Path: utzoo!utgpu!jarvis.csri.toronto.edu!mailrus!uwm.edu!zaphod.mps.ohio-state.edu!brutus.cs.uiuc.edu!psuvax1!psuvm!auvm!ASUACAD!ATW1H From: ATW1H@ASUACAD.BITNET (Dr David Dodell) Newsgroups: bit.listserv.mednews Subject: HICN305 News Part 2/3 Message-ID: Date: 10 Feb 90 22:50:44 GMT Sender: MEDNEWS - Health Info-Com Network Newsletter Lines: 599 Approved: NETNEWS@AUVM Gateway --- begin part 2 of 3 cut here --- (70%) shelters were in public schools, 38 (24%) in community centers, and 10 (6%) in churches. The number of persons housed per shelter ranged from five to 297 (mean: 64). The surveillance system monitored 158 shelters. On September 25, 9429 persons were housed in the shelters--20 (13%) of which lacked running water; on October 3, 7528 persons were housed in the shelters--all of which had running water. Three shelters were not monitored--one on the island of Culebra housing greater than 100 persons and two on the main island housing less than 10 persons each. From September 25 through September 29, five shelters reported a greater than 10% incidence of gastroenteritis. However, investigation failed to confirm these outbreaks; reported information either could not be verified or potential cases did not meet the PRDH gastroenteritis case definition (i.e., three or more loose stools within a 24-hour period). Outbreaks of head lice infestation were confirmed in 28 (18%) shelters; at least one case of lice was reported in each of 34 (22%) shelters. Outbreaks of influenza-like illness occurred in 18 (11%) shelters. Compared with persons housed in schools, those housed in community centers and churches were 4.2 and 3.4 times more likely, respectively, to have had an influenza-like illness. Reported by: D Jimenez, M Quiroga, A Santiago, J Villanueva, JV Rullan, MD, Commonwealth Epidemiologist, Div of Epidemiology, Puerto Rico Dept of Health. Div of Field Svcs, Epidemiology Program Office; Surveillance and Programs Br, Div of Environmental Hazards and Health Effects, Center for Environmental Health and Injury Control, CDC. Editorial Note: Before impending hurricanes and other potential disasters, Health InfoCom Network News Page 10 Volume 3, Number 5 February 10, 1990 many persons are reluctant to evacuate to shelters. In Puerto Rico, evacuation posed few problems, and the benefits of evacuation far outweighed the risks of residing in shelters. (The three persons who died during the impact phase of Hurricane Hugo had repeatedly refused to evacuate to shelters (1; CDC, unpublished data)). The PRDH surveillance did not detect or document serious disease outbreaks or other public health problems in the shelters; moreover, only a few minor health problems were identified in the shelters. The difference in risk for certain infectious diseases between persons housed in schools and persons housed in community centers and churches was not related to the number of persons per shelter or to overcrowding. One possible explanation for this difference was the use of multiple small rooms for housing persons at schools rather than the use of one large room at community centers and churches. The head lice infestation may have reflected endemic occurrence detected only incidentally by this surveillance system. The PRDH shelter surveillance system resulted in several public health inter ventions: provision of portable toilets to shelters that needed them; delivery of potable water to shelters that lacked drinking water; education of shelter residents about personal hygiene; and treatment of persons with head lice infestations. In addition, data from the surveillance system were useful in assessing and dispelling rumors that circulated the day after the hurricane about outbreaks of infectious diseases (including cholera) in the shelters, as well as ensuring that basic sanitary services and potable water were provided efficiently. Public health surveillance in large shelters, such as that established by the PRDH after Hurricane Hugo and after torrential rains in 1985 (2), should be part of the public health emergency response to disasters. Reference 1. CDC. Deaths associated with Hurricane Hugo--Puerto Rico. MMWR 1989;38:680- 2. 2. Dietz VJ, Sanderson L, Diaz L, Rigau-Perez JG. Morbidity/mortality surveillance after torrential rains, Puerto Rico (Abstract). In: Program and abstracts of the Epidemic Intelligence Service 35th Annual Conference. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1986:84. Health InfoCom Network News Page 11 Volume 3, Number 5 February 10, 1990 Aspergillus Endophthalmitis in Intravenous-Drug Users -- Kentucky Since May 1989, three cases of Aspergillus endophthalmitis, a potential cause of irreversible vision loss, have been reported in Louisville, Kentucky. All three patients were intravenous-drug users (IVDUs). The patients--ages 40, 32, and 24 years--had onsets of illness in May, August, and September, respectively. Two were male. Except for IV-drug use, no risk factors for this fungal endophthalmitis were identified. All three patients were seronegative for antibody to human immunodeficiency virus. Infection was unilateral in each patient and responded to treatment with amphotericin B and flucytosine following vitrectomy. All patients had some degree of permanent vision loss. In each case, diagnosis was made by culture of specimens obtained at vitrectomy; each culture grew Aspergillus flavus. None of the patients had systemic or other localized signs of infection. Two of the patients lived in the same apartment complex. The third lived approximately 1 mile away. Each denied any contact with the others. Common IV- injection practices included diluting drugs with tap water and filtering this mix through cotton or cigarette filters. All patients injected cocaine and a combination of pentazocine and tripelennamine. Reported by: CC Barr, MD, A Walsh, Humana University Hospital, B Wainscott, MD, Jefferson County Health Dept, Louisville; R Finger, MD, Acting State Epidemiologist, Dept for Health Svcs, Kentucky Cabinet for Human Resources. Div of Field Svcs, Epidemiology Program Office, CDC. Editorial Note: Fungal endophthalmitis is a recognized complication of IV-drug use (1). Infection results from hematogenous spread after nonsterile injection (2). Fungal endophthalmitis can develop slowly over weeks and occurs more frequently with Candida than with Aspergillus (3). Other risk factors associated with Aspergillus endophthalmitis include the use of antibiotics, corticosteroids, and immunosuppressive therapy (3). Vision loss can be limited in some patients by aggressive antibiotic and surgical treatment (4). Because Aspergillus species are ubiquitous molds and the patients reported here used common injection practices, the source of infection is difficult to determine. However, one possible explanation for the geographic and temporal clustering of these cases is a contaminated drug supply. Physicians should consider the diagnosis of fungal endophthalmitis in IVDUs with signs of intraocular infection. References 1. Elliott JH, O'Day DM, Gutow GS, Podgorski SF, Akrabawi P. Mycotic endophthalmitis in drug abusers. Am J Ophthalmol 1979;88:66-72. 2. Sugar HS, Mandell GH, Shalev J. Metastatic endophthalmitis associated with injection of addictive drugs. Am J Ophthalmol 1971;71:1055-8. 3. Hirst LW, Thomas JV, Green WR. Endophthalmitis. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 2nd ed. New York: Wiley, 1985:760-7. 4. Roney P, Barr CC, Chun CH, Raff MJ. Endogenous Aspergillus endophthalmitis. Rev Infect Dis 1986;8:955-8. Health InfoCom Network News Page 12 Volume 3, Number 5 February 10, 1990 Pseudomonas aeruginosa Corneal Infection Related to Mascara Applicator Trauma -- Georgia On January 11, 1989, a 47-year-old woman in Georgia scratched her left eye with a mascara applicator and subsequently had onset of progressive pain, light sensitivity, redness, and swelling of the eye. Examination by a physician on January 12 revealed a corneal abrasion; gentamicin ointment was instilled, and the eye was patched. Three days after onset, ophthalmologic consultation documented severely impaired vision and a corneal abscess in the patient's left eye, and the patient was admitted for treatment. Gram stain of corneal scrapings revealed gram-negative rods. Culture of the corneal scrapings and of a sample of the patient's mascara grew Pseudomonas aeruginosa with identical antibiotic susceptibility patterns. Following inpatient therapy, including subconjunctival gentamicin, the infection resolved; however, on discharge from the hospital, a dense inflammatory corneal infiltrate was present. Subsequently, diffuse neovascularization of the cornea developed; vision in the patient's eye has not improved. Reported by: LA Wilson, MD, Emory Univ, Atlanta; RK Sikes, DVM, State Epidemiologist, Georgia Dept of Human Resources. Meningitis and Special Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC. Editorial Note: Only nine cases of P. aeruginosa eye infections associated with mascara applicator trauma and mascara contamination have been reported (1-3). New mascara is rarely contaminated with bacteria but can become contaminated with P. aeruginosa and other bacteria after use (4,5). The case described here demonstrates the rapidity