- Email: [email protected]
STAPHYLOCOCCAL INFECTION IN CERVICAL GLANDS OF INFANTS
479
insulators in New York 14 also had
a
higher mortality
Letters
than this group of male workers, but here again the type of exposure differed and the follow-up period
longer. Smoking histories were obtained for 73% of the subjects. This follow-up rate compares favourably with a response-rate of 69% for males and 60% for females obtained by Doll and Hill 10 for British was
doctors. Our finding that the data on women support the multiplicative hypothesis of how the two carcinogens combine agrees with that of Selikoff et al.14 (who found that in male insulation workers in New York the relative risk of the smokers was approximately 9 times that of the non-smokers). The low number of non-smokers among men in our population prevented us from drawing any conclusion in this sex. While neither the New York nor the London survey is sufficient in itself to reject the additive hypothesis, the combination of the two provides very strong evidence in favour of the multiplicative hypothesis. Evidence of a multiplicative model is also provided by Doll 15 in an analysis of the data on radiation exposure and smoking in a survey of uranium miners. 111g As in the study of the New York insulation workers, the workers with heavy exposure to asbestos dust who were also smokers had a very high excess of lung cancer. This re-emphasises the importance of the health hazard of smoking being stressed to workers in the asbestos industry. It is a pleasure to acknowledge the cooperation of the Departof Health and Social Security and the Office of Population Census. We are also grateful to Dr. W. J. Smither and the Cape Asbestos Company for use of their valuable records, and to Dr. John Gilson and Prof. R. S. F. Schilling for help and advice. This study was undertaken with the assistance of a grant to M. L. N. from the Medical Research Council. ment
REFERENCES
5.
Doll, R. Br. J. industr. Med. 1955, 12, 81. Selikoff, I. J., Churg, J., Hammond, E. C. J. Am. med. Ass. 1964 188, 22. Buchanan, W. D. Ann. N.Y. Acad. Sci. 1965, 132, 507. Selikoff, I. J., Hammond, E. G., Churg, J. J. Am. med. Ass. 1968 204, 106. Newhouse, M. L., Williams, J. M. Br. J. prev. soc. Med. 1967, 21
6.
Newhouse, M. L., Wagner, J. C. Br. J. ind. Med. 1969, 26
1. 2. 3. 4.
35. 302.
Newhouse, M. L. ibid. p. 294. Newhouse, M. L., Berry, G., Wagner, J. C., Turok, M. E. ibid 29, 134. 9. Case, R. A., Lea, A. J. Br. J. prev. soc. Med. 1955, 9, 62. 10. Doll, R., Hill, A. B. Br. med. J. 1964, i, 1399. 11. Todd, G. F. Statistics of Smoking in the United Kingdom: Research Paper no. 1, 5th ed., p. 26. Tobacco Research Council, London 7. 8.
1969.
12. Todd, G. F. The
13.
Reliability of Statements about Smoking Habits Supplementary Report: Research Paper no. 2a. Tobacco Research Council, London, 1966. Registrar General, Decennial Supplement England and Wales 1961: Occupational Mortality Tables. H.M. Stationery Office 1971.
14.
Selikoff, I. J., Hammond, E. G., Churg, J. in Pneumoconiosis Proceedings of the International Conference, Johannesburg 1969 (edited by H. A. Shapiro); p. 180. Cape Town, 1970. Doll, R. J. R. statist. Soc. A, 1971, 134, 133.
15. 16. Lundin, F. E., Lloyd, J. W., Smith, E. M., Archer, V. E., Holaday, D. A. Hlth Physics, 1969, 16, 571.
to
the Editor
STAPHYLOCOCCAL INFECTION IN CERVICAL GLANDS OF INFANTS
SIR,-Lately, outbreaks of staphylococcal sepsis have been infrequently reported, but Staph. aureus is still present in infant nurseries. A relaxation in precautions against staphylococcal infection (e.g., discontinuing the use of hexachlorophane powder) may be followed by increased sepsis. of cervical abscess in infants under one year one area of Worcestershire in the years 1970 and 1971. The babies were brought for treatment at varying periods after birth (mean 86 days, range 15-181 days) with an abscess in the neck involving one of the tonsillar glands; all abscesses required incision, and response to treatment was satisfactory. There was little evidence of other staphylococcal sepsis in babies with abscesses, or of sepsis in other babies, apart from two who had osteomyelitis within 3 to 4 weeks of birth. A penicillinresistant strain of Staph. aureus was isolated from all infections ; phage typing showed an inhibition pattern with phage 81 (the epidemic strain) in 21 of the strains isolated from cervical abscesses; 4 strains were not typable and 2 27
were
cases
reported from
were not
typed.
