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In the United States Kaposi's sarcoma is at least 20,000 times more common in persons with acquired immunodeficiency syndrome (AIDS) than in the general population and 300 times more common than in other immunosuppressed groups. Among persons with the acquired immunodeficiency syndrome (AIDS) reported to Centers for Disease Control by March 31, 1989, 15% (13,616) had Kaposi's sarcoma. Kaposi's sarcoma was commoner among those who had acquired the human immunodeficiency virus (HIV) by sexual contact than parenterally, the percentage with Kaposi's sarcoma ranging from 1% in men with haemophilia to 21% in homosexual or bisexual men. Women were more likely to have Kaposi's sarcoma if their partners were bisexual men rather than intravenous drug users. Kaposi's sarcoma risk was not consistently related to age or race but varied across the United States, being greatest in the areas that were the initial foci of the AIDS epidemic. Thus Kaposi's sarcoma in persons with AIDS may be caused by an as yet unidentified infectious agent, transmitted mainly by sexual contact.

The usefulness of surveillance in relating chronic disease trends to recent changes in risk exposures is often questioned on the grounds that these trends respond slowly, reflecting long periods between aetiological exposures and clinical onset of disease. We challenge this preconception on the basis of a review of several important risk factors and diseases: alcohol and liver cirrhosis; tobacco and stroke, cardiovascular disease, and lung cancer; and oestrogens and endometrial cancer. Data from cohort, cross-sectional, and modelling studies demonstrate that the time between removal of exposures and the onset of decline in morbidity or mortality is not defined by the time between initial exposure and disease occurrence. Rather, the pattern of lifetime exposures (with recent exposures often having a dominant effect), the dynamics of the disease process, and the segment of the population with reduced exposures determine how soon the decline begins.

Background Governments may be overwhelmed by a large-scale public health emergency, such as a massive bioterrorist attack or natural disaster, requiring collaboration with businesses and other community partners to respond effectively. In Georgia, public health officials and members of the Business Executives for National Security have successfully collaborated to develop and test procedures for dispensing medications from the Strategic National Stockpile. Lessons learned from this collaboration should be useful to other public health and business leaders interested in developing similar partnerships. Methods The authors conducted a case study based on interviews with 26 government, business, and academic participants in this collaboration. Results The partnership is based on shared objectives to protect public health and assure community cohesion in the wake of a large-scale disaster, on the recognition that acting alone neither public health agencies nor businesses are likely to manage such a response successfully, and on the realization that business and community continuity are intertwined. The partnership has required participants to acknowledge and address multiple challenges, including differences in business and government cultures and operational constraints, such as concerns about the confidentiality of shared information, liability, and the limits of volunteerism. The partnership has been facilitated by a business model based on defining shared objectives, identifying mutual needs and vulnerabilities, developing carefully-defined projects, and evaluating proposed project methods through exercise testing. Through collaborative engagement in progressively more complex projects, increasing trust and understanding have enabled the partners to make significant progress in addressing these challenges. Conclusion As a result of this partnership, essential relationships have been established, substantial private resources and capabilities have been engaged in government preparedness programs, and a model for collaborative, emergency mass dispensing of pharmaceuticals has been developed, tested, and slated for expansion. The lessons learned from this collaboration in Georgia should be considered by other government and business leaders seeking to develop similar partnerships.

Background: Planning for voluntary smallpox vaccination of health and safety officials began in December 2002. Materials And Methods: Surveys were conducted among physicians and fire and police department personnel in Atlanta, Georgia. Information on demographics, willingness to receive smallpox vaccine, self-reported knowledge level, and potential vaccine contraindications was analyzed. Results: Forty-one percent of physicians (n = 199) were undecided on vaccination (32% would receive vaccine and 27% would not). Forty-eight percent of firefighters (n = 343) and 41% of police (n = 466) were undecided; 23% and 41% would receive vaccine, whereas 28% and 18% would not (fire and police, respectively). Absence of contraindications was associated with physicians' willingness to be vaccinated (P = 0.006). Many physicians (66%) and most public safety personnel (88%) considered themselves inadequately informed on smallpox vaccine. In a multivariate analysis, inadequately informed respondents were more likely to be undecided (OR = 2.23, CI = 1.39 to 3.56). Conclusions: Before implementation of the smallpox vaccination program, self-assessed knowledge about smallpox disease and vaccine were poor.

