Canada Diseases Rapport hebdomadaire des MAY maladies au Canada

Canada Diseases Rapport  hebdomadaire  des MAY maladies  au  Canada
CANADU\i\·
Rapport hebdomadaire des l?J~
maladies au Canada MAY - R
- 1987 ;
Canada Diseases
Weekly Report
Date of publication:
Date de publication:
ISSN 0382-232X
CONTAINED IN THIS ISSUE:
Vaccine Failure:
Haemophilus influenzae
Type B Polysaccharide Vaccine . • . . . •
Symptoms of Irritation Associated with
Exposure of Glutaraldehyde - United States.
May 2, 1987
2 mai 1987
Vol. 13-17
CONTENU DU PRESENT NUMERO:
Echec vaccinal:
Vaccin polysaccharidique
contre Haemophilus influenzae de type B
Symptomes d'irritations associees
une
exposition au glutaraldehyde - Etats-Unis
75
75
a
77
77
VACCINE FAILURE: HAEMOPH!LUS INFLUENZAE
TYPE B POLYSACCHARIDE VACCINE
ECHEC VACCINAL: VACCIN POLYSACCHARIDIQUE
CONTRE HAEMOPHILUS INFLUENZAE DE TYPE B
Case No 1: In November 1986, a 28-month-old adopted
mullato male from Dartmouth, Nova Scotia was given
Haemophilus influenzae type b (Hib) vaccine by his family
doctor. He was well for 40 days following vaccination
when his mother noted that he_ was lethargic. He subsequently developed a sore throat, low grade fever,
drooling, increasing respiratory difficulty with stridor,
and a muffled voice with a hoarse cough. There were no
complaints of headache or neck stiffness but he did have 3
episodes of vomiting before his initial assessment.
Cas n° 1: En novembre 1986, un gan;onnet mu!atre de 28
mois adopte par une famille de Dartmouth, Nouvelle-Ecosse
re<;:oit le vaccin contre Haemophilus influenzae de type B de
son medecin de famille. I! est bien portant pendant les 40
jours qui suivent sa vaccination, puis sa mere note un debut
de lethargie. Par la suite, ii manifeste un mal de gorge, une
febricule, une salivation excessive, et une gene respiratoire
croissante avec stridor; sa voix est assourdie avec une toux
rauque. I! ne se plaint pas de cephalee ni de raideur de la
nuque mais a 3 episodes de vomissements avant d'etre amene
chez le medecin.
The patient had no history of frequent infections,
airway problems or foreign body aspiration.
He was
receiving no medication, had no allergies or previous
significant illnesses. He attended a day-care centre 3
days per week, the last day being 4 days prior to onset of
symptoms.
Le petit malade n'a pas d'antecedents d'infections
frequentes, d'atteinte des voies aeriennes OU d'aspiration de
corps etrangers. I! ne prend pas de medicaments presentement, ne souffre pas d'allergies et n'a pas eu de maladies
graves par le passe. Il frequente une garderie 3 jours par
semaine, sa derniere visite remontant a 4 jours avant
!'apparition des symptomes.
On admission to hospital, he was not swallowing his
secretions and he appeared ill with respiratory distress
and stridor. His respiratory rate was 45 and temperature
was 38.5°C. His chest was clear with good air entry
bilaterally. The remainder of his physical examination
was normal.
Under general anaesthesia his epiglottis
appeared severely inflamed. Blood and epiglottic swabs
grew H. influenzae type b.
His white blood cell was
30.2xl09/L with 65% neutrophils, 19% bands, and 5%
lymphocytes. His hemoglobin was lllg/L and the platelet
count was 310xl09/L.
A son admission l'hopital, ii n'avale pas ses secretions
et semble souffrir d'une gene respiratoire avec stridor. Sa
frequence respiratoire est de 45 et il a une fievre de 3&,5°C.
