The Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation (NHF) has recently issued revised recommendations for the therapy of hemophilia (10). To physicians treating patients with hemophilia, they recommend that (1) cryoprecipitate be used in factor VIII-deficient newborn infants and children under 4 years of age and in newly identified patients never treated with factor VIII concentrates; (2) fresh frozen plasma be used in factor IX-deficient patients in the same categories; and (3) desmopressin (DDAVP) be used whenever possible in patients with mild or moderate hemophilia A. The majority of hemophilia patients do not fit in categories (1) through (3). For these patients, MASAC recommends that, "because heat-treated products appear to have no increase in untoward effects attributable to the heat treatment, treaters using coagulation factor concentrates should strongly consider changing to heat-treated products with the understanding that protection against AIDS is yet to be proven." They also recommend that all elective surgical procedures for hemophilia patients be evaluated with respect to possible advantages and disadvantages of surgical delays. Although the total number of hemophilia patients who have thus far developed clinical manifestations of AIDS is small relative to other AIDS risk groups, incidence rates for this group are high (3.6 cases/1,000 hemophilia A patients and 0.6/1,000 hemophilia B patients). Continued surveillance is important. Physicians diagnosing opportunistic infections or unusual neoplasms in hemophilia patients who have not received antecedent immunosuppressive therapy are requested to report these findings to local or state health departments and to CDC. In March 1983, the U.S. Public Health Service recommended that members of groups at increased risk of acquiring AIDS should refrain from donating plasma and/or blood (11). A specific serologic test will soon become available for screening purposes, and thus a safer factor concentrate product should result. The preliminary evidence concerning the effects of heat-treatment on the viability of the AIDS virus is strongly supportive of the usefulness of heat-treatment in reducing the potential for transmission of the AIDS virus in factor concentrate products and suggest that the use of nonheat-treated factor concentrates should be limited. CDC and NHF will continue to study the effects of heat-treated factor on the immune status of patients with hemophilia. References 1. CDC. Pneumocystis carinii pneumonia among persons with hemophilia A. MMWR 1982;31:365-7. 2. Tsang VC, Peralta JM, Simons AR. Enzyme-linked immunoelectrotransfer blot techniques (EITB) for studying the specificities of antigens and antibodies separated by gel electrophoresis. Methods Enzymol 1983;92:377-91. 3. Ramsey RB, Palmer EL, McDougal JS, et al. Antibody to lymphadenopathy-associated virus in haemophiliacs with and without AIDS. Lancet [Letter] 1984;11:397-8. 4. CDC. Unpublished data. 5. Levy JA, Mitra G, Mozen MM. Recovery and inactivation of infectious retroviruses from factor VIII concentrates. Lancet 1984;11:722-3. 6. McDougal JS, Cort SP, Kennedy MS, et al. Immunology for the detection and quantitation of infectious human retrovirus, lymphadenopathy-associated virus (LAV). J Immunol Methods (in press). 7. Spira TJ, Des Jarlais DC, Marmor M, et al. Prevalence of antibody to lymphadenopathy-associated virus among drug-detoxification patients in New York. N Engl J Med [Letter] 1984;311:467-8. 8. Curran JW, Lawrence DN, Jaffe H, et al. Acquired immunodeficiency syndrome (AIDS) associated with transfusions. N Engl J Med 1984;310:69-75. 9. Enck RE, Betts RF, Brown MR, Miller G. Viral serology (hepatitis B virus, cytomegalovirus, EpsteinBarr virus) and abnormal liver function tests in transfused patients with hereditary hemorrhagic diseases. Transfusion 1979;19:32-8. 10. National Hemophilia Foundation Medical and Scientific Advisory Council. Recommendations concerning AIDS and therapy of hemophilia (revised October 13, 1984). New York: National Hemophilia Foundation, 1984. 11. CDC. Prevention of acquired immune deficiency syndrome (AIDS): report of interagency recommendations. MMWR 1983;32:101-3. Epidemiologic Notes and Reports Organophosphate Insecticide Poisoning Among Siblings Mississippi On August 6, 1984, the Mississippi State Department of Health was informed of the death of an 11-year-old girl from Tunica County, Mississippi, and the hospitalization of her six siblings. The initial clinical diagnosis for the seven children was organophosphate poisoning. Neither the children's mother nor her live-in male companion was ill. Following is a summary of the State Department of Health's investigation. On August 2, five of the seven children had visited a local physician complaining of abdominal pain of 2 days' duration. One child also had fever and diarrhea. The physician diagnosed viral gastroenteritis and suggested fluids and rest. There was no improvement during the next day, and on