Canada Diseases Rapport hebdomadaire des maladies au Canada

Canada Diseases Rapport  hebdomadaire  des maladies  au  Canada
\
.
Canada Diseases
Weekly Report
Rapport hebdomadaire des
maladies au Canada
OalaolNilioalro: Augustl2, 1989
Dale da llJl:licalion: 12.0011989
ISSN 0382-232X
Vol.15-32
Contained in this issue:
Contenu du present numero:
Hepatitis AOutbreak In British Columbia, 1988-1989 . . • . . . . . . . • 163
FlambBe d'h0patile Aen Colombie-Britannique, 1988-1989 . . • . • • . . . • • . •. 163
Announcement • . . . . . . . . . . . • • • • . • • • • . . . • . . . . . . 166
Annonce . . . . . • . . . • . . . . . . . . . . . . • . . . . . • • C: ·\ ;'.(,•: fi ·, ,~ ;'./f6
(>~/
.AUG
1 19ffr
FLAMBEE D'HEPATITE A EN COLOMBIE-BRITANNIQUE,
1988-1989
HEPATITIS A OUTBREAK IN BRITISH COLUMBIA,
1988-1989
Introduction
Introduction
In the face of a decline in the incidence of hepatitis A in the
general public in most developed countries< 1>, drug abuse has
been recognized as a risk factor in recent outbreaks in the United
States<2> and the Scandinavian countries<3.4>, However, similar
observations have not been reported in the Canadian literature.
In the summer of 1988, an increasing number of hepatitis A
cases were first noticed at the Vancouver Downtown Community
Health Clinic (DCHC), which serves mainly the inner-city
population, and the Central Vancouver Island Health Unit.
Fifty-three of the 61 cases (87%) reported by the DCHC admitted
to drug use. This prompted the British Columbia Centre for
Disease Control (BCCDC) to review recently all reported cases
of hepatitis A in the province to detennine
(1) if there was an outbreak of hepatitis A in the province in
1988-early 1989, and
(2) the demographic characteristics of the reported cases.
Si, d 'un cote , l 'incidence de l'hepatite A chez le grand public est ala
baisse dans la plupart des pays industrialises< 1>, I 'usage de drogue a, d'un
autre oote, ete reconnu cornme un facteur de risque dans des flarnbees
recentes enregistrees aux Etats-Unis(Z) et dans les pays scandinaves<3.4>.
Rien de tel n' a toutefois ete signale dans la litterature canadienne.
Au cours de l'ete 1988, llllnombre croissant de cas d'hepatite A a
d 'abord ete observe ala Clinique cornmunautaire centre-ville de
Vancouver (DCHC), qui dessert surtout les quartiers centraux de la ville, et
au Service de sante du centre de l 'lle de Vancouver. Des 61 cas signales
par la DCHC, 53 (87%) ont admis prendre de la drogue. Le Centre
d'epidemiologie de la Colombie-Britanniq~e (BCCDC) a aussitot etudie
tous Jes cas d'Mpatite A recenses depuis peu dans la province, afin de
detenniner:
(1) si une flarnbee d'hepatite A sevissait en C.-B. en 1988 et au debut de
1989,
(2) et quelles etaient les caracteristiques demographiques des cas
signales.
En C.-B., l'hepatite A est lllle maladie adeclaration obligatoire. La
Division des statistiques demographiques du ministere de la Sante resume
Jes rapports de cas communiques par des laboratoires, des medecins et des
services de sante de la province. Les donnees sont ensuite classees en
tableau toutes Jes 4 semaines (periode definie cornme etant une periode de
declaration) et publiees dans le mensuel provincial Disease Surveillance.
Hepatitis A is a notifiable disease in B.C. The Vital Statistics
Division of the Ministry of Health summarizes reports of cases
from laboratories, physicians and health units in the province.
This information is then tabulated every 4 weeks, defined as a
reporting period, and published in the monthly provincial
publication, Disease Surveillance.
Rasul tats
Results
The total number of hepatitis A
cases reported in 1988 in the
province was 545, 3.4 times higher
than that reported in each of the
previous 2 years. A distinct
4-yearly cycle of reported cases is
noted since 1980, with peaks in
1980, 1984 and 1988(fable1).