Ses poumons sont degages avec une bonne arrivee d'air des 2
cotes. Tous ses autres signes sont normaux. Un examen
pratique sous anesthesie generale revele une epiglotte
fortement irritee. Des frottis de sang et de l'epiglotte
cultivent H. influenzae de type B. Sa formule leucocytaire
est la suivante: 30,2xl09/L, dont 65% de neutrophiles, 19%
de neutrophiles non segmentes et 5% de lymphocytes. Son
hemoglobine est de 11 lg/L et la numeration des plaquettes
est de 310xl09/L.
Following intubation, cefuroxime (lOOmg/kg) was
started. He was successfully extubated 48 hours later.
Rifampin was given to the patient, his 5-month-old
sibling, his parents, and his day-care contacts. He was
discharged 4 days after admission in good condition to
complete his 10-day course of antibiotic.
Apres intubation, on lui administre du cefuroxime
(lOOmg/kg). On lui retire le tube sans difficulte 48 heures
plus tard. On administre de la rifampine au petit malade, a
ses parents et leur deuxieme enfant de 5 mois, ainsi qu'aux
contacts du cas de reterence
la garderie. I! re<_;:oit son
conge de l'hopital apres un sejour de 4 jours et rentre a la
maison en bonne forme afin de completer son antibiotherapie
de 10 jours.
In view of the failure of the vaccination to prevent
this episode of H. influenzae infection, an immunological
assessment was done. His serum immunoglobulins were
normal with the exception of IgA which was minimally
elevated (IgA 0.84g/L, normal values range from 0.16 0.75).
Hemoglobin electrophoresis and complement
studies were normal.
Immunoglobin electrophoresis,
tetanus antibodies, H. influenzae serology, and_ allotyping
are pending.
On decide de proceder
une evaluation immunologique
du malade devant l'echec de la vaccination contre
H. influenzae. Ses immunoglobulines seriques sont normales
sauf qu'il affiche un taux legerement eleve d'lgA (IgA de
0,84~/L, valeurs normal es variant de O, 16 a 0,7 5). L'electrophorese de l'hemoglobine et les analyses du complement sont
normales.
On attend toujours Jes resultats de l'electrophorese de l'immunoglobuline, de la recherche d'anticorps
antitetaniques, des analyses serologiques de depistage de
H. influenzae, et de l'allotypie.
lsecond Class Kall Reghuation Ho. S670f
Health and Welfare
Canada
Sante et Bien-et re social
Canada
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deu.:dbae claue - l!nrep:htremeot n° 5670
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Case No 2: A 29-month-old Caucasian male from
St. John's, Newfoundland received H. influenzae type b
vaccine on 7 November 1986. Prior to this immunization, he
had no history of undue susceptibility to infection.
Following immunization, he remained well except for an
uncomplicated nonfebrile respiratory illness in the
subsequent month. On 8 January 1987, he developed fever,
irritability, and cough. He was examined in the hospital
emergency room where a chest x-ray revealed a left lower
lobe pulmonary infiltrate. White blood cell count showed a
leucocytosis. A blood culture taken at that time grew a
beta-lactamase positive H. influenzae type b. The child
made a rapid uneventful recovery following institution of
antibiotic therapy. Serum immunoglobulins, G, A, M and
lgG2 and C3, C4 were in the normal range.
Further
immunologic studies are underway.
Cas n° 2: Un bambin de 29 mois de race blanche de Saint-Jean de
Terre-Neuve re<;oit un vaccin contre H. influenzae de type B le 7
novembre 1986. Avant cette vaccination, ii n'affichait pas de
predisposition a des infections. Apres avoir re<;u le vaccin, ii reste
bien sauf pour un episode de trouble respiratoire afebrile et sans
complication le mo is sui vant. Le 8 janvier 1987, il manifeste une
fievre, de l'irritabilite et une toux. II est vu a l'urgence et la
radiographie de ses poumons revele un infiltrat pulmonaire du lobe
inferieur gauche. La numeration leucocytaire indique une leucocytose. Un specimen de sang preleve en meme temps cultive
H. influenzae de type B penicillinase positif. L'enfant se remet
rapidement sans complications apres l'amorce de l'antibiotherapie.
