CJ·· Canada Diseases Rapport hebdomada1re des maladies au Canada

CJ·· Canada Diseases Rapport  hebdomada1re  des maladies  au  Canada
.
CANA Of ANA
Rapport hebdomada1re des CJ··
maladies au Canada MAR 2 4 198-7
Canada Diseases
Weekly Report
ISSN 0382-232X
Date of publication:
Date de publication:
March 21, 1987
21 mars 1987
Vol. 13-11
CONTENU DU PRESENT NUMERO:
CONTAINED IN THIS ISSUE:
Botulism in Canada - Summary for 1986 . . .
Botulism in Sanikiluaq, Northwest Territories
Carbon l\fonoxide Poisoning - Quebec . . . .
Rapidly Progressive Dementia in a Patient
Who Received a Cadaveric Dura Mater
Graft - United States
Announcement . • . • . . . •
47
Le botulisme au Canada - Resume pour 1986.
Botulisme
Sanikiluaq, Territoires du NordOuest . . . . . . . . . . . . .
Intoxication oxycarbonee - Quebec . . . . . •
Demence
evolution rapide chez une patiente
ayant re~u une greffe durale cadaverique Etats-Unis
Ann once
a
48
48
a
49
50
47
48
1/.8
49
50
BOTULISM IN CANADA
- SUMMARY FOR 1986
LE BOTULISME AU CANADA
- RESUME POUR 1986
Three incidents of foodborne botulism type E were
confirmed in 1986, involving a total of 7 cases, all Inuits,
with 2 deaths (Table 1). Details on the incident that
occurred at Sanikiluaq in the Northwest Territories are
presented in the second article in this issue.
Trois episodes de botulisme de type E d'origine alimentaire ont ete confirmes en 1986; en tout, 7 personnes ont ete
touchees, toutes d'origine inuit, et 2 deces enregistr~s
(Tableau 1). Le deuxieme article du present numero decrit
!'episode enregistre Sanikiluaq dans !es Territoires du NordOuest.
a
Table 1. Foodborne Botulism in Canada, 1986/
Tableau 1. Botulisme d'origine alimentaire au Canada, 1986
Incident/
Episode
Month/
Mois
Location/
Endroit
Suspect
Food/
Aliment
soup9>nne
Total
Cases/
Total
des cas
Fatal
Cases/
Cas
mortels
Toxin
Type/
Type de
toxine
Specimens with
C. botulinum/
Echantillons contenant
C. botulinum
Toxin/
Toxine/
Microorganism/
Microorganisme
l
March/
Mars
Nain, Newfoundland/
Nain, Terre-Neuve
Seal meat/
Viande de
phoque
2
1
E
Food, Stool/
Aliments, selles
2
September/
Septembre
Sanikiluaq, Northwest
Territories/Sanikiluaq,
Territoires du Nordouest
Fermented
seal flipper/
Nageoire de
phoque
fermentee
4
0
E
Food, Stool/
Aliments, selles
3
October/
Octobre
Fort Chima, Quebec
Fort Chimo, Quebec/
Seal meat/
Viande de
phoque
1
J
E
Serum/
Serum
·In September, a case of nonfatal infant botulism type
A was reported from British Columbia. Both toxin and
viable Clostridium botulinum were detected in stool
specimens.
The infant, an 11-week-old resident of
Holberg, B.C., had been breast-fed and had not been given
honey. This is the fourth case of infant botulism in
Canada.
SOURCE:
A Hauschild, PhD, Botulism Reference
Service for Canada, Health Protection
Branch, Ottawa, Ontario; L Gauvreau, MD,
Centre Hospitalier de l'Universite Laval,
Sainte-Foy, Quebec; WA: ma~MB, ChB,
Provincial Laboratories, Vancouver, British
Columbia.
lsecond Class Kail Regi.st.ntioo No. 56701
Health and Welfare
Canada
Sante et Bien-etre social
Canada
En septembre, la Colombie-Britannique signalait un cas
non mortel de botulisme du nourrisson de type A. L'analyse
des selles permis d'isoler la toxine et un bacille Clostridium
botulinum viable. Le bebe, un nourrisson de 11 semaines de
Holberg, Colombie-Britannique, etait nourri au sein et n'avait
pas ingere de miel.
II s'agissait du quatrieme cas de
botulisme du nourrisson au Canada.