Babies in the area involved were mainly born in one of two small maternity hospitals; hospital 1 had a maximum of eighteen babies’ cots and hospital 2 a maximum of twenty-one cots. All cervical abscesses except 2 developed in babies born in hospital 1 (15/623 [2-4%] in 1970 and 10/699 [l°4%] in 1971). In hospital 2, 2/501 babies born in 1970 and 0/537 born in 1971 had cervical abscesses. No abscesses developed in 299 babies born at home during the 2-year period. No common contacts outside the hospitals were found; babies with infection were attended by several different general practitioners, district midwives, and health visitors. Since most of the infections occurred in babies born in hospital 1 and there was evidence of cross-infection with several types of Staph. aureus in the nursery, a number of precautions were introduced during 1971. 0.3% hexachlorophane powder was applied to the umbilicus, axillse, and groins of all babies when napkins were changed. The three nasal carriers of the epidemic strain on the staff were treated with a cream containing neomycin and chlorhexidine, and a hexachlorophane/detergent preparation was used by all staff for hand-washing. Other measures included changing babies in their own cots and only bathing before discharge from hospital. After the introduction of these precautions staphylococcal colonisation was reduced in the nursery and cervical abscesses gradually disappeared; none have so far been reported in 1972. The epidemic strain in hospital 1 was probably introduced on at least two occasions by a member of staff; none of the staff carrying the epidemic strains had contact with all the babies who later developed cervical abscesses, but there was cross-infection between babies in the nursery before hexachlorophane powder was reintroduced. We have no explanation for the occurrence of infection in the neck and the long interval between leaving hospital and infection. Although throat carriage of staphylococci has been reported in babies and it has been shown that the throat may remain colonised for long periods,1 there was no evidence that the epidemic strain in this hospital had a predilection for the throat. Two isolates of the epidemic strain were obtained from 134 throat swabs taken from babies either on discharge from hospital or at a follow-up examination 6 weeks later. The strain was also isolated 1. Hurst, V. J.
Hyg., Camb. 1957, 55, 299.
480 from 5 nasal swabs taken from the same babies, but none of these babies were subsequently infected. Most of the infected babies were delivered normally and cared for without any special procedures. Disposable mucus extractors were used at birth and no contamination of teats of feeding-bottles was found. Infection was not obviously related to previous antibiotic treatment, to length of stay in hospital, social class, or other sepsis in the family. Possibly infection was associated with a virus infection of the upper-respiratory tract, but there was no definite clinical evidence of this in most of the infected babies. The use of hexachlorophane powder was discontinued in hospital 1 at some time before this outbreak because of the possible risk of selection of gram-negative bacilli. More recently, suspicions of toxicity have encouraged other hospitals to discontinue the use of hexachlorophane products in their neonatal nurseries. However, hexachlorophane powder has been used successfully in Britain for 10 to 15 years without evidence of toxicity, and Dr. Alder and his colleagues (Aug. 19, p. 384) have demonstrated that blood levels of hexachlorophane were low when the powder was used as recommended in Bristol. Hospital Infection Research Laboratory, Summerfield Hospital, Birmingham B18 2QQ,
Lead poisoning from home brewing in glazed earthenis well recognised historically, and today in Yugoslavia, and in the U.S.A. from moonshine whisky. A case due to domestic soft drinks is unusual, and I have done 50,000 statutory examinations of lead-workers without seeing a case of classical lead poisoning. The blood-lead of 83 µg. per 100 ml. was obtained an unknown time after exposure had ceased, but correction
ware
G. A. J. AYLIFFE KATHLEEN M. BRIGHTWELL PAMELA M. BALL MARGARET M. DERRINGTON.
and Mid-Worcestershire
Group Laboratory.
