Michael E. St. Louis

Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study.

Background Sequelae of genital Chlamydia trachomatis infection in women are more strongly linked to repeat infections than to initial ones, and persistent or subsequent infections foster continued transmission. Objective To identify factors associated with persistent and recurrent chlamydial infection in young women that might influence prevention strategies. Methods Teenage and young adult women with uncomplicated C trachomatis infection attending reproductive health, sexually transmitted disease, and adolescent medicine clinics in five US cities were recruited to a cohort study. Persistent or recurrent chlamydial infection was detected by ligase chain reaction (LCR) testing of urine 1 month and 4 months after treatment. Results Among 1,194 women treated for chlamydial infection, 792 (66.4%) returned for the first follow-up visit , 50 (6.3%) of whom had positive LCR results. At that visit, women who resumed sex since treatment were more likely to have chlamydial infection (relative risk [RR], 2.0; 95% CI, 1.03–3.9), as were those who did not complete treatment (RR, 3.4; 95% CI, 1.6–7.3). Among women who tested negative for C trachomatis at the first follow-up visit, 36 (7.1%) of 505 had positive results by LCR at the second follow-up visit. Reinfection at this visit was not clearly associated with having a new sex partner or other sexual behavior risks; new infection was likely due to resumption of sex with untreated partners. Overall, 13.4% of women had persistent infection or became reinfected after a median of 4.3 months, a rate of 33 infections per 1,000 person months. Conclusions Persistent or recurrent infection is very common in young women with chlamydial infection. Improved strategies are needed to assure treatment of women’s male sex partners. Rescreening, or retesting of women for chlamydial infection a few months after treatment, also is recommended as a routine chlamydia prevention strategy.

A Prospective Study of Diarrhea and HIV-1 Infection among 429 Zairian Infants

BACKGROUND Persistent diarrhea is a prominent feature of the acquired immunodeficiency syndrome in adults, but its cause and its effect on children with human immunodeficiency virus (HIV) infection are largely unknown, particularly in Africa. METHODS We studied a birth cohort of 429 infants born to HIV-positive or HIV-negative mothers in Zaire to determine the incidence of acute, recurrent (> or = 2 episodes), and persistent (> or = 14 days) diarrhea; outcome; and risk factors. RESULTS Of the 238 infants whose mothers were HIV-positive, 53 were infected, 139 were uninfected, and the HIV status of 46 could not be determined. As compared with uninfected infants, infected infants had higher incidence rates for acute diarrhea (170 vs. 100 episodes per 100 child-years, P = 0.003), recurrent diarrhea (21 vs. 11, P = 0.12), and persistent diarrhea (19 vs. 4, P < 0.003). Persistent diarrhea developed in 11 HIV-infected infants; all but 1 died. It also developed in 19 uninfected infants; all but 1 survived. The prevalence of stool pathogens was similar in the two groups. In a multivariate model, persistent diarrhea in an infant was independently associated with symptomatic HIV type 1 infection in the mother (relative hazard, 1.5; P = 0.08). The incidence of persistent diarrhea in the uninfected infants of seropositive mothers was nearly double that in the uninfected infants of seronegative mothers (4.9 vs. 2.7 episodes per 100 child-years), and the risk increased if the mother died (relative hazard, 10.4). Significant growth impairment and severe immunosuppression occurred in the six to eight weeks before the onset of persistent diarrhea. CONCLUSIONS In Zaire, infants with HIV infection have an 11-fold increased risk of death from diarrhea, largely persistent diarrhea, which is often preceded by recurrent episodes of acute diarrhea, malnutrition, or immunosuppression. Illness and death of the mother increase that risk, even among her uninfected infants.

Etiology of Genital Ulcers and Prevalence of Human Immunodeficiency Virus Coinfection in 10 US Cities

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

Characteristics of persons with syphilis in areas of persisting syphilis in the United States: sustained transmission associated with concurrent partnerships.

