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(1988).
Sanitary
Product
Use
by
White,
Black,
and
Mexican
American
Women
JORDAN
W.
FINKELSTEIN,
MD
ALEXANDER
VON
EYE,
PhD
When
this
work
was
done,
Dr.
Finkelstein
was
with
the
Division
of
Adolescent
Health
Care,
Department
of
Pediatrics,
University
of
Texas
Medical
Branch,
Galveston.
He
is
now
Professor
of
Health
Behavior
and
Human
Development,
and
Pediatrics,
and
Dr.
von
Eye
is
Professor
of
Human
Development,
Pennsylvania
State
University.
Requests
for
tearsheets
to
J.
W.
Finklestein
MD,
Pennsylvania
State
University,
Department
of
Human
Development
and
Family
Studies,
University
Park,
PA
16802.
Synopsis
....................................
In
1988-89,
the
use
of
menstrual
sanitary
products
was
surveyed
among
699
white,
477
black,
and
425
Mexican
American
women
to
detect
age
and
racial
or
ethnic
differences
in
product
use
that
might
explain
the
differences
in
the
incidence
of
toxic
shock
syndrome
(TSS)
in
these
demographic
categories.
Forty
percent
of
the
women
had
never
used
tampons.
Significantly
more
whites
used
tampons
alone
(26
percent)
or
with
pads
(36
percent)
than
did
blacks.
Proportionately
more
blacks
used
tampons
alone
(16
percent)
or
with
pads
(27
percent)
compared
with
Mexican
Americans,
1I
percent
of
whom
used
tampons
alone
and
21
percent
of
whom
used
tampons
and
pads.
Since
a
substantial
proportion
of
black
women
used
tampons,
racial-ethnic
variations
in
use
patterns
alone
cannot
completely
explain
the
low
incidence
of
TSS
among
black
women.
Tampon
use
started
in
the
early
teen
years,
but
women
in
the
age
group
20-29
had
the
highest
fre-
quency
of
use
of
tampons
either
alone
(26
percent)
or
with
pads
(33
percent).
These
percentages
suggest
that
age-related
differences
in
product
use
may
not
explain
the
age-related
differences
in
the
incidence
of
TSS.
Fear
was
the
most
common
specific
reason
for
not
using
tampons
in
response
to
information
about
TSS.
Decreased
use
of
tampons
in
response
to
information
about
TSS
was
reported
by
39
percent
of
whites,
50
percent
of
blacks,
46
percent
of
Mexican
Americans,
and
by
36
percent
of
women
less
than
19
years,
41
percent
of
20-29-year-olds,
and
47
percent
of
women
30
years
and
older.
September-October
1990,
Vol.
105
No.
5
491
IN
NOVEMBER
1978,
Todd
and
coworkers
reported
a
severe
acute
disease
in
children
whose
symptoms
included
fever,
rash,
vomiting,
diarrhea,
sore
throat,
headache,
and
myalgias,
and
in
severe
cases,
hypo-
tensive
shock.
They
called
this
condition
toxic
shock
syndrome
(TSS)
(1).
In
subsequent
years,
TSS
was
reported
to
occur
mainly
among
young,
white
women
who
used
tampons
during
menses.
TSS
had
been
reported
rarely
in
nonwhite
women,
and
it
occurred
most
frequently
in
teenagers
and
young
adult
women
(2).
The
syndrome
was
most
commonly
caused
by
genital
infection
with
a
specific
strain
of
Sta-
phylococcus
aureus,
which
produced
a
specific
exotoxin
known
as
toxic
shock
syndrome
toxin
1,
(TSST-1).
However,
other
toxins,
agents,
and
micro-
bial
products
(such
as
endotoxin
of
gram
negative
bacilli)
may
be
involved.
These
toxins
probably
cause
a
cascade
of
events
involving
monokines,
lymphokines,
prostaglandins,
and
other
endogenous
toxic
products
to
produce
the
clinical
syndrome
(3).
As
research
into
TSS
continued,
and
it
became
clear
that
vaginal
tampons
played
a
significant
role
in
the
pathogenesis
of
TSS,
investigators
realized
that
little
was
known
about
the
use
of
sanitary
products
during
menses.
In
January
1981,
it
was
reported
that
70
per-
cent
of
women
in
the
United
States
used
tampons
(4).
These
data
were
obtained
in
telephone
interviews
of
manufacturers
conducted
in
July
1980.
