From <@uga.cc.uga.edu:owner-mednews@ASUACAD.BITNET> Sun Apr 2 13:15:57 1995 with BSMTP id 8710; Sun, 02 Apr 95 13:06:21 EDT UGA.CC.UGA.EDU (LMail V1.2a/1.8a) with BSMTP id 4141; Sun, 2 Apr 1995 13:06:04 -0400 HICNet Medical News Digest Sun, 02 Apr 1995 Volume 08 : Issue 11 Today's Topics: [MMWR] Co-incidence of HIV/AIDS and Tuberculosis [MMWR Mar 24] Anticholinergic Poisoning Associated with an Herbal Tea [MMWR] NIOSH Alert: Request for Assistance in Preventing Injuries and [MMWR] Foodborne Botulism -- Oklahoma, 1994 [MMWR] Notification of Syringe-Sharing and Sex Partners of [MMWR Mar 31] World Health Day -- April 7, 1995 Mass Vaccination with Oral Poliovirus Vaccine -- Asia and Europe, 1995 [MMWR] Diphtheria Acquired by U.S. Citizens in the Russian Federation +------------------------------------------------+ ! ! ! 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 *Asia/Pacific: http://biomed.nus.sg/MEDNEWS/welcome.html *Americas: http://cancer.med.upenn.edu:3000/ *Europe: http://www.dmu.ac.uk/ln/MEDNEWS/ Compilation Copyright 1995 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 Stephen Cristol, M.D. MPH, 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 ---------------------------------------------------------------------- To: hicnews Co-incidence of HIV/AIDS and Tuberculosis -- Chicago, 1982-1993 In 1985, the epidemic of human immunodeficiency virus (HIV) infection was recognized as an influence on the increasing occurrence of tuberculosis (TB) in the United States (1). Programs to control and prevent TB require information characterizing the interaction between HIV infection and TB, particularly in locally defined populations. This report describes the overall occurrence of TB in Chicago (1990 population: 2,783,726) during 1982-1993 and characterizes the co-incidence of TB and HIV/ acquired immunodeficiency syndrome (AIDS) in Chicago during 1989-1993. The Chicago Department of Public Health (CDPH) maintains computerized registries for all reported incident cases of TB and AIDS among city residents. This analysis compared the 3738 incident cases of TB registered from 1989 through 1993 with the 8207 cumulative cases of AIDS reported through March 1994. A match was defined as any person whose name appeared in both registries and was based on the patient's first name, last name, and date of birth. AIDS cases were reported based on the case definition in effect at the time of the report; for example, pulmonary TB in persons aged greater than or equal to 13 years was added as one of the AIDS-defining conditions in 1993. Racial/ethnic groups included in this analysis were non-Hispanic blacks, non-Hispanic whites, and Hispanics. Numbers of persons in other racial/ethnic groups were too small for meaningful analysis. From 1982 through 1987, cases of TB decreased by 39%, but from 1987 through 1993 cases increased 23% (Figure 1). The annual number of persons with TB but without AIDS reported during 1989-1993 increased from 633 to 677 (7%). During 1989-1993, a total of 458 co-incident cases of AIDS and TB were identified in Chicago. The proportion of co-incident cases increased from 8% (52 of 685 cases of TB) in 1989 to 15% (122 of 799 cases of TB) in 1993 (Figure 1). Pulmonary TB was the sole AIDS-defining illness for 77 (17%) of the 458 co-incident cases; 381 (83%) had TB and other AIDS-defining illnesses. During 1989-1993, non-Hispanic blacks accounted for 50% of the cases of AIDS, 62% of the cases of TB, and 71% of the co-incident cases (Table 1). Non-Hispanic whites accounted for 36% of cases of AIDS but smaller proportions of cases of TB (15%) and co-incident cases (12%), and Hispanics accounted for 14%-17% of cases of TB, AIDS, and co-incident cases. Injecting-drug use accounted for the highest proportion of co-incident cases (52%). The rates for the 5-year period for co-incident cases were 6.0 per 100,000 population for non-Hispanic blacks, 1.0 for non-Hispanic whites, and 2.8 for Hispanics. Among persons with co-incident cases, analysis of the year TB was reported in relation to the year AIDS with opportunistic illnesses other than pulmonary TB was diagnosed indicated that a small number (17 [4%]) of TB cases were reported greater than 2 calendar years before the diagnosis of AIDS (Table 2). Reported by: G Mueller, DVM, S Whitman, PhD, C Plummer, Epidemiology Program; Tuberculosis Control Program, Chicago Dept of Public Health. Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC. Editorial Note: During the mid-1980s, AIDS was identified among approximately 2% of TB cases in some areas (2-5). Although the proportion of TB cases attributed to HIV/AIDS has increased each year, the number of TB cases not co-incident with HIV/AIDS increased only slightly, suggesting that the increase in total TB cases would not have been as great in the absence of the HIV/AIDS epidemic. In Chicago, the percentage of cases varied by race/ethnicity; however, it is unclear whether these variations reflect differences in factors such as socioeconomic status, access to medical care, and prevalence of specific risks. Race is most likely a risk marker rather than a risk factor for TB and HIV infection; risk markers may be useful for identifying groups that should be targeted for prevention and education efforts. The 1993 expansion of the AIDS case definition to include pulmonary TB increased the number of co-incident cases identified in Chicago and facilitated earlier recognition of co-incident cases. If the expanded AIDS definition had not included pulmonary TB, these co-incident cases probably would have been detected through matching when different AIDS-defining conditions were diagnosed (except for persons who died before such conditions were diagnosed). In addition, changes in the epidemiology of TB have promoted modification of the management of TB cases to include testing for HIV infection and expanded the ability to detect co-incident TB and HIV/AIDS cases. Most TB cases that precede a diagnosis of AIDS by several years may not be attributable to the immunosuppression from HIV infection. However, the incubation of AIDS is long and variable. The finding that TB was rarely reported greater than 2 calendar years before AIDS was diagnosed suggests that the occurrence of TB in co-incident cases is related temporally with HIV immunosuppression. The findings in this report are subject to at least three limitations that probably