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.

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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.

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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