the morning of August 4, three children did not respond to vocal sounds, and the others were obviously ill. Later that day, all seven children presented to a Memphis, Tennessee, hospital with signs and symptoms of organophosphate poisoning. Two were in respiratory arrest, and the other five had various degrees of lethargy, increased salivation, increased respiratory secretions, and pinpoint pupils. All the children had depressed serum and erythrocyte cholinesterase levels (Table 1). One child could not be resuscitated and died. Preliminary autopsy findings were consistent with organophosphate poisoning and suggested ingestion as a primary route of exposure. A second child died August 9, and the other five children recovered and were discharged. A survey of local physicians and emergency rooms revealed no other similar cases. Because both adults in the household and a nearby adult neighbor were clinically well, it was felt that the source of poisoning was confined to the children's household. The male livein companion reported having sprayed the inside of the house July 26 with a solution of insecticide in an attempt to control spiders. He had obtained a nearly empty insecticide container TABLE 1. Concentrations of plasma cholinesterese (ChE), red blood cell (RBC) ChE, and urinary paranitrophenols (PNP)* in children and adults Mississippi, 1984 Plasma ChE per min per ml) RBC ChE A pH/hr) Urinary PNP (normal 0 ppm) 11 ་ 'An excretory product of organophosphate compounds. Children's samples taken August 4, and adults' samples taken August 8. §Deceased. Not available. **Mother, companion, neighbor, respectively. Insecticide Poisoning - Continued from the farm where he worked and had added water to it. He reported using a hand sprayer to spray the solution on the inside upper walls of three of the four rooms (excluding the kitchen) in the house. He reported no subsequent spraying, but the sprayer, still partly filled, was found on the back porch of the house the day after the children became ill. The house had no running water, and drinking water was obtained from the nearby neighbor's well and stored in an open ice chest. Therefore, contamination of the drinking water was considered a strong possibility for exposure. Samples of insecticide solution from the sprayer, water, prepared food, other liquids, and indoor and outdoor air were obtained (Table 2). The sprayer solution contained the organophosphate insecticide methyl parathion [(CHO)2-PS-O-CH ̧(NO2)CI] in a concentration nearly three times that used for outdoor agricultural spraying. The drinking water in the house contained methyl parathion in a concentration above the suggested no adverse response level (SNARL); water from the well was negative for methyl parathion. The air inside the house contained over 100 times the concentration of methyl parathion measured in the air in the same locality during the spraying season (2); the air on the porch contained only one-seventh the amount found inside. Food histories showed that, since the visit to the doctor August 2, the children had eaten primarily canned soups cooked with water and drunk liquids prepared with the household drinking water. In contrast, the adults apparently ate other foods (e.g., catfish) and drank more bottled soda. Samples of blood and urine from the adults were analyzed for evidence of exposure to organophosphate compounds and compared with those of the children (Table 1). The higher levels of exposure among the children are evident, although the adults were sampled several days later. It seems likely that the seven siblings were exposed to methyl parathion by multiple routes, primarily ingestion, inhalation, and possibly surface contact via contaminated clothing. § SNARL not established; typical ambient air values from a similar area in Mississippi were 200-400 μg/m3 (2). Insecticide Poisoning - Continued The absence of clinical illness in the two adults in the household may reflect lower levels of exposure due in part to different food intake. The 8-day delay between the reported spraying and the manifestation of classic symptoms of organophosphate poisoning is not explained. Efforts are under way to decontaminate the house and to reemphasize to the public the danger of organophosphate insecticides used inappropriately. Reported by A Dean, J Pugh, Tunica County Health Dept, K Embrey, District | Health Office, J Cain, MS, L 1. U.S. Environmental Protection Agency. Advisory opinions for toxic chemicals in drinking water. Criteria and Standards Division, U.S. Environmental Protection Agency, January 19, 1979. 2. Mississippi State Chemical Laboratory. Mississippi Epidemiologic Studies Program, Annual Report No. 9, Mississippi State University, Starkville, Mississippi, 1976. TABLE I. Summary-cases of specified notifiable diseases, United States 'The 1983 reports which appear in this table were collected before AIDS became a notifiable condition. **There were no cases of internationally imported measles for this week. |