APPENDIX A WORK GROUP PARTICIPANTS Elaine Abrams. M.D. Harlem Hospital Center Department of Pediatrics 506 Lenox Avenue New York, NY 10037 Rabbi Richard F. Address Regional Director Union of American Hebrew Congregations I17 South 17th Street. Room 2 I1 I Philadelphia, PA 19103 Manuel M. Album. D.D.S. American Society of Dentistry for Children 211 East Chicago Avenue Chicago, IL 6061 I Fern Allen. R.N. Cedars-Sinai Medical Center Department of Pediatrics 8700 Beverly Boulevard Los Angeles. CA 90048 James R. Allen, M.D. Assistant Director AIDS Program Centers for Disease Control Building 6. Room 288 Atlanta, GA 30333 Arthur J. Ammann, M.D. Director, Collaborative Medical Research Genentech. Inc. 460 Pt. San Bruno Boulevard South San Francisco, CA 94080 Janet Anderson, Ed.D. Staff Psychologist Hematology Division The Children's Hospital of Philadelphia Philadelphia Child Guidance Clinic 34th St&et and Civic Center Boulevard Philadelphia, PA 19104 Virginia Anderson, M.D Department of Pathology Armed Forces Institute-. Washington, DC 20906 Philip Banister. M.B., M.P.H.. F.R.C.P. (C) Health and Welfare Canada Health Service and Promotion Branch Ottawa, Ontario KIA lB4 Canada Stephen D. Barbour. M.D.. Ph.D. Division of Infectious Diseases The Children's Hospital of Philadelphia Philadelphia, PA 19104 Reverend Carl Bean Chairman National Minority AIDS Council 5882 W. Pica Boulevard. #210 Los Angeles, CA 90019 Myron Belfer. M.D. Chairman. Department of Psychiatry Harvard Medical School at The Cambridge Hospital 1493 Cambridge Street Cambridge. MA 02139 Jeffrey L. Black. M.D. Chairman. Task Force on AIDS American School Health Association University of California at San Diego 225 Dickenson Street San Diego, CA 92103 Mary G. Boland, M.S.N.. C.P.N.P. Director, AIDS Program Children's Hospital of New Jersey 15 South 9th Street Newark, NJ 07107 Shirley Bonnem Vice President Public Relations and Development The Children's Hospital of Philadelphia Philadelphia, PA 19104 76 G. Stephen Bowen, M.D. Medical Epidemiologist Acute Infectious Disease Epidemiology Div. Department of Health Box 90 Harrisburg, PA 17108 William Borkowsky, M.D. Bellevue Hospital Center/New York Universiiy Medical Center Pediatric Department First Avenue at East 27th Street New York. NY 10016 Elaine Brainerd. R.N., M.A. Consultant. School Health Services State Department of Education P.O. Box 2219 Hartford. CT 06145 Larry K. Brown. M.D. Rhode Island Hospital 593 Eddy Street Providence. RI02903 Philip Brunell, M.D. Department of Pediatrics Health Science Center University of Texas San Antonio, TX 78228 Georgia Buggs. R.N.. M.P.H. Division of Maternal and Child Health Department of Health and Human Services Rockville, MD 20857 Toni Cabat. M.S.W. Project Coordinator. AIDS Component Albert Einstein College of Medicine 1300 Morris Park Avenue Forchheimer Building, #401 Bronx. NY 10461 James Chin, M.D.. M.P.H. Special Programme on AIDS World Health Organization 121 I Geneva 27, Switzerland Marlene Cimons Los Angeles Times- Washington Bureau 1875 Eye Street NW. Suite 1100 Washington, DC 20006 Matt Clark Newsweek 444 Madison Ave. New York, NY 10022 Karen A. Clifford, J.D. Assistant Counsel Health Insurance Association of America 1025 Connecticut Ave.. NW Washington. DC 20036 Reverend Lynne Coggi AIDS Consultant National Mission National Episcopal Church 815 Second Avenue New York, NY 10017 Alan R. Cohen. M.D Senior Physician Division of Hematology The Children's Hospital of Philadelphia Philadelphia, PA 19104 Edward M. Connor. M.D. Associate Director Div. of Immunology and Infectious Disease Children's Hospital of New Jersey 15 South Ninth Street Newark. NJ 07107 Jolene Connor. R.N. Associate Director, AIDS Program Harlem Hospital 506 Lennox Avenue, Room 2146 New York. NY 10037 Louis Z. Cooper, M.D. Director and Professor of Pediatrics St. Luke`s-Roosevelt Hospital Center Amsterdam Avenue and 114th Street New York. NY 10019 Catherine Cowell, Ph.D. Director, Bureau of Nutrition City of New York, Department of Health 93 Worth Street, Room 714 New York, NY 10013 Mollie Coye State Commissioner of Health New Jersey State Department of Health Trenton. NJ 08625-0360 Leonard Davis Vice President Blue Cross of Greater Philadelphia 1333 Chestnut Street Philadelphia, PA 19106 77 William DeJong, Ph.D. Senior Research Associate Education Development Center. Inc. 55 Chapel Street Newton. MA 02160 Jane K. DeMaio Division of General Academic Education New Jersey State Department of Education 225 W. State Street Trenton, NJ 08625 Harold G. Devine, Jr.. M.M., C.A.G.S. Assistant Superintendent of Schools Swansea Public Schools One Gardners Neck Road Swansea. MA 02777 Eunice Diaz, M.S., M.P.H. Director, Health Promotion and Community Affairs White Memorial Medical Center 1720 Brooklyn Ave. Los Angeles, CA 90033 Steven Douglas, M.D. Director, Div. of Immunology and Allergy The Children's Hospital of Philadelphia Philadelphia, PA 19104 Walter R. Dowdle, Ph.D. Acting Deputy Director (AIDS) Centers for Disease Control 1600 Clifton Road, N.E. Building 1, Room 2122 Atlanta. GA 30333 Lisa Egbuonu, M.D., M.P.H. University of Pennsylvania 2-L Nursing Education Building Mail Code 6094 Philadelphia, PA 19104 Leon G. Epstein, M.D. Assistant Professor of Neurosciences and Pediatrics University of Medicine and Dentistrv of New Jersey 185 South Orange Avenue Newark, NJ 07 103-2757 Patricia Evans, R.N. Visiting Home Nurse 1326 Burnett Avenue Union, NJ 07083 Judith Feinberg. M.D. Treatment Branch/AIDS Program National Institute of Allergy and infectious Diseases National Institutes of Health Bethesda. MD 20892 Senih Fikrig. M.D. Professor of Immunology Downstate Medical Center 450 Clarkson Avenue Brooklyn, NY 11203 Loretta P. Finnegan. M.D. Director of Family Center Jefferson Medical College 111 South I Ith Street. Suite 6105 Philadelphia, PA 19107 Gerald W. Fischer. M.D. Professor of Pediatrics Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD 20814-4799 Mary Flannery The Philadelphia Daily NPMS 400 North Broad Street Philadelphia, PA 19101 Mary Fugate. R.N. American Red Cross Health Education 150 Amsterdam Avenue New York. NY 10023 Anna Garcia, M.S.W. Department of Pediatrics University of Miami School of Medicine Jackson Memorial Hospital Miami. FL 33124 Keith Geiger Vice President National Education Association 1201 16th Street, N.W. Washington, DC 20036 Sander G. Genser, M.D., M.P.H. National Institute of Drug Abuse Clinical Medicine Branch Rockville, MD 20857 78 Harold Ginzburg, M.D., I.D., M.P.H. Chief, Epidemiology Branch National Institute of Allergy and Infectious Diseases/AIDS Program National InstiNtes of Health Bethesda. MD 20892 Lenny Giteck Editor, 7&e Advocate 6922 Hollywood Boulevard, 10th Floor Los Angeles, CA 90028 Karen Glanz, Ph.D., M.P.H. Associate Professor Department of Health Education Temple University (062-56) Philadelphia, PA 19122 Robert Gleeson, M.D. Northwestern Mutual Life 720 E. Wisconsin Avenue Milwaukee, WI 53202 D. Jay Gloeb, M.D. Department of Obstetrics University of Miami School of Medicine 3120 Indiana Street Miami. FL 33133 Jackie Goldberg Board of Education Los Angeles Unified School District P.O. Box 3307 Los Angeles, CA 90051 Max Gomez. Ph.D. Health and Science Editor KYW-TV independence Mall East Philadelphia. PA 19106 Edward D. Gompetts. M.D. Director. Hemophilia Center Children's Hospital of Los Angeles 4650 Sunset Boulevard Los Angeles. CA 90027 Jesse Green, Ph.D. Director of Research New York University Medical Center New York. NY 10016 Phyllis Gurdin Leake and Watts Children's Home 463 Hawthorne Avenue Yonkers. NY 10705 Melvyn R. Haas. M.D. National Institute of Mental Health Parklawn Building, 7CI0 Rockville. MD 20857 Mary Ellen Haines United Church Board for Homeland Ministries 132 West 31st Street New York, NY 10001 Lorranie Hale, Ph.D. Hale House Center 68 Edgecomb Avenue New York, NY 10030 Neal Halsey, M.D. Director. Division of Disease Control School of Hygiene and Public Health Johns Hopkins University 600 