HICNet Medical News Digest Mon, 15 Aug 1994 Volume 07 : Issue 37 Today's Topics: [MMWR 15 July 94] Death from Fumigents in Railroad Cars [MMWR] Legionaire's Disease Associated with Cooling Towers [MMWR] Progress Towards Global Eradication of Poliomyelitis AIDS Daily News Summaries +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Mosaic WWW: http://biomed.nus.sg/MEDNEWS/welcome.html Compilation Copyright 1994 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine Martin I. Herman, M.D., LeBonheur Children's Medical Center, Memphis TN Stephen Cristol, M.D., Dept of Ophthalmology, Emory Univ, Atlanta, GA Subscription Requests = mednews@stat.com anonymous ftp = vm1.nodak.edu; directory HICNEWS FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Mon, 15 Aug 94 06:20:08 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 15 July 94] Death from Fumigents in Railroad Cars Message-ID: <0JP4qc2w165w@stat.com> Deaths Associated with Exposure to Fumigants in Railroad Cars -- United States Multiple incidents of illness and death following exposure to fumigated agricultural products in railroad cars have been reported by several states along the U.S.-Mexico border. From 1989 through 1993, the Texas Department of Health identified three incidents involving 11 exposed persons, resulting in two deaths. The California Environmental Protection Agency, Department of Pesticide Regulation, recorded two deaths in fumigated boxcars in 1989. This report summarizes the two most recent fatal incidents. Case 1 On September 18, 1993, during routine inspection of a train 450 miles east of El Paso, Texas, U.S. Immigration and Naturalization Service Border Patrol agents discovered four males (aged 12, 35, 39, and 52 years) in a hopper car containing loose bulk lima beans. These persons entered the rail car in El Paso through an unlocked top hatchway at approximately 7 a.m. While in the rail car, the men opened the hatch door as fresh air was needed, then closed it. They fell asleep and were discovered by border patrol agents at 11 p.m. When found, the three men were ill, and the 12-year-old was dead. The men reported nausea, vomiting, headache, and abdominal discomfort. The cause of death for the 12-year-old was listed as asphyxiation after inhalation of phosphine gas. No autopsy was conducted. One man was available for follow-up interview; he reported that he did not see any signs on the rail car that warned of pesticide use. According to border patrol reports, warning signs on the rail car indicated the beans had received routine fumigation with aluminum phosphide. Case 2 On March 29, 1989, the body of a 23-year-old man was discovered in a rice-filled rail car as it was unloaded in Maxwell, California. Autopsy results revealed phosphine in tissue samples. On March 17 in Houston, aluminum phosphide pellets had been deposited in the loaded railroad car. The rail car had been sealed with plastic and warning signs had been posted. Rips discovered in the plastic during unloading indicated that the car had been entered after fumigation. Reported by: D Perrotta, PhD, T Willis, D Salzman, J Borders, Bur of Epidemiology, Texas Dept of Health. L Mehler, MD, Pesticide Illness Surveillance Program, Worker Health and Safety Br, California Environmental Protection Agency. Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Surveillance Br, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. Editorial Note: Fumigant pesticides routinely are used to protect grains and legumes from insect damage during transport and storage. Before 1986, carbon tetrachloride and carbon disulfide mixtures were the primary fumigants used during rail transport. When these products were banned by the U.S. Environmental Protection Agency (EPA) (1,2), fumigation using phosphorus and sulfur compounds increased. Aluminum phosphide, which is highly insecticidal (3), has been used increasingly by the grain industry (4). Aluminum phosphide pellets, deposited into a loaded boxcar, react with moisture in the grain to create the toxic gas phosphine; the reaction can occur within 5 minutes (2). The U.S. Department of Transportation (DOT) requires that, after a loaded car is fumigated, it should remain out of transit for 48 hours. Once the gas completely dissipates, the food product is nontoxic (5). Fumigants, such as aluminum phosphide, can liberate toxic gases that are rapidly absorbed through the respiratory tract (6). Symptoms may begin immediately and can include fatigue, headache, nausea, vomiting, abdominal pain, cough, and shortness of breath. Acute poisoning, such as occurs after inhalation of phosphine, can lead to pulmonary edema, central nervous system depression, toxic myocarditis, and circulatory collapse (3). Aluminum phosphide cannot be detected in blood or urine (7). Treatment is symptomatic and supportive. Long-term effects may include genotoxicity (1). Both the DOT* and EPA (8) publish guidelines for placement of warning signs on transport vehicles or freight containers that have been fumigated or treated with poisonous substances. These guidelines vary regarding the size and placement of the sign and the wording, graphic symbols, and languages used on the sign. Carriers may conform to either agency's set of regulations and guidelines. DOT is reviewing its regulations for potential updating. Surveillance for pesticide poisoning is complicated by lack of uniform reporting guidelines and difficulty in attributing specific adverse health outcomes to pesticide exposure. Although 25 states require that illnesses caused by pesticides be reported, few actively solicit and follow up case reports (10). The Texas case report was detected through the Sentinel Event Notification System for Occupational Risk (SENSOR) program of CDC's National Institute for Occupational Safety and Health (NIOSH)**. Texas mandates reporting of only occupationally related pesticide exposures; persons who apply fumigants, agricultural workers, and grain inspectors may be exposed to high levels of fumigants. Nonoccupational exposures, such as in this report, can be reported to the Texas Department of Health; nonoccupational exposures and fatalities (9) may occur during residential application by unlicensed personnel or following improper disposal of fumigation pellets. California mandates that physicians report all illnesses caused by pesticides to local health officers. Deaths resulting from illegal entry into fumigated rail transport cars have not been reported previously. The incidents described here underscore the potential for state-based surveillance systems to identify new problems that require corrective measures. Appropriately placed, highly visible warning signs printed in English and other languages that incorporate symbols may have prevented these deaths. Other prevention measures should include adequate locking for all points of entry on rail cars. References 1. Garry VF, Griffith J, Danzl TJ, et al. Human genotoxicity: pesticide applicators and phosphine. Science 1989;246:251-5. 