HICNet Medical News Digest      Mon, 15 Aug 1994        Volume 07 : Issue 37

Today's Topics:

  [MMWR 15 July 94] Death from Fumigents in Railroad Cars
  [MMWR] Legionaire's Disease Associated with Cooling Towers
  [MMWR] Progress Towards Global Eradication of Poliomyelitis
  AIDS Daily News Summaries

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Date: Mon, 15 Aug 94 06:20:08 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 15 July 94] Death from Fumigents in Railroad Cars
Message-ID: <0JP4qc2w165w@stat.com>

         Deaths Associated with Exposure to Fumigants
            in Railroad Cars -- United States

     Multiple incidents of illness and death following exposure
to fumigated agricultural products in railroad cars have been
reported by several states along the U.S.-Mexico border. From
1989 through 1993, the Texas Department of Health identified
three incidents involving 11 exposed persons, resulting in two
deaths. The California Environmental Protection Agency,
Department of Pesticide Regulation, recorded two deaths in
fumigated boxcars in 1989. This report summarizes the two most
recent fatal incidents.

Case 1
     On September 18, 1993, during routine inspection of a train
450 miles east of El Paso, Texas, U.S. Immigration and
Naturalization Service Border Patrol agents discovered four males
(aged 12, 35, 39, and 52 years) in a hopper car containing loose
bulk lima beans. These persons entered the rail car in El Paso
through an unlocked top hatchway at approximately 7 a.m. While in
the rail car, the men opened the hatch door as fresh air was
needed, then closed it. They fell asleep and were discovered by
border patrol agents at 11 p.m.
     When found, the three men were ill, and the 12-year-old was
dead. The men reported nausea, vomiting, headache, and abdominal
discomfort. The cause of death for the 12-year-old was listed as
asphyxiation after inhalation of phosphine gas. No autopsy was
conducted.
     One man was available for follow-up interview; he reported
that he did not see any signs on the rail car that warned of
pesticide use. According to border patrol reports, warning signs
on the rail car indicated the beans had received routine
fumigation with aluminum phosphide.

Case 2
     On March 29, 1989, the body of a 23-year-old man was
discovered in a rice-filled rail car as it was unloaded in
Maxwell, California. Autopsy results revealed phosphine in tissue
samples. On March 17 in Houston, aluminum phosphide pellets had
been deposited in the loaded railroad car. The rail car had been
sealed with plastic and warning signs had been posted. Rips
discovered in the plastic during unloading indicated that the car
had been entered after fumigation.

Reported by: D Perrotta, PhD, T Willis, D Salzman, J Borders, Bur
of Epidemiology, Texas Dept of Health. L Mehler, MD, Pesticide
Illness Surveillance Program, Worker Health and Safety Br,
California Environmental Protection Agency. Health Studies Br,
Div of Environmental Hazards and Health Effects, National Center
for Environmental Health; Surveillance Br, Div of Surveillance,
Hazard Evaluations, and Field Studies, National Institute for
Occupational Safety and Health, CDC.

Editorial Note: Fumigant pesticides routinely are used to protect
grains and legumes from insect damage during transport and
storage. Before 1986, carbon tetrachloride and carbon disulfide
mixtures were the primary fumigants used during rail transport.
When these products were banned by the U.S. Environmental
Protection Agency (EPA) (1,2), fumigation using phosphorus and
sulfur compounds increased. Aluminum phosphide, which is highly
insecticidal (3), has been used increasingly by the grain
industry (4). Aluminum phosphide pellets, deposited into a loaded
boxcar, react with moisture in the grain to create the toxic gas
phosphine; the reaction can occur within 5 minutes (2). The U.S.
Department of Transportation (DOT) requires that, after a loaded
car is fumigated, it should remain out of transit for 48 hours.
Once the gas completely dissipates, the food product is nontoxic
(5).
     Fumigants, such as aluminum phosphide, can liberate toxic
gases that are rapidly absorbed through the respiratory tract
(6). Symptoms may begin immediately and can include fatigue,
headache, nausea, vomiting, abdominal pain, cough, and shortness
of breath. Acute poisoning, such as occurs after inhalation of
phosphine, can lead to pulmonary edema, central nervous system
depression, toxic myocarditis, and circulatory collapse (3).
Aluminum phosphide cannot be detected in blood or urine (7).
Treatment is symptomatic and supportive. Long-term effects may
include genotoxicity (1).
     Both the DOT* and EPA (8) publish guidelines for placement
of warning signs on transport vehicles or freight containers that
have been fumigated or treated with poisonous substances. These
guidelines vary regarding the size and placement of the sign and
the wording, graphic symbols, and languages used on the sign.
Carriers may conform to either agency's set of regulations and
guidelines. DOT is reviewing its regulations for potential
updating.
     Surveillance for pesticide poisoning is complicated by lack
of uniform reporting guidelines and difficulty in attributing
specific adverse health outcomes to pesticide exposure. Although
25 states require that illnesses caused by pesticides be
reported, few actively solicit and follow up case reports (10).
The Texas case report was detected through the Sentinel Event
Notification System for Occupational Risk (SENSOR) program of
CDC's National Institute for Occupational Safety and Health
(NIOSH)**. Texas mandates reporting of only occupationally
related pesticide exposures; persons who apply fumigants,
agricultural workers, and grain inspectors may be exposed to high
levels of fumigants. Nonoccupational exposures, such as in this
report, can be reported to the Texas Department of Health;
nonoccupational exposures and fatalities (9) may occur during
residential application by unlicensed personnel or following
improper disposal of fumigation pellets. California mandates that
physicians report all illnesses caused by pesticides to local
health officers.
     Deaths resulting from illegal entry into fumigated rail
transport cars have not been reported previously. The incidents
described here underscore the potential for state-based
surveillance systems to identify new problems that require
corrective measures. Appropriately placed, highly visible warning
signs printed in English and other languages that incorporate
symbols may have prevented these deaths. Other prevention
measures should include adequate locking for all points of entry
on rail cars.