N. Wolfe St. Baltimore. MD 21205 H. Allan Handford, M.D. Hemophilia Center of Central Pennsylvania Director, Division of Child Psychiatry Penn State University College of Medicine Hershey, PA 17033 James C. Harris, M.D. Associate Professor Division of Child Psychiatry Johns Hopkins University School of Medicine Baltimore. MD 21205 Machelle Harris. M.D. New York City Department of Health Bureau of Maternity Services and Family Planning 280 Broadway, Room 303 New York, NY loo07 Maurice Hattmen Acting Regional Administrator Health Care Financing Administration Box 7760 Philadelphia. PA 19101 Rashida Lorraine Hassan Blacks Educating Blacks About Sexual Health Issues 1319 Locust Street, Third Floor Philadelphia. PA 19107 Harry Haverkos, M.D. National Institute of Drug Abuse Clinical Medicine Branch Division of Clinical Research Rockville. MD 20857 Herbert Hazen Director School Health Services School District of Philadelphia Philadelphia. PA 19103 79 Margaret C. Heagarty. M Director of Pediatrics Harlem Ho&al Center New York, `NY 10032 .D. James Hegarty, M.D. Columbia University School of Public Health Sergievsky Center-Epidemiology 100 Haven New York. NY 10032 Karen Hein, M.D. Albert Einstein College of MedicinelMontefiore Hospital Director, AIDS in Adolescence Program Bronx. NY 10461 Jay H. Herman. M.D. Penn-Jersey Regional Blood Services American Red Cross 23rd and Chestnut Streets Philadelphia, PA 19103 Margaret W. Hilgartner, M.D. Director, Division of Pediatric Hematology/Oncology New York Hospital-Cornell Medical Center 525 E. 68th Street New York, NY 10021 Susan Holman. R.N., M.S. SUNY Downstate Medical Center 450 Clarkson Avenue Brooklyn, NY 11203 John J. Hutchings. M.D. Division of Maternal and Child Health Department of Health and Human Services Rockville, MD 20857 Vince L. Hutchins, M.D. Division of Maternal and Child Health Department of Health and Human Services Rockville. MD 20857 Cecilia Hutto, M.D. Assistant Professor of Pediatrics Division of Infectious Diseases University of Miami P.O. Box 016960 Miami. FL 33101 Earthamae Isaac Legislative Assistant to Senator Arlen Spector Senate Office Building, Room 303 Washington, DC 20510 Joyce Jackson, M.A. Coordinator, AIDS Community Support Unit New Jersey State Department of Health Division of Narcotic and Drug Abuse 20 Evergreen Place East Orange, NJ 07018 Rudolph E. Jackson, M.D. Professor and Acting Chairman Department of Pediatrics Morehouse School of Medicine 720 Westview Drive, SW Atlanta. GA 30310 Annette Johnson, M.S., R.D. Education Coordinator AIDS Institute-NY State Dept. of Health 10 East 40th Street New York. NY 10016 Stephen Joseph, M.D. Commissioner of Health City of New York New York, NY 10013 Vijay Joshi. M.D. Department of Pathology Children's Hospital of New Jersey 15 South 9th Street Newark, NJ 07107 LaVohn E. Josten, Ph.D.. R.N. Director of Nursing Minnesota State Department of Health Minneapolis, MN 55415 Emily Kahn Philadelphia Department of Health AIDS Program 500 S. Broad Street Philadelphia, PA 19146 Ram Kairam, M.D. Assistant Professor of Clinical Pediatrics and Clinical Neurology St. Luke'slRoosevelt Hospital Center Amsterdam Avenue and 1 Ith Street New York, NY 10025 Aditya Kaul, M.D. Associate Professor Department of Pediatrics New York Medical College 234 East 149th Street Bronx, NY 10451 Anne E. Keller, M.D. Director, Division of Rehabilitation Pennsylvania Department of Health Box 90 Harrisburg, PA 17 108 80 Judith Keresztes, R.N. Data Coordinator. AIDS Program Children's Hospital of New Jersey 15 South Ninth Street Newark, NJ 07 103-2757 Barbara P. Kern, M.A. Director, Special Child Health Service New Jersey State Department of Health 120 S. Stockton Street, CN 364 Trenton, NJ 08625 C. Everett Koop, M.D., S.C. Surgeon General, Public Health Service Department of Health and Human Services Hubert H. Humphrey Building 200 Independence Avenue, S.E. Washington, DC 20201 Keith Krasinski, M.D. Bellevue Hospital Center/New York University Medical Center Pediatric Department First Avenue at East 27th Street New York, NY 10016 Penelope G. Krener. M.D. Department of Pediatrics and Psychiatry University of California, Davis 2315 Stockton Boulevard Sacramento. CA 95817 Helen G. Kushnick General Management Corporation 9000 Sunset Blvd.. Suite 400 Los Angeles, CA 90069 George Lamb. M.D. Boston City Hospital Administration Building, 4th Floor 818 Harrison Avenue Boston. MA 02 118 Normand LaPointe. M.D., F.R.C.P Hopital Sainte-Justine 3175 Cote Sainte-Catherine Montreal. Quebec H3T lC5 Canada William D. Lassek. M.D. Regional Health Administrator. Region III Department of Health and Human Services P.O. Box 13716 Philadelphia. PA 19101 Sandra Nusinoff Lehrman. M.D. Department of Virology Burroughs Wellcome Company 3030 Cornwallis Road Research Triangle Park, N.C. 27709 Carol Levine Co-Director, AIDS Project The Hastings Center 255 Elm Road Briarcliff Manor. NY 10510 Harold W. Lischner, M.D. Chief, Section of Immunology and Rheumatology St. Christopher`s Hospital for Children 5th and Lehigh Streets Philadelphia, PA 19133 Gwendolyn Long Assistant Regional Administrator Division of Youth and Family Services 1180 Raymond Boulevard, 18th Floor Newark. NJ 07102 Sarah Long, M.D. Chief. Section of Infectious Diseases St. Christopher's Hospital for Children 5th and Lehigh Avenue Philadelphia, PA 19133 Michael W. Lowenstein Commercial Insight 696 Meadowbrook Lane Moylan, PA 19063 Evelyn G. Lowery Southern Christian Leadership Conference P.O. Box 42257 Atlanta, GA 3031 I Elaine Lugovoy, R.N.. M.A. Associate Director of Nursing Pediatric Home Health Care Community Health Care of North Jersey. Inc. 451 Lincoln Avenue Orange, NJ 07050 German V. Maisonet, Jr., M.D. Medical Director Minority AIDS Project Coldwater Canyon Hospital 642 I Coldwater Canyon North Hollywood, CA 91606 Robert W. Marion, M.D. Assistant Professor of Pediatrics Albert Einstein College of Medicine Jacobi Hospital-Room 803 Pelham Parkway and Eastchester Road Bronx. NY 10461 Mary Mastrucci, M.D. University of Miami School of Medicine Division of Immunology and Infectious Diseases P.O. Box 016960 Miami. FL 33101 81 Robert M. May, F.R.S., Ph.D. Department of Biology Princeton University Princeton, NJ 08544 Donald J. McConnell. M.A., M.Div. Executive Director, CT Alcohol and Drug Abuse Commission 999 Asylum Avenue Hartford, CT 06105 Kenneth McIntosh, M.D. Children's Hospital Chief of Clinical Infectious Diseases 300 Longwood Ave. Boston, MA 02115 Loretta McLaughlin, C.P.A. Vice-President - Finance Delaware Valley Hospital Council 1315 Walnut Street Philadelphia, PA 19107 Janet L. Mitchell, M.D. Director of Ambulatory Perinatology Assistant Professor Harvard Medical School Beth Israel Hospital 330 Brookline Ave. Boston, MA 022 15 Lawrence Miike, M.D., J.D. Senior Associate Office of Technology Assessment U.S. Congress Washington. DC 20510 Howard Minkoff, M.D. Downstate Medical Center Box 24 450 Clarkson Avenue Brooklyn, NY 11203 Anthony Minnefor, M.D. Chief of Infectious Disease Division St. Joseph's Hospital and Medical Center 703 Main Street Paterson, NJ 07523 John Modlin, M.D. Associate Professor of Pediatrics Johns Hopkins University School of Medicine 600 N. Wolfe Street Baltimore, MD 21205 Paul A. Moore, M.S.W. Assistant Director, AIDS Initiative New York City Health and Hospital Corporation 346 Broadway, Room 531 New York, NY 10013 Rachael More&i. M.D. Department of Pathology The Albert Einstein College of Medicine 1300 Morris Park Avenue Forchheimer Building #401 Bronx, NY 10461 Susan Morrison, M.D. Pediatric Infectious Diseases University of Medicine and Dentistry of New Jersey 185 South Orange Avenue Newark. NJ 07103-2757 Thomas M. Mundy. M.D. Assistant Professor of Pediatrics UCLA School of Medicine Cedars-Sinai Medical Center Box 48750 Los Angeles, CA 90048-0750 Solbritt Murphy. M.D. Acting Director. Division of Family Health Services New York Department of Health Albany, NY 12237 Andre Nahmias. M.D. Department of Pediatrics Emory University School of