Cadaveric kidneys for transplantation. A paradox of shortage in the face of plenty.

The number of cadaveric kidneys currently available for transplantation is insufficient; therefore, the Center for Disease Control (CDC) undertook a collaborative pilot project to increase the number of cadaveric kidneys available for transplantation. In phase one, a retrospective review of medical records of in-hospital deaths was done to determine the potential number of cadaveric kidney donors and to define the characteristics of potential donors. The medical records of 10,420 (43.1%) of the 24,164 patients who died in 67 acute-care hospitals in Georgia, Kansas, and Missouri were retrieved. In addition to determining suitability for donorship, criteria were developed to reflect the broadest range of criteria in use. By center-specific criteria there were 1.7 potential donors/100 in-hospital deaths, which could make available 109 kidneys/million population. By broad intercenter criteria there were 3.5 potential donors/100 in-hospital deaths, which could provide 232 kidneys/million population. During 1975, by center-specific criteria, kidneys from 19.3% of the suitable potential donors were retrieved. The small number of transplantable cadaveric kidneys retrieved was not attributable to lack of suitable organs but rather the failure to identify suitable donors, obtain consent, and retrieve the kidneys.

Increasing the supply of cadaveric kidneys for transplantation.

The number of cadaveric kidneys currently available for transplantation is insufficient. Therefore, the Center for Disease Control (CDC) undertook a collaborative project with the two transplant programs in Georgia to increase te retrieval of cadaveric kidneys. We used retrospective analysis to select productive hospitals, hospital-specific surveillance systems to identify potential donors, and procurement and retrieval evaluation to identify preventable deficiencies. During 900 hospital months of prospective surveillance, we identified a total of 555 potential donors by death record review, giving a potential donor rate of 2.3 donors/100 deaths (110 kidneys/million population/year). We observed an increase in the number of referrals, consent obtained from next of kin, and kidneys retrieved. This period of intensive activity demonstrated that additional kidneys can be retrieved by using systematic methods.

Genital herpes infections in private practice in the United States, 1966 to 1981.

We analyzed data on genital herpes infections in the United States from 1966 to 1981 collected by the National Disease and Therapeutic Index survey. The number of private physician-patient consultations for genital herpes increased tenfold during this period. The number of patient visits for newly diagnosed infections increased 7.5-fold. Women aged 20 to 24 years and men aged 25 to 29 years were more likely to consult a private physician for genital herpes than were patients in other age brackets. Our analysis suggests an increasing national incidence of genital herpes infections and supports the concept that genital herpes infections are epidemic in the United States.

Syphilis control. The historic context and epidemiologic basis for interrupting sexual transmission of Treponema pallidum.

Syphilis control has been the prototypic sexually transmitted disease (STD) public health program of the 20th century. However, the disease remains nearly as much an epidemiologic enigma as it did in the early 1900s. This article examines the historic and epidemiologic bases for syphilis control, using unpublished data to supplement a recent model of STD transmission. The authors recommend building on such traditional individually oriented strategies as case finding, partner notification, and presumptive treatment as a basis for future community-oriented, population-based strategies including (but not limited to) selective mass treatment in high-prevalence populations. Using epidemiologic information to target population-level interventions will be the paradigm for syphilis control in the 20th century.

Pelvic inflammatory disease in the United States. Epidemiology and trends among hospitalized women.

The Hospital Discharge Survey, conducted by the National Center for Health Statistics (Rockville, Md.), provides national estimates for conditions causing hospitalization in short-stay hospitals in the United States. The venereal Disease Control Division of the Centers for Disease Control (Atlanta, Ga.) obtained survey data for 1970-1975 and analyzed the epidemiology of pelvic inflammatory disease (PID) in women hospitalized for this disease. An average of greater than 211,000 female patients older than 10 years of age were hospitalized annually for PID. Acute salpingitis occurred predominantly in women younger than 30 years of age. Women of all races other than white had a PID rate 3.3 times greater than that of white women. Data obtained from the Commission on Professional and Hospital Activities were used for determination of the trend in hospitalizations for PID. In all races other than white, the trend appears stable; however the trend among white women is increasing.

Congenital syphilis revisited.

