Global prevalence and incidence estimates of selected curable STDs.

OBJECTIVES: To update the WHO global and regional estimates of the prevalence and incidence of syphilis, gonorrhoea, chlamydia, and trichomoniasis. METHODS: Prevalence estimates for syphilis, gonorrhoea, chlamydia, and trichomoniasis were generated for each of the nine UN regions for males and females between the ages of 15 and 49 in 1995 based on an extensive review of the published and unpublished medical literature since 1985. Incidence estimates were based on the prevalence figures and adjusted to take into account the estimated average duration of infection for each disease in a particular region. The latter was assumed to depend upon a number of factors including the duration of infection in the absence of treatment, the proportion of individuals who develop symptoms, the proportion of individuals treated, and the appropriateness of treatment. RESULTS: In 1995 there were over 333 million cases of the four major curable STDs in adults between the ages of 15 and 49--12 million cases of syphilis, 62 million cases of gonorrhoea, 89 million cases of chlamydia, and 170 million cases of trichomoniasis. Geographically, the vast majority of these cases were in the developing world reflecting the global population distribution. CONCLUSIONS: STDs are among the most common causes of illness in the world. Estimates of the global prevalence and incidence of these infections are limited by quantity and quality of data available from the different regions of the world. Improving global STD estimates will require more well designed epidemiological studies on the prevalence and duration of infection.

A cluster of blister-associated toxic shock syndrome in male military trainees and a study of staphylococcal carriage patterns.

In March-April 1985, toxic shock syndrome (TSS) developed in three male military trainees at one base secondary to infected blisters acquired while marching during basic combat training. One trainee died. Staphylococcus aureus was isolated from the blisters in all three patients, and the two strains available for testing both produced toxic shock syndrome toxin-1 (TSST-1). A culture survey identified carriage of S. aureus in 44% (145/333) of the trainees; carriage rates did not differ between the company with two ill trainees and a control company. Carriage was more frequent in the nose than foot (41% versus 9%, p less than 0.0001). White trainees were more likely to carry S. aureus than black trainees (47% versus 28%, p = 0.013), although the same proportion of strains was positive for TSST-1 in both races. The two strains obtained from the patients had similar but not identical phage typing patterns, but had identical antibiograms, and neither strain carried any plasmids. Based upon phage typing of the TSST-1 positive S. aureus strains isolated in the study, widespread carriage of the case strain(s) in other trainees was not found nor was clustering noted by barrack room. It is possible that differences in carriage rates may partially explain the low rate of TSS in blacks.

Knowledge, attitudes and practices concerning AIDS in Ugandans.

A survey of the knowledge, attitudes and practices of 3928 Ugandans concerning AIDS was done in two semi-rural communities in August 1987. Eighty-eight per cent of the respondents knew that AIDS could be acquired from other people and that having multiple sexual partners was high-risk behaviour. There were, however, many incorrect beliefs about HIV transmission, including belief in transmission by insect bites (37%), witchcraft (22%) and casual contact with ill people (21%). AIDS was believed to be curable by 15% of the respondents. As part of the survey, blood was obtained from 3907 (99%) participants; 421 (10.8%) had antibody to HIV-1 by enzyme-linked immunosorbent assay (ELISA) and females were more likely to be infected than males (12.5 versus 8.8%, relative risk 1.42). Factors significantly associated with HIV infection on univariate analysis include multiple sexual partners, sexually transmitted diseases (STDs), injections, and being female. Stratified analysis of a history of STDs in people who were monogamous still showed an association with HIV infection. Information about the AIDS epidemic is reaching the Ugandan population; however, changes in behaviour are slower to follow.

PIP: Knowledge, attitudes, and practices with regard to acquired immunodeficiency syndrome (AIDS) were surveyed among 3928 adults in 2 semi-rural communities of Uganda in 1987. 54% of respondents were female; the average age was 33 years and 57% were married. 203 (5%) were personally acquainted with an AIDS victim and 74% could identify at least 1 clinical symptom of AIDS. 88% correctly identified infected individuals as the major source of disease transmission; however, 37% believed AIDS could be spread by insect bites, 22% thought it could be spread through witchcraft. 22% identified dirty drinking water as a source of AIDS, and 47% thought sharing clothes with an AIDS victim would spread the disease. Ways of avoiding AIDS cited by respondents included avoiding sex with prostitutes (92%), reducing the number of sexual partners (89%), using condoms (41%), using antibiotics (23%), and getting protection from a witchdoctor (11%). 72% indicated they would be ashamed if a family member contracted AIDS, 38% felt AIDS victims deserve their punishment, and 56% favored isolating AIDS patients from the community. As part of the survey, blood samples were obtained from 3907 respondents, 421 (11%) of whom were seropositive for infection with human immunodeficiency virus (HIV). The HIV infection rate was 12.5% among females and 8.8% among males. Multiple sexual partners and a history of sexually transmitted diseases (STDs) were the factors most strongly associated with seropositivity. Although males in this study reported more sexual partners than females, the effect of multiple partners on HIV infection was more pronounced in females. This suggests that male-to-female heterosexual transmission predominates in Uganda.

