Overview 
 
 Toxic shock syndrome is a rare, life-threatening complication of certain types of bacterial infections. Often toxic shock syndrome results from toxins produced by Staphylococcus aureus (staph) bacteria, but the condition may also be caused by toxins produced by group A streptococcus (strep) bacteria. 
 
 Toxic shock syndrome has been associated primarily with the use of superabsorbent tampons. However, since manufacturers pulled certain types of tampons off the market, the incidence of toxic shock syndrome in menstruating women has declined. 
 
 Toxic shock syndrome can affect anyone, including men, children and postmenopausal women. Risk factors for toxic shock syndrome include skin wounds and surgery. 
 
 Symptoms 
 
 Possible signs and symptoms of toxic shock syndrome include: 
 
 A sudden high fever 
 
 Low blood pressure (hypotension) 
 
 Vomiting or diarrhea 
 
 A rash resembling a sunburn, particularly on your palms and soles 
 
 Confusion 
 
 Muscle aches 
 
 Redness of your eyes, mouth and throat 
 
 Seizures 
 
 Headaches 
 
 When to see a doctor 
 
 Call your doctor immediately if you have signs or symptoms of toxic shock syndrome. This is especially important if you've recently used tampons or if you have a skin or wound infection. 
 
 Causes 
 
 Most commonly, Staphylococcus aureus (staph) bacteria cause toxic shock syndrome. The syndrome can also be caused by group A streptococcus (strep) bacteria. 
 
 Risk factors 
 
 Toxic shock syndrome can affect anyone. About half the cases of toxic shock syndrome associated with Staphylococci bacteria occur in women of menstruating age; the rest occur in older women, men and children. Streptococcal toxic shock syndrome occurs in people of all ages. 
 
 Toxic shock syndrome has been associated with: 
 
 Having cuts or burns on your skin 
 
 Having had recent surgery 
 
 Using contraceptive sponges, diaphragms or superabsorbent tampons 
 
 Having a viral infection, such as the flu or chickenpox 
 
 Complications 
 
 Toxic shock syndrome can progress rapidly. Complications may include: 
 
 Shock 
 
 Renal failure 
 
 Death 
 
 Prevention 
 
 Manufacturers of tampons sold in the United States no longer use the materials or designs that were associated with toxic shock syndrome. Also, the Food and Drug Administration requires manufacturers to use standard measurement and labeling for absorbency and to print guidelines on the boxes. 
 
 If you use tampons, read the labels and use the lowest absorbency tampon you can. Change tampons frequently, at least every four to eight hours. Alternate using tampons and sanitary napkins, and use minipads when your flow is light. 
 
 Toxic shock syndrome can recur. People who've had it once can get it again. If you've had toxic shock syndrome or a prior serious staph or strep infection, don't use tampons. 

 Volume 5, Number 6—December 1999 
 
 Dispatch 
 
 Toxic Shock Syndrome in the United States: Surveillance Update, 1979–19961 
 
 Rana A. Hajjeh* , Arthur L. Reingold†, Alexis Weil*, Kathleen Shutt*, Anne Schuchat*, and Bradley A. Perkins* 
 
 Author affiliations: *Centers for Disease Control and Prevention, Atlanta, Georgia, USA; and †School of Public Health, University of California, Berkeley, California, USA 
 
 Cite This Article 
 
 Abstract Menstrual toxic shock syndrome (TSS) emerged as a public health threat to women of reproductive age in 1979–80. We reviewed surveillance data for the period 1979 to 1996, when 5,296 cases were reported, and discuss changes in the epidemiologic features of TSS. 
 
 Toxic shock syndrome (TSS) emerged as a result of changes in industry and personal behavior but responded to rapid public health action, including active surveillance (1). This illness received national attention in 1980 when unexplained febrile illness associated with shock, multiorgan dysfunction, and high death rates was reported in healthy young women from several states (2,3). This clinical syndrome had been described sporadically since the 1920s (4). The dramatic increase in the number of cases in 1979-80 spurred epidemiologic, clinical, and laboratory studies that resulted in better understanding of the association between high-absorbency tampons and TSS (5). These studies led to recommendations that substantially decreased the risk for TSS (6,7). 
 
