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                   Environmental Health

                        MILITARY ACTIVITIES

                              TILMAN A. RUFF
  Department of Social and Preventive Medicine, Monash Medical
    School, Alfred Hospital, Prahran, Victoria 3181, Australia

Summary                 Ciguatera fish poisoning is widespread in
                 the Pacific. Outbreaks and the rise in
incidence of the disease are related largely to military
activities that disturb coral reef ecology. Nuclear test
explosions and the setting up of the infrastructure for these                                                                  Fig I-The Pacific Islands.
tests are major components of such military activity.

                               INTRODUCTION                                                           symptoms may recur with ingestion of non-toxic fish,
   CIGUATERA, the commonest type of marine food                                                       alcohol, and other foods, or with factors such as intercurrent
                                                                                                      illness.6 Such "sensitisation" may persist for years after an
poisoning world wide, is caused by the ingestion of tropical                                          attack of ciguatera.
fish containing toxins1 produced by coral reef dinoflagellate
                                                                                                         The dinoflagellate species usually implicated in ciguatera
plankton species. The toxins have no observable effect on                                             is Gambierdiscus toxicus, the predominant benthic
fish, and the highest concentrations are found in large
predatory fish that feed on herbivorous fish, favoured by                                             dinoflagellate in Pacific coral reefs.’ Ciguatera endemicity
                                                                                                      correlates with the environmental density of G toxicus in
man for food. Ciguatera is especially common in the
                            2                                                                         French Polynesia, but not in other areas (eg, Queensland).
Caribbean and in the Pacific.
                                                                                                         The most striking factors precipitating ciguatera
   Ciguatera most commonly presents as an acute self-                                                 outbreaks are disturbances in the ecology of coral reefs, by
limited  syndrome of vomiting, diarrhoea, and abdominal                                               natural events such as storms, earthquakes, tidal waves, and
pain, accompanied by sensory and/or motor disturbances.
Weakness may necessitate             ventilatory support.                                             heavy rains, or by human activities such as construction
Bradydysrhythmias, myocardial depression, and vasomotor                                               works, explosions, and dredging.7-9 In this paper the relation
                                                                                                      with military activity is examined.
collapse may occur. Ciguatera during pregnancy may result
in abortion,3 premature labour, and neurological disease in
                                                                                                                        MILITARY-RELATED OUTBREAKS
the newborn,4and the disease may be transmitted by
breast-feeding.3 Ciguatera is occasionally fatal, but more                                               The Pacific Islands are divided ethnogeographically into
commonly it runs for weeks, months, or years, with                                                    three broad areas: Micronesia, Melanesia, and Polynesia (fig
constitutional symptoms,         diffuse    tingling pain,                                            1). The Pacific has been used extensively for military
temperature-reversal dysaesthesia, pruritus, and ataxia                                               activities. Naval, air, and communication facilities are
often being the most persistent symptoms. The diagnosis is                                            maintained in the region and three countries fire missiles to a
clinical and therapy is predominantly supportive and                                                  number of splashdown points. Nuclear test explosions have
symptomatic. Despite reports of striking improvement with                                             been conducted by the British in Australia (12 in 1952-57)
mannitol,S no treatment is of proven efficacy. Subsequent                                             and at Christmas and Malden Islands (9 in 1957-58). US
attacks tend to be more severe than first attacks, and                                                Pacific tests have been carried out at Enewetak and Bikini in

