ATW1H%ASUACAD.BITNET@oac.ucla.edu (Dr David Dodell) (08/15/89)
--- begin part 3 of 3 cut here ---
chest wall. On June 10, pain and numbness developed on the right side of his
back and then spread locally. Over the next 2 days, dysesthesia developed in
the lower limbs, along with generalized weakness, dizziness, difficulty in
swallowing, and copious oral secretions. On June 13, the patient collapsed and
had a respiratory arrest. Examination at the hospital revealed bilateral
conjunctivitis, depressed gag reflex, right-sided weakness, and small
vesicular lesions on the right side of his chest; his cerebrospinal fluid
(CSF) had a neutrophilic pleocytosis and an elevated protein level. He was
mechanically ventilated and given high-dose intravenous acyclovir (15 mg/kg
every 8 h). Magnetic resonance imaging (MRI) showed abnormalities of the
thalamus, midbrain, pons, and upper spinal cord. B virus was cultured from the
vesicular chest lesions. Total paralysis and coma rapidly ensued, and he died
on June 20.
Patient 2, a 20-year-old, had worked at the research facility from May 22
to June 2. On approximately May 30, a monkey bit the man's right thumb. On
June 15, he had fever and chills. Subsequent symptoms included severe
headaches, myalgia, difficulty in urinating, paresthesia, and dizziness. When
admitted to the hospital on June 20, the patient had a temperature of 104 F
and his CSF contained numerous lymphocytes. Treatment with intravenous
acyclovir (15 mg/kg every 8 h) was begun. Western blot of his CSF was
consistent with B virus IgM and IgG antibodies. Culture of a biopsy specimen
from the healed bite wound was inconclusive; further virologic studies are
pending. On June 23, his treatment was changed to intravenous ganciclovir (5
mg/kg every 12 h). MRI scans showed subtle defects in the thalamus and
midbrain. As of July 5, Patient 2 remained clinically stable, without fever or
headache and with decreasing paresthesia.
Active surveillance has been instituted for approximately 135 current or
former employees of the research facility who have had contact with monkeys or
monkey tissue since mid-April. In addition, persons who are likely to have had
contact with body fluids from either patient during the week before onset of
symptoms are being monitored for evidence of B virus infection.
Reported by: DS Davenport, MD, SC Ross, MD; GA Stoltman, PhD, Kalamazoo County
Health Dept, Kalamazoo; BA Kintner, DVM, HB McGee, MPH, WN Hall, MD, GR
Anderson, DVM, KR Wilcox Jr, MD, State Epidemiologist, Michigan Dept of Public
Health. JK Hilliard, PhD, Southwest Foundation for Biomedical Research, San
Antonio, Texas. Div of Viral Diseases, Center for Infectious Diseases; Div of
Field Svcs, Epidemiology Program Office, CDC.
Editorial Note: B virus infection is common and relatively benign in Old World
monkeys such as rhesus and cynomolgus; however, this virus is highly
pathogenic in humans (1). The two cases in Michigan are the first symptomatic
human cases reported since 1987. A cluster of four cases in Florida in 1987
(2) prompted CDC to convene a working group to formulate new guidelines for
the prevention of B virus infection in monkey handlers (3).
In efforts to adhere to these guidelines, training of all persons who
Health InfoCom Network News Page 20
Volume 2, Number 29 July 17, 1989
handle monkeys or monkey tissues is particularly important. Such training must
include the following: prevention of monkey-inflicted wounds, appropriate care
of such wounds when they occur, signs and symptoms that might indicate human
infection with B virus, and recognition of the severity of such infection.
References
1. Palmer AE. B virus, Herpesvirus simiae: historical perspective. J Med
Primatol 1987;16: 99-130.
2. CDC. B-virus infection in humans--Pensacola, Florida. MMWR 1987;36:289-
90,295-6.
3. CDC. Guidelines for prevention of Herpesvirus simiae (B virus) infection
in monkey handlers. MMWR 1987;36:680-82,687-9.
Health InfoCom Network News Page 21
Volume 2, Number 29 July 17, 1989
International Notes
Nutritional Status of Somali Refugees -- Eastern Ethiopia,
September 1988-May 1989
In summer 1988, as many as 400,000 refugees from northern Somalia entered
remote areas of eastern Ethiopia. The refugees were settled in one camp near
the hamlet of Hartisheik, one camp in Harshin (about 50 km beyond Hartisheik),
and three camps near Aware. There are no wells at any of these locations;
however, water can be trucked approximately 100 km from the town of Jijiga
(Figure 1).
