. Rapport hebdo1nac1aire des Canada Diseases

. Rapport  hebdo1nac1aire  des Canada Diseases
./'
\ \
Rapport hebdo1nac1aire des
inalaclies au Canada OCT
Canada Diseases
Weekly Report
ISSN 0382-232X
Date of publication:
Date de publication:
CONTAINED IN THIS ISSUE:
CONTENU DU PREsENT NUMERO:
Measles Epidemic in the Niagara Region of
Ontario, 1986-1987 . . . . . . . . . • .
Listeria monocytogenes Meningoencephalitis British Columbia . . . . . • . . . . . .
179
182
October 3, 1987
3 octobre 1987
.;';)
n
(J
Vol. 13-39
Epidemie de rougeole dans la region du Niagara
(Ontario), 1986-1987 • , . . . . . . , • .
Meningo-encephalite a Listeria monocytogenes
- Colombie-Britannique . , , . . • • • . ,
179
182
MEASLES EPIDEMIC IN THE NIAGARA
REGION OF ONTARIO, 1986-1987
EPIDEMIE DE ROUGEOLE DANS LA REGION
DU NIAGARA (ONTARIO), 1986-1987
On 9 December 1986, the Regional Niagara Health
Services Department was notified of 2 sibling cases of
measles which met the department's case definition, i.e.,
rash lasting >3 days; [ever >33.4°C; and at least one of
cough, coryza, conjunctivitis, and Koplik's spots. These
cases attended a private school where the immunization
rate was only approximately 50% because there was a
large number of· religious/concience exemptions.
Le 9 decembre 1986, on notifie le Service de sante
regional du Niagara que 2 cas repondant sa definition du cas
de rougeole on.t ete identifies chez des enfants d'une meme
famille, savoir: eruption durant >3 jours; fievre >38,4°C; et
au moins une des manifestations suivantes: toux, coryza,
conjonctivite et taches de Koplik.
Les enfants vises
frequenteht une ecole privee ou, en raison de nombreuses
exemptions pour motifs religieux ou moraux, le taux
d'immunisation n'est que d'environ 50%.
Once these 2 cases were confirmed serologically on
12 December, a community investigation and control
program was . instituted.
The following case-finding
techniques were used: all family physicians, pediatricians
and hospitals in the area were notified of the situation
and asked to report all suspected cases to the health
department; a similar request was made of the public who
was alerted to the case definition through the media; and
school health nurses checked school absentees for
symptoms fitting the case definition. Contacts of all
cases <including the entire population of the school
involved) were traced to determine their immunization
status and all susceptibles were immunized within 4 days
or excluded from school and social activities. By means
of the media, the public was asked to check immunization
status and seek vaccination if susceptible.
Two
emergency immunization clinics were held.
Des la confirmation serologique des 2 cas le 12
decembre, une enquete et des mesures de lutte sont amorcees
au sein de la collectivite.
Les techniques suivantes de
depistage des cas sont appliquees: tous Jes medecins de
famille, les pediatres et Jes hopitaux de la region sont
informes de la situation et pries de signaler au Service de
sante chaque cas suspect; cette requete est etendue au
public, qui est mis au courant de la definition de cas par les
medias; enfin, le personnel infirmier des ecoles verifie si Jes
absents presentent des symptomes compatibles avec la
definition de cas. Les contacts de tous Jes cas (notamment la
population entiere de l'ecole visee) font l'objet d'une relance
visant a determiner leur etat vaccinal, et tous Jes sujets
receptifs sont soit vaccines dans Jes 4 jours qui suivent, soit
exclus de l'ecole et des activites sociales. Par le biais des
medias, on demande a la population de verifier son statut
d'immunisation et de se faire vacciner en cas de receptivite.
Deux cliniques d'urgence sont organisees cette fin.
a
a
a
Figure I. Measles Cases by Date of Onset*, Niagara Region, 1986-1987/
Figure I. Cas de rougeole par date d'installation*, region du Niagara, 1986-1987
2'
22
1111111!11
20
Jlllill
18
(/')
foTAL CASES
l.1.JV'J
(/Jc:(
<CU
'--'
UJ
u..o
0
COHORT CASES
: 46
CAS CHEZ LA COHORTE
UJ
c::c::
W!Xl
l'Q::E:
::E:O
Tor AL
I&
: 13 2
DES CAS
L~
*Oates shown are first of a 2-day time Interval.
