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Diseases Subject to the International Health Regulations

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Diseases Subject to the International Health Regulations Diseases Subject to the International Health Regulations Cholera, yellow fever, and plague cases and deaths reported in the Region of the Americas up to 15 October 1980 Country and Yellow fever administrative Cholera Plague subdivision Cases Cases Deaths Cases BOLIVIA - 46 39 15 Cochabamba - 12 8 - La Paz - 32 30 15 Santa Cruz - 1 1 - Tarija - 1 - BRAZIL - 25 22 69 Ceará - - - 62 Goiás - 20 19 Maranhao - 4 2 - Pernambuco - - - 7 Rondónia - 1 1 - CANADA 3 - - - Quebec 1 - - Saskatchewan 2 - - COLOMBIA - 7 7 - Cesar - 1 1 - Guaviare - 1 1 - Meta - 1 1 - Norte de Santander - 1 1 - Putumayo - 3 3 - ECUADOR - 2 - Napo - 2 PERU - 24 19 - Ayacucho - 8 7 - Junín - 7 4 - San Martín - 7 7 - ...- 2 1 - UNITED STATES 8 - - 13 California 6 - 2 Maryland 1 - Nevada - - - 2 New Mexico - - - 9 Pennsylvania 1 - - VENEZUELA - 1 1 - Mérida - 1 1 -None. ... Data not available. I Accidental Smallpox Vaccination in Venezuela On 31 July 1980 a report was received that the previous vaccine (lot No. 48 produced by the National Institute of day a 10-month old child weighing 10 kg, who had been Health), rehydrated in the diluent of the Merieux Lab- taken for measles vaccination in Barquisimeto, Lara oratory measles vaccine. In a way, the accident provided State, had accidentally received in the left arm a sub- an opportunity for reinforcing the principle that those in cutaneous injection of 25 doses of freeze-dried smallpox charge of programs should supervise the immunizations 5 more closely. It also provided an example of what can The fact that smallpox vaccine was administered at all happen, and the state epidemiologists who were attend- prompts yet another important comment. Since this dis- ing a course on cold chain at the time in the ease has been officially eradicated throughout the world, Epidemiology Division, in Caracas, were informed of the one would wonder why Venezuela and other countries . incident. continue to vaccinate against it. It will be recalled that The smallpox vaccine used by mistake had been the last outbreak of alastrim occurred in May-April shipped in 1978 by the National Storage Facility to Bar- 1962, when the National Institute of Health (INH) quisimeto, where it had been kept under refrigeration confirmed 11 cases among the Pemone Indians of the (+40 to 80C) for two years. Once the error was dis- Great Savanna, in Bolívar State (on the Venezuelan- covered, the child was placed under close observation Brazilian border). The last cases of smallpox in the and treated with methisazone (Marboran), and on 31 Hemisphere were reported in April 1971 in Guanabara, July and 1 August received a total of 0.9 g orally. Brazil, 400 years after its introduction into the New The child felt no discomfort until 3 August (4th day World. following vaccination), when he registered a fever of In 1967 WHO launched the worldwide campaign for 38.5°C, and a papule, 2 cm in diameter and a hardened the eradication of smallpox, and a decade later an- center appeared; there was no axillary adenitis or change nounced that the last case of endemic smallpox had been in his general condition. On 4 August (5th day following recorded in Somalia in October 1977. inoculation), the child was examined by a physician of On 25 January 1980 WHO proclaimed that the eradi- the Epidemiology Division, and on that occasion was cation of smallpox throughout the world had been given 6 ml of antivaccinia gamma globulin of human ori- achieved, and stated that there was no reason to fear a gin, of which 1 ml was infiltrated around the lesion and 5 recurrence of the disease. On that date it also approved ml was administered intramuscularly. This material was the following recommendations: provided by the United States Armed Forces through the 1. That smallpox vaccination be discontinued in all Center for Disease Control, and was obtained through countries except in the case of research workers at special Caracas and the prompt intervention of PAHO (the risk. Washington offices). 2. That the vaccination requirement for international On 7 August (8th day after inoculation), the lesion re- travel be lifted. turned to normal size and the hardening and fever dis- 3. That 200 million doses of freeze-dried smallpox appeared. On 11 August (12th day after inoculation) the vaccine be kept in storage in two countries. child recovered completely. 