 TSS became a nationally notifiable disease in 1980 (8). After the initial epidemic, the number of reported cases decreased significantly. In 1986, active surveillance was conducted in many areas in the United States (total population 34 million) to confirm that trend (9). The cumulative incidence (0.5 per 100,000 population) confirmed the substantial decrease in the incidence of menstrual TSS observed in the passive surveillance system. Incidence rates decreased from 6 to 12 per 100,000 among women 12 to 49 years of age (10,11) in 1980 to 1 per 100,000 among women 15 to 44 years of age in 1986. These data also demonstrated that passive surveillance accurately described the demographic characteristics and case-fatality ratio of TSS cases (12,13). 
 
 Ongoing surveillance in the United States allows us to estimate the current incidence of TSS and monitor whether new menstrual or vaginal products affect the risk for disease. Other products, including high-absorbency disposable diapers, have raised similar questions regarding TSS in children. To address these questions and describe the current epidemiologic characteristics and recent temporal trends of the syndrome, we reviewed data from the ongoing national surveillance for TSS from 1979 through 1996, focusing on three periods: 1979 to 1980 (the epidemic years), 1981 to 1986 (a period of increased TSS awareness, culminating in active surveillance in 1986), and 1987 to 1996. 
 
 The Study The national TSS surveillance system has been described (8). Cases of TSS are reported to the Centers for Disease Control and Prevention (CDC) by state health departments in standardized case reports that include information on demographic and clinical characteristics, hospitalization status, outcome, laboratory data, products used during menses, and recurrence of menstruation-associated cases. We used the surveillance case definition for TSS revised in 1981, which requires five clinical criteria: fever, hypotension, rash, desquamation, and abnormalities in three or more organ systems (8). A definite case fulfilled all five criteria (unless the patient died before desquamation), and a probable case fulfilled four of the five criteria. For the purposes of this analysis and because information on desquamation was often unavailable because of death or early discharge, we included all TSS reports meeting either definition. A similar change regarding exclusion of desquamation was adopted in a retrospective study (14). A TSS case was considered menstrual if onset of symptoms occurred within 3 days of the beginning or end of menses; all other cases were considered nonmenstrual and were classified into three categories: surgical wounds, postpartum or postabortion, and other. Information on recurrent episodes of TSS was collected only from women with menstrual TSS, by asking them about a similar previous illness during menstruation. Data were analyzed by using SAS 6.1 (SAS, Cary, NC). The chi-square test was used to test for statistical significance. Figure From 1979 to 1996, 5,296 TSS cases were reported; 1,035 of these were reported from 1987 to 1996 (Figure). Overall, 93% of all TSS cases reported from 1979 to 1996 were among women. Although the proportion of menstrual cases decreased (Table), TSS affected mostly women. The median age was 22 years (3 days to 87 years); 91% were white. No significant seasonal variation was noted. For cases in which the source of the report was known (n = 2,118), 64% were reported by infection control practitioners and 28% by physicians. Menstrual TSS accounted for 74% of TSS cases during 1979 to 1996 (n = 5,296); this proportion, however, declined from 91% during 1979 and 1980 to 71% during 1981 to 1986 and 59% during 1987 to 1996. The median age of patients with menstrual TSS was 21 years, but 41% (n = 1,591) of menstrual TSS cases occurred in female patients 13 to 19 years of age. No significant change in the age distribution of menstrual cases was noted between the three periods (median age: 21 years, 1979 to 1980; 20 years, 1981 to 1986; 25 years, 1987 to 1996). Most (98%) patients with menstrual TSS cases for which the menstrual product was known (n = 3,457) reported tampon use, a proportion that did not change; 89% used tampons only, while 5.0% used both tampons and pads and 3% used tampons and minipads. The level of tampon absorbency was reported in only 41% (n = 1,385) of cases: 28% of patients used regular tampons, while 71% used super-absorbency tampons. Staphylococcus aureus was isolated from 90% of women with menstrual TSS who had vaginal cultures performed (n = 2,536). Of all the women with menstrual TSS, 1,606 (30%) responded to the question regarding recurrent disease, and 10% reported a previous illness similar to their TSS episode. Nonmenstrual cases also occurred mostly in women (73%) and whites (87%). During 1987 to 1996, the proportion of all TSS cases that were nonmenstrual averaged 41% (30% to 55%). Of nonmenstrual cases, 18.3% were reported after surgical procedures, 11.5% were postpartum or postabortion, and 23.1% had nonsurgical cutaneous lesions. The proportion of all nonmenstrual cases reported after surgical procedures increased from 14% during 1979 to 1986 to 27% during 1987 to 1996 (p <0.05). Among female nonmenstrual case-patients, 12% reported using barrier contraceptives (sponges and diaphragms); this proportion was, however, significantly less (p <0.05) in 1987 to 1996 (6%) than in 1979 to 1986 (14%). Fifty cases of TSS in children < 5 years of age were reported during the 17-year period; more than half of these occurred in children < 2 years of age, and most (61.7%) were associated with nonsurgical cutaneous lesions. The percentage of TSS associated with nonsurgical cutaneous lesions (23.1%) was higher among younger patients (overall case-fatality ratio 4% [n = 2 deaths]) than among patients with other nonmenstrual cases. Hospitalization status was known for 2,930 patients; 98% were hospitalized. The overall TSS case-fatality ratio was 4.1% (3% for menstrual cases, 5% for nonmenstrual cases) and was significantly higher among nonmenstrual cases (p <0.005). Among menstrual cases, the case-fatality ratio decreased significantly with time (from 5.5% in 1979 and 1980, to 2.8% in 1981 to 1986, to 1.8% in 1987 to 1996, chi-square for linear trend [p = 0.0001]). This trend was not observed among nonmenstrual cases (for the three time periods: 8.5%, 5.3%, and 6%, respectively). 
 