1 Les dates pr&:isees correspondent au premier jour d 'une p~riode de 2 jours.
12
10
=z
z
JO
21
1
u
2s
21
n
H
DECEMBER
D~CEHBRE
1987
19 8 6
(Second Class Kall Registration tto. 5670)
I
Health and Welfare
Canada
Sante et Bien-etre social
Canada
Courrler de la
- 179 -
dewi:l~a.e
cla$!!.I! - Enre istrement n° 5670
Canada
Investigation revealed that the first 2 reported cases
were actually secondary cases. The index case was a female
student in the same school who met the case definition on
24 November. Although there were sporadic cases in the
community at the time, the specific source of her infection
was not identified.
Il ressort de l'enquete que Jes premiers cas signales sont en fait
des cas secondaires. Le cas de reference est en effet une eleve de
la meme ecole qui a repondu a la definition de cas le 24 novembre.
cette
Malgre la presence de cas sporadiques dans la collectivite
date, la source precise de son infection n'est pas identifiee.
Between the time of onset of the epidemic in the
private school and l February 1987, there were 132 cases of
measles identified in students in 43 different schools in
addition to some in non-school-aged individuals.
The
epidemic curve is shown in Figure l. Table I gives the age
and sex distribution of cases as well as the attack rate by
age. The age distribution of the cases was similar to that
reported for Ontario in 1986(1) with approximately 40% of
the cases in the 5-9-year-old age group.
If differs
considerablv from the Canadian distribution reported for
1986(1) where the highest number of cases occurred in the
L0-14-year-old age group and the American experience(2)
which showed the highest number of cases in the 0-4-yearold age group.
Entre le moment OU l'epidemie se declare a l'ecole privee et le
l er fevrier 1987, on recense 132 cas de rougeole chez des eleves de
43 ecoles distinctes, et quelqu~s ·cas chez des sujets n'appartenant
pas au groupe d'age scolaire. La Figure l presente la courbe de
l'epidemie; et le Tableau 1, la ventilation des cas par age et par
sexe, ainsi que le taux d'atteinte par age. La ventilation par age se
rapproche du tableau observe en Ontario en 1986(0, le groupe des 5
9 ans comptant pour environ 40% des cas; mais s'ecarte considerablement de la situation observee cette meme annee, d'une part pour
!'ensemble du Canada OU Jes 10 14 ans representaient le groupe le
plus touche0) et, d'autre part, pour Jes Etats-Unis Ol! ce rang etait
occupe par Jes 0 4 ans(2),
a
a
a
a
Table I. Distribution of Measles Cases by Age Group and Sex/
Tableau I. Ventilation des cas de rougeole, par groupe d'age et sexe
Age Group
(in years)/
Groupe cl'age
(en annees)
Sex/
Sexe
Number of
Cases/
Nombre de
cas
Percent of
Total Cases/
Pourcentage de la
totalite des cas
Attack Rate
per IO 000/
Taux d'atteinte
pour IO 000
<
I
1-4
5-9
10-14
15-19
20-24
25-29
> 29
TOTAL
4
21
53
32
15
2
3
2
132
3.0
15.9
40.2
24.2
I 1.4
1.5
2.3
1.5
100.0
14.]
I J.8
22.3
12.I
5.1
0.6
l. l
0.1
Female/Fem in in
Male/Masculin
TOTAL
69
63
132
52.3
47.7
100.0
Table 2 indicates the preventability status of cases.
Twelve preventable cases were preschool children, 11 of
whom were siblings of school children whose parents had
signed religious/concience exemptions. The 5 remaining
preventable cases were beyond school age. No preventable
cases occurred in children in public schools, evidence of the
effectiveness of Ontario legislation requiring all school
children to be immunized against this disease.
Le Tableau 2 classe les cas seJon qu'ils etaient evitables OU non.
Douze des cas qui auraient pu etre evites concernaient des enfants
d'age prescolaire dont 11 etaient des freres et soeurs d'ecoliers pour
qui Jes parents avaient signe des demandes d'exemption pour motifs
religieux OU moraux. Les 5 autres cas evitables etaient d'age
postscolaire. Aucun cas evitable n'a ete recense parmi Jes eleves
des ecoles publiques, ce qui prouve l'efficacite de la legislation
ontarienne exigeant !'immunisation contre la rougeole de taus les
ecoliers.