2. Zaebest DD, Blade LM, Burroughs GE, Morrelli-Schroth P, Woodfin WJ. Phosphine exposure in grain elevators during fumigation with aluminum phosphide. Applied Industrial Hygiene 1988;3:146-54. 3. Jayaraman KS. Death pills from pesticide. Nature 1991;353:377. 4. Alavanja MC, Rush GA, Stewart P, Blair A. Proportionate mortality study of workers in the grain industry. J Natl Cancer Inst 1987;78:247-52. 5. Worthing CR, ed. The pesticide manual: a world compendium. 7th ed. In: The British Crop Protection Council. Suffolk, England: Lavenham Press Limited, 1983. 6. Morgan DP. Recognition and management of pesticide poisonings. 4th ed. Washington, DC: US Environmental Protection Agency, 1989; publication no. EPA-540/9-88/001. 7. Feldstein A, Heumann M, Barnett M. Fumigant intoxication during transport of grain by railroad. J Occup Med 1991;33:64-5. 8. US Environmental Protection Agency. Guidance for the reregistration of pesticide products containing aluminum or magnesium phosphide as the active ingredient. Washington, DC: US Environmental Protection Agency, 1986; report no. 540/RS-87-109. 9. Wilson R, Lovejoy FH, Jaeger RJ, Landrigan PL. Acute phosphine poisoning aboard a grain freighter. JAMA 1980;244:148-50. 10. US General Accounting Office. Pesticides on farms--limited capability exists to monitor occupational illnesses and injuries: report to the chairman, Committee on Agriculture, Nutrition, and Forestry, US Senate. Washington, DC: US General Accounting Office, December 1993; report no. GAO/PEMD-94-6. *CFR parts 172.201, 172.510, 173.9, and 49 CFR chapter 1 (10-1-92 Edition). **SENSOR is a program of cooperative agreements between NIOSH and state health departments to develop generalizable models for state-based occupational health surveillance. Fourteen states have been awarded cooperative agreements to develop surveillance systems for 12 conditions. ------------------------------ Date: Mon, 15 Aug 94 06:22:11 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Legionaire's Disease Associated with Cooling Towers Message-ID: Legionnaires' Disease Associated with Cooling Towers -- Massachusetts, Michigan, and Rhode Island, 1993 From July through October 1993, outbreaks of Legionnaires' disease (LD) were reported from communities in Massachusetts and Rhode Island and from a state prison in Michigan. Cooling towers (CTs) were identified as the source of all three outbreaks. This report summarizes investigations by state and local health officials and CDC and efforts to control these outbreaks. Massachusetts During July-August 1993, LD was diagnosed in 11 persons living in Fall River, Massachusetts. The mean age of patients was 59 years (range: 40-72 years); six were men. Three persons died. Three persons had Legionella pneumophila serogroup 1 (Lp-1) isolated from respiratory secretions, four had Lp-1 antigens detected in respiratory secretions by direct fluorescent antibody testing, three had fourfold rises in serum antibody titer to Lp-1, and one had both a fourfold rise in serum antibody titer and Lp-1 antigens detected in urine by radio-immunoassay. A case-control study, matching the 11 patients and 22 controls by primary physician, age, sex, and underlying medical condition, indicated that patients were more likely than controls to have visited sites within a 0.04-square-mile (0.1-square-km) neighborhood of Fall River in the 2 weeks before onset of illness (matched odds ratio [OR]=14.0; 95% confidence interval [CI]=1.6- 120.8); no other activities were significantly associated with acquiring LD. Water samples from seven CTs within the neighborhood and from the homes of culture-positive patients were taken approximately 1 month after onset of the last identified case of LD in the community and cultured for legionellae. All samples from potable water taps in patients' homes were culture-negative. Five isolates were cultured from four CTs. Lp-1 was cultured from two conjoined CTs on a building within the neighborhood and had the same monoclonal antibody subtype (MAS) and pulsed-field gel electrophoresis (PFGE) patterns as all three clinical isolates. The conjoined CTs were decontaminated on an emergency basis according to guidelines previously developed by a technical work group (1). The onset of the last identified case was August 10, and the CT was decontaminated on September 24. No additional cases were identified after decontamination. Michigan During August-September 1993, LD was diagnosed in 17 persons with pneumonia at a state prison in Michigan; 16 patients were inmates, and one was an employee. One patient died. The mean age of the patients was 47 years (range: 29-81 years); all were men. One person had Lp-1 cultured from respiratory secretions and, for 11, LD was diagnosed by a fourfold rise in titer of antibodies to Lp-1; five patients with pneumonia had evidence of LD by single convalescent-phase antibody titers of 512 or more. Water samples from wells and potable water taps in the prison and the prison hospital, from the prison hospital CT, and from a CT near the prison were cultured for legionellae. All of the potable water samples were culture-negative. Lp-1 was isolated from both CTs. The isolate from the CT located on the roof of the prison hospital had the same PFGE pattern as the single clinical isolate. Fourteen (0.6%) of 