LEAD POISONING: AN UNUSUAL COMPLICATION OF CYSTITIS
for the low
SIR,—A housewife of 53 presented on Oct. 11, 1971, with constant abdominal pain, shortness of breath, tiredness, and constipation. The pain had occurred previously in August during the third week of a holiday in Portugal. Physical examination was unremarkable, but haemoglobin was 9-9 g. per 100 ml. and reticulocytes 10%, with polychromasia and some basophilic stippling. A week later blood-lead was 83 µg. per 100 ml., and repeated severe
estimations
on
Nov. 2
at
the
same
and
a
haemoglobin levelgives a value of 83 x =122 µg. per 100 ml., which is much higher than the level (80 µg. per 100 ml.) commonly taken as the threshold for 2 poisoning. Sharston
Lodge,
Fortyfoot Road,
Leatherhead, Surrey.
M. K. WILLIAMS.
different laboratory
gave 63 (Jog. and 78 (Jog. per 100 ml. respectively. On Nov. 30 blood-lead was 54 µg. per 100 ml. Urinary leads of 89 µg. per litre (specific gravity 1010) and 156 µg. per litre
(specific gravity 1-014) on Dec. 10 and 11 unusually high level of lead absorption. was 13-2 g. per 100 ml. on Jan. 20, 1972. A diagnosis of lead poisoning was made, symptoms had by then subsided deleading
confirmed
an
Haemoglobin
but since the with penicillaminewas considered undesirable. Previous medical history revealed only tiredness and shortness of breath on bending, and normal blood-counts with haemoglobin levels of about 80% had been found in 1957, 1968, and 1969. Recurrent urinary-tract infections had resulted in three cystoscopies. Social, family, and occupational histories were unhelpful. The husband’s blood-lead was 17 µg. 100 and the hot and cold water-supplies in bathml., per room and kitchen all contained less than 0-01 p.p.m. of lead. The patient said she had not used lead-glazed earthenware in home brewing or unusual cosmetics. But at the end of November she telephoned to say she had just made some barley-water, as she was used to doing for her cystitis; and that the barley-water was stored for up to a week in an old earthenware jug (see figure). Analysis of the barleywater gave 376 p.p.m. of lead, equivalent to 214 mg. per pint, and subsequent tests showed that, after standing for 3 days in the jug, water contained 40 p.p.m. and lemon-water 467 p.p.m. She remembered making and drinking barleywater at the end of September but was uncertain of the dates of previous episodes. The jug had been bought in Greenwich Village, New York, in 1926.
HUMORAL IMMUNE RESPONSES IN CONGENITAL RUBELLA SIR,—Reports in this journal and elsewhere suggest that the humoral immune response in congenital rubella may differ from the response to postnatal rubella infection. It
originally believed that antibody persisted for many possibly for life, in congenital-rubella patients. Kenrick and his colleagues, however, found that 12% of congenital-rubella patients at 25 years of age had no detectable antibody (seronegative) by the haemagglutina-
was
years, and
tion-inhibition test 3; three years later the number of seronegatives had increased to 16%.4 Hardy and her colleagues5 have also reported a decline or loss of H.I. antibody in 50% of 60 children by 2-4 years of age; half were seronegative by this age. More recently, Schiff et al.6 have reported that, whereas antibody levels were well maintained for 2½ years, by 4 years 90% of congenitalrubella patients had declining titres or no detectable H.I. antibody. In Cooper’s extensive experience18.5 % of 270 patients were seronegative after 4 years of age and there was a progressive decline in the titres of H.i. antibody 1. Williams, M. K. Br. J. ind. Med. 1966, 23, 105. 2. British Medical Journal, 1968, iv, 501. 3. Kenrick, K. G., Slinn, R. F., Dorman, D. C., Menser, M. A. Lancet, 1968, i, 548. 4. Forrest, J. M., Honeyman, M. C., Menser, M. A. ibid. 1972, i, 1075. 5. Hardy, J. B., Sever, J. L., Gilkeson, M. R. J. Pediat. 1969, 75, 213. 6. Schiff, G. M., Sutherland, J., Light, I. in Prenatal Infections, 1970 (edited by O. Thalhammer); p. 31. Stuttgart, 1971. 7. Cooper, L. Z. Am. J. Dis. Child. 1971, 122, 397.
