George P. Schmid

The Spirochetal Etiology of Lyme Disease

We recovered a newly recognized spirochete from the blood, skin lesions (erythema chronicum migrans [ECM]), or cerebrospinal fluid of 3 of 56 patients with Lyme disease and from 21 of 110 nymphal or adult lxodes dammini ticks in Connecticut. These isolates and the original one from l. dammini appeared to have the same morphologic and immunologic features. In patients, specific IgM antibody titers usually reached a peak between the third and sixth week after the onset of disease; specific IgG antibody titers rose slowly and were generally highest months later when arthritis was present. Among 40 patients who had early disease only (ECM alone), 90 per cent had an elevated IgM titer (greater than or equal to 1:128) between the ECM phase and convalescence. Among 95 patients with later manifestations (involvement of the nervous system, heart, or joints), 94 per cent had elevated titers of IgG (greater than or equal to 1:128). In contrast, none of 80 control subjects had elevated IgG titers, and only three control patients with infectious mononucleosis had elevated IgM titers. We conclude that the I. dammini spirochete is the causative agent of Lyme disease.

Toxic-shock syndrome in menstruating women. Association with tampon use and Staphylococcus aureus and clinical features in 52 cases.

To determine the risk factors associated with toxic-shock syndrome (TSS) in menstruating women, we conducted a retrospective telephone study of 52 cases and 52 age-matched and sex-matched controls. Fifty-two cases and 44 controls used tampons (P < 0.02). Moreover, in case-control pairs in which both women used tampons, cases were more likely than controls to use tampons throughout menstruation (42 of 44 vs. 34 of 44, respectively; P < 0.05). There were no significant differences in brand of tampon used, degree of absorbency specified on label, frequency of tampon change, type of contraceptive used, frequency of sexual intercourse, or sexual intercourse during menstruation. Fourteen of 44 cases had one or more definite or probable recurrences during a subsequent menstrual period. In a separate study, Staphylococcus aureus was isolated from 62 of 64 women with TSS and from seven of 71 vaginal cultures obtained from healthy controls (P < 0.001).

Sexual and reproductive health: a matter of life and death.

Despite the call for universal access to reproductive health at the 4th International Conference on Population and Development in Cairo in 1994, sexual and reproductive health was omitted from the Millennium Development Goals and remains neglected (panel 1). Unsafe sex is the second most important risk factor for disability and death in the worlds poorest communities and the ninth most important in developed countries. Cheap effective interventions are available to prevent unintended pregnancy, provide safe abortions, help women safely through pregnancy and child birth, and prevent and treat sexually transmitted infections. Yet every year, more than 120 million couples have an unmet need for contraception, 80 million women have unintended pregnancies (45 million of which end in abortion), more than half a million women die from complications associated with pregnancy, childbirth, and the postpartum period, and 340 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections. Sexual and reproductive ill-health mostly affects women and adolescents. Women are disempowered in much of the developing world and adolescents, arguably, are disempowered everywhere. Sexual and reproductive health services are absent or of poor quality and underused in many countries because discussion of issues such as sexual intercourse and sexuality make people feel uncomfortable. The increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health.

An estimate of the global prevalence and incidence of herpes simplex virus type 2 infection

OBJECTIVE To estimate the global prevalence and incidence of herpes simplex virus type 2 (HSV-2) infection in 2003. METHODS A systematic review was undertaken of published seroprevalence surveys describing the prevalence or incidence of HSV-2 by age and gender. For each of 12 regions, pooled prevalence values by age and gender were generated in a random-effect model. HSV-2 incidence was then estimated from these pooled values using a constant-incidence model. Values of the HSV-2 seroprevalence from the model fits were applied to the total population to estimate the numbers of people infected. FINDINGS The total number of people aged 15-49 years who were living with HSV-2 infection worldwide in 2003 is estimated to be 536 million, while the total number of people who were newly infected with HSV-2 in 2003 is estimated to be 23.6 million. While the estimates are limited by poor availability of data, general trends are evident. For example, more women than men were infected, and the number infected increased with age. Although prevalence varied substantially by region, predicted prevalence was mostly higher in developing regions than developed regions. CONCLUSION The prevalence of HSV-2 is relatively easy to measure since infection is lifelong and has a specific serological test. The burden of disease is less easy to quantify. Despite the often sparse data on which these estimates are based, it is clear that HSV-2 infection is widespread. The dramatic differences in prevalence between regions are worthy of further exploration.