As part of routine nutritional surveillance in the camps, cluster sample
surveys (to measure weight-for-height (Wt/Ht)) of children less than 5 years
of age were done in Hartisheik and Harshin between September 1988 and May 1989
(Table 1, see page 461) (1). The surveys were carried out by Save the Children
Fund (SCF) (United Kingdom), a private voluntary organization working in
collaboration with the Ethiopian government and United Nations (U.N.)
agencies. Moderate malnutrition was defined as Wt/Ht between 70% and 79% of
the median of the reference population; severe malnutrition, as less than 70%.
Only 40% of children identified in the January survey as either moderately or
severely malnourished were registered in supplementary feeding programs in the
camps.
Also, SCF performed a mass screening of all children less than 5 years of
age in Hartisheik in January-February 1989, using mid-upper arm circumference
(MUAC) as the anthropometric measurement. When a MUAC of less than 13.5 cm was
used as the cutoff value, 28.7% of the 11,191 children screened were found to
be moderately or severely malnourished, a finding similar to that in the March
survey. During the mass screening, 66,663 persons of all ages were examined by
trained community health workers; 1437 refugees (2.1%) were found to have
symptoms and/or signs suggestive of clinical scurvy (i.e., bleeding gums and
painful, swollen joints). Of a subsample of 538 of these persons, 350 (65%)
had the diagnosis of scurvy confirmed by a physician. Thus, the prevalence of
scurvy by clinical examination was approximately 1%-2% in Hartisheik.
Although mortality reporting was not comprehensive for September 1988-May
1989, 60 cases of hepatitis and four hepatitis-related deaths were reported in
March. Identification of the type of hepatitis was not possible; however,
enterically transmitted non-A, non-B hepatitis has previously been reported
among East African refugees (2).
Between the September and January surveys, deliveries of water to the
camps improved; however, delivery of rations (cereal, vegetable oil, and
legumes) to Hartisheik was intermittent. Lentils and vegetable oil were not
available for regular food distributions, and cereal was the only consistent
source of calories. In addition, incomplete census data for the camps
contributed to delays in the distribution of rations; consequently, some
families may have received only 10-day rations for 3-to 4-week periods.
Reported by: Save the Children Fund, London, United Kingdom. Bur for Refugee
Programs, US Department of State. Technical Support Div, International Health
Program Office; Div of Nutrition, Center for Chronic Disease Prevention and
Health Promotion, CDC. Editorial Note: In general, refugees are dependent on
food rations provided by international donors and transported and distributed
by U.N. agencies and the government of the host country. Periodic surveys
continue to document the critical problem with malnutrition among Somali
refugee children in two camps in eastern Ethiopia. The malnutrition prevalence
rates reported for these Somali refugee children are higher than those
reported among refugee populations in Malawi and Thailand but are generally
Health InfoCom Network News Page 22
Volume 2, Number 29 July 17, 1989
comparable with those reported from Somalia and Sudan (Table 2) (3). Children
with Wt/Ht measurements less than 80% of the World Health Organization
reference population median are at increased risk of mortality (4,5). The
malnutrition prevalence rates reported in Hartisheik (March and May) and
Harshin (March) are similar to those in refugee situations in which high
mortality has been documented (e.g., Somalia and Sudan) (6). Collection of
mortality data in refugee emergencies is now a standard recommendation of the
Office of the United Nations High Commissioner for Refugees (7). Mortality
data are particularly important in settings in which malnutrition rates are
high because deaths among the most malnourished can reduce the number and
prevalence of malnourished survivors, thereby complicating interpretation of
nutritional survey data by relief agencies and organizations (8).
Scurvy, a fatal illness if untreated, has occurred among different East
African ref ugee populations in recent years (9-12)--at least in part because
rations provided to refugees often fail to provide the minimum daily vitamin C
requirement of 6 mg (13). To a great extent, logistic difficulties in
delivering sufficient quantities of vitamin C containing foods (e.g., fresh
vegetables and fruit) to refugees in remote regions of Africa may be
responsible for this problem. Cereals enriched with vitamin C prior to
shipment might help to reduce the occurrence of scurvy, although heat
stability of vitamin C is known to be a problem.
