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To determine the effects of human immunodeficiency virus (HIV) infection on pregnancy outcomes, we prospectively studied female intravenous drug users in a methadone program in New York City. Of 191 women with HIV status known prior to pregnancy, 17 (24%) of 70 seropositives and 26 (22%) of 121 seronegatives became pregnant during 28 months of follow-up. Including 54 additional women first tested for HIV antibody after becoming pregnant, 125 pregnancies were studied in 97 women (39 seropositive, 58 seronegative). None of the seropositive pregnant women had advanced HIV-related disease at entry, and only one developed symptomatic disease (oral candidiasis) during pregnancy. No differences were observed between groups in the frequency of spontaneous or elective abortion, ectopic pregnancy, preterm delivery, stillbirth, or low-birth-weight births. Among women giving birth to live infants, seropositives were more likely than seronegatives to be hospitalized for bacterial pneumonia during pregnancy and had an increased tendency for breech presentation, although these events were infrequent. There were otherwise no differences between groups in the occurrence of antenatal, intrapartum, or neonatal complications. Results suggest that asymptomatic HIV infection is not associated with a decreased pregnancy rate or an increased risk of adverse pregnancy outcomes in intravenous drug users, and that an acceleration in HIV-disease status during pregnancy is uncommon. [ABSTRACT FROM AUTHOR]

From 1981 to 1988, eighty percent of all women with the acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control were of reproductive age. Six pregnancy-associated deaths due to AIDS in this country have been reported in the medical literature. We identified 20 unpublished cases of women who died of AIDS during or within one year after termination of pregnancy. Analysis showed that these women were mostly black or Hispanic, half were intravenous drug abusers, and most died of Pneumocystis carinii pneumonia. Each pregnancy had an obstetric complication, primarily preterm delivery. The interval between diagnosis of AIDS and the death of these women ranged from one day to 15 months, with a mean interval of 113 days. Multiple reporting sources increased case detection and should be used for future investigations. Prospective case-control studies are needed to determine any further relationship between pregnancy complications and AIDS. [ABSTRACT FROM AUTHOR]

Objective To analyse the effect of Kenya's Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas. Methods We used data from the Kenya Health Workforce Informatics System on the nursing workforce to determine the effect of the Emergency Hiring Plan on nurse shortages and maldistribution. The total number of nurses, the number of nurses per 100 000 population and the opening of previously closed or new heath facilities were recorded. Findings Of the 18 181 nurses employed in Kenya's public sector in 2009, 1836 (10%) had been recruited since 2005 through the Emergency Hiring Plan. Nursing staff increased by 7% in hospitals, 13% in health centres and 15% in dispensaries. North Eastern province, which includes some of the most remote areas, benefited most: the number of nurses per 100 000 population increased by 37%. The next greatest increase was in Nyanza province, which has the highest prevalence of HIV infection in Kenya. Emergency Hiring Plan nurses enabled the number of functioning public health facilities to increase by 29%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. Conclusion The Emergency Hiring Plan for nurses significantly increased health services in Kenya's rural and underserved areas over the short term. Preliminary indicators of sustainability are promising, as most nurses hired are now civil servants. However, continued monitoring will be necessary over the long term to evaluate future nurse retention. The accurate workforce data provided by the Kenya Health Workforce Informatics System were essential for evaluating the effect of the Emergency Hiring Plan. [ABSTRACT FROM AUTHOR]