 Conclusions Our review of recent passive surveillance data confirms the declining trend previously noted by active surveillance in 1986. Changes observed in the epidemiologic characteristics of TSS include an increase in the proportion of nonmenstrual cases and the difference in the risk for death between menstrual and nonmenstrual cases. A number of factors could account for the observed decline, including the decrease in tampon absorbency, the standardized labeling required by the U.S. Food and Drug Administration; greater awareness of TSS among women; and the proliferation of educational materials for women, including tampon package inserts (12). However, at least 40% of menstrual TSS cases continue to affect women 13 to 19 years old, an age group not as likely to be aware of the risk for TSS and for whom further education may be needed. Over the last few years, two changes have occurred in tampon use and composition: 1) All-cotton tampons have been introduced and marketed as an alternative product; in vitro studies have not, however, found any differences in the effects of these new tampons on the production of toxic shock syndrome toxin-1 (TSST-1) or its adsorption (15). 2) Tampons marketed specifically for overnight use have also been introduced. TSST-1 toxin production is not the only indicator of the potential risk for TSS. Previous case-control studies found that exclusive use of tampons was associated with a higher risk for TSS than use in conjunction with pads (13). Continued surveillance will monitor the effect of these changes on TSS occurrence. However, because the syndrome is rare, only large changes in the use of higher absorbency products would be likely to come to public health attention. One of the important changes in the epidemiology of TSS is the increasing proportion of nonmenstrual cases, in particular, cases reported after surgical procedures. The factors contributing to this increase may include changes in delivery of surgical health-care services, with an increase in both outpatient procedures and the use of prosthetic devices. Hospitalizations caused by infections from prosthetic devices and postoperative infections increased significantly from 1980 to 1994 in the United States (16). In addition, the case-fatality ratio of nonmenstrual TSS cases did not decline, although the case-fatality ratio of menstrual TSS did. This difference in death rates could be due to several factors: nonmenstrual TSS may occur in less healthy (e.g., older) persons; diagnostic and reporting biases may result in more sensitive detection of severe cases of nonmenstrual TSS; decreased awareness of nonmenstrual TSS among health-care professionals may lead to increased deaths because of late treatment; and the nonspecific signs and symptoms of postoperative TSS may delay diagnosis (17). Further studies are needed to validate the difference in deaths between the two types of TSS and to clarify the risk factors for nonmenstrual TSS. Recent molecular studies of the gene that carries toxic shock toxin (18) may contribute to a better understanding of the emergence of TSS and transmission of toxin-producing strains of S. aureus and could improve prevention. Physicians, in particular surgeons, and other health-care professionals may need further education about the risks for nonmenstrual TSS. 
 