Ses taux d'immunoglobulines seriques G, A, M, IgG2, C3 et C4 se
situent dans les valeurs normales. Des etudes immunologiques plus
poussees sont en cours.
Discussion: H. influenzae type b systemic disease after Hib
immunization was first noted in the Finnish field trial (1974Vaccine failures
1976) involving 49 000 children(l).
occurred after immunization in only 2 children vaccinated
at 24 and 27 months of age. In the United States, Hib
vaccine was licensed in April 1985. Recently, Gran off in
St. Louis identified 55 vaccine failures; 4 (7%) were
black(2),
Discussion: Une atteinte generalisee a H. influenzae de type B
apres vaccination contre cet agent a ete notee pour la premiere fois
lors d'un essai sur le terrain portant sur 49 000 petits Finlandais de
1974 a 1976(1), Des echecs vaccinaux n'ont ete enregistres que chez
2 des enfants, vaccines a 24 et 27 mois respectivement. Aux
Etats-Unis, le vaccin contre Hib est autorise depuis avril 1985.
Granoff a note recemment 55 echecs vaccinaux St. Louis, dont 4
(7%) chez des noirs(2).
Genetic factors which might account for P,Oor immune
response to the vaccine have been identified(3), Among
blacks, those lacking the Km allotype have a higher
incidence of disease and a poorer immune response to Hib
polysaccharide. In Caucasians, the presence of the Gm
phenotype lacking G2m.23 was associated with a significant
higher relative risk for vaccine failure.
On a identifie certains facteurs genetiques qui pourraient
expliquer jusqu'a un certain point la faible reponse immunitaire au
vaccinO). On a note en effet que les noirs qui n'avaient pas
l'allotype Km avaient une incidence accrue de maladies et une
reponse immunitaire affaiblie au polysaccharide Hib. Chez les
blancs, la presence du phenotype Gm sans G2m.23 a ete associee a
un risque relatif significativement plus eleve d'echec vaccinal.
To the authors' knowledge, the cases presented here are
the first Hib vaccine failures reported in Canada.
Considering the small number of vaccine failures in blacks
noted in Granoff's paper, it is surprising that one of the first
reported Hib vaccine failures in Canada occurred in a black
child.
A. la connaissance des auteurs, !es cas presentes dans ce numero
constituent les premiers echecs associes au vaccin contre Hib a etre
enregistres au Canada.
Si l'on considere le nombre restreint
d'echecs vaccinaux signale par Granoff chez des noirs, ii est
surprenant de noter qu'un des premiers cas associes au vaccin antiHib et enregistres au Canada se soit produit chez un enfant de race
noire.
a
Le vaccin anti-Hib est adminstre de fac;:on systematique en
The use of the Hib vaccine became routine throughout
Nova Scotia after 1 December 1986 when the Provincial Nouvelle-Ecosse depuis le 1er decembre 1986, lorsque le ministere
Department of Health began to provide Hib to physicians for provincial de la Sante a commence a le distribuer aux medecins a
2-year-old children. Currently in the province, approxima- !'intention des enfants de 2 ans. Quelque 10 000 unites de vaccin ont
tely 10 000 units of vaccine have been distributed but it is ete distribuees jusqu'a maintenant mais on ignore le nombre exact
not possible to determine easily the number of doses de doses qui ont ete administrees (Dr P. Lavigne, ministere de la
administered (Dr. P. Lavigne, Department of Health, '.'lova Sante de la Nouvelle-Ecosse, communication personnelle, 1987).
Scotia: personal communication, 1987).
Vaccine efficacy has been reported to be approximately
80 to 90%0). However, prospective studies have not as yet
evaluated efficacy of vaccines used in Canada.
La vaccination serait efficace dans 80 a 90% des cas<O.
Toutefois, on n'a pas encore evalue au moyen d'etudes prospectives
l'efficacite des vaccins utilises au Canada.