13. Lee M, Davies DP, Chan YF Prone or supine for preterm babies? Lancet 1988; i:                            Christchurch: The Textile Institute, New Zealand Section, 1983: 107-16.
            1332.                                                                                     26 Bruck K. Heat production and temperature regulation. In: Stave U, ed. Perinatal
14 Davies DP Cot death m Hong Kong a rare problem? Lancet 1985; ii: 1346-49.                                 physiology New York: Plenum Medical Book Company, 1978: 455-98.
15. Sénécal J, Roussey M, Defawe G, Delahaye M, Piquemal B. Procubitus et mort subite   27 Lund CC, Browder NC. The estimation of areas of bums. Surg Gynecol Obstetr 1944;
            inattendue du nourrisson. Arch Fr Pediatr 1987; 44: 131-36.                                      79: 352-58.
16 Beal S Sleeping position and SIDS. Lancet 1988; ii: 512                                            28. Hey EN, O’Connell B. Oxygen consumption and heat balance in the cot-nursed baby.
17. Hassall IB, Vandenberg M. Infant sleep position: a New Zealand survey. NZ Med J                          Arch Dis Child 1970; 45: 335-43.
      1985, 98: 97-99                                                                                 29. Hey EN, Katz G. The optimum thermal environment for naked babies. Arch Dis
18. Nelson EAS,   Taylor BJ. Infant clothing, bedding and room heating in an area of high                    Child 1970; 45: 328-34.
      postneonatal mortality Paediatr Perinat Epidemiol (in press)                                    30. Hey EN, Katz G. Evaporative water loss in the new-born baby. J Physiol 1969; 200:
19. Wennergren G, Milerad J, Lagercrantz H, et al. The epidemiology of sudden infant                         605-19
       death syndrome and attacks of lifelessness m Sweden. Acta Paediatr Scand 1987;                 31 Haraguchi S, Fung RQ, Sasaki CT. Effect of hyperthermia on the laryngeal closure
      76: 898-906.                                                                                           reflex: Implications in the sudden infant death syndrome. Ann Otol Rhinol
20. Nicoll A, Davies L. How warm are babies kept at home? Health Visitor 1986; 59:                           Laryngol 1983; 92: 24-28.
        113-14                                                                                        32. Parmeggiani PL. Interaction between sleep and thermoregulation: an aspect of the
21. Eiser C, Town C, Tnpp J. Dress and care of infants in health and illness. Arch Dis                       control of behavioural states. Sleep 1987, 10: 426-35.
       Child 1985, 60: 465-70                                                                         33. Butkow N, Mitchell D, Laburn H, Kenedi E. Heat stroke and endotoxaemia in
22. Bacon C, Scott D, Jones P Heatstroke in well-wrapped infants. Lancet 1979; i: 422-25.                    rabbits. In: Hales JRS, ed. Thermal physiology. New York: Raven Press, 1984:
23. Stanton AN Overheating and cot death. Lancet 1984, ii: 1199-201.                                         511-14.
24. Sunderland R, Emery JL Febrile convulsions and cot death. Lancet 1981; ii: 176-78.                34. Milner AD. Recent theories on the cause of cot death. Br Med J 1987; 295: 1366-68
25. Weatherall IL Thermal properties of bedding. In. Story LF, ed. Proceedings of the                 35. Emery JL, Howat AJ, Vanend S, Vawter GF. Investigation of inborn errors of
       eleventh annual conference. Measurement, Construction, and Performance.                               metabolism in unexpected infant deaths. Lancet 1988; ii: 29-31.