SOURCE:
A Hauschild, PhD, Service de rcf erence pow· le
botulisme au Canada, Direction generale de la
protection de la sante, Ottawa, Ontario; Dr
L Gauvreau, Centre hospitalier de l'Universitc
Laval, Sainte-Foy,
Quebec; vr WA Black,
Laboratoires provinciaux, Vancouver, ColombieBritannique.
Courrler de l.!1 deu.xieme! classe - Enre htrel:IM!nt n° 5670
- 47 -
Canada
Notice:
Please make note of the following new office Nata: Veuillez noter !es changements de numeros de telephone
telephone numbers reported from the Botulism Reference suivants au Service de reference pour le botulisme: A. Hauschild,
Service: Dr. A. Hauschild - (613) 957-0884; (613) 975-1010 Ph.D., (613) 957-0884, (en dehors des heures de bureau, (613)
after hours; Dr. E. Todd - (613) 957-0884; (613) 957-1010 957-1010); E. Todd, Ph.D., (613) 957-0884, (en dehors des heures de
after hours; Dr. L. Gauvreau - (418) 656-4141, ext. 7882; bureau, (613) 957-1010); Dr L Gauvreau, (418) 656-4141, paste 7882;
and Dr. W.A. Black - (604) 660-6030 or (604) 660-6031.
et Dr W.A. Black, (604) 660-6030 ou 660-6031.
.
BOTULISM IN SANIKILUAQ,
NORTHWEST TERRITORIES
BOTULISME
A SANIKILUAQ, TERRITOIRES
DU NORD-OUEST
On 20 September 1986, a 32-year-old female presented
Le 20 septembre 1986, une femme de 32 ans se presente au
to the Sanikiluaq (Belcher Islands) Nursing Station with a 1- paste de soins infirmiers de Sanikiluaq (l!es Belcher) parce qu'elle
hour history of "tightness in her throat" associated with eprouve depuis une heure une legere gene respiratoire et se sent la
some mild difficulty in breathing. She had awakened that gorge "serree". A son reveil ce matin-la, elle avait la voix rauque et
morning with symptoms of a cold and a hoarse voice. The !es symptomes d'un rhume. La veille au soir, en compagnie d'une
previous evening, she and approximately 10 other people had dizaine de personnes, elle avait mange un repas de poisson cru, de
consumed a meal consisting of raw fish, seal meat, and viande de phoque et de nageoire de phoque fermentee. A ses dires,
fermented seal flipoer. According to the patient, the seal la na&eoire de phoque avait ete preparee de la fac;:on habituelle,
flipper had been prepared in the usual way, having been c'est-a-dire placee dans un seau en plastique, recouverte d'une
covered in seal fat in a plastic bucket and left on the porch couche de gras de phoque et laissee a fermenter sur le perron.
of the house to ferment. The weather had, however, been Toutefois, la semaine avait ete plus chaude qu'a la normale et qui
warmer that week and, in addition, the seal flipper had been plus est, on avait laisse fermenter la viande 7 jours au lieu des 3
allowed to ferment for 7 days instead of the usual 3. She jours habituels. Elle avait trouve d'ailleurs que la viande avait un
stated that the seal flipper had had an unusual taste.
drole de goOt.
Examination revealed only a hoarse voice. She had no
symptoms of diplopia and did not appear to be in any
respiratory distress.
The possibility of botulism was a
concern at the time, and the patient was instructed to
return immediately if any progression of her symptoms
occurred.
L'examen ne revele qu'un enrouement. Elle ne manifeste aucun
signe de diplopie et ne semble pas eprouver d'insuffisance respiratoire aigu!!. On soupc;:onne un botulisme et on lui recommande de se
representer sans tarder au poste s'il y a aggravement de ses
symptomes.
The patient returned to the nursing station 4 hours
Le sujet revient au paste de soins infirmiers 4 heures plus tard.
later. In ·addition to experiencing greater tightness in her La sensation de constriction du pharynx s'est aggravee, elle eprouve
throat and more difficulty in breathing, she was notably plus de difficulte
respirer, manifeste une dysarthrie et a la voix
dysarthric, and her voice was more hoarse.
