The Public Health Response to Toxic Shock Syndrome: A Historical Review and Lessons Learned

The toxic shock syndrome (TSS) crisis is a historical public health success story from which much can be learned and applied to contemporary public health issues. Following the first reports, multiple research teams initiated studies designed to ascertain the risk factors associated with TSS. Those studies evolved over several years – each building upon previous findings in an attempt to further understand both the nature and causes of toxic shock. After the first report of TSS in a May 1980 issue of the MMWR, multiple studies contributed to the body of knowledge that ultimately informed and facilitated interventions to reduce the incidence of TSS. Examination of the public health response to toxic shock syndrome highlights the effective use of epidemiological studies in successfully building a foundation for efficient responses to emerging problems and also highlights political and legal issues that remain for health professionals today. The toxic shock syndrome (TSS) crisis is a historical public health success story from which much can be learned and applied to contemporary public health issues. The research that has emerged illustrates the efficiency with which public health professionals can react and initiate interventions. Many studies played important roles in gaining control over the growing incidence of TSS. These studies evolved over the course of several years–each building upon previous findings to further understand both the nature and causes of toxic shock. It was this persistent and intensive research that informed and facilitated interventions to reduce TSS incidence. The Emergence of TSS Toxic shock syndrome is a potentially fatal disease “characterized by sudden onset of fever, chills, vomiting, diarrhea, muscle aches and rash. It can rapidly progress to severe and intractable hypotension and multisystem dysfunction” (Centers for Disease Control and Prevention [CDC], 2003, p.1). The standard case definition used in initial CDC studies consisted of the following: “1) temperature greater than 102°F, 2) hypotension, 3) rash, 4) desquamation, and 5) abnormalities in three or more organ systems” (Schuchat & Broome, 1991, p. 105). Reports of toxic shock syndrome first appeared in the Morbidity and Mortality Weekly Report (MMWR) on May 23, 1980, in response to growing concerns about the condition (CDC, 1997). In the months prior to publication of the MMWR article, health departments of two states, Wisconsin and Minnesota, received reports of toxic shock syndrome in young, menstruating women (Osterholm, Gibson, Mandel, & Davis, 1982). Since the first published report of TSS in 1978 was based on the manifestation of the condition in children (Todd, Fishaut, Kaprai, & Welch, 1978), unexpected reports of toxic shock in menstruating women prompted health departments to launch their own active investigations into the problem (Osterholm, Gibson et al., 1982). Following the first reports, researchers nationwide initiated a series of studies designed to ascertain risk factors associated with TSS. Although the specific approaches and methodologies of the research projects varied, each contributed to the working knowledge of toxic shock. The years that followed brought increased understanding of the syndrome (Schuchat & Broome, 1991). Epidemiological Evidence Epidemiological data regarding factors associated with toxic shock syndrome were gathered by multiple teams of investigators using different methodologies over a span of many years. Following the first report of TSS in a May 1980 issue of MMWR, several studies were conducted. The Wisconsin study, the first CDC study (CDC-I), the Utah study, a second CDC study (CDC-II), the Tri-State study, national passive surveillance by the CDC, a third CDC study (CDC-III), and a fourth CDC study (CDC-IV) contributed to the growing body of knowledge of toxic shock syndrome and its risk factors.