the Marshall Islands (66 in 1946-58), in the Johnston and                                    Micronesia. The most plausible explanation is the extensive
Christmas Island areas (36 in 1958-62), underwater in the                                    military infrastructure and activities related to the 66 nuclear
Pacific (4 in 1955-62), and at Amchitka, Alaska (3 in                                        test explosions at Enewetak and Bikini between 1946 and
1965-71). The French exploded 41 nuclear bombs in the                                        1958, and to the Kwajalein Missile Range. Alternative
atmosphere between 1966 and 1974, and continue                                               explanations have not been offered.
underground tests-101 as of November, 1988. French
nuclear tests in the Pacific take place at Moruroa and                                       Gilbert Islands, Kiribati (Central Pacific)
Fangataufa, two neighbouring coral atolls located in the                                       On several of the Gilbert Islands, outbreaks of ciguatera
Tuamotu archipelago in eastern French Polynesia.
                                                                                             were closely related temporally to naval shipping activities
                                                                                             and battles in the 1939-45 war, the link being clearest for
Marshall Islands, Micronesia                                                                 those at Butaritari and Tarawa (site of the 1943 Battle of
   These islands were the site of several battles during the                                 Tarawa).16
1939-45 war. As a result of military activity then, Kwajalein
and Majuro replaced Jaluit as the administrative and                                         Line Islands, Kiribati
commercial centre of the Marshalls. As the populations here                                     The first recorded outbreak at Fanning Island, previously
increased there were reports of ciguatera in these two areas, 10                             free of ciguatera, followed the dumping of war material (tank
especially at Majuro, the rise in the 1950s being attributed                                 mines, ammunition, batteries, and so on) by the US Army in
by the Marshallese to the nuclear test programmes carried                                    July, 1945, before evacuation of the island. 95 cases of
out there" between 1946 and 1958.
                                                                                             ciguatera were recorded in a population of 224 between
   Despite the reported absence of ciguatoxic fish from                                      February, 1946, and April, 1947.17 Except for 1 case illness
Enewetak in the years following nuclear test explosions                                      followed the eating of fish caught in areas where war material
there, severe outbreaks of ciguatera occurred in other atolls                                had been dumped. Toxicity decreased during the 1950s.18
in the Marshalls.9 Outpatient department records of the                                         This outbreak at Fanning was part of the more
Marshall Islands Memorial Hospital on Uliga Island of
                                                                                             widespread appearance of ciguatera through the northern
Majuro Atoll for 1955-57 suggested an average annual fish                                    Line Islands in the 1940s that started during the 1939-45
poisoning attack rate for the local population of 9-3%.12                                    war.19 Local residents reported that there had been no
Whereas clinic visits overall increased by 60% over this
                                                                                             ciguatoxicity before then. The only island unaffected was
period, gastrointestinal illness (much of which may have                                     Washington Island-the sole island in the group where
been ciguatera) and fish poisoning increased two to three
fold. Household surveys on Rita, Uliga, and Majuro Islands
                                                                                             military forces were not stationed and which no military
                                                                                             vessels visited.20 Palmyra Island, Kingman Reef, and
suggested an incidence rate for the previous year of around                                   Christmas and Fanning Islands, along with Johnston21 and
 15%.12 In health statistics for the whole US Micronesian
                                                                                             Midway Islands further to the north, were affected.
 Strategic Trust Territory, fish poisoning used to be
included under "accidents"-and in the late 1950s the
accident rate in the Marshalls was at least 50% higher than
                                                                                             Hao   Atoll, Tuamotu Archipelago, French Polynesia
that for the whole Territory. 12                                                                 The outbreak at Hao22 is the best known example of a
    In a 1982 survey requested by the WHO Regional Office,                                    military-related outbreak of ciguatera. Ciguatera had not
 56% of families in the Marshalls reported that at least one                                  occurred in Hao before January, 1965, when it is generally
 member had been poisoned within the last year.13                                             said that the French Commissariat a 1’Energie Atomique
    Only since 1982 have health statistics for the former US                                  (CEA) began to convert the atoll for use as a staging base for
 Strategic Trust Territory of the Pacific Islands (TTPI)                                      nuclear testing at Moruroa and Fangataufa Atolls, several
 been recorded separately for its components-the Northern                                     hundred kilometres to the south. Newspaper and Territorial
 Mariana Islands, the Federated States of Micronesia, the                                     Assembly records in fact show that members of the French
 Marshall Islands, and Belau. Between 1982 and 1987, the                                      Foreign Legion were illegally despatched to both Moruroa
 reported annual ciguatera incidence rate for the Marshall                                    and Hao, to begin construction work in July, 1963. The
 Islands averaged over 300 per 100 000 per year, more                                         building of an army camp for 2000 soldiers, a permanent
 than three times the rate of any other Micronesian territory                                 base for nuclear bomb assembly, and a large military airfield
                                                                                              with a 3500 m runway23,24 required the construction of piers
 (table I).14,15
    There is little doubt that                                                                and dredging of large quantities of coral.
                                        ciguatera continues to be a
                              in the Marshalls than elsewhere in                                 The first case of ciguatera reported from Hao involved
 greater     problem
                                                                                              fish caught at the original French landing site in August
                                                                                               1966. The disease then spread contiguously to other areas of
                                                                                              the atoll over the next 2 years. The first fish to become toxic
                                 ISLANDS, 1982-87
                                                                                              were herbivores; by April, 1968, carnivores were causing
                                                                                              poisoning. By mid- 1968, 43 % of the population of 650 had
                                                                                              been affected by ciguatera.22 Not till 1975 did toxicity in
                                                                                              herbivorous fish begin to fall.25