Il est done essentiel que les medecins comprennent que le
It is imperative that physicians are aware that Hib
vaccine, like other immunizing agents, is not 100% effective vaccin anti-Hib, comme d'autres agents immunisants, n'est pas
and that H. influenzae invasive disease cannot be prevented efficace a 100% et qu'il ne peut pas prevenir tout risque d'atteinte
with certainty. One should continue to monitor both the invasive a H. influenzae, d'ou !'importance de continuer a surveiller
incidence of H. influenzae type b invasive disease and !'incidence d'atteintes envahissantes a H. influenzae de type Bet des
vaccine failures and report them immediately. Vaccine echecs vaccinaux, et de les signaler sans tarder. Prendre note du
manufacturer and lot number should be recorded at the time fabricant et du numero de lot de chaque vaccin administre de fac;:on
of immunization in order to aid in subsequent investigation a faciliter l'enquete en cas d'echec de la vaccination. Ainsi, il
if vaccine failure occurs. With this information, reasons for devrait etre possible de trouver la cause du probleme et d'ameliorer
failures can be identified and improvements in efficacy can l'efficacite du produit vaccinal.
be made.
References:
References:
1.
Peltola H et al. Pediatrics 1977; 60:730-737.
l.
Peltola H et coll. Pediatrics 1977; 60:730-737.
2.
Granoff D et al. N Engl J Med 1986; 315:1584-1590.
2.
Granoff D et coll. N Engl J Med 1986; 315:1584-1590.
3.
Idem. J Infect Dis 1986; 154:257-264;
3.
Ibid. J Infect Dis 1986; 154:257-264.
SOURCE:
C Nijssen-Jordon, MD, in collaboration with R
Bortolussi, MD, R Ozere, MD, W Sprague, MD,
Izaak Walton Killam Hospital for Children,
Halifax, Nova Scotia; The Dr.
Charles A
John's,
Janeway Child Health Centre, St.
Newfoundland.
SOURCE:
- 76 -
Dr C Nijssen-Jordon,
en
collaboration
avec !es
Drs R Bortolussi, R Ozere, W Sprague, Izaak ~Valton
Killam Hospital for Children, Halif a:x, Nouvelle- Ecosse;
le Dr Charles A Janeway Child Health Centre,
Saint-Jean de Terre-Neuve.
International Notes
Notes internationales
SYMPTOMS OF IRRITATION ASSOCIATED WITH
EXPOSURE TO GLUT ARALDEHYDE - UNITED ST ATES
SYMPTOMES D'IRRIT ATIONS ASSOCIEES A UNE
EXPOSITION AU GLUTARALDEHYDE- ETATS--UNIS
During an evaluation by the National Institute for
Occupational Safety and Health (NIOSH) of exposures to
formaldehyde at a biomedical research hospital in Denver,
Colorado, several employees complained of irritation from
using another substance, glutaraldehyde0). At the hospital,
glutaraldehyde was present in solutions used for · tissue
fixation, histologic examinations, and disinfection and/or
cold-sterilization of respiratory therapy equipment.
In
October 1983, NIOSH investigated these complaints. To
measure airborne levels of glutaraldehyde, the investigator
collected 8 samples from personal breathing zones of
employees and 13 samples from area air during procedures
scheduled especially for the evaluation. The employees'
symptoms were recorded during informal interviews and on
medical questionnaires.
Lors d'une enquete menee par le National Institute for Occupational Safety and Health (NIOSH) sur !'exposition des employes du
formaldehyde dans un hopital de recherche biomedicale de Denver,
Colorado, plusieurs employes se sont plaints egalement d'irritations
associees
!'usage d'un autre produit, le glutaraldehyde0). On y
utilise cette substance pour fixer Jes tissus, dans Jes analyses
histologiques, de meme que pour desinfecter OU steriliser par Je
froid le materiel d'inhalotherapie. Le NIOSH fit enquete sur ces
plaintes en octobre 1983. Afin de mesurer Jes concentrations de
glutaraldehyde dans l'air, l'enqueteur preleva 8 echantillons d'air de
postes de travail d'employes et 13 echantillons d'air ambiant pris au
cours de procedes precis devant faire l'objet d'une evaluation. On
nota les symptomes decrits par les ernployes au cours d'entrevues
officieuses et dans des questionnaires medicaux.
