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About The daily Nebraskan. ([Lincoln, Neb.) 1901-current | View Entire Issue (Oct. 15, 1980)
Wednesday, October 15, 1980 page 6 daily nebraskan Toxic shock studies conducted ' yet exact cause still unknown Doctor discusses theories on toxic shock syndrome By Mary Kempkes It hasn't been easy studying toxic shock cases in Nebraska. The first two studies were performed from autopsy results. A UNL case was the first live case Ne braska doctors have had to go on said Dr. Monte Scott, an internal medicine special ist. Scott spoke Tuesday night to about 75 women at Bryan Memorial Hospital who came to ask questions about tampon use and their health. - The disease is caused by a vaginal staph bacteria (staphylocossus aureus), Scott said, and while the staph itself is not harm ful, the toxin it releases can cause severe repercussions. In milder cases, the woman may not even know she had the illness, Scott said. But when shock occurs, there is damage to the central nervous system (coma can occur), liver, heart and lungs. Recovery is slow in these cases, he said. Some patients cannot lift their head off the pillow after two weeks and organ damage may be per manent. The symptoms include chills, fever, severe muscle aches, nausea, vomiting and diarrhea. In advanced cases, the woman develops a sunburn-like rash which peels in the second week of recovery, he said. And in serious cases, the patient collapses and goes into shock. The onset of the disease varies, Scott said, but one Nebraska woman died within 48 hours of diagnosis. The typical victim is female, young, menstruating and using tampons. Rely is the tampon most often associated with toxic shock, he said, but all major tampons have been cited in statistics. Toxic shock caused by staph infection is not new, Scott said. There are recorded cases in men and children as early as 1927 but cases related to tampon use were first recorded in 1975. Statistics indicate that three out of every 100,000 menstruating women a year will develop the disease, Scott said, less than the chances of being killed in a car accident. The figures are pro bably underestimated, he said, since mild cases are not reported. The Center for Disease Control has not determined the cause for a recent surge in toxic shock cases but has several theories, Scott said. Tampons have been used for more than 20 years but at first they were little more than pieces of compressed cotton. Now they contain synthetics and chemicals in cluding nylon, polyester and deodorants which may increase staph growth, he said. But direct contamination by tampons has "been pretty much ruled out," he said. A second theory suggests tampons im pede menstrual flow, creating a favorable environment for staph. Also, plastic appli cators may irritate or scratch the vaginal wall allowing toxins into the bloodstream. But CDC is investigating a fourth theory that this strain of staph may be unique and stronger. By using an abundance of anti bodies to combat other illnesses and acne, Scott said, women may have created a "super staph" such as this one which is resistant to common types of penicillin. To reduce the .chances of contracting toxic shock syncrome, Scott suggests women either not use tampons or use them only intermittently with napkins. And don't use Rely tampons, he said. If a woman suspects she has contracted toxic shock syndrome, she should remove the tampon and call a doctor. The tampon should not be discarded, Scott said, because it must be used in testing to deter mine if the woman actually has the disease. By Beth Head rick There have been 408 cases of toxic shock syndrome reported to the Center for Disease Control in Atlanta, Ga. Forty deaths have been attributed to the disease, all of them women. Two of those women were from Lincoln. Dr. Marguerite Neill of the Special Pathogens Branch at CDC, said before Jan uary 1980, less than 100 toxic shock syn drome cases had been reported. Of the cases reported since January, 1980, 95 percent have been women. In May, the CDC correlated menstrua tion with the syndrome when findings showed that 95 percent of those cases occurred when women were having their menstrual periods, Neill said. It became apparent that the syndrome affects previ ously healthy women less than 30 years old during their menstrual periods. In June, the CDC studies showed that, in some way, tampons contribute to the syndrome. Although statistics show Rely to be the greatest risk to women, cases of the syn drome have occurred in women using all five of the major brands of tampons. Symptoms identified In tests of 42 women who had the syn drome, 71 percent used Rely, 19 percent used Playtex, 5 percent used Tampax, 2 percent used Kotex and 2 percent used OB. Now that the symptoms are identified, the earliest reports of cases can be found in 1975, Neill said. The original study recognizing the syn drome was in 1978 by Dr. James Todd in a British medical journal. The article focused on the syndrome's effects on children. Since then, the reported cases of the syndrome have increased sharply, with the disease now predominantly occurring in women. Neill said that it isn't known why there has been a sudden increase of the disease. She said because Rely tampons were intro duced on the market in different parts of the country at different times, it could have created a problem in establishing sig nificant statistics earlier. The other factor is that the public's and physician's aware ness of the symptoms has increased recent- The Food and Drug Administration's Bulletin said "the syndrome is character ized in its most severe form by sudden on set of high fever, vomiting, and diarrhea with rapid progression to hypotension and shock. Patients require large volumes of fluid and frequently require intensive care. Urine output is often decreased, and patients may be disoriented or combative. The case-fatality ratio is between 3 percent and 10 percent." Still unknown A bacterial organism called staphyloc occus aureaus produces the toxin that can develop