insulators in New York 14 also had
a
higher mortality
Letters
than this group of male workers, but here again the type of exposure differed and the follow-up period
longer. Smoking histories were obtained for 73% of the subjects. This follow-up rate compares favourably with a response-rate of 69% for males and 60% for females obtained by Doll and Hill 10 for British was
doctors. Our finding that the data on women support the multiplicative hypothesis of how the two carcinogens combine agrees with that of Selikoff et al.14 (who found that in male insulation workers in New York the relative risk of the smokers was approximately 9 times that of the non-smokers). The low number of non-smokers among men in our population prevented us from drawing any conclusion in this sex. While neither the New York nor the London survey is sufficient in itself to reject the additive hypothesis, the combination of the two provides very strong evidence in favour of the multiplicative hypothesis. Evidence of a multiplicative model is also provided by Doll 15 in an analysis of the data on radiation exposure and smoking in a survey of uranium miners. 111g As in the study of the New York insulation workers, the workers with heavy exposure to asbestos dust who were also smokers had a very high excess of lung cancer. This re-emphasises the importance of the health hazard of smoking being stressed to workers in the asbestos industry. It is a pleasure to acknowledge the cooperation of the Departof Health and Social Security and the Office of Population Census. We are also grateful to Dr. W. J. Smither and the Cape Asbestos Company for use of their valuable records, and to Dr. John Gilson and Prof. R. S. F. Schilling for help and advice. This study was undertaken with the assistance of a grant to M. L. N. from the Medical Research Council. ment
REFERENCES
5.
Doll, R. Br. J. industr. Med. 1955, 12, 81. Selikoff, I. J., Churg, J., Hammond, E. C. J. Am. med. Ass. 1964 188, 22. Buchanan, W. D. Ann. N.Y. Acad. Sci. 1965, 132, 507. Selikoff, I. J., Hammond, E. G., Churg, J. J. Am. med. Ass. 1968 204, 106. Newhouse, M. L., Williams, J. M. Br. J. prev. soc. Med. 1967, 21
6.
Newhouse, M. L., Wagner, J. C. Br. J. ind. Med. 1969, 26
1. 2. 3. 4.
35. 302.
Newhouse, M. L. ibid. p. 294. Newhouse, M. L., Berry, G., Wagner, J. C., Turok, M. E. ibid 29, 134. 9. Case, R. A., Lea, A. J. Br. J. prev. soc. Med. 1955, 9, 62. 10. Doll, R., Hill, A. B. Br. med. J. 1964, i, 1399. 11. Todd, G. F. Statistics of Smoking in the United Kingdom: Research Paper no. 1, 5th ed., p. 26. Tobacco Research Council, London 7. 8.
1969.
12. Todd, G. F. The
13.
Reliability of Statements about Smoking Habits Supplementary Report: Research Paper no. 2a. Tobacco Research Council, London, 1966. Registrar General, Decennial Supplement England and Wales 1961: Occupational Mortality Tables. H.M. Stationery Office 1971.
14.
Selikoff, I. J., Hammond, E. G., Churg, J. in Pneumoconiosis Proceedings of the International Conference, Johannesburg 1969 (edited by H. A. Shapiro); p. 180. Cape Town, 1970. Doll, R. J. R. statist. Soc. A, 1971, 134, 133.
15. 16. Lundin, F. E., Lloyd, J. W., Smith, E. M., Archer, V. E., Holaday, D. A. Hlth Physics, 1969, 16, 571.
to
the Editor
STAPHYLOCOCCAL INFECTION IN CERVICAL GLANDS OF INFANTS
SIR,-Lately, outbreaks of staphylococcal sepsis have been infrequently reported, but Staph. aureus is still present in infant nurseries. A relaxation in precautions against staphylococcal infection (e.g., discontinuing the use of hexachlorophane powder) may be followed by increased sepsis. of cervical abscess in infants under one year one area of Worcestershire in the years 1970 and 1971. The babies were brought for treatment at varying periods after birth (mean 86 days, range 15-181 days) with an abscess in the neck involving one of the tonsillar glands; all abscesses required incision, and response to treatment was satisfactory. There was little evidence of other staphylococcal sepsis in babies with abscesses, or of sepsis in other babies, apart from two who had osteomyelitis within 3 to 4 weeks of birth. A penicillinresistant strain of Staph. aureus was isolated from all infections ; phage typing showed an inhibition pattern with phage 81 (the epidemic strain) in 21 of the strains isolated from cervical abscesses; 4 strains were not typable and 2 27
were
cases
reported from
were not
typed.
