Updates

by Carol A. Kemper

Rev. Deresienski Stops Communion!

New York Times, November 28, 2004;18.

Two years ago, with the advent of SARS in the world, Catholic priests in Toronto held mass without communion, fearing the chalice may be a source for transmission for the virus. Now, because of this year’s flu vaccine shortage, the Roman Catholic Diocese in Burlington, VT. has taken the unprecedented step of withholding communion from parishioners, and has asked parishioners not to hug, kiss, or shake hands when they make the sign of peace. In addition to the parish of Rev. Stanley Deresienski (!) in Brattleboro, VT., about 130 churches and 148,000 parishioners are affected. The edict, which was issued by Bishop Angell (!!) began October 31, 2004, and is expected to end on Easter Sunday, March 27, 2005 (although whether the influenza season will be done by then is an open question).

Many people have embraced the change, according to the New York Times, not wanting to share a cup or shake hands "with a visibly sick person." One parishioner, who supported the ban, was quoted as saying, "There’s science and the germ theory, and there’s also our faith. God doesn’t discount the germ theory."

Whether common communion presents a public health hazard to participants has been a long-standing, but poorly substantiated concern. While it would not be surprising if there was low-level risk of transmission of certain respiratory illnesses during communion, such as the common cold virus, herpes simplex, or even strep throat, various studies have examined this question and found no significant risk of contagion, and no significant outbreaks of illness have been linked to sharing the chalice. One Texas women died of meningococcemia in 2002 after drinking from a common communion cup at Catholic mass, but the connection was never confirmed. Unfortunately, the alcohol content of communion wine is probably insufficient to function as a disinfectant, although there may be some theoretical benefit (a teleologic benefit?) to using real wine and not grape juice. Common sense dictates that people with active herpes, the flu, or other contagious respiratory illnesses refrain from taking common communion. Whatever happened to faith and washing hands?

Environmental Mimics of Chemical Warfare

Claborn DM. Military Medicine 2004; 169:958-961.

Symptoms of chemical warfare are varied, but can include skin rashes and blistering, burns, increased salivation, muscle tremors and weakness, and paralysis. However, a number of other exposures and infectious diseases can produce similar signs and symptoms, including various animal and insect bites, plant exposures, ingestion of certain marine toxins, cleaning agents, and pesticides. A recent example of the confusion that can occur in the battlefield was an outbreak of conjunctivitis and skin blisters that occurred in a group of marines during a military exercise. Military medical personnel could not, at first, identify the cause of the outbreak. Despite the fact that this occurred in Arizona, where there was no credible threat of chemical exposure, and the marines were quite stable, several marines, including at least 1 field level officer, were not assuaged, and threatened to seek civilian care. They were convinced they had been victim to some kind of chemical attack, similar to that seen during their training sessions on chemical warfare. Ironically, the marines had suffered a variation of a chemical attack: they had been hit by a band of rove beetles, flushed from their burrows by heavy rains. The rove beetle secretes a noxious toxin when it rubs up against you, resulting in large skin blisters and blebs and conjunctivitis.

Other interesting examples of things that can mimic nerve agents (such as organophophates) include the bites of certain snakes (such as cobras, kraits, and elapids), which can cause heavy salivation, tremors, paralysis and death; tick paralysis, which causes progressive numbness and paralysis; botulism, tetanus, and rabies. In addition, military personnel should keep in mind that agricultural products in other parts of the world may be over-treated with insecticides, pesticides, and fungicides, and could result in true organophosphate poisoning or other toxin ingestion. It is all just a matter of the level of exposure.

Skin conditions resembling vesicating warfare agents (like mustard and Levisite) include contact dermatitis, impetigo, herpes simplex or zoster, poison ivy, photosensitivity and allergic reactions, and thermal or chemical burns. Both rove and meloid beetles (known as blister beetles) can cause impressive skin blistering and conjunctivitis—these can be found in Africa, Southeast Asia, Australia, and South America. Caterpillars, millipedes, and spiders can cause severe urticaria (mimicking phosgene agents), blisters, eschars and necrotizing skin lesions. Although one would suspect these would result in isolated cases, and not affect a whole platoon, reports document the occurrence of caterpillar-induced urticaria occurring simultaneously in thousands of soldiers in the Middle East, when the desert wind kicked up a hive of caterpillars and scattered their spines in the wind.