2253 prisoners who used exercise yards each day adjacent (within 100 yards) to the prison hospital had LD, compared with two (0.1%) of the 2270 inmates who used yards at least 400 yards from the prison hospital (relative risk=7.1; 95% CI=1.6-31.0). The CT on the prison hospital was shut down on September 17 and decontaminated according to published guidelines (1). No new cases of LD were identified with onset after September 1. Rhode Island During August 30-October 20, 1993, LD was diagnosed in 17 patients who lived or worked in eastern Rhode Island. The patients' mean age was 54 years (range: 28-86 years); 11 were men. Two patients died. Seven patients had Lp-1 cultured from respiratory secretions and 10 had Lp-1 antigen detected in urine. A case-control study, matching the 17 patients with 33 controls by physician practice, age, sex, and underlying medical conditions, indicated that patients were more likely than controls to visit a 0.04-square-mile (0.1-square-km) section of downtown Providence (matched OR=6.5; 95% CI=1.4-30.9) in the 2 weeks before onset of illness. Water samples from the homes of six culture-positive patients were negative for legionellae by culture, but samples from 10 of 24 CTs and one of three decorative fountains in downtown Providence were positive for Lp-1. The environmental isolates were tested by MAS and PFGE; one isolate from a CT on a building located within the area had the same MAS and PFGE patterns as isolates cultured from four case-patients who reported visiting the LD-associated section of downtown Providence. No other sources of transmission were identified in the community. These Lp-1 isolates had MAS and PFGE patterns that were different than those from the Fall River outbreak (approximately 19 miles away); however, the PFGE patterns suggested that the isolates were genetically related. The CT was shut down and decontaminated on an emergency basis on October 26. No additional cases of LD associated with the area were identified after decontamination of the CT. Reported by: TE Gecewicz, L Saravo, Fall River Dept of Public Health; SM Lett, MD, PE Kludt, MPH, A DeMaria, Jr, MD, State Epidemiologist, Massachusetts Dept of Public Health. MG Stobierski, DVM, D Johnson, MD, W Hall, MD, S Dietrich, H Stiefel, S Robinson-Dunn, PhD, S Shah, Michigan Dept of Public Health; C Hutchinson, MD, Michigan Dept of Corrections. LA Mermel, DO, CH Giorgio, Rhode Island Hospital, Providence; L D'Agostino, M Rittman, U Bandy, MD, M Stoeckel, BT Matyas, MD, State Epidemiologist, Rhode Island Dept of Health. Div of Field Epidemiology, Epidemiology Program Office; Childhood and Respiratory Diseases Br and Emerging Pathogens Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Approximately 1000-1300 cases of LD are reported to CDC annually. However, because previous studies indicate that most cases are not diagnosed, the incidence of disease may be substantially higher (2). Legionella causes 1%-5% of community-acquired pneumonia in adults (3); most cases occur sporadically. The case-fatality rate of LD is 5%-30% (2). Diagnosis of LD requires heightened clinical suspicion. Culturing respiratory secretions for legionellae and testing urine for presence of antigen are not routinely performed for patients with community-acquired pneumonia. Although not widely used, urinary antigen detection is a sensitive (60%-80%), highly specific (more than 99%), and rapid method for diagnosing infection caused by Lp-1 (the cause of 90% of cases of LD) (4). In comparison, serial serum antibody titers require several weeks for definitive results. Single serum antibody titer results have low predictive value (positive and negative) and are not useful for diagnosing LD in nonoutbreak situations. However, they may be useful in identifying cases during outbreaks of LD when serial serum specimens are unavailable--as for some patients in the Michigan investigation--and when Legionella is suspected to be the cause of a substantial proportion of pneumonia under investigation. Although most cases of LD are not associated with outbreaks, investigations of outbreaks have provided most of the knowledge about transmission of the disease. LD can be transmitted by aerosol-producing devices (e.g., CTs [5,6], evaporative condensers [7,8], whirlpool spas [2], humidifiers [9], and decorative fountains [2]), and by potable water aerosolized by shower heads and tap-water faucets (2,10). CTs and evaporative condensers have been identified as sources of transmission of LD since the late 1970s. Although legionellae can be cultured in up to 40% of CTs, these devices are rarely associated with outbreaks of LD (1). To reduce CT-related LD, CDC recommends maintenance of all CTs in accordance with published guidelines. Although the attributable risk of CTs in sporadically occurring LD is unknown, the findings in this report indicate that CTs remain an important cause of outbreaks of LD. In each investigation, molecular typing of isolates confirmed the epidemiologic findings. CDC, in collaboration with other agencies, is establishing guidelines for prevention of LD, targeting CTs as well as other known sources of LD. References 1. Wise M, Addiss D, LaVenture M, et al. Control of Legionella in cooling towers: summary guidelines. Madison, Wisconsin: Wisconsin Department of Health and Social Services, 1987. 2. Breiman RF. Modes of transmission of epidemic and nonepidemic Legionella infection: directions for further study. In: Barbaree JM, Breiman RF, Dufour AP, eds. Legionella: current status and emerging perspectives. Washington, DC: American Society for Microbiology, 1993:30-5. 3. Hoge CW, Breiman RF. Advances in the epidemiology and control of Legionella infections. Epidemiol Rev 1991;13:329-40. 4. Edelstein PH. Laboratory diagnosis of Legionnaires' disease: an update from 1984. In: Barbaree JM, Breiman RF, Dufour AP, eds. Legionella: current status and emerging perspectives. Washington, DC: American Society for Microbiology, 1993:7-11. 5. Dondero TJ Jr, Rendtorff RC, Mallison GF, et al. An outbreak of Legionnaires' disease associated with a contaminated air-conditioning cooling tower. N Engl J Med 1980;302:365-70. 