eight (0.8%, 95% CI 0.4-1.6) were HIV seropositive. Of the 992 women for whom serum samples were tested for HBV markers, 91 (9.2%, 95% CI 7.5-11.2) had evidence of past or current HBV infection, and four (0.4%, 95% CI 0.1-1.1) were HBV carriers. The age-specific HBV prevalence ranged from 4.1% among women 15-19 years old to 18.5% among those at least 30 years old (P < .001, chi 2 test for trend). Anti-HCV prevalence was also higher among women at least 30 years old compared to younger women (3.1 versus 1.9%; prevalence ratio 1.6, 95% CI 0.6-4.9), although the difference was not statistically significant. Anti-HCV prevalence was higher among women with past or current HBV infection than among women who were not infected (7.7 versus 1.3%; prevalence ratio 5.8, 95% CI 2.3-14.3). CONCLUSIONS: The prevalence of chronic HBV and HCV infection among pregnant women tested in San Juan, Puerto Rico, is comparable to that among pregnant women in the United States. The prevalence of HIV infection among pregnant women in San Juan is higher than among childbearing women in the United States.

HIV infection among homeless adults and runaway youth, United States, 1989-1992. Field Services Branch.

OBJECTIVES: Homeless persons have an increased risk of HIV infection because of a high prevalence of HIV-related risk behaviors. These include drug use, sexual contact with persons at risk for HIV infection, and the exchange of sex for drugs. The objectives of this investigation were to describe HIV seroprevalence rates in homeless adults and runaway youth. METHODS: In 1989, the Centers for Disease Control and Prevention began collaboration with state and local health departments to conduct HIV seroprevalence surveys in homeless populations. Unlinked HIV seroprevalence surveys were conducted in 16 sites; 11 provided medical services primarily to homeless adults, and five to runaway youth aged < 25 years. RESULTS: From January 1989 through December 1992, annual surveys were conducted in 16 sites in 14 cities. Site-specific seroprevalence rates ranged from 0-21.1% (median, 3.3%). Among homeless adults in three sites, rates were higher among men who had sex with other men and those who injected drugs than among persons with other risk exposures (28.9 versus 5.3%). In general, rates were higher for heterosexual men than for women and higher among African Americans than whites. In sites providing services to homeless youth, HIV seroprevalence rates ranged from 0-7.3% (median, 2.3%). CONCLUSIONS: These data indicate that HIV infection among homeless adults and runaway youth is an important public health problem. HIV prevention and treatment should be integrated into comprehensive health and medical programs serving homeless populations.

Seroprevalence of HIV and risk behaviors among young homosexual and bisexual men. The San Francisco/Berkeley Young Men's Survey.

OBJECTIVE: To estimate the prevalence of human immunodeficiency virus (HIV) infection and risk behaviors among young homosexual and bisexual men sampled from public venues in San Francisco and Berkeley, Calif. DESIGN: A survey of 425 young homosexual and bisexual men sampled from 26 locations during 1992 and 1993. Participants were interviewed and blood specimens were drawn and tested for HIV, level of CD4+ T lymphocytes, and markers of hepatitis B and syphilis. SETTING: Public venues in San Francisco and Berkeley, including street corners and sidewalks, dance clubs, bars, and parks. POPULATION STUDIED: Homosexual and bisexual men aged 17 to 22 years. MAIN OUTCOME MEASURES: Prevalence of HIV infection and risk behaviors. RESULTS: The HIV seroprevalence was 9.4% (95% confidence interval, 6.8% to 12.6%). The prevalence of markers for hepatitis B was 19.8% (95% confidence interval, 16.1% to 23.9%), and that for syphilis was 1.0% (95% confidence interval, 0.3% to 2.4%). The HIV seroprevalence was significantly higher among African Americans (21.2%) than among other racial/ethnic groups (P = .002). Approximately one third (32.7%) of the participants reported unprotected anal intercourse, and 11.8% reported injecting drug use in the previous 6 months. At the time of interview, 70.0% of the HIV-infected men did not know that they were HIV seropositive, and only 22.5% were receiving medical care for HIV infection. CONCLUSIONS: The prevalence of HIV infection is high among this young population of homosexual and bisexual men, particularly among young African-American men. The high rates of HIV-related risk behaviors suggest a considerable risk for HIV transmission in this population. Prevention programs and health services need to be tailored to address the needs of a new generation of homosexual and bisexual men.

Measles vaccination in pediatric emergency departments during a measles outbreak.

OBJECTIVE: To determine the proportion of preschool-aged patients attending two inner-city hospital pediatric emergency departments (EDs) who were eligible for measles vaccination, to describe their demographic and clinical characteristics, and to assess the performance of the ED immunization programs that were implemented during a measles outbreak in vaccinating eligible children. DESIGN: Cross-sectional study. SETTING: Pediatric EDs of two urban hospitals in Chicago, Ill, in 1989. PARTICIPANTS: Children 6 months to 5 years of age seen in the EDs. INTERVENTION: None. MAIN OUTCOME MEASURES: The proportion of preschool-aged patients attending the two EDs who were eligible for measles vaccination and the proportion of vaccine-eligible children who were given measles vaccine. RESULTS: Of 508 ED patients at hospital A and 255 patients at hospital B, 18% and 29%, respectively, were considered to be vaccine eligible. The most common discharge diagnoses of eligible patients were viral syndrome, otitis media, and minor trauma. Of vaccine-eligible patients, 59% at hospitals A and B were not vaccinated in the ED. At hospital B, patients with an infectious or respiratory disease diagnosis were less likely to be vaccinated than those with other diagnoses (P < .05). CONCLUSIONS: Many children seen in these EDs were eligible for measles vaccination, and many eligible patients were not vaccinated. During community outbreaks of measles, optimal vaccination programs in pediatric EDs could increase vaccination coverage among inner-city preschool-aged children who may have limited access to health care.