HIV infection and breast-feeding: policy implications through a decision analysis model.

OBJECTIVES: (1) To develop a comprehensive decision analysis model to compare mortality associated with HIV transmission from breast-feeding with the mortality from not breast-feeding in different populations and (2) to perform sensitivity analyses to illustrate critical boundaries for guiding research and policy. METHODS: Using a decision tree, mortality rates were estimated for all children, children born to mothers infected during pregnancy, and children born to mothers who were uninfected at delivery. Given various assumptions about child mortality rates, relative risks of mortality among children who are not breast-fed compared with those who are (R), rates of HIV transmission from breast-feeding, HIV prevalence, and HIV incidence, scenarios were created and sensitivity analysis used to delineate critical boundaries. RESULTS: Our model shows that only in situations where R is approximately < or = 1.5 and HIV incidence/prevalence is high (prevalence > 10%, incidence > 5%) would universal breast-feeding result in equal or higher mortality compared with non-breast-feeding. Among populations in many developing countries, where there is a high relative risk of mortality if breast-feeding is not practiced, if R > 3, overall mortality is almost always lower among children who are breast-fed, even by HIV-infected mothers. In situations where maternal HIV status is known, the decision whether to breast-feed is largely dependent on the magnitude of additional mortality risk if the child is not breast-fed. The model illustrates the importance of distinguishing between population and individual recommendations. CONCLUSIONS: Based on available data, the model supports current World Health Organization and Centers for Disease Control recommendations on HIV infection and breast-feeding. Given the importance of breast-feeding and the global impact of HIV infection, more research is needed, especially to clarify the range of HIV transmission rates from breast-feeding and to expand specific assessments of relative risks for different areas of the world.

PIP: HIV/AIDS specialists have developed and applied 3 different scenarios to a comprehensive decision analysis model to estimate mortality rates for children of mothers infected with HIV during pregnancy and for children of mothers who were not infected with HIV during delivery. Scenario I represents Central Africa where HIV prevalence and incidence are high. Some scenario I assumptions are HIV prevalence in pregnant women of 30% and proportion of initially uninfected women who become infected after delivery during lactation (d) of 6%. Scenario II is a population where HIV epidemic is rather recent (e.g., some parts of Asia). Its assumptions are HIV prevalence of 5%, and s is 2%. Scenario III symbolizes high-risk populations in North America and Western Europe (HIV prevalence and s = 1%). The scenarios also consider child mortality rates and relative risks (RRs) of mortality of breast fed children and those who were not breast fed. Universal breast feeding would effect equal or higher mortality than non-breast feeding, when the RR of mortality is no more than 1.5 and HIV prevalence/incidence is high (high prevalence = 10% and high incidence = 5%). In developing countries, where the RR of mortality is high if children are not breast fed (RR 3), breast fed children have almost always lower child mortality than those who are not breast fed, regardless of HIV infection status. The decision to breast feed when the HIV status is known depends greatly on the degree of an additional mortality risk if an infant is not breast fed. The model substantiates WHO and CDC recommendations: HIV-positive women in the UK and the US should not breast feed, while those in developing countries with high RR of child mortality should breast feed. Additional research would define the range of HIV transmission rates from breast feeding and increase specific assessments of RRs for various parts of the world.

Impact of the human immunodeficiency virus epidemic on mortality in children, United States.

To assess the effect of the human immunodeficiency virus (HIV) epidemic on mortality in US children younger than 15 years of age and to identify associated causes of death, the authors examined final national mortality statistics for 1988, the most recent year for which such data are available. In 1988, there were 249 deaths attributed to HIV/acquired immunodeficiency syndrome (AIDS) in children younger than 15 years of age. Associated causes of death listed most frequently on 270 death certificates with any mention of HIV/AIDS included conditions within the AIDS surveillance case definition (30%), pneumonia (excluding Pneumocystis carinii pneumonia) (17%), septicemia (10%), and noninfectious respiratory diseases (8%). The impact of HIV/AIDS as a cause of death was most striking in the 1-through 4-year-old age group and in black and Hispanic children, particularly in the Northeast. By 1988 in New York State, HIV/AIDS was the first and second leading cause of death in Hispanic and black children 1 through 4 years of age, accounting for 15% and 16%, respectively, of all deaths in these age-race groups. With an estimated 1500 to 2000 HIV-infected children born in 1989, the impact of HIV on mortality in children will become more severe.