                                                                                              Gambier Islands, French Polynesia
                                                                                                  A   dinoflagellate organism was first clearly implicated as
                                                                                              a   cause    of ciguatera during the 1968 outbreak in the
                                                                                              Gambier Islands, after which it was named. Construction of
                                                                                              the military base at the Gambiers began in 1967.27 Before the
 Source. South Pacific   Epidemiological   and Health Informanon Service Annual   Reports,
                                                                                              detonation of the first hydrogen bomb on Aug 24, 1968, a
 1982-87  =’
                                                                                              fallout shelter was built for the local population on

                                                                  Several such submarine slides have accompanied nuclear
                                                                  tests,29 and extensive cracks and fissures have appeared on
                                                                  Moruroa, and large areas of the atoll continue to subside. 29,32

                                                                  Other Islands of Tuamotu    Archipelago, French Polynesia
                                                                     Military activity may also be implicated in the following
                                                                  outbreaks of ciguatera that have occurred since the 1960s in
                                                                  several atolls of the Tuamotus,30,31 especially since no other
                                                                  explanation has been offerred: (1) at Fakarava (western
                                                                  Tuamotus), which, like Mangareva, was visited by
                                                                  contaminated warships; and (2) at Pukarua and Reao
                                                                  (eastern Tuamotus), which lay within the "danger zone" for
                                                                  aircraft that applied during atmospheric tests.
                                                                     No data on ciguatera are available for Fangataufa, site of a
                                                                  military base, and reported to have been heavily
                                                                  contaminated by the first French thermonuclear explosion
Fig 2-Number of recorded cases of ciguatera in French Polynesia   (1968).23,32
  by year, 1960-84.
  Source: Bagnis R,   et   al.                                      RELATION BETWEEN RADIOACTIVITY AND CIGUATERA