undercounted the number of co-incident cases in Chicago. First, some matches between the two registries may have been missed because of discrepancies in the information used for matching (e.g., the transposition of first and last name between registries). Second, the lack of HIV testing data for all persons with TB limits analysis because some co-incident cases may be unrecognized. Third, because of reporting delays for AIDS cases, the final number of co-incident cases for the period covered by this report probably will increase (6,7). The finding that more than 15% of persons with newly diagnosed TB in Chicago were HIV positive underscores the importance of assessing the HIV status of all persons with TB, the need for prompt contact investigation, and the appropriate use of isoniazid preventive therapy in contacts (8). In addition, these findings suggest the need for intensified monitoring of the co-incidence of these two epidemics. Although registry reviews can assist in this effort, the methods are complex. Concerns about confidentiality limit the ability to conduct such TB and AIDS registry matches. Although in Chicago confidentiality precludes the direct reporting of persons with AIDS and TB directly to the TB- control program, CDPH recognizes the substantial impact of HIV/AIDS on the TB epidemic and the need for timely follow-up of contacts. Therefore, CDPH has instituted measures to both ensure and expedite TB case reporting among AIDS cases. TB-related AIDS case reports now must include the date of reporting to the TB-control program. AIDS case reports without this information are followed up by the AIDS surveillance program. Quarterly database reviews are conducted to ensure that all AIDS cases with possible TB have been reported to the TB-control program by the medical practitioner. This process has strengthened cooperation between the AIDS and TB programs to control these two epidemics in Chicago. Other state and local health departments should consider a similar process of matching TB and AIDS registries to better describe the comorbidity of TB and HIV. References 1. CDC. Tuberculosis--United States, 1985--and the possible impact of human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:74-6. 2. CDC. Tuberculosis and acquired immunodeficiency syndrome--Florida. MMWR 1986;35: 587-90. 3. CDC. Tuberculosis and AIDS--Connecticut. MMWR 1987;36:133-5. 4. CDC. Tuberculosis and acquired immunodeficiency syndrome--New York City. MMWR 1987; 36:785-90,795. 5. Cote TR, Nelson MR, Anderson SP, Martin RJ. The present and future of AIDS and tuberculosis in Illinois. Am J Public Health 1990;80:950-3. 6. CDC. Projections of the number of persons diagnosed with AIDS and the number of immunosuppressed HIV-infected persons--United States, 1992- 1994. MMWR 1992;41(no. RR-18):4. 7. Chicago Department of Public Health. Delay in reporting. In: AIDS Chicago. Chicago, Illinois: Chicago Department of Public Health, 1993:7. 8. CDC. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1989;38:236-8,243-50. ------------------------------ To: hicnews Herbal Tea Anticholinergic Poisoning Associated with an Herbal Tea -- New York City, 1994 Inadvertent anticholinergic poisoning can result from consumption of foods contaminated with plants that contain belladonna alkaloids. During March 1994, the New York City Department of Health (NYCDOH) investigated seven cases of anticholinergic poisoning in members of three families; three of the seven ill persons required emergency treatment for characteristic manifestations. For all cases, manifestations occurred within 2 hours after drinking tea made from leaves purchased commercially and labeled as Paraguay tea--an herbal tea derived from the plant Ilex paraguariensis, which is native to South America. This report summarizes the investigation of these cases. On March 20, a 39-year-old man and his 38-year-old wife shared a pot of Paraguay tea. Within 30 minutes after drinking the tea, both developed acute symptoms (including agitation and flushed skin). They were transported by ambulance to a local hospital. In the emergency department, the man was disoriented and agitated. Findings on examination included fever (101.2 F [38.4 C]), dilated and nonreactive pupils, and dry skin and oral mucous membranes; bowel sounds were absent. Anticholinergic poisoning was diagnosed based on clinical findings, and the New York City Poison Center (NYCPC) was notified. After treatment with two doses of intravenous physostigmine (2 mg each over 5 minutes), signs and symptoms completely resolved. Findings on examination of the woman included fever (100.8 F [38.2 C]), dilated and nonreactive pupils, and dry skin and oral mucosa. Her symptoms resolved without treatment. On March 21, a 20-year-old woman drank approximately 1 cup of Paraquay tea; approximately 1 hour later, she presented to a local emergency department with agitation, disorientation, and aphasia that progressed to stupor. Findings on examination included increased pulse (120 beats per minute), oral temperature of 98.2 F (36.8 C), dilated pupils, dry skin, and absent bowel sounds. Anticholinergic syndrome was diagnosed, and the NYCPC was notified. She received gastric lavage, activated charcoal, and a cathartic. Her mental status gradually improved, and she was discharged after 10 hours of observation. On March 23, four family members shared a pot of tea. Approximately 1 hour later, the 10-year-old son was transported by his parents to a local emergency department because of agitation and restlessness. Findings on examination included increased pulse (120 beats per minute), dilated and nonreactive pupils, flushed skin, dry mucous membranes, and hypoactive bowel sounds. Anticholinergic syndrome was diagnosed, and the NYCPC was notified. After treatment with two doses of intravenous physostigmine (0.5 mg each over 5 minutes), his manifestations resolved. Because the boy's 35-year-old mother and 40-year-old father reported symptoms, including dry mouth, the emergency department physician presumptively diagnosed anticholinergic syndrome in both parents. Their symptoms resolved without treatment. The boy's 18-year-old brother had left home for school immediately after drinking the tea. On returning home during the evening of March 23, he reported confusion and no knowledge of his whereabouts during the day. At the request of the NYCPC, the emergency department