Table 2. Distribution of Measles Cases by Preventability Status/
Tableau 2. Ventilation des cas de rougeole selon qu'ils etaient evitables OU non
Number of
Cases/
Nombre de
cas
Percent of
Total Cases/
Pourcentage de Ia
totalite des cas
NON-PREVENT ABLE/NON EVITABLES
Age < l year/ Ages de <I an
3.0
2
J.5
Immunized/Immunises
77
58.3
Exemption (Religion/Conscience)/
Exemption (motifs religieux/moraux)
32
Born before 1957/Nes avant 1957
Exemption (Medicall/Exemption (raisons medicates)
PREVENT /\BLE/EVIT ABLES
0
12.9
132
TOTAL
This outbreak lasted only 2 months.
Review of
outbreaks that occurred in the Niagara region in 197 5 and
1978 indicated that there were 390 and 664 cases and that
the epidemics lasted 6 and 8 months, respectively. In
contrast, the next outbreak, which occurred in 1985, involved
only 84 cases and lasted only 4 months. Ontario legislation
0
17
Cette poussee n'a dure que 2 mois. L'etude des poussees
connues par la region du Niagara en 1975 et en 1978 a revele que les
bilans respectifs avaient ete de 390 et de 664 cas, et que les
epidemies avaient dure 6 et 8 mois. La poussee enregistree par la
suite, soit celle de 1985, n'a toutefois fait que 84 cas et n'a dure que
4 mois.
L'introduction en 1982 de la legislation ontarienne
- 180 -
•
i
a
requiring all school children to be immunized, introduced in
1982, may have contributed to. the decrease in size, length
and frequency of outbreaks by reducing the population of
susceptibles in schools.
The outbreak reported here,
althou?,h it unfortunately occurred soon after the previous
epidemic and had an increased number of cases because it
involved a school with a low immunization rate, did reflect
the continuing trend to a shortening in the length of the
outbreak period. This can be attributed to improved quality
in school immunization data which allowed more rapid and
accurate identification of susceptibles.
reclamant !'immunisation de tous !es ecoliers peut avoir contribue
reduire !'importance, la dun;;e et la frequence des poussees en
di1ninuant la population receptive dans Jes ecoles. Meme si elle a
malheureusement suivi de pres l'epidemie anterieure et qu'elle s'est
soldee par un bilan accru de cas parce qu'elle portait sur une ecole
OU le taux d'immunisation etait faible, la poussee dont i1 est question
ici est conforme
la tendance qui se poursuit,
savoir:
la
diminution de la duree des poussees. Cet etat de choses peut
s'expliquer par la meilleure qualite des donnees des ecoles en
matiere d'immunisation, ce qui permet d'identifier de fa<;:on plus
rapide et plus precise les sujets receptifs.
A cohort of 136 equally exposed children, consisting of
all children in the private school and siblings in homes
associated with this school in which a case had occurred,
was studied.
Although an immunization program was
offered, no child was vaccinated because of religious
reasons after onset of the outbreak. The epidemic curve of
the 48 cases which occurred in this cohort is shown in
Figure L The distribution of case status for the cohort by
age, sex, and measles susceptibility is indicated in Table 3.
If those with a history of measles are excluded as not
susceptible, the vaccine efficacy can be calculated on the
remainder of the cohort as follows where VE = vaccine
efficacy and AR =attack rate:
On a etudie une cohorte de 136 enfants ayant fait l'objet d'une
exposition de meme degre, qui se composait de tous Jes eleves de
l'ecole privee, ainsi que des freres et soeurs de cas recenses
l'ecole. En raison de croyances religieuses, aucun enfant n'a ete
vaccine apres le debut de la poussee, malgre la mise sur pied d'un
programme d'immunisation.
La Figure I presente la courbe
epidemique des 48 cas recenses chez cette cohorte. Le Tableau 3
divise la cohorte en sujets malades et sujets sains, selon l'age, le
sexe et la receptivite
l'egard de la rougeole. Si les sujets ayant
des antecedents de rougeole sont exclus en tant que non-receptifs,
l'efficacite du vaccin (EV) pour !es autres membres de la cohorte
peut etre mesuree comme suit, TA representant le taux d'atteinte:
_ _ _A_R~(u_n_i_m_m-=-=u...,.ni_·z...,e'""'"d~)_-_A_R.,-'-(i_m""m_u_n_iz_e_d~)___ x 100
AR(unimmunized)
= 87%
VE=
a
a
a
a
EV
=
T A(non-immunises) - TA(immunises)
T A(non-immunises)
x 100
= 87%
Pour des limites de confiance de 95%, ce resultat se situe entre
73 et 93%.
Ninety-five percent confidence limits are 73% - 93%.
