Bureau of Epidemiology
Bureau of Epidemiology March 1997 Utah Department of Health
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Secondary Occupational Lead Exposure to Children
Antimicrobial Chemoprophylaxis For The Prevention of Meningocococcal Disease
Rohypnol - "Watch Your Drink"
Quarterly Report of Diseases of Low Frequency
Monthly Morbidity Summary

 

Secondary Occupational Lead Exposure to Children

Lead has been recognized as an environmental toxin since antiquity. In fact, lead poisoning is regarded as one of the earliest occupational diseases. Child lead poisoning can occur from exposure to environmental lead, lead based paint or as a consequence of secondary occupational lead exposure. Childhood lead poisoning was first recognized as a separate entity at the turn of the 20th century. During the 1960s, lead poisoning was increasingly recognized as an important pediatric public health problem in larger United States cities. Most of the effort was and continues to be directed towards environmental and lead based paint sources. However, occupational carry- home of lead may also be a source of child blood lead poisoning. Researchers found that lead contaminated dust and other materials may be inadvertently imported home on clothing, shoes, hands, or hair of an adult who has an occupation that is associated with lead. Adults who are unaware of that risk may play with children before changing clothes or showering. In addition, lead can drop off the adult’s clothing and person onto the surfaces of the home where children can be exposed.

In October 1996, a 15-month-old male child residing in Salt Lake County was reported to the Bureau of Epidemiology, Child Blood Lead Epidemiology and Surveillance (CBLES) Project with a presumptive elevated blood lead test. That test was confirmed a week later with a venous blood lead level of 30.6 g/dL. The Bureau of Epidemiology, Adult Blood Lead Epidemiology and Surveillance (ABLES) Project also received a report of an elevated blood lead level of 44.7 g/dL on the father of the child. The reports on the child were forwarded to the Salt Lake City /County Health Department who conducted nursing and environmental surveillance intervention. Salt Lake City/ County Health Department conducted an environmental risk inspection of the home and found that the child lived in an apartment that was built after the discontinuance of the use of lead-based paint. The home was clean and in good repair and maintenance. No lead based paint was found using X-ray fluorescence technology. There were no environmental sources of lead identified. The inspector noticed traces of grease in the carpet and took a wipe sample of the carpet. Those samples were tested and found to have 60 g of lead per square foot. The bureau conducted occupational and child risk assessment surveys with the father. Neither the father or mother participated in any hobbies or home activities that used lead. However, the father was employed at a radiator repair shop where he used lead and lead solder as part of his work. No precautions were taken at his work to protect him from lead exposure. The father had not received any training concerning the dangers of lead exposure.

"Child lead poisoning can occur from exposure to environmental lead, lead based paint or as a consequence of secondary occupational lead exposure."

The child’s pediatrician was interviewed by bureau staff. The physician reported that the child had come for a routine checkup. Because the checkup was funded by Medicaid, the physician had performed the initial blood lead screen. The physician reported that the child did not have any signs or symptoms that would suggest an elevated blood lead level.

The ABLES project was started in 1992 and the CBLES project was started in January 1996. Data obtained by surveillance under the ABLES project indicate that 37% of adults reported to the bureau with blood lead levels > 25 g/dL have children living at home who are under six years of age. The Centers for Disease Control and Prevention (CDC) recommends that all children under six years of age be tested annually for lead poisoning. That is particularly important if the child lives in an environment where they could be exposed to lead such as homes built before 1972, near environmental lead sources, or have parents or other adults in their home who work in lead related industries.

The Bureau of Epidemiology insures that children with elevated blood lead levels receive appropriate intervention. The bureau does that by referral to local health departments for nutritional and environmental counseling, providing information to the child’s parents or guardians about childhood blood lead poisoning and blood lead poisoning prevention, and coordinating environmental surveillance of the child’s home. The bureau also assists adults with elevated blood lead levels by providing them with information about ways of lowering their blood lead levels and by providing their employers with information about the Occupational Safety and Health Administration lead standard.

