Creutzfeldt-Jakob disease in a recipient of a dura mater graft processed in the US: cause or coincidence?

Iatrogenic Creutzfeldt-Jakob disease (CJD) has never been reported among recipients of dura mater grafts processed in the US. We recently investigated a report of such a case in a 72-year-old man with a typical clinical presentation of CJD. We found no evidence of CJD in either the 34-year-old donor or in other, proximal patients undergoing craniotomies. Although the graft may have caused the illness, sporadic CJD is a more likely explanation, with the graft being coincidental.

Seroprevalence and incidence of genital ulcer infections in a rural Ugandan population.

OBJECTIVES: To determine age-sex specific seroprevalence and incidence rates of Treponema pallidum, Haemophilus ducreyi, and HSV-2; to assess the association between HIV-1 status and incidence of these STIs; and HSV-2 serostatus with number of lifetime sexual partners. METHODS: Antibodies against HIV-1, T pallidum, H ducreyi, and HSV-2 infections were tested using approximately 1000 paired (2 year interval) sera collected from a rural adult (15-54 years) population cohort in south west Uganda. RESULTS: Overall HIV-1 prevalence was 4.9%. Prevalence for T pallidum was 12.9% among males and 12.6% among females. The corresponding rates for H ducreyi were 9.8% and 7.3% respectively. HSV-2 prevalence rates were considerably lower in males (36.0%) than in females (71.5%), p < 0.001. Incidence rates for T pallidum per 1000 person years of observation were 8.4 for males and 12.3 for females. The corresponding rates for H ducreyi were 24.6 and 20.0 and for HSV-2 were 73.2 and 122.9 per 1000 person years of observation, respectively. The RR of HSV-2 incidence was 3.69 in HIV seropositive cases versus HIV seronegative after adjusting for age and sex. The corresponding RR for H ducreyi was 3.50 among female HIV positive cases versus negatives with no effect seen in males. Association between HIV-1 prevalence and prevalence of other STIs was significant (Mantel-Haenszel test) for H ducreyi (p = 0.01) and for HSV-2 (p = 0.004) but not for T pallidum (p > 0.4). HSV-2 prevalence was associated with number of lifetime sexual partners (females, p = 0.003; males, p = 0.08). CONCLUSIONS: The results have provided a reliable estimate of the magnitude of the STI problem and demonstrated an association between HIV-1 status and serology of other STIs in a general rural population in sub-Saharan Africa. The study has also highlighted a correlation between HSV-2 seropositivity and number of reported lifetime sexual partners.

Herpes in the time of AIDS: a comparison of the epidemiology of HIV-1 and HSV-2 in young men in northern Thailand.

OBJECTIVES: To compare the epidemiologic pattern of HIV-1, a recently introduced sexually transmitted disease (STD) agent in Thailand, with the pattern of HSV-2, a well-established STD agent, so that future trends for both viruses can be better understood. METHODS: We obtained questionnaire data and determined HSV-2 (by specific gG-2) and HIV-1 seroreactivity in a cohort of 1,115 young male army conscripts who entered service in northern Thailand in 1991. RESULTS: Seroprevalence of HIV-1 and HSV-2 was 6.9% and 14.9%, respectively. For HSV-2-seropositive men who reported previous genital ulcers, HIV-1 seroprevalence was 32%. For most variables, there was a close correspondence between the prevalence ratios for HIV-1 and for HSV-2, except that prevalence ratios for HIV-1 tended to be greater than the corresponding ratios for HSV-2. The seroprevalence of both viruses was strongly related to early and frequent contact with female sex workers (FSWs), infrequent use of condoms with FSWs, and residence in the upper north region of Thailand. When differences in sexual behavior between the upper north and lower north were controlled for, the seroprevalence of both viruses still differed significantly by region. CONCLUSIONS: Although the seroprevalence levels of HSV-2 and HIV-1 were quite different in this cohort of Thai army conscripts in 1991, the patterns of infection in terms of demographic, residential, and behavioral variables were similar. Seroprevalence studies of HSV-2 in other populations, particularly where the HIV-1 epidemic is just beginning, may be useful in predicting which subgroups might be most vulnerable to the epidemic and could therefore benefit the most from public health intervention. Where differences in the patterns of the two viruses have been noted, we hypothesize that the pattern for HIV-1 will evolve toward that seen for HSV-2.