I describe what happened when a citizen called her state health department “after-hours” to report possible contamination of food at a commercial establishment. The call, inadequately handled by the health department, illustrates the need to assure quality of the public health responses to calls on a 24 hour, 7-day week basis. I examine possible reasons for the poor response. Health departments should consider training for those assigned to handle phone calls from the public, such as that provided to poison control center personnel. In addition, a quality assurance program should routinely assess the adequacy of public health responses. As medical care is available on an emergency basis, 24 hours a day, 7 days a week, emergency services for prevention of illness in the population should be available to the public at all times with the response provided by appropriately trained individuals.

To facilitate rapid detection of a future bioterrorist attack, an increasing number of public health departments are investing in new surveillance systems that target the early manifestations of bioterrorism-related disease. Whether this approach is likely to detect an epidemic sooner than reporting by alert clinicians remains unknown. The detection of a bioterrorism-related epidemic will depend on population characteristics, availability and use of health services, the nature of an attack, epidemiologic features of individual diseases, surveillance methods, and the capacity of health departments to respond to alerts. Predicting how these factors will combine in a bioterrorism attack may be impossible. Nevertheless, understanding their likely effect on epidemic detection should help define the usefulness of syndromic surveillance and identify approaches to increasing the likelihood that clinicians recognize and report an epidemic.

This report describes the data accumulated during the first 5 years of national surveillance for the human ehrlichioses in the United States and territories, from its initiation in 1997 through 2001. Reported cases of human monocytic and granulocytic ehrlichiosis (HME and HGE) and cases of "other ehrlichiosis" (OE), where the agent was unspecified, originated from 30 states. As anticipated, most HME cases were from the south-central and southeastern United States, while HGE was most commonly reported from the northeastern and upper-Midwestern region. State-level incident reports of 487 HME, 1,091 HGE, and 11 OE cases were evaluated. The average annual incidences of HME, HGE, and OE per million persons residing in states reporting disease were 0.7, 1.6, and 0.2, respectively. The median ages of HME (53 yr) and HGE cases (51 yr) were consistent with published patient series. Most (> 57%) ehrlichiosis patients were male. The results suggest that national surveillance for the ehrlichioses, although imperfect in coverage, will help define endemic regions and may be useful for monitoring long-term trends. Although the data appear representative of the demographic profiles established for HME and HGE, rigorous evaluation of the system is required. Methods are proposed for evaluating the quality and representativeness of HME and HGE surveillance data, using well-established surveillance systems for Rocky Mountain spotted fever and Lyme disease.

The current crisis with the Ebola virus vividly illustrates the priority that must be given to infectious diseases because of their potentially devastating consequences to individuals and to society. Few would argue against the need for more research on Ebola and the expedited development of a cure; however, recent incidents in biocontainment laboratories and the proliferation of such facilities globally raise concerns about safety and have split the scientific community. Scientists who defend research on dangerous pathogens as vital to protecting populations are opposed by those who fear the potential devastation caused by the intentional or unintentional release of pathogens from the lab. Achieving a “culture of safety,” so often alluded to after recent lapses in biosafety procedures, demands adopting a “culture of responsibility” as well.

ASM concurs with the highly disturbing conclusions of the Food and Drug Administration (FDA) Science Board Report to assess whether FDA science and technology can support current and future regulatory needs. For years, ASM and other scientific and health organizations have been warning of deteriorating scientific research, infrastructure, and personnel resources for the FDA, which is responsible for regulating approximately $1 trillion in consumer products annually. In just the past year, publicized discoveries of contaminated products from toys to pet food have reminded us of the FDA's critical role in safeguarding public health. As the study report emphatically states, the nation is at risk if FDA science is at risk.

Predictions that infectious diseases would be eliminated as a major threat to human health have been shattered by emerging and reemerging infections, among them acquired immunodeficiency syndrome (AIDS), hemorrhagic fevers, marked increases in infections caused by antimicrobial-resistant bacteria, and the resurgence of tuberculosis and malaria. Understanding the dynamics of emerging and reemerging infections is critical to efforts to reduce the morbidity and mortality of such infections, to establish policy related to preparedness for infectious threats, and for decisions on where to use limited resources in the fight against infections. In order to offer a multidisciplinary perspective, 23 infectious disease specialists, epidemiologists, geneticists, microbiologists, and population biologists participated in an open forum at Emory University on emerging and reemerging infectious diseases. As summarized below, the group addressed questions about the definition, the identification, the factors responsible for, and multidisciplinary approaches to emerging and reemerging infections.

