Margaret J. Oxtoby

Acquired immunodeficiency syndrome in Romania

After the initial description of acquired immunodeficiency syndrome (AIDS) in Romania in late 1989, national AIDS case surveillance was established with a modified version of the World Health Organisation (WHO) clinical case definition. This modified case definition requires that AIDS cases have both clinical and serological evidence of human immunodeficiency virus (HIV) infection. Before December, 1989, Romania had reported 13 AIDS cases to WHO. By Dec 31, 1990, 1168 AIDS cases were reported to Romanias Ministry of Health, of which 1094 (93.7%) occurred in children less than 13 years of age at diagnosis. Of these, 1086 (99.3%) were in infants and children less than 4 years of age, and 683 (62.4%) in abandoned children living in public institutions at the time of diagnosis. By Dec 31, 1990, 493 (45.1%) mothers of children with AIDS had been located and tested, and 37 (7.5%) were positive for HIV; 423 (38.7%) cases were in children who had received transfusions of unscreened blood, and 6 (0.5%) were in children with clotting disorders. HIV transmission through the improper use of needles and syringes is strongly suspected in most of the remaining 628 (57.4%) children with AIDS, most of whom had received multiple therapeutic injections. This outbreak demonstrates the serious potential for HIV transmission in medical facilities that intensively and improperly use parenteral therapy and have poor sterilisation technique.

Encephalopathy in children with perinatally acquired human immunodeficiency virus infection

OBJECTIVE To define the incidence, characteristics, and survival of children with perinatally acquired human immunodeficiency virus (HIV) infection and encephalopathy. DESIGN Cross-sectional and longitudinal data collected from 1811 HIV-infected children in a multicenter active surveillance study. SETTING Health departments and medical centers in six areas of the United States. RESULTS HIV encephalopathy was diagnosed in 178 (23%) of 766 children with perinatally acquired immunodeficiency syndrome (AIDS). The median age at diagnosis of encephalopathy was 19 months. Among infected children, the estimated risk of having HIV encephalopathy by age 12 months was 4.0% (95% confidence interval, 2.6% to 6.0%). Children with HIV encephalopathy had more hospitalizations (median, 4) than children with other AIDS-defining conditions (median, 2; p = 0.002) and lower CD4+ T-lymphocyte counts in the first year of life (median, 444 cells/mm3). Estimated median survival after diagnosis was 22 months, similar to the 20 months for children with Pneumocystis carinii pneumonia. CONCLUSION HIV encephalopathy in children with perinatally acquired AIDS is a common condition and is associated with severe morbidity evidenced by frequent hospitalizations, severe immunodeficiency, and short survival.

Identification of factors that disrupt negative air pressurization of respiratory isolation rooms.

OBJECTIVES To investigate the airflow characteristics of respiratory isolation rooms (IRs) and to evaluate the use of visible smoke as a monitoring tool. METHODS Industrial hygienists from the New York State Department of Health evaluated 140 designated IRs in 38 facilities within New York State during 1992 to 1998. The rooms were located in the following settings: hospitals (59%), correctional facilities (40%), and nursing homes (1%). Each room was tested with visible smoke for directional airflow into the patient room (ie, negative air pressure relative to adjacent areas). Information was obtained on each facilitys policies and procedures for maintaining and monitoring the operation of the IRs. RESULTS Inappropriate outward airflow was observed in 38% of the IRs tested. Multiple factors were associated with outward airflow direction, including ventilation systems not balanced (54% of failed rooms), shared anterooms (14%), turbulent airflow patterns (11%), and automated control system inaccuracies (10%). Of the 140 tested rooms, 38 (27%) had either electrical or mechanical devices to monitor air pressurization continuously. The direction of airflow at the door to 50% (19/38) of these rooms was the opposite of that indicated by the continuous monitors at the time of our evaluations. The inability of continuous monitors to indicate the direction of airflow was associated with instrument limitations (74%) and malfunction of the devices (26%). In one facility, daily smoke testing by infection control staff was responsible for identifying the malfunction of a state-of-the-art computerized ventilation monitoring and control system in a room housing a patient infectious with drug-resistant tuberculosis. CONCLUSION A substantial percentage of IRs did not meet the negative air pressure criterion. These failures were associated with a variety of characteristics in the design and operation of the IRs. Our findings indicate that a balanced ventilation system does not guarantee inward airflow direction. Devices that continuously monitor and, in some cases, control the pressurization of IRs had poor reliability. This study demonstrates the utility of using visible smoke for testing directional airflow of IRs, whether or not continuous monitors are used. Institutional tuberculosis control pro grams should include provisions for appropriate monitoring and maintenance of IR systems on a frequent basis, including the use of visible smoke.