PIP: Herpes simplex virus type 2 (HSV-2) has been in Thailand longer than has been HIV-1. The epidemiology of the 2 viruses was compared in an attempt to gain insight into likely future trends of the dissemination of HIV-1 and HSV-2 in the country. Findings are based upon questionnaire and serostatus data on a cohort of 1115 young male army conscripts who entered service in northern Thailand in 1991. The 1061 conscripts were 21 years old and the remainder were 22-27 years old. 879 were unmarried, 598 were farmers, and 55 were students. 6.9% of the young men were infected with HIV-1 and 14.9% with HSV-2. Among HSV-2-seropositive men who reported previous genital ulcers, HIV-1 seroprevalence was 32%. For most variables, there was a close correspondence between the prevalence ratios for HIV-1 and HSV-2, except that prevalence ratios for HIV-1 tended to be greater than the corresponding ratios for HSV-2. The seroprevalence of both viruses was strongly related to early and frequent contact with female prostitutes, infrequent condom use with such prostitutes, and residence in the upper northern region of Thailand. The patterns of infection were similar for the 2 viruses, suggesting the direction in which HIV-1 seroprevalence levels will go.

The epidemiology of chronic fatigue in San Francisco.

Despite considerable research on chronic fatigue syndrome (CFS) and conditions associated with unexplained chronic fatigue (CF), little is known about their prevalence and demographic distribution in the population. The present study describes the epidemiology and characteristics of self-reported CF and related conditions in a diverse urban community. The study used a cross-sectional telephone screening survey of households in San Francisco, followed by interviews with fatigued and nonfatigued residents. Respondents who appeared to meet case definition criteria for CFS, based on self-reported fatigue characteristics, symptoms, and medical history, were classified as CFS-like cases. Subjects who reported idiopathic chronic fatigue (ICF) that did not meet CFS criteria were classified as ICF-like cases. Screening interviews were completed for 8,004 households, providing fatigue and demographic information for 16,970 residents. Unexplained CF was extremely rare among household residents <18 years of age, but was reported by 2% of adult respondents. A total of 33 adults (0.2% of the study population) were classified as CFS-like cases and 259 (1.8%) as ICF-like cases. Neither condition clustered within households. CFS- and ICF-like illnesses were most prevalent among women and persons with annual household incomes below $40,000, and least prevalent among Asians. The prevalence of CFS-like illness was elevated among African Americans, Native Americans, and persons engaged in clerical occupations. Although CFS-like cases were more severely ill than those with ICF-like illness, a similar symptom pattern was observed in both groups. In conclusion, conditions associated with unexplained CF occur in all sociodemographic groups but appear to be most prevalent among women, persons with lower income, and some racial minorities.

Surveillance for chronic fatigue syndrome--four U.S. cities, September 1989 through August 1993.

