Date: Fri, 10 Feb 1995 08:54:54 +0500 From: ghmcleaf{CONTRACTOR/ASPEN/ghmcleaf}%NAC-GATEWAY.ASPEN@ace.aspensys.com MORBIDITY AND MORTALITY WEEKLY REPORT Centers for Disease Control and Prevention February 10, 1995 Update: AIDS Among Women -- United States, 1994 In 1993, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) was the fourth leading cause of death among women aged 25-44 years in the United States (1); in addition, the incidence of AIDS is increasing more rapidly among women than men (2). Women with AIDS reported in 1994 represented 13% of the cumulative total of 58,448 cases among women. This report presents characteristics of women and men reported with AIDS in 1994, summarizes trends in cases reported during 1985-1994, and describes findings of an HIV seroprevalence survey among childbearing women during 1989-1993.* AIDS Surveillance In 1994, of the 79,674 persons aged greater than or equal to 13 years reported with AIDS, 14,081 (18%) occurred among women-- nearly threefold greater than the proportion (534 [7%] of 8153) reported in 1985; in addition, the proportion of cases among women has increased steadily since 1985 (Figure 1). The median age of women reported with AIDS was 35 years, and women aged 15-44 years accounted for 84% of cases. More than three fourths (77%) of cases among women occurred among blacks and Hispanics, and rates for black and Hispanic women were 16 and seven times higher, respectively, than those for white women (Table 1). In 1994, the Northeast region accounted for the largest percentage of AIDS cases reported among women (44%), followed by the South (36%), West (9%), Midwest (7%), and Puerto Rico and U.S. territories (4%). In the Northeast, most cases among women occurred in urban areas; 1.4% of women with AIDS in the Northeast resided outside metropolitan statistical areas (MSAs) compared with 10.2% of women who resided outside MSAs in the South. Of all cases among women, 61% were reported from five states: New York (26%), Florida (13%), New Jersey (10%), California (7%), and Texas (5%). In 1994, 59% of AIDS cases among women were reported based on criteria added in the 1993 expanded AIDS surveillance case definition (3). This total included 7181 women with severe HIV-related immunosuppression (CD4+ T-lymphocytes less than 200 cells/uL or percentage of total lymphocytes less than 14), 557 with pulmonary tuberculosis, 376 with recurrent pneumonia, and 164 with invasive cervical cancer. In 1994, 41% of women with AIDS reported injecting-drug use; 38%, heterosexual contact with a partner at risk for or known to have HIV infection or AIDS; and 2%, receipt of contaminated blood or blood products; 19% had no specific HIV exposure reported. Of all women with AIDS who were initially reported without risk but who were later reclassified, most had heterosexual contact with an at-risk partner (66%) or a history of injecting-drug use (27%) (4). In 1994, of the 5353 women reported with AIDS attributed to heterosexual contact, 38% reported contact with a male partner who was an injecting-drug user; 7%, a bisexual male; 2%, a partner who had hemophilia or had received HIV-contaminated blood or blood products; and 53%, a partner who had documented HIV infection or AIDS but whose risk was unspecified. HIV Seroprevalence in Childbearing Women Using findings from the HIV Survey in Childbearing Women (SCBW) (5), an estimated 7000 HIV-infected women delivered infants in the United States during 1993. Assuming a perinatal transmission rate of 15%-30%, approximately 1000-2000 infants were perinatally infected with HIV during 1993. From 1989 through 1993, the annual prevalence of HIV infection among childbearing women remained relatively stable (1.6-1.7 per 1000), although prevalence varied regionally: in the Northeast, prevalence decreased from 4.1 to 3.4 per 1000; in the South, prevalence increased from 1.6 in 1989 to 2.0 in 1991 and remained stable through 1993. Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases; Office of Women's Health, Office of the Director; Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In 1994, as in previous years, the AIDS epidemic among women continued to disproportionately affect racial/ethnic minorities, primarily in the Northeast and South. AIDS among women was primarily associated with two modes of HIV transmission: injecting-drug use and heterosexual contact with an at-risk partner. The proportion of women in 1994 with unreported risk will decrease substantially after investigation by local and state health departments because, after follow-up, most women are found to have a recognized risk for HIV. Heterosexual contact is the most rapidly increasing transmission category for women (6). The disproportionate impact of HIV/AIDS among women in racial/ethnic minority groups reflects social and economic factors that have not been completely defined. Despite the methodologic limitations associated with use of race/ethnicity, these data have assisted in the development and implementation of community-based prevention efforts. The increase in the proportion of cases associated with heterosexual transmission will complicate accurate ascertainment of mode of transmission. In particular, women are more likely than men to be reported initially without a risk for HIV because both