Effective strategies to improve nutritional assessment and intervention at
Hartisheik and Harshin could include 1) regular and complete distribution of
rations-- including foods that contain vitamin C, 2) expansion of the system
of supplementary and therapeutic feeding programs to achieve better coverage
of malnourished children, 3) more complete collection of mortality data, and
4) continued monitoring of children's nutritional status. As of June 1989, the
weekly distribution of vitamin C tablets in these camps to all children less
than 5 years of age and to pregnant and lactating women and the active
enrollment of malnourished children in supplementary feeding programs have
been instituted. The Ethiopia Ministry of Health has recently published a
revised set of health relief management guidelines (14) that describe
principles for the management of relief programs for refugees and disaster-
affected populations. Because inaccurate refugee census data are associated
with inequitable distribution of rations, sustained and coordinated efforts by
all participating relief agencies will be required to solve this problem.
References
1. World Health Organization. Measuring change in nutritional status:
guidelines for assessing the nutritional impact of supplementary feeding
programmes for vulnerable groups. Geneva: World Health Organization, 1983.
2. CDC. Enterically transmitted non-A, non-B hepatitis--East Africa. MMWR
1987;36:241-4.
3. CDC. Nutritional and health assessment of Mozambican refugees in two
districts of Malawi, 1988. MMWR 1988;37:641-3.
4. Chen LC, Chowdhury AKMA, Huffman SL. Anthropometric assessment of energy-
protein malnutrition and subsequent risk of mortality among preschool aged
children. Am J Clin Nutr 1980;33:1836-45.
5. Heywood P. The functional significance of malnutrition--growth and
prospective risk of death in the highlands of Papua New Guinea. J Food
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Volume 2, Number 29 July 17, 1989
Nutr 1982;39:13-9.
6. Toole MJ, Waldman RJ. An analysis of mortality trends among refugee
populations in Somalia, Sudan, and Thailand. Bull WHO 1988;66:237-47.
7. Office of the United Nations High Commissioner for Refugees. Handbook for
emergencies. Geneva: United Nations High Commissioner for Refugees,
1982:100.
8. Nieburg P, Berry A, Steketee R, Binkin N, Dondero T, Nabil A. Limitations
of anthropometry during acute food shortages: high mortality can mask
refugees' deteriorating nutritional status. Disasters 1988;12:253-8.
9. Magan AM, Warsame M, Ali-Salad A-K, Toole MJ. An outbreak of scurvy in
Somali refugee camps. Disasters 1983;7:94-7.
10. Desenclos J-C, Berry AM, Padt R, Farah B, Segala C, Nabil AM.
Epidemiologic patterns of scurvy among Ethiopian refugees. Bull WHO (in
press).
11. World Health Organization. Nutrition: scurvy and food aid among refugees
in the Horn of Africa. Wkly Epidemiol Rec 1989;64:85-7.
12. Seaman J, Rivers JPW. Scurvy and anaemia in refugees. Lancet 1989;1:1204.
13. Brown RE, Berry A. Prevention of malnutrition and supplementary feeding
programs. In: Sandler RH, Jones TC, eds. Medical care of refugees. New
York: Oxford Univ Press, 1987:113-24.
14. Ethiopia Ministry of Health. Ethiopia: health relief management
guidelines. 3rd ed. Addis Ababa: Ethiopia Ministry of Health, 1987.
Health InfoCom Network News Page 24
Volume 2, Number 29 July 17, 1989
Current Trends
Imported Dengue -- United States, 1987
In 1987, 94 cases of imported dengue-like illness (i.e., illness following
exposures thought to have occurred outside the United States) were reported to
CDC from 29 states (Table 1). Eighteen cases (from 10 states and the District
of Columbia) were serologically or virologically confirmed as dengue; 53 were
serologically negative for dengue, and the etiology of 23 remained
undetermined because only a single early serum sample was received.
Travel histories indicated that the confirmed dengue infections had been
acquired in four countries in Latin America, three islands in the Caribbean,
five countries in Asia, and one country in Africa (Table 1). The infecting
virus serotype was determined for five patients: DEN-1 for patients infected
in Mexico and Venezuela, DEN-2 for patients infected in Indonesia and India,
and DEN-4 for a patient infected in El Salvador (Table 1). Among the 15
patients for whom age was reported, ages ranged from 22 to 79 years.