References
1. Garry VF, Griffith J, Danzl TJ, et al. Human genotoxicity:
pesticide applicators and phosphine. Science 1989;246:251-5.
2. Zaebest DD, Blade LM, Burroughs GE, Morrelli-Schroth P,
Woodfin WJ. Phosphine exposure in grain elevators during
fumigation with aluminum phosphide. Applied Industrial Hygiene
1988;3:146-54.
3. Jayaraman KS. Death pills from pesticide. Nature 1991;353:377.
4. Alavanja MC, Rush GA, Stewart P, Blair A. Proportionate
mortality study of workers in the grain industry. J Natl Cancer
Inst 1987;78:247-52.
5. Worthing CR, ed. The pesticide manual: a world compendium. 7th
ed. In: The British Crop Protection Council. Suffolk, England:
Lavenham Press Limited, 1983.
6. Morgan DP. Recognition and management of pesticide poisonings.
4th ed. Washington, DC: US Environmental Protection Agency, 1989;
publication no. EPA-540/9-88/001.
7. Feldstein A, Heumann M, Barnett M. Fumigant intoxication
during transport of grain by railroad. J Occup Med 1991;33:64-5.
8. US Environmental Protection Agency. Guidance for the
reregistration of pesticide products containing aluminum or
magnesium phosphide as the active ingredient. Washington, DC: US
Environmental Protection Agency, 1986; report no. 540/RS-87-109.
9. Wilson R, Lovejoy FH, Jaeger RJ, Landrigan PL. Acute phosphine
poisoning aboard a grain freighter. JAMA 1980;244:148-50.
10. US General Accounting Office. Pesticides on farms--limited
capability exists to monitor occupational illnesses and injuries:
report to the chairman, Committee on Agriculture, Nutrition, and
Forestry, US Senate. Washington, DC: US General Accounting
Office, December 1993; report no. GAO/PEMD-94-6.

*CFR parts 172.201, 172.510, 173.9, and 49 CFR chapter 1 (10-1-92
Edition).
**SENSOR is a program of cooperative agreements between NIOSH and
state health departments to develop generalizable models for
state-based occupational health surveillance. Fourteen states
have been awarded cooperative agreements to develop surveillance
systems for 12 conditions.



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

Date: Mon, 15 Aug 94 06:22:11 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Legionaire's Disease Associated with Cooling Towers
Message-ID: <oNP4qc3w165w@stat.com>

     Legionnaires' Disease Associated with Cooling Towers --
         Massachusetts, Michigan, and Rhode Island, 1993

     From July through October 1993, outbreaks of Legionnaires'
disease (LD) were reported from communities in Massachusetts and
Rhode Island and from a state prison in Michigan. Cooling towers
(CTs) were identified as the source of all three outbreaks. This
report summarizes investigations by state and local health
officials and CDC and efforts to control these outbreaks.

Massachusetts
     During July-August 1993, LD was diagnosed in 11 persons
living in Fall River, Massachusetts. The mean age of patients was
59 years (range: 40-72 years); six were men. Three persons died.
Three persons had Legionella pneumophila serogroup 1 (Lp-1)
isolated from respiratory secretions, four had Lp-1 antigens
detected in respiratory secretions by direct fluorescent antibody
testing, three had fourfold rises in serum antibody titer to
Lp-1, and one had both a fourfold rise in serum antibody titer
and Lp-1 antigens detected in urine by radio-immunoassay.
     A case-control study, matching the 11 patients and 22
controls by primary physician, age, sex, and underlying medical
condition, indicated that patients were more likely than controls
to have visited sites within a 0.04-square-mile (0.1-square-km)
neighborhood of Fall River in the 2 weeks before onset of illness
(matched odds ratio [OR]=14.0; 95% confidence interval [CI]=1.6-
120.8); no other activities were significantly associated with
acquiring LD.
     Water samples from seven CTs within the neighborhood and
from the homes of culture-positive patients were taken
approximately 1 month after onset of the last identified case of
LD in the community and cultured for legionellae. All samples
from potable water taps in patients' homes were culture-negative.
Five isolates were cultured from four CTs. Lp-1 was cultured from
two conjoined CTs on a building within the neighborhood and had
the same monoclonal antibody subtype (MAS) and pulsed-field gel
electrophoresis (PFGE) patterns as all three clinical isolates.
     The conjoined CTs were decontaminated on an emergency basis
according to guidelines previously developed by a technical work
group (1). The onset of the last identified case was August 10,
and the CT was decontaminated on September 24. No additional
cases were identified after decontamination.

Michigan
     During August-September 1993, LD was diagnosed in 17 persons
with pneumonia at a state prison in Michigan; 16 patients were
inmates, and one was an employee. One patient died. The mean age
of the patients was 47 years (range: 29-81 years); all were men.
One person had Lp-1 cultured from respiratory secretions and, for
11, LD was diagnosed by a fourfold rise in titer of antibodies to
Lp-1; five patients with pneumonia had evidence of LD by single
convalescent-phase antibody titers of 512 or more.
     Water samples from wells and potable water taps in the
prison and the prison hospital, from the prison hospital CT, and
from a CT near the prison were cultured for legionellae. All of
the potable water samples were culture-negative. Lp-1 was
isolated from both CTs. The isolate from the CT located on the
roof of the prison hospital had the same PFGE pattern as the
single clinical isolate.
     Fourteen (0.6%) of 2253 prisoners who used exercise yards
each day adjacent (within 100 yards) to the prison hospital had
LD, compared with two (0.1%) of the 2270 inmates who used yards
at least 400 yards from the prison hospital (relative risk=7.1;
95% CI=1.6-31.0).
     The CT on the prison hospital was shut down on September 17
and decontaminated according to published guidelines (1). No new
cases of LD were identified with onset after September 1.