physicians obtained samples of tea from each family for analysis. Samples consisted of packages of dried and chopped leaves and stems wrapped in clear cellophane; the package label identified a New York City distributor of South American foods. Analysis involved soaking 5 g of tea in 50 mL of methanol for 4 hours. From 1 uL of the liquid extract, the belladonna alkaloids atropine, scopolamine, and hyoscyamine were identified by gas chromatography/mass spectrometry. Quantitative analysis was not performed. Investigations by the NYCDOH, the NYCPC, and the Food and Drug Administration (FDA) indicated that the distributor had purchased the tea directly from farmers and had shipped it in bulk to New York City for packaging. Five cases of 24 packs had been delivered to one grocery store specializing in South American foods. Only one case had been sold; the remaining four cases were subsequently quarantined in accordance with New York City health statutes. The grocery store had no record of persons who had purchased the tea. On March 24, the NYCDOH issued a news release to educate the public about the hazards of drinking the contaminated Paraguay tea. No additional cases of anticholinergic poisoning associated with Paraguay tea were reported. Reported by: WJ Meggs, MD, R Weisman, PharmD, RS Hoffman, MD, R Shih, MD, SM Weimer, PhD, SM Fill, GJ Deannuntis, LR Goldfrank, MD, New York City Poison Center; CK Hsu, MD, S Sabo, MD, P Leo, MD, D Shastry, MD, K Rubin, MD, Elmhurst Hospital Medical Center, New York City; I Constantine, S Somwaru, A Munshi, PhD, Bur for Environmental Investigation, New York State Dept of Health. District Office, and Regional Laboratory, Food and Drug Administration, New York City. Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC. Editorial Note: Paraguay tea is made from the leaves of I. paraguariensis, a 20-foot-tall holly tree indigenous to Argentina, Brazil, and Paraguay. Common names for the plant include mate, yerba mate, and South American holly. The leaves contain caffeine, theophylline, and a nontoxic volatile oil but do not contain belladonna alkaloids. The dominant clinical features of the cases described in this report (i.e., tachycardia, fever, dilated pupils, and flushed skin) are characteristic of the anticholinergic effects associated with poisoning by belladonna alkaloids (1). In addition, patients responded to physostigmine, the treatment of choice for anticholinergic poisoning. The most likely explanation for the cases in this report is contamination of the Paraguay tea with leaves from a plant containing belladonna alkaloids. Previous reports of inadvertent anticholinergic poisoning resulting from contamination of foods with plants containing belladonna alkaloids have included consumption of hamburger seasoned with seeds from Angels' trumpet (Brugmansia X candida) (2) and consumption of contaminated honey (3), Chinese herbs (4), or porridge (5). This report underscores the need for persons who use herbal products to report any adverse reactions immediately to health authorities. In 1993, a total of 959 incidents of anticholinergic poisoning associated with consumption of plants containing belladonna alkaloids were reported to poison-control centers in the United States (6); 15 persons had symptoms requiring hospitalization. Because a large number of plants throughout the United States contain belladonna alkaloids, plants harvested for human consumption must be correctly identified. The public should be aware that all herbal products have the potential to be misidentified when collected, mislabeled, contaminated, or adulterated. Physicians and the public should úÿ úÿ(Continued from last message) report adverse reactions to herbal products to FDA's MedWatch Program, telephone (800) 332-1088 ([301] 738-7553). References 1. Gowdy JM. Stramonium intoxication: review of symptomatology in 212 cases. JAMA 1972; 221:585-7. 2. CDC. Datura poisoning from hamburger--Canada. MMWR 1984;33:282-3. 3. Marciniak J, Sikorski M. Intoxication with alkaloids of Datura stramonium and Datura inoxia following honey ingestion [Polish]. Pol Tyg Lek 1972;27:1002-3. 4. Yang MJ, Chen CC. Herbally induced anticholinergic intoxication: a report of three cases [Chinese]. Kao Hsiung I Hsueh Ko Hsueh Tsa Chih 1987;3:133-6. 5. Rwiza HT. Jimson weed food poisoning: an epidemic at Usangi rural government hospital. Trop Geogr Med 1991;43:85-90. 6. Litovitz TL, Clark LR, Soloway RA. 1993 Annual report of the Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1994;12:546-85. ------------------------------ To: hicnews Injuries and Notice to Readers: NIOSH Alert: Request for Assistance in Preventing Injuries and Deaths of Fire Fighters CDC's National Institute for Occupational Safety and Health (NIOSH) periodically issues alerts on workplace hazards that have caused death, serious injury, or illness to workers. One such alert, Request for Assistance in Preventing Injuries and Deaths of Fire Fighters (1) was recently published and is available to the public.* This alert warns fire departments to review their safety programs and emergency operating procedures because failures to establish and follow these programs and procedures are resulting in injuries and deaths of fire fighters. Based on reports to the National Fire Protection Association, 280 fire fighters died and approximately 100,000 were injured in the line of duty during 1990-1992, and based on reports to the NIOSH National Traumatic Occupational Fatalities Surveillance System, 278 fire fighters died from traumatic injuries during 1980-1989. The International Association of Fire Fighters reported that 1369 professional fire fighters died in the line of duty during 1970-1994. NIOSH has identified four factors essential to protecting fire fighters from injury and death: 1) following established firefighting policies and procedures, 2) implementing an adequate respirator- maintenance program, 3) establishing firefighter accountability at the fire scene, and 4) using personal-alert safety-system devices at the fire scene. Deficiencies in any of these procedures can create a life-threatening situation for fire fighters. The publication describes a case report in which two fire fighters died during a fire in a high-rise apartment building because these procedures were not followed. Recommendations are provided for fire departments and fire fighters to prevent injury