 

Antimicrobial Chemoprophylaxis For The Prevention of Meningocococcal Disease

Updated recommendations for the control and prevention of meningococcal disease were recently published in the Morbidity and Mortality Weekly Report, Recommendations and Reports, February 14, 1997/Vol. 46/ No. RR-5. In this report, the Advisory Committee on Immunization Practices (ACIP) updated the schedule for administering chemoprophylaxis. The following information has been abstracted from the complete report.

Antimicrobial chemoprophylaxis of close contacts of sporadic cases of meningococcal disease is the primary means for prevention of meningococcal disease in the United States (Table 1). Close contacts include a) household members, b) day care center contacts, and c) anyone directly exposed to the patient’s oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation or endotracheal tube management). The attack rate for household contacts exposed to patients who have sporadic meningococcal disease has been estimated to be four cases per 1,000 persons exposed, which is 500-800 times greater than for the total population. Because the rate of secondary disease for close contacts is highest during the first few days after onset of disease in the primary patient, antimicrobial chemoprophylaxis should be administered as soon as possible (ideally within 24 hours after the case is identified). Conversely, chemoprophylaxis administered >14 days after onset of illness in the index case-patient is probably of limited or no value. Oropharyngeal or nasopharyngeal cultures are not helpful in determining the need for chemoprophylaxis and may unnecessarily delay institution of this preventive measure.

Rifampin is administered twice daily for 2 days (600 mg every 12 hours for adults, 10 mg/kg of body weight every 12 hours for children > 1 month of age, and 5 mg/kg every 12 hours for infants < 1 month of age). Rifampin is effective in eradicating nasopharyngeal carriage of N. meningitidis. Rifampin is not recommended for pregnant women, because the drug is teratogenic in laboratory animals. Rifampin changes the color of urine to reddish-orange and is excreted in tears and other body fluids; it may cause permanent discoloration of soft contact lenses. Because the reliability of oral contraceptives may be affected by rifampin therapy, consideration should be given to using alternate contraceptive measures while rifampin is being administered.

In addition to rifampin, other antimicrobial agents are effective in reducing nasopharyngeal carriage of N. meningitidis. Ciprofloxacin in various dosage regimens is >90% effective in eradicating nasopharyngeal carriage. A single 500-mg oral dose of ciprofloxacin is a reasonable alternative to the multidose rifampin regimen. Ciprofloxacin levels in nasal secretions far exceed the MIC90 for N. meningitidis following oral dosing. Ciprofloxacin is not generally recommended for persons < 18 years of age or for pregnant and lactating women because the drug causes cartilage damage in immature laboratory animals. However, a recent international consensus report has concluded that ciprofloxacin can be used for chemoprophylaxis of children when no acceptable alternative therapy is available.

When ceftriaxone was administered in a single parenteral dose (an intramuscular dose of 125 mg for children and 250 mg for adults), it was 97%-100% effective in eradicating pharyngeal carriage of N. meningitidis. Thus, ceftriaxone (diluted in 1% lidocaine to reduce local pain after injection) is also a reasonable alternative for chemoprophylaxis.

Systemic antimicrobial therapy of meningococcal disease with agents other than ceftriaxone or other third-generation cephalosporins may not reliably eradicate nasopharyngeal carriage of N. meningitidis. If other agents have been used for treatment, the index patient should receive chemoprophylactic antibiotics for eradication of nasopharyngeal carriage before being discharged from the hospital.

CONCLUSIONS

N. meningitidis is the leading cause of bacterial meningitis in older children and young adults in the United States. The quadrivalent A, C, Y, and W-135 meningococcal vaccine available in the United States is recommended for control of serogroup C meningococcal disease outbreaks and for use among certain high-risk groups, including a) persons who have terminal complement deficiencies, b) persons who have anatomic or functional asplenia, and c) laboratory personnel who routinely are exposed to N. meningitidis in solutions that may be aerosolized. Vaccination also may benefit travelers to countries in which disease is hyperendemic or epidemic. Conjugate serogroup A and C meningococcal vaccines are being developed by using methods similar to those used for H. influenzae type B conjugate vaccines, and the efficacies of several experimental serogroup B meningococcal vaccines have been documented in older children and young adults.