Glutaraldehyde concentrations in personal breathing
zones ranged from non-detectable (ND) to 1.5 mg/m3; 6 of
the 8 samples exceeded the ceiling threshold limit value
(TLV) of 0.7 mg/m3 set by the American Conference of
Governmental Industrial Hygienists. Concentrations in area
air ranged from ND to 1.5 mg/m3; 6 of the 13 samples
exceeded the TL V. The Occupational Safety and Health
Administration has no standard and NIOSH has no
recommended exposure limit for occupational exposure to
glutaraldehyde.
Les concentrations de glutaraldehyde dans les postes de travail
variaient de valeurs non decelables (ND)
1,5 mg/m3: 6 des 8
echantillons depassaient le seuil d'exposition limite de 0,7 mg/m3
fixe par !'American Conference of Governmental Industrial
Hygienists. Les concentrations dans l'air ambiant pendant divers
procedes variaient de valeurs ND a 1,5 mg/m3; 6 des 13 echantillons
depassaient le seuil d'exposition Jimite. L'Occupational Safety and
Health Administration n'a prevu aucune norme pour cette substance
et le NIOSH n'a recomman~e aucune limite relative
!'exposition
professionnelle au glutaraldehyde.
Nine of the 11 nurses who were using solutions
containing glutaraldehyde as a disinfectant had symptoms of
some type of irritation. Eight reported skin symptoms,
ranging in severity from itching· or irritation to cracking and
bleeding; 7 reported eye irritation; 6 throat discomfort; 5
nasal discomfort; 5 chest tightne;;s or other pulmonary
discomfort; 4 cough; and 2 headachel2),
Neuf des 11 infirmieres qui utilisaient des solutions
desinfectantes
base de glutaraldehyde ont signale avoir eprouve
des symptomes d'irritation. Huit ont fait etat de problemes cutanes
alJant d'une simple demangeaison OU irritation
des crevasses et
saignements; 7 avaient une irritation oculaire; 6, une gene au niveau
de la gorge et 5, au niveau du nez; 5 ont mentionne une oppression
thoracique ou une autre gene pulmonaire; t+, une toux; et 2, des
cephalees(2).
Another NIOSH study currently in process indicates
that the Denver experience is not unique. Preliminary data
from this study conducted in Morristown, Pennsylvania,
reveal glutaraldehyde exposure concentrations and reported
irritation symptoms that closely resemble those from the
Denver evaluation(3),
D'apres une autre enquete en cours au NIOSH, !'experience de
Denver ne serait pas isolee. En effet, des donnees preliminaires
d'une etude effectuee a Morristown, Pennsylvanie, revelent une
du glutaraldehyde et des symptomes d'irritation qui
exposition
rappellent ceux de l'enquete de Denver(3).
Editorial Note: Glutaraldehyde is a saturated dialdehyde
with the formula CHO-CH2-CH2-CH2-CHO and a
molecular weight of 100.12. It has a pungent odor with a
threshold recognition level of O.Ot+ parts per million (ppm) by
volume in air; eye and respiratory irritation are noted at a
level of 0.3 ppm(t+),
Note de la r&laction: Le glutaraldehyde est un dialdehyde sature
(CHO-CH2-CH2-CH2-CHO) dont le poids moleculaire est de
100,12. II a une odeur piquante et un seuil de detection de O,Ot+ ppm
par volume d'air; des irritations oculaires et respiratoires ont ete
notees des concentrations de 0,3 ppm(t+).