Babies in the area involved were mainly born in one of two small maternity hospitals; hospital 1 had a maximum of eighteen babies’ cots and hospital 2 a maximum of twenty-one cots. All cervical abscesses except 2 developed in babies born in hospital 1 (15/623 [2-4%] in 1970 and 10/699 [l°4%] in 1971). In hospital 2, 2/501 babies born in 1970 and 0/537 born in 1971 had cervical abscesses. No abscesses developed in 299 babies born at home during the 2-year period. No common contacts outside the hospitals were found; babies with infection were attended by several different general practitioners, district midwives, and health visitors. Since most of the infections occurred in babies born in hospital 1 and there was evidence of cross-infection with several types of Staph. aureus in the nursery, a number of precautions were introduced during 1971. 0.3% hexachlorophane powder was applied to the umbilicus, axillse, and groins of all babies when napkins were changed. The three nasal carriers of the epidemic strain on the staff were treated with a cream containing neomycin and chlorhexidine, and a hexachlorophane/detergent preparation was used by all staff for hand-washing. Other measures included changing babies in their own cots and only bathing before discharge from hospital. After the introduction of these precautions staphylococcal colonisation was reduced in the nursery and cervical abscesses gradually disappeared; none have so far been reported in 1972. The epidemic strain in hospital 1 was probably introduced on at least two occasions by a member of staff; none of the staff carrying the epidemic strains had contact with all the babies who later developed cervical abscesses, but there was cross-infection between babies in the nursery before hexachlorophane powder was reintroduced. We have no explanation for the occurrence of infection in the neck and the long interval between leaving hospital and infection. Although throat carriage of staphylococci has been reported in babies and it has been shown that the throat may remain colonised for long periods,1 there was no evidence that the epidemic strain in this hospital had a predilection for the throat. Two isolates of the epidemic strain were obtained from 134 throat swabs taken from babies either on discharge from hospital or at a follow-up examination 6 weeks later. The strain was also isolated 1. Hurst, V. J.
Hyg., Camb. 1957, 55, 299.
480 from 5 nasal swabs taken from the same babies, but none of these babies were subsequently infected. Most of the infected babies were delivered normally and cared for without any special procedures. Disposable mucus extractors were used at birth and no contamination of teats of feeding-bottles was found. Infection was not obviously related to previous antibiotic treatment, to length of stay in hospital, social class, or other sepsis in the family. Possibly infection was associated with a virus infection of the upper-respiratory tract, but there was no definite clinical evidence of this in most of the infected babies. The use of hexachlorophane powder was discontinued in hospital 1 at some time before this outbreak because of the possible risk of selection of gram-negative bacilli. More recently, suspicions of toxicity have encouraged other hospitals to discontinue the use of hexachlorophane products in their neonatal nurseries. However, hexachlorophane powder has been used successfully in Britain for 10 to 15 years without evidence of toxicity, and Dr. Alder and his colleagues (Aug. 19, p. 384) have demonstrated that blood levels of hexachlorophane were low when the powder was used as recommended in Bristol. Hospital Infection Research Laboratory, Summerfield Hospital, Birmingham B18 2QQ,
Lead poisoning from home brewing in glazed earthenis well recognised historically, and today in Yugoslavia, and in the U.S.A. from moonshine whisky. A case due to domestic soft drinks is unusual, and I have done 50,000 statutory examinations of lead-workers without seeing a case of classical lead poisoning. The blood-lead of 83 µg. per 100 ml. was obtained an unknown time after exposure had ceased, but correction
ware
G. A. J. AYLIFFE KATHLEEN M. BRIGHTWELL PAMELA M. BALL MARGARET M. DERRINGTON.
and Mid-Worcestershire
Group Laboratory.