                                                                     The outbreaks cited above raise the question of whether

Mangareva. It was not only construction materials that were       radioactivity is related to ciguatera. The only reported study
 dumped in Mangareva lagoon. Warships often visited               addressing this issue was conducted in the Central Pacific 30
                                                                  years ago and was supported by the US Atomic Energy
Mangareva, the main island. Before each of the 41                 Commission.l1 No correlation between radioactivity and
atmospheric tests conducted between 1966 and 1974, the
3000 personnel on Moruroa, Tuamotu Archipelago, were              ciguatoxicity was found in fish from a variety of locations,
evacuated in a dozen or so warships, from which they              including Enewetak and Majuro; the possibility that nuclear
watched the explosion. The ships, radioactively                   explosions may have caused ciguatera by other means was
                                                                  not considered. Whether radioactive fallout is related to
contaminated to varying degrees, would then disperse to
atolls with large lagoons and wide passes-Mangareva, Hao,         ciguatera deserves further study, especially in view of the
                                                                  likelihood of sizeable leakage of radionuclides from Moruroa
or Fakarava. Within 24-48 h of arrival in these lagoons, the
                                                                  within 10-100 years.33
ships were washed down with seawater. When radioactivity
at Moruroa was considered to have fallen sufficiently,
usually 1-2 weeks after the explosion, the ships would return
the evacuated personnel to Moruroa. Despite concern by               Ciguatera is substantially underreported-the South
local government officials that some of the material dumped       Pacific Commission estimates that official statistics reflect
or washed into the lagoon was radioactively contaminated 24       only 10-20% of actual cases.14 The South Pacific
and despite requests to Centre d’Experimentation du               Epidemiological and Health Information Service has
Pacifique to clean up the lagoons it had polluted, these were     collected ciguatera morbidity and mortality data since
not cleaned,28 except at Moruroa, where in 1981 waste             1973.15 Although incomplete, their records form the best
disposal and safety trial areas were damaged by storms,           available database on overall ciguatera epidemiology in the
which resulted in the dispersal of large numbers of               South Pacific. For the region as a whole (excluding Papua
plutonium-containing bitumen fragments into the lagoon29          New Guinea), the reported annual incidence for 1987 was
   Between 1971 and 1980 the incidence of ciguatera in the        219 cases per 100 000 population per year. 15
Gambiers remained at above 30%, with a peak at 56% in                For the period 1973-87 rates more than three times the
1975.30 Between 1960 and 1984, the average number of              regional average were recorded in French (eastern)
attacks of ciguatera for each of the 500-600 inhabitants was      Polynesia, some of the isolated island groups in the north
57. Fishing had previously been the major source of               central Pacific (Kiribati, Tokelau, and Tuvalu), the
livelihood, and the high risk of poisoning from eating local      Marshall Islands in north-east Micronesia (data for 1982-87
fish has had a considerable social and nutritional impact.        only), and Vanuatu (1985-87).15 Compared with the
                                                                  experience in French Polynesia, ciguatera occurs less
Moruroa, Tuamotu Archipelago, French Polynesia                    commonly in the Melanesian nations to the west (Papua
                                                                  New Guinea and the Solomon Islands), where the
  Ever since the nuclear test explosions began, fishing in the
Moruroa lagoon has officially been banned, although this          population is less dependent on marine resources, and where
ban has not always been respected, particularly by                morbidity reporting is less complete.34
Polynesians23 Moruroa has had a high incidence of                   TABLE II-CIGUATERA INCIDENCE BY ARCHIPELAGO, FRENCH
ciguatera over the past two decades,31 during which there                                        POLYNESIA, 1960-84
has been extensive coral damage caused by the building of
the military infrastructure29 and by the explosions
themselves. The most striking example of direct damage
was a 100-140 kilotonne explosion beneath the reef at
Moruroa on July 25,1979, which caused a submarine slide
that dislocated 1 million m3 of coral and rock from the side of
the atoll and produced a tidal wave that swept over the
southern part of the atoll and through the Tuamotus.              Based   on:   Danielsson and   Danielsson35