Despite decades of experience with congenital syphilis, problems still arise in case definition, diagnostic evaluation, treatment, and follow-up. We reviewed all 50 cases of early congenital syphilis reported to the State of Texas in 1982. A large proportion of the infants were premature (39%), of low birth weight (38%), and symptomatic at birth (62%). Because of these findings, we believe that possible cases of asymptomatic congenital syphilis in Texas may be under-reported. Laboratory and/or roentgenographic findings were important to confirm the diagnosis of congenital syphilis. Over half of the asymptomatic infants had positive results of cerebrospinal fluid VDRLs. After diagnosis, the treatment of infants with penicillin varied considerably. While all 47 living infants were treated with penicillin, 21 different regimens were used. We urge all physicians to perform complete diagnostic evaluations on suspected infants consisting of a quantitative serum test for syphilis, serum IgM levels, a cerebrospinal fluid VDRL, roentgenographs of the long bones, and dark-field microscopy where indicated. Additionally, infants and their families need appropriate follow-up after treatment.

Epidemiology of the sexually transmitted diseases.

We stand on the threshold of a new era for the STDs. The traditional STDs remain serious public health problems, particularly in the developing world, but they pale by comparison with AIDS. We can expect that the number of most STDs will decrease as the "baby boom" generation ages. We may also witness a change in sexual behavior caused in part by the fear of contracting AIDS, genital herpes, and perhaps other STDs. The challenge for the future is to improve control of chlamydial and gonococcal infections to prevent late sequellae such as infertility and ectopic pregnancy; to give greater attention to behavior modification to prevent transmission of AIDS, HSV, and HPV; to improve control of STDs in developing countries; to develop vaccines for the viral STDs, which are most difficult to cure; and to develop a better understanding of the mechanisms by which STD agents interact with each other and their host to cause cancer.

Questionnaire survey of reported early congenital syphilis: problems in diagnosis, prevention, and treatment.

A retrospective questionnaire survey of a sample of 173 of the 360 cases of early congenital syphilis reported in 1972 revealed serious problems with diagnostic certainty, prevention, and treatment of congenital syphilis. Only 24 (13.9%) of the reported cases could be categorized as probably or definite cases based on criteria developed from a literature review. Forty percent of the mothers received no prenatal care and an additional 19% received no prenatal care until the third trimester. Initial and followup serologic testing was inadequate in those who received care. Eighty-three different penicillin treatment schedules were used in the treatment of 128 infants. Carefully reasoned diagnostic and therapeutic decision making about the management of congenital syphilis appears to be lacking.

Chancroid in the United States. Reestablishment of an old disease.

For 30 years, chancroid has been an uncommon and geographically localized disease in the United States; a mean of 878 cases were reported annually between 1971 and 1980. Since 1981, however, numerous outbreaks have established chancroid as an endemic disease in many additional areas and, in 1986, 3418 cases, the largest number since 1952, were reported. Cases are occurring preponderantly among men who patronize prostitutes, and infected individuals who have traveled from outbreak areas or from outside the United States are suspected of having contributed to the spread of disease. Efforts to eradicate disease in outbreak areas have been only occasionally effective and have been hampered by difficulty in locating potentially infected individuals and by travel by infected individuals. The failure to eradicate outbreaks leaves residual sources for new disease transmission into yet additional areas.

Antibiotic treatment of pelvic inflammatory disease. Trends among private physicians in the United States, 1966 through 1983.

Although pelvic inflammatory disease is the most common serious infection among young women of reproductive age in the United States, no nationwide data are available on the patterns of antibiotic treatment of this disease. To examine these patterns we analyzed over 25 million antibiotic prescriptions for treatment of pelvic inflammatory disease from 1966 through 1983, using the National Disease and Therapeutic Index. Most patients received a single antibiotic on an outpatient basis. Overall, use of natural penicillins declined markedly, and use of aminopenicillins more than doubled. Cephalosporins emerged as the most frequently prescribed antibiotic for hospitalized patients. Nationwide surveillance of treatment patterns may help to identify areas needing improvement through continuing education.

Trends in molluscum contagiosum in the United States, 1966-1983.

We analyzed data on molluscum contagiosum infection in the United States from two sources: the National Disease and Therapeutic Index Survey of private patients, collected during 1966-1983; and two sexually transmitted disease clinics, collected during 1977-1981. Patient visits to private physicians for molluscum contagiosum increased 11-fold from 1966 to 1983. Over the same time span, the proportion of private patient visits also increased: from 1.2 to 11.0 per 100,000 total clinic visits. Clinic patients, however, showed stable trends in proportions of individuals infected over the period 1977-1981. Clinic patients 15-24 years old and private patients aged 20-29 years were more likely to present with molluscum contagiosum than patients in other age categories. Like the prevalence of other viral sexually transmitted diseases in the private medical community, that of molluscum contagiosum infections appears to have increased dramatically over the 18-year span covered by this study.