women and their care providers may not recognize or report the risk behaviors of the woman or her partners (6). High rates of sexually transmitted diseases are associated with the use of noninjecting drugs and with the exchange of sex for drugs, money, or personal items that may account for increased heterosexual transmission among some women (7). In addition, some women who have sex with other women may be at risk for HIV infection if they inject drugs or have partners with high-risk behaviors (8). Findings from the SCBW indicate that approximately 7000 infants are born to HIV-infected women in the United States each year. Recent advances in the prevention of perinatal HIV transmission emphasize the need for women to know their HIV-infection status. Zidovudine therapy has been recommended for infected pregnant women and their newborns as an effective means for reducing the risk for perinatal HIV transmission (9). The Public Health Service is developing draft recommendations to establish policy regarding HIV counseling and testing of pregnant women to reduce vertical transmission and promote referrals for on-going health care. Women at highest risk for heterosexually acquired HIV infection include those whose heterosexual partners have high-risk behaviors (e.g., injecting-drug use), adolescents and young adults with multiple sex partners, and those with sexually transmitted diseases. To reduce HIV transmission to women, prevention programs should emphasize consistent condom use, the need for substance-abuse prevention and treatment services, and counseling to support decisions by women and their partners to reduce risk behaviors. Efforts to improve the prevention of HIV transmission in women also should include the development and evaluation of additional measures such as the female condom and microbicides. References 1. CDC. Annual summary of births, marriages, divorces, and deaths: United States, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994:18-20. (Monthly vital statistics report; vol 42, no. 13). 2. CDC. Update: acquired immunodeficiency syndrome--United States, 1994. MMWR 1995;44:64-7. 3. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41:(no. RR-17). 4. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, 1994;6(no. 1):20,25-7. 5. Gwinn M, Pappaioanou M, George JR, et al. Prevalence of HIV infection in childbearing women in the United States. JAMA 1991;265:1704-8. 6. CDC. Heterosexually acquired AIDS--United States, 1993. MMWR 1994;43:155-60. 7. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics: crack cocaine use and HIV infection among inner-city young adults. N Engl J Med 1994;331:1422-7. 8. Chu SY, Hammett TA, Buehler JW. Update: epidemiology of reported cases of AIDS in women who report sex only with other women, 1980- 1991. AIDS 1992;6:518-9. 9. CDC. Recommendations of the U.S. Public Health Service Task Force on the Use of Zidovudine to Reduce Perinatal Transmission of Human Immunodeficiency Virus. MMWR 1994;43(no. RR-11). * Single copies of this report will be available until Friday 10, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6005, Rockville, MD 20849-6003; telephone (800) 458-5231. Update: Influenza Activity -- United States, 1994-95 Season Influenza activity has increased throughout the United States since late November 1994; however, the level of activity* has varied widely in different parts of the country. This report summarizes results of influenza surveillance in the United States from October 2, 1994, through January 28, 1995. From November 27, 1994, through January 21, 1995, most influenza activity had been reported from the Northeast (Figure 1). Regional influenza activity was first reported the week ending December 3 in New York, and widespread activity was first reported the week ending January 7 in Connecticut and Virginia. Regional or widespread activity also was reported by Kentucky, Maryland, New Jersey, and Pennsylvania during the first 3 weeks of January. All other states reported either sporadic activity or no activity until the week ending January 28, when regional activity was reported for the first time in Arizona, Florida, and Wisconsin. From October 2, 1994, through January 28, 1995, a total of 686 influenza virus isolates were reported in the United States by the World Health Organization collaborating laboratories. Of these, 487 (71%) were type A, and 199 (29%) were type B. Of the 216 influenza A isolates that were subtyped, all have been type A(H3N2). Laboratory-diagnosed influenza has been reported from all regions; however, 84% of all isolates have been reported from the Mid-Atlantic and South Atlantic regions. In the Mid-Atlantic region, influenza type A accounted for 94% (259 of 276) of all isolates; in the South Atlantic region, influenza type B accounted for 59% (176 of 297) of isolates. As of January 27, influenza isolates were reported from 41 states; type A had been identified in 39 states and the District of Columbia, and influenza type B had been identified in 22 states and the District of Columbia (Figure 1). During the 17 weeks from October 2, 1994, through January 28, the proportion of pneumonia and influenza deaths among total deaths reported from 121 U.S. cities slightly exceeded the epidemic threshold** during 5 weeks but has not exceeded