Rhode Island
     During August 30-October 20, 1993, LD was diagnosed in 17
patients who lived or worked in eastern Rhode Island. The
patients' mean age was 54 years (range: 28-86 years); 11 were
men. Two patients died. Seven patients had Lp-1 cultured from
respiratory secretions and 10 had Lp-1 antigen detected in urine.
     A case-control study, matching the 17 patients with 33
controls by physician practice, age, sex, and underlying medical
conditions, indicated that patients were more likely than
controls to visit a 0.04-square-mile (0.1-square-km) section of
downtown Providence (matched OR=6.5; 95% CI=1.4-30.9) in the 2
weeks before onset of illness.
     Water samples from the homes of six culture-positive
patients were negative for legionellae by culture, but samples
from 10 of 24 CTs and one of three decorative fountains in
downtown Providence were positive for Lp-1. The environmental
isolates were tested by MAS and PFGE; one isolate from a CT on a
building located within the area had the same MAS and PFGE
patterns as isolates cultured from four case-patients who
reported visiting the LD-associated section of downtown
Providence. No other sources of transmission were identified in
the community. These Lp-1 isolates had MAS and PFGE patterns that
were different than those from the Fall River outbreak
(approximately 19 miles away); however, the PFGE patterns
suggested that the isolates were genetically related.
     The CT was shut down and decontaminated on an emergency
basis on October 26. No additional cases of LD associated with
the area were identified after decontamination of the CT.

Reported by: TE Gecewicz, L Saravo, Fall River Dept of Public
Health; SM Lett, MD, PE Kludt, MPH, A DeMaria, Jr, MD, State
Epidemiologist, Massachusetts Dept of Public Health. MG
Stobierski, DVM, D Johnson, MD, W Hall, MD, S Dietrich, H
Stiefel, S Robinson-Dunn, PhD, S Shah, Michigan Dept of Public
Health; C Hutchinson, MD, Michigan Dept of Corrections. LA
Mermel, DO, CH Giorgio, Rhode Island Hospital, Providence; L
D'Agostino, M Rittman, U Bandy, MD, M Stoeckel, BT Matyas, MD,
State Epidemiologist, Rhode Island Dept of Health. Div of Field
Epidemiology, Epidemiology Program Office; Childhood and
Respiratory Diseases Br and Emerging Pathogens Br, Div of
Bacterial and Mycotic Diseases, National Center for Infectious
Diseases, CDC.

Editorial Note: Approximately 1000-1300 cases of LD are reported
to CDC annually. However, because previous studies indicate that
most cases are not diagnosed, the incidence of disease may be
substantially higher (2). Legionella causes 1%-5% of
community-acquired pneumonia in adults (3); most cases occur
sporadically. The case-fatality rate of LD is 5%-30% (2).
     Diagnosis of LD requires heightened clinical suspicion.
Culturing respiratory secretions for legionellae and testing
urine for presence of antigen are not routinely performed for
patients with community-acquired pneumonia. Although not widely
used, urinary antigen detection is a sensitive (60%-80%), highly
specific (more than 99%), and rapid method for diagnosing
infection caused by Lp-1 (the cause of 90% of cases of LD) (4).
In comparison, serial serum antibody titers require several weeks
for definitive results. Single serum antibody titer results have
low predictive value (positive and negative) and are not useful
for diagnosing LD in nonoutbreak situations. However, they may be
useful in identifying cases during outbreaks of LD when serial
serum specimens are unavailable--as for some patients in the
Michigan investigation--and when Legionella is suspected to be
the cause of a substantial proportion of pneumonia under
investigation.
     Although most cases of LD are not associated with outbreaks,
investigations of outbreaks have provided most of the knowledge
about transmission of the disease. LD can be transmitted by
aerosol-producing devices (e.g., CTs [5,6], evaporative
condensers [7,8], whirlpool spas [2], humidifiers [9], and
decorative fountains [2]), and by potable water aerosolized by
shower heads and tap-water faucets (2,10).
     CTs and evaporative condensers have been identified as
sources of transmission of LD since the late 1970s. Although
legionellae can be cultured in up to 40% of CTs, these devices
are rarely associated with outbreaks of LD (1). To reduce
CT-related LD, CDC recommends maintenance of all CTs in
accordance with published guidelines.
     Although the attributable risk of CTs in sporadically
occurring LD is unknown, the findings in this report indicate
that CTs remain an important cause of outbreaks of LD. In each
investigation, molecular typing of isolates confirmed the
epidemiologic findings. CDC, in collaboration with other
agencies, is establishing guidelines for prevention of LD,
targeting CTs as well as other known sources of LD.

References
1. Wise M, Addiss D, LaVenture M, et al. Control of Legionella in
cooling towers: summary guidelines. Madison, Wisconsin: Wisconsin
Department of Health and Social Services, 1987.
2. Breiman RF. Modes of transmission of epidemic and nonepidemic
Legionella infection: directions for further study. In: Barbaree
JM, Breiman RF, Dufour AP, eds. Legionella: current status and
emerging perspectives. Washington, DC: American Society for
Microbiology, 1993:30-5.
3. Hoge CW, Breiman RF. Advances in the epidemiology and control
of Legionella infections. Epidemiol Rev 1991;13:329-40.
4. Edelstein PH. Laboratory diagnosis of Legionnaires' disease:
an update from 1984. In: Barbaree JM, Breiman RF, Dufour AP, eds.
Legionella: current status and emerging perspectives. Washington,
DC: American Society for Microbiology, 1993:7-11.
5. Dondero TJ Jr, Rendtorff RC, Mallison GF, et al. An outbreak
of Legionnaires' disease associated with a contaminated
air-conditioning cooling tower. N Engl J Med 1980;302:365-70.
6. Garbe PL, Davis BJ, Weisfeld JS, et al. Nosocomial
Legionnaires' disease: epidemiologic demonstration of cooling
towers as a source. JAMA 1985;254:521-4.
7. Cordes LG, Fraser DW, Skaliy P, et al. Legionnaires' disease
outbreak at an Atlanta, Georgia, country club: evidence for
spread from an evaporative condenser. Am J Epidemiol
1980;111:425-31.
8. Breiman RF, Cozen W, Fields BS, et al. Role of air sampling in
an investigation of an outbreak of Legionnaires' disease
associated with exposure to aerosols from an evaporative
condenser. J Infect Dis 1990;161:1257-61.
9. Mahoney FJ, Hoge CW, Farley TA, et al. Communitywide outbreak
of Legionnaires' disease associated with a grocery store mist
machine. J Infect Dis 1992;165:736-9.
10. Hanrahan JP, Morse, DL, Scharf VB, et al. A community
hospital outbreak of legionellosis: transmission by potable hot
water. Am J Epidemiol 1987;125:639-49.



