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Epidemiologic Notes and Reports

Dermatitis among Hospital Workers – Oregon

In November 1981, complaints of skin and respiratory irritation were reported to the National Institute for Occupational Safety and Health (NIOSH) by members of the housekeeping staff, which cleaned and disinfected patients' rooms at a community hospital in Oregon. The cleaning solutions the workers used contained a variety of irritating and toxic chemicals, including phenol, carbitol, ammonia, alcohols, detergents, waxes, and scrubbing compounds. Phenol was the principal ingredient of a germicidal solution applied to all objects and floors, when cleaning patients' rooms.

In January 1982, investigators from NIOSH interviewed 23 of 28 housekeeping employees who used these cleaning agents; for purposes of comparison, 11 workers selected at random from a list of employees not involved in housekeeping were also interviewed (1). Limited physical examinations were performed.

The 23 housekeeping employees reported the following symptoms with significantly greater frequency than did the employees not engaged in housekeeping: cough (43% for housekeeping employees and 9% for others), history of producing phlegm (56% and 0%), itching of the external ear (61% and 0%), sinus congestion (65% and 18%), and light-headedness while at work (56% and 0%). Four housekeeping employees had severe dermatitis of the hands and feet, and another four reported past histories of dermatitis. The onset of dermatitis for each of these patients was associated with a history of exposure of the skin to cleaning agents and disinfectants while at work. In two of the employees with dermatitis, transfer from the housekeeping department and leave reportedly resulted in marked improvement. Two of 11 nonhousekeeping employees reported histories of mild skin rash, but neither had evidence of current skin disease.

Changes in work practices were recommended to reduce skin exposures and associated dermatitis, including use of protective gloves and changes in application procedures (e.g., application of the germicide with a cloth rather than by spray bottle).

In April 1982, investigators collected air samples for analysis to determine the presence of airborne chemicals released from the cleaning agents. Post-shift urine samples were also collected from housekeeping employees to test for excretion of phenol. The results of the environmental tests (performed after NIOSH-recommended changes in work practices were being implemented) revealed that the workers were exposed to assorted airborne vapors of ammonia, carbitol, isopropyl alcohol, and petroleum distillates; however, concentrations were at very low levels. Results of tests for butyl cellosolve, cellosolve, ethanolamine, ethyl alcohol, formaldehyde, and phenol, were all below the lower limits of analytical detection (2). The mean urinary excretion among 23 housekeeping employees was 26.5 mg/g of creatinine (range: nondetectable to 187 mg/g creatinine); among eight nonhousekeeping employees, the mean urinary excretion of phenol was 9.8 mg/g creatinine) (range: nondetectable to 12.2 mg/g of creatinine) (p > 0.05)). Reported by US Public Health Service Region X Office, Seattle, Washington; Hazard Evaluations and Technical Assistance Br, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. Editorial Note: Workers in hospitals are exposed to a wide variety of chemicals known to be hazardous, including waste anesthetic gases (3), ethylene oxide (4), and formaldehyde (5). In this investigation, NIOSH found dermatitis, as well as an increased incidence of symptoms of respiratory irritation, among housekeeping workers in a hospital. Workers were exposed to Dermatitis Continued cleaning compounds containing phenol and were excreting phenol in their urine. Phenol has previously been shown to cause contact dermatitis following repeated exposure (6,7). It is possible that, in this episode, exposure to cleaning agents containing other solvents and irritating chemicals may also have contributed to the occurrence of dermatitis. Relatively simple precautions, such as work practices that limit the dispersal of solvents in the air and wearing personal protective gear, appear effective in reducing the hazard, by reducing contact of solvents with the skin. References 1. National Institute for Occupational Safety and Health. Health hazard evaluation report no. HETA

82-053-1263. Cincinnati, Ohio: National Institute for Occupational Safety and Health, 1983. 2. National Institute for Occupational Safety and Health. NIOSH manual of analytical methods. Vol 1-7,

2nd ed. Cincinnati, Ohio: National Institute for Occupational Safety and Health, 1977. (DHEW

(NIOSH) publication no. 77-157). 3. National Institute for Occupational Safety and Health. Health hazard evaluation report no. HETA