Table 3. School Cohort by Age Group, Sex and Immunization Status/
Tableau 3. Cohorte scolaire divisee par groupe d'lige, sexe et etat vaccinal
CASES/
SUJETS MALADES
Number/
(%)
Nombre
<
Age Group
(in years)/
Groupe d'lige
(en annees)
Sex/
Sexe
I
1-4
5-9
10-14
15-19
TOTAL
Female/
Feminin
Male/
Masculin
TOTAL
NON-CASES/
SUJETS SAINS
Number/
(%)
Nombre
2
(2.3)
5
(5.7)
38
35
8
88
(43.2)
(39,8)
(9. I)
(60.4)
34
(38.6)
(39.6)
54
(61. 4)
0
II
27
9
I
48
(0.0)
(22.9)
(56.3)
(18.8)
(2.1)
29
19
88
48
IMMUNIZATION STATUS/
ETAT VACCINAL
History of Measles
Antecedents de rougeole
I
(2.1)
20
(22.7)
Immunized/
Immunises
7
(14 .6)
58
(65.9)
Not Immunized/
Non-immunises
40
(89.3)
10
( 11.4)
TOTAL
48
The 7 immunized cases were examined in more detail.
In 5 of these cases, physician records confirmed that these
children received their M\llR vaccination between 1976 and
1982 - 3 at 12 months, I at 15 months, and lat 29 months of
age. In one of the remaining cases, records were not
available, but the physician involved normally immunizes
after a child's first birthday. In the other case, no record of
immunization could be found. In both cases, however, the
mother was quite certain that her child had been immunized
after the first birthday. If these 2 children are moved to
the unimmunized group, the vaccine efficacy increases to
90% with 95% confidence limits of 77% - 96%.
88
a
Les 7 cas immunises ont ete etudies plus fond. Pour 5 d'entre
eux, les dossiers medicaux ont confirme que les enfants avaient re<;:u
le vaccin ROR entre 1976 et 1982, soit 3 12 mois, 1 15 mois et 1
29 mois. Dans Jes 2 autres cas, ii a ete impossible d'obtenir Jes
dossiers, mais le medecin vise dans l'un d'eux vaccine generalement
les enfants apres leur premier anniversaire. De plus, dans ces 2 cas,
la mere etait absolument certaine que son enfant avait ete vaccine
apres son premier anniversaire. Si ces 2 enfants sont places dans le
groupe des non-immunises, l'efficacite du vaccin passe
90% et,
avec des limites de confiance de 95%, entre 77 et 96%.
a
a
a
a
- 181 -
References:
References:
!.
2.
2.
1.
Varughese PY, Acres SE. CDWR 1987; 13:23-28.
Centers for Disease Control. MMWR 1987; 36:301-305.
SOURCE:
Anne 0 Carter, MD, (formerly) Acting Medical
Officer of Health, Terry Delmore, Epidemiologist,
Craig
Reed, Information Services
Manager, Elizabeth Cook, Infectious Diseases
Nurse,
Regional Niagara Health Services
Department, St. Catharines, Ontario.
Varughese PY, Acres SE. RHMC 1987; 13:23-28.
Centers for Disease Control. MMWR 1987; 36:301-305.
SOURCE:
Dr Anne 0 Carter, (ancienneme1)t) Medecin-hygiiSniste
pal' interim, Tel'ry Delmore, EpiMmioloqiste, Craig
Reed, Directeur des Services d'inf ormation, Elizabeth
Cook, Infil"miere en inf ectiologie, Service de sante
rf"gional du Niagara, St. Catharines (Ontario).
Expose de cas
A Case Report
LISTERIA MONOCYTOGENES
MENINGOENCEPHALITIS - BRITISH COLUMBIA
MENINGO-ENCEPHALITE A
MONOCYTOGENES - COLOMBIE-BRIT ANNIQUE
On 12 May 1987, a 59-year-old male from Port Alberni
developed malaise, headache, nausea, and vomiting. His
condition worsened during the next 2 days, with delerium
and a decreased level of consciousness, and he was seen by
his physician and transferred to Victoria. On examination
he \vas febrile with meningismus; the white cell count was
18. l x l o9 /L with 11 % staff cells and toxic vacuolation of
neutrophils noted. The CSF was pale yellow and cloudy with
83 RBCs x 106/L and 1171 WBCs x 1Q6/L, with a differential
count of neutrophils 64%, lymphocytes 26% and monocytes
lQqr,, Glucose was 3.'3 mmol/L and protein 1.1 g/L. Some
pulmonary vascular congestion was noted on the chest X-ray
and a CT scan was normal with no evidence of subarachnoid
hemorrhage. By 16 May, both blood and CSF cultures grew
Listeria monocytogenes.
Immunoglobulin profile was
normal.