As Claborn acknowledged, "the threat of chemical warfare, whether real or perceived, has a lasting and adverse impact on health." Military personnel should be trained to understand the potential environmental causes of various signs and symptoms, and be able to differentiate between the effects of chemical warfare agents and other illness. This includes understanding the epidemiology and geographic distribution of various diseases, being able to do a proper epidemiologic investigation, and not immediately assuming the worst.

Malaria in Airline Crew Members

Byrne NJ, et al. J Travel Medicine. 2004;11:359-363.

Byrne et al examined the risk of falciparum malaria in airline crew members who lay-over in malaria-endemic areas. Apparently, a number of British airlines are opening new routes to Africa that involve layovers, although longer layovers are increasingly uncommon because of the need for greater business efficiency. Presumably, most British crew members are non-immune to falciparum malaria.

Various destinations, hotels, potential risk behaviors, and the number of nights of layover were examined. From 1994 to 2003, a total of 5 cases of falciparum malaria occurred in airline personnel; none resulted in death. Each of the individuals had engaged in some kind of risk behavior that increased their level of exposure, including 4 who dined al fresco and 1 who took advantage of an overnight safari. Two pilots were affected—both Boeing 767 pilots coming out of Entebbe and Dar es Salaam. Three crew members were affected on flights coming out of Accra, Lusaka, and Abidjan. Based on these cases, the annual risk to flight personnel for layovers in sub-saharan Africa was estimated at 1.6 per 100,000 nights (not bad, considering you wouldn’t want your pilot to come down with falciparum during flight).

By and large, crew members were good about using personnel protective equipment, such as proper clothing and DEET, although previous studies have documented less than 10% compliance with chemoprophylaxis. Airports were generally air-conditioned, and air conditioned transport to and from hotels was provided for all crew. All hotels were air-conditioned and centrally located in large urban areas, thereby reducing the risk. The risk was reduced even further in certain cities like Lagos, where personnel were not allowed to venture outside because of security risks (not a fun layover). Pilots who do their own walk-abouts and inspect the plane prior to take-off may be at slightly increased risk, although this was felt to be negligible.

Based on these data, Byrne and colleagues recommend that airline crews be more strongly educated about the use of insect repellent and protective clothing, and the avoidance of certain activities (sports and dining outdoors) between dusk and dawn. Prophylaxis with atovaquone-proguanil should only be recommended for those airline crew with non-standard layovers or stays in areas remote from large urban centers.

Paradoxical Effect of High-Dose Caspofungin

Stevens DA, et al. Antimicrob Agents Chemother. 2004;48:3407-3411.

Caspofungin, which is a non-competitive inhibitor of fungal cell wall glucan synthesis, is fungicidal in vitro against Candida species. Documented in vitro resistance has been rare, even after prolonged treatment, although clinical failure occurs. However, Stevens et al identified some clinical Candida albicans isolates that exhibited paradoxical turbid growth in broth at very high concentrations of caspofungin, far above their MICs. The frequency of this phenomena in clinical isolates submitted for susceptibility testing was 16%. In addition, among a select group of isolates, tested at concentrations up to 50 mcg/mL, 53% showed a mini-paradoxical effect; in other words, no turbid growth occurred but the isolates demonstrated incomplete cidal activity. Progeny of these isolates, grown in the absence of drug, did not demonstrate total resistance, but the paradoxical affect, similar to the parent, could be demonstrated 15 of 15 times. Interestingly, the addition of fluconazole, which acts synergistically with Caspofungin, eliminated the effect. Stevens and colleagues postulate that exposure to high drug concentrations could de-repress or activate unknown resistance mechanisms, which could have clinical consequences.

Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center Section Editor, Updates Section Editor, HIV, is Associate Editor for Infectious Disease Alert.