82-016-1206. Cincinnati, Ohio: National Institute for Occupational Safety and Health, 1982. 4. National Institute for Occupational Safety and Health. Health hazard evaluation report no. HETA

81-350-932. Cincinnati, Ohio: National Institute for Occupational Safety and Health, 1981. 5. National Institute for Occupational Safety and Health. Health hazard evaluation report no. HETA

82-205-1314. Cincinnati, Ohio: National Institute for Occupational Safety and Health, 1983. 6. Proctor NH, Hughes JP. Chemical hazards of the workplace. Philadelphia: JB Lippincott Company,

1978. 7. National Institute for Occupational Safety and Health. Occupational diseases: a guide to their recogni

tion. Revised ed. Cincinnati, Ohio: National Institute for Occupational Safety and Health, 1977. (DHEW (NIOSH) publication no. 77-181).

Sporotrichosis Among Hay-Mulching Workers

Oklahoma, New Mexico

Between June and September 1983, 12 cases of cutaneous sporotrichosis occurred among persons who had worked on three different hay-mulching crews based in Oklahoma and New Mexico. Each crew had used hay from the same fields in south-central Oklahoma to mulch road banks and building sites.

A private physician notified the Oklahoma Department of Health of one worker hospitalized for investigation of possible pulmonary sporotrichosis. Other cases were identified through reports from physicians and a survey of the six hay-mulch companies operating in Oklahoma and New Mexico. A case was defined as a person with a cutaneous lesion and serologic evidence of Sporothrix schenckii infection.

Three of five workers in a crew working in northern Texas developed S. schenckii infections; in another crew working in southern New Mexico, four of 12 workers developed infections; in a third crew working in central New Mexico, five of 21 workers who responded to a questionnaire developed infections. None of the patients had been exposed outside their work to roses, sphagnum moss, or hay. Ten of 12 patients had one or more lesions on the upper extremities; one of the remaining two had a single lesion on the upper chest; and the other, a single lesion on the lateral eyelid. Two additional workers had positive serologic tests but no clinical manifestations.

A questionnaire was administered to members of the three crews; 79% of the workers responded. No association was found between clinical infection and duration of work or work duty (loader, hay-blower, or driver). Exposure to fresh hay was not associated with infection in six workers who cut and baled hay at the implicated fields.

Sporotrichosis - Continued

The prairie hay used by the crews had been cut in August 1982. Normally, prairie hay is dried for 1-2 days in the field before baling, but because of rain, this crop was left in the field for 5-6 weeks before being baled; after baling, it was stored until May 1983. Samples obtained from soil and plants at the implicated field 2 months after the hay mulching were negative for S. schenckii. Reported by W Cook, MD, DJ Sexton, MD, Oklahoma City, B Gildon, J Booher, Comanche County Health Dept, P Hawkins, MPH, T Rickman, G Istre, MD, State Epidemiologist, Oklahoma State Dept of Health; V Ornelus, MD, P Acerra, Lovinn, / Nash, MD, Albuquerque, S Kearns, W Ricer, Carlsbad, R Ferguson, J Mann, MD, H Hull, MD, State Epidemiologist, New Mexico Health and Environment Dept; Div of Mycotic Diseases, Special Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases, Div of Field Svcs, Epidemiology Program Office, CDC. Editorial Note: S. schenckii is a dimorphic fungus. It is found worldwide in soil, plants, and decaying vegetation. Cutaneous sporotrichosis follows inoculation of spores into the skin and subcutaneous tissue. Infections of joints, central nervous system, and lungs occur, but are rare. Sporotrichosis following occupational exposure has been described previously among forestry workers (1), horticulturists, and miners (2,3). Infection following occupational exposure to prairie hay has not previously been reported, but two outbreaks have been described among children playing in old prairie hay (4,5). Health professionals attending workers with occupational exposure to decaying plant matter, including hay, should be alert for sporotrichosis as a cause of chronic skin disease. References 1. Powell KE, Taylor A, Phillips BJ, et al. Cutaneous sporotrichosis in forestry workers. Epidemic due to

contaminated sphagnum moss. JAMA 1978;240:232-5. 2. Conant NF. Medical mycology: Sporotrichum schenckii. In: Dobos RJ, Hirsch JG, eds. Bacterial and

mycotic infections of man. 4th ed. Philadelphia: JB Lippincott Company, 1965:853-6. 3. CDC. Sporotrichosis associated with Wisconsin sphagnum moss. MMWR 1982:31;542-4. 4. Dahl BA, Silberfarb PM, Sarosi GA, Weeks RJ, Tosh FE. Sporotrichosis in children. Report of an

epidemic. JAMA 1971;215:1980-2. 5. Laur WE, Posey RE, Waller JD. A familial epidemic of cutaneous sporotrichosis occurring in North

