Epidemiology of toxic shock syndrome in the United States: overview

Studies were undertaken to detect a possible reporting or diagnostic bias that might have affected the results of previous epidemiologic investigations of toxic shock syndrome (TSS). The methods used in this reassessment of initial findings regarding TSS epidemiology (which were obtained through passive- and active-surveillance systems) included record review and analysis of discharge diagnoses. Results obtained with both the latter methods confirmed the broad outlines of the descriptive epidemiology of TSS. Some recent studies have focused on nonmenstrual cases of TSS and on risk factors for the development of TSS. Key findings include the more frequent isolation from nonmenstrual TSS cases of Staphylococcus aureus strains not producing TSS toxin 1 and a higher case-fatality rate for cases in men and for "non-vaginal" cases in women than for vaginal cases (defined as menstrual, postpartum, vaginal nonmenstrual, and contraceptive cases). Studies of the relation between tampon use and TSS suggest that both the degree of absorbency and the chemical composition of the tampon are involved; however, the mechanism by which tampons increase the risk of TSS remains unknown. Contraceptive sponges and diaphragms may be linked to an increased risk of nonmenstrual TSS, whereas oral contraceptives may play a protective role; these possibilities require further study.