Background and Goal In areas with persistent syphilis, to characterize persons at higher risk for transmitting syphilis. Study Design Cohort study. Structured interviews of persons with early syphilis from four research centers were linked to outcomes of partner tracing. Results Of 743 persons with syphilis, 229 (31%) reported two or more partners in the previous month, and 57 (8%) received money or drugs for sex in the previous three months. Persons with at least one partner at an earlier stage of syphilis than themselves were defined as transmitters; 63 (8.5%) of persons with early syphilis met this definition. Having concurrent partners (two or more in one week in the last month) was independently associated with being a transmitter. Conclusion Sexual network/behavioral characteristics of syphilis patients and their partners, such as concurrency, can help identify persons at higher risk for transmitting syphilis who should receive emphasis in disease prevention activities.

High Prevalence and Incidence of Sexually Transmitted Diseases in Urban Adolescent Females Despite Moderate Risk Behaviors

To better understand the prevalence, incidence, and risk factors for sexually transmitted diseases (STDs) among female adolescents, a prospective 6-month cohort study was conducted at four teen clinics in a southeastern city. At enrollment, 260 (40%) of 650 sexually active females ages 14-19 years had an STD: chlamydia, 27%; herpes simplex virus type 2 (HSV-2), 14%; gonorrhea, 6%; trichomoniasis, 3%; and hepatitis B, 2%. At follow-up, 112 (23%) of 501 participants had an incident infection: chlamydia, 18%; HSV-2, 4%; gonorrhea, 4%; and trichomoniasis, 3%. At either enrollment or follow-up, 53% had >/=1 STD; of those with 1 lifetime partner, 30% had an STD. Having a new partner (odds ratio [OR], 2.2; 95% confidence interval [CI], 1. 1-4.2) or friends who sell cocaine (OR, 1.6; CI, 1.0-2.6) was independently associated with incident infection. STD incidence and prevalence were extremely high in this population, even in teenagers with only 1 lifetime partner. Individual risk behaviors appeared less important for STD risk than population factors.

Botulism from Chopped Garlic: Delayed Recognition of a Major Outbreak

Diagnosis of botulism in two teenaged sisters in Montreal led to the identification of 36 previously unrecognized cases of type B botulism in persons who had eaten at a restaurant in Vancouver, British Columbia, during the preceding 6 weeks. A case-control study implicated a new vehicle for botulism, commercial chopped garlic in soybean oil (P less than 10(-4)). Relatively mild and slowly progressive illness, dispersion of patients over at least eight provinces and states in three countries, and a previously unsuspected vehicle had contributed to prolonged misdiagnoses, including myasthenia gravis (six patients), psychiatric disorders (four), stroke (three), and others. Ethnic background influenced severity of illness: 60% of Chinese patients but only 4% of others needed mechanical ventilation (P less than 10(-3]. Trypsinization of serum was needed to show toxemia in one patient. Electromyography results with high-frequency repetitive stimulation corroborated the diagnosis of botulism up to 2 months after onset. Although botulism is a life-threatening disease, misdiagnosis may be common and large outbreaks can escape recognition completely.

HIV prevalence in patients with syphilis, United States.

Background: Among persons with a sexually transmitted disease (STD), the proportion who are also infected with HIV is a major factor influencing the public health impact of that STD on HIV transmission. Goal: To assess HIV infection in persons with syphilis in the United States. Study Design: A systematic literature review was conducted of U.S. studies with HIV seroprevalence data in patients with syphilis. Results: Thirty studies were identified and analyzed. The median HIV seroprevalence in men and women infected with syphilis was 15.7% (interquartile range [IQR]: 13.6‐21.8%), among men was 27.5% (23.1‐29.6%), and among women was 12.4% (8.3‐20.5%). Median odds ratios for men and women, men only, and women only were 4.5, 8.5, and 3.3, respectively. Seroprevalences among men who have sex with men (MSM) and injecting drug users (IDU) ranged from 64.3‐90.0% and 22.5‐70.6%, respectively. Conclusions: Despite substantial variability, HIV seroprevalence is high among patients with syphilis in the United States, identifying them as a critical target group for HIV prevention efforts.