Gonorrhea in the United States 1975-1984: is the giant only sleeping?

After a decade of increase, the number of cases of gonorrhea declined by 12% in the United States between 1975 and 1984. During the same period gonorrhea rates declined by 20%. We examined age-, sex-, and race-specific gonorrhea cases and rates to determine whether the national trend has been occurring in all population groups. The greatest percentage decline in rates was 22.6% among 25-44-year-old men of other-than-white race, and the only increase (0.5%) occurred among white teenaged women. To control gonorrhea and its complications more effectively, more focused screening of young women and more rapid treatment of their sexual partners are necessary.

Congenital syphilis. Why is it still occurring?

A total of 159 cases of early congenital syphilis were reported in the United States during 1982, with Texas reporting 50 cases. We reviewed these Texas cases to identify the most important characteristics on which to focus control efforts. Thirty-eight mothers were 25 years of age or younger; 33 were unmarried. All were from minority groups. No congenital syphilis occurred in whites. Blacks were twice as likely as Hispanics to have an infected infant. Foreign-born Hispanic women were three times more likely to be delivered of an infected child than Hispanics born in the United States. Attendance at prenatal care facilities significantly affected the risk of being delivered of an infected child in both black and Hispanic women; 31 women received no prenatal care. Based on these findings, congenital syphilis in Texas can be reduced primarily through improving prenatal care for high-risk populations and by refining casefinding efforts to control infectious syphilis in the community.

Gonorrhea in the United States: 1967-1979.

Sex-, race-, and age-specific gonorrhea cases and rates reported by public and private sources were studied. The role of the age, sex, and race composition of the population was used to explain changing trends of morbidity due to gonorrhea. Beginning in 1967, reported cases of gonorrhea in the United States increased at an annual rate of 13% through 1975, with increases in women twice those in men. The group aged 20-24 years had the highest age-specific rates of gonorrhea in both men and women, while the highest percentage increases were observed in the 15-19-year-old age group. Since 1975, numbers of reported cases have stabilized. Decreases in rates of gonorrhea were more pronounced in men than in women. Among all ages, the group aged 20-24 showed the largest decrease for race and sex categories, except for nonwhite women.

Syphilis in the United States: 1967-1979.

Reported data on cases of primary and secondary syphilis in the United States during 1967-1979 were analyzed by age, race, sex, and reporting source. Although the incidence of primary and secondary syphilis fluctuated little in the United States between 1967 and 1979, the ratio of male to female cases increased twofold, from 1.5:1 to 3:1. Cases in men, primarily those aged 25-39 years, reported by public clinics increased from 32% to 56% of the total cases reported; in particular, cases among white males reported by public clinics increased by 351%. The percentage of white men with early syphilis who attended public clinics and who reported at least one male sex partner increased from 38% in 1969 to 70% in 1979. These findings suggest that an essential change occurred in the epidemiology of early syphilis in the United States: white gay men became proportionately more burdened by the disease, and increasing transmission of the disease occurred within this segment of the population in the United States.

Chromosomally mediated resistance in Neisseria gonorrhoeae in the United States: results of surveillance and reporting, 1983-1984.

Between January 1983 and October 1984, 446 cases of infection due to chromosomally mediated resistance in Neisseria gonorrhoeae (CMRNG) were reported in 23 states. Eighty percent were detected as primary penicillin or ampicillin treatment failures. Gonococcal isolates were submitted from 175 (40%) for confirmation of resistance, susceptibility testing, gonococcal strain typing using monoclonal antibodies specific for outer membrane Protein I, and auxotyping. All were typed as Protein I serogroup IB (WII/WIII), and the majority were proline or prototrophic auxotypes. All were resistant in vitro to less than 1 microgram/ml of either penicillin or tetracycline. Comparing CMRNG with penicillinase-producing Neisseria gonorrhoeae (PPNG), we found that CMRNG were significantly more resistant to tetracycline and erythromycin, but PPNG were more resistant to penicillin (P less than .01). Because of increasing reports of gonococcal resistance in the United States, improved surveillance of clinical and laboratory resistance is needed in support of control and treatment recommendations for gonorrhea.