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

Date: Mon, 15 Aug 94 06:23:14 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Progress Towards Global Eradication of Poliomyelitis
Message-ID: <FPP4qc4w165w@stat.com>

 Progress Toward Global Eradication of Poliomyelitis, 1988-1993

     In May 1988, the World Health Organization (WHO) adopted a
resolution to eradicate poliomyelitis by the year 2000. Since
then, all six WHO regions have made substantial progress toward
this goal using three major control strategies: 1) maintaining
high coverage of children with at least three doses of oral
poliovirus vaccine (OPV3); 2) administering supplementary doses
of OPV to all young children (generally those aged less than 5
years) during National Immunization Days (NIDs)* and during
door-to-door vaccination campaigns in areas where wild poliovirus
circulation persists at low levels; and 3) developing sensitive
systems of epidemiologic and laboratory surveillance (1). This
report summarizes progress of the global polio eradication
initiative from 1988 through 1993.**

     Worldwide. Reported global vaccination coverage with OPV3 by
age 1 year increased from 67% in 1988 to 85% in 1990 but
decreased to 80% in 1992 and 81% in 1993 (Figure 1). From 1988
through 1993, reported cases of polio decreased 70%, from 32,286
to 9714 (Figure 1). During these years, there were substantial
decreases in the number of countries reporting polio cases (88
[45%] of 196 and 56 [27%] of 209, respectively) and the number of
countries reporting 100 or more cases per year (20 [10%] and 11
[5%], respectively) (Figure 2). In addition, the number of
countries reporting zero polio cases increased from 107 (55%) to
144 (69%).***

     African Region. Reported coverage with OPV3 increased from
44% in 1988 to 57% in 1991 but decreased to 49% in 1992 and 50%
in 1993. From 1988 through 1993, reported cases of polio
decreased from 4546 to 1437. The number of countries reporting
polio cases remained unchanged (37 [79%] of 47). In 1993, the
African region reported 15% of the global total of polio cases.
Despite reporting zero polio cases for more than 3 years, Namibia
reported an outbreak of 53 cases in 1993, probably as a result of
recent importation of wild poliovirus from a polio-endemic area.

     Region of the Americas. Reported coverage with OPV3
increased from 82% to 86%, while reported cases of polio
decreased from 340 to zero; the number of countries reporting
polio cases decreased from 13 (28%) to zero of 47. The last
confirmed case of paralytic polio caused by wild poliovirus
occurred in August 1991 in Peru.

     Eastern Mediterranean Region. Reported coverage with OPV3
increased from 69% to 75%, while reported cases of polio
increased from 2332 to 2451; the number of countries in the
region reporting polio decreased from 17 (71%) of 24 to 10 (43%)
of 23. In 1993, the Eastern Mediterranean Region reported 25% of
the global total of polio cases; 84% of the regional total was
reported from Pakistan (74%) and Sudan (10%). In 1993, Pakistan
and Sudan experienced large outbreaks (1803 and 252 reported
cases, respectively), primarily among unvaccinated children.
Despite OPV3 coverage of more than 85% and no reported cases for
at least 2 years, small outbreaks of type 1 also occurred in Oman
during 1988 and 1993 and in Jordan during 1991-92; all three
outbreaks were caused by importation of wild poliovirus from
other polio-endemic countries.

     European Region. Reported coverage with OPV3 decreased from
86% to 72%, while reported cases of polio decreased from 206 to
198; the number of countries reporting polio cases increased from
seven (23%) of 31 to 12 (24%) of 50. In 1993, the European Region
reported 2% of the global total of polio cases; 83% of the
regional total was from republics of the former Soviet Union.
Azerbaijan and Uzbekistan experienced outbreaks in 1993 (70 and
68 reported cases, respectively), primarily among unvaccinated
children. Despite coverage of 97% with three doses of inactivated
poliovirus vaccine and no reported polio cases for more than 10
years, the Netherlands experienced an outbreak of 71 cases during
1992-93 among members of a religious group who do not routinely
accept vaccination, caused by importation of wild poliovirus that
originated from the Indian subcontinent.

     Southeast Asia Region. Reported coverage with OPV3 increased
from 57% to 90%, while reported cases of polio decreased from
22,814 to 4414. The number of countries in the region reporting
polio cases decreased from nine (82%) to seven (64%) of 11. In
1993, the Southeast Asian Region reported 45% of the global total
of polio cases; 93% of the regional total was from India.

     Western Pacific Region. Reported coverage with OPV3
increased from 89% to 93%, while reported cases of polio
decreased from 2079 to 1214; the number of countries reporting
polio cases decreased from six (17%) to five (14%) of 35. In
1993, the Western Pacific Region reported 13% of the global total
of polio cases; 88% of the regional total was from the People's
Republic of China (54%) and Vietnam (34%). Despite OPV3 coverage
of 90% and no reported polio cases for 5 years, Malaysia
experienced a small outbreak in 1992 caused by importation of
wild poliovirus that originated from the Indian subcontinent.