Maternal exposure to stress during pregnancy is associated with an increased risk of psychiatric disorders in the offspring in later life. The mechanisms through which the effects of maternal stress are transmitted to the fetus are unclear, however the placenta, as the interface between mother and fetus, is likely to play a key role. Using a rat model, we investigated a role for placental oxidative stress in conveying the effects of maternal social stress to the fetus and the potential for treatment using a nanoparticle-bound antioxidant to prevent adverse outcomes in the offspring. Maternal psychosocial stress increased circulating corticosterone in the mother, but not in the fetuses. Maternal stress also induced oxidative stress in the placenta, but not in the fetal brain. Blocking oxidative stress using an antioxidant prevented the prenatal stress-induced anxiety phenotype in the male offspring, and prevented sex-specific neurobiological changes, specifically a reduction in dendrite lengths in the hippocampus, as well as reductions in the number of parvalbumin-positive neurons and GABA receptor subunits in the hippocampus and basolateral amygdala of the male offspring. Importantly, many of these effects were mimicked in neuronal cultures by application of placental-conditioned medium or fetal plasma from stressed pregnancies, indicating molecules released from the placenta may mediate the effects of prenatal stress on the fetal brain. Indeed, both placenta-conditioned medium and fetal plasma contained differentially abundant microRNAs following maternal stress, and their predicted targets were enriched for genes relevant to nervous system development and psychiatric disorders. The results highlight placental oxidative stress as a key mediator in transmitting the maternal social stress effects on the offspring's brain and behavior, and offer a potential intervention to prevent stress-induced fetal programming of affective disorders., Competing Interests: HS and TJP have previously consulted for Placentum Ltd. The University of Bristol has filed a patent application for the nanoparticle formulation used in this study and its application to pregnancy-related diseases. The other authors report no conflicts of interest., (© 2020 The Authors.)

The Centers for Disease Control and Prevention (CDC) has played a major role in controlling the HIV/AIDS epidemic in the United States. After implementation of perinatal zidovudine therapy in 1994, the efforts of the CDC and others produced a dramatic decline in perinatal HIV transmission. However, in recent years, approximately 300 perinatally infected infants have been born annually in the United States. To further reduce this number, the CDC has identified four prevention goals: improve prenatal care, recommend HIV testing, ensure treatment for HIV-infected pregnant women, and ensure follow-up care. To address these goals, the CDC launched a prevention plan consisting of surveillance, research, outreach strategies, grant programs, evaluation efforts, and policy development. Globally, the CDC tailors this plan to meet the needs of developing countries. The CDC provides technical assistance to international organizations to help develop, implement, and evaluate global prevention programs. Specific international sites are targeted for new research and programs to reduce perinatal HIV transmission.

In the USA, the AIDS epidemic has shown dramatic increases among women and children in the past decade with more than 70,000 cases in women and 7000 cases in children reported. Acquired immunodeficiency syndrome is the seventh leading cause of death in children aged 1-4 years and the fourth leading cause of death among women aged 25-44 years. Data from the National Survey of Childbearing Women, a blinded serosurvey of blood specimens left over from routine metabolic screening of most infants born in the USA, indicate that approximately 7000 HIV-infected women have given birth each year for the past several years. Human immunodeficiency virus infection disproportionately affects African-Americans and women of Hispanic ethnicity. Most cases in women and children have come from states along the east coast and large urban areas. Pneumocystis carinii pneumonia (PCP) continues to be the most commonly reported opportunistic infection in children with AIDS. As of 31 December, 1995, 2383 cases of PCP had been reported to the Centers for Disease Control and Prevention. Revised guidelines for PCP prophylaxis published in 1995 will hopefully provide a better means for preventing this deadly infection in children with AIDS. In 1994, a clinical trial (ACTG 076) found that the risk of perinatal transmission could be reduced by two-thirds with the use of a zidovudine regimen given antenatally, during labor and delivery, and postnatally to the infant. The US Public Health Service published guidelines based on these results, recommending voluntary HIV counseling and testing for all pregnant women in the USA and zidovudine therapy for those women found to be HIV-infected. Since implementation of these guidelines, cases of perinatally acquired AIDS in children have begun to decrease. Adequate resources for provision of care, outreach to women who do not receive prenatal care, training of healthcare personnel and attention to the many social and psychological needs of HIV-infected women and their children are key factors for further reduction of HIV infection in children.