6. Garbe PL, Davis BJ, Weisfeld JS, et al. Nosocomial Legionnaires' disease: epidemiologic demonstration of cooling towers as a source. JAMA 1985;254:521-4. 7. Cordes LG, Fraser DW, Skaliy P, et al. Legionnaires' disease outbreak at an Atlanta, Georgia, country club: evidence for spread from an evaporative condenser. Am J Epidemiol 1980;111:425-31. 8. Breiman RF, Cozen W, Fields BS, et al. Role of air sampling in an investigation of an outbreak of Legionnaires' disease associated with exposure to aerosols from an evaporative condenser. J Infect Dis 1990;161:1257-61. 9. Mahoney FJ, Hoge CW, Farley TA, et al. Communitywide outbreak of Legionnaires' disease associated with a grocery store mist machine. J Infect Dis 1992;165:736-9. 10. Hanrahan JP, Morse, DL, Scharf VB, et al. A community hospital outbreak of legionellosis: transmission by potable hot water. Am J Epidemiol 1987;125:639-49. ------------------------------ Date: Mon, 15 Aug 94 06:23:14 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Progress Towards Global Eradication of Poliomyelitis Message-ID: Progress Toward Global Eradication of Poliomyelitis, 1988-1993 In May 1988, the World Health Organization (WHO) adopted a resolution to eradicate poliomyelitis by the year 2000. Since then, all six WHO regions have made substantial progress toward this goal using three major control strategies: 1) maintaining high coverage of children with at least three doses of oral poliovirus vaccine (OPV3); 2) administering supplementary doses of OPV to all young children (generally those aged less than 5 years) during National Immunization Days (NIDs)* and during door-to-door vaccination campaigns in areas where wild poliovirus circulation persists at low levels; and 3) developing sensitive systems of epidemiologic and laboratory surveillance (1). This report summarizes progress of the global polio eradication initiative from 1988 through 1993.** Worldwide. Reported global vaccination coverage with OPV3 by age 1 year increased from 67% in 1988 to 85% in 1990 but decreased to 80% in 1992 and 81% in 1993 (Figure 1). From 1988 through 1993, reported cases of polio decreased 70%, from 32,286 to 9714 (Figure 1). During these years, there were substantial decreases in the number of countries reporting polio cases (88 [45%] of 196 and 56 [27%] of 209, respectively) and the number of countries reporting 100 or more cases per year (20 [10%] and 11 [5%], respectively) (Figure 2). In addition, the number of countries reporting zero polio cases increased from 107 (55%) to 144 (69%).*** African Region. Reported coverage with OPV3 increased from 44% in 1988 to 57% in 1991 but decreased to 49% in 1992 and 50% in 1993. From 1988 through 1993, reported cases of polio decreased from 4546 to 1437. The number of countries reporting polio cases remained unchanged (37 [79%] of 47). In 1993, the African region reported 15% of the global total of polio cases. Despite reporting zero polio cases for more than 3 years, Namibia reported an outbreak of 53 cases in 1993, probably as a result of recent importation of wild poliovirus from a polio-endemic area. Region of the Americas. Reported coverage with OPV3 increased from 82% to 86%, while reported cases of polio decreased from 340 to zero; the number of countries reporting polio cases decreased from 13 (28%) to zero of 47. The last confirmed case of paralytic polio caused by wild poliovirus occurred in August 1991 in Peru. Eastern Mediterranean Region. Reported coverage with OPV3 increased from 69% to 75%, while reported cases of polio increased from 2332 to 2451; the number of countries in the region reporting polio decreased from 17 (71%) of 24 to 10 (43%) of 23. In 1993, the Eastern Mediterranean Region reported 25% of the global total of polio cases; 84% of the regional total was reported from Pakistan (74%) and Sudan (10%). In 1993, Pakistan and Sudan experienced large outbreaks (1803 and 252 reported cases, respectively), primarily among unvaccinated children. Despite OPV3 coverage of more than 85% and no reported cases for at least 2 years, small outbreaks of type 1 also occurred in Oman during 1988 and 1993 and in Jordan during 1991-92; all three outbreaks were caused by importation of wild poliovirus from other polio-endemic countries. European Region. Reported coverage with OPV3 decreased from 86% to 72%, while reported cases of polio decreased from 206 to 198; the number of countries reporting polio cases increased from seven (23%) of 31 to 12 (24%) of 50. In 1993, the European Region reported 2% of the global total of polio cases; 83% of the regional total was from republics of the former Soviet Union. Azerbaijan and Uzbekistan experienced outbreaks in 1993 (70 and 68 reported cases, respectively), primarily among unvaccinated children. Despite coverage of 97% with three doses of inactivated poliovirus vaccine and no reported polio cases for more than 10 years, the Netherlands experienced an outbreak of 71 cases during 1992-93 among members of a religious group who do not routinely accept vaccination, caused by importation of wild poliovirus that originated from the Indian subcontinent. Southeast Asia Region. Reported coverage with OPV3 increased from 57% to 90%, while reported cases of polio decreased from 22,814 to 4414. The number of countries in the region reporting polio cases decreased from nine (82%) to seven (64%) of 11. In 1993, the Southeast Asian Region reported 45% of the global total of polio cases; 93% of the regional total was from India. Western Pacific Region. Reported coverage with OPV3 increased from 89% to 93%, while reported cases of polio decreased from 2079 to 1214; the number of countries reporting polio cases decreased from six (17%) to five (14%) of 35. In 1993, the Western Pacific Region reported 13% of the global total of polio cases; 88% of the regional total was from the People's Republic of China (54%) and Vietnam (34%). Despite OPV3 coverage of 90% and no reported polio cases for 5 years, Malaysia experienced a small outbreak in 1992 caused by importation of wild poliovirus that originated from the Indian subcontinent. Reported by: Expanded Program on