 Dr. Hajjeh is a medical epidemiologist in the Division of Bacterial and Mycotic Diseases Branch, CDC. Her areas of expertise and research interests include epidemiology of mycotic diseases, bacterial meningitis, and unexplained critical illnesses of possible infectious etiology. 
 
 References 
 
 U.S. Public Health Services . Addressing emerging infectious disease threats. A prevention strategy for the United States. Atlanta: Centers for Disease Control and Prevention; 1994 . Todd JK , Kapral FA , Fishaut M , Welch TR . Toxic shock syndrome associated with phage group 1 staphylococci. Lancet . 1978 ; 2 : 1116 – 8 . DOI PubMed Centers for Disease Control and Prevention . Toxic-shock syndrome–United States. MMWR Morb Mortal Wkly Rep . 1980 ; 29 : 229 – 30 . Broome CV . Epidemiology of toxic shock syndrome in the United States: Overview. Rev Infect Dis . 1989 ; 2 ( Suppl 1 ): S14 – 21 . Shands KN , Schmid GP , Dan BB , Blum D , Guidotti RJ , Hargrett NT , Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl J Med . 1980 ; 303 : 1436 – 42 . PubMed Centers for Disease Control and Prevention . Toxic shock syndrome–United States. MMWR Morb Mortal Wkly Rep . 1980 ;: 2979 . Centers for Disease Control and Prevention . Follow-up on toxic-shock syndrome. MMWR Morb Mortal Wkly Rep . 1980 ; 29 : 441 – 5 . Reingold AL , Hargrett NT , Shands KN , Dan BB , Schmid GP , Strickland BY , Toxic shock syndrome surveillance in the United States, 1980 to 1981. Ann Intern Med . 1982 ; 96 : 875 – 80 . PubMed Gaventa S , Reingold AL , Hightower AW , Broome CV , Schwartz B , Hoppe C , Active surveillance for toxic shock syndrome in the United States. 1986. Rev Infect Dis . 1989 ; 2 ( Suppl 1 ): S28 – 34 . Davis JP , Chesney PJ , Wand PJ , LaVenture M . Toxic-shock syndrome: epidemiologic features, recurrence, risk factors and prevention. N Engl J Med . 1980 ; 303 : 1429 – 35 . PubMed Latham RH , Kehrberg MW , Jacobson JA . Toxic shock syndrome in Utah: a case-control and surveillance study. Ann Intern Med . 1982 ; 96 : 906 – 8 . PubMed Schuchat A , Broome CV . Toxic shock syndrome and tampons. Epidemiol Rev . 1991 ; 13 : 99 – 112 . PubMed Centers for Disease Control and Prevention . Reduced incidence of menstrual toxic shock syndrome–United States, 1980-1990. MMWR Morb Mortal Wkly Rep . 1990 ; 39 : 421 – 4 . PubMed Petitti DB , Reingold AL . Update through 1985 on the incidence of toxic shock syndrome among members of a prepaid health plan. Rev Infect Dis . 1989 ; 11 ( Suppl 10 ): S22 – 7 . PubMed ): Schlievert PM . Comparison of cotton and cotton/rayon tampons for effect on production of toxic shock syndrome toxin. J Infect Dis . 1995 ; 172 : 1112 – 4 . PubMed Simonsen L , Conn LA , Pinner RW , Teutsch S . Trends in infectious disease hospitalizations in the United States, 1980-1994. Arch Intern Med . 1998 ; 158 : 1923 – 8 . DOI PubMed Hughes D , Stapleton J . Postoperative toxic shock syndrome. Iowa Med . 1991 ; 81 : 55 – 8 . PubMed Lindsay J , Ruzin A , Ross HF , Kurepina N , Novick RP . The gene for toxic shock toxin is carried by a family of mobile pathogenicity islands in Staphylococcus aureus. Mol Microbiol . 1998 ; 29 : 527 – 43 . DOI PubMed 
 
 Figure 
 
 Table 
 
 Table of Contents – Volume 5, Number 6—December 1999 

 A 16-year-old girl in British Columbia died of toxic shock syndrome related to her tampon use, a coroner found. 
 