LEAD POISONING: AN UNUSUAL COMPLICATION OF CYSTITIS
for the low
SIR,—A housewife of 53 presented on Oct. 11, 1971, with constant abdominal pain, shortness of breath, tiredness, and constipation. The pain had occurred previously in August during the third week of a holiday in Portugal. Physical examination was unremarkable, but haemoglobin was 9-9 g. per 100 ml. and reticulocytes 10%, with polychromasia and some basophilic stippling. A week later blood-lead was 83 µg. per 100 ml., and repeated severe
estimations
on
Nov. 2
at
the
same
and
a
haemoglobin levelgives a value of 83 x =122 µg. per 100 ml., which is much higher than the level (80 µg. per 100 ml.) commonly taken as the threshold for 2 poisoning. Sharston
Lodge,
Fortyfoot Road,
Leatherhead, Surrey.
M. K. WILLIAMS.
different laboratory
gave 63 (Jog. and 78 (Jog. per 100 ml. respectively. On Nov. 30 blood-lead was 54 µg. per 100 ml. Urinary leads of 89 µg. per litre (specific gravity 1010) and 156 µg. per litre
(specific gravity 1-014) on Dec. 10 and 11 unusually high level of lead absorption. was 13-2 g. per 100 ml. on Jan. 20, 1972. A diagnosis of lead poisoning was made, symptoms had by then subsided deleading
confirmed
an
Haemoglobin
but since the with penicillaminewas considered undesirable. Previous medical history revealed only tiredness and shortness of breath on bending, and normal blood-counts with haemoglobin levels of about 80% had been found in 1957, 1968, and 1969. Recurrent urinary-tract infections had resulted in three cystoscopies. Social, family, and occupational histories were unhelpful. The husband’s blood-lead was 17 µg. 100 and the hot and cold water-supplies in bathml., per room and kitchen all contained less than 0-01 p.p.m. of lead. The patient said she had not used lead-glazed earthenware in home brewing or unusual cosmetics. But at the end of November she telephoned to say she had just made some barley-water, as she was used to doing for her cystitis; and that the barley-water was stored for up to a week in an old earthenware jug (see figure). Analysis of the barleywater gave 376 p.p.m. of lead, equivalent to 214 mg. per pint, and subsequent tests showed that, after standing for 3 days in the jug, water contained 40 p.p.m. and lemon-water 467 p.p.m. She remembered making and drinking barleywater at the end of September but was uncertain of the dates of previous episodes. The jug had been bought in Greenwich Village, New York, in 1926.
HUMORAL IMMUNE RESPONSES IN CONGENITAL RUBELLA SIR,—Reports in this journal and elsewhere suggest that the humoral immune response in congenital rubella may differ from the response to postnatal rubella infection. It
originally believed that antibody persisted for many possibly for life, in congenital-rubella patients. Kenrick and his colleagues, however, found that 12% of congenital-rubella patients at 25 years of age had no detectable antibody (seronegative) by the haemagglutina-
was
years, and
tion-inhibition test 3; three years later the number of seronegatives had increased to 16%.4 Hardy and her colleagues5 have also reported a decline or loss of H.I. antibody in 50% of 60 children by 2-4 years of age; half were seronegative by this age. More recently, Schiff et al.6 have reported that, whereas antibody levels were well maintained for 2½ years, by 4 years 90% of congenitalrubella patients had declining titres or no detectable H.I. antibody. In Cooper’s extensive experience18.5 % of 270 patients were seronegative after 4 years of age and there was a progressive decline in the titres of H.i. antibody 1. Williams, M. K. Br. J. ind. Med. 1966, 23, 105. 2. British Medical Journal, 1968, iv, 501. 3. Kenrick, K. G., Slinn, R. F., Dorman, D. C., Menser, M. A. Lancet, 1968, i, 548. 4. Forrest, J. M., Honeyman, M. C., Menser, M. A. ibid. 1972, i, 1075. 5. Hardy, J. B., Sever, J. L., Gilkeson, M. R. J. Pediat. 1969, 75, 213. 6. Schiff, G. M., Sutherland, J., Light, I. in Prenatal Infections, 1970 (edited by O. Thalhammer); p. 31. Stuttgart, 1971. 7. Cooper, L. Z. Am. J. Dis. Child. 1971, 122, 397.