Toxic shock syndrome--United States. 1980
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Toxic shock syndrome--United States. 1980

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    As part of its commemoration of CDC's 50th anniversary, MMWR is reprinting selected MMWR articles of historical interest to public health, accompanied by a current editorial note. Reprinted below is the first MMWR report of toxic-shock syndrome, which was published May 23, 1980. Editorial Note Editorial Note 1997: Although case reports of "Staphylococcal scarlet fever" had been published in the medical literature as far back as the 1920s, a 1978 report describing seven cases of what was named toxic-shock syndrome (TSS) heralded the apparent emergence of TSS in late 1979 and early 1980 (1). The report about TSS in the May 23, 1980, MMWR and the veritable landslide of studies of TSS that followed demonstrate the speed and effectiveness with which astute clinicians -- together with public health officials, epidemiologists, and laboratory scientists -- can respond to an "emerging" infectious disease threat. Did TSS truly "emerge" at that time, or did the intensive case-finding efforts of clinicians and epidemiologists in states such as Wisconsin and Minnesota simply make it appear to "emerge"? The limited data available from retrospective chart-review studies that were designed to identify TSS cases, whether previously diagnosed or not, clearly demonstrated that the number of cases of TSS in women of reproductive age increased beginning in the late 1970s (2-4). Cases of TSS in men also occurred during that time but at a low and stable rate. Thus, what "emerged" during late 1979-early 1980 was not all TSS, but TSS in reproductive-aged women, particularly menstruating women, as reflected in the dramatic data presented in the MMWR report -- of the 55 reported cases, 95% occurred among women, and 95% of the cases among women for whom information was available had onset of their illness within the 5-day period following onset of menses. The startling proportion of TSS cases identified during 1979-1980 among women who had onset during menstruation led investigators to focus on understanding the risk factors for development of menstrual TSS, rather than TSS in general. The wave of rapidly completed case-control studies of menstrual TSS that followed clearly demonstrated that use of various brands and styles of tampons was by far the most important risk factor for TSS during menstruation (5-8). Although the relative importance of absorbency, chemical composition, and other tampon-related factors in determining the risk for menstrual TSS has remained difficult to determine, the most plausible explanation for the "emergence" of menstrual TSS in the late 1970s was the manufacture and widespread use of more absorbent tampons made of a variety of materials not previously used in tampons. There is no evidence to suggest that changes in Staphylococcus aureus, the source of the toxin that causes TSS, were responsible for the emergence of menstrual TSS. The week after the MMWR report appeared in May 1980, Dr. William Foege, the director of CDC at the time, testified before the Senate Subcommittee on Health regarding "toxic dumps." Given the widespread news media attention the MMWR report had received and a perceived connection between toxic dumps and toxic-shock syndrome, Dr. Foege also was asked about TSS at that hearing, and he optimistically promised "an answer" by the end of 1980. Although much more was learned about TSS during the years that followed (e.g., the biologically important properties of TSS toxin-I, the toxin responsible for most cases of TSS, particularly menstrual cases), in retrospect Dr. Foege was correct. From the public health point of view, before the end of 1980, enough was known about menstrual TSS based primarily on observational epidemiologic studies to promulgate recommendations (9,10) that led to a substantial reduction in the risk for menstrual TSS. 1997 Editorial Note by: Arthur L Reingold, MD, University of California, Berkeley. Gene W Matthews, JD, Legal Advisor to CDC. Claire V Broome, MD, Deputy Director, CDC.
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