Texas. Cutis 1979;23:205-8.

Erratum: Vol. 33, No. 1S

In the MMWR Supplement, "Adult Immunization: Recommendations of the Immunization Practices Advisory Committee (ACIP)," there is an error in Appendix 4. Page 64S, line 1, column 4, should read: Bivalent or tetravalent polysaccharide vaccine.

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. Govemment 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: ATTN: 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

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

Karen L. Foster, M.A. U.S. Government Printing Office: 1984-746-149/10028 Region IV

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Recent studies have provided important additional assurances concerning the safety of hepatitis B (HB) vaccine. The yarsinecurrently icensed in the Pnited States is produced from pooled plasma of hepatitis B surface antigen positive individuals, some of whom are also in high-risk groups for acquired immunodeficiency syndrome (AIDS). Concern has been expressed that the etiologic agent of AIDS might be present in the vaccine and survive the inactivation steps used in the manufacturing procedure. The concerns persisted, despite the fact that these steps were reportedly able to inactivate representative members of all known virus groups. The recent identification of a retrovirus as the etiologic agent of AIDS has allowed workers to (1) directly test the inactivation of the AIDS virus by the inactivation steps used in the vaccine manufacturing procedurer (2) look for the AIDS virus' nucleic acid sequences in the vaccine; and (3) look for serologic markers of infection from the AIDS virus in vaccine recipients. Concurrently, monitoring of AIDS patients and high-risk groups has continued in order to look for any epidemiologic evidence of an association between HB vaccine and AIDS.

The effect of the HB vaccine inactivation process on the AIDS virus and two other human retroviruses (HTLV-I and HTLV-11) was studied. Three separate inactivation steps are used in the manufacture of the U.S.-licensed HB vaccine: (1) 1 mg/ml pepsin, pH 2, 37 C (98.6 F), 18 hours; (2) 8 molar urea, 37 C (98.6 F), 4 hours; and (3) 0.01% formaldehyde, 37 C (98.6 F), 72 hours. In separate studies conducted between CDC and the vaccine manufacturer Merck, Sharp & Dohme (MSD), and between State University of New York (SUNY) Upstate Medical Center and MSD, cell culture supernatant fluid containing the AIDS virus and cultured cells containing HTLV-I, HTLV-11, and the AIDS virus were transported to MSD and individually exposed to the three inactivation steps. The materials were then returned to CDC and SUNY for detection of residual viral infectivity. Virus infectivity was assayed by adding the treated material to cultured lymphocytes and periodically monitoring these for signs of viral replication (reverse transcriptase activity and virus antigen expression) (1 ) and in the case of HTLV-I and HTLV-II, transformation (2,3). No residual virus was detected in material treated with formalin or urea, while material treated with pepsin at pH 2 did have residual virus present. Heat, an inactivation step used in vaccines manufactured outside the United States, has also been shown to inactivate the AIDS virus (4).

The second approach, which attempted to detect AIDS virus-related nucleic acid sequences using dot blot hybridization analysis of the vaccine with an AIDS virus deoxyribonucleic acid (DNA) probe, was done at MSD using as a positive control infected cellular (ribonucleic acid) RNA preparations provided by CDC. The vaccine contained no detectable AIDS virus-related sequences at a sensitivity of less than one picogram of DNA per 20-ug dose of vaccine.

The third approach attempted to detect seroconversion to AIDS virus antibodies in paired sera of HB vaccine recipients. Paired sera were examined at CDC using a highly sensitive and specific ELISA assay for the AIDS virus. No seroconversions were detected in 19 individuals


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