Epidemiology of transfusion-associated acquired immunodeficiency syndrome in children in the United States, 1981 through 1989.

From 1981 through 1989, 212 cases of transfusion-associated (TA) acquired immunodeficiency syndrome (AIDS) were reported to the Centers for Disease Control. In a study of the epidemiology of pediatric TA AIDS, this group was compared with perinatally acquired (PA) and adult TA AIDS cases. The number of pediatric TA AIDS cases reported each year began to stabilize in 1988 and declined 41% in 1989. Reported adult TA AIDS cases continued to increase by 33% in 1988 and declined by 15% in 1989. The number of reported PA cases has continued to increase each year. Seventy percent of the children with TA AIDS were transfused in their first year of life. The median age at diagnosis was 4 years (range 0.3 to 12.8 years) compared with a median age at diagnosis of 1 year (range 0.1 to 12.9 years) in the PA cases. Using a nonparametric estimation procedure for truncated data, the estimated incubation period from time of infection to diagnosis of AIDS was longer for pediatric TA AIDS cases than PA cases (median, 3.5 years vs 1.75 years) but shorter than for adult TA cases (median, 4.5 years). The median survival after diagnosis of TA AIDS in children did not differ from that in PA cases (13.7 vs 14.3 months) but was longer than in adult TA cases (5.6 months P less than .01). The decline in the reported incidence of pediatric and adult TA AIDS cases reflects the effects of donor deferral and donor screening for human immunodeficiency virus infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Perinatally acquired human immunodeficiency virus infection.

PIP: Following a brief introduction to the history of AIDS and the global impact of the AIDS epidemic, the important, yet difficult to research role of perinatally transmitted human immunodeficiency virus (HIV) from mother to infant is pointed out. Approximately 80% of all HIV infections in children in the US and Europe stem from perinatal transmission; similar rates are expected for sub-Saharan Africa and the Caribbean. Accordingly, current understanding of the epidemiology of HIV transmission from mothers to children is reviewed. While obstacles exist to AIDS surveillance, determining the frequency and timing of perinatal HIV transmission, planning treatment trials, and clinical treatment, information has been gained over the years from AIDS surveillance data, HIV seroprevalence surveys, and studies of HIV transmission and disease progression. The focus here is primarily upon information obtained since early 1988, methodological issues, and future research priorities. The scope of the HIV epidemic in the US and Europe is considered, with sections on the epidemiology of AIDS in women and children, the prevalence and incidence of HIV infection therein, and other surveillance approaches. Epidemic scope in Africa, the Caribbean, South America, Asia, and the Pacific is also addressed. Discussion also includes rates, risk factors, and mechanisms of transmission, as well as incubation period and clinical presentations of morbidity and mortality.^ieng

Detection of meningitis epidemics in Africa: a population-based analysis.

Portions of sub-Saharan Africa are subject to major epidemics of meningococcal meningitis that require early detection and rapid control. We evaluated the usefulness of weekly meningitis rates derived from active surveillance data in Burkina Faso for detecting a meningitis epidemic. By analysing the rates of disease in 40 x 40km2 areas within a study region of Burkina Faso, we found that a threshold of 15 cases/100,000/week averaged over 2 weeks was 72-93% sensitive and 92-100% specific in detecting epidemics exceeding 100 cases/100,000/year. During epidemic periods, the positive predictive value of this threshold approached 100% for detecting local epidemics. Additionally, meningitis incidence was proportional to village size, with villages greater than 8000 having the highest disease rates during a major group A meningococcal epidemic in 1983-1984. Despite the rudimentary nature of surveillance data available in many developing countries, these data can be used to detect the early emergence of meningitis epidemics. Additional studies are needed to determine the relevance of this approach for detecting epidemics.

Infection control practices in the home: a survey of households of HIV-infected persons with hemophilia.