   Between 1960 and 198430 there was clearly a general                  I thank Dr N. C. Gillespie (Southern Fisheries Research Centre,
                                                                     Queensland), Dr   N. D. Lewis (University of Hawaii at Manoa), and Dr
flare-up of ciguatera in French Polynesia, with more than            Struan K. Sutherland (Commonwealth Serum Laboratories, Melbourne) for
24 000 cases being recorded among a population that grew             reference materials and helpful comments; Prof J. J. McNeil (Monash
from 84 500 in 1962 to 174 000 by mid-1985. The incidence            University) for general support; Dr Michael Hamel-Green and Dr
rose sharply through the 1960s, peaking in 1972-75 at 1200           J. T. Andrews for planting the seed for this work; Ms Kaye Winfield, Ms
                                                                     Anne Fensome, and Ms Christine Hennins for typing the various versions of
per 100 000, a ten-fold increase over the 1960 figure (fig 2).       this paper; and Mr Rob Klinkhamer for preparing the illustrations.
Improved case reporting has never been presented as a
major reason for the increase.
    In the areas most affected-the eastern Tuamotu,                                                        REFERENCES
Gambier, and Marquesas Archipelagos-the decline in                    1. Anderson      DM, Lobel PS. The continuing enigma of ciguatera. Biol Bull 1987, 172:
 incidence which began in the mid 1970s has not been                         89-107.
                                                                      2. Gillespie NC. Ciguatera poisoning. In: Covacevich J, Davie P, Pearn J, eds Toxic
 sustained and the incidence in the 1980s remains high. The
                                                                             plants and animals: a guide for Australia. Brisbane; Queensland Museum, 1987.
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 extremes ranging from 56% in the Gambiers in 1975, to zero           3. Bagnis RA, Legrand A-M. Clinical features on 12 890 cases of ciguatera (fish
                                                                             poisoning) in French Polynesia. In: Gopalakrishnakone P, Tan CK, eds. Progress
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                                                                      4. Pearn JH, Harvey P, De Ambrosis W, Lewis R, McKay R Ciguatera and pregnancy
 may transport of fish. For example, in 1976 at least 38% of                  Med J Aust 1982; 1: 57-58.
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                                                                              treatment of ciguatera fish poisoning with intravenous mannitol. JAMA 1988; 259:
 fish caught in the Tuamotus.34 Pooling of data by                            2740-42.
 archipelago tends to dilute high incidence figures from               6. Gillespie NC, Lewis RJ, Pearn JH, et al. Ciguatera in Australia. Occurrence, clinical

 particular islands.                                                          features, pathophysiology and management. Med J Aust 1986; 145: 584-90.
                                                                       7 Gillespie NC. Possible origins of ciguatera. In: Covacevich J, Davie P, Pearn J, eds
    The basic biogeographical phenomenon of decreasing                        Toxic plants and animals. a guide for Australia. Brisbane, Queensland Museum,
  diversity of marine and terrestrial fauna from west to east in               1987: 171-79.
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  the Pacific may help explain the susceptibility of eastern                   public health aspects of marine food fish poisoning. Manila, Philippines: Regional
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                                                                        9. Banner AH The biological origin and transmission of ciguatera. In: Humm HJ, Lane
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                                                                      10. Randall JE. A survey of ciguatera at Enewetak and Bikini, Marshall Islands, with notes
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  may be less resilient to a variety of insults than their more       11. Helfrich P A study of the possible relationship between radioactivity and toxicity in
 diverse counterparts.                                                         fishes from the central Pacific. Technical Information Service Publication no
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                                                                                1960: 16
                                                                      12. Bartsch AF, McFarren EF. Fish poisoning: a problem in food intoxication. Pacific Sci
        CIGUATERA AND NUCLEAR TEST EXPLOSIONS                                   1962: XVI: 42-56.
                                                                       13. Lewis ND, Ciguatera in the Pacific; incidence and implications for marine resource
    The examples of ciguatera outbreaks and the changes in
                                                                                development In: Ragelis EP, ed. Seafood toxins. ACS Symposium Senes 262
 incidence of ciguatera cited above indicate that in the Pacific                Washington DC: American Chemical Society, 1984: 289-306.
                                                                       14. Ciguatera fish poisoning SPC/Fisheries 20/Information Paper 16. Noumea; South
 nuclear test explosions may be related to ciguatera both                       Pacific Commission, 1988
 directly and indirectly. Directly, nuclear explosions damage          15. South Pacific Epidemiological and Health Information Service. Annual reports,
 atolls and coral reefs and, if underground, may trigger                        1973-87 Noumea: South Pacific Commission, 1974-88.
                                                                       16. Cooper MJ. Ciguatera and other marine poisoning in the Gilbert Islands. Pacific Sci
 earthquakes. The indirect effects are probably larger and                      1964: XVIII: 411-40.
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 activities on fragile island and coral reef ecosystems. These                  J Aust 1947; II: 617-21.
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                                                                        22. Bagnis R Naissance et developpement d’une flambee de ciguatera dans un atoll des
 personnel.                                                                     Tuamotu. Rev Corps Sante 1969; 10: 783-95.
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                                                                              seront les payeurs. La Depeche de Tahiti Nov 3, 1982: 19.
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               Communicable Disease