PROBLEM/CONDITION: Although chronic fatigue syndrome (CFS) has been recognized as a cause of morbidity in the United States, the etiology of CFS is unknown. In addition, information is incomplete concerning the clinical spectrum and prevalence of CFS in the United States. REPORTING PERIOD COVERED: This report summarizes CFS surveillance data collected in four U.S. cities from September 1989 through August 1993. DESCRIPTION OF SYSTEM: A physician-based surveillance system for CFS was established in four U.S. metropolitan areas: Atlanta, Georgia; Wichita, Kansas; Grand Rapids, Michigan; and Reno, Nevada. The objectives of this surveillance system were to collect descriptive epidemiologic information from patients who had unexplained chronic fatigue, estimate the prevalence and incidence of CFS in defined populations, and describe the clinical course of CFS. Patients aged > or = 18 years who had had unexplained, debilitating fatigue or chronic unwellness for at least 6 months were referred by their physicians to a designated health professional(s) in their area. Those patients who participated in the surveillance system a) were interviewed by the health professional(s); b) completed a self-administered questionnaire that included their demographic information, medical history, and responses to the Beck Depression Inventory, the Diagnostic Interview Schedule, and the Sickness Impact Profile; c) submitted blood and urine samples for laboratory testing; and d) agreed to a review of their medical records. On the basis of this information, patients were assigned to one of four groups: those whose illnesses met the criteria of the 1988 CFS case definition (Group I); those whose fatigue or symptoms did not meet the criteria for CFS (Group II); those who had had an identifiable psychological disorder before onset of fatigue (Group III); and those who had evidence of other medical conditions that could have caused fatigue (Group IV). Patients assigned to Group III were further evaluated to determine the group to which they would have been assigned had psychological illness not been present, the epidemiologic characteristics of the illness and the frequency of symptoms among patients were evaluated, and the prevalence and incidence of CFS were estimated for each of the areas. RESULTS: Of the 648 patients referred to the CFS surveillance system, 565 (87%) agreed to participate. Of these, 130 (23%) were assigned to Group I; 99 (18%), Group II; 235 (42%), Group III; and 101 (18%), Group IV. Of the 130 CFS patients, 125 (96%) were white and 111 (85%) were women. The mean age of CFS patients at the onset of illness was 30 years, and the mean duration of illness at the time of the interview was 6.7 years. Most (96%) CFS patients had completed high school, and 38% had graduated from college. The median annual household income/for CFS patients was $40,000. In the four cities, the age-, sex-, and race-adjusted prevalences of CFS for the 4-year surveillance period ranged from 4.0 to 8.7 per 100,000 population. The age-adjusted 4-year prevalences of CFS among white women ranged from 8.8 to 19.5 per 100,000 population. INTERPRETATION: The results of this surveillance system were similar to those in previously published reports of CFS. Additional studies should be directed toward determining whether the data collected in this surveillance system were subject to selection bias (e.g., education and income levels might have influenced usage of the health-care system, and the populations of these four surveillance sites might not be representative of the U.S. population). ACTIONS TAKEN: In February 1997, CDC began a large-scale, cross-sectional study at one surveillance site (Wichita) to describe more completely the magnitude and epidemiology of unexplained chronic fatigue and CFS.

An epidemiologic study of fatigue with relevance for the chronic fatigue syndrome.

We surveyed households in four rural Michigan communities to confirm a reported cluster of cases resembling chronic fatigue syndrome (CFS) and to study the epidemiology of fatigue in a rural area. Data were collected from 1698 households. We did not confirm the reported cluster. The prevalence of households containing at least one fatigued person was similar between communities thought to harbor the cluster and communities selected for comparison. Symptoms and features of generic forms of fatigue were very similar to those often attributed to CFS.

Fatiguing illness among employees in three large state office buildings, California, 1993: was there an outbreak?

UNLABELLED: The objective was to determine if a cluster of chronic fatigue syndrome (CFS)-like illness had occurred among employees in two large state office buildings in northern California, and to identify risk factors for and features of fatiguing illness in this population. DESIGN: case-control study. POPULATION AND SETTING: Over 3300 current employees in two state office buildings and employees in a comparable "control" building. Information was collected on demographic and occupational variables, the occurrence of fatiguing illness for at least one month in the previous year, and the presence of 36 symptoms. A total of 3312 (82%) of 4035 employees returned questionnaires. Overall, 618 (18.7%) persons reported fatigue lasting at least one month; including 382 (11.5%) with fatigue of at least six months' duration and 75 (2.3%) with symptoms compatible with a CFS-like illness. Independent risk factors for fatigue lasting one month or longer were found to be Native American ethnicity (OR 2.4, CI 1.1,5.3), Hispanic ethnicity (OR 1.7, CI 1.3,2.3), female sex (OR 1.5, CI 1.2,1.9), gross household incomes of less than $50,000 (OR 1.3, CI 1.1,1.6), and less than a college education (OR 1.3, CI 1.1,1.6). Similar risks were observed for persons who reported fatigue lasting six months or longer. Female sex (OR 3.2, CI 1.7, 6.4) was the only independent risk factor found for those persons classified as having a CFS-like illness. Case prevalence rates for all three categories of fatigue, as determined by multivariate analysis, were not significantly different among buildings. Despite finding a substantial number of employees with fatiguing illness in the two state office buildings, the prevalence was not significantly different than that for a comparable control building. Previously unidentified risk factors for fatigue of at least one month and at least six months identified in this population included Hispanic ethnicity, not having completed college, and income below $50,000.

Immune responses associated with chronic fatigue syndrome: a case-control study.