Medicine 69 Butler Street, SE Atlanta, GA 30303 Linda Nelson, D.D.S. American Academy of Pediatric Dentistry 211 E. Chicago Avenue, Suite 1036 Chicago. IL 60611 Stephen W. Nicholas. M.D. Department of Pediatrics The Children's Hospital of Philadelphia Philadelphia, PA 19104 Brian Novick, M.D. Division of Clinical Allergy and Immunology Albert Einstein College of Medicine 1300 Morris Park Avenue Bronx, NY 10461 Rita O'Donnell Pediatric AIDS Surveillance Coordinator New York City Department of Health 125 Worth Street New York, NY 10013 Annette Gestreicher Editor-in-Chief, Medical lVor[d News 7676 Woodway Street Suite 112 Houston, TX 77063 82 James Oleske, M.D. Department of Pediatrics College of Medicine and Dentistry of New Jersey 100 Bergen Street Medical Science Building, F532 Newark, NJ 07 103 Gerald Oppenheimer, Ph.D. Associate Professor Department of Health and Nutrition Sciences Brooklyn College Brooklyn. NY 11215 Michael T. Osterholm, Ph.D.. M.P.H State Epidemiologist and Chief Minnesota Department of Health 717 S.E. Delaware Street Minneapolis. MN 55440 Margaret Oxtoby, M.D. Centers for Disease Control 1600 Clifton Road Atlanta, GA 30333 Savita Pahwa, M.D. Chief, Pediatric Immunology Division North Shore University Hospital 300 Community Drive Manhasset. New York 11030 Carmen Paris Health Education Philadelphia Dept. of Health AIDS Program 500 S. Broad Street Philadelphia. PA 19146 Wade P. Parks. M.D., Ph.D. Director of Pediatrics Division of Immunology & Infectious Disease University of Miami School of Medicine 1550 N.W. 10th Avenue Miami. FL 33136 Robert Parrott, M.D. Director Emeritus Children's Hospital National Medical Center 1 I I Michigan Avenue. NW Washington DC 20010 Jude C. Payne Research Analyst National Leadership Commission on Health Care 815 Connecticut Ave., NW Washington, DC 2OfJOl Cal Pierce Pediatric News 12230 Wilkins Ave. Rockville, MD 20852 Stanley A. Plotkin. M.D. Director, Division of Infectious Diseases The Children's Hospital of Philadelphia Philadelphia, PA I9104 B. Frank Polk, M.D. Professor of Epidemiology School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street Baltimore, MD 21205 Angelea Pot-tale, R.N. Department of OB/GYN Columbia Presbyterian Medical Center 622 W. 168th Street New York, NY 10032 Anna Portigal Parent Suki Ports Director, Minority Task Force on AIDS Council of Churches of the City of New York 92 St. Nicholas Avenue, IB New York City, NY 10026 Thomas C. Quinn, M.D.. M.S. National Institute of Allergy and Infectious Diseases Bethesda. MD 20892 Gerald V. Quinnan, Jr.. M.D. Division of Virology Food and Drug Administration Bethesda, MD 20892 Gary Remafedi, M.D. M.P.H. Assistant Professor of Pediatrics Adolescent Health Program University of Minnesota Hospital and Clinic Box 721, UMHC Minneapolis. MN 55455 Gloria Rodriguez, M.S.W. Public Health Consultant New Jersey State Department of Health 20 Evergreen Place. 4th Floor East Orange, NJ 07018 Martha F. Rogers, M.D. Medical Epidemiologist AIDS Program Centers of Disease Control Atlanta, GA 30333 Nancy G. Rowett Director of Public Relations Rhode Island Hospital 593 Eddy Street Providence, RI 02902 83 Arye Rubinstein, M.D. Professor of Pediatrics. Microbiology and Immunology Albert Einstein College of Medicine Bronx, NY 10461 George W. Rutherford. M.D. Medical Director. AIDS Office San Francisco Department of Public Health 1 I1 I Market Street San Francisco. CA 94103 Marie Saint Cyr-Delpe, M.S.W Haitian Coalition on AIDS 50 Court Street. Suite 605 Brooklyn, NY 11201 Madlene Sawyer, M.D. Department of Obstetrics/Gynecology University of Miami School of Medicine Jackson Memorial Hospital - R 136 P.O. Box 016960 Miami, FL 33101 Helen Schietinger. M.A.. R.N. Director, AIDS Education and Training Program California Nurses Association 1855 Folsom Street, Suite 670 San Francisco. CA 94103 Neil Schram, M.D. Kaiser-Permanente 25825 S. Vermont Avenue Harbor City. CA 90710-3599 Richard H. Schwarz, M.D. Professor and Chairman Department of Obstetrics and Gynecology Downstate Medical Center Brooklyn, NY 11023 Harvey Schweitzer Attorney 8 Columbia Avenue Takoma Park, MD 20912 Gwendolyn B. Scott, M.D. Associate Professor of Pediatrics Div. of Infectious Disease & Immunology University of Miami School of Medicine Box 016960 Miami, FL 33101 John Scott, R.N. Clinical Unit Coordinator Pediatric AIDS Program The Albert Einstein College of Medicine 1300 Morris Park Avenue Forchheimer Building, #401 Bronx, NY 10461 Jeffrey Seibert, Ph.D. Chair. Pediatric AIDS Task Force American Psychological Association Associate Professor. University of Miami P.O. Box 016820 Miami. FL 33101 Peter Selwyn. M.D. Medical Director Drug Abuse Treatment Program Montefiore Medical Center 1 I I East 2 10th Street Bronx, NY 10467 John Sever. M.D. Chief, Infectious Disease Branch. NINCDS National Institutes of Health Bldg 36. Room SD-06 Bethesda. MD 20892 Mary-Ann Shafer. M.D. Associate Director Division of Adolescent Medicine University of California at San Francisco San Francisco. CA 94143 Robert G. Sharrar. M.D., M.Sc. Director, Health Promotion/Disease Control Philadelphia Department of Public Health 500 South Broad Street Philadelphia, PA 19146 Karolynn Siegel. Ph.D. Director of Research Department of Social Work Memorial Sloan Kettering Cancer Center New York, NY 10021 Benjamin K. Silverman, M.D. Department of Emergency Medicine The Children's Hospital of Philadelphia 34th Street and Civic Center Boulevard Philadelphia. PA 19104 Peter Smith, M.D. Rhode Island Hospital 593 Eddy Street Providence, RI 02902 Shirley Smith, R.N., M.S. MCH Nursing Consultant Department of Health and Human Services JFK Federal Building Boston. MA 02902 George E. Sonsel, L.C.S.W. AIDS Project, Los Angeles 3670 Wilshire Boulevard. Suite 300 Los Angeles, CA 90010 Stephen Spector, M.D. Division of Infectious Diseases University of California San Diego Medical Center, H-814-H 225 Dickenson Street San Diego, CA 92103 Sari Staver Amen'can Medical News 535 North Dearborn Street Chicago, IL 60610 E. Richard Stiehm, M.D. University of California at Los Angeles Health Sciences Center Room 22-387 Los Angeles, CA 90024 Maria S. Suarez, M.D. Assistant Clinical Professor College of Physicians and Surgeons Columbia University Harlem Hospital/Pediatric Department 506 Lenox Avenue New York. NY 10037 Mary Tasker, M.S.W. Pediatric Social Worker Children's Hospital of New Jersey 15 South Ninth Street Newark. NJ 07107 Katy Taylor Deputy Director-AIDS Discrimination Unit New York City Commission on Human Rights 52 Duane Street, 7th Floor New York. NY loo07 Tom Tebbens Vice President Lewis, Gilman. Kynett. Inc. 1700 Market St. Philadelphia. PA 19106 Pauline Thomas, M.D. Director of AIDS Surveillance New York City Department of Health New York. NY 10013 James Troutman. M.D. Institute of Medicine 2101 Constitution Ave.. NW Washington, DC 20418 Diane W. Wara, M.D. Professor of Pediatrics University of California Medical Center San Francisco. CA 94143 Dottie Ward-Wimmer, R.N., B.A. Immunology Clinical Specialist Children's Hospital National Medical Center 111 Michigan Avenue, NW Washington, DC 20010 C.J. Wellington, M.D. Regional Program Consultant, MCH Room 306, Federal Office Building 50 United Nations Plaza San Francisco. CA 94102 Catherine M. Wilfert, M.D. Duke University Department of Pediatrics Division of Infectious Diseases Box 2951 Durham. NC 27710 English Willis, M.D. General Pediatrics The Children's Hospital of Philadelphia Philadelphia. PA 19104 Anne Willoughby, M.D.. M.P.H. Special Assistant for Pediatrics National Institute of Child Health and Human Development Landow 7C-05 Bethesda, MD 20892 Constance B. Wofsy, M.D. Co-Director. AIDS Activities 995 Potrero Avenue, Ward 84 San Francisco General Hospital San Francisco, CA 94110 Margaret Lynn Yonekura, M.D. Chief, Obstetrics Division of Maternal-Fetal Medicine Harbor UCLA Medical Center 1000 W. Carson Street Box #3 Torrence, CA 90509 Stephen Young, Coordinator, AIDS Health Services Division of Narcotics and Drug Abuse New Jersey State Department of HealthiCN 362 Trenton. NJ 08625 Joel Ziff Arthur Andersen and Company 5 Penn Center Philadelphia. PA 19103 85 APPENDIX B GROUP LEADERS James Chin, M.D., M.P.H. World Health Organization Louis Z. Cooper, M.D. St. Luke's-Roosevelt Hospital Center Jesse Green, Ph.D. New York University Medical Center Max Gomez, Ph.D. KYW-TV3, Philadelphia Margaret C. Heagarty, M.D. Harlem Hospital Center Stephen Joseph, M.D. Commissioner of Health. NYC Gloria Rodriguez, M.S.W. NJ State Department of Health Mary-Ann Shafer, M.D. University of California at San Francisco Pauline Thomas, M.D. Director of AIDS Surveillance, NYCDH Diane W. Wara, M.D. University of California at San Francisco RECORDERS Stephen Barbour, M.D. Jonathan Bell, M.D. Maryanne Bolton Erna Goulding, M.A.