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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

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 Lawrence Lee Miller, B.S. Biological Sciences, UCI

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 W. Scott Erdley, MS, RN, SUNY@UB School of Nursing

 Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF

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----------------------------------------------------------------------

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


 

(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


 

(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
***********************************************


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Editor, HICNet Medical Newsletter
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