An exploratory case-control study was conducted to assess whether the many reported differences in the immune function of chronic fatigue syndrome (CFS) patients are detectable in rigorously defined cases of CFS. Although many studies have reported differences between cases and controls in various measures of immune function, none of these differences were found in all studies. In this study, no differences were found in white blood cell numbers; immune complex, complement, or serum immunoglobulin levels; delayed type hypersensitivity and allergic responses; NK cell function; and proliferative responses to mitogens and antigens. Marginal differences were detected in cytokine responses and in cell surface markers in the total CFS population. However, when the patients were subgrouped by type of disease onset (gradual or sudden) or by how well they were feeling on the day of testing, more pronounced differences were seen.

Seroepidemiology of chronic fatigue syndrome: a case-control study.

We performed serological testing for a large number of infectious agents in 26 patients from Atlanta who had chronic fatigue syndrome (CFS) and in 50 controls matched by age, race, and sex. We did not find any agent associated with CFS. In addition, we did not find elevated levels of antibody to any of a wide range of agents examined. In particular, we did not find elevated titers of antibody to any herpesvirus, nor did we find evidence of enteroviral exposure in this group of patients.

Surveillance for congenital cytomegalovirus disease: a report from the National Congenital Cytomegalovirus Disease Registry.

A national surveillance program for congenital cytomegalovirus (CMV) disease was initiated in 1990. In 4 years 285 cases were reported without seasonal patterns. Mean birth statistics were as follows: gestational age, 36 weeks; weight, 2,224 g; length, 45 cm; and head circumference, 30 cm. Of the infants 68% had CNS involvement, which was significantly (P < .005) associated with a direct bilirubin level of > or = 3 mg/dL, petechiae, an alanine aminotransferase level of > 100 U/L, a platelet count of < or = 75,000/mm3, hepatomegaly, and splenomegaly (P < .05). Maternal demographics revealed that the mean age was 23 years (range, 13-38 years), 59% were white, 33% were black, 47% had low incomes (receiving Medicaid), and 45% were primiparous. Compared with 1990 birth statistics in the United States, mothers of infants with congenital CMV disease were younger, and a greater percentage of these mothers were black. Two distinct maternal groups were identified on the basis of age, socioeconomic status, and parity. This finding may reflect different modes of transmission and suggest target populations for future CMV vaccine initiatives.

The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group.

The complexities of the chronic fatigue syndrome and the methodologic problems associated with its study indicate the need for a comprehensive, systematic, and integrated approach to the evaluation, classification, and study of persons with this condition and other fatiguing illnesses. We propose a conceptual framework and a set of guidelines that provide such an approach. Our guidelines include recommendations for the clinical evaluation of fatigued persons, a revised case definition of the chronic fatigue syndrome, and a strategy for subgrouping fatigued persons in formal investigations.

Risk factors for genital papillomavirus infection in populations at high and low risk for cervical cancer.

This study sought to determine risk factors for genital infection with papillomavirus (HPV) in Panamanian women 20-49 years old. Subjects were randomly selected from Herrera and Panama provinces (cervical cancer incidence 79 and 25/100,000, respectively). Participants were interviewed to determine sexual behavior. Cervicovaginal lavage specimens were obtained to test for HPV DNA by commercial dot blot hybridization. HPV-16/18 DNA was detected significantly more frequently (5%) in Panama than Herrera (2%) samples (P = .002). Clearly, infection with high-risk HPV types alone cannot account for the differences in cervical cancer incidence between the two populations. HPV-16/18 detection decreased with increasing years of sexual experience among all women in Panama and among women with multiple partners in Herrera. However, HPV-16/18 detection did not change with sexual experience among monogamous women in Herrera. Thus, the epidemiology of HPV is complex and reflects both virus- and population-specific factors.

Seroprevalence and incidence of sexually transmitted diseases in a rural Ugandan population.