4. That some high-security laboratories be permitted to preserve and keep smallpox virus. Editorial Comment Worthy of mention is the fact that Venezuela has not In the case reported, the nurse thought she had pre- yet changed its Vaccination Law (1912) or its Regula- pared measles vaccine, which could be explained by the tions (1921), which make smallpox vaccination com- fact that there is some outward resemblance between the pulsory and lay down the standards for schoolchildren, containers of smallpox and measles vaccines. When pre- the Armed Forces, and international travelers. For the pared with the measles vaccine diluent, however, the last three years the Epidemiology Division has been de- smallpox vaccine is transparent, in distinct contrast to creasing the number of vaccinations, and the INH has the pinkish tint of the measles vaccine itself. In fact, it produced no vaccine since 1977; however, the INH keeps was the lack of color in the unused portion of the vaccine 7 kg of freeze-dried calf pulp, the equivalent of some 2 prepared that made the nurse realize the mistake. million doses. Moreover, the methisazone treatment was insufficient, Table 1 shows the vaccinations performed from 1968 since the recommended dosage for preventing postvac- to 1979 and the number of postvaccination deaths (en- cination lesions from measles vaccine is 80 mg per kg of cephalitis in children undergoing primary vaccination). body weight (the patient should have been given 8 g and As early as 1966 the Epidemiology Division had esti- not 0.9 g). mated a frequency of one case of encephalitis for every This accident calls attention once again to the need to 120,000 primary vaccinations in individuals at least five keep vaccines in the refrigerators of local health services years old, with a letality rate of 25 per cent. Fortunately, clearly identified and arranged, to ensure that the vac- the case described in this report had a happy outcome, cine administered is the right one. Priority should be but it does call attention to the urgency of strict com- given to these practical aspects in the training of vac- pliance with WHO recommendations. cination personnel, particularly since the containers of Finally, the National Health Department, the Epi- typhoid, DPT, and tetanus toxoid vaccines are identical. demiology Division, and the Legal Counsel of the Minis- e 6 Table 1. Smallpox vaccination and deaths from postvaccina- try of Health and Social Welfare and studying the legal tion reaction, Venezuela, 1968-1979. basis for amending the Vaccination Law in order to estab- Vaccinations (in thousands of doses) lish a policy in keeping with the WHO recommendations. Revaccina- Year Total Primary tions Deaths (Source: Boletín Epidemiológico Semanal 1968 1,592.8 663.7 929.1 1 1969 1,378.7 598.1 780.6 - No. 32, 3-9 August 1980. Division 1970 1,119.2 890.1 229.1 3 of Epidemiology, Ministry of Health 1971 870.0 630.6 239.4 2 and Social Welfare, Venezuela.) 1972 786.0 568.1 217.9 2 1973 691.7 480.0 211.7 - 1974 617.9 385.8 232.1 - 1975 526.2 311.3 214.9 1 1976 429.1 202.9 226.2 - 1977 387.0 177.1 209.9 - 1978 133.0 68.1 64.9 - 1979 66.6 ...... - Source: Morbidity Section, Epidemiology Division, Ministry of Health and Social Welfare.) Argentinian Hemorrhagic Fever Argentinian hemorrhagic fever (AHF) is an endemo- nually with a presumptive clinical diagnosis of AHF since epidemic anthropozoonosis that has gradually spread in 1958, when official records of this disease were begun. the pampas of Argentina, as shown in Figure 1. Table 1 shows the distribution of the cases studied in The etiologic agent of AHF is the Junín virus, one of Pergamino since 1965. As may be seen, an etiologic the four arenaviruses that are pathogenic for man, the diagnosis of AHF was established in approximately 70 other three being the virus of lymphocytic choriomen- per cent of the cases reported in Pergamino in that ingitis (LCM), that of Lassa fever, and the Machupo 15-year period. Most of the remaining 30 per cent of the virus, which causes Bolivian hemorrhagic fever. cases reported on the basis of a clinical diagnosis of AHF With the exception of the Lassa fever virus and the were patients who possibly suffered from virus infections Tamiami virus, all the other arenaviruses are found in of a different etiology. different geographic areas of Latin America. These Table 2 shows the distribution by sex and age group of viruses are associated with different rodent species in the cases with an etiologic diagnosis of AHF that were which they produce persistent infections that ensure their studied in Pergamino. The marked predominance of maintenance in nature. Each of these agents is found in males and of middle-aged persons is evident. autochthonous rodents of geographic regions that are Table 3 shows the results of a controlled therapeutic usually far removed from one another. However, in the study, which clearly demonstrates the effectiveness of im- AHF endemic region, the simultaneous activity of two mune plasma in reducing AHF case-fatality ratio if it is arenaviruses pathogenic for man-the Junín and the administered within eight days of onset of the disease.
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