The Morbidity and Mortality Weekly Report, circulation 62,000, is published by the Center for Disease Control, Atlanta, Georgia. The data in this report are provisional, based on weekly telegraphs 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 suc ceeding Friday. environmental hazards, or other public health problems of current interest to health officials. Send reports to: Center for Atlanta, Georgia 30333. The editor welcomes accounts of interesting cases, outbreaks, Disease Control, Attn.: Editor, Morbidity and Mortality V Send mailing list additions, deletions, and add be sure to give your former address, including zip for Disease Control, Attn.: Distribution Services, GSO, 1-SB-36, Atlanta, Georgia 30333. When requesting changes number, or send an old address label. Measles Vaccine-Continued children, all their close contacts who are susceptible to measles should be immunized. - Prior Immunization with Inactivated Measles Virus Vaccine On exposure to natural measles, some children previously inoculated with inactivated measles virus vaccine have had atypical measles, sometimes with severe symptoms. Adverse reactions, such as local induration and edema and fever, have at times been observed when live measles virus vaccine was administered to persons who had previously received inactivated vaccine. Despite the risk of local reaction, children who have previously been given inactivated vaccine alone or followed by live vaccine within 3 months should be revaccinated with live vaccine to avoid the severe atypical form of natural measles and to provide full and lasting protection. Simultaneous Administration of Certain Live Virus (See ACIP "General Recommendations on Immunization," MMWR 25(44):349, November 12, 1976.) COMMUNITYWIDE IMMUNIZATION PROGRAMS Universal immunization as part of good health care should be accomplished through routine and intensive programs carried out in physicians' offices and public health clinics. Programs aimed at vaccinating children against measles at about 15 months of age should be established by all communities. In addition, all susceptible children who are mingling for the first time with other children either at day-care centers, nursery schools, kindergartens, or elementary schools should be given vaccine because of the role they can play in spreading natural measles. Special Intensive Programs Communitywide immunization programs are good ways to distribute measles vaccine rapidly. Such programs continue to be important where there are many susceptible children. Attention should be directed toward systematically vaccinating susceptible children in both urban and rural areas. Control of Measles Epidemics Measles epidemics can be controlled by promptly vaccinating appropriate groups of children. Initially, programs should be geared to reach those epidemiologically at highest risk of disease. Preventing measles dissemination in outbreaks depends on rapidly vaccinating susceptibles in the outbreak area. Susceptibles must be identified quickly. During the control program, all persons who cannot give a documented past history of measles or of vaccination when more than 12 months of age should be vaccinated. In an outbreak, if a person's measles immunity status is in doubt, vaccinate. SURVEILLANCE Continued careful surveillance of measles and its complications is necessary to appraise nationwide and locally the effectiveness of measles immunization programs, particularly efforts to eradicate measles. Surveillance can delineate failure to achieve adequate levels of protection and define groups needing special attention. Although more than 80 million doses of live measles vaccine have now been distributed in the United States, continuous and careful review of adverse reactions is important. All serious reactions or suspected cases of measles in vaccinated children should be evaluated and reported in detail to local and state health officials as well as to the manufacturer (called for on the label). Current Trends Parasitic Disease Drug Service - Pentamidine Releases for Pneumocystis Pneumonia In November 1967, the Parasitic Disease Drug Service, CDC, became the sole supplier in the United States of pentamidine isethionate for the treatment of Pneumocystis pneumonia and the early stages of Gambian sleeping sickness. Since that time, clinical and laboratory information has been requested from physicians on all patients being treated with this drug. The data gathered on patients with suspected or confirmed Pneumocystis pneumonia during the first 3 years after pentamidine was added to the drug service have been reported previously (1,2). Approximately 200 pentamidine requests per year were received from 1967 through 1970. In 193 or 33% of these cases, the diagnosis of Pneumocystis pneumonia was histologically or cytologically confirmed. Overall, 42% of patients treated with pentamidine recovered; cure rates were 63% in patients treated for 9 or more days. Adverse reactions occurred in 40% of patients. The recent experience of the Parasitic Disease Drug Service with pentamidine requests has been similar. From July 1, 1971, to June 30, 1976, a total of 2,890 requests were received. The frequency of pentamidine requests has ranged from approximately 400 per year in 1971 and 1972 to a peak of 600 per year in 1975 and 1976. The diagnosis of Pneumocystis pneumonia was confirmed histologically or cytologically in approximately 45% of these cases. Cure rates of 50-60% in patients with Pneumocystis pneumonia were noted between 1971 and 1976. Adverse reactions to pentamidine were common. Immediate reactions (hypotension, nausea, vomiting, flushing, etc.) occurred in 8-10% of cases; local reactions (pain, abscess, or necrosis at the injection site) in 10-20%; and systemic reactions (renal insufficiency, hypoglycemia, abnormal liver function tests, etc.) in 25-40% of cases. Editorial Note: Pentamidine isethionate is generally considered the drug of choice for the treatment of Pneumocystis pneumonia, but the frequent adverse effects