Pneumocystis carinii pneumonia among US children with perinatally acquired HIV infection

F(2o) and urea, and intracervical laminaria. Case patients at 20 weeks’ gestation (n = 32) were compared with case patients at >20 weeks (n = 30) and with a matched group (n = 64; I:2 ratio) of control patients in whom cervical laminaria and intraamniotic urea were used with prostaglandin E2 vaginal suppositories. Results: The mean induction-to-abortion interval among the case patients (gestational age 16 to 27 weeks) was 13 h 11 min; 60 of 62 (97%) were delivered within 24 h. There was a statistically significant negative correlation between the induction-to-abortion interval and gestational age (p = 0.04). When patients at

Negative-Pressure monitoring of tuberculosis isolation rooms within New York State hospitals.

20 weeks and those at >20 weeks were compared, few differences were noted. The mean induction-toabortion interval for case patients at s 20 weeks was 13 hours 54 min versus 19 h 34 min for control patients (P = 0.001). One of 32 (3%) case patients remained undelivered beyond 24 hours compared with 17 of 64 (27%) control patients (P c 0.01). Immediate and delayed complications were uncommon in either group. Conclusion: Our study demonstrates that 15(s)15-methyl prostaglandin F(2o) can serve safely as a surrogate for prostaglandin F(h) when used in combination with urea and laminaria for termination of pregnancy. This technique appears safe for use through 27 weeks’ gestation; further investigation is encouraged.

Pneumococcal Vaccine and Isolates for the Centers for Disease Control

A previously published study recommended the daily use of visible smoke to test for negative air pressure in isolation rooms occupied by potentially infectious tuberculosis cases. Continuous monitoring devices were found to have poor reliability. Findings from our survey of engineering controls in acute-care hospitals within New York State support this recommendation.

Risk for perinatal HIV-1 transmission according to maternal immunologic, virologic, and placental factors

Excerpt To the editor: We want to emphasize that the Centers for Disease Control (CDC) continues to welcome isolates ofStreptococcus pneumoniaefrom persons who have previously received the pneumoco...

CD4 T-lymphocyte counts and Pneumocystis carinii pneumonia in pediatric HIV infection

lower than those seen in normal labor (P < 0.05). The concentration of PGFM in cord blood was signifïcantly higher (P C 0.0001) in the parous women who labored than in women delivered by elective cesarean section. There was no differente in the corresponding concentrations of PGEM (P = 0.9). Conclusions: These data show that spontaneous labor is associated with increased concentrations of prostaglandin metabohtes in the maternal plasma, and are consistent with PGF [2] being an important stimulator of uterine contractility, with a relative deIïciency of PGF [2] being associated with dysfunctional labor.

Nomenclature and research case definitions for neurologic manifestations of human immunodeficiency virus-type 1 (HIV-1) infection

The relationship between CD4 T-lymphocyte counts and infection with the human immunodeficiency virus (HIV) is retrospectively investigated for 266 HIV-infected and uninfected children who were born to infected women, including 39 with Pneumocystis carinii pneumonia (PCP), in a population-based surveillance study. Of 21 perinatally HIV-infected children with PCP only 10 (48%) had CD4 T-lymphocyte counts that were less than 500 x 10(6) cells/L (500 cells/mm3), compared with all 18 who were infected via blood transfusions or clotting factors. Among 68 children who were 1 year or younger, 18 (90%) of 20 PCP cases had CD4 T-lymphocyte counts that were less than 1500 x 10(6) cells/L (1500 cells/mm3) compared with only five (10%) of 48 children who did not have the acquired immunodeficiency syndrome (odds ratio, 77.4; 95% confidence interval, 19.7 to 313.4). The mean CD4 T-lymphocyte count was lower for the 39 PCP cases when compared with the 188 children who were at different stages of HIV infection and did not have the acquired immunodeficiency syndrome (AIDS) independent of age. The majority of perinatally HIV-infected children with PCP were 6 months or younger and 50% were previously unknown to be infected. Thus, HIV-positive children should be identified early and followed closely. CD4 T-lymphocyte counts may be useful in monitoring HIV-positive children and determining when to begin PCP prophylaxis.