a
a
a
a
a
a
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a
In health care facilities, glutaraldehyde is used as an
Dans les etablissements de soins de sante, on utilise souvent le
active ingredient in a number of chemical reagents and glutaraldehyde comme principe actif dans divers reactifs chimiques
germicides. Evidence indicates that glutaraldehyde can be a et germicides. II a ete demontre que cette substance est un
relativelY. strong irritant to the nose and a severe irritant to irritant relativement fort pour le nez et un irritant puissant des
the eyes(t+,5), It can produce skin staining and may be yeux(t+,5), En outre, le glutaraldehyde peut tacher la peau et y
slightly irritating to the skin(t+,6), It can also cause skin causer une legere irritation(t+,6). Une certaine sensibilisation de la
sensitization (allergic contact dermatitis) from occasional peau (dermatite de contact) a ete associee a des expositions
or incidental occupational exposures (CDC, unpublished professionnelles occasionnelles ou accessoires (CDC, donnees non
data)(t+), However, no epidemiologic studies on adverse publiees)(t+), Toutefois, la presse scientifique n'a pas documente
effects of glutaraldehyde have been reported in the d'etudes epidemiologiques sur Jes effets secondaires facheux du
literature.
Recent information suggests that although glutaraldehyde. Si, d'apres des donnees recentes, le glutaraldehyde
glutaraldehyde should not be considered mutagenic or ne serait pas mutagene ou carcinogene(7,8), on croit qu'il serait
carcinogenic(7,8),
it
may
produce fetotoxicity in responsable d'une fetotoxicite chez l'animaJ(7,9).
animals\7,9).
Within the past 10 years, the use of chemical
germicides containing glutaraldehyde has increased.
Originally developed as a quick-acting sporicidal agent that
lacked the undesirable health effects associated with
formaldehyde, glutaraldehyde-based germicides are now
used primarily to disinfect and/or sterilize a variety of
medical and dental equipment.
Les 10 dernieres annees ont vu un usage accru de germicides
Chimiques base de glutaraldehyde. Mis au point l'origine comme
sporicides action rapide ne presentant pas les effets secondaires
indesirables associes au formaldehyde, Jes germicides a base de
glutaraldehyde servent maintenant essentiellement desinfecter ou
asteriliser toute une gamme d'instruments medicaux et dentaires.
a
a
a
a
- 77 -
During the National Occupational Exposure Survey
(NOES) of 1981-1983, NIOSH found that glutaraldehyde was
used not only in several areas of the medical industry, but
also in photography, shoe repair, and tanning operations and
the manufacture of dyes (CDC, unpublished data). The
survey estimated that 14 000 workers were then being
exposed to glutaraldehyde in the industries described. These
data probably underestimate exposures because the
ingredients of many trade name products identified during
NOES have yet to be determined.
Au cours de l'enquete nationale sur Jes expositions
professionnelles menee de 1981 1983, le NIOSH a constate que ce
produit etait utilise non seulement dans le secteur medical mais
aussi en photographie, en cordonnerie, dans les operations de
tannerie et dans la fabrication de teintures (CDC donnees non
publiees). D'apres cette enquete, pres de 14 000 travailleurs de ces
secteurs etaient exposes a l'epoque au glutaraldehyde dans ces
industries. Ces chiffres ne representent probablement pas les taux
reels d'exposition parce que !'on n'a pas encore identifie tous les
ingredients entrant dans plusieurs des produits brevetes releves au
cours de l'enquete.
Because of the widespread and increasing use of
glutaraldehyde in many areas, public health professionals
should be aware of its potential for producing adverse health
effects.
En raison de !'usage generalise et croissant qui est fait du
glutaraldehyde dans de nombreux secteurs, ii importe de sensibiliser
les professionnels de la sante publique au risque d'effets secondaires
qui y sont associes.
References:
Reterences:
a
I.
National Institute for Occupational Safety and Health,
CDC.
Health hazard evaluation report no. HET A
83-074-1525. Cincinnati, Ohio: US Department of
Health and Human Services, Public Health Service,
1984.
1.
National Institute for Occupational Safety and Health, CDC.
Health hazard evaluation report no. HETA 83-071/.-1525.