She was encore plus rauque. Elle est somnolente et on observe un agrandissomnolent, and her pupils appeared large bilaterally. She sement bilateral des pupilles. Elle a la nausee et avait vomi depuis
· was nauseated and had been vomiting since leaving the son depart du poste quelques heures plus tot. Elle regurgite par le
nursing station earlier. She was noted to regurgitate fluids nez !es liquides qu'elle essaie d'avaler. On decide alors de la faire
up her- nose when she tried to swallow them. At this point, hospitaliser a Churchill, Manitoba, OU !'on confirme le diagnostic
she was transferred to Churchill, Manitoba, where the clinique de botulisme et on lui administre de l'antitoxine botulinique
clinical diagnosis of botulism was confirmed and trivalent trivalente (types A, B et E). On la fait passer aux soins intensifs du
botulinum antitoxin ABE administered.
She was sub- Centre des sciences de la sante a Winnipeg pour maintien des
sequently transferred to the Intensive Care Facility at the fonctions vitales. La detection de la toxine viable de Clostridium
Health Sciences Centre in Winnipeg where she received botulinum de type E dans Jes selles de la malade et des restes de
supportive care. The diagnosis of botulism was confirmed nageoire fermentee permet de confirmer le diagnotic de botulisme.
by the detection of viable Clostridium botulinum type E in
the patient's stool and in leftover fermented seal flipper.
a
In addition to the index case, 3 other people developed
symptoms of botulism, including dry throat and mouth and
difficulty swallowing. They were treated with antitoxin
Af\E and observed in hospital with no further progression of
their symptoms. The 7 other people involved in the dinner
party were asymptomatic and were given prophylactic intramuscular injections of botulism antitoxin.
SOURCE:
D Hellman, MD, (currently in the Depm·tment
of Anesthesia, University of British Columbia,
Vancouver), N Froese, MD, Churchill Health
Centre,
R Klages,
Environmental
Health
Officer, Keewatin Zone, Churchill, Manitoba;
P Tan-MacNeill, Sanikiluaq NW'sing Station,
Sanikiluaq, Northwest Territories; A Hauschild,
PhD, Botulism Reference Service, Health Protection Branch, Ottawa, Ontario.
En plus du cas de reference, 3 autres personnes ont eprouve des
symptomes de botulisme, notamment secheresse de la bouche et de
la gorge et troubles de la deglutition. Hospitalises, ils ont rec;:u de
l'antitoxine ABE et n'ont pas affiche d'autres symptomes. Les 7
autres convives sont demeures asymptomatiques et ont rec;:u des
injections intramusculaires prophylactiques d'antitoxine botulinique.
SOURCE:
Drs D Hellman, (presentement au Departement
d'anesthesie,
Universi~
of
British
Columbia,
Vancouver), N Froese, entre"Cle"sante de Churcnill,
R Klages, Agent d'hygiene du milieu, zone de Keewatin,
Churchill, Manitoba; P Tan-MacNeill, Paste de soins de
Sanikiluaq, Sanikiluaq, Territoires du Nord-Ouest;
A Hauschild, PhD, Service de rff erence pour le
botulisme, Direction generale de la protection de la
sante, Ottawa, Ontario.
INTOXICATION OXYCARBONEE - QUEBEC
CARBON MONOXIDE POISONING - QUEBEC
At approximately 09:30 h on I December 1986, 3'
emergency health dispatchers began to complain of nausea,
headache, and visual problems. About 30 minutes later,
they left work because their symptoms were getting worse.
By approximately 11:00 h, several others were beginning to
complain of the same symptoms.
Le rer decembre 1986 vers 9h30, trois repartiteurs d'Urgence
Sante commencent a se plaindre de nausees, de cephalees et de
troubles visuels. Ils doivent quitter leur emploi une demi-heure plus
tard car leurs syrnptomes s'aggravent. Vers 11 heures, plusieurs de
leurs collegues cornmencent a se plaindre des memes symptomes.
- 48 -
The number of comrlaints prompted management to
request the Montreal Fire Department to inspect the
premises because carbon monoxide poisoning was suspected.
This hypothesis was supported by the location of the air
intake for the building's ventilation system, i.e., it was
located very close to a service stairwell where many
vehicles parked when making deliveries. That particular
day, in addition to the regular deliveries, there was an
emergency vehicle with the motor running parked very close
to the ventilation system air intake.