Risk factors associated with HIV infection in Uganda.

Risk factor data were collected in 1,328 inpatients and outpatients in 1987 in 15 hospitals throughout Uganda; 42% were positive for HIV antibodies by ELISA. Seropositivity was associated with urban residence, sexually transmitted diseases (STD), number of sex partners, and sex for payment or with a person with an AIDS-like illness. Homosexuality and intravenous drug abuse, recognized risk factors in western countries, were not seen as risk factors. By multivariate analysis, urban residence and sex for payment were not independently associated with infection. Among females, number of sex partners, sex with a person with an AIDS-like illness, and numbers of episodes of STDs were significantly associated with seropositivity. In males, similar associations were seen, although number of reported sex partners was not independently associated with infection. These findings support the view that heterosexual contact is the predominant mode of transmission in Uganda and suggest that the main risk factors relate to high-risk heterosexual behavior.

The relationship of tampon characteristics to menstrual toxic shock syndrome.

The pathogenic basis for the association of tampons with toxic shock syndrome (TSS) has not been explained adequately. Absorbency and chemical composition of tampons are related, and no prior study has had a sufficient number of cases to evaluate these independently as risk factors for disease. We compared national TSS passive surveillance data on the 285 tampon-associated menstrual cases of TSS reported from 1983 to 1984 with data on age- and year-matched controls from national surveys of tampon usage. Users of all brands of tampons had elevated risks when compared with non-tampon users (odds ratio, 32.8; 95% confidence interval, 15.5, 69.6). Regardless of the chemical composition of the tampon, increasing absorbency increased the odds ratio for TSS. Chemical composition also influenced odds ratios. Polyacrylate-containing tampons had odds ratios that were elevated but, once controlled for absorbency, that were lower than the odds ratios for cotton, rayon, and cotton/rayon tampons. The strong association of absorbency with risk of illness would suggest that as a public health measure the use of a low-absorbency tampon is likely to reduce the risk of TSS in the user.

Dermatitis in grocery workers associated with high natural concentrations of furanocoumarins in celery.

A vesicular, peeling rash characteristic of a phytophototoxic dermatitis developed on the hands and arms of 30 of 127 grocery workers. The rash subsequently healed with residual hyperpigmentation. Produce workers had the highest attack rate, 100% (8 of 8, p less than 0.0001). Although contact with celery had the highest relative risk for disease (relative risk, 6.3; 95% confidence interval, 2.6, 19.2) and the strongest dose-response effect, an association with celery alone could not be shown because workers were also exposed to other produce. However, anecdotal evidence also suggested that celery might be involved. The disease-resistant, high-quality brand of celery carried by these stores had higher levels of furanocoumarins, potent photosensitizers and a known cause of phytophotodermatitis, than other brands (p = 0.01). A randomly selected nationwide sample of stores in this chain showed dermatitis in 13 of 17 states and 26% of produce workers surveyed. Plant breeding to produce a more disease-resistant celery stock may lead to increased levels of endogenous furanocoumarins, resulting in phytophotodermatitis in grocery workers.

Foodborne streptococcal pharyngitis after a party.

Following a private party in Río Piedras, PR, 23 (56 percent) of those who attended developed an illness characterized by pharyngitis, myalgia, fatigue, headache, and fever. Consumption of carrucho (conch) salad was significantly associated with illness (P = 0.013, Fisher's exact test). Group A beta-hemolytic streptococci (M nontypable T12, serum opacity factor positive) were isolated both from throat cultures in 11 of 47 persons who attended the party and from the implicated food. The original source of contamination of the conch salad was not identified. Because complications may still occur from such infections and only a small percentage of persons with sore throats seek medical attention and ultimately receive treatment for their illnesses, it is important to recognize these outbreaks.