The number of requests
received by the Provincial
Laboratory for serologic diagnosis
of hepatitis in 1988 increased by
7.2% over 1987 (Table 2). While
the rate oflaboratory-confirmed
hepatitis B decreased in i988, the
rate for hepatitis A increased by
about 5-fold.
I
l+I
~~
Second Class MalRegis~alion No, 5670
Health and Welfare
Canada
Table 1ffableau 1
Reported Hepatitis A Cases by Year In British Columbia/
Hepatite A: cas slgnales par annee, Colomble-Brltannlque
Year/
Numher of Cases/
Annee
N°re de cas
343
280
306
192
278
239
157
159
545
1980
1981
1982
1983
1984
1985
1986
1987
1988
I Coorrior de la dooxiemo classa- Enregis~ement n' 5670
I
Santa et Bien-etre social
Canada
Au total, 545 cas d'hepatite A ont
ere recenses dans la province en 1988,
soit 3,4 fois plus qu' au cours de
chacune des 2 annees precedentes.
Depuis 1980, le cycle est clairement
quadriennal, le nombre des cas
declares ayant emegistre des pies en
1980, en 1984 et en 1988(Tableau1).
Comparativement a1987, les
demandes de serodiagnostic d 'hepatite
reyues par le Laboratoire provincial
ont grimpe de 7,2% en 1988 (fableau
2). Si le taux des cas d'Mpatite B
confrrmes en laboratoire a diminue en
1988, celui de l 'hepatite A a apeu pres
quintuple.
163
Canada
Table 2/Tableau 2
Positive Rate of Hepatitis Diagnosed et the British Columbia Provincial Laboratory/
Diagnostic d'hepetlte: taux de posltlvlte au Laboratolre provincial de la Colomble·Brltannlque.
Period/
Perlode
No. of Requests/
Nbre de demandes
Hepatitis A/Hepallte A
No. Positive/
Rate/
Nbre de positifs
Taux
Hepatitis B/Hepatlte B
No. Positive/
Rate/
Nbre de positifs
Taux
Oct/oct 84 - Sep/sept 85
10881
188
1.73%
484
4.45%
Apr/avr 86 - Mar/mars 87
10768
69
0.64%
500
4.64%
Apr/avr 87 - Mar/mars 88
11195
80
0.71%
523
4.67%
Apr/avr 88 - Mar/mars 89
12000
501
4.18%
467
3.89%
Table 3 shows that the outbreak began in the 7th reporting period
Le Tableau 3 montre que la flambee s'est declaree au cours de la 7°
(June) of 1988, and ended by the 4th reporting period (April) of 1989. A
penode de declaration (juin) de 1988 pour se terminer avant la 4° periode
comparison between the non-epidemic period (defined as from the 1st
de declaration (avril) de 1989. La comparaison de la periode non
reporting period of 1986 22
epidernique (definie comme allant
December 1985 to the 6th
de la lre periode de declaration de
Table 3/Tableau 3
reporting period of 1988 3
1986- soit du 22 decembre 1985
Hepatitis A Reported In British Columbia by 4-Weekly Reporting Periods/
June 1988) and the epidemic
la 6° periode de 1988 soit au J'
Hepalile A: cas recenses en Colomble-Brllannique, par perlodes de
period (arbitrarily defined as
juin 1988) et de la periode
declaration de 4 semalnes
from the 7th reporting period
epidemique (arbitrairement
Mean•
Period/
of 1988 4 June 1988 to the
definie comme allant de la 7e
Moyenne•
Periods
1988
R**
1989
4th reporting period of 1989 8
periode de declaration de 1988
1
7
17
2.4
75
10.7
soit du 4 juin 1988 la 4e periode
April 1989), revealed
5.5
13
2
53
2.4
9.6
increases among all age
de 1989-soit au 8avril1989) a
13
3
16
1.2
69
5.3
18
1.8
10
4
47
4.7
groups, but especially among
revele des augmentations chez
32
23
5
34
1.4
1.5
those between 15-39 years of
tousles groupes d'iige, mais
10.5
27
6
2.6
age (Table 4). Jn the
surtout chez les 15 39 ans
7
11.5
37
3.2
pre-epidemic period, the
12.5
(Tableau 4). Le rapport
8
3.5
44
9
11
31
2.8
hommes-femmes, qui etait de
male-to-female ratio was
16.5
10
78
4.7
1,45: 1 en periode pre-epidemique,
1.45:1. This ratio increased to
82
16
11
5.1
1.93:1 during the epidemic
a atteint 1,93: 1 pendant la periode
12.5
12
80
6.4
9
epidernique.
period.