The global HIV epidemic is having a profound impact on the health and survival of children. As of 1994, it is estimated that about 2 million children worldwide (WHO, 1994) and 12 thousand children in the United States are HIV infected (Davis et al. 1995). Almost all HIV infection among infants and young children are from mother-to-infant transmission. By the year 2000, HIV is projected to infect 40 million men, women, and children unless effective prevention strategies are developed. Perinatal HIV transmission rates currently vary from 14-40% with the lowest rates being seen in Europe and highest rates in Africa. Known risk factors for perinatal transmission include advanced maternal HIV disease, lower CD4+ counts, and increased viral burden during pregnancy. Observational cohort data suggest that prenatal vitamin A levels, maternal drug use, and duration of membrane rupture during labor also are related to risk of transmission. The United States clinical trial utilizing an antiretroviral (zidovudine [AZT]) prenatally, intrapartum, and for 6 weeks to the infant demonstrated that perinatal HIV transmission was reduced by two-thirds. This dramatic result gives strong encouragement that simpler perinatal prevention strategies applicable to developing countries may also be successful. A number of international studies are underway or planned including perinatal vitamin A and micronutrient trials in Africa.

Objective: To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections., Method: The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost., Results: Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million., Conclusion: Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

New York City women (321) enrolled during 1986-1993 in an observational cohort study were analyzed retrospectively to determine the effectiveness of antenatal zidovudine in reducing perinatal transmission of human immunodeficiency virus type 1 (HIV-1) in women with various CD4+ lymphocyte counts (< 200, 200-499, > 499/microL). When CD4+ lymphocyte level was controlled for, women prescribed zidovudine during pregnancy were less likely to transmit HIV-1 to their infants (adjusted odds ratio, 0.36; 95% confidence interval, 0.14-0.92). There was no conclusive evidence that efficacy of zidovudine depended on CD4+ lymphocyte level, suggesting that women with severe CD4+ cell depression, who are at highest risk of transmitting HIV-1, may also benefit from zidovudine. Antenatal zidovudine treatment alone may substantially lower the risk of perinatal HIV-1 transmission. These data are consistent with the results of AIDS Clinical Trial Group protocol 076 and suggest that a substantial portion of zidovudine's protective effect may occur when used during the antenatal period.

We investigated children with CD4+ T lymphocytopenia to determine the magnitude and public health impact of this condition and to investigate possible causes. Children < 13 years old with CD4+ T lymphocyte counts below age-adjusted cutoffs (age < 24 months, 1000 cells/microliters; age > or = 24 months, 300 cells/microliters) or < 20% on 2 separate measurements were considered to have CD4+ T lymphocytopenia. We solicited information from clinicians and public health departments on these children and their families and collected blood for immunologic and retroviral testing. We identified 18 children (10 boys; 14 African-Americans) with a median age of 10 months at their first low CD4+ T lymphocyte measurement. Three children had had opportunistic infections and two still had low CD4+ T lymphocyte counts 5 and 7 years later. Of the 11 children born to human immunodeficiency virus (HIV)-infected mothers 7 were asymptomatic. Specimens from all children were negative for HIV and human T lymphotropic virus antibodies and negative for HIV by culture or polymerase chain reaction. Among 12 families interviewed no other HIV-seronegative family or household member had illnesses suggestive of immunosuppression. We conclude that negative retroviral tests and lack of illness among their family members do not support the hypothesis that a retrovirus causes CD4+ T lymphocytopenia among these children.(ABSTRACT TRUNCATED AT 250 WORDS)

In recent years, human immunodeficiency virus (HIV) infection has emerged as a leading cause of death among young children, most of whom acquired their infection perinatally. Without effective prevention efforts, transmission of HIV through heterosexual sex will continue to increase among women, and the number of perinatally infected children will mirror this increase. In 1994, researchers at the National Institutes of Health and its collaborators announced results from a randomized clinical trial indicating that zidovudine therapy administered to a select group of HIV-infected pregnant women and their newborns reduced the risk of perinatal transmission by two-thirds. This article reviews this clinical trial and its significant findings, discusses the ensuing recommendations from the US Public Health Service, discusses their implications for prenatal counseling and testing, and describes future research needs.