(1997). Antibiotics: Past, present, and future. Postgraduate Medicine: Vol. 101, No. 1, pp. 114-122.

Emerging infectious diseases such as prolonged diarrheal illness due to water-borne Cryptosporidium, hemorrhagic colitis and renal failure from food-borne E. coli O157:H7, and rodent-borne hantavirus pulmonary syndrome as well as reemerging infections such as tuberculosis, pertussis, and cholera vividly illustrate that we remain highly vulnerable to the microorganisms with which we share our environment. Prompt detection of new and resurgent infectious disease threats depends on careful monitoring by modern surveillance systems. This article focuses on five important elements of improved surveillance for emerging infections: 1) strengthening the national notifiable disease system, 2) establishing sentinel surveillance networks, 3) establishing population-based emerging infections programs, 4) developing a system for enhanced global surveillance, and 5) applying new tools and novel approaches to surveillance.

To compare AIDS-defining conditions in women and men, US adult AIDS cases diagnosed between January 1988 and June 1991 and reported to the Centers for Disease Control and Prevention through June 1992 were examined. For most AIDS-defining conditions, the prevalence was similar for women and men when differences in race/ethnicity and mode of transmission were accounted for. Pneumocystis carinii pneumonia was the most prevalent condition (> 50%) regardless of gender, race/ethnicity, or mode of transmission. By logistic regression analysis, among injection drug users, conditions reported significantly more frequently in women than in men include esophageal candidiasis (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.40-1.62), herpes simplex virus (HSV) disease (OR, 1.68; CI, 1.46-1.94), and cytomegalovirus (CMV) disease (OR, 1.43; CI, 1.18-1.73). More knowledge of the interrelationships in women between HIV infection and secondary opportunistic infections, including candidiasis and sexually transmitted disease (e.g., HSV and CMV) is needed.

Human immunodeficiency virus type 1 (HIV-1) transmission from infected patients to health-care workers has been well documented, but transmission from an infected health-care worker to a patient has not been reported. After identification of an acquired immunodeficiency syndrome (AIDS) patient who had no known risk factors for HIV infection but who had undergone an invasive procedure performed by a dentist with AIDS, six other patients of this dentist were found to be HIV-infected. Molecular biologic studies were conducted to complement the epidemiologic investigation. Portions of the HIV proviral envelope gene from each of the seven patients, the dentist, and 35 HIV-infected persons from the local geographic area were amplified by polymerase chain reaction and sequenced. Three separate comparative genetic analyses--genetic distance measurements, phylogenetic tree analysis, and amino acid signature pattern analysis--showed that the viruses from the dentist and five dental patients were closely related. These data, together with the epidemiologic investigation, indicated that these patients became infected with HIV while receiving care from a dentist with AIDS.

To determine if patients of a dentist with the acquired immunodeficiency syndrome (AIDS) became infected with human immunodeficiency virus (HIV) during their dental care and, if so, to identify possible mechanisms of transmission.Retrospective epidemiologic follow-up of the dentist, his office practice, and his former patients.The practice of a dentist with AIDS in Florida.A dentist with AIDS, his health care providers and employees, and former patients of the dentist, including eight HIV-infected patients.Identification of risks for HIV transmission (if present), degree of genetic relatedness of the viruses, and identification of infection control and other office practices.Five of the eight HIV-infected patients had no confirmed exposures to HIV other than the dental practice and were infected with HIV strains that were closely related to those of the dentist. Each of the five had invasive dental procedures, done by the dentist after he was diagnosed with AIDS. Four of these five patients shared visit days (P greater than 0.2). Breaches in infection control and other dental office practices to explain these transmissions could not be identified.Although the specific incident that resulted in HIV transmission to these patients remains uncertain, the epidemiologic evidence supports direct dentist-to-patient transmission rather than a patient-to-patient route.