Reported by: Expanded Program on Immunization, Global Program for
Vaccines, World Health Organization. Polio Eradication Activity,
National Immunization Program; Div of Viral and Rickettsial
Diseases, National Center for Infectious Diseases; International
Health Program Office, CDC.

Editorial Note: Since 1988, the global incidence of paralytic
polio has decreased substantially, and polio apparently has been
completely eliminated from the Region of the Americas (1,2). The
number of polio cases reported in 1993 represents a 33% decrease
compared with 1992 and a 70% decrease compared with 1988.
Furthermore, nearly three quarters of all countries reported zero
cases of polio in 1993, and polio-free zones are present or
emerging in the Americas, northern, southern, and eastern Africa,
the Arabian peninsula, western and central Europe, and the
Western Pacific (Figure 2).
     Despite this substantial progress overall, paralytic polio
remains highly endemic throughout the Indian subcontinent and
continues to occur in most countries of sub-Saharan Africa and
Asia, including many republics of the former Soviet Union (Figure
2). In 1993, nearly two thirds of all polio cases reported
worldwide were from the Indian subcontinent, including 42% from
India, 19% from Pakistan, and 2% from Bangladesh. Lower than
optimal levels of routine vaccination coverage, pockets of
unvaccinated children within otherwise highly vaccinated
populations, crowding, poor sanitation, and suboptimal
seroconversion to poliovirus types 1 and 3 following three
routine doses of OPV in many tropical and subtropical regions
probably contribute to ongoing wild poliovirus transmission in
these areas (1,3).
     In addition to remaining areas of endemic transmission,
outbreaks of paralytic polio have recently occurred in several
countries 2 or more years after the last reported case of polio,
despite high levels of routine vaccination coverage (4,5).
Genotypic comparisons between wild poliovirus strains in the
global laboratory network have demonstrated that outbreaks in
Oman (1988-89 and 1993), Jordan (1991-92), Malaysia (1992), and
the Netherlands (1992-93) occurred as a result of importation of
wild poliovirus from polio-endemic countries in the Indian
subcontinent (4,5). Thus, until polio is eradicated globally,
every polio-free country may be at risk for importation of wild
poliovirus from remaining polio-endemic reservoirs.
     Routine vaccination alone is probably insufficient to
eliminate wild poliovirus transmission in most countries, and
supplementary vaccination activities, including NIDs, are
necessary in countries where polio remains endemic (1,2,6-10). In
1993 and early 1994, NIDs were conducted for the first time in
China, Vietnam, Philippines, Laos, Iran, and Pakistan, which
together accounted for 31% of all polio cases reported globally;
by the end of 1994, at least 63 (30%) of 209 countries will be
conducting NIDs as a polio-control strategy. As more countries
adopt this strategy, further progress is expected toward global
eradication of polio.
     Despite substantial progress toward global eradication of
polio, several challenges remain, including 1) reversing the
decline in global routine vaccination levels; 2) increasing
vaccination levels in unvaccinated subpopulations; 3) preventing
the reintroduction of wild poliovirus into polio-free areas by
eliminating reservoirs in polio-endemic countries (particularly
the Indian subcontinent); 4) increasing the awareness of donor
agencies and governments in industrialized countries of the
substantial financial and humanitarian benefits of global
eradication of polio, thus engendering support from unaffected
countries beyond that already provided by organizations such as
Rotary International; 5) encouraging all countries that remain
polio-endemic to make polio eradication a priority activity,
including the implementation of NIDs and the initiation of acute
flaccid paralysis surveillance; and 6) providing support to
vaccination program managers for training to develop managerial
skills for implementing and maintaining effective vaccination and
surveillance programs in all countries. The success of the polio
eradication initiative will depend on finding solutions to these
financial, managerial, political, and technical challenges.

References
1. CDC. Progress toward global eradication of poliomyelitis,
1988-1991. MMWR 1993;42:486-7,493-5.
2. World Health Organization. Poliomyelitis in 1993. Wkly
Epidmiol Rec 1994;69:169-76.
3. Patriarca PA, Wright PS, John TJ. Factors affecting
immunogenicity of oral poliovirus vaccine in developing
countries: review. Rev Infect Dis 1991;13:926-39.
4. Reichler MR, Abbas A, Alexander J, et al. Outbreak of
poliomyelitis in a highly immunized population in Jordan
[Abstract]. In: Program and abstracts of the 32nd Interscience
Conference on Antimicrobial Agents and Chemotherapy. Washington,
DC: American Society for Microbiology, 1992.
5. Sutter RW, Patriarca PA, Brogan S, et al. Outbreak of
paralytic poliomyelitis in Oman: evidence for widespread
transmission among fully vaccinated children. Lancet
1991;338:715-20.
6. Hull HF, Ward NA, Hull BP, Milstien JB, de Quadros C.
Paralytic poliomyelitis: seasoned strategies, disappearing
disease. Lancet 1994;343:1331-7.
7. CDC. National Poliomyelitis Immunization Days--People's
Republic of China, 1993. MMWR 1993;42:837-9.
8. CDC. National Immunization Days and status of poliomyelitis
eradication--Philippines, 1993. MMWR 1994:43;6-7,13.
9. CDC. Progress toward poliomyelitis eradication--Egypt, 1993.
MMWR 1994;43:223-6.
10. CDC. Progress toward poliomyelitis eradication--Socialist
Republic of Vietnam, 1991-1993. MMWR 1994;43:387-91.

*Mass campaigns over a short period (days to weeks) in which two
doses of OPV are administered to all children in the target age
group, regardless of prior vaccination history, with an interval
of 4-6 weeks between doses.
**Based on surveillance data submitted to WHO as of July 1, 1994.
***The difference between the number of countries reporting polio
cases or zero cases and the total number of countries reflects
those not submitting reports.