Each patient had a classical dengue syndrome with onset of illness
occurring shortly after return to the United States. One patient, a 28-year-
old man with a primary DEN-2 infection acquired in India, reported bloody
diarrhea. No other hemorrhagic manifestations were reported.
Three of the confirmed cases were reported from Florida and Georgia, where
the principal vector of dengue, Aedes aegypti, occurs. Reported by:
Participating state health departments. Dengue Br, Div of Vector-Borne Viral
Diseases, Center for Infectious Diseases, CDC.
Editorial Note: Dengue is an acute viral disease caused by any of four dengue
virus serotypes and manifested by sudden onset of fever, headache, and
myalgia, and often by rash, nausea, and vomiting. Thrombocytopenia, as well
as hemorrhagic manifestations such as petechiae, epistaxis, and menorrhagia,
may also occur. Most infections result in relatively mild illness; however, a
small percentage of patients may have a severe form of the disease, dengue
hemorrhagic fever, which is characterized by severe hemorrhage and/or shock.
Dengue fever is widespread in the Caribbean, tropical America, Oceania,
Asia, and tropical Africa, and from 1977-1987 health-care providers in the
continental United States reported an annual average of 31 patients with
dengue acquired abroad (Table 2).
Because Ae. aegypti, the principal vector mosquito of dengue, is found in
the southeastern United States, indigenous transmission of dengue in these
areas is possible. The most recent known transmission within the continental
United States occurred in 1986 in an area of Texas infested by Ae. aegypti. An
Asian dengue vector, Ae. albopictus, has recently become established in focal
areas of the eastern United States as far north as latitude 42 N; however, no
case of disease transmission by this mosquito in the continental United States
has been documented (1).
Public health officials and clinicians should be aware of the potential
for dengue transmission in any area infested with dengue mosquito vectors.
Dengue should be considered in the differential diagnosis for any patient with
an acute febrile illness and a history of recent travel to tropical areas. If
dengue is suspected, the patient's hematocrit and platelet count should be
evaluated, and acute- ( less than 5 days from onset) and convalescent-phase
(greater than or equal to 14 days from onset) serum samples should be
obtained. Suspected dengue should be reported and serum samples sent for
confirmation through the state health department to: Dengue Branch, Division
of Vector-Borne Viral Diseases, Center for Infectious Diseases, CDC, GPO Box
4532, San Juan, Puerto Rico 00936; telephone (809) 749-4400.
Health InfoCom Network News Page 25
Volume 2, Number 29 July 17, 1989
Reference
1. CDC. Update: Aedes albopictus infestation--United States, Mexico. MMWR
1989;38:440, 445-6.
Health InfoCom Network News Page 26
Volume 2, Number 29 July 17, 1989
===============================================================================
News from the National Institute of Dental Research
===============================================================================
NIDR HOLDS CONFERENCES ON INDUSTRY COLLABORATION AND MINORITY
GROUP ISSUES
As part of the planning process to develop the National Institute of Dental
Research Long-Range Research Plan for the 1990's NIDR recently sponsored two
meetings to elicit contributions of industry and minority groups to the Plan.
The Long-Range Research Plan, developed by NIDR staff and experts from the
dental research community, contains the outline of the Institute's proposed
research objectives for the next decade and strategies to implement these
goals. The two NIDR-sponsored meetings also identified ways to increase both
NIDR collaboration with industry and mirority participation in dental
research.
INDUSTRY MEETING
"Dental Research--Industry Collaborations," held May 16 on the NIDR campus,
brought together representatives of private industry, academia, and the NIDR.
The meeting was chaired by Dr. Barbara Boyan, Director of the University-
Industry Cooperative Research Center at the University of Texas Health Science
Center in San Antonio.
The objectives of the conference were to present and discuss a summary of the
proposed research recommendations in the Long-Range Research Plan, including
possible implications for joint research activitives with industry; to
identify ways to increase collaborative efforts between private industry and
the dental research community and discuss NIDR's role in these efforts; and to
present NIDR evaluation activities relevant to joint research between industry
and scientists in academia and federal laboratories.
Stating that "there is a place for industry" in NIDR research, NIDR Director
Dr. Harald Loe emphasized that the conference on "Dental Research--Industry
Collaborations" provided an excellent opportunity for representatives of
industry to present their ideas and reactions to NIDR plans for research in
the 1990's. He also cited the need for industry collaboration to assist the
extramural dental research community with new developments in biotechnology
research and stressed the role industry can play in collaborative clinical
trials with the NIDR.