70
7.8
13
a
a
a
Eighteen of the 21 health
units/departments in the
province reported a higher
incidence of hepatitis A
during the epidemic period.
The greatest increase (at least 5
times higher than in the
non-epidemic period) occurred
in Vancouver, Capital Region
District, Richmond, Simon
Fraser and Upper Fraser health
jurisdictions. These health
units/departments cover urban,
suburban and rural areas~
Comment
Average number for 1986 and 1987 / Nombre moyen pour 1986et1987
•• 1988 relative to average for 1986 and 1987 I Rapport de 1988 a la moyenne de 1986 et 1987
Table 4/Tableau 4
Comparison of Hepatitis A Cases by Age Group Before and During
Outbreak/
Hepatlte A: comparalson des cas recenses avant et pendant la
flambee, par groupes d'age
Age/Age
Bofore•/Avant•
Durlng ../Pondant ..
%
%
<1
1-4
5-9
10-14
15-19
20-24
25-29
30-39
40-59
60+
Not Specified/
2
10
19
22
28
51
73
92
68
2
0.5%
2.3%
15
4.4%
22
5.2%
6.6%
11.9%
17.1%
21.5%
15.9%
5.6%
19
61
97
129
184
82
0.3%
2.2%
3.2%
2.75%
8.8%
14.0%
18.6%
Des 21 services da sante de la
province, 18 ont signale une
incidence accrue d'hepatite A
pendant la periode epidemique.
La hausse la plus marquee (au
moins 5 fois plus qu 'en periode
non epidemique) a ete emegistree
dans les secteurs sanitaires de
Vancouver, du district de la
region de la capitale, de
Richmond, de Simon Fraser, et de
Upper Fraser. Ces services
couvrent des regions urbaines,
suburbaines et rurales.
Commentalres
26.6%
We have confirmed that the
Nous avons confirme que
11.8%
incidence of hepatitis A in
I'incidence de l 'hepatite A en
2.7%
24
19
1988-early 1989 in British
C.-B. etaitplus elevee en 1988 et
Non precise
38
62
9.0%
8.9%
Columbia was higher than in
au debut de 1989 qu'au cours des
Total
427
100.0%
692
100.0%
the previous 2 years. This was
2 annees precedentes, ce qui
consistent with a cyclical
correspondait au tableau cyclique
• Before= from 22 December 1985 to 3 June 1988 / Avant=de 22 decembre 1985
pattern observed since 1980.
observe depuis 1980. n est peu
au 3 juln 1988
The increase is unlikely due to
probable que cette hausse soit
•• Durlng=epidemic period, arbitrarily defined as 4June1988 to 8 April 1989 /
Pendant=perlode epldemlque, definie arbltrairement comma allant du 4 juin 1988
correcting for under-reporting
attribuable la correction de la
au 8 avril 1989
and under-diagnosis of
sous-declaration et du
sous-diagnostic des annee_s
previous years, since the
number of requests for serologic diagnosis of hepatitis increased only by
anterieures, puisque les demandes de serodiagnostic d'hepatite n'ont
augmente que de 7,2% tandis que le taux de positivite pour l'hepatite A a
7 .2%, while the positive rate for hepatitis A increased by 489%. In
grimpe de 489%. En outre, le protocole et les methodes de diagnostic en
addition, the laboratory diagnostic protocol and procedures have not
laboratoiren'ontpas change depuis 3 ans.
changed in the past 3 years.
a
164
The outbreak was widespread, with no geographic clustering. Males in
the 15-39 age group had the highest percentage increase. This observation
is compatible with the suggestion that drug abuse may have been a factor in
this outbreak.
La flambee etait etendue, sans concentration geographique. Le plus grand
pourcentage d'augmentation a ere enregistre chez les hommes de 15 39 ans,
ce qui est compatible avec l'hypothese selon laquelle l'usage de drogue ait pu
etre un facteur de risque.