Devant la multitude des plaintes, la direction demande au
service des incendies d'inspecter les lieux car elle soupc;:onne une
intoxication au monoxyde de carbone. Cette hypothese reposait sur
le fait que la prise d'air du systeme de ventilation de !'edifice est
situee tout pres d'un escalier de service OU beaucoup de vehicules
stationnent !ors de la livraison de marchandises. Ce jour-la, en plus
des livraisons habituelles, on avait remarque tres pres de la prise
d'air, un camion d'urgence dont le moteur tournait.
After a cursory examination, the firemen confirmed the
administrators' suspicions. A physician from the Community
Health Department was asked to examine those employees
presenting with symptoms of poisoning. Eight of llJ. were
examined, the remaining 6 had already gone home. Of the 8
examined, 2 continued to present symptoms and signs compatible with carbon monoxide poisoning, although they had
been removed from the premises where the CO was circulating. The carboxyhemoglobin level in these 2 employees
was 3.5% and 5.5%, respectively, or equivalent to that found
in the average smoker.
Apres un examen sommaire, Jes pompiers confirment les
soupc;:ons des administrateurs.
On demande a un medecin du
Departement de sante communautaire d'examiner les employes
presentant des symptomes d'intoxication. Huit employes sur llJ. sont
examines, les autres chant rentres chez eux. Des 8 personnes
examinees, 2 ont continue a presenter des symptomes et des signes
compatibles avec une intoxication oxycarbonee meme s'ils avaient
quitte le local ou circulait le monoxyde de carbone. Le dosage de la
carboxyhemoglobine pratique chez ces 2 sujets donne des taux de
3,596 et de 5,5%, ce qui correspond au taux observe chez un fumeur
moyen.
Community Health Department officials recommended
that the ventilation system air intake be relocated, or a
fence be erected to prevent vehicles from parking in this
area. Flecause of this experience, it was also considered
important that employers not allow people who are
experiencing such symptoms to go home if they will be
driving themselves.
Le Departement de sante communautaire a recommande de
relocaliser la prise d'air du systeme de ventilation ou de poser une
cloture pour empecher le stationnement de vehicules a cet endroit.
Cette experience a fait ressortir !'importance de faire comprendre
aux employeurs 'qu'ils ne doivent pas laisser partir Jes sujets ayant
des symptomes si ceux-ci doivent conduire un vehicule.
SOURCE:
Y Robert, MD, Head of Public Health Service,
Community Health Department, H6pital SaintLuc, J-N Goupil, MD, Medical Aavisor, Saintllic Community Health Department, Montreal,
Quebec.
International Notes
SOURCE:
Drs l' Robert, Chef. du Service de sante publique,
DPpartement de sante communautaire de l'H6pital
Saint-Luc et J-N Goupil, Medecin conseil, Departement
de sante communautaire de Saint-Luc, Montreal,
Qw>bec.
Notes internationales
Demence a evolution rapide chez une
patiente ayant rec;:u une greffe durale
cadaverique - Etats-Unis
Rapidly Progressive Dementia in a
Patient Who Received a Cadaveric
Dura Mater Graft - United States
In mid-November 1986, a 28-year-old woman developed
A. la mi-novembre 1986, soit 19 mois apres la resection
gait ataxia 19 months after surgical resection of a choles- chirurgicale d'un cholesteatome (masse pseudokystique entouree d'un
teatoma (a cyst-like mass with a lining of stratified epithelium pavimenteux stratifie, siegeant le plus souvent dans
squamous epithelium which occurs most commonly in the l'oreille moyenne OU la region mastoYdienne), une femme de 28 ans
middle ear or mastoid region). During surgery she received developpe une demarche ataxique. Pendant !'intervention, on lui a
an imported, c,o..mmercially prepared, human dura mater greffe de la <lure-mere d'oi:lgine humaine, en preparation
graft (Lyodural..'2.1, Lot No. 2105, processed in 1982 by commerciale importee (Lyodural!!J, lot n° 2105, traite en 1982 par
B. Braun Melsungen AG of the Federal Republic of B. Braun Melsungen AG de la Republique federale d'Allemagne).
Germany). By early December, she required assistance with Des le debut de decembre, elle ne peut se deplacer sans aide et est
ambulation and had developed dysarthria. Two weeks later dysarthrique.