* Naynesh Kamani, M.D. Anne E. Kazak. Ph.D. Gary Marshall, M.D. Anthony Mauro, M.S.W. Stephen Nicholas, M.D. Marianne C. Raphaely ** Recorders are staff members of The Children's Hospital of Philadelphia. *Former Vice-President for Patient Care The Children's Hospital of Philadelphia **Member, Executive Council of Volunteer Organizations The Children's Hospital of Philadelphia Catherine M Wilfert, M.D. Duke University 86 APPENDIX C GUIDELINES FOR MANAGEMENT OF HIV INFECTION "Revision of the Case Definition of Acquired Immunodeficiency Syndrome," Morbidity and Mortality Weekly Report (MMWR), Vol. 34: 373-375, June 28, 1985. "Education and Foster Care of Children Infected with Human T-Lymphotropic Virus Type IIULymphadenopathy-Associated Virus," MMWR, Vol. 34: 5 17-52 1, August 30, 1985. "Heterosexual Transmission of Human T-Lymphotropic Virus Type IIULymphotropic-Associated Virus," MMWR, Vol. 34: 561-563, September 20, 1985. "Recommendations for Preventing Transmission of Infection with Human T-Lymphotropic Virus Type IIULymphadenopathy-Associated Virus in the Work- place," MMWR, Vol. 34: 681-685, November 15, 1985. "Recommendations for Assisting in the Prevention of Perinatal Transmis- sion of Human T-Lymphotropic Virus Type IIULymphadenopathy-Associated Virus and Acquired Immunodeficiency Syndrome," MMWR, Vol. 34: 721-732, December 6, 1985. "Recommendations for Preventing Transmission of Infection with Human T-Lymphotropic Virus Type IIULymphadenopathy-Associated Virus During Inva- sive Procedures, MMWR, Vol. 35: 221-223, April 11, 1986. "Immunization of Children Infected with HTLV-IIULAV," MMWR, Vol. 35: 595-605, September 26, 1986. "Classification System for Human Immunodeficiency Virus (HIV) Infection in Children under 13 Years of Age," MMWR, Vol. 36: 225-236, April 24, 1987. "Acquired Immune Deficiency Syndrome and HTLV-IIIILAV Infections," Report of the Committee on Infectious Diseases, American Academy of Pedi- atrics, Part 3: 81-87, 1986. "Prevention, Control, and Management of Infections in Day Care." in "Diseases spread through urine, blood. saliva, and other bodily fluids," Health in Day Care: A Manual for Health Professionals, American Academy of Pedi- atrics, 69-71, 1987. Confronting AIDS: Directions for Public Health, Health Care, and Research. Institute of Medicine, National Academy of Sciences, 1986. 87 APPENDIX D SELECTED READINGS Ammann AJ: The acquired immunodeficiency syndrome in infants and children. Ann Intern Med 1985; 103:734-7. Ammann AJ, Cowan M, Wara DW, Weintraub P, et al. : Acquired immunodefi- ciency in an infant: Possible transmission by means of blood products. Lancet 1983; 1:956-958. Ammann AJ, Wara DW, Dritz S, et al.: AIDS in an infant: Possible transmis- sion by means of blood products. Lancet 1983; 1:956. Andiman WA, Martin K, Rubinstein A, et al.: Opportunistic lymphoprolifera- tions associated with Epstein-Barr viral DNA in infants and children with AIDS. Lancet 1985; 1: 1390-93. Apparent transmission of HTLV-IIULAV from a child to a mother providing health care. MMWR 1986; 35-75. Barbour SD: Acquired immune deficiency syndrome of childhood. Pediatric Clinics of North America 1987; 34:247-268. Boland M, Gaskill TD: Managing AIDS in children. MCN 1984; 9:384. Chaisson RE, Allain JP, Leuther M, et al.: Significant changes in HIV antigen level in the serum of patients treated with azidothymidine. N Engl J Med 1987; 315:1610-11. Connor E, Mendelson J, Keresztes J, et al.: Lack of HTLV-III transmission for children with AIDS and AIDS Related Complex to household contacts. Inter- science Congress of Antimicrobial Agents and Chemotherapy. September 1986, New Orleans, LA. Cowan MJ, Hellman D, Chudwin D, et al.: Maternal transmission of AIDS. Pedi- atrics 1984; 73:382. Epstein LG, Sharer LR, Joshi VV, et al.: Progressive encephalopathy in chil- dren with Acquired Immune Deficiency Syndrome. Ann Neurol 1985; 17:488. Hellman D, Cowan MJ, Ammann AJ, et al.: Chronic active Epstein-Barr virus infections in two immunodeficient patients. J Pediat 1984; 103:584-588. 88 Johnson JP, Hammerberg 0, Walker IR, et al.: Early detection of HIV infection in a newborn. N Engl J Med 1987; 316:272-3. Joshi VV, Oleski JM, Minnefor AB, et al.: Pathology of suspected AIDS in chil- dren: A study of eight cases. Pediatr Pathol 1984; 2:71. Joshi VV, Connor EM, Oleski JM, et al.: Cardiovascular involvement in fatal cases of pediatric AIDS. ICAAC. September 1986, New Orleans, LA. Katz BZ, Andiman WA, Eastman R, et al.: Infection with two genotypes of Epstein-Barr virus in an infant with AIDS and lymphoma of the central nervous system. J Infect. Dis. 1986; 153:601-604. Marion RW, Wiznia AA, Hutcheon RG, et al.: The AIDS embryopathy: a recog- nizable pattern of craniofacial dysmorphism in children with AIDS. Am J Dis Child, in press. Oleski J, Connor E, Bobila R, et al.: The use of intravenous gamma globulin in children with the acquired immunodeficiency syndrome. Presented, Society for Pediatric Research, May 1986, Washington, DC. Parks W and Scott G: An overview of pediatric AIDS: approaches to diagnosis and outcome assessment. In AIDS: Modern concepts and therapeutic challenges. Ed. S Broder. Marcel Dekker, Inc., NY 1987; 245-262. Rogers MF: AIDS in children: a review of the clinical, epidemiological and public health aspects. Ped Infec Dis 1985; 4:3. Rubinstein A: Acquired immunodeficiency syndrome in infants. Am J Dis Child 1983; 137:825. Rubinstein A, Morecki R, Silverman B, et al.: Pulmonary disease in children with acquired immune deficiency and AIDS related complex. J Pediatr 1986; 108:498-503. Rubinstein A, Sickhck M, Gupta A, et al.: Acquired immunodeticiency with reversed T4/T8 ratios in infants born to promiscuous and drug addicted mothers. JAMA 1983; 249:2350-6. Schearer GM, Bernstein DC, Tung KS, et al.: A model for the selective loss of major histocompatibility complex self-restricted T cell immune responses during the development of acquired immune deficiency syndrome (AIDS). J Immunol 1986; 137:2514-21. Scott GB, Buck BE, Leterman JG, et al.: Acquired immunodeficiency syndrome in infants. N Engl J Med 1984; 310:76-81. Scott G, Buck B, Leterman J, Bloom F, and Parks W: Acquired immunodefi- ciency syndrome in Haitian infants. N Eng J Med 1984; 310:76-81. 