 Sara Manitoski was found dead on an overnight school trip in March 2017 near Vancouver Island, with an unknown cause of death. 
 
 Her friends left the cabin that morning for breakfast thinking that she was still sleeping, but when they returned she was still in bed with her alarm going off. Staff and students, along with emergency responders, attempted CPR on Manitoski but she did not recover. 
 
 Now, over a year later, the coroner has determined that she died of toxic shock syndrome, based on the strain of staphylococcus aureus found on a tampon that was in her body. The report states that she also had other signs of TSS, but notes that tampons are not the only cause of the bacterial infection. 
 
 Sara Manitoski Sara Manitoski/Facebook 
 
 “We know there is an association. And again, it’s very rare,” Island Health medical health officer Dee Hoyano told CTV Vancouver Island. “Certainly we know a person needs to have this particular bacteria to get sick, and then there may be something with tampon use, maybe prolonged tampon use, that puts that risk higher for developing a more widespread infection.” 
 
 Toxic shock syndrome is extremely rare — in 2016 there were just 40 reported cases in the United States, and about half were not related to menstruating women, Dr. Mary Jane Minkin, an ob-gyn from Yale University and member of PEOPLE’s Health Squad, told PEOPLE. 
 
 But when TSS does occur, it develops from toxins already present in the body. 
 
 “The first is vaginal colonization with a strain of S. aureus, which can make the toxin; the second is production by the S. aureus of the toxin; the third is penetration across the vaginal epithelium of enough toxin to cause disease; and the fourth is a lack of adequate titers of the neutralizing antibody to the toxin,” Dr. JoAnn Pinkerton, executive director of The North American Menopause Society told PEOPLE. 
 
 And women of younger ages are more susceptible to the disease. 
 
 “Younger women are more likely to get TSS, possibly because of more exposure through tampons or barrier contraceptive use,” Pinkerton said. “It may also be because they haven’t developed the antibodies yet.” 
 
 To reduce the chance of developing TSS, Pinkerton and Minkin recommend swapping out tampons every two to three hours, and avoid sleeping in them overnight. Additionally, it’s best to use lower-absorbency tampons to reduce dryness, and to switch off between tampons and pads. 
 
 However, Minkin said that women should not be overly concerned. 
 
 “The tampons themselves are not contaminated with bacteria,” she said. “The nasty staph organisms are unfortunately carried by us, not the tampons. So I would encourage all women to pay attention to their health, but not to worry.” 

 A coroner’s report has confirmed that a Canadian teen who died during an overnight school trip suffered from toxic shock syndrome (TSS). Sara Manitoski, who was on an outdoor education trip on Hornby Island, near Vancouver Island, was found lifeless in bed in March 2017. 
 
 Her friends had assumed the 16-year-old was sleeping and left for breakfast without her, but when they returned her phone alarm was going off and she was unresponsive. Paramedics and school staff unsuccessfully attempted CPR. 
 
 PHOTO CAPTURES MOMENT TODDLER'S LEG BROKE WHILE ON SLIDE WITH MOM 
 
 Now, more than a year later, the BC Coroners Service confirmed a strain of staphylococcus aureus on a tampon, as well as other symptoms consistent with TSS, were discovered, CTV News reported. TSS is a dangerous, sometimes fatal illness caused by bacterial toxins. It’s primarily linked to menstruating women who use super-absorbent tampons, but the infection can affect people of all ages, including men, children and postmenopausal women. 
 
 “We know there is an association,” Dee Hoyano, Island Health Medical officer, told CTV Vancouver Island. “Certainly we know a person needs to have this particular bacteria to get sick, and then there may be something with tampon use, maybe prolonged tampon use, that puts that risk higher for developing a more widespread infection.” 
 
 Manitoski’s sister, Carli Manitoski, took to Facebook to warn about TSS in December. 
 
 MAN WITNESSES DAUGHTER'S MARRIAGE DAY BEFORE CANCER DEATH 
 
 “After 9 agonizing months we have finally got confirmation that my litter sister passed away from Toxic Shock Syndrome or (TSS). Women need to be more educated on this subject, some of you might not even know TSS is,” she wrote. “They say getting TSS is incredibly rare but I know two people that have had it, with one barely surviving and my sister who died from it. Can it really be that rare? My sister complained of stomach cramps before going to bed and then she never woke up.” 
 