and death. Reference 1. NIOSH. Request for assistance in preventing injuries and deaths of fire fighters. Cincinnati: US Department of Health and Human Services, Public Health Service, CDC, 1994; DHHS publication no. (NIOSH)94-125. * Single copies of this document are available without charge from the Publications Office, Division of Standards Development and Technology Transfer, NIOSH, CDC, Mailstop C-13, 4676 Columbia Parkway, Cincinnati, OH 45226-1998; telephone (800) 356-4674 ([513] 533-8328 for persons outside the United States); fax (513) 533-8573. ------------------------------ To: hicnews Foodborne Botulism -- Oklahoma, 1994 On July 2, 1994, the Arkansas Department of Health and the Oklahoma State Department of Health were notified about a possible case of foodborne botulism. This report summarizes the investigation, which implicated consumption of improperly stored beef stew. On June 30, 1994, a 47-year-old resident of Oklahoma was admitted to an Arkansas hospital with subacute onset of progressive dizziness, blurred vision, slurred speech, difficulty swallowing, and nausea. Findings on examination included ptosis, extraocular palsies, facial paralysis, palatal weakness, and impaired gag reflex. The patient also had partially healed superficial knee wounds incurred while laying cement. He developed respiratory compromise and required mechanical ventilation. Differential diagnoses included wound and foodborne botulism, and botulism antitoxin was administered intravenously. Electromyography demonstrated an incremental response to rapid repetitive stimulation consistent with botulism. Anaerobic culture of the wounds were negative for Clostridium. However, analysis of a stool sample obtained on July 5 detected type A toxin, and culture of stool yielded C. botulinum. The patient was hospitalized for 49 days, including 42 days on mechanical ventilation, before being discharged. The patient had reported that, during the 24 hours before onset of symptoms, he had eaten home-canned green beans and a stew containing roast beef and potatoes. Although analysis of the leftover green beans was negative for botulism toxin, type A toxin was detected in the stew. The stew had been cooked, covered with a heavy lid, and left on the stove for 3 days before being eaten without reheating. No other persons had eaten the stew. Reported by: W Knubley, MD, Cooper Clinic, Fort Smith; TC McChesney, DVM, State Epidemiologist, Arkansas Dept of Health. J Mallonee, MPH, Acting State Epidemiologist, Oklahoma State Dept of Health. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: Botulism is a paralytic illness resulting from a potent toxin produced under anaerobic conditions by C. botulinum. Although foodborne botulism is rare in the United States (34 cases reported in 1994 [CDC, unpublished data, 1995]), manifestations can be severe and can progress rapidly. Because of the potential severity of disease and the possibility for exposure of many persons to contaminated products, foodborne botulism is a public health emergency requiring rapid investigation. When botulism is suggested by clinical manifestations, (e.g., descending neuroparalysis, ptosis, and extraocular palsies), physicians should obtain a thorough food history to assist in the diagnosis and in identifying and obtaining potentially contaminated leftover food. In the case described in this report, heat-resistant C. botulinum spores either survived the initial cooking or were introduced afterwards; the spores subsequently germinated and produced toxin. The lid of the pot or the gravy of the stew most likely provided the anaerobic environment necessary for toxin production. Previous cases with similar features have resulted from consumption of commercial pot pies (1) and onions sauteed in margarine (2), both of which were left at room temperature for greater than 4 hours after cooking. Most outbreaks of foodborne botulism in the United States result from eating improperly preserved home-canned foods (3); vegetables (especially asparagus, green beans, and peppers) account for most outbreaks caused by home-canning (CDC, unpublished data, 1995). A pressure cooker must be used to home-can vegetables safely because it can reach temperatures necessary to kill botulism spores (substantially greater than 212 F [greater than 100 C] for 10 minutes); however, specific times and pressures needed vary for different foods (4). Jams and jellies can be safely home-canned without a pressure cooker because their high sugar content will not support the growth of C. botulinum. Instructions for home-canning are available from county extension offices. Cooked foods should not be held at temperatures 40 F-140 F (4 C-60 C) for greater than 4 hours (5). Boiling food for 10 minutes before eating destroys any toxin present. CDC provides epidemiologic consultation and laboratory diagnostic services for suspected botulism cases and authorizes release of botulism antitoxin to state health departments and physicians in the United States. These services are available 24 hours a day from CDC through state health departments. References 1. CDC. Botulism and commercial pot pie--California. MMWR 1983;32:39- 40,45. 2. MacDonald KL, Spengler RF, Hatheway CL, Hargrett NT, Cohen ML. Type A botulism from sauteed onions: clinical and epidemiologic observations. JAMA 1985;253:1275-8. 3. St. Louis ME. Botulism. In: Evans AS, Brachman P, eds. Bacterial infections of humans: epidemiology and control. 2nd ed. New York: Plenum Publishing, 1991:115-31. 4. Extension Service, US Department of Agriculture. Complete guide to home canning. Washington, DC: US Department of Agriculture, Extension Service, September 1994. (Agriculture information bulletin no. 539). 