Immunization, Global Program for Vaccines, World Health Organization. Polio Eradication Activity, National Immunization Program; Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; International Health Program Office, CDC. Editorial Note: Since 1988, the global incidence of paralytic polio has decreased substantially, and polio apparently has been completely eliminated from the Region of the Americas (1,2). The number of polio cases reported in 1993 represents a 33% decrease compared with 1992 and a 70% decrease compared with 1988. Furthermore, nearly three quarters of all countries reported zero cases of polio in 1993, and polio-free zones are present or emerging in the Americas, northern, southern, and eastern Africa, the Arabian peninsula, western and central Europe, and the Western Pacific (Figure 2). Despite this substantial progress overall, paralytic polio remains highly endemic throughout the Indian subcontinent and continues to occur in most countries of sub-Saharan Africa and Asia, including many republics of the former Soviet Union (Figure 2). In 1993, nearly two thirds of all polio cases reported worldwide were from the Indian subcontinent, including 42% from India, 19% from Pakistan, and 2% from Bangladesh. Lower than optimal levels of routine vaccination coverage, pockets of unvaccinated children within otherwise highly vaccinated populations, crowding, poor sanitation, and suboptimal seroconversion to poliovirus types 1 and 3 following three routine doses of OPV in many tropical and subtropical regions probably contribute to ongoing wild poliovirus transmission in these areas (1,3). In addition to remaining areas of endemic transmission, outbreaks of paralytic polio have recently occurred in several countries 2 or more years after the last reported case of polio, despite high levels of routine vaccination coverage (4,5). Genotypic comparisons between wild poliovirus strains in the global laboratory network have demonstrated that outbreaks in Oman (1988-89 and 1993), Jordan (1991-92), Malaysia (1992), and the Netherlands (1992-93) occurred as a result of importation of wild poliovirus from polio-endemic countries in the Indian subcontinent (4,5). Thus, until polio is eradicated globally, every polio-free country may be at risk for importation of wild poliovirus from remaining polio-endemic reservoirs. Routine vaccination alone is probably insufficient to eliminate wild poliovirus transmission in most countries, and supplementary vaccination activities, including NIDs, are necessary in countries where polio remains endemic (1,2,6-10). In 1993 and early 1994, NIDs were conducted for the first time in China, Vietnam, Philippines, Laos, Iran, and Pakistan, which together accounted for 31% of all polio cases reported globally; by the end of 1994, at least 63 (30%) of 209 countries will be conducting NIDs as a polio-control strategy. As more countries adopt this strategy, further progress is expected toward global eradication of polio. Despite substantial progress toward global eradication of polio, several challenges remain, including 1) reversing the decline in global routine vaccination levels; 2) increasing vaccination levels in unvaccinated subpopulations; 3) preventing the reintroduction of wild poliovirus into polio-free areas by eliminating reservoirs in polio-endemic countries (particularly the Indian subcontinent); 4) increasing the awareness of donor agencies and governments in industrialized countries of the substantial financial and humanitarian benefits of global eradication of polio, thus engendering support from unaffected countries beyond that already provided by organizations such as Rotary International; 5) encouraging all countries that remain polio-endemic to make polio eradication a priority activity, including the implementation of NIDs and the initiation of acute flaccid paralysis surveillance; and 6) providing support to vaccination program managers for training to develop managerial skills for implementing and maintaining effective vaccination and surveillance programs in all countries. The success of the polio eradication initiative will depend on finding solutions to these financial, managerial, political, and technical challenges. References 1. CDC. Progress toward global eradication of poliomyelitis, 1988-1991. MMWR 1993;42:486-7,493-5. 2. World Health Organization. Poliomyelitis in 1993. Wkly Epidmiol Rec 1994;69:169-76. 3. Patriarca PA, Wright PS, John TJ. Factors affecting immunogenicity of oral poliovirus vaccine in developing countries: review. Rev Infect Dis 1991;13:926-39. 4. Reichler MR, Abbas A, Alexander J, et al. Outbreak of poliomyelitis in a highly immunized population in Jordan [Abstract]. In: Program and abstracts of the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1992. 5. Sutter RW, Patriarca PA, Brogan S, et al. Outbreak of paralytic poliomyelitis in Oman: evidence for widespread transmission among fully vaccinated children. Lancet 1991;338:715-20. 6. Hull HF, Ward NA, Hull BP, Milstien JB, de Quadros C. Paralytic poliomyelitis: seasoned strategies, disappearing disease. Lancet 1994;343:1331-7. 7. CDC. National Poliomyelitis Immunization Days--People's Republic of China, 1993. MMWR 1993;42:837-9. 8. CDC. National Immunization Days and status of poliomyelitis eradication--Philippines, 1993. MMWR 1994:43;6-7,13. 9. CDC. Progress toward poliomyelitis eradication--Egypt, 1993. MMWR 1994;43:223-6. 