Non-Hodgkin lymphoma is associated with HIV infection. We investigated the epidemiology and aetiology of AIDS-related non-Hodgkin lymphoma by analysing data from cases reported to the Centers for Disease Control, Atlanta, USA, up to June 30, 1989. During this period 97,258 AIDS cases were reported, of whom 2824 (2.9%) had non-Hodgkin lymphoma. The condition was about 60 times more common in AIDS patients than in the general US population. 1686 cases were immunoblastic lymphoma, 548 primary lymphoma of the brain, and 590 Burkitt's lymphoma, a condition which is not normally associated with immunosuppression. The proportion of AIDS patients with immunoblastic lymphoma increased from 0% in those under 1 year old to 3.5% in those aged 50 or more. Primary lymphoma of the brain was constant at 0.6% for all ages. The frequency of Burkitt's lymphoma increased from zero in infants to a peak at 10-19 years of age (1.8%). Each type of lymphoma was twice as common in whites as in blacks and in men as in women. Lymphoma was most common in patients with haemophilia or clotting disorders and least common in those born in the Caribbean or Africa who had acquired HIV by heterosexual contact. Epidemiological data suggested that whilst infectious agents (eg, Epstein-Barr virus) may be associated with development of non-Hodgkin lymphomas in AIDS patients there was probably no single cause for all the types of lymphoma. Perhaps the most puzzling question is why Burkitt's lymphoma is commonly associated with HIV infection but not with other types of immunosuppression.

Background: In 2001, terrorism led to emotional stress, disruptions in adherence to treatments and access to services, and exposure to environmental contaminants in New York City (NYC). Methods: To describe healthcare use following the terrorist attacks of 2001, we examined insurance claims for January 2000 to March 2002 among more than 2 million residents of the NYC region who were enrolled in the health plans of a large insurer, including overall use by care setting and use for selected conditions that may be associated with stress or other disaster consequences. For all enrollees and for those residing at varying distances from the World Trade Center (WTC), we compared observed use to expected use, based on comparable intervals in prior years and adjusted for seasonal and secular trends. Results: Use declined across all care settings in the 3 weeks following September 11. From October 1 to December 31, 2001, outpatient visits rose beyond expected both overall and for specific cardiovascular, gastrointestinal, and dermatologic conditions. Declines in overall mental health service use began immediately after September 11 and were sustained through March 2002. Changes in healthcare use were more marked among those residing within 10 miles of the WTC than those residing at greater distances. Conclusions: A transient decline in visits across all settings occurred immediately after September 11, followed by a sustained increase in demand for health care for conditions that may be associated with stress or other disaster consequences. Language: en

In Reply. —The comments by Dr Plaut illustrate the complacency about infectious diseases that has developed over the past 30 years in the United States and in many other developed countries. Such complacency has resulted in the deterioration of the public health system required to detect, respond to, and minimize the impact of infectious diseases as highlighted in a recent Institute of Medicine report on emerging infectious diseases. 1 In fact, infectious diseases are the leading cause of death worldwide and the third leading cause of death in the United States, 2,3 and the threats may be increasing. Many pathogens, such as Legionella pneumophila, Hantavirus, and Escherichia coli 0157:H7, have been recognized in the past 25 years, and diseases such as salmonellosis, shigellosis, and wild animal rabies have demonstrated a resurgence. In addition, the increasing problem of antimicrobial resistance has resulted in untreatable enterococcal blood-stream infections and dramatic increases in community-acquired

In Reply. —Our recent analysis of death certificate data showed that the death rate from infectious diseases increased 58% in the United States between 1980 and 1992. We share Dr Randall's reservations about the quality of death certificate data, but we also agree with him that the conclusion that infectious disease mortality has been increasing recently in this country is inescapable. We focused on underlying cause-of-death data to present a conservative estimate of the burden of infectious disease, though infectious diseases often contribute to deaths even when they are not designated as the underlying cause. The HIV epidemic provides the most apparent contribution to recent increases in mortality from infectious diseases. Further, the fact that both underlying and multiple cause-of-death data showed comparable upward trends is also evidence that the increasing death rate from infectious diseases is not merely an artifact of changes in the way death certificates are completed.