The aim of the study was to determine in a rural population the age- and sex-specific prevalence and incidence rates of serological reactivity of 5 common sexually transmitted diseases (STDs) and their association with HIV-1 antibody status. Of the adult population of two villages (529 adults aged 15 years or more) 294 provided an adequate blood specimen both on enrollment and at 12 months. The sera were tested at 3 collaborating laboratories for antibodies against HIV-1, Treponema pallidum, Haemophilus ducreyi, Chlamydia trachomatis and herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2). A sample of 45 children were tested for HSV-1 and HSV-2. Seroprevalence rates in adults on enrollment were 7.8% for HIV-1, 10.8% for active syphilis, 10.4% for H. ducreyi, 66.0% for C. trachomatis, 91.2% for HSV-1 and 67.9% for HSV-2. Males were significantly more likely than females to be seropositive for H. ducreyi (15.6% versus 6.6%), but less likely to be HSV-2 antibody positive (57.0% versus 74.4%). Reactivity to H. ducreyi, C. trachomatis and HSV-2 rose with increasing age. In contrast, active syphilis showed no age trend. All STDs tended to be more common in those HIV-1 seropositive. Incidence rates over the 12 months were nil for HIV-1, 0.5% for syphilis, 1.2% for H. ducreyi, 11.3% for C. trachomatis, and 16.7% for HSV-2. The results of this exploratory study indicate that all STDs included are common in this rural population. The high HSV-2 prevalence rate among adolescents suggests that HSV-2 may be an important risk factor for HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: A seroprevalence survey conducted in rural Uganda revealed a high potential for interaction between sexually transmitted diseases (STDs) such as herpes simplex virus type 2 (HSV-2) and human immunodeficiency virus (HIV). Venous blood samples were collected at baseline and one year later from 294 randomly selected adults aged 15 years or over from two neighboring villages. At baseline, 23 (7.8%) adults were HIV-positive; no seroconversion occurred during the one-year study period. STD prevalence rates were 10.8% for syphilis, 10.4% for Hemophilus ducreyi, 66.0% for Chlamydia trachomatis, and 91.2% for HSV-1 and 67.9% for HSV-2. More females (74.4%) than males (57.0%) were HSV-2 antibody-positive. Reactivity to H. ducreyi, C. trachomatis, and HSV-2 rose with increasing age, but there was no such trend for syphilis. HIV prevalence rates were 0.0% among those with no serologic evidence of previous STDs, 2.6% among those with one or two prior STDs, and 20.0% among those with three or four STD markers. Of particular concern was the high rate of HSV-2 prevalence among adolescents (85% among females aged 20-24 years and 82% in males aged 25-29 years). It is suggested that age-specific HSV-2 seroprevalence can provide an accurate marker of premarital sexual activity among Ugandan adolescents since it lacks the potential for bias associated with self-reporting in this population.

Cytomegalovirus seroprevalence in women bearing children in Jefferson County, Kentucky.

Symptomatic congenital cytomegalovirus (CMV) disease occurs almost exclusively in infants born to seronegative mothers who acquire the virus during pregnancy. This study sought to determine patterns of CMV immunity in women of childbearing age at one center participating in a national study. Cord blood specimens from 100 consecutive deliveries at each of three hospitals were tested for CMV-specific IgG. Mean age of women in this sample was 25.7 years; 76% were white, 60% were from middle and upper socioeconomic status, 64% were married, and 57% had other living children. Overall seroprevalence rate was 62%. Univariate analysis showed strong associations between seropositivity and lower socioeconomic status, non-white race, and age younger than 25 years (odds ratios, 4.4, 3.9, and 2.5, respectively). Stratification by socioeconomic status and race eliminated the effect of age. Stratification by socioeconomic status markedly reduced the effect of race, whereas stratification by race only moderately reduced the effect of lower socioeconomic status, which was the strongest predictor of seropositivity (odds ratio, 3.4). Seroprevalence was lowest among older white women of middle and upper socioeconomic status (47% seropositive). Development of longitudinal regional seroprevalence data will facilitate interpretation of data generated by the National CMV Registry.

Urban epizootic of rabies in Mexico: epidemiology and impact of animal bite injuries.