with which P. aeruginosa infection can progress and the severity of residual damage. Ophthalmologists and other health-care workers who evaluate patients with eye complaints should be aware of mascara applicator trauma as a potential risk factor for infection. Prompt ophthalmologic consultation should be obtained for suspected P. aeruginosa corneal infections. Further efforts are needed to delineate the epidemiology of Pseudomonas corneal infections related to mascara contamination. When the medical history suggests that antecedent mascara application may be associated with corneal infection, health-care workers should consider culturing the mascara of affected patients. Suspected cases should be reported through state health departments to the Meningitis and Special Pathogens Branch, Division of Bacterial Diseases, Center for Infectious Diseases, CDC, Mailstop C09, Atlanta, GA 30333; telephone (404) 639-3687. References 1. Wilson LA, Ahern DG. Pseudomonas-induced corneal ulcer associated with contaminated eye mascaras. Am J Ophthalmol 1977;84:112-9. 2. Thomas ET, Barton SN. The role of eye cosmetic contaminants in the pathogenesis of eye infection: an epidemiologic investigation. Ala J Med Sci 1978;15:246-51. 3. Reid FR, Wood TO. Pseudomonas corneal ulcer. Arch Ophthalmol 1979;97:1640- 1. Health InfoCom Network News Page 13 Volume 3, Number 5 February 10, 1990 4. Wilson LA, Kuehne JW, Hall SW, et al. Microbial contamination in ocular cosmetics. Am J Ophthalmol 1971;71:1298-302. 5. Ahern DG, Wilson LA, Julian AJ, et al. Microbial growth in eye cosmetics: contamination during use. Dev Ind Microbiol 1974;15:211-6. Health InfoCom Network News Page 14 Volume 3, Number 5 February 10, 1990 Update: Influenza Activity -- United States, 1989-90 Widespread influenza-like illness activity* for the 1989-90 influenza season was first reported the week ending December 16, 1989, in Montana and Utah. Four states (Mississippi, Montana, Texas, and Utah) reported widespread activity during the week ending December 30, and 10 states reported widespread activity during the week ending January 6, 1990. For the week ending January 13, 10 states reported widespread activity, 19 reported regional activity, and 22 reported sporadic activity (Figure 1). Visits to approximately 110 sentinel family practice physicians in 43 states for treatment of influenza-like illnesses have similarly increased, accounting for 9.5%, 8.8%, and 10.3% of all visits during the weeks ending December 30, January 6, and January 13, respectively, compared with a mean of 4.9% during the 4 weeks ending December 23. Approximately 3% of all patients seen by sentinel physicians for treatment of influenza-like illness have required hospitalization. Persons greater than or equal to 65 years of age are more likely to be hospitalized for influenza-like illness or complications than are persons less than 65 years of age (13.7% vs. 2.0%). Influenza A(H3N2) continues to be the predominant influenza strain, accounting for approximately 98% of the 335 isolates subtyped and reported to CDC so far this season. Influenza has been isolated in patients from all age groups. Culture-confirmed outbreaks of influenza A(H3N2) in nursing home residents have been reported from seven states. Since December 15, outbreaks of respiratory illness in 68 (21%) of 329 Connecticut nursing homes have been reported to the state health department; influenza A viruses have been isolated from patients at six of these nursing homes. In the 121 cities that report death certificate data regularly to CDC, 7.6% of deaths were associated with pneumonia and influenza for the week ending January 13. This percentage exceeds the epidemic threshold of 6.7% for the first time this influenza season. Reported by: ML Cartter, MD, JL Hadler, MD, State Epidemiologist, Connecticut State Dept of Health Svcs. State and territorial health department epidemiologists and state laboratory directors. WHO Collaborating Laboratories. Sentinel Physicians of the American Academy of Family Practice. Div of Surveillance and Epidemiologic Studies, Epidemiology Program Office; Epidemiology Office, Biometrics Activity, Influenza Br, Div of Viral and Rickettsial Diseases, Center for Infectious Diseases, CDC. Editorial Note: During influenza A outbreaks in nursing homes and other chronic-care facilities, the combined use of influenza vaccination and amantadine prophylaxis and treatment of both residents and employees may shorten the duration and severity of the outbreak (1-3). However, amantadine- resistant influenza viruses can emerge when amantadine is used for treatment (4-6). The