The number of hepatitis A cases associated with drug use at the DCHC,
reports of a drug abuser being the index case in another cluster, and the
results of this study led to the postulation that drug abuse was a prominent
factor in this provincial epidemic. An attempt was made to carry out a
case-control study to test this hypothesis. However, this effort was
frustrated by the transient nature of this group. Only 2 of the first 32 cases
diagnosed in the DCHC in 1988 could be traced for interviewing. Thus, the
role of drug abuse in this outbreak could not be established.
Le nombre de cas d'Mpatite A associes l'usage de drogue recenses la
DCHC, des rapports designant un toxicomane comme cas de reference dans
une autre grappe de cas, ainsi que les resultats de la presente etude, sont autant
de faits qui ont suggere le rOle important de la drogue dans cette epidemie
provinciale. Pour verifier cette hypothese, on a tenre d'effectuer une etude
prospective, mais l 'effort a echoue en raison de l 'itinerance du groupe vise.
Seulement 2 des 32 premiers cas diagnostiques la DCHC ont pu etre retraces
pour interview. II a done ere impossible d'etablir le role de la drogue dans la
flambee.
Hepatitis A is usually transmitted by the fecal-oral route. Percutaneous
transmission is rare because of a limited viremic phase of hepatitis A
virus(S), It is commonly accepted that poor hygiene contributes to hepatitis
A transmission among drug addicts<4>. Direct contamination of the drug by
the virus has been implicated in one outbreak (CDC, unpublished data). In
a Swedish outbreak<6 , it was postulated that a drug in the rectum likely
resulted in contamination of fingers. The virus was then introduced into the
mouth when the addicts sampled the drug's quality using their fingers, a
common practice among them.
L'Mpatite Ase transmet generalement par voie oro-fecale. La transmission
percutanee est rare, parce que le virus responsable a une phase de viremie
limitee(S). est communement accepte qu 'une hygiene mediocre contribue
la transmission de l'Mpatite A parmi les toxicomanes<4>, La contamination
directe de la drogue par le virus a ere incrirninee dans une flambee (CDC,
donnees non publiees). Dans une flambee recensee en Suede<6>, on a postulC
que la presence de drogue dans le rectum etait probablement responsable de la
contamination des doigts, et que le virus a ete introduit dans la bouche de
toxicomanes lorsque ces derniers ont goute la drogue avec leurs doigts pratique courante dans ce milieu.
An outbreak among drug abusers is often cyclical(?). It occurs when the
infection is introduced to the group at a time of low immunity. A short
contagious period, a lack of chronic carrier state, and herd immunity limit
an epidemic. Rebuilding of a susceptible population prepares the way for
the next epidemic.
Although a causal relationship could not be established between drug
abuse and hepatitis A in the winter of 1988, various health units introduced
campaigns targeted at this risk group following the initial report of such a
possible link. These programs probably helped to interrupt the epidemic.
This report also emphasized the shifting risk factor of hepatitis A.
Chez les toxicomanes, les flambees sont souvent cycliques<7>. Elles se
declarent lorsque I' infection s'introduit dans le groupe un moment OU
l'irnmunite y est faible. Une courte periode de contagion. I' absence de portage
chronique et l'irnmunite collective limitent une epidemie. La reconstitution
d 'une population sensible ouvre la voie la prochaine epidemie.
Meme si aucun lien causal n'a pu etre etabli entre l'usage de drogue et
l'Mpatite A au cours de l'hiver 1988, divers services de sanre ant-suite au
rapport initial formulant cette possibilite - lance des campagnes !'intention
des toxicomanes. Ces programmes ont probablement aide a juguler l'epidemie.
Le rapport a aussi souligne le facteur de risque changeant de l'Mpatite A.
Source: Timothy Ng, MD, BC Federal Field Epidemiologist, LCDC, John
D Farley, MD, Consultant Epidemiologist, BCCDC, Richard G
Mathias, Mn. Associate Professor, Department ofHealth Care
and Epidemiology, University ofBritish Columbia, Darryl Cook,
Virology Supervisor, BC Provincial Laboratory, John Bardsley,
MD, North Unit Medical Director, Vancouver Health
Department, Andrew Jin, MD, Community Medicine Resident,
Department of Health Care and Epidemiology, University of
British Columbia, Vancouver.