OBJECTIVE: To assess infection control practices and risk for human immunodeficiency virus (HIV) transmission in households where home infusion for hemophilia is used. DESIGN: Cross-sectional prospective survey from 1992 through 1994. SETTING: Hemophilia treatment centers. PARTICIPANTS: Human immunodeficiency virus (HIV)-infected persons with hemophilia who receive home infusions of clotting factor concentrate and their household members. MAIN OUTCOME MEASURES: Frequency of specific infection control practices in the home and the risk of HIV transmission to household members. RESULTS: We surveyed 235 persons from 75 families (79 HIV-infected persons with hemophilia and 156 household members) about infection control practices in the home. Forty-eight percent of household members surveyed helped with the infusion process. Of 74 members who assisted with infusion, 13 (18%) had sustained a needlestick injury, 11 of whom were injured during the past year. One hundred fifty household members tested for antibody to HIV were antibody negative. These household members had a total of 903 person-years of contact after HIV was diagnosed in the index case. Household members' adherence to recommended infection control measures was highest for washing hands after cleaning up infusion equipment and waste, and for using sharps disposal containers. Adherence was lowest for wearing gloves when helping with infusions and proper disposal of bloody waste from the infusion. CONCLUSIONS: No HIV transmission was found among persons living with HIV-infected persons with hemophilia, although there was a high rate of needlestick injuries during home infusion. Because persons who assisted with infusions often did not wear gloves and many households did not dispose of bloody waste properly, hemophilia treatment center personnel should emphasize these areas when training for home infusion. Adherence to appropriate infection control practices should help to keep the risk of HIV transmission in households extremely low.

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.

Susceptibility of relatively penicillin-resistant Streptococcus pneumoniae to newer cephalosporin antibiotics.

Antimicrobial susceptibilities were performed at the Centers for Disease Control on 3400 Streptococcus pneumoniae isolates that were collected during a national survey of serotype-distribution of pneumococci found in normally sterile body fluids. The results showed 126 isolates (3.7%) to be relatively resistant to penicillin (RPR). The RPR strains were tested for susceptibility to cefuroxime, ceftriaxone, cefotaxime, cefamandole, cefaclor, ceftazidime, and moxalactam. These newer generation cephalosporin drugs were tested either because of their ability to penetrate into the cerebrospinal fluid (CSF) or for their activity against pneumococci. Three hundred ninety-one pneumococci were tested with 179 resistant to at least one antimicrobial. The RPR strains were not categorically resistant to the cephalosporins but were fourfold more resistant to them than were the penicillin-susceptible strains. The three most effective antimicrobials in the study for RPR were cefuroxime, cefotaxime, and ceftriaxone [corrected]. Each gave MICs that were attainable in CSF for RPR. Fifty percent of the RPR were inhibited by 0.06 mg/ml and 90% by 0.25 micrograms/ml of these antimicrobials. The least effective were cefaclor, moxalactam, and ceftazidime.

Tuberculosis beliefs among recent Vietnamese refugees in New York State.

OBJECTIVE: To identify newly arrived Vietnamese refugees' beliefs about tuberculosis (TB) and TB education needs. METHODS: In 1994, the New York State Health Department and the Centers for Disease Control and Prevention conducted a survey of 51 newly arrived adult Vietnamese refugees in two New York counties. After being trained in interview methods, two bilingual researchers asked 32 open-ended questions on the causes of TB, TB treatment, and the disease's impact on work and social relationships. RESULTS: Respondents correctly viewed TB as an infectious lung disease with symptoms such as cough, weakness, and weight loss. Hard manual labor, smoking, alcohol consumption, and poor nutrition were believed to be risk factors. Many respondents incorrectly believed that asymptomatic latent infection is not possible and that infection inevitably leads to disease. Nearly all respondents anticipated that having tuberculosis would adversely impact their work, family, and community activities and relationships. CONCLUSIONS: Targeted patient education is needed to address misconceptions about TB among Vietnamese refugees and to help ensure adherence to prescribed treatment regimens.

Encephalopathy in children with perinatally acquired human immunodeficiency virus infection. Pediatric Spectrum of Disease Clinical Consortium.