MINORITY ISSUES MEETING
"Dental Research and Minority Oral Health Issues" held May 22, was sponsored
by NIDR's Office of Planning, Evaluation and Communications (OPEC), and
chaired by Dr. James Lipton, Chief of the OPEC Planning and Evaluation
Section.
The meeting was organized to explore the special oral health care needs of
minority groups and to identify methods for recruiting minorities into dental
research. Panelists included leaders from a variety of dental research
institutions, universities and the U.S. Public Health Services.
The staff of NIDR's Epidemiology and Oral Disease Prevention Program presented
Health InfoCom Network News Page 27
Volume 2, Number 29 July 17, 1989
data the showed the oral health of minorities to be far below that of whites.
The data confirmed that minorities have more missing teeth, more unfilled
caries, more periodontal disease, and more soft tissue lesions than do whites.
It also was shown that, in general, non-whites do not visit the dentist as
often as whites. A presentation on the use of dental insurance showed that
minorities rely on third party reimbursement, whereas whites more often use
out-of-pocket money.
The data presented were extrapolated from a number of sources and summarized
to obtain a general idea of the state of minority oral health. The fact that
there were no up-to-date data describing any single minority group prompted
many recommendations to the need for epidemiological studies specifically
designed to document the oral health of minorities. One important design
characteristic cited as a necessity was the establishment of clear definitions
for each minority group rather than aggregations such as "blacks and other
minorities."
NIDR LAUNCHES HIV STUDY: INAUGURATES STUDY FACILITY
On May 30 the National Institute of Dental Research (NIDR) and its co-sponsors
of a new study on the oral effects of the human immunodeficiency virus (HIV),
held an Open House at the study's research site. The clinic is located in a
newly renovated wing of the old hospital at Walter Reed Army Medical Center
(WRAMC). The event was held to thank the many people who worked toward
opening the clinic and launching the study.
The study, "The Natural History of Oral Manifestations of HIV Infection in a
United States Military Population," is part of a parent project begin
conducted by the Walter Reed Army Institute of Research (WRAIR) on the natural
history of HIV infection. The U.S. Army Dental Activity at Walter Reed and
the U.S. Army Institute of Dental Research (USAIDR) also are supporting the
project. The Henry M. Jackson Foundation (HMJF), a non-profit organization
that supports military medicine, is handling administrative management of the
study.
"I'm pleased to see this facility become a reality," said Dr. Harald Loe,
NIDR's Director. Dr. Loe credited the efforts of the Army Dental Corps and
the other collaborators for the successful development of the facility. Major
General Bill Lefler, Chief of the U.S. Army Dental Corps, said the project was
a tremendous milestone in the fight against AIDS.
Health InfoCom Network News Page 28
Volume 2, Number 29 July 17, 1989
===============================================================================
Food & Drug Administration News
===============================================================================
FDA STATEMENT ON UNAUTHORIZED AIDS DRUG STUDY
In the past few days there have been several media reports of a death
associated with an unauthorized use of trichosanthin, a plant derivative
commonly called "Compound Q," in people with AIDS. The following information
can be used to answer questions:
Trichosanthin is a plant protein, which researchers think may be an
effective agent against the AIDS virus. An FDA-sanctioned clinical study of
GLQ-223, a refined form of trichosanthin, was started at San Francisco General
Hospital in May 1989. This initial human study is designed to test the safety
of this drug's use in treating AIDS patients, and particularly to determine at
what dose levels the drug can be tolerated.
According to media reports, Project Inform, a San Francisco-based AIDS
activist group initiated distribution of a trichosanthin-based preparation
imported from China, supposedly to test its efficacy in AIDS patients.
Project Inform undertook this operation without an FDA sanction or approval,
and has apparently been conducting it for a number of months. There have been
several media reports that the death of one patient and the serious adverse
reactions of other patients participating in this informal study have been
either directly or indirectly linked to this trichosanthin-based product.
FDA is conducting an investigation of the Project Inform operation. The
scale and nature of the Project Inform operation are largely unknown to the
agency. The safety procedures in this study are not known and the exact
circumstances surrounding the death and other adverse reactions reported to
have occurred in this trial have not been ascertained. Questions also remain
about the exact composition of the product and whether it was illegally
imported into the country.