89 Scott G, Fischl M, Klimas N, et al.: Mothers of infants with acquired immunodefi- ciency syndrome (AIDS): Evidence for both symptomatic and asymptomatic carriers. JAMA 1985; 253:363-366. Shaw GM, Hahn BH, Epstein LG, et al.: HTLV-III Infection in brains of chil- dren and adults with AIDS encephalopathy. Science 1985; 277: 177. Sunderam G, McDonald RJ, Maniatis T, Oleske J, et al.: Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). JAMA 1986; 256:362-366. Weiss SH, Goedert JJ, Sarngadharan MC, et al.: Screening test for HTLV-III (AIDS agent) antibodies. JAMA 1985; 253:221-225. Ziegler JG, Cooper DA, Johnson RO, et al.: Postnatal transmission of AIDS- associated retrovirus from mother to infant. Lancet 1985; 1:896. APPENDIX E April 24, 1983 I Vol. 36 I No. 15 MOR8lOllY AND h4ORTAlJlY WEEKLY REPORT Current Trends Classification System for Human lmmunodeficiency Virus (HIV1 Infection in Children Under 13 Years of Age INTRODUCTION With the identification of the causative agent of the acquired immunodeficiency syndrome (AIDS). a broad spectrum of clinical manifestations has been attributed to infection with the human immunodeficiency virus &lIV). With the exception of the CDC surveillance definition for AIDS ( 1.2 1, no standard definitions for other manifestations of HIV infection have been de- veloped for children. Classification systems published to date have been developed primarily to categorize clinical presentations in adult patients and may not be entirely applicable to in- fants and children (3-5). Physicians from institutions caring for relatively large numbers of HIV-infected children report that only about half of their patients with symptomatic illness related to the infection fulfill the criteria of the CDC surveillance definition for AIDS (6, 7). To develop a classification system for HIV infection in children, CDC convened a panel of consultants' consisting of clinicians experienced in the diagnosis and management of children with HIV infection; public health physicians; representatives from the American Academy of Pediatrics, the Council of State and Territorial Epidemiologists, the Association for Maternal Child Health and Crippled Children's Programs, the National Institute on Drug Abuse/Alcohol, Drug Abuse and Mental Health Administration, the National Institute of Allergy and Infectious Diseases/National Institutes of Health, and the Division of Maternal and Child Health/Health Resources and Services Administration; and CDC. GOALS AND OBJECTIVES OF THE CLASSIFICATION SYSTEM The system was designed primarily for public health purposes, including epidemiologic studies, disease surveillance, prevention programs, and health-care planning and policy. The panel attempted to devise a simple scheme that could be subdivided as needed for different purposes. `P Brunell. MD, R Dawn. MD, American Academy of Pediatrics; J Chin, MD. State Epidemiologist Callfor- nia Dept of Health Svcs; L Cooper, MD, St Luke'+Roosevelt Hospital Center, New York City. J Oleske. MD, MPH, L Epstein. MD, Univ of Medicine and Dentistry of New Jersey; N Luban. MD, Children's HOSPI- tal National Medical Canter. Washington. DC; S Mailloux. MD, Assoc of Maternal Child Health and CriP- pled Children's Programs; S Pawha. MD. North Shore Univ Hospital, Cornell University Medical Center. Manhassett, NY; G Scott, MD. Univ of Miami School of Medicine; R Stiehm. MD, Univ of California. LOS Angeles; P Thomas, MD, New York CitY Dept of Health; D Wara, MD. Univ of California. San Francisco: D Williams, MD. Los Angeles County Hospital: J Witte. MD. MPH. Florida Dept of Health and Rehabll&+ tive Svcs. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES I PUBLIC HEALTH SERVICE 91 MMWR April 24,1987 HIV Infection - Continued DEFINITION OF HIV INFECTION IN CHILDREN (Table 1) Ideally, HIV infection in children is identified by the presence of the virus in blood or tissues, confirmed by culture or other laboratory detection methods. However, current tests-including culture-for detecting the virus or its antigens are not standardized and are not readily available. Detection of specific antibody to the virus is a sensitive and specific in- dicator of HIV infection in adults, since the majority of adults with antibody have had culture evidence of infection W 10 1. Similar studies involving children have not been reported. Also, the presence of passively transferred maternal antibody in infants limits the interpretation of a positive antibody test result in this age group. Most of the consultants believed that passively transferred maternal HIV antibody could sometimes persist for up to 15 months. For this reason, two definitions for infection in children are needed: one for infants and children up to 15 months of age who have been exposed to their infected mothers perinatally, and another for older children with perinatal infection and for infants and children of all ages acquiring the virus through other means. infants and children under 15 months of ege with perinetal infection -Infection in in- fants and children up to 15 months of age who were exposed to infected mothers in the perinatal period may be defined by one or more of the following: 1) the identification of the virus in blood or tissues, 2) the presence of HIV antibody as indicated by a repeatedly reactive screening test (e.g., enzyme immunoassay) plus a positive confirmatory test (e.g., Western blot, immunofluorescence assay) in an infant or child who has abnormal immunologic test re- sults indicating both humoral and cellular immunodeficiency (increased immunoglobulin levels, depressed T4 [T-helper] absolute cell count, absolute lymphopenia, decreased T4/T8 ratio) and who meets the requirements of one or more of the subclasses listed under class P-2 (described below), or 31 the confirmation that a child's symptoms meet the previously published CDC case definition for pediatric AIDS ( 1.2 ). The infection status of other perinatally exposed seropositive infants and children up to 15 months of age who lack one of the above immunologic or clinical criteria is indeterminate. These infants should be followed up for HIV-related illness, and they should be tested at regu- TABLE 1. Summaryof the definition of HlVinfection in children lnfentr end children under 15 months of ags with perfnatal infection 1) Virus in blood or tissues Or 2) HIV antibody and evidence of both cellular and humoral immune deficiency and one or more categories in Class P-2 31 Symptoms mekg CDC case definition for AIDS Older &ildrett with perinatal infection and children with HIV infection acquired throu@ other modes of transmission 1) Virus in blood or tissues Or 2) HIV antibody Or 3) Symptoms meeting CDC case definition for AIDS 92 Vol. 3WNo. lb MMWR HIV Infection - Continued lar intervals for persistence of antibody to HIV. Infants and children who become seronegative, are virus-culture negative (if blood or tissue samples are cultured). and continue to have no clinical or laboratory-confirmed abnormalities associated with HIV infection are unlikely to be infected. Older children with perinatal infaction ad children with HIV infaction acquired through other mode8 of tmnsmisoion -HIV infection in these children is defined by one or more of the following: 1) the identification of virus in blood or tissues, 2) the presence of HIV antibody (positive screening test plus confirmatory test) regardless of whether immunologic abnormalities or signs or symptoms are present, or 31 the confirmation that the child's symp- toms meet the previously published CDC case definition for pediatric AIDS (1.2 1. These definitions apply to children under 13 years of age. Persons 4 3 years of age and older should be classified according to the adult classification system (3 ). CLASSIFICATION SYSTEM CTabla 21 Children fulfilling the definition of HIV infection discussed above may be classified into one of two mutually exclusive classes based on the presence or absence of clinical signs and symptoms (Table 2). Class Pediatric-l (P- 1) is further subcategorized on the basis of the presence or absence of immunologic abnormalities, whereas Class P-2 is subdivided by specific disease patterns. Once a child has signs and symptoms and is therefore classified in P-2, he or she should not be reassigned to class P-l if signs and symptoms resolve. Perinatally exposed infants and children whose infection status is indeterminate are classi- fied into class P-O. a-8 P-O. hdeteninata infection. Includes perfnatally exposed infants and children up to 15 months of age who cannot be classified as definitely infected according to the above definition but who have antibody to HIV, indicating exposure to a mother who is infected. Class P-l. Asymptomatic infection. Includes patients who meet one of the above defini- TABLE 2. Summary of the classification of HIV infection in children under 13 yearn of age Class P-O. hdetorminate infection Class