Update: Toxic-Shock Syndrome -- United States

As of June 15, 1983, 2,204 cases of toxic-shock syndrome (TSS) meeting CDC's case criteria (1) have been reported to CDC. Of these, 2,108 (96%) were in females, and 96 were in males. Of the 2,023 cases in females in which menstrual status at the time of onset could be determined, 1,824 (90%) were associated with menstruation. Of the menstruation-associated cases, information on the type of sanitary product used was available for 1,535: 1,517 (99%) occurred in tampon-users; 17 (1%), in users of napkins and minipads exclusively; and one ( 1%), in a sea-sponge user.

Of the 1,827 cases in which race was specified, 1,774 (97%) occurred in white, non-Hispanics; 22 (1%), in black, non-Hispanics; 15 ( 1%), in Asians; 12 ( 1%), in Hispanics; and four ( 1%), in American Indians. Patients' ages ranged from 1 to 80 years, with 36% of cases occurring in individuals 15-19 years of age. Race and age distributions remained constant when examined by year of onset.

Of the 2,107 cases in which outcome was specified, 103 (5%) resulted in death. The case-fatality rates by year were: pre-1980--10%; 1980--5%; 1981--3%; 1982--3%; and 1983--5%.

The number of cases reported per year decreased in 1982 relative to 1980 and 1981 (Figure 3). At the same time, the proportion of cases not associated with menstruation increased. Non-menstrual TSS accounted for 7% of cases with onset in 1980, 18% in 1981, and 22% in 1982.

Cases have been reported from all 50 states and the District of Columbia (Figure 4). However, coincident with increases and decreases in the activity of case-finding in certain states, the distribution of cases by state has changed. For example, the proportion of 1982 cases reported by California, Minnesota, and Wisconsin was 26%, down from 35% of cases reported as of April 9, 1982. Utah and Colorado, both of which had active case-finding throughout 1980-1982, each noted a sharp decline in cases reported in 1981 relative to 1980, followed by an increase in cases in 1982, compared with 1981. (Utah: 1980--40 cases, 1981--21 cases, 1982--32 cases; Colorado: 1980--38 cases, 1981--19 cases, 1982--27 cases). Reported by Special Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Trends in the distribution of reported TSS cases, which were becoming apparent at the time of the last report on TSS surveillance, have continued (1). The number of new case reports received monthly has declined to approximately 35, and the proportion of cases not associated with menstruation has continued to increase.

While the activity of TSS case-finding has declined in some states, it has increased in others. Retrospective studies employing uniform case-finding methods will be required to determine to what extent the observed temporal trends in TSS reporting in these states reflect changes in the incidence of TSS rather than changes in reporting. However, in two states with active case-finding and unchanged surveillance methods for 1980 through 1982, the number of reported cases increased in 1982 after having fallen substantially in 1981, although the level reached was still below that of 1980.

TSS continues to be reported predominantly in young, white women who are menstruating at the time of onset. Almost 80% of cases with onset in 1982 were menstruation-associated, and of these, 99% were in tampon-users. Thus, it is important that medical professionals and the general public recognize that TSS continues to occur in association with menstruation and tampon use and in other circumstances. All suspected cases should be reported promptly to the appropriate local or state health department.

Reference

1. CDC. Toxic-shock syndrome, United States, 1970-1982. MMWR 1982;31:201-4.

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