frequency with which resistant isolates emerge and the extent of transmission of these viruses remain unknown; however, there is no evidence to suggest that amantadine-resistant viruses are more virulent or more transmissible than amantadine-sensitive viruses (5). Thus, the use of amantadine remains an appropriate outbreak-control measure. In closed populations such as nursing homes, ill persons who are receiving amantadine as treatment should be separated, whenever possible, from persons receiving amantadine as prophylaxis against influenza. The continued occurrence of influenza-like illness in an institution where amantadine is being used, and isolation of influenza viruses from persons who are receiving amantadine, should be reported through the state health department to CDC. Health InfoCom Network News Page 15 Volume 3, Number 5 February 10, 1990 References 1. ACIP. Prevention and control of influenza. MMWR 1988;37:361-4,369-73. 2. Atkinson WL, Arden NH, Patriarca PA, Leslie N, Lui KJ, Gohd R. Amantadine prophylaxis during an institutional outbreak of type A(H1N1) influenza. Arch Intern Med 1986;146:1751-6. 3. Mostow SR. Prevention, management and control of influenza: role of amantadine. Am J Med 1987;82(suppl 6A):35-41. 4. Mast EE, Davis JP, Harmon MW, Arden NH, Circo R, Tyszka GE. Emergence and possible transmission of amantadine-resistant viruses during nursing home outbreaks of influenza A(H3N2) (Abstract). In: Program and abstracts of the twenty-ninth Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1989:111. 5. Belshe RB, Burk B, Newman F, Cerruti RL, Sim IS. Resistance of influenza A virus to amantadine and rimantadine: results of one decade of surveillance. J Infect Dis 1989;159:430-5. 6. Hayden FG, Belshe RB, Clover RD, Hay AJ, Oakes MG, Soo W. Emergence and apparent transmission of rimantadine-resistant influenza A virus in families. N Engl J Med 1989;321:1696-1702. *Levels of activity are: 1) Sporadic--sporadically occurring influenza-like illness or culture-confirmed influenza, with no outbreaks detected; 2) Regional--outbreaks of influenza-like illness or culture-confirmed influenza in counties having a combined population of less than 50% of the state's total population; 3) Widespread--outbreaks of influenza-like illness or culture- confirmed influenza in counties having a combined population of greater than or equal to 50% of the state's total population. Health InfoCom Network News Page 16 Volume 3, Number 5 February 10, 1990 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Food & Drug Administration News ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Monday February 5, 1990 Milk Findings P90-10 Food and Drug Administration FOR IMMEDIATE RELEASE Bonnie Aikman - (301) 443-3285 Feb. 5, 1990 (Home) -- (301) 986-0697 A nationwide survey of milk has found no residues of any antibiotics, including sulfa drugs, the Food and Drug Administration announced today. The FDA findings, based on the most current technology, contradict earlier conclusions reached after an unconfirmed screening test sponsored by a national newspaper. Specifically, no sulfamethazine -- a suspect carcinogen no longer permitted for use in milk cows -- or other potentially dangerous drug was found in the 14-city survey of milk, FDA said. The federal survey confirms, using newer methods, the testing for antibiotics carried out by states under the National Conference of Interstate Milk Shippers. The conference program of inspection and testing costs more than $100 million a year. The states generally rely on a microbiological disk assay method originally designed primarily for the detection of penicillin, then the major drug used for dairy cows. The test also detects other antibiotics, but not with the same sensitivity. FDA had been perfecting tests for antibiotic residues in milk and used them in the new survey. FDA said the new methodologies will be made available for use by the states as well as the federal government. The methods were put into use for this survey after the Wall Street Journal on Dec. 29 and Jan. 2 claimed that currently used testing methods fail to detect antibiotics in milk. The newspaper said it had a laboratory test milk by a method called Charm II, which is not routinely used for pasteurized milk, and that in this "survey of 50 off-the-shelf samples collected before Christmas in 10 cities, 38 percent were found to be contaminated with antibiotics or sulfa drugs -- including sulfamethazine, a suspected carcinogen." Today's results indicate, however, that the "positives" in the newspaper's tests may have been false positives. The newspaper