Human Immunodeficiency Virus (HIV) infection is a growing problem for children worldwide. As of 31 December 1992, 4249 children with Acquired Immunodeficiency Syndrome (AIDS) under 13 years of age had been reported to the US Centers for Disease Control and Prevention (CDC). HIV is transmitted to children predominantly from their mothers. Nearly all cases of HIV infection acquired from blood transfusions in the United States occurred before donor-screening practices were implemented in March 1985. In 1991, approximately 7000 HIV-infected women gave birth to a liveborn infant in the United States, for a prevalence of 1.7 per 1000 women. Despite recent advances in prophylactic therapy for opportunistic infections, Pneumocystis carinii pneumonia remains the most common AIDS-defining illness in children in the United States. If these cases are to be prevented, children born to HIV-infected mothers will need to be identified early and monitored appropriately for CD4+ cell counts to determine the need for prophylaxis.

HIV infection is an important cause of morbidity and mortality in the pediatric population. Providers of health care to children need to be aware of the problem and the characteristics of the most affected populations. Early diagnosis of HIV infection is critical for initiating appropriate antiviral therapy and prophylactic treatment for opportunistic infections. Attending to the myriad of social problems these families face is equally important for providing an optimal chance for prolonged survival and a reasonably high quality of life.

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.

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.

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)

A prospective study was conducted in the Bronx, New York, of 70 infants of human immunodeficiency virus (HIV)-infected (n = 33) and uninfected (n = 37) mothers who had a history of intravenous drug use or of intravenous drug-using sex partners. Infants were observed from birth to a median age of 23 months (range 3 to 54 months). HIV infection was confirmed in seven infants (21%) of seropositive mothers; six developed HIV disease, with symptoms observed in the first year. Of these, three died (3, 9, and 36 months) of HIV-related causes; 3 of 4 survivors were greater than 25 months of age. HIV symptoms preceded or were concurrent with abnormalities in T-lymphocyte subsets; postneonatal polymerase chain reaction confirmed HIV infection in five infants with symptoms and one without symptoms. Among infants of seropositive mothers, seven without laboratory evidence of HIV (including polymerase chain reaction) had findings suggestive of HIV infection, including persistent generalized lymphadenopathy, hepatosplenomegaly, oral candidiasis, parotitis, and inverted T-lymphocyte ratios. These findings were not observed in infants of seronegative mothers. Although the presence of HIV proviral sequences was associated with HIV disease, the observation of indeterminate symptoms in at-risk infants indicates the importance of long-term clinical follow-up to exclude HIV infection. Disease manifestations in comparable infants of seronegative mothers are important for assessment of the impact of maternal drug use, development of specific clinical criteria for early diagnosis of HIV and eligibility for antiretroviral therapy.

A mathematical model was developed to assess the effect of various assumed prevalence rates of maternal human immunodeficiency virus (HIV) infection on perinatally acquired HIV infections and child survival. The model indicates that for children younger than 5 years, countries with low baseline mortality rates will experience greater relative increases in child mortality rates and larger proportions of HIV-caused deaths in children than countries with high mortality rates. It also suggests that perinatal HIV infection could become the most common cause of deaths in children in the developed world if maternal infection rates reach 2% to 3%. Rates of 25% to 30% would be needed to produce a similar effect in the developing world. Child survival gains in the last three decades in the developed world could be quickly erased at low levels of maternal HIV infection, but gains would not be completely offset in the developing world until more than 40% of mothers became infected with HIV. When basic demographic information and the maternal HIV infection rate are known, the model permits a direct assessment of infant and child mortality caused by HIV. It can also be used to estimate the prevalence of maternal HIV infection when values for all other variables are known.

Perinatal transmission of human immunodeficiency virus (HIV) continues to increase. In 1989 alone, it is estimated that 1750 infected children were born in the United States. Although transmission is spreading to areas outside the cities originally most affected, these cities continue to bear the greatest toll. Adolescents may be particularly vulnerable to HIV infection; education and counseling are critical for controlling the epidemic in this age group.

