Epidemiologic Notes and Reports Toxic-Shock Syndrome, United States, 1970-1982

As of April 9, 1982, 1,660 cases of toxic-shock syndrome (TSS) meeting the current CDC case definition* have been reported. To date, 492 cases with onset in 1981 have been reported compared with 867 cases with onset in 1980 (Figure 1). Eighty-eight cases have resulted in death (case-fatality ratio, 5.6% of those with known outcome), including 15 cases in 1981 (case-fatality ratio, 3.3%).

Demographic characteristics were analyzed for those cases for which relevant data were available. A total of 1,588 (96%) cases involved women, of whom at least 92% had onset during a menstrual period. Overall, 154 cases were known to have been unassociated with menstruation. The age range for all female patients was 1-64 years, with a mean of 22.9 years and a median of 21 years. The age range for 55 male patients was 1-75 years, with a mean of 24.5 years and a median of 20 years. Of the 1,355 cases in which the patient's race was known, 1,315 (97%) occurred in white non-Hispanics, including 98% of the menstrual cases and 90% of the nonmenstrual cases.

Nonmenstrual cases accounted for l5% of the reported cases with onset in 1981, compared with 6% of cases with onset before 1981. Nonmenstrual TSS has been seen following childbirth by vaginal delivery and cesarean section and in association with therapeutic abortions, infected surgical wounds, hydradenitis, lymphadenitis, deep abscesses, and infected cutaneous and subcutaneous lesions such as burns, abrasions, lacerations, furuncles, and insect bites.

TSS cases have been reported by all 50 states and the District of Columbia (Figure 2), but 35% of reported cases have come from 3 states, Minnesota, California, and Wisconsin. The 2 states with the highest reported incidence of TSS in 1980, Minnesota and Utah, noted different trends in reporting during the last quarter of 1980 and the first 2 quarters of 1981 (2,3). While the number of TSS cases per month reported in Utah declined in late 1980 and early 1981 relative to the number of cases reported in the late summer and early fall of l980 (Figure 3), no such decrease in reporting was observed in Minnesota (Figure 4). Reported by Conference of State and Territorial Epidemiologists; JC Forfang, MT Osterholm, PhD, MPH, AG Dean, MD, State Epidemiologist, Minnesota Dept of Heath; SJ Stolz, JM Vergeront, JP Davis, MD, State Epidemiologist, Wisconsin Dept of Health and Social Svcs; CR Nichols, RE Johns Jr, MD, State Epidemiologist, Utah Dept of Health; Field Svcs Div, Epidemiology Program Office, Special Pathogens Br, Bacterial Diseases Div, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: As demonstrated in Figures 1 and 2, TSS continues to occur throughout the United States. CDC is currently receiving approximately 50 case reports a month that meet the revised CDC case definition. The number of cases reported for the most recent months appears low because of delay between the onset of a case and the reporting of that case to CDC.

The observed decrease in reporting of menstrual TSS cases since the summer and early fall of 1980 has been noted previously (4). During the same period, the number of nonmenstrual TSS cases reported to CDC has not declined. The extent to which the observed change is due to a decrease in the incidence of TSS, as opposed to a decrease in the reporting of TSS to state health departments and CDC, is not known, although both factors are probably important (5).

Factors that might have affected the incidence of menstrual TSS during the last quarter of 1980 and the first half of 1981 include changes in the number of tampon users; in the way in which women use tampons; in the availability and frequency of use of different brands of tampons; in the rate of vaginal carriage of strains of Staphylococcus aureus capable of causing TSS; or in other unrecognized factors in the natural history of the disease.

Factors potentially affecting reporting of TSS during this period include increased recognition of the disease, waning media attention and publicity, variable activity of state and local health department surveillance programs, changes in referral patterns, and changes in the treatment of TSS.

TSS continues to be recognized primarily in young white women in association with menstruation and tampon use. However, TSS is also being recognized in an increasingly wide array of clinical settings and in association with staphylococcal infections at a variety of sites. Nonmenstrual TSS accounted for 15% of the cases having onset in 1981. This increase in the proportion of cases that are unassociated with menstruation is due in large part to the decrease in the number of menstrual cases being reported.

At present, it is important that physicians and the general public be aware that TSS continues to occur in association with menstruation and tampon use as well as in other circumstances. All suspected cases of TSS should be reported promptly to the appropriate state health department.

Women can markedly reduce their risk of TSS by not using tampons, and women who choose to wear tampons can reduce their risk by wearing them intermittently during each menstrual period. Informing women about TSS and advising them to remove their tampons and seek medical attention if they develop symptoms of the disease appear to be reasonable public health measures.

References

1. Follow-up on toxic-shock syndrome. MMWR 1980;29:441-5.

2. Osterholm MT, Forfang JC. Toxic shock syndrome in Minnesota: Results of an active-passive surveillance system. J Infect Dis 1982;145:458-64.

3. Latham RH, Kehrberg MW, Jacobson JA, Smith CB. Toxic-shock syndrome in Utah: A review of a case-control study and surveillance. Ann Intern Med (in press).

4. Toxic-shock syndrome--United States, 1970-1980. MMWR 1981;30:25-8, 33.

5. Reingold AL, Hargrett NT, Shands KN, et al. Toxic-shock syndrome surveillance in the United States 1980-81. Ann Intern Med (in press). *The current CDC case definition is the original case definition (1) with 2 modifications suggested by the Conference of State and Territorial Epidemiologists: 1) orthostatic dizziness is now considered sufficient evidence of hypotension, and 2) the presence of Staphylococcus aureus in blood cultures does not exclude a case from consideration. The change in case definition results in the reclassification of fewer than 5% of cases.

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