Source: Dr Timothy Ng, epidemiologistefederal regional de la C.-B, I.LCM,
Dr JohnD Farley, epidemiologiste-conseil, BCCDC, Dr Richard G
Mathias, professeur agrege, Departement des soins de sante et de
l' epidemiologie, Universite de la Colombie-Britannique, Darryl
Cook, superviseur de service de virologie, Laboratoire provincial de
la C.-B ., Dr John Bardsley, directeur medical de l' unite nord,
Service de sante de Vancouver, Dr Andrew Jin, resident en
medecine communautaire, Departement des soins de sante et de
l' epidemiologie, Universite de la Colombie-Britannique, Vancouver.
References
References
1.
Frosner GG, Papevangelou G, Butler R et al.Antibody against
1.
2.
hepatitis A in seven European countries. I. Comparison ofprevalence
data in different age groups. Am J Epidemiol 1979; 110:63-9.
Centers for Disease Control. Hepatitis A among drug abusers.
2.
a
a
a
a
n
a
a
a
a
Frosner GG, Papevangelou G, Butler R et coll. Antibody against hepatitis
A in seven European countries. I. Comparison ofprevalence data in
different age groups. Am J epidemiol 1979:110:63-9.
Centers for Disease Control. Hepatitis A among drug abusers. MMWR
1988; 37:297-301.
MMWR 1988; 37:297-301.
--
3 .. Widell A, Hansson BG, Moestrup T et al. Acute hepatitis A, Band
non-A in a Swedish community studied over a ten-year period. Scand
Jlnfect Dis 1982; 14:253-9.
3.
Widell A, Hansson BG, Moestrup T et coll. Acute hepatitis A, Band
non-A in a Swedish community studied over a ten-year period. Scand J
. Infect Dis 1982; 14:253-9.
--
4.
Scheutz F, Skinhoz P, Mark I. Viral hepatitis among parenteral drug
addicts attending a Danish addiction clinic. Scand Jinfect Dis 1983;
15:139-43.
4.
Scheutz F, Skinhoz P, Mark I. Viral hepatitis among parenteral drug
addicts attending a Danish addition clinic. Scand J Infect Dis 1983;
15:139-43.
5.
Lenib S. Type A viral hepatitis new developments in an old disease.
N Engl J Med 1985; 313:1059-67.
5.
Lenib S. Type A viral hepatitis new developments in an old disease.
NEngl JMed 1985; 313:1059-67.
6.
Sunddkvist T, Johansson B, Widell A. Rectum carried drugs may
spread hepatitis A among drug addicts. Scand J Infect Dis 1985;
6.
Sunddkvist T, Johansson B, Widell A. Rectum carried drugs may spread
hepatitis A among drug addicts. Scand J Infect Dis 1985; 17:1-4.
7.
Widell A, Hansson BG, Moestrup T, Nordenfelt E. Increased
7.
Widell A, Hansson BG, Moestrup T, Nordenfelt E. Increased occurrence
17:1-4.
occurrence of hepatitis A with cyclic outbreaks among drug addicts in
a Swedish community. Infection 1983; 11: 198-200.
of hepatitis A with cyclic outbreaks among drug addicts in a Swedish
community. Infection 1983; 11:198-200.
165
Announcement
An nonce
New WHO publication
FROM ALMA·ATA TO THE VEAR 2000
Reflections at the Midpoint
Nouvelle publication de l'OMS
FROM ALMA·ATA TO THE YEAR 2000
Reflections at the Midpoint
'The health conditioriS ofthe poor and deprived, who exist in virtually
all countries, and 'he costs in terms of human suffering and national
underdevelopment are so extreme that the question ofwhether the global
public health movement that began in Alma-Ata is viable or not is of the
highest international significance."
«Les conditions de sante des pauvres et des desherites, que l' on trouve
dans presque tousles pays, et lefardeau du point de vue de la souffrance
humaine et du sous-developpement national sont tels qu' ii est de la plus
haute importance sur le plan international de savoir si le mouvement
mondial de sante publique inaugure aAlma-Ata est viable OU non.»