Antimicrobial chemoprophylaxis of close contacts of patients who have sporadic cases of meningococcal disease is the primary means for prevention of meningococcal disease in the United States. Rifampin has been the drug of choice for chemoprophylaxis; however, data from recent studies document that single doses of ciprofloxacin or ceftriaxone are reasonable alternatives to the multidose rifampin regimen for chemoprophylaxis.

TABLE 1: Schedule for administering chemoprophylaxis against meningococcal disease

Duration & route

Drug Age group Dosage of administration*

Rifampin Children < 1 mo 5 mg/kg every 12 hrs 2 days

Children > 1 mo 10 mg/kg every 12 hrs 2 days

Adults 600 mg every 12 hrs 2 days

Ciprofloxacin Adults 500 mg single dose

Ceftriaxone Children < 15 yrs 125 mg single IM1 dose

Ceftriaxone Adults 250 mg single IM dose

*Oral administration unless indicated otherwise
1 Intramuscular.

 

Rohypnol - "Watch Your Drink"

Rohypnol (flunitrazepam) is a prescription sleeping aid that is part of a widely used class of prescription medications known as benzodiazepines. Recently there have been increasing reports of rohypnol being illegally diverted into the United States and used in women's drinks as a prelude to rape. At sufficient doses amnesia may occur with rohypnol use, which means that the victim may not remember the circumstances surrounding the rape and may not be in a position to identify the perpetrator. Rohypnol is manufactured abroad and is most likely being smuggled in from Mexico and Latin America. Although the majority of sexual assaults associated with this drug have occurred in Texas, Florida, and California, cases have also occurred throughout the nation.

Rohypnol is being added to drinks in order to sedate women and sexually assault them. Because this substance is colorless, tasteless, odorless and easily dissolved women may be unaware of its presence in their drink. Although overdose from rohypnol alone has not proved to be life-threatening, when mixed with alcohol, narcotics, or other CNS depressants, it can be lethal. Symptoms of rohypnol effects include: drowsiness, impaired motor skills, impaired judgment, disinhibition, dizziness, confusion and amnesia. Because only 10 percent of sexual assault victims report their cases to the police, and because the drug is known to impair short-term memory, rohypnol events probably occur more commonly than authorities think.

In an effort to assist law enforcement agencies in identifying victims, the manufacturer of rohypnol is now offering free testing designed to detect the drug in urine. Because rohypnol remains in the urine for 60 to 72 hours after ingestion, the closer to the time of ingestion, the more effective the assay will be in detecting the drug. Therefore, a urine sample should be taken from the victim immediately to increase the likelihood that the drug will be detected. Unless the dosage is very high, it is unlikely that the assay will detect rohypnol in urine collected 72 hours past ingestion.

Increasingly, STD Clinics, OBGYN's, private physicians, hospital emergency rooms, rape crisis centers and law enforcement agencies have shown interest in rohypnol and its impact on their clients. For further information regarding access to testing, contact Hoffmann-LaRoche's toll-free number, 1(800)608-6540. For general information on rohypnol, please call 1(800)720-1076.

 

Quarterly Report of Diseases of Low Frequency   Year-to-Date  January 1 - March 31,1997

(including a comparison for same time period 1993 - 1996)

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Utah Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary - March 1997 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to: 
The Bureau of Epidemiology Box 142870  Salt Lake City, UT 84114-2870  or call (801) 538-6191
Approval 8000008: Appropriation 3705 
Rod Betit, Executive Director Utah Department of Health
Charles Brokopp, Dr.P.H. Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director, Bureau of Epidemiology
Cristie Chesler, BA Managing Editor