the threshold for any 2 consecutive weeks. Reported by: Participating state and territorial epidemiologists and state public health laboratory directors. World Health Organization collaborating laboratories. Sentinel Physicians Influenza Surveillance System of the American Academy of Family Physicians. WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The increase in influenza activity in regions of the United States during December and January suggests the potential for increased activity in other regions during this influenza season. The timing of influenza activity can vary widely from one season to another; in some previous seasons, substantial influenza activity has occurred during April and May. Influenza vaccine can be administered after influenza activity has begun in a community; however, in these circumstances, short-term antiviral prophylaxis may be indicated because antibody may not develop until up to 2 weeks after vaccination (1). Health-care providers should be informed about findings of influenza surveillance, particularly when influenza types A and B are cocirculating, because of the availability of antiviral agents to treat and prevent influenza type A (1). Reference 1. ACIP. Prevention and control of influenza: part II, antiviral agents--recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994;43(no. RR-15). * Levels of activity are 1) sporadic--sporadically occurring influenza-like illness (ILI) or culture-confirmed influenza, with no outbreaks detected; 2) regional--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of less than 50% of the state's total population; and 3) widespread--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of greater than or equal to 50% of the state's total population. ** The epidemic threshold is 1.645 standard deviations above the seasonal baseline calculated using a periodic regression model applied to observed percentages since 1983. This baseline was calculated using a robust regression procedure. Notice to Readers Publication of Guidelines for the Prevention and Treatment of B Virus Infections in Exposed Persons Cercopithecine herpesvirus 1 (B virus) infection is widespread among Macaca genus primates; the virus is the biologic counterpart of herpes simplex virus in humans. B virus infection in humans is recognized as a rapidly ascending encephalomyelitis with a fatality rate of approximately 70%. The need for guidelines in prevention and treatment of human B virus infection was recognized in 1987 after a cluster of four symptomatic infections occurred among persons in Florida. CDC and the National Institutes of Health consulted primate veterinarians and herpesvirus experts to develop guidelines for preventing B virus infection in persons who work with macaques (1). Recommendations intended to minimize the risk for infection of laboratory workers exposed to B virus-contaminated primary rhesus monkey cell cultures were published in 1989 (2). Guidelines for primate handlers were expanded in 1990 in response to the recognition of filovirus infection in quarantined primates (3). Human infections with B virus remain an uncommon result of macaque-related injuries, and optimal diagnostic and therapeutic approaches are unclear. However, the increase in the use of macaques for research on simian retrovirus infection and hepatitis has expanded the number of potential incidents of human exposure. In January 1990, Emory University and CDC sponsored a B virus working group intended to formulate a rational approach to the prevention, detection, and management of human B virus infections. Written guidelines were developed based on information from published and unpublished cases, knowledge of the behavior of herpes simplex virus, and expert opinion. These guidelines (4) are intended to assist institutions in which macaques are handled in developing and enforcing effective standard operating procedures and quality-control interventions and to enable local physician consultants identified by the institutions to evaluate and treat persons with potential B virus exposure. Such institutions should keep a copy of these guidelines in bite/wound kits at the work site. Institutions also should provide copies of these guidelines to injured employees referred for medical evaluation; to the emergency rooms, clinics, or offices where injured employees will seek care; and to employees to give to their personal physician. More information on the guidelines is available from B Virus Guidelines, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC, Mailstop G-19, 1600 Clifton Road, NE, Atlanta, GA 30333. References 1. CDC. Guidelines for prevention of Herpesvirus simiae (B virus) infection in monkey handlers. MMWR 1987;36:680-2,687-9. 2. Wells DL, Lipper SL, Hilliard JK, et al. Herpesvirus simiae contamination of primary rhesus monkey kidney cell cultures: CDC recommendations to minimize risks to laboratory personnel. Diagn Microbiol Infect Dis 1989;12:333-5. 3. CDC. Update: Ebola-related filovirus infection in nonhuman primates and interim guidelines for handling nonhuman primates during transit and quarantine. MMWR 1990;39:22-4,29-30. 4. Holmes GP, Chapman LE, Stewart JA, et al. Guidelines for the prevention and treatment of B-virus infections in exposed persons. Clin Infect Dis 1995;20:421-39.