This book assesses the extent to which the social goal ofhllalth for all,
formalized a decade ago at the historic Alma-Ata conference, has
produced measurable changes in both the orientation of health services
and the welfare of humanity. Future-oriented in its purpose, the book
takes a hard look at the complexities behind this simple slogan, the
reasons for its successes and failures, and the main problems to be faced
in the coming decade. Throughout, an effort is made to cast the
humanitarian potential of this movement against the realities of a world
political and economic order that rarely gives priority to health.
Ce livre evalue dans quelle mesure le but social de la sanre pour tous,
enonce voici 10 ans a la conference historique d' Alma-Ata, a produit des
transformations mesurables en ce qui concerne aussi bien I'orientation des
services de sanre que le bien-etre du genre humain. Resolument axe sur
l'avenir, l'ouvrage examine sans complaisance les complexires que
dissimule ce slogan en apparence si simple, les raisons de ses succes et de
ses echecs et les prlncipaux problemes auxquels il faudra faire face dans la
prochaine decennie. D'un bout al' autre, il s 'efforce de situer le potentiel
humanitaire de ce mouvement au regard des realires d'un ordre politique et
economique mondial qui n' accorde que rarement la priorite a la sanre.
The book opens with a brief introduction to the Alma-Ata conference,
followed by a reproduction of key statements that have shaped the
health-for-all movement. Against this background, readers are then given
a detailed, critical assessment of what the vision of health for all has
achieved during its first decade of practical application. Drawing upon
material prepared for a 1988 conference held in Riga, the book first
explains the component principles of health for all and then questions
whether the widespread formal adoption of these principles has made any
difference in public health. While noting major gains in a number of
industrialized and developing countries, the book concentrates on the
plight of the poorest countries, where health conditions have either
remained the same or deteriorated. Readers are reminded that the
development process has done little to relieve the suffering of the world's
most vulnerable groups, that efforts to improve health now face a new set
of solution-resistant problems, and that socioeconomic progress will
stagnate unless these problems are quickly and effectively addressed. To
this end, the chapter concludes with a series of proposals for securing the
necessary motivation and support, followed by 10 detailed lines of action
that must be followed in order to address these problems in the spirit of
health for all through primary care.
Le livre commence par une breve introduction sur la Conference
d' Alma-Ata suivie du texte des prlncipales declarations qui ont fay<mne le
rnouvement de la sanre pour tous. Sur cette toile de fond, le lecteur trouve
ensuite une analyse detaillee et critique de ce que l'ideal de la sante pour
tous a permis de realiser pendant ses 10 premieres annees d •application
pratique. S 'inspirant de la documentation preparee pour une conference
tenue a Riga en 1988, la publication aborde en premier lieu !es principes
regissant la sanre pour tous, puis pose la question de savoir si l' adoption
officielle et generale de ces principes a effectivement entraln.e des
changements sur le plan de la sante publique. Tout en notant les progres
importants emegistres dans un certain nombre de pays industrialises ou en
developpement, le livre est centre sur le sort des pays les plus pauvres dans
Jesquels la situation sanitaire est demeuree la meme OU S 'est aggravee. Il est
rappele a:u lecteur que le processus de developpement n' a guere contribue a
soulager la souffrance des groupes les plus vulnerables dans le monde, que
les efforts deployes pour ameliorer la sante se heurtent aujourd'hui a une
sene de problemes nouveaux refractaires a toute solution et que le progres
socio-economique s'enlisera si l'onne s'attaque pas aces problemes
rapidement et d'une maniere efficace. Acet effet, le chapitre s 'acheve par
une serie de propositions visant assurer la motivation et l'appui
necessaires, suivie de 10 actions precises auxquelles il faudra se conformer
pour que ces problemes soient abordes dans l'esprit de la sante pour tous pru
le biais des soins de sante primaires.
Further discussion of these problems and proposed lines of action are
presented in the second main chapter, which records highlights from the
1988 Forty-first World Health Assembly, including an assessment of the
future of the health-for-all strategy, a round table on the tenth anniversary
of Alma-Ata, and resolutions concerning the need to develop leadership
for health for all. The book concludes with a critical review of the main
tasks to be faced in the coming years and a compelling reminder that
successes and failures will be measured in terms of human lives and
deaths.