Deux semaines plus tard, elle repond mal aux
she gave inappropriate responses to questions and developed questions qui lui sont posees et a des hallucinations visuelles. Au
visual hallucinations. By early January 1987, she developed debut de janvier 1987, elle est prise de spasmes myocloniques, et
myoclonic jerks and, on physical examination, was !'examen physique revele la demence. Le diagnostic de maladie de
demented. Diagnosis of Creutzfeldt-Jakob disease (CJD) Creutzfeldt-Jakob (MCJ) est confirme par une biopsie du cerveau
II n'y a pas
was confirmed by brain biopsy which demonstrated spongi- qui demontre une encephalopathie spongiforme.
She had no family history of d'antecedents de maladie neurodegenerative dans la famille, et la
form encephalopathy.
degenerative neurologic disease, nor had she received femme n'a pas rec;:u de somatotrophine humaine (STH) provenant d'un
cadaveric, pituitary-derived human growth hormone (HGH). prelevement necropsique d'hypophyse. Pendant les 3 mois qui ont
No patient with known CJD had surgery in the same precede !'intervention pratiquee sur cette femme, aucun malade que
neurosurgical suite in the 3 months prior to this woman's !'on savait atteint de MCJ n'a ete opere dans la meme salle de
neuro-chirurgie.
operation.
SOURCE:
Morbidity and Mortality Weekly Report, Vol 36,
SOURCE:
Morbidity and Mortality Weekly Report, Vol 36, no 4,
1987.
No 4, 1987.
Editorial-Comment: A Medical Device Alert concerning
Lyodura(!!J is being mailed to hospitals which may have used
this product between 1982 and 1986. At this time, the
Bureau of Communicable Disease Epidemiology, Laboratory
Centre for nisease Control, is not aware of any cases in
Canada of CJD associated with the use of cadaveric dura
mater. Information on such cases, if any, will be essential
in formulating additional guidelines for the use of such
tissue of human origin.
Commentaires de la redactionUne "Alerte - Instruments
medicaux", consacree au Lyodura®, est presentement adressee aux
hopitaux susceptibles d'avoir utilise le produit de 1982 a 1986.
Jusqu'ici, aucun cas canadien de MCJ associe a !'utilisation de duremere cadaverique n'a ete signale au Bureau de l'epidemiologie des
maladies transmissibles, Laboratoire de lutte contre la maladie. Or,
pour formuler de nouvelles directives en matiere d'utilisation de
tissu analogue d1ori9ine humaine, ii faudra des donnees sur de tels
cas - s'il y en a eu, evidemment.
- IJ.9 -
Consequently, the P.ureau would like to receive reports
of all cases of CJD with onset in 1983 or later and who were
recipients of ~ material derived from tissue of human
origin. Notification of such cases may be made through
your provincial epidemiologist to the Chief, Disease Surveillance [)ivision, LCDC, Ottawa, KIA OL2 (613) 957-1339.
This would not include recipients of human growth hormone,
for which there exists a registry. In provinces where CJD is
notifiable, please indicate on the provincial notification that
such material was implanted.
Le Bureau aimerait done recevoir des rapports sur taus Jes
sujets ayant manifeste une MCJ en 1983 ou apres, et ayant re<;:u un
materiel quelcongue tire de tissu d'origine humaine.
Les
declarations peuvent etre faites par le biais des epidemiologistes
provinciaux au Chef de la Division de la surveillance des maladies,
LLCM, Ottawa, KIA OL2, (613) 957-1339. Seraient exclus !es sujets
ayant re<;:u de la somatotrophine humaine, puisqu'un registre leur est
deja reserve. Dans !es provinces OU la declaration des cas de MCJ
est obligatoire, il faut preciser sur la formule de declaration qu'il y
a eu implant d'un tel materiel.
In addition, the f\ureau recommends that hospitals use
the appropriate infection control precautions for patients
known to have received the implicated lots of Lyodura®
during the period 1982 through 1986.
Precautions for
handling CNS tissues and body fluids of patients with CJD
are outlined in the publication Infection Control Guidelines
for Isolation and Precaution Techniques, Health and Welfare j'
Canada, 1985. A more definitive reference is that of Jarvis
(Jarvis WR.
Precautions for Creutzfeldt-Jakob disease. t
Infection Control 1982; 3:238-239).