No
actual
data
on
use
were
presented.
It
was
further
reported
that,
by
November-December
1980,
tampon
use
had
dropped
to
55
percent.
In
June
1982,
a
study
of
tampon
use
was
reported
by
Gustafson
and
coworkers
(5),
who
demon-
strated
that
age
and
racial
differences
in
tampon
use
could
explain
the
age
and
racial
differences
in
the
inci-
dence
of
TSS.
Our
study
was
done
to
detect
age
and
racial-ethnic
differences
in
product
use
that
might
explain
the
age
and
racial
ethnic
differences
in
the
incidence
of
TSS.
It
confirms
differences
in
use
of
sanitary
products
among
white
and
black
women
of
various
ages
and
adds
data
on
the
use
of
sanitary
products
by
Mexican
American
women.
It
fails,
however,
to
provide
an
explanation
for
age
and
racial-ethnic
differences
in
TSS
based
on
dif-
ferences
in
usage
by
the
various
groups.
Method
An
eight-item
questionnaire
was
responded
to
by
1,601
women
of
menstruating
age
who
personally
sought
care
or
brought
their
child
for
care
to
a
pediatric
outpatient
department
of
the
University
of
Texas
Medi-
cal
Branch.
The
refusal
rate
was
less
than
5
percent.
The
sample
was
composed
primarily
of
women
from
low
socioeconomic
backgrounds,
but
information
about
their
exact
socioeconomic
status
was
not
obtained.
Sampling
was
done
by
quotas
to
obtain
adequate
num-
bers
in
the
three
racial-ethnic
groups.
We
had
less
than
400
Mexican
American
subjects
with
ordinary
sam-
pling,
so
we
recruited
Mexican
American
women
until
we
had
at
least
400
in
that
group.
The
questions
asked
were
*
age,
*
racial
ethnic
group,
*
age
of
menarche,
*
current
use
of
sanitary
products,
*
lifetime
use
of
tampons,
*
reasons
for
nonuse
of
tampons,
*
age
of
first
use
of
tampons,
and
*
effect
of
information
about
TSS
on
current
use
of
tampons.
Although
this
was
a
quota
and
convenience,
and
not
a
random
sample,
univariate
statistical
analyses
(chi-
square
and
the
t-statistic)
were
performed.
Verbal
con-
sent
was
obtained
from
all
subjects,
as
required
by
the
Institutional
Review
Board.
The
study
was
conducted
from
January
1988
to
December
1989.
Hypotheses
to
be
tested
were
(a)
a
larger
proportion
of
younger
women
would
use
tampons
than
older
women,
(b)
a
larger
proportion
of
white
women
would
use
tampons
than
black
women,
a
larger
proportion
of
whom
would
use
tampons
than
Mexican
American
women,
(c)
information
about
TSS
would
cause
all
women
to
decrease
their
use
of
tampons,
(d)
fear
would
be
the
most
common
cause
for
nonuse
of
tampons.
Results
The
age
and
racial-ethnic
distribution
of
our
sample
is
shown
in
table
1.
There
were
no
significant
dif-
ferences
in
the
age
distribution
among
whites,
blacks,
and
Mexican
Americans.
Some
of
the
women
were
menopausal
or
had
had
hysterectomies,
so
the
totals
for
frequencies
in
other
variables
(such
as
current
use
of
products)
may
not
add
to
the
totals
in
table
1.
Age
of
menarche
was
12.73
+
1.88
for
whites
(mean
+
standard
deviation),
12.39
+
1.72
for
blacks,
and
12.40
±
1.66
for
Mexican
Americans.
The
dif-
ferences
were
not
significant.
Use
of
sanitary
products,
at
the
time
of
the
study,
by
race
is
shown
in
table
2.
Twenty-six
percent
of
whites,
16
percent
of
blacks,
and
11
percent
of
Mexican
Ameri-
cans
used
only
tampons
during
menses.
Thirty-six
per-
cent
of
whites,
27
percent
of
blacks,
and
21
percent
of
492
Public
Health
Reports
Table
1.
Characteristics
of
sample
by
racial-ethnic
group
and
age
Age
group
Mexican
(years)
White
Black
American
Total
10-14
...................
51
31
31
113
15-19
...................
95
86
72
253
20-29
...................
259
187
154
600
30-39
...................
184
116
119
419
40
and
older
.............
110
57
49
216
Total
..............
699
477
425
1,601
Table
2.