P-l. As'ympternatic infection Subclass A. Normal immune function Subclass 6. Abnormal immune function Subclass C. Immune function not tested aas P-2 Syrnptanatic infection Subclass A. Nonspecific findings Subclass 6. Progressive nrurologic disease Subclass C. Lymphoid interstitial pneumonitis Subclass D. Secondary infectious diseases Category D-l. Specified secondary infectious diseases listed in the CDC surveillance defini- tion for AIDS Category D-2. Recurrent serious bacterial infections Category D-3. Other specified secondary infectious diseases Subclass E. Secondary cancers Category E-l. Specified secondary cancers listed in the CDC surveillance definition for AIDS Category E-2. Other cancers possibly secondary to HIV infection Subclass F. Other diseases possibly due to HIV infection 93 HIV Infection - Continued MMWR April 24, 1987 tions for HIV infection but who have had no previous signs or symptoms that would have led to classification in Class P-2. These children may be subclassified on the basis of immunologic testing This testing should include quantitative immunoglobulins, complete blood count with differential, and T- lymphocyte subset quantitation. Results of functional testing of lymphocytes fmitogens. such as pokeweed) may also be abnormal in HIV-infected children, but it is less specific rn compari- son with immunoglobulin levels and lymphocyte subset analysis, and it may be impractical Subclass A - Normal immune function. Includes children with no immune abnormalities associated with HIV infection. Subclass 8 - Abnonrre/immune function. Includes children with one or more of the com- monly observed immune abnormalities associated with HIV infection, such as hypergam- maglobulinemia, T-helper fT4) lymphopenia, decreased T-helper/T-suppressor tT4iTS) ratio, and absolute lymphopenia. Other causes of these abnormalities must be excluded. Subclass C - Not tested. Includes children for whom no or incomplete (see above) rm- munologic testing has been done. Clamps P-2. Symptomatic infection. Includes patients meeting the above definitions for HIV infection and having signs and symptoms of infection. Other causes of these srgns and symptoms should be excluded. Subclasses are defined based on the type of signs and symp- toms that are present. Patients may be classified in more than one subclass. Subclass A - Nonspecific findings. Includes children with two or more unexplained non- specific findings persisting for more than 2 months, including fever, failure-to-thrive or weight loss of more than 10% of baseline, hepatomegaly. splenomegaly, generalized lym- phadenopathy (lymph nodes measuring at least 0.5 cm present in two or more sates. with bilateral lymph nodes counting as one site). parotitis. and diarrhea (three or more loose stools per day1 that is either persistent or recurrent (defined as two or more episodes of dr- arrhea accompanied by dehydration within a I-month period). Subclass f3 - Progressive neurologic disease. Includes children with one or more of the following progressive findings: 1) loss of developmental milestones or intellectual ability. 2) impaired brain growth (acquired microcephaly and/or brain atrophy demonstrated on computerized tomographic scan or magnetic resonance imaging scan), or 3) progressive symmetrical motor deficits manifested by two or more of these findings: paresis. abnormal tone, pathologic reflexes, ataxia, or gait disturbance. Subc/ass C - Lmphoid interstitial pneumonitis. Includes children with a histologically confirmed pneumonitis characterized by diffuse interstitial and peribronchiolar infiltration of lymphocytes and plasma cells and without identifiable pathogens, or, in the absence of a histologic diagnosis, a chronic pneumonitis-characterized by bilateral reticulonodular in- terstitial infiltrates with or without hilar Jymphadenopathy-present on chest X-ray for a period of at least 2 months and unresponsive to appropriate antimicrobial therapy. Other causes of interstitial infiltrates should be excluded, such as tuberculosis, Prreumocysfis carinii pneumonia, cytomegalovirus infection, or other viral or parasitic infections. subc/uss D - &condufyinfectious discuses. Includes children with a diagnosis of an in- fectious disease that occurs as a result of immune deficiency caused by infection with HIV. Category D-I. Includes patients with secondary infectious disease due to one of the specified infectious diseases listed in the CDC surveillance definition for AIDS: Pneu- mocystis carinii pneumonia; chronic cryptosporidiosis; disseminated toxoplasmosis with onset after 1 month of age; extra-intestinal strongyloidiasis; chronic isosporia- sis; candidiasis fesophage81, bronchial, or pulmonary): extrapulmonary cryptococco- 94 Vol. 36INo. 15 MMWA HIV Infection - Continued sis: disseminated histoplasmosis; noncutaneous, extrapulmonary. or disseminated mycobacterial infection (any species other than leprae); cytomegalovirus infection with onset after 1 month of age; chronic mucocutaneous or disseminated herpes simplex virus infection with onset after 1 month of age; extrapulmonary or dissem- inated coccidioidomycosis; nocardiosis; and progressive multifocal leuko- encephalopathy. Category D-2. Includes patients with unexplained, recurrent. serious bacterial infec- tions (two or more within a 2-year period) including sepsis, meningitis. pneumonia. abscess of an internal organ, and bone/joint infections. Category D-3. Includes patients with other infectious diseases, including oral candi- diasis persisting for 2 months or more, two or more episodes of herpes stomatitis within a year, or multidermatomal or disseminated herpes zoster infection. subc/ass E - secondary cancers. Includes children with any cancer described below in categories E-l and E-2. Category E- 7. Includes patients with the diagnosis of one or more kinds of cancer known to be associated with HIV infection as listed in the surveillance definition of AIDS and indicative of a defect in cell-mediated immunity: Kaposi's sarcoma, B-cell non-Hodgkin's lymphoma. or primary lymphoma of the brain. Category E-2. Includes patients with the diagnosis of other malignancies possibly as- sociated with HIV infection. %bc/ass F - other diseases. Includes children with other conditions possibly due to HIV infection not listed in the above subclasses, such as hepatitis, cardiopathy, nephropathy. hematologic disorders (anemia. thrombocytopenia). and dermatologic diseases. Reported by: AIDS Program, Center for Infectious Diseases, CDC. Editorial Note: This classification system is based on present knowledge and understanding of pediatric HIV infection and may need to be revised as new information becomes available New diagnostic tests, particularly antigen detection tests and HIV-specific IgM tests, may lead to a better definition of HIV infection in infants and children. Information from several natural history studies currently under way may necessitate changes in the subclasses based on clini- cal signs and symptoms. A definitive diagnosis of HIV infection in perinatally exposed infants and children under 15 months of age can be difficult. The infection status of these HIV-seropositive infants and children who are asymptomatic without immune abnormalities cannot be determined unless wrus culture or other antigen-detection tests are positive. Negative virus cultures do not necessarily mean the child is not infected, since the sensitivity of the culture may be low. De- creasing antibody titers have been helpful in diagnosing other perinatal infections, such as toxoplasmosis and cytomegalovirus. However, the pattern of HIV-antibody production in in- fants is not well defined. At present, close follow-up of these children (Class P-O) for signs and symptoms indicative of HIV infection and/or persistence of HIV antibody is recommended. The parents of children with HIV infection should be evaluated for HIV infection, particular- ly the mother. The child is often the first person in such families to become symptomatic. When HIV infection in a child is suspected, a careful history should be taken to elicit possible risk factors for the parents and the child. Appropriate laboratory tests, including HIV serology, should be offered. If the mother is seropositive. other children should be evaluated regarding their risk of perinatally acquired infection. lntrafamilial transmission, other than perinatal or sexual, is extremely unlikely. Identification of other infected family members allows for ap- propriate medical care and prevention of transmission to sexual partners and future children (1 7,121. 