The agency feels that the concerns raised by this operation point out the
need to conduct clinical studies in a scientific manner, that includes careful
study design, institutional monitoring mechanisms and consistent reporting
channels. Such studies assure the acquisition of good clinical data in the
shortest possible time, and ensure the safety of patients.
Health InfoCom Network News Page 29
Volume 2, Number 29 July 17, 1989
===============================================================================
Volunteers Needed for Studies/Research
===============================================================================
Title: 'A Study of GM-CSF in Combination with Zidovudine and Alpha
Interferon in the Treatment of Patients with HIV Infection".
The purpose of this study is to evaluate the laboratory and clinical
toxicity of the combination of zidovudine, alpha interferon and GM-CSF
(Granulocyte, Macrophage - Colony Stimulating Factor) on the neutropenia seen
when zidovudine and interferon-alpha are given together. Since the
combination of the two drugs has been shown to have both significant anti-
viral and anti-tumor activity, it is important to develop a treatment strategy
(using agents such as GM-CSF) which will allow this combination to be given to
a larger group of patients who might otherwise experience unacceptable
toxicities.
Eligibility criteria include:
1. Positive HIV serology.
2. CD4+ (T4+) counts between 200 and 500/cu mm.
3. No current opportunistic infection.
This is an outpatient protocol - patients will be taught to administer the
subcutaneous injections to themselves. The study is conducted as per the
following schedule:
1. Zidovudine 100 mg or 200 mg p.o. q4h for 4 weeks.
2. At week 4, alpha interferon (INTRON A, Schering-Plough) is
added, at 10 million units daily, given subcutaneously.
3. The INTRON is escalated by 5 million units every 2 weeks until
the granulocyte count falls below 1000 cells/ cu mm.
4. Once the granulocyte count is < 1000 cells/cu mm, GM-CSF
(rHuGM-CSF, Schering Plough) is begun at 1 mg/kg/day, given
subcutaneously.
5. The GM-CSF is escalated weekly to increase the granulocyte
count over 1500/cu mm.
6. Once the granulocyte count is stable over 1500/ cu mm on the
3 drugs, the patient is continued for a 16-week treatment
period on stable doses of the 3 drugs.
Potential side effects of zidovudine include headaches, nausea, hepatic
toxicity, and bone marrow suppression. Potential side effect effects of
interferon include flu-like symptoms (fever, malaise, headaches, myalgias),
fatigue, weight loss, leukopenia, and central nervous system symptoms
(numbness, tingling, depression, and difficulty concentrating). GM-CSF may
cause flu-like symptoms and bone pain.
Weekly visits to monitor clinical and laboratory parameters are arranged at
the National Institutes of Health Clinical Center, in the NIAID Outpatient
Clinic. Occasionally we may ask that a patient have a CBC with differential
and/or a SMAC done at a home laboratory through their primary physician. Each
study participant is followed by a R.N. who acts as a case manager. The study
coordinator for this prtocol is Victoria Davey, R.N., M.P.H., who can be
reached at (301) 496-7196.
Health InfoCom Network News Page 30
Volume 2, Number 29 July 17, 1989
Health InfoCom Network News Page 31
Volume 2, Number 29 July 17, 1989
===============================================================================
Meeting Announcements
===============================================================================
Informatica '90 Meeting Annoucment
Brian Mills
Email Bitnet: BMILLS@UMAB
The Medical Informatics Section from the Cuban Health Administration Society
is pleased to inform you about the celebration of the International event
"INFORMATICA '90" that will be held in February 19 to 25, 1990 in Havana,
Cuba. Inside this important event there going to take place a Medical
Informatics Conference during those days and also an exhibition will be held
at the same time. This INFORMATICA is the most important scientific meeting in
this sphere celebrated each two years in Latin America.
The topics that will be covered by the Medical Informatics Conference will be:
-Computer appliances in primary care -Informatics in the health administration
-Support for health research
I would be grateful if you can spread this information between your colleagues
in order to promote this activity and look for wider participation.
We are open to receive future contacts as a member of the INFORMATIC'90
Organizing Committee and as President of the Medical Informatics Conference.
Thank you very much for your help.
Armando Rosales
Director SAD, Ministry of Public Health, Calle M #260, Vedado. Havana 4, Cuba
Telex 511149 MSPCU Telephone: 32-9003"
Please direct any inquiries to Dr. Rosales directly. Please do not send any
inquiries to my account. Thank you.
Health InfoCom Network News Page 32
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