5. Food and Drug Administration. Food code, 1993. Washington, DC: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 1993. ------------------------------ To: hicnews Notification of Syringe-Sharing and Sex Partners of HIV-Infected Persons -- Pennsylvania, 1993-1994 In April 1993, a man incarcerated in a prison in Berks County in eastern Pennsylvania voluntarily requested testing for human immunodeficiency virus (HIV) antibody and was diagnosed with HIV infection. Following an interview and counseling by Pennsylvania Department of Health HIV Prevention Program (HIVPP) staff (1), he provided contact information about four persons with whom he had shared syringes to inject drugs before incarceration. As a result of follow-up investigation, HIV infection was diagnosed in two of these four persons. One of these two persons provided contact information about 47 partners, including 41 partners with whom he had shared syringes only and six with whom he had had sex and shared syringes. By May 1994, partner notification follow-up of the four partners of the index patient and all subsequently identified partners of HIV-infected persons identified a social network of 124 persons linked by syringe-sharing and/or sex. This report describes the findings of the investigation of this network during April 1993-May 1994 and limited additional information from June-September 1994. Of the 124 persons in the network, 113 were residents of a single community or its surrounding county. Of 121 persons contacted by HIVPP staff during the investigation, 68 (56%) were incarcerated in either the same prison as the index patient, a county prison in one of two adjacent counties, or one of two state prisons in other neighboring counties; 53 (44%) were residing in the community. HIVPP staff informed each of the 121 persons of their possible exposure to HIV (without disclosing the name of the HIV-infected person who had named them as a partner), offered HIV-antibody testing, and advised them about HIV-prevention measures (2). During posttest counseling, 21 HIV-infected persons gave information about their partners (range: one to four; 29 total). After those persons verified that their names had not been disclosed to these partners, the HIV- infected persons supplied information about 58 additional partners (3). Although HIVPP staff contacted partners in prisons, bars, and locations where illegal drugs were injected, at no time was staff safety threatened. Of the 121 persons interviewed, 108 (89%) were injecting-drug users (Table 1), and 91 (75%) had a history of previous and/or current incarceration. None of the injecting-drug users in the network reported drug use while in prison. Nearly all of the persons interviewed (118 [98%]) accepted HIV-antibody testing; of these, 44 (36%) were HIV-positive, including 33 (44%) of 75 males and 11 (26%) of 43 females. HIV antibody was detected in 18 (42%) of the 43 men with two or more HIV-infected partners and six (43%) of the 14 women with two or more HIV-infected partners. Sharing of syringes was the most common connection (98%) HIV- infected persons had with others in the network. A history of syringe-sharing (syringe-sharing only or both sex and syringe-sharing) was reported by 56 (76%) of 74 HIV-negative persons and all 44 HIV-positive persons. Nine (20%) persons chose to personally notify some of their partners and contacted 16 persons, all of whom requested HIV-antibody testing. The initial follow-up of the index patient and his contacts identified 21 persons (19 men and two women) who did not know they were HIV-infected. Further partner-notification activities during June-September 1994 identified 18 additional persons in the network, six of whom had HIV infection diagnosed; three were previously unaware of their infection. All persons who agreed to be tested for HIV antibody were counseled to adopt and maintain risk-reduction behavioral changes. Persons who tested HIV-positive were referred to medical, psychosocial, and substance-abuse treatment services (4). Through September 1994, HIVPP staff spent 2 1/2 to 10 hours locating and interviewing each contact. The estimated cost (hourly wage multiplied by staff time plus mileage) for partner notification of this network was $13,969. The average cost was $94 for each contact located and $583 for each of the 24 previously unknown cases of HIV infection identified. Reported by: K Waldron, MA, Pennsylvania AIDS Education and Training Center, Graduate School of Public Health, Univ of Pittsburgh. NC Breisch, HIV Prevention Program; J Hersh, MEd, JT Rankin, Jr, DVM, State Epidemiologist, Bur of Epidemiology, Pennsylvania Dept of Health. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Office of the Associate Director HIV/AIDS, CDC. Editorial Note: The partner-notification process identifies persons who are sex and/or syringe-sharing partners of HIV-infected persons, enables those persons to be informed of their possible exposure, and counsels them about the benefits of learning their serostatus. Identification of persons who are unaware of their HIV infection is important for interrupting HIV transmission: HIV-infected partners who previously were unaware of their infection can be counseled to adopt and maintain behavioral changes to prevent further transmission of HIV, and can be referred for psychosocial, substance-abuse, and medical treatment (including prevention of opportunistic infections) (4). Counseling and testing also can assist exposed but uninfected partners to recognize their risks for HIV infection and to initiate and sustain behavioral changes to reduce their risks. The findings in this report indicate that the partner notification method can be successful with persons who are incarcerated and persons who inject drugs. Other important elements of partner notification reflected in this investigation were that first, HIV-infected persons were counseled on risk reduction and health maintenance and referred to medical and other services; HIV-infected inmates also had access to the prison's drug- and alcohol-treatment program and prerelease planning for continuity of care. Second, health department notification services did not give the name of HIV-infected persons when they informed partners of their possible exposure. Third, a large proportion of the identified partners were located and accepted HIV-antibody testing. Fourth, the cost for locating HIV-infected persons was relatively low (5). Fifth, most HIV-infected persons asked health department staff to notify their partners. Finally, although HIVPP staff located many partners in areas associated with risk to personal safety, they were able to interview and provide HIV-antibody testing without incident. To ensure the effectiveness of partner notification, health departments should follow four principles. First, health department staff should be nonjudgmental, maintain confidentiality, offer voluntary testing, and reassure incarcerated contacts that those who are HIV-positive will not be housed separately and will be able to decide to whom their HIV test results will be disclosed. Second, the search for partners should be extended to a broad range of settings, including residences, workplaces, bars, settings where illegal drugs are injected, and prisons. Third, health department staff should help persons recognize and accept their HIV risk and explain the public health importance of reducing HIV transmission. Fourth, partners should be visited multiple times to underscore the urgency of the information, counsel them about the benefits of learning their serostatus, and reinforce the commitment of the health department to the process. The care the health department takes in not revealing the name and other information about HIV-infected persons is critical in ensuring that these persons provide reliable information to enable location of their sex and/or syringe-sharing partners. References 1. CDC. HIV counseling, testing and referral: standards and guidelines. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994. 2. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992;326:101-6. 3. Cates W, Toomey KE, Havlak GR, Bowen GS, Hinman AR. Partner notification and confidentiality of the index patient: its role in preventing HIV. Sex Transm Dis 1990;17:113-4. 4. Gallant JE, Moore RD, Chaisson RE. Prophylaxis for opportunistic infections in patients with HIV infection. Ann Intern Med 1994;120:932- 44. 5. Crystal S, Dengelegi L, Beck P, Dejowski E. AIDS contact notification: initial program results in New Jersey. AIDS Educ Prev 1990;2:284-95. ------------------------------ To: hicnews World Health Day -- April 7, 1995 "Target 2000--A World Without Polio" is the theme for the annual World Health Day on April 7, 1995 (1). In 1988, the World Health Organization (WHO) established as an objective the global eradication of poliomyelitis by the year 2000 (2). Progress toward this goal has included the elimination of endemic polio from the Western Hemisphere and the global reduction in reported polio by more than 70% since 1988--achievements that also have underscored the feasibility of eradicating this disease. In addition, strategies recommended by WHO for achieving polio eradication have been implemented in many countries with endemic polio (3). For example, the number of countries with endemic polio that have conducted National Immunization Days (NIDs) increased from 15 in 1988 to approximately 36 in 1995; an additional 25 countries are planning to conduct NIDs later this year. The global partnership among governments and organizations working toward this common goal includes polio-endemic countries, WHO, Rotary International, United Nations Children's Fund (UNICEF), the International Development Banks, and the governments of Australia, Canada, Japan, and the United States. On World Health Day, a program will be conducted in Washington, D.C., by the Pan American Health Organization and the WHO Regional Office for the Americas. Additional information about the global polio eradication initiative úÿ úÿ(Continued from last message) is available from WHO headquarters in Geneva, the regional offices of WHO, and CDC. Reported by: Special Program for Vaccines and Immunization, Pan American Health Organization, Washington, DC; Global Program for Vaccines and Immunization, World Health Organization, Geneva. Respiratory and Enterovirus Br, National Center for Infectious Diseases; International Health Program Office; Polio Eradication Activity, National Immunization Program, CDC. References 1. Global Program for Vaccines and Immunization, World Health Organization. World Health Day 1995 information kit. Geneva: World Health Organization, January 1995. 2. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva: World Health Organization, 1988. (Resolution WHA41.28). 3. Hull HF, Ward NA, Hull BP, Milstien JB, de Quadros C. Paralytic poliomyelitis: seasoned strategies, disappearing disease. Lancet 1994;343:1331-7. ------------------------------ To: hicnews Europe, 1995 Mass Vaccination with Oral Poliovirus Vaccine -- Asia and Europe, 1995 The theme of World Health Day, April 7, 1995, is "Target 2000--A World Without Polio" (1). In conjunction with World Health Day activities, 18 geographically contiguous countries in Europe, Central and South Asia, and the Middle East are conducting coordinated National Immunization Days (NIDs)* with oral poliovirus vaccine (OPV) (Figure 1). The World Health Organization (WHO) has designated this effort "Operation MECACAR" (MEditerranean, CAucasus, and Central Asian Republics). This report describes the efforts of this campaign and summarizes polio surveillance data for 1994. To maximize the geographic area covered and the number of children targeted simultaneously for mass vaccination with OPV, Operation MECACAR has been committed to by adjoining countries in Europe (Armenia, Azerbaijan, Bulgaria, Georgia, and Turkey), Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan), South Asia (Pakistan), and the Middle East (Afghanistan, Iran, Iraq, Jordan, Lebanon, Syria, and one national identity [Palestine**]). Approximately 56 million children aged less than 5 years have been targeted to receive two doses each of OPV (Table 1). Efforts have been planned and will be coordinated under the direction of both the European Regional Office (EURO) and the Eastern Mediterranean Regional Office (EMRO) of WHO. Participating countries in each region have provisionally reported a high proportion of the total polio cases in their respective regions in 1994. In EURO, participating countries reported 200 (95%) of the 211 cases reported in the region, including Uzbekistan with 117 cases; Tajikistan, 28; Turkey, 23; Azerbaijan, 17; Turkmenistan, six; Armenia, five; and Kazakhstan, four. Participating countries in EMRO reported 669 (69%) of the 973 cases reported in the region, including Pakistan with 520; Iran, 80; Iraq, 63; Jordan, four; and Lebanon, two. Some of the countries in these regions previously have conducted NIDs, including Azerbaijan (1993 and 1994), Lebanon (1994), Iran (1994), Syria (1993 and 1994), Pakistan (1994), and Uzbekistan (1994), while others conducted subnational immunization days. Based on the desirability of scheduling mass vaccination campaigns simultaneously and during the low polio incidence season, either the first round (EURO) or the second round (EMRO) of NIDs has been scheduled during March 24-April 29. Countries participating in Operation MECACAR are