OBJECTIVE: To define the incidence, characteristics, and survival of children with perinatally acquired human immunodeficiency virus (HIV) infection and encephalopathy. DESIGN: Cross-sectional and longitudinal data collected from 1811 HIV-infected children in a multicenter active surveillance study. SETTING: Health departments and medical centers in six areas of the United States. RESULTS: HIV encephalopathy was diagnosed in 178 (23%) of 766 children with perinatally acquired immunodeficiency syndrome (AIDS). The median age at diagnosis of encephalopathy was 19 months. Among infected children, the estimated risk of having HIV encephalopathy by age 12 months was 4.0% (95% confidence interval, 2.6% to 6.0%). Children with HIV encephalopathy had more hospitalizations (median, 4) than children with other AIDS-defining conditions (median, 2; p = 0.002) and lower CD4+ T-lymphocyte counts in the first year of life (median, 444 cells/mm3). Estimated median survival after diagnosis was 22 months, similar to the 20 months for children with Pneumocystis carinii pneumonia. CONCLUSION: HIV encephalopathy in children with perinatally acquired AIDS is a common condition and is associated with severe morbidity evidenced by frequent hospitalizations, severe immunodeficiency, and short survival.

Antimicrobial resistance of Streptococcus pneumoniae in the United States, 1979-1987. The Pneumococcal Surveillance Working Group.

The increasing number of Streptococcus pneumoniae isolates identified as relatively or fully resistant to penicillin or fully resistant to other antimicrobials in the United States supports the need to monitor for this resistance. Thus, 5459 S. pneumoniae isolates submitted to the Centers for Disease Control in 1979-1987 by 35 hospitals in a hospital-based pneumococcal surveillance system were evaluated. The MIC to penicillin or ampicillin was greater than or equal to 0.1 micrograms/ml for 274 (5%) isolates; 1 had an MIC of 4.0 micrograms/ml to penicillin. Seventeen (0.3%) were resistant to erythromycin (MIC, greater than or equal to 8 micrograms/ml), 157 (2.9%) were resistant to tetracycline (MIC, greater than or equal to 16 micrograms/ml), and 34 (0.6%) were resistant to sulfamethoxazole/trimethoprim (MIC, greater than or equal to 76 and 4 micrograms/ml). Isolates relatively resistant to penicillin represented 1.8% of isolates in 1979, 8% in 1982, and 3.6% in 1987. Sixty-five multiply resistant isolates were identified. Pneumococci from the southwestern United States (region 4) were more likely to be relatively resistant to penicillin. Using logistic regression analysis, serotypes 14 and 19A, isolates from region 4, and isolates from middle ear fluid were associated with penicillin resistance (P less than or equal to .008, chi 2. These data confirm that antimicrobial resistance among pneumococcal isolates remained at low levels in the United States through 1987.

Epidemiology of women with AIDS in the United States, 1981 through 1990. A comparison with heterosexual men with AIDS.

In the United States, women account for an increasing number and percentage of adults with the acquired immunodeficiency syndrome (AIDS). Overall, 51% of women with AIDS were infected through intravenous drug use and 29% through heterosexual contact; the proportion of intravenous drug users decreased, while the proportion attributed to heterosexual contact increased, between 1986 and 1990. Most women with AIDS were black or Hispanic (72%); residents of large metropolitan areas (73%), especially cities along the Atlantic coast; and of reproductive age (15 to 44 years) (85%). However, the proportion of women with AIDS reported by smaller cities and rural areas has increased from 22% in 1986 to 28% in 1990. The male-to-female ratio of heterosexuals with AIDS has remained about 2.4:1 since 1987. A comparison of women with AIDS to heterosexual men with AIDS showed that these two groups were similar by age, race, and geographic distribution. Also, survival times from AIDS diagnosis to death for women and heterosexual men with AIDS were not significantly different.

The immune spectrum in patients with pulmonary tuberculosis.

The immune response to mycobacterial antigens of 65 patients with pulmonary tuberculosis was studied using delayed skin test reactions and enzyme-linked immunosorbent antibody assays. Evidence for a spectrum of immune response was found. Six of 35 patients studied during the first month of therapy had tuberculin skin test anergy. Anergy was not related to state of nutrition or extent of disease, but it may have been associated with radiographically acute disease. The 6 anergic patients had somewhat higher antibody titers to mycobacterial protein, but not polysaccharide antigens, than did nonanergic patients.

Invasive group B streptococcal disease in adults. A population-based study in metropolitan Atlanta.