10. CDC. Progress toward poliomyelitis eradication--Socialist Republic of Vietnam, 1991-1993. MMWR 1994;43:387-91. *Mass campaigns over a short period (days to weeks) in which two doses of OPV are administered to all children in the target age group, regardless of prior vaccination history, with an interval of 4-6 weeks between doses. **Based on surveillance data submitted to WHO as of July 1, 1994. ***The difference between the number of countries reporting polio cases or zero cases and the total number of countries reflects those not submitting reports. ------------------------------ Date: Mon, 15 Aug 94 06:23:43 MST From: mednews (HICNet Medical News) To: hicnews Subject: AIDS Daily News Summaries Message-ID: <9PP4qc5w165w@stat.com> AIDS Daily News Summary The Centers for Disease Control and Prevention (CDC) National AIDS Clearinghouse makes available the following information as a public service only. Providing this information does not constitute endorsement by the CDC, the CDC Clearinghouse, or any other organization. Reproduction of this text is encouraged; however, copies may not be sold, and the CDC Clearinghouse should be cited as the source of this information. Copyright 1994, Information, Inc., Bethesda, MD In this issue: ************************************************************************ "HIV-1 Newborns" "PCP Prophylaxis in Paediatric HIV Infection: Time for a Change" "Syringe and Needle Exchange to Prevent HIV Infection" "Knowledge and Practice Among Injecting-Drug Users of Bleach Use for Equipment Disinfection--New York City, 1993" "Expanding the AIDS Arsenal" "Herpes Drug Can Raise AIDS Patients'Life Expectancy, Hopkins Team Says" "Guidelines for Preventing Transmission of Human Immunodeficiency Virus Through Transplantation of Human Tissue and Organs" "Thymomodulin" "Birth Outcomes Following Zidovudine Therapy in Pregnant Women" "NCAP's Guide on Evaluating HIV/AIDS-Service Programs Available from CDC National AIDS Clearinghouse" "Substance Use and HIV-Related Sexual Behaviors Among US High School Students: Are They Related?" "PML Treatment Update, Peptide T Possibility" "Team Finds HIV Immune System Booster" "FDA Approves Drug ddC as Single AIDS Treatment" "FDA Approves AZT for AIDS Pregnant Women" "Medarex Bispecific Neutralizes Broad Variety of Clinical HIV Strains" ************************************************************************ "HIV-1 Newborns" New England Journal of Medicine (06/30/94) Vol. 330, No. 26, P. 1905 (Speiser, Daniel E.; Wyler, Claire-Anne; Siegrist, Claire-Anne) Speiser et al. acknowledge that Blanche et al.'s study confirms the bimodal pattern of AIDS in newborns, and clearly demonstrates the link between the infant's survival and the severity of disease in the mother. These findings, however, do not offer an explanation for how HIV-infected babies can progress to AIDS in a matter of months. Speiser et al. suggest that HIV-1-specific immunologic intolerance may directly lead to rapid disease progression. This condition occurs when antigens present in the fetal thymus during early development are viewed as self-antigens, and the immature immune systems learns not to respond against them. Advanced disease in the mother, then, could result in early transmission in utero- possibly of a larger viral inoculum or more virulent HIV strains--that could infect the fetal thymus and, therefore, induce immunologic intolerance. "PCP Prophylaxis in Paediatric HIV Infection: Time for a Change" Lancet (07/02/94) Vol. 344, No. 8914, P. 5 (Kovacs, Joseph A.; Kovacs, Andrea A.S.) Despite major breakthroughs in prevention of Pneumocystis carinii pneumonia (PCP), the Centers for Disease Control and Prevention in 1992 received reports of 239 cases involving children under age 12. CDC guidelines for PCP prevention, which dictate that prophylaxis should begin when the CD4 count drops below the 200 level, are generally accepted by experts as valid. Because the normal CD4 count in uninfected babies and children is significantly higher than in adults, CD4 counts decrease with age, and PCP often is diagnosed in HIV-infected infants with CD4 counts higher than 200, separate guidelines have been developed for children. These guidelines, which recommend initiation of prophylaxis according to age-specific CD4 thresholds, have of late come under some question by the European Collaborative Study, which suggested that existing thresholds will not result in timely initiation of prophylaxis for most babies who develop PCP. If these findings are confirmed, alternative approaches for PCP prophylaxis should be considered. "Syringe and Needle Exchange to Prevent HIV Infection" J.A.M.A. (06/15/94) Vol. 271, No. 23, P. 1825 (Des Jarlais, Don C.; Watters, John K.; Fernando, Daniel et al.) Dr. Daniel Fernando challenged two articles on needle-exchange programs, noting the limitations of syringe exchanges. They are of limited efficacy if unaccompanied by liberal policies allowing increased availability of clean needles to intravenous drug users, he said. Liberal policies, Fernando argued, undermine the need to use dirty needles but--unlike needle-exchange programs--would not cost a thing. Des Jarlais et al. responded by clarifying that they are not supporting needle exchanges at the expense of supporting liberal laws permitting the sale and possession of injection paraphernalia, as suggested by Fernando. They cite a review of studies of legal access to injection equipment, which linked decreases in risky injections to increased over-the-counter sales of injection paraphernalia. They presented data documenting lower rates of HIV among IV drug users in states not having prescription requirements for possession of injection equipment. Also in reply to Fernando's criticisms, Watters et al. disagreed that needle-exchange programs undermine liberal laws deregulating injection paraphernalia. Conversely, they contend, needle exchanges directly resulted in the relaxation or repeal of antiparaphernalia laws in several states. "Knowledge and Practice Among Injecting-Drug Users of Bleach Use for Equipment Disinfection--New York City, 1993" M.M.W.R. (06/24/94) Vol. 43, No. 24, P. 439 (Marmor, M.; Wolfe, H.; Titus, S. et al.) The National Institute on Drug Abuse sponsored a study in New York City to determine intravenous drug users' knowledge about the use of bleach for disinfecting injection equipment. Bleach was recommended to reduce the possibility of HIV infection through shared needles because of its widespread availability, inexpensive cost, and ability to inactivate HIV. Of the one-fifth of active intravenous drug users who reported sharing injection equipment, however, only one fourth used bleach consistently. And among all active IV drug users, only one third knew both recommendations for correct bleach use. NIDA recommendations dictate that, in order for bleach to be a successful disinfectant of injection