 She said her sister was healthy, and that others need to educate themselves on safe tampon use. 
 
 “There is such little education on this and it needs to be brought to light,” she posted. “Such an unnecessary and tragic thing to happen to such an amazing young lady. I wouldn’t want this to happen to anyone else and if this post makes even one person aware and go look up and educate themselves on TSS then I am grateful.” 

 The BC Coroners Service has released its report into the death of 16-year-old Courtenay resident Sara Manitoski, who died last year while camping on Hornby Island. 
 
 Coroner Courtney Cote has concluded that Manitoski died of toxic shock syndrome (TSS). 
 
 The toxicology exam completed was negative for alcohol, prescription and illicit drugs. 
 
 Manitoski, a Grade 11 student in G.P. Vanier’s integrated studies outdoor education (Explore) program, was with fellow students on an overnight field trip at the Outdoor Education Centre in Tribune Bay Provincial Park. 
 
 RELATED: Courtenay high school rocked by death of student 
 
 According to the coroner’s report, Manitoski had complained during the day’s activities on March 14, of feeling unwell and suffering from cramps. 
 
 She retired to her shared cabin at approximately 9:50 p.m. 
 
 At approximately 7 a.m. March 15, the other students in the cabin went for breakfast. They returned at 7:30 to find Manitoski’s alarm sounding. 
 
 “Sara failed to shut the alarm off, another student checked on her and found her unresponsive,” the report states. “The students alerted the teachers, and emergency services were contacted and bystander cardiopulmonary resuscitation (CPR) was initiated by the teachers. BC Ambulance Service personnel and RCMP attended. Paramedics took over CPR; however, were unable to re-establish vital signs and resuscitation was discontinued.” 
 
 The report said Manitoski was “heard breathing rapidly and shallowly in the middle of the night for a short period of time and then stopped.” 
 
 The original examination found increased skin redness on the neck, upper arms, upper chest, lower abdomen and medial thighs. 
 
 Tests completed on a tampon found in place identified the presence of staphylococcus aureus. Both findings are consistent with toxic shock syndrome. 
 
 “The risk for toxic shock syndrome is increased with tampon use; however, tampon use is not the sole cause. Therefore, it is not possible to definitively exclude the tampon as causative,” said Cote in her report. 
 
 “[These] findings, as well as the symptoms Sara exhibited immediately prior to her death, are all consistent with the effects of toxic shock syndrome. I find that Sara Marie Manitoski died on Hornby Island on March 15, 2017, of toxic shock syndrome as a consequence of staphylococcus aureus. I classify this death as natural.” 
 
 The report was dated March 23, 2018. It was released to the Comox Valley Record on June 25.
– An overnight school trip last year turned tragic for a Canadian teen, and now a coroner has confirmed why. People reports 16-year-old Sara Manitoski, who was found unresponsive in her cabin bed after friends came back from breakfast, died of toxic shock syndrome, with the coroner's conclusion based on symptoms of the condition that Sara exhibited, as well as evidence of Staphylococcus aureus bacteria found on a tampon in her body. Per the coroner's report, Sara had told others on the trip she didn't feel well on March 14, 2017, complaining of stomach cramps, the Comox Valley Record reports. She went into her cabin for the night close to 10pm, and when her cabin mates returned from breakfast around 7:30 the next morning, she was still in bed, her alarm going off. CPR by teachers and paramedics was unsuccessful in resuscitating her. Per the Mayo Clinic, TSS is caused when Staphylococcus aureus bacteria creates toxins, causing high fever, seizures, and even death. Women are most at risk, especially young women who may not have built up antibodies, but men, kids, and postmenopausal women are also vulnerable. Other risk factors include burns or cuts on one's skin or a viral infection like the flu. Still, the condition is extremely rare—only 40 US cases were reported in 2016, per People—and for menstruating women, there are ways to prevent it, including swapping tampons out every few hours so bacteria doesn't have a chance to breed. "There is such little education on this and it needs to be brought to light," Sara's sister said on Facebook in December, per Fox News. "Such an unnecessary and tragic thing to happen to such an amazing young lady." (This model has made it her mission to spread the word on TSS.)