Le Bureau recommande en outre aux hopitaux d'appliquer les
rnesures anti-infectieuses qui s'impo%!nt pour les patients qui ont
re<;:u Jes lots incrirnines de Lyodura '-£9 au cours de la periode allant
de 1982 a la fin de 1986. Les precautions a prendre pour manipuler
des tissus du SNC et des liquides organiques provenant de malades
atteints de MCJ sont exposees dans le "Guide de prevention des
infections pour techniques d'isolement et precautions", publie en
1985 par Sante nationale et Bien-etre social. La question est traitee
de fa<;:on plus specifique par Jarvis (Jarvis WR. Precautions for
Creutzfeldt-Jakob disease. Infection Control 1982; 3:238-239).
-
Announcement
Ann once
1·
INFECTION CONTROL
LUTTE ANTI-INFECTIEUSE
25-29 May 1987
du 25 au 29 mai 1987
Regina, Saskatchewan
Regina, Saskatchewan
This workshop designed for hospital infection control
practitioners is sponsored by Continuing Nursing Education,
College of Nursing, University of Saskatchewan. The program will include sessions on microbiology, information
retrieval, infection control strategies, disinfection and
sterilization, principles of isolation, hospital epidemiology,
elements of surveillance, AIDS, basic principles of
descriptive statistics, quality assurance and accreditation
standards, and computer applications in infection control
surveillance.
Cet atelier con<;:u a !'intention des responsables de la lutte
infections dans. !es hopitaux est parraine par le departement d'education permanente en soins infirmiers, College of
Nursinp, University of Saskatchewan. Voici les points qui seront
abordes: microbiologie, extraction des renseignements, strategies
de Jutte centre !es infections, desinfection et sterilisation, principes
d'isolement, epiderniologie hos pi tali ere, elements de surveillance,
SIDA, principes fondamentaux de la statistique descriptive,
assurance de la qualite et normes d'agrement, et applications
informatiques dans la surveillance appliquee a la lutte antiinfectieuse.
I centre les
i
Pour de plus amples renseignetnents, se mettre en rapport avec
For further information, please contact Donna Barber,
Administrative Coordinator, Continuing Nursing Education, Donna Barber, Coordonnatrice administrative, Continuing Nursing
College of Nursing, University of Saskatchewan, Regina Education, College of Nursing, University of Saskatchewan, Regina
Office, c/o Plains Health Centre, 4500 Wascana Parkway, Office, c7o Plains Health Centre, 4500 Wascana Parkway, Regin~
Saskatchewan, 545 5W9 (tel.: (306) 584-6549).
Regina, Saskatchewan, S4S 5W9 (tel.: (306) 584-6549).
~
The Canada Diseases Weekly Report presents current information on infectious
and other diseases for surveillance purposes and is available free of charge upon
request. Many of the articles contain preliminary information and further
confirmation may be obtained from the sources quoted. The Department of
National Health and Welfare does not assume responsibility for accuracy or
authenticity. Contributions are welcome (in the official language of your
choice) from anyone working in the health field and will not preclude
publication elsewhere.
Le Rapport hebdomadaire des maladies au Canada, qui fournit des donnees pertinentes sur Jes
maladies infectieuses et les autres maladies dans le but de faciliter leur surveillance, peut
Ctre obtenu gratuitement sur demande. Un grand nombre d1articles ne contiennent que des
donnees sommaires mais des renseignements compiementaires peuvent etre obtenus en
s'adressant aux sources citees. Le minister~ de la Sante nationale et du Bien-i!tre social ne
peut etre tenu responsable de !'exactitude, ni de l'authenticitC des articles. Toute personne
oeuvrant dans le domaine de la sante est invitee collaborer (dans la langue officielle de son
choix) et la publication d'un article dans le present Rapport n'en empeche pas la publication
ailleurs.
Editor: Dr. S.E. Acres (613) 957-1339
Managing Editor: Eleanor Paulson (613) 957-1788
Circulation: Elizabeth Beckett (613) 957-0841
RCdacteur en chef: Dr S.E. Acres (613) 957-1339
RCdacteur administratif: Eleanor Paulson (613) 957-1788
Distribution: Elizabeth Beckett (613) 957-0841
Bureau of Communicable Disease Epidemiology
Laboratory Centre for Disease Control
Tunney's Pasture
OTTAWA, Ontario
Canada Kl A OL2
Bureau d'epidemiologie des maladies transmissibles
Laboratoire de lutte centre la maladie
Pare Tunney
Ottawa (Ontario)
Canada KI A OL2
- 50
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