Public health professionals generally have been complacent regarding the erosion of infectious disease surveillance, prevention, and control programs in the United States over the past two decades. 1-4 As infectious diseases have emerged or reemerged, some crises such as those posed by the emergence of the acquired immunodeficiency syndrome (AIDS) or resurgence of tuberculosis and measles have been addressed selectively. However, the infrastructure to maintain vigilance and to respond to most emergent or reemergent infectious diseases has generally continued to deteriorate. Consequently, for domestic problems ranging from outbreaks of cryptosporidiosis caused by contamination of municipal water supplies 5 to the currently growing crisis of antibiotic resistance, 6 efforts at surveillance, prevention, and control have frequently been delayed or inadequate. Global capacity to detect and respond to emerging diseases has also been compromised as surveillance networks have deteriorated and laboratory capacity for accurate diagnosis has declined in many countries. 2,7 There

Objective. —To evaluate recent trends in infectious diseases mortality in the United States. Design. —Descriptive study of infectious disease mortality, classifyingInternational Classification of Diseases, Ninth Revisioncodes as infectious diseases, consequence of infectious diseases, or not infectious diseases. Multiple cause-of-death tapes from the National Center for Health Statistics for the years 1980 through 1992 were used, with a focus on underlying cause-of-death data and on codes that exclusively represent infectious diseases. Setting. —United States. Subjects. —All persons who died between 1980 and 1992. Main Outcome Measure. —Death. Results. — Between 1980 and 1992, the death rate due to infectious diseases as the underlying cause of death increased 58%, from 41 to 65 deaths per 100 000 population in the United States. Age-adjusted mortality from infectious diseases increased 39% during the same period. Infectious diseases mortality increased 25% among those aged 65 years and older (from 271 to 338 per 100 000), and 6.3 times among 25- to 44-year-olds (from six to 38 deaths per 100000). Mortality due to respiratory tract infections increased 20%, from 25 to 30 deaths per 100 000, deaths attributed to human immunodeficiency virus increased from virtually none to 13 per 100000 in 1992, and the rate of death due to septicemia increased 83% from 4.2 to 7.7 per 100000. Conclusions. —Despite historical predictions that infectious diseases would wane in the United States, these data show that infectious diseases mortality in the United States has been increasing in recent years. (JAMA. 1996;275:189-193)

Objective. —To describe the spectrum of disease in persons with human mmunodeficiency virus (HIV) infection. Design. —Retrospective survey of medical records. Setting. —More than 50 clinics, hospitals, and private medical practices in nine US cities. Patients. —A total of 626 women and 7008 men 13 years of age or older with HIV infection who received medical care from January 1990 through March 1991 were consecutively enrolled. Main Outcome Measures. —Any history of diseases in the 1987 case definition for the acquired immunodeficiency syndrome (AIDS), and during the 12-month period preceding enrollment (baseline period), the occurrence of other major diseases, hospitalizations, and results of CD4 + lymphocyte counts. Results. —Thirty-two percent of persons met the 1987 case definition for AIDS. The occurrence of an AIDS-indicator disease during the baseline period ranged from 3% (33/1011) to 46% (1254/2748) among persons with CD4 + lymphocyte counts of 0.50 × 10 9 /L or greater and fewer than 0.20 × 10 9 /L (≥500 and + lymphocytes per microliter), respectively, and, at comparable CD4 + ymphocyte levels, was similar among women compared with men, and among persons who reported intravenous drug use compared with men who reported male-to-male sex. The frequency of one or more other major infectious diseases (eg, other pneumonias, bacterial sepsis, pulmonary tuberculosis) ranged from 6% to 16% among persons with CD4 + lymphocyte counts of 0.50 × 10 9 /L or greater and fewer than 0.20 × 10 9 /L, respectively; these illnesses were also associated with a history of intravenous drug use. Among persons who did not meet the 1987 AIDS case definition, 30% of those with an available CD4 + lymphocyte count had fewer CD4 + cells than 0.20 × 10 9 /L, 8% had one or more major infectious diseases, and 14% had one or more hospital admissions. Conclusions. —For every person with AIDS at these sites, two additional persons with HIV infection were receiving medical care, many of whom had severe immunosuppression and a broad spectrum of serious HIV-related disease. ( JAMA . 1992;267:1798-1805)

AIDS surveillance data are widely used in setting HIV intervention policies, and the effectiveness of these data depend on their completeness. We reviewed studies conducted by state and local health departments on the completeness of AIDS reporting. These studies identified AIDS cases through alternate data sources, such as death certificates, hospital discharge records, disease registries, or medication records. In most instances greater than 80% of AIDS cases detected through these studies had been reported, although lower levels of reporting were found in some outpatient settings. A comparison of vital records and AIDS surveillance confirmed that AIDS surveillance is identifying 70-90% of all HIV-related deaths in men 25-44 years of age. Historically, AIDS surveillance has emphasized reporting from hospitals. Efforts to maintain current levels of reporting, or to improve reporting, are challenged by the growth of the epidemic and by the increasing role of outpatient diagnosis of AIDS.