paraphernalia, it must be used at full strength, and must remain in contact with the equipment for a minimum of 30 seconds. Because of the inconsistent use and incomplete knowledge about bleach as a disinfectant, active IV drug addicts who reuse syringes that have already been used by another IV drug user are at high risk for HIV infection. "Expanding the AIDS Arsenal" U.S. News & World Report (07/11/94) Vol. 117, No. 2, P. 67 (Brink, Susan; Smith, Anne Kates; Rubin, Rita) The Food and Drug Administration recently approved a fourth drug to fight HIV infection. AIDS patients who cannot tolerate or no longer benefit from AZT, ddI, or ddC will now be able to take Stavudine, or D4T, which belongs to the same class of drugs as the other three. Stavudine does not cause anemia--one of the most serious side effects of AZT use--but it does have its disadvantages. Some patients experienced peripheral neuropathy, or pain, tingling, or numbness of the hands and feet. Stavudine, which will be sold under the name Zerit by Bristol-Myers Squibb, should be available by prescription sometime this month. The daily wholesale cost will be $6.22, roughly the same as that of AZT, and the manufacturer will help financially strapped patients find funding, or receive the drug free of charge. "Herpes Drug Can Raise AIDS Patients' Life Expectancy, Hopkins Team Says" Baltimore Sun (07/15/94) P. 7A (Selby, Holly) The anti-herpes drug acyclovir, used in combination with the anti-viral drug AZT, can prolong the life of end-stage AIDS patients by as much as 1-1/2 years, according to a Johns Hopkins University study. The results confirm data from a European clinical trial, as well as one conducted in Australia, notes Dr. Neil Graham, one of the study's authors. In both laboratory studies and human clinical trials, herpes simplex appears to worsen HIV infection. Acyclovir may benefit AIDS patients by halting this effect, Graham says. The study also indicates that 600 to 800 milligrams per day of acyclovir is beneficial to AIDS patients--a dose significantly lower than previously thought. The study does not determine whether the anti-herpes agent would help AIDS patients who are unable to tolerate AZT. "Guidelines for Preventing Transmission of Human Immunodeficiency Virus Through Transplantation of Human Tissue and Organs" M.M.W.R. (05/20/94) Vol. 43, No. RR-8, P. 1 Most transmission of HIV to organ and/or tissue recipients happened before the implementation of donor screening in 1985. Recommendations for preventing HIV transmission through human tissue and organs significantly reduced the risk for this mode of transmission. HIV transmission from an HIV-negative donor who was screened, however, alerted authorities to the need for revised guidelines. The Public Health Service formed a working group made up of representatives from various federal agencies, which concluded that revisions should be made to existing recommendations to further reduce the already low risk of HIV transmission through organ and tissue transplant. The new guidelines address the issues of donor screening, testing, and grounds for exclusion; inactivation or elimination of infectious agents before transplantation; timely detection, reporting, and tracking of potentially infected tissues, organs, and recipients; and recall of stored tissues from donors discovered to be HIV-positive. Also considered were the differences between the screening of living and dead donors and the differences between procuring and distributing organs and tissues. "Thymomodulin" AIDS Treatment News (07/08/94) No. 202, P. 1 (James, John S.; Getty, Jeff) Human trials of Thymomodulin, a substance manufactured from the thymus glands of calves, have demonstrated good results with various conditions in which the immune system is compromised. A small, observational study of HIV patients conducted several years ago in Europe also yielded promising results, including marked improvement in clinical condition, and improvement in blood work. These early findings, however, were not followed up. In Europe, they were seriously neglected, and all but completely abandoned in the United States. The scientific documentation, combined with anecdotal evidence from several HIV/AIDS patients, has convinced AIDS Treatment News that Thymomodulin is worth pursuing as a treatment for HIV and AIDS. The drug is approved in Italy and used as an immune treatment throughout Europe, but is not approved in the United States, although patients can obtain a personal supply. "Birth Outcomes Following Zidovudine Therapy in Pregnant Women" J.A.M.A. (07/06/94) Vol. 272, No. 1, P. 17 The Centers for Disease Control and Prevention estimates that there are 100,000 HIV-positive women of child-bearing age in the United States, and that 7,000 infants are born to infected mothers each year. The U.S. rate of perinatal HIV transmission among women not receiving antiretroviral therapy is 15 to 30 percent. Recent findings from a major clinical trial suggest that treating mothers and newborns with zidovudine may significantly lower the risk of HIV transmission. The CDC cautions, however, that potential risks linked to antiretroviral treatment during pregnancy should be carefully considered. The Zidovudine in Pregnancy Registry was installed in 1989 by the Wellcome Foundation, in conjunction with the CDC, to measure the incidence of infants with structural defects. An analysis of the registry finds that the observed proportion of birth defects among infants of women who received zidovudine therapy was 2 percent, not significantly different from the 3 percent that characterizes the general population. The findings, however, are preliminary, and the sample limited. The CDC says the registry must be sustained to monitor for possible birth defects among infants of women who received zidovudine therapy during pregnancy. "NCAP's Guide on Evaluating HIV/AIDS-Service Programs Available from CDC National AIDS Clearinghouse" It is one thing to operate a program, it is another to know whether it works. To help grantmakers and staff from HIV/AIDS programs, the National Community AIDS Partnership (NCAP) has published "Evaluating