OBJECTIVE: To define the incidence and clinical spectrum of group B streptococcus infection in adults. To characterize groups at increased risk for infection. DESIGN: Retrospective population-based surveillance of group B streptococcus infections occurring in adults. Patients were identified by review of microbiology records at all surveillance area hospital laboratories. Demographic and clinical data were abstracted from patient medical records. SETTING: Metropolitan Atlanta, Ga, 1982 through 1983. PATIENTS: We identified 70 adult patients with invasive group B streptococcus infections; 14 infections occurred in pregnant women and 56 in nonpregnant adults. RESULTS: The annual incidence of group B streptococcus infection in men and nonpregnant women was 2.4 cases per 100,000 population. Incidence increased with age and was higher in blacks than in whites. The case-fatality rate was 32%. Group B streptococcus was most often isolated from blood (71%) and soft tissue (16%). Common clinical presentations included skin and soft-tissue infection (36%), bacteremia without focus (34%), pneumonia (11%), arthritis (9%), and endocarditis (9%). Compared with the general population's risk of infection, the risk of infection in persons with diabetes mellitus was increased 10.5-fold (95% confidence interval [CI], 7.8 to 14.4); in persons with cancer, it was increased 16.4-fold (95% CI, 11.5 to 23.3). CONCLUSIONS: Group B streptococcus infections cause serious disease in adults as well as in neonates, providing an additional rationale for vaccine development. Determining the incidence of adult disease and groups at greatest risk will help in focusing prevention efforts.

Pneumocystis carinii pneumonia among US children with perinatally acquired HIV infection.

OBJECTIVE: To describe epidemiologic characteristics of Pneumocystis carinii pneumonia (PCP) among children with perinatally acquired human immunodeficiency virus (HIV) infection to guide prevention efforts. DESIGN: National acquired immunodeficiency syndrome (AIDS) surveillance of children aged 0 through 12 years, a multisite surveillance study of HIV infection in children aged 0 through 12 years, and the national HIV serosurvey of childbearing women. SETTING: Surveillance conducted by state and local health departments and reported to the Centers for Disease Control and Prevention 1982 through 1992. RESULTS: Pneumocystis carinii pneumonia was reported in 1374 (37%) of 3665 perinatally acquired AIDS cases. Over half of these cases occurred between 3 and 6 months of age. In 183 (64%) of 275 PCP cases reported in the special surveillance study, PCP was the first or only AIDS-defining condition diagnosed, and in 44% of cases, the child had not been evaluated for HIV infection before diagnosis of PCP. The estimated median survival after diagnosis of PCP was 19 months. CONCLUSIONS: Pneumocystis carinii pneumonia is a common and serious opportunistic infection that affects young children with HIV infection. Effective efforts to prevent PCP in this population will require identification as early as possible of children who may be infected with HIV.

Pediatric tuberculosis and human immunodeficiency virus infection in Palm Beach County, Florida.

OBJECTIVE: To describe the factors underlying an increasing incidence of tuberculosis in children. DESIGN: Descriptive case review. SETTING: Palm Beach County, Fla. PARTICIPANTS: Forty-four children with suspected and confirmed pediatric tuberculosis from 1985 through 1989. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: From 1988 through 1989, tuberculosis was confirmed in 15 children and suspected in another 16 compared with data from 1985 through 1987 in which the disease was confirmed in nine children and suspected in four. Pediatric tuberculosis occurred primarily in blacks younger than 5 years; the increase in the number of cases reported in 1988 and 1989 occurred only in blacks. One child in whom tuberculosis was confirmed during the recent period was infected with the human immunodeficiency virus (HIV); however, among children with suspected tuberculosis, four of the nine children tested were seropositive for HIV. There was no evidence of increased transmission of tuberculosis to children by HIV-seropositive adults compared with transmission by HIV-seronegative adults with TB. New adult tuberculosis cases in the county increased annually, from 92 cases in 1986 to 169 in 1989, of whom at least 36% were infected with HIV. CONCLUSIONS: The largest effect of the HIV epidemic on tuberculosis in children appeared to be indirect, through an increase in the number of adults with active tuberculosis serving as potential sources of tuberculosis infection for children. A direct effect of HIV infection in the progression of tuberculous disease in children is likely, but was not detected in this investigation. Case-finding for tuberculosis among children will need to increase, particularly in areas heavily affected by acquired immunodeficiency syndrome, but may be complicated by the difficulty of diagnosing tuberculosis in HIV-infected children.