In Reply. —We do not believe that five patients of a Florida dentist became infected with HIV as a consequence of exposure to the sweat of a dentist with AIDS. 1-3 None of the five infected patients reported any contact with perspiration from the dentist. Furthermore, HIV has not been demonstrated in "natural" eccrine sweat from HIV-infected patients, 4 nor is there evidence to indicate that hepatitis B virus, another bloodborne pathogen with epidemiologic transmission patterns similar to HIV, can be transmitted through this route. Although the precise mode of HIV transmission to these patients remains uncertain, all of the patients had dental care from the dentist after he was diagnosed with AIDS, and multiple opportunities existed for the dentist to sustain needlestick injuries (eg, during administration of local anesthetics, two-handed needle recapping procedures, and suturing) or cuts with a sharp instrument, particularly in poorly visualized operative sites. Alternatively, transmission

To quantify the effect of estrogen replacement therapy on breast cancer risk, we combined dose-response slopes of the relative risk of breast cancer against the duration of estrogen use across 16 studies. Using this summary dose-response slope, we calculated the proportional increase in risk of breast cancer for each year of estrogen use. For women who experienced any type of menopause, risk did not appear to increase until after at least 5 years of estrogen use. After 15 years of estrogen use, we found a 30% increase in the risk of breast cancer (relative risk, 1.3; 95% confidence interval [CI], 1.2 to 1.6). The increase in risk was largely due to results of studies that included premenopausal women or women using estradiol (with or without progestin), studies for which the estimated relative risk was 2.2 (CI, 1.4 to 3.4) after 15 years. Among women with a family history of breast cancer, those who had ever used estrogen replacement had a significantly higher risk (3.4; CI, 2.0 to 6.0) than those who had not (1.5; CI, 1.2 to 1.7). (JAMA. 1991;265:1985-1990)

To the Editor.— In our recently published study inJAMA,1we documented the rapidly increasing effect of human immunodeficiency virus (HIV) infection on mortality in young women. We also noted that 35% of death certificates in women 15 to 44 years of age that indicated HIV infection or the acquired immunodeficiency syndrome (AIDS) also listed specific AIDS-indicator illnesses. These data have been misinterpreted as evidence that only 35% of HIV-infected women who die have an AIDS-defining illness and that the surveillance case definition is less inclusive of women than men. In fact, the number of women who were reported to the Centers for Disease Control with AIDS-defining illness and who died in 1987 exceeds the number of deaths in 1987 in women that were attributed to HIV or AIDS on death certificates (Figure). The misinterpretation may reflect a confusion about the differences between the information available from vital statistics

To assess the effect of the human immunodeficiency virus (HIV) on mortality in US women 15 to 44 years of age and to identify associated causes of death, we examined final (1980 through 1987) and provisional (1988) national mortality statistics. Between 1985 and 1988, the death rate for HIV/acquired immunodeficiency syndrome (AIDS) quadrupled (0.6 per 100,000 to 2.5 per 100,000), and by 1987, HIV/AIDS had become one of the 10 leading causes of death. In 1988, the death rate for black women (10.3 per 100,000) was nine times the rate for white women (1.2 per 100,000). The majority of deaths in both black and white women occurred in women 25 to 34 years of age, for whom HIV-related deaths accounted for 11% and 3% of all deaths in 1988, respectively. Among 1157 death certificates that included any mention of HIV/AIDS in 1987, other leading diagnoses included drug abuse (27%), Pneumocystis carinii pneumonia (20%), other pneumonias (14%), septicemia (10%), other infections not in the AIDS surveillance definition (7%), nephritis (6%), liver diseases (4%), and anemias (4%). If current mortality trends continue, HIV/AIDS can be expected to become one of the five leading causes of death by 1991 in women of reproductive age. Because women infected with HIV are the major source of infection for infants, these trends in AIDS mortality in women forecast the impact of HIV on mortality in children as well.