associated with its use have prompted a search for a less toxic alternative. A recent randomized controlled trial in children Parasitic Disease - Continued with Pneumocystis pneumonia demonstrated that the oral combination antimicrobial agent, trimethoprim-sulfamethoxazole (commercially available under the brand names Septra and Bactrim), is equally effective and much less toxic than pentamidine (3). Eleven of 18 patients treated with pentamidine recovered compared with 13 of 19 treated with trimethoprim-sulfamethoxazole. Experience with trimethoprim-sulfamethoxazole for the treatment of Pneumocystis pneumonia in adults is limited, but 1 uncontrolled study showed cure rates equivalent to those obtained with pentamidine (4). Reported by Parasitic Diseases Div, Bur of Epidemiology, CDC. References 1. Western KA, Perera DR, Schultz MG: Pentamidine isethionate in the treatment of Pneumocystis carinii pneumonia. Ann Intern Med 73:695-702, 1970 2. Walzer PD, Perl DP, Krogstad DJ, et al.: Pneumocystis carinii pneumonia in the United States: Epidemiologic, diagnostic and clinical features. Ann Intern Med 80:83-93, 1974 3. Hughes WT: Treatment of Pneumocystis carinii pneumonitis. N Engl J Med 295:726-727, 1976 4. Lau WK, Young LS: Trimethoprim-sulfamethoxazole treatment of Pneumocystis carinii pneumonia in adults. N Engl J Med 295: 716-718, 1976 Influenza - Worldwide United States: A single isolate of an A/Victoria/75-like virus has been made from a California woman who became ill on October 11, the day she returned from a visit to the Far East. Since the beginning of the influenza immunization program a total of 14,182,152 inoculations have been given. The accompanying map illustrates the coverage rate (the number of doses administered divided by the population 18 years of age and older expressed as a percent) as of November 6, 1976. The highest 5 states or project areas are: Wyoming, 67.9%; Trust Territory, 58.3%; Alaska, 47.0%; Puerto FIGURE 1. Influenza vaccination coverage by state, November 6, 1976 Rico, 41.3%; and North Dakota, 37.7%. Reported by J Chin, MD, State Epidemiologist, California Dept of Health; and National Influenza Immunization Program, CDC. Worldwide: An outbreak of influenza occurred September 17-October 1 in an English boarding school. Fifteen of 250 students were affected with an influenza-like illness of moderate severity. The 4 strains of influenza B isolated showed some antigenic changes from B/Hong Kong/72 and were similar to other strains isolated the previous winter. Reported by the World Health Organization in the Weekly Epidemiologic Record 51(44):344, 1976. Epidemiologic Notes and Reports Thelaziasis - California A case of human eyeworm infestation, caused by Thelazia californiensis, was reported recently from California. Fewer than 20 cases of thelaziasis have been reported in the literature; of these, all cases caused by T. californiensis occurred in California. The patient was a 64-year-old woman from Butte County, who had been fishing in previous months in the western Sierra foothills and at Mt. Lassen. She was referred to an ophthalmologist because of persistent lacrimation from 1 eye. Slit lamp examination revealed several active, threadlike, translucent, whitish-gray worms of 10 mm length. Three worms were removed from the patient's conjunctival sac, and lacrimation stopped soon after. There was no evidence of corneal scarring. Worms were submitted to the State Microbial Disease Laboratory where they were confirmed as T. californiensis. Editorial Note: Adult nematodes of the genus Thelazia are small worms which locally parasitize the conjunctival sac and lacrimal duct of certain birds and mammals in many parts of the world. Human infestation is rare. When it occurs, the disease is mild; symptoms are limited to excessive lacrimation, conjunctivitis, and a sensation of a foreign body in the eye. Unilateral involvement is the rule. The adult worms, which measure 10-15 mm in length, migrate freely in the conjunctival sac but are not tissue invasive. Symptoms clear rapidly and completely after all worms are removed, which is easily done with forceps or a moistened applicator. Corneal scarring and opacification are potential complications, but these are only found in animals with heavy worm burdens and prolonged infestation. T. californiensis has been found in Arizona, California, New Mexico, Nevada, and Oregon. Adult worms have been recorded in bears, cats, coyotes, deer, dogs, foxes, jackrabbits, horses, sheep, and humans. In California the principal reservoirs are probably deer and jackrabbits. The life cycle T. californiensis, which is widely distributed throughout the state, is not fully known, but muscoid flies appear to be the vectors and intermediate hosts. Developmental forms of the worm have been found in wild flies of the Fannia species, and laboratory infection of F. canicularis has been successful. Oak woodlands of the Sierra foothills and coastal mountains are a favored habitat of the Fannia species. Humans are undoubtedly accidental hosts. From 19351970, 7 cases of T. californiensis in humans were reported in the literature; all occurred in California. Review of the 8 cases shows that all occurred in adults with such outdoor exposure as hunting, fishing, prospecting, and insect collecting. Six patients were exposed in the Sierra Nevada, 1 in the Mojave Desert, and 1 in rugged, brush-covered hills near San Diego. Few patients could recall exposure to flies or gnats. Most cases occurred in late summer or early fall. One patient indicated that the incubation period might be as short as 10 days. The diagnosis of thelaziasis depends on recognition of the primary symptoms of lacrimation and conjunctivitis along with identification of the worms. Worm specimens should be placed in 10% formalin and submitted to a reference laboratory. Reported by KJ Chiapella, MD, Chico, C Weinman, PhD, University of California at Berkeley, and R Roberto, MD, California Dept of Health, in California Morbidity, No. 23, June 18, 1976. |