Le 12 mai 1987, un habitant de Port Alberni age de 59 ans
manifeste un malaise, des cephalees, des nausees et des vomissements. Au cours des 2 jours suivants, son etat empire et on observe
du delire et une conscience diminuee. Examine par son medecin, le
malade est transporte Victoria. L'examen revele un sujet febrile
avec meningisme. La numeration leucocytaire est de 18,l x J09/L,
avec 11 % de polynucleaires non segmentes et vacuolisation toxique
des polynucleaires neutrophiles. Le LCR est jaune pale et trouble,
avec 83 erythrocytes et 1171 leucocytes x 106/L, la numeration
differentielle etant:
neutrophiles, 6496; lymphocytes, 26%; et
monocytes, 1096. La glycorachie est de 3,3 mmol/L et la proteinorachie, de 1,1 g/L. La radiographie thoracique montre un certain
degre de congestion vasculaire pulmonaire; et un tomodensitogramme se revele normal, sans signe d'hemorragie meningee. Au 16
mai, l'hemoculture et la culture de LCR permettent toutes 2 d'iso]er
Listeria monocytogenes.
Le profil des immunoglobulines est
normal.
This patient had been relatively healthy up to this
illness.
He had asthma and was being treated with
Beclovent ® and Vento Jin ® inhalers and Choledy 1® . He
was not on systemic steroids.
He was a "borderline"
diabetic with blood glucose controlled by diet. He was
employed as a road foreman and did not have contact with
livestock at home or work, except for the removal of a dead
deer killed by a vehicle 2 months before admission. He
drinks 12 bottles of beer and less than 5 ounces of spirits per
week.
Water supply was chlorinated municipal water.
Dietary history revealed an allergy to dairy products so he
avoids milk products except for small amounts of cheddar
cheese.
His meat consumption is varied and generally:
cooked well.
He eats no fruits but a wide variety of:
vegetables.
Avant cette atteinte, le sujet vise se portait relativement bien.
Asthmatique, il est traite avec des inhalateurs de Beclovent® et de
Ventolin ®, ainsi qu'avec du Choledyl®. II ne prend aucun sterciide
action generale. Cas "limite" de diabete, ii suit un regime pour
controler sa glycemie. Chef d'equipe pour !es services de la voirie,
il n'a eu aucun contact avec du betail la maison, ni au travail, si ce
n'est - 2 mois avant son hospitalisation - l'enlevement d'un cerf tue
par un vehicule. I! boit 12 bieres et moins de 5 onces de spiritueux
par semaine, et consomme de l'eau chloree provenant de l'aqueduc
municipal. Ses antecedents alimentaires revelent une allergie aux
produits laitiers; ii evite done d'en consommer, exception faite de
petites quantites de fromage cheddar. Son alimentation comprend
des viandes diverses, generalement bien cuites, ainsi qu'une grande
variete de legumes, mais aucun fruit.
a
a
a
On prescrit de la penicilline (6 millions d'unites i. v. q. 6h) et le
He was treated with penicillin (6 million units IV q6h) •
and gradually improved. He was discharged on 5 June, 21 ' malade se retablit progressivement. A con conge le 5 juin, soit
days after admission, with bilateral leg weakness which was i apres 21 jours d'hospitalisation, il presente une faiblesse aux jambes
en voie d'amelioration.
improving.
i
SOURCE:
B Emerson, MD, (formerly) Assistant Medical I SOURCE:
Health Officer, Central Vancouver Island i
Health Unit, British Colurnbia.
;
i
Dr B Emerson, (anciennement) Medecin-hygieniste
adjoint, Service central de sant8 de Z'l'Ie de Vancouver
(Colombie-Britannique).
I
-·· -······ ... ·-........ - ·--····················· ···1· .. -·· ... .... .. ......... ........ .... .... . ...... .. ......... .. ... -···--The Canada Diseases Weekly Report presents current inforiTintion on infectious
and other diseases for surveillance purposes end is available free of charge upon
request. Meny of the articles contain preliminary information and further
confirmation may be obtained from the sources quoted. The Department of
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Editor. Dr. S.E. Acres (613) 957-1339
Manaqing Editor: Eleanor Paulson (613) 957-1700
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Distribution: Dolly Riggins (61 J) 957-0841
Bureau of Communicable Disease Epidemiology
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Tunney's Pasture
OTTAWA, Ontarip
Canada l<IA OLZ
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Lahoratoire de lulte contre la maladie
Pare Tunney
Ottawa (Ontario)
Canada l<IA OLZ
- 182 -
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