HIV/AIDS Prevention Programs in Community-Based Organizations." The 141-page publication focuses on how to select the most effective evaluation strategy for media-based programs, individual and group training, and information and referral programs. Copies of "Evaluating HIV/AIDS Prevention Programs in Community-Based Organizations", CDC NAC Inventory No. D576, are $9.50 each. Supplies are limited; orders are accepted by telephone, FAX, or mail. Call 1-800-458-5231 and select the publication orders option at the voice prompt. Deaf Access/TDD is available through 1-800-243-7012; FAX, 301-251-5343; or mail: CDC National AIDS Clearinghouse P.O. Box 6003 Rockville, MD 20849-6003 "Substance Use and HIV-Related Sexual Behaviors Among US High School Students: Are They Related?" A.J.P.H. (07/94) Vol. 84, No. 7, P. 1116; (Lowry, Richard; Holtzman, Deborah; Truman, Benedict I. et al.) Lowry et al. set out to determine whether use of alcohol, cigarettes, marijuana, or hard drugs is linked to the likelihood of sexual behaviors that increase risk for HIV among adolescents. They used the 1990 national Youth Risk Behavior Survey to gather self-reported data from 11,631 high school students across the United States. Lowry and his colleagues found that those youngsters who reported no substance abuse were least likely to have had four or more sexual partners, least likely not to have used a condom, and least likely to have had sex at all. These risky behaviors were, on the other hand, most common among students who had used marijuana, cocaine, or other illicit drugs. The researchers conclude that HIV programs for adolescents must take into account the fact that substance abuse, through its association with unsafe sexual behaviors, may be an important factor in calculating risk of HIV infection and AIDS. "PML Treatment Update, Peptide T Possibility" AIDS Treatment News (06/17/94) No. 201, P. 3 (James, John S.) Progressive multifocal leukoencephalopathy (PML) is a relatively uncommon brain infection diagnosed in only about one percent of AIDS patients, usually in the late stages of disease. Many cases, however, are misdiagnosed--usually as toxoplasmosis or lymphoma. Because there is neither a cure, nor any FDA-approved treatments for PML, patients who are diagnosed are often informed by physicians that they will die shortly. Actually, there are a number of experimental treatments, and some individuals with PML have stabilized or improved, and lived fairly healthy lives for years. These treatments remain unproved, however, as controlled trials have not been conducted. The best source of information on PML is a privately published book, "Progressive Multifocal Leukoencephalopathy (PML): Case Studies and Potential Treatments" by Peter and Lisa Brosnan. The book includes a brief description of the infection, discussion of treatments that have been tried, and ones that have potential. "Team Finds HIV Immune System Booster" United Press International (07/27/94) Japanese scientists announced that their collaborative HIV research with an Australian team may support a disease-fighting strategy that calls for the injection of patients with their own lymphocytes. The method is based on the premise that lymphocytes attack foreign invaders in the body--but that quantities of these key immune-system agents drop significantly in HIV patients. An Australian team, headed by John Dwyer, conducted the experiment, and the Japanese team, led by Takashi Kurimura, did the research. Dwyer's group extracted highly active and healthy lymphocytes, matching them to those of an HIV-positive young man, and transferred the lymphocytes to him. After the procedure, the virus decreased dramatically. The young man regained his immunity, and the treatment still proved to be effective six months later. "FDA Approves Drug ddC as Single AIDS Treatment" Philadelphia Inquirer (08/09/94) P. A10 The U.S. Food and Drug Administration has granted marketing approval for zalcitabine, or ddC, as a single-drug treatment for HIV infection. The drug is sold under the brand name HIVID by Hoffmann-La Roche Inc. HIVID previously was approved only for use in combination with Burroughs Wellcome Co.'s AZT drug. Now, HIVID can be prescribed for adults with advanced HIV disease whose condition has progressed while taking AZT, and for adult HIV patients who cannot tolerate AZT. Related Stories: Washington Times (08/09) P. A10; Investor's Business Daily (08/09) P. A1 "FDA Approves AZT for AIDS Pregnant Women" Reuters (08/09/94) The U.S. Food and Drug Administration has approved the antiviral drug zidovudine (AZT) for use in preventing maternal-infant transmission of HIV. The drug, manufactured by Burroughs Wellcome Co., is now recommended as part of a regimen that includes oral AZT beginning 14 to 34 weeks after gestation, intravenous administration during labor, and an AZT syrup given to newborns. The agency said approval of the drug was based on the results of a federally funded study, which found that the rate of mother-infant HIV transmission was slashed by about two-thirds among women who were treated with AZT. "Medarex Bispecific Neutralizes Broad Variety of Clinical HIV Strains" HealthWire (08/08/94) Scientific collaborators of Medarex, Inc. announced on Monday the results of their study with Dr. Herve Raoul, Dr. Aloise Mabondzo, and colleagues in the laboratory of Professor Dominique Dormont of the Laboratoire de Neuropathologie Experimentale et Neurovirologie of C.E.A. in France. The results, presented at the Tenth International Conference on AIDS in Yokohama, Japan, showed that MDX-240, the company's Bispecific antibody product for AIDS, neutralizes infection of CD4 positive immune cells by clinical isolates--strains of HIV taken from infected patients. On August 3, Medarex announced the enrollment of subjects for Phase I/II clinical trials of MDX-240 to take place at two university hospitals in Europe. Medarex is a biopharmaceutical company specializing in treatments that enhance the body's natural immune system. ------------------------------ End of HICNet Medical News Digest V07 Issue #37 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD