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NEW ENGLAND 721
Boston, Mass.

168
Bridgeport, Conn. 52
Cambridge, Mass. 28
Fall River, Mass.
Hartford, Conn.

67 Lowell, Mass.

29 Lynn, Mass.

21 New Bedford, Mass. New Haven, Conn. 44 Providence, R.I.

65 Somerville, Mass. 16 Springfield, Mass. 55 Waterbury, Conn. 42 Worcester, Mass. 70 MID. ATLANTIC 2,838 Albany, NY,

54 Allentown, Pa.

19 Buffalo, N.Y.

134 Camden, N.J.

37 Elizabeth, N.J.

33 Erie, Pat

40 Jersey City, N.J.

50 N.Y. City, N.Y. 1,459 Newark, N.J.

50 Paterson, N.J.

42 Philadelphia, Pa. 392 Pittsburgh, Pat 105 Reading, Pa.

46 Rochester, NY.

113 Schenectady, N.Y. 18 Scranton, Pat

36 Syracuse, N.Y.

102 Trenton, N.J.

43 Utica, N.Y. Yonkers, N.Y.

35 E.N. CENTRAL 2,437 Akron, Ohio

51 Canton, Ohio

42 Chicago, III.S

564 Cincinnati, Ohio 191 Cleveland, Ohio 171 Columbus, Ohio 132 Dayton, Ohio

125 Detroit, Mich.

282 Evansville, Ind.

33 Fort Wayne, Ind.

52 Gary, Ind.

11 Grand Rapids, Mich. 73 Indianapolis, Ind. 170 Madison, Wis.

50 Milwaukee, Wis. 162 Peoria, III.

51 Rockford, III.

51 South Bend, Ind.

55 Toledo, Ohio

107 Youngstown, Ohio 64 W.N. CENTRAL 978 Des Moines, Iowa 57 Duluth, Minn.

27 Kansas City, Kans. Kansas City, Mo. 131 Lincoln, Nebr.

41 Minneapolis, Minn. 260 Omaha, Nebr.

115 St. Louis, Mo.

140 St. Paul, Minn.

72 Wichita, Kans.

97

1 3 2 4

60 S. ATLANTIC

1,596 996 327 173 20 Atlanta, Ga.

190 123 41 13 1 Baltimore, Md.

208 139 47

14 3 Charlotte, N.C.

130 89 26 10 Jacksonville, Fla. 137 81 32 12 1 Miami, Fla.

209 122 48 23 4 Norfolk, Va.

57 40 10 3 1 Richmond, Va.

105 70 24 8 3 Savannah, Ga.

75 55 14 3 5 St. Petersburg, Fla. 96 82 7 3 4 Tampa, Fla.

66 39 19 2 Washington, D.C. 287 130 55 77 5 Wilmington, Del. 36 26 4 5 6 E.S. CENTRAL

887 597 179 51 Birmingham, Ala. 124 86

20

7 180 Chattanooga, Tenn. 47 32 9 3 1 Knoxville, Tenn.

106 73

24 7 1 Louisville, Ky.

98 68 23 4 12 Memphis, Tenn. 221 145 38 14 1 Mobile, Ala.

74 23 6 5

Montgomery, Ala. 47 29 12 3 7 Nashville, Tenn. 132 90 30 7 1 85

W.S. CENTRAL 1,443 910 302 128
Austin, Tex.

45 25 14 5

44 Baton Rouge, La. 2

32 5 5 22 Corpus Christi, Tex. 64 47 10 2 4 Dallas, Tex.

192 108 41 23 9 El Paso, Tex.

50 34 13 3 Fort Worth, Tex 106 72 17 8 Houston, Tex. ß

308
176

74 34 Little Rock, Ark.

96 70 15 3 8

New Orleans, La. 107 65 26 15 1 San Antonio, Tex. 217

130

47 17 Shreveport, La

71 49

6 5 Tulsa, Okla.

143 102 25 7 120 MOUNTAIN

695 472 121 52 Albuquerque, N. Mex. 97 61 15 15 4 Colo. Springs, Colo. 46 30 13 2 16 Denver, Colo.

136 83 24 10 24

Las Vegas, Nev. 110 75 24 3 3 Ogden, Utah

24 18 4 2. Phoenix, Ariz.

112 80 20 7 Pueblo, Colo.

28 23 3 3

Salt Lake City, Utah 48 31 5 7 1 Tucson, Ariz.

94 71 13 1 PACIFIC

2,129 1,405 402 193 1 Berkeley, Calif.

22 16 4 2 7 Fresno, Calif.

89 63 17 5 2 Glendale, Calif.

28 21 5 1 6 Honolulu, Hawaii 75 54 13 4 10 Long Beach, Calif. 86 63 15 4 4 Los Angeles Calif. 609 376 127 66 9 Oakland, Calif.

78 57

3 6 Pasadena, Calif.

31 24

5 9 Portland, Oreg.

176

117 32 14 5 Sacramento, Calif. 180 119 38 13 66 San Diego, Calif. 144

95 30 12 6

San Francisco, Calif. 167 98 36 26
San Jose, Calif.

191
132

33 17 Seattle, Wash

145 91 24 16 12 Spokane, Wash.

58 45 6 4 Tacoma, Wash.

50 34 6 5 20 TOTAL

13,724** 9,151 2,672 1,124 11 2

8 11 6 1 7

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* Mortality data in this table are voluntarily reported from 121 cities in the United states, most of which have populations of 100,000 or more. A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not

included **Pneumonia and influenza, t Because of changes in reporting methods in these 3 Pennsylvania cities, these numbers are partial counts for the current week

Complete counts will be available in 4 to 6 weeks. t1 Total includes unknown ages.

Birth Defects Continued

Human birth defects also have been observed after prenatal exposure to etretinate (Tegison t, Roche Laboratories, A Division of Hoffmann-La Roche, Inc.), a drug approved in October 1986 for treatment of severe, recalcitrant psoriasis (2). Etretinate also carries Category X labeling. Measurable serum concentrations of this drug have been documented more than 2 years after cessation of therapy (5), and the risk of teratogenicity may extend for an indefinite period of time after therapy (6).

Isotretinoin embryopathy is a preventable syndrome, and the number of infants born with these problems can be reduced by following the guidelines developed cooperatively by FDA and the manufacturer, Hoffmann-La Roche, Inc. This information is distributed in the form of package inserts and patient information leaflets. Current information for prescribing Accutaneand TegisonTM has been published in the 1988 Physicians' Desk Reference (7). A summary of these guidelines follows: 1. Isotretinoin and etretinate should not be used by women who are pregnant or who

may become pregnant while taking the drug. 2. Pregnancy should be ruled out before treatment begins. This precaution may best

be accomplished by obtaining a negative pregnancy test no more than 2 weeks prior to the beginning of therapy and starting therapy on the second or third day

of the patient's next normal menstrual period. 3. An effective form of contraception should be used for at least 1 month before

therapy begins. 4. Women who have received isotretinoin should continue using an effective form of

contraception for 1 month after discontinuing treatment. 5. The period of time during which pregnancy must be avoided after treatment is

discontinued has not been determined for women who have received etretinate. 6. Female patients should be counseled on the risk of major birth defects associated

with first-trimester exposure to isotretinoin or etretinate. Should a pregnancy occur during treatment (or after treatment, in the case of etretinate), the woman

should consult her physician about the management of her pregnancy. In addition, patients should be counseled not to share these prescription drugs with friends or family members.

The approach suggested by these guidelines cannot be expected to prevent all fetal exposures. It can be anticipated that infants will be born with defects caused by first-trimester exposures to the synthetic retinoids isotretinoin and etretinate as long as these drugs are available for use. References 1. de la Cruz E, Sun S, Vangvanichyakorn K, Desposito F. Multiple congenital malformations

associated with maternal isotretinoin therapy. Pediatrics 1984;74:428-30. 2. Rosa FW, Wilk AL, Kelsey FO. Teratogen update: vitamin A congeners. Teratology 1986;

33:355-64. 3. Lammer EJ, Chen DT, Hoar RM, et al. Retinoic acid embryopathy. N Engl J Med 1985;

313:837-41. 4. Rosa FW. Teratogenicity of isotretinoin (Letter). Lancet 1983;2:513. 5. Food and Drug Administration. Etretinate approved. FDA Drug Bull 1986;16:16-7. 6. Roche Laboratories. Tegison brand of etretinate/Roche capsules (Package Insert). Nutley,

New Jersey: Hoffmann-La Roche, Roche Laboratories, 1986. 7. Medical Economics Company. Physicians' desk reference. 42nd ed. Oradell, New Jersey:

Medical Economics Company, 1988:1705,1746. *Use of trade names is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services or the Public Health Service.

Epidemiologic Notes and Reports

Scabies in Health-Care Facilities

lowa

Scabies continues to occur among residents and staff of lowa nursing homes and hospitals. For the 8-year period July 1979–June 1987, the lowa Department of Public Health confirmed scabies in 25 nursing homes, 1 hospital, 1 state institution, and 1 county residential care facility. Reports of scabies were received from 11 other facilities. A report of the investigation of this problem in three nursing homes follows.

Facility 1. In September 1985, scabies mites were found on three of seven nursing home patients with lesions suggestive of the disease. Skin scrapings from one of these patients yielded mites and eggs. He was successfully treated with an appropriate regimen of lindane lotion. The three visiting physical therapists who had treated the patient were also evaluated. Two had pruritic lesions compatible with scabies. A live mite was recovered in skin scrapings from one therapist, who was referred to her personal physician for treatment. Additional scabies cases were confirmed in this facility in December 1985 (1 of 3 positive) and November 1986 (5 of 19 positive).

Facility 2. In September 1985, skin scrapings from a 90-year-old nursing home patient with a persistent skin rash yielded 23 mites. The patient had been hospitalized briefly 3 weeks prior to this assessment, and evidence of transmission to hospital personnel was reported. The condition persisted, and the patient received monthly maintenance treatments until she died during a subsequent hospitalization.

Facility 3. In April 1987, an investigation revealed seven residents and three staff members with confirmed or probable scabies. All but two residents were confined to a ward of patients with Alzheimer's disease. The index patient, who had a rash of long duration, had transferred from another nursing home and probably had scabies upon arrival. Twice during 1986 the state health department had investigated the previous nursing home, which was the probable source of infestation, and had found rashes compatible with scabies but no positive scrapings. The index patient had been included in these investigations. Reported by: RW Currier, DVM, C Christie, BSN, LA Wintermeyer, MD, State Epidemiologist, lowa Dept of Public Health. Div of Host Factors, Center for Infectious Diseases, CDC. Editorial Note: Scabies becomes pandemic at approximately 30-year intervals (1,2). Evidence suggests that community scabies peaked in the mid-1970s but has persisted at high levels for the past 10 years (University of Minnesota, unpublished data).

Scabies is caused by infestation with the mite Sarcoptes scabiei and is a major problem in nursing homes, particularly among patients who are debilitated and require extensive hands-on care. Because treatment failure is common with approved scabicides (10% crotamiton cream/lotion, 1% lindane cream/lotion, and 10% sulfur in petrolatum), lengthy, intensive retreatment may be necessary.

These reports from lowa suggest that the scabies mite is introduced when infested patients are transferred between institutions. The quantity of mites carried by these patients expedites transmission, which can occur directly, through contact between residents, or indirectly, through contact with staff. Thus, for such institutional settings, it may be appropriate to screen new patients routinely, preferably before admission, if they have a pruritic rash.

Skin scraping is the only consistent means of detecting mites, assessing the degree of transmissibility, and evaluating treatment when skin lesions persist or Scabies Continued reappear (3). Any red, raised, pruritic skin lesions (especially on the upper back) that are not obviously due to other causes are suspect and should be scraped. Scraping will often yield Demodex folliculorum mites, which may produce lesions without extensive pruritis, in addition to S. scabiei. Treatment of residents, especially those with atypical, crusted rashes, should be aggressive (e.g., lindane lotion for 1 day, followed by 10% crotamiton lotion for 5 days, followed by a second lindane treatment). Treatment should include the entire body from the neck down, with special attention to the underside of well-trimmed fingernails.

Mass prophylaxis will not totally eliminate scabies, and the decision to use it should be based on the prevalence of scabies infestation in the facility. Follow-up examinations are recommended to assess overall control. Patients who cannot be successfully treated should receive monthly maintenance treatments for an extended period (e.g., applications of 10% crotamiton lotion for 2 days each month). Use of protective clothing and gloves by the nursing staff and isolation of patients would not serve any useful purpose since treatment failures usually reflect inadequate application of the scabicide to all appropriate body surfaces and not reinfestation from other patients or staff. Treatment failures occasionally result from resistance of mites to scabicides; failure for elderly, institutionalized persons may reflect concurrent cellmediated immunodeficiency (3).

Nursing personnel frequently acquire scabies, especially on the upper arms and abdomen, but rarely on the hands and wrists (4,5). Recovering mites in scrapings from these persons is difficult because they usually carry a small number of adult mites. Occasionally, personnel experience psychogenic scabies or acarophobia, especially after recent treatment. Standard treatment will usually eliminate the problem and should be given to the staff's family members. Health-care workers with persistent complaints are best managed by emotional support and repeated skin scrapings to demonstrate the absence of mites (6). References 1. Orkin M. Resurgence of scabies. JAMA 1971;217:593-7. 2. Orkin M, Maiback Hl. Current concepts in parasitology: this scabies pandemic. N Engl J Med

1978;298:496-8. 3. Juranek DD, Currier RW, Millikan LE. Scabies control in institutions. In: Orkin M, Maiback HI,

eds. Cutaneous infestations and insect bites. New York: Dekker, 1985:139-56. 4. Lerche NW, Currier RW, Juranek DD, Baer W, Dubay NJ. Atypical crusted “Norwegian"

scabies: report of nosocomial transmission in a community hospital and an approach to

control. Cutis 1983;31:637-42,668,684. 5. Cooper CL, Jackson MM. Outbreak of scabies in a small community hospital. Am J Infect

Control 1986;14:173-9. 6. Currier RW. Scabies and pediculosis: hospitalized mites and lice. Asepsis – The Infection

Control Forum 1984;6:13-21.

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The Morbidity and Mortality Weekly Report is prepared by the Centers for Disease Control, Atlanta, Georgia, and available on a paid subscription basis from the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402, (202) 783-3238.

The data in this report are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on Friday; compiled data on a national basis are officially released to the public on the succeeding Friday. The editor welcomes accounts of interesting cases, outbreaks, environmental hazards, or other public health problems of current interest to health officials. Such reports and any other matters pertaining to editorial or other textual considerations should be addressed to: Editor, Morbidity and Mortality Weekly Report, Centers for Disease Control, Atlanta, Georgia 30333. Director, Centers for Disease Control

Editor James O. Mason, M.D., Dr.P.H.

Michael B. Gregg, M.D. Director, Epidemiology Program Office

Managing Editor Carl W. Tyler, Jr., M.D.

Gwendolyn A. Ingraham

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