planning to repeat NIDs in 1996 and 1997. Reported by: Regional Office for Europe, Copenhagen; Regional Office for Eastern Mediterranean Region, Alexandria, Egypt; Global Program for Vaccines and Immunization, World Health Organization, Geneva. Respiratory and Enterovirus Br, National Center for Infectious Diseases; International Health Program Office; Polio Eradication Activity, National Immunization Program, CDC. Editorial Note: Since 1988, when the World Health Assembly (the governing body of WHO) adopted the goal of global polio eradication by the year 2000 (2), substantial progress has been made toward this goal. In particular, during 1994 the Western Hemisphere was certified free of wild poliovirus by an international certification commission (3). From 1988 through 1994, reported polio declined 82%, with particular progress in the Western Pacific Region of WHO, including China (4), Philippines (5), and Vietnam (6); polio-free zones are emerging in Western Europe, Southern and Northern Africa, and the Arabian Peninsula (7). The coordinated effort to vaccinate approximately 56 million children aged less than 5 years in 18 countries represents one of the largest public health events in history (4,8). Operation MECACAR will entail cooperation between countries with dramatically different political systems, economic organization, cultures, and religions. In particular, efforts include negotiations to curtail hostilities and, in countries with internal conflict or civil wars, to secure cease-fires during the vaccination campaigns. To ensure the success of previous NIDs, similar arrangements had been mediated in countries of the Americas (9) and in Philippines (5). Reported polio incidence in the European Region stabilized during the 1990s with approximately 200 cases reported each year. Consequently, further reductions in polio incidence and the elimination of poliovirus from the remaining polio-endemic countries will require supplementary vaccination activities, including NIDs. In the Eastern Mediterranean Region, substantial decreases in polio incidence have been achieved since 1988; however, approximately 2500 cases of polio were reported in 1993, and approximately 1000 cases were provisionally reported in 1994. Synchronized NIDs, if effectively implemented (i.e., vaccination of greater than 90% of the target population) and repeated as planned in 1996 and 1997, should decrease the incidence of polio substantially in these countries. The technical basis for achieving worldwide polio eradication already exists; persistent impediments to the eradication objective for the year 2000 include insufficient political will and inadequate resources. Operation MECACAR is supported by a coalition of organizations that includes WHO, United Nations Children's Fund (UNICEF), other bilateral and multilateral organizations, and Rotary International, which provided the funds for the OPV vaccine needed by member countries of the European Region to conduct NIDs in 1995. References 1. CDC. World Health Day--April 7, 1995. MMWR 1995;44:233. 2. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva: World Health Organization, 1988. (Resolution WHA41.28). 3. CDC. Certification of poliomyelitis eradication--the Americas, 1994. MMWR 1994;43:720-2. 4. CDC. Progress toward poliomyelitis eradication--People's Republic of China, 1990-1994. MMWR 1994;43:857-9. 5. CDC. National immunization days and status of poliomyelitis eradication- -Philippines, 1993. MMWR 1994;43:6-7,13. 6. CDC. Progress toward poliomyelitis eradication--Socialist Republic of Vietnam, 1991-1993. MMWR 1994;43:387-91. 7. CDC. Progress toward global eradication of poliomyelitis, 1988-1991. MMWR 1993;42: 486-7,493-5. 8. Pan American Health Organization. Measles elimination by the year 2000. EPI Newsletter 1994;6:1-2. 9. deQuadros CA, Andrus JK, Olive JM, de Macedo CG. Polio eradication from the Western hemisphere. Ann Rev Public Health 1992;13:239-52. *Mass campaigns over a short period (days to weeks) in which two doses of oral poliovirus vaccine are administered to all children in the target group, regardless of prior vaccination history, with an interval of 4-6 weeks between doses. **Includes the territories of Gaza, Jericho, and the West Bank. ------------------------------ To: hicnews Federation Diphtheria Acquired by U.S. Citizens in the Russian Federation and Ukraine -- 1994 -- Epidemic diphtheria has reemerged in 14 of the 15 New Independent States (NIS) of the former Soviet Union (1); during 1994, a provisional total of 47,802 cases and 1746 deaths from diphtheria were reported throughout the NIS. This report describes one confirmed and one probable case of diphtheria acquired in countries where the disease is epidemic (Russian Federation and Ukraine) by U.S. citizens during November and December 1994. Patient 1. A 42-year-old woman, born in Russia but living in the United States for several years, arrived in Moscow on November 22. She had onset of fever and sore throat on December 6 and was hospitalized on December 7 with a provisional diagnosis of diphtheria. Her vaccination history was unknown, and she was not aware of contact with diphtheria patients or carriers. She was treated with 9000 international units (IU) of equine diphtheria antitoxin, antibiotics, and prednisone. On December 8, she was transferred to a referral hospital in Helsinki; findings on examination included a pharyngeal membrane. Treatment included administration of 40,000 IU of antitoxin, penicillin G (for 6 days), and several days of roxithromycin. Toxigenic C. diphtheriae, biotype gravis, was isolated from a pharyngeal culture obtained December 9. Follow-up cultures on December 12 and 15 were negative. Her antitoxin level was measured in Helsinki by Vero cell neutralization assay and was greater than 5 IU/mL; however, the level measured by an enzyme immunoassay that is specific for human antibodies was less than 0.03 IU/mL, indicating that the Vero cell assay was detecting recently administered equine antitoxin. She recovered fully without complications. Patient 2. On November 28, a 22-year-old woman from New Jersey working in Kherson in southern Ukraine since June 1994 had onset of a sore throat; she was hospitalized on November 29 with a provisional diagnosis of diphtheria. She had received five doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP) during childhood and an adult formulation tetanus and diphtheria toxoids (Td) booster in August 1991. She had no recognized contact with a known diphtheria patient or carrier. Findings on examination included a tonsillar and posterior pharyngeal membrane. The patient had treated herself with ciprofloxacin for 1 day and had had at least one dose of oral penicillin before a throat culture was obtained (the culture was negative). Treatment comprised 80,000 IU of diphtheria antitoxin and a course of parenteral penicillin. A diphtheria antitoxin level of 0.2 IU/mL by Vero cell neutralization assay was detected in both a blood specimen obtained at the time of her arrival in Ukraine in June 1994 and a convalescent sample. She recovered fully without complications. Reported by: J Vuopio-Varkila, MD, R-M Olander, MSc, National Public Health Institute; V Valtonen, MD, Helsinki Univ Central Hospital, Helsinki, Finland. R Crooks, MD, C Stewart, Office of Medical Svcs, Peace Corps, Washington, DC. Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Child Vaccine Preventable Diseases Br, Div of Epidemiology and Surveillance, National Immunization Program, CDC. Editorial Note: Diphtheria is a potentially severe illness; among persons who are unvaccinated, the case-fatality rate ranges from 5% to 10%. The disease is rare in the United States: since 1980, five or fewer cases have been reported each year, and since 1988, all reported culture-confirmed cases have been imported. However, based on serologic studies, 20%-60% of U.S. adults aged greater than 20 years are susceptible to diphtheria (2,3). The two cases described in this report are the first known to have occurred among U.S. citizens from exposure during the current epidemic in the NIS and emphasize the risk for persons who travel to countries with epidemic diphtheria. In addition, these cases suggest the potential for importation of toxigenic strains of C. diphtheriae to the United States by persons who arrive from affected areas. Although importation of diphtheria from the NIS to the United States has not been reported, at least 20 imported cases related to this epidemic have been reported in European countries (4-6). The diagnosis of diphtheria was confirmed by culture in the first case in this report. Although diphtheria was not laboratory-confirmed in the second patient, the clinical diagnosis was made by physicians experienced in diagnosing and treating diphtheria, and the CDC case definition for a probable case was met (7). Her negative throat culture does not exclude the diagnosis because she had begun antibiotic therapy before the culture specimen was taken. In addition, levels of antitoxin greater than or equal to 0.1 IU, as those present in this patient, are considered to confer a relative degree of protection against disease (8); although no level of antitoxin provides absolute protection (8), this patient appeared to have relatively mild disease and did not develop toxic complications. Because clinical diphtheria may not induce protective immunity, the lack of an increase in postdisease antitoxin level would not exclude the diagnosis; booster vaccination with an age-appropriate diphtheria toxoid-containing vaccine is recommended during convalescence (8). To minimize the risk for diphtheria, all U.S. residents should be up-to-date for diphtheria vaccination, regardless of whether they plan international travel. The Advisory Committee on Immunization Practices recommends that all children receive a routine series of five doses of DTP (or diphtheria and tetanus toxoids for pediatric use [DT] if pertussis vaccine is contraindicated) with doses at ages 2, 4, 6, and 12-15 months, and 4-6 years; Td boosters should be given at age 11-16 years, and every 10 years thereafter (9,10). For persons aged greater than or equal to 7 years who have not been previously vaccinated against diphtheria, the primary series consists of three doses of Td, with intervals of 1-2 months between the first two doses and 6-12 months between the second and third doses; Td boosters should be given every 10 years thereafter. To improve diphtheria-specific levels of immunity within the population, active vaccination against tetanus given as part of wound management should involve use of a vaccine containing both diphtheria and tetanus toxoids rather than single antigen tetanus toxoid (i.e., DTP [or DT if pertussis vaccine is contraindicated] for children aged less than 7 years and Td for persons aged greater than or equal to 7 years). Travelers to areas with endemic diphtheria or outbreaks should consult their medical providers to ensure they are adequately vaccinated. Travelers should have completed a primary series of at least three doses of diphtheria toxoid and should have received the most recent dose of vaccine (either primary series or booster) within the previous 10 years. In addition, travelers to affected countries should be advised to contact a health-care provider promptly if they develop a sore throat during either travel or the 2-week period after return from travel. References 1. CDC. Diphtheria epidemic--New Independent States of the former Soviet Union, 1990-1994. MMWR 1995;44:177-81. 2. Crossley K, Irvine P, Warren JB, Lee BK, Mead K. Tetanus and diphtheria immunity in urban Minnesota adults. JAMA 1979;242:2298-3000. 3. Koblin BA, Townsend TR. Immunity to diphtheria and tetanus in inner-city women of child-bearing age. Am J Public Health 1989;79:1297- 8. 4. Lumio J, Jahkola M, Vuento R, Haikala O, Eskola J. Diphtheria after a visit to Russia. Lancet 1993;342:53-4. 5. Expanded Program on Immunization, World Health Organization. Recrudescence of diphtheria--Poland. Wkly Epidemiol Rec 1993;68:261-4. 6. De Zoysa A, Efstratiou A, George RC, Vuopio-Varkila J, Jahkola M, Rikushin Y. Diphtheria and travel [Letter]. Lancet 1993;342:446. 7. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):11. 8. Dixon JMS. Diphtheria. In: Topley WWC, Parker MT, Collier L, Wilson G, eds. Topley and Wilson's principles of bacteriology, virology, and immunity. Philadelphia: BC Decker, 1990:56-75. 9. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures--recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-10). 10. CDC. Recommended childhood immunization schedule--United States, January 1995. MMWR 1995;43:959-60. ------------------------------ End of HICNet Medical News Digest V08 Issue #11 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD