Negative-Pressure monitoring of tuberculosis isolation rooms within New York State hospitals.

A previously published study recommended the daily use of visible smoke to test for negative air pressure in isolation rooms occupied by potentially infectious tuberculosis cases. Continuous monitoring devices were found to have poor reliability. Findings from our survey of engineering controls in acute-care hospitals within New York State support this recommendation.

Analysis of Mycobacterium tuberculosis transmission patterns in a homeless shelter outbreak.

SETTING: From July 1997 through May 1998, ten tuberculosis (TB) cases were reported among men in a Syracuse New York homeless shelter for men. OBJECTIVE AND DESIGN: Investigation to determine extent of, and prevent further, transmission of Mycobacterium tuberculosis. RESULTS: Epidemiologic and laboratory evidence suggests that eight of the ten cases were related. Seven cases had isolates with matching six-band IS6110 DNA fingerprints; the isolate from another case had a closely related fingerprint pattern and this case was considered to be caused by a variant of the same strain. Isolates from eight cases had identical spoligotypes. The source case had extensive cavitary disease and stayed at the shelter nightly, while symptomatic, for almost 8 months before diagnosis. A contact investigation was conducted among 257 shelter users and staff, 70% of whom had a positive tuberculin skin test, including 21 with documented skin test conversions. CONCLUSIONS: An outbreak of related TB cases in a high-risk setting was confirmed through the use of IS6110 DNA fingerprinting in conjunction with spoligotyping and epidemiologic evidence. Because of the high rate of infection in the homeless population, routine screening for TB and preventive therapy for eligible persons should be considered in shelters.

Identification of factors that disrupt negative air pressurization of respiratory isolation rooms.

OBJECTIVES: To investigate the airflow characteristics of respiratory isolation rooms (IRs) and to evaluate the use of visible smoke as a monitoring tool. METHODS: Industrial hygienists from the New York State Department of Health evaluated 140 designated IRs in 38 facilities within New York State during 1992 to 1998. The rooms were located in the following settings: hospitals (59%), correctional facilities (40%), and nursing homes (1%). Each room was tested with visible smoke for directional airflow into the patient room (ie, negative air pressure relative to adjacent areas). Information was obtained on each facility's policies and procedures for maintaining and monitoring the operation of the IRs. RESULTS: Inappropriate outward airflow was observed in 38% of the IRs tested. Multiple factors were associated with outward airflow direction, including ventilation systems not balanced (54% of failed rooms), shared anterooms (14%), turbulent airflow patterns (11%), and automated control system inaccuracies (10%). Of the 140 tested rooms, 38 (27%) had either electrical or mechanical devices to monitor air pressurization continuously. The direction of airflow at the door to 50% (19/38) of these rooms was the opposite of that indicated by the continuous monitors at the time of our evaluations. The inability of continuous monitors to indicate the direction of airflow was associated with instrument limitations (74%) and malfunction of the devices (26%). In one facility, daily smoke testing by infection control staff was responsible for identifying the malfunction of a state-of-the-art computerized ventilation monitoring and control system in a room housing a patient infectious with drug-resistant tuberculosis. CONCLUSION: A substantial percentage of IRs did not meet the negative air pressure criterion. These failures were associated with a variety of characteristics in the design and operation of the IRs. Our findings indicate that a balanced ventilation system does not guarantee inward airflow direction. Devices that continuously monitor and, in some cases, control the pressurization of IRs had poor reliability. This study demonstrates the utility of using visible smoke for testing directional airflow of IRs, whether or not continuous monitors are used. Institutional tuberculosis control pro grams should include provisions for appropriate monitoring and maintenance of IR systems on a frequent basis, including the use of visible smoke.

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.

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.

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.

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.

Risk for perinatal HIV-1 transmission according to maternal immunologic, virologic, and placental factors.

OBJECTIVE: To evaluate how maternal and obstetric factors interact to influence mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission. DESIGN: Prospective, observational cohort study of children born to HIV-infected women to determine child's HIV infection status. The analysis then compared peripartum maternal, placental, and obstetric variables between HIV-1 transmitter and nontransmitter women. SETTING: Two large maternity wards in Kinshasa, Zaire. PARTICIPANTS: Consecutive sample of 324 HIV-1-infected women at delivery, with 254 HIV-seronegative women followed up as control subjects. PRINCIPAL OUTCOME MEASURES: HIV infection status of children, to classify each woman as an HIV-1 transmitter or nontransmitter. RESULTS: The highest transmission risk (TR) was associated with maternal p24 antigenemia (TR, 71%; relative risk [RR], 3.0; 95% confidence interval [CI], 1.7 to 5.2) and maternal CD8+ lymphocyte counts of at least 1.80 x 10(9)/L (1800/microL) (TR, 50%; RR, 2.2; 95% CI, 1.2 to 4.2). Among women with CD8+ lymphocyte counts of less than 1.80 x 10(9)/L, CD4+ lymphocyte counts of less than 0.60 x 10(9)/L were a risk factor (TR, 29%; RR, 2.2; 95% CI, 1.2 to 4.2). In women with neither high CD8+ nor low CD4+ lymphocyte counts, placental membrane inflammation was associated with perinatal transmission (TR, 40%; RR, 4.2; 95% CI, 1.3 to 13.7). In women with neither p24 antigenemia, high CD8+ or low CD4+ lymphocyte counts, nor placental membrane inflammation, the transmission risk was only 7%. Additional correlates of transmission included maternal anemia and fever, but not maternal sexually transmitted diseases. CONCLUSIONS: Identifiable subgroups of HIV-1-infected women based on maternal and placental characteristics had between a 7% and 71% risk of perinatal HIV-1 transmission. Not only the overall rate of transmission but the impact of different risk factors for transmission appear to vary over the course of HIV infection.

Safety and immunogenicity of bacille Calmette-Guérin, diphtheria-tetanus-pertussis, and oral polio vaccines in newborn children in Zaire infected with human immunodeficiency virus type 1.

OBJECTIVE: To determine the safety and immunogenicity of childhood vaccines in children with perinatally acquired human immunodeficiency virus type 1 (HIV-1) infection. DESIGN: Nonrandomized, prospective cohort study; 12-month follow-up period. SETTING: Obstetric wards and outpatient pediatric clinics at two large hospitals in Kinshasa, Zaire. PATIENTS: A total of 8108 pregnant women were screened for HIV-1 antibodies. The 474 children born to 466 seropositive women identified during screening and the 616 children born to 606 seronegative, age- and parity-matched women were vaccinated. INTERVENTION: The following vaccines were administered at the stated ages: bacille Calmette-Guérin (BCG) vaccine (2 days); trivalent oral Sabin poliomyelitis vaccine (2 days and 6, 10, and 14 weeks); and adsorbed diphtheria-tetanus-pertussis (DTP) vaccine (6, 10, and 14 weeks). MEASUREMENTS AND MAIN RESULTS: Protective antibody titers to tetanus and poliovirus types 1, 2, and 3 were achieved in 95% of all children. Among children with HIV-1 infection, 70.8% had protective antibody titers to diphtheria compared with 98.5% of uninfected children (p < 0.05). Geometric mean antibody titers to diphtheria and poliovirus types 1, 2, and 3 were significantly lower in children with HIV-1 infection than in uninfected children. Vaccine-associated side effects were similarly low in all children. CONCLUSIONS: The low incidence of side effects and the high proportion of children with HIV-1 infection who achieved protective postimmunization antibody titers support the continuing use of BCG, DTP, and oral polio vaccines in childhood immunization programs in HIV-1 endemic areas.

Multidisciplinary management from day one: the Neuro-care approach to motor neurone disease.

The Neuro-care approach offers a holistic, multidisciplinary, patient-centred, continuous strategy of care to unselected groups of neurological patients and their families including those with motor neurone disease (MND). The strategy for MND patients is an adapted version of one piloted on patients with Parkinson's disease. Between April 1990 and September 1992 12 MND patients were diagnosed, of whom five have died. The main features of the care strategy and the guidelines for giving the diagnosis are described. The characteristics of the patient group are identified and the high level of team activity vis-a-vis other patient groups is noted. The maintenance of patients in the community and the lack of resort to permanent institutional care are also recorded. Ethical issues arising during the project are discussed and the problems of measuring outcomes of care are acknowledged. General conclusions for MND management are drawn.

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.

Heterosexually transmitted human immunodeficiency virus infection among pregnant women in a rural Florida community.

BACKGROUND: In the United States, an increasing proportion of women infected with the human immunodeficiency virus (HIV) live in nonmetropolitan areas. Little is known, however, about the risk factors for HIV transmission in women outside large cities. METHODS: We interviewed and tested 1082 (99.8 percent) of 1084 consecutive pregnant women who registered for prenatal care at a public health clinic in western Palm Beach County, Florida. This rural agricultural area of about 36,000 people is known to have a high prevalence of HIV infection. RESULTS: The seroprevalence of HIV was 5.1 percent (52 of 1011 women). Black women who were neither Haitian nor Hispanic had the highest rate of infection (8.3 percent [48 of 575]). Only 4 of 1009 women (0.4 percent) reported ever injecting drugs, and the 4 were HIV-seronegative; however, 14 of 43 users of "crack" cocaine (33 percent) had HIV infection. At prenatal registration, 131 of 983 women (13 percent) tested positive for gonorrhea, chlamydial infection, or syphilis. By multivariate logistic-regression analysis, HIV infection was found to be independently associated with having used crack cocaine (odds ratio, 3.3; P < 0.001), having had more than two sexual partners (odds ratio, 4.6; P < 0.001), being black but neither Hispanic nor Haitian (odds ratio, 11; P < 0.001), having had sexual intercourse with a high-risk partner (odds ratio, 5.6; P < 0.001), and testing positive for syphilis (odds ratio, 3.1; P = 0.015). Nevertheless, 11 of the 52 HIV-infected women (21 percent) reported a total of only two to five sexual partners and no known high-risk partners, had never used crack cocaine, and had no positive tests for sexually transmitted disease. CONCLUSIONS: In the rural community we studied, most of the women with HIV infection acquired it through heterosexual contact. The increasing seroprevalence of HIV and the increasing incidence of syphilis and use of crack cocaine mean that other women may be at similar risk of acquiring heterosexually transmitted HIV infection.

Biologic, foster, and adoptive parents: care givers of children exposed perinatally to human immunodeficiency virus in the United States. The Pediatric Spectrum of Disease Clinical Consortium.

Children born to human immunodeficiency virus (HIV)-infected mothers often do not live with a biologic parent because of drug use, illness, or death of the mother. Public health officials need to know the number and proportion of children who will require care by someone other than a biologic parent (alternative care giver). The Pediatric Spectrum of Disease project, conducted in six different geographic regions in the United States, assesses issues specific to HIV in children. Among the information being collected in this study are data regarding the primary care giver. Of 1683 children born to HIV-infected mothers and enrolled through 1990, 55% (937) were living with a biologic parent, 10% (169) with another relative, 28% (455) were in foster care, 3% (55) had been adopted, and 4% (67) lived in group settings or with other care givers. In all locations and for all racial/ethnic groups, children of mothers who used intravenous drugs were more likely to be living with an alternative care giver than were children of mothers who had not used intravenous drugs (odds ratio 4.15). However, there were striking variations by study location (odds ratio range 1.4 to 7.2). The data suggest that maternal drug use may be the most important factor determining whether a child lives with a biologic parent and that there are also regional differences in alternative care placement.

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.

Parkinson's disease: the spectrum of disabilities.

The needs of people with Parkinson's disease (PD) go beyond the purely medical domain and often require collaborative management. A Panel Discussion at the "Hither neurology" Symposium included neurologists, a speech therapist, a geriatrician and a sociologist. Their discussion highlighted certain aspects of the disability and disadvantage associated with PD. The starting point was a video recording, "Parkinson's Disease: the personal view", in which the contributors were patients and carers. Topics covered included counselling at the time of diagnosis; subsequent access to clinics and to neurological advice; access to therapy; support in the community; fluctuating disability associated with "on-off" phenomena; driving; and sexual problems.

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.

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)

Acquired immunodeficiency syndrome in Romania.

After the initial description of acquired immunodeficiency syndrome (AIDS) in Romania in late 1989, national AIDS case surveillance was established with a modified version of the World Health Organisation (WHO) clinical case definition. This modified case definition requires that AIDS cases have both clinical and serological evidence of human immunodeficiency virus (HIV) infection. Before December, 1989, Romania had reported 13 AIDS cases to WHO. By Dec 31, 1990, 1168 AIDS cases were reported to Romania's Ministry of Health, of which 1094 (93.7%) occurred in children less than 13 years of age at diagnosis. Of these, 1086 (99.3%) were in infants and children less than 4 years of age, and 683 (62.4%) in abandoned children living in public institutions at the time of diagnosis. By Dec 31, 1990, 493 (45.1%) mothers of children with AIDS had been located and tested, and 37 (7.5%) were positive for HIV; 423 (38.7%) cases were in children who had received transfusions of unscreened blood, and 6 (0.5%) were in children with clotting disorders. HIV transmission through the improper use of needles and syringes is strongly suspected in most of the remaining 628 (57.4%) children with AIDS, most of whom had received multiple therapeutic injections. This outbreak demonstrates the serious potential for HIV transmission in medical facilities that intensively and improperly use parenteral therapy and have poor sterilisation technique.

PIP: As a recently established AIDS surveillance system has revealed, the overwhelming majority of AIDS cases in Romania have occurred among children. Before December 1989, Romania had reported only 13 cases of AIDS to the World Health Organization (WHO). But following the change in government at the end of 1989, the newly organized Ministry of Health requested emergency assistance from WHO is setting up a surveillance system, having heard reports of large numbers of children with HIV infection. Prior to the 1989 revolution, many parents would abandon their newly born infants, and many of these children would became wars of the state. The infants were cared for in either orphanages or chronic-care hospitals for malnourished children. By December 1990, the surveillance had uncovered 1168 AIDS cases, 1094 (93.7%) of whom were children under 13 years of age. This figure surpasses the total number of AIDS cases among children in all other European countries combined since 1981. Among Romania's infected children, 1086 (99.3%) were infants under 4 years of age, and 683 (62.4%) were wards of the state. As of December 1990, researchers had located and tested 493 (45.1%) of the mothers of children with AIDS. 37 (7.5%) of them tested HIV- positive. Researchers also found that 423 (38.7%) of the children had become infected through transfusion of unscreened blood, and that 6 (0/5%) cases were among children with clotting disorders. The surveillance experts suspect that the remaining 628 (57.4%) of the cases are among children who received multiple therapeutic injections, indicating the serious potential for HIV transmission in medical facilities that improperly use parenteral therapy and have poor sterilization techniques.