• Of 48 712 acquired immunodeficiency syndrome (AIDS) cases reported to the Centers for Disease Control from October 1987 through March 1989, 1239(2.5%) were diagnosed with extrapulmonary tuberculosis. Extrapulmonary tuberculosis was diagnosed in 1013 (2.3%) of the US-born persons with AIDS, compared with 26 (8%) of the Mexican-born, 82 (13%) of the Haitianborn, and 4 (1%) of the Cuban-born. Patients with AIDS with and without extrapulmonary tuberculosis were similar in age, except that extrapulmonary tuberculosis was relatively rare in patients with AIDS under the age of 10. Compared with white homosexual/bisexual men, black race (odds ratio, 2.7), intravenous drug use (odds ratio, 2.0), heterosexual AIDS transmission category (odds ratio, 1.9), and Hispanic ethnicity (odds ratio, 1.6) were independently associated with extrapulmonary tuberculosis. In 1988, extrapulmonary tuberculosis in persons known to be human immunodeficiency virus seropositive represented 21% of national extrapulmonary tuberculosis morbidity. ( Arch Intern Med . 1990;150:1913-1916)

In recent years, many individuals have developed models to predict the future course of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic at the local, state, and national levels. The number of forecasters and resulting projections reflects not only the complexity and uncertainties in predicting the epidemic, but also the critical importance of such estimates. 1 Many health care policies are based on these forecasts, which influence the scope and direction of both public and private initiatives related to HIV. Overall, the number of reported cases of AIDS in the United States continues to increase. During 1989, 35 238 cases were reported, for a yearly increase of 9.4% over the 32 196 cases reported during 1988. This increase is lower than in past years, partly because of the large number of previously diagnosed cases reported in 1988 that met only the expanded AIDS case definition. 2 However, even after

Although crude and age-adjusted mortality statistics are frequently used to quantify public health problems, they are heavily influenced by the underlying disease processes of the elderly. Alternative measures have been developed to reflect the mortality experience of younger age groups (i.e., premature mortality). We evaluated four different methods for tabulating premature mortality, one method weighted by the remaining life expectancy at death and three methods with constant end points using age spans from birth to 65 years, birth to 75 years, and 1 to 65 years. These alternatives provide dramatically different descriptions of premature mortality in the United States in 1984. In general, the constant end-point methods emphasize the different pattern of mortality among younger persons, while premature mortality computed by the remaining life expectancy method more closely resembles the pattern of crude mortality. Although no single method is preferable for all purposes, the constant end-point method best differentiates the leading causes of premature death.

Published studies on the contraction stress test (CST), the nonstress test (NST), and monitoring of fetal movement were reviewed to assess the accuracy and efficacy of these techniques. The false-negativity and false-positivity rates, sensitivity, and specificity of these tests were assessed with use of perinatal mortality and various measures of morbidity as outcomes. Both the CST and the NST generally demonstrated low sensitivity and high rates of false positivity. No randomized controlled trials have been conducted that are of sufficient size to demonstrate whether there is a significant difference in outcome following use of the CST or the NST. A single nonrandomized, controlled trial evaluating fetal-movement monitoring suggested clinical benefit. Direct costs of NSTs and CSTs in the United States were estimated to exceed $200 million per year. Yet the CST and the NST have not been demonstrated to be useful diagnostic tests. The CST, the NST, and fetal-movement monitoring are potentially useful screening tests. However, they require critical evaluation, with large randomized, controlled trials, to determine their efficacy and safety before their further diffusion into obstetrical practice.

The purpose of this review is to describe the historical and current practice of public health surveillance [in the United States] to discuss new directions for surveillance both in terms of new public health priorities and new methodological tools and to assess the limitations of surveillance. (EXCERPT)

We reviewed fatal injuries in Fulton County, Georgia, in collaboration with the medical examiner's office. This county encompasses most of the city of Atlanta and has a population of approximately 600,000 persons. Information collected for 1981 and 1982 was analyzed; and the results of blood alcohol content (BAC) testing and toxic screens were reviewed for all victims of homicide, suicide, and unintentional fatal injuries who died within six hours of being injured. Seventy-one percent of 271 homicide victims had been drinking, and 51 percent had BACs greater than or equal to 0.1 mg/dL. Of 153 suicide victims, 37 percent had been drinking and 20 percent had BACs greater than or equal to 0.1 mg/dL. Of 54 drivers who died in single-vehicle collisions, 78 percent had been drinking; 54 percent of 162 victims of nonvehicular unintentional fatal injuries had positive blood alcohol levels. There was little evidence of the use of psychotropic drugs among victims of fatal injury. Most of the victims of homicide and unintentional fatal injuries who had positive toxic screens also had a positive blood alcohol tests.

