On October 31, 1974, a 19-year-old, female college stu- lent was admitted to a New Jersey hospital with nausea and vomiting. In the next 3 hours she became comatose and uffered a respiratory arrest. The diagnosis of meningococcal meningitis was made from a spinal fluid gram stain taken hortly after admission, and spinal fluid culture yielded Neis- eria meningitidis, serogroup C. Despite intensive supportive care and massive doses of penicillin, the patient had a down- ill course and died on November 9. Epidemiologic investigation revealed 3 groups of people who had had varying degrees of contact with the patient. All hospital contacts were given an initial dose of 200 mg of minocycline followed by 4 doses of 100 mg every 4 hours, for a total dose of 600 mg. The second group of 13 college contacts were prescribed 200 mg of minocycline followed TABLE I. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES (Cumulative totals include revised and delayed reports through previous weeks) VESTIBULAR REACTIONS - Continued by 100 mg twice daily for 5 days. The third group of 32 household and family contacts received a variety of dosage regimens of minocycline from several different sources. On November 2, hospital authorities informed the New Jersey State Health Department of a large number of vestibular reactions (dizziness, vertigo, nausea, or vomiting) among those persons who had received minocycline prophylaxis. Through the cooperation of the hospital, the college health service, and the patient's family, all of the people in the 3 groups who received minocycline were identified, and a questionnaire was completed on each individual. Table 1 shows the occurrence of adverse reactions following the administration of minocycline to the 83 people in the 3 groups. Sixty-five persons experienced adverse reactions after receiving minocycline, and 63 of the 83 (76%) had vestibular symptoms. Fifty-eight of the 63 persons with vestibular symptoms (92%) experienced onset after a total dose of only 400 mg of minocycline (Table 2). Thirty-four (54%) of the 63 persons had onset within 11 hours after receiving the initial dose of minocycline (Table 3). Because symptoms usually occurred at home when the affected persons were apart, reactions due to hysteria are unlikely. The minocycline associated with these adverse effects came from different lots. (Reported by Ronald Altman, MD, Director, Epidemiologic Services, Kenneth Black, Field Representative, Martin Gold field, MD, Assistant Commissioner, Division of Laborator and Epidemiology, New Jersey State Department of Healt Special Pathogens Branch, Bacterial Diseases Division, Burea of Epidemiology, CDC, and an EIS Officer.) Editorial Note This is the second report of unusually high incidence off vestibular reactions associated with the use of minocycline this country (1). Studies in England (2,3) and Brazil (4) using minocycline processed in those countries indicate tha symptoms related to the vestibular system occurred in less than 30% of individuals taking this drug, even when it wa given in single doses of as much as 400 mg (3). The mine cycline used in England is manufactured there, while th used in Brazil is imported in powder form from a US manufacturer. None of the persons in the Brazilian study sought medical attention for their vestibular reactions. Until it is clear that the minocycline manufactured a the U.S. no longer produces an inordinately high incidence d adverse reactions, physicians are encouraged to consider alter native drugs. For prophylaxis of meningococcal disease, 600) mg of rifampin every 12 hours for 2 days (4 total doses), recommended (5). Such treatment should be limited to house hold contacts or others who have had contact with the ora secretions of patients. If prior information shows that an err demic strain is sulfa sensitive, then sulfa is the drug of choic but under no circumstances should chemoprophylaxis be de layed while awaiting results of antibiotic sensitivity tests ysicians who continue prescribing minocycline should advise tients of possible serious vestibular side effects that may : particularly dangerous to motorists. Patients and physicians e encouraged to report such reactions. ferences Williams DN, Laughlin LW, Lee YH: Minocycline: possible vestibular le effects. Lancet 2, 744-746, 1974 Nicol CD, Oriel JD: Minocycline: possible vestibular side effects. Itter to the editor. Lancet 2, 1260, 1974 4344 11 3. Masterton G, Schofield CBS: Side effects of minocycline hydrochloride. Letter to the editor. Lancet 2, 1139, 1974 4. Center for Disease Control: Data from an investigation of adverse effects of minocycline in Brazil, 1974. Special Pathogens Branch, Bacterial Diseases Division, Bureau of Epidemiology, CDC 5. Munford RS, Sussuarana de Vasconcelos AJ, Phillips CJ, Gelli DS, Gorman GW, Risi JB, Feldman RA: Eradication of carriage of Neisseria meningitidis in families: a study in Brazil. J Infect Dis 129:644-649, 1974 New York, New Jersey, Illinois, Mississippi An outbreak of febrile upper respiratory disease among tients at a nursing home in the metropolitan New York ty