Le deuxieme chapitre principal examine plus avant ces problemes et les
actions proposees: il decrit les points saillants de la Quarante et Unieme
Assemblee mondiale de la Sanre en 1988, notamment une evaluation de
l'avenir de la strategie de la sante pour tous, une table ronde sur le dixieme
anniversaire d' Alma-Ata et des resolutions concernant la necessite de
developper le «leadership» de la sante pour tous. L'ouvrage s'acheve par
une analyse critique des tiiches prlncipales auxquelles il faudra faire face
dans les prochaines annees en rappelant avec .force que les succes et les
echecs seront mesures en termes de vies humaines et de deres.
This publication, available only in English at this time, can be
obtained in Canada from the Canadian Public Health Association, 1565
Carling Avenue, Suite 400, Ottawa, Ontario KlZ 8Rl (Tel:(613)
725-3769)- Attention: Ms L.A. Clarke. Cost is $31.50 per copy
including postage and handling.
Cette publication n'estpresentement offerte qu'en version anglaise et
franyaise. Pour se procurer un exemplaire au Canada, s 'adresser a
l' Association canadienne de sante publique, 1565, avenue Carling, Suite
400, Ottawa (Ontario) KlZ 8Rl (tel: (613) 725-3769), I' attention de:
Madame L.A. Clarke. Prix: 31,50$ l'exemplaire, frais de port et de
manutention inclus.
The Cana.de.Oiseaon We8ij Aeporlpresen\5 etrientlnformation on iifoofous an:t oil« dsetS&s br 1trW11arw::e pirpocea and 15
11Va1atte fl'fJe of du11ge upon reqwst. M~ of te amdes contnh preliminary iifounation rnd 1111wr QJnfi:nnPon may be obtained ftom
ht aourms quo~. The Dcplltneot of N1tional Hff1fl ardWf!AfNe does not uwne responsiNily~J a~q or auhnfdt(.
Con1n1l.11ons am welcome (in to ollicial l1ngueoo of yot.r dtob} from anyoM mkhg In !he healil f.dd ard wit notpmduda pvbtCetion
La R1!9P'rtmbdomridsi1e dea malades eo CModa, qui fourritdMd~ perinonWlii w1 ie,, mtiodles inflcfouros ollos eut'M mrilacfos
dans le b.ttdo facifliltleut 5\.rY81INl<J),pevl6t'o ob!l!nugtflVhtmootavrdemwtOO. Ung1andnombnl d'rides necooliJMMtqUlt des
tbmOOs comma!rn mai5 des ren&dgnEl'noots comtl&nenta!tes peweottito ott.muson s'adfosWtt aux mutooa d~s. Le mhl~o do la
Sam§ nation.ale otdu 5en~o IOd!I no paut Mre regpontal:le d& flU~fb.rle, rri de l'tutran6dt6 des ~01. Tou!e po1ti:1rne oewranldans
a
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ledomai1adela"111!estnli!llrtlOlllabor«(denslal~eoffici~ledeEOnd1olx)elfal'l~~alond\.l\8!1idodan1lopre..ntRopportrien
elSM!'em.
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Df. $. E. M8'
Bc!Mlflc Adv!IOr.
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Editor:
E1tan0< PAUison
Clrwlatton:
Dolly Rggins
D11k1op Pu~lllllna:
Ceboroh Chopm"'
rureau of Communicable
Epd"1lio~Vf
l.Jtboretory ConV• bro;,..,., Col1V~
o;.,,...
(613)
(613)
(613)
(613)
Con1~llmdentlflquo:
157.0325
157-1788
157.()8.\1
157-7845
R6dac:bice1neh1f:
D11~lb.rl011:
O' S.E. Aaes
68S110f P01Jl!on
DollyRg~ns
~llque:
Ceboroh Chopmon
rureaud'lpijlm~log~dos malmlies lmn$mlwij.,
Labourtotte 00 lutb cont-e la mated'ie
Pr4TUMO'f
Tumey'sPartJte
OTTAWA,Q\tario
ottwa (On!Ario) •
c.n.d• KIA Ol2
Ceru\daKIA<IU
166
(613)
1&13)
613)
(613)
05H325
957·1788
157-0841
157-7845
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