Cincinnati, Ohio:
US Department of Health and Human
Services, Public Health Servic~, 1984.
2.
National Institute for Occupational Safety and Health,
Health hazard evaluation report no. HETA
CDC.
83-048-1347.
Cincinnati, Ohio: US Department of
Health and Human Services, Public Health Service,
1983.
2.
National Institute for Occupational Safety and Health, CDC.
Health hazard evaluation report no. HETA 83-048-1347.
Cincinnati, Ohio:
US Department of Health and Human
Services, Public Health Servic~, 1983.
3.
National Institute for Occupational Safety and Health,
CDC.
Health hazard evaluation report no. HET A
86-226-1769.
Cincinnati, Ohio: US Department of
Health and Human Services, Public Health Service,
1987.
3.
National Institute for Occupational Safety and Health, CDC.
Health hazard evaluation report no. HETA 86-226-1769.
Cincinnati, Ohio:
US Department of Health and Human
Services, Public Health Servic~, 1987.
4.
American Conference of Governmental Industrial
Documentation of the threshold limit
Hygienists.
values and biological exposure indices. 5th ed.
Cincinnati,
Ohio:
American
Conference
of
Governmental Industrial Hygienists, 1986.
4.
American Conference of Governmental Industrial Hygienists.
Documentation of the threshold limit values and biological
exposure indices.
5th ed. Cincinnati, Ohio:
American
Conference of Governmental Industrial Hygienists, 1986.
5.
Stonehill AA
20:458-465.
5.
Stonehill AA et coll. Am J Hosp Pharm 1963; 20:458-465.
6.
Jordan WP JR et al. Arch Dermatol 1972; 105:94-95.
6.
Jordon WP Jr et coll. Arch Dermatol 1972; 105:94-95.
7.
National Institute for Occupational Safety and Health,
CDC. Registry of toxic effects of chemical substances.
Cincinnati, Ohio: US Department of Health and Human
Services, Public Health Service, 1982; DHHS publication no. (NIOSH)81- l 16.
7.
National Institute for Occupational Safety and Health, CDC..:
Registry of toxic effects of chemical substances. Cincinnati,
Ohio: US Department of Health and Human Services, Publi~
Health Service, 1982; DHHS publication no. (NIOSH)81-116.
8.
Van Lente Fetal. Cell 1975; 5:45-50.
8.
Van Lente F et coll. Cell 1975; 5:45-50.
9.
Marks TA et al. Teratology 1980; 22:51-58.
9.
Marks TA et coll. Teratology 1980; 22:51-58.
SOURCE:
et al.
Am
J
Hosp Pharm
1963;
Morbidity and Mortality Weekly Report, Vol 36,
No 12, 1987.
The Canada Diseases Weekly Report presents current information on infectious
and other diseases for surveillance purposes and is available free of charge upon
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National Health and Welfare does not assume responsibility for accuracy or
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Editor: Dr. S.E. Acres (613) 957-1339
Managing Editor: Eleanor Paulson (613) 957-1788
Circulation: Elizabeth Beckett (613) 957-0841
Bureau of Communicable Disease Epidemiology
Laboratory Centre for Disease Control
Tunney's Pasture
OTT AW A, Ontario
Canada KIA OL2
SOURCE:
Morbidity and Mortality Weekly Report, Vol 36, no 12,
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peut etre tenu responsable de !'exactitude, ni de l'authenticite des articles. Toute personne
oeuvrant dans le domaine de la sante est invitee co!laborer (dans la langue officielle de son
choix) et la publication d'un article dans le present Rapport n'en empeche pas la publication
ailleurs.
a
Redacteur en chef: or S.E. Acres (613) 957-1339
Redacteur administratif: Eleanor Paulson (613) 957-1788
Distribution: Elizabeth Beckett (613) 957-0841
Bureau d'epid.!miologie des maladies transmissibles
Laboratoire de Jutte contre la maladie
Pare Tunney
Ottawa (Ontario)
Canada KIA OL2
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