95 MMWR April 24, 1987 HIV Infection - Continued The nonspecific term AIDS-related complex has been widely used to describe symptomat- ic HIV-infected children who do not meet the CDC case definition for AIDS Thus classiflcatlon system categorizes these children more specifically under Class P-2. The development and publication of this classification system does not imply any immedi- ate change in the definition of pediatric AIDS used by CDC for reporting purposes ( 1.2) Changes in this definition require approval by state and local health departments However, changes in the definition for reporting cases have been proposed by CDC and are awaiting state and local approval. Written comments are encouraged. They should be mailed to the AIDS Program, Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333 References 1 .CDC. Update acquwed immunodefictency syndrome (AIDS)-United States MMWR 1984.32 688-91. 2.CDC Revision of the case defimtlon of acqwed lmmunodeflclency syndrome for nattonal reporting-UnIted States. MMWR 1985;34:373-5 3.CDC. Classification system for human T-lymphotropic virus type Ill/lymphadenopathy-assoclaled virus infections. MMWR 1986;35:334-9. 4.Redfield RR. Wright DC, Tramont EC. The Walter Reed staging classlflcatlon for HTLV-III/LAV tnfec- tion.NEngIJMed1986;314.131-2. August 30, 1985 / Vol 34 I No. 34 517 Educatron and Foster Care of Children Infected with HTLV-IWLAV MORBIDITY AND MORTALITY WEEKLY REPORT Current Trends Education and Foster Care of Children Infected with Human T-Lymphotropic Virus Type Ill/ Lymphadenopathy-Associated Virus The information and recommendations contained in this document were developed and compiled by CDC in consultation with individuals appointed by their organizations to represent the Conference of State and Territorial Epidemiologists, the Association of State and Territo- rial Health Officers, the National Association of County Health Officers, the Division of Mater- nal and Child Health (Health Resources and Services Administrationl. the National Association for Elementary School Principals, the National Association of State School Nurse Consultants, the National Congress of Parents and Teachers, and the Children's Aid Societv. The consult- ants also included the mother of a child with acquired immunodeficiencv syndrome (AIDSI. a legal advisor to a state education department, and several pediatricians who are experts In the field of pediatric AIDS. This document is made available to assist state and local health and education departments in developing guidelines for their particular situations and locations These recommendations apply to all children known to be infected with human T-lympho- tropic virus type Ill/lymphadenopathy-associated virus (HTLV-III/LAW. This includes children with AIDS as defined for reporting purposes (Table 1 I; children who are diagnosed by their physicians as having an illness due to infection with HTLV-IIIILAV but who do not meet the case definition; and children who are asymptomatic but have virologic or serologic evidence of infection with HTLV-III/LAV. These recommendations do not apply to siblings of infected children unless they are also infected. BACKGROUND The Scope of the Problem. As of August 20. 1985. 183 of the 12,599 reported cases of AIDS in the United States were among children under 18 years of age. This number is expect- ed to double in the next year. Children with AIDS have been reported from 23 states. the Dis- trict of Columbia, and Puerto Rico, with 75% residing in New York. California. Flonda. and New Jersey. The 183 AIDS patients reported to CDC represent only the most severe form of HTLV- IWLAV infection, i.e., those children who develop opportunistic infections or maliynancles (Table 1). As in adults with HTLV-III/LAV infection, many infected children may have milder ill- ness or may be asymptomatic. Legal Issues. Among the legal issues to be considered in forming guldelines for the educa- tion and foster care of HTLV-III/LAV-infected children are the civil nghts aspects of public U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES I PUBLIC HEALTH SERVICE 97 MMWR August 30,lQW HTL V-III/LA V - Continued TABLE 1. Provisional case definition for acquired immunodeficiency rrdrome (AIDS) surveillance of children For the limited purposes of epidemiologic surveillance. CDC defines a case of pediatric ac- quired immunodeficlency syndrome (AIDS) as a child who has had: 1. A reliably diagnosed disease at least moderately indicative of underfying cellular immuno- deficiency, and 2. No known cause of underlying cellular lmmunodeficiency or any other reduced resistance reported to be associated with that disease. The diseases accepted as sufficiently indicative of underlying cellular tmmunodefictency are the same as those used in defining AIDS in adults. In the absence of these opportunistic diseases. a histologically confirmed diagnosis of chronic lymphoid interstitial pneumonitis will be consId- ered indicabve of AIDS unless test(s) for HTLV-IIIILAV are negative. Congenital infections. a.g , toxoplasmosis or herpes simplex virus infection in the first month after bvth or cytamegalowrus infection in the first 6 months after birth must be exluded. Specific conditions that must be excluded in a child are: 1. Primary tmmunodeficiency diseases-severe combined immunodefictency. DiGeorge syn- drome, Wiskott-Aldrich syndrome, ataxia-talangiectasIa. graft versus host disease. neu- tropenta, neutrophil function abnormality, agammaglobulinemla, or hypogammaglobullne- mia with raised IgM. 2. Secondary immunodeficiency associated with immunosuppressive therapy. lymphoreticu- lar malignancy, or starvation school attendance, the protections for handicapped children under 20 USC. 1401 et seq and 29 USC. 794, the confidentiality of a student's school record under state laws and under 20 USC. 12329. and employee right-to-know statutes for public employees m some states. Confidentiality bsues. The diagnosis of AIDS or associated illnesses evokes much fear from others in contact with the patient and may evoke suspicion of life styles that may not be acceptable to some persons. Parents of HTLV-WLAV-infected children should be aware of the potential for social isolation should the child's condition become known to others in the care or educational setting. School, day-care, and social service personnel and others involved in educating and caring for these children should be sensitive to the need for confidentiality and the right to privacy in these cases. ASSESSMENT OF RISKS Risk Factors for Acquiring HTLV-III/LM Infection and Transmission. In adults and ado- lescents, HLTV-IWLAV is transmitted primarily through sexual contact (homosexual or hetero- sexual) and through parenteral exposure to infected blood or blood products. HTLV-IWLAV has been isolated from blood, semen, saliva, and tears but transmission has not been docu- mented from saliva and tears. Adults at increased risk for acquiring HTLV-WLAV include homosexual/bisexual men, intravenous drug abusers, persons transfused with contaminated blood or blood products, and sexual contacts of persons with HTLV-IWLAV infection or in groups at increased risk for infection. The majority of infected children acquire the virus from their infected mothers in the perinatal period ( I-4). In utero or intrapartum transmission are likely. and one child reported from Australia apparently acquired the virus postnatally. possibly from ingestion of breast milk (5). Children may also become infected through transfusion of blood or blood products that contain the virus. Seventy percent of the pediatric cases reported to CDC occurred among children whose parent had AIDS or was a member of a group at increased risk of ac- quiring HTLV-III/LAV infection; 20% of the cases occurred among children who had received blood or blood products; and for 10%. investigations are incomplete. 