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

Date: Mon, 15 Aug 94 06:23:43 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: AIDS Daily News Summaries
Message-ID: <9PP4qc5w165w@stat.com>

AIDS Daily News Summary

The Centers for Disease Control and Prevention (CDC) National AIDS
Clearinghouse makes available the following information as a public
service only. Providing this information does not constitute endorsement
by the CDC, the CDC Clearinghouse, or any other organization. Reproduction
of this text is encouraged; however, copies may not be sold, and the CDC
Clearinghouse should be cited as the source of this information.
Copyright 1994, Information, Inc., Bethesda, MD


     In this issue:
     ************************************************************************
     "HIV-1 Newborns"
     "PCP Prophylaxis in Paediatric HIV Infection: Time for a Change"
     "Syringe and Needle Exchange to Prevent HIV Infection"
     "Knowledge and Practice Among Injecting-Drug Users of Bleach Use
      for Equipment Disinfection--New York City, 1993"
     "Expanding the AIDS Arsenal"
     "Herpes Drug Can Raise AIDS Patients'Life Expectancy, Hopkins Team Says"
     "Guidelines for Preventing Transmission of Human Immunodeficiency
      Virus Through Transplantation of Human Tissue and Organs"
     "Thymomodulin"
     "Birth Outcomes Following Zidovudine Therapy in Pregnant Women"
     "NCAP's Guide on Evaluating HIV/AIDS-Service Programs
      Available from CDC National AIDS Clearinghouse"
     "Substance Use and HIV-Related Sexual Behaviors Among
      US High School Students: Are They Related?"
     "PML Treatment Update, Peptide T Possibility"
     "Team Finds HIV Immune System Booster"
     "FDA Approves Drug ddC as Single AIDS Treatment"
     "FDA Approves AZT for AIDS Pregnant Women"
     "Medarex Bispecific Neutralizes Broad Variety
      of Clinical HIV Strains"
     ************************************************************************


                            "HIV-1 Newborns"
    New England Journal of Medicine (06/30/94) Vol. 330, No. 26, P. 1905
     (Speiser, Daniel E.;  Wyler, Claire-Anne;  Siegrist, Claire-Anne)

     Speiser et al. acknowledge that Blanche et al.'s study confirms the
bimodal pattern of AIDS in newborns, and clearly demonstrates the link
between the infant's survival and the severity of disease in the mother.
These findings, however, do not offer an explanation for how HIV-infected
babies can progress to AIDS in a matter of months.  Speiser et al. suggest
that HIV-1-specific immunologic intolerance may directly lead to rapid
disease progression.  This condition occurs when antigens present in the
fetal thymus during early development are viewed as self-antigens, and the
immature immune systems learns not to respond against them.  Advanced
disease in the mother, then, could result in early transmission in utero-
possibly of a larger viral inoculum or more virulent HIV strains--that
could infect the fetal thymus and, therefore, induce immunologic
intolerance.


     "PCP Prophylaxis in Paediatric HIV Infection: Time for a Change"
               Lancet (07/02/94) Vol. 344, No. 8914, P. 5
                 (Kovacs, Joseph A.; Kovacs, Andrea A.S.)

     Despite major breakthroughs in prevention of Pneumocystis carinii
pneumonia (PCP), the Centers for Disease Control and Prevention
in 1992 received reports of 239 cases involving children under
age 12.  CDC guidelines for PCP prevention, which dictate that
prophylaxis should begin when the CD4 count drops below the 200
level, are generally accepted by experts as valid.  Because the
normal CD4 count in uninfected babies and children is
significantly higher than in adults, CD4 counts decrease with
age, and PCP often is diagnosed in HIV-infected infants with CD4
counts higher than 200, separate guidelines have been developed
for children.  These guidelines, which recommend initiation of
prophylaxis according to age-specific CD4 thresholds, have of
late come under some question by the European Collaborative
Study, which suggested that existing thresholds will not result
in timely initiation of prophylaxis for most babies who develop
PCP.  If these findings are confirmed, alternative approaches for
PCP prophylaxis should be considered.


          "Syringe and Needle Exchange to Prevent HIV Infection"
              J.A.M.A. (06/15/94) Vol. 271, No. 23, P. 1825
      (Des Jarlais, Don C.;  Watters, John K.;  Fernando, Daniel et al.)

     Dr. Daniel Fernando challenged two articles on needle-exchange
programs, noting the limitations of syringe exchanges.  They are
of limited efficacy if unaccompanied by liberal policies allowing
increased availability of clean needles to intravenous drug
users, he said.  Liberal policies, Fernando argued, undermine the
need to use dirty needles but--unlike needle-exchange
programs--would not cost a thing.  Des Jarlais et al. responded
by clarifying that they are not supporting needle exchanges at
the expense of supporting liberal laws permitting the sale and
possession of injection paraphernalia, as suggested by Fernando.
They cite a review of studies of legal access to injection
equipment, which linked decreases in risky injections to
increased over-the-counter sales of injection paraphernalia.
They presented data documenting lower rates of HIV among IV drug
users in states not having prescription requirements for
possession of injection equipment.  Also in reply to Fernando's
criticisms, Watters et al. disagreed that needle-exchange
programs undermine liberal laws deregulating injection
paraphernalia.  Conversely, they contend, needle exchanges
directly resulted in the relaxation or repeal of
antiparaphernalia laws in several states.


         "Knowledge and Practice Among Injecting-Drug Users
   of Bleach Use for Equipment Disinfection--New York City, 1993"
            M.M.W.R. (06/24/94) Vol. 43, No. 24, P. 439
            (Marmor, M.;  Wolfe, H.;  Titus, S. et al.)