area occurred during the last week of December. Approxately 28 of 115 patients had clinical febrile upper respirary disease. Five of these 28 patients developed pneumonia, id 1 of the 5 died. Four of 11 throat washings grew influiza A virus. Reported by Carol Nunez, PHN Epidemiologist, John S. arr, MD, Director, Bureau of Infectious Disease Control; ephen J. Millian, MD, Director, Virus Diagnosis Laboratory, ew York City Bureau of Laboratories; and an EIS Officer.) ew Jersey A nosocomial outbreak of influenza, confined to 1 floor a hospital in Trenton, occurred during the first week of nuary 1975. Approximately 16 patients and 6 hospital aff developed influenza-like disease. Isolates of influenza A ere obtained. Reported by Ronald Altman, MD, State Epidemiologist, and artin Goldfield, MD, Director, Bureau of Laboratories and idemiology, New Jersey State Department of Health; Wilm J. Dougherty, MD, Director of Medical Affairs, Mercer ospital, Trenton; and an EIS Officer.) linois An increase in emergency room visits associated with fluenza-like disease has been noted in Aurora and Carbonale, and influenza A virus has been isolated. An outbreak of fluenza-like disease has also occurred in a college in Galesurg. In addition, isolates of influenza A have been obtained om sporadic cases in Chicago. Reported by Marilee Santanni, RN, Copely Memorial Hosital, Aurora; James L. Weiler, MD, Student Health Center, nox College, Galesburg; Bryon Berlin, MD, Northwestern !emorial Hospital, Chicago; John B. Amadio, PhD, Public 'ealth Administrator, Jackson County Health Department; 'arvey Pretula, Microbiologist, and Richard A. Morrisey, hief, Division of Laboratories, and Bryon J. Francis, MD, tate Epidemiologist, Illinois Department of Public Health.) lississippi Outbreaks of influenza-like disease have been reported 1 Jackson, Indianola, and Greenwood. Reported by Alfia Rausa, MD, District IV Health Officer nd Durward L. Blakey, MD, State Epidemiologist, Mississippi tate Board of Health.) ditorial Note Measurements of influenza morbidity, such as the numer of hospital emergency room visits, school absenteeism, nd private physician reporting, indicate influenza activity is n the rise in the northeastern and mid-western United tates. Mortality data of pneumonia and influenza deaths from 121 U.S. cities (Figure 1) exceeded the epidemic threshold in the 2nd week of January 1975. The only 2 areas to have pneumonia and influenza deaths above the epidemic threshold for 2 consecutive weeks are the South Atlantic and East South Central regions of the country. This trend correlates well with the morbidity data on influenza activity previously reported from these regions of the country (see MMWR, Vol. 23, No. 50 and Vol. 24, No. 1). Furthermore, in the second week of January, pneumonia and influenza deaths have for the first time exceeded the expected level in the West North Central, East North Central, West South Central, Mountain, and Pacific regions. These deaths probably reflect early influenza activity in these regions. Deaths are reported to CDC each week by the Vital Statistics Offices of 121 United States cities and are published in Table IV of the Morbidity and Mortality Weekly Report (MMWR). The totals are compiled from death certificates filed each week and may include some deaths which occurred in preceding weeks. This information reflects influenza activity by showing a rise in mortality usually 2 to 4 weeks after the clinical disease is noted to be widespread. These mortality data provide some of the best available nationwide epidemiologic evidence of the extent and severity of an influenza epidemic. The expected mortality level is determined by using weekly data from the previous 4- or 5-year period, omitting data for epidemic periods and fitting the data to a mathematical model by least squares (1,2,3). The method works well in general because a seasonal pattern is observed each year. Charts are prepared in which the reported numbers of deaths are shown as dots joined by line segments. The solid line for each mortality category is the expected number of deaths. The dashed line is the "epidemic threshold," a criterion for the recognition of significant deviations in excess of the expected number (1,2,3). The charts are drawn to a scale that allows the distance between the expected and threshold levels to be constant for every curve. This device allows one to compare the influenza activity among regions by glancing at the regional chart. Although the chart's vertical labels are different, regional comparison of the absolute distance between observed and threshold levels shows whether the mortality is significantly higher in one region than another. References 1. Collins SD, Lehmann J: Excess deaths from influenza and pneumonia and from important chronic diseases during epidemic periods. 1918-1951 (PHS Pub No. 213). Washington, GPO, 1953 2. Serfling RE: Methods for current statistical analysis of excess pneumonia-influenza deaths. Public Health Rep 78:494-506, 1963 3. Center for Disease Control: Morbidity and Mortality Weekly Rep 14(1):8-11, 9 Jan 1965 |