Current
use
of
sanitary
products
by
racial-ethnic
group,
1988-89
Mexican
White
Blacks
Amenrcan
Product
used
Number
Percent
Number
Percent
Number
Percent
Tampons
only
...
178
25.9
75
16.1
44
10.7
Pads
only
......
259
37.8
265
56.9
280
68.3
Both
...........
249
36.3
126
27.0
86
21.0
Total
.
...
686
...
466
...
410
...
Table
3.
Current
use
of
sanitary
products
by
age
group
(years),
1988-89
10-14
15-19
20-29
30-39
40
and
older
Product
use
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Tampons
only
......................
17
10.1
41
15.8
158
26.1
69
16.4
21
10.3
Pads
only
..........................
122
72.6
138
53.3
250
41.3
221
52.6
129
63.2
Both
............................
29
17.3
80
30.9
198
32.7
130
31.0
54
26.5
Total
........................
168
...
259
...
606
...
420
...
204
...
NOTE:
The
age
group
totals
differ
among
these
tables
because
not
all
subjects
answered
all
questions,
and
some
responded
to
more
than
one
category.
Mexican
Americans
used
tampons
and
pads
during
menses.
Thirty-eight
percent
of
white,
57
percent
of
black,
and
68
percent
of
Mexican
American
women
used
pads
only.
These
differences
between
racial-ethnic
groups
in
all
three
categories
of
sanitary
product
use
are
highly
significant
(P
<
.001).
The
use
of
sanitary
products
by
age
is
shown
in
table
3.
There
were
significantly
(P
<
.001)
fewer
users
of
tampons
either
as
the
only
method
or
with
pads
and
significantly
more
users
of
pads
alone
among
those
ages
10
through
19
years.
Use
of
tampons
as
the
only
method
or
in
conjunction
with
pads
peaked
at
ages
20-
29
years.
Use
of
pads
alone
was
greatest
at
ages
less
than
15
years,
and
at
ages
40
and
older.
When
use
of
a
method
is
controlled,
significant
dif-
ferences
in
current
use
by
racial-ethnic
group
and
age
appear
only
for
those
who
used
pads
alone
(table
4).
In
the
10-14
age
range,
a
significant
proportion
of
whites
(46
percent)
used
pads
alone
compared
with
the
other
groups
(P
<
.001).,
Between
15
and
19
years,
blacks
and
Mexican
Americans
used
pads
alone
significantly
more
than
whites
(24
percent;
P
<
.05).
This
difference
was
maintained
through
age
29;
after
that
age,
a
sig-
nificantly
greater
proportion
of
Mexican
Americans
(P
<
.05)
than
blacks
and
whites
used
only
pads.
At
age
40
or
older,
the
pattern
of
pad
use
was
the
same
as
in
the
10-14-year
group.
For
those
women
who
had
ever
used
tampons,
the
first
use
occurred
before
age
15
in
89
percent
of
whites,
88
percent
of
blacks,
and
95
percent
of
Mexican
Ameri-
cans.
Use
of
tampons
at
some
point
in
their
life
was
reported
by
87
percent
of
the
whites,
88
percent
of
the
blacks,
and
86
percent
of
the
Mexican
Americans.
Of
Table
4.
Use
of
pads
only
by
age
and
racial-ethnic
group,
1988-89
Mexican
White
Black
American
Age
(years)
Number
Percent
Number
Percent
Number
Percent
10-14
..........
40
45.9
23
26.5
24
27.6
15-19
..........
32
23.7
56
41.4
47
34.9
20-29
..........
70
28.9
85
35.1
87
36.0
30-39
..........
63
29.6
64
30.0
86
40.4
40
or
older
......
54
42.5
37
29.1
36
28.4
Total
.....
259
...
265
...
280
...
Table
5.
Distribution
of
633
nonusers
of
tampons
by
age
and
racial-ethnic
group
Age
and
Number
Percent
Percent
of
racial-ethnic
of
of
racial-ethnic
group
nonusers
all
nonusers
group
19
years
and
younger,
total
179
99.1
'28.3
White
..................
65
36.3
30.5
Black
.................
56
31.3
28.7
Mexican
American
......
58
32.4
25.8
20-29
years,
total
.........
201
97.1
131.8
White
..................
55
27.4
25.8
Black
.................
68
33.8
34.9
Mexican
American
......
76
34.9
34.7
30-39
years,
total
.........