     The National Institute on Drug Abuse sponsored a study in New
York City to determine intravenous drug users' knowledge about
the use of bleach for disinfecting injection equipment.  Bleach
was recommended to reduce the possibility of HIV infection
through shared needles because of its widespread availability,
inexpensive cost, and ability to inactivate HIV.  Of the
one-fifth of active intravenous drug users who reported sharing
injection equipment, however, only one fourth used bleach
consistently.  And among all active IV drug users, only one third
knew both recommendations for correct bleach use.  NIDA
recommendations dictate that, in order for bleach to be a
successful disinfectant of injection paraphernalia, it must be
used at full strength, and must remain in contact with the
equipment for a minimum of 30 seconds.  Because of the
inconsistent use and incomplete knowledge about bleach as a
disinfectant, active IV drug addicts who reuse syringes that have
already been used by another IV drug user are at high risk for
HIV infection.


                    "Expanding the AIDS Arsenal"
        U.S. News & World Report (07/11/94) Vol. 117, No. 2, P. 67
             (Brink, Susan;  Smith, Anne Kates;  Rubin, Rita)

     The Food and Drug Administration recently approved a fourth drug
to fight HIV infection.  AIDS patients who cannot tolerate or no
longer benefit from AZT, ddI, or ddC will now be able to take
Stavudine, or D4T, which belongs to the same class of drugs as
the other three.  Stavudine does not cause anemia--one of the
most serious side effects of AZT use--but it does have its
disadvantages.  Some patients experienced peripheral neuropathy,
or pain, tingling, or numbness of the hands and feet.  Stavudine,
which will be sold under the name Zerit by Bristol-Myers Squibb,
should be available by prescription sometime this month.  The
daily wholesale cost will be $6.22, roughly the same as that of
AZT, and the manufacturer will help financially strapped patients
find funding, or receive the drug free of charge.


               "Herpes Drug Can Raise AIDS Patients'
                Life Expectancy, Hopkins Team Says"
                  Baltimore Sun (07/15/94) P. 7A
                         (Selby, Holly)

     The anti-herpes drug acyclovir, used in combination with the
anti-viral drug AZT, can prolong the life of end-stage AIDS
patients by as much as 1-1/2 years, according to a Johns Hopkins
University study.  The results confirm data from a European
clinical trial, as well as one conducted in Australia, notes Dr.
Neil Graham, one of the study's authors.  In both laboratory
studies and human clinical trials, herpes simplex appears to
worsen HIV infection.  Acyclovir may benefit AIDS patients by
halting this effect, Graham says.  The study also indicates that
600 to 800 milligrams per day of acyclovir is beneficial to AIDS
patients--a dose significantly lower than previously thought.
The study does not determine whether the anti-herpes agent would
help AIDS patients who are unable to tolerate AZT.


    "Guidelines for Preventing Transmission of Human Immunodeficiency
        Virus Through Transplantation of Human Tissue and Organs"
              M.M.W.R. (05/20/94) Vol. 43, No. RR-8, P. 1

     Most transmission of HIV to organ and/or tissue recipients
happened before the implementation of donor screening in 1985.
Recommendations for preventing HIV transmission through human
tissue and organs significantly reduced the risk for this mode of
transmission.  HIV transmission from an HIV-negative donor who
was screened, however, alerted authorities to the need for
revised guidelines.  The Public Health Service formed a working
group made up of representatives from various federal agencies,
which concluded that revisions should be made to existing
recommendations to further reduce the already low risk of HIV
transmission through organ and tissue transplant.  The new
guidelines address the issues of donor screening, testing, and
grounds for exclusion; inactivation or elimination of infectious
agents before transplantation; timely detection, reporting, and
tracking of potentially infected tissues, organs, and recipients;
and recall of stored tissues from donors discovered to be
HIV-positive.  Also considered were the differences between the
screening of living and dead donors and the differences between
procuring and distributing organs and tissues.


                    "Thymomodulin"
      AIDS Treatment News (07/08/94) No. 202, P. 1
              (James, John S.; Getty, Jeff)
     Human trials of Thymomodulin, a substance manufactured from
the thymus glands of calves, have demonstrated good results with
various conditions in which the immune system is compromised.   A
small, observational study of HIV patients conducted several
years ago in Europe also yielded promising results, including
marked improvement in clinical condition, and improvement in
blood work.  These early findings, however, were not followed up.
In Europe, they were seriously neglected, and all but completely
abandoned in the United States.  The scientific documentation,
combined with anecdotal evidence from several HIV/AIDS patients,
has convinced AIDS Treatment News that Thymomodulin is worth
pursuing as a treatment for HIV and AIDS.  The drug is approved
in Italy and used as an immune treatment throughout Europe, but
is not approved in the United States, although patients can
obtain a personal supply.


    "Birth Outcomes Following Zidovudine Therapy in Pregnant Women"
             J.A.M.A. (07/06/94) Vol. 272, No. 1, P. 17

     The Centers for Disease Control and Prevention estimates that
there are 100,000 HIV-positive women of child-bearing age in the
United States, and that 7,000 infants are born to infected
mothers each year.  The U.S. rate of perinatal HIV transmission
among women not receiving antiretroviral therapy is 15 to 30
percent.  Recent findings from a major clinical trial suggest
that treating mothers and newborns with zidovudine may
significantly lower the risk of HIV transmission.  The CDC
cautions, however, that potential risks linked to antiretroviral
treatment during pregnancy should be carefully considered.  The
Zidovudine in Pregnancy Registry was installed in 1989 by the
Wellcome Foundation, in conjunction with the CDC, to measure the
incidence of infants with structural defects.  An analysis of the
registry finds that the observed proportion of birth defects
among infants of women who received zidovudine therapy was 2
percent, not significantly different from the 3 percent that
characterizes the general population.  The findings, however, are
preliminary, and the sample limited.  The CDC says the registry
must be sustained to monitor for possible birth defects among
infants of women who received zidovudine therapy during
pregnancy.