Head-to-Head Multicenter Comparison of DNA Probe and Nucleic Acid Amplification Tests for Chlamydia trachomatis Infection in Women Performed with an Improved Reference Standard

ABSTRACT Few evaluations of tests for Chlamydia trachomatis have compared nucleic acid amplification tests (NAATs) with diagnostic tests other than those by culture. In a five-city study of 3,551 women, we compared the results of commercial ligase chain reaction (LCR) and PCR tests performed on cervical swabs and urine with the results of PACE 2 tests performed on cervical swabs, using independent reference standards that included both cervical swabs and urethral swab-urine specimens. Using cervical culture as a standard, the sensitivities of PACE 2, LCR, and PCR tests with cervical specimens were 78.1, 96.9, and 89.9%, respectively, and the specificities were 99.3, 97.5, and 98.2%, respectively. Using either cervical swab or urine LCR-positive tests as the standard decreased sensitivities to 60.8% for PACE 2 and to 75.8 and 74.9% for PCR with cervical swabs and urine, respectively. Specificities increased to 99.7% for PACE 2 and to 99.7 and 99.4% for PCR with cervical swabs and urine, respectively. Sensitivities with a cervical swab-urine PCR standard were 61.9% for PACE 2 and 85.5 and 80.8% for LCR with cervical swabs and urine, respectively. Specificities were 99.6% for PACE 2 and 99.0 and 98.9% for LCR with cervical swabs and urine, respectively. Cervical swab versus urine differences were significant only for PCR specificities (P = 0.034). Overall, LCR sensitivity exceeded that of PCR, and sensitivities obtained with cervical swabs exceeded those obtained with urine specimens by small amounts. These data have substantiated, using a large multicenter sample and a patient standard, that LCR and PCR tests performed on endocervical swabs and urine are superior to PACE 2 tests for screening C. trachomatis infections in women. In our study, NAATs improved the detection of infected women by 17 to 38% compared to PACE 2.

Trends in Pelvic Inflammatory Disease Hospital Discharges and Ambulatory Visits, United States, 1985–2001

Objective: The objective of this study was to describe the estimated trends in incidence of pelvic inflammatory disease (PID) among reproductive-aged women in hospital and ambulatory settings. Study: Analyses of PID estimates were performed. Three nationally representative surveys conducted by the National Center for Health Statistics (NCHS): National Hospital Discharge Survey (NHDS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and National Ambulatory Medical Care Survey (NAMCS), were used to obtain the estimates of PID (defined by International Classification of Diseases, 9th Revision codes). National Disease and Therapeutic Index (NDTI) estimates were reviewed for comparison. Results: Rates of hospitalized PID declined 68% overall from 1985 through 2001 (P <0.0001). Ambulatory data support a decrease in PID from 1985 to 2001. From 1995 to 2001, approximately 769,859 cases of acute and unspecified PID were diagnosed annually, 91% in ambulatory settings. Conclusions: PID has decreased in hospital and ambulatory settings. The expanded national surveys in outpatient and emergency departments provide more complete estimates for PID. Optimal management of PID should target ambulatory settings, where the majority of cases are diagnosed and treated.

Estimated incidence and prevalence of genital Chlamydia trachomatis infections in the United States, 1996.

BACKGROUND AND OBJECTIVE Because genital Chlamydia trachomatis infections and their sequelae have a major impact on individuals and the health care system, it is important to periodically update estimates of chlamydia incidence and prevalence in the United States. STUDY DESIGN Chlamydia incidence and prevalence were estimated using: (1) a method based on estimates of population-specific chlamydia prevalence, and (2) a method based on the chlamydia-to-gonorrhea case rate ratio. RESULTS Using the prevalence-based method, point prevalence among persons 15 to 44 years of age was estimated to be 1.6 million chlamydial infections, and annual incidence, 2.4 million cases per year. Using a method based on the ratio of reported gonorrhea to chlamydia, incidence was estimated to be 2.8 million infections per year, and prevalence, 1.9 million. Adjustment for sensitivity of diagnostic tests yielded annual incidence estimates of 2.5 to 3.3 million infections. CONCLUSIONS Using two methods, we estimated the annual incidence of chlamydial infections in the United States among persons 15 to 44 years of age to be approximately 3 million infections. Critical data needed for more precise estimates include: sensitivity of current diagnostics, better data on infections in males, the current extent of underdetection and underreporting, and better data on duration of infection in men and women.