Recent confirmation of intrinsic bacterial contamination of 10% povidone-iodine solution has raised questions regarding the bactericidal mechanism of iodophors and the possibility for survival of vegetative bacterial cells in iodophor solutions. In this laboratory investigation, five different species were exposed to various dilutions of three commercial preparations of 10% povidone-iodine solution; survival was assessed after exposure for time periods varying between 0 and 8 min. All brands of povidone-iodine solution tested demonstrated more rapid killing of Staphylococcus aureus and Mycobacterium chelonei at dilutions of 1:2, 1:4, 1:10, 1:50, and 1:100 than did the stock solutions, S. aureus survived a 2-min exposure to full-strength povidone-iodine solution but did not survive a 15-s exposure to a 1:100 dilution of the iodophor. Both stock and dilute preparations of 10% povidone-iodine solution demonstrated rapid bactericidal action against Klebsiella pneumoniae, Pseudomonas cepacia, and Streptococcus mitis.

Automated peritoneal dialysis systems have helped make intermittent peritoneal dialysis an alternative to hemodialysis for long-term management of patients with end-stage renal disease. However, if not cleaned and maintained properly, these machines provide a reservoir for pathogens. The microbiologic barriers in these machines are not impenetrable, but sterile dialy-sate fluid can be produced if the machines are adequately cleaned and disinfected. Potential shortcomings of the microbiologic barriers are discussed, and guidelines to prevent contamination of the internal parts of a machine are suggested.

As of December 31, 1988, 82,764 cases of acquired immunodeficiency syndrome (AIDS) and more than 46,000 AIDS-related deaths had been reported in the United States. In 1987, AIDS deaths accounted for 9% of the total mortality among men 25 to 34 years of age. Projections suggest that the impact of human immunodeficiency virus (HIV) infection on morbidity and mortality in young adults and children will continue to increase, with an estimated 50,000 cases projected to be diagnosed in 1989. The mean latency period between infection and diagnosis of AIDS is estimated to be more than seven years, and 78% to 100% of persons infected with HIV are predicted to develop AIDS within 15 years of onset of infection. Rates of seroconversions have been decreasing since 1984 among cohorts of homosexual HIV-seronegative men, and the proportion of AIDS cases among homosexual men is decreasing. In contrast, the proportion of AIDS cases attributed to intravenous drug use is increasing, with 33% of AIDS cases reported in 1988 occurring among intravenous drug users, their sex partners, or children of women who are intravenous drug users or sex partners of intravenous drug users. Worldwide, the differences in the epidemiology of HIV infection and AIDS are primarily due to differences in the proportions of the modes of transmission and in the time in which HIV infection was introduced.

After an outbreak of peritoneal infections attributed to intrinsic contamination of a poloxamer-iodine solution with Pseudomonas aeruginosa , the manufacturer of the contaminated solution permitted investigation and sampling of materials within the plant. Pseudomonas spp. were recovered from two different unopened lots of solution and from numerous water samples obtained at the plant. The isolates from water identical to those of an isolate recovered from Prepodyne solution (West-Agro Chemical Co., Inc., Westwood, Kans., manufactured for AMSCO Medical Products Div., Erie, Pa.) manufactured 1 month earlier at the same plant. P. aeruginosa was not recovered from incoming city water. P. aeruginosa was recovered from sterile water and poloxamer-iodine after 48 h of incubation in a plant polyvinyl chloride pipe. Scanning electron micrographs of polyvinyl chloride pipe used in the plant showed massive concentrations of rod-shaped and coccobacillary cells apparently embedded in interior deposits of the pipe. Manufacturers of iodophors should be aware that pipes or other surfaces colonized with bacteria may be a source of contamination of their products.