From 1 July 1987 to 31 December 1988, a total of 317 animals (91% of which were dogs) were confirmed to have rabies in Hermosillo, Mexico. The median age of rabid dogs was 1 year, 69% were male, and 98% were owned. The epizootic started in the southern areas of the city, rapidly involved the entire city, and persisted mainly in lower socioeconomic status areas. The area of the city and mean household size were significant predictor variables for the population density of rabid dogs around household clusters (Poisson linear regression, P < 0.001 and P = 0.03, resp). Approximately 2.5% of city residents were bitten by dogs in 1987, with the rate of reported dog bite injuries being positively correlated with mean household size and the proportion of households that owned dogs. Visits to the city health centre for evaluation of possible exposures to rabies increased by 135% after the start of the epizootic; approximately 273 per 100,000 city residents were administered a full or partial course of rabies post-exposure prophylaxis in 1987. Children were at greatest risk for exposures to rabies, accounting for 60% of all reported animal bite injuries evaluated at the health centre. Also they were more likely than older persons to have received bite injuries to the head, face, and neck (odds ratio = 21.6, 95% confidence interval = 5.4, 186.5).

PIP: Almost all cases of human rabies result from bites by rabid dogs. Controlling dog rabies is therefore crucial for humans. 317 animals, 91% of which were dogs, were confirmed to have rabies in Hermosillo, Mexico, from July 1, 1987, to December 31, 1988. The dogs were of median age 1 year, 69% were male, and 98% were owned. The epizootic started in the southern areas of the city, spread quickly through the city, and persisted largely in lower socioeconomic status areas. Approximately 2.5% of city residents were bitten by dogs in 1987, with the rate of reported dog bite injuries positively correlated with mean household size and the proportion of households which owned dogs. Visits to the city health center for evaluation of possible exposures to rabies increased by 135% after the start of the epizootic over which approximately 273 per 100,000 city residents were administered a full or partial course of rabies post-exposure prophylaxis in 1987. Comprising 60% of all reported animal bite injuries evaluated at the center, children were at greatest risk for exposures to rabies. Children were also more likely than older people to have received bite injuries to the head, face, and neck.

A field evaluation in Mexico of four baits for oral rabies vaccination of dogs.

We evaluated four baits for the delivery of oral rabies vaccines to dogs. In a controlled study in a town in rural Mexico, 177 randomly selected dogs were assigned to receive one of four experimental baits (two of which were developed by the Denver Wildlife Research Center [DWRC]): one of two cylindrical polyurethane sponges with a corn meal coating (one fried in corn oil [DWRC-corn], the other in fish oil [DWRC-fish]), a fish-flavored polymer bait, or a wax bait. Each dog was also offered a commercial dog biscuit. We recorded whether or not the bait was completely consumed, and used the following measures to estimate the amount of oropharyngeal contact with each bait: total chewing time, presence of pieces of bait on the ground following administration, the total area of ground surrounding the location of ingestion that was covered with green dye contained in each bait, and condition of ampules that contained the dye. The dog biscuits were completely consumed significantly more often than the baits (155 of 176 [88%] for the biscuits versus 89 of 176 [50.5%] for the four baits; P less than 10(-6)), but were chewed for a significantly shorter time than the baits (mean time 34 sec for the biscuit versus 60-82 sec for the four baits: P less than 0.001). The ideal bait would probably combine the attractiveness of the commercial biscuit and the ability of the sponge baits to promote contact with the mucous membranes.

Prevention of canine rabies in rural Mexico: an epidemiologic study of vaccination campaigns.

We compared three vaccination strategies in three rural communities in Mexico to determine the factors associated with the success of vaccination programs in areas where canine rabies is poorly controlled. In town A, intensive publicity and community participation were used; owners were instructed to bring their dogs to temporary centralized clinics for vaccination. In town B, only brief precampaign publicity was used, followed by vaccination at a centralized site. Minimal publicity was also used in town C, but the vaccination campaign was conducted house to house. A total of 5,426 residents and 1,597 dogs were counted in the three towns (mean human:dog ratio 3.4:1). In Town A, 70.1% (472 of 673) of the dogs were vaccinated; the campaign required 40 person-minutes per dog. Significantly greater proportions were vaccinated in town B (262 of 318 [82.4%]; P less than 0.001) and town C (483 of 561 [86.1%]; P less than 0.00001); each of these latter campaigns required 10 person-minutes per dog. The following factors were positively associated (by multivariate analyses) with vaccination of individual dogs: non-intensive publicity, house-to-house vaccination, dogs owned by a single member of the household, and dogs acquired greater than 15 days after birth. Intensive publicity did not increase the overall success of the vaccination program; the efficiency of centralized versus and house-to-house vaccination was comparable.