into the syndrome. Just how tam pon use contributes to the bacteria growth is still unknown. Currently, studies are being done bv the FDA, the Center for Disease Control and state health departments to try and answci these questions. Procter and Gamble, makers of Rely, also is investigating causes of the syn drome, said Marjorie Bradford, public rela tions spokesperson for the corporation. Rely announced on Sept. 22 that sales of their product would be suspended. By Oct. 13, virtually all Rely tampons were removed from the market, she said. On Oct. 6, Procter and Gamble started a four-week series of announcements in volving 600 television stations, 350 radio stations and 1,200 newspapers warning women to stop using Rely and to get a re fund for any unused Rely tampons they have. Both product lines of Rely, super and regular tampons, have been called off the market. One theory suggests that the super absorbancy Rely tampon increased the risk because it is often left in the body longer, allowing the growth of the toxin. Another theory is that the synthetic materials used in the super absorbancy tampons are adding to the problem. Bradford said the tampon is made of polyester sponges with cellulose material for absorbancy. The whole tampon is en closed in a polyester overwrap and the string is made from polyester. Theories suggested The cellulose has been used for years in other products, such as surgical sutures, she said. Other theories suggest that the tampons' bacterial organism is carried by the fingers when the tampon is inserted. Another sug gestion is that the tampon provides a favor able environment for the toxin regardless of how it is introduced into the system, or that the use of tampons may traumatize the vaginal mucosa, causing ah imbalance and allowing the bacteria to grow. Neill said the Surgeon General generally has been misquoted. She said he does not recommend women stop using tampons. Women should be aware of the symp toms, she said. If a woman is concerned, she could alternate between the use of tampons and pads or change the tampon more often. Dr. Harlan Papenfuss, the coroner's physician to Lancaster County who per formed an autopsy on the two Lincoln women who died said the majority of fatal cases die within 24 hours of diagnosis. Papenfuss said he agrees that the super absorbancy tampons left inside the body all day provide a way for the toxin to grow if the bacteria already has colonized. He also recommended changing tampons every three or four hours. The FDA is developing a Federal Regis ter proposal to require warnings of the connection between toxic shock syndrome and tampon use be put on all packages. Women who wish to get a refund on Rely should send the unused tampons and the package to : Rely, P.O. Box 85519, Cincinnati, Ohio 45202. Legal aspects of shock syndrome are investigated By Mary Kempkes The mother of a UNL student who contracted toxic shock syndrome-the disease associated with tampon use said she suspected the disease caused a neart murmur. Barbara Hungerford, whose daughter dropped out of school and off the track team last month because of illness, said Gina did not have a heart murmur in August when she had a physical examination, but one was found after she contracted toxic shock syndrome. The heart murmur and other conditions have not clear ed up, Mrs. Hungerford said, but Gina is steadily recuper ating and gaining back her strength. (Gina, a 20-year-old junior, was admitted to Bryan Memorial Hospital Sept. 4. Mrs. Hungerford said Gina thought she had the flu, but the night of her hospital admission, her temperature peaked between 106 and 107 degrees before going into shock. Hungerford said she and her husband had not decided whether or not to sue Proctor and Gamble, makers of the Rely tampons Gina had used for about two years. She said she is skeptical of other women who were suing the company. "You hear all of these cases, but vou don't lennu if they had the actual disease," she said. No one from Nebraska has filed suit, but the husband of Lori A. Crawford, 17, who died Aug. 17, from toxic shock, said he is considering legal action. Max Crawford said his wife was using Kotex tampons at the time of her death. Area lawyers also are skeptical as to whether women will be able to collect on the suits. They say the proof of liability is shaky. "One of the elements the plaintiff would have to dem onstrate is that the product was the cause of a damaging condition or injury," said John Strong, Dean of UNL Law College. The cause of toxic shock syndrome is unknown, even though the Center for Disease Control in Atlanta has spec ulated the disease is caused by a staphylococus infection. Other doctors said the construction of tampons in the last 20 years has changed and they may now contain some element that supports an overgrowth of staphylococcus. Studies now are being conducted to determine which, if any, element is the cause. Suing Proctor and Gamble would involve technical i.'ironn riiffirutt frr o I i r ;1 nA experts would have to be called for testimony, which, at this point, would be based on opinion. Law Professor John Heidt said the case for the plaintiffs against the company looks better than most product liability suits. But it's definately not open and shut, he said. By removing Rely from the market, "There seems to be an admission of guilt," Heidt said. But the court may not allow that action as evidence, he said, not wislung to discourage oilier companies from removing suspected faulty products from consumer use. "I would think they (the plaintiffs) have adequate evidence," Strong said. Studies being conducted about Rely's connection to toxic shock syndrome may save the plaintiff from gather ing his own evidence, Heidt said. An August study found that 70 percent of toxic shock syndrome victims in one group had used Rely tampons. The first few cases will be important to Proctor and Gamble, Strong said. If they lose, it may bring other suits and set a precedent for their success.' If they win, they will fight subsequent suits harder.