150
99.9
'23.7
White
..................
47
31.3
22.1
Black
.................
41
27.3
21.0
Mexican
American
......
62
41.3
27.6
40
and
older
years,
total
...
103
100.0
116.3
White
..................
46
44.7
21.6
Black
.................
30
29.1
15.4
Mexican
American
......
27
26.2
12.0
Grand
total:
White
..................
213
33.6
...
Black
.................
195
30.8
...
Mexican
American
......
225
35.5
...
'Within
the
specific
age
group.
September-ctober
1990,
Vol.
105
No.
5
493
Table
6.
Reasons
for
nonuse
of
tampons
by
race,
1988-89
Mexican
White
Blacks
American
Reason
for
nonuse
Number
Percent
Number
Percent
Number
Percent
I'm
single
........................
4
1.6
20
7.8
15
14.4
I'm
not
old
enough.
16
6.3
9
3.5
6
2.2
I'm
afraid
.44
17.3
89
34.6
96
35.7
Toxic
shock
syndrome
.43
16.9
27
10.5
31
11.5
Other
.147
57.8
112
43.6
121
44.9
Total
......................
254
...
257
...
269
...
Table
7.
Reasons
for
nonuse
of
tampons
by
age
(years),
1988-89
10-14
15-19
20-29
30-39
40
and
older
Reason
for
nonuse
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
I'm
single
.........................
15
11.7
8
5.9
14
5.9
5
2.5
4
3.0
I'm
not
old
enough
........
........
22
17.2
6
4.4
3
1.3
3
1.5
1
0.75
I'm
afraid
.........................
51
39.8
59
43.4
69
29.0
49
24.3
22
16.4
Toxic
shock
syndrome
.......
......
6
4.7
13
9.6
34
14.3
39
19.3
14
10.4
Other
...........................
34
26.6
50
36.8
118
49.6
106
52.5
93
69.4
Total
.......................
128
...
136
...
238
...
202
...
134
...
Table
8.
Change
in
use
of
tampons
based
on
knowledge
of
toxic
shock
syndrome
by
racial-ethnic
group
Mexican
White
Blacks
American
Change
in
use
Number
Percent
Number
Percent
Number
Percent
Increase
........
9
1.6
19
6.0
1
1
5.2
Decrease
.......
211
38.6
159
49.8
97
45.8
No
change
......
326
59.8
141
44.2
104
49.0
Total
.....
546
...
319
...
212
...
those
who
had
used
tampons
at
some
point
in
their
life,
28
percent
were
currently
age
19
or
younger,
32
percent
were
20-29,
24
percent
were
30-39,
and
16
percent
were
older
than
40.
These
differences
are
not
significant.
Of
the
women,
39.5
percent
had
never
used
tampons.
Of
these
(table
5),
34
percent
were
white,
31
percent
were
black,
and
36
percent
were
Mexican
American.
These
differences
are
not
significant.
For
those
who
had
never
used
tampons,
28
percent
were
currently
younger
than
19
years,
32
percent
were
20-29
years,
24
percent
were
30-39
years,
and
16
percent
were
40
or
older.
There
are
no
significant
differences.
The
questionnaire
listed
the
following
reasons
for
never
having
used
tampons:
"I'm
not
married,"
"I'm
not
old
enough,"
"I'm
afraid,"
"I
might
get
TSS,"
and
"other."
The
most
common
reason
was
"other"
accounting
for
between
57.8
percent
(whites)
to
43.6
percent
(blacks).
The
reason
"I'm
afraid"
ranked
next
in
importance
followed
by
fear
of
TSS
(table
6).
There
were
also
differences
in
reasons
for
not
ever
using
tampons
according
to
age.
These
data
are
shown
in
table
7.
"I'm
afraid"
was
the
most
common
reason
for
those
under
age
19.
The
proportion
of
respondents
in
this
category
decreased
with
increasing
age.
The
next
largest
category
was
"other,"
which
was
lowest
(27
percent)
in
the
less
than
15-year
age
group
and
was
highest
(69
percent)
in
the
40
and
older
age
group.
Fear
of
TSS
was
lowest
(5
percent)
in
the
youngest
group
and
highest
(19
percent)
in
the
30-39
years
group.
Information
about
TSS
caused
a
significant
decrease
in
use
of
tampons
in
all
racial-ethnic
groups.
However,
significantly
greater
proportions
of
blacks
and
Mexican
Americans
than
whites
decreased
use
(P
<
.001,
table
8).