       "NCAP's Guide on Evaluating HIV/AIDS-Service Programs
          Available from CDC National AIDS Clearinghouse"

It is one thing to operate a program, it is another to know whether
it works. To help grantmakers and staff from HIV/AIDS programs, the
National Community AIDS Partnership (NCAP) has published
"Evaluating HIV/AIDS Prevention Programs in Community-Based
Organizations." The 141-page publication focuses on how to select
the most effective evaluation strategy for media-based programs,
individual and group training, and information and referral
programs. Copies of "Evaluating HIV/AIDS Prevention Programs in
Community-Based Organizations", CDC NAC Inventory No. D576, are
$9.50 each. Supplies are limited; orders are accepted by telephone,
FAX, or mail. Call 1-800-458-5231 and select the publication orders
option at the voice prompt. Deaf Access/TDD  is available through
1-800-243-7012; FAX, 301-251-5343; or mail:

              CDC National AIDS Clearinghouse
              P.O. Box 6003
              Rockville, MD 20849-6003


          "Substance Use and HIV-Related Sexual Behaviors Among
                US High School Students: Are They Related?"
                A.J.P.H. (07/94) Vol. 84, No. 7, P. 1116;
    (Lowry, Richard;  Holtzman, Deborah;  Truman, Benedict I. et al.)

     Lowry et al. set out to determine whether use of alcohol,
cigarettes, marijuana, or hard drugs is linked to the likelihood
of sexual behaviors that increase risk for HIV among adolescents.
They used the 1990 national Youth Risk Behavior Survey to gather
self-reported data from 11,631 high school students across the
United States.  Lowry and his colleagues found that those
youngsters who reported no substance abuse were least likely to
have had four or more sexual partners, least likely not to have
used a condom, and least likely to have had sex at all.  These
risky behaviors were, on the other hand, most common among
students who had used marijuana, cocaine, or other illicit drugs.
The researchers conclude that HIV programs for adolescents must
take into account the fact that substance abuse, through its
association with unsafe sexual behaviors, may be an important
factor in calculating risk of HIV infection and AIDS.


       "PML Treatment Update, Peptide T Possibility"
       AIDS Treatment News (06/17/94) No. 201, P. 3
                    (James, John S.)

     Progressive multifocal leukoencephalopathy (PML) is a relatively
uncommon brain infection diagnosed in only about one percent of
AIDS patients, usually in the late stages of disease.  Many
cases, however, are misdiagnosed--usually as toxoplasmosis or
lymphoma.  Because there is neither a cure, nor any FDA-approved
treatments for PML, patients who are diagnosed are often informed
by physicians that they will die shortly.  Actually, there are a
number of experimental treatments, and some individuals with PML
have stabilized or improved, and lived fairly healthy lives for
years.  These treatments remain unproved, however, as controlled
trials have not been conducted.  The best source of information
on PML is a privately published book, "Progressive Multifocal
Leukoencephalopathy (PML): Case Studies and Potential Treatments"
by Peter and Lisa Brosnan.  The book includes a brief description
of the infection, discussion of treatments that have been tried,
and ones that have potential.


            "Team Finds HIV Immune System Booster"
            United Press International (07/27/94)

     Japanese scientists announced that their collaborative HIV
research with an Australian team may support a disease-fighting
strategy that calls for the injection of patients with their own
lymphocytes.  The method is based on the premise that lymphocytes
attack foreign invaders in the body--but that quantities of these
key immune-system agents drop significantly in HIV patients.  An
Australian team, headed by John Dwyer, conducted the experiment,
and the Japanese team, led by Takashi Kurimura, did the research.
Dwyer's group extracted highly active and healthy lymphocytes,
matching them to those of an HIV-positive young man, and
transferred the lymphocytes to him.  After the procedure, the
virus decreased dramatically.   The young man regained his
immunity, and the treatment still proved to be effective six
months later.


          "FDA Approves Drug ddC as Single AIDS Treatment"
              Philadelphia Inquirer (08/09/94) P. A10

     The U.S. Food and Drug Administration has granted marketing
approval for zalcitabine, or ddC, as a single-drug treatment for
HIV infection.  The drug is sold under the brand name HIVID by
Hoffmann-La Roche Inc.   HIVID previously was approved only for
use in combination with Burroughs Wellcome Co.'s AZT drug.  Now,
HIVID can be prescribed for adults with advanced HIV disease
whose condition has progressed while taking AZT, and for adult
HIV patients who cannot tolerate AZT.  Related Stories:
Washington Times (08/09) P. A10; Investor's Business Daily
(08/09) P. A1


            "FDA Approves AZT for AIDS Pregnant Women"
                        Reuters (08/09/94)

     The U.S. Food and Drug Administration has approved the antiviral
drug zidovudine (AZT) for use in preventing maternal-infant
transmission of HIV.  The drug, manufactured by Burroughs
Wellcome Co., is now recommended as part of a regimen that
includes oral AZT beginning 14 to 34 weeks after gestation,
intravenous administration during labor, and an AZT syrup given
to newborns.  The agency said approval of the drug was based on
the results of a federally funded study, which found that the
rate of mother-infant HIV transmission was slashed by about
two-thirds among women who were treated with AZT.


           "Medarex Bispecific Neutralizes Broad Variety
                    of Clinical HIV Strains"
                     HealthWire (08/08/94)

     Scientific collaborators of Medarex, Inc. announced on Monday the
results of their study with Dr. Herve Raoul, Dr. Aloise Mabondzo,
and colleagues in the laboratory of Professor Dominique Dormont
of the Laboratoire de Neuropathologie Experimentale et
Neurovirologie of C.E.A. in France.  The results, presented at
the Tenth International Conference on AIDS in Yokohama, Japan,
showed that MDX-240, the company's Bispecific antibody product
for AIDS, neutralizes infection of CD4 positive immune cells by
clinical isolates--strains of HIV taken from infected patients.
On August 3, Medarex announced the enrollment of subjects for
Phase I/II clinical trials of MDX-240 to take place at two
university hospitals in Europe.  Medarex is a biopharmaceutical
company specializing in treatments that enhance the body's
natural immune system.



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

End of HICNet Medical News Digest V07 Issue #37
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-1165
Bitnet  : ATW1H@ASUACAD