        JAN WELCH1           MARGARET WEBSTER2
                  J. E. BANATVALA1
    Department of Virology, United Medical and Dental Schools
   (St Thomas’ Campus), London SE1 7EH;1 Infection Control,
     St Thomas’ Hospital;2 and PHLS Communicable Disease
            Surveillance Centre, London NW9 5HT3

Summary             When       hepatitis B developed in 3
                 patients  who had had gynaecological
surgery, the surgeon was found to be a carrier of hepatitis B e
antigen. Of 268 patients operated on by this surgeon in one
hospital, 247 were screened for markers of recent or current
hepatitis B. 22 (9%) had such markers, associated with
symptoms in 5. The operations carrying greatest risk of
infection were hysterectomy (10/42) and caesarean section
(10/51). These findings strengthen the case for vaccination
of all surgeons and medical students against hepatitis B.

   THE occupational risk to health-care workers of acquiring
hepatitis B, although small, is well-recognised. Trans-
mission from staff to patients has also been described in
association with gynaecological surgery,12 cardiac surgery,
dentistry,45 and general practicealthough it appears to be
an uncommon cause of acute hepatitis B virus (HBV)
infection. We describe a seroprevalence study of contacts
after an outbreak of hepatitis B which was traced to a
                           THE OUTBREAK

   In April, 1987,2women were found to be positive for hepatitis B
surface antigen (HBsAg), neither of whom had any obvious risk
factors for infection. The investigations were done because one had
acute hepatitis, and the other-a symptom-free diabetic-had
abnormal liver function when tested to see if she was suitable to be
entered into a drug trial. A computer search for previous laboratory
investigations on these patients revealed that both women had been
patients on the same gynaecological ward several months before.
The lists of patients found to be HBsAg-positive during the
preceding months were examined, and another woman with no
obvious risk factors was identified; she had had a caesarean section
several months before. The notes of these 3 patients were obtained;
no patient had any apparent risk factors for hepatitis B, but all had
been operated on by the same surgeon. A blood sample from this
individual was obtained and found to be positive for HBsAg and
hepatitis B e antigen (HBeAg). Electron microscopy of serum
showed an abundance of HBsAg and numerous Dane particles.
  The surgeon stopped operating immediately. A committee to
manage the outbreak was set up, and included representatives from
the hospital’s unit management and infection control teams, and
obstetrics and gynaecology department; the Department of Health
and Social Security; and the Communicable Disease Surveillance

33 Hochstein MP, O’Sullivan MJ. Geothermal systems created by underground nuclear                Pacific Islands Monthly 1985; 56: 29-30.
      testing. implications for long-term, direct effects of underground testing Paper    36. Lewis ND. Ciguatera-parameters ofa tropical health problem. Human Ecol 1984; 12:
      presented to International Scientific Symposium on a Nuclear Test Ban, Las                 253-73.
     Vegas, Jan 15-16, 1988. 23.                                                          37. Merritt ML. Physical and biological effects of Cannikin. Report no NVO-123
34. Lewis ND Epidemiology and impact of ciguatera in the Pacific   a review.   Mar Fish          Washington DC: US Atomic Energy Commission, 1973: 106.
       Rev 1986, 48: 6-13                                                                 38. Bagnis R. How to appraise and prevent the risk of ciguatera: realities and outlook
35. Danielsson M-T, Danielsson B. The Mangareva story   Greenpeace v Gambierdiscus.              SPC/Fisheries 20/WP 14. Noumea: South Pacific Commission, 1988

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