Information
about
TSS
was
also
associated
with
a
significant
decrease
(P
<
.002)
in
use
of
tampons
with
increasing
age
(table
9)
up
to
age
40
and
older.
This
was
determined
using
a
general
chi-square
test
and
a
test
for
trend.
In
both
analyses,
between
35
and
51
per-
cent
of
women
decreased
tampon
use
in
response
to
information
about
the
risks
of
TSS.
Discussion
At
the
time
of
this
study,
a
significant
proportion
of
white
women
(62
percent)
used
tampons
either
as
their
only
method
or
with
pads
compared
with
black
women
(43
percent)
and
Mexican
American
women
(32
per-
cent).
The
difference
is
less
than
that
reported
by
Gustafson
and
coworkers
(5)-85
percent
for
white
women
and
50
percent
for
black
women.
These
dif-
494
Public
Hialth
Reports
Table
9.
Change
in
use
of
tampons
based
on
knowledge
of
toxic
shock
syndrome
by
age
(years)
10-14
15-19
20-29
30-39
40
and
older
Change
in
use
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Increase
...........
...............
6
8.1
9
5.6
16
3.2
8
2.7
4
4.2
Decrease
.........................
26
35.1
59
36.4
209
41.4
151
51.4
41
43.2
No
change
.......................
42
56.8
94
58.0
280
55.4
135
45.9
50
52.6
Total
.......................
74
...
162
...
505
...
294
...
95
...
ferences
in
tampon
use
by
the
different
racial-ethnic
groups
may
explain
why
TSS
is
reported
more
fre-
quently
among
whites
and
almost
not
at
all
among
blacks
(2).
However,
43
percent
of
black
women
did
report
using
tampons,
and
16
percent
reported
tampon
use
as
their
only
method.
It
would
seem
highly
unlikely
that
this
somewhat
lower
use
of
tampons
by
blacks
would
be
the
only
explanation
for
the
paucity
of
cases
of
TSS
in
blacks.
Other
explanations
might
include
dif-
ferences
in
reporting
by
health
care
providers
for
blacks
and
whites
and
differences
in
making
the
diagnosis
for
blacks
and
whites.
It
may
be
more
difficult
to
see
the
rash
on
patients
with
darkly
pigmented
skin,
and
thus
one
of
the
major
criteria
may
be
missed
(2).
However,
there
may
be
other
differences
between
black
and
white
women
that
would
account
for
the
difference
in
incidence.
Other
risk
factors
for
TSS
such
as
marital
status,
parity,
con-
traceptive
methods
used,
frequency
of
sexual
inter-
course,
frequency
of
sexual
intercourse
during
menstruation
have
been
eliminated
(6),
but
it
is
not
clear
if
these
factors
have
been
examined
separately
for
black
women.
The
hypothesis
that
a
significant
propor-
tion
of
white
women
would
use
tampons
compared
with
black
women
and
Mexican
American
women
was
substantiated.
We
found,
as
did
Gustafson,
that
use
of
tampons
peaked
in
the
age
range
of
the twenties.
Thereafter,
use
of
tampons
declined
and
the
use
of
pads
increased.
Of
those
who
used
tampons
at
some
point
in
their
life,
88-
95
percent
tried
them
for
the
first
time
before
age
15.
Whisnant
and
coworkers
(7)
reported
that
girls
who
used
tampons
began
use
within
a
"year
or
two"
after
menarche.
For
those
women
who
currently
used
tam-
pons,
or
who
used
both
tampons
and
pads,
there
were
no
significant
differences
in
use
related
to
either
age
or
racial-ethnic
group.
However,
for
those
women
who
currently
used
pads
only,
there
were
both
age
related
and
racial-ethnic
differences.
Pads
alone
were
used
by
a
significant
proportion
of
whites
until
age
15
when
a
larger
percentage
of
blacks
used
them.
From
ages
20
to
39,
large
proportions
of
Mexican
American
women,
compared
with
the
other
two
groups,
used
pads
alone.
After
age
40,
a
greater
proportion
of
whites
used
pads
alone
than
did
the
other
groups.
The
hypothesis
that
more
women
under
20
years
would
use
tampons
than
older
women
can
be
rejected
(table
4).
This
finding
is
not
consistent
with
the
hypothesis
that
women
in
this
age
range
have
the
highest
incidence
of
TSS
because
they
use
tampons
more
frequently
than
women
in
the
other
age
groups.
Forty
percent
of
this
sample have
never
used
tampons
and
49-55
percent
of
women
were
not
using
tampons
at
the
time
of
this
study.
In
1965,
Wheatley
and
coworkers
(8)
reported
that
32.3
percent
of
903
women
in
their
practice
used
only
tampons,
49.5
percent
used
only
pads,
and
18.2
percent
used
both.
Thus,
there
seems
to
be
a
decrease
in
the
use
of
pads
as
the
sole
method
of
protection
over
time.
Industry
has
reported
figures
of
30
percent
for
life-
time
nonuse
of
tampons
and
45
percent
for
current
non-
use
in
1981
(4).
The
differences
between
these
statistics
and
the
ones
in
this
report
are
small
and,
if
real,
may
be
due
to
the
decrease
in
use
of
tampons
after
the
publicity
generated
by
the
media
coverage
of
TSS
and
its
relation
to
tampon
use
as
well
as
by
the
package
inserts
in
tam-
pon
products
that
warn
about
the
increased
risk
for
TSS
among
users
of
tampons.
A
substantial
decrease
(35.1-51.4
percent)
in
use
of
tampons
was
found
in
this
sample,
which
seems
to
be
associated
with
information
related
to
TSS.
These
declines
in
tampon
use
are
simi-
lar
to
the
decreases
reported
by
Gustafson
and
coworkers
(5),
which
ranged
from
30
to
44
percent.
In
this
sample,
50
percent
of
blacks
decreased
use,
while
in
Gustafson's
sample
39
percent
of
younger
and
44
percent
of
older
blacks
decreased
tampon
use.
In
Gustafson's
series,
30
percent
younger
and
37
percent
of
older
white
women
decreased
use
in
response
to
information
about
TSS.
For
our
respondents,
there
was
a
significant
trend
of
decreasing
tampon
use
related
to
TSS
from
35
percent
for
women
below
age
14
to
51
percent
for
women
ages
30-39
years.
It
would
seem
that
the
proportion
of
women
who
decreased
use
of
tampons
because
of
the
risk
of
TSS
is
about
the
same
today
as
it
was
in
1980-81
(5).
This
confirms
the
hypothesis
that
information
about
TSS
would
cause
women
to
decrease
their
use
of
tampons.
This
paper
is
the
first
report
on
product
use
by
Mexican
American
women.
Significantly
fewer
Mexican
American
women
than
the
other
groups
cur-
Septnber-October
1990,
Vol.
105
No.
5
495
rently
use
tampons
either
as
the
only
method
(11
per-
cent)
or
with
pads
(21
percent).
However,
they
were
no
different
in
age
at
first
use
of
tampons
(less
than
15
years),
lifetime
use
of
tampons
(86
percent),
nor
are
they
overrepresented
among
those
who
had
never
used
tampons
(36
percent).
They
are
significantly
more
likely
(14
percent)
to
not
use
tampons
because
of
being
unmarried
than
either
black
or
white
women.
This
con-
firms
the
hypothesis
that
this
group
would
use
tampons
less
frequently
than
other
women.
Thus,
age-related
use
of
tampons
does
not
explain
the
higher
incidence
of
TSS
in
younger
women,
and
differences
in
racial-ethnic
use
of
tampons
seem
insuffi-
cient
to
explain
the
rarity
of
TSS
among
black
women.
References...................................
1.
Todd,
J.
,
Fishaut,
M.
,
Kapral,
F.
,
and
Welch,
T.:
Toxic
shock
syndrome
associated
with
phage
group-I
staphylococci.
Lancet
No.
8100:
1116-1118
(1978).
2.
Gaventa,
S.,
et
al.:
Active
surveillance
for
toxic
shock
syn-
drome
in
the
United
States,
1986.
Rev
Infec
Dis
(supp.)
11:
S28-S34
(1989).
3.
Parsonnet,
J.:
Mediator
in
the
pathogenesis
of
toxic
shock
syn-
drome:
overview.
Rev
Infec
Dis
(supp.)
11:
S263-S269
(1989).
4.
Toxic
shock
syndrome.
MMWR
30:
25-33,
Jan.
30,
1981.
5.
Gustafson,
T.
L.,
et
al.:
Survey
of
tampon
use
and
toxic
shock
syndrome,
Tennessee,
1979
to
1981.
Am
J
Obstet
Gynecol
143:
369-374
(1982).