Background and Methods: To estimate the magnitude of the human immunodeficiency virus (HIV) epidemic among university students, we conducted a blinded HIV-seroprevalence survey at 19 universities throughout the United States. HIV-antibody testing was performed on blood collected for routine medical purposes at the student health centers of the participating institutions. At each campus, from 250 to 1000 blood specimens were collected consecutively and tested for HIV antibodies by enzyme-linked immunosorbent assay and Western blot analysis. Nonidentifying demographic data were linked with the test results., Results: Of 16,863 specimens in the sample, 30 (0.2 percent) were positive for antibodies to HIV. Positive specimens were found at 9 of the 19 schools. All were from students over 18 years old; 19 (63 percent) were from students over 24. All but 2 of the 30 infected students were men. The seroprevalence rate for men was 0.5 percent (95 percent confidence interval, 0.3 to 0.7), and for women it was 0.02 percent (95 percent confidence interval, 0.002 to 0.066). Seroprevalence increased with age--from 0.08 percent (95 percent confidence interval, 0.04 to 0.15) for students 18 to 24 years old to 1.0 percent (95 percent confidence interval, 0.2 to 2.9) for those 40 or older., Conclusions: HIV infection is present on U.S. university campuses, although the rate appears to be far lower than that of populations known to be at high risk. The potential clearly exists, however, for the further spread of HIV infection in this population, and preventive measures are needed.

From 1981 to 1989, the number of women with HIV infection and acquired immunodeficiency syndrome (AIDS) increased rapidly. Most women were infected through intravenous drug use or sexual contact with an infected man. Most children were infected through mother-to-infant transmission during pregnancy or delivery. Available data suggest that the rapid increase in the number of women with AIDS will continue for at least the next few years.

The possibility of transmission of the human immunodeficiency virus (HIV) from infected children to their contacts has been confronted in households, schools, day-care centers, and other child care settings. Cases reported to the Centers for Disease Control and several studies of close contacts of HIV-infected patients suggested that the risk of transmission in these settings is extremely low. However, most of these studies involved infected adults or older children. Younger children, who drool, bite, mouth toys, and are incontinent, may be more likely to transmit HIV in these settings. To assess this possibility, the authors tested 89 members of households in which 25 children with HIV infection, most of whom were preschool-aged, resided. Household members had close personal contact with the infected children. They shared many items likely to be soiled with blood and body fluids, such as toys, toothbrushes, eating utensils, toilets, and bathtubs. Hugging, kissing, sharing a bed, and bathing together were common. Household members were tested no sooner than 4 months after initial contact with the infected child, to allow adequate time for sero-conversion. All 89 participating household members were anti-HIV seronegative, and 78 who were tested were serum p24 antigen negative. It was concluded from this study and other evidence that the risk of transmission from children to their contacts is extremely low and has not been clearly documented in the household setting.

An outbreak of Kawasaki syndrome occurred in eastern Colorado during April and May, 1982. 48% of 23 cases had been exposed to the application of rug shampoo in the home in the 30 days before onset of disease, compared with 10% of 30 matched neighbourhood controls and 11% of 56 randomly chosen, matched community controls (p less than 0.01). The interval between rug shampooing and onset of disease was 16-25 days in 9 of 11 cases; 4 of the 9 had intervals of exactly 20 days. Although many brands of shampoo and three different methods of application were used, all but 1 of the cases had walked or crawled on the shampooed rugs within 2 h, the interval being significantly longer for those controls who had been exposed to the shampoo. 3 of 5 sporadic cases in Colorado who fell ill after November, 1981, had similar histories of exposure, as did 9 of 15 sporadic cases in eight other states who were contacted after the Colorado investigation. These findings suggest that exposure to the application of rug shampoo may be a risk factor for some cases of Kawasaki syndrome, although the mechanism remains to be determined.