98 Vol. 34lNo. 34 HTL V-III/LAV - Continued MMWR Msk of Transmission in the School, Day-Care or Foster-Care Setting. None of the identified cases of HTLV-IWLAV infection in the United States are known to have been trans- mitted in the school, day-care, or foster-care setting or through other casual person- to-person contact. Other than the sexual partners of HTLV-IWLAV-infected patients and in- fants born to infected mothers, none of the family members of the over 12,000 AIDS patients reported to CDC have been reported to have AIDS. Six studies of family members of patients with HTLV-IWLAV infection have failed to demonstrate HTLV-IWLAV transmission to adults who were not sexual contacts of the infected patients or to older children who were not likely at risk from perinatal transmission (6- 1 f I. Based on current evidence, casual person-to-person contact as would occur among schoolchildren appears to pose no risk. However, studies of the risk of transmission through contact between younger children and neurologically handicapped children who lack control of their body secretions are very limited. Based on experience with other communicable dis- eases, a theoretical potential for transmission would be greatest among these children. It should be emphasized that any theoretical transmission would most likely involve exposure of open skin lesions or mucous membranes to blood and possibly other body fluids of an in- fected person. Risks to the Child with HTLV-III/LAV Infection. HTLV-III/LAV infection may result in im- munodeficiency. Such children may have a greater risk of encountering infectious agents in a school or day-care setting than at home. Foster homes with multiple children may also in- crease the risk. In addition, younger children and neurologically handicapped children who may display behaviors such as mouthing of toys would be expected to be at greater risk for acquiring infections. lmmunodepressed children are also at greater risk of suffering severe complications from such infections as chickenpox. cytomegalovirus, tuberculosis, herpes sim- plex, and measles. Assessment of the risk to the immunodepressed child is best made by the child's physician who is aware of the child's immune status. The risk of acquiring iome infec- tions, such as chickenpox. may be reduced by prompt use of specific immune globulin follow- ing a known exposure. RECOMMENDATIONS 1. Decisions regarding the type of educational and care setting for HTLV-III/LAV-infected children should be based on the behavior, neurologic development, and physical con- dition of the child and the expected type of interaction with others in that setting. These decisions are best made using the team approach including the child's physi- cian, public health personnel, the child's parent or guardian. and personnel associated with the proposed care or educational setting. In each case, risks and benefits to both the infected child and to others in the setting should be weighed. 2. For most infected school-aged children, the benefits of an unrestricted setting would outweigh the risks of their acquiring potentially harmful infections in the setting and the apparent nonexistent risk of transmission of HTLV-III/LAV. These children should be allowed to attend school and after-school day-care and to be placed in a foster home in an unrestricted setting. 3. For the infected preschool-aged child and for some neurologically handicapped chil- dren who lack control of their body secretions or who display behavior, such as biting, and those children who have uncoverable, oozing lesions, a more restricted environ- ment is advisable until more is known about transmission in these settings. Children in- fected with HTLV-III/LAV should be cared for and educated in settings that minimize exposure of other children to blood or body fluids. 99 HTLV-III/lAV - Continued MMW R August 30.1985 4 Care involving exposure to the infected child's body fluids and excrement, such as feeding and diaper changing, should be performed by persons who are aware of the child's HTLV-IIIILAV infection and the modes of possible transmission, In any setting involving an HTLV-III/LAV-infected person, good handwashing after exposure to blood and body fluids and before caring for another child should be observed, and gloves should be worn if open lesions are present on the caretaker's hands. Any open lesions on the infected person should also be covered. 5. Because other infechons in addition to HTLV-III/LAV can be present In blood or body fluids, all schools and day-care facilities, regardless of whether children with HTLV-III/ LAV infection are attending, should adopt routine procedures for handling blood or body fluids. Soiled surfaces should be promptly cleaned with disinfectants, such as household bleach (diluted 1 part bleach to 10 parts water). Disposable towels or tissues should be used whenever possible, and mops should be rinsed in the drsinfect- ant. Those who are cleaning should avoid exposure of open skin lesions or mucous membranes to the blood or body fluids. 6. The hygrenic practices of children with HTLV-IIIILAV infection may improve as the child matures. Alternatively, the hygienic practrces may deteriorate if the child's con- dition worsens. Evaluation to assess the need for a restricted environment should be performed regularly. 7. Physicians caring for children born to mothers with AIDS or at increased risk of ac- quiring HTLV-III/LAV infection should consider testing the children for evidence of HTLV-III/LAV infection for medical reasons. For example, vaccination of infected children with live virus vaccines, such as the measles-mumps-rubella vaccine (MMR), may be hazardous. These children also need to be followed closely for problems with growth and development and given prompt and aggressive therapy for infections and exposure to potentially lethal infections, such as varicella. In the event that an antiviral agent or other therapy for HTLV-WLAV infection becomes available, these children should be considered for such therapy. Knowledge that a child is infected will allow parents and other caretakers to take precautions when exposed to the blood and body fluids of the child. 8. Adoption and foster-care agencies should consider adding HTLV-III/LAV screening to their routine medical evaluations of children at increased risk of infection before place- ment in the foster or adoptive home, since these parents must make decisions regard- ing the medical care of the child and must consider the possible social and psycholog- ical effects on their families. 9. Mandatory screening as a condition for school entry is not warranted based on availa- ble data. 10. Persons involved in the care and education of HTLV-III/LAV-infected children should respect the child's right to privacy, including maintaining confidential records. The number of personnel who are aware of the child's condition should be kept at a mini- mum needed to assure proper care of the child and to detect situations where the potential for transmission may increase (e.g.. bleeding injury). 11, All educational and public health departments, regardless of whether HTLV-III/ LAV-infected children are involved, are strongly encouraged to inform parents, chil- dren, and educators regarding HTLV-WLAV and its transmission. Such education would greatly assist efforts to provide the best care and education for infected children while minimizing the risk of transmission to others. 100