6.
Follow-up
on
toxic
shock
syndrome-United
States.
MMWR
29:
297-299,
June
27,
1980.
7.
Whisnant,
L.,
Brett,
E.,
and
Zegans,
L.:
Adolescent
girls
and
menstruation.
Adolesc
Psychiatry
7:
157-171
(1979).
8.
Wheatley,
R.
E.,
Menkin,
M.
F.,
Bardes,
E.
D.,
and
Rock,
J.:
Tampons
in
menstrual
hygiene.
JAMA
192:
697-700,
May
24,
1965.
AIDS-Related
Knowledge,
Attitudes,
and
Precautionary
Behaviors
Among
Emergency
Medical
Professionals
MICHAEL
S.
SMYSER,
MPH
JENNIFER
BRYCE,
EdD
JILL
G.
JOSEPH,
PhD
Mr.
Smyser
was
a
consultant
to
the
Special
Office
on
AIDS
Pre-
vention
of
the
Michigan
Department
of
Public
Health
for
the
duration
of
this
study
and
is
currently
HIV
Seroprevalence
Coordinator
for
the
HIV/AIDS
Office
of
Epidemiology
and
Surveillance
of
the
Wash-
ington
State
Department
of
Health.
Dr.
Bryce
was
the
Coordinator
of
Research
for
the
Special
Office
on
AIDS
Prevention
of
the
Michigan
Department
of
Public
Health
during
the
period
of
this
research;
she
is
now
an
Evaluation
Specialist
in
the
International
Health
Program
Office
of
the
Centers
for
Disease
Control,
Atlanta,
GA.
Dr.
Joseph
is
an
Associate
Professor
in
the
Department
of
Epidemiology
at
the
Uni-
versity
of
Michigan,
Ann
Arbor.
This
research
was
conducted
with
the
support
of
the
Centers
for
Disease
Control
under
a
cooperative
agreement
with
the
Special
Office
on
AIDS
Prevention,
Center
for
Health
Promotion,
Michigan
Department
of
Public
Health.
Technical
assistance
was
provided
by
the
Department's
Division
of
Emergency
Medical
Services,
Bureau
of
Health
Facilities.
Tearsheet
requests
to
Michael
Smyser,
HIV/AIDS
Office
of
Epi-
demiology
and
Surveillance,
Washington
State
Department
of
Health,
1610
N.E.
150th
St.,
Seattle,
WA
98155-7224.
Synopsis
....................................
AIDS-related
knowledge,
attitudes,
and
precaution-
ary
behaviors
were
assessed
among
a
random
sample
of
Michigan-licensed
emergency
medical
service
(EMS)
professionals
between
June
and
August
1988.
Of
2,000
mailed
questionnaires,
1,020
were
returned
(51
percent
response),
and
997
of
the
returned
questionnaires
were
used
in
the
final
analysis.
Survey
results
indicated
that
most
respondents
were
able
to
correctly
identify
the
transmission
routes
of
the
human
immunodeficiency
virus
(HIV),
but
many
re-
spondents
had
misconceptions
about
nonviable
routes,
the
incidence
of
HIV
infection
among
health
care
workers,
and
some
aspects
of
the
natural
history
of
HIV.
More
than
half
of
the
respondents
(56.6
percent)
believed
that
their
chances
of
becoming
infected
with
HIV
were
"somewhat
high"
or
"very
high,"
although
the
number
of
documented
HIV
seroconversions
due
to
occupational
HIV
exposures
in
health
care
settings
is
low.
Although
only
six
respondents
(0.6
percent)
reported
that
they
had
refused
treatment
to
patients
known.
or
suspected
to
be
infected
with
HIV,
25
percent
felt
that
EMS
professionals
should
be
allowed
to
refuse
treatment
under
such
circumstances.
Potential
exposures
to
HIV
were
assessed
through
respondents'
reports
of
three
activities in
the
6
months
prior
to
the
survey.
For
each
activity,
use
of
universal
precautions
recommended
by
the
Centers
for
Disease
Control
was
also
assessed.
In
general,
few
respondents
reported
the
consistent
use
of
precautions.
While
the
majority
of
those
attempting
resuscitations
(86.9
per-
cent)
reported
that
they
always
use
a
protective
device,
only
36.7
percent
of
those
treating
bleeding
patients
reported
that
they
always
wear
gloves,
and
only
21.9
496
Public
Halth
Reports