HIV Voluntary Counseling and Testing and Behavioral Risk Reduction in Developing Countries: A Meta-analysis, 1990–2005

The effectiveness of HIV voluntary counseling and testing (VCT) in reducing HIV risk behaviors in developing countries was assessed using meta-analytic methods. A standardized protocol was used for searching, acquiring, and extracting study data and meta-analyzing the results. Seven studies met the inclusion criteria. VCT recipients were significantly less likely to engage in unprotected sex when compared to behaviors before receiving VCT, or as compared to participants who had not received VCT [OR 1.69; 95%CI 1.25–2.31]. VCT had no significant effect on the number of sex partners [OR 1.22; 95%CI 0.89–1.67]. While these findings provide only moderate evidence in support of VCT as an effective prevention strategy, neither do they negate the need to expand access to HIV testing and counseling services. Such expansion, however, must be accompanied by rigorous evaluation in order to test, refine and maximize the preventive benefits of learning one’s HIV infection status through HIV testing and counseling.

Male circumcision for HIV prevention: from evidence to action?

An estimated 2.5 million people were newly infected with HIV in 2007 of whom two-thirds live in sub-Saharan Africa. In the context of the urgent need for intensified and expanded HIV prevention efforts the conclusive results of three randomized controlled trials (RCT) showing that male circumcision reduces the risk of HIV-acquisition by approximately 60% are both promising and challenging. Translation of these research findings into public health policy is complex and will be context specific. To guide this translation we estimate the global prevalence and distribution of male circumcision summarize the evidence of an impact on HIV incidence and highlight the major public health opportunities and challenges raised by these findings. (excerpt)

Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections

During the past year, a group has argued that unsafe injections are a major if not the main mode of HIV-1 transmission in sub-Saharan Africa. We review the main arguments used to question the epidemiological interpretations on the lead role of unsafe sex in HIV-1 transmission, and conclude there is no compelling evidence that unsafe injections are a predominant mode of HIV-1 transmission in sub-Saharan Africa. Conversely, though there is a clear need to eliminate all unsafe injections, epidemiological evidence indicates that sexual transmission continues to be by far the major mode of spread of HIV-1 in the region. Increased efforts are needed to reduce sexual transmission of HIV-1.

Bacterial Vaginosis: Review of Treatment Options and Potential Clinical Indications for Therapy

We reviewed data on the treatment of bacterial vaginosis published from 1989 through 1992 (articles published after the 1989 publication of the Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines). This review suggests that oral metronidazole (500 mg twice daily for 7 days) is the preferred treatment for bacterial vaginosis. Other effective (but alternative) treatment regimens include single-dose metronidazole (2 g orally), 2% clindamycin vaginal cream (once daily for 7 days), 0.75% metronidazole vaginal gel (twice daily for 5 days), and oral clindamycin (300 mg twice daily for 7 days). Data do not support the practice of routine treatment of male sex partners of infected females. Treatment of bacterial vaginosis during pregnancy should focus on the elimination of symptoms; data on adverse pregnancy outcomes for women with bacterial vaginosis remain insufficient to recommend treatment of asymptomatic patients. Before performing surgical abortion, treatment of bacterial vaginosis (symptomatic or asymptomatic) should be considered to prevent pelvic inflammatory disease.

Economic and programmatic aspects of congenital syphilis prevention

A review of the economic and programmatic aspects of congenital syphilis was conducted and recommendations made for improvement of its prevention. Congenital syphilis is a preventable disease and the tools to prevent it have been available for decades. In both industrialized and developing countries, but particularly the latter, the prevention of congenital syphilis by antenatal screening is cost-effective and may be cost-saving. Yet, globally, there are probably >500 000 fetal deaths a year from congenital syphilis, a figure rivalling that from mother-to-child transmission of human immunodeficiency virus (HIV), which receives far greater attention. The reasons that congenital syphilis persists vary, with international and national under-appreciation of the burden of congenital syphilis and insufficient political will to provide effective antenatal screening programmes probably being the main reasons. All causes are amenable to effective intervention programmes. The prevention of congenital syphilis should be a global priority; international agencies and national programmes should be committed to improving antenatal care (ANC) services including syphilis detection and prevention.

Toxic Shock Syndrome Surveillance in the United States, 1980 to 1981

Between 1 January 1980 and 18 October 1981, investigators from the Centers for Disease Control collected information on 1407 cases of toxic shock syndrome using a nationwide passive surveillance system. Ninety-two percent of the reported cases were associated with menstruation. Information available on the type of menstrual device used shows that 99% of the cases occurred in tampon users. Menstrual cases occurred predominantly in whites (98%) under the age of 25 (65%). The case/fatality ratio for menstrual toxic shock syndrome was 3.1% for cases with onset in 1981. The distribution of reported cases by date of onset showed a gradual increase in the number reported before the summer of 1980, a sharp increase during the summer and early fall of 1980, a marked decrease in the late fall of 1980, and a subsequent gradual decrease. Factors affecting the incidence and reporting of toxic shock syndrome during these periods include changes in the number of tampon users, changes in the availability and usage patterns of tampons, changes in the prevalence of toxin-producing strains of Staphylococcus aureus, improved recognition of the syndrome, and publicity.