published the Charm II screening test's "positive" results although they had not been confirmed by other methods. FDA said at the time that the figures reported by the paper were the result of a test that could only detect classes of drugs, and that the test was not specific for sulfamethazine. The agency also said the levels reported would not constitute a health threat. Nevertheless, FDA said it was beginning its own tests. In doing so, the agency duplicated the testing methodology -- Charm II -- and got "positives" similar to those reported by the Wall Street Journal for drugs overall. That is, FDA's use of the Charm II test showed "positives" for 51 percent of the samples. About a dozen also registered as suspicious using FDA's High Pressure Liquid Chromatography methodology, but none was confirmed by other, more specific methods -- gas chromatography and mass Health InfoCom Network News Page 17 Volume 3, Number 5 February 10, 1990 spectrum detection. FDA found no confirmation of sulfamethazine, which is not approved for use in milk-producing animals, nor of chloramphenicol, a compound not approved for use in any food-producing animal. The testing also specifically targeted penicillin, as it can cause allergic reactions at some levels, but no penicillin was found. "Since one error with one milk cow can cause a detectable residue of sulfamethazine in the pooled milk of 70,000 cows, our study indicates that the American dairy farmer is using animal drugs carefully and conscientiously, and that the milk supply does not contain unsafe drug residues," FDA's Center for Veterinary Medicine Director Gerald Guest, D.V.M., said. Most milk testing is performed under the $100 million program of the National Conference of Interstate Milk Shippers, a cooperative effort of all 50 states and the FDA. The results of FDA's survey show that the National Conference's testing -- in which more than 1.2 million samples are tested for antibiotics each year -- has been basically sound, FDA said today. The agency said, however, that it and cooperating states would begin using the newest generation of laboratory tests to help ensure that neither a real antibiotic residue problem nor a "media scare" disturbs the milk supply. Dr. Guest said, "It also is time to review the appropriateness of supplementing testing for antibiotic residues with newer methods which can detect residues of drugs other than antibiotics that are sometimes used to treat animals." The 70 samples in the current tests were collected, five each, in Atlanta, Baltimore, Boston, Chicago, Dallas, Denver, Kansas City, Los Angeles, Miami, Minneapolis-St. Paul, Philadelphia, New York, San Francisco and Seattle. Testing continues on some of the 70 samples and may eventually identify traces of animal drugs at levels of no public health concern. To further ensure the wholesomeness and safety of the nation's milk, the FDA plans to: -- regularly monitor pasteurized milk for the presence of drug residues. This would supplement the testing carried out by the states under the National Conference of Interstate Milk Shippers. -- work through the conference for the adoption by the states of appropriate new procedures, including new analytical methods and for the continuation of programs that educate the farmer about proper drug use to prevent any drug residues and that penalize the farmer when warranted. (Such economic penalties currently include the dumping of violative milk, without compensation.) In addition, FDA said it will continue research, development and validation of new analytical methods. #### Monday January 29, 1990 FDA APPROVES AIDS DRUG--FLUCONAZOLE P90-8 Food and Drug Administration FOR IMMEDIATE RELEASE Brad Stone -- (301) 443-3285 Jan. 29, 1990 Home -- (703) 892-0468 Health InfoCom Network News Page 18 Volume 3, Number 5 February 10, 1990 The Food and Drug Administration today approved the drug fluconazole as an alternative treatment for two serious, AIDS-related fungal infections -- one of which is a life-threatening type of meningitis. The new drug was approved for treating cryptococcal meningitis, an inflammation of the brain and nervous system that often affects people with AIDS. The drug was also approved for treating candidiasis, a fungal infection that is most often manifested by sores in the mouth and throat, and which is estimated to afflict 80 to 90 percent of people at advanced stages of infection with the AIDS virus. Treatments already exist for these infections but their use is limited by side effects or other factors. For example, the drug amphotericin B usually is effective in treating an initial episode of cryptococcal meningitis. This conventional therapy can result in serious adverse reactions including impairment of kidney function, and suppression of bone marrow, as well as less serious side-effects such as fever and nausea. A significant proportion of treated patients relapse within a matter of months and require maintenance therapy for the rest of their lives. Lifetime treatment with fluconazole is also recommended for AIDS patients with cryptococcal meningitis who have relapsed, but these patients would likely experience fewer side-effects than those receiving chronic treatment with amphotericin B. HHS Secretary Louis W. Sullivan, M.D., said, "Fluconazole offers an effective alternative treatment for people with AIDS, cancer and other diseases whose weakened immune systems make them susceptible to cryptococcal meningitis or candidiasis." HHS Assistant Secretary for Health James Mason, M.D., Dr.P.H., said fluconazole is the latest in a series of approved therapies that may help improve the quality of life for people with AIDS. Two studies comparing fluconazole to amphotericin B for cryptococcal meningitis showed that fluconazole provided comparable efficacy for the infection with fewer side effects such as kidney insufficiency. In a controlled comparison study involving AIDS patients with esophageal candidiasis, fluconazole was found to be comparable in efficacy to the drug ketoconazole. Similar results were obtained in trials comparing fluconazole with the drug clotrimazole in the treatment of candidiasis in people with AIDS and people with cancer. Although the drug appears to be well tolerated by most patients, it has been associated with abdominal discomfort and nausea. Less commonly, it has been associated with signs of liver damage. In rare instances, fluconazole has been linked to severe skin rashes and fatal hepatic necrosis, a form of liver failure. The drug will be marketed in both a tablet and intravenous form under the trade name Diflucan, by its manufacturer, Pfizer Inc. of New York, N.Y. #### Monday January 29, 1990 Ban on FD&C RED DYE P90-9 Food and Drug Administration FOR IMMEDIATE RELEASE Emil Corwin (202) 245-1144 Health InfoCom Network News Page 19 Volume 3, Number 5 February 10, 1990 Jan. 29, 1990 (Home) (202) 244-6242 HHS Secretary Louis W. Sullivan, M.D., today announced that the Food and Drug Administration will terminate the "provisional" uses of color additive FD&C Red No. 3. This action is required under federal law because laboratory tests have shown that very high doses of this red color additive administered in the diet of male rats were associated with thyroid tumors. "The actual risk posed by Red No. 3 is extremely small; however, federal law in this area is clear," Secretary Sullivan said. "There have been laboratory studies which showed that very high doses of Red No. 3, administered directly in the diet, caused cancer in rats. In these circumstances, small as the risk is, we have no choice under the law but to end the provisional listing of this product." Today's action prevents further use of this color additive in about one fifth of its uses -- in cosmetics such as lipsticks, in externally applied drugs and, as a pigment form called "lakes," in food, drugs and cosmetics. Under the so-called Delaney Clause of the 1960 Color Additive amendments to the Food, Drug and Cosmetics Act, products shown to have carcinogenic effect in laboratory tests, no matter how small, cannot be approved for use by FDA. The decision to ban the uses of Red No. 3, therefore, is not based on risk but on the legal mandate of the Delaney Clause. The risk of Red No. 3 is estimated to be no larger than one in a hundred thousand over a lifetime of consumption. This estimate errs on the side of safety, and the risk may actually be smaller. The conservative risk estimate procedures have been established to overwhelmingly ensure that carcinogens are not added to the food supply. The overall risk from natural disasters (e.g., earthquakes, hurricanes, etc.) is close to seven in 10,000. For manmade disasters (e.g., major railroad accidents, major air crashes, etc.) the risk is close to six in 100,000 per lifetime. Although these "actual" risks are not directly comparable to those for Red No. 3 -- the Red No. 3 risks are worst case estimates from animal data -- the comparison helps put the risk in perspective. Secretary Sullivan noted that the National Academy of Sciences has recommended that the Delaney Clause be replaced by a "negligible risk" standard, especially to reflect significant technological advances since 1960 --- end part 2 of 3 cut here ---